PAYER_NAME,LOCATION,BILL_TYPE,PT_SUMMARY,PRIMARY_CODE,PRIMARY_CODE_DESCRIPTION,GROSS_CHARGES,CASH_PRICE_INPATIENT,CASH_PRICE_OUTPATIENT,PAYER_NEGOTIATED_RATE,MIN_NEGOTIATED_RATE,MAX_NEGOTIATED_RATE,,,FULL CHARGEMASTER ->,,,DESCRIPTION,REV CODE,CPT CODE,UNIT PRICE
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,PR ANESTHESIA UPPER GI ENDOSCOPIC PX N,964,731,$22.05 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,PR ANESTHESIA LOWER INTST ENDOSCOPIC P,964,811,$22.05 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,PR ANESTHESIA LOWER INTST ENDOSCOPIC P,964,812,$22.05 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,PR ANESTHESIA COMBINED UPPER&LOWER GI ,964,813,$22.05 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,PR FINE NEEDLE ASPIRATION BX W/O IMG G,975,10021,$420.22 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,PR FINE NEEDLE ASPIRATION BX W/O IMG G,975,10021,$420.22 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,PR DRAIN SKIN ABSCESS SIMPLE,521,10060,$328.49 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,PR DRAIN SKIN ABSCESS SIMPLE,521,10060,$328.49 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",74.81,74.81,74.81,43.9,43.9,55.21,,,,,,PR DRAIN SKIN ABSCESS COMPLIC,521,10061,$565.36 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,171.63,171.63,215.86,,,,,,PR DRAIN SKIN ABSCESS COMPLIC,521,10061,$565.36 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Professional,Outpatient,99349,Established patient home visit for problem of moderate to high severity (typically 40 minutes) [HCPCS 99349],331.09,331.09,331.09,194.28,194.28,194.28,,,,,,PR DRAIN PILONIDAL CYST SIMPL,521,10080,$573.84 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,13.87,13.87,17.44,,,,,,PR DRAIN PILONIDAL CYST SIMPL,521,10080,$573.84 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,50.83,50.83,63.93,,,,,,PR REMOVE FOREIGN BODY SIMPLE,521,10120,$413.22 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,60.08,60.08,75.56,,,,,,PR REMOVE FOREIGN BODY SIMPLE,521,10120,$413.22 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,36.97,36.97,46.49,,,,,,PR REMOVE FOREIGN BODY COMPLIC,521,10121,$735.16 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,36.65,36.65,46.1,,,,,,PR REMOVE FOREIGN BODY COMPLIC,521,10121,$735.16 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,78.56,78.56,98.8,,,,,,PR DRAINAGE OF HEMATOMA/FLUID,521,10140,$461.31 
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Skilled Nursing Facility,Professional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,87.8,87.8,110.43,,,,,,PR DRAINAGE OF HEMATOMA/FLUID,521,10140,$461.31 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,13.87,13.87,17.44,,,,,,PR PUNCTURE DRAINAGE OF LESION,521,10160,$353.78 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",,Professional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],55.13,55.13,55.13,32.35,32.35,40.69,,,,,,PR PUNCTURE DRAINAGE OF LESION,521,10160,$353.78 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",,Professional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,18.48,18.48,23.25,,,,,,"PR DEBRIDEMENT, INFECTED SKIN, UP TO 1",521,11000,$153.78 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,"PR DEBRIDEMENT, INFECTED SKIN, UP TO 1",521,11000,$153.78 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,"PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,=<2",521,11042,$341.66 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,"PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,=<2",521,11042,$341.66 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,"PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUS",521,11043,$625.59 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,"PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUS",521,11043,$625.59 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,"PR TRIM HYPERKERATOTIC SKIN LESION, ON",521,11055,$171.84 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,"PR TRIM HYPERKERATOTIC SKIN LESION, ON",521,11055,$171.84 
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,PR TANGENTIAL BIOPSY SKIN SINGLE LESIO,521,11102,$272.58 
BCBS OF MINNESOTA - Medicare Part A,Clinic,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,86.62,86.62,86.62,,,,,,PR TANGENTIAL BIOPSY SKIN SINGLE LESIO,521,11102,$272.58 
BCBS OF MINNESOTA - Medicare Part A,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,PR TANGENTIAL BIOPSY SKIN EA SEP/ADDIT,521,11103,$69.46 
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,PR TANGENTIAL BIOPSY SKIN EA SEP/ADDIT,521,11103,$69.46 
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,PR PUNCH BIOPSY SKIN SINGLE LESION,521,11104,$136.61 
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,PR PUNCH BIOPSY SKIN SINGLE LESION,521,11104,$136.61 
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,PR PUNCH BIOPSY SKIN EA SEP/ADDITIONAL,521,11105,$69.46 
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,PR PUNCH BIOPSY SKIN EA SEP/ADDITIONAL,521,11105,$69.46 
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,PR INCISIONAL BIOPSY SKIN SINGLE LESIO,521,11106,$136.61 
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,PR INCISIONAL BIOPSY SKIN SINGLE LESIO,521,11106,$136.61 
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,PR INCISIONAL BIOPSY SKIN EA SEP/ADDIT,521,11107,$69.46 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3415.15,3186.97,4561.97,,,,,,PR INCISIONAL BIOPSY SKIN EA SEP/ADDIT,521,11107,$69.46 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1557.61,1453.54,2080.66,,,,,,"PR REMOVAL OF SKIN TAGS, UP TO 15",521,11200,$240.89 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6346.62,5922.57,8477.82,,,,,,"PR REMOVAL OF SKIN TAGS, UP TO 15",521,11200,$240.89 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9459.3,8827.29,12635.76,,,,,,"PR REMOVAL OF SKIN TAGS, EACH ADD 10",521,11201,$50.11 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9018.71,8416.13,12047.21,,,,,,"PR REMOVAL OF SKIN TAGS, EACH ADD 10",521,11201,$50.11 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2419.85,2258.17,3232.44,,,,,,"PR SHAV SKIN LES <5MM TRUNK,ARM,LEG",521,11300,$273.58 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2853.41,2662.76,3811.59,,,,,,"PR SHAV SKIN LES <5MM TRUNK,ARM,LEG",521,11300,$273.58 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3441.73,3211.77,4597.47,,,,,,"PR SHAV SKIN LES 6-10MM TRUNK,ARM,LEG",521,11301,$331.49 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,132.67,62.19,148.68,,,,,,"PR SHAV SKIN LES 6-10MM TRUNK,ARM,LEG",521,11301,$331.49 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],343.06,343.06,343.06,225.91,201.31,253.18,,,,,,"PR SHAV SKIN LES 11-20MM TRUNK,ARM,LEG",521,11302,$383.05 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3415.15,3186.97,4561.97,,,,,,"PR SHAV SKIN LES 11-20MM TRUNK,ARM,LEG",521,11302,$383.05 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1557.61,1453.54,2080.66,,,,,,"PR SHAV SKIN LES >21MM TRUNK,ARM,LEG",521,11303,$421.50 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6346.62,5922.57,8477.82,,,,,,"PR SHAV SKIN LES >21MM TRUNK,ARM,LEG",521,11303,$421.50 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9459.3,8827.29,12635.76,,,,,,PR SHAV SKIN LES <5MM REMAINDR BODY,521,11305,$287.18 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9018.71,8416.13,12047.21,,,,,,PR SHAV SKIN LES <5MM REMAINDR BODY,521,11305,$287.18 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2419.85,2258.17,3232.44,,,,,,PR SHAV SKIN LES 6-10MM REMAINDR BODY,521,11306,$336.34 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2853.41,2662.76,3811.59,,,,,,PR SHAV SKIN LES 6-10MM REMAINDR BODY,521,11306,$336.34 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3441.73,3211.77,4597.47,,,,,,PR SHAV SKIN LES 11-20MM REMAINDR BODY,521,11307,$392.79 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,PR SHAV SKIN LES 11-20MM REMAINDR BODY,521,11307,$392.79 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,111.58,111.58,152.56,,,,,,PR SHAV SKIN LES >21MM REMAINDR BODY,521,11308,$419.56 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,103.58,103.58,126.16,,,,,,PR SHAV SKIN LES >21MM REMAINDR BODY,521,11308,$419.56 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],155.4,155.4,155.4,106.23,106.23,113.83,,,,,,"PR SHAV SKIN LES <5MM FACE,FACIAL",521,11310,$315.88 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1302.77,1302.77,1781.3,,,,,,"PR SHAV SKIN LES <5MM FACE,FACIAL",521,11310,$315.88 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1280.09,1280.09,1750.29,,,,,,"PR SHAV SKIN LES 6-10MM FACE,FACIAL",521,11311,$374.28 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,59.22,59.22,80.97,,,,,,"PR SHAV SKIN LES 6-10MM FACE,FACIAL",521,11311,$374.28 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,69.99,69.99,95.69,,,,,,"PR SHAV SKIN LES 11-20MM FACE,FACIAL",521,11312,$432.71 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,"PR SHAV SKIN LES 11-20MM FACE,FACIAL",521,11312,$432.71 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,"PR SHAV SKIN LES >21MM FACE,FACIAL",521,11313,$504.21 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,53.83,53.83,73.61,,,,,,"PR SHAV SKIN LES >21MM FACE,FACIAL",521,11313,$504.21 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,43.07,43.07,58.89,,,,,,"PR EXC SKIN BENIG <5MM TRUNK,ARM,LEG",521,11400,$342.17 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,"PR EXC SKIN BENIG <5MM TRUNK,ARM,LEG",521,11400,$342.17 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.82,108.82,108.82,74.39,74.39,101.71,,,,,,"PR EXC SKIN BENIG 0.6-1CM TRUNK,ARM,LE",521,11401,$416.10 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,42.7,42.7,58.38,,,,,,"PR EXC SKIN BENIG 0.6-1CM TRUNK,ARM,LE",521,11401,$416.10 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,75.2,75.2,102.82,,,,,,"PR EXC SKIN BENIG 1.1-2CM TRUNK,ARM,LE",521,11402,$460.85 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,87.05,87.05,119.02,,,,,,"PR EXC SKIN BENIG 1.1-2CM TRUNK,ARM,LE",521,11402,$460.85 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,79.32,79.32,108.45,,,,,,"PR EXC SKIN BENIG 2.1-3CM TRUNK,ARM,LE",521,11403,$529.39 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,145.61,145.61,199.09,,,,,,"PR EXC SKIN BENIG 2.1-3CM TRUNK,ARM,LE",521,11403,$529.39 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,102.29,102.29,139.86,,,,,,"PR EXC SKIN BENIG 3.1-4CM TRUNK,ARM,LE",521,11404,$599.88 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",74.81,74.81,74.81,49.26,43.9,55.21,,,,,,"PR EXC SKIN BENIG 3.1-4CM TRUNK,ARM,LE",521,11404,$599.88 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,132.67,62.19,148.68,,,,,,"PR EXC SKIN BENIG >4CM TRUNK,ARM,LEG",521,11406,$851.21 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,192.6,171.63,215.86,,,,,,"PR EXC SKIN BENIG >4CM TRUNK,ARM,LEG",521,11406,$851.21 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,258.62,230.46,289.84,,,,,,PR EXC SKIN BENIG <5MM REMAINDR BODY,521,11420,$345.08 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99496,Transitional care management services with face-to-face visits within 7 days of discharge (high complexity) [HCPCS 99496],659.52,659.52,659.52,434.29,434.29,434.29,,,,,,PR EXC SKIN BENIG <5MM REMAINDR BODY,521,11420,$345.08 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],206.06,206.06,206.06,135.69,63.61,152.07,,,,,,PR EXC SKIN BENIG 0.6-1CM REMAINDR BOD,521,11421,$433.11 
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,93015,"Heart and blood vessel stress test with EKG monitoring, physician supervision, interpretation, and report (exercise or drug-induced) [HCPCS 93015]",226.89,226.89,226.89,149.41,149.41,167.44,,,,,,PR EXC SKIN BENIG 0.6-1CM REMAINDR BOD,521,11421,$433.11 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,11200,Skin tag removal (up to and including 15 tags) [HCPCS 11200],240.89,240.89,240.89,176.45,176.45,200.57,,,,,,PR EXC SKIN BENIG 1.1-2CM REMAINDR BOD,521,11422,$486.11 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,17000,Destruction of pre-cancerous skin lesion/growth (first lesion/growth) [HCPCS 17000],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,PR EXC SKIN BENIG 1.1-2CM REMAINDR BOD,521,11422,$486.11 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,17003,Destruction of each additional pre-cancerous skin lesions/growths (2 to 14 lesions/growths) [HCPCS 17003],32.24,32.24,32.24,23.62,23.62,23.62,,,,,,PR EXC SKIN BENIG 2.1-3CM REMAINDR BOD,521,11423,$551.79 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,17110,Destruction of non-cancerous skin lesions/growths other than skin tags (up to 14 lesions/growths) [HCPCS 17110],304.71,304.71,304.71,223.2,223.2,284.81,,,,,,PR EXC SKIN BENIG 2.1-3CM REMAINDR BOD,521,11423,$551.79 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,29580,Strapping application of unna boot [HCPCS 29580],171.28,171.28,171.28,125.46,125.46,125.46,,,,,,PR EXC SKIN BENIG 3.1-4CM REMAINDR BOD,521,11424,$634.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,54.8,51.14,69.92,,,,,,PR EXC SKIN BENIG 3.1-4CM REMAINDR BOD,521,11424,$634.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,26.15,24.4,33.37,,,,,,PR EXC SKIN BENIG >4CM REMAINDR BODY,521,11426,$903.72 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,PR EXC SKIN BENIG >4CM REMAINDR BODY,521,11426,$903.72 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,"PR EXC SKIN BENIG <5MM FACE,FACIAL",521,11440,$381.11 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,149.36,149.36,190.59,,,,,,"PR EXC SKIN BENIG <5MM FACE,FACIAL",521,11440,$381.11 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,211.38,211.38,269.74,,,,,,"PR EXC SKIN BENIG 0.6-1CM FACE,FACIAL",521,11441,$465.74 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],439.89,439.89,439.89,322.22,322.22,322.22,,,,,,"PR EXC SKIN BENIG 0.6-1CM FACE,FACIAL",521,11441,$465.74 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,"PR EXC SKIN BENIG 1.1-2CM FACE,FACIAL",521,11442,$516.79 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,"PR EXC SKIN BENIG 1.1-2CM FACE,FACIAL",521,11442,$516.79 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,"PR EXC SKIN BENIG 2.1-3CM FACE,FACIAL",521,11443,$612.10 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,"PR EXC SKIN BENIG 2.1-3CM FACE,FACIAL",521,11443,$612.10 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],242.81,242.81,242.81,177.86,165.98,177.86,,,,,,"PR EXC SKIN BENIG 3.1-4CM FACE,FACIAL",521,11444,$764.81 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99305,Initial nursing facility visit by admitting physician for problem of moderate severity (typically 35 minutes per day) [HCPCS 99305],348.95,348.95,348.95,255.61,255.61,255.61,,,,,,"PR EXC SKIN BENIG 3.1-4CM FACE,FACIAL",521,11444,$764.81 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,86.62,86.62,86.62,,,,,,"PR EXC SKIN BENIG >4CM FACE,FACIAL",521,11446,"$1,050.80 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,"PR EXC SKIN BENIG >4CM FACE,FACIAL",521,11446,"$1,050.80 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],245.78,245.78,245.78,180.03,180.03,180.03,,,,,,HC SWING BED-HOSPICE,115,1150000,$771.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99348,Established patient home visit for problem of low to moderate severity (typically 25 minutes) [HCPCS 99348],217.63,217.63,217.63,159.41,159.41,159.41,,,,,,"PR EXC SKIN MALIG <5MM TRUNK,ARM,LEG",521,11600,$535.82 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99417,New or established patient office or outpatient visit with physician to diagnose and treat illness or injury beyond required time of primary visit (each additional 15 minutes of total time) [HCPCS 99417],27.3,27.3,27.3,20,20,20,,,,,,"PR EXC SKIN MALIG <5MM TRUNK,ARM,LEG",521,11600,$535.82 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,366.17,341.72,366.17,,,,,,"PR EXC SKIN MALIG 0.6-1CM TRUNK,ARM,LE",521,11601,$622.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,99496,Transitional care management services with face-to-face visits within 7 days of discharge (high complexity) [HCPCS 99496],659.52,659.52,659.52,483.1,483.1,483.1,,,,,,"PR EXC SKIN MALIG 0.6-1CM TRUNK,ARM,LE",521,11601,$622.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,G0101,Ca screen;pelvic/breast exam [HCPCS G0101],106.03,106.03,106.03,77.67,77.67,77.67,,,,,,"PR EXC SKIN MALIG 1.1-2CM TRUNK,ARM,LE",521,11602,$671.12 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,G0402,Initial preventive exam [HCPCS G0402],448.28,448.28,448.28,328.37,328.37,328.37,,,,,,"PR EXC SKIN MALIG 1.1-2CM TRUNK,ARM,LE",521,11602,$671.12 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,G0438,"Ppps, initial visit [HCPCS G0438]",459.96,459.96,459.96,336.92,336.92,336.92,,,,,,"PR EXC SKIN MALIG 2.1-3CM TRUNK,ARM,LE",521,11603,$763.06 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,G0439,"Ppps, subseq visit [HCPCS G0439]",312,312,312,228.54,213.28,228.54,,,,,,"PR EXC SKIN MALIG 2.1-3CM TRUNK,ARM,LE",521,11603,$763.06 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,G0511,Ccm/bhi by rhc/fqhc 20min mo [HCPCS G0511],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,"PR EXC SKIN MALIG 3.1-4CM TRUNK,ARM,LE",521,11604,$849.11 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,G2025,Dis site tele svcs rhc/fqhc [HCPCS G2025],96.63,96.63,96.63,70.78,70.78,70.78,,,,,,"PR EXC SKIN MALIG 3.1-4CM TRUNK,ARM,LE",521,11604,$849.11 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.2,1.12,1.53,,,,,,"PR EXC SKIN MALIG >4CM TRUNK,ARM,LEG",521,11606,"$1,207.90 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,"PR EXC SKIN MALIG >4CM TRUNK,ARM,LEG",521,11606,"$1,207.90 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,P3000,Screen pap by tech w md supv [HCPCS P3000],69.3,69.3,69.3,50.76,50.76,64.77,,,,,,PR EXC SKIN MALIG <5MM REMAINDR BODY,521,11620,$538.24 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Clinic,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,52.79,52.79,67.36,,,,,,PR EXC SKIN MALIG <5MM REMAINDR BODY,521,11620,$538.24 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,PR EXC SKIN MALIG 0.6-1CM REMAINDR BOD,521,11621,$624.83 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,PR EXC SKIN MALIG 0.6-1CM REMAINDR BOD,521,11621,$624.83 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,PR EXC SKIN MALIG 1.1-2CM REMAINDR BOD,521,11622,$692.52 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,PR EXC SKIN MALIG 1.1-2CM REMAINDR BOD,521,11622,$692.52 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,PR EXC SKIN MALIG 2.1-3CM REMAINDR BOD,521,11623,$810.17 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,PR EXC SKIN MALIG 2.1-3CM REMAINDR BOD,521,11623,$810.17 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,PR EXC SKIN MALIG 3.1-4CM REMAINDR BOD,521,11624,$915.22 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,PR EXC SKIN MALIG 3.1-4CM REMAINDR BOD,521,11624,$915.22 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",22.05,22.05,22.05,16.15,15.07,16.15,,,,,,PR EXC SKIN MALIG >4CM REMAINDR BODY,521,11626,"$1,098.43 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,PR EXC SKIN MALIG >4CM REMAINDR BODY,521,11626,"$1,098.43 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,"PR EXC SKIN MALIG <5MM FACE,FACIAL",521,11640,$551.39 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,813,"Anesthesia provided during sophagus, stomach, small bowel, and/or large bowel  procedure with endoscope [HCPCS 00813]",18.52,18.52,18.52,13.57,13.57,17.31,,,,,,"PR EXC SKIN MALIG <5MM FACE,FACIAL",521,11640,$551.39 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],328.49,328.49,328.49,240.62,240.62,240.62,,,,,,"PR EXC SKIN MALIG 0.6-1CM FACE,FACIAL",521,11641,$646.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",474.18,474.18,474.18,347.34,324.15,443.22,,,,,,"PR EXC SKIN MALIG 0.6-1CM FACE,FACIAL",521,11641,$646.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,12004,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (7.6 to 12.5 cm) [HCPCS 12004]",345.82,345.82,345.82,253.31,253.31,253.31,,,,,,"PR EXC SKIN MALIG 1.1-2CM FACE,FACIAL",521,11642,$732.86 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,616.07,574.94,786.13,,,,,,"PR EXC SKIN MALIG 1.1-2CM FACE,FACIAL",521,11642,$732.86 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,20611,Large joint or joint capsule fluid removal and/or injection with needle and ultrasound guidance including recording and reporting [HCPCS 20611],841.05,841.05,841.05,616.07,616.07,786.13,,,,,,"PR EXC SKIN MALIG 2.1-3CM FACE,FACIAL",521,11643,$860.25 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,27096,Anesthetic or steroid injection into hip joint with imaging guidance [HCPCS 27096],431.55,431.55,431.55,316.11,316.11,316.11,,,,,,"PR EXC SKIN MALIG 2.1-3CM FACE,FACIAL",521,11643,$860.25 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,29580,Strapping application of unna boot [HCPCS 29580],171.28,171.28,171.28,125.46,125.46,125.46,,,,,,"PR EXC SKIN MALIG 3.1-4CM FACE,FACIAL",521,11644,"$1,058.70 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,29581,Vein wound compression system application to lower leg below knee including ankle and foot [HCPCS 29581],354.7,354.7,354.7,259.82,242.47,259.82,,,,,,"PR EXC SKIN MALIG 3.1-4CM FACE,FACIAL",521,11644,"$1,058.70 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,"PR EXC SKIN MALIG >4CM FACE,FACIAL",521,11646,"$1,373.30 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,"PR EXC SKIN MALIG >4CM FACE,FACIAL",521,11646,"$1,373.30 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,36430,Blood or blood products transfusion [HCPCS 36430],222.77,222.77,222.77,163.18,163.18,163.18,,,,,,PR TRIM NAIL(S),521,11719,$38.45 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,36591,Blood specimen collection from a completely implantable venous access device [HCPCS 36591],196.88,196.88,196.88,144.21,144.21,144.21,,,,,,PR TRIM NAIL(S),521,11719,$38.45 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1081.15,1008.97,1379.59,,,,,,PR REMOVAL OF NAIL PLATE,521,11730,$301.29 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,PR REMOVAL OF NAIL PLATE,521,11730,$301.29 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,PR REMOVE ADDITIONAL NAIL PLATE,521,11732,$91.02 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,PR REMOVE ADDITIONAL NAIL PLATE,521,11732,$91.02 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,PR DRAIN BLOOD FROM UNDER NAIL,521,11740,$146.53 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,130.59,121.87,130.59,,,,,,PR DRAIN BLOOD FROM UNDER NAIL,521,11740,$146.53 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,51705,Bladder tube change (simple) [HCPCS 51705],502.74,502.74,502.74,368.26,368.26,368.26,,,,,,PR REMOVAL OF NAIL BED,521,11750,$427.36 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,62323,Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,PR REMOVAL OF NAIL BED,521,11750,$427.36 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64450,Anesthetic agent and/or steroid injection into other peripheral nerve or branch [HCPCS 64450],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,PR RECONSTRUC OF NAIL BED,521,11760,$529.96 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64454,Anesthetic agent and/or steroid injection into genicular nerve branches of knee with imaging imaging guidance [HCPCS 64454],918.75,918.75,918.75,672.98,672.98,672.98,,,,,,PR RECONSTRUC OF NAIL BED,521,11760,$529.96 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64483,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483],2741.55,2741.55,2741.55,2008.19,2008.19,2008.19,,,,,,"PR EXCISION OF NAIL FOLD, TOE",521,11765,$462.96 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64484,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (each additional level) [HCPCS 64484],585.9,585.9,585.9,429.17,429.17,429.17,,,,,,"PR EXCISION OF NAIL FOLD, TOE",521,11765,$462.96 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64490,Upper or middle spine facet joint injections with imaging guidance (first level) [HCPCS 64490],2741.55,2741.55,2741.55,2008.19,2008.19,2562.53,,,,,,PR REMV PILONIDAL LESION SIMPLE,521,11770,$840.61 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64491,Upper or middle spine facet joint injections with imaging guidance (second level) [HCPCS 64491],676.2,676.2,676.2,495.32,495.32,495.32,,,,,,PR REMV PILONIDAL LESION SIMPLE,521,11770,$840.61 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2008.19,1874.12,2562.53,,,,,,PR REMV PILONIDAL LESION EXTENS,975,11771,"$1,591.74 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,423.79,395.5,540.77,,,,,,PR REMV PILONIDAL LESION EXTENS,975,11771,"$1,591.74 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64495,Lower or sacral spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64495],591.15,591.15,591.15,433.02,404.11,552.55,,,,,,PR REMV PILONIDAL LESION COMPLIC,521,11772,"$1,959.52 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64624,Genicular nerve branches of knee destruction by injection with imaging guidance [HCPCS 64624],1653.75,1653.75,1653.75,1211.37,1211.37,1211.37,,,,,,PR REMV PILONIDAL LESION COMPLIC,521,11772,"$1,959.52 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],6570.9,6570.9,6570.9,4813.18,4491.87,6141.82,,,,,,"PR INJECTION INTO SKIN LESIONS, UP TO ",521,11900,$149.42 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],670.95,670.95,670.95,491.47,458.66,627.14,,,,,,"PR INJECTION INTO SKIN LESIONS, UP TO ",521,11900,$149.42 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,490.7,457.94,626.16,,,,,,PR REMOVAL OF CONTRACEPTIVE CAPSUL,521,11976,$390.12 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",808.5,808.5,808.5,592.23,552.69,755.7,,,,,,PR REMOVAL OF CONTRACEPTIVE CAPSUL,521,11976,$390.12 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,70491,"Neck CT scan of the soft tissue of the neck with contrast to examine injury, foreign bodies, or tumors [HCPCS 70491]",1178.1,1178.1,1178.1,862.96,862.96,1101.17,,,,,,PR INSERTION DRUG DELIVERY IMPLANT,521,11981,$277.24 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,70492,"Neck CT scan of the soft tissue of the neck without contrast, followed by contrast to examine injury, foreign bodies, or tumors [HCPCS 70492]",1426.43,1426.43,1426.43,1044.86,975.11,1044.86,,,,,,PR INSERTION DRUG DELIVERY IMPLANT,521,11981,$277.24 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,70544,Imaging of head blood vessels by MRA without contrast [HCPCS 70544],2213.4,2213.4,2213.4,1621.32,1513.08,2068.86,,,,,,PR REMOVAL DRUG IMPLANT DEVICE,521,11982,$314.67 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,70551,Imaging of brain by MRI without contrast [HCPCS 70551],2008.13,2008.13,2008.13,1470.96,1372.76,1470.96,,,,,,PR REMOVAL DRUG IMPLANT DEVICE,521,11982,$314.67 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",3284.4,3284.4,3284.4,2405.82,2245.22,3069.93,,,,,,PR REMOVAL W/ REINSERT DRUG IMPLANT DE,521,11983,$621.60 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,73.99,69.05,94.41,,,,,,PR REMOVAL W/ REINSERT DRUG IMPLANT DE,521,11983,$621.60 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,HC SWING BED,120,1200000,"$1,215.51 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],139.86,139.86,139.86,102.45,102.45,102.45,,,,,,HC RESPITE CARE,120,1200002,$276.03 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],159.29,159.29,159.29,116.68,108.89,148.89,,,,,,HC RESPITE CARE LEVEL II,120,1200004,$276.03 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,71120,Breast bone x-ray (minimum of 2 views) [HCPCS 71120],128.21,128.21,128.21,93.91,93.91,93.91,,,,,,PR REPR SUPERF WND BODY <2.5CM,521,12001,$243.73 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,672.6,627.7,858.27,,,,,,PR REPR SUPERF WND BODY <2.5CM,521,12001,$243.73 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,837.58,781.66,1068.78,,,,,,PR REPR SUP NPTERF WND BODY 2.6-7.5,521,12002,$296.70 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,119.56,111.58,152.56,,,,,,PR REPR SUP NPTERF WND BODY 2.6-7.5,521,12002,$296.70 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,PR REPR SUPERF WND BODY 7.6-12.5,521,12004,$345.82 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72052,"Spinal x-ray of upper spine including bending views, complete study (6 or more views) [HCPCS 72052]",233.1,233.1,233.1,170.75,170.75,170.75,,,,,,PR REPR SUPERF WND BODY 7.6-12.5,521,12004,$345.82 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72070,Spinal x-ray of middle spine (2 views) [HCPCS 72070],124.32,124.32,124.32,91.06,84.99,116.2,,,,,,PR REPR SUPERF WND BODY 12.6-20,521,12005,$456.18 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,PR REPR SUPERF WND BODY 12.6-20,521,12005,$456.18 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],190.37,190.37,190.37,139.45,130.14,177.94,,,,,,PR REPR SUPERF WND BODY 20.1-30,521,12006,$537.89 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",906.68,906.68,906.68,664.14,619.81,847.47,,,,,,PR REPR SUPERF WND BODY 20.1-30,521,12006,$537.89 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72128,"Spinal CT scan of middle spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72128]",906.68,906.68,906.68,664.14,619.81,664.14,,,,,,PR REPR SUPERF WND FACE <2.5CM,521,12011,$296.24 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",900.9,900.9,900.9,659.91,615.86,842.07,,,,,,PR REPR SUPERF WND FACE <2.5CM,521,12011,$296.24 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72141,Imaging of upper spinal canal by MRI without contrast [HCPCS 72141],1954.58,1954.58,1954.58,1431.73,1336.15,1826.95,,,,,,PR REPR SUPERF WND FACE 2.6-5,521,12013,$308.35 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72146,Imaging of middle spinal canal by MRI without contrast [HCPCS 72146],1954.58,1954.58,1954.58,1431.73,1336.15,1431.73,,,,,,PR REPR SUPERF WND FACE 2.6-5,521,12013,$308.35 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1431.73,1336.15,1826.95,,,,,,PR REPR SUPERF WND FACE 5.1-7.5,521,12014,$374.49 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72158,"Imaging of lower spinal canal by MRI without contrast, followed by contrast [HCPCS 72158]",3302.25,3302.25,3302.25,2418.9,2257.42,2418.9,,,,,,PR REPR SUPERF WND FACE 5.1-7.5,521,12014,$374.49 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],112.67,112.67,112.67,82.53,77.02,82.53,,,,,,PR REPR SUPERF WND FACE 7.6-12.5,521,12015,$452.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72195,Imaging of pelvis by MRI without contrast [HCPCS 72195],2391.9,2391.9,2391.9,1752.07,1752.07,1752.07,,,,,,PR REPR SUPERF WND FACE 7.6-12.5,521,12015,$452.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72197,"Imaging of pelvis by MRI without contrast, followed by contrast [HCPCS 72197]",3525.38,3525.38,3525.38,2582.34,2582.34,2582.34,,,,,,PR CLOSURE SUPERF WND DEHIS SIMPLE,521,12020,$797.46 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72202,X-ray of joints at hip bone and sacrum (3 or more views) [HCPCS 72202],147.63,147.63,147.63,108.14,100.92,108.14,,,,,,PR CLOSURE SUPERF WND DEHIS SIMPLE,521,12020,$797.46 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,72220,X-ray of sacrum and tailbone (minimum of 2 views) [HCPCS 72220],120.44,120.44,120.44,88.22,88.22,88.22,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG <2.5CM",521,12031,$685.23 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73020,Shoulder x-ray (single view) [HCPCS 73020],81.59,81.59,81.59,59.76,55.77,59.76,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG <2.5CM",521,12031,$685.23 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG 2.6-7.5",521,12032,$823.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],120.44,120.44,120.44,88.22,82.33,88.22,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG 2.6-7.5",521,12032,$823.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],112.67,112.67,112.67,82.53,77.02,93.81,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG 7.6-12.",521,12034,$879.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",120.44,120.44,120.44,88.22,88.22,112.58,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG 7.6-12.",521,12034,$879.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],112.67,112.67,112.67,82.53,77.02,105.31,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG 12.6-20",521,12035,"$1,043.08 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,110.99,103.58,126.16,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG 12.6-20",521,12035,"$1,043.08 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG 20.1-30",521,12036,"$1,159.63 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],139.86,139.86,139.86,102.45,95.61,130.73,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG 20.1-30",521,12036,"$1,159.63 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1516.71,1415.46,1935.39,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG >30CM",521,12037,"$1,313.26 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,"PR LAYR CLOS WND TRUNK,ARM,LEG >30CM",521,12037,"$1,313.26 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],155.4,155.4,155.4,113.83,106.23,113.83,,,,,,PR LAYR CLOS WND REST BODY <2.5CM,521,12041,$686.69 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73551,Thighbone x-ray (single view) [HCPCS 73551],112.67,112.67,112.67,82.53,82.53,82.53,,,,,,PR LAYR CLOS WND REST BODY <2.5CM,521,12041,$686.69 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73552,Thighbone x-ray (minimum of 2 views) [HCPCS 73552],135.98,135.98,135.98,99.61,99.61,99.61,,,,,,PR LAYR CLOS WND REST BODY 2.6-7.5,521,12042,$816.13 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,96.76,90.3,123.46,,,,,,PR LAYR CLOS WND REST BODY 2.6-7.5,521,12042,$816.13 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,PR LAYR CLOS WND REST BODY 7.6-12.5,521,12044,"$1,009.24 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],170.94,170.94,170.94,125.21,116.85,125.21,,,,,,PR LAYR CLOS WND REST BODY 7.6-12.5,521,12044,"$1,009.24 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73565,"Knee x-ray of both knees, standing (front to back view) [HCPCS 73565]",151.52,151.52,151.52,110.99,110.99,141.63,,,,,,PR LAYR CLOS WND REST BODY 12.6-20,521,12045,"$1,100.53 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],120.44,120.44,120.44,88.22,82.33,112.58,,,,,,PR LAYR CLOS WND REST BODY 12.6-20,521,12045,"$1,100.53 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,PR LAYR CLOS WND REST BODY 20.1-30,521,12046,"$1,316.14 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],108.78,108.78,108.78,79.68,79.68,101.68,,,,,,PR LAYR CLOS WND REST BODY 20.1-30,521,12046,"$1,316.14 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,"PR LAYR CLOS WND FACE,FACIAL <2.5CM",521,12051,$738.77 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,79.68,74.36,101.68,,,,,,"PR LAYR CLOS WND FACE,FACIAL <2.5CM",521,12051,$738.77 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",900.9,900.9,900.9,659.91,615.86,659.91,,,,,,"PR LAYR CLOS WND FACE,FACIAL 2.5-5",521,12052,$828.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1510.18,1409.36,1927.05,,,,,,"PR LAYR CLOS WND FACE,FACIAL 2.5-5",521,12052,$828.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],112.67,112.67,112.67,82.53,77.02,105.31,,,,,,"PR LAYR CLOS WND FACE,FACIAL 5.1-7.5",521,12053,$968.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],139.86,139.86,139.86,102.45,95.61,130.73,,,,,,"PR LAYR CLOS WND FACE,FACIAL 5.1-7.5",521,12053,$968.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",1160.78,1160.78,1160.78,850.27,793.51,1084.98,,,,,,"PR LAYR CLOS WND FACE,FACIAL 7.6-12.5",521,12054,"$1,016.90 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1395.96,1302.77,1781.3,,,,,,"PR LAYR CLOS WND FACE,FACIAL 7.6-12.5",521,12054,"$1,016.90 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",2142.53,2142.53,2142.53,1569.4,1464.63,1569.4,,,,,,HC ROOM & NURSING SP,121,,"$1,215.51 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],454.55,454.55,454.55,332.96,310.73,424.87,,,,,,CAH ROOM & NURSING TELEMETRY OR ISOLAT,121,1211000,"$1,447.04 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",341.88,341.88,341.88,250.43,233.71,250.43,,,,,,PR REPR CMPL WND TRUNK 1.1-2.5CM,521,13100,$929.05 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],481.74,481.74,481.74,352.87,329.32,450.28,,,,,,PR REPR CMPL WND TRUNK 1.1-2.5CM,521,13100,$929.05 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,261.81,244.33,334.08,,,,,,PR REPR CMPL WND TRUNK 2.6-7.5CM,521,13101,"$1,091.62 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76706,Abdominal aorta ultrasound for screening of abdominal aortic aneurysm [HCPCS 76706],446.78,446.78,446.78,327.27,305.42,327.27,,,,,,PR REPR CMPL WND TRUNK 2.6-7.5CM,521,13101,"$1,091.62 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76775,Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775],229.22,229.22,229.22,167.9,156.69,167.9,,,,,,"PR REPR CMPL WND SCALP,EXTR 1.1-2.5",521,13120,$968.47 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],481.74,481.74,481.74,352.87,329.32,450.28,,,,,,"PR REPR CMPL WND SCALP,EXTR 1.1-2.5",521,13120,$968.47 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",431.24,431.24,431.24,315.88,294.8,403.08,,,,,,"PR REPR CMPL WND SCALP,EXTR 2.6-7.5",521,13121,"$1,170.45 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",190.37,190.37,190.37,139.45,139.45,139.45,,,,,,"PR REPR CMPL WND SCALP,EXTR 2.6-7.5",521,13121,"$1,170.45 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,76870,Imaging of scrotum by ultrasound [HCPCS 76870],202.59,202.59,202.59,148.4,148.4,148.4,,,,,,"PR REP,SKIN,SCALP/EXTREM+5CM/<",521,13122,$354.69 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,72.55,67.71,92.58,,,,,,"PR REP,SKIN,SCALP/EXTREM+5CM/<",521,13122,$354.69 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,77065,Mammography of one breast for diagnosis [HCPCS 77065],524.48,524.48,524.48,384.18,358.53,490.23,,,,,,"PR REPR CMPL WND HEAD,FAC,HAND 1.1-2.5",521,13131,"$1,060.41 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,392.72,366.5,501.12,,,,,,"PR REPR CMPL WND HEAD,FAC,HAND 1.1-2.5",521,13131,"$1,060.41 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,77080,"Bone density measurement of the axial skeleton (hips, pelvis, spine) [HCPCS 77080]",155.4,155.4,155.4,113.83,106.23,145.25,,,,,,"PR REPR CMPL WND HEAD,FAC,HAND 2.6-7.5",975,13132,"$1,325.48 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,"PR REPR CMPL WND HEAD,FAC,HAND 2.6-7.5",975,13132,"$1,325.48 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,"PR REP,FACE,GENITAL,HAND,FT+5CM/<",981,13133,$480.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,"PR REP,FACE,GENITAL,HAND,FT+5CM/<",981,13133,$480.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,"PR REPR CMPL WND LID,NOS,EAR 1.1-2.5",521,13151,"$1,155.75 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80069,Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069],70.88,70.88,70.88,51.92,48.45,59.01,,,,,,"PR REPR CMPL WND LID,NOS,EAR 1.1-2.5",521,13151,"$1,155.75 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",63,63,63,46.15,43.07,58.89,,,,,,"PR REPR CMPL WND LID,NOS,EAR 2.5-7.5",521,13152,"$1,369.41 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80158,Lab analysis to measure the amount of cyclosporine in blood specimen [HCPCS 80158],141.75,141.75,141.75,103.83,103.83,103.83,,,,,,"PR REPR CMPL WND LID,NOS,EAR 2.5-7.5",521,13152,"$1,369.41 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80162,Lab analysis to measure the amount of total digoxin in blood specimen [HCPCS 80162],102.38,102.38,102.38,74.99,74.99,74.99,,,,,,"PR REP,EYELID,NOSE,EAR,LIP+5CM",521,13153,$535.50 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80164,Lab analysis to measure the amount of total valproic acid in blood specimen [HCPCS 80164],110.25,110.25,110.25,80.76,80.76,80.76,,,,,,"PR REP,EYELID,NOSE,EAR,LIP+5CM",521,13153,$535.50 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80185,Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185],102.38,102.38,102.38,74.99,69.99,74.99,,,,,,"PR ADJ TISS XFER SCALP,EXTREM <10SQCM",521,14020,"$1,881.64 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,80305,Drug screening read by direct visual reading [HCPCS 80305],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,"PR ADJ TISS XFER SCALP,EXTREM <10SQCM",521,14020,"$1,881.64 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,"PR ADJ TISS XFER HEAD,FAC,HAND <10SQCM",521,14040,"$2,049.02 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,"PR ADJ TISS XFER HEAD,FAC,HAND <10SQCM",521,14040,"$2,049.02 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,81270,Lab genetic analysis of the Janus kinase 2 gene variant [HCPCS 81270],724.5,724.5,724.5,530.7,530.7,530.7,,,,,,PR SKIN PINCH GRAFT PROCEDURE <2CM,521,15050,"$1,585.55 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,PR SKIN PINCH GRAFT PROCEDURE <2CM,521,15050,"$1,585.55 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"PR SPLIT GRFT,HEAD,FAC,HAND,FEET <100S",521,15120,"$2,291.63 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82164,Lab analysis to measure the angiotensin l - converting enzyme (ACE) level [HCPCS 82164],118.13,118.13,118.13,86.53,86.53,86.53,,,,,,"PR SPLIT GRFT,HEAD,FAC,HAND,FEET <100S",521,15120,"$2,291.63 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,PR REVISION OF LOWER EYELID,521,15820,"$1,633.41 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82272,Lab analysis to measure the amount of blood in stool specimen by peroxidase activity [HCPCS 82272],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,PR REVISION OF LOWER EYELID,521,15820,"$1,633.41 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],236.25,236.25,236.25,173.05,161.5,220.82,,,,,,PR REVISION OF UPPER EYELID,521,15822,"$1,269.91 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82378,Lab analysis to measure the carcinoembryonic antigen (cea) protein level [HCPCS 82378],149.63,149.63,149.63,109.6,109.6,109.6,,,,,,PR REVISION OF UPPER EYELID,521,15822,"$1,269.91 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82525,Lab analysis to measure the copper level [HCPCS 82525],94.5,94.5,94.5,69.22,69.22,69.22,,,,,,PR INITIAL RX BURN(S) 1ST DEGREE,521,16000,$197.53 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82533,Lab analysis to measure the amount of total cortisol (hormone) [HCPCS 82533],126,126,126,92.3,86.13,117.77,,,,,,PR INITIAL RX BURN(S) 1ST DEGREE,521,16000,$197.53 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,PR DRESS/DEBRID SMALL BURN NO ANES,521,16020,$223.36 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,PR DRESS/DEBRID SMALL BURN NO ANES,521,16020,$223.36 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,PR DRESS/DEBRID MED BURN NO ANESTH,521,16025,$413.49 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],39.38,39.38,39.38,28.85,26.92,32.79,,,,,,PR DRESS/DEBRID MED BURN NO ANESTH,521,16025,$413.49 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82595,Lab analysis to measure the amount of cryoglobulin (protein) in blood specimen [HCPCS 82595],47.25,47.25,47.25,34.61,34.61,34.61,,,,,,PR DRESS/DEBRID LARGE BURN NO ANESTH,521,16030,$520.97 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],118.13,118.13,118.13,86.53,80.75,110.42,,,,,,PR DRESS/DEBRID LARGE BURN NO ANESTH,521,16030,$520.97 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",307.13,307.13,307.13,224.97,209.95,224.97,,,,,,"PR DESTRUC PREMALIGNANT, FIRST LESION",521,17000,$177.16 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,80.76,75.37,103.05,,,,,,"PR DESTRUC PREMALIGNANT, FIRST LESION",521,17000,$177.16 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],118.13,118.13,118.13,86.53,80.75,86.53,,,,,,"PR DESTRUC PREMALIGNANT,2-14 LESIONS",521,17003,$6.95 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82784,Lab analysis to measure the amount of gammaglobulin (immune system protein) [HCPCS 82784],246.57,246.57,246.57,180.61,168.56,180.61,,,,,,"PR DESTRUC PREMALIGNANT,2-14 LESIONS",521,17003,$6.95 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,"PR DESTRUC PREMALIGNANT,15+ LESIONS",521,17004,$430.28 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83010,Lab analysis to measure the haptoglobin (serum protein) level in serum specimen [HCPCS 83010],102.38,102.38,102.38,74.99,69.99,74.99,,,,,,"PR DESTRUC PREMALIGNANT,15+ LESIONS",521,17004,$430.28 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],527.63,527.63,527.63,386.49,360.69,386.49,,,,,,PR DESTRUCTION BENIGN LESIONS UP TO 14,521,17110,$304.71 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,PR DESTRUCTION BENIGN LESIONS UP TO 14,521,17110,$304.71 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],94.5,94.5,94.5,69.22,64.6,69.22,,,,,,PR DESTRUCTION BENIGN LESIONS 15 OR MO,521,17111,$357.77 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83520,Lab analysis to measure the amount of substance by other immunoassay technique [HCPCS 83520],329.28,329.28,329.28,241.2,225.1,241.2,,,,,,PR DESTRUCTION BENIGN LESIONS 15 OR MO,521,17111,$357.77 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,PR CHEMICAL CAUTERIZATION OF GRANULATI,521,17250,$231.16 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],70.88,70.88,70.88,51.92,48.45,66.25,,,,,,PR CHEMICAL CAUTERIZATION OF GRANULATI,521,17250,$231.16 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,69.22,64.6,88.33,,,,,,HC ICU ROOM & NURSING,200,,"$1,794.32 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"PR EXPLORE WOUND,EXTREMITY",521,20103,"$1,565.56 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,"PR EXPLORE WOUND,EXTREMITY",521,20103,"$1,565.56 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83721,Lab analysis to measure the LDL cholesterol level [HCPCS 83721],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,PR REMOVAL OF FOREIGN BODY,521,20520,$573.22 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,PR REMOVAL OF FOREIGN BODY,521,20520,$573.22 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],307.13,307.13,307.13,224.97,209.95,287.07,,,,,,PR INJECT CARPAL TUNNEL,521,20526,$285.60 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83921,Lab analysis to measure the organic acid level in urine specimen [HCPCS 83921],165.38,165.38,165.38,121.14,113.05,121.14,,,,,,PR INJECT CARPAL TUNNEL,521,20526,$285.60 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83930,Lab analysis to measure osmolality (concentration) in blood specimen [HCPCS 83930],55.13,55.13,55.13,40.38,40.38,40.38,,,,,,PR INJECT TENDON SHEATH/LIGAMENT,521,20550,$196.35 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83935,Lab analysis to measure osmolality (concentration) in urine specimen [HCPCS 83935],55.13,55.13,55.13,40.38,40.38,40.38,,,,,,PR INJECT TENDON SHEATH/LIGAMENT,521,20550,$196.35 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],322.88,322.88,322.88,236.51,220.72,268.83,,,,,,PR INJECT TENDON ORIGIN/INSERT,521,20551,$151.31 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],39.38,39.38,39.38,28.85,26.92,28.85,,,,,,PR INJECT TENDON ORIGIN/INSERT,521,20551,$151.31 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],39.38,39.38,39.38,28.85,26.92,28.85,,,,,,"PR INJECT TRIGGER POINT, 1 OR 2",521,20552,$192.15 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,103.83,96.9,132.49,,,,,,"PR INJECT TRIGGER POINT, 1 OR 2",521,20552,$192.15 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],31.5,31.5,31.5,23.07,21.53,23.07,,,,,,"PR INJECT TRIGGER POINTS, > 3",521,20553,$217.35 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],31.5,31.5,31.5,23.07,21.53,26.23,,,,,,"PR INJECT TRIGGER POINTS, > 3",521,20553,$217.35 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84165,Lab analysis to measure the amount of protein in serum specimen [HCPCS 84165],86.63,86.63,86.63,63.46,59.22,63.46,,,,,,PR ARTHROCENTESIS ASPIR&/INJ SMALL JT/,521,20600,$180.60 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84295,Lab analysis to measure the sodium level in blood specimen [HCPCS 84295],39.38,39.38,39.38,28.85,28.85,28.85,,,,,,PR ARTHROCENTESIS ASPIR&/INJ SMALL JT/,521,20600,$180.60 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],204.75,204.75,204.75,149.98,139.97,191.38,,,,,,PR ARTHROCENTESIS ASPIR&/INJ INTERM JT,521,20605,$186.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],55.13,55.13,55.13,40.38,37.69,40.38,,,,,,PR ARTHROCENTESIS ASPIR&/INJ INTERM JT,521,20605,$186.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],70.88,70.88,70.88,51.92,48.45,66.25,,,,,,PR ARTHROCENTESIS ASPIR&/INJ MAJOR JT/,521,20610,$228.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,PR ARTHROCENTESIS ASPIR&/INJ MAJOR JT/,521,20610,$228.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",39.38,39.38,39.38,28.85,26.92,36.81,,,,,,PR ARTHROCENTESIS ASPIR&/INJ MAJOR JT/,521,20611,$300.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",39.38,39.38,39.38,28.85,26.92,36.81,,,,,,PR ARTHROCENTESIS ASPIR&/INJ MAJOR JT/,521,20611,$300.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],47.25,47.25,47.25,34.61,34.61,34.61,,,,,,PR ASPIRAT/INJECTION GANGLION CYST(S),521,20612,$166.88 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",110.25,110.25,110.25,80.76,75.37,103.05,,,,,,PR ASPIRAT/INJECTION GANGLION CYST(S),521,20612,$166.88 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",133.88,133.88,133.88,98.07,91.52,125.14,,,,,,"PR EXCISE LESION,BACK OR FLANK",975,21930,"$1,331.27 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,"PR EXCISE LESION,BACK OR FLANK",975,21930,"$1,331.27 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84520,Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520],31.5,31.5,31.5,23.07,23.07,23.07,,,,,,"PR CLOSED RX PROX HUMERUS FX,MANIP",521,23605,"$1,259.72 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,"PR CLOSED RX PROX HUMERUS FX,MANIP",521,23605,"$1,259.72 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84630,"Lab analysis to measure the zinc level in blood, serum, or urine specimen [HCPCS 84630]",86.63,86.63,86.63,63.46,63.46,63.46,,,,,,PR CLOSED RX GR TUBEROSITY HUM FX,521,23620,$726.27 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,84681,Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681],165.38,165.38,165.38,121.14,121.14,121.14,,,,,,PR CLOSED RX GR TUBEROSITY HUM FX,521,23620,$726.27 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85007,Lab analysis to identify white blood cells (manual) with microscope [HCPCS 85007],31.5,31.5,31.5,23.07,21.53,23.07,,,,,,PR CLOSED RX SHLDR DISLOCATION,521,23650,$860.41 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,PR CLOSED RX SHLDR DISLOCATION,521,23650,$860.41 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,"PR CLOSED RX SHLDR DISLOC,ANESTHESIA",521,23655,$761.72 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",47.25,47.25,47.25,34.61,32.3,39.34,,,,,,"PR CLOSED RX SHLDR DISLOC,ANESTHESIA",521,23655,$761.72 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85045,Lab analysis to measure red blood count (automated test) [HCPCS 85045],31.5,31.5,31.5,23.07,21.53,23.07,,,,,,PR INCIS/DRAIN ARM/ELBOW INFECT BURSA,521,23931,$791.31 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,PR INCIS/DRAIN ARM/ELBOW INFECT BURSA,521,23931,$791.31 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85384,Lab analysis to measure fibrinogen (factor 1) activity [HCPCS 85384],78.75,78.75,78.75,57.68,57.68,57.68,,,,,,PR REMOVAL OF ELBOW BURSA,521,24105,$974.73 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,PR REMOVAL OF ELBOW BURSA,521,24105,$974.73 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR EXCIS/CURET BENIGN ELBOW LESN,521,24120,"$1,460.93 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,PR EXCIS/CURET BENIGN ELBOW LESN,521,24120,"$1,460.93 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,PR CLOSED RX MID HUMERUS FRACTURE,521,24500,$969.06 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86039,Lab analysis to screen for autoimmune disorders by titer [HCPCS 86039],86.63,86.63,86.63,63.46,59.22,63.46,,,,,,PR CLOSED RX MID HUMERUS FRACTURE,521,24500,$969.06 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,"PR CLOSED RX MID HUMERUS FX,MANIPULATN",521,24505,"$1,394.94 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86156,Lab analysis to identify antibodies to cold agglutinin (protein) to screen for infection or disease [HCPCS 86156],63,63,63,46.15,43.07,46.15,,,,,,"PR CLOSED RX MID HUMERUS FX,MANIPULATN",521,24505,"$1,394.94 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],94.5,94.5,94.5,69.22,64.6,69.22,,,,,,PR CLOSED RX ELBOW DISLOCATION,521,24600,$995.53 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86225,Lab analysis to identify antibodies to native or double stranded DNA [HCPCS 86225],110.25,110.25,110.25,80.76,80.76,80.76,,,,,,PR CLOSED RX ELBOW DISLOCATION,521,24600,$995.53 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],187.54,187.54,187.54,137.37,128.2,137.37,,,,,,"PR CLOSED RX ELBOW DISLOCATN,ANESTHESI",521,24605,"$1,303.49 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86317,Lab analysis to identify infectious agent antibodies (quantitative) [HCPCS 86317],118.13,118.13,118.13,86.53,80.75,110.42,,,,,,"PR CLOSED RX ELBOW DISLOCATN,ANESTHESI",521,24605,"$1,303.49 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86334,Lab analysis by immunologic analysis technique on serum (immunofixation) [HCPCS 86334],453.79,453.79,453.79,332.4,332.4,332.4,,,,,,"PR CLOSED RX RADIAL HEAD DISLOC,CHILD",521,24640,$276.95 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"PR CLOSED RX RADIAL HEAD DISLOC,CHILD",521,24640,$276.95 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],488.25,488.25,488.25,357.64,333.77,456.37,,,,,,PR CLOSED RX RADIAL HEAD/NECK FX,521,24650,$709.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86618,Lab analysis to identify antibodies to Borrelia burgdorferi (Lyme disease bacteria) [HCPCS 86618],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,PR CLOSED RX RADIAL HEAD/NECK FX,521,24650,$709.30 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86706,Lab analysis to identify Hepatitis B surface antibodies [HCPCS 86706],86.63,86.63,86.63,63.46,59.22,63.46,,,,,,CLOSED TX ULNAR FRACTURE PROX END W/O ,521,24670,$788.07 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],110.25,110.25,110.25,80.76,75.37,103.05,,,,,,CLOSED TX ULNAR FRACTURE PROX END W/O ,521,24670,$788.07 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,CLOSED TX ULNAR FRACTURE PROX END W MA,521,24675,"$1,272.23 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,CLOSED TX ULNAR FRACTURE PROX END W MA,521,24675,"$1,272.23 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR EXCIS PRIMARY GANGLION WRIST,521,25111,$887.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,86922,Lab blood analysis to confirm blood unit compatibility by antiglobulin technique [HCPCS 86922],307.13,307.13,307.13,224.97,224.97,224.97,,,,,,PR EXCIS PRIMARY GANGLION WRIST,521,25111,$887.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],395.91,395.91,395.91,290,270.64,370.06,,,,,,PR CLOSED RX RADIAL SHAFT FX,521,25500,$753.07 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],70.88,70.88,70.88,51.92,48.45,51.92,,,,,,PR CLOSED RX RADIAL SHAFT FX,521,25500,$753.07 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87046,Lab analysis of stool culture to identify bacteria and additional pathogens [HCPCS 87046],70.88,70.88,70.88,51.92,48.45,51.92,,,,,,PR CLOSED RX RAD/ULNA SHAFT FX,521,25560,$769.64 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",70.88,70.88,70.88,51.92,48.45,66.25,,,,,,PR CLOSED RX RAD/ULNA SHAFT FX,521,25560,$769.64 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],63,63,63,46.15,43.07,58.89,,,,,,PR CLOSED RX DIST RAD/ULNA FX,521,25600,$900.08 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,PR CLOSED RX DIST RAD/ULNA FX,521,25600,$900.08 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,46.15,43.07,58.89,,,,,,"PR CLOSED RX DIST RAD/ULNA FX,MANIPUL",521,25605,"$1,455.11 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],63,63,63,46.15,43.07,58.89,,,,,,"PR CLOSED RX DIST RAD/ULNA FX,MANIPUL",521,25605,"$1,455.11 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87177,Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177],70.88,70.88,70.88,51.92,48.45,51.92,,,,,,PR CLOSED RX NAVICULAR FX,521,25622,$827.03 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",70.88,70.88,70.88,51.92,48.45,66.25,,,,,,PR CLOSED RX NAVICULAR FX,521,25622,$827.03 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87209,Lab analysis of complex special stain to identify parasites [HCPCS 87209],141.75,141.75,141.75,103.83,96.9,103.83,,,,,,"PR DRAIN FINGER ABSCESS,SIMPLE",521,26010,$825.93 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87210,"Lab analysis of wet mount to identify bacteria, fungi, or parasites [HCPCS 87210]",47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"PR DRAIN FINGER ABSCESS,SIMPLE",521,26010,$825.93 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87220,"Lab analysis of wet mount from skin, hair, or nails to examine tissue fungi or parasites [HCPCS 87220]",31.5,31.5,31.5,23.07,21.53,29.44,,,,,,"PR EXCIS TENDON SHEATH LESION, HAND/FI",521,26160,"$1,559.70 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.82,108.82,108.82,79.71,74.39,101.71,,,,,,"PR EXCIS TENDON SHEATH LESION, HAND/FI",521,26160,"$1,559.70 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87324,Lab analysis by immunoassay (ELISA) to identify clostridium difficile toxins (stool pathogen) [HCPCS 87324],94.5,94.5,94.5,69.22,64.6,69.22,,,,,,"PR MANIPULATE FINGER JT W/ ANESTH,EACH",521,26340,$937.68 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87389,Lab analysis by immunoassay (ELISA) to identify HIV-1 and HIV-2 [HCPCS 87389],189,189,189,138.44,129.2,176.66,,,,,,"PR MANIPULATE FINGER JT W/ ANESTH,EACH",521,26340,$937.68 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,45.75,42.7,58.38,,,,,,"PR TREAT THUMB DISLOC,MANIPULATN",521,26641,"$1,031.64 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],94.5,94.5,94.5,69.22,64.6,69.22,,,,,,"PR TREAT THUMB DISLOC,MANIPULATN",521,26641,"$1,031.64 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",94.5,94.5,94.5,69.22,64.6,69.22,,,,,,PR CLOSED RX MC-P DISLOC,521,26700,$893.45 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],291.38,291.38,291.38,213.44,199.19,213.44,,,,,,PR CLOSED RX MC-P DISLOC,521,26700,$893.45 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,"PR CLOSE RX PROX/MID FING SHFT FX,MANI",521,26725,$917.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87799,Lab analysis by nucleic acid (DNA or RNA) to measure the amount of organisms [HCPCS 87799],338.63,338.63,338.63,248.05,248.05,248.05,,,,,,"PR CLOSE RX PROX/MID FING SHFT FX,MANI",521,26725,$917.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,PR CLOSED RX IP JT DISLOCATION,521,26770,$756.80 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,87807,Lab analysis by immunoassay to identify respiratory syncytial virus (RSV) [HCPCS 87807],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,PR CLOSED RX IP JT DISLOCATION,521,26770,$756.80 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,88304,Pathology lab analysis of tissue with microscope (moderately low complexity) [HCPCS 88304],322.88,322.88,322.88,236.51,236.51,236.51,,,,,,PR AMPUTATION FINGER/THUMB,521,26951,"$1,688.98 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,409.56,382.22,522.62,,,,,,PR AMPUTATION FINGER/THUMB,521,26951,"$1,688.98 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,88312,Pathology lab analysis of special stained specimen slides to identify organisms with interpretation and report [HCPCS 88312],247.74,247.74,247.74,181.47,181.47,181.47,,,,,,HC CROUPETTE/DAY,270,2700024,$20.84 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,88342,Pathology lab analysis of special stained specimen slides to examine tissue (initial procedure) [HCPCS 88342],842.63,842.63,842.63,617.23,576.02,787.61,,,,,,PR INJECT SI JOINT ARTHRGRPHY&/ANES/ST,521,27096,$414.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,89055,Lab analysis to measure the amount of white blood cells in stool specimen [HCPCS 89055],31.5,31.5,31.5,23.07,21.53,23.07,,,,,,PR INJECT SI JOINT ARTHRGRPHY&/ANES/ST,521,27096,$414.