hospital_name last_updated_on version hospital_location hospital_address license_number|NJ "To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated." Saint Peter's University Hospital 10/28/2025 2.0.0 Easton Avenue "254 Easton Ave, New Brunswick, NJ 08901" 11205|NJ TRUE Description Plan_Code Code|1 Code|1|type Setting drug_unit_of_measurement drug_type_of_measurement standard_charge|gross standard_charge|discounted_cash payer_name plan_name modifiers standard_charge | negotiated_percentage estimated_amount standard_charge | min standard_charge | max standard_charge | negotiated_dollar standard_charge | methodology mnemonic additional_generic_notes standard_charge | negotiated_algorithm Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 48050 216 DRG Inpatient 0.01 0.01 Aetna Aetna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 48050 460 DRG Inpatient 416122.79 53834.63 Aetna Aetna Commercial 0.16 67434.92 0.16 416122.79 0.16 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 48050 470 DRG Inpatient 167912.19 21723.13 Aetna Aetna Commercial 0.21 34689.93 0.21 167912.19 0.21 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 48050 473 DRG Inpatient 100687.91 13026.19 Aetna Aetna Commercial 0.45 45362.20 0.45 100687.91 0.45 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 48050 743 DRG Inpatient 102691.67 13285.42 Aetna Aetna Commercial 0.21 21421.95 0.21 102691.67 0.21 Case Rate 743 Priced NORMAL NEWBORN 48050 795 DRG Inpatient 6266.93 2335.00 Aetna Aetna Commercial 0.29 1828.85 0.29 6266.93 0.29 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 48050 807 DRG Inpatient 116469.59 4193.00 Aetna Aetna Commercial 0.09 10840.59 0.09 116469.59 0.09 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 48050 788 DRG Inpatient 76050.77 4538.00 Aetna Aetna Commercial 0.17 12810.20 0.17 76050.77 0.17 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 48050 59400 CPT Inpatient 116469.59 4193.00 Aetna Aetna Commercial 0.09 10840.59 0.09 116469.59 0.09 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 48050 59510 CPT Inpatient 76050.77 4538.00 Aetna Aetna Commercial 0.17 12810.20 0.17 76050.77 0.17 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 48050 59610 CPT Inpatient 116469.59 4193.00 Aetna Aetna Commercial 0.09 10840.59 0.09 116469.59 0.09 Case Rate 59610 Priced "Psychotherapy, 30 min" 48050 90832 CPT Outpatient 577.50 91.21 Aetna Aetna Commercial 0.19 107.59 0.19 577.50 0.19 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 48050 90834 CPT Outpatient 44134.65 271.96 Aetna Aetna Commercial 0.18 7830.67 0.18 44134.65 0.18 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 48050 90837 CPT Outpatient 2240.70 442.93 Aetna Aetna Commercial 0.01 0.01 0.01 2240.70 0.01 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 48050 90846 CPT Outpatient 0.01 131.50 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 48050 90847 CPT Outpatient 44134.65 369.97 Aetna Aetna Commercial 0.18 7830.67 0.18 44134.65 0.18 Fee Schedule 90847 Priced Group psychotherapy 48050 90853 CPT Outpatient 44134.65 101.99 Aetna Aetna Commercial 0.18 7830.67 0.18 44134.65 0.18 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 48050 99203 CPT Outpatient 3480.75 176.07 Aetna Aetna Commercial 0.14 473.40 0.14 3480.75 0.14 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 48050 99204 CPT Outpatient 2103.15 233.39 Aetna Aetna Commercial 0.09 183.30 0.09 2103.15 0.09 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 48050 99205 CPT Outpatient 4970.70 314.28 Aetna Aetna Commercial 0.04 183.30 0.04 4970.70 0.04 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 48050 99243 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 48050 99244 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 48050 99385 CPT Outpatient 1114.05 185.90 Aetna Aetna Commercial 0.18 197.57 0.18 1114.05 0.18 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 48050 99386 CPT Outpatient 4877.25 185.90 Aetna Aetna Commercial 0.14 684.45 0.14 4877.25 0.14 Fee Schedule 99386 Priced Routine venipuncture 48050 36415 CPT Outpatient 127.05 19.57 Aetna Aetna Commercial 0.04 5.01 0.04 127.05 0.04 Fee Schedule 36415 Priced Basic Metabolic Panel 48050 80048 CPT Outpatient 576.45 88.78 Aetna Aetna Commercial 0.03 19.35 0.03 576.45 0.03 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 48050 80053 CPT Outpatient 763.35 117.56 Aetna Aetna Commercial 0.03 21.87 0.03 763.35 0.03 Fee Schedule 80053 Priced Obstetric blood test panel 48050 80055 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 48050 80061 CPT Outpatient 1349.25 197.77 Aetna Aetna Commercial 0.02 30.65 0.02 1349.25 0.02 Fee Schedule 80061 Priced Kidney function panel test 48050 80069 CPT Outpatient 716.10 104.95 Aetna Aetna Commercial 0.03 19.87 0.03 716.10 0.03 Fee Schedule 80069 Priced Liver function panel test 48050 80076 CPT Outpatient 716.10 104.95 Aetna Aetna Commercial 0.03 18.70 0.03 716.10 0.03 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 48050 81000 CPT Outpatient 144.90 21.18 Aetna Aetna Commercial 0.05 7.26 0.05 144.90 0.05 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 48050 81001 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Fee Schedule 81001 Priced Automated urinalysis test 48050 81002 CPT Outpatient 57.75 8.89 Aetna Aetna Commercial 0.10 5.84 0.10 57.75 0.10 Fee Schedule 81002 Priced Automated urinalysis test 48050 81003 CPT Outpatient 219.45 33.80 Aetna Aetna Commercial 0.02 5.13 0.02 219.45 0.02 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 48050 82306 CPT Outpatient 1880.55 289.62 Aetna Aetna Commercial 0.04 67.75 0.04 1880.55 0.04 Fee Schedule 82306 Priced Glycosylated hemoglobin test 48050 83036 CPT Outpatient 494.55 76.17 Aetna Aetna Commercial 0.04 22.22 0.04 494.55 0.04 Fee Schedule 83036 Priced PSA (prostate specific antigen) 48050 84153 CPT Outpatient 1177.05 181.28 Aetna Aetna Commercial 0.04 42.09 0.04 1177.05 0.04 Fee Schedule 84153 Priced PSA (prostate specific antigen) 48050 84154 CPT Outpatient 598.50 92.17 Aetna Aetna Commercial 0.07 42.09 0.07 598.50 0.07 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 48050 84443 CPT Outpatient 519.75 80.05 Aetna Aetna Commercial 0.07 38.46 0.07 519.75 0.07 Fee Schedule 84443 Priced Chorionic gonadotropin assay 48050 84703 CPT Outpatient 785.40 120.96 Aetna Aetna Commercial 0.02 17.22 0.02 785.40 0.02 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 48050 85025 CPT Outpatient 635.25 97.83 Aetna Aetna Commercial 0.03 17.78 0.03 635.25 0.03 Fee Schedule 85025 Priced "Complete blood count, automated" 48050 85027 CPT Outpatient 576.45 88.78 Aetna Aetna Commercial 0.03 14.80 0.03 576.45 0.03 Fee Schedule 85027 Priced "Blood test, clotting time" 48050 85610 CPT Outpatient 404.25 62.26 Aetna Aetna Commercial 0.02 8.99 0.02 404.25 0.02 Fee Schedule 85610 Priced Coagulation assessment blood test 48050 85730 CPT Outpatient 17.22 2.65 Aetna Aetna Commercial 0.80 13.74 0.80 17.22 0.80 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 48050 86003 CPT Outpatient 32.55 5.01 Aetna Aetna Commercial 0.37 11.94 0.37 32.55 0.37 Fee Schedule 86003 Priced Tb test cell immun measure 48050 86480 CPT Outpatient 530.25 81.66 Aetna Aetna Commercial 0.27 141.85 0.27 530.25 0.27 Fee Schedule 86480 Priced Urine culture/colony count 48050 87086 CPT Outpatient 763.35 117.56 Aetna Aetna Commercial 0.02 18.46 0.02 763.35 0.02 Fee Schedule 87086 Priced Hpylori stool ia 48050 87338 CPT Outpatient 785.40 120.96 Aetna Aetna Commercial 0.04 32.91 0.04 785.40 0.04 Fee Schedule 87338 Priced Cytopath eval fna report 48050 88173 CPT Outpatient 750.75 115.62 Aetna Aetna Commercial 0.21 160.32 0.21 750.75 0.21 Fee Schedule 88173 Priced Tissue exam by pathologist 48050 88302 CPT Outpatient 635.25 97.83 Aetna Aetna Commercial 0.07 46.56 0.07 635.25 0.07 Fee Schedule 88302 Priced Tissue exam by pathologist 48050 88305 CPT Outpatient 323.40 49.81 Aetna Aetna Commercial 0.18 58.59 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 48050 11042 CPT Outpatient 2668.05 481.45 Aetna Aetna Commercial 0.18 473.39 0.18 2668.05 0.18 Case Rate 11042 Priced Deb subq tissue add-on 48050 11045 CPT Outpatient 4652.55 330.00 Aetna Aetna Commercial 0.18 825.50 0.18 4652.55 0.18 Case Rate 11045 Priced Dx bronchoscope/lavage 48050 31624 CPT Outpatient 41223.00 7602.31 Aetna Aetna Commercial 0.15 6024.74 0.15 41223.00 0.15 Case Rate 31624 Priced Bronchoscopy/lung bx each 48050 31628 CPT Outpatient 49048.65 9045.51 Aetna Aetna Commercial 0.12 6024.74 0.12 49048.65 0.12 Case Rate 31628 Priced Blood transfusion service 48050 36430 CPT Outpatient 9166.50 574.93 Aetna Aetna Commercial 0.16 1491.86 0.16 9166.50 0.16 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 48050 43235 CPT Outpatient 8856.75 1633.35 Aetna Aetna Commercial 0.38 3343.05 0.38 8856.75 0.38 Case Rate 43235 Priced Endoscopic us exam esoph 48050 43237 CPT Outpatient 23867.55 4401.63 Aetna Aetna Commercial 0.14 3343.05 0.14 23867.55 0.14 Case Rate 43237 Priced Egd us fine needle bx/aspir 48050 43238 CPT Outpatient 30690.45 5659.90 Aetna Aetna Commercial 0.11 3343.05 0.11 30690.45 0.11 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 48050 43239 CPT Outpatient 40191.90 7412.15 Aetna Aetna Commercial 0.08 3343.05 0.08 40191.90 0.08 Case Rate 43239 Priced Ercp remove duct calculi 48050 43264 CPT Outpatient 34335.00 6332.03 Aetna Aetna Commercial 0.18 6024.74 0.18 34335.00 0.18 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 48050 45378 CPT Outpatient 13991.25 889.35 Aetna Aetna Commercial 0.24 3343.05 0.24 13991.25 0.24 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 48050 45380 CPT Outpatient 22215.90 4097.04 Aetna Aetna Commercial 0.15 3343.05 0.15 22215.90 0.15 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 48050 45385 CPT Outpatient 119569.80 22050.95 Aetna Aetna Commercial 0.03 3343.05 0.03 119569.80 0.03 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 48050 45391 CPT Outpatient 24923.85 4596.43 Aetna Aetna Commercial 0.13 3343.05 0.13 24923.85 0.13 Case Rate 45391 Priced Fragmenting of kidney stone 48050 50590 CPT Outpatient 40930.05 7548.28 Aetna Aetna Commercial 0.15 6024.74 0.15 40930.05 0.15 Case Rate 50590 Priced Fetal non-stress test 48050 59025 CPT Outpatient 3153.15 477.76 Aetna Aetna Commercial 0.18 559.46 0.18 3153.15 0.18 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 48050 64483 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 64483 Priced Tympanometry 48050 92567 CPT Outpatient 2224.95 98.50 Aetna Aetna Commercial 0.18 394.75 0.18 2224.95 0.18 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 48050 93000 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 93000 Priced Cardiovascular stress test 48050 93017 CPT Outpatient 3076.50 532.96 Aetna Aetna Commercial 0.19 578.40 0.19 3076.50 0.19 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 48050 93452 CPT Outpatient 55621.65 8611.87 Aetna Aetna Commercial 0.18 9861.48 0.18 55621.65 0.18 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 48050 95810 CPT Outpatient 20341.65 3373.48 Aetna Aetna Commercial 0.11 2314.26 0.11 20341.65 0.11 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 48050 95811 CPT Outpatient 22491.00 3731.18 Aetna Aetna Commercial 0.10 2314.26 0.10 22491.00 0.10 Case Rate 95811 Priced Eeg 41-60 minutes 48050 95812 CPT Outpatient 5578.65 925.83 Aetna Aetna Commercial 0.18 989.81 0.18 5578.65 0.18 Case Rate 95812 Priced Genetic counseling 30 min 48050 96040 CPT Outpatient 0.01 102.81 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 96040 Priced Chemo iv infusion 1 hr 48050 96413 CPT Outpatient 4856.25 472.45 Aetna Aetna Commercial 0.08 378.82 0.08 4856.25 0.08 Case Rate 96413 Priced Ultrasound therapy 48050 97035 CPT Outpatient 2111.55 134.99 Aetna Aetna Commercial 0.20 416.23 0.20 2111.55 0.20 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 48050 97110 CPT Outpatient 6494.25 92.86 Aetna Aetna Commercial 0.20 1280.19 0.20 6494.25 0.20 Case Rate 97110 Priced Gait training therapy 48050 97116 CPT Outpatient 4723.95 110.61 Aetna Aetna Commercial 0.20 931.13 0.20 4723.95 0.20 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 48050 70450 CPT Outpatient 8566.95 835.61 Aetna Aetna Commercial 0.20 1748.63 0.20 8566.95 0.20 Case Rate 70450 Priced Mri brain stem w/o dye 48050 70551 CPT Outpatient 7861.35 1361.31 Aetna Aetna Commercial 0.09 708.00 0.09 7861.35 0.09 Case Rate 70551 Priced MRI scan of brain before and after contrast 48050 70553 CPT Outpatient 10882.20 1625.88 Aetna Aetna Commercial 0.11 1192.53 0.11 10882.20 0.11 Case Rate 70553 Priced X-ray exam chest 2 views 48050 71046 CPT Outpatient 859.95 150.37 Aetna Aetna Commercial 0.18 152.58 0.18 859.95 0.18 Case Rate 71046 Priced Ct thorax w/o dye 48050 71250 CPT Outpatient 7288.05 1261.63 Aetna Aetna Commercial 0.13 941.23 0.13 7288.05 0.13 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 48050 72082 CPT Outpatient 2022.30 253.33 Aetna Aetna Commercial 0.07 145.39 0.07 2022.30 0.07 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 48050 72100 CPT Outpatient 1599.15 277.38 Aetna Aetna Commercial 0.04 57.96 0.04 1599.15 0.04 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 48050 72110 CPT Outpatient 1389.15 241.04 Aetna Aetna Commercial 0.06 80.50 0.06 1389.15 0.06 Case Rate 72110 Priced MRI scan of lower spinal canal 48050 72148 CPT Outpatient 7861.35 1361.31 Aetna Aetna Commercial 0.09 672.65 0.09 7861.35 0.09 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 48050 72193 CPT Outpatient 13671.00 1412.01 Aetna Aetna Commercial 0.09 1220.64 0.09 13671.00 0.09 Case Rate 72193 Priced X-ray exam of shoulder 48050 73030 CPT Outpatient 1452.15 251.43 Aetna Aetna Commercial 0.03 47.55 0.03 1452.15 0.03 Case Rate 73030 Priced X-ray exam of elbow 48050 73080 CPT Outpatient 1356.60 235.68 Aetna Aetna Commercial 0.04 54.48 0.04 1356.60 0.04 Case Rate 73080 Priced X-ray exam of forearm 48050 73090 CPT Outpatient 1243.20 215.26 Aetna Aetna Commercial 0.03 42.35 0.03 1243.20 0.03 Case Rate 73090 Priced X-ray exam of wrist 48050 73110 CPT Outpatient 1243.20 215.26 Aetna Aetna Commercial 0.05 64.89 0.05 1243.20 0.05 Case Rate 73110 Priced X-ray exam of hand 48050 73130 CPT Outpatient 1243.20 215.26 Aetna Aetna Commercial 0.04 53.62 0.04 1243.20 0.04 Case Rate 73130 Priced X-ray exam hips bi 2 views 48050 73521 CPT Outpatient 970.20 228.41 Aetna Aetna Commercial 0.07 68.35 0.07 970.20 0.07 Case Rate 73521 Priced X-ray exam of knee 3 48050 73562 CPT Outpatient 802.20 139.12 Aetna Aetna Commercial 0.08 64.01 0.08 802.20 0.08 Case Rate 73562 Priced X-ray exam of lower leg 48050 73590 CPT Outpatient 1243.20 215.26 Aetna Aetna Commercial 0.04 49.29 0.04 1243.20 0.04 Case Rate 73590 Priced X-ray exam of ankle 48050 73610 CPT Outpatient 1378.65 239.31 Aetna Aetna Commercial 0.04 55.36 0.04 1378.65 0.04 Case Rate 73610 Priced X-ray exam of foot 48050 73630 CPT Outpatient 975.45 169.41 Aetna Aetna Commercial 0.05 50.15 0.05 975.45 0.05 Case Rate 73630 Priced MRI scan of leg joint 48050 73721 CPT Outpatient 7861.35 1361.31 Aetna Aetna Commercial 0.10 762.37 0.10 7861.35 0.10 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 48050 74177 CPT Outpatient 14222.25 1412.01 Aetna Aetna Commercial 0.11 1600.87 0.11 14222.25 0.11 Case Rate 74177 Priced Contrst x-ray exam of throat 48050 74210 CPT Outpatient 0.01 440.39 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 74210 Priced X-ray exam surgical specimen 48050 76098 CPT Outpatient 6141.45 407.86 Aetna Aetna Commercial 0.98 6024.74 0.98 6141.45 0.98 Case Rate 76098 Priced Us exam of head and neck 48050 76536 CPT Outpatient 5512.50 955.18 Aetna Aetna Commercial 0.04 217.46 0.04 5512.50 0.04 Case Rate 76536 Priced Ultrasound breast limited 48050 76642 CPT Outpatient 5777.10 127.70 Aetna Aetna Commercial 0.07 415.05 0.07 5777.10 0.07 Case Rate 76642 Priced Ultrasound of abdomen 48050 76700 CPT Outpatient 4917.15 851.88 Aetna Aetna Commercial 0.04 201.86 0.04 4917.15 0.04 Case Rate 76700 Priced Echo exam of abdomen 48050 76705 CPT Outpatient 3836.70 665.17 Aetna Aetna Commercial 0.04 152.45 0.04 3836.70 0.04 Case Rate 76705 Priced Us exam abdo back wall comp 48050 76770 CPT Outpatient 5171.25 895.48 Aetna Aetna Commercial 0.04 187.97 0.04 5171.25 0.04 Case Rate 76770 Priced Us exam abdo back wall lim 48050 76775 CPT Outpatient 3969.00 686.97 Aetna Aetna Commercial 0.02 72.69 0.02 3969.00 0.02 Case Rate 76775 Priced Ob us < 14 wks single fetus 48050 76801 CPT Outpatient 2006.55 347.98 Aetna Aetna Commercial 0.09 181.04 0.09 2006.55 0.09 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 48050 76805 CPT Outpatient 3969.00 686.97 Aetna Aetna Commercial 0.13 526.82 0.13 3969.00 0.13 Case Rate 76805 Priced Ob us detailed sngl fetus 48050 76811 CPT Outpatient 2844.45 492.99 Aetna Aetna Commercial 0.07 210.38 0.07 2844.45 0.07 Case Rate 76811 Priced Ob us nuchal meas 1 gest 48050 76813 CPT Outpatient 1044.75 180.83 Aetna Aetna Commercial 0.14 150.71 0.14 1044.75 0.14 Case Rate 76813 Priced Ob us limited fetus(s) 48050 76815 CPT Outpatient 6428.10 639.90 Aetna Aetna Commercial 0.09 574.86 0.09 6428.10 0.09 Case Rate 76815 Priced Ob us follow-up per fetus 48050 76816 CPT Outpatient 4818.45 833.88 Aetna Aetna Commercial 0.09 428.49 0.09 4818.45 0.09 Case Rate 76816 Priced Transvaginal us obstetric 48050 76817 CPT Outpatient 6428.10 476.73 Aetna Aetna Commercial 0.09 574.86 0.09 6428.10 0.09 Case Rate 76817 Priced Fetal biophys profil w/o nst 48050 76819 CPT Outpatient 1741.95 302.65 Aetna Aetna Commercial 0.07 125.58 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 48050 76830 CPT Outpatient 9305.10 806.54 Aetna Aetna Commercial 0.04 401.97 0.04 9305.10 0.04 Case Rate 76830 Priced Us exam scrotum 48050 76870 CPT Outpatient 6328.35 1096.55 Aetna Aetna Commercial 0.01 88.29 0.01 6328.35 0.01 Case Rate 76870 Priced Us exam infant hips dynamic 48050 76885 CPT Outpatient 3836.70 665.17 Aetna Aetna Commercial 0.07 269.47 0.07 3836.70 0.07 Case Rate 76885 Priced Mammography of one breast 48050 77065 CPT Outpatient 3451.35 192.07 Aetna Aetna Commercial 0.11 370.05 0.11 3451.35 0.11 Case Rate 77065 Priced Mammography of both breasts 48050 77066 CPT Outpatient 5777.10 235.68 Aetna Aetna Commercial 0.07 415.05 0.07 5777.10 0.07 Case Rate 77066 Priced "Mamography, screening bilateral" 48050 77067 CPT Outpatient 1416.45 205.57 Aetna Aetna Commercial 0.19 271.64 0.19 1416.45 0.19 Case Rate 77067 Priced X-rays for bone age 48050 77072 CPT Outpatient 2022.30 163.87 Aetna Aetna Commercial 0.07 145.39 0.07 2022.30 0.07 Case Rate 77072 Priced Joint survey single view 48050 77077 CPT Outpatient 985.95 171.14 Aetna Aetna Commercial 0.05 51.03 0.05 985.95 0.05 Case Rate 77077 Priced Dxa bone density axial 48050 77080 CPT Outpatient 3257.10 319.09 Aetna Aetna Commercial 0.11 346.92 0.11 3257.10 0.11 Case Rate 77080 Priced Fna bx w/us gdn 1st les 48050 10005 CPT Outpatient 5512.50 547.24 Aetna Aetna Commercial 1.09 6024.74 1.09 5512.50 1.09 Case Rate 10005 Priced Fna bx w/us gdn ea addl 48050 10006 CPT Outpatient 10628.10 594.83 Aetna Aetna Commercial 0.57 6024.74 0.57 10628.10 0.57 Case Rate 10006 Priced Drainage of hematoma/fluid 48050 10140 CPT Outpatient 23209.20 1081.95 Aetna Aetna Commercial 0.26 6024.74 0.26 23209.20 0.26 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 48050 11042 CPT Outpatient 2668.05 481.45 Aetna Aetna Commercial 0.18 473.39 0.18 2668.05 0.18 Case Rate 11042 Priced Deb bone 20 sq cm/< 48050 11044 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 11044 Priced Removal of skin tags 4.0 cm 48050 11406 CPT Outpatient 19967.85 3427.81 Aetna Aetna Commercial 0.30 6024.74 0.30 19967.85 0.30 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 48050 11424 CPT Outpatient 0.01 1004.93 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 11424 Priced Remove pilonidal cyst simple 48050 11770 CPT Outpatient 19173.00 3291.37 Aetna Aetna Commercial 0.31 6024.74 0.31 19173.00 0.31 Case Rate 11770 Priced Replace tissue expander 48050 11970 CPT Outpatient 59239.95 10169.52 Aetna Aetna Commercial 0.10 6024.74 0.10 59239.95 0.10 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 48050 14020 CPT Outpatient 32166.75 5521.96 Aetna Aetna Commercial 0.19 6024.74 0.19 32166.75 0.19 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 48050 14060 CPT Outpatient 25993.80 1374.69 Aetna Aetna Commercial 0.23 6024.74 0.23 25993.80 0.23 Case Rate 14060 Priced Wound prep trk/arm/leg 48050 15002 CPT Outpatient 41748.00 1441.73 Aetna Aetna Commercial 0.14 6024.74 0.14 41748.00 0.14 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 48050 15271 CPT Outpatient 24343.20 3769.48 Aetna Aetna Commercial 0.17 4182.25 0.17 24343.20 0.17 Case Rate 15271 Priced Acellular derm matrix implt 48050 15777 CPT Outpatient 101672.55 17453.79 Aetna Aetna Commercial 0.06 6024.74 0.06 101672.55 0.06 Case Rate 15777 Priced Exc skin abd 48050 15830 CPT Outpatient 54696.60 9389.58 Aetna Aetna Commercial 0.11 6024.74 0.11 54696.60 0.11 Case Rate 15830 Priced Dressing change not for burn 48050 15852 CPT Outpatient 0.01 290.74 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 15852 Priced Suction lipectomy trunk 48050 15877 CPT Outpatient 63741.30 10942.26 Aetna Aetna Commercial 0.09 6024.74 0.09 63741.30 0.09 Case Rate 15877 Priced Suction lipectomy lwr extrem 48050 15879 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 15879 Priced Drainage of breast lesion 48050 19000 CPT Outpatient 10143.00 594.83 Aetna Aetna Commercial 0.59 6024.74 0.59 10143.00 0.59 Case Rate 19000 Priced Bx breast 1st lesion strtctc 48050 19081 CPT Outpatient 12341.70 1250.69 Aetna Aetna Commercial 0.49 6024.74 0.49 12341.70 0.49 Case Rate 19081 Priced Bx breast add lesion us imag 48050 19084 CPT Outpatient 29058.75 547.24 Aetna Aetna Commercial 0.21 6024.74 0.21 29058.75 0.21 Case Rate 19084 Priced Biopsy of breast open 48050 19101 CPT Outpatient 39545.10 2737.82 Aetna Aetna Commercial 0.15 6024.74 0.15 39545.10 0.15 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 48050 19120 CPT Outpatient 35761.95 2737.82 Aetna Aetna Commercial 0.17 6024.74 0.17 35761.95 0.17 Case Rate 19120 Priced Excision breast lesion 48050 19125 CPT Outpatient 33184.20 0.01 Aetna Aetna Commercial 0.18 6024.74 0.18 33184.20 0.18 Case Rate 19125 Priced Perq device breast 1st imag 48050 19281 CPT Outpatient 6141.45 598.61 Aetna Aetna Commercial 0.98 6024.74 0.98 6141.45 0.98 Case Rate 19281 Priced Perq device breast ea imag 48050 19282 CPT Outpatient 8379.00 319.04 Aetna Aetna Commercial 0.72 6024.74 0.72 8379.00 0.72 Case Rate 19282 Priced Partial mastectomy 48050 19301 CPT Outpatient 39157.65 6722.06 Aetna Aetna Commercial 0.15 6024.74 0.15 39157.65 0.15 Case Rate 19301 Priced Mast simple complete 48050 19303 CPT Outpatient 105389.55 18091.87 Aetna Aetna Commercial 0.06 6024.74 0.06 105389.55 0.06 Case Rate 19303 Priced Reduction of large breast 48050 19318 CPT Outpatient 65239.65 11199.47 Aetna Aetna Commercial 0.09 6024.74 0.09 65239.65 0.09 Case Rate 19318 Priced Immediate breast prosthesis 48050 19340 CPT Outpatient 113100.75 19415.63 Aetna Aetna Commercial 0.05 6024.74 0.05 113100.75 0.05 Case Rate 19340 Priced Delayed breast prosthesis 48050 19342 CPT Outpatient 56988.75 9783.07 Aetna Aetna Commercial 0.11 6024.74 0.11 56988.75 0.11 Case Rate 19342 Priced Breast reconstruction 48050 19357 CPT Outpatient 101672.55 17453.79 Aetna Aetna Commercial 0.06 6024.74 0.06 101672.55 0.06 Case Rate 19357 Priced Breast reconstruction 48050 19366 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 19366 Priced Revise breast reconstruction 48050 19380 CPT Outpatient 61493.25 10556.34 Aetna Aetna Commercial 0.10 6024.74 0.10 61493.25 0.10 Case Rate 19380 Priced Removal of support implant 48050 20680 CPT Outpatient 42329.70 7266.60 Aetna Aetna Commercial 0.14 6024.74 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 48050 22856 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 22856 Priced Treat humerus fracture 48050 24538 CPT Outpatient 51237.90 4775.24 Aetna Aetna Commercial 0.12 6024.74 0.12 51237.90 0.12 Case Rate 24538 Priced Remove wrist tendon lesion 48050 25111 CPT Outpatient 25855.20 4438.48 Aetna Aetna Commercial 0.23 6024.74 0.23 25855.20 0.23 Case Rate 25111 Priced Incise finger tendon sheath 48050 26055 CPT Outpatient 15862.35 2723.04 Aetna Aetna Commercial 0.38 6024.74 0.38 15862.35 0.38 Case Rate 26055 Priced Treat finger fracture each 48050 26727 CPT Outpatient 22779.75 2030.47 Aetna Aetna Commercial 0.26 6024.74 0.26 22779.75 0.26 Case Rate 26727 Priced Revision of knee joint 48050 27446 CPT Outpatient 67882.50 11653.16 Aetna Aetna Commercial 0.23 15708.20 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 48050 27447 CPT Outpatient 130698.75 22436.62 Aetna Aetna Commercial 0.12 15708.20 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 48050 27485 CPT Outpatient 43310.40 7434.95 Aetna Aetna Commercial 0.14 6024.74 0.14 43310.40 0.14 Case Rate 27485 Priced Repair achilles tendon 48050 27650 CPT Outpatient 38246.25 3762.57 Aetna Aetna Commercial 0.16 6024.74 0.16 38246.25 0.16 Case Rate 27650 Priced Treatment of ankle fracture 48050 27792 CPT Outpatient 36101.10 6197.36 Aetna Aetna Commercial 0.17 6024.74 0.17 36101.10 0.17 Case Rate 27792 Priced Treatment of ankle fracture 48050 27814 CPT Outpatient 49405.65 8481.30 Aetna Aetna Commercial 0.12 6024.74 0.12 49405.65 0.12 Case Rate 27814 Priced Removal of foot lesion 48050 28080 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 28080 Priced Repair of hammertoe 48050 28285 CPT Outpatient 68603.85 11776.99 Aetna Aetna Commercial 0.09 6024.74 0.09 68603.85 0.09 Case Rate 28285 Priced Correction hallux valgus 48050 28296 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 28296 Priced Shoulder arthroscopy/surgery 48050 29823 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 48050 29826 CPT Outpatient 49840.35 8555.93 Aetna Aetna Commercial 0.07 3343.05 0.07 49840.35 0.07 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 48050 29881 CPT Outpatient 35556.15 6103.81 Aetna Aetna Commercial 0.09 3343.05 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 48050 29882 CPT Outpatient 61099.50 10488.75 Aetna Aetna Commercial 0.05 3343.05 0.05 61099.50 0.05 Case Rate 29882 Priced Percut bx lung/mediastinum 48050 32405 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 32405 Priced Aspirate pleura w/ imaging 48050 32555 CPT Outpatient 14597.10 687.29 Aetna Aetna Commercial 0.41 6024.74 0.41 14597.10 0.41 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 48050 32664 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 32664 Priced Repair blood vessel lesion 48050 35190 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 35190 Priced Endovenous laser 1st vein 48050 36478 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 36478 Priced Insert tunneled cv cath 48050 36561 CPT Outpatient 53531.10 3292.99 Aetna Aetna Commercial 0.11 6024.74 0.11 53531.10 0.11 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 48050 36569 CPT Outpatient 31421.25 1299.06 Aetna Aetna Commercial 0.19 6024.74 0.19 31421.25 0.19 Case Rate 36569 Priced Removal tunneled cv cath 48050 36590 CPT Outpatient 1996.05 273.95 Aetna Aetna Commercial 3.02 6024.74 3.02 1996.05 3.02 Case Rate 36590 Priced Av fuse uppr arm basilic 48050 36819 CPT Outpatient 56861.70 9761.26 Aetna Aetna Commercial 0.11 6024.74 0.11 56861.70 0.11 Case Rate 36819 Priced Av fusion direct any site 48050 36821 CPT Outpatient 42953.40 7373.67 Aetna Aetna Commercial 0.14 6024.74 0.14 42953.40 0.14 Case Rate 36821 Priced Artery-vein autograft 48050 36825 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 36825 Priced Artery-vein nonautograft 48050 36830 CPT Outpatient 53656.05 9210.96 Aetna Aetna Commercial 0.11 6024.74 0.11 53656.05 0.11 Case Rate 36830 Priced Av fistula revision open 48050 36832 CPT Outpatient 52492.65 9011.24 Aetna Aetna Commercial 0.11 6024.74 0.11 52492.65 0.11 Case Rate 36832 Priced Av fistula revision 48050 36833 CPT Outpatient 37098.60 6368.59 Aetna Aetna Commercial 0.16 6024.74 0.16 37098.60 0.16 Case Rate 36833 Priced Intro cath dialysis circuit 48050 36903 CPT Outpatient 77541.45 10669.90 Aetna Aetna Commercial 0.08 6024.74 0.08 77541.45 0.08 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 48050 36906 CPT Outpatient 96694.50 16175.64 Aetna Aetna Commercial 0.06 6024.74 0.06 96694.50 0.06 Case Rate 36906 Priced Fem/popl revas w/tla 48050 37224 CPT Outpatient 200076.45 5139.31 Aetna Aetna Commercial 0.05 9861.48 0.05 200076.45 0.05 Case Rate 37224 Priced Fem/popl revasc stnt & ather 48050 37227 CPT Outpatient 117170.55 18045.38 Aetna Aetna Commercial 0.08 9861.48 0.08 117170.55 0.08 Case Rate 37227 Priced Revise leg vein 48050 37700 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 37700 Priced Ligate/strip long leg vein 48050 37722 CPT Outpatient 27815.55 4775.00 Aetna Aetna Commercial 0.22 6024.74 0.22 27815.55 0.22 Case Rate 37722 Priced Stab phleb veins xtr 10-20 48050 37765 CPT Outpatient 26561.85 4559.78 Aetna Aetna Commercial 0.23 6024.74 0.23 26561.85 0.23 Case Rate 37765 Priced Biopsy/removal lymph nodes 48050 38500 CPT Outpatient 35955.15 6172.30 Aetna Aetna Commercial 0.17 6024.74 0.17 35955.15 0.17 Case Rate 38500 Priced Biopsy/removal lymph nodes 48050 38525 CPT Outpatient 101194.80 17371.77 Aetna Aetna Commercial 0.06 6024.74 0.06 101194.80 0.06 Case Rate 38525 Priced Laparoscopy lymph node biop 48050 38570 CPT Outpatient 65631.30 11266.71 Aetna Aetna Commercial 0.09 6024.74 0.09 65631.30 0.09 Case Rate 38570 Priced Laparoscopy lymphadenectomy 48050 38571 CPT Outpatient 84031.50 14425.41 Aetna Aetna Commercial 0.07 6024.74 0.07 84031.50 0.07 Case Rate 38571 Priced Laparoscopy lymphadenectomy 48050 38572 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 38572 Priced Ra tracer id of sentinl node 48050 38792 CPT Outpatient 2868.60 432.48 Aetna Aetna Commercial 2.10 6024.74 2.10 2868.60 2.10 Case Rate 38792 Priced Excision of gum lesion 48050 41825 CPT Outpatient 11580.45 1987.98 Aetna Aetna Commercial 0.52 6024.74 0.52 11580.45 0.52 Case Rate 41825 Priced Reconstruct cleft palate 48050 42200 CPT Outpatient 36703.80 6300.82 Aetna Aetna Commercial 0.16 6024.74 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 48050 42820 CPT Outpatient 17232.60 2958.26 Aetna Aetna Commercial 0.35 6024.74 0.35 17232.60 0.35 Case Rate 42820 Priced Control throat bleeding 48050 42960 CPT Outpatient 24066.00 4131.33 Aetna Aetna Commercial 0.25 6024.74 0.25 24066.00 0.25 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 48050 43235 CPT Outpatient 8856.75 1633.35 Aetna Aetna Commercial 0.38 3343.05 0.38 8856.75 0.38 Case Rate 43235 Priced Laparoscopy fundoplasty 48050 43280 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 48050 43282 CPT Outpatient 84344.40 14479.12 Aetna Aetna Commercial 0.07 6024.74 0.07 84344.40 0.07 Case Rate 43282 Priced Laparoscopy appendectomy 48050 44970 CPT Outpatient 82300.05 14128.18 Aetna Aetna Commercial 0.07 6024.74 0.07 82300.05 0.07 Case Rate 44970 Priced Diagnostic sigmoidoscopy 48050 45330 CPT Outpatient 17286.15 542.26 Aetna Aetna Commercial 0.19 3343.05 0.19 17286.15 0.19 Case Rate 45330 Priced Needle biopsy of liver 48050 47000 CPT Outpatient 10398.15 1225.34 Aetna Aetna Commercial 0.58 6024.74 0.58 10398.15 0.58 Case Rate 47000 Priced Removal of gallbladder using an endoscope 48050 47562 CPT Outpatient 58430.40 10030.55 Aetna Aetna Commercial 0.10 6024.74 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 48050 47563 CPT Outpatient 71747.55 12316.66 Aetna Aetna Commercial 0.08 6024.74 0.08 71747.55 0.08 Case Rate 47563 Priced Abd paracentesis w/imaging 48050 49083 CPT Outpatient 6979.35 1113.95 Aetna Aetna Commercial 0.86 6024.74 0.86 6979.35 0.86 Case Rate 49083 Priced Diag laparo separate proc 48050 49320 CPT Outpatient 31629.15 5429.67 Aetna Aetna Commercial 0.19 6024.74 0.19 31629.15 0.19 Case Rate 49320 Priced Laparoscopy biopsy 48050 49321 CPT Outpatient 41892.90 7191.61 Aetna Aetna Commercial 0.14 6024.74 0.14 41892.90 0.14 Case Rate 49321 Priced Laparoscopy aspiration 48050 49322 CPT Outpatient 34392.75 5904.09 Aetna Aetna Commercial 0.18 6024.74 0.18 34392.75 0.18 Case Rate 49322 Priced Lap insert tunnel ip cath 48050 49324 CPT Outpatient 39264.75 6740.45 Aetna Aetna Commercial 0.15 6024.74 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 48050 49329 CPT Outpatient 58696.05 10076.16 Aetna Aetna Commercial 0.10 6024.74 0.10 58696.05 0.10 Case Rate 49329 Priced Ins tun ip cath for dial opn 48050 49421 CPT Outpatient 25460.40 3319.30 Aetna Aetna Commercial 0.24 6024.74 0.24 25460.40 0.24 Case Rate 49421 Priced Remove tunneled ip cath 48050 49422 CPT Outpatient 25515.00 4380.08 Aetna Aetna Commercial 0.24 6024.74 0.24 25515.00 0.24 Case Rate 49422 Priced Rpr ing hernia init reduce 48050 49500 CPT Outpatient 19594.05 3363.65 Aetna Aetna Commercial 0.31 6024.74 0.31 19594.05 0.31 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 48050 49505 CPT Outpatient 34915.65 5993.85 Aetna Aetna Commercial 0.17 6024.74 0.17 34915.65 0.17 Case Rate 49505 Priced Prp i/hern init block >5 yr 48050 49507 CPT Outpatient 29794.80 5114.77 Aetna Aetna Commercial 0.20 6024.74 0.20 29794.80 0.20 Case Rate 49507 Priced Rerepair ing hernia reduce 48050 49520 CPT Outpatient 36940.05 6341.38 Aetna Aetna Commercial 0.16 6024.74 0.16 36940.05 0.16 Case Rate 49520 Priced Rpr ventral hern init reduc 48050 49560 CPT Outpatient 53177.25 9128.76 Aetna Aetna Commercial 0.11 6024.74 0.11 53177.25 0.11 Case Rate 49560 Priced Rpr ventral hern init block 48050 49561 CPT Outpatient 30755.55 5279.70 Aetna Aetna Commercial 0.20 6024.74 0.20 30755.55 0.20 Case Rate 49561 Priced Rerepair ventrl hern reduce 48050 49565 CPT Outpatient 69917.40 12002.49 Aetna Aetna Commercial 0.09 6024.74 0.09 69917.40 0.09 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 48050 49585 CPT Outpatient 41806.80 7176.83 Aetna Aetna Commercial 0.14 6024.74 0.14 41806.80 0.14 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 48050 49587 CPT Outpatient 37320.15 6406.63 Aetna Aetna Commercial 0.16 6024.74 0.16 37320.15 0.16 Case Rate 49587 Priced Lap ing hernia repair init 48050 49650 CPT Outpatient 41932.80 7198.46 Aetna Aetna Commercial 0.14 6024.74 0.14 41932.80 0.14 Case Rate 49650 Priced Lap ing hernia repair recur 48050 49651 CPT Outpatient 46915.05 8053.75 Aetna Aetna Commercial 0.13 6024.74 0.13 46915.05 0.13 Case Rate 49651 Priced Lap vent/abd hernia repair 48050 49652 CPT Outpatient 51294.60 8805.57 Aetna Aetna Commercial 0.12 6024.74 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 48050 49653 CPT Outpatient 46102.35 7914.24 Aetna Aetna Commercial 0.13 6024.74 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 48050 49654 CPT Outpatient 47221.65 8106.38 Aetna Aetna Commercial 0.13 6024.74 0.13 47221.65 0.13 Case Rate 49654 Priced Lap inc hern repair comp 48050 49655 CPT Outpatient 54590.55 9371.38 Aetna Aetna Commercial 0.11 6024.74 0.11 54590.55 0.11 Case Rate 49655 Priced Lap inc hernia repair recur 48050 49656 CPT Outpatient 55443.15 9517.74 Aetna Aetna Commercial 0.11 6024.74 0.11 55443.15 0.11 Case Rate 49656 Priced Removal of kidney stone 48050 50080 CPT Outpatient 53165.70 9126.78 Aetna Aetna Commercial 0.11 6024.74 0.11 53165.70 0.11 Case Rate 50080 Priced Removal of kidney stone 48050 50081 CPT Outpatient 66931.20 11489.86 Aetna Aetna Commercial 0.09 6024.74 0.09 66931.20 0.09 Case Rate 50081 Priced Renal biopsy perq 48050 50200 CPT Outpatient 43096.20 1225.34 Aetna Aetna Commercial 0.14 6024.74 0.14 43096.20 0.14 Case Rate 50200 Priced Plmt nephroureteral catheter 48050 50433 CPT Outpatient 64566.60 1424.48 Aetna Aetna Commercial 0.09 6024.74 0.09 64566.60 0.09 Case Rate 50433 Priced Laparo radical nephrectomy 48050 50545 CPT Outpatient 43449.00 7458.75 Aetna Aetna Commercial 0.14 6024.74 0.14 43449.00 0.14 Case Rate 50545 Priced Laparoscope proc ureter 48050 50949 CPT Outpatient 49986.30 8580.98 Aetna Aetna Commercial 0.12 6024.74 0.12 49986.30 0.12 Case Rate 50949 Priced Injection for bladder x-ray 48050 51600 CPT Outpatient 3285.45 89.22 Aetna Aetna Commercial 1.83 6024.74 1.83 3285.45 1.83 Case Rate 51600 Priced Cystoscopy 48050 52000 CPT Outpatient 22149.75 3802.37 Aetna Aetna Commercial 0.15 3343.05 0.15 22149.75 0.15 Case Rate 52000 Priced Cystoscopy & ureter catheter 48050 52005 CPT Outpatient 42529.20 2095.77 Aetna Aetna Commercial 0.08 3343.05 0.08 42529.20 0.08 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 48050 52204 CPT Outpatient 31274.25 5368.75 Aetna Aetna Commercial 0.11 3343.05 0.11 31274.25 0.11 Case Rate 52204 Priced Cystoscopy and treatment 48050 52224 CPT Outpatient 13445.25 2308.10 Aetna Aetna Commercial 0.25 3343.05 0.25 13445.25 0.25 Case Rate 52224 Priced Cystoscopy and treatment 48050 52234 CPT Outpatient 28510.65 4894.33 Aetna Aetna Commercial 0.12 3343.05 0.12 28510.65 0.12 Case Rate 52234 Priced Cystoscopy and treatment 48050 52235 CPT Outpatient 29417.85 5050.06 Aetna Aetna Commercial 0.11 3343.05 0.11 29417.85 0.11 Case Rate 52235 Priced Cystoscopy and treatment 48050 52240 CPT Outpatient 33933.90 5825.32 Aetna Aetna Commercial 0.10 3343.05 0.10 33933.90 0.10 Case Rate 52240 Priced Cystoscopy and treatment 48050 52281 CPT Outpatient 22159.20 3804.00 Aetna Aetna Commercial 0.15 3343.05 0.15 22159.20 0.15 Case Rate 52281 Priced Remove bladder stone 48050 52317 CPT Outpatient 27085.80 4649.73 Aetna Aetna Commercial 0.12 3343.05 0.12 27085.80 0.12 Case Rate 52317 Priced Remove bladder stone 48050 52318 CPT Outpatient 26685.75 4581.05 Aetna Aetna Commercial 0.13 3343.05 0.13 26685.75 0.13 Case Rate 52318 Priced Cystoscopy and treatment 48050 52332 CPT Outpatient 115306.80 19794.33 Aetna Aetna Commercial 0.03 3343.05 0.03 115306.80 0.03 Case Rate 52332 Priced Cystouretero w/stone remove 48050 52352 CPT Outpatient 42420.00 7282.10 Aetna Aetna Commercial 0.08 3343.05 0.08 42420.00 0.08 Case Rate 52352 Priced Cystouretero w/lithotripsy 48050 52353 CPT Outpatient 38608.50 6627.79 Aetna Aetna Commercial 0.16 6024.74 0.16 38608.50 0.16 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 48050 52356 CPT Outpatient 36255.45 6223.85 Aetna Aetna Commercial 0.17 6024.74 0.17 36255.45 0.17 Case Rate 52356 Priced Prostatectomy (turp) 48050 52601 CPT Outpatient 35371.35 6072.08 Aetna Aetna Commercial 0.17 6024.74 0.17 35371.35 0.17 Case Rate 52601 Priced Laser surgery of prostate 48050 52648 CPT Outpatient 24264.45 4165.40 Aetna Aetna Commercial 0.25 6024.74 0.25 24264.45 0.25 Case Rate 52648 Priced Revision of urethra 48050 53450 CPT Outpatient 16209.90 2782.70 Aetna Aetna Commercial 0.37 6024.74 0.37 16209.90 0.37 Case Rate 53450 Priced Urology surgery procedure 48050 53899 CPT Outpatient 25368.00 134.83 Aetna Aetna Commercial 0.24 6024.74 0.24 25368.00 0.24 Case Rate 53899 Priced Circumcision w/regionl block 48050 54150 CPT Outpatient 14700.00 2523.50 Aetna Aetna Commercial 0.41 6024.74 0.41 14700.00 0.41 Case Rate 54150 Priced Circum 28 days or older 48050 54161 CPT Outpatient 19186.65 3293.71 Aetna Aetna Commercial 0.31 6024.74 0.31 19186.65 0.31 Case Rate 54161 Priced Lysis penil circumic lesion 48050 54162 CPT Outpatient 19795.65 3398.25 Aetna Aetna Commercial 0.30 6024.74 0.30 19795.65 0.30 Case Rate 54162 Priced Repair of circumcision 48050 54163 CPT Outpatient 16391.55 2813.88 Aetna Aetna Commercial 0.37 6024.74 0.37 16391.55 0.37 Case Rate 54163 Priced Reconstruction of urethra 48050 54324 CPT Outpatient 32880.75 5644.53 Aetna Aetna Commercial 0.18 6024.74 0.18 32880.75 0.18 Case Rate 54324 Priced Revise penis/urethra 48050 54332 CPT Outpatient 19968.90 3427.99 Aetna Aetna Commercial 0.30 6024.74 0.30 19968.90 0.30 Case Rate 54332 Priced Insert self-contd prosthesis 48050 54401 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 54401 Priced Removal of testis 48050 54520 CPT Outpatient 35442.75 6084.34 Aetna Aetna Commercial 0.17 6024.74 0.17 35442.75 0.17 Case Rate 54520 Priced Reduce testis torsion 48050 54600 CPT Outpatient 55049.40 9450.15 Aetna Aetna Commercial 0.11 6024.74 0.11 55049.40 0.11 Case Rate 54600 Priced Suspension of testis 48050 54640 CPT Outpatient 26860.05 4610.98 Aetna Aetna Commercial 0.22 6024.74 0.22 26860.05 0.22 Case Rate 54640 Priced Removal of hydrocele 48050 55040 CPT Outpatient 27277.95 4682.71 Aetna Aetna Commercial 0.22 6024.74 0.22 27277.95 0.22 Case Rate 55040 Priced Biopsy of prostate gland 48050 55700 CPT Outpatient 28699.65 4926.77 Aetna Aetna Commercial 0.21 6024.74 0.21 28699.65 0.21 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 48050 55866 CPT Outpatient 93088.80 15980.24 Aetna Aetna Commercial 0.06 6024.74 0.06 93088.80 0.06 Case Rate 55866 Priced Closure of vagina 48050 57120 CPT Outpatient 34369.65 5900.12 Aetna Aetna Commercial 0.18 6024.74 0.18 34369.65 0.18 Case Rate 57120 Priced Repair of vagina 48050 57200 CPT Outpatient 25247.25 4334.11 Aetna Aetna Commercial 0.24 6024.74 0.24 25247.25 0.24 Case Rate 57200 Priced Anterior colporrhaphy 48050 57240 CPT Outpatient 36210.30 6216.10 Aetna Aetna Commercial 0.09 3343.05 0.09 36210.30 0.09 Case Rate 57240 Priced Repair rectum & vagina 48050 57250 CPT Outpatient 40441.80 6942.51 Aetna Aetna Commercial 0.15 6024.74 0.15 40441.80 0.15 Case Rate 57250 Priced Cmbn ant pst colprhy 48050 57260 CPT Outpatient 46323.90 7952.27 Aetna Aetna Commercial 0.13 6024.74 0.13 46323.90 0.13 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 48050 57265 CPT Outpatient 42586.95 7310.76 Aetna Aetna Commercial 0.14 6024.74 0.14 42586.95 0.14 Case Rate 57265 Priced Repair of bowel bulge 48050 57268 CPT Outpatient 36865.50 6328.58 Aetna Aetna Commercial 0.09 3343.05 0.09 36865.50 0.09 Case Rate 57268 Priced Colpopexy extraperitoneal 48050 57282 CPT Outpatient 45629.85 7833.12 Aetna Aetna Commercial 0.13 6024.74 0.13 45629.85 0.13 Case Rate 57282 Priced Repair bladder defect 48050 57288 CPT Outpatient 43069.95 7393.67 Aetna Aetna Commercial 0.14 6024.74 0.14 43069.95 0.14 Case Rate 57288 Priced Bx/curett