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,26.15,24.4,33.37,,,,,,"PR CLOSED RX SPONT HIP DISLOC,ANESTH",521,27257,$920.31 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,92507,"Speech, language, voice, communication, and/or hearing processing disorder treatment [HCPCS 92507]",316.06,316.06,316.06,231.51,216.06,231.51,,,,,,"PR CLOSED RX SPONT HIP DISLOC,ANESTH",521,27257,$920.31 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,92523,Speech sound production evaluation with evaluation of language comprehension and expression [HCPCS 92523],773.52,773.52,773.52,566.6,566.6,566.6,,,,,,PR CLOSED RX POST HIP ARTHRPLAS DISLOC,521,27265,"$1,120.58 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,92610,Swallowing function evaluation [HCPCS 92610],346.62,346.62,346.62,253.9,253.9,253.9,,,,,,PR CLOSED RX POST HIP ARTHRPLAS DISLOC,521,27265,"$1,120.58 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,"PR REMV FOREIGN BODY,KNEE/THIGH,DEEP",521,27372,"$1,628.28 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,"PR REMV FOREIGN BODY,KNEE/THIGH,DEEP",521,27372,"$1,628.28 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,PR CLOSED RX KNEE DISLOC+ANESTH,521,27552,"$1,620.68 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,84.99,79.32,108.45,,,,,,PR CLOSED RX KNEE DISLOC+ANESTH,521,27552,"$1,620.68 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93225,"External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]",376.55,376.55,376.55,275.82,257.41,351.96,,,,,,PR CLOSED RX KNEECAP DISLOCATN,521,27560,"$1,006.32 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],118,118,118,86.44,80.66,110.29,,,,,,PR CLOSED RX KNEECAP DISLOCATN,521,27560,"$1,006.32 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,"PR CLOSED RX TIBIA SHAFT FX,MANIPULATN",521,27752,"$1,439.52 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],784.77,784.77,784.77,574.84,536.47,574.84,,,,,,"PR CLOSED RX TIBIA SHAFT FX,MANIPULATN",521,27752,"$1,439.52 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",477.86,477.86,477.86,350.03,350.03,446.66,,,,,,PR CLOSED RX PROX/SHAFT FIBULA FX,521,27780,$830.43 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,93976,"Abdominal, pelvic, and/or scrotal arterial inflow and venous outflow ultrasound (limited study) [HCPCS 93976]",644.91,644.91,644.91,472.4,472.4,472.4,,,,,,PR CLOSED RX PROX/SHAFT FIBULA FX,521,27780,$830.43 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,94010,Total and timed exhaled air capacity measurement and graphic recording [HCPCS 94010],187.53,187.53,187.53,137.37,128.2,137.37,,,,,,"PR CLOSED RX DIST FIBULA FX,MANIP",521,27788,"$1,179.62 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],79.71,79.71,79.71,58.39,54.49,74.5,,,,,,"PR CLOSED RX DIST FIBULA FX,MANIP",521,27788,"$1,179.62 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,95249,Continuous sugar (glucose) level monitoring in tissue fluid with sensor under skin [HCPCS 95249],182.66,182.66,182.66,133.8,124.87,170.73,,,,,,PR CLOSED TX BIMALLEOLAR ANKLE FRACTUR,521,27810,"$1,261.11 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,95810,"Sleep pattern monitoring of patient in sleep lab, sleep staging with 4 or more parameters of sleep (6 years of age or older) [HCPCS 95810]",2755.06,2755.06,2755.06,2018.08,1883.36,2575.15,,,,,,PR CLOSED TX BIMALLEOLAR ANKLE FRACTUR,521,27810,"$1,261.11 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,"PR CLOSED RX TRIMALLEOLAR FX,MANIP",521,27818,"$1,307.78 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,62.44,58.27,79.67,,,,,,"PR CLOSED RX TRIMALLEOLAR FX,MANIP",521,27818,"$1,307.78 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,328.8,306.85,419.57,,,,,,PR CLOSED RX ANKLE DISLOCATN,521,27840,"$1,043.02 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",137.53,137.53,137.53,100.74,94.02,128.55,,,,,,PR CLOSED RX ANKLE DISLOCATN,521,27840,"$1,043.02 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,"PR REMV FOOT FOREIGN BODY,SUBCUTANEOUS",521,28190,$697.48 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,183.16,170.93,233.72,,,,,,"PR REMV FOOT FOREIGN BODY,SUBCUTANEOUS",521,28190,$697.48 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,75.78,70.72,96.69,,,,,,PR CLOSED RX TARSAL DISLOCATION,521,28540,$541.77 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96376,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]",103.45,103.45,103.45,75.78,75.78,75.78,,,,,,PR CLOSED RX TARSAL DISLOCATION,521,28540,$541.77 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96402,"Chemotherapy administration beneath the skin or into muscle (hormonal, anti-cancer) [HCPCS 96402]",166.69,166.69,166.69,122.1,122.1,122.1,,,,,,PR CLOSED RX MT-PHAL TOE DISLOCATION,521,28630,$423.72 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96413,"Chemotherapy administration into vein by infusion (up to 1 hour, single drug) [HCPCS 96413]",887.54,887.54,887.54,650.12,606.72,650.12,,,,,,PR CLOSED RX MT-PHAL TOE DISLOCATION,521,28630,$423.72 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96415,Chemotherapy administration into vein by infusion (each additional hour) [HCPCS 96415],190.89,190.89,190.89,139.83,130.49,139.83,,,,,,PR APPLY LONG ARM CAST,521,29065,$254.93 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,96523,Implanted venous access drug delivery device irrigation [HCPCS 96523],145.85,145.85,145.85,106.84,99.7,106.84,,,,,,PR APPLY LONG ARM CAST,521,29065,$254.93 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97012,Mechanical traction application to 1 or more areas [HCPCS 97012],59.56,59.56,59.56,43.63,40.72,43.63,,,,,,PR APPLY FOREARM CAST,521,29075,$230.13 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,34.76,32.44,44.36,,,,,,PR APPLY FOREARM CAST,521,29075,$230.13 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,PR APPLY LONG ARM SPLINT,521,29105,$223.42 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,91.58,85.46,116.86,,,,,,PR APPLY LONG ARM SPLINT,521,29105,$223.42 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,87.28,81.45,111.37,,,,,,"PR APPLY FOREARM SPLINT,STATIC",981,29125,$185.22 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,81.4,75.97,103.87,,,,,,"PR APPLY FOREARM SPLINT,STATIC",981,29125,$185.22 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,"PR APPLY FINGER SPLINT,STATIC",521,29130,$110.40 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,"PR APPLY FINGER SPLINT,STATIC",521,29130,$110.40 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97165,Occupational therapy evaluation (typically 30 minutes) [HCPCS 97165],269.72,269.72,269.72,197.57,184.38,197.57,,,,,,PR STRAPPING OF ELBOW OR WRIST,521,29260,$82.25 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97166,Occupational therapy evaluation (typically 45 minutes) [HCPCS 97166],269.72,269.72,269.72,197.57,197.57,197.57,,,,,,PR STRAPPING OF ELBOW OR WRIST,521,29260,$82.25 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],129.65,129.65,129.65,94.97,88.63,107.95,,,,,,PR STRAPPING OF HAND OR FINGER,521,29280,$83.19 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97535,Training activities for home and self-care management (each 15 minutes) [HCPCS 97535],137.76,137.76,137.76,100.91,94.17,100.91,,,,,,PR STRAPPING OF HAND OR FINGER,521,29280,$83.19 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97602,Dead tissue removal from wounds per session [HCPCS 97602],295.2,295.2,295.2,216.23,201.8,216.23,,,,,,PR APPLY LONG LEG CAST,521,29345,$361.41 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,97802,Medical nutrition therapy assessment and intervention (each 15 minutes) [HCPCS 97802],99.44,99.44,99.44,72.84,67.98,92.95,,,,,,PR APPLY LONG LEG CAST,521,29345,$361.41 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],20,20,20,14.65,13.67,18.69,,,,,,PR APPLY SHORT LEG CAST,521,29405,$214.07 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],122.17,122.17,122.17,89.49,89.49,89.49,,,,,,PR APPLY SHORT LEG CAST,521,29405,$214.07 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,"PR APPLY SHORT LEG CAST,WALKER",521,29425,$205.81 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],252.37,252.37,252.37,184.86,184.86,184.86,,,,,,"PR APPLY SHORT LEG CAST,WALKER",521,29425,$205.81 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99235,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of moderate severity (50 minutes per day) [HCPCS 99235],280.15,280.15,280.15,205.21,205.21,205.21,,,,,,PR APPLY LOWER LEG SPLINT,521,29515,$190.25 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],116.39,116.39,116.39,85.26,79.56,85.26,,,,,,PR APPLY LOWER LEG SPLINT,521,29515,$190.25 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,164.29,153.32,209.63,,,,,,PR APPLY OF PASTE BOOT,521,29580,$171.28 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,PR APPLY OF PASTE BOOT,521,29580,$171.28 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,PR REMV/REVISN FULL ARM/LEG CAST,521,29705,$171.73 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,PR REMV/REVISN FULL ARM/LEG CAST,521,29705,$171.73 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,99291,Critical care delivery to critically ill or injured patient (first 30-74 minutes) [HCPCS 99291],1455.88,1455.88,1455.88,1066.43,1066.43,1066.43,,,,,,PR REMOVE NASAL FOREIGN BODY,521,30300,$519.38 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,PR REMOVE NASAL FOREIGN BODY,521,30300,$519.38 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,A0426,Als 1 [HCPCS A0426],1414.62,1414.62,1414.62,1036.21,1036.21,1036.21,,,,,,"PR CTRL NOSEBLEED,ANTER,SIMPLE",521,30901,$389.29 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,"PR CTRL NOSEBLEED,ANTER,SIMPLE",521,30901,$389.29 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,A0428,Bls [HCPCS A0428],1250.24,1250.24,1250.24,915.8,915.8,915.8,,,,,,"PR CTRL NOSEBLEED,ANTER,COMPLEX",521,30903,$618.49 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,A0429,Bls-emergency [HCPCS A0429],1250.24,1250.24,1250.24,915.8,854.66,1168.6,,,,,,"PR CTRL NOSEBLEED,ANTER,COMPLEX",521,30903,$618.49 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,A0434,Specialty care transport [HCPCS A0434],2399.25,2399.25,2399.25,1757.45,1757.45,2242.58,,,,,,"PR CTRL NOSEBLEED,POST,W/PACKS &/OR CA",521,30905,$921.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.75,2.56,2.75,,,,,,"PR CTRL NOSEBLEED,POST,W/PACKS &/OR CA",521,30905,$921.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,156.02,145.61,199.09,,,,,,PR REPEAT CONTROL OF NOSEBLEED,521,30906,$959.21 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,109.6,102.29,139.86,,,,,,PR REPEAT CONTROL OF NOSEBLEED,521,30906,$959.21 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,PR INSERT EMERGENCY ENDOTRACH AIRWAY,521,31500,$299.83 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,107.85,100.65,137.63,,,,,,PR INSERT EMERGENCY ENDOTRACH AIRWAY,521,31500,$299.83 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,HC SCLEROTHERAPY SPIDER VEINS,360,36468,$173.65 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",153.22,153.22,153.22,112.23,104.74,112.23,,,,,,HC FACIAL BONES MIN 3 VIEWS,320,70150,$178.71 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,37.11,34.63,42.18,,,,,,HC NOSE BONES MIN 3 VIEWS,320,70160,$139.86 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0390,Trauma respons w/hosp criti [HCPCS G0390],3386.05,3386.05,3386.05,2480.28,2314.7,3164.94,,,,,,HC ORBITS MIN 4 VIEWS,320,70200,$182.60 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0472,Hep c screen high risk/other [HCPCS G0472],112.29,112.29,112.29,82.25,82.25,82.25,,,,,,HC SINUSES LESS THAN 3 VIEWS,320,70210,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,G0499,Hepb screen high risk indiv [HCPCS G0499],123.84,123.84,123.84,90.71,90.71,90.71,,,,,,HC SINUSES COMPLETE MIN 3 VIEWS,320,70220,$143.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J0456,Azithromycin [HCPCS J0456],23,23,23,16.85,15.72,16.85,,,,,,HC SKULL <4 VIEWS,320,70250,$139.86 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J0897,Denosumab injection [HCPCS J0897],30.26,30.26,30.26,22.17,22.17,28.28,,,,,,HC SKULL COMPLETE MIN 4 VIEWS,320,70260,$170.94 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J1160,Digoxin injection [HCPCS J1160],23,23,23,16.85,16.85,16.85,,,,,,HC T-M JOINT BILATERAL,320,70330,$202.02 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J1745,Infliximab not biosimil 10mg [HCPCS J1745],126.57,126.57,126.57,92.71,86.52,92.71,,,,,,HC SOFT TISSUE NECK,320,70360,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],11.5,11.5,11.5,8.42,7.86,8.42,,,,,,HC CERVICAL SPINE 4 OR 5 VIEWS,320,72050,$198.14 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],23,23,23,16.85,15.72,21.5,,,,,,HC CERVICAL SPINE 6 OR MORE VIEWS,320,72052,$233.10 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],11.5,11.5,11.5,8.42,7.86,10.75,,,,,,HC SCOLIOSIS,320,72069,$98.40 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,HC THORACIC SPINE 3 VIEWS,320,72072,$151.52 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],15.75,15.75,15.75,11.54,10.77,11.54,,,,,,HC THORACIC SPINE W OBLIQUES,320,72074,$160.91 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J2785,Regadenoson injection [HCPCS J2785],152.56,152.56,152.56,111.75,111.75,111.75,,,,,,HC THORACOLUMBAR 2 VIEWS,320,72080,$132.09 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J2997,Alteplase recombinant [HCPCS J2997],134.92,134.92,134.92,98.83,92.23,98.83,,,,,,HC LUMBAR SPINE 2 VIEWS,320,72100,$147.63 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],23,23,23,16.85,15.72,21.5,,,,,,HC LUMBAR SPINE COM,320,72110,$190.37 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J3245,"Inj., tildrakizumab, 1 mg [HCPCS J3245]",248.01,248.01,248.01,181.67,181.67,181.67,,,,,,HC LUMBAR COMP W BENDING,320,72114,$233.10 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],11.5,11.5,11.5,8.42,7.86,10.75,,,,,,HC LUMBAR BENDING 4VIEWS,320,72120,$155.40 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.7,1.59,1.7,,,,,,HC PELVIS,320,72170,$112.67 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,16.96,15.83,21.64,,,,,,HC PELVIS MINIMUM 3 VIEWS,320,72190,$159.29 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,HC SI JOINT 1 OR 2 VIEWS,320,72200,$124.32 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],57.75,57.75,57.75,42.3,39.48,42.3,,,,,,HC SACROILIAC JOINTS,320,72202,$147.63 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],53.5,53.5,53.5,39.19,36.57,50.01,,,,,,HC SACRUN COCCYX MIN 2 VIEWS,320,72220,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,40.29,37.6,51.41,,,,,,HC CLAVICLE COMPLETE,320,73000,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],3559.7,3559.7,3559.7,2607.48,2607.48,2607.48,,,,,,HC SCAPULA COMPLETE,320,73010,$108.78 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Outpatient,P9040,Rbc leukoreduced irradiated [HCPCS P9040],844.32,844.32,844.32,618.46,618.46,618.46,,,,,,HC SHOULDER 1 VIEW,320,73020,$81.59 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,HC SHOULDER MIN 2 VIEWS,320,73030,$128.21 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,HC AC JOINTS,320,73050,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,HC HUMERUS 2 VIEWS,320,73060,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,HC ELBOW 2 VIEWS,320,73070,$112.67 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,HC ELBOW MIN 3 VIEWS,320,73080,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,HC FOREARM 2 VIEWS,320,73090,$112.67 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,HC WRIST 2 VIEWS,320,73100,$128.21 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,HC WRIST COMP MIN 3 VIEWS,320,73110,$151.52 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],328.49,328.49,328.49,240.62,240.62,240.62,,,,,,HC HAND 2 VIEWS,320,73120,$116.55 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,616.07,574.94,786.13,,,,,,HC HAND MIN 3 VIEWS,320,73130,$135.98 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,20611,Large joint or joint capsule fluid removal and/or injection with needle and ultrasound guidance including recording and reporting [HCPCS 20611],841.05,841.05,841.05,616.07,616.07,786.13,,,,,,HC FINGER MIN 2 VIEWS,320,73140,$139.86 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1081.15,1008.97,1379.59,,,,,,HC KNEE 1 OR 2 VIEWS,320,73560,$132.09 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,HC KNEE MIN 3 VIEWS,320,73562,$151.52 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,HC KNEE 4 OR MORE VIEWS,320,73564,$170.94 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,HC STANDING KNEES,320,73565,$151.52 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,HC TIBIA FIBULA 2 VIEW,320,73590,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,62323,Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,HC X-RAY ANKLE 2 VIEWS,320,73600,$124.32 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64454,Anesthetic agent and/or steroid injection into genicular nerve branches of knee with imaging imaging guidance [HCPCS 64454],918.75,918.75,918.75,672.98,672.98,672.98,,,,,,HC ANKLE MIN 3 VIEWS,320,73610,$135.98 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64483,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483],2741.55,2741.55,2741.55,2008.19,2008.19,2008.19,,,,,,HC FOOT 2 VIEWS,320,73620,$108.78 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64484,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (each additional level) [HCPCS 64484],585.9,585.9,585.9,429.17,429.17,429.17,,,,,,HC FOOT MIN 3 VIEWS,320,73630,$128.21 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2008.19,1874.12,2562.53,,,,,,HC HEEL MIN 2 VIEWS,320,73650,$108.78 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,423.79,395.5,540.77,,,,,,HC TOE MIN 2 VIEWS,320,73660,$108.78 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64495,Lower or sacral spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64495],591.15,591.15,591.15,433.02,404.11,552.55,,,,,,HC ABDOMEN 4 VIEWS,320,74022,$190.37 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64624,Genicular nerve branches of knee destruction by injection with imaging guidance [HCPCS 64624],1653.75,1653.75,1653.75,1211.37,1211.37,1211.37,,,,,,HC FLURO GUID NDL PLCMNT,320,77002,$393.90 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],6570.9,6570.9,6570.9,4813.18,4491.87,6141.82,,,,,,HC BONE SURVEY LMTD,320,77074,$248.64 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],670.95,670.95,670.95,491.47,458.66,627.14,,,,,,HC BONE SURVEY COMPLETE,320,77075,$372.96 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,HC OSSEOUS SURVEY INFANT,320,77076,$404.04 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,81015,Lab analysis of urine specimen with microscope [HCPCS 81015],23.63,23.63,23.63,17.31,17.31,17.31,,,,,,"HC JOINT SURVEY,SNGL V,2 OR M JOINTS",320,77077,$178.71 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93015,"Heart and blood vessel stress test with EKG monitoring, physician supervision, interpretation, and report (exercise or drug-induced) [HCPCS 93015]",226.89,226.89,226.89,166.2,166.2,212.07,,,,,,HC DEXASCAN,320,77080,$155.40 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,HC MANDIBLE LESS THAN 4 VIEWS,320,70100,$143.75 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,29.59,29.59,29.59,,,,,,HC MANDIBLE 4 OR MORE VIEWS,320,70110,$167.06 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],108.82,108.82,108.82,79.71,79.71,79.71,,,,,,HC STERNO-CLAV JTS MIN 3 V,320,71130,$155.40 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],405.17,405.17,405.17,296.79,296.79,296.79,,,,,,HC SPINE SINGLE VIEW,320,72020,$93.24 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99234,Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of low severity (40 minutes per day) [HCPCS 99234],208.37,208.37,208.37,152.63,152.63,152.63,,,,,,HC CERVICAL SPINE 2/3 VIEWS,320,72040,$147.63 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],116.39,116.39,116.39,85.26,79.56,85.26,,,,,,HC KNEE MIN 3 VIEWS BILATERAL,320,73562,$151.52 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,164.29,153.32,209.63,,,,,,"HC DEXA 1 OR MORE STIES,AXIAL SKELETON",320,77085,$235.00 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,HC ORBIT XRAY FOR FOREIGN BODY,320,70030,$120.44 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,HC SPINE THORACIC 2 VIEWS,320,72070,$124.32 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,HC DEXA BONE DENSITY PERIPHERAL,320,77081,$124.32 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],242.81,242.81,242.81,177.86,165.98,177.86,,,,,,HC X-RAY EXAM ENTIRE SPINE 2/3 VW,320,72082,$264.18 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99305,Initial nursing facility visit by admitting physician for problem of moderate severity (typically 35 minutes per day) [HCPCS 99305],348.95,348.95,348.95,255.61,255.61,255.61,,,,,,HC X-RAY EXAM HIP UNI 1 VW,320,73501,$124.32 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,86.62,86.62,86.62,,,,,,HC X-RAY EXAM HIP UNI 2-3 VW,320,73502,$174.83 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,HC X-RAY EXAM HIP BIL 2 VW,320,73521,$155.40 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,144.35,144.35,144.35,,,,,,HC X-RAY EXAM FEMUR 1 VW,320,73551,$112.67 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,HC X-RAY EXAM FEMUR 2/>,320,73552,$135.98 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,20600,Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600],574.5,574.5,574.5,177.35,177.35,177.35,,,,,,HC XR EXAM HIP BI 5/> VW,320,73523,$233.10 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],228.9,228.9,228.9,70.66,70.66,168.93,,,,,,HC X-RAY EXAM HIP BIL 3-4 VWS,320,73522,$202.02 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,30901,Simple control of nose bleed (limited cautery and/or packing) [HCPCS 30901],672.91,672.91,672.91,207.73,207.73,207.73,,,,,,HC XRAY ABDOMEN 1 VIEW,320,74018,$112.67 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1021.2,1021.2,1021.2,315.24,315.24,753.65,,,,,,HC XRAY ABDOMEN 2 VIEWS,320,74019,$139.86 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],585.76,585.76,585.76,180.82,180.82,385.72,,,,,,HC XRAY ABDOMEN 3+ VIEWS,320,74021,$163.17 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1328.95,1328.95,1328.95,410.25,410.25,980.77,,,,,,HC CDSM EVICORE,329,G1001,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],739.73,739.73,739.73,228.35,228.35,487.11,,,,,,HC CDSM MEDCURRENT,329,G1002,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,55.04,55.04,55.04,,,,,,HC CDSM MEDICALIS,329,G1003,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,51705,Bladder tube change (simple) [HCPCS 51705],235,235,235,72.54,72.54,72.54,,,,,,HC CDSM NDSC,329,G1004,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,62323,Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323],496.65,496.65,496.65,153.32,153.32,327.04,,,,,,HC CDSM AIM,329,G1007,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],705.6,705.6,705.6,217.82,217.82,464.64,,,,,,HC CDSM CRANBERRY PK,329,G1008,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],705.6,705.6,705.6,217.82,217.82,464.64,,,,,,HC CDSM SAGE HEALTH,329,G1009,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64495,Lower or sacral spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64495],967.05,967.05,967.05,298.53,298.53,636.8,,,,,,HC CDSM STANSON,329,G1010,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],1701,1701,1701,525.1,525.1,1120.11,,,,,,HC CDSM QUALIFIED NOS,329,G1011,$0.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],1701,1701,1701,525.1,525.1,1120.11,,,,,,HC RIB 2 VIEWS,324,71100,$139.86 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,18.63,18.63,18.63,,,,,,HC RIBS UNILATERAL 2 V PA CHEST,324,71101,$159.29 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,12.47,12.47,12.47,,,,,,"HC RIBS ONLY,BILATERAL 3 VIEWS",324,71110,$167.06 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],270.89,270.89,270.89,83.62,83.62,178.38,,,,,,HC RIBS BILAT W/PA CHEST 4 VIEWS,324,71111,$202.02 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],368.13,368.13,368.13,113.64,113.64,242.41,,,,,,HC STERNUM MIN 2 VIEWS,324,71120,$128.21 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99226,Subsequent observation care (typically 35 minutes per day) [HCPCS 99226],275.52,275.52,275.52,85.05,85.05,181.43,,,,,,HC XRAY CHEST 1 VIEW,324,71045,$101.01 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],103.03,103.03,103.03,31.81,31.81,67.85,,,,,,HC XRAY CHEST 2 VIEWS,324,71046,$128.21 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],191.01,191.01,191.01,58.96,58.96,125.78,,,,,,HC XRAY CHEST 4+ VIEWS,324,71048,$174.83 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",192.17,192.17,192.17,59.32,59.32,126.54,,,,,,PR TUBE THORACOSTOMY INCLUDES WATER SE,521,32551,$487.36 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",284.78,284.78,284.78,87.91,87.91,210.17,,,,,,PR TUBE THORACOSTOMY INCLUDES WATER SE,521,32551,$487.36 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,50.75,50.75,121.32,,,,,,PR THORACENTESIS NEEDLE/CATH PLEURA W/,960,32554,"$2,444.90 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,87.55,87.55,209.31,,,,,,PR THORACENTESIS NEEDLE/CATH PLEURA W/,960,32554,"$2,444.90 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],458.42,458.42,458.42,141.51,141.51,338.31,,,,,,PR PERQ DRAINAGE PLEURA INSERT CATH W/,521,32556,"$2,103.15 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],242.81,242.81,242.81,74.96,74.96,159.89,,,,,,PR PERQ DRAINAGE PLEURA INSERT CATH W/,521,32556,"$2,103.15 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99305,Initial nursing facility visit by admitting physician for problem of moderate severity (typically 35 minutes per day) [HCPCS 99305],348.95,348.95,348.95,107.72,107.72,107.72,,,,,,"HC CHEMO NONHORM ANTINEOPL,SQ/IM",331,96401,$137.55 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,36.5,36.5,77.87,,,,,,HC CHEMO HORMON ANTINEOPL SC IM,331,96402,$166.69 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,57.39,57.39,122.42,,,,,,"HC CHEMO,IV INFUSION,1 HR",335,96413,$887.54 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],245.78,245.78,245.78,75.87,75.87,75.87,,,,,,"HC CHEMO,IV INFUSION,ADDL HR",335,96415,$190.89 
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,60.84,60.84,129.77,,,,,,HC NM PARATHYROID IMAGING,341,78070,"$1,184.93 "
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],896.36,896.36,896.36,276.71,276.71,661.51,,,,,,HC NM BONE LIMITED,341,78300,$916.86 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3415.15,3186.97,4561.97,,,,,,HC NM BONE MULTIPLE AREAS,341,78305,"$1,107.23 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1557.61,1453.54,2080.66,,,,,,HC NM BONE WHOLE BODY/JOINT SCAN,341,78306,"$1,200.47 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6346.62,5922.57,8477.82,,,,,,HC NM BONE THREE-PHASE,341,78315,"$1,383.06 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9459.3,8827.29,12635.76,,,,,,HC NM VENOUS THROMBOSIS BILATERAL,341,78458,$819.74 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9018.71,8416.13,12047.21,,,,,,HC NM CARDIAC BLOOD POOL (MUGA),341,78472,$905.21 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2419.85,2258.17,3232.44,,,,,,HC NM CARDIAC REST-EXERCISE MUGA,341,78473,"$1,149.96 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2853.41,2662.76,3811.59,,,,,,HC NM PERFUSION LUNG,341,78580,$944.06 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3441.73,3211.77,4597.47,,,,,,HC NM BRAIN FLOW IMAGE,341,78610,$695.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC NM DMSA RENAL SCAN,341,78700,$683.76 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,87.64,87.64,119.84,,,,,,HC NM RENOGRAM,341,78707,$928.52 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],118.13,118.13,118.13,80.75,80.75,110.42,,,,,,HC NM MAG3 RENOGRAM W PHARM,341,78708,$703.19 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,87.05,87.05,119.02,,,,,,HC NUC MED CYSTOGRAM,341,78740,$866.36 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Professional,Outpatient,96127,Emotional or behavioral assessment for screening of condtions like ADHD or depression with scoring and documentation (brief assessment) [HCPCS 96127],13.13,13.13,13.13,8.65,8.65,9.69,,,,,,HC NM TESTICULAR IMAGING W/VASC FLOW,341,78761,$843.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",74.81,74.81,74.81,49.26,43.9,55.21,,,,,,HC TUMOR;SPECT,341,78803,"$1,550.12 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,134.27,134.27,150.48,,,,,,"HC NM HT MUSCLE IMAGE SPECT,MULTIPLE",341,78452,"$1,872.57 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],439.89,439.89,439.89,289.67,289.67,324.64,,,,,,HC NM HIDA IMAGE,341,78226,"$1,309.25 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,132.67,62.19,148.68,,,,,,HC NM HIDA WITH CCK,341,78227,"$1,767.68 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,192.6,171.63,215.86,,,,,,"HC BRAIN,STATIC ONLY",341,78605,$796.43 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,258.62,230.46,289.84,,,,,,"HC BRAIN,STATIC AND FLOW",341,78606,"$1,320.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,93015,"Heart and blood vessel stress test with EKG monitoring, physician supervision, interpretation, and report (exercise or drug-induced) [HCPCS 93015]",226.89,226.89,226.89,149.41,149.41,167.44,,,,,,"HC KIDNEY,STATIC & FLOW",341,78701,$870.24 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,97802,Medical nutrition therapy assessment and intervention (each 15 minutes) [HCPCS 97802],99.44,99.44,99.44,65.48,65.48,73.39,,,,,,HC MYOCARDIAL INFARCT IMAGE (REST FILM,341,78468,$944.62 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],109.98,109.98,109.98,72.42,33.95,81.17,,,,,,HC THYROID UPTAKE MEASUREMENT,341,78012,$412.11 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,108.25,50.75,121.32,,,,,,HC THYROID IMAGING W/BLOOD FLOW,341,78013,$765.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3415.15,3186.97,4561.97,,,,,,HC NM THYROID IMAGING,341,78014,"$1,289.60 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1557.61,1453.54,2080.66,,,,,,HC NM CARDIOLITE PER SYRINGE,343,A9500,$213.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6346.62,5922.57,8477.82,,,,,,HC MDP PER DOSE,343,A9503,$112.29 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9459.3,8827.29,12635.76,,,,,,HC CHOLETEC PER DOSE,343,A9537,$344.47 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9018.71,8416.13,12047.21,,,,,,HC NUC MEBROFENIN,343,A9537,$211.85 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2419.85,2258.17,3232.44,,,,,,HC CT SOFT TISSUE NECK W/O DYE,350,70490,$958.65 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2853.41,2662.76,3811.59,,,,,,HC CT SOFT TISSUE NECK W/DYE,350,70491,"$1,178.10 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3441.73,3211.77,4597.47,,,,,,HC CT SOFT TISSUE NECK W/WO DYE,350,70492,"$1,426.43 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,12.66,12.66,17.31,,,,,,HC CTA CHEST,350,71275,"$1,767.15 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",474.18,474.18,474.18,324.15,324.15,443.22,,,,,,HC CT SPINE CERVICAL W/DYE,350,72126,"$1,137.68 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",577.24,577.24,577.24,394.6,394.6,539.55,,,,,,HC CT SPINE CERVICAL W/WO DYE,352,72127,"$1,345.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",576.35,576.35,576.35,393.99,393.99,393.99,,,,,,HC CT SPINE THORACIC W/O DYE,350,72128,$906.68 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC CT SPINE THORACIC W/DYE,350,72129,"$1,149.23 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC CT SPINE THORACIC W/WO DYE,350,72130,"$1,345.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1008.97,1008.97,1379.59,,,,,,HC CT SPINE LUMBAR W/O DYE,350,72131,$900.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1118.18,1118.18,1528.91,,,,,,HC CT SPINE LUMBAR W/DYE,350,72132,"$1,143.45 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,457.94,457.94,626.16,,,,,,HC CT SPINE LUMBAR W/WO DYE,350,72133,"$1,816.31 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",808.5,808.5,808.5,552.69,552.69,755.7,,,,,,HC CT UPPER EXTREM W/O DYE,350,73200,"$1,039.50 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",3284.4,3284.4,3284.4,2245.22,2245.22,3069.93,,,,,,HC CT UPPER EXTREM W/DYE,350,73201,"$1,299.38 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,69.05,69.05,94.41,,,,,,HC CT UPPER EXTREM W/WO DYE,350,73202,"$1,622.78 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,87.64,87.64,119.84,,,,,,HC CT LOWER EXTREM W/O DYE,350,73700,$900.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],159.29,159.29,159.29,108.89,108.89,148.89,,,,,,HC CT LOWER EXTREM W/DYE,350,73701,"$1,131.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,627.7,627.7,858.27,,,,,,HC CT LOWER EXTREM W/WO DYE,350,73702,"$1,357.13 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,781.66,781.66,1068.78,,,,,,HC CT BRAIN W/O DYE,351,70450,$669.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,100.92,100.92,137.99,,,,,,HC CT BRAIN W/DYE,351,70460,$952.88 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",906.68,906.68,906.68,619.81,619.81,847.47,,,,,,HC CT BRAIN W/WO DYE,351,70470,"$1,114.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",900.9,900.9,900.9,615.86,615.86,842.07,,,,,,HC CT ORBITS/FOSSA/SELLA/IAC,351,70480,"$1,166.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1336.15,1336.15,1826.95,,,,,,HC CT ORBITS/FOSSA/SELLA/IAC W/DYE,351,70481,"$1,305.15 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,72156,"Imaging of spinal canal by MRI without contrast, followed by contrast [HCPCS 72156]",3311.18,3311.18,3311.18,2263.52,2263.52,2263.52,,,,,,HC CT ORBITS/FOSSA/SELLA/IAC W/WO DYE,351,70482,"$1,443.75 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,72157,"Imaging of middle spinal canal by MRI without contrast, followed by contrast [HCPCS 72157]",3320.1,3320.1,3320.1,2269.62,2269.62,2269.62,,,,,,HC CT FACIAL BONES W/O DYE,351,70486,$808.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,72158,"Imaging of lower spinal canal by MRI without contrast, followed by contrast [HCPCS 72158]",3302.25,3302.25,3302.25,2257.42,2257.42,2418.9,,,,,,HC CT MAXILOFACIAL W/DYE,351,70487,$975.98 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,87.64,87.64,119.84,,,,,,HC CT MAXILOFACIAL W/WO DYE,351,70488,"$1,183.88 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],112.67,112.67,112.67,77.02,77.02,105.31,,,,,,HC CT THORAX WO CONTRAST,352,71250,$918.23 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],135.98,135.98,135.98,92.96,92.96,127.1,,,,,,HC CT THORAX W+WO CONTRAST,352,71270,"$1,351.35 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],139.86,139.86,139.86,95.61,95.61,130.73,,,,,,HC CT SPINE CERVICAL W/O DYE,352,72125,$906.68 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73220,"Imaging of arm by MRI without contrast, followed by contrast [HCPCS 73220]",4319.7,4319.7,4319.7,2952.95,2952.95,2952.95,,,,,,HC CT PELVIS W/O DYE,352,72192,$843.15 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1415.46,1415.46,1935.39,,,,,,HC CT PELVIS W/DYE,352,72193,"$1,414.88 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,119.51,119.51,163.41,,,,,,HC CT PELVIS W/WO DYE,352,72194,"$1,588.13 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,90.3,90.3,123.46,,,,,,HC CT ABD W/O DYE,352,74150,$866.25 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,103.58,103.58,141.63,,,,,,HC CT ABD W/DYE,352,74160,"$1,443.75 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,92.96,92.96,127.1,,,,,,HC CT ABD W/WO DYE,352,74170,"$1,622.78 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,87.64,87.64,119.84,,,,,,HC CT THORAX W CONTRAST,352,71260,"$1,143.45 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,74.36,74.36,101.68,,,,,,HC LDCT FOR LUNG CANCER SCREEN,352,71271,$163.22 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",900.9,900.9,900.9,615.86,615.86,659.91,,,,,,HC CT ABD/PELVIS W/O CONTRAST,352,74176,"$1,160.78 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1409.36,1409.36,1927.05,,,,,,HC CT ABD/PELVIS W/CONTRAST,352,74177,"$1,905.75 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",1160.78,1160.78,1160.78,793.51,793.51,1084.98,,,,,,HC CT ABD/PELVIS W/O&W CONTRAST,352,74178,"$2,142.53 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1302.77,1302.77,1781.3,,,,,,HC CT TOBACCO HX CHEST,352,71250,$203.74 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",419.58,419.58,419.58,286.82,286.82,392.18,,,,,,"HC INJ TRIGGER POINT,3 OR MORE",360,20553,$841.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,244.33,244.33,334.08,,,,,,PR INJECTIONS SCLEROSANT FOR SPIDER VE,521,36468,$295.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],64.83,64.83,64.83,44.32,44.32,60.6,,,,,,PR INJECTIONS SCLEROSANT FOR SPIDER VE,521,36468,$295.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,67.71,67.71,92.58,,,,,,HC BLOOD ADMIN 2+ HRS,391,36430,$0.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,366.5,366.5,501.12,,,,,,HC BLOOD ADMIN 0-2 HRS,391,36430,$222.77 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,77080,"Bone density measurement of the axial skeleton (hips, pelvis, spine) [HCPCS 77080]",155.4,155.4,155.4,106.23,106.23,145.25,,,,,,HC BLOOD TRANSFUSION/DAY,391,36430,$222.77 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1280.09,1280.09,1750.29,,,,,,HC TOMO MAMMO DIAGN ADD-ON,401,G0279,$153.22 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,43.07,43.07,58.89,,,,,,HC DIAGNOSTIC MAMMO CAD UNILATERAL,401,77065,$524.48 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,59.22,59.22,80.97,,,,,,HC DIAGNOSTIC MAMMO CAD BILATERAL,401,77066,$664.34 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,69.99,69.99,95.69,,,,,,HC SURGICAL PATH-LEVEL III,312,88304,$322.88 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,80069,Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069],70.88,70.88,70.88,48.45,48.45,59.01,,,,,,HC SURGICAL PATH-LEVEL IV,312,88305,$254.68 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",63,63,63,43.07,43.07,58.89,,,,,,HC SURGICAL PATH-LEVEL II,312,88302,$244.13 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,80305,Drug screening read by direct visual reading [HCPCS 80305],102.38,102.38,102.38,69.99,69.99,95.69,,,,,,HC SURGICAL PATH-LEVEL V,312,88307,$568.40 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],133.88,133.88,133.88,91.52,91.52,125.14,,,,,,HC SPECIAL STAIN-GROUP I,312,88312,$247.74 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,80307,Drug screening read by chemistry analyzers [HCPCS 80307],488.25,488.25,488.25,333.77,333.77,333.77,,,,,,HC IMMUNOPEROXIDASE STAIN,312,88342,$236.16 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC SURGICAL PATH-LEVEL VI,312,88309,$790.66 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,10.77,10.77,14.72,,,,,,HC SURGICAL PATH-LEVEL I,312,88300,$126.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",39.38,39.38,39.38,26.92,26.92,36.81,,,,,,HC SPECIAL STAIN - GROUP II,312,88313,$226.89 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC MANUAL WBC DIFFERENTIAL,305,85007,$31.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC ECHO EXAM OF HEAD,402,76506,$450.66 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,HC US EXAM HEAD/NECK,402,76536,$454.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],236.25,236.25,236.25,161.5,161.5,220.82,,,,,,HC US EXAM ABDOMEN COMPLETE,402,76700,$481.74 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,HC US ECHO EXAM OF ABDOMEN,402,76705,$357.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],94.5,94.5,94.5,64.6,64.6,88.33,,,,,,HC US RETROPERIT (RENAL LAAA),402,76770,$442.89 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,"HC US RETROPERIT LTD (RENAL,LAAA)",402,76775,$229.22 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],39.38,39.38,39.38,26.92,26.92,32.79,,,,,,HC US OB COMPLETE(<14 WKS),402,76801,$477.86 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],118.13,118.13,118.13,80.75,80.75,110.42,,,,,,HC MULTIPLE GESTATION(<14 WKS),402,76802,$248.64 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,75.37,75.37,103.05,,,,,,HC US PREGNANCY >=14WKS SNGL FETUS,402,76805,$547.79 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,53.83,53.83,73.61,,,,,,HC US PREGNANCY >= 14WKS ADDL FETUS,402,76810,$357.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC US PREGNANCY LMTD,402,76815,$330.23 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],70.88,70.88,70.88,48.45,48.45,66.25,,,,,,HC FOLLOW UP/REPEAT OB,402,76816,$442.89 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC US TRANSVAGINAL(OB),402,76817,$376.85 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,HC BIO PROFILE,402,76819,$341.88 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83721,Lab analysis to measure the LDL cholesterol level [HCPCS 83721],86.63,86.63,86.63,59.22,59.22,80.97,,,,,,HC US TRANSVAGINAL,402,76830,$481.74 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,HC US PELVIC COMPLETE,402,76856,$431.24 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],307.13,307.13,307.13,209.95,209.95,287.07,,,,,,HC US PELVIC LIMITED,402,76857,$190.37 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83921,Lab analysis to measure the organic acid level in urine specimen [HCPCS 83921],165.38,165.38,165.38,113.05,113.05,121.14,,,,,,HC US SCROTUM,402,76870,$202.59 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],322.88,322.88,322.88,220.72,220.72,268.83,,,,,,HC PROSTATE TRANSRECTAL,402,76872,$617.72 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],39.38,39.38,39.38,26.92,26.92,28.85,,,,,,HC US GUIDANCE/NDL PLACEMENT,402,76942,$78.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],165.38,165.38,165.38,113.05,113.05,154.58,,,,,,HC US FETAL BIOPSY PROFILE W/NST,402,76818,$462.32 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,96.9,96.9,132.49,,,,,,HC US GUIDANCE/NDL PLACEMENT,402,76942,$78.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84155,Lab analysis to measure the total protein level in blood specimen [HCPCS 84155],31.5,31.5,31.5,21.53,21.53,23.07,,,,,,HC US XTR NON-VASC LMTD,402,76882,$64.83 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],31.5,31.5,31.5,21.53,21.53,26.23,,,,,,HC ULTRASOUND OF EXTREMITY,402,76881,$303.03 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84165,Lab analysis to measure the amount of protein in serum specimen [HCPCS 84165],86.63,86.63,86.63,59.22,59.22,63.46,,,,,,HC ULTRASOUND EXAM AAA SCREEN,402,76706,$446.78 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],70.88,70.88,70.88,48.45,48.45,66.25,,,,,,HC US BREAST UNILAT W/AXILLA COMPLETE,402,76641,$419.58 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,91.52,91.52,125.14,,,,,,HC US BREAST UNILAT W/AXILLA LIMITED,402,76642,$341.88 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",39.38,39.38,39.38,26.92,26.92,36.81,,,,,,"HC ULTRASOUND PROCEDURE,UNLISTED",402,76999,$191.01 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",39.38,39.38,39.38,26.92,26.92,36.81,,,,,,RBC'S WASHED,390,P9022,$970.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",133.88,133.88,133.88,91.52,91.52,125.14,,,,,,HC TOMO SCREENING BILAT ADD-ON,403,77063,$99.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,64.6,64.6,88.33,,,,,,HC SCREENING MAMMO CAD BILATERAL,403,77067,$536.13 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",118.13,118.13,118.13,80.75,80.75,110.42,,,,,,"HC VENTILATION ASSIST,INITIAL",410,94002,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],63,63,63,43.07,43.07,58.89,,,,,,HC AIRWAY INHALATION TRMT,410,94640,$79.71 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,43.07,43.07,58.89,,,,,,HC CPAP/DAY,410,94660,$286.53 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",47.25,47.25,47.25,32.3,32.3,39.34,,,,,,HC DEMO/EVAL-AEROSOL,410,94664,$74.89 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],78.75,78.75,78.75,53.83,53.83,73.61,,,,,,"HC CHEST PHYSIOTHERAPY,INITIAL",410,94667,$111.07 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,21.53,21.53,29.44,,,,,,"HC CHEST PHYSIOTHERAPY,SUBSEQUENT",410,94668,$128.79 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC AIRWAY INHALATION TRMT SUBSQ,410,94640,$79.71 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC C-PAP,410,94660,$286.53 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86008,Lab analysis to identify antibody IgE to allergic substance (each recombinant or purified component) [HCPCS 86008],23.67,23.67,23.67,16.18,16.18,16.18,,,,,,"PR EXCIS TONGUE LESN,ANT 2/3+CLOS",521,41112,$958.51 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],94.5,94.5,94.5,64.6,64.6,88.33,,,,,,"PR EXCIS TONGUE LESN,ANT 2/3+CLOS",521,41112,$958.51 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86039,Lab analysis to screen for autoimmune disorders by titer [HCPCS 86039],86.63,86.63,86.63,59.22,59.22,63.46,,,,,,PR DRAINAGE OF GUM LESION,521,41800,$805.07 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,PR DRAINAGE OF GUM LESION,521,41800,$805.07 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC TRACTION MECHANICAL,420,97012,$59.56 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],31.5,31.5,31.5,21.53,21.53,29.44,,,,,,HC UNATTEND E-STIM,420,97014,$56.76 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86618,Lab analysis to identify antibodies to Borrelia burgdorferi (Lyme disease bacteria) [HCPCS 86618],133.88,133.88,133.88,91.52,91.52,125.14,,,,,,HC GAIT TRAINING,420,97116,$119.15 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86664,"Lab analysis to identify antibodies to Epstein-Barr virus (mononucleosis virus), nuclear antigen [HCPCS 86664]",141.75,141.75,141.75,96.9,96.9,96.9,,,,,,HC ORTHO MGT/TRAINING INITIAL,420,97760,$194.84 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],110.25,110.25,110.25,75.37,75.37,103.05,,,,,,"HC STRAPPING,THORAX",360,29200,$128.94 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],70.88,70.88,70.88,48.45,48.45,51.92,,,,,,"HC STRAPPING,ELBOW OR WRIST",360,29260,$118.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87046,Lab analysis of stool culture to identify bacteria and additional pathogens [HCPCS 87046],70.88,70.88,70.88,48.45,48.45,51.92,,,,,,"HC STRAPPING,HAND OR FINGER",360,29280,$119.77 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",70.88,70.88,70.88,48.45,48.45,66.25,,,,,,"HC STRAPPING,HIP",360,29520,$138.77 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,"HC STRAPPING,KNEE",360,29530,$120.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,43.07,43.07,58.89,,,,,,"HC STRAPPING,ANKLE OR FOOT",360,29540,$111.38 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87116,Lab analysis of any culture to identify acid-fast bacilli [HCPCS 87116],28.57,28.57,28.57,19.53,19.53,19.53,,,,,,"HC NEG PRESSURE WOUND TX,< 50 CM",420,97605,$172.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.82,108.82,108.82,74.39,74.39,101.71,,,,,,HC MULTI LAYER COMPRESSION APPLICATION,360,29581,$354.70 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87324,Lab analysis by immunoassay (ELISA) to identify clostridium difficile toxins (stool pathogen) [HCPCS 87324],94.5,94.5,94.5,64.6,64.6,69.22,,,,,,HC ROM TEST-EXTREMITY/TRUNK,420,95851,$86.21 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87389,Lab analysis by immunoassay (ELISA) to identify HIV-1 and HIV-2 [HCPCS 87389],189,189,189,129.2,129.2,176.66,,,,,,HC NONMD ONLINE ASSMT 5-10 MIN,420,G2061,$32.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,42.7,42.7,58.38,,,,,,HC NONMD ONLINE ASSMT 11-20 MIN,272,G2062,$56.70 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],94.5,94.5,94.5,64.6,64.6,69.22,,,,,,HC NONMD ONLINE ASSMT 21> MIN,420,G2063,$89.25 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",94.5,94.5,94.5,64.6,64.6,69.22,,,,,,HC PT EVAL LOW COMPLEX 20 MIN,424,97161,$337.10 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],236.25,236.25,236.25,161.5,161.5,220.82,,,,,,HC PT EVAL MOD COMPLEX 30 MIN,424,97162,$337.10 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],291.38,291.38,291.38,199.19,199.19,213.44,,,,,,HC PT EVAL HIGH COMPLEX 45 MIN,424,97163,$337.10 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],275.63,275.63,275.63,188.42,188.42,257.63,,,,,,HC PT RE-EVAL EST PLAN OF CARE,424,97164,$231.98 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],157.91,157.91,157.91,107.95,107.95,147.6,,,,,,HC VASOPNEUMATIC DEVICE,430,97016,$75.24 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,75.2,75.2,102.82,,,,,,HC WHIRLPOOL,430,97022,$91.46 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,91.52,91.52,125.14,,,,,,HC E-STIM 15 MIN,430,97032,$71.78 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,382.22,382.22,522.62,,,,,,HC IONTOPHORESIS 15 MIN,430,97033,$103.03 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,51.14,51.14,69.92,,,,,,HC CONTRAST BATHS 15 MIN,430,97034,$70.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,24.4,24.4,33.37,,,,,,HC ULTRASOUND 15 MIN,430,97035,$47.46 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,87.05,87.05,119.02,,,,,,HC THERAP EX 15MIN,430,97110,$120.39 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,79.32,79.32,108.45,,,,,,HC NEUROMUSC RE-ED 15MIN,430,97112,$125.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],118,118,118,80.66,80.66,110.29,,,,,,HC MANUAL THERAPY 15MIN,430,97140,$111.13 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,489.89,489.89,669.83,,,,,,HC THERAP ACTIVITY 15MIN,430,97530,$129.65 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],784.77,784.77,784.77,536.47,536.47,574.84,,,,,,HC S I TECHNIQUES 15 MIN,430,97533,$114.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,94010,Total and timed exhaled air capacity measurement and graphic recording [HCPCS 94010],187.53,187.53,187.53,128.2,128.2,137.37,,,,,,HC SELF-CARE/HM MGMT TX 15MIN,430,97535,$137.76 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],79.71,79.71,79.71,54.49,54.49,74.5,,,,,,HC COM/WORK RE-INTEGRA 15 MIN,430,97537,$118.08 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,147.59,147.59,201.8,,,,,,HC WHEELCHAIR MGMT/PROP 15 MIN,430,97542,$121.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,58.27,58.27,79.67,,,,,,HC SELECT DEBRIDE 20 SQ CENT OR <,430,97597,$295.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,306.85,306.85,419.57,,,,,,HC SELECT DEBRIDE > 20 SQ CENT,430,97598,$96.09 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,61.37,61.37,83.92,,,,,,HC NON-SELECTIVE DEBRIDEMENT,430,97602,$295.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,170.93,170.93,233.72,,,,,,HC E-STIM-UNATTENDED,430,G0283,$54.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,70.72,70.72,96.69,,,,,,HC RANGE OF MOTION TEST-EXTREMITY/TRUN,430,95851,$89.13 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,96523,Implanted venous access drug delivery device irrigation [HCPCS 96523],145.85,145.85,145.85,99.7,99.7,106.84,,,,,,PR ESOPHAGOSCOPY FLEXIBLE TRANSNASAL D,521,43197,$470.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,32.44,32.44,44.36,,,,,,PR ESOPHAGOSCOPY FLEXIBLE TRANSNASAL D,521,43197,$470.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,82.3,82.3,112.53,,,,,,PR ESOPHAGOSCOPY FLEXIBLE TRANSORAL DI,521,43200,$660.46 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,85.46,85.46,116.86,,,,,,PR ESOPHAGOSCOPY FLEXIBLE TRANSORAL DI,521,43200,$660.46 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,81.45,81.45,111.37,,,,,,PR ESOPHAGOGASTRODUODENOSCOPY TRANSORA,975,43235,$852.01 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,75.97,75.97,103.87,,,,,,PR ESOPHAGOGASTRODUODENOSCOPY TRANSORA,975,43235,$852.01 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,230.44,230.44,315.09,,,,,,PR EGD TRANSORAL BIOPSY SINGLE/MULTIPL,521,43239,"$1,021.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,230.44,230.44,315.09,,,,,,PR EGD TRANSORAL BIOPSY SINGLE/MULTIPL,521,43239,"$1,021.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],231.98,231.98,231.98,158.58,158.58,216.83,,,,,,PR EGD INJECTION SCLEROSIS ESOPHGL/GAS,521,43243,$667.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],129.65,129.65,129.65,88.63,88.63,107.95,,,,,,PR EGD INJECTION SCLEROSIS ESOPHGL/GAS,521,43243,$667.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,97535,Training activities for home and self-care management (each 15 minutes) [HCPCS 97535],137.76,137.76,137.76,94.17,94.17,100.91,,,,,,PR EGD DILATION GASTRIC/DUODENAL STRIC,521,43245,"$1,639.05 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,98960,Patient self-management education and training each 30 minutes (individual patient) [HCPCS 98960],169.02,169.02,169.02,115.54,115.54,115.54,,,,,,PR EGD DILATION GASTRIC/DUODENAL STRIC,521,43245,"$1,639.05 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],20,20,20,13.67,13.67,18.69,,,,,,PR EGD FLEXIBLE FOREIGN BODY REMOVAL,975,43247,"$1,032.15 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,83.51,83.51,114.18,,,,,,PR EGD FLEXIBLE FOREIGN BODY REMOVAL,975,43247,"$1,032.15 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],116.39,116.39,116.39,79.56,79.56,85.26,,,,,,PR EGD BALLOON DILATION ESOPHAGUS <30 ,521,43249,"$2,423.40 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,153.32,153.32,209.63,,,,,,PR EGD BALLOON DILATION ESOPHAGUS <30 ,521,43249,"$2,423.40 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,229.66,229.66,314.01,,,,,,PR EGD REMOVAL TUMOR POLYP/OTHER LESIO,975,43251,"$1,326.15 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,419.76,419.76,573.94,,,,,,PR EGD REMOVAL TUMOR POLYP/OTHER LESIO,975,43251,"$1,326.15 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,18.99,18.99,25.97,,,,,,HC OT EVAL LOW COMPLEX 30 MIN,434,97165,$269.72 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1014.52,1014.52,1387.17,,,,,,HC OT EVAL MOD COMPLEX 45 MIN,434,97166,$269.72 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,A0429,Bls-emergency [HCPCS A0429],1250.24,1250.24,1250.24,854.66,854.66,1168.6,,,,,,HC OT EVAL HIGH COMPLEX 60 MIN,434,97167,$269.72 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,145.61,145.61,199.09,,,,,,HC OT RE-EVAL EST PLAN OF CARE,434,97168,$165.54 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,102.29,102.29,139.86,,,,,,"PR GASTRIC INTUBATION/ASPIRATION, DIAG",521,43754,$499.95 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,990.78,990.78,1354.71,,,,,,"PR GASTRIC INTUBATION/ASPIRATION, DIAG",521,43754,$499.95 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,100.65,100.65,137.63,,,,,,PR PERQ REPLACEMENT GTUBE NOT REQ REVJ,521,43762,"$1,452.82 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,34.63,34.63,42.18,,,,,,PR PERQ REPLACEMENT GTUBE NOT REQ REVJ,521,43762,"$1,452.82 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J1170,Hydromorphone injection [HCPCS J1170],23,23,23,15.72,15.72,21.5,,,,,,PR PERQ REPLACEMENT GTUBE REQ REVJ GST,521,43763,"$1,452.82 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],11.5,11.5,11.5,7.86,7.86,8.42,,,,,,PR PERQ REPLACEMENT GTUBE REQ REVJ GST,521,43763,"$1,452.82 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],11.5,11.5,11.5,7.86,7.86,10.75,,,,,,HC SPEECH/HEARING THERAPY INDIV,440,92507,$316.06 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],23,23,23,15.72,15.72,21.5,,,,,,HC SPEECH/HEARING THERAPY GROUP,440,92508,$152.81 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J2360,Orphenadrine injection [HCPCS J2360],7.72,7.72,7.72,5.28,5.28,5.65,,,,,,HC DYSPHAGIA STUDY,440,92526,$348.75 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,31.45,31.45,43,,,,,,HC CLINIC EVAL/SWALLOW,440,92610,$346.62 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",4.15,4.15,4.15,2.84,2.84,3.88,,,,,,HC ASSESS APHASIA-PER HOUR,440,96105,$409.77 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J2765,Metoclopramide hcl injection [HCPCS J2765],23,23,23,15.72,15.72,21.5,,,,,,HC DEV/TEST-LIMITED,918,96110,$111.13 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,4.54,4.54,6.21,,,,,,HC ENDOSCOPY SWALLOW TEST,440,92612,$166.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J2997,Alteplase recombinant [HCPCS J2997],134.92,134.92,134.92,92.23,92.23,98.83,,,,,,PR MOBILIZE SPLENIC FLEX,521,44139,$327.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],23,23,23,15.72,15.72,21.5,,,,,,PR MOBILIZE SPLENIC FLEX,521,44139,$327.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.12,1.12,1.53,,,,,,PR PART REMOVAL COLON W ANASTOMOSIS,975,44140,"$3,683.57 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.59,1.59,1.7,,,,,,PR PART REMOVAL COLON W ANASTOMOSIS,975,44140,"$3,683.57 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,15.83,15.83,21.64,,,,,,PR PART REMOVAL COLON W COLOPROCTOSTOM,975,44145,"$4,555.26 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,37.6,37.6,51.41,,,,,,PR PART REMOVAL COLON W COLOPROCTOSTOM,975,44145,"$4,555.26 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],57.75,57.75,57.75,39.48,39.48,42.3,,,,,,HC EVAL OF SPEECH SOUND LANG COMPREHEN,444,92523,$773.52 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],53.5,53.5,53.5,36.57,36.57,50.01,,,,,,HC EVACUATION SUBUNGUAL HEMATOMA,360,11740,$82.19 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,37.6,37.6,51.41,,,,,,HC REPR SUPERF WND BODY 12.6-20,360,12005,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,88142,Lab analysis of vaginal or cervical cells (pap test) with manual screening under physician supervision [HCPCS 88142],157.5,157.5,157.5,103.71,103.71,116.24,,,,,,HC REPR SUPERF WND BODY 20.1-30,360,12006,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,49.26,49.26,55.21,,,,,,HC REPR SUPERF WND FACE 5.1-7.5,360,12014,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,90670,"Pneumococcal conjugate, 13 valent vaccine for injection into muscle [HCPCS 90670]",225.75,225.75,225.75,148.66,148.66,148.66,,,,,,"HC REPR CMPL WND SCALP,EXTR 1.1-2.5",360,13120,$848.40 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,23.51,23.51,26.35,,,,,,HC CLOSED RX CLAVICLE FRACTURE,360,23500,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,90732,Pneumococcal polysaccharide vaccine for injection beneath the skin or into muscle (2 years of age or older) [HCPCS 90732],119.7,119.7,119.7,78.82,78.82,78.82,,,,,,HC CLOSED RX MID HUMERUS FRACTURE,360,24500,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,15.07,7.06,15.07,,,,,,"HC CLOSED RX MID HUMERUS FX,MANIPULATN",360,24505,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,96127,Emotional or behavioral assessment for screening of condtions like ADHD or depression with scoring and documentation (brief assessment) [HCPCS 96127],13.13,13.13,13.13,8.65,8.65,9.69,,,,,,HC CLOSED RX ELBOW DISLOCATION,360,24600,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",74.81,74.81,74.81,49.26,43.9,55.21,,,,,,"HC CLOSED RX RADIAL HEAD DISLOC,CHILD",360,24640,$538.81 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,134.27,134.27,150.48,,,,,,HC CLOSED RX PROX ULNA FRACTURE,360,24670,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,190.03,169.34,212.97,,,,,,HC CLOSED RX ULNA SHAFT FX,360,25530,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],439.89,439.89,439.89,289.67,289.67,324.64,,,,,,HC CLOSED RX RAD/ULNA SHAFT FX,360,25560,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],62.79,62.79,62.79,41.35,41.35,46.34,,,,,,HC CLOSED RX MC-P DISLOC,360,26700,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,80.44,71.68,90.15,,,,,,HC CLOSED RX IP JT DISLOCATION,360,26770,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,132.67,62.19,148.68,,,,,,HC CLOSED RX POST HIP ARTHRPLAS DISLOC,360,27265,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,192.6,171.63,215.86,,,,,,HC TREAT KNEECAP DISLOCATION,360,27560,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,258.62,230.46,289.84,,,,,,HC CLOSED RX MT-PHAL TOE DISLOCATION,360,28630,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],343.06,343.06,343.06,225.91,201.31,253.18,,,,,,HC APPLY FOREARM CAST,360,29075,$447.72 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99417,New or established patient office or outpatient visit with physician to diagnose and treat illness or injury beyond required time of primary visit (each additional 15 minutes of total time) [HCPCS 99417],27.3,27.3,27.3,17.98,17.98,17.98,,,,,,HC APPLY HAND/WRIST CAST,360,29085,$223.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,329.18,329.18,368.92,,,,,,HC APPLY LONG ARM SPLINT,360,29105,$223.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,4.37,4.37,4.9,,,,,,"HC APPLY FOREARM SPLINT,STATIC",360,29125,$336.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.08,1.08,1.21,,,,,,HC APPLY FINGER SPLINT,360,29130,$214.78 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Professional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,47.46,22.25,53.19,,,,,,HC STRAPPING OF SHOULDER,360,29240,$164.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Other Professional Setting,Professional,Outpatient,99441,Telephone evaluation and management visit with physician to diagnose and treat illness or injury (5-10 minutes of medical discussion) [HCPCS 99441],36.75,36.75,36.75,24.2,24.2,24.2,,,,,,HC APPLY LONG LEG CAST,360,29345,$703.13 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",22.05,22.05,22.05,14.52,14.52,16.27,,,,,,HC APPLY SHORT LEG CAST,360,29405,$416.48 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],22.05,22.05,22.05,14.52,14.52,16.27,,,,,,"HC APPLY SHORT LEG CAST,WALKER",360,29425,$400.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,11976,Implantable contraceptive capsules removal [HCPCS 11976],390.12,390.12,390.12,256.89,256.89,256.89,,,,,,HC APPLY LONG LEG SPLINT,360,29505,$445.88 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",243.73,243.73,243.73,160.5,160.5,160.5,,,,,,HC APPLY LOWER LEG SPLINT,360,29515,$370.13 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,20552,Trigger points injection into 1 or 2 muscles [HCPCS 20552],460.95,460.95,460.95,303.54,303.54,303.54,,,,,,HC REMV/REVISN BOOT/BODY CAST,360,29700,$223.42 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],228.9,228.9,228.9,150.73,70.66,168.93,,,,,,HC REMV/REVISN FULL ARM/LEG CAST,360,29705,$334.11 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1021.2,1021.2,1021.2,672.46,315.24,753.65,,,,,,HC REMOVE NASAL FOREIGN BODY,360,30300,$144.70 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],539.46,539.46,539.46,355.23,355.23,398.12,,,,,,"HC CONTROL NOSE BLEED,INITIAL",360,30905,$329.92 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1328.95,1328.95,1328.95,875.11,410.25,980.77,,,,,,"HC CONTROL NOSE BLEED,SUBSEQUENT",360,30906,$319.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,62323,Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323],496.65,496.65,496.65,327.04,153.32,327.04,,,,,,HC PLCMT OF NEEDLE INTRAOSSEO,360,36680,$285.94 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,64445,Anesthetic agent and/or steroid injection into sciatic nerve of lower back and leg [HCPCS 64445],460.95,460.95,460.95,303.54,303.54,303.54,,,,,,HC INSERT BLADDER CATHETER,360,51701,$96.09 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,64483,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483],816.9,816.9,816.9,537.93,252.18,537.93,,,,,,HC INSERT TEMP BLADDER CATHETER,360,51702,$178.28 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,64484,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (each additional level) [HCPCS 64484],816.9,816.9,816.9,537.93,537.93,537.93,,,,,,HC REMV EXT CANAL FOREIGN BODY,360,69200,$115.76 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],206.06,206.06,206.06,135.69,63.61,152.07,,,,,,HC CPR,360,92950,$380.86 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,93015,"Heart and blood vessel stress test with EKG monitoring, physician supervision, interpretation, and report (exercise or drug-induced) [HCPCS 93015]",226.89,226.89,226.89,149.41,149.41,167.44,,,,,,HC TPA,360,92977,$417.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],47.84,47.84,47.84,31.5,14.77,35.31,,,,,,HC IPECAC ADMINISTRATION,450,99175,$127.34 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,95810,"Sleep pattern monitoring of patient in sleep lab, sleep staging with 4 or more parameters of sleep (6 years of age or older) [HCPCS 95810]",2755.06,2755.06,2755.06,1814.21,1814.21,1814.21,,,,,,HC ED LEVEL I,450,99281,$116.39 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,97802,Medical nutrition therapy assessment and intervention (each 15 minutes) [HCPCS 97802],99.44,99.44,99.44,65.48,65.48,73.39,,,,,,HC ED LEVEL II,450,99282,$224.28 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,98960,Patient self-management education and training each 30 minutes (individual patient) [HCPCS 98960],338.04,338.04,338.04,222.6,222.6,222.6,,,,,,HC ED LEVEL III,450,99283,$335.95 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],263.94,263.94,263.94,173.8,81.48,173.8,,,,,,HC ED LEVEL IV,450,99284,$614.04 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],55.57,55.57,55.57,36.59,17.15,41.01,,,,,,HC ED LEVEL V,450,99285,$891.29 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],109.98,109.98,109.98,72.42,33.95,81.17,,,,,,HC CRITICAL CARE 1ST HOUR,450,99291,"$1,455.88 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,108.25,50.75,121.32,,,,,,HC WOUND CLOS/TISSUE ADHESIV ONLY,490,G0168,$225.74 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,186.76,87.55,209.31,,,,,,HC CLOSED RX DIST FIBULA FX,360,27786,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,129.77,60.84,129.77,,,,,,HC APPLY LONG ARM CAST,360,29065,$495.97 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],896.36,896.36,896.36,590.25,276.71,661.51,,,,,,"PR PROCTOSIGMOIDOSCOPY,RIGID,DIAGNOS",521,45300,$130.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,2,Professional,Outpatient,99441,Telephone evaluation and management visit with physician to diagnose and treat illness or injury (5-10 minutes of medical discussion) [HCPCS 99441],36.75,36.75,36.75,24.2,24.2,24.2,,,,,,"PR PROCTOSIGMOIDOSCOPY,RIGID,DIAGNOS",521,45300,$130.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,137.72,137.72,188.31,,,,,,PR COLONOSCOPY FLX DX W/COLLJ SPEC WHE,975,45378,$539.46 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,199.95,199.95,273.39,,,,,,PR COLONOSCOPY FLX DX W/COLLJ SPEC WHE,975,45378,$539.46 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,268.48,268.48,367.09,,,,,,PR COLONOSCOPY W/BIOPSY SINGLE/MULTIPL,975,45380,$585.76 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Clinic,Institutional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],242.81,242.81,242.81,165.98,165.98,177.86,,,,,,PR COLONOSCOPY W/BIOPSY SINGLE/MULTIPL,975,45380,$585.76 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,127.08,127.08,136.17,,,,,,PR COLSC FLX WITH DIRECTED SUBMUCOSAL ,521,45381,"$1,174.95 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Clinic,Institutional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,341.72,341.72,366.17,,,,,,PR COLSC FLX WITH DIRECTED SUBMUCOSAL ,521,45381,"$1,174.95 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Clinic,Institutional,Outpatient,99499,Unlisted service requiring evaluation and management [HCPCS 99499],298.67,298.67,298.67,204.17,204.17,204.17,,,,,,PR COLSC FLX W/REMOVAL LESION BY HOT B,975,45384,"$1,328.95 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Clinic,Institutional,Outpatient,G0439,"Ppps, subseq visit [HCPCS G0439]",312,312,312,213.28,213.28,228.54,,,,,,PR COLSC FLX W/REMOVAL LESION BY HOT B,975,45384,"$1,328.95 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Home Health,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,132.67,62.19,148.68,,,,,,PR COLSC FLX W/RMVL OF TUMOR POLYP LES,975,45385,$739.73 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Home Health,Professional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,77.87,36.5,77.87,,,,,,PR COLSC FLX W/RMVL OF TUMOR POLYP LES,975,45385,$739.73 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Home Health,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,122.42,57.39,122.42,,,,,,PR COLSC FLEXIBLE W/TRANSENDOSCOPIC BA,521,45386,"$1,698.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3415.15,3186.97,4561.97,,,,,,PR COLSC FLEXIBLE W/TRANSENDOSCOPIC BA,521,45386,"$1,698.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1557.61,1453.54,2080.66,,,,,,PR COLONOSCOPY FLX ABLATION TUMOR POLY,975,45388,"$8,088.15 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6346.62,5922.57,8477.82,,,,,,PR COLONOSCOPY FLX ABLATION TUMOR POLY,975,45388,"$8,088.15 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9459.3,8827.29,12635.76,,,,,,HC DEBRIDE INFECTED SKIN,360,11000,$299.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9018.71,8416.13,12047.21,,,,,,HC SPIROMETRY,460,94010,$187.53 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2419.85,2258.17,3232.44,,,,,,HC PRE/POST SPIRO,460,94060,$313.48 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2853.41,2662.76,3811.59,,,,,,HC PULSE OXIMETRY SINGLE,460,94760,$12.29 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3441.73,3211.77,4597.47,,,,,,"PR HEMORRHOIDECTOMY,EXTERNAL",975,46250,"$1,205.40 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",22.05,22.05,22.05,15.07,15.07,16.15,,,,,,"PR HEMORRHOIDECTOMY,EXTERNAL",975,46250,"$1,205.40 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],18.52,18.52,18.52,12.66,12.66,17.31,,,,,,"PR REMOVAL ANAL FISTULA,SUBCUTANEOUS",975,46270,"$1,426.19 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,12.66,12.66,17.31,,,,,,"PR REMOVAL ANAL FISTULA,SUBCUTANEOUS",975,46270,"$1,426.19 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,11730,Nail plate removal (single nail plate) [HCPCS 11730],301.29,301.29,301.29,205.96,205.96,205.96,,,,,,PR ANOSCOPY DX W/COLLJ SPEC BR/WA SPX ,975,46600,$114.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",474.18,474.18,474.18,324.15,324.15,443.22,,,,,,PR ANOSCOPY DX W/COLLJ SPEC BR/WA SPX ,975,46600,$114.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",577.24,577.24,577.24,394.6,394.6,539.55,,,,,,"PR LAP,CHOLECYSTECTOMY",975,47562,"$1,809.37 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",576.35,576.35,576.35,393.99,393.99,393.99,,,,,,"PR LAP,CHOLECYSTECTOMY",975,47562,"$1,809.37 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,12031,"Intermediate repair of wound of scalp, underarms, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12031]",685.23,685.23,685.23,468.42,468.42,468.42,,,,,,HC CARDIOVERSION,480,92960,$546.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,12032,"Intermediate repair of wound of scalp, underarms, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12032]",823.01,823.01,823.01,562.61,562.61,562.61,,,,,,HC TTE W/DOPPLER COMPLETE,483,93306,$716.63 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,12051,"Intermediate repair of wound of face, ears, eyelids, nose, lips, and/or mouth (2.5 cm or less) [HCPCS 12051]",738.77,738.77,738.77,505.02,505.02,505.02,,,,,,HC ECHO EXAM OF HEART COMPLETE,483,93307,$305.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,12053,"Intermediate repair of wound of face, ears, eyelids, nose, lips, and/or mouth (5.1 to 7.5 cm) [HCPCS 12053]",968.9,968.9,968.9,662.34,662.34,662.34,,,,,,HC ECHO EXAM OF HEART LMTD,483,93308,$341.25 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,13120,"Complex repair of wound of scalp, arms, and/or legs (1.1 to 2.5 cm) [HCPCS 13120]",968.47,968.47,968.47,662.05,662.05,709.4,,,,,,HC DOPPLER ECHO EXAM COMPLETE,483,93320,$184.28 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,20552,Trigger points injection into 1 or 2 muscles [HCPCS 20552],841.05,841.05,841.05,574.94,574.94,786.13,,,,,,HC DOPPLER COLOR FLOW ADDON,483,93325,$85.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,20600,Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600],841.05,841.05,841.05,574.94,574.94,616.07,,,,,,HC ECHO TRANSTHORACIC,483,93350,$516.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,574.94,574.94,786.13,,,,,,HC TTE W/WO FOL W/CON DOPPLER,483,C8929,"$1,804.79 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,29125,Short arm splint application forearm to hand (non-moveable) [HCPCS 29125],336.05,336.05,336.05,229.72,229.72,314.11,,,,,,HC STRESS TEST,482,93017,$116.03 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,29581,Vein wound compression system application to lower leg below knee including ankle and foot [HCPCS 29581],354.7,354.7,354.7,242.47,242.47,259.82,,,,,,"HC I & D ABSCESS, SMPL",360,10060,$296.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,31500,Breathing tube insertion into windpipe cartilage with endoscope (emergent) [HCPCS 31500],316.03,316.03,316.03,216.04,216.04,216.04,,,,,,"HC I & D ABSCESS, CMPLX",360,10061,$296.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,"HC I & D PILONIDAL CYST,SMPL",360,10080,$296.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,"HC I & D PILONIDAL CYST,CMPLX",360,10081,"$1,604.66 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1008.97,1008.97,1379.59,,,,,,"HC REMOVE FOREIGN BODY,SMPL",360,10120,$803.93 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1635.72,1635.72,1635.72,1118.18,1118.18,1528.91,,,,,,"HC REMOVE FOREIGN BODY,CMPLX",360,10121,"$1,430.26 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],1635.72,1635.72,1635.72,1118.18,1118.18,1528.91,,,,,,HC DRAINAGE OF HEMATOMA/FLUID,360,10140,$897.49 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1118.18,1118.18,1528.91,,,,,,HC PUNCTURE DRAINAGE OF LESION,360,10160,$296.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1118.18,1118.18,1528.91,,,,,,HC DEBRIDE SKIN/TISSUE,360,11042,$664.70 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,121.87,121.87,130.59,,,,,,HC DEBRIDE TISSUE/MUSCLE,360,11043,$495.46 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,1874.12,1874.12,2562.53,,,,,,HC TRIM SKIN LESION,360,11055,$334.32 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,395.5,395.5,540.77,,,,,,HC REMOVAL OF SKIN TAGS,360,11200,$169.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,64495,Lower or sacral spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64495],591.15,591.15,591.15,404.11,404.11,552.55,,,,,,HC REMOVE SKIN TAGS ADD-ON,360,11201,$97.49 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],6570.9,6570.9,6570.9,4491.87,4491.87,6141.82,,,,,,"HC SHAV SKIN LES <5MM TRUNK,ARM,LEG",360,11300,$224.58 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],670.95,670.95,670.95,458.66,458.66,627.14,,,,,,"HC SHAV SKIN LES 6-10MM TRUNK,ARM,LEG",360,11301,$224.58 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,65210,Foreign body removal from conjunctiva or sclera of external eye [HCPCS 65210],243.39,243.39,243.39,166.38,166.38,166.38,,,,,,"HC SHAV SKIN LES 11-20MM TRUNK,ARM,LEG",360,11302,$224.58 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70160,Nasal bones x-ray taken from side to side for complete exam (minimum of 3 views) [HCPCS 70160],139.86,139.86,139.86,95.61,95.61,95.61,,,,,,"HC SHAV SKIN LES >21MM TRUNK,ARM,LEG",360,11303,$265.09 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70360,Neck x-ray to examine soft tissue for any obstructions and/or foreign bodies within the throat or neck [HCPCS 70360],120.44,120.44,120.44,82.33,82.33,82.33,,,,,,HC SHAV SKIN LES <5MM REMAINDR BODY,360,11305,$259.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,457.94,457.94,626.16,,,,,,HC SHAV SKIN LES 6-10MM REMAINDR BODY,360,11306,$259.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70480,"Skull CT scan to examine the bones of the eye and ear without contrast to examine injury, foreign bodies, or tumors [HCPCS 70480]",1166.55,1166.55,1166.55,797.45,797.45,797.45,,,,,,HC SHAV SKIN LES 11-20MM REMAINDR BODY,360,11307,$259.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",808.5,808.5,808.5,552.69,552.69,755.7,,,,,,HC SHAV SKIN LES >21MM REMAINDR BODY,360,11308,$259.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70492,"Neck CT scan of the soft tissue of the neck without contrast, followed by contrast to examine injury, foreign bodies, or tumors [HCPCS 70492]",1426.43,1426.43,1426.43,975.11,975.11,1044.86,,,,,,"HC SHAV SKIN LES <5MM FACE,FACIAL",360,11310,$259.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70544,Imaging of head blood vessels by MRA without contrast [HCPCS 70544],2213.4,2213.4,2213.4,1513.08,1513.08,2068.86,,,,,,"HC SHAV SKIN LES 6-10MM FACE,FACIAL",360,11311,$259.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70551,Imaging of brain by MRI without contrast [HCPCS 70551],2008.13,2008.13,2008.13,1372.76,1372.76,1470.96,,,,,,"HC SHAV SKIN LES 11-20MM FACE,FACIAL",360,11312,$259.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",3284.4,3284.4,3284.4,2245.22,2245.22,3069.93,,,,,,"HC SHAV SKIN LES >21MM FACE,FACIAL",360,11313,$259.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,69.05,69.05,94.41,,,,,,"HC EXC BENIG .1-.5CM TRUNK,ARM,LEG",360,11400,$665.70 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,87.64,87.64,119.84,,,,,,"HC EXC SKIN BENIG 0.6-1CM TRUNK,ARM,LE",360,11401,$809.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,627.7,627.7,858.27,,,,,,"HC EXC SKIN BENIG 1.1-2CM TRUNK,ARM,LE",360,11402,$896.60 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,781.66,781.66,1068.78,,,,,,"HC EXC SKIN BENIG 2.1-3CM TRUNK,ARM,LE",360,11403,"$1,029.95 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,111.58,111.58,152.56,,,,,,"HC EXC SKIN BENIG 3.1-4CM TRUNK,ARM,LE",360,11404,"$1,167.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],147.63,147.63,147.63,100.92,100.92,137.99,,,,,,"HC EXC SKIN BENIG >4CM TRUNK,ARM,LEG",360,11406,"$1,656.06 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72070,Spinal x-ray of middle spine (2 views) [HCPCS 72070],124.32,124.32,124.32,84.99,84.99,116.2,,,,,,HC EXC SKIN BENIG <5MM REMAINDR BODY,360,11420,$671.37 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,100.92,100.92,137.99,,,,,,HC EXC SKIN BENIG 0.6-1CM REMAINDR BOD,360,11421,$842.63 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],190.37,190.37,190.37,130.14,130.14,177.94,,,,,,HC EXC SKIN BENIG 1.1-2CM REMAINDR BOD,360,11422,$945.74 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",906.68,906.68,906.68,619.81,619.81,847.47,,,,,,HC EXC SKIN BENIG 2.1-3CM REMAINDR BOD,360,11423,"$1,073.52 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72128,"Spinal CT scan of middle spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72128]",906.68,906.68,906.68,619.81,619.81,664.14,,,,,,HC EXC SKIN BENIG 3.1-4CM REMAINDR BOD,360,11424,"$1,235.22 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",900.9,900.9,900.9,615.86,615.86,842.07,,,,,,HC EXC SKIN BENIG >4CM REMAINDR BODY,360,11426,"$1,758.23 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72141,Imaging of upper spinal canal by MRI without contrast [HCPCS 72141],1954.58,1954.58,1954.58,1336.15,1336.15,1826.95,,,,,,"HC EXC SKIN BENIG <5MM FACE,FACIAL",360,11440,$741.46 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72146,Imaging of middle spinal canal by MRI without contrast [HCPCS 72146],1954.58,1954.58,1954.58,1336.15,1336.15,1431.73,,,,,,"HC EXC SKIN BENIG 0.6-1CM FACE,FACIAL",360,11441,$906.10 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1336.15,1336.15,1826.95,,,,,,"HC EXC SKIN BENIG 1.1-2CM FACE,FACIAL",360,11442,"$1,005.43 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72149,Imaging of lower spinal canal by MRI with contrast [HCPCS 72149],2793.53,2793.53,2793.53,1909.66,1909.66,1909.66,,,,,,"HC EXC SKIN BENIG 2.1-3CM FACE,FACIAL",360,11443,"$1,190.86 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],112.67,112.67,112.67,77.02,77.02,82.53,,,,,,"HC EXC SKIN BENIG 3.1-4CM FACE,FACIAL",360,11444,"$1,487.96 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,72202,X-ray of joints at hip bone and sacrum (3 or more views) [HCPCS 72202],147.63,147.63,147.63,100.92,100.92,108.14,,,,,,"HC EXC SKIN BENIG >4CM FACE,FACIAL",360,11446,"$2,044.35 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73000,"Collar bone x-ray, complete study [HCPCS 73000]",120.44,120.44,120.44,82.33,82.33,88.22,,,,,,"HC EXC SKIN MALIG <5MM TRUNK,ARM,LEG",360,11600,"$1,042.44 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73020,Shoulder x-ray (single view) [HCPCS 73020],81.59,81.59,81.59,55.77,55.77,59.76,,,,,,"HC EXC SKIN MALIG 0.6-1CM TRUNK,ARM,LE",360,11601,"$1,210.97 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,87.64,87.64,119.84,,,,,,"HC EXC SKIN MALIG 1.1-2CM TRUNK,ARM,LE",360,11602,"$1,305.68 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],120.44,120.44,120.44,82.33,82.33,88.22,,,,,,"HC EXC SKIN MALIG 2.1-3CM TRUNK,ARM,LE",360,11603,"$1,484.54 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],112.67,112.67,112.67,77.02,77.02,93.81,,,,,,"HC EXC SKIN MALIG 3.1-4CM TRUNK,ARM,LE",360,11604,"$1,651.97 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,103.58,103.58,126.16,,,,,,"HC EXC SKIN MALIG >4CM TRUNK,ARM,LEG",360,11606,"$2,350.01 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],116.55,116.55,116.55,79.67,79.67,108.94,,,,,,HC EXC SKIN MALIG 0.6-1CM REMAINDR BOD,360,11621,"$1,215.64 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],135.98,135.98,135.98,92.96,92.96,127.1,,,,,,HC EXC SKIN MALIG 1.1-2CM REMAINDR BOD,360,11622,"$1,347.31 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],139.86,139.86,139.86,95.61,95.61,130.73,,,,,,HC EXC SKIN MALIG 2.1-3CM REMAINDR BOD,360,11623,"$1,576.21 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1415.46,1415.46,1935.39,,,,,,HC EXC SKIN MALIG 3.1-4CM REMAINDR BOD,360,11624,"$1,780.59 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,119.51,119.51,163.41,,,,,,HC EXC SKIN MALIG >4CM REMAINDR BODY,360,11626,"$2,137.01 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],155.4,155.4,155.4,106.23,106.23,113.83,,,,,,"HC EXC SKIN MALIG <5CM FACE,FACIAL",360,11640,"$1,072.73 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,90.3,90.3,123.46,,,,,,"HC EXC SKIN MALIG 0.6-1CM FACE,FACIAL",360,11641,"$1,258.27 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,103.58,103.58,141.63,,,,,,"HC EXC SKIN MALIG 1.1-2CM FACE,FACIAL",360,11642,"$1,425.80 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],170.94,170.94,170.94,116.85,116.85,125.21,,,,,,"HC EXC SKIN MALIG 2.1-3CM FACE,FACIAL",360,11643,"$1,673.65 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],120.44,120.44,120.44,82.33,82.33,112.58,,,,,,"HC EXC SKIN MALIG 3.1-4CM FACE,FACIAL",360,11644,"$2,059.73 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,92.96,92.96,127.1,,,,,,"HC EXC SKIN MALIG >4CM FACE,FACIAL",360,11646,"$2,671.78 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,87.64,87.64,119.84,,,,,,HC REMOVE NAIL PLATE,360,11730,$169.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73650,Foot x-ray at heel of foot (minimum of 2 views) [HCPCS 73650],108.78,108.78,108.78,74.36,74.36,101.68,,,,,,HC REMOVE NAIL PLATE ADD-ON,360,11732,$177.08 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,74.36,74.36,101.68,,,,,,HC REMOVE NAIL BED,360,11750,$831.44 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",900.9,900.9,900.9,615.86,615.86,659.91,,,,,,HC REPAIR NAIL BED,360,11760,$429.48 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73718,Imaging of leg by MRI without contrast [HCPCS 73718],2320.5,2320.5,2320.5,1586.29,1586.29,1586.29,,,,,,"HC EXCISION OF NAIL FOLD, TOE",360,11765,$197.96 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1409.36,1409.36,1927.05,,,,,,HC REMV PILONIDAL LESION SMPL,360,11770,"$1,635.43 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],112.67,112.67,112.67,77.02,77.02,105.31,,,,,,HC REMV PILONIDAL LESION EXTENS,360,11771,"$3,143.23 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],139.86,139.86,139.86,95.61,95.61,130.73,,,,,,HC REMV PILONIDAL LESION COMPLIC,360,11772,"$3,812.29 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,74022,"Abdominal x-ray, complete study including 2 or more views of abdomen and single view of chest  [HCPCS 74022]",190.37,190.37,190.37,130.14,130.14,130.14,,,,,,HC INJECT SKIN LESIONS,360,11900,$290.69 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",1160.78,1160.78,1160.78,793.51,793.51,1084.98,,,,,,HC INJECT SKIN LESIONS ADD-ON,360,11901,$169.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1302.77,1302.77,1781.3,,,,,,HC REMOVE CONTRACEPTIVE CAP,360,11976,$758.99 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,74178,"Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]",2142.53,2142.53,2142.53,1464.63,1464.63,1569.4,,,,,,HC INSERT DRUG IMPLANT DEVICE,360,11981,$202.65 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],454.55,454.55,454.55,310.73,310.73,424.87,,,,,,HC REMOVE DRUG IMPLANT DEVICE,360,11982,$612.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",419.58,419.58,419.58,286.82,286.82,392.18,,,,,,HC REPR SUPERF WND BODY <2.5CM,360,12001,$474.18 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",341.88,341.88,341.88,233.71,233.71,250.43,,,,,,HC REPR SUP NPTERF WND BODY 2.6-7.5,360,12002,$577.24 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],481.74,481.74,481.74,329.32,329.32,450.28,,,,,,HC REPR SUPERF WND BODY 7.6-12.5,360,12004,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,244.33,244.33,334.08,,,,,,HC REPR SUPERF WND FACE <2.5CM,360,12011,$576.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76706,Abdominal aorta ultrasound for screening of abdominal aortic aneurysm [HCPCS 76706],446.78,446.78,446.78,305.42,305.42,327.27,,,,,,HC REPR SUPERF WND FACE 2.6-5,360,12013,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76775,Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775],229.22,229.22,229.22,156.69,156.69,167.9,,,,,,HC REPR SUPERF WND FACE 7.6-12.5,360,12015,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76801,"Abdominal ultrasound of pregnant uterus during first trimester, less than 14 weeks 0 days (single or first fetus) [HCPCS 76801]",477.86,477.86,477.86,326.67,326.67,446.66,,,,,,HC CLOSURE SUPERF WND DEHIS SMPL,360,12020,"$1,551.48 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76815,"Abdominal ultrasound of pregnant uterus limited to fetal position, heart beat, and amniotic fluid volume (1 or more fetuses) [HCPCS 76815]",330.23,330.23,330.23,225.75,225.75,225.75,,,,,,"HC LAYR CLOS WND TRUNK,ARM,LEG <2.5CM",360,12031,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76816,Abdominal ultrasound of pregnant uterus for re-evaluation of fetus (per fetus) [HCPCS 76816],442.89,442.89,442.89,302.76,302.76,413.97,,,,,,"HC LAYR CLOS WND TRUNK,ARM,LEG 2.6-7.5",360,12032,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],481.74,481.74,481.74,329.32,329.32,450.28,,,,,,"HC LAYR CLOS WND TRUNK,ARM,LEG 7.6-12.",360,12034,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",431.24,431.24,431.24,294.8,294.8,403.08,,,,,,"HC LAYR CLOS WND TRUNK,ARM,LEG 12.6-20",360,12035,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],64.83,64.83,64.83,44.32,44.32,60.6,,,,,,"HC LAYR CLOS WND TRUNK,ARM,LEG 20.1-30",360,12036,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,76942,Ultrasound guidance for needle placement including imaging supervision of procedure and interpretation of results [HCPCS 76942],160,160,160,109.38,109.38,117.2,,,,,,"HC LAYR CLOS WND TRUNK,ARM,LEG >30CM",360,12037,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,67.71,67.71,92.58,,,,,,HC LAYR CLOS WND REST BODY <2.5CM,360,12041,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,77065,Mammography of one breast for diagnosis [HCPCS 77065],524.48,524.48,524.48,358.53,358.53,490.23,,,,,,HC LAYR CLOS WND REST BODY 2.6-7.5,360,12042,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,77066,Mammography of both breasts for diagnosis [HCPCS 77066],664.34,664.34,664.34,454.14,454.14,454.14,,,,,,HC LAYR CLOS WND REST BODY 7.6-12.5,360,12044,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,366.5,366.5,501.12,,,,,,HC LAYR CLOS WND REST BODY 12.6-20,360,12045,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,77080,"Bone density measurement of the axial skeleton (hips, pelvis, spine) [HCPCS 77080]",155.4,155.4,155.4,106.23,106.23,145.25,,,,,,HC LAYR CLOS WND REST BODY 20.1-30,360,12046,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1280.09,1280.09,1750.29,,,,,,HC LAYR CLOS WND FACIAL<2.5CM,360,12051,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,43.07,43.07,58.89,,,,,,"HC LAYR CLOS WND FACE,FACIAL 2.5-5",360,12052,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,59.22,59.22,80.97,,,,,,"HC LAYR CLOS WND FACE,FACIAL 5.1-7.5",360,12053,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,69.99,69.99,95.69,,,,,,"HC LAYR CLOS WND FACE,FACIAL 7.6-12.5",360,12054,$289.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80069,Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069],70.88,70.88,70.88,48.45,48.45,59.01,,,,,,HC REPR CMPL WND TRUNK 2.6-7.5CM,360,13101,$933.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",63,63,63,43.07,43.07,58.89,,,,,,"HC REPR CMPL WND SCALP,EXTR 2.6-7.5",360,13121,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80175,Lab analysis to measure the amount of lamotrigine in blood specimen [HCPCS 80175],149.63,149.63,149.63,102.29,102.29,102.29,,,,,,"HC REP,SKIN,SCALP/EXTREM+5CM/<",360,13122,$690.06 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80178,Lab analysis to measure the amount of lithium in blood specimen [HCPCS 80178],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,"HC REPR CMPL WND HEAD,FAC,HAND 1.1-2.5",360,13131,$595.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80185,Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185],102.38,102.38,102.38,69.99,69.99,74.99,,,,,,"HC REPR CMPL WND HEAD,FAC,HAND 2.6-7.5",360,13132,$933.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80197,Lab analysis to measure the amount of tacrolimus in blood specimen [HCPCS 80197],110.25,110.25,110.25,75.37,75.37,103.05,,,,,,"HC REP,FACE,GENITAL,HAND,FT+5CM/<",360,13133,$172.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80280,Lab analysis to measure the amount of vedolizumab in serum specimen [HCPCS 80280],173.57,173.57,173.57,118.65,118.65,118.65,,,,,,"HC REPR CMPL WND LID,NOS,EAR <1CM",360,13150,$636.70 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80305,Drug screening read by direct visual reading [HCPCS 80305],102.38,102.38,102.38,69.99,69.99,95.69,,,,,,"HC REPR CMPL WND LID,NOS,EAR 2.5-7.5",360,13152,$933.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],133.88,133.88,133.88,91.52,91.52,125.14,,,,,,"HC ADJ TISS XFER SCALP,EXTREM <10SQCM",360,14020,"$3,660.77 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],62.69,62.69,62.69,42.85,42.85,58.6,,,,,,"HC ADJ TISS XFER HEAD,FAC,HAND <10SQCM",360,14040,"$3,986.43 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC REVISION OF LOWER EYELID,360,15820,"$3,586.33 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,10.77,10.77,14.72,,,,,,HC REVISION OF UPPER EYELID,360,15822,"$3,586.33 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",39.38,39.38,39.38,26.92,26.92,36.81,,,,,,HC DRESS/DEBRID SMALL BURN,360,16020,$434.54 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC DRESS/DEBRID MED BURN NO ANESTH,360,16025,$327.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82088,Lab analysis to measure the aldosterone hormone level in blood specimen [HCPCS 82088],322.88,322.88,322.88,220.72,220.72,220.72,,,,,,HC DRESS/DEBRID LARGE BURN NO ANESTH,360,16030,$327.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82105,Lab analysis to measure the the alpha-fetoprotein (AFP) level in serum specimen [HCPCS 82105],133.88,133.88,133.88,91.52,91.52,98.07,,,,,,HC DESTRUCT PREMALG LESION,360,17000,$169.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,"HC DESTRUCT PREMALG LES, 2-14",360,17003,$32.24 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82247,Lab analysis to measure the total bilirubin level [HCPCS 82247],39.38,39.38,39.38,26.92,26.92,26.92,,,,,,HC DESTROY PREMLG LESIONS 15+,360,17004,$837.11 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,"HC DESTRUCT BENIGN LESION, 1-14",360,17110,$169.02 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82272,Lab analysis to measure the amount of blood in stool specimen by peroxidase activity [HCPCS 82272],31.5,31.5,31.5,21.53,21.53,29.44,,,,,,"HC DESTRUCT BENIGN LESION, 15+",360,17111,$252.37 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],236.25,236.25,236.25,161.5,161.5,220.82,,,,,,HC CHEM CAUTERY GRANULATN TISSUE,360,17250,$449.72 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82310,Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310],39.38,39.38,39.38,26.92,26.92,26.92,,,,,,HC BIOPSY BREAST W/O IMAGE,360,19100,$804.41 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82533,Lab analysis to measure the amount of total cortisol (hormone) [HCPCS 82533],126,126,126,86.13,86.13,117.77,,,,,,"HC BIOPSY OF BREAST, OPEN",360,19101,"$1,750.51 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,HC REMOVE BREAST LESION,360,19120,"$2,615.50 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],94.5,94.5,94.5,64.6,64.6,88.33,,,,,,HC EXPLORE WOUND EXTREMITY,360,20103,"$3,045.84 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,HC REMOVAL OF FOREIGN BODY,360,20520,"$1,115.21 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],39.38,39.38,39.38,26.92,26.92,32.79,,,,,,"HC THERAPEUTIC INJ, CARPAL TUNNEL",360,20526,$841.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],118.13,118.13,118.13,80.75,80.75,110.42,,,,,,HC INJ TENDON SHEATH/LIGAMENT,360,20550,$841.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82627,Lab analysis to measure the dehydroepiandrosterone (DHEA-S) hormone level [HCPCS 82627],173.25,173.25,173.25,118.43,118.43,161.94,,,,,,HC INJ TENDON ORIGIN/INSERTION,360,20551,$294.37 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",307.13,307.13,307.13,209.95,209.95,224.97,,,,,,"HC INJ TRIGGER POINT,1 OR 2",360,20552,$841.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82668,Lab analysis to measure the erythropoietin (protein) level [HCPCS 82668],149.63,149.63,149.63,102.29,102.29,102.29,,,,,,HC DRAIN/INJECT SMALL JOINT/BURSA,360,20600,$841.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],220.5,220.5,220.5,150.73,150.73,206.1,,,,,,HC DRAIN/INJECT MEDIUM JOINT/BURSA,360,20605,$841.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82677,Lab analysis to measure the estriol (hormone) level [HCPCS 82677],189,189,189,129.2,129.2,129.2,,,,,,HC RAD INJECT/ASPIR JNTMAJOR,360,20610,$841.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,75.37,75.37,103.05,,,,,,HC ASPIRATE/INJ GANGLION CYST,360,20612,$324.66 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],118.13,118.13,118.13,80.75,80.75,86.53,,,,,,HC REDUCE TEMPOROMANDIBL DISLOC,360,21480,$306.77 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82784,Lab analysis to measure the amount of gammaglobulin (immune system protein) [HCPCS 82784],246.57,246.57,246.57,168.56,168.56,180.61,,,,,,"HC REMOVE LESION,BACK OR FLANK",360,21930,"$2,574.86 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],31.5,31.5,31.5,21.53,21.53,29.44,,,,,,"HC CLOSED RX PROX HUMERUS FX,MANIP",360,23605,"$2,450.81 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",149.63,149.63,149.63,102.29,102.29,139.86,,,,,,HC CLOSED RX GR TUBEROSITY HUM FX,360,23620,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83002,"Lab analysis to measure the gonadotropin, luteinizing (reproductive hormone) level [HCPCS 83002]",149.63,149.63,149.63,102.29,102.29,139.86,,,,,,HC CLOSED RX SHLDR DISLOCATION,360,23650,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83010,Lab analysis to measure the haptoglobin (serum protein) level in serum specimen [HCPCS 83010],102.38,102.38,102.38,69.99,69.99,74.99,,,,,,"HC CLOSED RX SHLDR DISLOC,ANESTHESIA",360,23655,"$2,464.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],527.63,527.63,527.63,360.69,360.69,386.49,,,,,,HC DRAIN ARM BURSA,360,23931,"$1,539.51 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,53.83,53.83,73.61,,,,,,HC REMOVE ELBOW BURSA,360,24105,"$3,706.72 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],94.5,94.5,94.5,64.6,64.6,69.22,,,,,,HC REMOVE ELBOW LESION,360,24120,"$3,706.72 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83520,Lab analysis to measure the amount of substance by other immunoassay technique [HCPCS 83520],329.28,329.28,329.28,225.1,225.1,241.2,,,,,,"HC CLOSED RX ELBOW DISLOCATN,ANESTHESI",360,24605,"$2,464.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83525,Lab analysis to measure the amount of  total insulin [HCPCS 83525],86.63,86.63,86.63,59.22,59.22,59.22,,,,,,HC CLOSED RX RADIAL HEAD/NECK FX,360,24650,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,"HC CLOSED RX RADIAL HEAD/NECK FX,MANIP",360,24655,"$1,195.00 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],70.88,70.88,70.88,48.45,48.45,66.25,,,,,,"HC CLOSED RX PROX ULNA FX,MANIPULATN",360,24675,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,64.6,64.6,88.33,,,,,,HC EXCIS PRIMARY GANGLION WRIST,360,25111,"$3,706.72 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC CLOSED RX RADIAL SHAFT FX,360,25500,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,HC CLOSED RX DIST RAD/ULNA FX,360,25600,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83721,Lab analysis to measure the LDL cholesterol level [HCPCS 83721],86.63,86.63,86.63,59.22,59.22,80.97,,,,,,"HC CLOSED RX DIST RAD/ULNA FX,MANIPUL",360,25605,$945.78 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,HC CLOSED RX NAVICULAR FX,360,25622,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],307.13,307.13,307.13,209.95,209.95,287.07,,,,,,"HC DRAIN FINGER ABSCESS,SMPL",360,26010,$296.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83921,Lab analysis to measure the organic acid level in urine specimen [HCPCS 83921],165.38,165.38,165.38,113.05,113.05,121.14,,,,,,HC REMOVE TENDON SHEATH LESION,360,26160,"$3,034.45 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],322.88,322.88,322.88,220.72,220.72,268.83,,,,,,HC MANIPULATE FINGER WITH ANESTH,360,26340,$945.78 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84100,Lab analysis to measure the phosphate level [HCPCS 84100],39.38,39.38,39.38,26.92,26.92,28.85,,,,,,HC CLOSED RX METACARPAL FX,360,26600,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],39.38,39.38,39.38,26.92,26.92,28.85,,,,,,HC CLOSED RX PROX/MID FING SHFT FX,360,26720,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],165.38,165.38,165.38,113.05,113.05,154.58,,,,,,"HC CLOSE RX PROX/MID FING SHFT FX,MANI",360,26725,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],149.63,149.63,149.63,102.29,102.29,139.86,,,,,,HC AMPUTATION FINGER/THUMB,360,26951,"$2,637.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,96.9,96.9,132.49,,,,,,HC AMPUTATION FINGER/THUMB+FLAPS,360,26952,"$2,807.24 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],31.5,31.5,31.5,21.53,21.53,26.23,,,,,,HC INJECTION HIP ARTHROGRAM,360,27093,$395.91 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84244,Lab analysis to measure the renin (kidney enzyme) level in plasma specimen [HCPCS 84244],173.25,173.25,173.25,118.43,118.43,118.43,,,,,,HC INJECTION SACROILIAC JOINT,360,27096,$431.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],204.75,204.75,204.75,139.97,139.97,191.38,,,,,,"HC CLOSED RX SPONT HIP DISLOC,ANESTH",360,27257,"$2,464.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],55.13,55.13,55.13,37.69,37.69,40.38,,,,,,HC REMOVE FOREIGN BODY,360,27372,"$3,167.85 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],70.88,70.88,70.88,48.45,48.45,66.25,,,,,,"HC CLOSED RX TIBIA SHAFT FX,MANIPULATN",360,27752,"$2,800.61 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,91.52,91.52,125.14,,,,,,HC CLOSED RX PROX/SHAFT FIBULA FX,360,27780,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",39.38,39.38,39.38,26.92,26.92,36.81,,,,,,"HC CLOSED RX DIST FIBULA FX,MANIP",360,27788,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",39.38,39.38,39.38,26.92,26.92,36.81,,,,,,HC CLOSED RX BIMALLEOLAR FX,360,27808,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",110.25,110.25,110.25,75.37,75.37,103.05,,,,,,"HC CLOSED RX BIMALLEOLAR FX,MANIP",360,27810,$324.14 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",133.88,133.88,133.88,91.52,91.52,125.14,,,,,,"HC CLOSED RX TRIMALLEOLAR FX,MANIP",360,27818,$945.78 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,64.6,64.6,88.33,,,,,,HC CLOSED RX WEIGHT BEAR DIST TIBIA,360,27824,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,HC CLOSED RX ANKLE DISLOCATN,360,27840,$913.36 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",118.13,118.13,118.13,80.75,80.75,110.42,,,,,,HC EXPLOR METATARSO-PHALANG JT,360,28022,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],63,63,63,43.07,43.07,58.89,,,,,,HC REMOVE FOOT LESION SNGL EA,360,28080,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85007,Lab analysis to identify white blood cells (manual) with microscope [HCPCS 85007],31.5,31.5,31.5,21.53,21.53,23.07,,,,,,"HC REMOVE FOOT LESION,TENDON,SHEALTH,C",360,28090,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],15.75,15.75,15.75,10.77,10.77,10.77,,,,,,HC FULL EXCIS 5TH METATARSAL HEAD,360,28113,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],15.75,15.75,15.75,10.77,10.77,14.72,,,,,,HC REMOVE HEEL SPUR,360,28119,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,43.07,43.07,58.89,,,,,,HC PARTIAL REMOVAL OF ANKLE/HEEL,360,28120,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",47.25,47.25,47.25,32.3,32.3,39.34,,,,,,HC PARTIAL REMOVAL OF FOOT BONE,360,28122,"$3,184.91 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85045,Lab analysis to measure red blood count (automated test) [HCPCS 85045],31.5,31.5,31.5,21.53,21.53,23.07,,,,,,HC PART REMV PHALANX OF TOE,360,28124,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85049,Lab analysis to measure platelet count (automated test) [HCPCS 85049],31.5,31.5,31.5,21.53,21.53,21.53,,,,,,"HC REMV FOOT FOREIGN BODY,SUBCUTANEOUS",360,28190,"$1,356.97 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],78.75,78.75,78.75,53.83,53.83,73.61,,,,,,"HC REPAIR EXTEN LEG TENDON,PRIM,EA",360,28208,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,21.53,21.53,29.44,,,,,,HC REVISION OF FOOT TENDON,360,28238,"$10,240.36 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC REPAIR OF HAMMERTOE,360,28285,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC PART REMOVAL OF FOOT BONE,360,28288,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86021,Lab analysis to identify antibodies to white blood cells [HCPCS 86021],118.13,118.13,118.13,80.75,80.75,80.75,,,,,,HC REPAIR HALLUX RIGIDUS,360,28289,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],94.5,94.5,94.5,64.6,64.6,88.33,,,,,,"HC CORRECT BUNION,METATARSAL OSTEOTOMY",360,28296,"$5,821.69 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,26.92,26.92,36.81,,,,,,"HC CORRECT BUNION,PHALANX OSTEOTOMY",360,28298,"$5,821.69 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86141,Lab analysis to measure the amount of C-reactive protein in serum by high sensitivity assay to identify infection or inflammation [HCPCS 86141],102.38,102.38,102.38,69.99,69.99,69.99,,,,,,"HC CORRECT BUNION,OTHR METHODS",360,28299,"$5,821.69 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86156,Lab analysis to identify antibodies to cold agglutinin (protein) to screen for infection or disease [HCPCS 86156],63,63,63,43.07,43.07,46.15,,,,,,HC OSTEOTOMY METATARSAL (NOT 1ST),360,28308,"$3,755.34 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86160,Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160],94.5,94.5,94.5,64.6,64.6,69.22,,,,,,HC CLOSED RX METATARSAL FX,360,28470,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86200,Lab analysis to identify antibodies for rheumatoid arthritis assessment [HCPCS 86200],133.88,133.88,133.88,91.52,91.52,91.52,,,,,,"HC CONTROL NOSE BLEED,SMPL",360,30901,$202.59 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86235,Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235],187.54,187.54,187.54,128.2,128.2,137.37,,,,,,"HC CONTROL NOSE BLEED,CMPLX",360,30903,$219.95 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],94.5,94.5,94.5,64.6,64.6,64.6,,,,,,HC INSERT EMERGENCY AIRWAY,360,31500,$316.03 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86308,Lab analysis to screen for mononucleosis (mono) [HCPCS 86308],39.38,39.38,39.38,26.92,26.92,32.79,,,,,,HC INSERTION OF CHEST TUBE,360,32551,$974.73 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86317,Lab analysis to identify infectious agent antibodies (quantitative) [HCPCS 86317],118.13,118.13,118.13,80.75,80.75,110.42,,,,,,HC CVC PLMT >5 YEARS OLD,360,36556,"$1,130.54 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86336,Lab analysis to measure the amount of reproductive organ horomone (inhibin A) [HCPCS 86336],126,126,126,86.13,86.13,86.13,,,,,,"HC REMOVE TUNNEL CV ACCESS DEVICE, W P",360,36590,"$1,159.94 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],118.13,118.13,118.13,80.75,80.75,110.42,,,,,,HC DECLOT VASCULAR DEVICE,360,36593,$166.69 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC BONE MARROW ASPIRATION,360,38220,$886.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],488.25,488.25,488.25,333.77,333.77,456.37,,,,,,HC BONE MARROW BIOPSY,360,38221,$838.16 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],31.5,31.5,31.5,21.53,21.53,29.44,,,,,,HC CHANGE OF BLADDER TUBE SMPL,360,51705,$502.74 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86618,Lab analysis to identify antibodies to Borrelia burgdorferi (Lyme disease bacteria) [HCPCS 86618],133.88,133.88,133.88,91.52,91.52,125.14,,,,,,HC CYSTOURETHROSCOPY,360,52000,"$1,117.36 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86706,Lab analysis to identify Hepatitis B surface antibodies [HCPCS 86706],86.63,86.63,86.63,59.22,59.22,63.46,,,,,,HC SLITTING OF PREPUCE,360,54001,"$3,677.77 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86762,Lab analysis to identify antibodies to Rubella (German measles virus) [HCPCS 86762],110.25,110.25,110.25,75.37,75.37,103.05,,,,,,HC CIRCUMCISION 28 DAYS OR OLDER,360,54161,"$4,023.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86780,Lab analysis to identify antibodies to Treponema pallidum [HCPCS 86780],102.38,102.38,102.38,69.99,69.99,95.69,,,,,,HC REMOVAL OF TESTIS SMPL,360,54520,"$4,023.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86800,Lab analysis to identify antibodies to thyroglobulin (thyroid protein) [HCPCS 86800],126,126,126,86.13,86.13,104.91,,,,,,HC REMOVE HYDROCELE,360,55040,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],110.25,110.25,110.25,75.37,75.37,103.05,,,,,,HC REMOVAL OF SPERM DUCT(S),360,55250,"$1,917.30 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],78.75,78.75,78.75,53.83,53.83,73.61,,,,,,HC DRAIN GLAND ABSCESS,360,56420,$284.78 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC SURGERY FOR VULVAR LESION,360,56440,"$3,440.46 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],23.63,23.63,23.63,16.15,16.15,22.09,,,,,,HC REMOVE VAGINAL GLAND LESION,360,56740,"$3,440.46 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],395.91,395.91,395.91,270.64,270.64,370.06,,,,,,HC BIOPSY OF CERVIX,360,57500,$760.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87045,Lab analysis of stool culture to identify bacteria [HCPCS 87045],70.88,70.88,70.88,48.45,48.45,51.92,,,,,,HC BIOPSY OF UTERUS LINING,360,58100,$511.98 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87046,Lab analysis of stool culture to identify bacteria and additional pathogens [HCPCS 87046],70.88,70.88,70.88,48.45,48.45,51.92,,,,,,HC DILATION & CURETTAGE,360,58120,"$1,476.30 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",70.88,70.88,70.88,48.45,48.45,66.25,,,,,,HC INSERT INTRAUTERINE DEVICE,360,58300,$483.84 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],70.88,70.88,70.88,48.45,48.45,51.92,,,,,,HC REMOVE INTRAUTERINE DEVICE(IUD,360,58301,$532.82 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],63,63,63,43.07,43.07,58.89,,,,,,"HC SPINAL PUNCTURE,DIAGNOSTIC",360,62270,"$2,216.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],55.13,55.13,55.13,37.69,37.69,51.53,,,,,,"HC SPINAL PUNCTURE,THERAPEUTIC",360,62272,"$2,216.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,43.07,43.07,58.89,,,,,,HC TRIGEMINAL NERVE BLOCK,360,64400,$998.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],63,63,63,43.07,43.07,58.89,,,,,,HC OCCIPITAL NERVE BLOCK,360,64405,$998.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87147,Lab analysis to identify organisms by an immunologic technique (other than immunoflurescence) [HCPCS 87147],39.38,39.38,39.38,26.92,26.92,26.92,,,,,,HC SUPRASCAPULAR NERVE BLOCK,360,64418,"$2,216.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87177,Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177],70.88,70.88,70.88,48.45,48.45,51.92,,,,,,"HC INTERCOSTAL NERVE BLOCK,SNG",360,64420,"$2,216.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",70.88,70.88,70.88,48.45,48.45,66.25,,,,,,"HC INTERCOSTAL NERVE BLOCK,MLT",360,64421,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],31.5,31.5,31.5,21.53,21.53,23.07,,,,,,HC PUDENDAL NERVE BLOCK,360,64430,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87209,Lab analysis of complex special stain to identify parasites [HCPCS 87209],141.75,141.75,141.75,96.9,96.9,103.83,,,,,,HC INJ SCIATIC NERVE,360,64445,"$2,216.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87210,"Lab analysis of wet mount to identify bacteria, fungi, or parasites [HCPCS 87210]",47.25,47.25,47.25,32.3,32.3,44.16,,,,,,HC PERIPHERAL NERVE BLOCK,360,64450,"$2,216.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87220,"Lab analysis of wet mount from skin, hair, or nails to examine tissue fungi or parasites [HCPCS 87220]",31.5,31.5,31.5,21.53,21.53,29.44,,,,,,HC PLANTAR NERVE BLOCK,360,64455,$998.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.82,108.82,108.82,74.39,74.39,101.71,,,,,,HC INJ FORAMEN EPIDURAL L/S,360,64483,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87324,Lab analysis by immunoassay (ELISA) to identify clostridium difficile toxins (stool pathogen) [HCPCS 87324],94.5,94.5,94.5,64.6,64.6,69.22,,,,,,HC INJ FORAMEN EPIDURAL ADDON,360,64484,$585.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87338,"Lab analysis by immunoassay (ELISA) to identify helicobacter pylori in stool (multiple-step method, qualitative or semiquantitative) [HCPCS 87338]",110.25,110.25,110.25,75.37,75.37,75.37,,,,,,HC SPENOPALATINE GANGL NERVE BLOCK,360,64505,$998.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87340,Lab analysis by immunoassay (ELISA) to identify Hepatitis B surface antigen [HCPCS 87340],78.75,78.75,78.75,53.83,53.83,73.61,,,,,,HC STELLATE GANGLION NERVE BLOCK,360,64510,$846.30 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87389,Lab analysis by immunoassay (ELISA) to identify HIV-1 and HIV-2 [HCPCS 87389],189,189,189,129.2,129.2,176.66,,,,,,HC LUMBAR SYMPATHETIC NERVE BLOCK,360,64520,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,42.7,42.7,58.38,,,,,,HC CELIAC PLEXUS NERVE BLOCK,360,64530,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87427,Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427],94.5,94.5,94.5,64.6,64.6,69.22,,,,,,HC DESTROY NERVE FACE MUSCLE,360,64612,$446.85 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87449,"Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]",94.5,94.5,94.5,64.6,64.6,69.22,,,,,,HC CRYOABLATION,360,64640,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],236.25,236.25,236.25,161.5,161.5,220.82,,,,,,HC REMOVE FB FROM EYE SUPERF CONJUNC,360,65205,$198.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87493,Lab analysis by nucleic acid (DNA or RNA) to identify clostridium difficile by amplified probe technique [HCPCS 87493],291.38,291.38,291.38,199.19,199.19,213.44,,,,,,HC REMOVE FB FROM EYE EMBED CONJUNC,360,65210,$243.39 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],275.63,275.63,275.63,188.42,188.42,257.63,,,,,,HC REMOVE FB FROM EYE CORNEA NO SLIT,360,65220,$313.32 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],157.91,157.91,157.91,107.95,107.95,147.6,,,,,,HC EXCIS PTERYGIUM,360,65420,"$2,654.43 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,75.2,75.2,102.82,,,,,,"HC EXCIS PTERYGIUM,W GRAFT",360,65426,"$3,950.97 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,91.52,91.52,125.14,,,,,,"HC INCISE INNER EYE ADHESNS,INCISN",360,65865,"$2,654.43 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,87807,Lab analysis by immunoassay to identify respiratory syncytial virus (RSV) [HCPCS 87807],102.38,102.38,102.38,69.99,69.99,95.69,,,,,,"HC GLAUCOMA SURG,TRABECU AB EXTERNO",360,66170,"$3,950.97 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,382.22,382.22,522.62,,,,,,HC FOLLOWUP SURGERY OF EYE,360,66250,"$2,654.43 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,88342,Pathology lab analysis of special stained specimen slides to examine tissue (initial procedure) [HCPCS 88342],842.63,842.63,842.63,576.02,576.02,787.61,,,,,,HC REMOVAL OF IRIS,360,66625,"$1,582.48 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,89055,Lab analysis to measure the amount of white blood cells in stool specimen [HCPCS 89055],31.5,31.5,31.5,21.53,21.53,23.07,,,,,,"HC DISCISSION,2ND CATARACT,LASER",360,66821,"$1,755.65 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,51.14,51.14,69.92,,,,,,HC REPOSITION INTRAOCULAR LENS,360,66825,"$3,950.97 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,24.4,24.4,33.37,,,,,,"HC CATARACT SURG W IOL,1 STAGE",360,66984,"$4,224.17 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,92507,"Speech, language, voice, communication, and/or hearing processing disorder treatment [HCPCS 92507]",316.06,316.06,316.06,216.06,216.06,231.51,,,,,,HC PART REMOVAL EYE FLUID ANT APPROACH,360,67005,"$3,557.38 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,92526,Swallowing and/or oral feeding function treatment [HCPCS 92526],348.75,348.75,348.75,238.41,238.41,238.41,,,,,,HC PART REMOVAL EYE FLUID MECH VIRECTO,360,67010,"$6,864.72 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,87.05,87.05,119.02,,,,,,HC DRAIN EYELID ABSCESS,360,67700,$553.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,79.32,79.32,108.45,,,,,,"HC EXCIS CHALAZION,SINGLE",360,67800,$553.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93225,"External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]",376.55,376.55,376.55,257.41,257.41,351.96,,,,,,"HC FIX LID PTOSIS,LEVATR RESEC,INTERN",360,67903,"$3,240.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],118,118,118,80.66,80.66,110.29,,,,,,"HC FIX LID PTOSIS,LEVATR RESEC,EXTERN",360,67904,"$3,240.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,489.89,489.89,669.83,,,,,,"HC FIX ECTROPION,SUTURE",360,67914,"$3,240.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],784.77,784.77,784.77,536.47,536.47,574.84,,,,,,"HC FIX ECTROPION,ENTENSV LID REPAIR",360,67917,"$3,240.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,93970,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]",765.35,765.35,765.35,523.19,523.19,560.62,,,,,,HC FIX ENTROPION SUTRE,360,67921,"$3,240.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],79.71,79.71,79.71,54.49,54.49,74.5,,,,,,HC REMOVE IMPACTED EAR WAX,360,69210,$115.76 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,95249,Continuous sugar (glucose) level monitoring in tissue fluid with sensor under skin [HCPCS 95249],182.66,182.66,182.66,124.87,124.87,170.73,,,,,,"HC INCISE EARDRUM,ASPIR,GEN ANESTH",360,69421,"$2,735.47 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,95810,"Sleep pattern monitoring of patient in sleep lab, sleep staging with 4 or more parameters of sleep (6 years of age or older) [HCPCS 95810]",2755.06,2755.06,2755.06,1883.36,1883.36,2575.15,,,,,,HC REMOVE VENTILATING TUBE OTHER MD,360,69424,"$2,735.47 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,95811,Sleep pattern monitoring of patient in sleep lab with continued pressured respiratory assistance by mask or breathing tube (6 years of age or older) [HCPCS 95811],2879.07,2879.07,2879.07,1968.13,1968.13,2691.07,,,,,,HC CREATE EARDRUM OPENING LOCAL ANESTH,360,69433,"$1,186.56 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,95851,"Arm, leg, or each spine section range of motion testing [HCPCS 95851]",89.13,89.13,89.13,60.93,60.93,60.93,,,,,,HC CREATE EARDRUM OPENING GEN ANESTH,360,69436,"$2,735.47 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,147.59,147.59,201.8,,,,,,HC SCRN COLONOSCOPY HI RISK,490,G0105,"$1,449.35 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,58.27,58.27,79.67,,,,,,HC SCRN COLONOSCOPY NOT HI RISK,490,G0121,"$1,449.35 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,306.85,306.85,419.57,,,,,,HC ESOPHAGOSCOPY,360,43200,"$1,284.94 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",137.53,137.53,137.53,94.02,94.02,128.55,,,,,,"HC REMOVE GASTRIC PORT,OPEN",360,43887,"$2,645.17 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",195.49,195.49,195.49,133.64,133.64,143.2,,,,,,"HC EXCIS TONGUE LESN,ANT 2/3+CLOS",360,41112,"$1,782.01 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,61.37,61.37,83.92,,,,,,HC DRAINAGE OF GUM LESION,360,41800,$296.35 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,170.93,170.93,233.72,,,,,,HC INTRO GASTRO TUBE,360,44500,"$1,040.71 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,70.72,70.72,96.69,,,,,,"HC EXCIS LESN,PALATE/UVULA",360,42104,"$2,735.47 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96413,"Chemotherapy administration into vein by infusion (up to 1 hour, single drug) [HCPCS 96413]",887.54,887.54,887.54,606.72,606.72,650.12,,,,,,"HC PROCTOSIGMOIDOSCOPY,DX",360,45300,"$2,027.00 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,96415,Chemotherapy administration into vein by infusion (each additional hour) [HCPCS 96415],190.89,190.89,190.89,130.49,130.49,139.83,,,,,,HC INCISION OF ANAL ABSCESS,360,46050,"$1,163.61 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97012,Mechanical traction application to 1 or more areas [HCPCS 97012],59.56,59.56,59.56,40.72,40.72,43.63,,,,,,HC LIGATION OF HEMORRHOID(S),360,46221,"$1,454.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,32.44,32.44,44.36,,,,,,HC REMOVE ANAL TAGS,360,46230,"$1,552.37 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,82.3,82.3,112.53,,,,,,HC HEMORRHOIDECTOMY EXTERNAL,360,46250,"$2,503.52 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,85.46,85.46,116.86,,,,,,HC REMOVE ANAL FISTULA SUBCUT,360,46270,"$2,760.71 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,81.45,81.45,111.37,,,,,,HC REMOVE PHARYNX FOREIGN BODY,360,42809,$115.76 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,75.97,75.97,103.87,,,,,,HC TONSILLECTOMY/ADENOIDECT<12YRS,360,42820,"$4,249.64 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,230.44,230.44,315.09,,,,,,HC TONSILLECTOMY/ADENOIDECT>12YRS,360,42821,"$4,249.64 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,230.44,230.44,315.09,,,,,,HC REMOVAL OF ADENOIDS PRIMARY <12YRS,360,42830,"$7,754.93 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],231.98,231.98,231.98,158.58,158.58,216.83,,,,,,HC EXCISION OF ANAL LESION(S),360,46922,"$1,555.52 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97165,Occupational therapy evaluation (typically 30 minutes) [HCPCS 97165],269.72,269.72,269.72,184.38,184.38,197.57,,,,,,HC LAPAROSCOPIC CHOLECYSTECTOMY,360,47562,"$8,274.70 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],129.65,129.65,129.65,88.63,88.63,107.95,,,,,,HC RPR INITIAL HERNIA >5 YRS REDUC,360,49505,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97535,Training activities for home and self-care management (each 15 minutes) [HCPCS 97535],137.76,137.76,137.76,94.17,94.17,100.91,,,,,,"HC RPR INGUINAL HERNIA,REDUCE",360,49520,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97602,Dead tissue removal from wounds per session [HCPCS 97602],295.2,295.2,295.2,201.8,201.8,216.23,,,,,,"HC RPR INGUINAL HERNIA,BLOCKED",360,49521,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,97802,Medical nutrition therapy assessment and intervention (each 15 minutes) [HCPCS 97802],99.44,99.44,99.44,67.98,67.98,92.95,,,,,,"HC RPR INIT FEMORAL HERNIA,REDUCE",360,49550,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,98960,Patient self-management education and training each 30 minutes (individual patient) [HCPCS 98960],169.02,169.02,169.02,115.54,115.54,115.54,,,,,,"HC RPR HERNIA,REDUC",360,49560,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],20,20,20,13.67,13.67,18.69,,,,,,HC RPR HERNIA RECURR REDUCE,360,49565,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,83.51,83.51,114.18,,,,,,HC RPR HERNIA W/MESH,360,49568,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],116.39,116.39,116.39,79.56,79.56,85.26,,,,,,HC REPAIR UMBILICAL HERNIA 5+YRS REDUC,360,49585,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,153.32,153.32,209.63,,,,,,HC REPAIR UMBILICAL HERNIA 5+YRS STRAN,360,49587,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,229.66,229.66,314.01,,,,,,HC LAPARO HERNIA REPAIR INITIAL,360,49650,"$8,274.70 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,419.76,419.76,573.94,,,,,,HC LAPAROSCOPY INGUINAL HERNIA,360,49651,"$8,274.70 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,609.29,609.29,833.09,,,,,,"HC TREAT FINGER FRACTURE,EACH",360,26740,$314.87 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,18.99,18.99,25.97,,,,,,HC DESTROY CERV/THOR FACET JNT,360,64633,"$6,570.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1014.52,1014.52,1387.17,,,,,,HC DESTROY C/TH FACET JNT ADDL,360,64634,$765.45 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A0429,Bls-emergency [HCPCS A0429],1250.24,1250.24,1250.24,854.66,854.66,1168.6,,,,,,HC DESTROY LUMB/SAC FACET JNT,360,64635,"$6,570.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A0433,Als 2 [HCPCS A0433],2148.55,2148.55,2148.55,1468.75,1468.75,1573.81,,,,,,HC DESTROY L/S FACET JNT ADDL,360,64636,$670.95 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A0998,Ambulance response/treatment [HCPCS A0998],550,550,550,375.98,375.98,375.98,,,,,,HC REMOVE/INSERT DRUG IMPLANT,360,11983,$660.45 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A4590,Special casting material [HCPCS A4590],241.94,241.94,241.94,165.39,165.39,226.14,,,,,,HC ARTHROPLASTY INTERPHALANGEAL JNT,360,26535,"$6,864.72 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.56,2.56,2.75,,,,,,"HC ECTROPION REPAIR,CAUTERIZATION",360,67915,"$3,240.20 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,145.61,145.61,199.09,,,,,,"HC REPAIR OF IRIS,CILIARY BODY",360,66680,"$3,950.97 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,102.29,102.29,139.86,,,,,,HC CRICOIDTHROIDOTOMY,360,31605,"$2,412.49 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,990.78,990.78,1354.71,,,,,,HC DELIVERY OF PLACENTA,360,59414,"$3,440.46 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,100.65,100.65,137.63,,,,,,HC TREAT KNEE DISLOCATION,360,27552,"$2,536.36 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,990.78,990.78,1354.71,,,,,,HC PARTIAL REMOVAL OF COLON,360,44140,"$19,900.73 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0123,Screen cerv/vag thin layer [HCPCS G0123],91.17,91.17,91.17,62.32,62.32,62.32,,,,,,"HC REPAIR ING HERNIA,SLIDIN",360,49525,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0279,"Tomosynthesis, mammo [HCPCS G0279]",153.22,153.22,153.22,104.74,104.74,112.23,,,,,,HC ASPIRATE PLEURA W/O IMAGING,360,32554,"$1,180.83 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,34.63,34.63,42.18,,,,,,HC COLECT W/COLOPROCTOSTOMY,360,44145,"$12,728.09 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,G0390,Trauma respons w/hosp criti [HCPCS G0390],3386.05,3386.05,3386.05,2314.7,2314.7,3164.94,,,,,,HC SUTURE SBD DEHISCENCE,360,49900,"$5,556.60 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J0456,Azithromycin [HCPCS J0456],23,23,23,15.72,15.72,16.85,,,,,,HC CHEMODENERV MUSC NECK DYSTON,360,64616,$454.94 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],14.45,14.45,14.45,9.88,9.88,9.88,,,,,,HC CHEMODENERV 1 EXTREMITY 1-4,360,64642,$796.45 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J1170,Hydromorphone injection [HCPCS J1170],23,23,23,15.72,15.72,21.5,,,,,,HC REPAIR UMBILICAL LESION,360,49600,"$5,751.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J1745,Infliximab not biosimil 10mg [HCPCS J1745],126.57,126.57,126.57,86.52,86.52,92.71,,,,,,HC CHEMODENERV MUSCLE MIGRAINE,360,64615,$443.37 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],11.5,11.5,11.5,7.86,7.86,8.42,,,,,,HC APPLY MULTI-LAYER COMPRS-ARM/HAND,360,29584,$250.95 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],23,23,23,15.72,15.72,21.5,,,,,,HC DRAIN/INJ MAJOR JOINT/BURSA W/US,360,20611,$841.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],11.5,11.5,11.5,7.86,7.86,10.75,,,,,,HC NJX INTERLAMINAR CRV/THRC W/IMG,360,62321,"$2,216.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],23,23,23,15.72,15.72,21.5,,,,,,HC NJX INTERLAMINAR LMBR/SAC W/IMG,360,62323,"$2,216.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2360,Orphenadrine injection [HCPCS J2360],7.72,7.72,7.72,5.28,5.28,5.65,,,,,,HC INSERT CATH PLEURA W/O IMAGING,360,32556,"$2,560.00 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,31.45,31.45,43,,,,,,HC STRAPPING LOW BACK,360,29799,$263.94 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2543,Piperacillin/tazobactam [HCPCS J2543],15.75,15.75,15.75,10.77,10.77,11.54,,,,,,HC INJ PARAVERT F JNT C/T 1 LEV,360,64490,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],2.16,2.16,2.16,1.48,1.48,2.02,,,,,,HC INJ PARAVERT F JNT C/T 2 LEV,360,64491,$676.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",4.15,4.15,4.15,2.84,2.84,3.88,,,,,,HC INJ PARAVERT F JNT C/T 3 LEV,360,64492,$680.40 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2765,Metoclopramide hcl injection [HCPCS J2765],23,23,23,15.72,15.72,21.5,,,,,,HC INJ PARAVERT F JNT L/S 1 LEV,360,64493,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,4.54,4.54,6.21,,,,,,HC INJ PARAVERT F JNT L/S 2 LEV,360,64494,$578.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],23,23,23,15.72,15.72,21.5,,,,,,HC INJ PARAVERT F JNT L/S 3 LEV,360,64495,$591.15 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.12,1.12,1.53,,,,,,HC SKIN PINCH GRAFT,360,15050,$694.58 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],11.5,11.5,11.5,7.86,7.86,10.75,,,,,,"HC NERVE BLOCK INJ,AXILLARY",360,64417,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.59,1.59,1.7,,,,,,"HC GASTRIC INTUB & ASP,THER",360,43753,$251.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J3480,Inj potassium chloride [HCPCS J3480],13.2,13.2,13.2,9.02,9.02,10.99,,,,,,HC N BLOCK INJ HYPOGAS PLXS,360,64517,"$2,741.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,15.83,15.83,21.64,,,,,,HC TANGENTIAL BX SNGL SKIN LESION,360,11102,$265.09 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,37.6,37.6,51.41,,,,,,HC TANGENTIAL BX ADDL SKIN LESION,360,11103,$281.24 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],57.75,57.75,57.75,39.48,39.48,42.3,,,,,,HC PUNCH BX SNGL SKIN LESION,360,11104,$265.09 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],53.5,53.5,53.5,36.57,36.57,50.01,,,,,,HC PUNCH BX ADDL SKIN LESION,360,11105,$320.99 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,37.6,37.6,51.41,,,,,,HC INCISIONAL BX SNGL SKIN LESION,360,11106,$265.09 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Outpatient,Q3027,Inj beta interferon im 1 mcg [HCPCS Q3027],92.48,92.48,92.48,63.22,63.22,63.22,,,,,,HC INCISIONAL BX ADDL SKIN LESION,360,11107,$381.62 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],328.49,328.49,328.49,216.31,216.31,242.43,,,,,,HC INJECT AA&/STRD NERVES NRVTG SI JOI,360,64451,$893.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,11104,Skin lesion biopsy with punch tool to remove sample including all layers of skin (single lesion) [HCPCS 11104],136.61,136.61,136.61,89.96,89.96,100.82,,,,,,HC INJECT AA&/STRD GENICULAR NRV BRANC,360,64454,$918.75 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,17000,Destruction of pre-cancerous skin lesion/growth (first lesion/growth) [HCPCS 17000],408.46,408.46,408.46,268.97,268.97,268.97,,,,,,HC DESTRUCT NEUROLYTIC AGT GENICULAR N,360,64624,"$1,653.75 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,17003,Destruction of each additional pre-cancerous skin lesions/growths (2 to 14 lesions/growths) [HCPCS 17003],408.46,408.46,408.46,268.97,268.97,268.97,,,,,,HC DX LUMBAR SIGNAL PNXR W/FLUOR/CT,360,62328,"$1,009.05 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,17110,Destruction of non-cancerous skin lesions/growths other than skin tags (up to 14 lesions/growths) [HCPCS 17110],304.71,304.71,304.71,200.65,200.65,224.88,,,,,,HC THERAPEUTIC SPINAL PNXR CSF FLUOR/C,360,62329,"$1,271.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,69209,Impacted ear wax removal by washing [HCPCS 69209],321.86,321.86,321.86,211.94,211.94,237.53,,,,,,"PR REPAIR ING HERNIA,5+Y/O,REDUCIBL",975,49505,"$1,435.46 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,88142,Lab analysis of vaginal or cervical cells (pap test) with manual screening under physician supervision [HCPCS 88142],157.5,157.5,157.5,103.71,103.71,116.24,,,,,,"PR REPAIR ING HERNIA,5+Y/O,REDUCIBL",975,49505,"$1,435.46 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,49.26,49.26,55.21,,,,,,"PR REPAIR RECURR INGUIN HERN,REDUCIBL",975,49520,"$1,737.59 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",26.46,26.46,26.46,17.42,17.42,17.42,,,,,,"PR REPAIR RECURR INGUIN HERN,REDUCIBL",975,49520,"$1,737.59 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,90651,Human papilloma virus (HPV) nonavalent vaccine for injection into muscle (3 dose schedule) [HCPCS 90651],664.83,664.83,664.83,437.79,437.79,437.79,,,,,,PR REPAIR SLIDING INGUINAL HERNIA,975,49525,"$1,577.85 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,90670,"Pneumococcal conjugate, 13 valent vaccine for injection into muscle [HCPCS 90670]",225.75,225.75,225.75,148.66,148.66,148.66,,,,,,PR REPAIR SLIDING INGUINAL HERNIA,975,49525,"$1,577.85 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,90686,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent, preservation free) [HCPCS 90686]",19.95,19.95,19.95,13.14,13.14,13.14,,,,,,"PR REPAIR INCISIONAL HERNIA,REDUCIBLE",975,49560,"$2,024.68 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,23.51,23.51,26.35,,,,,,"PR REPAIR INCISIONAL HERNIA,REDUCIBLE",975,49560,"$2,024.68 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,90732,Pneumococcal polysaccharide vaccine for injection beneath the skin or into muscle (2 years of age or older) [HCPCS 90732],119.7,119.7,119.7,78.82,78.82,78.82,,,,,,"PR REPAIR RECURR INCIS HERNIA,REDUC",975,49565,"$2,110.35 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,15.07,7.06,15.07,,,,,,"PR REPAIR RECURR INCIS HERNIA,REDUC",975,49565,"$2,110.35 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],63.67,63.67,63.67,41.93,41.93,46.99,,,,,,PR IMPLANT MESH HERNIA REPAIR/DEBRIDEM,975,49568,$729.