of cervix w/scope 48050 57454 CPT Outpatient 2888.55 442.93 Aetna Aetna Commercial 2.09 6024.74 2.09 2888.55 2.09 Case Rate 57454 Priced Conization of cervix 48050 57520 CPT Outpatient 26728.80 4588.44 Aetna Aetna Commercial 0.23 6024.74 0.23 26728.80 0.23 Case Rate 57520 Priced Conization of cervix 48050 57522 CPT Outpatient 22737.75 3903.31 Aetna Aetna Commercial 0.26 6024.74 0.26 22737.75 0.26 Case Rate 57522 Priced Biopsy of uterus lining 48050 58100 CPT Outpatient 2371.95 194.80 Aetna Aetna Commercial 2.54 6024.74 2.54 2371.95 2.54 Case Rate 58100 Priced Catheter for hysterography 48050 58340 CPT Outpatient 6322.05 131.04 Aetna Aetna Commercial 0.95 6024.74 0.95 6322.05 0.95 Case Rate 58340 Priced Reopen fallopian tube 48050 58350 CPT Outpatient 46507.65 7983.81 Aetna Aetna Commercial 0.13 6024.74 0.13 46507.65 0.13 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 48050 58542 CPT Outpatient 64194.90 11020.12 Aetna Aetna Commercial 0.09 6024.74 0.09 64194.90 0.09 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 48050 58544 CPT Outpatient 51020.55 8758.53 Aetna Aetna Commercial 0.12 6024.74 0.12 51020.55 0.12 Case Rate 58544 Priced Laparoscopic myomectomy 48050 58545 CPT Outpatient 56946.75 9775.86 Aetna Aetna Commercial 0.11 6024.74 0.11 56946.75 0.11 Case Rate 58545 Priced Laparo-vag hyst incl t/o 48050 58552 CPT Outpatient 57228.15 9824.17 Aetna Aetna Commercial 0.11 6024.74 0.11 57228.15 0.11 Case Rate 58552 Priced Hysteroscopy biopsy 48050 58558 CPT Outpatient 28581.00 2077.02 Aetna Aetna Commercial 0.21 6024.74 0.21 28581.00 0.21 Case Rate 58558 Priced Hysteroscopy remove myoma 48050 58561 CPT Outpatient 35222.25 6046.49 Aetna Aetna Commercial 0.17 6024.74 0.17 35222.25 0.17 Case Rate 58561 Priced Hysteroscopy ablation 48050 58563 CPT Outpatient 38399.55 6591.92 Aetna Aetna Commercial 0.16 6024.74 0.16 38399.55 0.16 Case Rate 58563 Priced Tlh uterus 250 g or less 48050 58570 CPT Outpatient 43316.70 7436.03 Aetna Aetna Commercial 0.14 6024.74 0.14 43316.70 0.14 Case Rate 58570 Priced Tlh w/t/o 250 g or less 48050 58571 CPT Outpatient 48603.45 8343.59 Aetna Aetna Commercial 0.12 6024.74 0.12 48603.45 0.12 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 48050 58573 CPT Outpatient 52905.30 9082.08 Aetna Aetna Commercial 0.11 6024.74 0.11 52905.30 0.11 Case Rate 58573 Priced Laparoscopy remove adnexa 48050 58661 CPT Outpatient 47008.50 8069.79 Aetna Aetna Commercial 0.07 3343.05 0.07 47008.50 0.07 Case Rate 58661 Priced Laparoscopy excise lesions 48050 58662 CPT Outpatient 45053.40 7734.17 Aetna Aetna Commercial 0.13 6024.74 0.13 45053.40 0.13 Case Rate 58662 Priced Treat ectopic pregnancy 48050 59151 CPT Outpatient 74690.70 12821.90 Aetna Aetna Commercial 0.08 6024.74 0.08 74690.70 0.08 Case Rate 59151 Priced Treatment of miscarriage 48050 59812 CPT Outpatient 56109.90 9632.20 Aetna Aetna Commercial 0.11 6024.74 0.11 56109.90 0.11 Case Rate 59812 Priced Partial removal of thyroid 48050 60220 CPT Outpatient 53639.25 9208.07 Aetna Aetna Commercial 0.11 6024.74 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 48050 60240 CPT Outpatient 98252.70 16866.71 Aetna Aetna Commercial 0.06 6024.74 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 48050 60500 CPT Outpatient 150495.45 25835.05 Aetna Aetna Commercial 0.04 6024.74 0.04 150495.45 0.04 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 48050 62322 CPT Outpatient 43709.40 514.24 Aetna Aetna Commercial 0.14 6024.74 0.14 43709.40 0.14 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 48050 62323 CPT Outpatient 8304.45 467.31 Aetna Aetna Commercial 0.73 6024.74 0.73 8304.45 0.73 Case Rate 62323 Priced Low back disk surgery 48050 63030 CPT Outpatient 50287.65 8632.71 Aetna Aetna Commercial 0.12 6024.74 0.12 50287.65 0.12 Case Rate 63030 Priced Inc for vagus n elect impl 48050 64568 CPT Outpatient 124562.55 21383.24 Aetna Aetna Commercial 0.05 6024.74 0.05 124562.55 0.05 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 48050 66821 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 66821 Priced Removal of cataract with insertion of lens 48050 66984 CPT Outpatient 0.01 0.01 Aetna Aetna Commercial 1.00 0.01 1.00 0.01 1.00 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 48047 216 DRG Inpatient 0.01 0.01 Aetna Aetna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 48047 460 DRG Inpatient 416122.79 53834.63 Aetna Aetna Medicare 0.09 36507.56 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 48047 470 DRG Inpatient 167912.19 21723.13 Aetna Aetna Medicare 0.11 18221.64 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 48047 473 DRG Inpatient 100687.91 13026.19 Aetna Aetna Medicare 0.24 23973.82 0.24 100687.91 0.24 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 48047 743 DRG Inpatient 102691.67 13285.42 Aetna Aetna Medicare 0.11 11317.53 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 48047 795 DRG Inpatient 6266.93 2335.00 Aetna Aetna Medicare 0.49 3065.24 0.49 6266.93 0.49 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 48047 807 DRG Inpatient 116469.59 4193.00 Aetna Aetna Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 48047 788 DRG Inpatient 76050.77 4538.00 Aetna Aetna Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 48047 59400 CPT Inpatient 116469.59 4193.00 Aetna Aetna Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 48047 59510 CPT Inpatient 76050.77 4538.00 Aetna Aetna Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 48047 59610 CPT Inpatient 116469.59 4193.00 Aetna Aetna Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59610 Priced "Psychotherapy, 30 min" 48047 90832 CPT Outpatient 577.50 91.21 Aetna Aetna Medicare 0.29 166.55 0.29 577.50 0.29 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 48047 90834 CPT Outpatient 44134.65 271.96 Aetna Aetna Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 48047 90837 CPT Outpatient 2240.70 442.93 Aetna Aetna Medicare 0.04 84.05 0.04 2240.70 0.04 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 48047 90846 CPT Outpatient 0.01 131.50 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 48047 90847 CPT Outpatient 44134.65 369.97 Aetna Aetna Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90847 Priced Group psychotherapy 48047 90853 CPT Outpatient 44134.65 101.99 Aetna Aetna Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 48047 99203 CPT Outpatient 3480.75 176.07 Aetna Aetna Medicare 0.12 403.52 0.12 3480.75 0.12 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 48047 99204 CPT Outpatient 2103.15 233.39 Aetna Aetna Medicare 0.19 390.94 0.19 2103.15 0.19 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 48047 99205 CPT Outpatient 4970.70 314.28 Aetna Aetna Medicare 0.09 462.07 0.09 4970.70 0.09 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 48047 99243 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 48047 99244 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 48047 99385 CPT Outpatient 1114.05 185.90 Aetna Aetna Medicare 0.19 207.05 0.19 1114.05 0.19 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 48047 99386 CPT Outpatient 4877.25 185.90 Aetna Aetna Medicare 0.02 98.87 0.02 4877.25 0.02 Fee Schedule 99386 Priced Routine venipuncture 48047 36415 CPT Outpatient 127.05 19.57 Aetna Aetna Medicare 0.02 3.02 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 48047 80048 CPT Outpatient 576.45 88.78 Aetna Aetna Medicare 0.02 11.70 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 48047 80053 CPT Outpatient 763.35 117.56 Aetna Aetna Medicare 0.02 13.22 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 48047 80055 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 48047 80061 CPT Outpatient 1349.25 197.77 Aetna Aetna Medicare 0.01 18.53 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 48047 80069 CPT Outpatient 716.10 104.95 Aetna Aetna Medicare 0.02 12.01 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 48047 80076 CPT Outpatient 716.10 104.95 Aetna Aetna Medicare 0.02 11.31 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 48047 81000 CPT Outpatient 144.90 21.18 Aetna Aetna Medicare 0.03 4.39 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 48047 81001 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Fee Schedule 81001 Priced Automated urinalysis test 48047 81002 CPT Outpatient 57.75 8.89 Aetna Aetna Medicare 0.06 3.53 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 48047 81003 CPT Outpatient 219.45 33.80 Aetna Aetna Medicare 0.01 3.11 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 48047 82306 CPT Outpatient 1880.55 289.62 Aetna Aetna Medicare 0.02 40.96 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 48047 83036 CPT Outpatient 494.55 76.17 Aetna Aetna Medicare 0.03 13.44 0.03 494.55 0.03 Fee Schedule 83036 Priced PSA (prostate specific antigen) 48047 84153 CPT Outpatient 1177.05 181.28 Aetna Aetna Medicare 0.02 25.45 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 48047 84154 CPT Outpatient 598.50 92.17 Aetna Aetna Medicare 0.04 25.45 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 48047 84443 CPT Outpatient 519.75 80.05 Aetna Aetna Medicare 0.04 23.25 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 48047 84703 CPT Outpatient 785.40 120.96 Aetna Aetna Medicare 0.01 10.40 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 48047 85025 CPT Outpatient 635.25 97.83 Aetna Aetna Medicare 0.02 10.75 0.02 635.25 0.02 Fee Schedule 85025 Priced "Complete blood count, automated" 48047 85027 CPT Outpatient 576.45 88.78 Aetna Aetna Medicare 0.02 8.95 0.02 576.45 0.02 Fee Schedule 85027 Priced "Blood test, clotting time" 48047 85610 CPT Outpatient 404.25 62.26 Aetna Aetna Medicare 0.01 5.43 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 48047 85730 CPT Outpatient 17.22 2.65 Aetna Aetna Medicare 0.48 8.31 0.48 17.22 0.48 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 48047 86003 CPT Outpatient 32.55 5.01 Aetna Aetna Medicare 0.22 7.23 0.22 32.55 0.22 Fee Schedule 86003 Priced Tb test cell immun measure 48047 86480 CPT Outpatient 530.25 81.66 Aetna Aetna Medicare 0.16 85.75 0.16 530.25 0.16 Fee Schedule 86480 Priced Urine culture/colony count 48047 87086 CPT Outpatient 763.35 117.56 Aetna Aetna Medicare 0.01 11.16 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 48047 87338 CPT Outpatient 785.40 120.96 Aetna Aetna Medicare 0.03 19.90 0.03 785.40 0.03 Fee Schedule 87338 Priced Cytopath eval fna report 48047 88173 CPT Outpatient 750.75 115.62 Aetna Aetna Medicare 0.08 57.32 0.08 750.75 0.08 Fee Schedule 88173 Priced Tissue exam by pathologist 48047 88302 CPT Outpatient 635.25 97.83 Aetna Aetna Medicare 0.04 28.54 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 48047 88305 CPT Outpatient 323.40 49.81 Aetna Aetna Medicare 0.18 57.32 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 48047 11042 CPT Outpatient 2668.05 481.45 Aetna Aetna Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb subq tissue add-on 48047 11045 CPT Outpatient 4652.55 330.00 Aetna Aetna Medicare 0.09 403.52 0.09 4652.55 0.09 Case Rate 11045 Priced Dx bronchoscope/lavage 48047 31624 CPT Outpatient 41223.00 7602.31 Aetna Aetna Medicare 0.19 7805.52 0.19 41223.00 0.19 Case Rate 31624 Priced Bronchoscopy/lung bx each 48047 31628 CPT Outpatient 49048.65 9045.51 Aetna Aetna Medicare 0.25 12292.51 0.25 49048.65 0.25 Case Rate 31628 Priced Blood transfusion service 48047 36430 CPT Outpatient 9166.50 574.93 Aetna Aetna Medicare 0.08 731.71 0.08 9166.50 0.08 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 48047 43235 CPT Outpatient 8856.75 1633.35 Aetna Aetna Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Endoscopic us exam esoph 48047 43237 CPT Outpatient 23867.55 4401.63 Aetna Aetna Medicare 0.12 2840.90 0.12 23867.55 0.12 Case Rate 43237 Priced Egd us fine needle bx/aspir 48047 43238 CPT Outpatient 30690.45 5659.90 Aetna Aetna Medicare 0.06 1914.48 0.06 30690.45 0.06 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 48047 43239 CPT Outpatient 40191.90 7412.15 Aetna Aetna Medicare 0.07 2698.70 0.07 40191.90 0.07 Case Rate 43239 Priced Ercp remove duct calculi 48047 43264 CPT Outpatient 34335.00 6332.03 Aetna Aetna Medicare 0.21 7043.47 0.21 34335.00 0.21 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 48047 45378 CPT Outpatient 13991.25 889.35 Aetna Aetna Medicare 0.07 926.48 0.07 13991.25 0.07 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 48047 45380 CPT Outpatient 22215.90 4097.04 Aetna Aetna Medicare 0.08 1815.96 0.08 22215.90 0.08 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 48047 45385 CPT Outpatient 119569.80 22050.95 Aetna Aetna Medicare 0.01 1648.12 0.01 119569.80 0.01 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 48047 45391 CPT Outpatient 24923.85 4596.43 Aetna Aetna Medicare 0.07 1778.07 0.07 24923.85 0.07 Case Rate 45391 Priced Fragmenting of kidney stone 48047 50590 CPT Outpatient 40930.05 7548.28 Aetna Aetna Medicare 0.09 3683.90 0.09 40930.05 0.09 Case Rate 50590 Priced Fetal non-stress test 48047 59025 CPT Outpatient 3153.15 477.76 Aetna Aetna Medicare 0.06 198.89 0.06 3153.15 0.06 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 48047 64483 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 64483 Priced Tympanometry 48047 92567 CPT Outpatient 2224.95 98.50 Aetna Aetna Medicare 0.14 308.98 0.14 2224.95 0.14 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 48047 93000 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 93000 Priced Cardiovascular stress test 48047 93017 CPT Outpatient 3076.50 532.96 Aetna Aetna Medicare 0.10 308.98 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 48047 93452 CPT Outpatient 55621.65 8611.87 Aetna Aetna Medicare 0.06 3385.39 0.06 55621.65 0.06 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 48047 95810 CPT Outpatient 20341.65 3373.48 Aetna Aetna Medicare 0.05 1074.10 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 48047 95811 CPT Outpatient 22491.00 3731.18 Aetna Aetna Medicare 0.05 1074.10 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 48047 95812 CPT Outpatient 5578.65 925.83 Aetna Aetna Medicare 0.06 308.98 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 48047 96040 CPT Outpatient 0.01 102.81 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 96040 Priced Chemo iv infusion 1 hr 48047 96413 CPT Outpatient 4856.25 472.45 Aetna Aetna Medicare 0.55 2654.07 0.55 4856.25 0.55 Case Rate 96413 Priced Ultrasound therapy 48047 97035 CPT Outpatient 2111.55 134.99 Aetna Aetna Medicare 0.04 85.29 0.04 2111.55 0.04 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 48047 97110 CPT Outpatient 6494.25 92.86 Aetna Aetna Medicare 0.05 355.13 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 48047 97116 CPT Outpatient 4723.95 110.61 Aetna Aetna Medicare 0.06 289.20 0.06 4723.95 0.06 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 48047 70450 CPT Outpatient 8566.95 835.61 Aetna Aetna Medicare 0.06 551.80 0.06 8566.95 0.06 Case Rate 70450 Priced Mri brain stem w/o dye 48047 70551 CPT Outpatient 7861.35 1361.31 Aetna Aetna Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 70551 Priced MRI scan of brain before and after contrast 48047 70553 CPT Outpatient 10882.20 1625.88 Aetna Aetna Medicare 0.04 429.92 0.04 10882.20 0.04 Case Rate 70553 Priced X-ray exam chest 2 views 48047 71046 CPT Outpatient 859.95 150.37 Aetna Aetna Medicare 0.11 94.43 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 48047 71250 CPT Outpatient 7288.05 1261.63 Aetna Aetna Medicare 0.02 127.10 0.02 7288.05 0.02 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 48047 72082 CPT Outpatient 2022.30 253.33 Aetna Aetna Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 48047 72100 CPT Outpatient 1599.15 277.38 Aetna Aetna Medicare 0.08 127.10 0.08 1599.15 0.08 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 48047 72110 CPT Outpatient 1389.15 241.04 Aetna Aetna Medicare 0.09 127.10 0.09 1389.15 0.09 Case Rate 72110 Priced MRI scan of lower spinal canal 48047 72148 CPT Outpatient 7861.35 1361.31 Aetna Aetna Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 48047 72193 CPT Outpatient 13671.00 1412.01 Aetna Aetna Medicare 0.02 208.54 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 48047 73030 CPT Outpatient 1452.15 251.43 Aetna Aetna Medicare 0.07 94.43 0.07 1452.15 0.07 Case Rate 73030 Priced X-ray exam of elbow 48047 73080 CPT Outpatient 1356.60 235.68 Aetna Aetna Medicare 0.07 94.43 0.07 1356.60 0.07 Case Rate 73080 Priced X-ray exam of forearm 48047 73090 CPT Outpatient 1243.20 215.26 Aetna Aetna Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73090 Priced X-ray exam of wrist 48047 73110 CPT Outpatient 1243.20 215.26 Aetna Aetna Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 48047 73130 CPT Outpatient 1243.20 215.26 Aetna Aetna Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73130 Priced X-ray exam hips bi 2 views 48047 73521 CPT Outpatient 970.20 228.41 Aetna Aetna Medicare 0.13 127.10 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 48047 73562 CPT Outpatient 802.20 139.12 Aetna Aetna Medicare 0.12 94.43 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 48047 73590 CPT Outpatient 1243.20 215.26 Aetna Aetna Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73590 Priced X-ray exam of ankle 48047 73610 CPT Outpatient 1378.65 239.31 Aetna Aetna Medicare 0.07 94.43 0.07 1378.65 0.07 Case Rate 73610 Priced X-ray exam of foot 48047 73630 CPT Outpatient 975.45 169.41 Aetna Aetna Medicare 0.10 94.43 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 48047 73721 CPT Outpatient 7861.35 1361.31 Aetna Aetna Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 48047 74177 CPT Outpatient 14222.25 1412.01 Aetna Aetna Medicare 0.03 429.92 0.03 14222.25 0.03 Case Rate 74177 Priced Contrst x-ray exam of throat 48047 74210 CPT Outpatient 0.01 440.39 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 74210 Priced X-ray exam surgical specimen 48047 76098 CPT Outpatient 6141.45 407.86 Aetna Aetna Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 76098 Priced Us exam of head and neck 48047 76536 CPT Outpatient 5512.50 955.18 Aetna Aetna Medicare 0.02 127.10 0.02 5512.50 0.02 Case Rate 76536 Priced Ultrasound breast limited 48047 76642 CPT Outpatient 5777.10 127.70 Aetna Aetna Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 48047 76700 CPT Outpatient 4917.15 851.88 Aetna Aetna Medicare 0.03 127.10 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 48047 76705 CPT Outpatient 3836.70 665.17 Aetna Aetna Medicare 0.03 127.10 0.03 3836.70 0.03 Case Rate 76705 Priced Us exam abdo back wall comp 48047 76770 CPT Outpatient 5171.25 895.48 Aetna Aetna Medicare 0.02 127.10 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 48047 76775 CPT Outpatient 3969.00 686.97 Aetna Aetna Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 48047 76801 CPT Outpatient 2006.55 347.98 Aetna Aetna Medicare 0.06 127.10 0.06 2006.55 0.06 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 48047 76805 CPT Outpatient 3969.00 686.97 Aetna Aetna Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 48047 76811 CPT Outpatient 2844.45 492.99 Aetna Aetna Medicare 0.09 268.63 0.09 2844.45 0.09 Case Rate 76811 Priced Ob us nuchal meas 1 gest 48047 76813 CPT Outpatient 1044.75 180.83 Aetna Aetna Medicare 0.12 127.10 0.12 1044.75 0.12 Case Rate 76813 Priced Ob us limited fetus(s) 48047 76815 CPT Outpatient 6428.10 639.90 Aetna Aetna Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76815 Priced Ob us follow-up per fetus 48047 76816 CPT Outpatient 4818.45 833.88 Aetna Aetna Medicare 0.03 127.10 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 48047 76817 CPT Outpatient 6428.10 476.73 Aetna Aetna Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76817 Priced Fetal biophys profil w/o nst 48047 76819 CPT Outpatient 1741.95 302.65 Aetna Aetna Medicare 0.07 127.10 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 48047 76830 CPT Outpatient 9305.10 806.54 Aetna Aetna Medicare 0.03 254.21 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 48047 76870 CPT Outpatient 6328.35 1096.55 Aetna Aetna Medicare 0.02 127.10 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 48047 76885 CPT Outpatient 3836.70 665.17 Aetna Aetna Medicare 0.02 94.43 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 48047 77065 CPT Outpatient 3451.35 192.07 Aetna Aetna Medicare 0.05 158.33 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 48047 77066 CPT Outpatient 5777.10 235.68 Aetna Aetna Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 48047 77067 CPT Outpatient 1416.45 205.57 Aetna Aetna Medicare 0.05 63.90 0.05 1416.45 0.05 Case Rate 77067 Priced X-rays for bone age 48047 77072 CPT Outpatient 2022.30 163.87 Aetna Aetna Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 77072 Priced Joint survey single view 48047 77077 CPT Outpatient 985.95 171.14 Aetna Aetna Medicare 0.13 124.57 0.13 985.95 0.13 Case Rate 77077 Priced Dxa bone density axial 48047 77080 CPT Outpatient 3257.10 319.09 Aetna Aetna Medicare 0.06 191.00 0.06 3257.10 0.06 Case Rate 77080 Priced Fna bx w/us gdn 1st les 48047 10005 CPT Outpatient 5512.50 547.24 Aetna Aetna Medicare 0.13 726.50 0.13 5512.50 0.13 Case Rate 10005 Priced Fna bx w/us gdn ea addl 48047 10006 CPT Outpatient 10628.10 594.83 Aetna Aetna Medicare 0.07 726.50 0.07 10628.10 0.07 Case Rate 10006 Priced Drainage of hematoma/fluid 48047 10140 CPT Outpatient 23209.20 1081.95 Aetna Aetna Medicare 0.27 6181.44 0.27 23209.20 0.27 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 48047 11042 CPT Outpatient 2668.05 481.45 Aetna Aetna Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb bone 20 sq cm/< 48047 11044 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 11044 Priced Removal of skin tags 4.0 cm 48047 11406 CPT Outpatient 19967.85 3427.81 Aetna Aetna Medicare 0.09 1700.21 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 48047 11424 CPT Outpatient 0.01 1004.93 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 11424 Priced Remove pilonidal cyst simple 48047 11770 CPT Outpatient 19173.00 3291.37 Aetna Aetna Medicare 0.15 2826.15 0.15 19173.00 0.15 Case Rate 11770 Priced Replace tissue expander 48047 11970 CPT Outpatient 59239.95 10169.52 Aetna Aetna Medicare 0.52 30989.99 0.52 59239.95 0.52 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 48047 14020 CPT Outpatient 32166.75 5521.96 Aetna Aetna Medicare 0.06 1999.63 0.06 32166.75 0.06 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 48047 14060 CPT Outpatient 25993.80 1374.69 Aetna Aetna Medicare 0.31 7937.33 0.31 25993.80 0.31 Case Rate 14060 Priced Wound prep trk/arm/leg 48047 15002 CPT Outpatient 41748.00 1441.73 Aetna Aetna Medicare 0.21 8825.17 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 48047 15271 CPT Outpatient 24343.20 3769.48 Aetna Aetna Medicare 0.08 1999.63 0.08 24343.20 0.08 Case Rate 15271 Priced Acellular derm matrix implt 48047 15777 CPT Outpatient 101672.55 17453.79 Aetna Aetna Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 15777 Priced Exc skin abd 48047 15830 CPT Outpatient 54696.60 9389.58 Aetna Aetna Medicare 0.12 6325.99 0.12 54696.60 0.12 Case Rate 15830 Priced Dressing change not for burn 48047 15852 CPT Outpatient 0.01 290.74 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 15852 Priced Suction lipectomy trunk 48047 15877 CPT Outpatient 63741.30 10942.26 Aetna Aetna Medicare 0.17 10877.73 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 48047 15879 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 15879 Priced Drainage of breast lesion 48047 19000 CPT Outpatient 10143.00 594.83 Aetna Aetna Medicare 0.08 790.40 0.08 10143.00 0.08 Case Rate 19000 Priced Bx breast 1st lesion strtctc 48047 19081 CPT Outpatient 12341.70 1250.69 Aetna Aetna Medicare 0.14 1758.68 0.14 12341.70 0.14 Case Rate 19081 Priced Bx breast add lesion us imag 48047 19084 CPT Outpatient 29058.75 547.24 Aetna Aetna Medicare 0.07 1975.03 0.07 29058.75 0.07 Case Rate 19084 Priced Biopsy of breast open 48047 19101 CPT Outpatient 39545.10 2737.82 Aetna Aetna Medicare 0.23 8988.74 0.23 39545.10 0.23 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 48047 19120 CPT Outpatient 35761.95 2737.82 Aetna Aetna Medicare 0.12 4298.03 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 48047 19125 CPT Outpatient 33184.20 0.01 Aetna Aetna Medicare 0.26 8661.10 0.26 33184.20 0.26 Case Rate 19125 Priced Perq device breast 1st imag 48047 19281 CPT Outpatient 6141.45 598.61 Aetna Aetna Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 19281 Priced Perq device breast ea imag 48047 19282 CPT Outpatient 8379.00 319.04 Aetna Aetna Medicare 0.15 1290.61 0.15 8379.00 0.15 Case Rate 19282 Priced Partial mastectomy 48047 19301 CPT Outpatient 39157.65 6722.06 Aetna Aetna Medicare 0.20 7846.47 0.20 39157.65 0.20 Case Rate 19301 Priced Mast simple complete 48047 19303 CPT Outpatient 105389.55 18091.87 Aetna Aetna Medicare 0.28 29200.15 0.28 105389.55 0.28 Case Rate 19303 Priced Reduction of large breast 48047 19318 CPT Outpatient 65239.65 11199.47 Aetna Aetna Medicare 0.10 6577.10 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 48047 19340 CPT Outpatient 113100.75 19415.63 Aetna Aetna Medicare 0.13 14822.97 0.13 113100.75 0.13 Case Rate 19340 Priced Delayed breast prosthesis 48047 19342 CPT Outpatient 56988.75 9783.07 Aetna Aetna Medicare 0.36 20246.20 0.36 56988.75 0.36 Case Rate 19342 Priced Breast reconstruction 48047 19357 CPT Outpatient 101672.55 17453.79 Aetna Aetna Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 19357 Priced Breast reconstruction 48047 19366 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 19366 Priced Revise breast reconstruction 48047 19380 CPT Outpatient 61493.25 10556.34 Aetna Aetna Medicare 0.21 13212.28 0.21 61493.25 0.21 Case Rate 19380 Priced Removal of support implant 48047 20680 CPT Outpatient 42329.70 7266.60 Aetna Aetna Medicare 0.14 5804.91 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 48047 22856 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 22856 Priced Treat humerus fracture 48047 24538 CPT Outpatient 51237.90 4775.24 Aetna Aetna Medicare 0.19 9816.98 0.19 51237.90 0.19 Case Rate 24538 Priced Remove wrist tendon lesion 48047 25111 CPT Outpatient 25855.20 4438.48 Aetna Aetna Medicare 0.06 1654.95 0.06 25855.20 0.06 Case Rate 25111 Priced Incise finger tendon sheath 48047 26055 CPT Outpatient 15862.35 2723.04 Aetna Aetna Medicare 0.12 1931.13 0.12 15862.35 0.12 Case Rate 26055 Priced Treat finger fracture each 48047 26727 CPT Outpatient 22779.75 2030.47 Aetna Aetna Medicare 0.16 3574.88 0.16 22779.75 0.16 Case Rate 26727 Priced Revision of knee joint 48047 27446 CPT Outpatient 67882.50 11653.16 Aetna Aetna Medicare 0.23 15567.47 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 48047 27447 CPT Outpatient 130698.75 22436.62 Aetna Aetna Medicare 0.12 15604.41 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 48047 27485 CPT Outpatient 43310.40 7434.95 Aetna Aetna Medicare 0.26 11063.75 0.26 43310.40 0.26 Case Rate 27485 Priced Repair achilles tendon 48047 27650 CPT Outpatient 38246.25 3762.57 Aetna Aetna Medicare 0.29 11041.86 0.29 38246.25 0.29 Case Rate 27650 Priced Treatment of ankle fracture 48047 27792 CPT Outpatient 36101.10 6197.36 Aetna Aetna Medicare 0.21 7581.28 0.21 36101.10 0.21 Case Rate 27792 Priced Treatment of ankle fracture 48047 27814 CPT Outpatient 49405.65 8481.30 Aetna Aetna Medicare 0.16 7766.50 0.16 49405.65 0.16 Case Rate 27814 Priced Removal of foot lesion 48047 28080 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 28080 Priced Repair of hammertoe 48047 28285 CPT Outpatient 68603.85 11776.99 Aetna Aetna Medicare 0.20 13986.50 0.20 68603.85 0.20 Case Rate 28285 Priced Correction hallux valgus 48047 28296 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 28296 Priced Shoulder arthroscopy/surgery 48047 29823 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 48047 29826 CPT Outpatient 49840.35 8555.93 Aetna Aetna Medicare 0.15 7312.64 0.15 49840.35 0.15 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 48047 29881 CPT Outpatient 35556.15 6103.81 Aetna Aetna Medicare 0.09 3306.24 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 48047 29882 CPT Outpatient 61099.50 10488.75 Aetna Aetna Medicare 0.19 11577.74 0.19 61099.50 0.19 Case Rate 29882 Priced Percut bx lung/mediastinum 48047 32405 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 32405 Priced Aspirate pleura w/ imaging 48047 32555 CPT Outpatient 14597.10 687.29 Aetna Aetna Medicare 0.05 711.62 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 48047 32664 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 32664 Priced Repair blood vessel lesion 48047 35190 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 35190 Priced Endovenous laser 1st vein 48047 36478 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 36478 Priced Insert tunneled cv cath 48047 36561 CPT Outpatient 53531.10 3292.99 Aetna Aetna Medicare 0.06 3342.08 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 48047 36569 CPT Outpatient 31421.25 1299.06 Aetna Aetna Medicare 0.06 1811.50 0.06 31421.25 0.06 Case Rate 36569 Priced Removal tunneled cv cath 48047 36590 CPT Outpatient 1996.05 273.95 Aetna Aetna Medicare 0.82 1641.71 0.82 1996.05 0.82 Case Rate 36590 Priced Av fuse uppr arm basilic 48047 36819 CPT Outpatient 56861.70 9761.26 Aetna Aetna Medicare 0.17 9459.82 0.17 56861.70 0.17 Case Rate 36819 Priced Av fusion direct any site 48047 36821 CPT Outpatient 42953.40 7373.67 Aetna Aetna Medicare 0.16 7056.50 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 48047 36825 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 36825 Priced Artery-vein nonautograft 48047 36830 CPT Outpatient 53656.05 9210.96 Aetna Aetna Medicare 0.17 9346.72 0.17 53656.05 0.17 Case Rate 36830 Priced Av fistula revision open 48047 36832 CPT Outpatient 52492.65 9011.24 Aetna Aetna Medicare 0.23 12046.01 0.23 52492.65 0.23 Case Rate 36832 Priced Av fistula revision 48047 36833 CPT Outpatient 37098.60 6368.59 Aetna Aetna Medicare 0.28 10242.79 0.28 37098.60 0.28 Case Rate 36833 Priced Intro cath dialysis circuit 48047 36903 CPT Outpatient 77541.45 10669.90 Aetna Aetna Medicare 0.24 18454.26 0.24 77541.45 0.24 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 48047 36906 CPT Outpatient 96694.50 16175.64 Aetna Aetna Medicare 0.27 26216.69 0.27 96694.50 0.27 Case Rate 36906 Priced Fem/popl revas w/tla 48047 37224 CPT Outpatient 200076.45 5139.31 Aetna Aetna Medicare 0.14 27878.39 0.14 200076.45 0.14 Case Rate 37224 Priced Fem/popl revasc stnt & ather 48047 37227 CPT Outpatient 117170.55 18045.38 Aetna Aetna Medicare 0.17 19636.18 0.17 117170.55 0.17 Case Rate 37227 Priced Revise leg vein 48047 37700 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 37700 Priced Ligate/strip long leg vein 48047 37722 CPT Outpatient 27815.55 4775.00 Aetna Aetna Medicare 0.37 10398.58 0.37 27815.55 0.37 Case Rate 37722 Priced Stab phleb veins xtr 10-20 48047 37765 CPT Outpatient 26561.85 4559.78 Aetna Aetna Medicare 0.52 13740.66 0.52 26561.85 0.52 Case Rate 37765 Priced Biopsy/removal lymph nodes 48047 38500 CPT Outpatient 35955.15 6172.30 Aetna Aetna Medicare 0.11 3918.72 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 48047 38525 CPT Outpatient 101194.80 17371.77 Aetna Aetna Medicare 0.19 18851.15 0.19 101194.80 0.19 Case Rate 38525 Priced Laparoscopy lymph node biop 48047 38570 CPT Outpatient 65631.30 11266.71 Aetna Aetna Medicare 0.28 18089.66 0.28 65631.30 0.28 Case Rate 38570 Priced Laparoscopy lymphadenectomy 48047 38571 CPT Outpatient 84031.50 14425.41 Aetna Aetna Medicare 0.26 22194.38 0.26 84031.50 0.26 Case Rate 38571 Priced Laparoscopy lymphadenectomy 48047 38572 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 38572 Priced Ra tracer id of sentinl node 48047 38792 CPT Outpatient 2868.60 432.48 Aetna Aetna Medicare 0.15 440.09 0.15 2868.60 0.15 Case Rate 38792 Priced Excision of gum lesion 48047 41825 CPT Outpatient 11580.45 1987.98 Aetna Aetna Medicare 0.30 3440.87 0.30 11580.45 0.30 Case Rate 41825 Priced Reconstruct cleft palate 48047 42200 CPT Outpatient 36703.80 6300.82 Aetna Aetna Medicare 0.16 5937.71 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 48047 42820 CPT Outpatient 17232.60 2958.26 Aetna Aetna Medicare 0.64 11027.66 0.64 17232.60 0.64 Case Rate 42820 Priced Control throat bleeding 48047 42960 CPT Outpatient 24066.00 4131.33 Aetna Aetna Medicare 0.20 4852.02 0.20 24066.00 0.20 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 48047 43235 CPT Outpatient 8856.75 1633.35 Aetna Aetna Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Laparoscopy fundoplasty 48047 43280 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 48047 43282 CPT Outpatient 84344.40 14479.12 Aetna Aetna Medicare 0.13 10981.07 0.13 84344.40 0.13 Case Rate 43282 Priced Laparoscopy appendectomy 48047 44970 CPT Outpatient 82300.05 14128.18 Aetna Aetna Medicare 0.08 6988.44 0.08 82300.05 0.08 Case Rate 44970 Priced Diagnostic sigmoidoscopy 48047 45330 CPT Outpatient 17286.15 542.26 Aetna Aetna Medicare 0.11 1880.24 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 48047 47000 CPT Outpatient 10398.15 1225.34 Aetna Aetna Medicare 0.20 2101.24 0.20 10398.15 0.20 Case Rate 47000 Priced Removal of gallbladder using an endoscope 48047 47562 CPT Outpatient 58430.40 10030.55 Aetna Aetna Medicare 0.10 5965.34 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 48047 47563 CPT Outpatient 71747.55 12316.66 Aetna Aetna Medicare 0.09 6769.21 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 48047 49083 CPT Outpatient 6979.35 1113.95 Aetna Aetna Medicare 0.14 944.67 0.14 6979.35 0.14 Case Rate 49083 Priced Diag laparo separate proc 48047 49320 CPT Outpatient 31629.15 5429.67 Aetna Aetna Medicare 0.42 13201.26 0.42 31629.15 0.42 Case Rate 49320 Priced Laparoscopy biopsy 48047 49321 CPT Outpatient 41892.90 7191.61 Aetna Aetna Medicare 0.32 13491.42 0.32 41892.90 0.32 Case Rate 49321 Priced Laparoscopy aspiration 48047 49322 CPT Outpatient 34392.75 5904.09 Aetna Aetna Medicare 0.39 13396.33 0.39 34392.75 0.39 Case Rate 49322 Priced Lap insert tunnel ip cath 48047 49324 CPT Outpatient 39264.75 6740.45 Aetna Aetna Medicare 0.15 5972.32 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 48047 49329 CPT Outpatient 58696.05 10076.16 Aetna Aetna Medicare 0.29 17162.20 0.29 58696.05 0.29 Case Rate 49329 Priced Ins tun ip cath for dial opn 48047 49421 CPT Outpatient 25460.40 3319.30 Aetna Aetna Medicare 0.15 3702.67 0.15 25460.40 0.15 Case Rate 49421 Priced Remove tunneled ip cath 48047 49422 CPT Outpatient 25515.00 4380.08 Aetna Aetna Medicare 0.13 3342.08 0.13 25515.00 0.13 Case Rate 49422 Priced Rpr ing hernia init reduce 48047 49500 CPT Outpatient 19594.05 3363.65 Aetna Aetna Medicare 0.56 11018.31 0.56 19594.05 0.56 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 48047 49505 CPT Outpatient 34915.65 5993.85 Aetna Aetna Medicare 0.21 7278.08 0.21 34915.65 0.21 Case Rate 49505 Priced Prp i/hern init block >5 yr 48047 49507 CPT Outpatient 29794.80 5114.77 Aetna Aetna Medicare 0.25 7306.28 0.25 29794.80 0.25 Case Rate 49507 Priced Rerepair ing hernia reduce 48047 49520 CPT Outpatient 36940.05 6341.38 Aetna Aetna Medicare 0.20 7341.71 0.20 36940.05 0.20 Case Rate 49520 Priced Rpr ventral hern init reduc 48047 49560 CPT Outpatient 53177.25 9128.76 Aetna Aetna Medicare 0.18 9686.73 0.18 53177.25 0.18 Case Rate 49560 Priced Rpr ventral hern init block 48047 49561 CPT Outpatient 30755.55 5279.70 Aetna Aetna Medicare 0.24 7522.67 0.24 30755.55 0.24 Case Rate 49561 Priced Rerepair ventrl hern reduce 48047 49565 CPT Outpatient 69917.40 12002.49 Aetna Aetna Medicare 0.14 10018.26 0.14 69917.40 0.14 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 48047 49585 CPT Outpatient 41806.80 7176.83 Aetna Aetna Medicare 0.23 9650.59 0.23 41806.80 0.23 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 48047 49587 CPT Outpatient 37320.15 6406.63 Aetna Aetna Medicare 0.20 7369.53 0.20 37320.15 0.20 Case Rate 49587 Priced Lap ing hernia repair init 48047 49650 CPT Outpatient 41932.80 7198.46 Aetna Aetna Medicare 0.14 5784.73 0.14 41932.80 0.14 Case Rate 49650 Priced Lap ing hernia repair recur 48047 49651 CPT Outpatient 46915.05 8053.75 Aetna Aetna Medicare 0.26 12396.08 0.26 46915.05 0.26 Case Rate 49651 Priced Lap vent/abd hernia repair 48047 49652 CPT Outpatient 51294.60 8805.57 Aetna Aetna Medicare 0.12 6001.15 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 48047 49653 CPT Outpatient 46102.35 7914.24 Aetna Aetna Medicare 0.13 5907.33 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 48047 49654 CPT Outpatient 47221.65 8106.38 Aetna Aetna Medicare 0.22 10246.22 0.22 47221.65 0.22 Case Rate 49654 Priced Lap inc hern repair comp 48047 49655 CPT Outpatient 54590.55 9371.38 Aetna Aetna Medicare 0.19 10557.83 0.19 54590.55 0.19 Case Rate 49655 Priced Lap inc hernia repair recur 48047 49656 CPT Outpatient 55443.15 9517.74 Aetna Aetna Medicare 0.19 10492.84 0.19 55443.15 0.19 Case Rate 49656 Priced Removal of kidney stone 48047 50080 CPT Outpatient 53165.70 9126.78 Aetna Aetna Medicare 0.32 16951.33 0.32 53165.70 0.32 Case Rate 50080 Priced Removal of kidney stone 48047 50081 CPT Outpatient 66931.20 11489.86 Aetna Aetna Medicare 0.30 20375.49 0.30 66931.20 0.30 Case Rate 50081 Priced Renal biopsy perq 48047 50200 CPT Outpatient 43096.20 1225.34 Aetna Aetna Medicare 0.23 9703.00 0.23 43096.20 0.23 Case Rate 50200 Priced Plmt nephroureteral catheter 48047 50433 CPT Outpatient 64566.60 1424.48 Aetna Aetna Medicare 0.27 17570.80 0.27 64566.60 0.27 Case Rate 50433 Priced Laparo radical nephrectomy 48047 50545 CPT Outpatient 43449.00 7458.75 Aetna Aetna Medicare 0.03 1190.00 0.03 43449.00 0.03 Case Rate 50545 Priced Laparoscope proc ureter 48047 50949 CPT Outpatient 49986.30 8580.98 Aetna Aetna Medicare 0.34 17208.73 0.34 49986.30 0.34 Case Rate 50949 Priced Injection for bladder x-ray 48047 51600 CPT Outpatient 3285.45 89.22 Aetna Aetna Medicare 0.08 268.63 0.08 3285.45 0.08 Case Rate 51600 Priced Cystoscopy 48047 52000 CPT Outpatient 22149.75 3802.37 Aetna Aetna Medicare 0.36 7975.55 0.36 22149.75 0.36 Case Rate 52000 Priced Cystoscopy & ureter catheter 48047 52005 CPT Outpatient 42529.20 2095.77 Aetna Aetna Medicare 0.21 9136.51 0.21 42529.20 0.21 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 48047 52204 CPT Outpatient 31274.25 5368.75 Aetna Aetna Medicare 0.18 5745.54 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 48047 52224 CPT Outpatient 13445.25 2308.10 Aetna Aetna Medicare 0.54 7303.88 0.54 13445.25 0.54 Case Rate 52224 Priced Cystoscopy and treatment 48047 52234 CPT Outpatient 28510.65 4894.33 Aetna Aetna Medicare 0.27 7572.52 0.27 28510.65 0.27 Case Rate 52234 Priced Cystoscopy and treatment 48047 52235 CPT Outpatient 29417.85 5050.06 Aetna Aetna Medicare 0.25 7276.20 0.25 29417.85 0.25 Case Rate 52235 Priced Cystoscopy and treatment 48047 52240 CPT Outpatient 33933.90 5825.32 Aetna Aetna Medicare 0.27 9046.24 0.27 33933.90 0.27 Case Rate 52240 Priced Cystoscopy and treatment 48047 52281 CPT Outpatient 22159.20 3804.00 Aetna Aetna Medicare 0.26 5688.66 0.26 22159.20 0.26 Case Rate 52281 Priced Remove bladder stone 48047 52317 CPT Outpatient 27085.80 4649.73 Aetna Aetna Medicare 0.27 7426.56 0.27 27085.80 0.27 Case Rate 52317 Priced Remove bladder stone 48047 52318 CPT Outpatient 26685.75 4581.05 Aetna Aetna Medicare 0.28 7361.57 0.28 26685.75 0.28 Case Rate 52318 Priced Cystoscopy and treatment 48047 52332 CPT Outpatient 115306.80 19794.33 Aetna Aetna Medicare 0.18 20580.50 0.18 115306.80 0.18 Case Rate 52332 Priced Cystouretero w/stone remove 48047 52352 CPT Outpatient 42420.00 7282.10 Aetna Aetna Medicare 0.38 16312.79 0.38 42420.00 0.38 Case Rate 52352 Priced Cystouretero w/lithotripsy 48047 52353 CPT Outpatient 38608.50 6627.79 Aetna Aetna Medicare 0.24 9133.86 0.24 38608.50 0.24 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 48047 52356 CPT Outpatient 36255.45 6223.85 Aetna Aetna Medicare 0.25 9133.86 0.25 36255.45 0.25 Case Rate 52356 Priced Prostatectomy (turp) 48047 52601 CPT Outpatient 35371.35 6072.08 Aetna Aetna Medicare 0.25 8684.69 0.25 35371.35 0.25 Case Rate 52601 Priced Laser surgery of prostate 48047 52648 CPT Outpatient 24264.45 4165.40 Aetna Aetna Medicare 0.37 9020.55 0.37 24264.45 0.37 Case Rate 52648 Priced Revision of urethra 48047 53450 CPT Outpatient 16209.90 2782.70 Aetna Aetna Medicare 0.35 5679.84 0.35 16209.90 0.35 Case Rate 53450 Priced Urology surgery procedure 48047 53899 CPT Outpatient 25368.00 134.83 Aetna Aetna Medicare 0.27 6862.63 0.27 25368.00 0.27 Case Rate 53899 Priced Circumcision w/regionl block 48047 54150 CPT Outpatient 14700.00 2523.50 Aetna Aetna Medicare 0.14 2090.37 0.14 14700.00 0.14 Case Rate 54150 Priced Circum 28 days or older 48047 54161 CPT Outpatient 19186.65 3293.71 Aetna Aetna Medicare 0.11 2049.61 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 48047 54162 CPT Outpatient 19795.65 3398.25 Aetna Aetna Medicare 0.85 16823.10 0.85 19795.65 0.85 Case Rate 54162 Priced Repair of circumcision 48047 54163 CPT Outpatient 16391.55 2813.88 Aetna Aetna Medicare 0.24 4010.49 0.24 16391.55 0.24 Case Rate 54163 Priced Reconstruction of urethra 48047 54324 CPT Outpatient 32880.75 5644.53 Aetna Aetna Medicare 0.28 9303.52 0.28 32880.75 0.28 Case Rate 54324 Priced Revise penis/urethra 48047 54332 CPT Outpatient 19968.90 3427.99 Aetna Aetna Medicare 0.18 3589.47 0.18 19968.90 0.18 Case Rate 54332 Priced Insert self-contd prosthesis 48047 54401 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 54401 Priced Removal of testis 48047 54520 CPT Outpatient 35442.75 6084.34 Aetna Aetna Medicare 0.34 12158.30 0.34 35442.75 0.34 Case Rate 54520 Priced Reduce testis torsion 48047 54600 CPT Outpatient 55049.40 9450.15 Aetna Aetna Medicare 0.28 15402.48 0.28 55049.40 0.28 Case Rate 54600 Priced Suspension of testis 48047 54640 CPT Outpatient 26860.05 4610.98 Aetna Aetna Medicare 0.28 7428.84 0.28 26860.05 0.28 Case Rate 54640 Priced Removal