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,95115,Allergen injection in incremental dosages (single injection) [HCPCS 95115],24.82,24.82,24.82,16.34,16.34,16.34,,,,,,PR IMPLANT MESH HERNIA REPAIR/DEBRIDEM,975,49568,$729.31 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,96127,Emotional or behavioral assessment for screening of condtions like ADHD or depression with scoring and documentation (brief assessment) [HCPCS 96127],13.13,13.13,13.13,8.65,8.65,9.69,,,,,,"PR REPAIR UMBILICAL HERN,5+Y/O,REDUC",975,49585,"$1,227.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",74.81,74.81,74.81,49.26,43.9,55.21,,,,,,"PR REPAIR UMBILICAL HERN,5+Y/O,REDUC",975,49585,"$1,227.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,134.27,134.27,150.48,,,,,,PR REPAIR SMALL OMPHALOCELE,521,49600,"$2,008.48 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,190.03,169.34,212.97,,,,,,PR REPAIR SMALL OMPHALOCELE,521,49600,"$2,008.48 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],439.89,439.89,439.89,289.67,289.67,324.64,,,,,,"PR LAP,INGUINAL HERNIA REPR,INITIAL",975,49650,"$1,183.10 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],62.79,62.79,62.79,41.35,41.35,46.34,,,,,,"PR LAP,INGUINAL HERNIA REPR,INITIAL",975,49650,"$1,183.10 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,80.44,71.68,90.15,,,,,,"PR LAP,INGUINAL HERNIA REPR,RECUR",975,49651,"$1,539.65 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,132.67,62.19,148.68,,,,,,"PR LAP,INGUINAL HERNIA REPR,RECUR",975,49651,"$1,539.65 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,192.6,171.63,215.86,,,,,,HC LARYNGEAL FUNCTION STUDY,510,92520,$297.51 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,258.62,230.46,289.84,,,,,,HC ALLERGEN IMMUN;SINGLE INJECTIO,510,95115,$31.26 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99382,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99382],313.4,313.4,313.4,206.37,206.37,206.37,,,,,,HC ALLERGEN IMMUN;2 OR MORE INJEC,510,95117,$38.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],413.63,413.63,413.63,272.38,272.38,272.38,,,,,,"HC GLUCOSE MONITORING,CONTINUOUS",920,95250,$280.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],270.09,270.09,270.09,177.85,177.85,199.33,,,,,,HC GLUCOSE MONITOR REPORT READING,510,95251,$44.10 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],287.64,287.64,287.64,189.41,189.41,212.28,,,,,,HC CONT GLUC MNTR PT PROV EQP,920,95249,$182.66 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],286.64,286.64,286.64,188.75,188.75,211.54,,,,,,"PR INSERT,NON-INDWELLING BLADDER CATHE",521,51701,$120.65 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99394,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (12-17 years of age) [HCPCS 99394],314.86,314.86,314.86,207.34,207.34,207.34,,,,,,"PR INSERT,TEMP INDWELLING BLAD CATH,SI",975,51702,$178.28 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],322.65,322.65,322.65,212.47,212.47,238.12,,,,,,"PR CHANGE OF BLADDER TUBE,SIMPLE",975,51705,$235.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],343.06,343.06,343.06,225.91,201.31,253.18,,,,,,"PR SLIT PREPUCE,DORSAL OR LATERAL,NOT ",521,54001,$505.88 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99417,New or established patient office or outpatient visit with physician to diagnose and treat illness or injury beyond required time of primary visit (each additional 15 minutes of total time) [HCPCS 99417],27.3,27.3,27.3,17.98,17.98,17.98,,,,,,HC MILEAGE,542,A0425,$27.78 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99421,"Online digital evaluation and management service for an established patient to diagnose and treat illness or injury, for up to 7 days (cumulative time during the 7 days 5-10 minutes) [HCPCS 99421]",31.82,31.82,31.82,20.95,20.95,20.95,,,,,,HC ALS 1 ER,542,A0427,"$1,484.08 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99441,Telephone evaluation and management visit with physician to diagnose and treat illness or injury (5-10 minutes of medical discussion) [HCPCS 99441],36.75,36.75,36.75,24.2,24.2,24.2,,,,,,"HC BLS,ER",542,A0429,"$1,250.24 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99442,Telephone evaluation and management visit with physician to diagnose and treat illness or injury (11-20 minutes of medical discussion) [HCPCS 99442],72.45,72.45,72.45,47.71,47.71,47.71,,,,,,HC ALS 2,542,A0433,"$2,148.55 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,329.18,329.18,368.92,,,,,,HC SPECIAL CARE TRANSPORT,540,A0434,"$2,399.25 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99496,Transitional care management services with face-to-face visits within 7 days of discharge (high complexity) [HCPCS 99496],659.52,659.52,659.52,434.29,434.29,434.29,,,,,,HC BLS,542,A0428,"$1,250.24 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,99499,Unlisted service requiring evaluation and management [HCPCS 99499],101.87,101.87,101.87,67.08,67.08,67.08,,,,,,HC ALS NON-EMERGENT,542,A0426,"$1,414.62 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,G0101,Ca screen;pelvic/breast exam [HCPCS G0101],98.12,98.12,98.12,64.61,64.61,64.61,,,,,,"PR REMOVAL OF HYDROCELE,TUNICA,UNILAT",975,55040,$923.79 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,G0123,Screen cerv/vag thin layer [HCPCS G0123],91.17,91.17,91.17,60.04,60.04,60.04,,,,,,PR FIT/INSERT INTRAVAG SUPPORT DEVICE,983,57160,$213.00 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],5.75,5.75,5.75,3.79,3.79,4.24,,,,,,PR BIOPSY OF UTERUS LINING,983,58100,$305.61 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,4.37,4.37,4.9,,,,,,PR INSERT INTRAUTERINE DEVICE,983,58300,$426.67 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.08,1.08,1.21,,,,,,PR REMOVE INTRAUTERINE DEVICE,983,58301,$532.51 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.53,1.53,1.71,,,,,,"PR OBSTETRICAL CARE,VAG DELIV ONLY",521,59409,"$2,177.70 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,P3000,Screen pap by tech w md supv [HCPCS P3000],69.3,69.3,69.3,45.63,45.63,45.63,,,,,,PR DELIVER PLACENTA,521,59414,$265.65 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,Q0091,Obtaining screen pap smear [HCPCS Q0091],116.33,116.33,116.33,76.6,76.6,76.6,,,,,,HC MRI ORBIT/FACE/NECK W/DYE,610,70542,"$2,793.53 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,47.46,22.25,53.19,,,,,,HC MRI ORBIT/FACE/NECK W/WO DYE,610,70543,"$3,516.45 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Professional,Outpatient,S0630,Removal of sutures [HCPCS S0630],52.5,52.5,52.5,34.57,34.57,34.57,,,,,,HC MRA HEAD W/O DYE,610,70544,"$2,213.40 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Other Professional Setting,Professional,Outpatient,99441,Telephone evaluation and management visit with physician to diagnose and treat illness or injury (5-10 minutes of medical discussion) [HCPCS 99441],36.75,36.75,36.75,24.2,24.2,24.2,,,,,,HC MRA HEAD W/WO DYE,610,70546,"$3,346.88 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",22.05,22.05,22.05,14.52,14.52,16.27,,,,,,HC MRA NECK W/O DYE,610,70547,"$2,222.33 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],22.05,22.05,22.05,14.52,14.52,16.27,,,,,,HC MRA NECK W/WO DYE,610,70549,"$3,516.45 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],22.05,22.05,22.05,14.52,14.52,16.27,,,,,,HC MRI-CHEST WO DYE,610,71550,"$3,578.93 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,813,"Anesthesia provided during sophagus, stomach, small bowel, and/or large bowel  procedure with endoscope [HCPCS 00813]",22.05,22.05,22.05,14.52,14.52,14.52,,,,,,HC MRI CHEST WO/W DYE,610,71552,"$4,998.00 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,10061,Abscess incision and drainage (complicated procedure or multiple abscesses) [HCPCS 10061],565.36,565.36,565.36,372.29,372.29,372.29,,,,,,HC MRI PELVIS WO DYE,610,72195,"$2,391.90 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,10120,Incision into deepest layer of skin for foreign body removal (simple procedure) [HCPCS 10120],413.22,413.22,413.22,272.11,272.11,272.11,,,,,,HC MRI PELVIS W/WO DYE,610,72197,"$3,525.38 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,11976,Implantable contraceptive capsules removal [HCPCS 11976],390.12,390.12,390.12,256.89,256.89,256.89,,,,,,HC MRI UPPER EXT W/O DYE,610,73218,"$3,186.23 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",243.73,243.73,243.73,160.5,160.5,160.5,,,,,,HC MRI-UPPER EXT W/WO DYE,610,73220,"$4,319.70 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",296.7,296.7,296.7,195.38,195.38,195.38,,,,,,HC MRI-UPPER EXT JOINT W/O DYE,610,73221,"$2,070.60 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,12004,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (7.6 to 12.5 cm) [HCPCS 12004]",629.44,629.44,629.44,414.49,414.49,414.49,,,,,,HC MRI UPPER EXT JOINT W/WO DYE,610,73223,"$4,078.73 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,12011,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]",296.24,296.24,296.24,195.07,195.07,195.07,,,,,,HC MRI LOWER EXT W/O DYE,610,73718,"$2,320.50 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,12013,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.6 to 5.0 cm) [HCPCS 12013]",472.74,472.74,472.74,311.3,311.3,311.3,,,,,,HC MRI-LOWER EXT W/WO DYE,610,73720,"$3,516.45 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,12032,"Intermediate repair of wound of scalp, underarms, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12032]",823.01,823.01,823.01,541.95,541.95,607.38,,,,,,HC MRI-LOWER EXT JOINT W/O DYE,610,73721,"$2,061.68 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,12034,"Intermediate repair of wound of scalp, underarms, trunk, arms, and/or legs (7.6 to 12.5 cm) [HCPCS 12034]",989.28,989.28,989.28,651.44,651.44,651.44,,,,,,HC MRI LOWER EXT JOINT W/WO DYE,610,73723,"$4,069.80 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,20552,Trigger points injection into 1 or 2 muscles [HCPCS 20552],460.95,460.95,460.95,303.54,303.54,303.54,,,,,,HC MRI-ABDOMEN W/O DYE,610,74181,"$2,025.98 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],228.9,228.9,228.9,150.73,70.66,168.93,,,,,,HC MRI ABDOMEN W/WO DYE,610,74183,"$3,525.38 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,29125,Short arm splint application forearm to hand (non-moveable) [HCPCS 29125],185.22,185.22,185.22,121.97,121.97,136.69,,,,,,HC MRA ABDOMEN W/WO DYE,610,74185,"$3,498.60 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1021.2,1021.2,1021.2,672.46,315.24,753.65,,,,,,HC MRI-TMJ,611,70336,"$2,775.68 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],539.46,539.46,539.46,355.23,355.23,398.12,,,,,,HC MRI-BRAIN/BRAIN STEM,611,70551,"$2,008.13 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],585.76,585.76,585.76,385.72,180.82,385.72,,,,,,HC MRI-BRAIN WITH CONTRAST,611,70552,"$2,784.60 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1328.95,1328.95,1328.95,875.11,410.25,980.77,,,,,,HC MRI-BRAIN W/WO DYE,611,70553,"$3,284.40 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],739.73,739.73,739.73,487.11,228.35,487.11,,,,,,HC MRI BRAIN W/O DYE,611,70557,$568.40 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,45386,Colon (large bowel) examination and widening by balloon with flexible endoscope [HCPCS 45386],3027.85,3027.85,3027.85,1993.84,1993.84,1993.84,,,,,,HC MRI BRAIN W/DYE,611,70558,$949.25 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,62321,Spinal canal injection of substance into upper or middle back with imaging guidance [HCPCS 62321],535.5,535.5,535.5,352.63,352.63,352.63,,,,,,HC MRI BRAIN W/O & W/DYE,611,70559,"$5,655.00 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64445,Anesthetic agent and/or steroid injection into sciatic nerve of lower back and leg [HCPCS 64445],460.95,460.95,460.95,303.54,303.54,303.54,,,,,,HC MRI-C-SPINE W/O DYE,612,72141,"$1,954.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64483,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483],816.9,816.9,816.9,537.93,252.18,537.93,,,,,,HC MRI-T-SPINE W/O DYE,612,72146,"$1,954.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64484,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (each additional level) [HCPCS 64484],816.9,816.9,816.9,537.93,537.93,537.93,,,,,,HC MRI-L-SPINE W/O DYE,612,72148,"$1,954.58 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],705.6,705.6,705.6,464.64,217.82,464.64,,,,,,HC MRI-LUMBAR W/DYE,612,72149,"$2,793.53 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],705.6,705.6,705.6,464.64,217.82,464.64,,,,,,HC MRI C-SPINE W/WO DYE,612,72156,"$3,311.18 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64495,Lower or sacral spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64495],967.05,967.05,967.05,636.8,298.53,636.8,,,,,,HC MRI T-SPINE W/WO DYE,612,72157,"$3,320.10 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],1701,1701,1701,1120.11,525.1,1120.11,,,,,,HC MRI L-SPINE W/WO DYE,612,72158,"$3,302.25 "
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],1701,1701,1701,1120.11,525.1,1120.11,,,,,,PR DIAGNOSTIC LUMBAR SPINAL PUNCTURE,964,62270,$310.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,76942,Ultrasound guidance for needle placement including imaging supervision of procedure and interpretation of results [HCPCS 76942],160,160,160,105.36,105.36,105.36,,,,,,PR DIAGNOSTIC LUMBAR SPINAL PUNCTURE,964,62270,$310.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],206.06,206.06,206.06,135.69,63.61,152.07,,,,,,PR THERAPEUTIC SPINAL PUNCTURE DRAINAG,521,62272,$439.95 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,83.85,83.85,93.98,,,,,,PR THERAPEUTIC SPINAL PUNCTURE DRAINAG,521,62272,$439.95 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,15.07,7.06,15.07,,,,,,PR NJX DX/THER SBST INTRLMNR CRV/THRC ,,62321,$535.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,93015,"Heart and blood vessel stress test with EKG monitoring, physician supervision, interpretation, and report (exercise or drug-induced) [HCPCS 93015]",226.89,226.89,226.89,149.41,149.41,167.44,,,,,,PR NJX DX/THER SBST INTRLMNR CRV/THRC ,,62321,$535.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],47.84,47.84,47.84,31.5,14.77,35.31,,,,,,PR NJX DX/THER SBST INTRLMNR LMBR/SAC ,,62323,$496.65 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,95249,Continuous sugar (glucose) level monitoring in tissue fluid with sensor under skin [HCPCS 95249],182.66,182.66,182.66,120.28,56.39,120.28,,,,,,PR NJX DX/THER SBST INTRLMNR LMBR/SAC ,,62323,$496.65 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,95250,Continuous sugar (glucose) level monitoring (minimum of 72 hours) [HCPCS 95250],441,441,441,290.4,290.4,290.4,,,,,,PR DIAGNOSTIC LUMBAR SPINAL PUNCTURE W,521,62328,$449.40 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,95810,"Sleep pattern monitoring of patient in sleep lab, sleep staging with 4 or more parameters of sleep (6 years of age or older) [HCPCS 95810]",2755.06,2755.06,2755.06,1814.21,1814.21,1814.21,,,,,,PR DIAGNOSTIC LUMBAR SPINAL PUNCTURE W,521,62328,$449.40 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,95811,Sleep pattern monitoring of patient in sleep lab with continued pressured respiratory assistance by mask or breathing tube (6 years of age or older) [HCPCS 95811],2879.07,2879.07,2879.07,1895.87,1895.87,1895.87,,,,,,PR THERAPEUTIC SPINAL PNXR DRAINAGE CS,521,62329,$564.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,97802,Medical nutrition therapy assessment and intervention (each 15 minutes) [HCPCS 97802],99.44,99.44,99.44,65.48,65.48,73.39,,,,,,PR THERAPEUTIC SPINAL PNXR DRAINAGE CS,521,62329,$564.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,97803,Medical nutrition therapy re-assessment and intervention (each 15 minutes) [HCPCS 97803],86.18,86.18,86.18,56.75,56.75,63.6,,,,,,PR INJECTION AA&/STRD TRIGEMINAL NERVE,521,64400,$249.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,132.67,62.19,148.68,,,,,,PR INJECTION AA&/STRD TRIGEMINAL NERVE,521,64400,$249.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],192.17,192.17,192.17,126.54,59.32,126.54,,,,,,PR INJECTION AA&/STRD GREATER OCCIPITA,964,64405,$268.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],263.94,263.94,263.94,173.8,81.48,173.8,,,,,,PR INJECTION AA&/STRD GREATER OCCIPITA,964,64405,$268.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],491.99,491.99,491.99,323.98,323.98,323.98,,,,,,PR INJECTION AA&/STRD AXILLARY NERVE,521,64417,$303.45 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99221,Initial hospital inpatient care (typically 30 minutes per day) [HCPCS 99221],270.89,270.89,270.89,178.38,83.62,178.38,,,,,,PR INJECTION AA&/STRD AXILLARY NERVE,521,64417,$303.45 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],368.13,368.13,368.13,242.41,113.64,242.41,,,,,,PR INJECTION AA&/STRD SUPRASCAPULAR NE,521,64418,$284.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],191.01,191.01,191.01,125.78,58.96,125.78,,,,,,PR INJECTION AA&/STRD SUPRASCAPULAR NE,521,64418,$284.55 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99226,Subsequent observation care (typically 35 minutes per day) [HCPCS 99226],275.52,275.52,275.52,181.43,85.05,181.43,,,,,,PR INJECTION AA&/STRD INTERCOSTAL NRV ,521,64420,$298.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],103.03,103.03,103.03,67.85,31.81,67.85,,,,,,PR INJECTION AA&/STRD INTERCOSTAL NRV ,521,64420,$298.20 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],191.01,191.01,191.01,125.78,58.96,125.78,,,,,,PR INJECTION AA&/STRD INTERCOSTAL NRV ,521,64421,$127.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],275.52,275.52,275.52,181.43,85.05,181.43,,,,,,PR INJECTION AA&/STRD INTERCOSTAL NRV ,521,64421,$127.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",192.17,192.17,192.17,126.54,59.32,126.54,,,,,,PR INJECTION AA&/STRD PUDENDAL NERVE,521,64430,$274.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",284.78,284.78,284.78,187.53,87.91,210.17,,,,,,PR INJECTION AA&/STRD PUDENDAL NERVE,521,64430,$274.05 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],55.57,55.57,55.57,36.59,17.15,41.01,,,,,,PR INJECTION AA&/STRD SCIATIC NERVE,521,64445,$268.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],109.98,109.98,109.98,72.42,33.95,81.17,,,,,,PR INJECTION AA&/STRD SCIATIC NERVE,521,64445,$268.80 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,108.25,50.75,121.32,,,,,,PR INJECTION AA&/STRD OTHER PERIPHERAL,964,64450,$213.15 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,186.76,87.55,209.31,,,,,,PR INJECTION AA&/STRD OTHER PERIPHERAL,964,64450,$213.15 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],458.42,458.42,458.42,301.87,141.51,338.31,,,,,,PR INJECTION AA&/STRD NERVES NRVTG SI ,521,64451,$396.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99291,Critical care delivery to critically ill or injured patient (first 30-74 minutes) [HCPCS 99291],748.32,748.32,748.32,492.77,231.01,492.77,,,,,,PR INJECTION AA&/STRD NERVES NRVTG SI ,521,64451,$396.90 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],242.81,242.81,242.81,159.89,74.96,159.89,,,,,,PR INJECTION AA&/STRD GENICULAR NRV BR,521,64454,$409.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,122.42,57.39,122.42,,,,,,PR INJECTION AA&/STRD GENICULAR NRV BR,521,64454,$409.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,99357,Prolonged inpatient or observation hospital service requiring time beyond the usual service with direct patient contact (each additional 30 minutes) [HCPCS 99357],252,252,252,165.94,165.94,165.94,,,,,,PR NJX AA&/STRD PLANTAR COMMON DIGITAL,964,64455,$173.25 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],896.36,896.36,896.36,590.25,276.71,661.51,,,,,,PR NJX AA&/STRD PLANTAR COMMON DIGITAL,964,64455,$173.25 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,96.96,96.96,108.66,,,,,,PR NJX AA&/STRD TFRML EPI LUMBAR/SACRA,521,64483,$556.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],897.31,897.31,897.31,590.88,277,662.21,,,,,,PR NJX AA&/STRD TFRML EPI LUMBAR/SACRA,521,64483,$556.50 
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,G0123,Screen cerv/vag thin layer [HCPCS G0123],91.17,91.17,91.17,60.04,60.04,60.04,,,,,,PR NJX AA&/STRD TFRML EPI LUMBAR/SACRA,521,64484,$260.40 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,PR NJX AA&/STRD TFRML EPI LUMBAR/SACRA,521,64484,$260.40 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,NJX DX/THER AGT PVRT FACET JT CRV/THRC,521,64490,$527.10 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,NJX DX/THER AGT PVRT FACET JT CRV/THRC,521,64490,$527.10 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,NJX DX/THER AGT PVRT FACET JT CRV/THRC,521,64491,$300.30 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,NJX DX/THER AGT PVRT FACET JT CRV/THRC,521,64491,$300.30 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,NJX DX/THER AGT PVRT FACET JT CRV/THRC,521,64492,$303.45 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,NJX DX/THER AGT PVRT FACET JT CRV/THRC,521,64492,$303.45 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,NJX DX/THER AGT PVRT FACET JT LMBR/SAC,521,64493,$447.30 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,NJX DX/THER AGT PVRT FACET JT LMBR/SAC,521,64493,$447.30 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,29.59,29.59,29.59,,,,,,NJX DX/THER AGT PVRT FACET JT LMBR/SAC,521,64494,$258.30 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,NJX DX/THER AGT PVRT FACET JT LMBR/SAC,521,64494,$258.30 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,NJX DX/THER AGT PVRT FACET JT LMBR/SAC,521,64495,$261.45 
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],206.06,206.06,206.06,63.61,63.61,152.07,,,,,,NJX DX/THER AGT PVRT FACET JT LMBR/SAC,521,64495,$261.45 
AETNA - Medicare Part A,Clinic,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,"PR INJECT NERV BLCK,SPHENOPALAT GANGLN",521,64505,$484.05 
AETNA - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,"PR INJECT NERV BLCK,SPHENOPALAT GANGLN",521,64505,$484.05 
AETNA - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,"PR INJECT NERV BLCK,STELLATE GANGLION",521,64510,$374.85 
AETNA - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,"PR INJECT NERV BLCK,STELLATE GANGLION",521,64510,$374.85 
AETNA - Medicare Part A,Clinic,Institutional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,366.17,341.72,366.17,,,,,,"PR N BLOCK INJ, HYPOGAS PLXS",521,64517,$624.75 
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,"PR N BLOCK INJ, HYPOGAS PLXS",521,64517,$624.75 
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,"PR INJECT NERV BLCK,PARAVERT SYMPATH",521,64520,$412.65 
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,"PR INJECT NERV BLCK,PARAVERT SYMPATH",521,64520,$412.65 
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,"PR INJECT NERV BLCK,CELIAC PLEXUS",521,64530,$460.95 
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,"PR INJECT NERV BLCK,CELIAC PLEXUS",521,64530,$460.95 
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,PR CHEMODNRVTJ MUSC MUSC INNERVATED FA,521,64612,$354.24 
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,PR CHEMODNRVTJ MUSC MUSC INNERVATED FA,521,64612,$354.24 
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,PR CHEMODERVATE FACIAL/TRIGEM/CERV MUS,521,64615,$366.96 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR CHEMODERVATE FACIAL/TRIGEM/CERV MUS,521,64615,$366.96 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,119.56,111.58,152.56,,,,,,PR CHEMODENERVATION MUSCLE NECK UNILAT,521,64616,$291.72 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],454.55,454.55,454.55,332.96,310.73,424.87,,,,,,PR CHEMODENERVATION MUSCLE NECK UNILAT,521,64616,$291.72 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,PR DESTRUCTION NEUROLYTIC AGT GENICULA,521,64624,$735.00 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,PR DESTRUCTION NEUROLYTIC AGT GENICULA,521,64624,$735.00 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,PR DSTR NROLYTC AGNT PARVERTEB FCT SNG,,64633,"$1,120.35 "
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,PR DSTR NROLYTC AGNT PARVERTEB FCT SNG,,64633,"$1,120.35 "
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,PR DSTR NROLYTC AGNT PARVERTEB FCT ADD,,64634,$340.20 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,PR DSTR NROLYTC AGNT PARVERTEB FCT ADD,,64634,$340.20 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,PR DSTR NROLYTC AGNT PARVERTEB FCT SNG,,64635,"$1,104.60 "
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],488.25,488.25,488.25,357.64,333.77,456.37,,,,,,PR DSTR NROLYTC AGNT PARVERTEB FCT SNG,,64635,"$1,104.60 "
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,87389,Lab analysis by immunoassay (ELISA) to identify HIV-1 and HIV-2 [HCPCS 87389],189,189,189,138.44,129.2,176.66,,,,,,PR DSTR NROLYTC AGNT PARVERTEB FCT ADD,,64636,$298.20 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,PR DSTR NROLYTC AGNT PARVERTEB FCT ADD,,64636,$298.20 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,PR INJECT RX OTHER PERIPH NERVE,521,64640,$585.90 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,87.28,81.45,111.37,,,,,,PR INJECT RX OTHER PERIPH NERVE,521,64640,$585.90 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,PR CHEMODENERVATION ONE EXTREMITY 1-4 ,521,64642,$331.09 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,G0472,Hep c screen high risk/other [HCPCS G0472],112.29,112.29,112.29,82.25,82.25,82.25,,,,,,PR CHEMODENERVATION ONE EXTREMITY 1-4 ,521,64642,$331.09 
AETNA - Medicare Part A,Hospital,Institutional,Outpatient,G0499,Hepb screen high risk indiv [HCPCS G0499],123.84,123.84,123.84,90.71,90.71,90.71,,,,,,PR CHEMODENERVATION 1 EXTREMITY EA ADD,521,64643,$217.63 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,149.36,149.36,190.59,,,,,,PR CHEMODENERVATION 1 EXTREMITY EA ADD,521,64643,$217.63 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,"PR REMV F.B.,EYE,SUPERF CONJUNC",981,65205,$157.44 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,"PR REMV F.B.,EYE,SUPERF CONJUNC",981,65205,$157.44 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,"PR REMV F.B.,EYE,CORNEA,NO SLIT",981,65220,$162.07 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,"PR REMV F.B.,EYE,CORNEA,NO SLIT",981,65220,$162.07 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,PR XCAPSL CTRC RMVL INSJ IO LENS PROST,521,66984,"$4,224.17 "
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,PR XCAPSL CTRC RMVL INSJ IO LENS PROST,521,66984,"$4,224.17 "
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,"PR DRAIN EXT EAR ABSC/BLOOD,SIMPLE",983,69000,$535.98 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,"PR DRAIN EXT EAR ABSC/BLOOD,SIMPLE",983,69000,$535.98 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,PR REMV EXT CANAL FOREIGN BODY,981,69200,$353.07 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR REMV EXT CANAL FOREIGN BODY,981,69200,$353.07 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,PR REMOVAL IMPACTED CERUMEN IRRIGATION,521,69209,$120.39 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,PR REMOVAL IMPACTED CERUMEN IRRIGATION,521,69209,$120.39 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],481.74,481.74,481.74,352.87,329.32,450.28,,,,,,PR REMOVAL IMPACTED CERUMEN INSTRUMENT,981,69210,$144.70 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,PR REMOVAL IMPACTED CERUMEN INSTRUMENT,981,69210,$144.70 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,HC PACU/IP MIN,710,,$260.46 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",63,63,63,46.15,43.07,58.89,,,,,,HC VAGINAL DELIVERY,722,59409,"$3,440.46 "
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,HC ROUTINE EKG,730,93005,$127.34 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"HC RHYTHM ECG,TRACING",730,93041,$92.61 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,82105,Lab analysis to measure the the alpha-fetoprotein (AFP) level in serum specimen [HCPCS 82105],133.88,133.88,133.88,98.07,91.52,98.07,,,,,,HC EKG-12 LEADS-IPPE,730,G0403,$127.34 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,EKG MASTER,730,93000,$173.65 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,103.83,96.9,132.49,,,,,,HC ECG MONITOR/RECORD UP TO 48 HRS,731,93225,$376.55 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,HC SCANNING ANALYSIS W/REPORT,731,93226,$534.62 
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,HC EXT ECG >48HR<7D RECORDING,731,93242,$35.00 
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,HC EXT ECG >7D<15D RECORDING,731,93246,$118.00 
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,HC EVENT MONITOR,732,93228,$231.53 
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,"HC EEG,AWAKE & ASLEEP",740,95819,"$1,040.71 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,"HC UPPER GI ENDOSCOPY,DX",750,43235,"$1,475.97 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,"HC UPPER GI ENDOSCOPY,BIOPSY",750,43239,"$1,475.97 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,HC UPPER GI-INJ SCLEROSIS ESO/GAS,750,43243,"$2,329.95 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,HC UPPER GI SCOPE DILATE STRICTURE,750,43245,"$1,220.10 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,HC OPERATIVE UPPER GI ENDOSCOPY,750,43247,"$2,329.95 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,HC UPPER GI BALLOON DILATION,750,43249,"$2,329.95 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,"HC UP GI ENDOSCOPY,REMV TUMOR,SNARE",750,43251,"$2,329.95 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,HC COLONOSCOPY,750,45378,"$1,635.72 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,HC COLONOSCOPY W/BIOPSY(S),750,45380,"$1,635.72 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,"HC COLONOSCOPY,SUBMUCOUS INJ",750,45381,"$1,590.75 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,HC COLONOSCOPY/POLYPECTOMY,750,45384,"$1,635.72 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,69.22,64.6,88.33,,,,,,HC COLONOSCOPY/POLYPECTOMY SNARE,750,45385,"$1,635.72 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,HC COLONOSCOPY DILATE STRICTURE,750,45386,"$1,590.75 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,HC COLONOSCOPY W/ABLATION,750,45388,"$1,590.75 "
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,HC OFFICE VISIT-EST PATIENT LEVEL II,510,99212,$55.57 
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Outpatient,A0428,Bls [HCPCS A0428],1250.24,1250.24,1250.24,915.8,915.8,915.8,,,,,,HC HOURLY OBSERVATION,762,G0378,$50.66 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,HC ICU HOURLY OBS,762,G0378,$0.00 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,HC OUT OF ROOM PROCEDURE,9999,,$0.00 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,HC IN ROOM PROCEDURE,9999,,$0.00 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,HC OBSERVATION DISCHARGE,9999,7620022,$0.00 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,HC HOURLY OBSERVATION W/MONITOR,762,G0378,$0.00 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,PR SONO GUIDED NEEDLE PLACEMENT,521,76942,$160.00 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,PR SONO GUIDED NEEDLE PLACEMENT,521,76942,$160.00 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,HC VISIT TO DETERMINE LDCT ELIGIBILITY,770,G0296,$100.72 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,HC IMMUNIZATION ADMINISTRATION,771,90471,$74.81 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Outpatient,64454,Anesthetic agent and/or steroid injection into genicular nerve branches of knee with imaging imaging guidance [HCPCS 64454],918.75,918.75,918.75,672.98,672.98,672.98,,,,,,HC IMMUNIZATION ADMIN EA ADDL,771,90472,$27.78 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,MYOCARDIAL SPECT MULTIPLE STUDIES,960,78452,$206.06 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,62.44,58.27,79.67,,,,,,MYOCARDIAL SPECT MULTIPLE STUDIES,960,78452,$206.06 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,CHG ASSAY OF ALCOHOL (ETHANOL) BREATH,300,82075,$97.24 
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,CHG ASSAY OF ALCOHOL (ETHANOL) BREATH,300,82075,$97.24 
GERBER LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,17000,Destruction of pre-cancerous skin lesion/growth (first lesion/growth) [HCPCS 17000],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,HC RENAL DIALYSIS,821,90999,$571.87 
GERBER LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,HC PERITONEAL DIALYSIS OP/OBS,830,90945,$245.42 
GERBER LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,CHG TB INTRADERMAL TEST,300,86580,$28.94 
GERBER LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,CHG TB INTRADERMAL TEST,300,86580,$28.94 
GERBER LIFE INS. CO. - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,HC STAT THERAPIST DIRECT TIME,9999,,$0.00 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,CHG CYTOPATH CERV/VAG THIN LAYER,311,88142,$157.50 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,CHG CYTOPATH CERV/VAG THIN LAYER,311,88142,$157.50 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,PR SPORTS PHYSICAL CLINIC,521,,$28.94 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,OFFICE VISIT NO-CHG,9999,,$0.00 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,"PR IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOX",771,90471,$74.81 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,"PR IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOX",771,90471,$74.81 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,PR MENB-4C RECOMBNT PROT & OUTER MEMB ,636,90620,$281.50 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,PR 4VHPV VACCINE 3 DOSE SCHEDULE FOR I,636,90649,$97.65 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR 9VHPV VACC 2/3 DOSE SCHED IM USE,636,90651,$361.50 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,PR IIV3 VACCINE SPLIT VIRUS 0.5 ML DOS,636,90658,$11.55 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,PR IIV VACCINE PRESERV FREE INCREASED ,636,90662,$58.80 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,PR PCV13 VACCINE FOR INTRAMUSCULAR USE,636,90670,$225.75 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,PR IIV4 VACC PRESRV FREE 0.5 ML DOS FO,636,90686,$35.00 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,PR IIV4 VACC SPLIT VIRUS 0.5 ML DOS FO,636,90688,$18.90 
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,PR TD VACCINE PRSRV FREE 7 YRS OR OLDE,636,90714,$26.25 
HEALTH PARTNERS - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,"PR TDAP VACCINE >7 YO, IM",636,90715,$35.70 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,PR PPSV23 VACCINE 2 YRS OR OLDER FOR S,636,90732,$167.75 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,HC NEUROBEH STATUS EXAM BY PSYCH/PHYS,918,96116,$405.17 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,HC SLEEP OXIMETRY,920,95807,"$1,838.87 "
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,HC POLYSOMNOGRAM;SLEEP STG;4+,920,95810,"$2,755.06 "
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,HC POLYSOMNOGRAM;SLEEP STG;4+CPAP,920,95811,"$2,879.07 "
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,HC CAROTID DOPPLER,921,93880,$784.77 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,HC CAROTID UNILAT/LTD DOPPLER,921,93882,$505.05 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,HC DUPLEX LOWER EXTREMITY,921,93925,$998.45 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,HC DUPLEX LOWER EXT FOLLOW UP,921,93926,$590.52 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,119.56,111.58,152.56,,,,,,HC DUPLEX ARTERIAL UPPER,921,93930,$808.08 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,72.55,67.71,92.58,,,,,,HC VENOUS IMAGING,921,93970,$765.35 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,392.72,366.5,501.12,,,,,,HC UNILAT/LTD VENOUS,921,93971,$477.86 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,HC ABD ORGAN DUPLEX,921,93975,"$1,087.80 "
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,HC DUPLEX ABD ORGAN FOLLOW UP,921,93976,$644.91 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,HC ABD VASCULATURE DUPLEX,921,93978,$738.15 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,80069,Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069],70.88,70.88,70.88,51.92,48.45,59.01,,,,,,"HC DOPPLER UPPER EXT,ARTERIES",921,93890,$759.40 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,80197,Lab analysis to measure the amount of tacrolimus in blood specimen [HCPCS 80197],110.25,110.25,110.25,80.76,75.37,103.05,,,,,,PR HEART/LUNG RESUSCITATION (CPR),521,92950,$872.51 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR HEART/LUNG RESUSCITATION (CPR),521,92950,$872.51 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,PR CARDIOVERSION ELECTIVE ARRHYTHMIA E,521,92960,$432.71 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],39.38,39.38,39.38,28.85,26.92,32.79,,,,,,PR CARDIOVERSION ELECTIVE ARRHYTHMIA E,521,92960,$432.71 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"PR ELECTROCARDIOGRAM, COMPLETE",521,93000,$45.74 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,"PR ELECTROCARDIOGRAM, COMPLETE",521,93000,$45.74 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],31.5,31.5,31.5,23.07,21.53,26.23,,,,,,"PR ELECTROCARDIOGRAM, TRACING",521,93005,$20.66 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,PR ELECTROCARDIOGRAM REPORT,521,93010,$22.88 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,PR ELECTROCARDIOGRAM REPORT,521,93010,$22.88 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",47.25,47.25,47.25,34.61,32.3,39.34,,,,,,PR CV STRS TST XERS&/OR RX CONT ECG W/,521,93015,$226.89 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,PR CV STRS TST XERS&/OR RX CONT ECG W/,521,93015,$226.89 
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,109.6,102.29,139.86,,,,,,PR CV STRS TST XERS&/OR RX CONT ECG W/,521,93016,$60.34 
HIGHMARK INC - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,PR CV STRS TST XERS&/OR RX CONT ECG W/,521,93016,$60.34 
HIGHMARK INC - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,"PR CARDIAC STRESS TST,TRACING ONLY",730,93017,$113.45 
HIGHMARK INC - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,"PR CARDIAC STRESS TST,TRACING ONLY",730,93017,$113.45 
HIGHMARK INC - Medicare Part A,Clinic,Institutional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,366.17,341.72,366.17,,,,,,"PR CARDIAC STRESS TST,INTERP/REPT ONLY",521,93018,$40.39 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,"PR CARDIAC STRESS TST,INTERP/REPT ONLY",521,93018,$40.39 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,PR EXTERNAL ECG REC>7D<15D RECORDING,521,93246,$118.00 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,PR EXTERNAL ECG REC>7D<15D RECORDING,521,93246,$118.00 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,"HC HYDRATION IV INFUSION,INIT",260,96360,$215.90 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,HC HYDRATION IV INFUSION ADD-ON,260,96361,$85.24 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,"HC THER/PROPH/DIAG IV INF,INIT",260,96365,$448.88 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,HC THER/PROPH/DIAG IV INF ADD-ON,260,96366,$137.53 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,HC THER/PROP/DG ADDL SEQ IV INF,260,96367,$195.49 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,HC THER/DIAG CONCURRENT INFUSION,260,96368,$0.00 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,"HC THER/PROPH/DIAG INJ,SC/IM",260,96372,$89.78 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,672.6,627.7,858.27,,,,,,"HC THER/PROPH/DIAG INJ,IV PUSH",260,96374,$250.05 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,HC TX/PROP/DG INJ NEW DRUG ADDON,260,96375,$103.45 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,HC TX/PROP/DG INJ SAME DRUG ADDON,260,96376,$0.00 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,HC PIC/PORT FLUSH,761,96523,$145.85 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,HC PHLEBOTOMY IN INFUSION CTR,940,99195,$534.14 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,87807,Lab analysis by immunoassay to identify respiratory syncytial virus (RSV) [HCPCS 87807],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,PR BREATHING CAPACITY TEST,521,94010,$96.39 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,PR BREATHING CAPACITY TEST,521,94010,$96.39 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,PR EVAL OF BRONCHOSPASM,521,94060,$161.12 
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,328.8,306.85,419.57,,,,,,PR EVAL OF BRONCHOSPASM,521,94060,$161.12 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,71.68,71.68,90.15,,,,,,PR VITAL CAPACITY TEST,521,94150,$68.30 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,PR VITAL CAPACITY TEST,521,94150,$68.30 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,HC DIABETES TRAIN/INDIV 30 MIN,942,G0108,$147.24 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,HC DIABETES EDUCATION,942,G0109,$41.19 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,HC CARDIAC REHAB/PHASE I NON-MONITORED,943,93797,$81.04 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,HC PHASE II MONITORED,943,93798,$119.24 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,"HC CARDIAC REHAB PHASE III,INITIAL",943,93797,$81.04 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,PR PRESSURIZED/NONPRESSURIZED INHALATI,982,94640,$63.67 
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,PR PRESSURIZED/NONPRESSURIZED INHALATI,982,94640,$63.67 
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,"PR IMMUNOTHERAPY, ONE INJECTION",521,95115,$24.82 
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,"PR IMMUNOTHERAPY, ONE INJECTION",521,95115,$24.82 
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,"PR IMMUNOTHERAPY, 2+ INJECTIONS",521,95117,$28.71 
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,"PR IMMUNOTHERAPY, 2+ INJECTIONS",521,95117,$28.71 
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,PR CONT GLUC MONITORING PATIENT PROVID,521,95249,
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,PR CONTINUOUS GLUCOSE MONITORING ANALY,521,95251,$132.30 
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,PR CONTINUOUS GLUCOSE MONITORING ANALY,521,95251,$132.30 
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,PR BEHAV ASSMT W/SCORE & DOCD/STAND IN,521,96127,$13.13 
HIGHMARK INC - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],275.52,275.52,275.52,85.05,85.05,181.43,,,,,,PR BEHAV ASSMT W/SCORE & DOCD/STAND IN,521,96127,$13.13 
HIGHMARK INC - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",192.17,192.17,192.17,59.32,59.32,126.54,,,,,,PR THER PROPHYLACTIC/DX INJECTION SUBQ,521,96372,$38.45 
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,17110,Destruction of non-cancerous skin lesions/growths other than skin tags (up to 14 lesions/growths) [HCPCS 17110],304.71,304.71,304.71,223.2,223.2,284.81,,,,,,PR THER PROPHYLACTIC/DX INJECTION SUBQ,521,96372,$38.45 
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,PR DEBRIDEMENT OPEN WOUND 20 SQ CM<,521,97597,$263.83 
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,PR DEBRIDEMENT OPEN WOUND 20 SQ CM<,521,97597,$263.83 
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,PR RMVL DEVITAL TISS N-SLCTV DBRDMT W/,521,97602,$224.35 
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,PR RMVL DEVITAL TISS N-SLCTV DBRDMT W/,521,97602,$224.35 
"HUMANA, INC. - Medicare Part A",Clinic,Institutional,Outpatient,G2025,Dis site tele svcs rhc/fqhc [HCPCS G2025],96.63,96.63,96.63,70.78,70.78,70.78,,,,,,PR POST-OP FOLLOW-UP VISIT,521,99024,$0.00 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,PR POST-OP FOLLOW-UP VISIT,521,99024,$0.00 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,SPECIAL ANESTHESIA SERVICE,,99100,$0.01 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,PR SPECIAL SERVICE/PROC/REPORT,521,99199,$101.87 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,PR OFFICE/OUTPATIENT NEW SF MDM 15-29 ,521,99202,$203.90 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,PR OFFICE/OUTPATIENT NEW LOW MDM 30-44,521,99203,$288.58 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,PR OFFICE/OUTPATIENT NEW MODERATE MDM ,521,99204,$439.89 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,PR OFFICE/OUTPATIENT NEW HIGH MDM 60-7,521,99205,$555.67 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,PR OFFICE/OUTPATIENT EST PT MAY NOT RE,521,99211,$62.79 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,PR OFFICE/OUTPATIENT ESTABLISHED SF MD,521,99212,$122.16 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR OFFICE/OUTPATIENT ESTABLISHED LOW M,521,99213,$201.47 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,64624,Genicular nerve branches of knee destruction by injection with imaging guidance [HCPCS 64624],1653.75,1653.75,1653.75,1211.37,1211.37,1211.37,,,,,,PR OFFICE/OUTPATIENT ESTABLISHED MOD M,521,99214,$292.49 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,73.99,69.05,94.41,,,,,,PR OFFICE/OUTPATIENT ESTABLISHED HIGH ,521,99215,$392.74 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,PR OBSERVATION CARE DISCHARGE MANAGEME,982,99217,$192.17 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,672.6,627.7,858.27,,,,,,PR OBSERVATION CARE DISCHARGE MANAGEME,982,99217,$192.17 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,837.58,781.66,1068.78,,,,,,PR INITIAL OBSERVATION CARE/DAY 30 MIN,982,99218,$263.94 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,PR INITIAL OBSERVATION CARE/DAY 30 MIN,982,99218,$263.94 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],139.86,139.86,139.86,102.45,95.61,130.73,,,,,,PR INITIAL OBSERVATION CARE/DAY 50 MIN,982,99219,$360.02 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,73200,"Arm CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73200]",1039.5,1039.5,1039.5,761.43,761.43,971.62,,,,,,PR INITIAL OBSERVATION CARE/DAY 50 MIN,982,99219,$360.02 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,96.76,90.3,123.46,,,,,,PR INITIAL OBSERVATION CARE/DAY 70 MIN,982,99220,$491.99 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,PR INITIAL OBSERVATION CARE/DAY 70 MIN,982,99220,$491.99 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1395.96,1302.77,1781.3,,,,,,PR INITIAL HOSPITAL CARE/DAY 30 MINUTE,982,99221,$270.89 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,261.81,244.33,334.08,,,,,,PR INITIAL HOSPITAL CARE/DAY 50 MINUTE,982,99222,$368.13 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],64.83,64.83,64.83,47.49,44.32,60.6,,,,,,PR INITIAL HOSPITAL CARE/DAY 70 MINUTE,982,99223,$539.46 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,72.55,67.71,92.58,,,,,,PR SBSQ OBSERVATION CARE/DAY 15 MINUTE,982,99224,$106.50 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,392.72,366.5,501.12,,,,,,PR SBSQ OBSERVATION CARE/DAY 15 MINUTE,982,99224,$106.50 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,PR SBSQ OBSERVATION CARE/DAY 25 MINUTE,982,99225,$191.01 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,PR SBSQ OBSERVATION CARE/DAY 25 MINUTE,982,99225,$191.01 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,PR SBSQ OBSERVATION CARE/DAY 35 MINUTE,982,99226,$275.52 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,PR SBSQ OBSERVATION CARE/DAY 35 MINUTE,982,99226,$275.52 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,PR SBSQ HOSPITAL CARE/DAY 15 MINUTES,982,99231,$103.03 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,PR SBSQ HOSPITAL CARE/DAY 25 MINUTES,982,99232,$191.01 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,PR SBSQ HOSPITAL CARE/DAY 35 MINUTES,982,99233,$275.52 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,PR OBSERVATION/INPATIENT HOSPITAL CARE,982,99234,$357.70 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,PR OBSERVATION/INPATIENT HOSPITAL CARE,982,99234,$357.70 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,PR OBSERVATION/INPATIENT HOSPITAL CARE,982,99235,$449.16 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,PR OBSERVATION/INPATIENT HOSPITAL CARE,982,99235,$449.16 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,PR OBSERVATION/INPATIENT HOSPITAL CARE,982,99236,$579.97 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,183.16,170.93,233.72,,,,,,PR OBSERVATION/INPATIENT HOSPITAL CARE,982,99236,$579.97 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,75.78,70.72,96.69,,,,,,"PR HOSPITAL DISCHARGE DAY,<30 MIN",982,99238,$192.17 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,34.76,32.44,44.36,,,,,,"PR HOSPITAL DISCHARGE DAY,<30 MIN",982,99238,$192.17 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,"PR HOSPITAL DISCHARGE DAY,>30 MIN",982,99239,$284.78 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,81.4,75.97,103.87,,,,,,"PR HOSPITAL DISCHARGE DAY,>30 MIN",982,99239,$284.78 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,PR INITL INPATIENT CONSULT NEW/ESTAB P,521,99251,$128.50 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,PR INITL INPATIENT CONSULT NEW/ESTAB P,981,99252,$192.17 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,PR EMERGENCY DEPARTMENT VISIT LIMITED/,981,99281,$55.57 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],108.82,108.82,108.82,79.71,79.71,79.71,,,,,,PR EMERGENCY DEPARTMENT VISIT LIMITED/,981,99281,$55.57 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],405.17,405.17,405.17,296.79,296.79,296.79,,,,,,PR EMERGENCY DEPARTMENT VISIT LOW/MODE,981,99282,$109.98 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,PR EMERGENCY DEPARTMENT VISIT LOW/MODE,981,99282,$109.98 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,PR EMERGENCY DEPARTMENT VISIT MODERATE,981,99283,$164.39 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,PR EMERGENCY DEPARTMENT VISIT MODERATE,981,99283,$164.39 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,PR EMERGENCY DEPARTMENT VISIT HIGH/URG,981,99284,$283.62 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.75,2.56,2.75,,,,,,PR EMERGENCY DEPARTMENT VISIT HIGH/URG,981,99284,$283.62 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,PR EMERGENCY DEPT VISIT HIGH SEVERITY&,981,99285,$458.42 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,37.11,34.63,42.18,,,,,,PR EMERGENCY DEPT VISIT HIGH SEVERITY&,981,99285,$458.42 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,"PR CRITICAL CARE, E/M 30-74 MINUTES",521,99291,$748.32 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.7,1.59,1.7,,,,,,"PR CRITICAL CARE, E/M 30-74 MINUTES",521,99291,$748.32 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,"PR CRITICAL CARE, ADDL 30 MIN",521,99292,$329.35 
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,40.29,37.6,51.41,,,,,,"PR CRITICAL CARE, ADDL 30 MIN",521,99292,$329.35 
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,PR INITIAL NURSING FACILITY CARE/DAY 2,521,99304,$242.81 
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,PR INITIAL NURSING FACILITY CARE/DAY 3,521,99305,$348.95 
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,PR INITIAL NURSING FACILITY CARE/DAY 4,521,99306,$449.17 
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,PR SBSQ NURSING FACILITY CARE/DAY E/M ,521,99307,$118.25 
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,PR SBSQ NURSING FACIL CARE/DAY MINOR C,521,99308,$185.90 
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,PR SBSQ NURSING FACIL CARE/DAY NEW PRO,521,99309,$245.78 
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,PR SBSQ NURSING FACIL CARE/DAY UNSTABL,521,99310,$362.58 
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,"PR NURSING FAC DISCHRGE DAY,1-30 MIN",521,99315,$197.07 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Institutional,Outpatient,20611,Large joint or joint capsule fluid removal and/or injection with needle and ultrasound guidance including recording and reporting [HCPCS 20611],841.05,841.05,841.05,616.07,616.07,786.13,,,,,,"PR NURSING FAC DISCHRGE DAY,MORE 30 MI",521,99316,$283.72 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],108.82,108.82,108.82,79.71,79.71,79.71,,,,,,PR HOME VISIT NEW PATIENT LOW SEVERITY,521,99341,$142.39 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Institutional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],405.17,405.17,405.17,296.79,296.79,296.79,,,,,,PR HOME VISIT NEW PATIENT MOD SEVERITY,521,99342,$206.06 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,PR HOME VST NEW PATIENT MOD-HI SEVERIT,521,99343,$335.72 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,64454,Anesthetic agent and/or steroid injection into genicular nerve branches of knee with imaging imaging guidance [HCPCS 64454],409.5,409.5,409.5,126.41,126.41,240.29,,,,,,PR HOME VISIT NEW PATIENT HI SEVERITY ,521,99344,$470.00 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],368.13,368.13,368.13,113.64,113.64,242.41,,,,,,PR HOME VISIT NEW PT UNSTABL/SIGNIF NE,521,99345,$570.71 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],191.01,191.01,191.01,58.96,58.96,125.78,,,,,,PR HOME VISIT EST PT SELF LIMITED/MINO,521,99347,$147.47 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",192.17,192.17,192.17,59.32,59.32,126.54,,,,,,PR HOME VISIT EST PT LOW-MOD SEVERITY ,521,99348,$217.63 
"HUMANA, INC. - Medicare Part B",Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,87.55,87.55,209.31,,,,,,PR HOME VISIT EST PT MOD-HI SEVERITY 4,521,99349,$331.09 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,PR HOME VST EST PT UNSTABLE/SIGNIF NEW,521,99350,$457.26 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,PR PROLONGED SVC I/P OR OBS SETTING 1S,521,99356,$252.00 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,PR PROLONGED SVC I/P OR OBS SETTING 1S,521,99356,$252.00 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,PR PROLONGED SVC I/P REQ UNIT/FLOOR TI,521,99357,$252.00 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,PR PROLONGED SVC I/P REQ UNIT/FLOOR TI,521,99357,$252.00 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,"PR PREVENTIVE VISIT,NEW,INFANT < 1 YR",521,99381,$299.31 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,"PR PREVENTIVE VISIT,NEW,AGE 1-4",521,99382,$313.40 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,"PR PREVENTIVE VISIT,NEW,AGE5-11",521,99383,$326.55 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,"PR PREVENTIVE VISIT,NEW,12-17",521,99384,$368.85 
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,"PR PREVENTIVE VISIT,NEW,18-39",521,99385,$357.68 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,"PR PREVENTIVE VISIT,NEW,40-64",521,99386,$413.63 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,"PR PREVENTIVE VISIT,NEW,65 & OVER",521,99387,$449.14 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,"PR PREVENTIVE VISIT,EST, INFANT < 1 YR",521,99391,$270.09 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,"PR PREVENTIVE VISIT,EST,AGE 1-4",521,99392,$287.64 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,"PR PREVENTIVE VISIT,EST,AGE5-11",521,99393,$286.64 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,"PR PREVENTIVE VISIT,EST,12-17",521,99394,$314.86 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,"PR PREVENTIVE VISIT,EST,18-39",521,99395,$322.65 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,"PR PREVENTIVE VISIT,EST,40-64",521,99396,$343.06 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,"PR PREVENTIVE VISIT,EST,65 & OVER",521,99397,$368.85 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,PR SMOKING/TOBACCO CESSATION COUNSELIN,521,99406,$40.89 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR SMOKING/TOBACCO CESSATION COUNSELIN,521,99407,$77.34 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,72.55,67.71,92.58,,,,,,PR PROLONGED OFFICE/OUTPATIENT E/M SVC,521,99417,$27.30 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,392.72,366.5,501.12,,,,,,PR PHY/QHP ONLINE E-VISIT EST PT 5-10 ,521,99421,$31.82 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,PR ONLINE DIGITAL E/M SVC EST PT <7 D ,521,99422,$63.23 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,PR PHY/QHP ONLINE E-VISIT 21> MIN,521,99423,$102.23 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,80.76,75.37,103.05,,,,,,PR PHYS/QHP TELEPHONE EVALUATION 5-10 ,521,99441,$36.75 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,PR PHYS/QHP TELEPHONE EVALUATION 11-20,521,99442,$72.45 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,PR PHYS/QHP TELEPHONE EVALUATION 21-30,521,99443,$108.02 
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,PR CHRONIC CARE MGMT SVCS STAFF 1ST 20,521,99490,$111.45 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,17111,Destruction of non-cancerous skin lesions/growths other than skin tags (15 or more lesions/growths) [HCPCS 17111],357.77,357.77,357.77,262.07,262.07,262.07,,,,,,PR TRANSITIONAL CARE MANAGE SERVICE 14,521,99495,$499.89 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,69209,Impacted ear wax removal by washing [HCPCS 69209],120.39,120.39,120.39,88.19,88.19,88.19,,,,,,PR TRANSITIONAL CARE MANAGE SERVICE 7 ,521,99496,$659.52 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,54.8,51.14,69.92,,,,,,PR ADVANCE CARE PLANNING FIRST 30 MINS,521,99497,$230.18 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,90472,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (each additional vaccine) [HCPCS 90472]",27.78,27.78,27.78,20.35,20.35,20.35,,,,,,UNLISTED E/M SERVICE,521,99499,$57.89 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,26.15,24.4,33.37,,,,,,PR DOT PHYSICAL,521,99499,$101.87 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,PR PRE-EMPLOYMENT PHYSICAL,521,99499,$298.67 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,PR DRUG SCREEN W/O KIT,521,99499,$69.46 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,211.38,211.38,269.74,,,,,,PR ADMIN INFLUENZA VIRUS VAC,771,G0008,$74.81 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],439.89,439.89,439.89,322.22,322.22,322.22,,,,,,PR ADMIN PNEUMOCOCCAL VACCINE,771,G0009,$33.57 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],555.67,555.67,555.67,407.03,407.03,519.38,,,,,,PR ADMIN PNEUMOCOCCAL VACCINE,771,G0009,$33.57 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,PR COMM SVCS BY RHC/FQHC 5 MIN,521,G0071,$29.40 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,PR CA SCREEN;PELVIC/BREAST EXAM,521,G0101,$106.03 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,PR PROSTATE CA SCREENING; DRE,521,G0102,$61.82 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,PR COLORECTAL SCRN; HI RISK IND,521,G0105,$896.36 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,86.62,86.62,86.62,,,,,,PR COLORECTAL SCRN; HI RISK IND,521,G0105,$896.36 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,PR COLON CA SCRN NOT HI RSK IND,521,G0121,$897.31 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],245.78,245.78,245.78,180.03,180.03,180.03,,,,,,PR COLON CA SCRN NOT HI RSK IND,521,G0121,$897.31 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,366.17,341.72,366.17,,,,,,PR LDCT ELIGIBILITY VISIT,521,G0296,$106.05 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,99496,Transitional care management services with face-to-face visits within 7 days of discharge (high complexity) [HCPCS 99496],659.52,659.52,659.52,483.1,483.1,483.1,,,,,,PR LDCT ELIGIBILITY VISIT,521,G0296,$106.05 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,G0438,"Ppps, initial visit [HCPCS G0438]",459.96,459.96,459.96,336.92,336.92,336.92,,,,,,PR IPPE,521,G0402,$448.28 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,G0439,"Ppps, subseq visit [HCPCS G0439]",312,312,312,228.54,213.28,228.54,,,,,,"ELECTROCARDIOGRAM,COMPLET IPPE",521,G0403,$46.31 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,G0511,Ccm/bhi by rhc/fqhc 20min mo [HCPCS G0511],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,"ELECTROCARDIOGRAM,COMPLET IPPE",521,G0403,$46.31 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,G2025,Dis site tele svcs rhc/fqhc [HCPCS G2025],96.63,96.63,96.63,70.78,70.78,70.78,,,,,,"PR PPPS, INITIAL VISIT",521,G0438,$459.96 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,4.86,4.54,6.21,,,,,,"PR PPPS, SUBSEQ VISIT",521,G0439,$312.00 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.2,1.12,1.53,,,,,,PR DEPRESSION SCREEN ANNUAL,521,G0444,$49.17 
MEDICA PART A ONLY - Medicare Part A,Clinic,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.7,1.59,1.7,,,,,,PR BEHAVIOR COUNSEL OBESITY 15M,521,G0447,$70.57 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,PR CCM/BHI BY RHC/FQHC 20MIN MO,521,G0511,$177.16 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,PR REMOTE IMAGE SUBMIT BY PT,521,G2010,$37.80 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,PR VIRTUAL VISIT BY MD/QHP,521,G2012,$32.31 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,PR DIS SITE TELE SVCS RHC/FQHC,521,G2025,$96.63 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,RX CERTIFIED EHR,521,G8553,$0.00 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,"PR INFLUENZA A H1N1,ADMIN W COU",771,G9141,$48.63 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,"PR INFLUENZA A H1N1,ADMIN W COU",771,G9141,$48.63 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,"HC INFLUENZA A H1N1, VACCINE",636,G9142,$0.00 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",22.05,22.05,22.05,16.15,15.07,16.15,,,,,,PR AMIODARONE HCL,636,J0282,$5.25 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,PR PENICILLIN G BENZATHINE INJ,636,J0561,$14.45 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,813,"Anesthesia provided during sophagus, stomach, small bowel, and/or large bowel  procedure with endoscope [HCPCS 00813]",18.52,18.52,18.52,13.57,13.57,17.31,,,,,,"PR INJECTION,ONABOTULINUMTOXINA",636,J0585,$13.23 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,11104,Skin lesion biopsy with punch tool to remove sample including all layers of skin (single lesion) [HCPCS 11104],265.09,265.09,265.09,194.18,194.18,194.18,,,,,,PR CEFTRIAXONE SODIUM INJECTION,636,J0696,$0.63 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",474.18,474.18,474.18,347.34,324.15,443.22,,,,,,PR DEXAMETHASONE 1MG INJ,636,J1100,$0.13 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,13120,"Complex repair of wound of scalp, arms, and/or legs (1.1 to 2.5 cm) [HCPCS 13120]",968.47,968.47,968.47,709.4,662.05,709.4,,,,,,PR DIPHENHYDRAMINE HCL INJECTIO,636,J1200,$0.95 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,616.07,574.94,786.13,,,,,,PR INJ ENOXAPARIN SODIUM,636,J1650,$0.70 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,29581,Vein wound compression system application to lower leg below knee including ankle and foot [HCPCS 29581],354.7,354.7,354.7,259.82,242.47,259.82,,,,,,PR KETOROLAC TROMETHAMINE INJ,636,J1885,$0.55 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR ORPHENADRINE INJECTION,636,J2360,$7.72 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,PR ONDANSETRON HCL INJECTION,636,J2405,$0.09 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1081.15,1008.97,1379.59,,,,,,PR PROMETHAZINE HCL INJECTION,636,J2550,$2.16 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,PR METHYLPREDNISOLONE INJECTION,636,J2930,$6.64 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,130.59,121.87,130.59,,,,,,PR TRIAMCINOLONE ACETONIDE INJ,636,J3301,$1.64 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,62323,Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,PR VITAMIN B12 INJECTION,636,J3420,$2.32 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,64405,Anesthetic agent and/or steroid injection into greater occipital nerve of upper neck and back of head [HCPCS 64405],998.55,998.55,998.55,731.44,731.44,731.44,,,,,,PR LIDOCAINE 1%,250,J3490,$23.15 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,64450,Anesthetic agent and/or steroid injection into other peripheral nerve or branch [HCPCS 64450],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,PR MARCAINE .5%,250,J3490,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,64483,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483],2741.55,2741.55,2741.55,2008.19,2008.19,2008.19,,,,,,"PR KYLEENA, 19.5 MG",636,J7296,"$3,208.00 "
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2008.19,1874.12,2562.53,,,,,,"PR MIRENA, 52 MG",636,J7298,"$3,208.00 "
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,423.79,395.5,540.77,,,,,,PR INTRAUT COPPER CONTRACEPTIVE,636,J7300,$422.90 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,64495,Lower or sacral spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64495],591.15,591.15,591.15,433.02,404.11,552.55,,,,,,"PR SKYLA, 13.5 MG",636,J7301,"$2,823.11 "
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,490.7,457.94,626.16,,,,,,PR PROVENTIL (ALBUTEROL),636,J7611,$11.58 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,70551,Imaging of brain by MRI without contrast [HCPCS 70551],2008.13,2008.13,2008.13,1470.96,1372.76,1470.96,,,,,,PR IPRATROPIUM BROMIDE NON-COMP,636,J7644,$8.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",3284.4,3284.4,3284.4,2405.82,2245.22,3069.93,,,,,,PR BACITRACIN ZINC TOP OINT,250,J9999,$9.95 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,73.99,69.05,94.41,,,,,,LH KNEE STRAP CHO-PAT,420,LH00119,$28.94 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH BLANKET WARMER ADULT BLANKET,270,LH00121,$46.31 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],159.29,159.29,159.29,116.68,108.89,148.89,,,,,,LH ANESTHESIA,370,,$661.50 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,672.6,627.7,858.27,,,,,,LH INFECTIOUS DISEASE (VIRAL RESPIRATO,310,0241U,$427.89 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,837.58,781.66,1068.78,,,,,,"LH COMFORT CALL,TRMT ROOM,NON ER",761,99211,$45.15 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,119.56,111.58,152.56,,,,,,"LH TREATMENT ROOM,LOW LEVEL",761,99212,$55.57 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,"LH DEBRIDEMENT,SKIN PARTIAL 1ST 20/< S",450,97597,$238.48 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72080,Spinal x-ray of junction of middle and lower spine (2 views) [HCPCS 72080],132.09,132.09,132.09,96.76,96.76,96.76,,,,,,"LH DEBRIDEMENT,SKIN PARTIAL 1ST 20/< S",450,97597,$263.83 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,"LH WRIST BRACE 11"" UNIVERSAL-LEFT",270,LH11781,$23.15 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],190.37,190.37,190.37,139.45,130.14,177.94,,,,,,"LH WRIST BRACE 11"" UNIVERSAL-RIGHT",270,LH11782,$23.15 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",906.68,906.68,906.68,664.14,619.81,847.47,,,,,,LH CAUTERY,270,12002,$231.00 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72128,"Spinal CT scan of middle spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72128]",906.68,906.68,906.68,664.14,619.81,664.14,,,,,,LH CAUTERY,270,12002,$231.00 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",900.9,900.9,900.9,659.91,615.86,842.07,,,,,,LH POSTERIOR CHAMBER INTRAOCULAR LENS,276,V2632,$173.65 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72146,Imaging of middle spinal canal by MRI without contrast [HCPCS 72146],1954.58,1954.58,1954.58,1431.73,1336.15,1431.73,,,,,,"LH EYE PACK, SUPPLIES",270,LH120056,$347.29 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1431.73,1336.15,1826.95,,,,,,LH OXYGEN DUAL DIAL VENT STYLE MASK,410,LH14113,$9.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],112.67,112.67,112.67,82.53,77.02,82.53,,,,,,LH DRESSING/MEPILEX BORDER SACRUM 7.2X,270,LH16021,$32.41 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH DRESSING/MEPILEX BORDER SACRUM 7.2X,270,LH16021,$32.41 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],112.67,112.67,112.67,82.53,77.02,93.81,,,,,,LH DRESSING/MEPILEX BORDER 6X6,270,LH16022,$30.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],112.67,112.67,112.67,82.53,77.02,105.31,,,,,,LH DRESSING/MEPILEX BORDER 6X6,270,LH16022,$30.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,110.99,103.58,126.16,,,,,,LH DRESSING/MEPILEX BORDER 4X4,270,LH16023,$10.42 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,LH MEPILEX 4X4,270,LH16024,$10.42 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,LH DRESSING/MEPILEX BORDER 4X8,270,,$31.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],155.4,155.4,155.4,113.83,106.23,113.83,,,,,,LH DRESSING/MEPILEX BORDER 4X8,270,,$31.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,96.76,90.3,123.46,,,,,,LH PURSE STRING DEVICE,270,,$321.25 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,LH ARTICULATING ENDOSCOPIC LINEAR CUTT,270,,$651.17 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,LH ENDOSCOPIC LINEAR CUTTER RELOADS GR,270,,$289.41 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH ENDOSCOPIC LINEAR CUTTER RELOADS BL,270,,$289.41 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,79.68,74.36,101.68,,,,,,LH BIOPATCH DISK,270,,$28.94 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1510.18,1409.36,1927.05,,,,,,LH STOMAHESIVE POWDER,270,LH17375,$16.21 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],112.67,112.67,112.67,82.53,77.02,105.31,,,,,,LH C-PAP MASK,410,LH180000,$382.02 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],139.86,139.86,139.86,102.45,95.61,130.73,,,,,,LH OXYGEN USE/DAY,271,LH18060,$167.85 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",1160.78,1160.78,1160.78,850.27,793.51,1084.98,,,,,,LH OXYGEN/HOUR,450,LH18061,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1395.96,1302.77,1781.3,,,,,,LH CANNULA SUPPORT,270,LH18070,$4.05 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,261.81,244.33,334.08,,,,,,LH ROOM HUMIDIFIER/DAY,410,LH18090,$11.58 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,76775,Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775],229.22,229.22,229.22,167.9,156.69,167.9,,,,,,LH CROUP TENT WITHOUT OXYGEN,271,LH18110,$69.46 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",190.37,190.37,190.37,139.45,139.45,139.45,,,,,,LH ULTRASONIC NEBULIZER SETUP,270,LH18190,$20.84 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],64.83,64.83,64.83,47.49,44.32,60.6,,,,,,LH ROOM HUMIDIFIER,410,LH18200,$13.89 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,LH OXYGEN MASK,270,LH18220,$9.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,LH OXYGEN CANNULA,271,LH18230,$9.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,LH OXYGEN CANNULA SUPPORT,410,LH18231,$4.63 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,LH OXYGEN CONNECTING TUBING,410,LH18240,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,80162,Lab analysis to measure the amount of total digoxin in blood specimen [HCPCS 80162],102.38,102.38,102.38,74.99,74.99,74.99,,,,,,LH LARGE BORE TUBING,410,LH18260,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH LARGE BORE TUBING/SHORT,410,LH18261,$1.74 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,LH AEROSOL MASK,410,LH18270,$9.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH REBREATHING MASK,410,LH18280,$9.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH CROUP TENT SUPPLIES,271,LH18300,$74.09 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82272,Lab analysis to measure the amount of blood in stool specimen by peroxidase activity [HCPCS 82272],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,LH CROUP TENT (DISP)SUPPLIES,271,LH18301,$28.94 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],236.25,236.25,236.25,173.05,161.5,220.82,,,,,,LH TEE ADAPTOR,410,LH18320,$3.48 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,LH VOLUMETRIC EXERCISER(SEE ALSO 18021,270,LH18340,$20.84 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,LH OXYGEN MONITER,410,LH18360,$17.37 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],118.13,118.13,118.13,86.53,80.75,110.42,,,,,,LH PULSE OXIMETRY SATURATION SINGLE,272,94760,$4.20 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,80.76,75.37,103.05,,,,,,LH NASAL TRANSDUCER (OXISENSOR),410,LH18371,$40.52 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH OXIBAND,410,LH18375,$3.48 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"LH MASK, ANESTHESIA, DISP.",270,LH200015,$9.85 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],70.88,70.88,70.88,51.92,48.45,66.25,,,,,,LH 4.0MM EGG BUR (DR FANOUS),270,LH200153,$303.30 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,69.22,64.6,88.33,,,,,,"LH BLADE,SHORT,MEDIUM,LONG NARROW (FAN",270,LH200154,$171.33 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"LH SURGICAL K-WIRE 6"" DR. FANOUS",270,LH200155,$46.31 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,LH ARM SLING,270,LH200160,$13.89 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],307.13,307.13,307.13,224.97,209.95,287.07,,,,,,LH ARM SPLINTS,270,LH200170,$11.58 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],39.38,39.38,39.38,28.85,26.92,28.85,,,,,,LH BABY WIPES,270,LH200185,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,LH CATHETER 3-WAY IRRIGATION 16FR&18FR,270,LH200341,$46.31 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,"LH CANE, ADJUSTABLE ALUMINUM",290,E0100,$34.73 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH CANES QUAD/3 PRONG,290,E0105,$52.09 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,"LH CANE,LARGE BASE QUAD",290,E0105,$52.09 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,LH CAST CUSHION,270,LH200410,$8.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH CAST SHOE,270,LH200420,$17.37 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,LH CATHETER COUDE 18FR,270,LH200427,$46.31 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH CATHETER-COUDE 16FR FOLEY,270,LH200428,$46.31 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,"LH CATHETER, COUDE -14FR. FOLEY",270,LH200429,$46.31 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,LH CATHERIZATION SUPPLIES,270,LH200431,$55.57 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH 3 WAY CATH./COUDE CATH SUPPLIES,270,LH200432,$108.82 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH CATHETER-FOLEY,270,LH200440,$8.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH CATHETER-3WAY,270,LH200450,$8.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,"LH OLIVE TIP CATHETER, 5FR",270,LH200452,$39.36 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH CATHETER TRAY WITH 18 FR. FOLEY,270,LH200486,$10.42 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,86922,Lab blood analysis to confirm blood unit compatibility by antiglobulin technique [HCPCS 86922],307.13,307.13,307.13,224.97,224.97,224.97,,,,,,LH CATHETER TRAY FOR STRAIGHT CATH.,270,LH200490,$8.11 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],395.91,395.91,395.91,290,270.64,370.06,,,,,,LH FEMALE CATH KIT,270,LH200492,$9.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],63,63,63,46.15,43.07,58.89,,,,,,LH CATHETER IRRIGATION,270,LH200494,$23.15 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,46.15,43.07,58.89,,,,,,LH CAUDAL ANESTHESIA TRAY,270,LH200500,$18.52 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],63,63,63,46.15,43.07,58.89,,,,,,LH CERVICAL COLLAR (UNIVERSAL),270,lh200510,$19.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",70.88,70.88,70.88,51.92,48.45,66.25,,,,,,LH CERVICAL COLLAR-STIFFNECK,270,LH200519,$39.36 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,45.75,42.7,58.38,,,,,,LH CERVICAL COLLAR,270,LH200520,$52.09 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,LH CLAVICLE BRACE,270,LH200550,$13.89 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,LH COCK-UP SPLINT,270,LH200570,$19.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,87807,Lab analysis by immunoassay to identify respiratory syncytial virus (RSV) [HCPCS 87807],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,LH COCK-UP SPLINT,270,LH200570,$19.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,409.56,382.22,522.62,,,,,,LH EZ-WRAP WRIST SPLINT,270,LH200571,$23.15 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,88312,Pathology lab analysis of special stained specimen slides to identify organisms with interpretation and report [HCPCS 88312],247.74,247.74,247.74,181.47,181.47,181.47,,,,,,LH COCOA BUTTER,270,LH200579,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,88342,Pathology lab analysis of special stained specimen slides to examine tissue (initial procedure) [HCPCS 88342],842.63,842.63,842.63,617.23,576.02,787.61,,,,,,LH WALKER TRAY-INVACARE,290,LH200581,$104.19 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,26.15,24.4,33.37,,,,,,LH NASAL RHINO ROCKET,270,LH200597,$34.73 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,LH NASAL RHINO ROCKET,270,LH200597,$34.73 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,84.99,79.32,108.45,,,,,,LH NASAL PACKING-EPITAXIS CATHETER,270,LH200598,$107.66 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93225,"External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]",376.55,376.55,376.55,275.82,257.41,351.96,,,,,,LH COLOSTOMY BAGS,270,LH200600,$5.15 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],118,118,118,86.44,80.66,110.29,,,,,,LH CONTACT LENS CASE,270,LH200601,$2.32 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,LH UROSTOMY POUCH,270,LH200603,$10.42 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],784.77,784.77,784.77,574.84,536.47,574.84,,,,,,LH CRUTCHES UNDERARM WOOD,270,E0112,$40.52 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,93970,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]",765.35,765.35,765.35,560.62,523.19,560.62,,,,,,LH CRUTCHES - PAIR FOREARM,270,E0110,$148.18 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],79.71,79.71,79.71,58.39,54.49,74.5,,,,,,LH CRUTCH CUSHIONS,270,LH200650,$5.22 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,94660,CPAP (continuous positive airway pressure) mask or breathing tube initiation and management for night time respiratory muscle rest [HCPCS 94660],286.53,286.53,286.53,209.88,209.88,209.88,,,,,,LH CRUTCH GRIPS HAND CUSHION,270,LH200651,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,95249,Continuous sugar (glucose) level monitoring in tissue fluid with sensor under skin [HCPCS 95249],182.66,182.66,182.66,133.8,124.87,170.73,,,,,,LH CRUTCH TIPS,270,LH200660,$8.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,"LH CANE TIP 7/8""",270,LH200661,$2.32 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,62.44,58.27,79.67,,,,,,LH BONE MARROW BIOPSY NEEDLE,270,LH200685,$40.52 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,328.8,306.85,419.57,,,,,,LH DEFIB-PADS,270,LH200690,$9.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",137.53,137.53,137.53,100.74,94.02,128.55,,,,,,LH DERMOPLAST,270,LH200730,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96367,"Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]",195.49,195.49,195.49,143.2,133.64,143.2,,,,,,LH DESTITIN OINTMENT,270,LH200740,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,LH CONSTANT CARE BARRIER,270,LH200741,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,183.16,170.93,233.72,,,,,,"LH DIAPERS,INFANT",270,LH200750,$6.66 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,75.78,70.72,96.69,,,,,,"LH DIAPERS,TODDLER",270,LH200760,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,96523,Implanted venous access drug delivery device irrigation [HCPCS 96523],145.85,145.85,145.85,106.84,99.7,106.84,,,,,,LH DIAPERS  ADULT,270,LH200770,$6.95 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,34.76,32.44,44.36,,,,,,"LH DIAPERS,ELASTIC ADULT",270,LH200771,$8.68 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,"LH ELBOW ORTHOSIS,W/O JOINTS CUSTOM FA",290,L3702,$507.05 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,91.58,85.46,116.86,,,,,,LH DISPOS-A-BAG,270,LH200780,$7.53 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,87.28,81.45,111.37,,,,,,LH URINARY LEG BAG WITH TUBING,270,A4358,$20.84 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,81.4,75.97,103.87,,,,,,LH URINARY LEG BAG (BAG ONLY),270,LH200786,$12.74 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,LH CURETTE - EXPLORA UTERINE,270,LH200803,$12.74 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,"LH AMBU BAG, PEDS OR ADULT",270,LH200805,$37.04 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],231.98,231.98,231.98,169.93,158.58,216.83,,,,,,"LH AMBU BAG, INFANT",270,LH200806,$46.31 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97165,Occupational therapy evaluation (typically 30 minutes) [HCPCS 97165],269.72,269.72,269.72,197.57,184.38,197.57,,,,,,"LH RETURN ELECTRODE, CAUTERY",270,LH200808,$6.95 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],129.65,129.65,129.65,94.97,88.63,107.95,,,,,,"LH SUCTON COAGULATOR, TONSIL SURG",270,LH200809,$13.89 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97535,Training activities for home and self-care management (each 15 minutes) [HCPCS 97535],137.76,137.76,137.76,100.91,94.17,100.91,,,,,,LH DRAINAGE BAG,270,LH200810,$6.95 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,97602,Dead tissue removal from wounds per session [HCPCS 97602],295.2,295.2,295.2,216.23,201.8,216.23,,,,,,LH DRESSING APPLICATION,270,LH200831,$28.94 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,164.29,153.32,209.63,,,,,,LH GLUCOSE FINGER STICK SUPPLIES,271,LH200832,$25.47 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,LH DUO-DERM 4X4   REG.,270,LH200840,$18.52 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,LH DUO-DERM,270,LH200850,$32.41 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,LH DUODERM 4 X 4  THIN,270,LH200851,$11.58 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,LH AQUACEL AG 4X4-1/4INCH,270,A6242,$55.57 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,LH TRANSIGEL CONFORMABLE GEL 4X4,270,LH200855,$11.58 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,A0428,Bls [HCPCS A0428],1250.24,1250.24,1250.24,915.8,915.8,915.8,,,,,,LH ELASTIC SURGICAL STOCKINGS,270,LH200900,$13.89 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,A0429,Bls-emergency [HCPCS A0429],1250.24,1250.24,1250.24,915.8,854.66,1168.6,,,,,,LH ELASTIC SURGICAL STOCKINGS,270,LH200910,$25.47 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.75,2.56,2.75,,,,,,LH ELASTIC SURGICAL STOCKINGS,270,LH200920,$28.94 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,156.02,145.61,199.09,,,,,,LH ELECTRODE-SCALP/FETAL MONITOR,270,LH200931,$11.58 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,109.6,102.29,139.86,,,,,,LH PACEMAKER ELECTRODE LIFEPAK 12,270,LH200938,$69.46 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,LH ELECTRODES,270,LH200939,$2.90 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,107.85,100.65,137.63,,,,,,"LH PACEMAKER ELECTRODE, ADULT",270,LH200941,$115.76 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,"LH PACEMAKER ELECTRODE, PEDIATRIC",270,LH200942,$115.76 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,37.11,34.63,42.18,,,,,,LH ELECTRODE FOR PT,270,LH200943,$27.78 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,G0390,Trauma respons w/hosp criti [HCPCS G0390],3386.05,3386.05,3386.05,2480.28,2314.7,3164.94,,,,,,LH ELECTRODES-QUICK-COMBO CLINIC LP 50,270,LH200944,$86.82 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J0897,Denosumab injection [HCPCS J0897],30.26,30.26,30.26,22.17,22.17,28.28,,,,,,LH ELECTRODE FOR DEFIB. AMBULANCE,270,LH200945,$39.36 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J1170,Hydromorphone injection [HCPCS J1170],23,23,23,16.85,15.72,21.5,,,,,,LH ELECTRODE-IONTOPHORESIS,270,LH200946,$23.15 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],11.5,11.5,11.5,8.42,7.86,8.42,,,,,,LH ELECTRODE-ESTIM,270,LH200947,$12.16 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2360,Orphenadrine injection [HCPCS J2360],7.72,7.72,7.72,5.65,5.28,5.65,,,,,,LH ENEMA,270,LH200960,$5.79 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,LH ENSURE,270,LH200970,$2.32 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],2.16,2.16,2.16,1.58,1.48,2.02,,,,,,LH ENSURE OR RESOURCE OR OSMOLITE,270,LH200980,$55.57 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.7,1.59,1.7,,,,,,LH ISOSOURCE HN LIQ,270,LH201003,$83.35 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J3480,Inj potassium chloride [HCPCS J3480],13.2,13.2,13.2,9.67,9.02,10.99,,,,,,LH JEVITY LIQ,270,LH201004,$64.83 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,16.96,15.83,21.64,,,,,,LH ISOSOURCE HN  PER CAN,270,LH201005,$3.48 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,LH JEVITY PLUS  8 OZ,270,LH201008,$61.35 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J7040,Normal saline solution infus [HCPCS J7040],57.75,57.75,57.75,42.3,39.48,42.3,,,,,,LH FEEDING TUBE ATTACHMENT,270,20100,$9.26 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],53.5,53.5,53.5,39.19,36.57,50.01,,,,,,LH ENTERAL FEEDING TUBE,270,20101,$34.73 
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,40.29,37.6,51.41,,,,,,LH NESTLE PROBALANCE 24-8OZ.CANS,270,LH201011,$55.57 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,LH ENTERAL PUMP BAG,270,20102,$6.95 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,LH ENTERAL PUMB TUBING,270,20103,$8.11 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,LH EPIDURAL ANESTHESIA TRAY,270,LH201040,$57.89 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,"LH ESMARCH 4"" BANDAGE",270,LH201069,$19.68 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,LH ABDUCTION SPLINT - THUMB,270,LH201081,$17.37 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,LH FINGER SPLINTS W/ VELCRO,270,LH201082,$11.58 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,LH ABDUCTION FINGER SPLINT,270,LH201085,$13.89 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,LH FLATUS BAG,270,LH201090,$8.68 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,LH MITRAFLEX -4X4,270,LH201161,$11.58 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,106.75,87.64,119.84,,,,,,LH GROUNDING PADS,270,LH201170,$6.95 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,52.45,43.07,58.89,,,,,,LH DURAPREP,270,LH201171,$9.85 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,52.45,43.07,58.89,,,,,,LH GASTRIC LAVAGE KIT,270,LH201172,$17.37 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.82,108.82,108.82,90.6,74.39,101.71,,,,,,LH HEAD HALTER,270,LH201210,$2.90 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,111.47,91.52,125.14,,,,,,"LH CERVICAL TRACTION KIT, OVERDOOR",290,E0855,$86.82 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,87807,Lab analysis by immunoassay to identify respiratory syncytial virus (RSV) [HCPCS 87807],102.38,102.38,102.38,85.24,69.99,95.69,,,,,,LH HEEL PROTECTORS,270,LH201220,$11.58 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,179.76,147.59,201.8,,,,,,LH HEEL CUSHION-SAGE,270,LH201221,$115.76 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,279.71,229.66,314.01,,,,,,LH HEEL LIFTS-ADJUSTABLE,270,L3334,$74.09 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,23.13,18.99,25.97,,,,,,"LH HAND SPLINT, METACARPAL",270,LH201230,$20.84 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,A0429,Bls-emergency [HCPCS A0429],1250.24,1250.24,1250.24,1040.95,854.66,1168.6,,,,,,LH ICE GRIPPER FOR CANE,270,LH201239,$13.89 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,42.18,34.63,42.18,,,,,,LH SURGICAL HALF-SHEET,270,LH201313,$5.79 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,19.27,15.83,21.64,,,,,,LH GOWN & TOWEL,270,LH201314,$5.79 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],115.76,115.76,115.76,96.38,84.79,96.38,,,,,,LH LUMBAR ROLL,270,LH201315,$23.15 
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],192.17,192.17,192.17,112.77,59.32,126.54,,,,,,"LH MINOR PACK, SURGERY",270,LH201317,$23.15 
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH KAST CAP,270,LH201320,$5.79 
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH KALTOSTAT WOUND DRESSING,270,LH201321,$12.74 
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,"LH KINESIO TAPE 2""BEIGE",273,A4452,$23.15 
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH KNEE BRACE(IMMOBILIZER),270,LH201360,$57.89 
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH KNEE SLEEVE,270,LH201361,$34.73 
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH KNEE SLEEVE W/BUTTRESS,270,LH201362,$40.52 
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH KNEE PATCH,270,LH201363,$5.79 
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH K-PAD,270,LH201370,$28.94 
"MEDICA, PART B ONLY - Medicare Part B",Skilled Nursing Facility,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH SHOULDER IMMOBILIZER,270,LH201371,$40.52 
"MEDICA, PART B ONLY - Medicare Part B",Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,LH SHOULDER IMMOBILIZER,270,LH201372,$17.37 
"MEDICA, PART B ONLY - Medicare Part B",Skilled Nursing Facility,Institutional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,144.35,144.35,144.35,,,,,,LH LUMBO-SACRAL SUPPORTS,290,LH201440,$192.17 
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH SACRO-ILLIAC SUPPORT,290,L0625,$106.50 
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH LUMBO SACRAL CAMP ELCROSS SUPPORTS,270,LH201442,$63.67 
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH MALECOT CATHETERS,270,LH201450,$11.58 
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH COLLES SPLINT,270,LH201461,$16.21 
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH FOREARM SPLINT,270,LH201462,$13.89 
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH MEATACARPAL SPLINT,270,LH201463,$20.84 
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH MEDICO PASTE BANDAGE,270,LH201480,$11.58 
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH UNNA BOOT,270,LH201481,$31.26 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,20553,Trigger points injection into 3 or more muscles [HCPCS 20553],841.05,841.05,841.05,616.07,616.07,616.07,,,,,,LH MEDIC ALERT SET-UP,271,LH201482,$34.73 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH MEDIC ALERT SET-UP,271,LH201482,$34.73 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH MEDIC ALERT MONTHLY RENT,271,LH201483,$14.48 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,62323,Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,LH MEDIC ALERT MONTHLY RENT,271,LH201483,$14.48 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64490,Upper or middle spine facet joint injections with imaging guidance (first level) [HCPCS 64490],2741.55,2741.55,2741.55,2008.19,2008.19,2562.53,,,,,,LH MILLER ABBOTT TUBE,270,LH201490,$39.36 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64491,Upper or middle spine facet joint injections with imaging guidance (second level) [HCPCS 64491],676.2,676.2,676.2,495.32,495.32,495.32,,,,,,LH MOUTHWASH,270,LH201520,$0.87 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64634,Upper or middle spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64634],765.45,765.45,765.45,560.69,560.69,560.69,,,,,,LH NEUTRAGENA SOAP,270,LH201525,$5.79 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],670.95,670.95,670.95,491.47,458.66,627.14,,,,,,"LH NEEDLES, WINGED RT. ANGLE",270,LH201540,$11.58 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,76942,Ultrasound guidance for needle placement including imaging supervision of procedure and interpretation of results [HCPCS 76942],160,160,160,117.2,109.38,117.2,,,,,,LH NASAL PACKING..FOAM,270,LH201549,$28.94 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,77002,Fluoroscopic guidance for needle placement  [HCPCS 77002],393.9,393.9,393.9,288.53,288.53,288.53,,,,,,LH NOZ-STOP,270,LH201550,$19.68 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,LH NASAL DRESSING HOLDER,270,LH201551,$9.26 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,LH NUBREDE  4X4,270,LH201559,$3.48 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93015,"Heart and blood vessel stress test with EKG monitoring, physician supervision, interpretation, and report (exercise or drug-induced) [HCPCS 93015]",226.89,226.89,226.89,166.2,166.2,212.07,,,,,,LH NU GAUZE PACKING STRIPS,270,LH201560,$6.95 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,LH NU GAUZE PACKING STRIPS,270,LH201570,$9.26 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,29.59,29.59,29.59,,,,,,LH NU GAUZE PACKING STRIPS,270,LH201580,$9.26 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],108.82,108.82,108.82,79.71,79.71,79.71,,,,,,LH MESH PANTIES,270,LH201619,$5.79 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],115.76,115.76,115.76,84.79,84.79,96.38,,,,,,"LH PROMISE PADS, FIT MESH PANT",270,LH201622,$6.95 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],405.17,405.17,405.17,296.79,296.79,296.79,,,,,,LH OP SITE,270,LH201640,$0.00 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,164.29,153.32,209.63,,,,,,LH ORAL SWAB KIT,270,LH201650,$13.89 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,LH NEG PRESSURE WOUND THER ELECTRICAL ,947,E2402,$232.68 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,LH WOUND CARE SET NEG PRESSURE WOUND T,947,A6550,$85.67 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,LH CANISTER DISPOSABLE USED W/SUCTION ,947,A7000,$87.98 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,144.35,144.35,144.35,,,,,,LH PACEMAKER AND LEAD WIRE KIT,270,LH201670,$231.53 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,LH PEDIALYTE,270,LH201690,$8.11 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,LH PELVIC TRACTION BELT,270,LH201700,$20.27 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],1701,1701,1701,525.1,525.1,1120.11,,,,,,LH MOIST-STIR SPRAY,270,LH201721,$9.85 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],1701,1701,1701,525.1,525.1,1120.11,,,,,,LH MISC. SUPPLIES,270,LH201723,$0.00 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,77002,Fluoroscopic guidance for needle placement  [HCPCS 77002],393.9,393.9,393.9,121.6,121.6,121.6,,,,,,LH PORTO VAC,270,LH201750,$40.52 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],47.84,47.84,47.84,14.77,14.77,35.31,,,,,,LH PROPEAK WHEELCHAIR CUSHION,270,LH201769,$6.95 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,95249,Continuous sugar (glucose) level monitoring in tissue fluid with sensor under skin [HCPCS 95249],182.66,182.66,182.66,56.39,56.39,120.28,,,,,,LH PRO PEAK MATTRESS,270,LH201770,$17.37 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],192.17,192.17,192.17,59.32,59.32,126.54,,,,,,LH LEG WALKER(CAM WALKER),270,L4370,$369.29 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],263.94,263.94,263.94,81.48,81.48,173.8,,,,,,LH ANKLE BRACE-AIR CAST,270,LH201774,$69.46 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],368.13,368.13,368.13,113.64,113.64,242.41,,,,,,LH ANKLE BRACE,270,LH201775,$41.67 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99223,Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223],539.46,539.46,539.46,166.53,166.53,166.53,,,,,,LH ANKLE BRACE-AS0,270,LH201776,$50.94 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99225,Subsequent observation care (typically 25 minutes per day) [HCPCS 99225],191.01,191.01,191.01,58.96,58.96,125.78,,,,,,LH ANKLE BRACE-AS0,270,LH201776,$50.94 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],103.03,103.03,103.03,31.81,31.81,67.85,,,,,,"LH MORGAN LENS, EYE FLUSH",270,LH201777,$57.89 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],191.01,191.01,191.01,58.96,58.96,125.78,,,,,,LH PEAK FLOWMETER - ADULT,270,LH201781,$23.15 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",192.17,192.17,192.17,59.32,59.32,126.54,,,,,,LH PEAK FLOWMETER - ADULT,270,LH201781,$23.15 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],55.57,55.57,55.57,17.15,17.15,41.01,,,,,,LH PEAK FLOWMETER - PEDIATRIC,270,LH201782,$23.15 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,50.75,50.75,121.32,,,,,,LH SORBSAN DRESSING 4X4,270,LH201841,$13.31 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,87.55,87.55,209.31,,,,,,"LH XEROFLO DRESSING, 5X9",270,LH201842,$5.79 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,57.39,57.39,122.42,,,,,,LH LYOFOAM -8,270,LH201851,$18.52 
MEDICARE SERVICE CENTER - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],897.31,897.31,897.31,277,277,662.21,,,,,,LH LYOFOAM - 4,270,A6251,$11.58 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,LH SHAVER - MEDI REUSABLE,270,LH201869,$34.73 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,LH SHEEPSKINS,270,LH201870,$17.37 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH SHOE-POST OP,270,LH201891,$28.94 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH ANOSCOPE,270,LH201905,$1.45 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH SITZETTE,270,LH201910,$5.79 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH SKIN PREP TRAYS,270,LH201920,$7.53 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH SMOKE EVACUATOR TUBE,270,LH201931,$28.94 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH SOL. ADM SET FOR PCA PUMP,270,LH201991,$6.95 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH IV FILTER - EXTENSION SET,270,LH202005,$17.37 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH SPINAL NEEDLE- 22G X 5,270,LH202031,$17.37 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH SPINAL NEEDLE-GERTIE MARX,270,LH202032,$19.68 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH LUMBAR PUNCTURE TRAY,270,LH202040,$28.94 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],155.4,155.4,155.4,113.83,106.23,113.83,,,,,,LH SPINAL ANESTHESIA TRAY,270,LH202045,$46.31 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,LH SUCTION SET-UP SUPPLIES,271,LH202070,$28.94 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,LH SURGICEL,270,LH202100,$16.21 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH SURGICEL,270,LH202120,$20.84 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH TRIPLE ANTIBIOTIC OINTMENT,270,LH202179,$11.58 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,103.83,96.9,132.49,,,,,,LH TAMPAX,270,LH202180,$2.90 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH TEGADERM,270,LH202360,$8.11 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,LH TENNIS ELBOW STRAP,270,LH202381,$9.26 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH THORACENTESIS TRAY,270,LH202410,$57.89 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,LH THORACIC CATHETER,270,LH202411,$13.89 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,328.8,306.85,419.57,,,,,,LH PARACENTESIS/THORACENTESIS TRAY,270,LH202412,$115.76 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,LH TRACHEOTOMY TUBE,270,20245,$17.37 
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,LH TRACHEOTOMY TRAY,270,LH202460,$37.04 
MUTUAL OF OMAHA - Commercial-Indemnity,,Professional,Outpatient,99199,"Unlisted procedure, service, or report [HCPCS 99199]",739.73,739.73,739.73,434.07,434.07,434.07,,,,,,LH TRACHEOTOMY CATHETER  6MM,270,LH202461,$162.07 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,LH TRACH DRESSING  4X4 DRAIN DRESSING,270,LH202462,$20.84 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,LH TRACH NECKBAND,270,LH202463,$6.95 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,LH TRACH KIT (STERILE),270,LH202464,$4.05 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,LH TRACHEA CARE,270,LH202465,$215.32 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,LH TUBE FEEDING,270,LH202466,$90.30 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,LH TUCKS,270,LH202470,$5.79 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,LH UMBILICAL CATHETER TRAY,270,LH202480,$37.04 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,LH UNDERWATER CHEST DRAINAGE SYSTE,270,20250,$115.76 
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Outpatient,99199,"Unlisted procedure, service, or report [HCPCS 99199]",101.87,101.87,101.87,84.82,84.82,84.82,,,,,,LH URINE METER,270,20251,$30.10 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,11200,Skin tag removal (up to and including 15 tags) [HCPCS 11200],240.89,240.89,240.89,176.45,176.45,200.57,,,,,,LH VINYL INVALID CUSHION,270,LH202570,$6.95 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,17000,Destruction of pre-cancerous skin lesion/growth (first lesion/growth) [HCPCS 17000],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,LH WALKERS RIGID - ADJUSTABLE,290,E0130,$104.19 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,LH WALKERS-W/SEAT & BASKET,290,LH202581,$173.65 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,LH WALKING HEELS,270,LH202590,$8.68 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,149.36,149.36,190.59,,,,,,LH REACHER,270,LH202599,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,211.38,211.38,269.74,,,,,,LH COLD PACK - REUSABLE,270,LH202605,$34.73 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],439.89,439.89,439.89,322.22,322.22,322.22,,,,,,"LH ENDURASPLINT 2""X10""",270,LH202609,$17.37 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,LH SPLINT 3 X 12 ENDURASPLINT,270,LH202610,$28.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,LH SAMS SPLINT  4 1/2 X 36 ORANGE/BLUE,270,LH202611,$27.78 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,LH SPLINT 4 X 30 ENDURASPLINT,270,LH202615,$40.52 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,LH FORM FITTED THUMB SPLINT,270,L3913,$475.79 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,86.62,86.62,86.62,,,,,,LH FEEDING PUMP,270,LH203020,$28.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,LH FEEDING TUBE SETS FOR PUMP,270,LH203031,$17.37 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99309,Subsequent nursing facility visit for patient that has developed a major complication or new major problem (typically 25 minutes per day) [HCPCS 99309],245.78,245.78,245.78,180.03,180.03,180.03,,,,,,LH CARDIAC MONITOR,270,LH203050,$86.82 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,366.17,341.72,366.17,,,,,,LH OXYGEN MONITOR,270,LH203060,$115.76 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,G0511,Ccm/bhi by rhc/fqhc 20min mo [HCPCS G0511],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,LH CSR-BIOCARE-32OZ.BAG FLAVORED DRINK,270,LH203080,$14.12 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,G2025,Dis site tele svcs rhc/fqhc [HCPCS G2025],96.63,96.63,96.63,70.78,70.78,70.78,,,,,,LH ZEPHIRAN,270,LH203085,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Clinic,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,52.79,52.79,67.36,,,,,,LH CENTRAL VEIN CATH SET,270,LH203090,$138.92 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,"LH STERICUFF, PNU.TOURNIQUET  18",270,LH204011,$55.57 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH PNEAUMATIC TOURNIQUET ..LEG,270,LH204012,$69.46 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH STRYKER,270,LH204030,$11.58 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH HEAT LAMP,270,LH204050,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH CAST SUPPLIES / REMOVAL,270,A4590,$241.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH CAST - FULL ARM - FIBERGLASS,270,LH205040,$94.93 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH CAST-SHORT LEG(ANKLE TO KNEE)FIBERG,270,LH205060,$81.04 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH CAST - FULL LEG - FIBERGLASS,270,LH205080,$156.28 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",22.05,22.05,22.05,16.15,15.07,16.15,,,,,,LH CAST-FULL LEG WALKING-FIBERGLASS,270,LH205100,$185.22 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,LH CAST-WALK.HEEL APPLI/REINFOR FIBERG,270,LH205120,$40.52 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,LH CAST REMOVAL - PLASTER,270,LH205130,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH CAST REMOVAL - FIBERGLASS,270,LH205140,$28.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1081.15,1008.97,1379.59,,,,,,LH COVER-ROLL BANDAGE,270,LH205150,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH LEUKOTAPE,270,LH205155,$13.89 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,64483,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483],2741.55,2741.55,2741.55,2008.19,2008.19,2008.19,,,,,,"LH HAND PUTTY, OCCUPAT.THERAPY",270,LH205160,$7.53 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,64484,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (each additional level) [HCPCS 64484],585.9,585.9,585.9,429.17,429.17,429.17,,,,,,LH FOAM EXERCISER FOR THE HAND- PT/OT,270,LH205161,$5.79 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,64490,Upper or middle spine facet joint injections with imaging guidance (first level) [HCPCS 64490],2741.55,2741.55,2741.55,2008.19,2008.19,2562.53,,,,,,LH MEFIX TAPE 2,270,LH205170,$10.42 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,64491,Upper or middle spine facet joint injections with imaging guidance (second level) [HCPCS 64491],676.2,676.2,676.2,495.32,495.32,495.32,,,,,,LH MEFIX TAPE 4,270,LH205175,$19.68 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2008.19,1874.12,2562.53,,,,,,LH ARM SPLINT..FIBERGLASS STATIC,270,29125,$46.31 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,490.7,457.94,626.16,,,,,,LH LEG SPLINT..FIBERGLASS,270,29515,$52.09 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,70551,Imaging of brain by MRI without contrast [HCPCS 70551],2008.13,2008.13,2008.13,1470.96,1372.76,1470.96,,,,,,LH LEG-LARGE ALUMINUM TIBIA/FIBULA,270,A4570,$57.89 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",3284.4,3284.4,3284.4,2405.82,2245.22,3069.93,,,,,,LH LEG-MEDIUM ALUMINUM UNPADDED,270,LH205202,$57.89 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,73.99,69.05,94.41,,,,,,LH LEG SMALL ALUMINUM UNPADDED,270,LH205203,$57.89 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH BIOPSY FORCEP-UROLOGICAL,270,LH205215,$92.61 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71100,Rib cage x-ray of ribs on one side of body (2 views) [HCPCS 71100],139.86,139.86,139.86,102.45,102.45,102.45,,,,,,LH FOOT CRADLE,270,LH205216,$17.37 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],159.29,159.29,159.29,116.68,108.89,148.89,,,,,,LH BATH CHAIR-ADJUSTABLE W/O BACK,290,E0240,$52.09 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,672.6,627.7,858.27,,,,,,LH BATH TRANSFER BENCH,270,E0245,$144.70 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,837.58,781.66,1068.78,,,,,,LH WALKER BASKETS,270,LH205581,$39.36 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,LH CIRCO ELECTRIC BED SUPPLIES,270,LH2200010,$28.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,LH K-PAD MOTOR UNIT,270,LH220010,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",900.9,900.9,900.9,659.91,615.86,842.07,,,,,,LH WHEELCHAIR RENT,290,LH220015,$28.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1431.73,1336.15,1826.95,,,,,,LH BED RENTAL,290,LH220016,$28.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,72202,X-ray of joints at hip bone and sacrum (3 or more views) [HCPCS 72202],147.63,147.63,147.63,108.14,100.92,108.14,,,,,,LH COMMODE RENTAL,290,LH220017,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH PACEMAKER AND LEAD WIRE KIT,270,LH220020,$231.53 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,LH WALKER - GLIDER/WHEEL KIT,290,LH220040,$138.92 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1516.71,1415.46,1935.39,,,,,,LH WALKER SKI GLIDES,290,LH220041,$34.73 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,LH WALKER WHEELS-NON/SWIVEL,270,E0155,$28.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,LH WALKER WHEELS 5INCH,290,E0155,$46.31 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],120.44,120.44,120.44,88.22,82.33,112.58,,,,,,LH EQUIPMENT RENTAL - MISC.,290,LH220390,$0.00 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,LH IV START SUPPLIES,271,LH240011,$34.73 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH PORTA-CATH SUPPLIES,270,LH240012,$78.72 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,79.68,74.36,101.68,,,,,,LH NG TUBE PLACEMENT/MAINTANENCE,270,LH240112,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",900.9,900.9,900.9,659.91,615.86,659.91,,,,,,"LH STERICUFF, PNU TOURNIQUET 34",270,LH24012,$64.83 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1510.18,1409.36,1927.05,,,,,,LH FLU VACCINE ADMINISTRATION,771,90471,$74.81 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1395.96,1302.77,1781.3,,,,,,LH CAUTERY MACHINE,270,LH260050,$86.82 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],454.55,454.55,454.55,332.96,310.73,424.87,,,,,,"LH CAUTERY, SURGICAL FINE TIP",270,LH260051,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76642,"Breast ultrasound (one breast, limited) [HCPCS 76642]",341.88,341.88,341.88,250.43,233.71,250.43,,,,,,"LH EYE CAUTERY, STERILE",270,LH260052,$23.15 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,261.81,244.33,334.08,,,,,,LH CAUTERY PENCIL-SURGICAL,270,LH260053,$8.68 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76775,Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775],229.22,229.22,229.22,167.9,156.69,167.9,,,,,,LH DEFIBRILLATOR IN ER,270,LH260060,$86.82 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],481.74,481.74,481.74,352.87,329.32,450.28,,,,,,LH MONITOR IN ER,270,LH260070,$86.82 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",431.24,431.24,431.24,315.88,294.8,403.08,,,,,,LH ER OP OBSERVATION 0-3 HRS,762,99219,$289.41 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,77080,"Bone density measurement of the axial skeleton (hips, pelvis, spine) [HCPCS 77080]",155.4,155.4,155.4,113.83,106.23,145.25,,,,,,LH ER OP OBSERVATION >3 HRS,762,99219,$405.17 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,LH DERMABOND PRODUCT,272,LH272000,$57.89 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,LH WATER FOR IRRIGATIN 1000 ML,270,LH2F7114,$5.79 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,LH WATER FOR IRRIGATIN  1500 ML,270,LH2F7115,$5.79 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,LH 0.9% SODIUM CHLORIDE IRRIGATION,272,A4216,$5.79 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,80162,Lab analysis to measure the amount of total digoxin in blood specimen [HCPCS 80162],102.38,102.38,102.38,74.99,74.99,74.99,,,,,,LH WBC,300,85048,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH RBC AUTO,300,85041,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,LH HGB,300,85018,$15.75 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH HCT,300,85014,$15.75 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],236.25,236.25,236.25,173.05,161.5,220.82,,,,,,LH PLATELETS AUTO,300,85049,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],118.13,118.13,118.13,86.53,80.75,110.42,,,,,,LH ESR AUTO,300,85652,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,80.76,75.37,103.05,,,,,,LH RETIC % AUTO,300,85045,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,82746,Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746],118.13,118.13,118.13,86.53,80.75,86.53,,,,,,LH ETOH SERUM,300,80320,$62.69 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH GLUCOSE,300,82947,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH BUN,300,84520,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],70.88,70.88,70.88,51.92,48.45,66.25,,,,,,"LH CREATININE, BLOOD",300,82565,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,69.22,64.6,88.33,,,,,,LH NA SER/PLAS/BLD,300,84295,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,LH K+ SER/PLS/BLD,300,84132,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],307.13,307.13,307.13,224.97,209.95,287.07,,,,,,LH CHLORIDE BLOOD,300,82435,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,LH CO 2,300,82374,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH AMYLASE,300,82150,$47.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH ALT (SGPT),300,84460,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,LH AST (SGOT),300,84450,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH ALK PHOS,300,84075,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,LH TROPONIN I,300,84484,$94.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH ALBUMIN SER/PLAS/BLD,300,82040,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,LH T PROTEIN 24 HR REF,300,84156,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH TOTAL PROTEIN,300,84155,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH TOTAL BILIRUBIN,300,82247,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH DIRECT BILIRUBIN,300,82248,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH LDH,300,83615,$47.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,86922,Lab blood analysis to confirm blood unit compatibility by antiglobulin technique [HCPCS 86922],307.13,307.13,307.13,224.97,224.97,224.97,,,,,,LH CALCIUM TOTAL,300,82310,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,46.15,43.07,58.89,,,,,,LH CK (CREA KINASE) TOTAL,300,82550,$55.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,LH CK-MB,300,82553,$94.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,LH GAMMA-GT,300,82977,$55.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,409.56,382.22,522.62,,,,,,LH MAGNESIUM,300,83735,$55.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,88342,Pathology lab analysis of special stained specimen slides to examine tissue (initial procedure) [HCPCS 88342],842.63,842.63,842.63,617.23,576.02,787.61,,,,,,LH PHOSPHORUS,300,84100,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,LH URIC ACID BLOOD,300,84550,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,84.99,79.32,108.45,,,,,,LH CHOLESTEROL SER/BLD TOTAL,300,82465,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],118,118,118,86.44,80.66,110.29,,,,,,LH TRIGLYCERIDES,300,84478,$47.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,LH HDL CHOLESTEROL,300,83718,$63.00 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],784.77,784.77,784.77,574.84,536.47,574.84,,,,,,LH T4 TOTAL REF,300,84436,$55.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,94060,Amount and speed of breathed air measurement and graphic recording before and after medication administration [HCPCS 94060],313.48,313.48,313.48,229.62,229.62,229.62,,,,,,LH T3 UPTAKE REF,300,84479,$47.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,95811,Sleep pattern monitoring of patient in sleep lab with continued pressured respiratory assistance by mask or breathing tube (6 years of age or older) [HCPCS 95811],2879.07,2879.07,2879.07,2108.92,1968.13,2691.07,,,,,,LH TSH,300,84443,$133.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,LH DIGOXIN TOTAL,300,80162,$102.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,328.8,306.85,419.57,,,,,,LH DILANTIN TOTAL,300,80185,$102.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,LH THEOPHYLINE REF,300,80198,$110.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,183.16,170.93,233.72,,,,,,LH APTT,300,85730,$47.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,75.78,70.72,96.69,,,,,,LH GRAM STAIN,300,87205,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,96523,Implanted venous access drug delivery device irrigation [HCPCS 96523],145.85,145.85,145.85,106.84,99.7,106.84,,,,,,LH CULTURE ANAEROBE REF.,300,87075,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,34.76,32.44,44.36,,,,,,LH CULTURE EAR REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,LH CULTURE EYE REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,87.28,81.45,111.37,,,,,,LH CULTURE FLUID REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,81.4,75.97,103.87,,,,,,LH CULTURE N/P REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,LH CULTURE NOSE REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,LH CULTURE PENIS REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],231.98,231.98,231.98,169.93,158.58,216.83,,,,,,LH CULTURE RECTAL REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97165,Occupational therapy evaluation (typically 30 minutes) [HCPCS 97165],269.72,269.72,269.72,197.57,184.38,197.57,,,,,,LH CULTURE SPINAL REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,97535,Training activities for home and self-care management (each 15 minutes) [HCPCS 97535],137.76,137.76,137.76,100.91,94.17,100.91,,,,,,LH CULTURE SPUTUM REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],20,20,20,14.65,13.67,18.69,,,,,,LH CULTURE THROAT REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,"LH URINE BACT CULT ID, EACH",300,87088,$63.00 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,LH CULTURE VAGINAL REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,LH CULTURE WOUND REF,300,87070,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,LH SENSITIVITY EA MULTI-ANTIMICROB PER,300,87186,$70.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,LH BCA REF,300,87040,$78.75 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.75,2.56,2.75,,,,,,LH BCAN,300,87040,$78.75 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,156.02,145.61,199.09,,,,,,LH CBC WC,300,85025,$63.00 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,109.6,102.29,139.86,,,,,,LH COLD AGGL SCREENING,300,86156,$63.00 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,107.85,100.65,137.63,,,,,,LH CRYSTALS,300,89060,$55.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,LH GASTROCULT,300,82270,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,37.11,34.63,42.18,,,,,,LH GLUCOSE WC/LC,300,82947,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,G0390,Trauma respons w/hosp criti [HCPCS G0390],3386.05,3386.05,3386.05,2480.28,2314.7,3164.94,,,,,,LH HCT WC,300,85014,$15.75 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J0897,Denosumab injection [HCPCS J0897],30.26,30.26,30.26,22.17,22.17,28.28,,,,,,LH HGB WC,300,85048,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J1940,Furosemide injection [HCPCS J1940],11.5,11.5,11.5,8.42,7.86,8.42,,,,,,LH MONO,300,86308,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],23,23,23,16.85,15.72,21.5,,,,,,LH MONO WC,300,86308,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,"LH OCCULT BLOOD 1-3 CARDS,DIAGNOSTIC",300,82272,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.7,1.59,1.7,,,,,,LH OCCULT BLOOD WC 1-3 CARDS,300,82272,$31.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J3480,Inj potassium chloride [HCPCS J3480],13.2,13.2,13.2,9.67,9.02,10.99,,,,,,LH PLATELETS WC,300,85048,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,16.96,15.83,21.64,,,,,,LH PREGNANCY,300,84703,$63.00 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,LH PREGNANCY WC,300,84703,$63.00 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,40.29,37.6,51.41,,,,,,LH UA WALHALLA CLINIC,300,81001,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Outpatient,P9016,Rbc leukocytes reduced [HCPCS P9016],3559.7,3559.7,3559.7,2607.48,2607.48,2607.48,,,,,,LH UA MUNICH CLINIC,300,81003,$15.75 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH WBC WC,300,85048,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH ABO,300,86900,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH BLD TYPE RH,300,86901,$23.63 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH ANTIBODY SCREEN RBC EA SER TECHNIQ,300,86850,$78.75 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH COOMBS (DAT) REF,300,86880,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH XMATCHA 1 ANTIGLOB TECHNIQ,300,86922,$307.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH XMATCH 1 INCUB TECHNIQ (IGM),300,86921,$219.95 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH RBC UNIT 1,390,P9016,$711.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,27096,Anesthetic or steroid injection into hip joint with imaging guidance [HCPCS 27096],431.55,431.55,431.55,316.11,316.11,316.11,,,,,,LH RBC UNIT 2,390,P9016,"$1,423.88 "
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1081.15,1008.97,1379.59,,,,,,LH RBC UNIT 3,390,P9016,"$2,135.82 "
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH RBC UNIT 4,390,P9016,"$2,847.76 "
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH RBC UNIT 5,390,P9016,"$3,559.70 "
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,130.59,121.87,130.59,,,,,,LH RBC UNIT 6,390,P9016,$711.94 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,62323,Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,LH PLT. PHERESIS FA,300,36513,$965.46 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2008.19,1874.12,2562.53,,,,,,LH 17 KETO-STERIOI TOTAL,300,83593,$501.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,423.79,395.5,540.77,,,,,,LH 5HIAA REF,300,83497,$102.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64633,Upper or middle spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64633],6570.9,6570.9,6570.9,4813.18,4813.18,4813.18,,,,,,LH ALCOHOL REF,300,82075,$99.56 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,LH ALDOLASE REF,300,82085,$78.75 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,LH ALDOSTERONE-SER REF,300,82088,$322.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],108.82,108.82,108.82,79.71,79.71,79.71,,,,,,LH ALDOSTERONE-URI,300,82088,$322.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,LH ALK PHOS-BONE  REF,300,84075,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,LH A-FETO-PROTEIN SERUM REF,300,82105,$133.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99291,Critical care delivery to critically ill or injured patient (first 30-74 minutes) [HCPCS 99291],1455.88,1455.88,1455.88,1066.43,1066.43,1066.43,,,,,,LH AMMONIA REF,300,82140,$118.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,144.35,144.35,144.35,,,,,,LH ANTI CARDIOLPI REF,300,86147,$196.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1328.95,1328.95,1328.95,410.25,410.25,980.77,,,,,,LH ANTI-DNA REF NATIVE/DOUBL,300,86225,$110.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64490,Upper or middle spine facet joint injections with imaging guidance (first level) [HCPCS 64490],827.4,827.4,827.4,255.42,255.42,255.42,,,,,,LH ASO REF,300,86060,$55.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64491,Upper or middle spine facet joint injections with imaging guidance (second level) [HCPCS 64491],827.4,827.4,827.4,255.42,255.42,255.42,,,,,,LH C-ANCA REF,300,86021,$118.13 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64633,Upper or middle spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64633],1460.55,1460.55,1460.55,450.87,450.87,450.87,,,,,,LH C-PEPTIDE REF,300,84681,$165.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64634,Upper or middle spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64634],1460.55,1460.55,1460.55,450.87,450.87,450.87,,,,,,LH C-REACTIVE PROTEIN,300,86140,$39.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],368.13,368.13,368.13,113.64,113.64,242.41,,,,,,LH CA 125 REF,300,86304,$165.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99231,Subsequent hospital inpatient care (typically 15 minutes per day) [HCPCS 99231],103.03,103.03,103.03,31.81,31.81,67.85,,,,,,LH CAFFINE REF,300,86304,$165.38 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],191.01,191.01,191.01,58.96,58.96,125.78,,,,,,LH CALC URINE REF,300,82340,$47.25 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],275.52,275.52,275.52,85.05,85.05,181.43,,,,,,LH CARBOXY HGB REF,300,82375,$94.50 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",192.17,192.17,192.17,59.32,59.32,126.54,,,,,,LH CATHECHOLAMINES REF,300,82384,$196.88 
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,50.75,50.75,121.32,,,,,,LH CEA REF,300,82378,$149.63 
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,LH CERULOPLASIN R,300,82390,$86.63 
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,LH CH 50 REF,300,86162,$157.50 
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,LH CHY SLIDE STAIN,300,83518,$71.78 
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,LH CHLAMYDIA PROBE REF,300,87491,$236.25 
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,LH COMPLEMENT C REF,300,86160,$94.50 
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,LH CMP 4 REF,300,86160,$94.50 
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,LH COPROPORPYRINS,300,84120,$118.13 
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,LH CORTISOL-SERUM,300,82533,$126.00 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,LH CORTISOL-URINE,300,82530,$133.88 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2282.61,1874.12,2562.53,,,,,,LH CULTURE STOOL REF SALM/SHIG,300,87045,$70.88 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,481.7,395.5,540.77,,,,,,LH CULTURE VIRAL,300,87252,$204.75 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,84.1,69.05,94.41,,,,,,LH CYCLOLSPORINE REF,300,80158,$141.75 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,52.45,43.07,58.89,,,,,,LH D-DIMER QUANT,300,85379,$78.75 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,72.13,59.22,80.97,,,,,,LH DISOPYRAMIDE R,300,80299,$149.63 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],133.88,133.88,133.88,111.47,91.52,125.14,,,,,,"LH EBV, EARLY AG",300,86663,$102.38 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],62.69,62.69,62.69,52.2,42.85,58.6,,,,,,LH ENDOMYSIAL AB 1,300,86255,$94.50 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,78.68,64.6,88.33,,,,,,LH ESTRIOL REF,300,82677,$189.00 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,52.45,43.07,58.89,,,,,,LH ESTROGEN TOTAL REF,300,82672,$173.25 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,32.79,26.92,36.81,,,,,,LH EXTRAC NUC AB,300,86235,$141.75 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,91.59,75.2,102.82,,,,,,LH FACTOR 9 REF,300,85250,$149.63 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,106.02,87.05,119.02,,,,,,LH FACTOR 11 REF,300,85270,$141.75 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],79.71,79.71,79.71,66.37,54.49,74.5,,,,,,LH FACTOR 13 REF CLOTTING; FACTOR IX (,300,85250,$149.63 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,373.74,306.85,419.57,,,,,,LH FANA REF,300,86038,$94.50 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,74.75,61.37,83.92,,,,,,LH FECAL FAT QUAL REF,300,82705,$39.38 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,86.13,70.72,96.69,,,,,,LH FERRITIN,300,82728,$110.25 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,167.74,137.72,188.31,,,,,,LH FIBRINOGEN REF ACTIVITY,300,85384,$78.75 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,243.53,199.95,273.39,,,,,,LH FOLATE,300,82746,$118.13 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,279.71,229.66,314.01,,,,,,LH FREE PSA REF,300,84154,$141.75 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,742.09,609.29,833.09,,,,,,LH FREE T4 REF,300,84439,$70.88 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,42.18,34.63,42.18,,,,,,LH FSH REF,300,83001,$149.63 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],23,23,23,19.15,15.72,21.5,,,,,,LH GASTRIN REF,300,82941,$141.75 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,38.3,31.45,43,,,,,,LH GC AMP PROBE REF,300,87591,$275.63 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,5.53,4.54,6.21,,,,,,LH GENTAMICIN,300,80170,$126.00 