of hydrocele 48047 55040 CPT Outpatient 27277.95 4682.71 Aetna Aetna Medicare 0.27 7369.91 0.27 27277.95 0.27 Case Rate 55040 Priced Biopsy of prostate gland 48047 55700 CPT Outpatient 28699.65 4926.77 Aetna Aetna Medicare 0.13 3731.04 0.13 28699.65 0.13 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 48047 55866 CPT Outpatient 93088.80 15980.24 Aetna Aetna Medicare 0.24 22017.24 0.24 93088.80 0.24 Case Rate 55866 Priced Closure of vagina 48047 57120 CPT Outpatient 34369.65 5900.12 Aetna Aetna Medicare 0.43 14932.00 0.43 34369.65 0.43 Case Rate 57120 Priced Repair of vagina 48047 57200 CPT Outpatient 25247.25 4334.11 Aetna Aetna Medicare 0.31 7732.37 0.31 25247.25 0.31 Case Rate 57200 Priced Anterior colporrhaphy 48047 57240 CPT Outpatient 36210.30 6216.10 Aetna Aetna Medicare 0.53 19223.69 0.53 36210.30 0.53 Case Rate 57240 Priced Repair rectum & vagina 48047 57250 CPT Outpatient 40441.80 6942.51 Aetna Aetna Medicare 0.56 22691.64 0.56 40441.80 0.56 Case Rate 57250 Priced Cmbn ant pst colprhy 48047 57260 CPT Outpatient 46323.90 7952.27 Aetna Aetna Medicare 0.66 30437.82 0.66 46323.90 0.66 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 48047 57265 CPT Outpatient 42586.95 7310.76 Aetna Aetna Medicare 0.43 18248.88 0.43 42586.95 0.43 Case Rate 57265 Priced Repair of bowel bulge 48047 57268 CPT Outpatient 36865.50 6328.58 Aetna Aetna Medicare 0.49 18090.91 0.49 36865.50 0.49 Case Rate 57268 Priced Colpopexy extraperitoneal 48047 57282 CPT Outpatient 45629.85 7833.12 Aetna Aetna Medicare 0.66 30324.80 0.66 45629.85 0.66 Case Rate 57282 Priced Repair bladder defect 48047 57288 CPT Outpatient 43069.95 7393.67 Aetna Aetna Medicare 0.56 24109.88 0.56 43069.95 0.56 Case Rate 57288 Priced Bx/curett of cervix w/scope 48047 57454 CPT Outpatient 2888.55 442.93 Aetna Aetna Medicare 0.11 329.27 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 48047 57520 CPT Outpatient 26728.80 4588.44 Aetna Aetna Medicare 0.16 4211.41 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 48047 57522 CPT Outpatient 22737.75 3903.31 Aetna Aetna Medicare 0.15 3411.24 0.15 22737.75 0.15 Case Rate 57522 Priced Biopsy of uterus lining 48047 58100 CPT Outpatient 2371.95 194.80 Aetna Aetna Medicare 0.08 198.89 0.08 2371.95 0.08 Case Rate 58100 Priced Catheter for hysterography 48047 58340 CPT Outpatient 6322.05 131.04 Aetna Aetna Medicare 0.04 268.63 0.04 6322.05 0.04 Case Rate 58340 Priced Reopen fallopian tube 48047 58350 CPT Outpatient 46507.65 7983.81 Aetna Aetna Medicare 0.38 17563.57 0.38 46507.65 0.38 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 48047 58542 CPT Outpatient 64194.90 11020.12 Aetna Aetna Medicare 0.37 24060.91 0.37 64194.90 0.37 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 48047 58544 CPT Outpatient 51020.55 8758.53 Aetna Aetna Medicare 0.65 33216.81 0.65 51020.55 0.65 Case Rate 58544 Priced Laparoscopic myomectomy 48047 58545 CPT Outpatient 56946.75 9775.86 Aetna Aetna Medicare 0.17 9718.98 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 48047 58552 CPT Outpatient 57228.15 9824.17 Aetna Aetna Medicare 0.32 18381.02 0.32 57228.15 0.32 Case Rate 58552 Priced Hysteroscopy biopsy 48047 58558 CPT Outpatient 28581.00 2077.02 Aetna Aetna Medicare 0.25 7238.81 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 48047 58561 CPT Outpatient 35222.25 6046.49 Aetna Aetna Medicare 0.27 9531.42 0.27 35222.25 0.27 Case Rate 58561 Priced Hysteroscopy ablation 48047 58563 CPT Outpatient 38399.55 6591.92 Aetna Aetna Medicare 0.51 19555.87 0.51 38399.55 0.51 Case Rate 58563 Priced Tlh uterus 250 g or less 48047 58570 CPT Outpatient 43316.70 7436.03 Aetna Aetna Medicare 0.26 11083.71 0.26 43316.70 0.26 Case Rate 58570 Priced Tlh w/t/o 250 g or less 48047 58571 CPT Outpatient 48603.45 8343.59 Aetna Aetna Medicare 0.30 14369.35 0.30 48603.45 0.30 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 48047 58573 CPT Outpatient 52905.30 9082.08 Aetna Aetna Medicare 0.32 16722.51 0.32 52905.30 0.32 Case Rate 58573 Priced Laparoscopy remove adnexa 48047 58661 CPT Outpatient 47008.50 8069.79 Aetna Aetna Medicare 0.18 8686.07 0.18 47008.50 0.18 Case Rate 58661 Priced Laparoscopy excise lesions 48047 58662 CPT Outpatient 45053.40 7734.17 Aetna Aetna Medicare 0.38 17220.22 0.38 45053.40 0.38 Case Rate 58662 Priced Treat ectopic pregnancy 48047 59151 CPT Outpatient 74690.70 12821.90 Aetna Aetna Medicare 0.09 6630.70 0.09 74690.70 0.09 Case Rate 59151 Priced Treatment of miscarriage 48047 59812 CPT Outpatient 56109.90 9632.20 Aetna Aetna Medicare 0.07 4075.96 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 48047 60220 CPT Outpatient 53639.25 9208.07 Aetna Aetna Medicare 0.11 6088.34 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 48047 60240 CPT Outpatient 98252.70 16866.71 Aetna Aetna Medicare 0.06 5905.23 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 48047 60500 CPT Outpatient 150495.45 25835.05 Aetna Aetna Medicare 0.06 9768.16 0.06 150495.45 0.06 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 48047 62322 CPT Outpatient 43709.40 514.24 Aetna Aetna Medicare 0.28 12235.33 0.28 43709.40 0.28 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 48047 62323 CPT Outpatient 8304.45 467.31 Aetna Aetna Medicare 16.45 136591.28 16.45 8304.45 16.45 Case Rate 62323 Priced Low back disk surgery 48047 63030 CPT Outpatient 50287.65 8632.71 Aetna Aetna Medicare 0.30 14893.92 0.30 50287.65 0.30 Case Rate 63030 Priced Inc for vagus n elect impl 48047 64568 CPT Outpatient 124562.55 21383.24 Aetna Aetna Medicare 0.27 33814.93 0.27 124562.55 0.27 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 48047 66821 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 66821 Priced Removal of cataract with insertion of lens 48047 66984 CPT Outpatient 0.01 0.01 Aetna Aetna Medicare 1.00 0.01 1.00 0.01 1.00 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 74047 216 DRG Inpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 74047 460 DRG Inpatient 416122.79 53834.63 Cigna Cigna Medicare 0.09 36507.56 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 74047 470 DRG Inpatient 167912.19 21723.13 Cigna Cigna Medicare 0.11 18221.64 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 74047 473 DRG Inpatient 100687.91 13026.19 Cigna Cigna Medicare 0.24 23973.82 0.24 100687.91 0.24 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 74047 743 DRG Inpatient 102691.67 13285.42 Cigna Cigna Medicare 0.11 11317.53 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 74047 795 DRG Inpatient 6266.93 2335.00 Cigna Cigna Medicare 0.49 3065.24 0.49 6266.93 0.49 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 74047 807 DRG Inpatient 116469.59 4193.00 Cigna Cigna Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 74047 788 DRG Inpatient 76050.77 4538.00 Cigna Cigna Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 74047 59400 CPT Inpatient 116469.59 4193.00 Cigna Cigna Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 74047 59510 CPT Inpatient 76050.77 4538.00 Cigna Cigna Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 74047 59610 CPT Inpatient 116469.59 4193.00 Cigna Cigna Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59610 Priced "Psychotherapy, 30 min" 74047 90832 CPT Outpatient 577.50 91.21 Cigna Cigna Medicare 0.29 166.55 0.29 577.50 0.29 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 74047 90834 CPT Outpatient 44134.65 271.96 Cigna Cigna Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 74047 90837 CPT Outpatient 2240.70 442.93 Cigna Cigna Medicare 0.04 84.05 0.04 2240.70 0.04 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 74047 90846 CPT Outpatient 0.01 131.50 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 74047 90847 CPT Outpatient 44134.65 369.97 Cigna Cigna Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90847 Priced Group psychotherapy 74047 90853 CPT Outpatient 44134.65 101.99 Cigna Cigna Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 74047 99203 CPT Outpatient 3480.75 176.07 Cigna Cigna Medicare 0.12 403.52 0.12 3480.75 0.12 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 74047 99204 CPT Outpatient 2103.15 233.39 Cigna Cigna Medicare 0.19 390.94 0.19 2103.15 0.19 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 74047 99205 CPT Outpatient 4970.70 314.28 Cigna Cigna Medicare 0.09 462.07 0.09 4970.70 0.09 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 74047 99243 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 74047 99244 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 74047 99385 CPT Outpatient 1114.05 185.90 Cigna Cigna Medicare 0.19 207.05 0.19 1114.05 0.19 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 74047 99386 CPT Outpatient 4877.25 185.90 Cigna Cigna Medicare 0.02 98.87 0.02 4877.25 0.02 Fee Schedule 99386 Priced Routine venipuncture 74047 36415 CPT Outpatient 127.05 19.57 Cigna Cigna Medicare 0.02 3.02 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 74047 80048 CPT Outpatient 576.45 88.78 Cigna Cigna Medicare 0.02 11.70 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 74047 80053 CPT Outpatient 763.35 117.56 Cigna Cigna Medicare 0.02 13.22 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 74047 80055 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 74047 80061 CPT Outpatient 1349.25 197.77 Cigna Cigna Medicare 0.01 18.53 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 74047 80069 CPT Outpatient 716.10 104.95 Cigna Cigna Medicare 0.02 12.01 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 74047 80076 CPT Outpatient 716.10 104.95 Cigna Cigna Medicare 0.02 11.31 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 74047 81000 CPT Outpatient 144.90 21.18 Cigna Cigna Medicare 0.03 4.39 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 74047 81001 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 74047 81002 CPT Outpatient 57.75 8.89 Cigna Cigna Medicare 0.06 3.53 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 74047 81003 CPT Outpatient 219.45 33.80 Cigna Cigna Medicare 0.01 3.11 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 74047 82306 CPT Outpatient 1880.55 289.62 Cigna Cigna Medicare 0.02 40.96 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 74047 83036 CPT Outpatient 494.55 76.17 Cigna Cigna Medicare 0.03 13.44 0.03 494.55 0.03 Fee Schedule 83036 Priced PSA (prostate specific antigen) 74047 84153 CPT Outpatient 1177.05 181.28 Cigna Cigna Medicare 0.02 25.45 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 74047 84154 CPT Outpatient 598.50 92.17 Cigna Cigna Medicare 0.04 25.45 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 74047 84443 CPT Outpatient 519.75 80.05 Cigna Cigna Medicare 0.04 23.25 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 74047 84703 CPT Outpatient 785.40 120.96 Cigna Cigna Medicare 0.01 10.40 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 74047 85025 CPT Outpatient 635.25 97.83 Cigna Cigna Medicare 0.02 10.75 0.02 635.25 0.02 Fee Schedule 85025 Priced "Complete blood count, automated" 74047 85027 CPT Outpatient 576.45 88.78 Cigna Cigna Medicare 0.02 8.95 0.02 576.45 0.02 Fee Schedule 85027 Priced "Blood test, clotting time" 74047 85610 CPT Outpatient 404.25 62.26 Cigna Cigna Medicare 0.01 5.43 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 74047 85730 CPT Outpatient 17.22 2.65 Cigna Cigna Medicare 0.48 8.31 0.48 17.22 0.48 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 74047 86003 CPT Outpatient 32.55 5.01 Cigna Cigna Medicare 0.22 7.23 0.22 32.55 0.22 Fee Schedule 86003 Priced Tb test cell immun measure 74047 86480 CPT Outpatient 530.25 81.66 Cigna Cigna Medicare 0.16 85.75 0.16 530.25 0.16 Fee Schedule 86480 Priced Urine culture/colony count 74047 87086 CPT Outpatient 763.35 117.56 Cigna Cigna Medicare 0.01 11.16 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 74047 87338 CPT Outpatient 785.40 120.96 Cigna Cigna Medicare 0.03 19.90 0.03 785.40 0.03 Fee Schedule 87338 Priced Cytopath eval fna report 74047 88173 CPT Outpatient 750.75 115.62 Cigna Cigna Medicare 0.08 57.32 0.08 750.75 0.08 Fee Schedule 88173 Priced Tissue exam by pathologist 74047 88302 CPT Outpatient 635.25 97.83 Cigna Cigna Medicare 0.04 28.54 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 74047 88305 CPT Outpatient 323.40 49.81 Cigna Cigna Medicare 0.18 57.32 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 74047 11042 CPT Outpatient 2668.05 481.45 Cigna Cigna Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb subq tissue add-on 74047 11045 CPT Outpatient 4652.55 330.00 Cigna Cigna Medicare 0.09 403.52 0.09 4652.55 0.09 Case Rate 11045 Priced Dx bronchoscope/lavage 74047 31624 CPT Outpatient 41223.00 7602.31 Cigna Cigna Medicare 0.19 7805.52 0.19 41223.00 0.19 Case Rate 31624 Priced Bronchoscopy/lung bx each 74047 31628 CPT Outpatient 49048.65 9045.51 Cigna Cigna Medicare 0.25 12292.51 0.25 49048.65 0.25 Case Rate 31628 Priced Blood transfusion service 74047 36430 CPT Outpatient 9166.50 574.93 Cigna Cigna Medicare 0.08 731.71 0.08 9166.50 0.08 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 74047 43235 CPT Outpatient 8856.75 1633.35 Cigna Cigna Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Endoscopic us exam esoph 74047 43237 CPT Outpatient 23867.55 4401.63 Cigna Cigna Medicare 0.12 2840.90 0.12 23867.55 0.12 Case Rate 43237 Priced Egd us fine needle bx/aspir 74047 43238 CPT Outpatient 30690.45 5659.90 Cigna Cigna Medicare 0.06 1914.48 0.06 30690.45 0.06 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 74047 43239 CPT Outpatient 40191.90 7412.15 Cigna Cigna Medicare 0.07 2698.70 0.07 40191.90 0.07 Case Rate 43239 Priced Ercp remove duct calculi 74047 43264 CPT Outpatient 34335.00 6332.03 Cigna Cigna Medicare 0.21 7043.47 0.21 34335.00 0.21 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 74047 45378 CPT Outpatient 13991.25 889.35 Cigna Cigna Medicare 0.07 926.48 0.07 13991.25 0.07 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 74047 45380 CPT Outpatient 22215.90 4097.04 Cigna Cigna Medicare 0.08 1815.96 0.08 22215.90 0.08 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 74047 45385 CPT Outpatient 119569.80 22050.95 Cigna Cigna Medicare 0.01 1648.12 0.01 119569.80 0.01 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 74047 45391 CPT Outpatient 24923.85 4596.43 Cigna Cigna Medicare 0.07 1778.07 0.07 24923.85 0.07 Case Rate 45391 Priced Fragmenting of kidney stone 74047 50590 CPT Outpatient 40930.05 7548.28 Cigna Cigna Medicare 0.09 3683.90 0.09 40930.05 0.09 Case Rate 50590 Priced Fetal non-stress test 74047 59025 CPT Outpatient 3153.15 477.76 Cigna Cigna Medicare 0.06 198.89 0.06 3153.15 0.06 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 74047 64483 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 74047 92567 CPT Outpatient 2224.95 98.50 Cigna Cigna Medicare 0.14 308.98 0.14 2224.95 0.14 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 74047 93000 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 74047 93017 CPT Outpatient 3076.50 532.96 Cigna Cigna Medicare 0.10 308.98 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 74047 93452 CPT Outpatient 55621.65 8611.87 Cigna Cigna Medicare 0.06 3385.39 0.06 55621.65 0.06 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 74047 95810 CPT Outpatient 20341.65 3373.48 Cigna Cigna Medicare 0.05 1074.10 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 74047 95811 CPT Outpatient 22491.00 3731.18 Cigna Cigna Medicare 0.05 1074.10 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 74047 95812 CPT Outpatient 5578.65 925.83 Cigna Cigna Medicare 0.06 308.98 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 74047 96040 CPT Outpatient 0.01 102.81 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 74047 96413 CPT Outpatient 4856.25 472.45 Cigna Cigna Medicare 0.55 2654.07 0.55 4856.25 0.55 Case Rate 96413 Priced Ultrasound therapy 74047 97035 CPT Outpatient 2111.55 134.99 Cigna Cigna Medicare 0.04 85.29 0.04 2111.55 0.04 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 74047 97110 CPT Outpatient 6494.25 92.86 Cigna Cigna Medicare 0.05 355.13 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 74047 97116 CPT Outpatient 4723.95 110.61 Cigna Cigna Medicare 0.06 289.20 0.06 4723.95 0.06 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 74047 70450 CPT Outpatient 8566.95 835.61 Cigna Cigna Medicare 0.06 551.80 0.06 8566.95 0.06 Case Rate 70450 Priced Mri brain stem w/o dye 74047 70551 CPT Outpatient 7861.35 1361.31 Cigna Cigna Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 70551 Priced MRI scan of brain before and after contrast 74047 70553 CPT Outpatient 10882.20 1625.88 Cigna Cigna Medicare 0.04 429.92 0.04 10882.20 0.04 Case Rate 70553 Priced X-ray exam chest 2 views 74047 71046 CPT Outpatient 859.95 150.37 Cigna Cigna Medicare 0.11 94.43 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 74047 71250 CPT Outpatient 7288.05 1261.63 Cigna Cigna Medicare 0.02 127.10 0.02 7288.05 0.02 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 74047 72082 CPT Outpatient 2022.30 253.33 Cigna Cigna Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 74047 72100 CPT Outpatient 1599.15 277.38 Cigna Cigna Medicare 0.08 127.10 0.08 1599.15 0.08 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 74047 72110 CPT Outpatient 1389.15 241.04 Cigna Cigna Medicare 0.09 127.10 0.09 1389.15 0.09 Case Rate 72110 Priced MRI scan of lower spinal canal 74047 72148 CPT Outpatient 7861.35 1361.31 Cigna Cigna Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 74047 72193 CPT Outpatient 13671.00 1412.01 Cigna Cigna Medicare 0.02 208.54 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 74047 73030 CPT Outpatient 1452.15 251.43 Cigna Cigna Medicare 0.07 94.43 0.07 1452.15 0.07 Case Rate 73030 Priced X-ray exam of elbow 74047 73080 CPT Outpatient 1356.60 235.68 Cigna Cigna Medicare 0.07 94.43 0.07 1356.60 0.07 Case Rate 73080 Priced X-ray exam of forearm 74047 73090 CPT Outpatient 1243.20 215.26 Cigna Cigna Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73090 Priced X-ray exam of wrist 74047 73110 CPT Outpatient 1243.20 215.26 Cigna Cigna Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 74047 73130 CPT Outpatient 1243.20 215.26 Cigna Cigna Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73130 Priced X-ray exam hips bi 2 views 74047 73521 CPT Outpatient 970.20 228.41 Cigna Cigna Medicare 0.13 127.10 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 74047 73562 CPT Outpatient 802.20 139.12 Cigna Cigna Medicare 0.12 94.43 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 74047 73590 CPT Outpatient 1243.20 215.26 Cigna Cigna Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73590 Priced X-ray exam of ankle 74047 73610 CPT Outpatient 1378.65 239.31 Cigna Cigna Medicare 0.07 94.43 0.07 1378.65 0.07 Case Rate 73610 Priced X-ray exam of foot 74047 73630 CPT Outpatient 975.45 169.41 Cigna Cigna Medicare 0.10 94.43 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 74047 73721 CPT Outpatient 7861.35 1361.31 Cigna Cigna Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 74047 74177 CPT Outpatient 14222.25 1412.01 Cigna Cigna Medicare 0.03 429.92 0.03 14222.25 0.03 Case Rate 74177 Priced Contrst x-ray exam of throat 74047 74210 CPT Outpatient 0.01 440.39 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 74047 76098 CPT Outpatient 6141.45 407.86 Cigna Cigna Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 76098 Priced Us exam of head and neck 74047 76536 CPT Outpatient 5512.50 955.18 Cigna Cigna Medicare 0.02 127.10 0.02 5512.50 0.02 Case Rate 76536 Priced Ultrasound breast limited 74047 76642 CPT Outpatient 5777.10 127.70 Cigna Cigna Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 74047 76700 CPT Outpatient 4917.15 851.88 Cigna Cigna Medicare 0.03 127.10 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 74047 76705 CPT Outpatient 3836.70 665.17 Cigna Cigna Medicare 0.03 127.10 0.03 3836.70 0.03 Case Rate 76705 Priced Us exam abdo back wall comp 74047 76770 CPT Outpatient 5171.25 895.48 Cigna Cigna Medicare 0.02 127.10 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 74047 76775 CPT Outpatient 3969.00 686.97 Cigna Cigna Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 74047 76801 CPT Outpatient 2006.55 347.98 Cigna Cigna Medicare 0.06 127.10 0.06 2006.55 0.06 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 74047 76805 CPT Outpatient 3969.00 686.97 Cigna Cigna Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 74047 76811 CPT Outpatient 2844.45 492.99 Cigna Cigna Medicare 0.09 268.63 0.09 2844.45 0.09 Case Rate 76811 Priced Ob us nuchal meas 1 gest 74047 76813 CPT Outpatient 1044.75 180.83 Cigna Cigna Medicare 0.12 127.10 0.12 1044.75 0.12 Case Rate 76813 Priced Ob us limited fetus(s) 74047 76815 CPT Outpatient 6428.10 639.90 Cigna Cigna Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76815 Priced Ob us follow-up per fetus 74047 76816 CPT Outpatient 4818.45 833.88 Cigna Cigna Medicare 0.03 127.10 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 74047 76817 CPT Outpatient 6428.10 476.73 Cigna Cigna Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76817 Priced Fetal biophys profil w/o nst 74047 76819 CPT Outpatient 1741.95 302.65 Cigna Cigna Medicare 0.07 127.10 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 74047 76830 CPT Outpatient 9305.10 806.54 Cigna Cigna Medicare 0.03 254.21 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 74047 76870 CPT Outpatient 6328.35 1096.55 Cigna Cigna Medicare 0.02 127.10 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 74047 76885 CPT Outpatient 3836.70 665.17 Cigna Cigna Medicare 0.02 94.43 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 74047 77065 CPT Outpatient 3451.35 192.07 Cigna Cigna Medicare 0.05 158.33 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 74047 77066 CPT Outpatient 5777.10 235.68 Cigna Cigna Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 74047 77067 CPT Outpatient 1416.45 205.57 Cigna Cigna Medicare 0.05 63.90 0.05 1416.45 0.05 Case Rate 77067 Priced X-rays for bone age 74047 77072 CPT Outpatient 2022.30 163.87 Cigna Cigna Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 77072 Priced Joint survey single view 74047 77077 CPT Outpatient 985.95 171.14 Cigna Cigna Medicare 0.13 124.57 0.13 985.95 0.13 Case Rate 77077 Priced Dxa bone density axial 74047 77080 CPT Outpatient 3257.10 319.09 Cigna Cigna Medicare 0.06 191.00 0.06 3257.10 0.06 Case Rate 77080 Priced Fna bx w/us gdn 1st les 74047 10005 CPT Outpatient 5512.50 547.24 Cigna Cigna Medicare 0.13 726.50 0.13 5512.50 0.13 Case Rate 10005 Priced Fna bx w/us gdn ea addl 74047 10006 CPT Outpatient 10628.10 594.83 Cigna Cigna Medicare 0.07 726.50 0.07 10628.10 0.07 Case Rate 10006 Priced Drainage of hematoma/fluid 74047 10140 CPT Outpatient 23209.20 1081.95 Cigna Cigna Medicare 0.27 6181.44 0.27 23209.20 0.27 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 74047 11042 CPT Outpatient 2668.05 481.45 Cigna Cigna Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb bone 20 sq cm/< 74047 11044 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 74047 11406 CPT Outpatient 19967.85 3427.81 Cigna Cigna Medicare 0.09 1700.21 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 74047 11424 CPT Outpatient 0.01 1004.93 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 74047 11770 CPT Outpatient 19173.00 3291.37 Cigna Cigna Medicare 0.15 2826.15 0.15 19173.00 0.15 Case Rate 11770 Priced Replace tissue expander 74047 11970 CPT Outpatient 59239.95 10169.52 Cigna Cigna Medicare 0.52 30989.99 0.52 59239.95 0.52 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 74047 14020 CPT Outpatient 32166.75 5521.96 Cigna Cigna Medicare 0.06 1999.63 0.06 32166.75 0.06 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 74047 14060 CPT Outpatient 25993.80 1374.69 Cigna Cigna Medicare 0.31 7937.33 0.31 25993.80 0.31 Case Rate 14060 Priced Wound prep trk/arm/leg 74047 15002 CPT Outpatient 41748.00 1441.73 Cigna Cigna Medicare 0.21 8825.17 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 74047 15271 CPT Outpatient 24343.20 3769.48 Cigna Cigna Medicare 0.08 1999.63 0.08 24343.20 0.08 Case Rate 15271 Priced Acellular derm matrix implt 74047 15777 CPT Outpatient 101672.55 17453.79 Cigna Cigna Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 15777 Priced Exc skin abd 74047 15830 CPT Outpatient 54696.60 9389.58 Cigna Cigna Medicare 0.12 6325.99 0.12 54696.60 0.12 Case Rate 15830 Priced Dressing change not for burn 74047 15852 CPT Outpatient 0.01 290.74 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 74047 15877 CPT Outpatient 63741.30 10942.26 Cigna Cigna Medicare 0.17 10877.73 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 74047 15879 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 74047 19000 CPT Outpatient 10143.00 594.83 Cigna Cigna Medicare 0.08 790.40 0.08 10143.00 0.08 Case Rate 19000 Priced Bx breast 1st lesion strtctc 74047 19081 CPT Outpatient 12341.70 1250.69 Cigna Cigna Medicare 0.14 1758.68 0.14 12341.70 0.14 Case Rate 19081 Priced Bx breast add lesion us imag 74047 19084 CPT Outpatient 29058.75 547.24 Cigna Cigna Medicare 0.07 1975.03 0.07 29058.75 0.07 Case Rate 19084 Priced Biopsy of breast open 74047 19101 CPT Outpatient 39545.10 2737.82 Cigna Cigna Medicare 0.23 8988.74 0.23 39545.10 0.23 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 74047 19120 CPT Outpatient 35761.95 2737.82 Cigna Cigna Medicare 0.12 4298.03 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 74047 19125 CPT Outpatient 33184.20 0.01 Cigna Cigna Medicare 0.26 8661.10 0.26 33184.20 0.26 Case Rate 19125 Priced Perq device breast 1st imag 74047 19281 CPT Outpatient 6141.45 598.61 Cigna Cigna Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 19281 Priced Perq device breast ea imag 74047 19282 CPT Outpatient 8379.00 319.04 Cigna Cigna Medicare 0.15 1290.61 0.15 8379.00 0.15 Case Rate 19282 Priced Partial mastectomy 74047 19301 CPT Outpatient 39157.65 6722.06 Cigna Cigna Medicare 0.20 7846.47 0.20 39157.65 0.20 Case Rate 19301 Priced Mast simple complete 74047 19303 CPT Outpatient 105389.55 18091.87 Cigna Cigna Medicare 0.28 29200.15 0.28 105389.55 0.28 Case Rate 19303 Priced Reduction of large breast 74047 19318 CPT Outpatient 65239.65 11199.47 Cigna Cigna Medicare 0.10 6577.10 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 74047 19340 CPT Outpatient 113100.75 19415.63 Cigna Cigna Medicare 0.13 14822.97 0.13 113100.75 0.13 Case Rate 19340 Priced Delayed breast prosthesis 74047 19342 CPT Outpatient 56988.75 9783.07 Cigna Cigna Medicare 0.36 20246.20 0.36 56988.75 0.36 Case Rate 19342 Priced Breast reconstruction 74047 19357 CPT Outpatient 101672.55 17453.79 Cigna Cigna Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 19357 Priced Breast reconstruction 74047 19366 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 74047 19380 CPT Outpatient 61493.25 10556.34 Cigna Cigna Medicare 0.21 13212.28 0.21 61493.25 0.21 Case Rate 19380 Priced Removal of support implant 74047 20680 CPT Outpatient 42329.70 7266.60 Cigna Cigna Medicare 0.14 5804.91 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 74047 22856 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 74047 24538 CPT Outpatient 51237.90 4775.24 Cigna Cigna Medicare 0.19 9816.98 0.19 51237.90 0.19 Case Rate 24538 Priced Remove wrist tendon lesion 74047 25111 CPT Outpatient 25855.20 4438.48 Cigna Cigna Medicare 0.06 1654.95 0.06 25855.20 0.06 Case Rate 25111 Priced Incise finger tendon sheath 74047 26055 CPT Outpatient 15862.35 2723.04 Cigna Cigna Medicare 0.12 1931.13 0.12 15862.35 0.12 Case Rate 26055 Priced Treat finger fracture each 74047 26727 CPT Outpatient 22779.75 2030.47 Cigna Cigna Medicare 0.16 3574.88 0.16 22779.75 0.16 Case Rate 26727 Priced Revision of knee joint 74047 27446 CPT Outpatient 67882.50 11653.16 Cigna Cigna Medicare 0.23 15567.47 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 74047 27447 CPT Outpatient 130698.75 22436.62 Cigna Cigna Medicare 0.12 15604.41 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 74047 27485 CPT Outpatient 43310.40 7434.95 Cigna Cigna Medicare 0.26 11063.75 0.26 43310.40 0.26 Case Rate 27485 Priced Repair achilles tendon 74047 27650 CPT Outpatient 38246.25 3762.57 Cigna Cigna Medicare 0.29 11041.86 0.29 38246.25 0.29 Case Rate 27650 Priced Treatment of ankle fracture 74047 27792 CPT Outpatient 36101.10 6197.36 Cigna Cigna Medicare 0.21 7581.28 0.21 36101.10 0.21 Case Rate 27792 Priced Treatment of ankle fracture 74047 27814 CPT Outpatient 49405.65 8481.30 Cigna Cigna Medicare 0.16 7766.50 0.16 49405.65 0.16 Case Rate 27814 Priced Removal of foot lesion 74047 28080 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 74047 28285 CPT Outpatient 68603.85 11776.99 Cigna Cigna Medicare 0.20 13986.50 0.20 68603.85 0.20 Case Rate 28285 Priced Correction hallux valgus 74047 28296 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 74047 29823 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 74047 29826 CPT Outpatient 49840.35 8555.93 Cigna Cigna Medicare 0.15 7312.64 0.15 49840.35 0.15 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 74047 29881 CPT Outpatient 35556.15 6103.81 Cigna Cigna Medicare 0.09 3306.24 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 74047 29882 CPT Outpatient 61099.50 10488.75 Cigna Cigna Medicare 0.19 11577.74 0.19 61099.50 0.19 Case Rate 29882 Priced Percut bx lung/mediastinum 74047 32405 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 74047 32555 CPT Outpatient 14597.10 687.29 Cigna Cigna Medicare 0.05 711.62 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 74047 32664 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 74047 35190 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 74047 36478 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 74047 36561 CPT Outpatient 53531.10 3292.99 Cigna Cigna Medicare 0.06 3342.08 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 74047 36569 CPT Outpatient 31421.25 1299.06 Cigna Cigna Medicare 0.06 1811.50 0.06 31421.25 0.06 Case Rate 36569 Priced Removal tunneled cv cath 74047 36590 CPT Outpatient 1996.05 273.95 Cigna Cigna Medicare 0.82 1641.71 0.82 1996.05 0.82 Case Rate 36590 Priced Av fuse uppr arm basilic 74047 36819 CPT Outpatient 56861.70 9761.26 Cigna Cigna Medicare 0.17 9459.82 0.17 56861.70 0.17 Case Rate 36819 Priced Av fusion direct any site 74047 36821 CPT Outpatient 42953.40 7373.67 Cigna Cigna Medicare 0.16 7056.50 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 74047 36825 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 74047 36830 CPT Outpatient 53656.05 9210.96 Cigna Cigna Medicare 0.17 9346.72 0.17 53656.05 0.17 Case Rate 36830 Priced Av fistula revision open 74047 36832 CPT Outpatient 52492.65 9011.24 Cigna Cigna Medicare 0.23 12046.01 0.23 52492.65 0.23 Case Rate 36832 Priced Av fistula revision 74047 36833 CPT Outpatient 37098.60 6368.59 Cigna Cigna Medicare 0.28 10242.79 0.28 37098.60 0.28 Case Rate 36833 Priced Intro cath dialysis circuit 74047 36903 CPT Outpatient 77541.45 10669.90 Cigna Cigna Medicare 0.24 18454.26 0.24 77541.45 0.24 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 74047 36906 CPT Outpatient 96694.50 16175.64 Cigna Cigna Medicare 0.27 26216.69 0.27 96694.50 0.27 Case Rate 36906 Priced Fem/popl revas w/tla 74047 37224 CPT Outpatient 200076.45 5139.31 Cigna Cigna Medicare 0.14 27878.39 0.14 200076.45 0.14 Case Rate 37224 Priced Fem/popl revasc stnt & ather 74047 37227 CPT Outpatient 117170.55 18045.38 Cigna Cigna Medicare 0.17 19636.18 0.17 117170.55 0.17 Case Rate 37227 Priced Revise leg vein 74047 37700 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 74047 37722 CPT Outpatient 27815.55 4775.00 Cigna Cigna Medicare 0.37 10398.58 0.37 27815.55 0.37 Case Rate 37722 Priced Stab phleb veins xtr 10-20 74047 37765 CPT Outpatient 26561.85 4559.78 Cigna Cigna Medicare 0.52 13740.66 0.52 26561.85 0.52 Case Rate 37765 Priced Biopsy/removal lymph nodes 74047 38500 CPT Outpatient 35955.15 6172.30 Cigna Cigna Medicare 0.11 3918.72 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 74047 38525 CPT Outpatient 101194.80 17371.77 Cigna Cigna Medicare 0.19 18851.15 0.19 101194.80 0.19 Case Rate 38525 Priced Laparoscopy lymph node biop 74047 38570 CPT Outpatient 65631.30 11266.71 Cigna Cigna Medicare 0.28 18089.66 0.28 65631.30 0.28 Case Rate 38570 Priced Laparoscopy lymphadenectomy 74047 38571 CPT Outpatient 84031.50 14425.41 Cigna Cigna Medicare 0.26 22194.38 0.26 84031.50 0.26 Case Rate 38571 Priced Laparoscopy lymphadenectomy 74047 38572 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 74047 38792 CPT Outpatient 2868.60 432.48 Cigna Cigna Medicare 0.15 440.09 0.15 2868.60 0.15 Case Rate 38792 Priced Excision of gum lesion 74047 41825 CPT Outpatient 11580.45 1987.98 Cigna Cigna Medicare 0.30 3440.87 0.30 11580.45 0.30 Case Rate 41825 Priced Reconstruct cleft palate 74047 42200 CPT Outpatient 36703.80 6300.82 Cigna Cigna Medicare 0.16 5937.71 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 74047 42820 CPT Outpatient 17232.60 2958.26 Cigna Cigna Medicare 0.64 11027.66 0.64 17232.60 0.64 Case Rate 42820 Priced Control throat bleeding 74047 42960 CPT Outpatient 24066.00 4131.33 Cigna Cigna Medicare 0.20 4852.02 0.20 24066.00 0.20 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 74047 43235 CPT Outpatient 8856.75 1633.35 Cigna Cigna Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Laparoscopy fundoplasty 74047 43280 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 74047 43282 CPT Outpatient 84344.40 14479.12 Cigna Cigna Medicare 0.13 10981.07 0.13 84344.40 0.13 Case Rate 43282 Priced Laparoscopy appendectomy 74047 44970 CPT Outpatient 82300.05 14128.18 Cigna Cigna Medicare 0.08 6988.44 0.08 82300.05 0.08 Case Rate 44970 Priced Diagnostic sigmoidoscopy 74047 45330 CPT Outpatient 17286.15 542.26 Cigna Cigna Medicare 0.11 1880.24 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 74047 47000 CPT Outpatient 10398.15 1225.34 Cigna Cigna Medicare 0.20 2101.24 0.20 10398.15 0.20 Case Rate 47000 Priced Removal of gallbladder using an endoscope 74047 47562 CPT Outpatient 58430.40 10030.55 Cigna Cigna Medicare 0.10 5965.34 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 74047 47563 CPT Outpatient 71747.55 12316.66 Cigna Cigna Medicare 0.09 6769.21 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 74047 49083 CPT Outpatient 6979.35 1113.95 Cigna Cigna Medicare 0.14 944.67 0.14 6979.35 0.14 Case Rate 49083 Priced Diag laparo separate proc 74047 49320 CPT Outpatient 31629.15 5429.67 Cigna Cigna Medicare 0.42 13201.26 0.42 31629.15 0.42 Case Rate 49320 Priced Laparoscopy biopsy 74047 49321 CPT Outpatient 41892.90 7191.61 Cigna Cigna Medicare 0.32 13491.42 0.32 41892.90 0.32 Case Rate 49321 Priced Laparoscopy aspiration 74047 49322 CPT Outpatient 34392.75 5904.09 Cigna Cigna Medicare 0.39 13396.33 0.39 34392.75 0.39 Case Rate 49322 Priced Lap insert tunnel ip cath 74047 49324 CPT Outpatient 39264.75 6740.45 Cigna Cigna Medicare 0.15 5972.32 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 74047 49329 CPT Outpatient 58696.05 10076.16 Cigna Cigna Medicare 0.29 17162.20 0.29 58696.05 0.29 Case Rate 49329 Priced Ins tun ip cath for dial opn 74047 49421 CPT Outpatient 25460.40 3319.30 Cigna Cigna Medicare 0.15 3702.67 0.15 25460.40 0.15 Case Rate 49421 Priced Remove tunneled ip cath 74047 49422 CPT Outpatient 25515.00 4380.08 Cigna Cigna Medicare 0.13 3342.08 0.13 25515.00 0.13 Case Rate 49422 Priced Rpr ing hernia init reduce 74047 49500 CPT Outpatient 19594.05 3363.65 Cigna Cigna Medicare 0.56 11018.31 0.56 19594.05 0.56 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 74047 49505 CPT Outpatient 34915.65 5993.85 Cigna Cigna Medicare 0.21 7278.08 0.21 34915.65 0.21 Case Rate 49505 Priced Prp i/hern init block >5 yr 74047 49507 CPT Outpatient 29794.80 5114.77 Cigna Cigna Medicare 0.25 7306.28 0.25 29794.80 0.25 Case Rate 49507 Priced Rerepair ing hernia reduce 74047 49520 CPT Outpatient 36940.05 6341.38 Cigna Cigna Medicare 0.20 7341.71 0.20 36940.05 0.20 Case Rate 49520 Priced Rpr ventral hern init reduc 74047 49560 CPT Outpatient 53177.25 9128.76 Cigna Cigna Medicare 0.18 9686.73 0.18 53177.25 0.18 Case Rate 49560 Priced Rpr ventral hern init block 74047 49561 CPT Outpatient 30755.55 5279.70 Cigna Cigna Medicare 0.24 7522.67 0.24 30755.55 0.24 Case Rate 49561 Priced Rerepair ventrl hern reduce 74047 49565 CPT Outpatient 69917.40 12002.49 Cigna Cigna Medicare 0.14 10018.26 0.14 69917.40 0.14 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 74047 49585 CPT Outpatient 41806.80 7176.83 Cigna Cigna Medicare 0.23 9650.59 0.23 41806.80 0.23 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 74047 49587 CPT Outpatient 37320.15 6406.63 Cigna Cigna Medicare 0.20 7369.53 0.20 37320.15 0.20 Case Rate 49587 Priced Lap ing hernia repair init 74047 49650 CPT Outpatient 41932.80 7198.46 Cigna Cigna Medicare 0.14 5784.73 0.14 41932.80 0.14 Case Rate 49650 Priced Lap ing hernia repair recur 74047 49651 CPT Outpatient 46915.05 8053.75 Cigna Cigna Medicare 0.26 12396.08 0.26 46915.05 0.26 Case Rate 49651 Priced Lap vent/abd hernia repair 74047 49652 CPT Outpatient 51294.60 8805.57 Cigna Cigna Medicare 0.12 6001.15 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 74047 49653 CPT Outpatient 46102.35 7914.24 Cigna Cigna Medicare 0.13 5907.33 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 74047 49654 CPT Outpatient 47221.65 8106.38 Cigna Cigna Medicare 0.22 10246.22 0.22 47221.65 0.22 Case Rate 49654 Priced Lap inc hern repair comp 74047 49655 CPT Outpatient 54590.55 9371.38 Cigna Cigna Medicare 0.19 10557.83 0.19 54590.55 0.19 Case Rate 49655 Priced Lap inc hernia repair recur 74047 49656 CPT Outpatient 55443.15 9517.74 Cigna Cigna Medicare 0.19 10492.84 0.19 55443.15 0.19 Case Rate 49656 Priced Removal of kidney stone 74047 50080 CPT Outpatient 53165.70 9126.78 Cigna Cigna Medicare 0.32 16951.33 0.32 53165.70 0.32 Case Rate 50080 Priced Removal of kidney stone 74047 50081 CPT Outpatient 66931.20 11489.86 Cigna Cigna Medicare 0.30 20375.49 0.30 66931.20 0.30 Case Rate 50081 Priced Renal biopsy perq 74047 50200 CPT Outpatient 43096.20 1225.34 Cigna Cigna Medicare 0.23 9703.00 0.23 43096.20 0.23 Case Rate 50200 Priced Plmt nephroureteral catheter 74047 50433 CPT Outpatient 64566.60 1424.48 Cigna Cigna Medicare 0.27 17570.80 0.27 64566.60 0.27 Case Rate 50433 Priced Laparo radical nephrectomy 74047 50545 CPT Outpatient 43449.00 7458.75 Cigna Cigna Medicare 0.03 1190.00 0.03 43449.00 0.03 Case Rate 50545 Priced Laparoscope proc ureter 74047 50949 CPT Outpatient 49986.30 8580.98 Cigna Cigna Medicare 0.34 17208.73 0.34 49986.30 0.34 Case Rate 50949 Priced Injection for bladder x-ray 74047 51600 CPT Outpatient 3285.45 89.22 Cigna Cigna Medicare 0.08 268.63 0.08 3285.45 0.08 Case Rate 51600 Priced Cystoscopy 74047 52000 CPT Outpatient 22149.75 3802.37 Cigna Cigna Medicare 0.36 7975.55 0.36 22149.75 0.36 Case Rate 52000 Priced Cystoscopy & ureter catheter 74047 52005 CPT Outpatient 42529.20 2095.77 Cigna Cigna Medicare 0.21 9136.51 0.21 42529.20 0.21 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 74047 52204 CPT Outpatient 31274.25 5368.75 Cigna Cigna Medicare 0.18 5745.54 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 74047 52224 CPT Outpatient 13445.25 2308.10 Cigna Cigna Medicare 0.54 7303.88 0.54 13445.25 0.54 Case Rate 52224 Priced Cystoscopy and treatment 74047 52234 CPT Outpatient 28510.65 4894.33 Cigna Cigna Medicare 0.27 7572.52 0.27 28510.65 0.27 Case Rate 52234 Priced Cystoscopy and treatment 74047 52235 CPT Outpatient 29417.85 5050.06 Cigna Cigna Medicare 0.25 7276.20 0.25 29417.85 0.25 Case Rate 52235 Priced Cystoscopy and treatment 74047 52240 CPT Outpatient 33933.90 5825.32 Cigna Cigna Medicare 0.27 9046.24 0.27 33933.90 0.27 Case Rate 52240 Priced Cystoscopy and treatment 74047 52281 CPT Outpatient 22159.20 3804.00 Cigna Cigna Medicare 0.26 5688.66 0.26 22159.20 0.26 Case Rate 52281 Priced Remove bladder stone 74047 52317 CPT Outpatient 27085.80 4649.73 Cigna Cigna Medicare 0.27 7426.56 0.27 27085.80 0.27 Case Rate 52317 Priced Remove bladder stone 74047 52318 CPT Outpatient 26685.75 4581.05 Cigna Cigna Medicare 0.28 7361.57 0.28 26685.75 0.28 Case Rate 52318 Priced Cystoscopy and treatment 74047 52332 CPT Outpatient 115306.80 19794.33 Cigna Cigna Medicare 0.18 20580.50 0.18 115306.80 0.18 Case Rate 52332 Priced Cystouretero w/stone remove 74047 52352 CPT Outpatient 42420.00 7282.10 Cigna Cigna Medicare 0.38 16312.79 0.38 42420.00 0.38 Case Rate 52352 Priced Cystouretero w/lithotripsy 74047 52353 CPT Outpatient 38608.50 6627.79 Cigna Cigna Medicare 0.24 9133.86 0.24 38608.50 0.24 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 74047 52356 CPT Outpatient 36255.45 6223.85 Cigna Cigna Medicare 0.25 9133.86 0.25 36255.45 0.25 Case Rate 52356 Priced Prostatectomy (turp) 74047 52601 CPT Outpatient 35371.35 6072.08 Cigna Cigna Medicare 0.25 8684.69 0.25 35371.35 0.25 Case Rate 52601 Priced Laser surgery of prostate 74047 52648 CPT Outpatient 24264.45 4165.40 Cigna Cigna Medicare 0.37 9020.55 0.37 24264.45 0.37 Case Rate 52648 Priced Revision of urethra 74047 53450 CPT Outpatient 16209.90 2782.70 Cigna Cigna Medicare 0.35 5679.84 0.35 16209.90 0.35 Case Rate 53450 Priced Urology surgery procedure 74047 53899 CPT Outpatient 25368.00 134.83 Cigna Cigna Medicare 0.27 6862.63 0.27 25368.00 0.27 Case Rate 53899 Priced Circumcision w/regionl block 74047 54150 CPT Outpatient 14700.00 2523.50 Cigna Cigna Medicare 0.14 2090.37 0.14 14700.00 0.14 Case Rate 54150 Priced Circum 28 days or older 74047 54161 CPT Outpatient 19186.65 3293.71 Cigna Cigna Medicare 0.11 2049.61 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 74047 54162 CPT Outpatient 19795.65 3398.25 Cigna Cigna Medicare 0.85 16823.10 0.85 19795.65 0.85 Case Rate 54162 Priced Repair of circumcision 74047 54163 CPT Outpatient 16391.55 2813.88 Cigna Cigna Medicare 0.24 4010.49 0.24 16391.55 0.24 Case Rate 54163 Priced Reconstruction of urethra 74047 54324 CPT Outpatient 32880.75 5644.53 Cigna Cigna Medicare 0.28 9303.52 0.28 32880.75 0.28 Case Rate 54324 Priced Revise penis/urethra 74047 54332 CPT Outpatient 19968.90 3427.99 Cigna Cigna Medicare 0.18 3589.47 0.18 19968.90 0.18 Case Rate 54332 Priced Insert self-contd prosthesis 74047 54401 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 74047 54520 CPT Outpatient 35442.75 6084.34 Cigna Cigna Medicare 0.34 12158.30 0.34 35442.75 0.34 Case Rate 54520 Priced Reduce testis torsion 74047 54600 CPT Outpatient 55049.40 9450.15 Cigna Cigna Medicare 0.28 15402.48 0.28 55049.40 0.28 Case Rate 54600 Priced Suspension of testis 74047 54640 CPT Outpatient 26860.05 4610.98 Cigna Cigna Medicare 0.28 7428.84 0.28 26860.05 0.28 Case Rate 54640 Priced Removal of hydrocele 74047 55040 CPT Outpatient 27277.95 4682.71 Cigna Cigna Medicare 0.27 7369.91 0.27 27277.95 0.27 Case Rate 55040 Priced Biopsy of prostate gland 74047 55700 CPT Outpatient 28699.65 4926.77 Cigna Cigna Medicare 0.13 3731.04 0.13 28699.65 0.13 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 74047 55866 CPT Outpatient 93088.80 15980.24 Cigna Cigna Medicare 0.24 22017.24 0.24 93088.80 0.24 Case Rate 55866 Priced Closure of vagina 74047 57120 CPT Outpatient 34369.65 5900.12 Cigna Cigna Medicare 0.43 14932.00 0.43 34369.65 0.43 Case Rate 57120 Priced Repair of vagina 74047 57200 CPT Outpatient 25247.25 4334.11 Cigna Cigna Medicare 0.31 7732.37 0.31 25247.25 0.31 Case Rate 57200 Priced Anterior colporrhaphy 74047 57240 CPT Outpatient 36210.30 6216.10 Cigna Cigna Medicare 0.53 19223.69 0.53 36210.30 0.53 Case Rate 57240 Priced Repair rectum & vagina 74047 57250 CPT Outpatient 40441.80 6942.51 Cigna Cigna Medicare 0.56 22691.64 0.56 40441.80 0.56 Case Rate 57250 Priced Cmbn ant pst colprhy 74047 57260 CPT Outpatient 46323.90 7952.27 Cigna Cigna Medicare 0.66 30437.82 0.66 46323.90 0.66 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 74047 57265 CPT Outpatient 42586.95 7310.76 Cigna Cigna Medicare 0.43 18248.88 0.43 42586.95 0.43 Case Rate 57265 Priced Repair of bowel bulge 74047 57268 CPT Outpatient 36865.50 6328.58 Cigna Cigna Medicare 0.49 18090.91 0.49 36865.50 0.49 Case Rate 57268 Priced Colpopexy extraperitoneal 74047 57282 CPT Outpatient 45629.85 7833.12 Cigna Cigna Medicare 0.66 30324.80 0.66 45629.85 0.66 Case Rate 57282 Priced Repair bladder defect 74047 57288 CPT Outpatient 43069.95 7393.67 Cigna Cigna Medicare 0.56 24109.88 0.56 43069.95 0.56 Case Rate 57288 Priced Bx/curett of cervix w/scope 74047 57454 CPT Outpatient 2888.55 442.93 Cigna Cigna Medicare 0.11 329.27 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 74047 57520 CPT Outpatient 26728.80 4588.44 Cigna Cigna Medicare 0.16 4211.41 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 74047 57522 CPT Outpatient 22737.75 3903.31 Cigna Cigna Medicare 0.15 3411.24 0.15 22737.75 0.15 Case Rate 57522 Priced Biopsy of uterus lining 74047 58100 CPT Outpatient 2371.95 194.80 Cigna Cigna Medicare 0.08 198.89 0.08 2371.95 0.08 Case Rate 58100 Priced Catheter for hysterography 74047 58340 CPT Outpatient 6322.05 131.04 Cigna Cigna Medicare 0.04 268.63 0.04 6322.05 0.04 Case Rate 58340 Priced Reopen fallopian tube 74047 58350 CPT Outpatient 46507.65 7983.81 Cigna Cigna Medicare 0.38 17563.57 0.38 46507.65 0.38 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 74047 58542 CPT Outpatient 64194.90 11020.12 Cigna Cigna Medicare 0.37 24060.91 0.37 64194.90 0.37 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 74047 58544 CPT Outpatient 51020.55 8758.53 Cigna Cigna Medicare 0.65 33216.81 0.65 51020.55 0.65 Case Rate 58544 Priced Laparoscopic myomectomy 74047 58545 CPT Outpatient 56946.75 9775.86 Cigna Cigna Medicare 0.17 9718.98 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 74047 58552 CPT Outpatient 57228.15 9824.17 Cigna Cigna Medicare 0.32 18381.02 0.32 57228.15 0.32 Case Rate 58552 Priced Hysteroscopy biopsy 74047 58558 CPT Outpatient 28581.00 2077.02 Cigna Cigna Medicare 0.25 7238.81 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 74047 58561 CPT Outpatient 35222.25 6046.49 Cigna Cigna Medicare 0.27 9531.42 0.27 35222.25 0.27 Case Rate 58561 Priced Hysteroscopy ablation 74047 58563 CPT Outpatient 38399.55 6591.92 Cigna Cigna Medicare 0.51 19555.87 0.51 38399.55 0.51 Case Rate 58563 Priced Tlh uterus 250 g or less 74047 58570 CPT Outpatient 43316.70 7436.03 Cigna Cigna Medicare 0.26 11083.71 0.26 43316.70 0.26 Case Rate 58570 Priced Tlh w/t/o 250 g or less 74047 58571 CPT Outpatient 48603.45 8343.59 Cigna Cigna Medicare 0.30 14369.35 0.30 48603.45 0.30 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 74047 58573 CPT Outpatient 52905.30 9082.08 Cigna Cigna Medicare 0.32 16722.51 0.32 52905.30 0.32 Case Rate 58573 Priced Laparoscopy remove adnexa 74047 58661 CPT Outpatient 47008.50 8069.79 Cigna Cigna Medicare 0.18 8686.07 0.18 47008.50 0.18 Case Rate 58661 Priced Laparoscopy excise lesions 74047 58662 CPT Outpatient 45053.40 7734.17 Cigna Cigna Medicare 0.38 17220.22 0.38 45053.40 0.38 Case Rate 58662 Priced Treat ectopic pregnancy 74047 59151 CPT Outpatient 74690.70 12821.90 Cigna Cigna Medicare 0.09 6630.70 0.09 74690.70 0.09 Case Rate 59151 Priced Treatment of miscarriage 74047 59812 CPT Outpatient 56109.90 9632.20 Cigna Cigna Medicare 0.07 4075.96 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 74047 60220 CPT Outpatient 53639.25 9208.07 Cigna Cigna Medicare 0.11 6088.34 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 74047 60240 CPT Outpatient 98252.70 16866.71 Cigna Cigna Medicare 0.06 5905.23 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 74047 60500 CPT Outpatient 150495.45 25835.05 Cigna Cigna Medicare 0.06 9768.16 0.06 150495.45 0.06 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 74047 62322 CPT Outpatient 43709.40 514.24 Cigna Cigna Medicare 0.28 12235.33 0.28 43709.40 0.28 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 74047 62323 CPT Outpatient 8304.45 467.31 Cigna Cigna Medicare 16.45 136591.28 16.45 8304.45 16.45 Case Rate 62323 Priced Low back disk surgery 74047 63030 CPT Outpatient 50287.65 8632.71 Cigna Cigna Medicare 0.30 14893.92 0.30 50287.65 0.30 Case Rate 63030 Priced Inc for vagus n elect impl 74047 64568 CPT Outpatient 124562.55 21383.24 Cigna Cigna Medicare 0.27 33814.93 0.27 124562.55 0.27 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 74047 66821 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 74047 66984 CPT Outpatient 0.01 0.01 Cigna Cigna Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 177047 216 DRG Inpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 177047 460 DRG Inpatient 416122.79 53834.63 Clover Clover Medicare 0.09 36507.56 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 177047 470 DRG Inpatient 167912.19 21723.13 Clover Clover Medicare 0.11 18221.64 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 177047 473 DRG Inpatient 100687.91 13026.19 Clover Clover Medicare 0.24 23973.82 0.24 100687.91 0.24 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 177047 743 DRG Inpatient 102691.67 13285.42 Clover Clover Medicare 0.11 11317.53 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 177047 795 DRG Inpatient 6266.93 2335.00 Clover Clover Medicare 0.49 3065.24 0.49 6266.93 0.49 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 177047 807 DRG Inpatient 116469.59 4193.00 Clover Clover Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 177047 788 DRG Inpatient 76050.77 4538.00 Clover Clover Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 177047 59400 CPT Inpatient 116469.59 4193.00 Clover Clover Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 177047 59510 CPT Inpatient 76050.77 4538.00 Clover Clover Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 177047 59610 CPT Inpatient 116469.59 4193.00 Clover Clover Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59610 Priced "Psychotherapy, 30 min" 177047 90832 CPT Outpatient 577.50 91.21 Clover Clover Medicare 0.29 166.55 0.29 577.50 0.29 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 177047 90834 CPT Outpatient 44134.65 271.96 Clover Clover Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 177047 90837 CPT Outpatient 2240.70 442.93 Clover Clover Medicare 0.04 84.05 0.04 2240.70 0.04 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 177047 90846 CPT Outpatient 0.01 131.50 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 177047 90847 CPT Outpatient 44134.65 369.97 Clover Clover Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90847 Priced Group psychotherapy 177047 90853 CPT Outpatient 44134.65 101.99 Clover Clover Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 177047 99203 CPT Outpatient 3480.75 176.07 Clover Clover Medicare 0.12 403.52 0.12 3480.75 0.12 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 177047 99204 CPT Outpatient 2103.15 233.39 Clover Clover Medicare 0.19 390.94 0.19 2103.15 0.19 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 177047 99205 CPT Outpatient 4970.70 314.28 Clover Clover Medicare 0.09 462.07 0.09 4970.70 0.09 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 177047 99243 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 177047 99244 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 177047 99385 CPT Outpatient 1114.05 185.90 Clover Clover Medicare 0.19 207.05 0.19 1114.05 0.19 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 177047 99386 CPT Outpatient 4877.25 185.90 Clover Clover Medicare 0.02 98.87 0.02 4877.25 0.02 Fee Schedule 99386 Priced Routine venipuncture 177047 36415 CPT Outpatient 127.05 19.57 Clover Clover Medicare 0.02 3.02 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 177047 80048 CPT Outpatient 576.45 88.78 Clover Clover Medicare 0.02 11.70 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 177047 80053 CPT Outpatient 763.35 117.56 Clover Clover Medicare 0.02 13.22 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 177047 80055 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 177047 80061 CPT Outpatient 1349.25 197.77 Clover Clover Medicare 0.01 18.53 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 177047 80069 CPT Outpatient 716.10 104.95 Clover Clover Medicare 0.02 12.01 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 177047 80076 CPT Outpatient 716.10 104.95 Clover Clover Medicare 0.02 11.31 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 177047 81000 CPT Outpatient 144.90 21.18 Clover Clover Medicare 0.03 4.39 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 177047 81001 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 177047 81002 CPT Outpatient 57.75 8.89 Clover Clover Medicare 0.06 3.53 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 177047 81003 CPT Outpatient 219.45 33.80 Clover Clover Medicare 0.01 3.11 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 177047 82306 CPT Outpatient 1880.55 289.62 Clover Clover Medicare 0.02 40.96 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 177047 83036 CPT Outpatient 494.55 76.17 Clover Clover Medicare 0.03 13.44 0.03 494.55 0.03 Fee Schedule 83036 Priced PSA (prostate specific antigen) 177047 84153 CPT Outpatient 1177.05 181.28 Clover Clover Medicare 0.02 25.45 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 177047 84154 CPT Outpatient 598.50 92.17 Clover Clover Medicare 0.04 25.45 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 177047 84443 CPT Outpatient 519.75 80.05 Clover Clover Medicare 0.04 23.25 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 177047 84703 CPT Outpatient 785.40 120.96 Clover Clover Medicare 0.01 10.40 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 177047 85025 CPT Outpatient 635.25 97.83 Clover Clover Medicare 0.02 10.75 0.02 635.25 0.02 Fee Schedule 85025 Priced "Complete blood count, automated" 177047 85027 CPT Outpatient 576.45 88.78 Clover Clover Medicare 0.02 8.95 0.02 576.45 0.02 Fee Schedule 85027 Priced "Blood test, clotting time" 177047 85610 CPT Outpatient 404.25 62.26 Clover Clover Medicare 0.01 5.43 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 177047 85730 CPT Outpatient 17.22 2.65 Clover Clover Medicare 0.48 8.31 0.48 17.22 0.48 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 177047 86003 CPT Outpatient 32.55 5.01 Clover Clover Medicare 0.22 7.23 0.22 32.55 0.22 Fee Schedule 86003 Priced Tb test cell immun measure 177047 86480 CPT Outpatient 530.25 81.66 Clover Clover Medicare 0.16 85.75 0.16 530.25 0.16 Fee Schedule 86480 Priced Urine culture/colony count 177047 87086 CPT Outpatient 763.35 117.56 Clover Clover Medicare 0.01 11.16 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 177047 87338 CPT Outpatient 785.40 120.96 Clover Clover Medicare 0.03 19.90 0.03 785.40 0.03 Fee Schedule 87338 Priced Cytopath eval fna report 177047 88173 CPT Outpatient 750.75 115.62 Clover Clover Medicare 0.08 57.32 0.08 750.75 0.08 Fee Schedule 88173 Priced Tissue exam by pathologist 177047 88302 CPT Outpatient 635.25 97.83 Clover Clover Medicare 0.04 28.54 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 177047 88305 CPT Outpatient 323.40 49.81 Clover Clover Medicare 0.18 57.32 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 177047 11042 CPT Outpatient 2668.05 481.45 Clover Clover Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb subq tissue add-on 177047 11045 CPT Outpatient 4652.55 330.00 Clover Clover Medicare 0.09 403.52 0.09 4652.55 0.09 Case Rate 11045 Priced Dx bronchoscope/lavage 177047 31624 CPT Outpatient 41223.00 7602.31 Clover Clover Medicare 0.19 7805.52 0.19 41223.00 0.19 Case Rate 31624 Priced Bronchoscopy/lung bx each 177047 31628 CPT Outpatient 49048.65 9045.51 Clover Clover Medicare 0.25 12292.51 0.25 49048.65 0.25 Case Rate 31628 Priced Blood transfusion service 177047 36430 CPT Outpatient 9166.50 574.93 Clover Clover Medicare 0.08 731.71 0.08 9166.50 0.08 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 177047 43235 CPT Outpatient 8856.75 1633.35 Clover Clover Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Endoscopic us exam esoph 177047 43237 CPT Outpatient 23867.55 4401.63 Clover Clover Medicare 0.12 2840.90 0.12 23867.55 0.12 Case Rate 43237 Priced Egd us fine needle bx/aspir 177047 43238 CPT Outpatient 30690.45 5659.90 Clover Clover Medicare 0.06 1914.48 0.06 30690.45 0.06 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 177047 43239 CPT Outpatient 40191.90 7412.15 Clover Clover Medicare 0.07 2698.70 0.07 40191.90 0.07 Case Rate 43239 Priced Ercp remove duct calculi 177047 43264 CPT Outpatient 34335.00 6332.03 Clover Clover Medicare 0.21 7043.47 0.21 34335.00 0.21 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 177047 45378 CPT Outpatient 13991.25 889.35 Clover Clover Medicare 0.07 926.48 0.07 13991.25 0.07 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 177047 45380 CPT Outpatient 22215.90 4097.04 Clover Clover Medicare 0.08 1815.96 0.08 22215.90 0.08 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 177047 45385 CPT Outpatient 119569.80 22050.95 Clover Clover Medicare 0.01 1648.12 0.01 119569.80 0.01 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 177047 45391 CPT Outpatient 24923.85 4596.43 Clover Clover Medicare 0.07 1778.07 0.07 24923.85 0.07 Case Rate 45391 Priced Fragmenting of kidney stone 177047 50590 CPT Outpatient 40930.05 7548.28 Clover Clover Medicare 0.09 3683.90 0.09 40930.05 0.09 Case Rate 50590 Priced Fetal non-stress test 177047 59025 CPT Outpatient 3153.15 477.76 Clover Clover Medicare 0.06 198.89 0.06 3153.15 0.06 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 177047 64483 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 177047 92567 CPT Outpatient 2224.95 98.50 Clover Clover Medicare 0.14 308.98 0.14 2224.95 0.14 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 177047 93000 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 177047 93017 CPT Outpatient 3076.50 532.96 Clover Clover Medicare 0.10 308.98 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 177047 93452 CPT Outpatient 55621.65 8611.87 Clover Clover Medicare 0.06 3385.39 0.06 55621.65 0.06 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 177047 95810 CPT Outpatient 20341.65 3373.48 Clover Clover Medicare 0.05 1074.10 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 177047 95811 CPT Outpatient 22491.00 3731.18 Clover Clover Medicare 0.05 1074.10 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 177047 95812 CPT Outpatient 5578.65 925.83 Clover Clover Medicare 0.06 308.98 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 177047 96040 CPT Outpatient 0.01 102.81 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 177047 96413 CPT Outpatient 4856.25 472.45 Clover Clover Medicare 0.55 2654.07 0.55 4856.25 0.55 Case Rate 96413 Priced Ultrasound therapy 177047 97035 CPT Outpatient 2111.55 134.99 Clover Clover Medicare 0.04 85.29 0.04 2111.55 0.04 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 177047 97110 CPT Outpatient 6494.25 92.86 Clover Clover Medicare 0.05 355.13 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 177047 97116 CPT Outpatient 4723.95 110.61 Clover Clover Medicare 0.06 289.20 0.06 4723.95 0.06 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 177047 70450 CPT Outpatient 8566.95 835.61 Clover Clover Medicare 0.06 551.80 0.06 8566.95 0.06 Case Rate 70450 Priced Mri brain stem w/o dye 177047 70551 CPT Outpatient 7861.35 1361.31 Clover Clover Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 70551 Priced MRI scan of brain before and after contrast 177047 70553 CPT Outpatient 10882.20 1625.88 Clover Clover Medicare 0.04 429.92 0.04 10882.20 0.04 Case Rate 70553 Priced X-ray exam chest 2 views 177047 71046 CPT Outpatient 859.95 150.37 Clover Clover Medicare 0.11 94.43 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 177047 71250 CPT Outpatient 7288.05 1261.63 Clover Clover Medicare 0.02 127.10 0.02 7288.05 0.02 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 177047 72082 CPT Outpatient 2022.30 253.33 Clover Clover Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 177047 72100 CPT Outpatient 1599.15 277.38 Clover Clover Medicare 0.08 127.10 0.08 1599.15 0.08 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 177047 72110 CPT Outpatient 1389.15 241.04 Clover Clover Medicare 0.09 127.10 0.09 1389.15 0.09 Case Rate 72110 Priced MRI scan of lower spinal canal 177047 72148 CPT Outpatient 7861.35 1361.31 Clover Clover Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 177047 72193 CPT Outpatient 13671.00 1412.01 Clover Clover Medicare 0.02 208.54 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 177047 73030 CPT Outpatient 1452.15 251.43 Clover Clover Medicare 0.07 94.43 0.07 1452.15 0.07 Case Rate 73030 Priced X-ray exam of elbow 177047 73080 CPT Outpatient 1356.60 235.68 Clover Clover Medicare 0.07 94.43 0.07 1356.60 0.07 Case Rate 73080 Priced X-ray exam of forearm 177047 73090 CPT Outpatient 1243.20 215.26 Clover Clover Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73090 Priced X-ray exam of wrist 177047 73110 CPT Outpatient 1243.20 215.26 Clover Clover Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 177047 73130 CPT Outpatient 1243.20 215.26 Clover Clover Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73130 Priced X-ray exam hips bi 2 views 177047 73521 CPT Outpatient 970.20 228.41 Clover Clover Medicare 0.13 127.10 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 177047 73562 CPT Outpatient 802.20 139.12 Clover Clover Medicare 0.12 94.43 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 177047 73590 CPT Outpatient 1243.20 215.26 Clover Clover Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73590 Priced X-ray exam of ankle 177047 73610 CPT Outpatient 1378.65 239.31 Clover Clover Medicare 0.07 94.43 0.07 1378.65 0.07 Case Rate 73610 Priced X-ray exam of foot 177047 73630 CPT Outpatient 975.45 169.41 Clover Clover Medicare 0.10 94.43 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 177047 73721 CPT Outpatient 7861.35 1361.31 Clover Clover Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 177047 74177 CPT Outpatient 14222.25 1412.01 Clover Clover Medicare 0.03 429.92 0.03 14222.25 0.03 Case Rate 74177 Priced Contrst x-ray exam of throat 177047 74210 CPT Outpatient 0.01 440.39 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 177047 76098 CPT Outpatient 6141.45 407.86 Clover Clover Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 76098 Priced Us exam of head and neck 177047 76536 CPT Outpatient 5512.50 955.18 Clover Clover Medicare 0.02 127.10 0.02 5512.50 0.02 Case Rate 76536 Priced Ultrasound breast limited 177047 76642 CPT Outpatient 5777.10 127.70 Clover Clover Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 177047 76700 CPT Outpatient 4917.15 851.88 Clover Clover Medicare 0.03 127.10 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 177047 76705 CPT Outpatient 3836.70 665.17 Clover Clover Medicare 0.03 127.10 0.03 3836.70 0.03 Case Rate 76705 Priced Us exam abdo back wall comp 177047 76770 CPT Outpatient 5171.25 895.48 Clover Clover Medicare 0.02 127.10 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 177047 76775 CPT Outpatient 3969.00 686.97 Clover Clover Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 177047 76801 CPT Outpatient 2006.55 347.98 Clover Clover Medicare 0.06 127.10 0.06 2006.55 0.06 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 177047 76805 CPT Outpatient 3969.00 686.97 Clover Clover Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 177047 76811 CPT Outpatient 2844.45 492.99 Clover Clover Medicare 0.09 268.63 0.09 2844.45 0.09 Case Rate 76811 Priced Ob us nuchal meas 1 gest 177047 76813 CPT Outpatient 1044.75 180.83 Clover Clover Medicare 0.12 127.10 0.12 1044.75 0.12 Case Rate 76813 Priced Ob us limited fetus(s) 177047 76815 CPT Outpatient 6428.10 639.90 Clover Clover Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76815 Priced Ob us follow-up per fetus 177047 76816 CPT Outpatient 4818.45 833.88 Clover Clover Medicare 0.03 127.10 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 177047 76817 CPT Outpatient 6428.10 476.73 Clover Clover Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76817 Priced Fetal biophys profil w/o nst 177047 76819 CPT Outpatient 1741.95 302.65 Clover Clover Medicare 0.07 127.10 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 177047 76830 CPT Outpatient 9305.10 806.54 Clover Clover Medicare 0.03 254.21 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 177047 76870 CPT Outpatient 6328.35 1096.55 Clover Clover Medicare 0.02 127.10 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 177047 76885 CPT Outpatient 3836.70 665.17 Clover Clover Medicare 0.02 94.43 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 177047 77065 CPT Outpatient 3451.35 192.07 Clover Clover Medicare 0.05 158.33 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 177047 77066 CPT Outpatient 5777.10 235.68 Clover Clover Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 177047 77067 CPT Outpatient 1416.45 205.57 Clover Clover Medicare 0.05 63.90 0.05 1416.45 0.05 Case Rate 77067 Priced X-rays for bone age 177047 77072 CPT Outpatient 2022.30 163.87 Clover Clover Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 77072 Priced Joint survey single view 177047 77077 CPT Outpatient 985.95 171.14 Clover Clover Medicare 0.13 124.57 0.13 985.95 0.13 Case Rate 77077 Priced Dxa bone density axial 177047 77080 CPT Outpatient 3257.10 319.09 Clover Clover Medicare 0.06 191.00 0.06 3257.10 0.06 Case Rate 77080 Priced Fna bx w/us gdn 1st les 177047 10005 CPT Outpatient 5512.50 547.24 Clover Clover Medicare 0.13 726.50 0.13 5512.50 0.13 Case Rate 10005 Priced Fna bx w/us gdn ea addl 177047 10006 CPT Outpatient 10628.10 594.83 Clover Clover Medicare 0.07 726.50 0.07 10628.10 0.07 Case Rate 10006 Priced Drainage of hematoma/fluid 177047 10140 CPT Outpatient 23209.20 1081.95 Clover Clover Medicare 0.27 6181.44 0.27 23209.20 0.27 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 177047 11042 CPT Outpatient 2668.05 481.45 Clover Clover Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb bone 20 sq cm/< 177047 11044 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 177047 11406 CPT Outpatient 19967.85 3427.81 Clover Clover Medicare 0.09 1700.21 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 177047 11424 CPT Outpatient 0.01 1004.93 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 177047 11770 CPT Outpatient 19173.00 3291.37 Clover Clover Medicare 0.15 2826.15 0.15 19173.00 0.15 Case Rate 11770 Priced Replace tissue expander 177047 11970 CPT Outpatient 59239.95 10169.52 Clover Clover Medicare 0.52 30989.99 0.52 59239.95 0.52 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 177047 14020 CPT Outpatient 32166.75 5521.96 Clover Clover Medicare 0.06 1999.63 0.06 32166.75 0.06 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 177047 14060 CPT Outpatient 25993.80 1374.69 Clover Clover Medicare 0.31 7937.33 0.31 25993.80 0.31 Case Rate 14060 Priced Wound prep trk/arm/leg 177047 15002 CPT Outpatient 41748.00 1441.73 Clover Clover Medicare 0.21 8825.17 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 177047 15271 CPT Outpatient 24343.20 3769.48 Clover Clover Medicare 0.08 1999.63 0.08 24343.20 0.08 Case Rate 15271 Priced Acellular derm matrix implt 177047 15777 CPT Outpatient 101672.55 17453.79 Clover Clover Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 15777 Priced Exc skin abd 177047 15830 CPT Outpatient 54696.60 9389.58 Clover Clover Medicare 0.12 6325.99 0.12 54696.60 0.12 Case Rate 15830 Priced Dressing change not for burn 177047 15852 CPT Outpatient 0.01 290.74 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 177047 15877 CPT Outpatient 63741.30 10942.26 Clover Clover Medicare 0.17 10877.73 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 177047 15879 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 177047 19000 CPT Outpatient 10143.00 594.83 Clover Clover Medicare 0.08 790.40 0.08 10143.00 0.08 Case Rate 19000 Priced Bx breast 1st lesion strtctc 177047 19081 CPT Outpatient 12341.70 1250.69 Clover Clover Medicare 0.14 1758.68 0.14 12341.70 0.14 Case Rate 19081 Priced Bx breast add lesion us imag 177047 19084 CPT Outpatient 29058.75 547.24 Clover Clover Medicare 0.07 1975.03 0.07 29058.75 0.07 Case Rate 19084 Priced Biopsy of breast open 177047 19101 CPT Outpatient 39545.10 2737.82 Clover Clover Medicare 0.23 8988.74 0.23 39545.10 0.23 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 177047 19120 CPT Outpatient 35761.95 2737.82 Clover Clover Medicare 0.12 4298.03 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 177047 19125 CPT Outpatient 33184.20 0.01 Clover Clover Medicare 0.26 8661.10 0.26 33184.20 0.26 Case Rate 19125 Priced Perq device breast 1st imag 177047 19281 CPT Outpatient 6141.45 598.61 Clover Clover Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 19281 Priced Perq device breast ea imag 177047 19282 CPT Outpatient 8379.00 319.04 Clover Clover Medicare 0.15 1290.61 0.15 8379.00 0.15 Case Rate 19282 Priced Partial mastectomy 177047 19301 CPT Outpatient 39157.65 6722.06 Clover Clover Medicare 0.20 7846.47 0.20 39157.65 0.20 Case Rate 19301 Priced Mast simple complete 177047 19303 CPT Outpatient 105389.55 18091.87 Clover Clover Medicare 0.28 29200.15 0.28 105389.55 0.28 Case Rate 19303 Priced Reduction of large breast 177047 19318 CPT Outpatient 65239.65 11199.47 Clover Clover Medicare 0.10 6577.10 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 177047 19340 CPT Outpatient 113100.75 19415.63 Clover Clover Medicare 0.13 14822.97 0.13 113100.75 0.13 Case Rate 19340 Priced Delayed breast prosthesis 177047 19342 CPT Outpatient 56988.75 9783.07 Clover Clover Medicare 0.36 20246.20 0.36 56988.75 0.36 Case Rate 19342 Priced Breast reconstruction 177047 19357 CPT Outpatient 101672.55 17453.79 Clover Clover Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 19357 Priced Breast reconstruction 177047 19366 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 177047 19380 CPT Outpatient 61493.25 10556.34 Clover Clover Medicare 0.21 13212.28 0.21 61493.25 0.21 Case Rate 19380 Priced Removal of support implant 177047 20680 CPT Outpatient 42329.70 7266.60 Clover Clover Medicare 0.14 5804.91 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 177047 22856 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 177047 24538 CPT Outpatient 51237.90 4775.24 Clover Clover Medicare 0.19 9816.98 0.19 51237.90 0.19 Case Rate 24538 Priced Remove wrist tendon lesion 177047 25111 CPT Outpatient 25855.20 4438.48 Clover Clover Medicare 0.06 1654.95 0.06 25855.20 0.06 Case Rate 25111 Priced Incise finger tendon sheath 177047 26055 CPT Outpatient 15862.35 2723.04 Clover Clover Medicare 0.12 1931.13 0.12 15862.35 0.12 Case Rate 26055 Priced Treat finger fracture each 177047 26727 CPT Outpatient 22779.75 2030.47 Clover Clover Medicare 0.16 3574.88 0.16 22779.75 0.16 Case Rate 26727 Priced Revision of knee joint 177047 27446 CPT Outpatient 67882.50 11653.16 Clover Clover Medicare 0.23 15567.47 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 177047 27447 CPT Outpatient 130698.75 22436.62 Clover Clover Medicare 0.12 15604.41 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 177047 27485 CPT Outpatient 43310.40 7434.95 Clover Clover Medicare 0.26 11063.75 0.26 43310.40 0.26 Case Rate 27485 Priced Repair achilles tendon 177047 27650 CPT Outpatient 38246.25 3762.57 Clover Clover Medicare 0.29 11041.86 0.29 38246.25 0.29 Case Rate 27650 Priced Treatment of ankle fracture 177047 27792 CPT Outpatient 36101.10 6197.36 Clover Clover Medicare 0.21 7581.28 0.21 36101.10 0.21 Case Rate 27792 Priced Treatment of ankle fracture 177047 27814 CPT Outpatient 49405.65 8481.30 Clover Clover Medicare 0.16 7766.50 0.16 49405.65 0.16 Case Rate 27814 Priced Removal of foot lesion 177047 28080 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 177047 28285 CPT Outpatient 68603.85 11776.99 Clover Clover Medicare 0.20 13986.50 0.20 68603.85 0.20 Case Rate 28285 Priced Correction hallux valgus 177047 28296 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 177047 29823 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 177047 29826 CPT Outpatient 49840.35 8555.93 Clover Clover Medicare 0.15 7312.64 0.15 49840.35 0.15 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 177047 29881 CPT Outpatient 35556.15 6103.81 Clover Clover Medicare 0.09 3306.24 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 177047 29882 CPT Outpatient 61099.50 10488.75 Clover Clover Medicare 0.19 11577.74 0.19 61099.50 0.19 Case Rate 29882 Priced Percut bx lung/mediastinum 177047 32405 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 177047 32555 CPT Outpatient 14597.10 687.29 Clover Clover Medicare 0.05 711.62 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 177047 32664 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 177047 35190 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 177047 36478 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 177047 36561 CPT Outpatient 53531.10 3292.99 Clover Clover Medicare 0.06 3342.08 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 177047 36569 CPT Outpatient 31421.25 1299.06 Clover Clover Medicare 0.06 1811.50 0.06 31421.25 0.06 Case Rate 36569 Priced Removal tunneled cv cath 177047 36590 CPT Outpatient 1996.05 273.95 Clover Clover Medicare 0.82 1641.71 0.82 1996.05 0.82 Case Rate 36590 Priced Av fuse uppr arm basilic 177047 36819 CPT Outpatient 56861.70 9761.26 Clover Clover Medicare 0.17 9459.82 0.17 56861.70 0.17 Case Rate 36819 Priced Av fusion direct any site 177047 36821 CPT Outpatient 42953.40 7373.67 Clover Clover Medicare 0.16 7056.50 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 177047 36825 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 177047 36830 CPT Outpatient 53656.05 9210.96 Clover Clover Medicare 0.17 9346.72 0.17 53656.05 0.17 Case Rate 36830 Priced Av fistula revision open 177047 36832 CPT Outpatient 52492.65 9011.24 Clover Clover Medicare 0.23 12046.01 0.23 52492.65 0.23 Case Rate 36832 Priced Av fistula revision 177047 36833 CPT Outpatient 37098.60 6368.59 Clover Clover Medicare 0.28 10242.79 0.28 37098.60 0.28 Case Rate 36833 Priced Intro cath dialysis circuit 177047 36903 CPT Outpatient 77541.45 10669.90 Clover Clover Medicare 0.24 18454.26 0.24 77541.45 0.24 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 177047 36906 CPT Outpatient 96694.50 16175.64 Clover Clover Medicare 0.27 26216.69 0.27 96694.50 0.27 Case Rate 36906 Priced Fem/popl revas w/tla 177047 37224 CPT Outpatient 200076.45 5139.31 Clover Clover Medicare 0.14 27878.39 0.14 200076.45 0.14 Case Rate 37224 Priced Fem/popl revasc stnt & ather 177047 37227 CPT Outpatient 117170.55 18045.38 Clover Clover Medicare 0.17 19636.18 0.17 117170.55 0.17 Case Rate 37227 Priced Revise leg vein 177047 37700 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 177047 37722 CPT Outpatient 27815.55 4775.00 Clover Clover Medicare 0.37 10398.58 0.37 27815.55 0.37 Case Rate 37722 Priced Stab phleb veins xtr 10-20 177047 37765 CPT Outpatient 26561.85 4559.78 Clover Clover Medicare 0.52 13740.66 0.52 26561.85 0.52 Case Rate 37765 Priced Biopsy/removal lymph nodes 177047 38500 CPT Outpatient 35955.15 6172.30 Clover Clover Medicare 0.11 3918.72 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 177047 38525 CPT Outpatient 101194.80 17371.77 Clover Clover Medicare 0.19 18851.15 0.19 101194.80 0.19 Case Rate 38525 Priced Laparoscopy lymph node biop 177047 38570 CPT Outpatient 65631.30 11266.71 Clover Clover Medicare 0.28 18089.66 0.28 65631.30 0.28 Case Rate 38570 Priced Laparoscopy lymphadenectomy 177047 38571 CPT Outpatient 84031.50 14425.41 Clover Clover Medicare 0.26 22194.38 0.26 84031.50 0.26 Case Rate 38571 Priced Laparoscopy lymphadenectomy 177047 38572 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 177047 38792 CPT Outpatient 2868.60 432.48 Clover Clover Medicare 0.15 440.09 0.15 2868.60 0.15 Case Rate 38792 Priced Excision of gum lesion 177047 41825 CPT Outpatient 11580.45 1987.98 Clover Clover Medicare 0.30 3440.87 0.30 11580.45 0.30 Case Rate 41825 Priced Reconstruct cleft palate 177047 42200 CPT Outpatient 36703.80 6300.82 Clover Clover Medicare 0.16 5937.71 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 177047 42820 CPT Outpatient 17232.60 2958.26 Clover Clover Medicare 0.64 11027.66 0.64 17232.60 0.64 Case Rate 42820 Priced Control throat bleeding 177047 42960 CPT Outpatient 24066.00 4131.33 Clover Clover Medicare 0.20 4852.02 0.20 24066.00 0.20 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 177047 43235 CPT Outpatient 8856.75 1633.35 Clover Clover Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Laparoscopy fundoplasty 177047 43280 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 177047 43282 CPT Outpatient 84344.40 14479.12 Clover Clover Medicare 0.13 10981.07 0.13 84344.40 0.13 Case Rate 43282 Priced Laparoscopy appendectomy 177047 44970 CPT Outpatient 82300.05 14128.18 Clover Clover Medicare 0.08 6988.44 0.08 82300.05 0.08 Case Rate 44970 Priced Diagnostic sigmoidoscopy 177047 45330 CPT Outpatient 17286.15 542.26 Clover Clover Medicare 0.11 1880.24 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 177047 47000 CPT Outpatient 10398.15 1225.34 Clover Clover Medicare 0.20 2101.24 0.20 10398.15 0.20 Case Rate 47000 Priced Removal of gallbladder using an endoscope 177047 47562 CPT Outpatient 58430.40 10030.55 Clover Clover Medicare 0.10 5965.34 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 177047 47563 CPT Outpatient 71747.55 12316.66 Clover Clover Medicare 0.09 6769.21 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 177047 49083 CPT Outpatient 6979.35 1113.95 Clover Clover Medicare 0.14 944.67 0.14 6979.35 0.14 Case Rate 49083 Priced Diag laparo separate proc 177047 49320 CPT Outpatient 31629.15 5429.67 Clover Clover Medicare 0.42 13201.26 0.42 31629.15 0.42 Case Rate 49320 Priced Laparoscopy biopsy 177047 49321 CPT Outpatient 41892.90 7191.61 Clover Clover Medicare 0.32 13491.42 0.32 41892.90 0.32 Case Rate 49321 Priced Laparoscopy aspiration 177047 49322 CPT Outpatient 34392.75 5904.09 Clover Clover Medicare 0.39 13396.33 0.39 34392.75 0.39 Case Rate 49322 Priced Lap insert tunnel ip cath 177047 49324 CPT Outpatient 39264.75 6740.45 Clover Clover Medicare 0.15 5972.32 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 177047 49329 CPT Outpatient 58696.05 10076.16 Clover Clover Medicare 0.29 17162.20 0.29 58696.05 0.29 Case Rate 49329 Priced Ins tun ip cath for dial opn 177047 49421 CPT Outpatient 25460.40 3319.30 Clover Clover Medicare 0.15 3702.67 0.15 25460.40 0.15 Case Rate 49421 Priced Remove tunneled ip cath 177047 49422 CPT Outpatient 25515.00 4380.08 Clover Clover Medicare 0.13 3342.08 0.13 25515.00 0.13 Case Rate 49422 Priced Rpr ing hernia init reduce 177047 49500 CPT Outpatient 19594.05 3363.65 Clover Clover Medicare 0.56 11018.31 0.56 19594.05 0.56 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 177047 49505 CPT Outpatient 34915.65 5993.85 Clover Clover Medicare 0.21 7278.08 0.21 34915.65 0.21 Case Rate 49505 Priced Prp i/hern init block >5 yr 177047 49507 CPT Outpatient 29794.80 5114.77 Clover Clover Medicare 0.25 7306.28 0.25 29794.80 0.25 Case Rate 49507 Priced Rerepair ing hernia reduce 177047 49520 CPT Outpatient 36940.05 6341.38 Clover Clover Medicare 0.20 7341.71 0.20 36940.05 0.20 Case Rate 49520 Priced Rpr ventral hern init reduc 177047 49560 CPT Outpatient 53177.25 9128.76 Clover Clover Medicare 0.18 9686.73 0.18 53177.25 0.18 Case Rate 49560 Priced Rpr ventral hern init block 177047 49561 CPT Outpatient 30755.55 5279.70 Clover Clover Medicare 0.24 7522.67 0.24 30755.55 0.24 Case Rate 49561 Priced Rerepair ventrl hern reduce 177047 49565 CPT Outpatient 69917.40 12002.49 Clover Clover Medicare 0.14 10018.26 0.14 69917.40 0.14 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 177047 49585 CPT Outpatient 41806.80 7176.83 Clover Clover Medicare 0.23 9650.59 0.23 41806.80 0.23 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 177047 49587 CPT Outpatient 37320.15 6406.63 Clover Clover Medicare 0.20 7369.53 0.20 37320.15 0.20 Case Rate 49587 Priced Lap ing hernia repair init 177047 49650 CPT Outpatient 41932.80 7198.46 Clover Clover Medicare 0.14 5784.73 0.14 41932.80 0.14 Case Rate 49650 Priced Lap ing hernia repair recur 177047 49651 CPT Outpatient 46915.05 8053.75 Clover Clover Medicare 0.26 12396.08 0.26 46915.05 0.26 Case Rate 49651 Priced Lap vent/abd hernia repair 177047 49652 CPT Outpatient 51294.60 8805.57 Clover Clover Medicare 0.12 6001.15 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 177047 49653 CPT Outpatient 46102.35 7914.24 Clover Clover Medicare 0.13 5907.33 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 177047 49654 CPT Outpatient 47221.65 8106.38 Clover Clover Medicare 0.22 10246.22 0.22 47221.65 0.22 Case Rate 49654 Priced Lap inc hern repair comp 177047 49655 CPT Outpatient 54590.55 9371.38 Clover Clover Medicare 0.19 10557.83 0.19 54590.55 0.19 Case Rate 49655 Priced Lap inc hernia repair recur 177047 49656 CPT Outpatient 55443.15 9517.74 Clover Clover Medicare 0.19 10492.84 0.19 55443.15 0.19 Case Rate 49656 Priced Removal of kidney stone 177047 50080 CPT Outpatient 53165.70 9126.78 Clover Clover Medicare 0.32 16951.33 0.32 53165.70 0.32 Case Rate 50080 Priced Removal of kidney stone 177047 50081 CPT Outpatient 66931.20 11489.86 Clover Clover Medicare 0.30 20375.49 0.30 66931.20 0.30 Case Rate 50081 Priced Renal biopsy perq 177047 50200 CPT Outpatient 43096.20 1225.34 Clover Clover Medicare 0.23 9703.00 0.23 43096.20 0.23 Case Rate 50200 Priced Plmt nephroureteral catheter 177047 50433 CPT Outpatient 64566.60 1424.48 Clover Clover Medicare 0.27 17570.80 0.27 64566.60 0.27 Case Rate 50433 Priced Laparo radical nephrectomy 177047 50545 CPT Outpatient 43449.00 7458.75 Clover Clover Medicare 0.03 1190.00 0.03 43449.00 0.03 Case Rate 50545 Priced Laparoscope proc ureter 177047 50949 CPT Outpatient 49986.30 8580.98 Clover Clover Medicare 0.34 17208.73 0.34 49986.30 0.34 Case Rate 50949 Priced Injection for bladder x-ray 177047 51600 CPT Outpatient 3285.45 89.22 Clover Clover Medicare 0.08 268.63 0.08 3285.45 0.08 Case Rate 51600 Priced Cystoscopy 177047 52000 CPT Outpatient 22149.75 3802.37 Clover Clover Medicare 0.36 7975.55 0.36 22149.75 0.36 Case Rate 52000 Priced Cystoscopy & ureter catheter 177047 52005 CPT Outpatient 42529.20 2095.77 Clover Clover Medicare 0.21 9136.51 0.21 42529.20 0.21 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 177047 52204 CPT Outpatient 31274.25 5368.75 Clover Clover Medicare 0.18 5745.54 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 177047 52224 CPT Outpatient 13445.25 2308.10 Clover Clover Medicare 0.54 7303.88 0.54 13445.25 0.54 Case Rate 52224 Priced Cystoscopy and treatment 177047 52234 CPT Outpatient 28510.65 4894.33 Clover Clover Medicare 0.27 7572.52 0.27 28510.65 0.27 Case Rate 52234 Priced Cystoscopy and treatment 177047 52235 CPT Outpatient 29417.85 5050.06 Clover Clover Medicare 0.25 7276.20 0.25 29417.85 0.25 Case Rate 52235 Priced Cystoscopy and treatment 177047 52240 CPT Outpatient 33933.90 5825.32 Clover Clover Medicare 0.27 9046.24 0.27 33933.90 0.27 Case Rate 52240 Priced Cystoscopy and treatment 177047 52281 CPT Outpatient 22159.20 3804.00 Clover Clover Medicare 0.26 5688.66 0.26 22159.20 0.26 Case Rate 52281 Priced Remove bladder stone 177047 52317 CPT Outpatient 27085.80 4649.73 Clover Clover Medicare 0.27 7426.56 0.27 27085.80 0.27 Case Rate 52317 Priced Remove bladder stone 177047 52318 CPT Outpatient 26685.75 4581.05 Clover Clover Medicare 0.28 7361.57 0.28 26685.75 0.28 Case Rate 52318 Priced Cystoscopy and treatment 177047 52332 CPT Outpatient 115306.80 19794.33 Clover Clover Medicare 0.18 20580.50 0.18 115306.80 0.18 Case Rate 52332 Priced Cystouretero w/stone remove 177047 52352 CPT Outpatient 42420.00 7282.10 Clover Clover Medicare 0.38 16312.79 0.38 42420.00 0.38 Case Rate 52352 Priced Cystouretero w/lithotripsy 