Medica - Commercial-HMO,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,45.79,37.6,51.41,,,,,,LH GLUCAGON REF,300,82943,$112.29 
Medica - Commercial-HMO,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,171.63,171.63,215.86,,,,,,LH HAPTOGLOBIN; QUANTITATIVE,300,83010,$102.38 
Medica - Commercial-HMO,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,230.46,230.46,289.84,,,,,,"LH HCG, SERUM REF",300,84702,$118.13 
Medica - Commercial-HMO,Hospital,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],343.06,343.06,343.06,201.31,201.31,253.18,,,,,,LH HELICOBACTER PY,300,86677,$133.88 
Medica - Commercial-HMO,Skilled Nursing Facility,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2282.61,1874.12,2562.53,,,,,,"LH HEPATITIS PANEL, ACUTE",300,80074,$378.00 
Medica - Commercial-HMO,Skilled Nursing Facility,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,481.7,395.5,540.77,,,,,,LH HEPATITIS PROFILE ACUTE,300,80074,$378.00 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,149.36,149.36,190.59,,,,,,LH HEPATITIS C PROFILE RNA,300,87522,$338.63 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH HBSAG REF,300,87340,$78.75 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH HEPATITIS C REF,300,86803,$110.25 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH HGB ELECTROPHOR,300,83020,$102.38 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH HISTONE REF,300,83516,$94.50 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH HIV-1 STATE REF,300,86701,$70.88 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH HIV 1 REF,300,87389,$70.88 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH HLA B27 REF,300,86812,$204.75 
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH HOMOCYSTEINE REF,300,83090,$141.75 
"NGS AMERICAN, INC - Medicare Part A",Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,LH HTLV-1 REF,300,LH300195,$34.73 
"NGS AMERICAN, INC - Medicare Part A",Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,LH HVA REF,300,83150,$173.25 
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH HYDROXPROLINE TOTAL U,300,83505,$189.00 
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH IBC,300,83550,$70.88 
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH IGG REF,300,82784,$70.88 
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH IGM REF,300,82784,$70.88 
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH IMMUNOFIXATION,300,86334,$173.25 
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH INFLUENZA AB A,300,86710,$110.25 
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH INFLUENZA AB B,300,86710,$110.25 
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH IRON,300,83540,$47.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,17000,Destruction of pre-cancerous skin lesion/growth (first lesion/growth) [HCPCS 17000],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,LH K URINE REF,300,84133,$39.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,17110,Destruction of non-cancerous skin lesions/growths other than skin tags (up to 14 lesions/growths) [HCPCS 17110],304.71,304.71,304.71,223.2,223.2,284.81,,,,,,LH K STOOL REF,300,84999,$138.92 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,149.36,149.36,190.59,,,,,,LH LEAD REF,300,83655,$94.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,211.38,211.38,269.74,,,,,,LH LH REF,300,83002,$149.63 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,LH LIPASE,300,83690,$55.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,LH LITHIUM REF,300,80178,$55.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,LH LYME DISEASE REF,300,86618,$133.88 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,LH METANEPHRINES URINE REF,300,83835,$87.90 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,99417,New or established patient office or outpatient visit with physician to diagnose and treat illness or injury beyond required time of primary visit (each additional 15 minutes of total time) [HCPCS 99417],27.3,27.3,27.3,20,20,20,,,,,,LH METHYLMOLONIC A,300,83921,$85.35 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,G2025,Dis site tele svcs rhc/fqhc [HCPCS G2025],96.63,96.63,96.63,70.78,70.78,70.78,,,,,,LH MITOCHONDRIAL A,300,86255,$94.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Clinic,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,52.79,52.79,67.36,,,,,,LH MYCOPLASMA PNEU,300,86738,$102.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH NA STOOL REF,300,84999,$138.92 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH NA URINE REF,300,84300,$39.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH NAP REF,300,80192,$133.88 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH NEURON REF,300,83519,$141.75 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH NEURONTIN (GABA),300,80299,$149.63 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH NORTRIPTYLINE,300,80335,$128.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH O & P REF,300,87177,$70.88 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH OSMOLALITY SERUM,300,83930,$55.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",22.05,22.05,22.05,16.15,15.07,16.15,,,,,,LH OSMOLALITY STOOL,300,84999,$138.92 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,LH PKU REF,300,84030,$47.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",474.18,474.18,474.18,347.34,324.15,443.22,,,,,,LH PORPHOBILINOGE QUANT,300,84110,$63.00 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,20552,Trigger points injection into 1 or 2 muscles [HCPCS 20552],841.05,841.05,841.05,616.07,574.94,786.13,,,,,,LH PORPHYRINES REF,300,84120,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH PRA REF,300,84244,$173.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH CASCADING RELEX (REF),300,86038,$94.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1081.15,1008.97,1379.59,,,,,,LH ANAPLASMA PCR REF,300,87798,$275.63 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH EXTRACTABLE ANTIGEN SM/RNP REF,300,86235,$141.75 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,64445,Anesthetic agent and/or steroid injection into sciatic nerve of lower back and leg [HCPCS 64445],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,LH ANTIGRANULOCYTE AB REF,300,86021,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2008.19,1874.12,2562.53,,,,,,LH MUMPS VIRUS,300,86735,$102.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,423.79,395.5,540.77,,,,,,LH VARICELLA ZOSTER IGM REF,300,86787,$102.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],6570.9,6570.9,6570.9,4813.18,4491.87,6141.82,,,,,,LH PRENATAL PRO RE,300,80055,$378.00 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],670.95,670.95,670.95,491.47,458.66,627.14,,,,,,LH PROCAINAMIDE W/ METABOLITES,300,80192,$133.88 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,490.7,457.94,626.16,,,,,,LH PROGESTERONE REF,300,84144,$165.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH PROLACTIN REF,300,84146,$149.63 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",906.68,906.68,906.68,664.14,619.81,847.47,,,,,,LH PROTEIN ELECTRO REF,300,84165,$86.63 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1431.73,1336.15,1826.95,,,,,,LH FACTOR VII REF,300,85230,$141.75 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH PTH REF,300,83970,$322.88 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73060,Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060],120.44,120.44,120.44,88.22,82.33,88.22,,,,,,LH QUINIDIN REF,300,80194,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,110.99,103.58,126.16,,,,,,LH RA FACTOR QUANT,300,86431,$47.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,LH RITALIN REF,300,80299,$149.63 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1516.71,1415.46,1935.39,,,,,,LH RPR REF,300,86592,$31.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,LH RSV CULTURE REF,300,87252,$204.75 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,LH RUBELLA SCREEN,300,86762,$110.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,LH SALICYLATES REF,300,80299,$52.34 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH SMEAR SPECIAL GRP II REF,300,88313,$197.96 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1510.18,1409.36,1927.05,,,,,,LH SJOGREN'S ANTIBODY REF,300,86235,$141.75 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1395.96,1302.77,1781.3,,,,,,LH STONE KIDNEY INFRD SPECT,300,82365,$94.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,76775,Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775],229.22,229.22,229.22,167.9,156.69,167.9,,,,,,LH STREP SCREEN REF,300,87880,$133.88 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],64.83,64.83,64.83,47.49,44.32,60.6,,,,,,LH TBG REF,300,84442,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,LH TEGRETOL TOTAL,300,80156,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,LH TESTOSTERONE TOTAL REF,300,84403,$204.75 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,LH THYROGLOBULIN A,300,86800,$126.00 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,LH TISSUE LEVEL 1,300,88300,$126.00 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH TISSUE LEVEL 2,300,88302,$244.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,80.76,75.37,103.05,,,,,,LH TISSUE LEVEL 3,300,88304,$322.88 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH TISSUE LEVEL 4,300,88305,$254.68 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH TISSUE LEVEL 5,300,88307,$568.40 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH TISSUE LEVEL 6,300,88309,$790.66 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,LH TRANSFERRIN,300,84466,$102.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,LH URIC ACID 24 UR,300,84560,$39.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH VALPROIC ACID REF TOTAL,300,80164,$110.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH VANCOMYCIN REF,300,80202,$110.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,409.56,382.22,522.62,,,,,,LH VIRAL RESP ADULT,300,86603,$102.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,88342,Pathology lab analysis of special stained specimen slides to examine tissue (initial procedure) [HCPCS 88342],842.63,842.63,842.63,617.23,576.02,787.61,,,,,,LH VIRAL RESP CHILD,300,86603,$102.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,LH VITAMIN B12,300,82607,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,84.99,79.32,108.45,,,,,,LH VITAMIN D PANEL REF,300,82652,$307.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,LH VMA REF,300,84585,$126.00 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,LH WBC STOOL REF,300,89055,$31.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,62.44,58.27,79.67,,,,,,LH XYLOSE TOLERANCE,300,84620,$93.77 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,328.8,306.85,419.57,,,,,,LH ZPP REF,300,84202,$113.45 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,LH PARASITE ID RE,300,87999,$135.44 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,183.16,170.93,233.72,,,,,,LH CYTOLOGY UA REF,300,88108,$180.59 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,75.78,70.72,96.69,,,,,,LH ALPHA 1 ANTITRY TOTAL,300,82103,$102.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97012,Mechanical traction application to 1 or more areas [HCPCS 97012],59.56,59.56,59.56,43.63,40.72,43.63,,,,,,LH SMOOTH MUSCLE A,300,86255,$94.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,LH ERYTHROPOEITIN,300,82668,$149.63 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,91.58,85.46,116.86,,,,,,LH ANTITHROMBIN III ACTIVITY,300,85300,$94.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,87.28,81.45,111.37,,,,,,LH CMPLEMENT C1Q,300,86160,$94.50 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,81.4,75.97,103.87,,,,,,LH P-ANCA REF,300,86021,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,LH CA27.29 REF,300,86300,$165.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,LH PHENOBARBITAL REF,300,80184,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,97602,Dead tissue removal from wounds per session [HCPCS 97602],295.2,295.2,295.2,216.23,201.8,216.23,,,,,,LH MIXING STUDY,300,85730,$47.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,164.29,153.32,209.63,,,,,,"LH CMV AB, IGG, SE",300,86644,$110.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,LH THYROID PEROXID,300,86376,$118.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,LH ENA,300,86235,$141.75 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.75,2.56,2.75,,,,,,LH RUSSELL VIPER VENOM TIME; DILUTED,300,85613,$78.75 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,156.02,145.61,199.09,,,,,,LH VON WILLEBRAND ANTIGEN,300,85246,$181.13 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,LH LEUKO ALK PHOS,300,85540,$70.88 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,107.85,100.65,137.63,,,,,,LH SEMEN ANALYSIS PRESENCE/MOTILITY OF,300,89300,$56.72 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J0897,Denosumab injection [HCPCS J0897],30.26,30.26,30.26,22.17,22.17,28.28,,,,,,LH CRP HIGH SENSITIV REF,300,86141,$102.38 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,LH DHEA-SULFATE R,300,82627,$173.25 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.7,1.59,1.7,,,,,,LH ACID PHOS PROST,300,84066,$76.41 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,LH FRAGILE X STUDY,300,81243,$237.45 
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,40.29,37.6,51.41,,,,,,LH CHROMOSOME ANALYSIS CT 15-20 CELLS,300,88262,$984.38 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH HEPATITIS A IGM REF,300,86709,$86.63 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH NUCLEOTIDASE R,300,83915,$86.63 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH PROT ELECTRO UA REF,300,84166,$141.75 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH LIPOPROTEIN (A) RE,300,83695,$62.73 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH RABIES ANTIBODY,300,86317,$118.13 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,"LH CYSTINE, URINE SNGL QUANT EA SPECMN",300,82131,$181.13 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,"LH OXALATE, URINE",300,83945,$110.25 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,"LH OSMOLALITY, URINE",300,83935,$55.13 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],109.98,109.98,109.98,33.95,33.95,81.17,,,,,,"LH RENIN, SERUM R",300,84244,$173.25 
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,57.39,57.39,122.42,,,,,,"LH CHLORIDE, URINE",300,82436,$47.25 
PREMERA BLUE CROSS - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,LH EOSINOPHIL COUN,300,85008,$23.63 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH CRYOGLOBULINS QUAL/SEMI-QUANT,300,82595,$47.25 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH ACETAMINOPHEN,300,80299,$74.67 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH CITRATE URINE R,300,82507,$220.50 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH MAGNESIUM URINE,300,83735,$55.13 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH PHOSPHATE URINE,300,84105,$47.25 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH PH URINE REF,300,83986,$31.50 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH HERPES ZOSTER R,300,86787,$102.38 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,"LH EBNA, AB, IGG",300,86664,$141.75 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH EBV CAPSID AG,300,86665,$141.75 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,"LH CMV AB, IGM RE",300,86645,$133.88 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,LH NEUT CYTOPLASMI,300,86021,$118.13 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,LH HIV 1/HIV-2 EI,300,87389,$189.00 
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,LH IGA REF,300,82784,$70.88 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,13.87,13.87,17.44,,,,,,LH ESTRADIOL TOTAL REF,300,82670,$220.50 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,,Professional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],70.88,70.88,70.88,41.59,41.59,52.31,,,,,,"LH INSULIN, SERUM TOTAL",300,83525,$86.63 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,,Professional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,78.56,78.56,98.8,,,,,,"LH VIT D-OH, D2, D3",300,82306,$236.25 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,LH IGE REF,300,82785,$126.00 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,"LH MYOGLOBIN, URINE",300,83874,$102.38 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,LH ASPERGILLUS AB,300,86606,$46.31 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,LH HEP C RNA PCR R,300,87521,$275.63 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,LH KOH PREP SKN/HAIR/NL,300,87220,$31.50 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,LH WET MOUNT,300,87210,$47.25 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,LH HEMO-CHROM REF,300,81256,$650.59 
PREMIER ADMIN SOLUTIONS-ICL 1381 - Commercial-Indemnity,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,LH HEAVY METAL URIN ARSENIC,300,82175,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,188.31,137.72,188.31,,,,,,LH IMMUNO ELEC UR,300,86335,$228.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,4561.97,3186.97,4561.97,,,,,,"LH KAPPA/LAMBDA LIGHT CHAIN,EACH",300,83520,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,2080.66,1453.54,2080.66,,,,,,LH METANEPHRINES,300,83835,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,8477.82,5922.57,8477.82,,,,,,LH ROTAVIRUS STOOL,300,87425,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,12635.76,8827.29,12635.76,,,,,,LH FLECAINIDE REF,300,80299,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,12047.21,8416.13,12047.21,,,,,,LH EOSINOPHILS UA REF,300,85999,$23.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,3232.44,2258.17,3232.44,,,,,,LH CULTURE AERO ADDL DEF ID,300,87077,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,3811.59,2662.76,3811.59,,,,,,LH RAPID STREP,300,87301,$108.81 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,4597.47,3211.77,4597.47,,,,,,LH HEPATITIS B COR,300,86704,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,17110,Destruction of non-cancerous skin lesions/growths other than skin tags (up to 14 lesions/growths) [HCPCS 17110],304.71,304.71,304.71,284.81,223.2,284.81,,,,,,LH HEPATITIS B SUR,300,86706,$86.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,88142,Lab analysis of vaginal or cervical cells (pap test) with manual screening under physician supervision [HCPCS 88142],157.5,157.5,157.5,147.22,147.22,147.22,,,,,,LH RAPID STREP WC,300,87301,$108.82 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,69.92,51.14,69.92,,,,,,LH TOPIRAMATE REF,300,80201,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,90670,"Pneumococcal conjugate, 13 valent vaccine for injection into muscle [HCPCS 90670]",225.75,225.75,225.75,211.01,211.01,211.01,,,,,,"LH CALCIUM, IONIZE",300,82330,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,90686,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent, preservation free) [HCPCS 90686]",35,35,35,32.71,29.14,32.71,,,,,,LH MICROALBUMIN W,300,82043,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,33.37,24.4,33.37,,,,,,LH CULTURE STOOL REF NON-SALM/SHIG,300,87046,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,21.39,16.76,21.39,,,,,,"LH CULTURE FUNGAL SKN,HAIR,NAIL",300,87101,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,95117,Allergen injection in incremental dosages (2 or more injections) [HCPCS 95117],38.2,38.2,38.2,35.71,31.81,35.71,,,,,,LH COCCIDIOIDES AN,300,86635,$86.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96127,Emotional or behavioral assessment for screening of condtions like ADHD or depression with scoring and documentation (brief assessment) [HCPCS 96127],13.13,13.13,13.13,12.27,9.62,12.27,,,,,,LH SPUTUM TO STATE,300,87118,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,83.92,61.37,83.92,,,,,,LH TOBRAMYCIN LEVEL REF,300,80200,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,190.59,149.36,190.59,,,,,,LH TOBRAMYCIN TROUGH REF,300,80200,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,269.74,211.38,269.74,,,,,,LH BETA 2 MICROGLOBULIN,300,82232,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99205,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205],555.67,555.67,555.67,519.38,407.03,519.38,,,,,,"LH GIARIDA AG, STOOL",300,87329,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,114.18,83.51,114.18,,,,,,LH HLA DR & DQ RE,300,86817,$505.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,188.31,137.72,188.31,,,,,,"LH HLA A,B,C REF",300,86813,$456.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,273.39,199.95,273.39,,,,,,"LH VARICELLA AB, 1",300,86787,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,367.09,268.48,367.09,,,,,,"LH HYDROXYPROGESTERONE, 17-D",300,83498,$212.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],270.09,270.09,270.09,252.45,252.45,252.45,,,,,,LH FACTOR II REF,300,85210,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],287.64,287.64,287.64,268.86,268.86,268.86,,,,,,LH RISTOCETIN REF,300,85245,$181.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],286.64,286.64,286.64,267.92,267.92,267.92,,,,,,LH CALCITONIN REF,300,82308,$212.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],322.65,322.65,322.65,301.58,301.58,301.58,,,,,,LH CA 19-9 REF TUMOR ANTIGEN,300,86316,$165.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],343.06,343.06,343.06,320.66,285.63,320.66,,,,,,LH CORTISOL STIMUL,300,80400,$259.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,99421,"Online digital evaluation and management service for an established patient to diagnose and treat illness or injury, for up to 7 days (cumulative time during the 7 days 5-10 minutes) [HCPCS 99421]",31.82,31.82,31.82,29.74,29.74,29.74,,,,,,LH TACROLIMUS,300,80197,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,6.21,4.54,6.21,,,,,,"LH GLIADIN AB, IGG",300,83516,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,P3000,Screen pap by tech w md supv [HCPCS P3000],69.3,69.3,69.3,64.77,50.76,64.77,,,,,,LH URINE MICROALBUMIN-WC,300,82043,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,67.36,52.79,67.36,,,,,,LH IMMUNOGLOBULINS,300,82784,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],328.49,328.49,328.49,242.43,216.31,242.43,,,,,,LH AFB SMEAR REF,300,87206,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,69209,Impacted ear wax removal by washing [HCPCS 69209],321.86,321.86,321.86,237.53,211.94,237.53,,,,,,LH FREE T3 REF,300,84481,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,96127,Emotional or behavioral assessment for screening of condtions like ADHD or depression with scoring and documentation (brief assessment) [HCPCS 96127],13.13,13.13,13.13,9.69,8.65,9.69,,,,,,LH SPOROTRICHOSIS,300,86671,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,150.48,134.27,150.48,,,,,,LH IGF-1,300,84305,$165.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,212.97,169.34,212.97,,,,,,LH BCR ABL TRANSLO,300,88237,"$1,134.00 "
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99204,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204],439.89,439.89,439.89,324.64,289.67,324.64,,,,,,LH UREA NITROGEN R URINE,300,84540,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,90.15,71.68,90.15,,,,,,LH TESTOSTERONE FR,300,84402,$204.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,148.68,62.19,148.68,,,,,,LH SOMATOMEDIN IGF,300,84305,$165.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,215.86,171.63,215.86,,,,,,"LH ANAFRANIL, SERUM",300,80299,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,289.84,230.46,289.84,,,,,,"LH COMPLEMENT, EAC",300,86160,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],287.64,287.64,287.64,212.28,189.41,212.28,,,,,,LH THYROGLOBULIN,300,84432,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],343.06,343.06,343.06,253.18,201.31,253.18,,,,,,LH ANTI-PHOSPHOLIPID PANEL REF,300,86146,$196.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,4.9,4.37,4.9,,,,,,LH ETHSUXIDMIDE REF,300,80168,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Professional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,53.19,22.25,53.19,,,,,,LH RAPAMUNE REF,300,80299,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Religious Care,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,25.97,18.99,25.97,,,,,,LH METHYLPHENIDATE,300,80299,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Religious Care,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1387.17,1014.52,1387.17,,,,,,LH TSH REFLEX REF,300,84443,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Religious Care,Institutional,Outpatient,A0429,Bls-emergency [HCPCS A0429],1250.24,1250.24,1250.24,1168.6,854.66,1168.6,,,,,,LH PTH/RP REF,300,83519,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],18.52,18.52,18.52,17.31,12.66,17.31,,,,,,LH CAROTENE REF,300,82380,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,17.31,12.66,17.31,,,,,,LH FACTOR V MUT,300,81241,$632.07 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,813,"Anesthesia provided during sophagus, stomach, small bowel, and/or large bowel  procedure with endoscope [HCPCS 00813]",18.52,18.52,18.52,17.31,13.57,17.31,,,,,,LH PROTEIN C REF,300,85303,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",474.18,474.18,474.18,443.22,324.15,443.22,,,,,,LH PROTEIN S FREE REF,300,85306,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",577.24,577.24,577.24,539.55,394.6,539.55,,,,,,LH CARDIOLIPIN AB,300,86147,$196.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,20551,Tendon attachment (to bone) injection [HCPCS 20551],294.37,294.37,294.37,275.15,275.15,275.15,,,,,,LH ACTIVATED PROT,300,85335,$136.61 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,20552,Trigger points injection into 1 or 2 muscles [HCPCS 20552],841.05,841.05,841.05,786.13,574.94,786.13,,,,,,LH PROTHROMBIN GEN  REF,300,85610,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,20605,Medium joint or joint capsule fluid removal and/or injection with needle [HCPCS 20605],841.05,841.05,841.05,786.13,786.13,786.13,,,,,,LH COAG CONSULT,300,80500,$181.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,20611,Large joint or joint capsule fluid removal and/or injection with needle and ultrasound guidance including recording and reporting [HCPCS 20611],841.05,841.05,841.05,786.13,616.07,786.13,,,,,,LH CANNABINOIDS NATURAL REF,300,80349,$71.78 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,25500,Broken forearm bone treatment at the mid portion on the thumb side of the arm without manipulation (closed treatment) [HCPCS 25500],753.07,753.07,753.07,703.89,703.89,703.89,,,,,,"LH IMMUNO ELEC, SE",300,84165,$86.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,29125,Short arm splint application forearm to hand (non-moveable) [HCPCS 29125],336.05,336.05,336.05,314.11,229.72,314.11,,,,,,LH DNA DOUBLE,300,86225,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,29584,"Vein wound compression system application to upper arm, forearm, hand, and fingers [HCPCS 29584]",250.95,250.95,250.95,234.56,234.56,234.56,,,,,,LH HEAVY METAL BLOOD  REF LEAD,300,83655,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,22.09,16.15,22.09,,,,,,"LH ASCA IGA, IGG REF",300,86671,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],23.63,23.63,23.63,22.09,16.15,22.09,,,,,,LH TIS TRANSFLUT A,300,83520,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1379.59,1008.97,1379.59,,,,,,LH ACE REF,300,82164,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1635.72,1635.72,1635.72,1528.91,1118.18,1528.91,,,,,,LH CELIAC SPRUE RE,300,86255,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],1635.72,1635.72,1635.72,1528.91,1118.18,1528.91,,,,,,LH BLOOD GASES 2/> ANALYTES,300,82803,$223.32 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1528.91,1118.18,1528.91,,,,,,LH CREATININE CLEARANCE,300,82575,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1528.91,1118.18,1528.91,,,,,,LH CBC/DIFF(H-1),300,85025,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,62321,Spinal canal injection of substance into upper or middle back with imaging guidance [HCPCS 62321],2216.55,2216.55,2216.55,2071.81,2071.81,2071.81,,,,,,LH CBC AUTO W/O DIFF(H-4),300,85027,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,64490,Upper or middle spine facet joint injections with imaging guidance (first level) [HCPCS 64490],2741.55,2741.55,2741.55,2562.53,2008.19,2562.53,,,,,,LH H-6,300,85007,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,64492,Upper or middle spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64492],680.4,680.4,680.4,635.97,635.97,635.97,,,,,,LH HBA 1C,300,83036,$78.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2562.53,1874.12,2562.53,,,,,,LH PRO-1 BASIC METABOLIC,300,80048,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,540.77,395.5,540.77,,,,,,LH PRO-2 ELECTROLYTE PANEL,300,80051,$55.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,64495,Lower or sacral spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64495],591.15,591.15,591.15,552.55,404.11,552.55,,,,,,LH PRO-3 CMP,300,80053,$86.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],6570.9,6570.9,6570.9,6141.82,4491.87,6141.82,,,,,,LH PRO-4 HEPATIC FUNCTION PANEL,300,80076,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],670.95,670.95,670.95,627.14,458.66,627.14,,,,,,LH PROFILE 5 LIPID PANEL,300,80061,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,626.16,457.94,626.16,,,,,,LH PRO-6 RENAL FUNCTION PANEL,300,80069,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",808.5,808.5,808.5,755.7,552.69,755.7,,,,,,LH PROTIME,300,85610,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,70490,"Neck CT scan of the soft tissue of the neck without contrast to examine injury, foreign bodies, or tumors [HCPCS 70490]",958.65,958.65,958.65,896.05,896.05,896.05,,,,,,LH URINE MICROALBUIM(U-1) SEIMQUANT,300,82044,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,70491,"Neck CT scan of the soft tissue of the neck with contrast to examine injury, foreign bodies, or tumors [HCPCS 70491]",1178.1,1178.1,1178.1,1101.17,862.96,1101.17,,,,,,LH UA,300,81001,$22.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,70544,Imaging of head blood vessels by MRA without contrast [HCPCS 70544],2213.4,2213.4,2213.4,2068.86,1513.08,2068.86,,,,,,LH UA-MICRO,300,81015,$23.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,70553,"Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]",3284.4,3284.4,3284.4,3069.93,2245.22,3069.93,,,,,,LH PHOSPHROUS UA REF,300,84105,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,94.41,69.05,94.41,,,,,,LH PHENYTOIN FREE,300,80186,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,119.84,87.64,119.84,,,,,,LH PTH ANTIBODY REF.,300,83519,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,71101,Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101],159.29,159.29,159.29,148.89,108.89,148.89,,,,,,"LH PSA HYB, TOTAL DIAGNOSTIC",300,84153,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,858.27,627.7,858.27,,,,,,LH RBC P-PORPHYRIN REF.,300,84202,$113.45 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,1068.78,781.66,1068.78,,,,,,"LH CULTURE, OTHER AEROB.",300,87070,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,152.56,111.58,152.56,,,,,,LH THROMBIN TIME PLASMA,300,85670,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,71275,"CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]",1767.15,1767.15,1767.15,1651.76,1651.76,1651.76,,,,,,LH HTLV I & II REFLEX,300,86790,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],147.63,147.63,147.63,137.99,100.92,137.99,,,,,,LH HISTAMINE UA,300,83088,$236.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72070,Spinal x-ray of middle spine (2 views) [HCPCS 72070],124.32,124.32,124.32,116.2,84.99,116.2,,,,,,LH PROPANOLOL LAB TEST,300,80299,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,137.99,100.92,137.99,,,,,,LH CHLORIDE STOOL REF,300,82438,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72110,Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110],190.37,190.37,190.37,177.94,130.14,177.94,,,,,,LH CHLAMYDIA SERUM,300,86632,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",906.68,906.68,906.68,847.47,619.81,847.47,,,,,,LH LEGIONELLA URINE R,300,87449,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72131,"Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]",900.9,900.9,900.9,842.07,615.86,842.07,,,,,,"LH MALARIA, BLOOD REF.",300,87207,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72141,Imaging of upper spinal canal by MRI without contrast [HCPCS 72141],1954.58,1954.58,1954.58,1826.95,1336.15,1826.95,,,,,,"LH EBV,CAPSID HB, IGM REF.",300,86665,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1826.95,1336.15,1826.95,,,,,,LH CENTROMERE ANTIBODY REF.,300,86235,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,72192,"Pelvis CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 72192]",843.15,843.15,843.15,788.09,788.09,788.09,,,,,,LH RNP ANTIBODY REF.,300,86235,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,119.84,87.64,119.84,,,,,,LH INTRINSIC FACTOR ANTIBODIES,300,86340,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73080,"Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]",120.44,120.44,120.44,112.58,88.22,112.58,,,,,,"LH VISCOSITY, SERUM REF",300,85810,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],112.67,112.67,112.67,105.31,77.02,105.31,,,,,,LH PSA CANCER SCREEN,300,G0103,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73100,Wrist x-ray (2 views) [HCPCS 73100],128.21,128.21,128.21,119.84,119.84,119.84,,,,,,LH KETONE BODIES PLAMA REF,300,82010,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73120,Hand x-ray (2 views) [HCPCS 73120],116.55,116.55,116.55,108.94,79.67,108.94,,,,,,LH ARYLSULFATASE SERUM REF SPECTROPHOT,300,84311,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],135.98,135.98,135.98,127.1,92.96,127.1,,,,,,LH ARYLSULFATASE URINE REF,300,84311,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],139.86,139.86,139.86,130.73,95.61,130.73,,,,,,LH ANTI X A REF (HEPARIN ASSAY),300,85520,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73200,"Arm CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73200]",1039.5,1039.5,1039.5,971.62,761.43,971.62,,,,,,LH RENIN PLASMA REF,300,84244,$173.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1935.39,1415.46,1935.39,,,,,,LH MYCOBACTERIA D-PROBE REF,300,87556,$145.87 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,163.41,119.51,163.41,,,,,,LH CYCLIC AMP(URINE) REF,300,82030,$268.57 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,123.46,90.3,123.46,,,,,,LH BILIRUBIN PANEL,300,82248,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,141.63,103.58,141.63,,,,,,LH C1 ESTERANCE REF,300,83520,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73565,"Knee x-ray of both knees, standing (front to back view) [HCPCS 73565]",151.52,151.52,151.52,141.63,110.99,141.63,,,,,,LH C2 REF,300,86160,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73590,Lower leg x-ray (2 views) [HCPCS 73590],120.44,120.44,120.44,112.58,82.33,112.58,,,,,,LH GROUP B STREP-VAG & ANAL,300,87081,$55.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73600,Ankle x-ray (2 views) [HCPCS 73600],124.32,124.32,124.32,116.2,116.2,116.2,,,,,,LH INFLUENZA A,300,87804,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,127.1,92.96,127.1,,,,,,LH INFLUENZA B,300,87804,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73620,Foot x-ray (2 views) [HCPCS 73620],108.78,108.78,108.78,101.68,79.68,101.68,,,,,,LH TISSUE TRANSGLUTAMINASE,300,83520,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73650,Foot x-ray at heel of foot (minimum of 2 views) [HCPCS 73650],108.78,108.78,108.78,101.68,74.36,101.68,,,,,,LH ACID HEMOLYSIS (HAM TEST),300,85475,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,101.68,74.36,101.68,,,,,,LH CRYPTOSPERIDIUM STOOL REF,300,87272,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1927.05,1409.36,1927.05,,,,,,LH TYPHUS ANTIBODY REF,300,86000,$55.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],112.67,112.67,112.67,105.31,77.02,105.31,,,,,,LH INFLUENZA A - WALHALLA CLINIC,300,87804,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,74019,Abdominal x-ray (2 views) [HCPCS 74019],139.86,139.86,139.86,130.73,95.61,130.73,,,,,,LH INFLUENZA B WALHALLA CLINIC,300,87804,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",1160.78,1160.78,1160.78,1084.98,793.51,1084.98,,,,,,LH PARIETAL CELL ANTIBODY REF.,300,86255,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1781.3,1302.77,1781.3,,,,,,LH SALMONELLA TOTAL AB REF,300,86768,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],454.55,454.55,454.55,424.87,310.73,424.87,,,,,,LH HEMOSIDERIN QUALITATIVE UA REF,300,83070,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76641,"Breast ultrasound (one breast, complete) [HCPCS 76641]",419.58,419.58,419.58,392.18,286.82,392.18,,,,,,LH PREALBUMIN REF.,300,84134,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76700,Abdominal ultrasound (complete) [HCPCS 76700],481.74,481.74,481.74,450.28,329.32,450.28,,,,,,LH RETICULIN ANTIBODY REF,300,86255,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,334.08,244.33,334.08,,,,,,LH OXCARBAZEPINE REF,300,80183,$65.48 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76801,"Abdominal ultrasound of pregnant uterus during first trimester, less than 14 weeks 0 days (single or first fetus) [HCPCS 76801]",477.86,477.86,477.86,446.66,326.67,446.66,,,,,,LH ACTH PLASMA REF,300,82024,$307.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76816,Abdominal ultrasound of pregnant uterus for re-evaluation of fetus (per fetus) [HCPCS 76816],442.89,442.89,442.89,413.97,302.76,413.97,,,,,,LH WBC & DIFF FLUID REF,300,89051,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],376.85,376.85,376.85,352.24,352.24,352.24,,,,,,"LH GLUCOSE, FLUID EXCL BLOOD REF",300,82945,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],481.74,481.74,481.74,450.28,329.32,450.28,,,,,,LH ANTI SSA/RO REF,300,86235,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",431.24,431.24,431.24,403.08,294.8,403.08,,,,,,LH ANTI SSB/LA REF,300,86235,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,76882,Joint or other non-blood vessel structure of arm or leg ultrasound (partial) [HCPCS 76882],64.83,64.83,64.83,60.6,44.32,60.6,,,,,,LH CYSTOLOGY FLUID EXCL CERV/VAG REFER,300,88104,$148.18 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,92.58,67.71,92.58,,,,,,LH HERPES TYPE 1 & 2 IGM REF,300,86695,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,77065,Mammography of one breast for diagnosis [HCPCS 77065],524.48,524.48,524.48,490.23,358.53,490.23,,,,,,LH LEAD 24HR US REF.,300,83655,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,501.12,366.5,501.12,,,,,,LH HCV RNA REF,300,87521,$275.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,77080,"Bone density measurement of the axial skeleton (hips, pelvis, spine) [HCPCS 77080]",155.4,155.4,155.4,145.25,106.23,145.25,,,,,,LH HCV GENOTYPING REF,300,87902,"$2,023.88 "
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1750.29,1280.09,1750.29,,,,,,LH HCV VIRAL LOAD REF,300,87522,$338.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,58.89,43.07,58.89,,,,,,LH MICRO UA WALHALLA CLINIC,300,81015,$23.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,80.97,59.22,80.97,,,,,,LH COPPER 24HR UA REF,300,82525,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,95.69,69.99,95.69,,,,,,"LH TOTAL PROTIEN UA, RANDOM REF SERUM,",300,84155,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",63,63,63,58.89,43.07,58.89,,,,,,"LH CREATININE UA, RANDOM REF",300,82570,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80178,Lab analysis to measure the amount of lithium in blood specimen [HCPCS 80178],55.13,55.13,55.13,51.53,37.69,51.53,,,,,,LH CREATINE URINE REF.,300,82540,$123.87 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80197,Lab analysis to measure the amount of tacrolimus in blood specimen [HCPCS 80197],110.25,110.25,110.25,103.05,75.37,103.05,,,,,,LH SCREENING OCCULT BLOOD 1-3 CARDS,300,82270,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80299,Lab analysis of therapeutic drug not elsewhere specified [HCPCS 80299],149.63,149.63,149.63,139.86,139.86,139.86,,,,,,LH UROVISION REF.,300,88271,$165.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80305,Drug screening read by direct visual reading [HCPCS 80305],102.38,102.38,102.38,95.69,69.99,95.69,,,,,,LH SEROTONIN SERUM REF,300,84260,$244.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],133.88,133.88,133.88,125.14,91.52,125.14,,,,,,LH C1 ESTERACE INHIBITOR NEPH,300,83883,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],62.69,62.69,62.69,58.6,42.85,58.6,,,,,,LH AMINDEUELINIC & PORPH. REF ENZYME A,300,82657,$173.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,22.09,16.15,22.09,,,,,,LH UA MICRO WALHALLA,300,81015,$23.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,14.72,10.77,14.72,,,,,,LH CHLAMYDIA PNEUNONIAE ANTI REF,300,86632,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",39.38,39.38,39.38,36.81,26.92,36.81,,,,,,LH INDIRECT BILIRUBIN,300,LH300590,$0.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,44.16,32.3,44.16,,,,,,LH BK POLUMD VIRUS REF,300,87798,$275.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],47.25,47.25,47.25,44.16,32.3,44.16,,,,,,"LH TTG-IGA,IGG REF",300,83516,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],39.38,39.38,39.38,36.81,26.92,36.81,,,,,,LH ANTIGLOMERCULU BASEMENT MEMBRANE RE,300,83520,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82272,Lab analysis to measure the amount of blood in stool specimen by peroxidase activity [HCPCS 82272],31.5,31.5,31.5,29.44,21.53,29.44,,,,,,LH WEST NILE VIRUS AB IGG,300,86789,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],236.25,236.25,236.25,220.82,161.5,220.82,,,,,,LH CMV ANTIGENEMIA ASSAY REF,300,86644,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82533,Lab analysis to measure the amount of total cortisol (hormone) [HCPCS 82533],126,126,126,117.77,86.13,117.77,,,,,,LH BORDETELLA PERTUSSIS/PCR REF,300,87798,$275.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,51.53,37.69,51.53,,,,,,LH BNP,300,83880,$307.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82553,Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553],94.5,94.5,94.5,88.33,64.6,88.33,,,,,,LH LAMOTRIGINE  REF,300,80175,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],39.38,39.38,39.38,36.81,26.92,36.81,,,,,,LH SCABIES REF,300,87220,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],118.13,118.13,118.13,110.42,80.75,110.42,,,,,,LH EXTRACTABLE ANTIGEN SM/RNP REF,300,86235,$187.54 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82627,Lab analysis to measure the dehydroepiandrosterone (DHEA-S) hormone level [HCPCS 82627],173.25,173.25,173.25,161.94,118.43,161.94,,,,,,LH JO-1 ANTIBODY REF,300,86235,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],220.5,220.5,220.5,206.1,150.73,206.1,,,,,,LH SCLERODERMA ANITBODY SCL-70 REF,300,86235,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,103.05,75.37,103.05,,,,,,LH CORTISONE REF MASS SPECTOMETRY,300,83789,$189.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,82947,Lab analysis to measure the glucose (sugar) level in blood [HCPCS 82947],31.5,31.5,31.5,29.44,21.53,29.44,,,,,,LH T3 TOTAL REF,300,84480,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83001,"Lab analysis to measure the gonadotropin, follicle stimulating (reproductive hormone) level [HCPCS 83001]",149.63,149.63,149.63,139.86,102.29,139.86,,,,,,"LH COPPER SERUM, REF",300,82525,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83002,"Lab analysis to measure the gonadotropin, luteinizing (reproductive hormone) level [HCPCS 83002]",149.63,149.63,149.63,139.86,102.29,139.86,,,,,,LH BUN BODY FLUID REF,300,84520,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,73.61,53.83,73.61,,,,,,LH CREATININE BODY FLUID REF,300,82570,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83498,"Lab analysis to measure the hydroxyprogesterone, 17-d (synthetic hormone) level [HCPCS 83498]",212.63,212.63,212.63,198.75,198.75,198.75,,,,,,LH VITAMIN E REF,300,84446,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,44.16,32.3,44.16,,,,,,LH HERPES PCR DNA AMP REF,300,87529,$275.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],70.88,70.88,70.88,66.25,48.45,66.25,,,,,,LH ALUMINUM REF,300,82108,$196.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,88.33,64.6,88.33,,,,,,LH ALK PHOS ISOENZYME REF,300,84080,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83615,Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615],47.25,47.25,47.25,44.16,32.3,44.16,,,,,,LH ANTI LKM-1 REF,300,86376,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83655,Lab analysis to measure the lead level in blood specimen [HCPCS 83655],94.5,94.5,94.5,88.33,88.33,88.33,,,,,,LH HELICOBACTER PYLORI STOOL REF,300,87338,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],55.13,55.13,55.13,51.53,37.69,51.53,,,,,,LH CARBAMAZEPINE FREE REFF,300,80156,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83721,Lab analysis to measure the LDL cholesterol level [HCPCS 83721],86.63,86.63,86.63,80.97,59.22,80.97,,,,,,LH TICIHOMONAS CULTURE VAGINAL REF,300,87081,$55.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,51.53,37.69,51.53,,,,,,LH CYCLIC CITRILLINATED PEPTIDE REF,300,86200,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],307.13,307.13,307.13,287.07,209.95,287.07,,,,,,LH COLD HEMAGGLUTININS TITER REF,300,86157,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],165.38,165.38,165.38,154.58,113.05,154.58,,,,,,"LH RBC, FOLATE REF",300,82747,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],149.63,149.63,149.63,139.86,102.29,139.86,,,,,,LH BENZODIAZEPINE PANEL REF,300,80346,$221.11 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,132.49,96.9,132.49,,,,,,LH MEASLES ANTIBODY IGG REF,300,86765,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84402,Lab analysis to measure free testosterone (hormone) level in serum specimen [HCPCS 84402],204.75,204.75,204.75,191.38,191.38,191.38,,,,,,LH FASTTSH,300,84443,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],204.75,204.75,204.75,191.38,139.97,191.38,,,,,,LH BIOINTACT PTH REF,300,82310,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84425,Lab analysis to measure the vitamin B-1 (thiamine) level in blood specimen [HCPCS 84425],165.38,165.38,165.38,154.58,154.58,154.58,,,,,,LH SERUM OXLATE(OXALIC ACID) REF,300,83945,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],70.88,70.88,70.88,66.25,48.45,66.25,,,,,,LH ALPHA 1 ANTI QN REF,300,82103,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,125.14,91.52,125.14,,,,,,LH TBHCG2,300,84702,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",39.38,39.38,39.38,36.81,26.92,36.81,,,,,,LH LD ISO ENZYME REF,300,83625,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",39.38,39.38,39.38,36.81,26.92,36.81,,,,,,LH ACETYL CHOLINE REF,300,84238,$291.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84466,Lab analysis to measure the transferrin (iron binding protein) level in serum specimen [HCPCS 84466],102.38,102.38,102.38,95.69,95.69,95.69,,,,,,LH FRUCTOSAMINE REF,300,82985,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",110.25,110.25,110.25,103.05,75.37,103.05,,,,,,LH VITAMIN B1 (THIAMINE) REF,300,84425,$165.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",133.88,133.88,133.88,125.14,91.52,125.14,,,,,,LH ZINC REF,300,84630,$86.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,88.33,64.6,88.33,,,,,,LH FDP-FIBINOGEN DEGRATION PRODUCTS AG,300,85362,$55.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,36.81,26.92,36.81,,,,,,LH RSV DFA SERUM REF,300,87280,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",118.13,118.13,118.13,110.42,80.75,110.42,,,,,,LH MANGANESE REF,300,83785,$193.33 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],63,63,63,58.89,43.07,58.89,,,,,,LH CHROMIUM REF,300,82495,$157.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],15.75,15.75,15.75,14.72,10.77,14.72,,,,,,LH CADMIUM REF,300,82300,$189.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,58.89,43.07,58.89,,,,,,LH ANTIPHOSPHOLIPID PANEL REF,300,86146,$196.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,85379,Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379],78.75,78.75,78.75,73.61,53.83,73.61,,,,,,LH HCG SERUM QUALITATIVE REF,300,84703,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,29.44,21.53,29.44,,,,,,LH RSV SWAB,300,87807,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,22.09,16.15,22.09,,,,,,"LH BLOOD TYPE AG,EACH",300,86902,$23.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],47.25,47.25,47.25,44.16,32.3,44.16,,,,,,LH CD-4 CELL COUNT REF,300,86361,$212.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],94.5,94.5,94.5,88.33,64.6,88.33,,,,,,LH KEPPRA(LEVETIRACETAM) REF,300,80299,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,36.81,26.92,36.81,,,,,,LH MYASTHENIA GRAVIS PANEL 2 REF,300,84238,$291.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86317,Lab analysis to identify infectious agent antibodies (quantitative) [HCPCS 86317],118.13,118.13,118.13,110.42,80.75,110.42,,,,,,LH HPV TYPING DNA REF,300,87999,$171.33 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],118.13,118.13,118.13,110.42,80.75,110.42,,,,,,LH HEPATITIS D IGM REF,300,86692,$312.56 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],47.25,47.25,47.25,44.16,32.3,44.16,,,,,,LH HEPATITIS E IGG REF,300,86790,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],488.25,488.25,488.25,456.37,333.77,456.37,,,,,,LH HEPATITIS E IGM REF,300,86790,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86592,Lab analysis to screen for syphilis [HCPCS 86592],31.5,31.5,31.5,29.44,21.53,29.44,,,,,,LH NICOTINE(COTININE) REF,300,80323,$189.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86618,Lab analysis to identify antibodies to Borrelia burgdorferi (Lyme disease bacteria) [HCPCS 86618],133.88,133.88,133.88,125.14,91.52,125.14,,,,,,LH CMV QUANT REF,300,87497,$338.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86762,Lab analysis to identify antibodies to Rubella (German measles virus) [HCPCS 86762],110.25,110.25,110.25,103.05,75.37,103.05,,,,,,LH WBC CSF,300,85032,$34.73 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86769,Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769],95.55,95.55,95.55,89.31,89.31,89.31,,,,,,LH RBC MANUAL CSF,300,85032,$34.73 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86780,Lab analysis to identify antibodies to Treponema pallidum [HCPCS 86780],102.38,102.38,102.38,95.69,69.99,95.69,,,,,,LH GLUCOSE CSF,300,82945,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86787,Lab analysis to identify antibodies to varicella-zoster virus (chicken pox) [HCPCS 86787],102.38,102.38,102.38,95.69,95.69,95.69,,,,,,LH TOTAL PROTEIN ELECTRO CSF,300,84166,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],110.25,110.25,110.25,103.05,75.37,103.05,,,,,,LH LDH CSF,300,83615,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86812,"Lab analysis to evaluate autoimmune disease, A, B, or C (single antigen) [HCPCS 86812]",204.75,204.75,204.75,191.38,191.38,191.38,,,,,,LH COMPELMENT C5 REF,300,86160,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86850,Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850],78.75,78.75,78.75,73.61,53.83,73.61,,,,,,LH CORTISOL SALIVARY REF,300,82533,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86900,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900],23.63,23.63,23.63,22.09,16.15,22.09,,,,,,LH CARNITIRE REF,300,82379,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,86901,Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901],23.63,23.63,23.63,22.09,16.15,22.09,,,,,,LH LACTIC ACID,300,83605,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],395.91,395.91,395.91,370.06,270.64,370.06,,,,,,LH PYRIDOINE PYRIDOXAL VIT B6 REF,300,84207,$220.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",70.88,70.88,70.88,66.25,48.45,66.25,,,,,,LH SENSORY NEUROPATHY PROFILE REF,300,83516,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],63,63,63,58.89,43.07,58.89,,,,,,LH ALPHA 1-ANTITRYSPIN PHENO SERUM,300,82104,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87081,Lab analysis to screen for pathogenic organisms [HCPCS 87081],55.13,55.13,55.13,51.53,37.69,51.53,,,,,,LH CO-71 SOLUBLE TRANSFERRIN REC REF,300,84238,$291.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,58.89,43.07,58.89,,,,,,LH VANCOMYCIN TROUGH REF,300,80202,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],63,63,63,58.89,43.07,58.89,,,,,,LH VANCOMYCIN PEAK REF,300,80202,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",70.88,70.88,70.88,66.25,48.45,66.25,,,,,,LH JAK2 MUTATION REF,300,81270,$724.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87210,"Lab analysis of wet mount to identify bacteria, fungi, or parasites [HCPCS 87210]",47.25,47.25,47.25,44.16,32.3,44.16,,,,,,LH ACETO ACETIC ACID REF,300,82010,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87220,"Lab analysis of wet mount from skin, hair, or nails to examine tissue fungi or parasites [HCPCS 87220]",31.5,31.5,31.5,29.44,21.53,29.44,,,,,,LH BETA-HYDRO-BUTYL REF,300,82010,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.82,108.82,108.82,101.71,74.39,101.71,,,,,,LH LEGIONELLA PNEUMOHPLIA SERUM REF,300,86713,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87340,Lab analysis by immunoassay (ELISA) to identify Hepatitis B surface antigen [HCPCS 87340],78.75,78.75,78.75,73.61,53.83,73.61,,,,,,LH PARVOVIRUS B19 AB,300,86747,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87389,Lab analysis by immunoassay (ELISA) to identify HIV-1 and HIV-2 [HCPCS 87389],189,189,189,176.66,129.2,176.66,,,,,,LH ANTI-HU AB WEST BLOT REF,300,84181,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,58.38,42.7,58.38,,,,,,LH PM-SCI ANTIBODIES REF,300,86235,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],236.25,236.25,236.25,220.82,161.5,220.82,,,,,,LH PNEUMOCCAL AG UA REF,300,86403,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87522,Lab analysis to measure the amount of Hepatitis C virus [HCPCS 87522],338.63,338.63,338.63,316.52,316.52,316.52,,,,,,LH INHIBIN A REF,300,86336,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],275.63,275.63,275.63,257.63,188.42,257.63,,,,,,LH CCP ANTIBODY REF,300,86200,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],157.91,157.91,157.91,147.6,107.95,147.6,,,,,,LH ALLERGY TEST EGGS REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,102.82,75.2,102.82,,,,,,LH ALLERGY EGG WHITE REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,125.14,91.52,125.14,,,,,,LH HERPES TYPE II REF,300,86696,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,87807,Lab analysis by immunoassay to identify respiratory syncytial virus (RSV) [HCPCS 87807],102.38,102.38,102.38,95.69,69.99,95.69,,,,,,LH VON WILLEBRAND FACTOR PANEL REF,300,85730,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,88142,Lab analysis of vaginal or cervical cells (pap test) with manual screening under physician supervision [HCPCS 88142],157.5,157.5,157.5,147.22,147.22,147.22,,,,,,"LH VITAMIN D 1,25 DI HYDRO REF",300,82652,$307.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,522.62,382.22,522.62,,,,,,LH VITAMIN B 6 REF,300,84207,$220.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,88342,Pathology lab analysis of special stained specimen slides to examine tissue (initial procedure) [HCPCS 88342],842.63,842.63,842.63,787.61,576.02,787.61,,,,,,LH FACTOR VIII (8) REF,300,85240,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,69.92,51.14,69.92,,,,,,LH FACTOR X (10) REF,300,85260,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,33.37,24.4,33.37,,,,,,LH PRO-8 (CARDIC),300,84484,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,119.02,87.05,119.02,,,,,,LH VENIPUNCTURE,300,36415,$23.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,93015,"Heart and blood vessel stress test with EKG monitoring, physician supervision, interpretation, and report (exercise or drug-induced) [HCPCS 93015]",226.89,226.89,226.89,212.07,166.2,212.07,,,,,,LH INFLAMMATORY BOWEL DISEASE REF,300,86671,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,108.45,79.32,108.45,,,,,,LH T- PROTEIN FLUID REF,300,84157,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,93225,"External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]",376.55,376.55,376.55,351.96,257.41,351.96,,,,,,LH INTRAOSSEUS SUPPLIES,270,LH300687,$416.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],118,118,118,110.29,80.66,110.29,,,,,,LH LDH FLUID REF,300,LH300688,$87.98 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,669.83,489.89,669.83,,,,,,LH THROMBOSIS PANEL REF,300,85303,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,93971,"Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]",477.86,477.86,477.86,446.66,350.03,446.66,,,,,,LH KETONES SERUM REF,300,82010,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],79.71,79.71,79.71,74.5,54.49,74.5,,,,,,LH ANA PROFILE REF,300,86038,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,95249,Continuous sugar (glucose) level monitoring in tissue fluid with sensor under skin [HCPCS 95249],182.66,182.66,182.66,170.73,124.87,170.73,,,,,,LH SULFATE UA REF,300,84392,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,95250,Continuous sugar (glucose) level monitoring (minimum of 72 hours) [HCPCS 95250],280,280,280,261.72,261.72,261.72,,,,,,LH ALCOHOL DOT,300,82075,$97.24 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,95810,"Sleep pattern monitoring of patient in sleep lab, sleep staging with 4 or more parameters of sleep (6 years of age or older) [HCPCS 95810]",2755.06,2755.06,2755.06,2575.15,1883.36,2575.15,,,,,,LH IGA SUBCLASSES REF,300,82784,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,95811,Sleep pattern monitoring of patient in sleep lab with continued pressured respiratory assistance by mask or breathing tube (6 years of age or older) [HCPCS 95811],2879.07,2879.07,2879.07,2691.07,1968.13,2691.07,,,,,,LH PROTEINASE-3 ANTIBODY REF,300,86021,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,201.8,147.59,201.8,,,,,,LH PROTIME INR WC,300,85610,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,79.67,58.27,79.67,,,,,,LH MTHFR  REF,300,81270,$724.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,419.57,306.85,419.57,,,,,,LH BCA X 2 REF,300,87040,$78.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",137.53,137.53,137.53,128.55,94.02,128.55,,,,,,LH BCAN X 3 REF,300,87040,$78.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,83.92,61.37,83.92,,,,,,LH BCA X 2 REF,300,87040,$263.94 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,233.72,170.93,233.72,,,,,,LH BCAN X 3 REF,300,87040,$395.91 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,96.69,70.72,96.69,,,,,,LH GENTAMICIN PEAK REF,300,80170,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,44.36,32.44,44.36,,,,,,LH LYSOZYME SERUM REF,300,85549,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,112.53,82.3,112.53,,,,,,LH DRUG SCREEN 10 - MEDICARE,300,G0481,$115.76 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,116.86,85.46,116.86,,,,,,LH MYELOPEROXIDASE AB REF,300,86021,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,111.37,81.45,111.37,,,,,,LH ALLERGY MEADOW GRASS REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,103.87,75.97,103.87,,,,,,LH ALLERGY RYE GRASS REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,315.09,230.44,315.09,,,,,,LH ALLERGY WHEAT REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,315.09,230.44,315.09,,,,,,LH EBV VIRUS PANEL REF NUCL AG,300,86664,$118.13 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],231.98,231.98,231.98,216.83,158.58,216.83,,,,,,LH RESP ALLERGY PROFILE REF QUANTITATI,300,82785,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97802,Medical nutrition therapy assessment and intervention (each 15 minutes) [HCPCS 97802],99.44,99.44,99.44,92.95,67.98,92.95,,,,,,LH IGD   REF,300,82784,$70.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,97803,Medical nutrition therapy re-assessment and intervention (each 15 minutes) [HCPCS 97803],86.18,86.18,86.18,80.55,80.55,80.55,,,,,,LH IGG LATEX REF,300,86001,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],20,20,20,18.69,13.67,18.69,,,,,,LH FIS BCR/ABL REF,300,88271,$165.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,209.63,153.32,209.63,,,,,,LH GROWTH HORMONE REF,300,83003,$133.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,314.01,229.66,314.01,,,,,,LH TOXOPLASMA ANTIBODIES REF,300,86777,$110.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,573.94,419.76,573.94,,,,,,LH BABESIA AB,300,86753,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,833.09,609.29,833.09,,,,,,LH ANAPLASMA PHAGOCYTOPHILUM REF,300,86666,$78.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,25.97,18.99,25.97,,,,,,LH MYGOLOBIN SERUM REF,300,83874,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1387.17,1014.52,1387.17,,,,,,LH CARDIO CRP REF,300,86141,$102.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,A0434,Specialty care transport [HCPCS A0434],2399.25,2399.25,2399.25,2242.58,1757.45,2242.58,,,,,,LH REVERSE T3 REF,300,84482,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,A4590,Special casting material [HCPCS A4590],241.94,241.94,241.94,226.14,165.39,226.14,,,,,,LH RAST(MILK ALLERGY) REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,199.09,145.61,199.09,,,,,,LH LDL,300,83721,$86.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,139.86,102.29,139.86,,,,,,LH NORWALK VIRUS REF,300,87449,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,1354.71,990.78,1354.71,,,,,,"LH MICROALBUMIN, URINE QUANT",300,82043,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,137.63,100.65,137.63,,,,,,LH ALBUMIN FLUID REF,300,82042,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1354.71,990.78,1354.71,,,,,,LH REDUCE SUBSTANCE STOOL REF,300,84376,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,G0390,Trauma respons w/hosp criti [HCPCS G0390],3386.05,3386.05,3386.05,3164.94,2314.7,3164.94,,,,,,LH PRO-10(CHOL/LDL),300,82465,$31.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J0897,Denosumab injection [HCPCS J0897],30.26,30.26,30.26,28.28,22.17,28.28,,,,,,LH PRO-11(HDL/LDL),300,83718,$63.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J1170,Hydromorphone injection [HCPCS J1170],23,23,23,21.5,15.72,21.5,,,,,,LH PRO-12(TRIG/LDL),300,84478,$47.25 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],23,23,23,21.5,15.72,21.5,,,,,,LH BUPRENORPHINE REF,300,80348,$365.81 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],11.5,11.5,11.5,10.75,7.86,10.75,,,,,,LH VASOPRESSIN REF,300,84588,$267.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],23,23,23,21.5,15.72,21.5,,,,,,LH RAST(BERMUD. GRASS) REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,43,31.45,43,,,,,,LH RAST (TIMOTHY GRASS) REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J2550,Promethazine hcl injection [HCPCS J2550],2.16,2.16,2.16,2.02,1.48,2.02,,,,,,LH RAST (HOUSE DUST H1) REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",4.15,4.15,4.15,3.88,2.84,3.88,,,,,,LH RAST (HOUSE DUST H2) REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J2765,Metoclopramide hcl injection [HCPCS J2765],23,23,23,21.5,15.72,21.5,,,,,,LH ROCKY MOUNTAIN SF(SPOTTED FEVER),300,86757,$149.63 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,6.21,4.54,6.21,,,,,,LH SRP AUTO ANTIBODY REF,300,86235,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],23,23,23,21.5,15.72,21.5,,,,,,LH MI-2 AUTO ANTIBODY REF,300,LH300738,$170.17 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.53,1.12,1.53,,,,,,LH DEXA SURPRRESSION REF,300,82533,$126.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],11.5,11.5,11.5,10.75,7.86,10.75,,,,,,LH H1N1 REF,300,LH300740,$0.00 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,21.64,15.83,21.64,,,,,,LH BETA 2-GLY PRO ANTI REF,300,86146,$196.88 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,51.41,37.6,51.41,,,,,,LH URIC ACID CRYSTALS OTH SOURCE REF,300,84560,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],53.5,53.5,53.5,50.01,36.57,50.01,,,,,,LH VITAMIN A(RETINOL) REF,300,84590,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,51.41,37.6,51.41,,,,,,LH VITAMIN B2 (RIBOFLAVIN) REF,300,84252,$157.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],22.05,22.05,22.05,16.27,14.52,16.27,,,,,,LH BLOOD COUNT; HEMOGLOBIN,300,85018,$15.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1328.95,1328.95,1328.95,980.77,410.25,980.77,,,,,,LH FACTOR X CHROMOGEMIC REF,300,85260,$141.75 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,121.32,50.75,121.32,,,,,,LH HEPATITIS CHRONIC PANEL 1 HBCAB TOT,300,86704,$94.50 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,209.31,87.55,209.31,,,,,,LH COFFEE IGE REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Commercial-Mut Defined,Skilled Nursing Facility,Professional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],896.36,896.36,896.36,661.51,276.71,661.51,,,,,,LH STRAWBERRY IGE REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,17000,Destruction of pre-cancerous skin lesion/growth (first lesion/growth) [HCPCS 17000],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,LH PEANUT IGE REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,130.59,121.87,130.59,,,,,,LH ORANGE IGE REF,300,86003,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,54.8,51.14,69.92,,,,,,LH TB GOLD REF,300,86480,$488.25 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,26.15,24.4,33.37,,,,,,LH M-TP,300,84156,$31.50 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,"LH OXCODONE, QL URINE REF",300,80365,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,96127,Emotional or behavioral assessment for screening of condtions like ADHD or depression with scoring and documentation (brief assessment) [HCPCS 96127],13.13,13.13,13.13,9.62,9.62,12.27,,,,,,LH CREATININE 24/HR URINE,300,82570,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,LH IMMUNOHISTOCHEMISTRY REF,300,88342,$236.16 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,LH FTA-ABS REF,300,86780,$102.38 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,LH VENIPUNCTURE,300,36415,$23.63 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,LH VENIPUNCTURE X 3,300,36415,$23.63 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,86.62,86.62,86.62,,,,,,LH TISSUE LEVEL 3 X2 REF,300,88304,$322.88 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,LH TISSUE LEVEL 3 X3 REF,300,88304,$322.88 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,144.35,144.35,144.35,,,,,,LH TISSUE LEVEL 3 X 4 REF,300,88304,$322.88 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,366.17,341.72,366.17,,,,,,LH TISSUE LEVEL 3 X 5 REF,300,88304,$322.88 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,G0439,"Ppps, subseq visit [HCPCS G0439]",312,312,312,228.54,213.28,228.54,,,,,,LH TISSUE LEVEL 3 X 6 REF,300,88304,$322.88 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,G0511,Ccm/bhi by rhc/fqhc 20min mo [HCPCS G0511],177.16,177.16,177.16,129.77,129.77,129.77,,,,,,LH TISSUE LEVEL 4 X 2 REF,300,88305,$559.13 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,G2025,Dis site tele svcs rhc/fqhc [HCPCS G2025],96.63,96.63,96.63,70.78,70.78,70.78,,,,,,LH TISSUE LEVEL 4 X 3 REF,300,88305,$559.13 