177047 52353 CPT Outpatient 38608.50 6627.79 Clover Clover Medicare 0.24 9133.86 0.24 38608.50 0.24 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 177047 52356 CPT Outpatient 36255.45 6223.85 Clover Clover Medicare 0.25 9133.86 0.25 36255.45 0.25 Case Rate 52356 Priced Prostatectomy (turp) 177047 52601 CPT Outpatient 35371.35 6072.08 Clover Clover Medicare 0.25 8684.69 0.25 35371.35 0.25 Case Rate 52601 Priced Laser surgery of prostate 177047 52648 CPT Outpatient 24264.45 4165.40 Clover Clover Medicare 0.37 9020.55 0.37 24264.45 0.37 Case Rate 52648 Priced Revision of urethra 177047 53450 CPT Outpatient 16209.90 2782.70 Clover Clover Medicare 0.35 5679.84 0.35 16209.90 0.35 Case Rate 53450 Priced Urology surgery procedure 177047 53899 CPT Outpatient 25368.00 134.83 Clover Clover Medicare 0.27 6862.63 0.27 25368.00 0.27 Case Rate 53899 Priced Circumcision w/regionl block 177047 54150 CPT Outpatient 14700.00 2523.50 Clover Clover Medicare 0.14 2090.37 0.14 14700.00 0.14 Case Rate 54150 Priced Circum 28 days or older 177047 54161 CPT Outpatient 19186.65 3293.71 Clover Clover Medicare 0.11 2049.61 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 177047 54162 CPT Outpatient 19795.65 3398.25 Clover Clover Medicare 0.85 16823.10 0.85 19795.65 0.85 Case Rate 54162 Priced Repair of circumcision 177047 54163 CPT Outpatient 16391.55 2813.88 Clover Clover Medicare 0.24 4010.49 0.24 16391.55 0.24 Case Rate 54163 Priced Reconstruction of urethra 177047 54324 CPT Outpatient 32880.75 5644.53 Clover Clover Medicare 0.28 9303.52 0.28 32880.75 0.28 Case Rate 54324 Priced Revise penis/urethra 177047 54332 CPT Outpatient 19968.90 3427.99 Clover Clover Medicare 0.18 3589.47 0.18 19968.90 0.18 Case Rate 54332 Priced Insert self-contd prosthesis 177047 54401 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 177047 54520 CPT Outpatient 35442.75 6084.34 Clover Clover Medicare 0.34 12158.30 0.34 35442.75 0.34 Case Rate 54520 Priced Reduce testis torsion 177047 54600 CPT Outpatient 55049.40 9450.15 Clover Clover Medicare 0.28 15402.48 0.28 55049.40 0.28 Case Rate 54600 Priced Suspension of testis 177047 54640 CPT Outpatient 26860.05 4610.98 Clover Clover Medicare 0.28 7428.84 0.28 26860.05 0.28 Case Rate 54640 Priced Removal of hydrocele 177047 55040 CPT Outpatient 27277.95 4682.71 Clover Clover Medicare 0.27 7369.91 0.27 27277.95 0.27 Case Rate 55040 Priced Biopsy of prostate gland 177047 55700 CPT Outpatient 28699.65 4926.77 Clover Clover Medicare 0.13 3731.04 0.13 28699.65 0.13 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 177047 55866 CPT Outpatient 93088.80 15980.24 Clover Clover Medicare 0.24 22017.24 0.24 93088.80 0.24 Case Rate 55866 Priced Closure of vagina 177047 57120 CPT Outpatient 34369.65 5900.12 Clover Clover Medicare 0.43 14932.00 0.43 34369.65 0.43 Case Rate 57120 Priced Repair of vagina 177047 57200 CPT Outpatient 25247.25 4334.11 Clover Clover Medicare 0.31 7732.37 0.31 25247.25 0.31 Case Rate 57200 Priced Anterior colporrhaphy 177047 57240 CPT Outpatient 36210.30 6216.10 Clover Clover Medicare 0.53 19223.69 0.53 36210.30 0.53 Case Rate 57240 Priced Repair rectum & vagina 177047 57250 CPT Outpatient 40441.80 6942.51 Clover Clover Medicare 0.56 22691.64 0.56 40441.80 0.56 Case Rate 57250 Priced Cmbn ant pst colprhy 177047 57260 CPT Outpatient 46323.90 7952.27 Clover Clover Medicare 0.66 30437.82 0.66 46323.90 0.66 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 177047 57265 CPT Outpatient 42586.95 7310.76 Clover Clover Medicare 0.43 18248.88 0.43 42586.95 0.43 Case Rate 57265 Priced Repair of bowel bulge 177047 57268 CPT Outpatient 36865.50 6328.58 Clover Clover Medicare 0.49 18090.91 0.49 36865.50 0.49 Case Rate 57268 Priced Colpopexy extraperitoneal 177047 57282 CPT Outpatient 45629.85 7833.12 Clover Clover Medicare 0.66 30324.80 0.66 45629.85 0.66 Case Rate 57282 Priced Repair bladder defect 177047 57288 CPT Outpatient 43069.95 7393.67 Clover Clover Medicare 0.56 24109.88 0.56 43069.95 0.56 Case Rate 57288 Priced Bx/curett of cervix w/scope 177047 57454 CPT Outpatient 2888.55 442.93 Clover Clover Medicare 0.11 329.27 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 177047 57520 CPT Outpatient 26728.80 4588.44 Clover Clover Medicare 0.16 4211.41 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 177047 57522 CPT Outpatient 22737.75 3903.31 Clover Clover Medicare 0.15 3411.24 0.15 22737.75 0.15 Case Rate 57522 Priced Biopsy of uterus lining 177047 58100 CPT Outpatient 2371.95 194.80 Clover Clover Medicare 0.08 198.89 0.08 2371.95 0.08 Case Rate 58100 Priced Catheter for hysterography 177047 58340 CPT Outpatient 6322.05 131.04 Clover Clover Medicare 0.04 268.63 0.04 6322.05 0.04 Case Rate 58340 Priced Reopen fallopian tube 177047 58350 CPT Outpatient 46507.65 7983.81 Clover Clover Medicare 0.38 17563.57 0.38 46507.65 0.38 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 177047 58542 CPT Outpatient 64194.90 11020.12 Clover Clover Medicare 0.37 24060.91 0.37 64194.90 0.37 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 177047 58544 CPT Outpatient 51020.55 8758.53 Clover Clover Medicare 0.65 33216.81 0.65 51020.55 0.65 Case Rate 58544 Priced Laparoscopic myomectomy 177047 58545 CPT Outpatient 56946.75 9775.86 Clover Clover Medicare 0.17 9718.98 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 177047 58552 CPT Outpatient 57228.15 9824.17 Clover Clover Medicare 0.32 18381.02 0.32 57228.15 0.32 Case Rate 58552 Priced Hysteroscopy biopsy 177047 58558 CPT Outpatient 28581.00 2077.02 Clover Clover Medicare 0.25 7238.81 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 177047 58561 CPT Outpatient 35222.25 6046.49 Clover Clover Medicare 0.27 9531.42 0.27 35222.25 0.27 Case Rate 58561 Priced Hysteroscopy ablation 177047 58563 CPT Outpatient 38399.55 6591.92 Clover Clover Medicare 0.51 19555.87 0.51 38399.55 0.51 Case Rate 58563 Priced Tlh uterus 250 g or less 177047 58570 CPT Outpatient 43316.70 7436.03 Clover Clover Medicare 0.26 11083.71 0.26 43316.70 0.26 Case Rate 58570 Priced Tlh w/t/o 250 g or less 177047 58571 CPT Outpatient 48603.45 8343.59 Clover Clover Medicare 0.30 14369.35 0.30 48603.45 0.30 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 177047 58573 CPT Outpatient 52905.30 9082.08 Clover Clover Medicare 0.32 16722.51 0.32 52905.30 0.32 Case Rate 58573 Priced Laparoscopy remove adnexa 177047 58661 CPT Outpatient 47008.50 8069.79 Clover Clover Medicare 0.18 8686.07 0.18 47008.50 0.18 Case Rate 58661 Priced Laparoscopy excise lesions 177047 58662 CPT Outpatient 45053.40 7734.17 Clover Clover Medicare 0.38 17220.22 0.38 45053.40 0.38 Case Rate 58662 Priced Treat ectopic pregnancy 177047 59151 CPT Outpatient 74690.70 12821.90 Clover Clover Medicare 0.09 6630.70 0.09 74690.70 0.09 Case Rate 59151 Priced Treatment of miscarriage 177047 59812 CPT Outpatient 56109.90 9632.20 Clover Clover Medicare 0.07 4075.96 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 177047 60220 CPT Outpatient 53639.25 9208.07 Clover Clover Medicare 0.11 6088.34 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 177047 60240 CPT Outpatient 98252.70 16866.71 Clover Clover Medicare 0.06 5905.23 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 177047 60500 CPT Outpatient 150495.45 25835.05 Clover Clover Medicare 0.06 9768.16 0.06 150495.45 0.06 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 177047 62322 CPT Outpatient 43709.40 514.24 Clover Clover Medicare 0.28 12235.33 0.28 43709.40 0.28 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 177047 62323 CPT Outpatient 8304.45 467.31 Clover Clover Medicare 16.45 136591.28 16.45 8304.45 16.45 Case Rate 62323 Priced Low back disk surgery 177047 63030 CPT Outpatient 50287.65 8632.71 Clover Clover Medicare 0.30 14893.92 0.30 50287.65 0.30 Case Rate 63030 Priced Inc for vagus n elect impl 177047 64568 CPT Outpatient 124562.55 21383.24 Clover Clover Medicare 0.27 33814.93 0.27 124562.55 0.27 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 177047 66821 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 177047 66984 CPT Outpatient 0.01 0.01 Clover Clover Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 280047 216 DRG Inpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 280047 460 DRG Inpatient 416122.79 53834.63 Horizon Horizon Medicare 0.09 36507.56 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 280047 470 DRG Inpatient 167912.19 21723.13 Horizon Horizon Medicare 0.11 18221.64 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 280047 473 DRG Inpatient 100687.91 13026.19 Horizon Horizon Medicare 0.24 23973.82 0.24 100687.91 0.24 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 280047 743 DRG Inpatient 102691.67 13285.42 Horizon Horizon Medicare 0.11 11317.53 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 280047 795 DRG Inpatient 6266.93 2335.00 Horizon Horizon Medicare 0.49 3065.24 0.49 6266.93 0.49 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 280047 807 DRG Inpatient 116469.59 4193.00 Horizon Horizon Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 280047 788 DRG Inpatient 76050.77 4538.00 Horizon Horizon Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 280047 59400 CPT Inpatient 116469.59 4193.00 Horizon Horizon Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 280047 59510 CPT Inpatient 76050.77 4538.00 Horizon Horizon Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 280047 59610 CPT Inpatient 116469.59 4193.00 Horizon Horizon Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59610 Priced "Psychotherapy, 30 min" 280047 90832 CPT Outpatient 577.50 91.21 Horizon Horizon Medicare 0.29 166.55 0.29 577.50 0.29 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 280047 90834 CPT Outpatient 44134.65 271.96 Horizon Horizon Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 280047 90837 CPT Outpatient 2240.70 442.93 Horizon Horizon Medicare 0.04 84.05 0.04 2240.70 0.04 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 280047 90846 CPT Outpatient 0.01 131.50 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 280047 90847 CPT Outpatient 44134.65 369.97 Horizon Horizon Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90847 Priced Group psychotherapy 280047 90853 CPT Outpatient 44134.65 101.99 Horizon Horizon Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 280047 99203 CPT Outpatient 3480.75 176.07 Horizon Horizon Medicare 0.12 403.52 0.12 3480.75 0.12 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 280047 99204 CPT Outpatient 2103.15 233.39 Horizon Horizon Medicare 0.19 390.94 0.19 2103.15 0.19 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 280047 99205 CPT Outpatient 4970.70 314.28 Horizon Horizon Medicare 0.09 462.07 0.09 4970.70 0.09 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 280047 99243 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 280047 99244 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 280047 99385 CPT Outpatient 1114.05 185.90 Horizon Horizon Medicare 0.19 207.05 0.19 1114.05 0.19 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 280047 99386 CPT Outpatient 4877.25 185.90 Horizon Horizon Medicare 0.02 98.87 0.02 4877.25 0.02 Fee Schedule 99386 Priced Routine venipuncture 280047 36415 CPT Outpatient 127.05 19.57 Horizon Horizon Medicare 0.02 3.02 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 280047 80048 CPT Outpatient 576.45 88.78 Horizon Horizon Medicare 0.02 11.70 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 280047 80053 CPT Outpatient 763.35 117.56 Horizon Horizon Medicare 0.02 13.22 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 280047 80055 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 280047 80061 CPT Outpatient 1349.25 197.77 Horizon Horizon Medicare 0.01 18.53 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 280047 80069 CPT Outpatient 716.10 104.95 Horizon Horizon Medicare 0.02 12.01 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 280047 80076 CPT Outpatient 716.10 104.95 Horizon Horizon Medicare 0.02 11.31 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 280047 81000 CPT Outpatient 144.90 21.18 Horizon Horizon Medicare 0.03 4.39 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 280047 81001 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 280047 81002 CPT Outpatient 57.75 8.89 Horizon Horizon Medicare 0.06 3.53 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 280047 81003 CPT Outpatient 219.45 33.80 Horizon Horizon Medicare 0.01 3.11 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 280047 82306 CPT Outpatient 1880.55 289.62 Horizon Horizon Medicare 0.02 40.96 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 280047 83036 CPT Outpatient 494.55 76.17 Horizon Horizon Medicare 0.03 13.44 0.03 494.55 0.03 Fee Schedule 83036 Priced PSA (prostate specific antigen) 280047 84153 CPT Outpatient 1177.05 181.28 Horizon Horizon Medicare 0.02 25.45 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 280047 84154 CPT Outpatient 598.50 92.17 Horizon Horizon Medicare 0.04 25.45 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 280047 84443 CPT Outpatient 519.75 80.05 Horizon Horizon Medicare 0.04 23.25 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 280047 84703 CPT Outpatient 785.40 120.96 Horizon Horizon Medicare 0.01 10.40 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 280047 85025 CPT Outpatient 635.25 97.83 Horizon Horizon Medicare 0.02 10.75 0.02 635.25 0.02 Fee Schedule 85025 Priced "Complete blood count, automated" 280047 85027 CPT Outpatient 576.45 88.78 Horizon Horizon Medicare 0.02 8.95 0.02 576.45 0.02 Fee Schedule 85027 Priced "Blood test, clotting time" 280047 85610 CPT Outpatient 404.25 62.26 Horizon Horizon Medicare 0.01 5.43 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 280047 85730 CPT Outpatient 17.22 2.65 Horizon Horizon Medicare 0.48 8.31 0.48 17.22 0.48 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 280047 86003 CPT Outpatient 32.55 5.01 Horizon Horizon Medicare 0.22 7.23 0.22 32.55 0.22 Fee Schedule 86003 Priced Tb test cell immun measure 280047 86480 CPT Outpatient 530.25 81.66 Horizon Horizon Medicare 0.16 85.75 0.16 530.25 0.16 Fee Schedule 86480 Priced Urine culture/colony count 280047 87086 CPT Outpatient 763.35 117.56 Horizon Horizon Medicare 0.01 11.16 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 280047 87338 CPT Outpatient 785.40 120.96 Horizon Horizon Medicare 0.03 19.90 0.03 785.40 0.03 Fee Schedule 87338 Priced Cytopath eval fna report 280047 88173 CPT Outpatient 750.75 115.62 Horizon Horizon Medicare 0.08 57.32 0.08 750.75 0.08 Fee Schedule 88173 Priced Tissue exam by pathologist 280047 88302 CPT Outpatient 635.25 97.83 Horizon Horizon Medicare 0.04 28.54 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 280047 88305 CPT Outpatient 323.40 49.81 Horizon Horizon Medicare 0.18 57.32 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 280047 11042 CPT Outpatient 2668.05 481.45 Horizon Horizon Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb subq tissue add-on 280047 11045 CPT Outpatient 4652.55 330.00 Horizon Horizon Medicare 0.09 403.52 0.09 4652.55 0.09 Case Rate 11045 Priced Dx bronchoscope/lavage 280047 31624 CPT Outpatient 41223.00 7602.31 Horizon Horizon Medicare 0.19 7805.52 0.19 41223.00 0.19 Case Rate 31624 Priced Bronchoscopy/lung bx each 280047 31628 CPT Outpatient 49048.65 9045.51 Horizon Horizon Medicare 0.25 12292.51 0.25 49048.65 0.25 Case Rate 31628 Priced Blood transfusion service 280047 36430 CPT Outpatient 9166.50 574.93 Horizon Horizon Medicare 0.08 731.71 0.08 9166.50 0.08 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 280047 43235 CPT Outpatient 8856.75 1633.35 Horizon Horizon Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Endoscopic us exam esoph 280047 43237 CPT Outpatient 23867.55 4401.63 Horizon Horizon Medicare 0.12 2840.90 0.12 23867.55 0.12 Case Rate 43237 Priced Egd us fine needle bx/aspir 280047 43238 CPT Outpatient 30690.45 5659.90 Horizon Horizon Medicare 0.06 1914.48 0.06 30690.45 0.06 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 280047 43239 CPT Outpatient 40191.90 7412.15 Horizon Horizon Medicare 0.07 2698.70 0.07 40191.90 0.07 Case Rate 43239 Priced Ercp remove duct calculi 280047 43264 CPT Outpatient 34335.00 6332.03 Horizon Horizon Medicare 0.21 7043.47 0.21 34335.00 0.21 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 280047 45378 CPT Outpatient 13991.25 889.35 Horizon Horizon Medicare 0.07 926.48 0.07 13991.25 0.07 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 280047 45380 CPT Outpatient 22215.90 4097.04 Horizon Horizon Medicare 0.08 1815.96 0.08 22215.90 0.08 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 280047 45385 CPT Outpatient 119569.80 22050.95 Horizon Horizon Medicare 0.01 1648.12 0.01 119569.80 0.01 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 280047 45391 CPT Outpatient 24923.85 4596.43 Horizon Horizon Medicare 0.07 1778.07 0.07 24923.85 0.07 Case Rate 45391 Priced Fragmenting of kidney stone 280047 50590 CPT Outpatient 40930.05 7548.28 Horizon Horizon Medicare 0.09 3683.90 0.09 40930.05 0.09 Case Rate 50590 Priced Fetal non-stress test 280047 59025 CPT Outpatient 3153.15 477.76 Horizon Horizon Medicare 0.06 198.89 0.06 3153.15 0.06 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 280047 64483 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 280047 92567 CPT Outpatient 2224.95 98.50 Horizon Horizon Medicare 0.14 308.98 0.14 2224.95 0.14 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 280047 93000 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 280047 93017 CPT Outpatient 3076.50 532.96 Horizon Horizon Medicare 0.10 308.98 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 280047 93452 CPT Outpatient 55621.65 8611.87 Horizon Horizon Medicare 0.06 3385.39 0.06 55621.65 0.06 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 280047 95810 CPT Outpatient 20341.65 3373.48 Horizon Horizon Medicare 0.05 1074.10 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 280047 95811 CPT Outpatient 22491.00 3731.18 Horizon Horizon Medicare 0.05 1074.10 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 280047 95812 CPT Outpatient 5578.65 925.83 Horizon Horizon Medicare 0.06 308.98 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 280047 96040 CPT Outpatient 0.01 102.81 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 280047 96413 CPT Outpatient 4856.25 472.45 Horizon Horizon Medicare 0.55 2654.07 0.55 4856.25 0.55 Case Rate 96413 Priced Ultrasound therapy 280047 97035 CPT Outpatient 2111.55 134.99 Horizon Horizon Medicare 0.04 85.29 0.04 2111.55 0.04 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 280047 97110 CPT Outpatient 6494.25 92.86 Horizon Horizon Medicare 0.05 355.13 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 280047 97116 CPT Outpatient 4723.95 110.61 Horizon Horizon Medicare 0.06 289.20 0.06 4723.95 0.06 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 280047 70450 CPT Outpatient 8566.95 835.61 Horizon Horizon Medicare 0.06 551.80 0.06 8566.95 0.06 Case Rate 70450 Priced Mri brain stem w/o dye 280047 70551 CPT Outpatient 7861.35 1361.31 Horizon Horizon Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 70551 Priced MRI scan of brain before and after contrast 280047 70553 CPT Outpatient 10882.20 1625.88 Horizon Horizon Medicare 0.04 429.92 0.04 10882.20 0.04 Case Rate 70553 Priced X-ray exam chest 2 views 280047 71046 CPT Outpatient 859.95 150.37 Horizon Horizon Medicare 0.11 94.43 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 280047 71250 CPT Outpatient 7288.05 1261.63 Horizon Horizon Medicare 0.02 127.10 0.02 7288.05 0.02 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 280047 72082 CPT Outpatient 2022.30 253.33 Horizon Horizon Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 280047 72100 CPT Outpatient 1599.15 277.38 Horizon Horizon Medicare 0.08 127.10 0.08 1599.15 0.08 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 280047 72110 CPT Outpatient 1389.15 241.04 Horizon Horizon Medicare 0.09 127.10 0.09 1389.15 0.09 Case Rate 72110 Priced MRI scan of lower spinal canal 280047 72148 CPT Outpatient 7861.35 1361.31 Horizon Horizon Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 280047 72193 CPT Outpatient 13671.00 1412.01 Horizon Horizon Medicare 0.02 208.54 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 280047 73030 CPT Outpatient 1452.15 251.43 Horizon Horizon Medicare 0.07 94.43 0.07 1452.15 0.07 Case Rate 73030 Priced X-ray exam of elbow 280047 73080 CPT Outpatient 1356.60 235.68 Horizon Horizon Medicare 0.07 94.43 0.07 1356.60 0.07 Case Rate 73080 Priced X-ray exam of forearm 280047 73090 CPT Outpatient 1243.20 215.26 Horizon Horizon Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73090 Priced X-ray exam of wrist 280047 73110 CPT Outpatient 1243.20 215.26 Horizon Horizon Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 280047 73130 CPT Outpatient 1243.20 215.26 Horizon Horizon Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73130 Priced X-ray exam hips bi 2 views 280047 73521 CPT Outpatient 970.20 228.41 Horizon Horizon Medicare 0.13 127.10 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 280047 73562 CPT Outpatient 802.20 139.12 Horizon Horizon Medicare 0.12 94.43 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 280047 73590 CPT Outpatient 1243.20 215.26 Horizon Horizon Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73590 Priced X-ray exam of ankle 280047 73610 CPT Outpatient 1378.65 239.31 Horizon Horizon Medicare 0.07 94.43 0.07 1378.65 0.07 Case Rate 73610 Priced X-ray exam of foot 280047 73630 CPT Outpatient 975.45 169.41 Horizon Horizon Medicare 0.10 94.43 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 280047 73721 CPT Outpatient 7861.35 1361.31 Horizon Horizon Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 280047 74177 CPT Outpatient 14222.25 1412.01 Horizon Horizon Medicare 0.03 429.92 0.03 14222.25 0.03 Case Rate 74177 Priced Contrst x-ray exam of throat 280047 74210 CPT Outpatient 0.01 440.39 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 280047 76098 CPT Outpatient 6141.45 407.86 Horizon Horizon Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 76098 Priced Us exam of head and neck 280047 76536 CPT Outpatient 5512.50 955.18 Horizon Horizon Medicare 0.02 127.10 0.02 5512.50 0.02 Case Rate 76536 Priced Ultrasound breast limited 280047 76642 CPT Outpatient 5777.10 127.70 Horizon Horizon Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 280047 76700 CPT Outpatient 4917.15 851.88 Horizon Horizon Medicare 0.03 127.10 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 280047 76705 CPT Outpatient 3836.70 665.17 Horizon Horizon Medicare 0.03 127.10 0.03 3836.70 0.03 Case Rate 76705 Priced Us exam abdo back wall comp 280047 76770 CPT Outpatient 5171.25 895.48 Horizon Horizon Medicare 0.02 127.10 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 280047 76775 CPT Outpatient 3969.00 686.97 Horizon Horizon Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 280047 76801 CPT Outpatient 2006.55 347.98 Horizon Horizon Medicare 0.06 127.10 0.06 2006.55 0.06 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 280047 76805 CPT Outpatient 3969.00 686.97 Horizon Horizon Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 280047 76811 CPT Outpatient 2844.45 492.99 Horizon Horizon Medicare 0.09 268.63 0.09 2844.45 0.09 Case Rate 76811 Priced Ob us nuchal meas 1 gest 280047 76813 CPT Outpatient 1044.75 180.83 Horizon Horizon Medicare 0.12 127.10 0.12 1044.75 0.12 Case Rate 76813 Priced Ob us limited fetus(s) 280047 76815 CPT Outpatient 6428.10 639.90 Horizon Horizon Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76815 Priced Ob us follow-up per fetus 280047 76816 CPT Outpatient 4818.45 833.88 Horizon Horizon Medicare 0.03 127.10 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 280047 76817 CPT Outpatient 6428.10 476.73 Horizon Horizon Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76817 Priced Fetal biophys profil w/o nst 280047 76819 CPT Outpatient 1741.95 302.65 Horizon Horizon Medicare 0.07 127.10 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 280047 76830 CPT Outpatient 9305.10 806.54 Horizon Horizon Medicare 0.03 254.21 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 280047 76870 CPT Outpatient 6328.35 1096.55 Horizon Horizon Medicare 0.02 127.10 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 280047 76885 CPT Outpatient 3836.70 665.17 Horizon Horizon Medicare 0.02 94.43 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 280047 77065 CPT Outpatient 3451.35 192.07 Horizon Horizon Medicare 0.05 158.33 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 280047 77066 CPT Outpatient 5777.10 235.68 Horizon Horizon Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 280047 77067 CPT Outpatient 1416.45 205.57 Horizon Horizon Medicare 0.05 63.90 0.05 1416.45 0.05 Case Rate 77067 Priced X-rays for bone age 280047 77072 CPT Outpatient 2022.30 163.87 Horizon Horizon Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 77072 Priced Joint survey single view 280047 77077 CPT Outpatient 985.95 171.14 Horizon Horizon Medicare 0.13 124.57 0.13 985.95 0.13 Case Rate 77077 Priced Dxa bone density axial 280047 77080 CPT Outpatient 3257.10 319.09 Horizon Horizon Medicare 0.06 191.00 0.06 3257.10 0.06 Case Rate 77080 Priced Fna bx w/us gdn 1st les 280047 10005 CPT Outpatient 5512.50 547.24 Horizon Horizon Medicare 0.13 726.50 0.13 5512.50 0.13 Case Rate 10005 Priced Fna bx w/us gdn ea addl 280047 10006 CPT Outpatient 10628.10 594.83 Horizon Horizon Medicare 0.07 726.50 0.07 10628.10 0.07 Case Rate 10006 Priced Drainage of hematoma/fluid 280047 10140 CPT Outpatient 23209.20 1081.95 Horizon Horizon Medicare 0.27 6181.44 0.27 23209.20 0.27 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 280047 11042 CPT Outpatient 2668.05 481.45 Horizon Horizon Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb bone 20 sq cm/< 280047 11044 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 280047 11406 CPT Outpatient 19967.85 3427.81 Horizon Horizon Medicare 0.09 1700.21 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 280047 11424 CPT Outpatient 0.01 1004.93 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 280047 11770 CPT Outpatient 19173.00 3291.37 Horizon Horizon Medicare 0.15 2826.15 0.15 19173.00 0.15 Case Rate 11770 Priced Replace tissue expander 280047 11970 CPT Outpatient 59239.95 10169.52 Horizon Horizon Medicare 0.52 30989.99 0.52 59239.95 0.52 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 280047 14020 CPT Outpatient 32166.75 5521.96 Horizon Horizon Medicare 0.06 1999.63 0.06 32166.75 0.06 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 280047 14060 CPT Outpatient 25993.80 1374.69 Horizon Horizon Medicare 0.31 7937.33 0.31 25993.80 0.31 Case Rate 14060 Priced Wound prep trk/arm/leg 280047 15002 CPT Outpatient 41748.00 1441.73 Horizon Horizon Medicare 0.21 8825.17 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 280047 15271 CPT Outpatient 24343.20 3769.48 Horizon Horizon Medicare 0.08 1999.63 0.08 24343.20 0.08 Case Rate 15271 Priced Acellular derm matrix implt 280047 15777 CPT Outpatient 101672.55 17453.79 Horizon Horizon Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 15777 Priced Exc skin abd 280047 15830 CPT Outpatient 54696.60 9389.58 Horizon Horizon Medicare 0.12 6325.99 0.12 54696.60 0.12 Case Rate 15830 Priced Dressing change not for burn 280047 15852 CPT Outpatient 0.01 290.74 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 280047 15877 CPT Outpatient 63741.30 10942.26 Horizon Horizon Medicare 0.17 10877.73 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 280047 15879 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 280047 19000 CPT Outpatient 10143.00 594.83 Horizon Horizon Medicare 0.08 790.40 0.08 10143.00 0.08 Case Rate 19000 Priced Bx breast 1st lesion strtctc 280047 19081 CPT Outpatient 12341.70 1250.69 Horizon Horizon Medicare 0.14 1758.68 0.14 12341.70 0.14 Case Rate 19081 Priced Bx breast add lesion us imag 280047 19084 CPT Outpatient 29058.75 547.24 Horizon Horizon Medicare 0.07 1975.03 0.07 29058.75 0.07 Case Rate 19084 Priced Biopsy of breast open 280047 19101 CPT Outpatient 39545.10 2737.82 Horizon Horizon Medicare 0.23 8988.74 0.23 39545.10 0.23 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 280047 19120 CPT Outpatient 35761.95 2737.82 Horizon Horizon Medicare 0.12 4298.03 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 280047 19125 CPT Outpatient 33184.20 0.01 Horizon Horizon Medicare 0.26 8661.10 0.26 33184.20 0.26 Case Rate 19125 Priced Perq device breast 1st imag 280047 19281 CPT Outpatient 6141.45 598.61 Horizon Horizon Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 19281 Priced Perq device breast ea imag 280047 19282 CPT Outpatient 8379.00 319.04 Horizon Horizon Medicare 0.15 1290.61 0.15 8379.00 0.15 Case Rate 19282 Priced Partial mastectomy 280047 19301 CPT Outpatient 39157.65 6722.06 Horizon Horizon Medicare 0.20 7846.47 0.20 39157.65 0.20 Case Rate 19301 Priced Mast simple complete 280047 19303 CPT Outpatient 105389.55 18091.87 Horizon Horizon Medicare 0.28 29200.15 0.28 105389.55 0.28 Case Rate 19303 Priced Reduction of large breast 280047 19318 CPT Outpatient 65239.65 11199.47 Horizon Horizon Medicare 0.10 6577.10 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 280047 19340 CPT Outpatient 113100.75 19415.63 Horizon Horizon Medicare 0.13 14822.97 0.13 113100.75 0.13 Case Rate 19340 Priced Delayed breast prosthesis 280047 19342 CPT Outpatient 56988.75 9783.07 Horizon Horizon Medicare 0.36 20246.20 0.36 56988.75 0.36 Case Rate 19342 Priced Breast reconstruction 280047 19357 CPT Outpatient 101672.55 17453.79 Horizon Horizon Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 19357 Priced Breast reconstruction 280047 19366 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 280047 19380 CPT Outpatient 61493.25 10556.34 Horizon Horizon Medicare 0.21 13212.28 0.21 61493.25 0.21 Case Rate 19380 Priced Removal of support implant 280047 20680 CPT Outpatient 42329.70 7266.60 Horizon Horizon Medicare 0.14 5804.91 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 280047 22856 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 280047 24538 CPT Outpatient 51237.90 4775.24 Horizon Horizon Medicare 0.19 9816.98 0.19 51237.90 0.19 Case Rate 24538 Priced Remove wrist tendon lesion 280047 25111 CPT Outpatient 25855.20 4438.48 Horizon Horizon Medicare 0.06 1654.95 0.06 25855.20 0.06 Case Rate 25111 Priced Incise finger tendon sheath 280047 26055 CPT Outpatient 15862.35 2723.04 Horizon Horizon Medicare 0.12 1931.13 0.12 15862.35 0.12 Case Rate 26055 Priced Treat finger fracture each 280047 26727 CPT Outpatient 22779.75 2030.47 Horizon Horizon Medicare 0.16 3574.88 0.16 22779.75 0.16 Case Rate 26727 Priced Revision of knee joint 280047 27446 CPT Outpatient 67882.50 11653.16 Horizon Horizon Medicare 0.23 15567.47 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 280047 27447 CPT Outpatient 130698.75 22436.62 Horizon Horizon Medicare 0.12 15604.41 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 280047 27485 CPT Outpatient 43310.40 7434.95 Horizon Horizon Medicare 0.26 11063.75 0.26 43310.40 0.26 Case Rate 27485 Priced Repair achilles tendon 280047 27650 CPT Outpatient 38246.25 3762.57 Horizon Horizon Medicare 0.29 11041.86 0.29 38246.25 0.29 Case Rate 27650 Priced Treatment of ankle fracture 280047 27792 CPT Outpatient 36101.10 6197.36 Horizon Horizon Medicare 0.21 7581.28 0.21 36101.10 0.21 Case Rate 27792 Priced Treatment of ankle fracture 280047 27814 CPT Outpatient 49405.65 8481.30 Horizon Horizon Medicare 0.16 7766.50 0.16 49405.65 0.16 Case Rate 27814 Priced Removal of foot lesion 280047 28080 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 280047 28285 CPT Outpatient 68603.85 11776.99 Horizon Horizon Medicare 0.20 13986.50 0.20 68603.85 0.20 Case Rate 28285 Priced Correction hallux valgus 280047 28296 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 280047 29823 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 280047 29826 CPT Outpatient 49840.35 8555.93 Horizon Horizon Medicare 0.15 7312.64 0.15 49840.35 0.15 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 280047 29881 CPT Outpatient 35556.15 6103.81 Horizon Horizon Medicare 0.09 3306.24 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 280047 29882 CPT Outpatient 61099.50 10488.75 Horizon Horizon Medicare 0.19 11577.74 0.19 61099.50 0.19 Case Rate 29882 Priced Percut bx lung/mediastinum 280047 32405 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 280047 32555 CPT Outpatient 14597.10 687.29 Horizon Horizon Medicare 0.05 711.62 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 280047 32664 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 280047 35190 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 280047 36478 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 280047 36561 CPT Outpatient 53531.10 3292.99 Horizon Horizon Medicare 0.06 3342.08 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 280047 36569 CPT Outpatient 31421.25 1299.06 Horizon Horizon Medicare 0.06 1811.50 0.06 31421.25 0.06 Case Rate 36569 Priced Removal tunneled cv cath 280047 36590 CPT Outpatient 1996.05 273.95 Horizon Horizon Medicare 0.82 1641.71 0.82 1996.05 0.82 Case Rate 36590 Priced Av fuse uppr arm basilic 280047 36819 CPT Outpatient 56861.70 9761.26 Horizon Horizon Medicare 0.17 9459.82 0.17 56861.70 0.17 Case Rate 36819 Priced Av fusion direct any site 280047 36821 CPT Outpatient 42953.40 7373.67 Horizon Horizon Medicare 0.16 7056.50 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 280047 36825 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 280047 36830 CPT Outpatient 53656.05 9210.96 Horizon Horizon Medicare 0.17 9346.72 0.17 53656.05 0.17 Case Rate 36830 Priced Av fistula revision open 280047 36832 CPT Outpatient 52492.65 9011.24 Horizon Horizon Medicare 0.23 12046.01 0.23 52492.65 0.23 Case Rate 36832 Priced Av fistula revision 280047 36833 CPT Outpatient 37098.60 6368.59 Horizon Horizon Medicare 0.28 10242.79 0.28 37098.60 0.28 Case Rate 36833 Priced Intro cath dialysis circuit 280047 36903 CPT Outpatient 77541.45 10669.90 Horizon Horizon Medicare 0.24 18454.26 0.24 77541.45 0.24 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 280047 36906 CPT Outpatient 96694.50 16175.64 Horizon Horizon Medicare 0.27 26216.69 0.27 96694.50 0.27 Case Rate 36906 Priced Fem/popl revas w/tla 280047 37224 CPT Outpatient 200076.45 5139.31 Horizon Horizon Medicare 0.14 27878.39 0.14 200076.45 0.14 Case Rate 37224 Priced Fem/popl revasc stnt & ather 280047 37227 CPT Outpatient 117170.55 18045.38 Horizon Horizon Medicare 0.17 19636.18 0.17 117170.55 0.17 Case Rate 37227 Priced Revise leg vein 280047 37700 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 280047 37722 CPT Outpatient 27815.55 4775.00 Horizon Horizon Medicare 0.37 10398.58 0.37 27815.55 0.37 Case Rate 37722 Priced Stab phleb veins xtr 10-20 280047 37765 CPT Outpatient 26561.85 4559.78 Horizon Horizon Medicare 0.52 13740.66 0.52 26561.85 0.52 Case Rate 37765 Priced Biopsy/removal lymph nodes 280047 38500 CPT Outpatient 35955.15 6172.30 Horizon Horizon Medicare 0.11 3918.72 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 280047 38525 CPT Outpatient 101194.80 17371.77 Horizon Horizon Medicare 0.19 18851.15 0.19 101194.80 0.19 Case Rate 38525 Priced Laparoscopy lymph node biop 280047 38570 CPT Outpatient 65631.30 11266.71 Horizon Horizon Medicare 0.28 18089.66 0.28 65631.30 0.28 Case Rate 38570 Priced Laparoscopy lymphadenectomy 280047 38571 CPT Outpatient 84031.50 14425.41 Horizon Horizon Medicare 0.26 22194.38 0.26 84031.50 0.26 Case Rate 38571 Priced Laparoscopy lymphadenectomy 280047 38572 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 280047 38792 CPT Outpatient 2868.60 432.48 Horizon Horizon Medicare 0.15 440.09 0.15 2868.60 0.15 Case Rate 38792 Priced Excision of gum lesion 280047 41825 CPT Outpatient 11580.45 1987.98 Horizon Horizon Medicare 0.30 3440.87 0.30 11580.45 0.30 Case Rate 41825 Priced Reconstruct cleft palate 280047 42200 CPT Outpatient 36703.80 6300.82 Horizon Horizon Medicare 0.16 5937.71 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 280047 42820 CPT Outpatient 17232.60 2958.26 Horizon Horizon Medicare 0.64 11027.66 0.64 17232.60 0.64 Case Rate 42820 Priced Control throat bleeding 280047 42960 CPT Outpatient 24066.00 4131.33 Horizon Horizon Medicare 0.20 4852.02 0.20 24066.00 0.20 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 280047 43235 CPT Outpatient 8856.75 1633.35 Horizon Horizon Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Laparoscopy fundoplasty 280047 43280 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 280047 43282 CPT Outpatient 84344.40 14479.12 Horizon Horizon Medicare 0.13 10981.07 0.13 84344.40 0.13 Case Rate 43282 Priced Laparoscopy appendectomy 280047 44970 CPT Outpatient 82300.05 14128.18 Horizon Horizon Medicare 0.08 6988.44 0.08 82300.05 0.08 Case Rate 44970 Priced Diagnostic sigmoidoscopy 280047 45330 CPT Outpatient 17286.15 542.26 Horizon Horizon Medicare 0.11 1880.24 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 280047 47000 CPT Outpatient 10398.15 1225.34 Horizon Horizon Medicare 0.20 2101.24 0.20 10398.15 0.20 Case Rate 47000 Priced Removal of gallbladder using an endoscope 280047 47562 CPT Outpatient 58430.40 10030.55 Horizon Horizon Medicare 0.10 5965.34 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 280047 47563 CPT Outpatient 71747.55 12316.66 Horizon Horizon Medicare 0.09 6769.21 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 280047 49083 CPT Outpatient 6979.35 1113.95 Horizon Horizon Medicare 0.14 944.67 0.14 6979.35 0.14 Case Rate 49083 Priced Diag laparo separate proc 280047 49320 CPT Outpatient 31629.15 5429.67 Horizon Horizon Medicare 0.42 13201.26 0.42 31629.15 0.42 Case Rate 49320 Priced Laparoscopy biopsy 280047 49321 CPT Outpatient 41892.90 7191.61 Horizon Horizon Medicare 0.32 13491.42 0.32 41892.90 0.32 Case Rate 49321 Priced Laparoscopy aspiration 280047 49322 CPT Outpatient 34392.75 5904.09 Horizon Horizon Medicare 0.39 13396.33 0.39 34392.75 0.39 Case Rate 49322 Priced Lap insert tunnel ip cath 280047 49324 CPT Outpatient 39264.75 6740.45 Horizon Horizon Medicare 0.15 5972.32 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 280047 49329 CPT Outpatient 58696.05 10076.16 Horizon Horizon Medicare 0.29 17162.20 0.29 58696.05 0.29 Case Rate 49329 Priced Ins tun ip cath for dial opn 280047 49421 CPT Outpatient 25460.40 3319.30 Horizon Horizon Medicare 0.15 3702.67 0.15 25460.40 0.15 Case Rate 49421 Priced Remove tunneled ip cath 280047 49422 CPT Outpatient 25515.00 4380.08 Horizon Horizon Medicare 0.13 3342.08 0.13 25515.00 0.13 Case Rate 49422 Priced Rpr ing hernia init reduce 280047 49500 CPT Outpatient 19594.05 3363.65 Horizon Horizon Medicare 0.56 11018.31 0.56 19594.05 0.56 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 280047 49505 CPT Outpatient 34915.65 5993.85 Horizon Horizon Medicare 0.21 7278.08 0.21 34915.65 0.21 Case Rate 49505 Priced Prp i/hern init block >5 yr 280047 49507 CPT Outpatient 29794.80 5114.77 Horizon Horizon Medicare 0.25 7306.28 0.25 29794.80 0.25 Case Rate 49507 Priced Rerepair ing hernia reduce 280047 49520 CPT Outpatient 36940.05 6341.38 Horizon Horizon Medicare 0.20 7341.71 0.20 36940.05 0.20 Case Rate 49520 Priced Rpr ventral hern init reduc 280047 49560 CPT Outpatient 53177.25 9128.76 Horizon Horizon Medicare 0.18 9686.73 0.18 53177.25 0.18 Case Rate 49560 Priced Rpr ventral hern init block 280047 49561 CPT Outpatient 30755.55 5279.70 Horizon Horizon Medicare 0.24 7522.67 0.24 30755.55 0.24 Case Rate 49561 Priced Rerepair ventrl hern reduce 280047 49565 CPT Outpatient 69917.40 12002.49 Horizon Horizon Medicare 0.14 10018.26 0.14 69917.40 0.14 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 280047 49585 CPT Outpatient 41806.80 7176.83 Horizon Horizon Medicare 0.23 9650.59 0.23 41806.80 0.23 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 280047 49587 CPT Outpatient 37320.15 6406.63 Horizon Horizon Medicare 0.20 7369.53 0.20 37320.15 0.20 Case Rate 49587 Priced Lap ing hernia repair init 280047 49650 CPT Outpatient 41932.80 7198.46 Horizon Horizon Medicare 0.14 5784.73 0.14 41932.80 0.14 Case Rate 49650 Priced Lap ing hernia repair recur 280047 49651 CPT Outpatient 46915.05 8053.75 Horizon Horizon Medicare 0.26 12396.08 0.26 46915.05 0.26 Case Rate 49651 Priced Lap vent/abd hernia repair 280047 49652 CPT Outpatient 51294.60 8805.57 Horizon Horizon Medicare 0.12 6001.15 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 280047 49653 CPT Outpatient 46102.35 7914.24 Horizon Horizon Medicare 0.13 5907.33 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 280047 49654 CPT Outpatient 47221.65 8106.38 Horizon Horizon Medicare 0.22 10246.22 0.22 47221.65 0.22 Case Rate 49654 Priced Lap inc hern repair comp 280047 49655 CPT Outpatient 54590.55 9371.38 Horizon Horizon Medicare 0.19 10557.83 0.19 54590.55 0.19 Case Rate 49655 Priced Lap inc hernia repair recur 280047 49656 CPT Outpatient 55443.15 9517.74 Horizon Horizon Medicare 0.19 10492.84 0.19 55443.15 0.19 Case Rate 49656 Priced Removal of kidney stone 280047 50080 CPT Outpatient 53165.70 9126.78 Horizon Horizon Medicare 0.32 16951.33 0.32 53165.70 0.32 Case Rate 50080 Priced Removal of kidney stone 280047 50081 CPT Outpatient 66931.20 11489.86 Horizon Horizon Medicare 0.30 20375.49 0.30 66931.20 0.30 Case Rate 50081 Priced Renal biopsy perq 280047 50200 CPT Outpatient 43096.20 1225.34 Horizon Horizon Medicare 0.23 9703.00 0.23 43096.20 0.23 Case Rate 50200 Priced Plmt nephroureteral catheter 280047 50433 CPT Outpatient 64566.60 1424.48 Horizon Horizon Medicare 0.27 17570.80 0.27 64566.60 0.27 Case Rate 50433 Priced Laparo radical nephrectomy 280047 50545 CPT Outpatient 43449.00 7458.75 Horizon Horizon Medicare 0.03 1190.00 0.03 43449.00 0.03 Case Rate 50545 Priced Laparoscope proc ureter 280047 50949 CPT Outpatient 49986.30 8580.98 Horizon Horizon Medicare 0.34 17208.73 0.34 49986.30 0.34 Case Rate 50949 Priced Injection for bladder x-ray 280047 51600 CPT Outpatient 3285.45 89.22 Horizon Horizon Medicare 0.08 268.63 0.08 3285.45 0.08 Case Rate 51600 Priced Cystoscopy 280047 52000 CPT Outpatient 22149.75 3802.37 Horizon Horizon Medicare 0.36 7975.55 0.36 22149.75 0.36 Case Rate 52000 Priced Cystoscopy & ureter catheter 280047 52005 CPT Outpatient 42529.20 2095.77 Horizon Horizon Medicare 0.21 9136.51 0.21 42529.20 0.21 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 280047 52204 CPT Outpatient 31274.25 5368.75 Horizon Horizon Medicare 0.18 5745.54 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 280047 52224 CPT Outpatient 13445.25 2308.10 Horizon Horizon Medicare 0.54 7303.88 0.54 13445.25 0.54 Case Rate 52224 Priced Cystoscopy and treatment 280047 52234 CPT Outpatient 28510.65 4894.33 Horizon Horizon Medicare 0.27 7572.52 0.27 28510.65 0.27 Case Rate 52234 Priced Cystoscopy and treatment 280047 52235 CPT Outpatient 29417.85 5050.06 Horizon Horizon Medicare 0.25 7276.20 0.25 29417.85 0.25 Case Rate 52235 Priced Cystoscopy and treatment 280047 52240 CPT Outpatient 33933.90 5825.32 Horizon Horizon Medicare 0.27 9046.24 0.27 33933.90 0.27 Case Rate 52240 Priced Cystoscopy and treatment 280047 52281 CPT Outpatient 22159.20 3804.00 Horizon Horizon Medicare 0.26 5688.66 0.26 22159.20 0.26 Case Rate 52281 Priced Remove bladder stone 280047 52317 CPT Outpatient 27085.80 4649.73 Horizon Horizon Medicare 0.27 7426.56 0.27 27085.80 0.27 Case Rate 52317 Priced Remove bladder stone 280047 52318 CPT Outpatient 26685.75 4581.05 Horizon Horizon Medicare 0.28 7361.57 0.28 26685.75 0.28 Case Rate 52318 Priced Cystoscopy and treatment 280047 52332 CPT Outpatient 115306.80 19794.33 Horizon Horizon Medicare 0.18 20580.50 0.18 115306.80 0.18 Case Rate 52332 Priced Cystouretero w/stone remove 280047 52352 CPT Outpatient 42420.00 7282.10 Horizon Horizon Medicare 0.38 16312.79 0.38 42420.00 0.38 Case Rate 52352 Priced Cystouretero w/lithotripsy 280047 52353 CPT Outpatient 38608.50 6627.79 Horizon Horizon Medicare 0.24 9133.86 0.24 38608.50 0.24 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 280047 52356 CPT Outpatient 36255.45 6223.85 Horizon Horizon Medicare 0.25 9133.86 0.25 36255.45 0.25 Case Rate 52356 Priced Prostatectomy (turp) 280047 52601 CPT Outpatient 35371.35 6072.08 Horizon Horizon Medicare 0.25 8684.69 0.25 35371.35 0.25 Case Rate 52601 Priced Laser surgery of prostate 280047 52648 CPT Outpatient 24264.45 4165.40 Horizon Horizon Medicare 0.37 9020.55 0.37 24264.45 0.37 Case Rate 52648 Priced Revision of urethra 280047 53450 CPT Outpatient 16209.90 2782.70 Horizon Horizon Medicare 0.35 5679.84 0.35 16209.90 0.35 Case Rate 53450 Priced Urology surgery procedure 280047 53899 CPT Outpatient 25368.00 134.83 Horizon Horizon Medicare 0.27 6862.63 0.27 25368.00 0.27 Case Rate 53899 Priced Circumcision w/regionl block 280047 54150 CPT Outpatient 14700.00 2523.50 Horizon Horizon Medicare 0.14 2090.37 0.14 14700.00 0.14 Case Rate 54150 Priced Circum 28 days or older 280047 54161 CPT Outpatient 19186.65 3293.71 Horizon Horizon Medicare 0.11 2049.61 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 280047 54162 CPT Outpatient 19795.65 3398.25 Horizon Horizon Medicare 0.85 16823.10 0.85 19795.65 0.85 Case Rate 54162 Priced Repair of circumcision 280047 54163 CPT Outpatient 16391.55 2813.88 Horizon Horizon Medicare 0.24 4010.49 0.24 16391.55 0.24 Case Rate 54163 Priced Reconstruction of urethra 280047 54324 CPT Outpatient 32880.75 5644.53 Horizon Horizon Medicare 0.28 9303.52 0.28 32880.75 0.28 Case Rate 54324 Priced Revise penis/urethra 280047 54332 CPT Outpatient 19968.90 3427.99 Horizon Horizon Medicare 0.18 3589.47 0.18 19968.90 0.18 Case Rate 54332 Priced Insert self-contd prosthesis 280047 54401 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 280047 54520 CPT Outpatient 35442.75 6084.34 Horizon Horizon Medicare 0.34 12158.30 0.34 35442.75 0.34 Case Rate 54520 Priced Reduce testis torsion 280047 54600 CPT Outpatient 55049.40 9450.15 Horizon Horizon Medicare 0.28 15402.48 0.28 55049.40 0.28 Case Rate 54600 Priced Suspension of testis 280047 54640 CPT Outpatient 26860.05 4610.98 Horizon Horizon Medicare 0.28 7428.84 0.28 26860.05 0.28 Case Rate 54640 Priced Removal of hydrocele 280047 55040 CPT Outpatient 27277.95 4682.71 Horizon Horizon Medicare 0.27 7369.91 0.27 27277.95 0.27 Case Rate 55040 Priced Biopsy of prostate gland 280047 55700 CPT Outpatient 28699.65 4926.77 Horizon Horizon Medicare 0.13 3731.04 0.13 28699.65 0.13 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 280047 55866 CPT Outpatient 93088.80 15980.24 Horizon Horizon Medicare 0.24 22017.24 0.24 93088.80 0.24 Case Rate 55866 Priced Closure of vagina 280047 57120 CPT Outpatient 34369.65 5900.12 Horizon Horizon Medicare 0.43 14932.00 0.43 34369.65 0.43 Case Rate 57120 Priced Repair of vagina 280047 57200 CPT Outpatient 25247.25 4334.11 Horizon Horizon Medicare 0.31 7732.37 0.31 25247.25 0.31 Case Rate 57200 Priced Anterior colporrhaphy 280047 57240 CPT Outpatient 36210.30 6216.10 Horizon Horizon Medicare 0.53 19223.69 0.53 36210.30 0.53 Case Rate 57240 Priced Repair rectum & vagina 280047 57250 CPT Outpatient 40441.80 6942.51 Horizon Horizon Medicare 0.56 22691.64 0.56 40441.80 0.56 Case Rate 57250 Priced Cmbn ant pst colprhy 280047 57260 CPT Outpatient 46323.90 7952.27 Horizon Horizon Medicare 0.66 30437.82 0.66 46323.90 0.66 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 280047 57265 CPT Outpatient 42586.95 7310.76 Horizon Horizon Medicare 0.43 18248.88 0.43 42586.95 0.43 Case Rate 57265 Priced Repair of bowel bulge 280047 57268 CPT Outpatient 36865.50 6328.58 Horizon Horizon Medicare 0.49 18090.91 0.49 36865.50 0.49 Case Rate 57268 Priced Colpopexy extraperitoneal 280047 57282 CPT Outpatient 45629.85 7833.12 Horizon Horizon Medicare 0.66 30324.80 0.66 45629.85 0.66 Case Rate 57282 Priced Repair bladder defect 280047 57288 CPT Outpatient 43069.95 7393.67 Horizon Horizon Medicare 0.56 24109.88 0.56 43069.95 0.56 Case Rate 57288 Priced Bx/curett of cervix w/scope 280047 57454 CPT Outpatient 2888.55 442.93 Horizon Horizon Medicare 0.11 329.27 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 280047 57520 CPT Outpatient 26728.80 4588.44 Horizon Horizon Medicare 0.16 4211.41 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 280047 57522 CPT Outpatient 22737.75 3903.31 Horizon Horizon Medicare 0.15 3411.24 0.15 22737.75 0.15 Case Rate 57522 Priced Biopsy of uterus lining 280047 58100 CPT Outpatient 2371.95 194.80 Horizon Horizon Medicare 0.08 198.89 0.08 2371.95 0.08 Case Rate 58100 Priced Catheter for hysterography 280047 58340 CPT Outpatient 6322.05 131.04 Horizon Horizon Medicare 0.04 268.63 0.04 6322.05 0.04 Case Rate 58340 Priced Reopen fallopian tube 280047 58350 CPT Outpatient 46507.65 7983.81 Horizon Horizon Medicare 0.38 17563.57 0.38 46507.65 0.38 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 280047 58542 CPT Outpatient 64194.90 11020.12 Horizon Horizon Medicare 0.37 24060.91 0.37 64194.90 0.37 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 280047 58544 CPT Outpatient 51020.55 8758.53 Horizon Horizon Medicare 0.65 33216.81 0.65 51020.55 0.65 Case Rate 58544 Priced Laparoscopic myomectomy 280047 58545 CPT Outpatient 56946.75 9775.86 Horizon Horizon Medicare 0.17 9718.98 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 280047 58552 CPT Outpatient 57228.15 9824.17 Horizon Horizon Medicare 0.32 18381.02 0.32 57228.15 0.32 Case Rate 58552 Priced Hysteroscopy biopsy 280047 58558 CPT Outpatient 28581.00 2077.02 Horizon Horizon Medicare 0.25 7238.81 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 280047 58561 CPT Outpatient 35222.25 6046.49 Horizon Horizon Medicare 0.27 9531.42 0.27 35222.25 0.27 Case Rate 58561 Priced Hysteroscopy ablation 280047 58563 CPT Outpatient 38399.55 6591.92 Horizon Horizon Medicare 0.51 19555.87 0.51 38399.55 0.51 Case Rate 58563 Priced Tlh uterus 250 g or less 280047 58570 CPT Outpatient 43316.70 7436.03 Horizon Horizon Medicare 0.26 11083.71 0.26 43316.70 0.26 Case Rate 58570 Priced Tlh w/t/o 250 g or less 280047 58571 CPT Outpatient 48603.45 8343.59 Horizon Horizon Medicare 0.30 14369.35 0.30 48603.45 0.30 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 280047 58573 CPT Outpatient 52905.30 9082.08 Horizon Horizon Medicare 0.32 16722.51 0.32 52905.30 0.32 Case Rate 58573 Priced Laparoscopy remove adnexa 280047 58661 CPT Outpatient 47008.50 8069.79 Horizon Horizon Medicare 0.18 8686.07 0.18 47008.50 0.18 Case Rate 58661 Priced Laparoscopy excise lesions 280047 58662 CPT Outpatient 45053.40 7734.17 Horizon Horizon Medicare 0.38 17220.22 0.38 45053.40 0.38 Case Rate 58662 Priced Treat ectopic pregnancy 280047 59151 CPT Outpatient 74690.70 12821.90 Horizon Horizon Medicare 0.09 6630.70 0.09 74690.70 0.09 Case Rate 59151 Priced Treatment of miscarriage 280047 59812 CPT Outpatient 56109.90 9632.20 Horizon Horizon Medicare 0.07 4075.96 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 280047 60220 CPT Outpatient 53639.25 9208.07 Horizon Horizon Medicare 0.11 6088.34 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 280047 60240 CPT Outpatient 98252.70 16866.71 Horizon Horizon Medicare 0.06 5905.23 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 280047 60500 CPT Outpatient 150495.45 25835.05 Horizon Horizon Medicare 0.06 9768.16 0.06 150495.45 0.06 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 280047 62322 CPT Outpatient 43709.40 514.24 Horizon Horizon Medicare 0.28 12235.33 0.28 43709.40 0.28 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 280047 62323 CPT Outpatient 8304.45 467.31 Horizon Horizon Medicare 16.45 136591.28 16.45 8304.45 16.45 Case Rate 62323 Priced Low back disk surgery 280047 63030 CPT Outpatient 50287.65 8632.71 Horizon Horizon Medicare 0.30 14893.92 0.30 50287.65 0.30 Case Rate 63030 Priced Inc for vagus n elect impl 280047 64568 CPT Outpatient 124562.55 21383.24 Horizon Horizon Medicare 0.27 33814.93 0.27 124562.55 0.27 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 280047 66821 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 280047 66984 CPT Outpatient 0.01 0.01 Horizon Horizon Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 581047 216 DRG Inpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 581047 460 DRG Inpatient 416122.79 53834.63 Humana Humana Medicare 0.09 36507.56 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 581047 470 DRG Inpatient 167912.19 21723.13 Humana Humana Medicare 0.11 18221.64 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 581047 473 DRG Inpatient 100687.91 13026.19 Humana Humana Medicare 0.24 23973.82 0.24 100687.91 0.24 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 581047 743 DRG Inpatient 102691.67 13285.42 Humana Humana Medicare 0.11 11317.53 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 581047 795 DRG Inpatient 6266.93 2335.00 Humana Humana Medicare 0.49 3065.24 0.49 6266.93 0.49 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 581047 807 DRG Inpatient 116469.59 4193.00 Humana Humana Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 581047 788 DRG Inpatient 76050.77 4538.00 Humana Humana Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 581047 59400 CPT Inpatient 116469.59 4193.00 Humana Humana Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 581047 59510 CPT Inpatient 76050.77 4538.00 Humana Humana Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 581047 59610 CPT Inpatient 116469.59 4193.00 Humana Humana Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59610 Priced "Psychotherapy, 30 min" 581047 90832 CPT Outpatient 577.50 91.21 Humana Humana Medicare 0.29 166.55 0.29 577.50 0.29 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 581047 90834 CPT Outpatient 44134.65 271.96 Humana Humana Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 581047 90837 CPT Outpatient 2240.70 442.93 Humana Humana Medicare 0.04 84.05 0.04 2240.70 0.04 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 581047 90846 CPT Outpatient 0.01 131.50 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 581047 90847 CPT Outpatient 44134.65 369.97 Humana Humana Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90847 Priced Group psychotherapy 581047 90853 CPT Outpatient 44134.65 101.99 Humana Humana Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 581047 99203 CPT Outpatient 3480.75 176.07 Humana Humana Medicare 0.12 403.52 0.12 3480.75 0.12 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 581047 99204 CPT Outpatient 2103.15 233.39 Humana Humana Medicare 0.19 390.94 0.19 2103.15 0.19 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 581047 99205 CPT Outpatient 4970.70 314.28 Humana Humana Medicare 0.09 462.07 0.09 4970.70 0.09 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 581047 99243 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 581047 99244 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 581047 99385 CPT Outpatient 1114.05 185.90 Humana Humana Medicare 0.19 207.05 0.19 1114.05 0.19 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 581047 99386 CPT Outpatient 4877.25 185.90 Humana Humana Medicare 0.02 98.87 0.02 4877.25 0.02 Fee Schedule 99386 Priced Routine venipuncture 581047 36415 CPT Outpatient 127.05 19.57 Humana Humana Medicare 0.02 3.02 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 581047 80048 CPT Outpatient 576.45 88.78 Humana Humana Medicare 0.02 11.70 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 581047 80053 CPT Outpatient 763.35 117.56 Humana Humana Medicare 0.02 13.22 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 581047 80055 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 581047 80061 CPT Outpatient 1349.25 197.77 Humana Humana Medicare 0.01 18.53 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 581047 80069 CPT Outpatient 716.10 104.95 Humana Humana Medicare 0.02 12.01 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 581047 80076 CPT Outpatient 716.10 104.95 Humana Humana Medicare 0.02 11.31 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 581047 81000 CPT Outpatient 144.90 21.18 Humana Humana Medicare 0.03 4.39 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 581047 81001 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 581047 81002 CPT Outpatient 57.75 8.89 Humana Humana Medicare 0.06 3.53 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 581047 81003 CPT Outpatient 219.45 33.80 Humana Humana Medicare 0.01 3.11 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 581047 82306 CPT Outpatient 1880.55 289.62 Humana Humana Medicare 0.02 40.96 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 581047 83036 CPT Outpatient 494.55 76.17 Humana Humana Medicare 0.03 13.44 0.03 494.55 0.03 Fee Schedule 83036 Priced PSA (prostate specific antigen) 581047 84153 CPT Outpatient 1177.05 181.28 Humana Humana Medicare 0.02 25.45 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 581047 84154 CPT Outpatient 598.50 92.17 Humana Humana Medicare 0.04 25.45 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 581047 84443 CPT Outpatient 519.75 80.05 Humana Humana Medicare 0.04 23.25 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 581047 84703 CPT Outpatient 785.40 120.96 Humana Humana Medicare 0.01 10.40 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 581047 85025 CPT Outpatient 635.25 97.83 Humana Humana Medicare 0.02 10.75 0.02 635.25 0.02 Fee Schedule 85025 Priced "Complete blood count, automated" 581047 85027 CPT Outpatient 576.45 88.78 Humana Humana Medicare 0.02 8.95 0.02 576.45 0.02 Fee Schedule 85027 Priced "Blood test, clotting time" 581047 85610 CPT Outpatient 404.25 62.26 Humana Humana Medicare 0.01 5.43 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 581047 85730 CPT Outpatient 17.22 2.65 Humana Humana Medicare 0.48 8.31 0.48 17.22 0.48 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 581047 86003 CPT Outpatient 32.55 5.01 Humana Humana Medicare 0.22 7.23 0.22 32.55 0.22 Fee Schedule 86003 Priced Tb test cell immun measure 581047 86480 CPT Outpatient 530.25 81.66 Humana Humana Medicare 0.16 85.75 0.16 530.25 0.16 Fee Schedule 86480 Priced Urine culture/colony count 581047 87086 CPT Outpatient 763.35 117.56 Humana Humana Medicare 0.01 11.16 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 581047 87338 CPT Outpatient 785.40 120.96 Humana Humana Medicare 0.03 19.90 0.03 785.40 0.03 Fee Schedule 87338 Priced Cytopath eval fna report 581047 88173 CPT Outpatient 750.75 115.62 Humana Humana Medicare 0.08 57.32 0.08 750.75 0.08 Fee Schedule 88173 Priced Tissue exam by pathologist 581047 88302 CPT Outpatient 635.25 97.83 Humana Humana Medicare 0.04 28.54 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 581047 88305 CPT Outpatient 323.40 49.81 Humana Humana Medicare 0.18 57.32 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 581047 11042 CPT Outpatient 2668.05 481.45 Humana Humana Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb subq tissue add-on 581047 11045 CPT Outpatient 4652.55 330.00 Humana Humana Medicare 0.09 403.52 0.09 4652.55 0.09 Case Rate 11045 Priced Dx bronchoscope/lavage 581047 31624 CPT Outpatient 41223.00 7602.31 Humana Humana Medicare 0.19 7805.52 0.19 41223.00 0.19 Case Rate 31624 Priced Bronchoscopy/lung bx each 581047 31628 CPT Outpatient 49048.65 9045.51 Humana Humana Medicare 0.25 12292.51 0.25 49048.65 0.25 Case Rate 31628 Priced Blood transfusion service 581047 36430 CPT Outpatient 9166.50 574.93 Humana Humana Medicare 0.08 731.71 0.08 9166.50 0.08 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 581047 43235 CPT Outpatient 8856.75 1633.35 Humana Humana Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Endoscopic us exam esoph 581047 43237 CPT Outpatient 23867.55 4401.63 Humana Humana Medicare 0.12 2840.90 0.12 23867.55 0.12 Case Rate 43237 Priced Egd us fine needle bx/aspir 581047 43238 CPT Outpatient 30690.45 5659.90 Humana Humana Medicare 0.06 1914.48 0.06 30690.45 0.06 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 581047 43239 CPT Outpatient 40191.90 7412.15 Humana Humana Medicare 0.07 2698.70 0.07 40191.90 0.07 Case Rate 43239 Priced Ercp remove duct calculi 581047 43264 CPT Outpatient 34335.00 6332.03 Humana Humana Medicare 0.21 7043.47 0.21 34335.00 0.21 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 581047 45378 CPT Outpatient 13991.25 889.35 Humana Humana Medicare 0.07 926.48 0.07 13991.25 0.07 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 581047 45380 CPT Outpatient 22215.90 4097.04 Humana Humana Medicare 0.08 1815.96 0.08 22215.90 0.08 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 581047 45385 CPT Outpatient 119569.80 22050.95 Humana Humana Medicare 0.01 1648.12 0.01 119569.80 0.01 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 581047 45391 CPT Outpatient 24923.85 4596.43 Humana Humana Medicare 0.07 1778.07 0.07 24923.85 0.07 Case Rate 45391 Priced Fragmenting of kidney stone 581047 50590 CPT Outpatient 40930.05 7548.28 Humana Humana Medicare 0.09 3683.90 0.09 40930.05 0.09 Case Rate 50590 Priced Fetal non-stress test 581047 59025 CPT Outpatient 3153.15 477.76 Humana Humana Medicare 0.06 198.89 0.06 3153.15 0.06 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 581047 64483 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 581047 92567 CPT Outpatient 2224.95 98.50 Humana Humana Medicare 0.14 308.98 0.14 2224.95 0.14 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 581047 93000 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 581047 93017 CPT Outpatient 3076.50 532.96 Humana Humana Medicare 0.10 308.98 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 581047 93452 CPT Outpatient 55621.65 8611.87 Humana Humana Medicare 0.06 3385.39 0.06 55621.65 0.06 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 581047 95810 CPT Outpatient 20341.65 3373.48 Humana Humana Medicare 0.05 1074.10 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 581047 95811 CPT Outpatient 22491.00 3731.18 Humana Humana Medicare 0.05 1074.10 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 581047 95812 CPT Outpatient 5578.65 925.83 Humana Humana Medicare 0.06 308.98 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 581047 96040 CPT Outpatient 0.01 102.81 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 581047 96413 CPT Outpatient 4856.25 472.45 Humana Humana Medicare 0.55 2654.07 0.55 4856.25 0.55 Case Rate 96413 Priced Ultrasound therapy 581047 97035 CPT Outpatient 2111.55 134.99 Humana Humana Medicare 0.04 85.29 0.04 2111.55 0.04 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 581047 97110 CPT Outpatient 6494.25 92.86 Humana Humana Medicare 0.05 355.13 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 581047 97116 CPT Outpatient 4723.95 110.61 Humana Humana Medicare 0.06 289.20 0.06 4723.95 0.06 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 581047 70450 CPT Outpatient 8566.95 835.61 Humana Humana Medicare 0.06 551.80 0.06 8566.95 0.06 Case Rate 70450 Priced Mri brain stem w/o dye 581047 70551 CPT Outpatient 7861.35 1361.31 Humana Humana Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 70551 Priced MRI scan of brain before and after contrast 581047 70553 CPT Outpatient 10882.20 1625.88 Humana Humana Medicare 0.04 429.92 0.04 10882.20 0.04 Case Rate 70553 Priced X-ray exam chest 2 views 581047 71046 CPT Outpatient 859.95 150.37 Humana Humana Medicare 0.11 94.43 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 581047 71250 CPT Outpatient 7288.05 1261.63 Humana Humana Medicare 0.02 127.10 0.02 7288.05 0.02 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 581047 72082 CPT Outpatient 2022.30 253.33 Humana Humana Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 581047 72100 CPT Outpatient 1599.15 277.38 Humana Humana Medicare 0.08 127.10 0.08 1599.15 0.08 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 581047 72110 CPT Outpatient 1389.15 241.04 Humana Humana Medicare 0.09 127.10 0.09 1389.15 0.09 Case Rate 72110 Priced MRI scan of lower spinal canal 581047 72148 CPT Outpatient 7861.35 1361.31 Humana Humana Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 581047 72193 CPT Outpatient 13671.00 1412.01 Humana Humana Medicare 0.02 208.54 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 581047 73030 CPT Outpatient 1452.15 251.43 Humana Humana Medicare 0.07 94.43 0.07 1452.15 0.07 Case Rate 73030 Priced X-ray exam of elbow 581047 73080 CPT Outpatient 1356.60 235.68 Humana Humana Medicare 0.07 94.43 0.07 1356.60 0.07 Case Rate 73080 Priced X-ray exam of forearm 581047 73090 CPT Outpatient 1243.20 215.26 Humana Humana Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73090 Priced X-ray exam of wrist 581047 73110 CPT Outpatient 1243.20 215.26 Humana Humana Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 581047 73130 CPT Outpatient 1243.20 215.26 Humana Humana Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73130 Priced X-ray exam hips bi 2 views 581047 73521 CPT Outpatient 970.20 228.41 Humana Humana Medicare 0.13 127.10 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 581047 73562 CPT Outpatient 802.20 139.12 Humana Humana Medicare 0.12 94.43 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 581047 73590 CPT Outpatient 1243.20 215.26 Humana Humana Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73590 Priced X-ray exam of ankle 581047 73610 CPT Outpatient 1378.65 239.31 Humana Humana Medicare 0.07 94.43 0.07 1378.65 0.07 Case Rate 73610 Priced X-ray exam of foot 581047 73630 CPT Outpatient 975.45 169.41 Humana Humana Medicare 0.10 94.43 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 581047 73721 CPT Outpatient 7861.35 1361.31 Humana Humana Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 581047 74177 CPT Outpatient 14222.25 1412.01 Humana Humana Medicare 0.03 429.92 0.03 14222.25 0.03 Case Rate 74177 Priced Contrst x-ray exam of throat 581047 74210 CPT Outpatient 0.01 440.39 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 581047 76098 CPT Outpatient 6141.45 407.86 Humana Humana Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 76098 Priced Us exam of head and neck 581047 76536 CPT Outpatient 5512.50 955.18 Humana Humana Medicare 0.02 127.10 0.02 5512.50 0.02 Case Rate 76536 Priced Ultrasound breast limited 581047 76642 CPT Outpatient 5777.10 127.70 Humana Humana Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 581047 76700 CPT Outpatient 4917.15 851.88 Humana Humana Medicare 0.03 127.10 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 581047 76705 CPT Outpatient 3836.70 665.17 Humana Humana Medicare 0.03 127.10 0.03 3836.70 0.03 Case Rate 76705 Priced Us exam abdo back wall comp 581047 76770 CPT Outpatient 5171.25 895.48 Humana Humana Medicare 0.02 127.10 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 581047 76775 CPT Outpatient 3969.00 686.97 Humana Humana Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 581047 76801 CPT Outpatient 2006.55 347.98 Humana Humana Medicare 0.06 127.10 0.06 2006.55 0.06 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 581047 76805 CPT Outpatient 3969.00 686.97 Humana Humana Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 581047 76811 CPT Outpatient 2844.45 492.99 Humana Humana Medicare 0.09 268.63 0.09 2844.45 0.09 Case Rate 76811 Priced Ob us nuchal meas 1 gest 581047 76813 CPT Outpatient 1044.75 180.83 Humana Humana Medicare 0.12 127.10 0.12 1044.75 0.12 Case Rate 76813 Priced Ob us limited fetus(s) 581047 76815 CPT Outpatient 6428.10 639.90 Humana Humana Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76815 Priced Ob us follow-up per fetus 581047 76816 CPT Outpatient 4818.45 833.88 Humana Humana Medicare 0.03 127.10 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 581047 76817 CPT Outpatient 6428.10 476.73 Humana Humana Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76817 Priced Fetal biophys profil w/o nst 581047 76819 CPT Outpatient 1741.95 302.65 Humana Humana Medicare 0.07 127.10 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 581047 76830 CPT Outpatient 9305.10 806.54 Humana Humana Medicare 0.03 254.21 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 581047 76870 CPT Outpatient 6328.35 1096.55 Humana Humana Medicare 0.02 127.10 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 581047 76885 CPT Outpatient 3836.70 665.17 Humana Humana Medicare 0.02 94.43 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 581047 77065 CPT Outpatient 3451.35 192.07 Humana Humana Medicare 0.05 158.33 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 581047 77066 CPT Outpatient 5777.10 235.68 Humana Humana Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 581047 77067 CPT Outpatient 1416.45 205.57 Humana Humana Medicare 0.05 63.90 0.05 1416.45 0.05 Case Rate 77067 Priced X-rays for bone age 581047 77072 CPT Outpatient 2022.30 163.87 Humana Humana Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 77072 Priced Joint survey single view 581047 77077 CPT Outpatient 985.95 171.14 Humana Humana Medicare 0.13 124.57 0.13 985.95 0.13 Case Rate 77077 Priced Dxa bone density axial 581047 77080 CPT Outpatient 3257.10 319.09 Humana Humana Medicare 0.06 191.00 0.06 3257.10 0.06 Case Rate 77080 Priced Fna bx w/us gdn 1st les 581047 10005 CPT Outpatient 5512.50 547.24 Humana Humana Medicare 0.13 726.50 0.13 5512.50 0.13 Case Rate 10005 Priced Fna bx w/us gdn ea addl 581047 10006 CPT Outpatient 10628.10 594.83 Humana Humana Medicare 0.07 726.50 0.07 10628.10 0.07 Case Rate 10006 Priced Drainage of hematoma/fluid 581047 10140 CPT Outpatient 23209.20 1081.95 Humana Humana Medicare 0.27 6181.44 0.27 23209.20 0.27 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 581047 11042 CPT Outpatient 2668.05 481.45 Humana Humana Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb bone 20 sq cm/< 581047 11044 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 581047 11406 CPT Outpatient 19967.85 3427.81 Humana Humana Medicare 0.09 1700.21 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 581047 11424 CPT Outpatient 0.01 1004.93 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 581047 11770 CPT Outpatient 19173.00 3291.37 Humana Humana Medicare 0.15 2826.15 0.15 19173.00 0.15 Case Rate 11770 Priced Replace tissue expander 581047 11970 CPT Outpatient 59239.95 10169.52 Humana Humana Medicare 0.52 30989.99 0.52 59239.95 0.52 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 581047 14020 CPT Outpatient 32166.75 5521.96 Humana Humana Medicare 0.06 1999.63 0.06 32166.75 0.06 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 581047 14060 CPT Outpatient 25993.80 1374.69 Humana Humana Medicare 0.31 7937.33 0.31 25993.80 0.31 Case Rate 14060 Priced Wound prep trk/arm/leg 581047 15002 CPT Outpatient 41748.00 1441.73 Humana Humana Medicare 0.21 8825.17 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 581047 15271 CPT Outpatient 24343.20 3769.48 Humana Humana Medicare 0.08 1999.63 0.08 24343.20 0.08 Case Rate 15271 Priced Acellular derm matrix implt 581047 15777 CPT Outpatient 101672.55 17453.79 Humana Humana Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 15777 Priced Exc skin abd 581047 15830 CPT Outpatient 54696.60 9389.58 Humana Humana Medicare 0.12 6325.99 0.12 54696.60 0.12 Case Rate 15830 Priced Dressing change not for burn 581047 15852 CPT Outpatient 0.01 290.74 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 581047 15877 CPT Outpatient 63741.30 10942.26 Humana Humana Medicare 0.17 10877.73 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 581047 15879 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 581047 19000 CPT Outpatient 10143.00 594.83 Humana Humana Medicare 0.08 790.40 0.08 10143.00 0.08 Case Rate 19000 Priced Bx breast 1st lesion strtctc 581047 19081 CPT Outpatient 12341.70 1250.69 Humana Humana Medicare 0.14 1758.68 0.14 12341.70 0.14 Case Rate 19081 Priced Bx breast add lesion us imag 581047 19084 CPT Outpatient 29058.75 547.24 Humana Humana Medicare 0.07 1975.03 0.07 29058.75 0.07 Case Rate 19084 Priced Biopsy of breast open 581047 19101 CPT Outpatient 39545.10 2737.82 Humana Humana Medicare 0.23 8988.74 0.23 39545.10 0.23 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 581047 19120 CPT Outpatient 35761.95 2737.82 Humana Humana Medicare 0.12 4298.03 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 581047 19125 CPT Outpatient 33184.20 0.01 Humana Humana Medicare 0.26 8661.10 0.26 33184.20 0.26 Case Rate 19125 Priced Perq device breast 1st imag 581047 19281 CPT Outpatient 6141.45 598.61 Humana Humana Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 19281 Priced Perq device breast ea imag 581047 19282 CPT Outpatient 8379.00 319.04 Humana Humana Medicare 0.15 1290.61 0.15 8379.00 0.15 Case Rate 19282 Priced Partial mastectomy 581047 19301 CPT Outpatient 39157.65 6722.06 Humana Humana Medicare 0.20 7846.47 0.20 39157.65 0.20 Case Rate 19301 Priced Mast simple complete 581047 19303 CPT Outpatient 105389.55 18091.87 Humana Humana Medicare 0.28 29200.15 0.28 105389.55 0.28 Case Rate 19303 Priced Reduction of large breast 581047 19318 CPT Outpatient 65239.65 11199.47 Humana Humana Medicare 0.10 6577.10 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 581047 19340 CPT Outpatient 113100.75 19415.63 Humana Humana Medicare 0.13 14822.97 0.13 113100.75 0.13 Case Rate 19340 Priced Delayed breast prosthesis 581047 19342 CPT Outpatient 56988.75 9783.07 Humana Humana Medicare 0.36 20246.20 0.36 56988.75 0.36 Case Rate 19342 Priced Breast reconstruction 581047 19357 CPT Outpatient 101672.55 17453.79 Humana Humana Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 19357 Priced Breast reconstruction 581047 19366 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 581047 19380 CPT Outpatient 61493.25 10556.34 Humana Humana Medicare 0.21 13212.28 0.21 61493.25 0.21 Case Rate 19380 Priced Removal of support implant 581047 20680 CPT Outpatient 42329.70 7266.60 Humana Humana Medicare 0.14 5804.91 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 581047 22856 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 581047 24538 CPT Outpatient 51237.90 4775.24 Humana Humana Medicare 0.19 9816.98 0.19 51237.90 0.19 Case Rate 24538 Priced Remove wrist tendon lesion 581047 25111 CPT Outpatient 25855.20 4438.48 Humana Humana Medicare 0.06 1654.95 0.06 25855.20 0.06 Case Rate 25111 Priced Incise finger tendon sheath 581047 26055 CPT Outpatient 15862.35 2723.04 Humana Humana Medicare 0.12 1931.13 0.12 15862.35 0.12 Case Rate 26055 Priced Treat finger fracture each 581047 26727 CPT Outpatient 22779.75 2030.47 Humana Humana Medicare 0.16 3574.88 0.16 22779.75 0.16 Case Rate 26727 Priced Revision of knee joint 581047 27446 CPT Outpatient 67882.50 11653.16 Humana Humana Medicare 0.23 15567.47 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 581047 27447 CPT Outpatient 130698.75 22436.62 Humana Humana Medicare 0.12 15604.41 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 581047 27485 CPT Outpatient 43310.40 7434.95 Humana Humana Medicare 0.26 11063.75 0.26 43310.40 0.26 Case Rate 27485 Priced Repair achilles tendon 581047 27650 CPT Outpatient 38246.25 3762.57 Humana Humana Medicare 0.29 11041.86 0.29 38246.25 0.29 Case Rate 27650 Priced Treatment of ankle fracture 581047 27792 CPT Outpatient 36101.10 6197.36 Humana Humana Medicare 0.21 7581.28 0.21 36101.10 0.21 Case Rate 27792 Priced Treatment of ankle fracture 581047 27814 CPT Outpatient 49405.65 8481.30 Humana Humana Medicare 0.16 7766.50 0.16 49405.65 0.16 Case Rate 27814 Priced Removal of foot lesion 581047 28080 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 581047 28285 CPT Outpatient 68603.85 11776.99 Humana Humana Medicare 0.20 13986.50 0.20 68603.85 0.20 Case Rate 28285 Priced Correction hallux valgus 581047 28296 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 581047 29823 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 581047 29826 CPT Outpatient 49840.35 8555.93 Humana Humana Medicare 0.15 7312.64 0.15 49840.35 0.15 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 581047 29881 CPT Outpatient 35556.15 6103.81 Humana Humana Medicare 0.09 3306.24 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 581047 29882 CPT Outpatient 61099.50 10488.75 Humana Humana Medicare 0.19 11577.74 0.19 61099.50 0.19 Case Rate 29882 Priced Percut bx lung/mediastinum 581047 32405 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 581047 32555 CPT Outpatient 14597.10 687.29 Humana Humana Medicare 0.05 711.62 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 581047 32664 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 581047 35190 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 581047 36478 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 581047 36561 CPT Outpatient 53531.10 3292.99 Humana Humana Medicare 0.06 3342.08 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 581047 36569 CPT Outpatient 31421.25 1299.06 Humana Humana Medicare 0.06 1811.50 0.06 31421.25 0.06 Case Rate 36569 Priced Removal tunneled cv cath 581047 36590 CPT Outpatient 1996.05 273.95 Humana Humana Medicare 0.82 1641.71 0.82 1996.05 0.82 Case Rate 36590 Priced Av fuse uppr arm basilic 581047 36819 CPT Outpatient 56861.70 9761.26 Humana Humana Medicare 0.17 9459.82 0.17 56861.70 0.17 Case Rate 36819 Priced Av fusion direct any site 581047 36821 CPT Outpatient 42953.40 7373.67 Humana Humana Medicare 0.16 7056.50 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 581047 36825 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 581047 36830 CPT Outpatient 53656.05 9210.96 Humana Humana Medicare 0.17 9346.72 0.17 53656.05 0.17 Case Rate 36830 Priced Av fistula revision open 581047 36832 CPT Outpatient 52492.65 9011.24 Humana Humana Medicare 0.23 12046.01 0.23 52492.65 0.23 Case Rate 36832 Priced Av fistula revision 581047 36833 CPT Outpatient 37098.60 6368.59 Humana Humana Medicare 0.28 10242.79 0.28 37098.60 0.28 Case Rate 36833 Priced Intro cath dialysis circuit 581047 36903 CPT Outpatient 77541.45 10669.90 Humana Humana Medicare 0.24 18454.26 0.24 77541.45 0.24 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 581047 36906 CPT Outpatient 96694.50 16175.64 Humana Humana Medicare 0.27 26216.69 0.27 96694.50 0.27 Case Rate 36906 Priced Fem/popl revas w/tla 581047 37224 CPT Outpatient 200076.45 5139.31 Humana Humana Medicare 0.14 27878.39 0.14 200076.45 0.14 Case Rate 37224 Priced Fem/popl revasc stnt & ather 581047 37227 CPT Outpatient 117170.55 18045.38 Humana Humana Medicare 0.17 19636.18 0.17 117170.55 0.17 Case Rate 37227 Priced Revise leg vein 581047 37700 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 581047 37722 CPT Outpatient 27815.55 4775.00 Humana Humana Medicare 0.37 10398.58 0.37 27815.55 0.37 Case Rate 37722 Priced Stab phleb veins xtr 10-20 581047 37765 CPT Outpatient 26561.85 4559.78 Humana Humana Medicare 0.52 13740.66 0.52 26561.85 0.52 Case Rate 37765 Priced Biopsy/removal lymph nodes 581047 38500 CPT Outpatient 35955.15 6172.30 Humana Humana Medicare 0.11 3918.72 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 581047 38525 CPT Outpatient 101194.80 17371.77 Humana Humana Medicare 0.19 18851.15 0.19 101194.80 0.19 Case Rate 38525 Priced Laparoscopy lymph node biop 581047 38570 CPT Outpatient 65631.30 11266.71 Humana Humana Medicare 0.28 18089.66 0.28 65631.30 0.28 Case Rate 38570 Priced Laparoscopy lymphadenectomy 581047 38571 CPT Outpatient 84031.50 14425.41 Humana Humana Medicare 0.26 22194.38 0.26 84031.50 0.26 Case Rate 38571 Priced Laparoscopy lymphadenectomy 581047 38572 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 581047 38792 CPT Outpatient 2868.60 432.48 Humana Humana Medicare 0.15 440.09 0.15 2868.60 0.15 Case Rate 38792 Priced Excision of gum lesion 581047 41825 CPT Outpatient 11580.45 1987.98 Humana Humana Medicare 0.30 3440.87 0.30 11580.45 0.30 Case Rate 41825 Priced Reconstruct cleft palate 581047 42200 CPT Outpatient 36703.80 6300.82 Humana Humana Medicare 0.16 5937.71 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 581047 42820 CPT Outpatient 17232.60 2958.26 Humana Humana Medicare 0.64 11027.66 0.64 17232.60 0.64 Case Rate 42820 Priced Control throat bleeding 581047 42960 CPT Outpatient 24066.00 4131.33 Humana Humana Medicare 0.20 4852.02 0.20 24066.00 0.20 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 581047 43235 CPT Outpatient 8856.75 1633.35 Humana Humana Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Laparoscopy fundoplasty 581047 43280 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 581047 43282 CPT Outpatient 84344.40 14479.12 Humana Humana Medicare 0.13 10981.07 0.13 84344.40 0.13 Case Rate 43282 Priced Laparoscopy appendectomy 581047 44970 CPT Outpatient 82300.05 14128.18 Humana Humana Medicare 0.08 6988.44 0.08 82300.05 0.08 Case Rate 44970 Priced Diagnostic sigmoidoscopy 581047 45330 CPT Outpatient 17286.15 542.26 Humana Humana Medicare 0.11 1880.24 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 581047 47000 CPT Outpatient 10398.15 1225.34 Humana Humana Medicare 0.20 2101.24 0.20 10398.15 0.20 Case Rate 47000 Priced Removal of gallbladder using an endoscope 581047 47562 CPT Outpatient 58430.40 10030.55 Humana Humana Medicare 0.10 5965.34 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 581047 47563 CPT Outpatient 71747.55 12316.66 Humana Humana Medicare 0.09 6769.21 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 581047 49083 CPT Outpatient 6979.35 1113.95 Humana Humana Medicare 0.14 944.67 0.14 6979.35 0.14 Case Rate 49083 Priced Diag laparo separate proc 581047 49320 CPT Outpatient 31629.15 5429.67 Humana Humana Medicare 0.42 13201.26 0.42 31629.15 0.42 Case Rate 49320 Priced Laparoscopy biopsy 581047 49321 CPT Outpatient 41892.90 7191.61 Humana Humana Medicare 0.32 13491.42 0.32 41892.90 0.32 Case Rate 49321 Priced Laparoscopy aspiration 581047 49322 CPT Outpatient 34392.75 5904.09 Humana Humana Medicare 0.39 13396.33 0.39 34392.75 0.39 Case Rate 49322 Priced Lap insert tunnel ip cath 581047 49324 CPT Outpatient 39264.75 6740.45 Humana Humana Medicare 0.15 5972.32 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 581047 49329 CPT Outpatient 58696.05 10076.16 Humana Humana Medicare 0.29 17162.20 0.29 58696.05 0.29 Case Rate 49329 Priced Ins tun ip cath for dial opn 581047 49421 CPT Outpatient 25460.40 3319.30 Humana Humana Medicare 0.15 3702.67 0.15 25460.40 0.15 Case Rate 49421 Priced Remove tunneled ip cath 581047 49422 CPT Outpatient 25515.00 4380.08 Humana Humana Medicare 0.13 3342.08 0.13 25515.00 0.13 Case Rate 49422 Priced Rpr ing hernia init reduce 581047 49500 CPT Outpatient 19594.05 3363.65 Humana Humana Medicare 0.56 11018.31 0.56 19594.05 0.56 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 581047 49505 CPT Outpatient 34915.65 5993.85 Humana Humana Medicare 0.21 7278.08 0.21 34915.65 0.21 Case Rate 49505 Priced Prp i/hern init block >5 yr 581047 49507 CPT Outpatient 29794.80 5114.77 Humana Humana Medicare 0.25 7306.28 0.25 29794.80 0.25 Case Rate 49507 Priced Rerepair ing hernia reduce 581047 49520 CPT Outpatient 36940.05 6341.38 Humana Humana Medicare 0.20 7341.71 0.20 36940.05 0.20 Case Rate 49520 Priced Rpr ventral hern init reduc 581047 49560 CPT Outpatient 53177.25 9128.76 Humana Humana Medicare 0.18 9686.73 0.18 53177.25 0.18 Case Rate 49560 Priced Rpr ventral hern init block 581047 49561 CPT Outpatient 30755.55 5279.70 Humana Humana Medicare 0.24 7522.67 0.24 30755.55 0.24 Case Rate 49561 Priced Rerepair ventrl hern reduce 581047 49565 CPT Outpatient 69917.40 12002.49 Humana Humana Medicare 0.14 10018.26 0.14 69917.40 0.14 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 581047 49585 CPT Outpatient 41806.80 7176.83 Humana Humana Medicare 0.23 9650.59 0.23 41806.80 0.23 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 581047 49587 CPT Outpatient 37320.15 6406.63 Humana Humana Medicare 0.20 7369.53 0.20 37320.15 0.20 Case Rate 49587 Priced Lap ing hernia repair init 581047 49650 CPT Outpatient 41932.80 7198.46 