SANFORD HEALTH PLAN - Medicare Part A,Clinic,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,52.79,52.79,67.36,,,,,,LH TISSUE LEVEL 4 X 4 REF,300,88305,$559.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH TISSUE LEVEL 4 X 5 REF,300,88305,$559.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH TISSUE LEVEL 4 X 6 REF,300,88305,$559.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH PROT/CREAT UA RATIO,300,82570,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH BK VIRUS PCR QUANT. REF,300,87799,$338.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH CORTISOL 24HR UA REF,300,82530,$133.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH TESTESTERONE BIO REF,300,82040,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,LH C-DIFF DNA-PCR REF,300,87493,$291.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,LH SELENIUM REF,300,84255,$204.75 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,LH FRANCISELLA TULAREMIA REF,300,86000,$55.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,LH FUNGAL DISEASE ANTI ASPERGIL REF,300,86606,$118.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],328.49,328.49,328.49,240.62,240.62,240.62,,,,,,LH QUAD SCREEN PANEL  REF,300,81511,$370.06 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,20553,Trigger points injection into 3 or more muscles [HCPCS 20553],841.05,841.05,841.05,616.07,616.07,616.07,,,,,,LH HYDROCODONE REF,300,80361,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,616.07,574.94,786.13,,,,,,"LH VIRUS ISOLATION,SHELL VIAL",300,87254,$96.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,29581,Vein wound compression system application to lower leg below knee including ankle and foot [HCPCS 29581],354.7,354.7,354.7,259.82,242.47,259.82,,,,,,LH PROTEIN ELECTRO REFLEX IFE REF,300,84155,$31.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH NEUTROPHIL ANTIBODY REF,300,86021,$118.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,36591,Blood specimen collection from a completely implantable venous access device [HCPCS 36591],196.88,196.88,196.88,144.21,144.21,144.21,,,,,,LH T-CELL GENE STUDY BETA REF,300,81340,$480.42 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH COXSACKIE B PANEL REF,300,86658,$102.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH VITAMIN B3 NIACIN,300,84591,$133.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,490.7,457.94,626.16,,,,,,LH GLUCOSE 6 PHOSPHATE QUANTITATIVE,300,82955,$78.75 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",808.5,808.5,808.5,592.23,552.69,755.7,,,,,,LH SHBG,300,84270,$173.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,73.99,69.05,94.41,,,,,,LH CULTURE SCREEN ONLY,300,87081,$55.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH BORDETELLA PERTUSSIS CULTURE,300,87081,$55.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,71250,"Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]",918.23,918.23,918.23,672.6,627.7,858.27,,,,,,LH BORDETELLA PERTUSSIS PCR,300,87798,$275.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,837.58,781.66,1068.78,,,,,,"LH FECAL FAT,TOTAL QUANT",300,82710,$133.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,119.56,111.58,152.56,,,,,,LH MERCURY QUANT,300,83825,$126.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,72040,Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,LH SUPER SATURATION PROFILE/URINE 24HR,300,LH300798,$781.40 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,"LH ACETONE,BLOOD",300,82010,$63.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,72141,Imaging of upper spinal canal by MRI without contrast [HCPCS 72141],1954.58,1954.58,1954.58,1431.73,1336.15,1826.95,,,,,,"LH SERUM  BY RED CELL ABSORPTION,EACH",300,86978,$120.58 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1431.73,1336.15,1826.95,,,,,,"LH ANTIBODY ID,EACH PANEL",300,86870,$354.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73000,"Collar bone x-ray, complete study [HCPCS 73000]",120.44,120.44,120.44,88.22,82.33,88.22,,,,,,"LH DIRECT ANTIHUMAN GLOBULIN,EACH",300,86880,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73020,Shoulder x-ray (single view) [HCPCS 73020],81.59,81.59,81.59,59.76,55.77,59.76,,,,,,"LH ANTIBODY ELUTION,EACH",300,86860,$259.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,LH EXTENDED PHENOTYPE RBC EXCL ABO RH(,300,86905,$31.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,110.99,103.58,126.16,,,,,,"LH RED CELL PRE-TREATMENT,EACH",300,86970,$112.30 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1516.71,1415.46,1935.39,,,,,,"LH RH PHENOTYPING,COMPLETE",300,86906,$63.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,LH NOROVIRUS RNA STOOL,300,87798,$275.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,96.76,90.3,123.46,,,,,,LH OPIATE CONFORMATION URINE,300,80361,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,"LH FENTANYL & NORFENTANL,URINE",300,80354,$162.07 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73650,Foot x-ray at heel of foot (minimum of 2 views) [HCPCS 73650],108.78,108.78,108.78,79.68,74.36,101.68,,,,,,"LH AG CLASS I (E,K)",300,86880,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1510.18,1409.36,1927.05,,,,,,LH URO RISK,300,LH300811,$600.81 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],112.67,112.67,112.67,82.53,77.02,105.31,,,,,,LH NEUTROPHIL FUNCTION,300,82657,$173.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",1160.78,1160.78,1160.78,850.27,793.51,1084.98,,,,,,LH TPMT ACTIVITY,300,82657,$173.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1395.96,1302.77,1781.3,,,,,,LH COXSACKIE ANTIBODY,300,86658,$102.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,261.81,244.33,334.08,,,,,,"LH NOROVIRUS RNA,RT_PCR",300,87798,$275.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,76775,Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775],229.22,229.22,229.22,167.9,156.69,167.9,,,,,,LH TSI (THYROID STIMULATING IMMUNOGLOB,300,84445,$401.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,76870,Imaging of scrotum by ultrasound [HCPCS 76870],202.59,202.59,202.59,148.4,148.4,148.4,,,,,,LH TPMT ACTIVITY MASS SPECTOMETRY,300,83789,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,LH LEUKEMIA/LYMPHOMA EVALUATION 1ST MA,300,88184,$535.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,"LH CULTURE,YEAST/ID",300,87102,$63.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,LH MITOCHONDRIA M2 ANTIBODY,300,83520,$133.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,LH OXYCODONE CONFORMATION GC/MS URINE,300,80635,$175.96 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",63,63,63,46.15,43.07,58.89,,,,,,LH METHADONE GC/MS URINE,300,80358,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,80305,Drug screening read by direct visual reading [HCPCS 80305],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,LH HYPERSENSITIVITY PNEUMONITIS EVAL I,300,86609,$102.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH ASPERGILLUS FUMIGATUS (M3) IGE,300,86003,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,LH PCP,300,83992,$338.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH COCAINE,300,80353,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,LH TRICYCLIC ANTI DEPRESSANTS,300,80335,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],236.25,236.25,236.25,173.05,161.5,220.82,,,,,,LH BARBITURATE GC/MS URINE,300,80345,$175.96 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,LH MYCOBACTERIUM TUBERCULOSIS COMPLEX ,300,87556,$330.75 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,82652,"Lab analysis to measure the dihydroxyvitamin D, 1, 25 level in serum or plasma specimen [HCPCS 82652]",307.13,307.13,307.13,224.97,209.95,224.97,,,,,,LH PORT&LINE DRAW,300,36591,$196.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,LH CAPILLARY DRAW,300,36416,$23.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,69.22,64.6,88.33,,,,,,LH METHYLMALONIC ACID GC/MS/MC,300,83921,$165.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,LH CASEIN (F78) IGG,300,86003,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,83721,Lab analysis to measure the LDL cholesterol level [HCPCS 83721],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,LH ALLERGEN GLUTEN IGG,300,86001,$26.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,LH STREP PNEUMONIAE IGG ANTIBODY (23 S,300,86317,$118.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],307.13,307.13,307.13,224.97,209.95,287.07,,,,,,LH LEISHMANIA ANTIBODY (IGG),300,86717,$178.28 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,103.83,96.9,132.49,,,,,,"LH C1 INHIBITOR,FUNCTIONAL",300,86161,$94.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,"LH C1 ESTERASE INHIBITOR,PROTEIN",300,86160,$94.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH HELICOBACTER PYLORI STOOL,300,87338,$110.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH CALPROTECTIN STOOL,300,83993,$157.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,LH ANCA VASCULITIDES,300,86021,$118.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH ALDOSTERONE/RENIN RATIO LC/MS/MS,300,82088,$322.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,"LH CALPROTECTIN,STOOL",300,83993,$157.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,23.07,21.53,29.44,,,,,,LH STRONGYLOIDES AB (IGG),300,86682,$102.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,LH PDGFRA,300,81314,"$1,003.66 "
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,LH T-CELL RECEPTOR (TCR) BETA GENE,300,81340,$673.74 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],395.91,395.91,395.91,290,270.64,370.06,,,,,,LH LYME DISEASE,300,87801,$551.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,87077,Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077],63,63,63,46.15,43.07,58.89,,,,,,LH MALARIA IFA SCREEN,300,86750,$83.07 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,46.15,43.07,58.89,,,,,,LH MICROFILARIAE DETECTION,300,87210,$47.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,87088,Lab analysis of urine culture to identify bacteria [HCPCS 87088],63,63,63,46.15,43.07,58.89,,,,,,"LH BUPRENOPHINE,QUANT,URINE",300,80348,$175.96 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,87186,"Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]",70.88,70.88,70.88,51.92,48.45,66.25,,,,,,LH IGF BINDING PROTEIN-3,300,83520,$110.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,45.75,42.7,58.38,,,,,,LH VON WILLEBRAND FACTOR ANTIGEN,300,85246,$181.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,"LH WEST NILE VIRUS,RNA",300,87798,$275.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,LH VORICONAZOLE LC/MS/MS,300,80299,$149.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,409.56,382.22,522.62,,,,,,LH PREALBUMIN,300,84134,$118.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,LH COLLAGEN TYPE 1 C-TELOPEPTIDE (CTX),300,82523,$149.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,84.99,79.32,108.45,,,,,,LH THYROID CANCER MARKER AB,300,86800,$126.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],118,118,118,86.44,80.66,110.29,,,,,,LH DHEA UNCONJUGATED,300,82626,$196.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,LH THC/RATIO URINE,300,80349,$86.82 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],784.77,784.77,784.77,574.84,536.47,574.84,,,,,,"LH BENZODIAZEPINES, QUANTITATIVE",300,80346,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,93976,"Abdominal, pelvic, and/or scrotal arterial inflow and venous outflow ultrasound (limited study) [HCPCS 93976]",644.91,644.91,644.91,472.4,472.4,472.4,,,,,,LH STREP GROUP B ANTIGEN,300,86403,$94.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,LH ANTI-MULLERIAN HORMONE,300,83520,$133.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,62.44,58.27,79.67,,,,,,LH DRUG SCREEN 1-7 CLASSES,300,G0480,$115.76 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,328.8,306.85,419.57,,,,,,LH FECAL GLOBIN IMMUNO SCRN,300,82274,$126.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",137.53,137.53,137.53,100.74,94.02,128.55,,,,,,LH FECAL GLOBIN IMMUNO,300,82274,$126.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,LH CYANIDE BLOOD,300,82600,$201.43 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,183.16,170.93,233.72,,,,,,LH VARICELLA-ZOSTER VIRUS AB ACIF,300,86787,$102.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,75.78,70.72,96.69,,,,,,LH COCCIDIOIDES ANTIBODIES TO TP&F ANT,300,86635,$86.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96413,"Chemotherapy administration into vein by infusion (up to 1 hour, single drug) [HCPCS 96413]",887.54,887.54,887.54,650.12,606.72,650.12,,,,,,LH VDRL,300,86592,$31.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,96415,Chemotherapy administration into vein by infusion (each additional hour) [HCPCS 96415],190.89,190.89,190.89,139.83,130.49,139.83,,,,,,"LH WEST NILE VIRUS AB,IGM",300,86788,$133.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,34.76,32.44,44.36,,,,,,LH BLASTOMYCES,300,86612,$162.07 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,LH HISTOPLASMA,300,86698,$123.87 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,91.58,85.46,116.86,,,,,,LH MRSA SCREEN,300,87081,$55.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,87.28,81.45,111.37,,,,,,LH HEPATITIS B SURFACE AB,300,86317,$118.13 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,81.4,75.97,103.87,,,,,,LH HEPATITIS B CORE AB IGM,300,86705,$94.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,LH QUANTIFERON TB FOLD,300,86480,$488.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,LH URINALYSIS AUTO W/O MICRO,300,81003,$15.75 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97165,Occupational therapy evaluation (typically 30 minutes) [HCPCS 97165],269.72,269.72,269.72,197.57,184.38,197.57,,,,,,LH SEX HORMONE BINDING GLOBULIN (SHGB),300,84270,$173.25 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,97535,Training activities for home and self-care management (each 15 minutes) [HCPCS 97535],137.76,137.76,137.76,100.91,94.17,100.91,,,,,,LH URINE PREGNANCY TEST,300,81025,$70.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],108.82,108.82,108.82,79.71,79.71,79.71,,,,,,LH OLANZAPINE (ZYPRESA),300,80342,$189.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],405.17,405.17,405.17,296.79,296.79,296.79,,,,,,LH URINE PREGNANCY TEST BY VISUAL COLO,300,81025,$70.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],116.39,116.39,116.39,85.26,79.56,85.26,,,,,,LH CYSTIC FIBROSIS SCREEN,300,81220,$162.07 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,LH LEVETIRACTAM,300,80177,$102.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,LH ESTROGENS FRACTIONATED,300,82671,$252.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,LH IGA SUBCLASSES REF,300,82784,$246.57 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,LH C.DIFF-IA,300,87449,$94.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,LH C.DIFF-TOXINS,300,87324,$94.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,A0434,Specialty care transport [HCPCS A0434],2399.25,2399.25,2399.25,1757.45,1757.45,2242.58,,,,,,"LH HBV DNA,QUANT,PCR",300,87517,$338.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.75,2.56,2.75,,,,,,"LH EBV DNA, QUANT PCR",300,87799,$338.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,156.02,145.61,199.09,,,,,,"LH CULTURE URINE,COLONY COUNT",300,87086,$63.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,109.6,102.29,139.86,,,,,,LH CULTURE SESNITIVITY ENZYME,300,87185,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,"LH CULTURE TYPING,IMMUNOLOGIC",300,87147,$39.38 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,107.85,100.65,137.63,,,,,,LH ANA TITER PATTERN REF,300,86039,$86.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,LH SALM/SHIG CULTURE REF,300,87045,$70.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,G0378,Hospital observation per hr [HCPCS G0378],50.66,50.66,50.66,37.11,34.63,42.18,,,,,,LH CAMPY CULTURE,300,87046,$70.88 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,J0897,Denosumab injection [HCPCS J0897],30.26,30.26,30.26,22.17,22.17,28.28,,,,,,LH SHRGA TOXINS ECOLI,300,87427,$94.50 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,J1745,Infliximab not biosimil 10mg [HCPCS J1745],126.57,126.57,126.57,92.71,86.52,92.71,,,,,,LH ANAEROBIC CULTURE ID,300,87076,$63.00 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,"LH O&P SMEAR,COMPLEX STAIN",300,87209,$141.75 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,J2785,Regadenoson injection [HCPCS J2785],152.56,152.56,152.56,111.75,111.75,111.75,,,,,,"LH CULTURE DEF ID,FUNGAL MOLD",300,87107,$78.75 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,J3262,Tocilizumab injection [HCPCS J3262],10.09,10.09,10.09,7.39,7.39,7.39,,,,,,LH FISH BCR/ABL IP SITU 100-200 CELLS ,300,88275,$401.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.7,1.59,1.7,,,,,,LH PREGNENOLONE,300,84140,$95.70 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,LH INFLIXIMAB LEVEL,300,80230,$149.63 
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Outpatient,J7050,Normal saline solution infus [HCPCS J7050],53.5,53.5,53.5,39.19,36.57,50.01,,,,,,"LH THYROGLOBULIN,IMMUNO",300,84432,$126.00 
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,LH ANTIBODY TITER,300,86886,$39.38 
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,LH FRAGILE X ALLELES,300,82144,$100.33 
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,LH CHROMOSOMAL MICROARRAY,300,81229,"$1,751.90 "
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,LH AMINO ACID ANALYSIS 2 TO 5 QUANT EA,300,82136,$161.36 
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,LH PYRUVIC ACID,300,84210,$56.30 
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,LH ACYLCARNITINE QUANT EA SPEC,300,82017,$133.88 
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,"LH ORGANIC ACIDS QUAL,URINE",300,83919,$126.00 
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,"LH AMINO ACID ANALYSIS,PLASMA 6/> QUAN",300,82139,$133.88 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,20553,Trigger points injection into 3 or more muscles [HCPCS 20553],841.05,841.05,841.05,616.07,616.07,616.07,,,,,,LH DRUG SCREEN 10 - NON-MEDICARE,300,80306,$133.88 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,20600,Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600],841.05,841.05,841.05,616.07,574.94,616.07,,,,,,LH HYDROMORPHONE,300,80361,$189.00 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,616.07,574.94,786.13,,,,,,HC ONCOHEME NGS,300,81450,"$3,750.85 "
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH ANTI-DRUG AB,300,83520,$133.88 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,LH ADALIMUMAB LEVEL,300,80145,$149.63 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,130.59,121.87,130.59,,,,,,"LH PHOSPHATIDYLSERINE ANTIBODIES (IGG,",300,86148,$60.57 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,62323,Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323],2216.55,2216.55,2216.55,1623.62,1623.62,1623.62,,,,,,LH ANTIPHOSPHOLIPID ANTIBODIES (IGG & ,300,83516,$94.50 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,76942,Ultrasound guidance for needle placement including imaging supervision of procedure and interpretation of results [HCPCS 76942],160,160,160,117.2,109.38,117.2,,,,,,"LH CULTURE FUNGAL (NOT SKIN,HAIR,NAIL)",300,87102,$63.00 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,LH FUNGAL SMEAR FLUORES/AF STAIN,300,87206,$39.38 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,LH JAK2 V617F QUALITATIVE,300,81270,$724.50 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,LH HANTAVIRUS ANTIBODY IGG,300,86790,$102.38 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,144.35,144.35,144.35,,,,,,LH HANTAVIRUS ANTIBODY IGM,300,86790,$102.38 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,23650,Dislocated shoulder treatment with manipulation (closed treatment) [HCPCS 23650],860.41,860.41,860.41,265.61,265.61,265.61,,,,,,LH KLEIHAUER-BETKE STAIN,300,85460,$63.00 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,55.04,55.04,55.04,,,,,,LH SICKLE CELL SCREEN,300,85660,$47.25 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],206.06,206.06,206.06,63.61,63.61,152.07,,,,,,LH OCCULT BLOOD IMMUNO-MEDICARE SCREEN,300,G0328,$141.75 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,7.06,7.06,15.07,,,,,,LH OCCULT BLOOD FECAL GLOBIN IMMUNO,300,82274,$126.00 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,18.63,18.63,18.63,,,,,,LH CONCENTRATION FOR INFECTIOUS AGENTS,300,87015,$55.13 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,12.47,12.47,12.47,,,,,,LH GENERAL HEALTH PANEL,300,80050,$370.13 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,50.75,50.75,121.32,,,,,,"LH CULTURE,MYCOBACTERIUM (AFB)",300,87116,$28.57 
SANFORD HEALTH PLAN - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,87.55,87.55,209.31,,,,,,"LH CUTURE DEF ID,FUNGAL,YEAST",300,87106,$78.75 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,731,"Anesthesia provided during esophagus, stomach, and/or upper small bowel procedure with endoscope [HCPCS 00731]",22.05,22.05,22.05,16.27,14.52,16.27,,,,,,"LH CANDIDA SPECIES,DIRECT PROBE",300,87480,$157.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],22.05,22.05,22.05,16.27,14.52,16.27,,,,,,"LH GARDNERELLA VAGINALIS,DIRECT PROBE",300,87510,$157.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],22.05,22.05,22.05,16.27,14.52,16.27,,,,,,"LH TRICHOMONAS VAGINALIS,DIRECT PROBE",300,87660,$157.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,10060,Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060],328.49,328.49,328.49,242.43,216.31,242.43,,,,,,LH HEPATITIS BE AG,300,87350,$94.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,11104,Skin lesion biopsy with punch tool to remove sample including all layers of skin (single lesion) [HCPCS 11104],136.61,136.61,136.61,100.82,89.96,100.82,,,,,,LH HEPATITIS BE AB,300,86707,$94.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,12031,"Intermediate repair of wound of scalp, underarms, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12031]",819.3,819.3,819.3,604.64,604.64,604.64,,,,,,LH HCV QUANT RT PCR,300,87522,$338.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,12032,"Intermediate repair of wound of scalp, underarms, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12032]",823.01,823.01,823.01,607.38,541.95,607.38,,,,,,LH ESCHERICHIA COLI 0157 CULTURE,300,87046,$70.88 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,12051,"Intermediate repair of wound of face, ears, eyelids, nose, lips, and/or mouth (2.5 cm or less) [HCPCS 12051]",10619.59,10619.59,10619.59,7837.26,7837.26,7837.26,,,,,,"LH ADENOVIRUS ANTIGEN,EIA",300,87301,$64.68 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,17110,Destruction of non-cancerous skin lesions/growths other than skin tags (up to 14 lesions/growths) [HCPCS 17110],304.71,304.71,304.71,224.88,200.65,224.88,,,,,,"LH NOROVIRUS,EIA,STOOL",300,87449,$94.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],228.9,228.9,228.9,168.93,70.66,168.93,,,,,,LH INFLIXIMAB ANTI DRUG ANTIBODY,300,,$133.88 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,25600,Broken forearm bone treatment at the wrist area on the thumb side of the wrist without manipulation (closed treatment) [HCPCS 25600],763.49,763.49,763.49,563.46,563.46,563.46,,,,,,LH CULTURE ID BY DNA SEQUENCING,300,87153,$905.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,29125,Short arm splint application forearm to hand (non-moveable) [HCPCS 29125],185.22,185.22,185.22,136.69,121.97,136.69,,,,,,"LH NEUTRALIZATION TEST,VIRAL",300,86382,$83.56 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.44,13.87,17.44,,,,,,"LH WHEY,IGE",300,86003,$39.38 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],55.13,55.13,55.13,40.69,32.35,40.69,,,,,,"LH CASEIN,IGE",300,86008,$23.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1021.2,1021.2,1021.2,753.65,315.24,753.65,,,,,,LH PROCALCITONIN,300,84145,$212.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],539.46,539.46,539.46,398.12,355.23,398.12,,,,,,LH POSACONAZOLE,300,80187,$244.56 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1328.95,1328.95,1328.95,980.77,410.25,980.77,,,,,,LH ACETYLCHOLINE RECEPTOR BINDING ANTI,300,83519,$141.75 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,69209,Impacted ear wax removal by washing [HCPCS 69209],321.86,321.86,321.86,237.53,211.94,237.53,,,,,,LH ACETYLCHOLINE RECEPTOR MODULATING A,300,83519,$141.75 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,70150,Facial bones x-ray for injuries or lesions (minimum of 3 views) [HCPCS 70150],178.71,178.71,178.71,131.89,131.89,131.89,,,,,,LH ACETYLCHOLINE RECEPTOR BLOCKING ANT,300,83519,$141.75 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,70450,"Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]",669.9,669.9,669.9,494.39,494.39,494.39,,,,,,LH SUSCEPTIBILITY DISK METHOD PER PLAT,300,87184,$55.13 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,70486,"Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]",808.5,808.5,808.5,596.67,596.67,596.67,,,,,,"LH DRUG TEST PRES,CHEM ANALYZER",300,80307,$488.25 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,74.55,74.55,74.55,,,,,,LH SKELETAL MUSCLE RELAXANT 1-2,300,80369,$101.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,94.62,94.62,94.62,,,,,,LH DRUG TEST NOS,300,80375,$93.89 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,71260,"Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]",1143.45,1143.45,1143.45,843.87,843.87,843.87,,,,,,"LH H PYLORI,UREA BREATH TEST",300,83013,$527.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,108.95,108.95,108.95,,,,,,LH MSH2 GENE FULL SEQ,300,81295,"$1,092.14 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,72125,"Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]",906.68,906.68,906.68,669.13,669.13,669.13,,,,,,LH MSH2 GENE DUP.DELETE VARIANT,300,81297,$610.30 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,72170,Pelvis x-ray (1 or 2 views) [HCPCS 72170],112.67,112.67,112.67,83.15,83.15,83.15,,,,,,LH MLH1 GENE FULL SEQ,300,81292,"$1,932.49 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,72202,X-ray of joints at hip bone and sacrum (3 or more views) [HCPCS 72202],147.63,147.63,147.63,108.95,108.95,108.95,,,,,,LH MLH1 GENE DUP/DELETE VARIANT,300,81294,$579.12 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73010,Shoulder blade x-ray complete study [HCPCS 73010],108.78,108.78,108.78,80.28,80.28,80.28,,,,,,LH MSH6 GENE FULL SEQ,300,81298,"$1,836.49 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,94.62,94.62,94.62,,,,,,LH MSH6 GENE DUP/DELETE VARIANT,300,81300,$680.98 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],112.67,112.67,112.67,83.15,83.15,83.15,,,,,,LH PMS2 GENE FULL SEQ,300,81317,"$1,935.63 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73090,Arm x-ray of forearm (2 views) [HCPCS 73090],112.67,112.67,112.67,83.15,83.15,83.15,,,,,,LH PMS2 GENE DUP/DELETE VARIANT,300,81319,$582.27 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,111.82,111.82,111.82,,,,,,LH MOPATH PROCEDURE LEVEL 4,300,81403,$529.90 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73130,Hand x-ray (minimum of 2 views) [HCPCS 73130],135.98,135.98,135.98,100.35,100.35,100.35,,,,,,LH YERSINA CULTURE,300,87046,$70.88 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73140,Finger(s) x-ray (minimum of 2 views) [HCPCS 73140],139.86,139.86,139.86,103.22,103.22,103.22,,,,,,"LH LRBC,IRRADIATED EA UNIT",390,P9040,$844.32 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1528.1,1528.1,1528.1,,,,,,LH EHRLICHIA CHAFFEENSIS,300,86666,$78.75 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,97.48,97.48,97.48,,,,,,"LH TRICHOMONAS VAGINALIS RNA, AMP QUAL",300,87661,$275.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,111.82,111.82,111.82,,,,,,LH HLA A29 BIRDSHOT RETINOCHOROIDOPATH,300,81374,$582.75 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,94.62,94.62,94.62,,,,,,LH ARSENIC,300,82175,$149.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73650,Foot x-ray at heel of foot (minimum of 2 views) [HCPCS 73650],108.78,108.78,108.78,80.28,80.28,80.28,,,,,,LH NON-CDC CORONAVIRUS (COVID-19),300,U0002,$205.54 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,80.28,80.28,80.28,,,,,,LH P190 BCR-ABL1,300,81207,"$1,141.88 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1521.52,1521.52,1521.52,,,,,,LH P210 BCR-ABL1,300,81206,"$1,291.50 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,74176,"Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]",1160.78,1160.78,1160.78,856.66,856.66,856.66,,,,,,LH CORONAVIRUS (COVID-19) PCR,300,87635,$110.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1406.44,1406.44,1406.44,,,,,,"LH VIT D 25-OH,TOTAL",300,82306,$236.25 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,74183,"Imaging of abdomen by MRI without contrast, followed by contrast [HCPCS 74183]",3525.38,3525.38,3525.38,2601.73,2601.73,2601.73,,,,,,LH TRAB,300,83520,$133.88 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],454.55,454.55,454.55,335.46,335.46,335.46,,,,,,LH ZONISAMIDE,300,80203,$102.38 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,76801,"Abdominal ultrasound of pregnant uterus during first trimester, less than 14 weeks 0 days (single or first fetus) [HCPCS 76801]",477.86,477.86,477.86,352.66,352.66,352.66,,,,,,"LH ALLERGEN SPECIFIC IGE,EACH",300,86003,$39.38 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,76817,Vaginal ultrasound of pregnant uterus with imaging documentation [HCPCS 76817],376.85,376.85,376.85,278.12,278.12,278.12,,,,,,"LH ASPERGILLUS ANTIGEN,EIA,SERUM",300,87305,$94.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,76830,Imaging of pelvis by ultrasound through vagina [HCPCS 76830],481.74,481.74,481.74,355.52,355.52,355.52,,,,,,LH ASPERGILLUS FUMIGATUS (M3) IGG,300,86001,$63.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,76856,"Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]",431.24,431.24,431.24,318.26,318.26,318.26,,,,,,"LH BILE ACIDS,TOTAL",300,82239,$133.88 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,73.1,73.1,73.1,,,,,,LH ACTIVATED PROTEIN C RESISTANCE,300,85307,$118.13 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,395.66,395.66,395.66,,,,,,LH TRICYCLIC & CYCLICALS 6 OR MORE,300,80337,$114.43 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,77080,"Bone density measurement of the axial skeleton (hips, pelvis, spine) [HCPCS 77080]",155.4,155.4,155.4,114.69,114.69,114.69,,,,,,LH ANTIDEPRESSANT NOT SPECIFIED,300,80338,$114.43 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],206.06,206.06,206.06,152.07,63.61,152.07,,,,,,LH ANTIDEPRESSANTS CLASS 1 OR 2,300,80332,$91.43 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.49,36.97,46.49,,,,,,"LH CORONAVIRUS (COVID-19) ANTIBODY,IGG",300,86769,$95.55 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.93,50.83,63.93,,,,,,LH IGG SUBCLASS,300,82787,$63.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,75.56,60.08,75.56,,,,,,"LH HEPATITIS A AB, TOTAL",300,86708,$94.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",63,63,63,46.49,46.49,46.49,,,,,,LH CORONAVIRUS (COVID-19) ANTIGEN,300,87426,$62.46 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80183,Lab analysis to measure the amount of oxcarbazepine in serum or plasma specimen [HCPCS 80183],65.48,65.48,65.48,48.32,48.32,48.32,,,,,,"LH PREGABLIN,URINE,QUANT",300,80366,$168.22 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80197,Lab analysis to measure the amount of tacrolimus in blood specimen [HCPCS 80197],110.25,110.25,110.25,81.36,81.36,81.36,,,,,,"LH PREGABLIN,URINE,QUANT,MEDICARE",300,G0480,$168.22 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80202,Lab analysis to measure the amount of vancomycin (antibiotic) in serum specimen [HCPCS 80202],110.25,110.25,110.25,81.36,81.36,81.36,,,,,,"LH DRUG SCREEN,URINE,PP DIR OBS",300,80305,$102.38 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80306,Drug screening read by direct visual reading with instrument assistance [HCPCS 80306],133.88,133.88,133.88,98.8,98.8,98.8,,,,,,LH HCV SCREEN HIGH RISK INDIV AND OTHE,300,G0472,$112.29 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],62.69,62.69,62.69,46.27,46.27,46.27,,,,,,"LH SELENIUM, BLOOD",300,84255,$204.75 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.44,17.44,17.44,,,,,,LH SOLUBLE TRANSFERRIN RECEPTOR,300,84238,$291.38 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.62,11.62,11.62,,,,,,LH AMYLASE ISOENZYME,300,82150,$47.25 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82040,"Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]",39.38,39.38,39.38,29.06,29.06,29.06,,,,,,"LH LYME DISEASE ANTIBODIES CONFIRM,EAC",300,86617,$67.86 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.87,34.87,34.87,,,,,,LH LYSOZYME (RK208) IGE,300,86003,$22.88 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82150,Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150],47.25,47.25,47.25,34.87,34.87,34.87,,,,,,LH SM MUSCLE AB TITER,300,86256,$52.79 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82247,Lab analysis to measure the total bilirubin level [HCPCS 82247],39.38,39.38,39.38,29.06,29.06,29.06,,,,,,LH HBV SCREEN NON-PREG HIGH RISK INDIV,300,G0499,$123.84 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82306,Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306],236.25,236.25,236.25,174.35,174.35,174.35,,,,,,LH MYCOPHENOLIC ACID,300,80180,$136.05 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82533,Lab analysis to measure the amount of total cortisol (hormone) [HCPCS 82533],126,126,126,92.99,92.99,92.99,,,,,,LH PANCREATIC ELASTASE-1,300,83520,$329.28 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],39.38,39.38,39.38,29.06,29.06,29.06,,,,,,"LH RHEUMATOID FACTOR,EACH",300,83520,$75.65 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82607,Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607],118.13,118.13,118.13,87.18,87.18,87.18,,,,,,LH HIV-1 RNA QUANT PCR,300,87536,$372.79 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82627,Lab analysis to measure the dehydroepiandrosterone (DHEA-S) hormone level [HCPCS 82627],173.25,173.25,173.25,127.86,127.86,127.86,,,,,,LH CRYPTOCOCCAL AG,300,86403,$50.56 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82670,Lab analysis to measure the amount of total estradiol (hormone) [HCPCS 82670],220.5,220.5,220.5,162.73,162.73,162.73,,,,,,"LH FLUNITRAZEPAM, QUANT, SERUM",300,80346,$155.82 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,81.36,81.36,81.36,,,,,,"LH FLUNITRAZEPAM, QUANT, SERUM (MEDICA",300,G0480,$155.82 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83013,Lab analysis to identify helicobacter pylori in breath specimen [HCPCS 83013],527.63,527.63,527.63,389.39,389.39,389.39,,,,,,"LH FLUNITRAZEPAM, QUANT, URINE",300,80346,$221.84 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,58.12,58.12,58.12,,,,,,"LH FLUNITRAZEPAM, QUANT, (MEDICARE)",300,G0480,$221.84 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83516,Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516],94.5,94.5,94.5,69.74,69.74,69.74,,,,,,LH ARTERIAL PUNCTURE,300,36600,$92.81 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,34.87,34.87,34.87,,,,,,LH COVIDE COLLECTION FEE,300,C9803,$33.79 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],70.88,70.88,70.88,52.31,52.31,52.31,,,,,,"LH BILE ACIDS,PREGNANCY",300,82542,$173.02 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,69.74,69.74,69.74,,,,,,LH COVID COLLECTION FEE,300,G2023,$34.49 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],55.13,55.13,55.13,40.69,40.69,40.69,,,,,,LH DRUG SCREENING - URINE (DOT COLL.),300,LH301595,$52.09 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83721,Lab analysis to measure the LDL cholesterol level [HCPCS 83721],86.63,86.63,86.63,63.93,63.93,63.93,,,,,,LH EXAM LEVEL III BLOOD DRAW & UA,300,LH301596,$119.24 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,40.69,40.69,40.69,,,,,,LH EXAM LEVEL II BLOOD DRAW & UA,300,LH301597,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84075,Lab analysis to measure the phosphatase (enzyme) level (alkaline) [HCPCS 84075],39.38,39.38,39.38,29.06,29.06,29.06,,,,,,LH EXAM LEVEL I QUESTIONNAIRE,300,LH301598,$55.57 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84132,Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132],39.38,39.38,39.38,29.06,29.06,29.06,,,,,,LH LONG TERM CARE EXAM,300,LH301599,$173.65 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84144,Lab analysis to measure the progesterone (reproductive hormone) level in serum specimen [HCPCS 84144],165.38,165.38,165.38,122.05,122.05,122.05,,,,,,LH EASY CAP II CO2 DETECTOR,270,LH400380,$23.15 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84146,Lab analysis to measure the prolactin (milk producing hormone) level in serum specimen [HCPCS 84146],149.63,149.63,149.63,110.43,110.43,110.43,,,,,,LH TETANUS-DIPTH-PERTUSSIS (ADACEL),636,90715,$35.70 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,104.61,104.61,104.61,,,,,,LH PREVENT ANTI-REFLUX FILTER (BARD),270,LH420756,$20.27 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84403,Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403],204.75,204.75,204.75,151.11,151.11,151.11,,,,,,LH FILTER LINE CO2 MONITOR SET,270,,$44.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84425,Lab analysis to measure the vitamin B-1 (thiamine) level in blood specimen [HCPCS 84425],165.38,165.38,165.38,122.05,122.05,122.05,,,,,,LH FLUID WARMING SET HOTLINE (INJ PORT,270,LH420759,$31.26 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84436,Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436],55.13,55.13,55.13,40.69,40.69,40.69,,,,,,LH FLU VACCINATION IIV3 SPLT 0.5ML IM,636,90658,$11.55 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],70.88,70.88,70.88,52.31,41.59,52.31,,,,,,LH FLU VACCINATION IIV3 SPLT 0.5ML IM,636,90658,$11.55 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,98.8,78.56,98.8,,,,,,LH MOISTURE BARRIER W/ANTI FUNGAL,270,LH421131,$11.58 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",39.38,39.38,39.38,29.06,29.06,29.06,,,,,,LH PICC LINE-STAT LOCK SUPPLY,270,LH421446,$23.15 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",39.38,39.38,39.38,29.06,29.06,29.06,,,,,,LH THUMB SPICA SPLINT-PROCARE,270,L3999,$34.73 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84478,Lab analysis to measure the triglycerides level in serum or plasma specimen [HCPCS 84478],47.25,47.25,47.25,34.87,34.87,34.87,,,,,,LH SPIROMETRY-THE BREATHER DEVICE,270,LH422243,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84480,"Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]",110.25,110.25,110.25,81.36,81.36,81.36,,,,,,LH PNEUMOCCAL PPSV23 VACCINE 2/> YO,636,90732,$119.70 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",133.88,133.88,133.88,98.8,98.8,98.8,,,,,,LH PNEUMOCCAL PPSV23 VACCINE 2/> YO,636,90732,$119.70 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,69.74,69.74,69.74,,,,,,LH ANESTHESIA EAR,370,120,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,29.06,29.06,29.06,,,,,,LH ANESTHESIA TYMPANOTOMY,370,126,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84630,"Lab analysis to measure the zinc level in blood, serum, or urine specimen [HCPCS 84630]",86.63,86.63,86.63,63.93,63.93,63.93,,,,,,LH ANESTHESIA EYE PROC NOS,370,140,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,84702,"Lab analysis to measure the gonadotropin, chorionic (reproductive hormone) level in serum specimen [HCPCS 84702]",118.13,118.13,118.13,87.18,87.18,87.18,,,,,,LH ANESTHESIA LENS SURGERY/MINUTE,370,142,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,85014,Lab analysis to measure red blood cell concentration [HCPCS 85014],15.75,15.75,15.75,11.62,11.62,11.62,,,,,,LH ANESTHESIA IRIDECTOMY,370,147,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,85018,Lab analysis to measure blood count (hemoglobin) [HCPCS 85018],15.75,15.75,15.75,11.62,11.62,11.62,,,,,,LH ANESTHESIA LESION RML SOFT TISSUE B,370,164,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.49,36.97,46.49,,,,,,LH ANESTHESIA T&A,370,170,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,85610,Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610],31.5,31.5,31.5,23.25,18.48,23.25,,,,,,LH ANESTHESIA HEAD/NECK/PTRUNK,370,300,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,17.44,17.44,17.44,,,,,,"LH ANESTHESIA SKIN,EXT,TRUNK",370,400,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,85730,Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730],47.25,47.25,47.25,34.87,34.87,34.87,,,,,,LH ANESTHESIA BREAST RADIAL OR MODIFIE,370,404,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86038,Lab analysis to screen for autoimmune disorders [HCPCS 86038],94.5,94.5,94.5,69.74,69.74,69.74,,,,,,LH ANESTHESIA ELECT CONV ARRYTHM,370,410,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,29.06,29.06,29.06,,,,,,LH ANESTHESIA UPPER GASTRO ENDOSCOPIC ,370,731,$22.05 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86255,Lab analysis to screen for antibody to noninfectious agents [HCPCS 86255],189,189,189,139.48,139.48,139.48,,,,,,LH ANESTHESIA EGD,370,740,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86308,Lab analysis to screen for mononucleosis (mono) [HCPCS 86308],39.38,39.38,39.38,29.06,29.06,29.06,,,,,,LH ANESTHESIA HERNIA RPR UPPER ABD,370,750,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86317,Lab analysis to identify infectious agent antibodies (quantitative) [HCPCS 86317],118.13,118.13,118.13,87.18,87.18,87.18,,,,,,"LH ANESTHESIA,SURGERY INTRAPERITONEAL ",370,790,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],118.13,118.13,118.13,87.18,87.18,87.18,,,,,,LH ANESTHESIA COLONOSCOPY EXCL SCRN,370,810,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86431,Lab analysis to measure rheumatoid factor level [HCPCS 86431],47.25,47.25,47.25,34.87,34.87,34.87,,,,,,LH ANESTHESIA LOWER INTESTINAL ENDOSCO,370,811,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],488.25,488.25,488.25,360.33,360.33,360.33,,,,,,LH ANESTHESIA SCREENING COLONOSCOPY PR,370,812,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86618,Lab analysis to identify antibodies to Borrelia burgdorferi (Lyme disease bacteria) [HCPCS 86618],133.88,133.88,133.88,98.8,98.8,98.8,,,,,,LH ANESTHESIA COMBINED UPPER & LOWER G,370,813,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86780,Lab analysis to identify antibodies to Treponema pallidum [HCPCS 86780],102.38,102.38,102.38,75.56,75.56,75.56,,,,,,LH ANESTHESIA INGUINAL HERNIA,370,830,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],110.25,110.25,110.25,81.36,81.36,81.36,,,,,,LH ANESTHESIA REPAIR OF HERNIA V&A LWR,370,832,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],78.75,78.75,78.75,58.12,58.12,58.12,,,,,,LH ANESTHESIA APPENDECTOMY,370,840,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",70.88,70.88,70.88,52.31,52.31,52.31,,,,,,LH ANESTHESIA ANORECTAL PROCEDURE,370,902,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,46.49,46.49,46.49,,,,,,LH ANESTHESIA CYSTOSCOPY,370,910,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.81,108.81,108.81,80.3,80.3,80.3,,,,,,LH ANESTHESIA SURG MALE GENITALIA,370,920,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87340,Lab analysis by immunoassay (ELISA) to identify Hepatitis B surface antigen [HCPCS 87340],78.75,78.75,78.75,58.12,58.12,58.12,,,,,,LH ANESTHESIA VASECTOMY UNILAT/BILAT,370,921,$17.37 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,46.1,36.65,46.1,,,,,,LH ANESTHESIA D&C,370,940,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87491,Lab analysis by nucleic acid (DNA or RNA) to identify chlamydia trachomatis by amplified probe technique [HCPCS 87491],236.25,236.25,236.25,174.35,174.35,174.35,,,,,,"LH ANESTHESIA LOWER LEG,ANKLE,FOOT CLO",370,1462,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87591,Lab analysis by nucleic acid (DNA or RNA) to identify Neisseria gonorrhoeae (gonorrhoeae bacteria) by amplified probe technique [HCPCS 87591],275.63,275.63,275.63,203.41,203.41,203.41,,,,,,LH ANESTHESIA OPEN PROC LOWER EXT NERV,370,1470,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87624,Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624],110.53,110.53,110.53,81.57,81.57,81.57,,,,,,"LH ANESTHESIA OPEN BONES,LOWER LEG,ANK",370,1480,$18.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,81.18,81.18,81.18,,,,,,SPECIAL ANESTHESIA SERVICE AGE <1 OR >,370,99100,$0.01 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,98.8,78.56,98.8,,,,,,LH POLYPECTOMY SNARE,270,45386,$57.89 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,87807,Lab analysis by immunoassay to identify respiratory syncytial virus (RSV) [HCPCS 87807],102.38,102.38,102.38,75.56,75.56,75.56,,,,,,LH BIOPSY FORCEPS-LG CAPACITY W/NEEDLE,270,45387,$67.15 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,88142,Lab analysis of vaginal or cervical cells (pap test) with manual screening under physician supervision [HCPCS 88142],157.5,157.5,157.5,116.24,103.71,116.24,,,,,,LH COLONOSCOPY SPOT INK MARKER,270,LH45389,$46.31 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],254.68,254.68,254.68,187.95,187.95,187.95,,,,,,LH BIOPSY FORCEPS-JUMBO CAP W/NEEDLE,270,LH45391,$101.87 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,88342,Pathology lab analysis of special stained specimen slides to examine tissue (initial procedure) [HCPCS 88342],236.16,236.16,236.16,174.29,174.29,174.29,,,,,,LH SPLINT FABRICATION - HAND BASED,290,L3808,$691.10 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,55.21,49.26,55.21,,,,,,LH SPLINT FABRICATION-FOREARM BASED,290,L3808,$691.10 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,26.35,23.51,26.35,,,,,,LH WHIRLPOOL TREATMENT,761,97022,$95.66 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.98,83.85,93.98,,,,,,LH STRAPPING - ANKLE,420,29540,$111.38 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,93015,"Heart and blood vessel stress test with EKG monitoring, physician supervision, interpretation, and report (exercise or drug-induced) [HCPCS 93015]",226.89,226.89,226.89,167.44,149.41,167.44,,,,,,LH STRAPPING - KNEE,420,29530,$120.55 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,85.63,85.63,85.63,,,,,,LH STRAPPING ELBOW/WRIST,270,29260,$63.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,93225,"External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]",376.55,376.55,376.55,277.89,277.89,277.89,,,,,,LH GAIT BELT,270,LH48191,$16.21 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],47.84,47.84,47.84,35.31,14.77,35.31,,,,,,LH OVERDOOR PULLEY SET-UP,290,E0860,$40.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,528.87,528.87,528.87,,,,,,LH CERVICAL TRACTION UNIT-OVERDOOR,290,E0860,$81.04 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],63.67,63.67,63.67,46.99,41.93,46.99,,,,,,LH KNEE-O-PRENE HINGED KNEE SLEEVE,290,L1810,$329.92 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,95117,Allergen injection in incremental dosages (2 or more injections) [HCPCS 95117],28.71,28.71,28.71,21.19,21.19,21.19,,,,,,LH MISC. PHYSICAL THERAPY,270,LH48415,$0.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,96127,Emotional or behavioral assessment for screening of condtions like ADHD or depression with scoring and documentation (brief assessment) [HCPCS 96127],13.13,13.13,13.13,9.69,8.65,9.69,,,,,,LH HAND EXERCISER - PT,420,LH48416,$50.94 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,159.33,159.33,159.33,,,,,,LH PACKS - SALINE,270,LH48530,$23.15 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,62.91,62.91,62.91,,,,,,LH SOAKS,270,LH48550,$23.15 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,331.27,331.27,331.27,,,,,,LH TRACTION SET UP-BUCKS EXTENSION,940,LH500010,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",137.53,137.53,137.53,101.5,101.5,101.5,,,,,,LH TRACTION SET UP-CERVICAL,940,LH500020,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",74.81,74.81,74.81,55.21,43.9,55.21,,,,,,LH TRACTION SET UP-KNEE (BOHLER BRAUN),940,LH500030,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,184.54,184.54,184.54,,,,,,LH TRACTION SET UP-OVERHEAD CERVICAL,940,LH500040,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,76.35,76.35,76.35,,,,,,LH TRACTION SET UP-PELVIC,940,LH500050,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97035,Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035],47.46,47.46,47.46,35.03,35.03,35.03,,,,,,LH TRACTION SET UP-GRAVITY LUMBAR RED,940,LH500060,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.85,88.85,88.85,,,,,,LH TRACTION-BUCKS EXTENSION,940,LH500070,$40.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,92.26,92.26,92.26,,,,,,LH TRACTION-CERVICAL,940,LH500080,$40.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,82.01,82.01,82.01,,,,,,LH TRACTION-KNEE (BOHLER-BRAUN),940,LH500090,$40.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,248.78,248.78,248.78,,,,,,LH TRACTION-OVERHEAD CERVICAL,940,LH500100,$40.52 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,248.78,248.78,248.78,,,,,,LH GRAVITY LUMBAR REDUCTION,940,LH500120,$63.67 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97164,Physical therapy re-evaluation (typically 20 minutes) [HCPCS 97164],231.98,231.98,231.98,171.2,171.2,171.2,,,,,,LH TRACTION SET UP-TRAPEZE BAR,940,LH500130,$34.73 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97802,Medical nutrition therapy assessment and intervention (each 15 minutes) [HCPCS 97802],99.44,99.44,99.44,73.39,65.48,73.39,,,,,,LH 4 LAYER COMPRESSION BANDAGING SYST ,270,A6545,$34.73 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,97803,Medical nutrition therapy re-assessment and intervention (each 15 minutes) [HCPCS 97803],86.18,86.18,86.18,63.6,56.75,63.6,,,,,,LH 4 LAYER COMPRESSION BANDAGING SYST ,270,A6545,$34.73 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,150.48,134.27,150.48,,,,,,LH ADMIN OF SYNAGIS ONLY SUBQ/IM,982,96372,$74.81 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,212.97,169.34,212.97,,,,,,"LH PHYSICIAN E&M VISIT,TRMT ROOM",761,99212,$81.04 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99211,Established patient office or outpatient visit with physician or other healthcare professional to diagnose and treat illness or injury (presenting problem is minimal) [HCPCS 99211],62.79,62.79,62.79,46.34,41.35,46.34,,,,,,LH CROSS-MATCH; INCUBATION TECHNIQUE,300,86921,$69.46 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,90.15,71.68,90.15,,,,,,LH MOLECULE NUCLEIC AMPLIFICATION 2 SE,300,86334,$175.96 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,148.68,62.19,148.68,,,,,,LH MOLECULE NUCLEIC AMPLIICATION 1 ADD,300,86334,$453.79 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,215.86,171.63,215.86,,,,,,"LH NUCLEIC ACID,  HIGH RESOLUTE",300,87801,$453.79 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,289.84,230.46,289.84,,,,,,LH IMMUNHISTOCHEMISTRY,300,88342,$842.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",284.78,284.78,284.78,210.17,87.91,210.17,,,,,,LH BLOOD TYPING ABO,300,86900,$23.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],55.57,55.57,55.57,41.01,17.15,41.01,,,,,,"LH BLOOD TYPING, RH (D)",300,LH700008,$35.89 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],109.98,109.98,109.98,81.17,33.95,81.17,,,,,,LH RBC ANTIBODY IDENTIFICATION,300,86870,$142.39 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,121.32,50.75,121.32,,,,,,"LH BLOOD TYPING ABO, PATIENT SERUM",300,86900,$23.63 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,209.31,87.55,209.31,,,,,,LH SUPPLY FOR V/Q SCAN,270,LH78990,$75.24 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],458.42,458.42,458.42,338.31,141.51,338.31,,,,,,LH BASIC METABOLIC PANEL CALCIUM IONIZ,300,80047,$34.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99385,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99385],357.68,357.68,357.68,263.97,263.97,263.97,,,,,,LH NICOTINE&METABOLITES LC/MS,300,80323,$189.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99391,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (infant younger than 1 year of age) [HCPCS 99391],270.09,270.09,270.09,199.33,177.85,199.33,,,,,,LH THERAPEUTIC DRUG ASSAYS,300,80181,$139.80 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99392,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (1-4 years of age) [HCPCS 99392],287.64,287.64,287.64,212.28,189.41,212.28,,,,,,LH CHG DRUG ASSAY VEDOLIZUMAB,300,80280,$173.57 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99393,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (5-11 years of age) [HCPCS 99393],286.64,286.64,286.64,211.54,188.75,211.54,,,,,,LH URINALYSIS BY DIPSTICK OR TABLET RE,300,81002,$8.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99395,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99395],322.65,322.65,322.65,238.12,212.47,238.12,,,,,,LH ALCHOL DRUG TESTING,300,82075,$97.24 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],343.06,343.06,343.06,253.18,201.31,253.18,,,,,,LH HELICOBACTER PYLORI; DRUG ADMINISTR,300,83014,$20.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,368.92,329.18,368.92,,,,,,"HC HEMOGLOBIN, GLYCOSYLATED A1C",300,83037,$43.70 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.5,20.5,20.5,,,,,,"LH KAPPA/LAMBDA LIGHT CHAINS, FREE WIT",300,83521,$212.33 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1095.25,1095.25,1095.25,,,,,,LH BLOOD COUNT; HEMATOCRIT (HCT),300,85014,$6.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],426,426,426,314.39,314.39,314.39,,,,,,LH SUSCEPTBILTY STDY ANTIMICRBIAL AGNT,300,87181,$12.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,110.43,87.8,110.43,,,,,,LH CRYPTOSPORIDIUM AG IA,306,87328,$103.65 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],896.36,896.36,896.36,661.51,276.71,661.51,,,,,,LH INFLUENZA A/B BY PCR,300,87502,$160.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,108.66,96.96,108.66,,,,,,LH INFECTIOUS AGENT DETECTION BY NUCLE,300,87624,$157.91 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],897.31,897.31,897.31,662.21,277,662.21,,,,,,"LH INFLUEZA A/B, SARS, COV2, RSV BY PC",300,87631,$250.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,G0390,Trauma respons w/hosp criti [HCPCS G0390],3386.05,3386.05,3386.05,2498.9,2498.9,2498.9,,,,,,LH RESPIRATORY SYNCYTIAL VIRUS,300,87634,$140.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J0561,Penicillin g benzathine inj [HCPCS J0561],425.5,425.5,425.5,314.02,314.02,314.02,,,,,,LH IADNA S AUREUS METHICILLIN RESIST A,300,87641,$88.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J1940,Furosemide injection [HCPCS J1940],23,23,23,16.97,16.97,16.97,,,,,,LH GROUP A STREP BY PCR,300,87651,$70.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],23,23,23,16.97,16.97,16.97,,,,,,LH IADNA STREPTOCOCCUS GROUP B AMPLIFI,300,87653,$88.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],23,23,23,16.97,16.97,16.97,,,,,,LH IAADIADOO NOT OTHERWISE SPECIFIED,300,87899,$41.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],23,23,23,16.97,16.97,16.97,,,,,,LH CYTOPATH CERV/VAG THIN LAYER,300,88142,$157.50 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J2405,Ondansetron hcl injection [HCPCS J2405],5.75,5.75,5.75,4.24,3.79,4.24,,,,,,LH CYTOPATH C/V THIN LAYER REDO,300,88143,$123.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",4.58,4.58,4.58,3.38,3.38,3.38,,,,,,LH FLOW CYTOMETRY TECHNIQUE FOR DNA OR,300,88185,$44.76 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,4.9,4.37,4.9,,,,,,LH CELL COUNT MISCELLANEOUS BODY FLUID,300,89050,$12.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],23,23,23,16.97,16.97,16.97,,,,,,LH FLU VACCINE IIV4 SPLT 0.5ML IM,636,90688,$18.90 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.21,1.08,1.21,,,,,,LH FLU VACCINE IIV4 SPLT 0.5ML IM,636,90688,$18.19 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J3370,Vancomycin hcl injection [HCPCS J3370],11.5,11.5,11.5,8.49,8.49,8.49,,,,,,LH HOLTER PHYSICIAN REVIEW & INTERP,731,LH93272,$774.45 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J3420,Vitamin b12 injection [HCPCS J3420],2.32,2.32,2.32,1.71,1.53,1.71,,,,,,LH DIET TEACHING INITIAL 1 PT 15 MIN,942,97802,$99.44 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23,23,23,16.97,16.97,16.97,,,,,,LH DIET TEACHING F/U 1 PT 15 MIN,942,97803,$86.18 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.59,40.59,40.59,,,,,,LH DIET TEACHING GROUP 30 MIN,942,97804,$44.99 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,53.19,22.25,53.19,,,,,,LH DIETICIAN CONSULT,942,LH97805,$0.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,,Professional,Outpatient,Q9967,"Locm 300-399mg/ml iodine,1ml [HCPCS Q9967]",4.11,4.11,4.11,3.03,3.03,3.03,,,,,,LH DIABETIC TEACHING 1 PT 30 MIN,942,98960,$169.02 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,4561.97,3186.97,4561.97,,,,,,LH DIABETIC TEACH 2-4 PTS 30 MIN,942,98961,$56.72 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,2080.66,1453.54,2080.66,,,,,,LH DIABETIC TEACHING 5-8 PTS 30 MIN,942,98962,$56.72 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,8477.82,5922.57,8477.82,,,,,,LH DIABETIC TEACHING-PRE,942,LH98963,$34.73 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,12635.76,8827.29,12635.76,,,,,,LH LAB HANDLING FEE,300,99000,$20.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,12047.21,8416.13,12047.21,,,,,,LH EMERGENCY FEE,402,LH99050,$173.65 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,3232.44,2258.17,3232.44,,,,,,"LH COMFORT CALL,ER",450,99211,$122.17 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,3811.59,2662.76,3811.59,,,,,,LH LAB DRAW FEE***CLINIC USE ONLY,510,99211,$11.58 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,4597.47,3211.77,4597.47,,,,,,LH OUTREACH CONSULTS,510,99213,$65.98 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,786.13,574.94,786.13,,,,,,"LH NON ER PROCEDURES,SIG,CYSTO,STRESS",510,99215,$127.34 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,22.09,16.15,22.09,,,,,,LH OBS CARE DISCH NOT ADMITTED SAME DA,762,99217,$108.82 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,72070,Spinal x-ray of middle spine (2 views) [HCPCS 72070],124.32,124.32,124.32,116.2,84.99,116.2,,,,,,LH OBSERVATION INITIAL-LOW SEVERITY 30,762,99218,$115.76 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,137.99,100.92,137.99,,,,,,LH OBSERVATION INITIAL MODERATE SEVERI,762,99219,$187.54 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,119.84,87.64,119.84,,,,,,LH OBSERVATION INITIAL HIGH SEVERITY,762,99220,$252.37 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,76705,Abdominal ultrasound (limited) [HCPCS 76705],357.42,357.42,357.42,334.08,244.33,334.08,,,,,,LH OBSERVATION ADMIT/DISCH LOW SEVERIT,762,99234,$208.37 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,80.97,59.22,80.97,,,,,,LH OBSERVATION ADMIT/DISCH MOD SEVERIT,762,99235,$280.15 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,95.69,69.99,95.69,,,,,,LH OBSERVATION ADMIT/DISCH HIGH SEVERI,762,99236,$346.13 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,82565,Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565],39.38,39.38,39.38,36.81,26.92,36.81,,,,,,UNLISTED EVALUATION & MANAGEMENT SERVI,521,99499,$57.89 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,73.61,53.83,73.61,,,,,,LH AMBULANCE RESPONSE AND TREATMENT NO,540,A0998,$550.00 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,83721,Lab analysis to measure the LDL cholesterol level [HCPCS 83721],86.63,86.63,86.63,80.97,59.22,80.97,,,,,,"LH SCREENING CYTOPATHOLOGY, CERVICAL O",923,G0123,$91.17 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,125.14,91.52,125.14,,,,,,LH TRAUMA ACTIVATION ASSOC W/ CRIT CAR,689,G0390,"$3,386.05 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,58.89,43.07,58.89,,,,,,LH TRAUMA ACTIVATION BEYOND LEVEL IV A,689,G0390,"$3,386.05 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,112.53,82.3,112.53,,,,,,LH TRAUMA ACTIVATION LEVEL I ASSOC W/ ,681,G0390,"$3,386.05 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,25.97,18.99,25.97,,,,,,LH TRAUMA ACTIVATION LEVEL III ASSOC W,683,G0390,"$3,386.05 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1387.17,1014.52,1387.17,,,,,,LH TRAUMA ACTIVATION LEVEL IV ASSOC W/,684,G0390,"$3,386.05 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1354.71,990.78,1354.71,,,,,,LH TRAUMA ACTIVATION LEVEL II ASSOC W/,682,G0390,"$3,386.05 "
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,J2250,Inj midazolam hydrochloride [HCPCS J2250],11.5,11.5,11.5,10.75,7.86,10.75,,,,,,LH BEHAVIOR COUNSEL OBESITY 15M,942,G0447,$68.65 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,J2704,"Inj, propofol, 10 mg [HCPCS J2704]",4.15,4.15,4.15,3.88,2.84,3.88,,,,,,PR SCREEN PAP BY TECH W MD SUPV,311,P3000,$69.30 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,J3010,Fentanyl citrate injection [HCPCS J3010],23,23,23,21.5,15.72,21.5,,,,,,PR OBTAINING SCREEN PAP SMEAR,521,Q0091,$116.33 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,J3301,Triamcinolone acet inj nos [HCPCS J3301],1.64,1.64,1.64,1.53,1.12,1.53,,,,,,"PR FLUZONE VACC, 3 YRS & >, IM",636,Q2038,$28.94 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,21.64,15.83,21.64,,,,,,PR TELEHEALTH FACILITY FEE,521,Q3014,$72.07 
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,51.41,37.6,51.41,,,,,,PR REMOVAL OF SUTURES,521,S0630,$52.50 
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Clinic,Institutional,Outpatient,G2025,Dis site tele svcs rhc/fqhc [HCPCS G2025],96.63,96.63,96.63,70.78,70.78,70.78,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Clinic,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,52.79,52.79,67.36,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1395.96,1302.77,1781.3,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,76857,"Pelvis ultrasound, not pregnancy related (limited) [HCPCS 76857]",190.37,190.37,190.37,139.45,139.45,139.45,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,103.83,96.9,132.49,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,65.76,61.37,83.92,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,87.28,81.45,111.37,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,J0897,Denosumab injection [HCPCS J0897],30.26,30.26,30.26,22.17,22.17,28.28,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",192.17,192.17,192.17,59.32,59.32,126.54,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,12001,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]",474.18,474.18,474.18,347.34,324.15,443.22,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,616.07,574.94,786.13,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,27096,Anesthetic or steroid injection into hip joint with imaging guidance [HCPCS 27096],431.55,431.55,431.55,316.11,316.11,316.11,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1081.15,1008.97,1379.59,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],6570.9,6570.9,6570.9,4813.18,4491.87,6141.82,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],670.95,670.95,670.95,491.47,458.66,627.14,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,29.59,29.59,29.59,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1328.95,1328.95,1328.95,410.25,410.25,980.77,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],191.01,191.01,191.01,58.96,58.96,125.78,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Clinic,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Clinic,Institutional,Outpatient,G0071,Comm svcs by rhc/fqhc 5 min [HCPCS G0071],29.4,29.4,29.4,21.54,21.54,21.54,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,812,Anesthesia provided during diagnostic examination of large bowel with an endoscope [HCPCS 00812],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,70544,Imaging of head blood vessels by MRA without contrast [HCPCS 70544],2213.4,2213.4,2213.4,1621.32,1513.08,2068.86,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,70551,Imaging of brain by MRI without contrast [HCPCS 70551],2008.13,2008.13,2008.13,1470.96,1372.76,1470.96,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,73.99,69.05,94.41,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,73221,Imaging of arm joint by MRI without contrast [HCPCS 73221],2070.6,2070.6,2070.6,1516.71,1415.46,1935.39,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,73721,Imaging of leg joint by MRI without contrast [HCPCS 73721],2061.68,2061.68,2061.68,1510.18,1409.36,1927.05,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],1872.57,1872.57,1872.57,1371.66,1280.09,1750.29,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,69.22,64.6,88.33,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],395.91,395.91,395.91,290,270.64,370.06,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,46.15,43.07,58.89,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,45.75,42.7,58.38,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,93017,Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017],116.03,116.03,116.03,84.99,79.32,108.45,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],784.77,784.77,784.77,574.84,536.47,574.84,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,62.44,58.27,79.67,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,328.8,306.85,419.57,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,96366,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]",137.53,137.53,137.53,100.74,94.02,128.55,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,183.16,170.93,233.72,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,75.78,70.72,96.69,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,81.4,75.97,103.87,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,A0428,Bls [HCPCS A0428],1250.24,1250.24,1250.24,915.8,915.8,915.8,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.75,2.56,2.75,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,A9500,Tc99m sestamibi [HCPCS A9500],213,213,213,156.02,145.61,199.09,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,G0108,Diab manage trn  per indiv [HCPCS G0108],147.24,147.24,147.24,107.85,100.65,137.63,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,G0472,Hep c screen high risk/other [HCPCS G0472],112.29,112.29,112.29,82.25,82.25,82.25,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,29.59,29.59,29.59,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1328.95,1328.95,1328.95,410.25,410.25,980.77,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],739.73,739.73,739.73,228.35,228.35,487.11,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],206.06,206.06,206.06,63.61,63.61,152.07,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],108.82,108.82,108.82,79.71,79.71,79.71,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],115.76,115.76,115.76,84.79,84.79,96.38,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],739.73,739.73,739.73,228.35,228.35,487.11,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,78452,Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452],206.06,206.06,206.06,63.61,63.61,152.07,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,18.63,18.63,18.63,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,50.75,50.75,121.32,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],458.42,458.42,458.42,141.51,141.51,338.31,,,,,,,,,
UMR - Commercial-PPO,,Professional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,13.87,13.87,17.44,,,,,,,,,
UMR - Commercial-PPO,,Professional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,36.97,36.97,46.49,,,,,,,,,
UMR - Commercial-PPO,,Professional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,60.08,60.08,75.56,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,106.75,87.64,119.84,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1586.73,1302.77,1781.3,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],454.55,454.55,454.55,378.46,310.73,424.87,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,77080,"Bone density measurement of the axial skeleton (hips, pelvis, spine) [HCPCS 77080]",155.4,155.4,155.4,129.39,106.23,145.25,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,52.45,43.07,58.89,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,72.13,59.22,80.97,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,85.24,69.99,95.69,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,13.11,10.77,14.72,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,39.34,32.3,44.16,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,65.57,53.83,73.61,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,111.47,91.52,125.14,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84450,"Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]",39.38,39.38,39.38,32.79,26.92,36.81,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,84460,"Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]",39.38,39.38,39.38,32.79,26.92,36.81,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,52.45,43.07,58.89,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],110.25,110.25,110.25,91.79,75.37,103.05,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,52,42.7,58.38,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,91.59,75.2,102.82,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,111.47,91.52,125.14,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,87807,Lab analysis by immunoassay to identify respiratory syncytial virus (RSV) [HCPCS 87807],102.38,102.38,102.38,85.24,69.99,95.69,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,90471,"Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]",74.81,74.81,74.81,62.29,51.14,69.92,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,90686,"Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent, preservation free) [HCPCS 90686]",35,35,35,29.14,29.14,32.71,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,95117,Allergen injection in incremental dosages (2 or more injections) [HCPCS 95117],38.2,38.2,38.2,31.81,31.81,35.71,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,70.97,58.27,79.67,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96365,"Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]",448.88,448.88,448.88,373.74,306.85,419.57,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,86.13,70.72,96.69,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,100.24,82.3,112.53,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,99.2,81.45,111.37,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,280.67,230.44,315.09,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,240.27,211.38,269.74,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,101.71,83.51,114.18,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,167.74,137.72,188.31,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,243.53,199.95,273.39,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,327,268.48,367.09,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,511.25,419.76,573.94,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,124.58,102.29,139.86,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J3480,Inj potassium chloride [HCPCS J3480],13.2,13.2,13.2,10.99,9.02,10.99,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,45.79,37.6,51.41,,,,,,,,,
UMR - Commercial-PPO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,118.22,62.19,148.68,,,,,,,,,
UMR - Commercial-PPO,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,171.63,171.63,215.86,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,72.13,59.22,80.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,13.11,10.77,14.72,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,82550,Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550],55.13,55.13,55.13,45.9,37.69,51.53,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,52.45,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,32.79,26.92,36.81,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,179.76,147.59,201.8,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,279.71,229.66,314.01,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,45.79,37.6,51.41,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,12002,"Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]",577.24,577.24,577.24,480.61,394.6,539.55,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,106.75,87.64,119.84,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,126.16,103.58,126.16,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,113.22,92.96,127.1,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,73630,"Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]",128.21,128.21,128.21,106.75,87.64,119.84,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,90.57,74.36,101.68,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,74018,Abdominal x-ray (single view) [HCPCS 74018],112.67,112.67,112.67,93.81,77.02,105.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,76536,Head and neck ultrasound [HCPCS 76536],454.55,454.55,454.55,378.46,310.73,424.87,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,52.45,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,72.13,59.22,80.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,85.24,69.99,95.69,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,80069,Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069],70.88,70.88,70.88,59.01,48.45,59.01,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,13.11,10.77,14.72,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,82248,Lab analysis to measure the direct bilirubin level [HCPCS 82248],39.38,39.38,39.38,32.79,26.92,36.81,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,82570,Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570],39.38,39.38,39.38,32.79,26.92,32.79,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,82728,Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728],110.25,110.25,110.25,91.79,75.37,103.05,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,65.57,53.83,73.61,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,83540,Lab analysis to measure the iron level [HCPCS 83540],47.25,47.25,47.25,39.34,32.3,44.16,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,83550,Lab analysis to measure the iron binding capacity [HCPCS 83550],70.88,70.88,70.88,59.01,48.45,66.25,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,78.68,64.6,88.33,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,45.9,37.69,51.53,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,83970,Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970],322.88,322.88,322.88,268.83,220.72,268.83,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,84156,Lab analysis to measure the total protein level in urine specimen [HCPCS 84156],31.5,31.5,31.5,26.23,21.53,26.23,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,84439,Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439],70.88,70.88,70.88,59.01,48.45,66.25,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,111.47,91.52,125.14,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,84481,"Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]",133.88,133.88,133.88,111.47,91.52,125.14,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,32.79,26.92,36.81,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,52.45,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,85027,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]",47.25,47.25,47.25,39.34,32.3,39.34,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,85652,Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,86140,Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140],39.38,39.38,39.38,32.79,26.92,36.81,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,86376,Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376],118.13,118.13,118.13,98.36,80.75,110.42,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,86480,Lab analysis to idenitfy tuberculosis (TB) by gamma interferon release assay [HCPCS 86480],488.25,488.25,488.25,406.52,333.77,456.37,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,86800,Lab analysis to identify antibodies to thyroglobulin (thyroid protein) [HCPCS 86800],126,126,126,104.91,86.13,104.91,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],395.91,395.91,395.91,329.63,270.64,370.06,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.82,108.82,108.82,90.6,74.39,101.71,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,52,42.7,58.38,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,91.59,75.2,102.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,111.47,91.52,125.14,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,90715,"Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]",35.7,35.7,35.7,29.72,24.4,33.37,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,179.76,147.59,201.8,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,100.24,82.3,112.53,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,92.53,75.97,103.87,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,280.67,230.44,315.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99000,Specimen handling and/or conveyance for transfer from physician office to laboratory [HCPCS 99000],20,20,20,16.65,13.67,18.69,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,169.77,149.36,190.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,240.27,211.38,269.74,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,167.74,137.72,188.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,243.53,199.95,273.39,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,327,268.48,367.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,186.74,153.32,209.63,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,279.71,229.66,314.01,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,511.25,419.76,573.94,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99396,Established patient well visit (preventive medicine re-evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99396],343.06,343.06,343.06,285.63,285.63,320.66,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,99441,Telephone evaluation and management visit with physician to diagnose and treat illness or injury (5-10 minutes of medical discussion) [HCPCS 99441],36.75,36.75,36.75,30.6,30.6,30.6,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,124.58,102.29,139.86,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,J3490,Drugs unclassified injection [HCPCS J3490],23.15,23.15,23.15,19.27,15.83,21.64,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,45.79,37.6,51.41,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,60.01,52.79,67.36,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,118.22,62.19,148.68,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,171.63,171.63,215.86,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,230.46,230.46,289.84,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Professional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,42.29,22.25,53.19,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Skilled Nursing Facility,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,186.74,153.32,209.63,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,279.71,229.66,314.01,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,166.43,87.55,209.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,72.13,59.22,80.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,80320,Lab analysis to measure alcohols levels in blood specimen [HCPCS 80320],62.69,62.69,62.69,52.2,42.85,58.6,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,52.45,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,167.74,137.72,188.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,186.74,153.32,209.63,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,16.76,16.76,21.39,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,99307,"Subsequent nursing facility visit for patient that is stable, recovering, or improving ( typically 10 minutes per day) [HCPCS 99307]",118.25,118.25,118.25,86.62,86.62,86.62,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,99495,Transitional care management services with face-to-face visits within 14 days of discharge (moderate complexity) [HCPCS 99495],499.89,499.89,499.89,366.17,341.72,366.17,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Clinic,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,52.79,52.79,67.36,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,73.99,69.05,94.41,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,72100,Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100],147.63,147.63,147.63,108.14,100.92,137.99,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,72148,Imaging of lower spinal canal by MRI without contrast [HCPCS 72148],1954.58,1954.58,1954.58,1431.73,1336.15,1826.95,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,72202,X-ray of joints at hip bone and sacrum (3 or more views) [HCPCS 72202],147.63,147.63,147.63,108.14,100.92,108.14,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,93.91,87.64,119.84,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73110,"Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]",151.52,151.52,151.52,110.99,103.58,126.16,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73502,Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502],174.83,174.83,174.83,128.06,119.51,163.41,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73521,Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521],155.4,155.4,155.4,113.83,106.23,113.83,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73560,Knee x-ray (1 or 2 views) [HCPCS 73560],132.09,132.09,132.09,96.76,90.3,123.46,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,110.99,103.58,141.63,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73564,Knee x-ray (4 or more views) [HCPCS 73564],170.94,170.94,170.94,125.21,116.85,125.21,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73610,Ankle x-ray (minimum of 3 views) [HCPCS 73610],135.98,135.98,135.98,99.61,92.96,127.1,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,73700,"Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]",900.9,900.9,900.9,659.91,615.86,659.91,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1395.96,1302.77,1781.3,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,82044,Lab analysis to identify the microalbumin (protein) in urine specimen [HCPCS 82044],47.25,47.25,47.25,34.61,32.3,44.16,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,57.68,53.83,73.61,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,87070,"Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]",70.88,70.88,70.88,51.92,48.45,66.25,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,87075,Lab analysis of any culture (except blood) to identify anaerobic bacteria [HCPCS 87075],70.88,70.88,70.88,51.92,48.45,51.92,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,87205,Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205],31.5,31.5,31.5,23.07,21.53,23.07,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,524.93,489.89,669.83,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,93880,Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880],784.77,784.77,784.77,574.84,536.47,574.84,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,96360,Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360],215.9,215.9,215.9,158.15,147.59,201.8,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,97112,Physical therapy procedure to re-educate brain-to-nerve-to-muscle function (each 15 minutes) [HCPCS 97112],125.02,125.02,125.02,91.58,85.46,116.86,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,81.4,75.97,103.87,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,97162,Physical therapy evaluation (typically 30 minutes) [HCPCS 97162],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,33.7,31.45,43,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Outpatient,J7120,Ringers lactate infusion [HCPCS J7120],55,55,55,40.29,37.6,51.41,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,11200,Skin tag removal (up to and including 15 tags) [HCPCS 11200],240.89,240.89,240.89,200.57,176.45,200.57,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,36416,Blood sample collection by skin puncture [HCPCS 36416],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73070,Elbow x-ray (2 views) [HCPCS 73070],112.67,112.67,112.67,93.81,77.02,93.81,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,73562,Knee x-ray (3 views) [HCPCS 73562],151.52,151.52,151.52,126.16,103.58,141.63,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,74177,"Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]",1905.75,1905.75,1905.75,1586.73,1302.77,1781.3,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,52.45,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,72.13,59.22,80.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,85.24,69.99,95.69,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,13.11,10.77,14.72,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83036,Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036],78.75,78.75,78.75,65.57,53.83,73.61,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,83690,Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690],55.13,55.13,55.13,45.9,37.69,51.53,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84443,Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443],133.88,133.88,133.88,111.47,91.52,125.14,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,78.68,64.6,88.33,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,84703,Lab analysis to identify gonadotropin (reproductive hormone) in serum or urine specimen [HCPCS 84703],63,63,63,52.45,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,52.45,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86308,Lab analysis to screen for mononucleosis (mono) [HCPCS 86308],39.38,39.38,39.38,32.79,26.92,32.79,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],110.25,110.25,110.25,91.79,75.37,103.05,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87301,Lab analysis by immunoassay (ELISA) to identify adenovirus enteric types 40 and 41 [HCPCS 87301],108.82,108.82,108.82,90.6,74.39,101.71,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87426,Lab analysis by immunoassay (ELISA) to identify the severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen [HCPCS 87426],62.46,62.46,62.46,52,42.7,58.38,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,91.59,75.2,102.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,111.47,91.52,125.14,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,106.02,87.05,119.02,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93010,Routine EKG (electrocardiogram) interpretation and report [HCPCS 93010],22.88,22.88,22.88,19.05,16.76,21.39,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,93306,"Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]",716.63,716.63,716.63,596.67,489.89,669.83,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96372,"Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]",89.78,89.78,89.78,74.75,61.37,83.92,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,208.19,170.93,233.72,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,96375,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]",103.45,103.45,103.45,86.13,70.72,96.69,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99202,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 15-29 minutes) [HCPCS 99202],203.9,203.9,203.9,169.77,149.36,190.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,101.71,83.51,114.18,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,167.74,137.72,188.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,243.53,199.95,273.39,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,327,268.48,367.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,279.71,229.66,314.01,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,99386,Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386],413.63,413.63,413.63,344.39,344.39,344.39,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2270,Morphine sulfate injection [HCPCS J2270],23,23,23,19.15,15.72,21.5,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,J2930,Methylprednisolone injection [HCPCS J2930],6.64,6.64,6.64,5.53,4.54,6.21,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,60.01,52.79,67.36,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,169.34,169.34,212.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,118.22,62.19,148.68,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,171.63,171.63,215.86,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,230.46,230.46,289.84,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Professional,Outpatient,99443,Telephone evaluation and management visit with physician to diagnose and treat illness or injury (21-30 minutes of medical discussion) [HCPCS 99443],108.02,108.02,108.02,63.39,63.39,63.39,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,279.71,229.66,314.01,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,511.25,419.76,573.94,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,700.26,574.94,786.13,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,23650,Dislocated shoulder treatment with manipulation (closed treatment) [HCPCS 23650],860.41,860.41,860.41,716.38,716.38,716.38,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,73030,"Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]",128.21,128.21,128.21,106.75,87.64,119.84,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,208.19,170.93,233.72,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,240.27,211.38,269.74,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,186.74,153.32,209.63,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Outpatient,J2400,Chloroprocaine hcl injection [HCPCS J2400],46,46,46,38.3,31.45,43,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Skilled Nursing Facility,Institutional,Outpatient,23650,Dislocated shoulder treatment with manipulation (closed treatment) [HCPCS 23650],860.41,860.41,860.41,716.38,716.38,716.38,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Skilled Nursing Facility,Professional,Outpatient,64454,Anesthetic agent and/or steroid injection into genicular nerve branches of knee with imaging imaging guidance [HCPCS 64454],409.5,409.5,409.5,240.29,126.41,240.29,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,89.48,83.51,114.18,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99215,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 40-54 minutes) [HCPCS 99215],392.74,392.74,392.74,287.68,268.48,367.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Clinic,Institutional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],242.81,242.81,242.81,177.86,165.98,177.86,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,811,Anesthesia provided during procedure on large bowel with an endoscope [HCPCS 00811],18.52,18.52,18.52,13.57,12.66,17.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71045,Chest x-ray (single view) [HCPCS 71045],101.01,101.01,101.01,73.99,69.05,94.41,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71046,Chest x-ray (2 views) [HCPCS 71046],128.21,128.21,128.21,93.91,87.64,119.84,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,71271,Chest CT scan without contrast to screen for lung cancer (low dose) [HCPCS 71271],163.22,163.22,163.22,119.56,111.58,152.56,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,73660,Toe(s) x-ray (minimum of 2 views) [HCPCS 73660],108.78,108.78,108.78,79.68,74.36,101.68,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,76706,Abdominal aorta ultrasound for screening of abdominal aortic aneurysm [HCPCS 76706],446.78,446.78,446.78,327.27,305.42,327.27,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,77063,Digital tomography of both breasts (screening exam) [HCPCS 77063],99.05,99.05,99.05,72.55,67.71,92.58,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,77067,Mammography of both breasts (screening exam) [HCPCS 77067],536.13,536.13,536.13,392.72,366.5,501.12,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80048,"Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose,  potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]",63,63,63,46.15,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80053,Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053],86.63,86.63,86.63,63.46,59.22,80.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80061,Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80076,"Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]",63,63,63,46.15,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,80305,Drug screening read by direct visual reading [HCPCS 80305],102.38,102.38,102.38,74.99,69.99,95.69,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,81001,Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001],23.63,23.63,23.63,17.31,16.15,22.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,81003,Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003],15.75,15.75,15.75,11.54,10.77,14.72,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83605,"Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]",94.5,94.5,94.5,69.22,64.6,88.33,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83735,Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735],55.13,55.13,55.13,40.38,37.69,51.53,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,83880,Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880],307.13,307.13,307.13,224.97,209.95,287.07,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84153,Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153],141.75,141.75,141.75,103.83,96.9,132.49,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84484,Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484],94.5,94.5,94.5,69.22,64.6,88.33,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,84550,Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550],39.38,39.38,39.38,28.85,26.92,36.81,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,85025,"Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]",63,63,63,46.15,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87040,Lab analysis of blood culture to identify bacteria [HCPCS 87040],395.91,395.91,395.91,290,270.64,370.06,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87086,Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086],63,63,63,46.15,43.07,58.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87635,Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635],110,110,110,80.58,75.2,102.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,87804,Lab analysis by immunoassay to identify influenza virus [HCPCS 87804],133.88,133.88,133.88,98.07,91.52,125.14,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,88305,Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305],559.13,559.13,559.13,409.56,382.22,522.62,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,93005,Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005],127.34,127.34,127.34,93.28,87.05,119.02,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,94640,Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment)  [HCPCS 94640],79.71,79.71,79.71,58.39,54.49,74.5,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96361,Hydration administration into vein by infusion (each additional hour) [HCPCS 96361],85.24,85.24,85.24,62.44,58.27,79.67,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,96374,"Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]",250.05,250.05,250.05,183.16,170.93,233.72,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,88.19,82.3,112.53,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,87.28,81.45,111.37,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,246.93,230.44,315.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,214.25,199.95,273.39,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,164.29,153.32,209.63,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,A0425,Ground mileage [HCPCS A0425],27.78,27.78,27.78,20.35,18.99,25.97,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,A0427,Als1-emergency [HCPCS A0427],1484.08,1484.08,1484.08,1087.09,1014.52,1387.17,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,A0429,Bls-emergency [HCPCS A0429],1250.24,1250.24,1250.24,915.8,854.66,1168.6,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,A0433,Als 2 [HCPCS A0433],2148.55,2148.55,2148.55,1573.81,1468.75,1573.81,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,A9270,Non-covered item or service [HCPCS A9270],3.75,3.75,3.75,2.75,2.56,2.75,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,G0472,Hep c screen high risk/other [HCPCS G0472],112.29,112.29,112.29,82.25,82.25,82.25,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J2060,Lorazepam injection [HCPCS J2060],23,23,23,16.85,15.72,21.5,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,J7030,Normal saline solution infus [HCPCS J7030],55,55,55,40.29,37.6,51.41,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,52.79,52.79,67.36,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Professional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,62.19,62.19,148.68,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Professional,Outpatient,Q3014,Telehealth facility fee [HCPCS Q3014],72.07,72.07,72.07,22.25,22.25,53.19,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,12013,"Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.6 to 5.0 cm) [HCPCS 12013]",308.35,308.35,308.35,225.87,225.87,225.87,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,20610,Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610],841.05,841.05,841.05,616.07,574.94,786.13,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,27096,Anesthetic or steroid injection into hip joint with imaging guidance [HCPCS 27096],431.55,431.55,431.55,316.11,316.11,316.11,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,43239,"Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]",1475.97,1475.97,1475.97,1081.15,1008.97,1379.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,45380,Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,45384,"Colon (large bowel) examination and tissue abnormalities, tumors, or polyps removal by hot biopsy forceps with flexible endoscope [HCPCS 45384]",1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,45385,Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,130.59,121.87,130.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,64483,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483],2741.55,2741.55,2741.55,2008.19,2008.19,2008.19,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2008.19,1874.12,2562.53,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,423.79,395.5,540.77,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,64495,Lower or sacral spine facet joint injections with imaging guidance (third and any additional level(s)) [HCPCS 64495],591.15,591.15,591.15,433.02,404.11,552.55,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],6570.9,6570.9,6570.9,4813.18,4491.87,6141.82,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],670.95,670.95,670.95,491.47,458.66,627.14,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,29.59,29.59,29.59,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99217,Hospital observation care on discharge date [HCPCS 99217],108.82,108.82,108.82,79.71,79.71,79.71,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99218,Initial observation care (typically 30 minutes) [HCPCS 99218],115.76,115.76,115.76,84.79,84.79,96.38,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99281,Emergency department visit for minor problem [HCPCS 99281],116.39,116.39,116.39,85.26,79.56,85.26,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],224.28,224.28,224.28,164.29,153.32,209.63,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,144.35,144.35,144.35,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,G0105,Colorectal scrn; hi risk ind [HCPCS G0105],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Institutional,Outpatient,G0121,Colorectal cancer screening; colonoscopy on invididual not meeting high risk [HCPCS G0121],1449.35,1449.35,1449.35,1061.65,990.78,1354.71,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,20611,Large joint or joint capsule fluid removal and/or injection with needle and ultrasound guidance including recording and reporting [HCPCS 20611],300.3,300.3,300.3,92.7,92.7,92.7,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,51702,Indwelling bladder catheter insertion (simple) [HCPCS 51702],178.28,178.28,178.28,55.04,55.04,55.04,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,64483,Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483],816.9,816.9,816.9,252.18,252.18,537.93,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],705.6,705.6,705.6,217.82,217.82,464.64,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],705.6,705.6,705.6,217.82,217.82,464.64,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,64635,Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635],1701,1701,1701,525.1,525.1,1120.11,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,64636,Lower or sacral spinal facet joint nerves destruction with imaging guidance (each additional facet joint) [HCPCS 64636],1701,1701,1701,525.1,525.1,1120.11,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,93246,EKG (electrocardiogram) recording for greatre than 7 days up to 15 days to monitor heart rhythm [HCPCS 93246],47.84,47.84,47.84,14.77,14.77,35.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99222,Initial hospital inpatient care (typically 50 minutes per day) [HCPCS 99222],368.13,368.13,368.13,113.64,113.64,242.41,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],191.01,191.01,191.01,58.96,58.96,125.78,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99233,Subsequent hospital inpatient care (typically 35 minutes per day) [HCPCS 99233],275.52,275.52,275.52,85.05,85.05,181.43,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99238,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (30 minutes or less) [HCPCS 99238]",192.17,192.17,192.17,59.32,59.32,126.54,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99239,"Hospital discharge day management includes time for final patient examination, discussion of hospital stay, instructions for continuing care, and preparation of discharge records (more than 30 minutes) [HCPCS 99239]",284.78,284.78,284.78,87.91,87.91,210.17,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99282,Emergency department visit for problem of low to moderate severity [HCPCS 99282],109.98,109.98,109.98,33.95,33.95,81.17,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,50.75,50.75,121.32,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],283.62,283.62,283.62,87.55,87.55,209.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],458.42,458.42,458.42,141.51,141.51,338.31,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99291,Critical care delivery to critically ill or injured patient (first 30-74 minutes) [HCPCS 99291],748.32,748.32,748.32,231.01,231.01,492.77,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99292,Critical care delivery to critically ill or injured patient (each additional 30 minutes) [HCPCS 99292],329.35,329.35,329.35,101.67,101.67,101.67,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],242.81,242.81,242.81,74.96,74.96,159.89,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Skilled Nursing Facility,Professional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,60.84,60.84,129.77,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,100.24,82.3,112.53,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,97116,Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116],119.15,119.15,119.15,99.2,81.45,111.37,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,97161,Physical therapy evaluation (typically 20 minutes) [HCPCS 97161],337.1,337.1,337.1,280.67,230.44,315.09,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,97530,Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530],129.65,129.65,129.65,107.95,88.63,107.95,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,99212,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 10-19 minutes) [HCPCS 99212],122.16,122.16,122.16,101.71,83.51,114.18,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,167.74,137.72,188.31,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Outpatient,99214,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-39 minutes) [HCPCS 99214],292.49,292.49,292.49,243.53,199.95,273.39,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,36415,Needle insertion into vein for collection of blood sample [HCPCS 36415],23.63,23.63,23.63,19.67,16.15,22.09,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,86803,Lab analysis to identify Hepatitis C antibodies [HCPCS 86803],110.25,110.25,110.25,91.79,75.37,103.05,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-PPO",Hospital,Institutional,Outpatient,G0103,Psa screening [HCPCS G0103],149.63,149.63,149.63,124.58,102.29,139.86,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3496.41,3186.97,4561.97,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1594.68,1453.54,2080.66,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,6497.63,5922.57,8477.82,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,9684.38,8827.29,12635.76,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,9233.3,8416.13,12047.21,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2477.43,2258.17,3232.44,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2921.3,2662.76,3811.59,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3523.62,3211.77,4597.47,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Outpatient,97110,"Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]",120.39,120.39,120.39,100.24,82.3,112.53,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Outpatient,97140,Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140],111.13,111.13,111.13,92.53,75.97,103.87,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,45378,Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378],1635.72,1635.72,1635.72,1198.16,1118.18,1528.91,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],2741.55,2741.55,2741.55,2008.19,1874.12,2562.53,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],578.55,578.55,578.55,423.79,395.5,540.77,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93016,Heart and blood vessel stress test with EKG monitoring and physician supervision (exercise or drug-induced) [HCPCS 93016],60.34,60.34,60.34,44.2,44.2,44.2,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,93018,"Heart and blood vessel stress test with EKG monitoring, physician interpretation, and report (exercise or drug-induced) [HCPCS 93018]",40.39,40.39,40.39,29.59,29.59,29.59,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99220,Initial observation care (typically 70 minutes) [HCPCS 99220],252.37,252.37,252.37,184.86,184.86,184.86,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],335.95,335.95,335.95,246.08,229.66,314.01,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99285,Emergency department visit for problem with significant threat to life [HCPCS 99285],891.29,891.29,891.29,652.87,609.29,833.09,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64493,Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493],705.6,705.6,705.6,217.82,217.82,464.64,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64494,Lower or sacral spine facet joint injections with imaging guidance (second level) [HCPCS 64494],705.6,705.6,705.6,217.82,217.82,464.64,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99219,Initial observation care (typically 50 minutes) [HCPCS 99219],360.02,360.02,360.02,111.14,111.14,111.14,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99232,Subsequent hospital inpatient care (typically 25 minutes per day) [HCPCS 99232],191.01,191.01,191.01,58.96,58.96,125.78,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,99283,Emergency department visit for problem of moderate severity [HCPCS 99283],164.39,164.39,164.39,50.75,50.75,121.32,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64454,Anesthetic agent and/or steroid injection into genicular nerve branches of knee with imaging imaging guidance [HCPCS 64454],918.75,918.75,918.75,672.98,672.98,672.98,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,64624,Genicular nerve branches of knee destruction by injection with imaging guidance [HCPCS 64624],1653.75,1653.75,1653.75,1211.37,1211.37,1211.37,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Skilled Nursing Facility,Professional,Outpatient,64454,Anesthetic agent and/or steroid injection into genicular nerve branches of knee with imaging imaging guidance [HCPCS 64454],409.5,409.5,409.5,126.41,126.41,240.29,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Clinic,Institutional,Outpatient,99203,New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203],288.58,288.58,288.58,211.38,211.38,269.74,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,27096,Anesthetic or steroid injection into hip joint with imaging guidance [HCPCS 27096],431.55,431.55,431.55,316.11,316.11,316.11,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99284,Emergency department visit for problem of high severity [HCPCS 99284],614.04,614.04,614.04,449.78,419.76,573.94,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99304,Initial nursing facility visit by admitting physician for problem of low severity (typically 25 minutes per day) [HCPCS 99304],242.81,242.81,242.81,177.86,165.98,177.86,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99308,Subsequent nursing facility visit for patient that is responding inadequately to therapy or has develoed a minor complication (typically 15 minutes per day) [HCPCS 99308],185.9,185.9,185.9,136.17,127.08,136.17,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Skilled Nursing Facility,Institutional,Outpatient,99315,"Nursing facility discharge day management includes total time spent by physician for final patient examination, discussion of nursing facility stay, instructions for continuing care, 30 minutes or les [HCPCS 99315]",197.07,197.07,197.07,144.35,144.35,144.35,,,,,,,,,
ASURIS - Medicare Part A,Clinic,Institutional,Outpatient,99213,Established patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 20-29 minutes) [HCPCS 99213],201.47,201.47,201.47,147.58,137.72,188.31,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,179,Respiratory infections & inflammations without complications,5381.58,5381.58,5381.58,3186.97,3186.97,4561.97,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,192,Chronic Lung Disease without complications,2454.48,2454.48,2454.48,1453.54,1453.54,2080.66,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,195,Pneumonia without complications,10000.97,10000.97,10000.97,5922.57,5922.57,8477.82,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,204,Respiratory signs & symptoms,14905.93,14905.93,14905.93,8827.29,8827.29,12635.76,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,552,Medical back problems without major complications,14211.64,14211.64,14211.64,8416.13,8416.13,12047.21,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,641,Nutritional or Metabolic Disorders without major complications,3813.19,3813.19,3813.19,2258.17,2258.17,3232.44,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,690,Kidney & urinary Infection without complications,4496.39,4496.39,4496.39,2662.76,2662.76,3811.59,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,948,"General symptoms of illness such as fever, pain, shortness of breath",5423.46,5423.46,5423.46,3211.77,3211.77,4597.47,,,,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,952.11,93.59,1541.15,,,,,,,,,
"ADMINISTRATIVE CONCEPTS, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,952.11,93.59,1541.15,,,,,,,,,
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1026.26,93.59,1541.15,,,,,,,,,
"ATRIO HEALTH PLANS, INC. - Commercial-HMO",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1026.26,93.59,1541.15,,,,,,,,,
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1541.15,93.59,1541.15,,,,,,,,,
BCBS OF MINNESOTA - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1541.15,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,303.15,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,303.15,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,912.24,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,912.24,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,919.78,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF ND - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,919.78,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,332.81,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF ND - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,332.81,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,770.75,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-HMO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,770.75,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1079.74,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-POS,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1079.74,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,791.18,93.59,1541.15,,,,,,,,,
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA - Commercial-PPO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,791.18,93.59,1541.15,,,,,,,,,
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,423.12,93.59,1541.15,,,,,,,,,
CENTRAL UNITED LIFE INSURANCE - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,423.12,93.59,1541.15,,,,,,,,,
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,937.89,93.59,1541.15,,,,,,,,,
AETNA - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,937.89,93.59,1541.15,,,,,,,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,832.26,93.59,1541.15,,,,,,,,,
CIGNA HEALTH & LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,832.26,93.59,1541.15,,,,,,,,,
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1010.33,93.59,1541.15,,,,,,,,,
EMPIRE BLUE CROSS BLUE SHIELD I - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1010.33,93.59,1541.15,,,,,,,,,
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,938.01,93.59,1541.15,,,,,,,,,
EMPIRE BLUE CROSS BLUE SHIELD II - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,938.01,93.59,1541.15,,,,,,,,,
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,808.92,93.59,1541.15,,,,,,,,,
GERBER LIFE INS. CO. - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,808.92,93.59,1541.15,,,,,,,,,
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,854.38,93.59,1541.15,,,,,,,,,
HEALTH PARTNERS - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,854.38,93.59,1541.15,,,,,,,,,
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,972.29,93.59,1541.15,,,,,,,,,
HIGHMARK INC - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,972.29,93.59,1541.15,,,,,,,,,
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,877.11,93.59,1541.15,,,,,,,,,
"ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. - Commercial-PPO",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,877.11,93.59,1541.15,,,,,,,,,
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,400.27,93.59,1541.15,,,,,,,,,
HIGHMARK INC - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,400.27,93.59,1541.15,,,,,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,915.16,93.59,1541.15,,,,,,,,,
"HUMANA, INC. - Medicare Part A",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,915.16,93.59,1541.15,,,,,,,,,
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,303.15,93.59,1541.15,,,,,,,,,
"HUMANA, INC. - Medicare Part B",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,303.15,93.59,1541.15,,,,,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1253.31,93.59,1541.15,,,,,,,,,
"INSURANCE ADMIN SOLUTIONS, LLC - Medicare Part A",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1253.31,93.59,1541.15,,,,,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,870.79,93.59,1541.15,,,,,,,,,
LOYAL AMERICAN LIFE INSURANCE CO - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,870.79,93.59,1541.15,,,,,,,,,
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,919.29,93.59,1541.15,,,,,,,,,
MEDICA PART A ONLY - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,919.29,93.59,1541.15,,,,,,,,,
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1179.04,93.59,1541.15,,,,,,,,,
MEDICA SELF INSURED  A THIRD PARTY ADMIN - Commercial-POS,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1179.04,93.59,1541.15,,,,,,,,,
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,268.14,93.59,1541.15,,,,,,,,,
"MEDICA, PART B ONLY - Medicare Part B",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,268.14,93.59,1541.15,,,,,,,,,
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,185.73,93.59,1541.15,,,,,,,,,
MEDICARE SERVICE CENTER - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,185.73,93.59,1541.15,,,,,,,,,
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,977.76,93.59,1541.15,,,,,,,,,
AMERICAN BENEFIT CORPORATION - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,977.76,93.59,1541.15,,,,,,,,,
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,103.2,93.59,1541.15,,,,,,,,,
MUTUAL OF OMAHA - Commercial-Indemnity,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,103.2,93.59,1541.15,,,,,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,933.88,93.59,1541.15,,,,,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,933.88,93.59,1541.15,,,,,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,269.72,93.59,1541.15,,,,,,,,,
MUTUAL OF OMAHA INSURANCE COMP - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,269.72,93.59,1541.15,,,,,,,,,
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1173.45,93.59,1541.15,,,,,,,,,
Medica - Commercial-HMO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1173.45,93.59,1541.15,,,,,,,,,
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1254.28,93.59,1541.15,,,,,,,,,
NALC HEALTH BENEFIT PLAN - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1254.28,93.59,1541.15,,,,,,,,,
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1002.67,93.59,1541.15,,,,,,,,,
"NGS AMERICAN, INC - Medicare Part A",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1002.67,93.59,1541.15,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,934,93.59,1541.15,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,934,93.59,1541.15,,,,,,,,,
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,93.59,93.59,1541.15,,,,,,,,,
PALMETTO GBA - RAILROAD MEDICARE - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,93.59,93.59,1541.15,,,,,,,,,
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,840.53,93.59,1541.15,,,,,,,,,
PREMERA BLUE CROSS - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,840.53,93.59,1541.15,,,,,,,,,
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1118.27,93.59,1541.15,,,,,,,,,
SANFORD HEALTH PLAN - Commercial-Mut Defined,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1118.27,93.59,1541.15,,,,,,,,,
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,949.68,93.59,1541.15,,,,,,,,,
SANFORD HEALTH PLAN - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,949.68,93.59,1541.15,,,,,,,,,
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,497.99,93.59,1541.15,,,,,,,,,
SANFORD HEALTH PLAN - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,497.99,93.59,1541.15,,,,,,,,,
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,942.63,93.59,1541.15,,,,,,,,,
SANFORD HEALTH PLAN-ICL 8509 - Commercial-PPO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,942.63,93.59,1541.15,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,946.15,93.59,1541.15,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,946.15,93.59,1541.15,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,376.93,93.59,1541.15,,,,,,,,,
SECURE ADMINISTRATIVE SOLUTIONS - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,376.93,93.59,1541.15,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,935.94,93.59,1541.15,,,,,,,,,
SMW AND PROGRAM OF THE SMWNHF - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,935.94,93.59,1541.15,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,221.71,93.59,1541.15,,,,,,,,,
AMERICAN CONTINENTAL INSU. - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,221.71,93.59,1541.15,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,980.19,93.59,1541.15,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,980.19,93.59,1541.15,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,242.13,93.59,1541.15,,,,,,,,,
THRIVENT FINANCIAL FOR LUTHERANS - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,242.13,93.59,1541.15,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,384.22,93.59,1541.15,,,,,,,,,
TRANSAMERICA PREMIER LIFE INS - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,384.22,93.59,1541.15,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,910.3,93.59,1541.15,,,,,,,,,
UMR - Commercial-PPO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,910.3,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1215.51,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-EPO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1215.51,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1136.38,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-HMO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1136.38,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,890.6,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-Indemnity,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,890.6,93.59,1541.15,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1011.18,93.59,1541.15,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1011.18,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,903.12,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-POS,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,903.12,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,333.41,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Commercial-PPO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,333.41,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,578.22,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE INSURANCE COMPANY - Medicare-HMO,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,578.22,93.59,1541.15,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,885.38,93.59,1541.15,,,,,,,,,
"UNITED HEALTHCARE SERVICES, INC. - Commercial-POS",Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,885.38,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1048.99,93.59,1541.15,,,,,,,,,
UNITED HEALTHCARE SERVICESINC. - Commercial-POS,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1048.99,93.59,1541.15,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,398.57,93.59,1541.15,,,,,,,,,
UNITEDHEALTH GROUP - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,398.57,93.59,1541.15,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,185.37,93.59,1541.15,,,,,,,,,
UNITEDHEALTHCARE - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,185.37,93.59,1541.15,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,957.58,93.59,1541.15,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,957.58,93.59,1541.15,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,390.06,93.59,1541.15,,,,,,,,,
WEBTPA EMPLOYER SERVICES - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,390.06,93.59,1541.15,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,356.39,93.59,1541.15,,,,,,,,,
AMERICAN REPUBLIC/ENTERPRISE - Medicare Part B,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,356.39,93.59,1541.15,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,120,GENERAL CLASSIFICATION - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1266.44,93.59,1541.15,,,,,,,,,
ASURIS - Medicare Part A,Hospital,Institutional,Inpatient,121,MEDICAL/SURGICAL/GYN - SEMI-PRIVATE ROOM,1215.51,1215.51,1215.51,1266.44,93.59,1541.15,,,,,,,,,