Humana Humana Medicare 0.14 5784.73 0.14 41932.80 0.14 Case Rate 49650 Priced Lap ing hernia repair recur 581047 49651 CPT Outpatient 46915.05 8053.75 Humana Humana Medicare 0.26 12396.08 0.26 46915.05 0.26 Case Rate 49651 Priced Lap vent/abd hernia repair 581047 49652 CPT Outpatient 51294.60 8805.57 Humana Humana Medicare 0.12 6001.15 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 581047 49653 CPT Outpatient 46102.35 7914.24 Humana Humana Medicare 0.13 5907.33 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 581047 49654 CPT Outpatient 47221.65 8106.38 Humana Humana Medicare 0.22 10246.22 0.22 47221.65 0.22 Case Rate 49654 Priced Lap inc hern repair comp 581047 49655 CPT Outpatient 54590.55 9371.38 Humana Humana Medicare 0.19 10557.83 0.19 54590.55 0.19 Case Rate 49655 Priced Lap inc hernia repair recur 581047 49656 CPT Outpatient 55443.15 9517.74 Humana Humana Medicare 0.19 10492.84 0.19 55443.15 0.19 Case Rate 49656 Priced Removal of kidney stone 581047 50080 CPT Outpatient 53165.70 9126.78 Humana Humana Medicare 0.32 16951.33 0.32 53165.70 0.32 Case Rate 50080 Priced Removal of kidney stone 581047 50081 CPT Outpatient 66931.20 11489.86 Humana Humana Medicare 0.30 20375.49 0.30 66931.20 0.30 Case Rate 50081 Priced Renal biopsy perq 581047 50200 CPT Outpatient 43096.20 1225.34 Humana Humana Medicare 0.23 9703.00 0.23 43096.20 0.23 Case Rate 50200 Priced Plmt nephroureteral catheter 581047 50433 CPT Outpatient 64566.60 1424.48 Humana Humana Medicare 0.27 17570.80 0.27 64566.60 0.27 Case Rate 50433 Priced Laparo radical nephrectomy 581047 50545 CPT Outpatient 43449.00 7458.75 Humana Humana Medicare 0.03 1190.00 0.03 43449.00 0.03 Case Rate 50545 Priced Laparoscope proc ureter 581047 50949 CPT Outpatient 49986.30 8580.98 Humana Humana Medicare 0.34 17208.73 0.34 49986.30 0.34 Case Rate 50949 Priced Injection for bladder x-ray 581047 51600 CPT Outpatient 3285.45 89.22 Humana Humana Medicare 0.08 268.63 0.08 3285.45 0.08 Case Rate 51600 Priced Cystoscopy 581047 52000 CPT Outpatient 22149.75 3802.37 Humana Humana Medicare 0.36 7975.55 0.36 22149.75 0.36 Case Rate 52000 Priced Cystoscopy & ureter catheter 581047 52005 CPT Outpatient 42529.20 2095.77 Humana Humana Medicare 0.21 9136.51 0.21 42529.20 0.21 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 581047 52204 CPT Outpatient 31274.25 5368.75 Humana Humana Medicare 0.18 5745.54 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 581047 52224 CPT Outpatient 13445.25 2308.10 Humana Humana Medicare 0.54 7303.88 0.54 13445.25 0.54 Case Rate 52224 Priced Cystoscopy and treatment 581047 52234 CPT Outpatient 28510.65 4894.33 Humana Humana Medicare 0.27 7572.52 0.27 28510.65 0.27 Case Rate 52234 Priced Cystoscopy and treatment 581047 52235 CPT Outpatient 29417.85 5050.06 Humana Humana Medicare 0.25 7276.20 0.25 29417.85 0.25 Case Rate 52235 Priced Cystoscopy and treatment 581047 52240 CPT Outpatient 33933.90 5825.32 Humana Humana Medicare 0.27 9046.24 0.27 33933.90 0.27 Case Rate 52240 Priced Cystoscopy and treatment 581047 52281 CPT Outpatient 22159.20 3804.00 Humana Humana Medicare 0.26 5688.66 0.26 22159.20 0.26 Case Rate 52281 Priced Remove bladder stone 581047 52317 CPT Outpatient 27085.80 4649.73 Humana Humana Medicare 0.27 7426.56 0.27 27085.80 0.27 Case Rate 52317 Priced Remove bladder stone 581047 52318 CPT Outpatient 26685.75 4581.05 Humana Humana Medicare 0.28 7361.57 0.28 26685.75 0.28 Case Rate 52318 Priced Cystoscopy and treatment 581047 52332 CPT Outpatient 115306.80 19794.33 Humana Humana Medicare 0.18 20580.50 0.18 115306.80 0.18 Case Rate 52332 Priced Cystouretero w/stone remove 581047 52352 CPT Outpatient 42420.00 7282.10 Humana Humana Medicare 0.38 16312.79 0.38 42420.00 0.38 Case Rate 52352 Priced Cystouretero w/lithotripsy 581047 52353 CPT Outpatient 38608.50 6627.79 Humana Humana Medicare 0.24 9133.86 0.24 38608.50 0.24 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 581047 52356 CPT Outpatient 36255.45 6223.85 Humana Humana Medicare 0.25 9133.86 0.25 36255.45 0.25 Case Rate 52356 Priced Prostatectomy (turp) 581047 52601 CPT Outpatient 35371.35 6072.08 Humana Humana Medicare 0.25 8684.69 0.25 35371.35 0.25 Case Rate 52601 Priced Laser surgery of prostate 581047 52648 CPT Outpatient 24264.45 4165.40 Humana Humana Medicare 0.37 9020.55 0.37 24264.45 0.37 Case Rate 52648 Priced Revision of urethra 581047 53450 CPT Outpatient 16209.90 2782.70 Humana Humana Medicare 0.35 5679.84 0.35 16209.90 0.35 Case Rate 53450 Priced Urology surgery procedure 581047 53899 CPT Outpatient 25368.00 134.83 Humana Humana Medicare 0.27 6862.63 0.27 25368.00 0.27 Case Rate 53899 Priced Circumcision w/regionl block 581047 54150 CPT Outpatient 14700.00 2523.50 Humana Humana Medicare 0.14 2090.37 0.14 14700.00 0.14 Case Rate 54150 Priced Circum 28 days or older 581047 54161 CPT Outpatient 19186.65 3293.71 Humana Humana Medicare 0.11 2049.61 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 581047 54162 CPT Outpatient 19795.65 3398.25 Humana Humana Medicare 0.85 16823.10 0.85 19795.65 0.85 Case Rate 54162 Priced Repair of circumcision 581047 54163 CPT Outpatient 16391.55 2813.88 Humana Humana Medicare 0.24 4010.49 0.24 16391.55 0.24 Case Rate 54163 Priced Reconstruction of urethra 581047 54324 CPT Outpatient 32880.75 5644.53 Humana Humana Medicare 0.28 9303.52 0.28 32880.75 0.28 Case Rate 54324 Priced Revise penis/urethra 581047 54332 CPT Outpatient 19968.90 3427.99 Humana Humana Medicare 0.18 3589.47 0.18 19968.90 0.18 Case Rate 54332 Priced Insert self-contd prosthesis 581047 54401 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 581047 54520 CPT Outpatient 35442.75 6084.34 Humana Humana Medicare 0.34 12158.30 0.34 35442.75 0.34 Case Rate 54520 Priced Reduce testis torsion 581047 54600 CPT Outpatient 55049.40 9450.15 Humana Humana Medicare 0.28 15402.48 0.28 55049.40 0.28 Case Rate 54600 Priced Suspension of testis 581047 54640 CPT Outpatient 26860.05 4610.98 Humana Humana Medicare 0.28 7428.84 0.28 26860.05 0.28 Case Rate 54640 Priced Removal of hydrocele 581047 55040 CPT Outpatient 27277.95 4682.71 Humana Humana Medicare 0.27 7369.91 0.27 27277.95 0.27 Case Rate 55040 Priced Biopsy of prostate gland 581047 55700 CPT Outpatient 28699.65 4926.77 Humana Humana Medicare 0.13 3731.04 0.13 28699.65 0.13 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 581047 55866 CPT Outpatient 93088.80 15980.24 Humana Humana Medicare 0.24 22017.24 0.24 93088.80 0.24 Case Rate 55866 Priced Closure of vagina 581047 57120 CPT Outpatient 34369.65 5900.12 Humana Humana Medicare 0.43 14932.00 0.43 34369.65 0.43 Case Rate 57120 Priced Repair of vagina 581047 57200 CPT Outpatient 25247.25 4334.11 Humana Humana Medicare 0.31 7732.37 0.31 25247.25 0.31 Case Rate 57200 Priced Anterior colporrhaphy 581047 57240 CPT Outpatient 36210.30 6216.10 Humana Humana Medicare 0.53 19223.69 0.53 36210.30 0.53 Case Rate 57240 Priced Repair rectum & vagina 581047 57250 CPT Outpatient 40441.80 6942.51 Humana Humana Medicare 0.56 22691.64 0.56 40441.80 0.56 Case Rate 57250 Priced Cmbn ant pst colprhy 581047 57260 CPT Outpatient 46323.90 7952.27 Humana Humana Medicare 0.66 30437.82 0.66 46323.90 0.66 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 581047 57265 CPT Outpatient 42586.95 7310.76 Humana Humana Medicare 0.43 18248.88 0.43 42586.95 0.43 Case Rate 57265 Priced Repair of bowel bulge 581047 57268 CPT Outpatient 36865.50 6328.58 Humana Humana Medicare 0.49 18090.91 0.49 36865.50 0.49 Case Rate 57268 Priced Colpopexy extraperitoneal 581047 57282 CPT Outpatient 45629.85 7833.12 Humana Humana Medicare 0.66 30324.80 0.66 45629.85 0.66 Case Rate 57282 Priced Repair bladder defect 581047 57288 CPT Outpatient 43069.95 7393.67 Humana Humana Medicare 0.56 24109.88 0.56 43069.95 0.56 Case Rate 57288 Priced Bx/curett of cervix w/scope 581047 57454 CPT Outpatient 2888.55 442.93 Humana Humana Medicare 0.11 329.27 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 581047 57520 CPT Outpatient 26728.80 4588.44 Humana Humana Medicare 0.16 4211.41 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 581047 57522 CPT Outpatient 22737.75 3903.31 Humana Humana Medicare 0.15 3411.24 0.15 22737.75 0.15 Case Rate 57522 Priced Biopsy of uterus lining 581047 58100 CPT Outpatient 2371.95 194.80 Humana Humana Medicare 0.08 198.89 0.08 2371.95 0.08 Case Rate 58100 Priced Catheter for hysterography 581047 58340 CPT Outpatient 6322.05 131.04 Humana Humana Medicare 0.04 268.63 0.04 6322.05 0.04 Case Rate 58340 Priced Reopen fallopian tube 581047 58350 CPT Outpatient 46507.65 7983.81 Humana Humana Medicare 0.38 17563.57 0.38 46507.65 0.38 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 581047 58542 CPT Outpatient 64194.90 11020.12 Humana Humana Medicare 0.37 24060.91 0.37 64194.90 0.37 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 581047 58544 CPT Outpatient 51020.55 8758.53 Humana Humana Medicare 0.65 33216.81 0.65 51020.55 0.65 Case Rate 58544 Priced Laparoscopic myomectomy 581047 58545 CPT Outpatient 56946.75 9775.86 Humana Humana Medicare 0.17 9718.98 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 581047 58552 CPT Outpatient 57228.15 9824.17 Humana Humana Medicare 0.32 18381.02 0.32 57228.15 0.32 Case Rate 58552 Priced Hysteroscopy biopsy 581047 58558 CPT Outpatient 28581.00 2077.02 Humana Humana Medicare 0.25 7238.81 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 581047 58561 CPT Outpatient 35222.25 6046.49 Humana Humana Medicare 0.27 9531.42 0.27 35222.25 0.27 Case Rate 58561 Priced Hysteroscopy ablation 581047 58563 CPT Outpatient 38399.55 6591.92 Humana Humana Medicare 0.51 19555.87 0.51 38399.55 0.51 Case Rate 58563 Priced Tlh uterus 250 g or less 581047 58570 CPT Outpatient 43316.70 7436.03 Humana Humana Medicare 0.26 11083.71 0.26 43316.70 0.26 Case Rate 58570 Priced Tlh w/t/o 250 g or less 581047 58571 CPT Outpatient 48603.45 8343.59 Humana Humana Medicare 0.30 14369.35 0.30 48603.45 0.30 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 581047 58573 CPT Outpatient 52905.30 9082.08 Humana Humana Medicare 0.32 16722.51 0.32 52905.30 0.32 Case Rate 58573 Priced Laparoscopy remove adnexa 581047 58661 CPT Outpatient 47008.50 8069.79 Humana Humana Medicare 0.18 8686.07 0.18 47008.50 0.18 Case Rate 58661 Priced Laparoscopy excise lesions 581047 58662 CPT Outpatient 45053.40 7734.17 Humana Humana Medicare 0.38 17220.22 0.38 45053.40 0.38 Case Rate 58662 Priced Treat ectopic pregnancy 581047 59151 CPT Outpatient 74690.70 12821.90 Humana Humana Medicare 0.09 6630.70 0.09 74690.70 0.09 Case Rate 59151 Priced Treatment of miscarriage 581047 59812 CPT Outpatient 56109.90 9632.20 Humana Humana Medicare 0.07 4075.96 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 581047 60220 CPT Outpatient 53639.25 9208.07 Humana Humana Medicare 0.11 6088.34 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 581047 60240 CPT Outpatient 98252.70 16866.71 Humana Humana Medicare 0.06 5905.23 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 581047 60500 CPT Outpatient 150495.45 25835.05 Humana Humana Medicare 0.06 9768.16 0.06 150495.45 0.06 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 581047 62322 CPT Outpatient 43709.40 514.24 Humana Humana Medicare 0.28 12235.33 0.28 43709.40 0.28 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 581047 62323 CPT Outpatient 8304.45 467.31 Humana Humana Medicare 16.45 136591.28 16.45 8304.45 16.45 Case Rate 62323 Priced Low back disk surgery 581047 63030 CPT Outpatient 50287.65 8632.71 Humana Humana Medicare 0.30 14893.92 0.30 50287.65 0.30 Case Rate 63030 Priced Inc for vagus n elect impl 581047 64568 CPT Outpatient 124562.55 21383.24 Humana Humana Medicare 0.27 33814.93 0.27 124562.55 0.27 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 581047 66821 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 581047 66984 CPT Outpatient 0.01 0.01 Humana Humana Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 562047 216 DRG Inpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 562047 460 DRG Inpatient 416122.79 53834.63 United United Medicare 0.09 36507.56 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 562047 470 DRG Inpatient 167912.19 21723.13 United United Medicare 0.11 18221.64 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 562047 473 DRG Inpatient 100687.91 13026.19 United United Medicare 0.24 23973.82 0.24 100687.91 0.24 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 562047 743 DRG Inpatient 102691.67 13285.42 United United Medicare 0.11 11317.53 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 562047 795 DRG Inpatient 6266.93 2335.00 United United Medicare 0.49 3065.24 0.49 6266.93 0.49 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 562047 807 DRG Inpatient 116469.59 4193.00 United United Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 562047 788 DRG Inpatient 76050.77 4538.00 United United Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 562047 59400 CPT Inpatient 116469.59 4193.00 United United Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 562047 59510 CPT Inpatient 76050.77 4538.00 United United Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 562047 59610 CPT Inpatient 116469.59 4193.00 United United Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59610 Priced "Psychotherapy, 30 min" 562047 90832 CPT Outpatient 577.50 91.21 United United Medicare 0.29 166.55 0.29 577.50 0.29 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 562047 90834 CPT Outpatient 44134.65 271.96 United United Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 562047 90837 CPT Outpatient 2240.70 442.93 United United Medicare 0.04 84.05 0.04 2240.70 0.04 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 562047 90846 CPT Outpatient 0.01 131.50 United United Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 562047 90847 CPT Outpatient 44134.65 369.97 United United Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90847 Priced Group psychotherapy 562047 90853 CPT Outpatient 44134.65 101.99 United United Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 562047 99203 CPT Outpatient 3480.75 176.07 United United Medicare 0.12 403.52 0.12 3480.75 0.12 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 562047 99204 CPT Outpatient 2103.15 233.39 United United Medicare 0.19 390.94 0.19 2103.15 0.19 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 562047 99205 CPT Outpatient 4970.70 314.28 United United Medicare 0.09 462.07 0.09 4970.70 0.09 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 562047 99243 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 562047 99244 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 562047 99385 CPT Outpatient 1114.05 185.90 United United Medicare 0.19 207.05 0.19 1114.05 0.19 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 562047 99386 CPT Outpatient 4877.25 185.90 United United Medicare 0.02 98.87 0.02 4877.25 0.02 Fee Schedule 99386 Priced Routine venipuncture 562047 36415 CPT Outpatient 127.05 19.57 United United Medicare 0.02 3.02 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 562047 80048 CPT Outpatient 576.45 88.78 United United Medicare 0.02 11.70 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 562047 80053 CPT Outpatient 763.35 117.56 United United Medicare 0.02 13.22 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 562047 80055 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 562047 80061 CPT Outpatient 1349.25 197.77 United United Medicare 0.01 18.53 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 562047 80069 CPT Outpatient 716.10 104.95 United United Medicare 0.02 12.01 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 562047 80076 CPT Outpatient 716.10 104.95 United United Medicare 0.02 11.31 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 562047 81000 CPT Outpatient 144.90 21.18 United United Medicare 0.03 4.39 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 562047 81001 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 562047 81002 CPT Outpatient 57.75 8.89 United United Medicare 0.06 3.53 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 562047 81003 CPT Outpatient 219.45 33.80 United United Medicare 0.01 3.11 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 562047 82306 CPT Outpatient 1880.55 289.62 United United Medicare 0.02 40.96 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 562047 83036 CPT Outpatient 494.55 76.17 United United Medicare 0.03 13.44 0.03 494.55 0.03 Fee Schedule 83036 Priced PSA (prostate specific antigen) 562047 84153 CPT Outpatient 1177.05 181.28 United United Medicare 0.02 25.45 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 562047 84154 CPT Outpatient 598.50 92.17 United United Medicare 0.04 25.45 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 562047 84443 CPT Outpatient 519.75 80.05 United United Medicare 0.04 23.25 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 562047 84703 CPT Outpatient 785.40 120.96 United United Medicare 0.01 10.40 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 562047 85025 CPT Outpatient 635.25 97.83 United United Medicare 0.02 10.75 0.02 635.25 0.02 Fee Schedule 85025 Priced "Complete blood count, automated" 562047 85027 CPT Outpatient 576.45 88.78 United United Medicare 0.02 8.95 0.02 576.45 0.02 Fee Schedule 85027 Priced "Blood test, clotting time" 562047 85610 CPT Outpatient 404.25 62.26 United United Medicare 0.01 5.43 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 562047 85730 CPT Outpatient 17.22 2.65 United United Medicare 0.48 8.31 0.48 17.22 0.48 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 562047 86003 CPT Outpatient 32.55 5.01 United United Medicare 0.22 7.23 0.22 32.55 0.22 Fee Schedule 86003 Priced Tb test cell immun measure 562047 86480 CPT Outpatient 530.25 81.66 United United Medicare 0.16 85.75 0.16 530.25 0.16 Fee Schedule 86480 Priced Urine culture/colony count 562047 87086 CPT Outpatient 763.35 117.56 United United Medicare 0.01 11.16 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 562047 87338 CPT Outpatient 785.40 120.96 United United Medicare 0.03 19.90 0.03 785.40 0.03 Fee Schedule 87338 Priced Cytopath eval fna report 562047 88173 CPT Outpatient 750.75 115.62 United United Medicare 0.08 57.32 0.08 750.75 0.08 Fee Schedule 88173 Priced Tissue exam by pathologist 562047 88302 CPT Outpatient 635.25 97.83 United United Medicare 0.04 28.54 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 562047 88305 CPT Outpatient 323.40 49.81 United United Medicare 0.18 57.32 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 562047 11042 CPT Outpatient 2668.05 481.45 United United Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb subq tissue add-on 562047 11045 CPT Outpatient 4652.55 330.00 United United Medicare 0.09 403.52 0.09 4652.55 0.09 Case Rate 11045 Priced Dx bronchoscope/lavage 562047 31624 CPT Outpatient 41223.00 7602.31 United United Medicare 0.19 7805.52 0.19 41223.00 0.19 Case Rate 31624 Priced Bronchoscopy/lung bx each 562047 31628 CPT Outpatient 49048.65 9045.51 United United Medicare 0.25 12292.51 0.25 49048.65 0.25 Case Rate 31628 Priced Blood transfusion service 562047 36430 CPT Outpatient 9166.50 574.93 United United Medicare 0.08 731.71 0.08 9166.50 0.08 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 562047 43235 CPT Outpatient 8856.75 1633.35 United United Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Endoscopic us exam esoph 562047 43237 CPT Outpatient 23867.55 4401.63 United United Medicare 0.12 2840.90 0.12 23867.55 0.12 Case Rate 43237 Priced Egd us fine needle bx/aspir 562047 43238 CPT Outpatient 30690.45 5659.90 United United Medicare 0.06 1914.48 0.06 30690.45 0.06 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 562047 43239 CPT Outpatient 40191.90 7412.15 United United Medicare 0.07 2698.70 0.07 40191.90 0.07 Case Rate 43239 Priced Ercp remove duct calculi 562047 43264 CPT Outpatient 34335.00 6332.03 United United Medicare 0.21 7043.47 0.21 34335.00 0.21 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 562047 45378 CPT Outpatient 13991.25 889.35 United United Medicare 0.07 926.48 0.07 13991.25 0.07 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 562047 45380 CPT Outpatient 22215.90 4097.04 United United Medicare 0.08 1815.96 0.08 22215.90 0.08 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 562047 45385 CPT Outpatient 119569.80 22050.95 United United Medicare 0.01 1648.12 0.01 119569.80 0.01 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 562047 45391 CPT Outpatient 24923.85 4596.43 United United Medicare 0.07 1778.07 0.07 24923.85 0.07 Case Rate 45391 Priced Fragmenting of kidney stone 562047 50590 CPT Outpatient 40930.05 7548.28 United United Medicare 0.09 3683.90 0.09 40930.05 0.09 Case Rate 50590 Priced Fetal non-stress test 562047 59025 CPT Outpatient 3153.15 477.76 United United Medicare 0.06 198.89 0.06 3153.15 0.06 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 562047 64483 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 562047 92567 CPT Outpatient 2224.95 98.50 United United Medicare 0.14 308.98 0.14 2224.95 0.14 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 562047 93000 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 562047 93017 CPT Outpatient 3076.50 532.96 United United Medicare 0.10 308.98 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 562047 93452 CPT Outpatient 55621.65 8611.87 United United Medicare 0.06 3385.39 0.06 55621.65 0.06 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 562047 95810 CPT Outpatient 20341.65 3373.48 United United Medicare 0.05 1074.10 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 562047 95811 CPT Outpatient 22491.00 3731.18 United United Medicare 0.05 1074.10 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 562047 95812 CPT Outpatient 5578.65 925.83 United United Medicare 0.06 308.98 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 562047 96040 CPT Outpatient 0.01 102.81 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 562047 96413 CPT Outpatient 4856.25 472.45 United United Medicare 0.55 2654.07 0.55 4856.25 0.55 Case Rate 96413 Priced Ultrasound therapy 562047 97035 CPT Outpatient 2111.55 134.99 United United Medicare 0.04 85.29 0.04 2111.55 0.04 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 562047 97110 CPT Outpatient 6494.25 92.86 United United Medicare 0.05 355.13 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 562047 97116 CPT Outpatient 4723.95 110.61 United United Medicare 0.06 289.20 0.06 4723.95 0.06 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 562047 70450 CPT Outpatient 8566.95 835.61 United United Medicare 0.06 551.80 0.06 8566.95 0.06 Case Rate 70450 Priced Mri brain stem w/o dye 562047 70551 CPT Outpatient 7861.35 1361.31 United United Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 70551 Priced MRI scan of brain before and after contrast 562047 70553 CPT Outpatient 10882.20 1625.88 United United Medicare 0.04 429.92 0.04 10882.20 0.04 Case Rate 70553 Priced X-ray exam chest 2 views 562047 71046 CPT Outpatient 859.95 150.37 United United Medicare 0.11 94.43 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 562047 71250 CPT Outpatient 7288.05 1261.63 United United Medicare 0.02 127.10 0.02 7288.05 0.02 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 562047 72082 CPT Outpatient 2022.30 253.33 United United Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 562047 72100 CPT Outpatient 1599.15 277.38 United United Medicare 0.08 127.10 0.08 1599.15 0.08 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 562047 72110 CPT Outpatient 1389.15 241.04 United United Medicare 0.09 127.10 0.09 1389.15 0.09 Case Rate 72110 Priced MRI scan of lower spinal canal 562047 72148 CPT Outpatient 7861.35 1361.31 United United Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 562047 72193 CPT Outpatient 13671.00 1412.01 United United Medicare 0.02 208.54 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 562047 73030 CPT Outpatient 1452.15 251.43 United United Medicare 0.07 94.43 0.07 1452.15 0.07 Case Rate 73030 Priced X-ray exam of elbow 562047 73080 CPT Outpatient 1356.60 235.68 United United Medicare 0.07 94.43 0.07 1356.60 0.07 Case Rate 73080 Priced X-ray exam of forearm 562047 73090 CPT Outpatient 1243.20 215.26 United United Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73090 Priced X-ray exam of wrist 562047 73110 CPT Outpatient 1243.20 215.26 United United Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 562047 73130 CPT Outpatient 1243.20 215.26 United United Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73130 Priced X-ray exam hips bi 2 views 562047 73521 CPT Outpatient 970.20 228.41 United United Medicare 0.13 127.10 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 562047 73562 CPT Outpatient 802.20 139.12 United United Medicare 0.12 94.43 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 562047 73590 CPT Outpatient 1243.20 215.26 United United Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73590 Priced X-ray exam of ankle 562047 73610 CPT Outpatient 1378.65 239.31 United United Medicare 0.07 94.43 0.07 1378.65 0.07 Case Rate 73610 Priced X-ray exam of foot 562047 73630 CPT Outpatient 975.45 169.41 United United Medicare 0.10 94.43 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 562047 73721 CPT Outpatient 7861.35 1361.31 United United Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 562047 74177 CPT Outpatient 14222.25 1412.01 United United Medicare 0.03 429.92 0.03 14222.25 0.03 Case Rate 74177 Priced Contrst x-ray exam of throat 562047 74210 CPT Outpatient 0.01 440.39 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 562047 76098 CPT Outpatient 6141.45 407.86 United United Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 76098 Priced Us exam of head and neck 562047 76536 CPT Outpatient 5512.50 955.18 United United Medicare 0.02 127.10 0.02 5512.50 0.02 Case Rate 76536 Priced Ultrasound breast limited 562047 76642 CPT Outpatient 5777.10 127.70 United United Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 562047 76700 CPT Outpatient 4917.15 851.88 United United Medicare 0.03 127.10 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 562047 76705 CPT Outpatient 3836.70 665.17 United United Medicare 0.03 127.10 0.03 3836.70 0.03 Case Rate 76705 Priced Us exam abdo back wall comp 562047 76770 CPT Outpatient 5171.25 895.48 United United Medicare 0.02 127.10 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 562047 76775 CPT Outpatient 3969.00 686.97 United United Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 562047 76801 CPT Outpatient 2006.55 347.98 United United Medicare 0.06 127.10 0.06 2006.55 0.06 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 562047 76805 CPT Outpatient 3969.00 686.97 United United Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 562047 76811 CPT Outpatient 2844.45 492.99 United United Medicare 0.09 268.63 0.09 2844.45 0.09 Case Rate 76811 Priced Ob us nuchal meas 1 gest 562047 76813 CPT Outpatient 1044.75 180.83 United United Medicare 0.12 127.10 0.12 1044.75 0.12 Case Rate 76813 Priced Ob us limited fetus(s) 562047 76815 CPT Outpatient 6428.10 639.90 United United Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76815 Priced Ob us follow-up per fetus 562047 76816 CPT Outpatient 4818.45 833.88 United United Medicare 0.03 127.10 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 562047 76817 CPT Outpatient 6428.10 476.73 United United Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76817 Priced Fetal biophys profil w/o nst 562047 76819 CPT Outpatient 1741.95 302.65 United United Medicare 0.07 127.10 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 562047 76830 CPT Outpatient 9305.10 806.54 United United Medicare 0.03 254.21 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 562047 76870 CPT Outpatient 6328.35 1096.55 United United Medicare 0.02 127.10 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 562047 76885 CPT Outpatient 3836.70 665.17 United United Medicare 0.02 94.43 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 562047 77065 CPT Outpatient 3451.35 192.07 United United Medicare 0.05 158.33 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 562047 77066 CPT Outpatient 5777.10 235.68 United United Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 562047 77067 CPT Outpatient 1416.45 205.57 United United Medicare 0.05 63.90 0.05 1416.45 0.05 Case Rate 77067 Priced X-rays for bone age 562047 77072 CPT Outpatient 2022.30 163.87 United United Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 77072 Priced Joint survey single view 562047 77077 CPT Outpatient 985.95 171.14 United United Medicare 0.13 124.57 0.13 985.95 0.13 Case Rate 77077 Priced Dxa bone density axial 562047 77080 CPT Outpatient 3257.10 319.09 United United Medicare 0.06 191.00 0.06 3257.10 0.06 Case Rate 77080 Priced Fna bx w/us gdn 1st les 562047 10005 CPT Outpatient 5512.50 547.24 United United Medicare 0.13 726.50 0.13 5512.50 0.13 Case Rate 10005 Priced Fna bx w/us gdn ea addl 562047 10006 CPT Outpatient 10628.10 594.83 United United Medicare 0.07 726.50 0.07 10628.10 0.07 Case Rate 10006 Priced Drainage of hematoma/fluid 562047 10140 CPT Outpatient 23209.20 1081.95 United United Medicare 0.27 6181.44 0.27 23209.20 0.27 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 562047 11042 CPT Outpatient 2668.05 481.45 United United Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb bone 20 sq cm/< 562047 11044 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 562047 11406 CPT Outpatient 19967.85 3427.81 United United Medicare 0.09 1700.21 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 562047 11424 CPT Outpatient 0.01 1004.93 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 562047 11770 CPT Outpatient 19173.00 3291.37 United United Medicare 0.15 2826.15 0.15 19173.00 0.15 Case Rate 11770 Priced Replace tissue expander 562047 11970 CPT Outpatient 59239.95 10169.52 United United Medicare 0.52 30989.99 0.52 59239.95 0.52 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 562047 14020 CPT Outpatient 32166.75 5521.96 United United Medicare 0.06 1999.63 0.06 32166.75 0.06 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 562047 14060 CPT Outpatient 25993.80 1374.69 United United Medicare 0.31 7937.33 0.31 25993.80 0.31 Case Rate 14060 Priced Wound prep trk/arm/leg 562047 15002 CPT Outpatient 41748.00 1441.73 United United Medicare 0.21 8825.17 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 562047 15271 CPT Outpatient 24343.20 3769.48 United United Medicare 0.08 1999.63 0.08 24343.20 0.08 Case Rate 15271 Priced Acellular derm matrix implt 562047 15777 CPT Outpatient 101672.55 17453.79 United United Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 15777 Priced Exc skin abd 562047 15830 CPT Outpatient 54696.60 9389.58 United United Medicare 0.12 6325.99 0.12 54696.60 0.12 Case Rate 15830 Priced Dressing change not for burn 562047 15852 CPT Outpatient 0.01 290.74 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 562047 15877 CPT Outpatient 63741.30 10942.26 United United Medicare 0.17 10877.73 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 562047 15879 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 562047 19000 CPT Outpatient 10143.00 594.83 United United Medicare 0.08 790.40 0.08 10143.00 0.08 Case Rate 19000 Priced Bx breast 1st lesion strtctc 562047 19081 CPT Outpatient 12341.70 1250.69 United United Medicare 0.14 1758.68 0.14 12341.70 0.14 Case Rate 19081 Priced Bx breast add lesion us imag 562047 19084 CPT Outpatient 29058.75 547.24 United United Medicare 0.07 1975.03 0.07 29058.75 0.07 Case Rate 19084 Priced Biopsy of breast open 562047 19101 CPT Outpatient 39545.10 2737.82 United United Medicare 0.23 8988.74 0.23 39545.10 0.23 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 562047 19120 CPT Outpatient 35761.95 2737.82 United United Medicare 0.12 4298.03 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 562047 19125 CPT Outpatient 33184.20 0.01 United United Medicare 0.26 8661.10 0.26 33184.20 0.26 Case Rate 19125 Priced Perq device breast 1st imag 562047 19281 CPT Outpatient 6141.45 598.61 United United Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 19281 Priced Perq device breast ea imag 562047 19282 CPT Outpatient 8379.00 319.04 United United Medicare 0.15 1290.61 0.15 8379.00 0.15 Case Rate 19282 Priced Partial mastectomy 562047 19301 CPT Outpatient 39157.65 6722.06 United United Medicare 0.20 7846.47 0.20 39157.65 0.20 Case Rate 19301 Priced Mast simple complete 562047 19303 CPT Outpatient 105389.55 18091.87 United United Medicare 0.28 29200.15 0.28 105389.55 0.28 Case Rate 19303 Priced Reduction of large breast 562047 19318 CPT Outpatient 65239.65 11199.47 United United Medicare 0.10 6577.10 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 562047 19340 CPT Outpatient 113100.75 19415.63 United United Medicare 0.13 14822.97 0.13 113100.75 0.13 Case Rate 19340 Priced Delayed breast prosthesis 562047 19342 CPT Outpatient 56988.75 9783.07 United United Medicare 0.36 20246.20 0.36 56988.75 0.36 Case Rate 19342 Priced Breast reconstruction 562047 19357 CPT Outpatient 101672.55 17453.79 United United Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 19357 Priced Breast reconstruction 562047 19366 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 562047 19380 CPT Outpatient 61493.25 10556.34 United United Medicare 0.21 13212.28 0.21 61493.25 0.21 Case Rate 19380 Priced Removal of support implant 562047 20680 CPT Outpatient 42329.70 7266.60 United United Medicare 0.14 5804.91 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 562047 22856 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 562047 24538 CPT Outpatient 51237.90 4775.24 United United Medicare 0.19 9816.98 0.19 51237.90 0.19 Case Rate 24538 Priced Remove wrist tendon lesion 562047 25111 CPT Outpatient 25855.20 4438.48 United United Medicare 0.06 1654.95 0.06 25855.20 0.06 Case Rate 25111 Priced Incise finger tendon sheath 562047 26055 CPT Outpatient 15862.35 2723.04 United United Medicare 0.12 1931.13 0.12 15862.35 0.12 Case Rate 26055 Priced Treat finger fracture each 562047 26727 CPT Outpatient 22779.75 2030.47 United United Medicare 0.16 3574.88 0.16 22779.75 0.16 Case Rate 26727 Priced Revision of knee joint 562047 27446 CPT Outpatient 67882.50 11653.16 United United Medicare 0.23 15567.47 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 562047 27447 CPT Outpatient 130698.75 22436.62 United United Medicare 0.12 15604.41 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 562047 27485 CPT Outpatient 43310.40 7434.95 United United Medicare 0.26 11063.75 0.26 43310.40 0.26 Case Rate 27485 Priced Repair achilles tendon 562047 27650 CPT Outpatient 38246.25 3762.57 United United Medicare 0.29 11041.86 0.29 38246.25 0.29 Case Rate 27650 Priced Treatment of ankle fracture 562047 27792 CPT Outpatient 36101.10 6197.36 United United Medicare 0.21 7581.28 0.21 36101.10 0.21 Case Rate 27792 Priced Treatment of ankle fracture 562047 27814 CPT Outpatient 49405.65 8481.30 United United Medicare 0.16 7766.50 0.16 49405.65 0.16 Case Rate 27814 Priced Removal of foot lesion 562047 28080 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 562047 28285 CPT Outpatient 68603.85 11776.99 United United Medicare 0.20 13986.50 0.20 68603.85 0.20 Case Rate 28285 Priced Correction hallux valgus 562047 28296 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 562047 29823 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 562047 29826 CPT Outpatient 49840.35 8555.93 United United Medicare 0.15 7312.64 0.15 49840.35 0.15 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 562047 29881 CPT Outpatient 35556.15 6103.81 United United Medicare 0.09 3306.24 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 562047 29882 CPT Outpatient 61099.50 10488.75 United United Medicare 0.19 11577.74 0.19 61099.50 0.19 Case Rate 29882 Priced Percut bx lung/mediastinum 562047 32405 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 562047 32555 CPT Outpatient 14597.10 687.29 United United Medicare 0.05 711.62 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 562047 32664 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 562047 35190 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 562047 36478 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 562047 36561 CPT Outpatient 53531.10 3292.99 United United Medicare 0.06 3342.08 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 562047 36569 CPT Outpatient 31421.25 1299.06 United United Medicare 0.06 1811.50 0.06 31421.25 0.06 Case Rate 36569 Priced Removal tunneled cv cath 562047 36590 CPT Outpatient 1996.05 273.95 United United Medicare 0.82 1641.71 0.82 1996.05 0.82 Case Rate 36590 Priced Av fuse uppr arm basilic 562047 36819 CPT Outpatient 56861.70 9761.26 United United Medicare 0.17 9459.82 0.17 56861.70 0.17 Case Rate 36819 Priced Av fusion direct any site 562047 36821 CPT Outpatient 42953.40 7373.67 United United Medicare 0.16 7056.50 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 562047 36825 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 562047 36830 CPT Outpatient 53656.05 9210.96 United United Medicare 0.17 9346.72 0.17 53656.05 0.17 Case Rate 36830 Priced Av fistula revision open 562047 36832 CPT Outpatient 52492.65 9011.24 United United Medicare 0.23 12046.01 0.23 52492.65 0.23 Case Rate 36832 Priced Av fistula revision 562047 36833 CPT Outpatient 37098.60 6368.59 United United Medicare 0.28 10242.79 0.28 37098.60 0.28 Case Rate 36833 Priced Intro cath dialysis circuit 562047 36903 CPT Outpatient 77541.45 10669.90 United United Medicare 0.24 18454.26 0.24 77541.45 0.24 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 562047 36906 CPT Outpatient 96694.50 16175.64 United United Medicare 0.27 26216.69 0.27 96694.50 0.27 Case Rate 36906 Priced Fem/popl revas w/tla 562047 37224 CPT Outpatient 200076.45 5139.31 United United Medicare 0.14 27878.39 0.14 200076.45 0.14 Case Rate 37224 Priced Fem/popl revasc stnt & ather 562047 37227 CPT Outpatient 117170.55 18045.38 United United Medicare 0.17 19636.18 0.17 117170.55 0.17 Case Rate 37227 Priced Revise leg vein 562047 37700 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 562047 37722 CPT Outpatient 27815.55 4775.00 United United Medicare 0.37 10398.58 0.37 27815.55 0.37 Case Rate 37722 Priced Stab phleb veins xtr 10-20 562047 37765 CPT Outpatient 26561.85 4559.78 United United Medicare 0.52 13740.66 0.52 26561.85 0.52 Case Rate 37765 Priced Biopsy/removal lymph nodes 562047 38500 CPT Outpatient 35955.15 6172.30 United United Medicare 0.11 3918.72 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 562047 38525 CPT Outpatient 101194.80 17371.77 United United Medicare 0.19 18851.15 0.19 101194.80 0.19 Case Rate 38525 Priced Laparoscopy lymph node biop 562047 38570 CPT Outpatient 65631.30 11266.71 United United Medicare 0.28 18089.66 0.28 65631.30 0.28 Case Rate 38570 Priced Laparoscopy lymphadenectomy 562047 38571 CPT Outpatient 84031.50 14425.41 United United Medicare 0.26 22194.38 0.26 84031.50 0.26 Case Rate 38571 Priced Laparoscopy lymphadenectomy 562047 38572 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 562047 38792 CPT Outpatient 2868.60 432.48 United United Medicare 0.15 440.09 0.15 2868.60 0.15 Case Rate 38792 Priced Excision of gum lesion 562047 41825 CPT Outpatient 11580.45 1987.98 United United Medicare 0.30 3440.87 0.30 11580.45 0.30 Case Rate 41825 Priced Reconstruct cleft palate 562047 42200 CPT Outpatient 36703.80 6300.82 United United Medicare 0.16 5937.71 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 562047 42820 CPT Outpatient 17232.60 2958.26 United United Medicare 0.64 11027.66 0.64 17232.60 0.64 Case Rate 42820 Priced Control throat bleeding 562047 42960 CPT Outpatient 24066.00 4131.33 United United Medicare 0.20 4852.02 0.20 24066.00 0.20 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 562047 43235 CPT Outpatient 8856.75 1633.35 United United Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Laparoscopy fundoplasty 562047 43280 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 562047 43282 CPT Outpatient 84344.40 14479.12 United United Medicare 0.13 10981.07 0.13 84344.40 0.13 Case Rate 43282 Priced Laparoscopy appendectomy 562047 44970 CPT Outpatient 82300.05 14128.18 United United Medicare 0.08 6988.44 0.08 82300.05 0.08 Case Rate 44970 Priced Diagnostic sigmoidoscopy 562047 45330 CPT Outpatient 17286.15 542.26 United United Medicare 0.11 1880.24 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 562047 47000 CPT Outpatient 10398.15 1225.34 United United Medicare 0.20 2101.24 0.20 10398.15 0.20 Case Rate 47000 Priced Removal of gallbladder using an endoscope 562047 47562 CPT Outpatient 58430.40 10030.55 United United Medicare 0.10 5965.34 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 562047 47563 CPT Outpatient 71747.55 12316.66 United United Medicare 0.09 6769.21 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 562047 49083 CPT Outpatient 6979.35 1113.95 United United Medicare 0.14 944.67 0.14 6979.35 0.14 Case Rate 49083 Priced Diag laparo separate proc 562047 49320 CPT Outpatient 31629.15 5429.67 United United Medicare 0.42 13201.26 0.42 31629.15 0.42 Case Rate 49320 Priced Laparoscopy biopsy 562047 49321 CPT Outpatient 41892.90 7191.61 United United Medicare 0.32 13491.42 0.32 41892.90 0.32 Case Rate 49321 Priced Laparoscopy aspiration 562047 49322 CPT Outpatient 34392.75 5904.09 United United Medicare 0.39 13396.33 0.39 34392.75 0.39 Case Rate 49322 Priced Lap insert tunnel ip cath 562047 49324 CPT Outpatient 39264.75 6740.45 United United Medicare 0.15 5972.32 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 562047 49329 CPT Outpatient 58696.05 10076.16 United United Medicare 0.29 17162.20 0.29 58696.05 0.29 Case Rate 49329 Priced Ins tun ip cath for dial opn 562047 49421 CPT Outpatient 25460.40 3319.30 United United Medicare 0.15 3702.67 0.15 25460.40 0.15 Case Rate 49421 Priced Remove tunneled ip cath 562047 49422 CPT Outpatient 25515.00 4380.08 United United Medicare 0.13 3342.08 0.13 25515.00 0.13 Case Rate 49422 Priced Rpr ing hernia init reduce 562047 49500 CPT Outpatient 19594.05 3363.65 United United Medicare 0.56 11018.31 0.56 19594.05 0.56 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 562047 49505 CPT Outpatient 34915.65 5993.85 United United Medicare 0.21 7278.08 0.21 34915.65 0.21 Case Rate 49505 Priced Prp i/hern init block >5 yr 562047 49507 CPT Outpatient 29794.80 5114.77 United United Medicare 0.25 7306.28 0.25 29794.80 0.25 Case Rate 49507 Priced Rerepair ing hernia reduce 562047 49520 CPT Outpatient 36940.05 6341.38 United United Medicare 0.20 7341.71 0.20 36940.05 0.20 Case Rate 49520 Priced Rpr ventral hern init reduc 562047 49560 CPT Outpatient 53177.25 9128.76 United United Medicare 0.18 9686.73 0.18 53177.25 0.18 Case Rate 49560 Priced Rpr ventral hern init block 562047 49561 CPT Outpatient 30755.55 5279.70 United United Medicare 0.24 7522.67 0.24 30755.55 0.24 Case Rate 49561 Priced Rerepair ventrl hern reduce 562047 49565 CPT Outpatient 69917.40 12002.49 United United Medicare 0.14 10018.26 0.14 69917.40 0.14 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 562047 49585 CPT Outpatient 41806.80 7176.83 United United Medicare 0.23 9650.59 0.23 41806.80 0.23 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 562047 49587 CPT Outpatient 37320.15 6406.63 United United Medicare 0.20 7369.53 0.20 37320.15 0.20 Case Rate 49587 Priced Lap ing hernia repair init 562047 49650 CPT Outpatient 41932.80 7198.46 United United Medicare 0.14 5784.73 0.14 41932.80 0.14 Case Rate 49650 Priced Lap ing hernia repair recur 562047 49651 CPT Outpatient 46915.05 8053.75 United United Medicare 0.26 12396.08 0.26 46915.05 0.26 Case Rate 49651 Priced Lap vent/abd hernia repair 562047 49652 CPT Outpatient 51294.60 8805.57 United United Medicare 0.12 6001.15 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 562047 49653 CPT Outpatient 46102.35 7914.24 United United Medicare 0.13 5907.33 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 562047 49654 CPT Outpatient 47221.65 8106.38 United United Medicare 0.22 10246.22 0.22 47221.65 0.22 Case Rate 49654 Priced Lap inc hern repair comp 562047 49655 CPT Outpatient 54590.55 9371.38 United United Medicare 0.19 10557.83 0.19 54590.55 0.19 Case Rate 49655 Priced Lap inc hernia repair recur 562047 49656 CPT Outpatient 55443.15 9517.74 United United Medicare 0.19 10492.84 0.19 55443.15 0.19 Case Rate 49656 Priced Removal of kidney stone 562047 50080 CPT Outpatient 53165.70 9126.78 United United Medicare 0.32 16951.33 0.32 53165.70 0.32 Case Rate 50080 Priced Removal of kidney stone 562047 50081 CPT Outpatient 66931.20 11489.86 United United Medicare 0.30 20375.49 0.30 66931.20 0.30 Case Rate 50081 Priced Renal biopsy perq 562047 50200 CPT Outpatient 43096.20 1225.34 United United Medicare 0.23 9703.00 0.23 43096.20 0.23 Case Rate 50200 Priced Plmt nephroureteral catheter 562047 50433 CPT Outpatient 64566.60 1424.48 United United Medicare 0.27 17570.80 0.27 64566.60 0.27 Case Rate 50433 Priced Laparo radical nephrectomy 562047 50545 CPT Outpatient 43449.00 7458.75 United United Medicare 0.03 1190.00 0.03 43449.00 0.03 Case Rate 50545 Priced Laparoscope proc ureter 562047 50949 CPT Outpatient 49986.30 8580.98 United United Medicare 0.34 17208.73 0.34 49986.30 0.34 Case Rate 50949 Priced Injection for bladder x-ray 562047 51600 CPT Outpatient 3285.45 89.22 United United Medicare 0.08 268.63 0.08 3285.45 0.08 Case Rate 51600 Priced Cystoscopy 562047 52000 CPT Outpatient 22149.75 3802.37 United United Medicare 0.36 7975.55 0.36 22149.75 0.36 Case Rate 52000 Priced Cystoscopy & ureter catheter 562047 52005 CPT Outpatient 42529.20 2095.77 United United Medicare 0.21 9136.51 0.21 42529.20 0.21 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 562047 52204 CPT Outpatient 31274.25 5368.75 United United Medicare 0.18 5745.54 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 562047 52224 CPT Outpatient 13445.25 2308.10 United United Medicare 0.54 7303.88 0.54 13445.25 0.54 Case Rate 52224 Priced Cystoscopy and treatment 562047 52234 CPT Outpatient 28510.65 4894.33 United United Medicare 0.27 7572.52 0.27 28510.65 0.27 Case Rate 52234 Priced Cystoscopy and treatment 562047 52235 CPT Outpatient 29417.85 5050.06 United United Medicare 0.25 7276.20 0.25 29417.85 0.25 Case Rate 52235 Priced Cystoscopy and treatment 562047 52240 CPT Outpatient 33933.90 5825.32 United United Medicare 0.27 9046.24 0.27 33933.90 0.27 Case Rate 52240 Priced Cystoscopy and treatment 562047 52281 CPT Outpatient 22159.20 3804.00 United United Medicare 0.26 5688.66 0.26 22159.20 0.26 Case Rate 52281 Priced Remove bladder stone 562047 52317 CPT Outpatient 27085.80 4649.73 United United Medicare 0.27 7426.56 0.27 27085.80 0.27 Case Rate 52317 Priced Remove bladder stone 562047 52318 CPT Outpatient 26685.75 4581.05 United United Medicare 0.28 7361.57 0.28 26685.75 0.28 Case Rate 52318 Priced Cystoscopy and treatment 562047 52332 CPT Outpatient 115306.80 19794.33 United United Medicare 0.18 20580.50 0.18 115306.80 0.18 Case Rate 52332 Priced Cystouretero w/stone remove 562047 52352 CPT Outpatient 42420.00 7282.10 United United Medicare 0.38 16312.79 0.38 42420.00 0.38 Case Rate 52352 Priced Cystouretero w/lithotripsy 562047 52353 CPT Outpatient 38608.50 6627.79 United United Medicare 0.24 9133.86 0.24 38608.50 0.24 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 562047 52356 CPT Outpatient 36255.45 6223.85 United United Medicare 0.25 9133.86 0.25 36255.45 0.25 Case Rate 52356 Priced Prostatectomy (turp) 562047 52601 CPT Outpatient 35371.35 6072.08 United United Medicare 0.25 8684.69 0.25 35371.35 0.25 Case Rate 52601 Priced Laser surgery of prostate 562047 52648 CPT Outpatient 24264.45 4165.40 United United Medicare 0.37 9020.55 0.37 24264.45 0.37 Case Rate 52648 Priced Revision of urethra 562047 53450 CPT Outpatient 16209.90 2782.70 United United Medicare 0.35 5679.84 0.35 16209.90 0.35 Case Rate 53450 Priced Urology surgery procedure 562047 53899 CPT Outpatient 25368.00 134.83 United United Medicare 0.27 6862.63 0.27 25368.00 0.27 Case Rate 53899 Priced Circumcision w/regionl block 562047 54150 CPT Outpatient 14700.00 2523.50 United United Medicare 0.14 2090.37 0.14 14700.00 0.14 Case Rate 54150 Priced Circum 28 days or older 562047 54161 CPT Outpatient 19186.65 3293.71 United United Medicare 0.11 2049.61 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 562047 54162 CPT Outpatient 19795.65 3398.25 United United Medicare 0.85 16823.10 0.85 19795.65 0.85 Case Rate 54162 Priced Repair of circumcision 562047 54163 CPT Outpatient 16391.55 2813.88 United United Medicare 0.24 4010.49 0.24 16391.55 0.24 Case Rate 54163 Priced Reconstruction of urethra 562047 54324 CPT Outpatient 32880.75 5644.53 United United Medicare 0.28 9303.52 0.28 32880.75 0.28 Case Rate 54324 Priced Revise penis/urethra 562047 54332 CPT Outpatient 19968.90 3427.99 United United Medicare 0.18 3589.47 0.18 19968.90 0.18 Case Rate 54332 Priced Insert self-contd prosthesis 562047 54401 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 562047 54520 CPT Outpatient 35442.75 6084.34 United United Medicare 0.34 12158.30 0.34 35442.75 0.34 Case Rate 54520 Priced Reduce testis torsion 562047 54600 CPT Outpatient 55049.40 9450.15 United United Medicare 0.28 15402.48 0.28 55049.40 0.28 Case Rate 54600 Priced Suspension of testis 562047 54640 CPT Outpatient 26860.05 4610.98 United United Medicare 0.28 7428.84 0.28 26860.05 0.28 Case Rate 54640 Priced Removal of hydrocele 562047 55040 CPT Outpatient 27277.95 4682.71 United United Medicare 0.27 7369.91 0.27 27277.95 0.27 Case Rate 55040 Priced Biopsy of prostate gland 562047 55700 CPT Outpatient 28699.65 4926.77 United United Medicare 0.13 3731.04 0.13 28699.65 0.13 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 562047 55866 CPT Outpatient 93088.80 15980.24 United United Medicare 0.24 22017.24 0.24 93088.80 0.24 Case Rate 55866 Priced Closure of vagina 562047 57120 CPT Outpatient 34369.65 5900.12 United United Medicare 0.43 14932.00 0.43 34369.65 0.43 Case Rate 57120 Priced Repair of vagina 562047 57200 CPT Outpatient 25247.25 4334.11 United United Medicare 0.31 7732.37 0.31 25247.25 0.31 Case Rate 57200 Priced Anterior colporrhaphy 562047 57240 CPT Outpatient 36210.30 6216.10 United United Medicare 0.53 19223.69 0.53 36210.30 0.53 Case Rate 57240 Priced Repair rectum & vagina 562047 57250 CPT Outpatient 40441.80 6942.51 United United Medicare 0.56 22691.64 0.56 40441.80 0.56 Case Rate 57250 Priced Cmbn ant pst colprhy 562047 57260 CPT Outpatient 46323.90 7952.27 United United Medicare 0.66 30437.82 0.66 46323.90 0.66 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 562047 57265 CPT Outpatient 42586.95 7310.76 United United Medicare 0.43 18248.88 0.43 42586.95 0.43 Case Rate 57265 Priced Repair of bowel bulge 562047 57268 CPT Outpatient 36865.50 6328.58 United United Medicare 0.49 18090.91 0.49 36865.50 0.49 Case Rate 57268 Priced Colpopexy extraperitoneal 562047 57282 CPT Outpatient 45629.85 7833.12 United United Medicare 0.66 30324.80 0.66 45629.85 0.66 Case Rate 57282 Priced Repair bladder defect 562047 57288 CPT Outpatient 43069.95 7393.67 United United Medicare 0.56 24109.88 0.56 43069.95 0.56 Case Rate 57288 Priced Bx/curett of cervix w/scope 562047 57454 CPT Outpatient 2888.55 442.93 United United Medicare 0.11 329.27 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 562047 57520 CPT Outpatient 26728.80 4588.44 United United Medicare 0.16 4211.41 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 562047 57522 CPT Outpatient 22737.75 3903.31 United United Medicare 0.15 3411.24 0.15 22737.75 0.15 Case Rate 57522 Priced Biopsy of uterus lining 562047 58100 CPT Outpatient 2371.95 194.80 United United Medicare 0.08 198.89 0.08 2371.95 0.08 Case Rate 58100 Priced Catheter for hysterography 562047 58340 CPT Outpatient 6322.05 131.04 United United Medicare 0.04 268.63 0.04 6322.05 0.04 Case Rate 58340 Priced Reopen fallopian tube 562047 58350 CPT Outpatient 46507.65 7983.81 United United Medicare 0.38 17563.57 0.38 46507.65 0.38 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 562047 58542 CPT Outpatient 64194.90 11020.12 United United Medicare 0.37 24060.91 0.37 64194.90 0.37 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 562047 58544 CPT Outpatient 51020.55 8758.53 United United Medicare 0.65 33216.81 0.65 51020.55 0.65 Case Rate 58544 Priced Laparoscopic myomectomy 562047 58545 CPT Outpatient 56946.75 9775.86 United United Medicare 0.17 9718.98 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 562047 58552 CPT Outpatient 57228.15 9824.17 United United Medicare 0.32 18381.02 0.32 57228.15 0.32 Case Rate 58552 Priced Hysteroscopy biopsy 562047 58558 CPT Outpatient 28581.00 2077.02 United United Medicare 0.25 7238.81 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 562047 58561 CPT Outpatient 35222.25 6046.49 United United Medicare 0.27 9531.42 0.27 35222.25 0.27 Case Rate 58561 Priced Hysteroscopy ablation 562047 58563 CPT Outpatient 38399.55 6591.92 United United Medicare 0.51 19555.87 0.51 38399.55 0.51 Case Rate 58563 Priced Tlh uterus 250 g or less 562047 58570 CPT Outpatient 43316.70 7436.03 United United Medicare 0.26 11083.71 0.26 43316.70 0.26 Case Rate 58570 Priced Tlh w/t/o 250 g or less 562047 58571 CPT Outpatient 48603.45 8343.59 United United Medicare 0.30 14369.35 0.30 48603.45 0.30 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 562047 58573 CPT Outpatient 52905.30 9082.08 United United Medicare 0.32 16722.51 0.32 52905.30 0.32 Case Rate 58573 Priced Laparoscopy remove adnexa 562047 58661 CPT Outpatient 47008.50 8069.79 United United Medicare 0.18 8686.07 0.18 47008.50 0.18 Case Rate 58661 Priced Laparoscopy excise lesions 562047 58662 CPT Outpatient 45053.40 7734.17 United United Medicare 0.38 17220.22 0.38 45053.40 0.38 Case Rate 58662 Priced Treat ectopic pregnancy 562047 59151 CPT Outpatient 74690.70 12821.90 United United Medicare 0.09 6630.70 0.09 74690.70 0.09 Case Rate 59151 Priced Treatment of miscarriage 562047 59812 CPT Outpatient 56109.90 9632.20 United United Medicare 0.07 4075.96 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 562047 60220 CPT Outpatient 53639.25 9208.07 United United Medicare 0.11 6088.34 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 562047 60240 CPT Outpatient 98252.70 16866.71 United United Medicare 0.06 5905.23 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 562047 60500 CPT Outpatient 150495.45 25835.05 United United Medicare 0.06 9768.16 0.06 150495.45 0.06 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 562047 62322 CPT Outpatient 43709.40 514.24 United United Medicare 0.28 12235.33 0.28 43709.40 0.28 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 562047 62323 CPT Outpatient 8304.45 467.31 United United Medicare 16.45 136591.28 16.45 8304.45 16.45 Case Rate 62323 Priced Low back disk surgery 562047 63030 CPT Outpatient 50287.65 8632.71 United United Medicare 0.30 14893.92 0.30 50287.65 0.30 Case Rate 63030 Priced Inc for vagus n elect impl 562047 64568 CPT Outpatient 124562.55 21383.24 United United Medicare 0.27 33814.93 0.27 124562.55 0.27 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 562047 66821 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 562047 66984 CPT Outpatient 0.01 0.01 United United Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 717001 216 DRG Inpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 717001 460 DRG Inpatient 416122.79 53834.63 Wellcare Wellcare Medicare 0.09 36507.56 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 717001 470 DRG Inpatient 167912.19 21723.13 Wellcare Wellcare Medicare 0.11 18221.64 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 717001 473 DRG Inpatient 100687.91 13026.19 Wellcare Wellcare Medicare 0.24 23973.82 0.24 100687.91 0.24 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 717001 743 DRG Inpatient 102691.67 13285.42 Wellcare Wellcare Medicare 0.11 11317.53 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 717001 795 DRG Inpatient 6266.93 2335.00 Wellcare Wellcare Medicare 0.49 3065.24 0.49 6266.93 0.49 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 717001 807 DRG Inpatient 116469.59 4193.00 Wellcare Wellcare Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 717001 788 DRG Inpatient 76050.77 4538.00 Wellcare Wellcare Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 717001 59400 CPT Inpatient 116469.59 4193.00 Wellcare Wellcare Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 717001 59510 CPT Inpatient 76050.77 4538.00 Wellcare Wellcare Medicare 0.12 9231.95 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 717001 59610 CPT Inpatient 116469.59 4193.00 Wellcare Wellcare Medicare 0.06 7013.77 0.06 116469.59 0.06 Case Rate 59610 Priced "Psychotherapy, 30 min" 717001 90832 CPT Outpatient 577.50 91.21 Wellcare Wellcare Medicare 0.29 166.55 0.29 577.50 0.29 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 717001 90834 CPT Outpatient 44134.65 271.96 Wellcare Wellcare Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 717001 90837 CPT Outpatient 2240.70 442.93 Wellcare Wellcare Medicare 0.04 84.05 0.04 2240.70 0.04 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 717001 90846 CPT Outpatient 0.01 131.50 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 717001 90847 CPT Outpatient 44134.65 369.97 Wellcare Wellcare Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90847 Priced Group psychotherapy 717001 90853 CPT Outpatient 44134.65 101.99 Wellcare Wellcare Medicare 0.07 3195.22 0.07 44134.65 0.07 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 717001 99203 CPT Outpatient 3480.75 176.07 Wellcare Wellcare Medicare 0.12 403.52 0.12 3480.75 0.12 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 717001 99204 CPT Outpatient 2103.15 233.39 Wellcare Wellcare Medicare 0.19 390.94 0.19 2103.15 0.19 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 717001 99205 CPT Outpatient 4970.70 314.28 Wellcare Wellcare Medicare 0.09 462.07 0.09 4970.70 0.09 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 717001 99243 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 717001 99244 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 717001 99385 CPT Outpatient 1114.05 185.90 Wellcare Wellcare Medicare 0.19 207.05 0.19 1114.05 0.19 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 717001 99386 CPT Outpatient 4877.25 185.90 Wellcare Wellcare Medicare 0.02 98.87 0.02 4877.25 0.02 Fee Schedule 99386 Priced Routine venipuncture 717001 36415 CPT Outpatient 127.05 19.57 Wellcare Wellcare Medicare 0.02 3.02 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 717001 80048 CPT Outpatient 576.45 88.78 Wellcare Wellcare Medicare 0.02 11.70 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 717001 80053 CPT Outpatient 763.35 117.56 Wellcare Wellcare Medicare 0.02 13.22 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 717001 80055 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 717001 80061 CPT Outpatient 1349.25 197.77 Wellcare Wellcare Medicare 0.01 18.53 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 717001 80069 CPT Outpatient 716.10 104.95 Wellcare Wellcare Medicare 0.02 12.01 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 717001 80076 CPT Outpatient 716.10 104.95 Wellcare Wellcare Medicare 0.02 11.31 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 717001 81000 CPT Outpatient 144.90 21.18 Wellcare Wellcare Medicare 0.03 4.39 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 717001 81001 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 717001 81002 CPT Outpatient 57.75 8.89 Wellcare Wellcare Medicare 0.06 3.53 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 717001 81003 CPT Outpatient 219.45 33.80 Wellcare Wellcare Medicare 0.01 3.11 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 717001 82306 CPT Outpatient 1880.55 289.62 Wellcare Wellcare Medicare 0.02 40.96 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 717001 83036 CPT Outpatient 494.55 76.17 Wellcare Wellcare Medicare 0.03 13.44 0.03 494.55 0.03 Fee Schedule 83036 Priced PSA (prostate specific antigen) 717001 84153 CPT Outpatient 1177.05 181.28 Wellcare Wellcare Medicare 0.02 25.45 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 717001 84154 CPT Outpatient 598.50 92.17 Wellcare Wellcare Medicare 0.04 25.45 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 717001 84443 CPT Outpatient 519.75 80.05 Wellcare Wellcare Medicare 0.04 23.25 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 717001 84703 CPT Outpatient 785.40 120.96 Wellcare Wellcare Medicare 0.01 10.40 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 717001 85025 CPT Outpatient 635.25 97.83 Wellcare Wellcare Medicare 0.02 10.75 0.02 635.25 0.02 Fee Schedule 85025 Priced "Complete blood count, automated" 717001 85027 CPT Outpatient 576.45 88.78 Wellcare Wellcare Medicare 0.02 8.95 0.02 576.45 0.02 Fee Schedule 85027 Priced "Blood test, clotting time" 717001 85610 CPT Outpatient 404.25 62.26 Wellcare Wellcare Medicare 0.01 5.43 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 717001 85730 CPT Outpatient 17.22 2.65 Wellcare Wellcare Medicare 0.48 8.31 0.48 17.22 0.48 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 717001 86003 CPT Outpatient 32.55 5.01 Wellcare Wellcare Medicare 0.22 7.23 0.22 32.55 0.22 Fee Schedule 86003 Priced Tb test cell immun measure 717001 86480 CPT Outpatient 530.25 81.66 Wellcare Wellcare Medicare 0.16 85.75 0.16 530.25 0.16 Fee Schedule 86480 Priced Urine culture/colony count 717001 87086 CPT Outpatient 763.35 117.56 Wellcare Wellcare Medicare 0.01 11.16 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 717001 87338 CPT Outpatient 785.40 120.96 Wellcare Wellcare Medicare 0.03 19.90 0.03 785.40 0.03 Fee Schedule 87338 Priced Cytopath eval fna report 717001 88173 CPT Outpatient 750.75 115.62 Wellcare Wellcare Medicare 0.08 57.32 0.08 750.75 0.08 Fee Schedule 88173 Priced Tissue exam by pathologist 717001 88302 CPT Outpatient 635.25 97.83 Wellcare Wellcare Medicare 0.04 28.54 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 717001 88305 CPT Outpatient 323.40 49.81 Wellcare Wellcare Medicare 0.18 57.32 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 717001 11042 CPT Outpatient 2668.05 481.45 Wellcare Wellcare Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb subq tissue add-on 717001 11045 CPT Outpatient 4652.55 330.00 Wellcare Wellcare Medicare 0.09 403.52 0.09 4652.55 0.09 Case Rate 11045 Priced Dx bronchoscope/lavage 717001 31624 CPT Outpatient 41223.00 7602.31 Wellcare Wellcare Medicare 0.19 7805.52 0.19 41223.00 0.19 Case Rate 31624 Priced Bronchoscopy/lung bx each 717001 31628 CPT Outpatient 49048.65 9045.51 Wellcare Wellcare Medicare 0.25 12292.51 0.25 49048.65 0.25 Case Rate 31628 Priced Blood transfusion service 717001 36430 CPT Outpatient 9166.50 574.93 Wellcare Wellcare Medicare 0.08 731.71 0.08 9166.50 0.08 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 717001 43235 CPT Outpatient 8856.75 1633.35 Wellcare Wellcare Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Endoscopic us exam esoph 717001 43237 CPT Outpatient 23867.55 4401.63 Wellcare Wellcare Medicare 0.12 2840.90 0.12 23867.55 0.12 Case Rate 43237 Priced Egd us fine needle bx/aspir 717001 43238 CPT Outpatient 30690.45 5659.90 Wellcare Wellcare Medicare 0.06 1914.48 0.06 30690.45 0.06 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 717001 43239 CPT Outpatient 40191.90 7412.15 Wellcare Wellcare Medicare 0.07 2698.70 0.07 40191.90 0.07 Case Rate 43239 Priced Ercp remove duct calculi 717001 43264 CPT Outpatient 34335.00 6332.03 Wellcare Wellcare Medicare 0.21 7043.47 0.21 34335.00 0.21 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 717001 45378 CPT Outpatient 13991.25 889.35 Wellcare Wellcare Medicare 0.07 926.48 0.07 13991.25 0.07 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 717001 45380 CPT Outpatient 22215.90 4097.04 Wellcare Wellcare Medicare 0.08 1815.96 0.08 22215.90 0.08 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 717001 45385 CPT Outpatient 119569.80 22050.95 Wellcare Wellcare Medicare 0.01 1648.12 0.01 119569.80 0.01 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 717001 45391 CPT Outpatient 24923.85 4596.43 Wellcare Wellcare Medicare 0.07 1778.07 0.07 24923.85 0.07 Case Rate 45391 Priced Fragmenting of kidney stone 717001 50590 CPT Outpatient 40930.05 7548.28 Wellcare Wellcare Medicare 0.09 3683.90 0.09 40930.05 0.09 Case Rate 50590 Priced Fetal non-stress test 717001 59025 CPT Outpatient 3153.15 477.76 Wellcare Wellcare Medicare 0.06 198.89 0.06 3153.15 0.06 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 717001 64483 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 717001 92567 CPT Outpatient 2224.95 98.50 Wellcare Wellcare Medicare 0.14 308.98 0.14 2224.95 0.14 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 717001 93000 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 717001 93017 CPT Outpatient 3076.50 532.96 Wellcare Wellcare Medicare 0.10 308.98 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 717001 93452 CPT Outpatient 55621.65 8611.87 Wellcare Wellcare Medicare 0.06 3385.39 0.06 55621.65 0.06 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 717001 95810 CPT Outpatient 20341.65 3373.48 Wellcare Wellcare Medicare 0.05 1074.10 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 717001 95811 CPT Outpatient 22491.00 3731.18 Wellcare Wellcare Medicare 0.05 1074.10 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 717001 95812 CPT Outpatient 5578.65 925.83 Wellcare Wellcare Medicare 0.06 308.98 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 717001 96040 CPT Outpatient 0.01 102.81 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 717001 96413 CPT Outpatient 4856.25 472.45 Wellcare Wellcare Medicare 0.55 2654.07 0.55 4856.25 0.55 Case Rate 96413 Priced Ultrasound therapy 717001 97035 CPT Outpatient 2111.55 134.99 Wellcare Wellcare Medicare 0.04 85.29 0.04 2111.55 0.04 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 717001 97110 CPT Outpatient 6494.25 92.86 Wellcare Wellcare Medicare 0.05 355.13 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 717001 97116 CPT Outpatient 4723.95 110.61 Wellcare Wellcare Medicare 0.06 289.20 0.06 4723.95 0.06 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 717001 70450 CPT Outpatient 8566.95 835.61 Wellcare Wellcare Medicare 0.06 551.80 0.06 8566.95 0.06 Case Rate 70450 Priced Mri brain stem w/o dye 717001 70551 CPT Outpatient 7861.35 1361.31 Wellcare Wellcare Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 70551 Priced MRI scan of brain before and after contrast 717001 70553 CPT Outpatient 10882.20 1625.88 Wellcare Wellcare Medicare 0.04 429.92 0.04 10882.20 0.04 Case Rate 70553 Priced X-ray exam chest 2 views 717001 71046 CPT Outpatient 859.95 150.37 Wellcare Wellcare Medicare 0.11 94.43 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 717001 71250 CPT Outpatient 7288.05 1261.63 Wellcare Wellcare Medicare 0.02 127.10 0.02 7288.05 0.02 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 717001 72082 CPT Outpatient 2022.30 253.33 Wellcare Wellcare Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 717001 72100 CPT Outpatient 1599.15 277.38 Wellcare Wellcare Medicare 0.08 127.10 0.08 1599.15 0.08 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 717001 72110 CPT Outpatient 1389.15 241.04 Wellcare Wellcare Medicare 0.09 127.10 0.09 1389.15 0.09 Case Rate 72110 Priced MRI scan of lower spinal canal 717001 72148 CPT Outpatient 7861.35 1361.31 Wellcare Wellcare Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 717001 72193 CPT Outpatient 13671.00 1412.01 Wellcare Wellcare Medicare 0.02 208.54 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 717001 73030 CPT Outpatient 1452.15 251.43 Wellcare Wellcare Medicare 0.07 94.43 0.07 1452.15 0.07 Case Rate 73030 Priced X-ray exam of elbow 717001 73080 CPT Outpatient 1356.60 235.68 Wellcare Wellcare Medicare 0.07 94.43 0.07 1356.60 0.07 Case Rate 73080 Priced X-ray exam of forearm 717001 73090 CPT Outpatient 1243.20 215.26 Wellcare Wellcare Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73090 Priced X-ray exam of wrist 717001 73110 CPT Outpatient 1243.20 215.26 Wellcare Wellcare Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 717001 73130 CPT Outpatient 1243.20 215.26 Wellcare Wellcare Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73130 Priced X-ray exam hips bi 2 views 717001 73521 CPT Outpatient 970.20 228.41 Wellcare Wellcare Medicare 0.13 127.10 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 717001 73562 CPT Outpatient 802.20 139.12 Wellcare Wellcare Medicare 0.12 94.43 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 717001 73590 CPT Outpatient 1243.20 215.26 Wellcare Wellcare Medicare 0.08 94.43 0.08 1243.20 0.08 Case Rate 73590 Priced X-ray exam of ankle 717001 73610 CPT Outpatient 1378.65 239.31 Wellcare Wellcare Medicare 0.07 94.43 0.07 1378.65 0.07 Case Rate 73610 Priced X-ray exam of foot 717001 73630 CPT Outpatient 975.45 169.41 Wellcare Wellcare Medicare 0.10 94.43 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 717001 73721 CPT Outpatient 7861.35 1361.31 Wellcare Wellcare Medicare 0.03 268.63 0.03 7861.35 0.03 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 717001 74177 CPT Outpatient 14222.25 1412.01 Wellcare Wellcare Medicare 0.03 429.92 0.03 14222.25 0.03 Case Rate 74177 Priced Contrst x-ray exam of throat 717001 74210 CPT Outpatient 0.01 440.39 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 717001 76098 CPT Outpatient 6141.45 407.86 Wellcare Wellcare Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 76098 Priced Us exam of head and neck 717001 76536 CPT Outpatient 5512.50 955.18 Wellcare Wellcare Medicare 0.02 127.10 0.02 5512.50 0.02 Case Rate 76536 Priced Ultrasound breast limited 717001 76642 CPT Outpatient 5777.10 127.70 Wellcare Wellcare Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 717001 76700 CPT Outpatient 4917.15 851.88 Wellcare Wellcare Medicare 0.03 127.10 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 717001 76705 CPT Outpatient 3836.70 665.17 Wellcare Wellcare Medicare 0.03 127.10 0.03 3836.70 0.03 Case Rate 76705 Priced Us exam abdo back wall comp 717001 76770 CPT Outpatient 5171.25 895.48 Wellcare Wellcare Medicare 0.02 127.10 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 717001 76775 CPT Outpatient 3969.00 686.97 Wellcare Wellcare Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 717001 76801 CPT Outpatient 2006.55 347.98 Wellcare Wellcare Medicare 0.06 127.10 0.06 2006.55 0.06 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 717001 76805 CPT Outpatient 3969.00 686.97 Wellcare Wellcare Medicare 0.03 127.10 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 717001 76811 CPT Outpatient 2844.45 492.99 Wellcare Wellcare Medicare 0.09 268.63 0.09 2844.45 0.09 Case Rate 76811 Priced Ob us nuchal meas 1 gest 717001 76813 CPT Outpatient 1044.75 180.83 Wellcare Wellcare Medicare 0.12 127.10 0.12 1044.75 0.12 Case Rate 76813 Priced Ob us limited fetus(s) 717001 76815 CPT Outpatient 6428.10 639.90 Wellcare Wellcare Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76815 Priced Ob us follow-up per fetus 717001 76816 CPT Outpatient 4818.45 833.88 Wellcare Wellcare Medicare 0.03 127.10 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 717001 76817 CPT Outpatient 6428.10 476.73 Wellcare Wellcare Medicare 0.04 254.21 0.04 6428.10 0.04 Case Rate 76817 Priced Fetal biophys profil w/o nst 717001 76819 CPT Outpatient 1741.95 302.65 Wellcare Wellcare Medicare 0.07 127.10 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 717001 76830 CPT Outpatient 9305.10 806.54 Wellcare Wellcare Medicare 0.03 254.21 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 717001 76870 CPT Outpatient 6328.35 1096.55 Wellcare Wellcare Medicare 0.02 127.10 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 717001 76885 CPT Outpatient 3836.70 665.17 Wellcare Wellcare Medicare 0.02 94.43 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 717001 77065 CPT Outpatient 3451.35 192.07 Wellcare Wellcare Medicare 0.05 158.33 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 717001 77066 CPT Outpatient 5777.10 235.68 Wellcare Wellcare Medicare 0.03 158.33 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 717001 77067 CPT Outpatient 1416.45 205.57 Wellcare Wellcare Medicare 0.05 63.90 0.05 1416.45 0.05 Case Rate 77067 Priced X-rays for bone age 717001 77072 CPT Outpatient 2022.30 163.87 Wellcare Wellcare Medicare 0.13 254.21 0.13 2022.30 0.13 Case Rate 77072 Priced Joint survey single view 717001 77077 CPT Outpatient 985.95 171.14 Wellcare Wellcare Medicare 0.13 124.57 0.13 985.95 0.13 Case Rate 77077 Priced Dxa bone density axial 717001 77080 CPT Outpatient 3257.10 319.09 Wellcare Wellcare Medicare 0.06 191.00 0.06 3257.10 0.06 Case Rate 77080 Priced Fna bx w/us gdn 1st les 717001 10005 CPT Outpatient 5512.50 547.24 Wellcare Wellcare Medicare 0.13 726.50 0.13 5512.50 0.13 Case Rate 10005 Priced Fna bx w/us gdn ea addl 717001 10006 CPT Outpatient 10628.10 594.83 Wellcare Wellcare Medicare 0.07 726.50 0.07 10628.10 0.07 Case Rate 10006 Priced Drainage of hematoma/fluid 717001 10140 CPT Outpatient 23209.20 1081.95 Wellcare Wellcare Medicare 0.27 6181.44 0.27 23209.20 0.27 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 717001 11042 CPT Outpatient 2668.05 481.45 Wellcare Wellcare Medicare 0.15 403.52 0.15 2668.05 0.15 Case Rate 11042 Priced Deb bone 20 sq cm/< 717001 11044 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 717001 11406 CPT Outpatient 19967.85 3427.81 Wellcare Wellcare Medicare 0.09 1700.21 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 717001 11424 CPT Outpatient 0.01 1004.93 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 717001 11770 CPT Outpatient 19173.00 3291.37 Wellcare Wellcare Medicare 0.15 2826.15 0.15 19173.00 0.15 Case Rate 11770 Priced Replace tissue expander 717001 11970 CPT Outpatient 59239.95 10169.52 Wellcare Wellcare Medicare 0.52 30989.99 0.52 59239.95 0.52 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 717001 14020 CPT Outpatient 32166.75 5521.96 Wellcare Wellcare Medicare 0.06 1999.63 0.06 32166.75 0.06 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 717001 14060 CPT Outpatient 25993.80 1374.69 Wellcare Wellcare Medicare 0.31 7937.33 0.31 25993.80 0.31 Case Rate 14060 Priced Wound prep trk/arm/leg 717001 15002 CPT Outpatient 41748.00 1441.73 Wellcare Wellcare Medicare 0.21 8825.17 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 717001 15271 CPT Outpatient 24343.20 3769.48 Wellcare Wellcare Medicare 0.08 1999.63 0.08 24343.20 0.08 Case Rate 15271 Priced Acellular derm matrix implt 717001 15777 CPT Outpatient 101672.55 17453.79 Wellcare Wellcare Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 15777 Priced Exc skin abd 717001 15830 CPT Outpatient 54696.60 9389.58 Wellcare Wellcare Medicare 0.12 6325.99 0.12 54696.60 0.12 Case Rate 15830 Priced Dressing change not for burn 717001 15852 CPT Outpatient 0.01 290.74 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 717001 15877 CPT Outpatient 63741.30 10942.26 Wellcare Wellcare Medicare 0.17 10877.73 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 717001 15879 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 717001 19000 CPT Outpatient 10143.00 594.83 Wellcare Wellcare Medicare 0.08 790.40 0.08 10143.00 0.08 Case Rate 19000 Priced Bx breast 1st lesion strtctc 717001 19081 CPT Outpatient 12341.70 1250.69 Wellcare Wellcare Medicare 0.14 1758.68 0.14 12341.70 0.14 Case Rate 19081 Priced Bx breast add lesion us imag 717001 19084 CPT Outpatient 29058.75 547.24 Wellcare Wellcare Medicare 0.07 1975.03 0.07 29058.75 0.07 Case Rate 19084 Priced Biopsy of breast open 717001 19101 CPT Outpatient 39545.10 2737.82 Wellcare Wellcare Medicare 0.23 8988.74 0.23 39545.10 0.23 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 717001 19120 CPT Outpatient 35761.95 2737.82 Wellcare Wellcare Medicare 0.12 4298.03 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 717001 19125 CPT Outpatient 33184.20 0.01 Wellcare Wellcare Medicare 0.26 8661.10 0.26 33184.20 0.26 Case Rate 19125 Priced Perq device breast 1st imag 717001 19281 CPT Outpatient 6141.45 598.61 Wellcare Wellcare Medicare 0.21 1290.61 0.21 6141.45 0.21 Case Rate 19281 Priced Perq device breast ea imag 717001 19282 CPT Outpatient 8379.00 319.04 Wellcare Wellcare Medicare 0.15 1290.61 0.15 8379.00 0.15 Case Rate 19282 Priced Partial mastectomy 717001 19301 CPT Outpatient 39157.65 6722.06 Wellcare Wellcare Medicare 0.20 7846.47 0.20 39157.65 0.20 Case Rate 19301 Priced Mast simple complete 717001 19303 CPT Outpatient 105389.55 18091.87 Wellcare Wellcare Medicare 0.28 29200.15 0.28 105389.55 0.28 Case Rate 19303 Priced Reduction of large breast 717001 19318 CPT Outpatient 65239.65 11199.47 Wellcare Wellcare Medicare 0.10 6577.10 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 717001 19340 CPT Outpatient 113100.75 19415.63 Wellcare Wellcare Medicare 0.13 14822.97 0.13 113100.75 0.13 Case Rate 19340 Priced Delayed breast prosthesis 717001 19342 CPT Outpatient 56988.75 9783.07 Wellcare Wellcare Medicare 0.36 20246.20 0.36 56988.75 0.36 Case Rate 19342 Priced Breast reconstruction 717001 19357 CPT Outpatient 101672.55 17453.79 Wellcare Wellcare Medicare 0.23 23568.79 0.23 101672.55 0.23 Case Rate 19357 Priced Breast reconstruction 717001 19366 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 717001 19380 CPT Outpatient 61493.25 10556.34 Wellcare Wellcare Medicare 0.21 13212.28 0.21 61493.25 0.21 Case Rate 19380 Priced Removal of support implant 717001 20680 CPT Outpatient 42329.70 7266.60 Wellcare Wellcare Medicare 0.14 5804.91 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 717001 22856 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 717001 24538 CPT Outpatient 51237.90 4775.24 Wellcare Wellcare Medicare 0.19 9816.98 0.19 51237.90 0.19 Case Rate 24538 Priced Remove wrist tendon lesion 717001 25111 CPT Outpatient 25855.20 4438.48 Wellcare Wellcare Medicare 0.06 1654.95 0.06 25855.20 0.06 Case Rate 25111 Priced Incise finger tendon sheath 717001 26055 CPT Outpatient 15862.35 2723.04 Wellcare Wellcare Medicare 0.12 1931.13 0.12 15862.35 0.12 Case Rate 26055 Priced Treat finger fracture each 717001 26727 CPT Outpatient 22779.75 2030.47 Wellcare Wellcare Medicare 0.16 3574.88 0.16 22779.75 0.16 Case Rate 26727 Priced Revision of knee joint 717001 27446 CPT Outpatient 67882.50 11653.16 Wellcare Wellcare Medicare 0.23 15567.47 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 717001 27447 CPT Outpatient 130698.75 22436.62 Wellcare Wellcare Medicare 0.12 15604.41 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 717001 27485 CPT Outpatient 43310.40 7434.95 Wellcare Wellcare Medicare 0.26 11063.75 0.26 43310.40 0.26 Case Rate 27485 Priced Repair achilles tendon 717001 27650 CPT Outpatient 38246.25 3762.57 Wellcare Wellcare Medicare 0.29 11041.86 0.29 38246.25 0.29 Case Rate 27650 Priced Treatment of ankle fracture 717001 27792 CPT Outpatient 36101.10 6197.36 Wellcare Wellcare Medicare 0.21 7581.28 0.21 36101.10 0.21 Case Rate 27792 Priced Treatment of ankle fracture 717001 27814 CPT Outpatient 49405.65 8481.30 Wellcare Wellcare Medicare 0.16 7766.50 0.16 49405.65 0.16 Case Rate 27814 Priced Removal of foot lesion 717001 28080 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 717001 28285 CPT Outpatient 68603.85 11776.99 Wellcare Wellcare Medicare 0.20 13986.50 0.20 68603.85 0.20 Case Rate 28285 Priced Correction hallux valgus 717001 28296 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 717001 29823 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 717001 29826 CPT Outpatient 49840.35 8555.93 Wellcare Wellcare Medicare 0.15 7312.64 0.15 49840.35 0.15 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 717001 29881 CPT Outpatient 35556.15 6103.81 Wellcare Wellcare Medicare 0.09 3306.24 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 717001 29882 CPT Outpatient 61099.50 10488.75 Wellcare Wellcare Medicare 0.19 11577.74 0.19 61099.50 0.19 Case Rate 29882 Priced Percut bx lung/mediastinum 717001 32405 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 717001 32555 CPT Outpatient 14597.10 687.29 Wellcare Wellcare Medicare 0.05 711.62 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 717001 32664 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 717001 35190 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 717001 36478 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 717001 36561 CPT Outpatient 53531.10 3292.99 Wellcare Wellcare Medicare 0.06 3342.08 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 717001 36569 CPT Outpatient 31421.25 1299.06 Wellcare Wellcare Medicare 0.06 1811.50 0.06 31421.25 0.06 Case Rate 36569 Priced Removal tunneled cv cath 717001 36590 CPT Outpatient 1996.05 273.95 Wellcare Wellcare Medicare 0.82 1641.71 0.82 1996.05 0.82 Case Rate 36590 Priced Av fuse uppr arm basilic 717001 36819 CPT Outpatient 56861.70 9761.26 Wellcare Wellcare Medicare 0.17 9459.82 0.17 56861.70 0.17 Case Rate 36819 Priced Av fusion direct any site 717001 36821 CPT Outpatient 42953.40 7373.67 Wellcare Wellcare Medicare 0.16 7056.50 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 717001 36825 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 717001 36830 CPT Outpatient 53656.05 9210.96 Wellcare Wellcare Medicare 0.17 9346.72 0.17 53656.05 0.17 Case Rate 36830 Priced Av fistula revision open 717001 36832 CPT Outpatient 52492.65 9011.24 Wellcare Wellcare Medicare 0.23 12046.01 0.23 52492.65 0.23 Case Rate 36832 Priced Av fistula revision 717001 36833 CPT Outpatient 37098.60 6368.59 Wellcare Wellcare Medicare 0.28 10242.79 0.28 37098.60 0.28 Case Rate 36833 Priced Intro cath dialysis circuit 717001 36903 CPT Outpatient 77541.45 10669.90 Wellcare Wellcare Medicare 0.24 18454.26 0.24 77541.45 0.24 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 717001 36906 CPT Outpatient 96694.50 16175.64 Wellcare Wellcare Medicare 0.27 26216.69 0.27 96694.50 0.27 Case Rate 36906 Priced Fem/popl revas w/tla 717001 37224 CPT Outpatient 200076.45 5139.31 Wellcare Wellcare Medicare 0.14 27878.39 0.14 200076.45 0.14 Case Rate 37224 Priced Fem/popl revasc stnt & ather 717001 37227 CPT Outpatient 117170.55 18045.38 Wellcare Wellcare Medicare 0.17 19636.18 0.17 117170.55 0.17 Case Rate 37227 Priced Revise leg vein 717001 37700 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 717001 37722 CPT Outpatient 27815.55 4775.00 Wellcare Wellcare Medicare 0.37 10398.58 0.37 27815.55 0.37 Case Rate 37722 Priced Stab phleb veins xtr 10-20 717001 37765 CPT Outpatient 26561.85 4559.78 Wellcare Wellcare Medicare 0.52 13740.66 0.52 26561.85 0.52 Case Rate 37765 Priced Biopsy/removal lymph nodes 717001 38500 CPT Outpatient 35955.15 6172.30 Wellcare Wellcare Medicare 0.11 3918.72 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 717001 38525 CPT Outpatient 101194.80 17371.77 Wellcare Wellcare Medicare 0.19 18851.15 0.19 101194.80 0.19 Case Rate 38525 Priced Laparoscopy lymph node biop 717001 38570 CPT Outpatient 65631.30 11266.71 Wellcare Wellcare Medicare 0.28 18089.66 0.28 65631.30 0.28 Case Rate 38570 Priced Laparoscopy lymphadenectomy 717001 38571 CPT Outpatient 84031.50 14425.41 Wellcare Wellcare Medicare 0.26 22194.38 0.26 84031.50 0.26 Case Rate 38571 Priced Laparoscopy lymphadenectomy 717001 38572 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 717001 38792 CPT Outpatient 2868.60 432.48 Wellcare Wellcare Medicare 0.15 440.09 0.15 2868.60 0.15 Case Rate 38792 Priced Excision of gum lesion 717001 41825 CPT Outpatient 11580.45 1987.98 Wellcare Wellcare Medicare 0.30 3440.87 0.30 11580.45 0.30 Case Rate 41825 Priced Reconstruct cleft palate 717001 42200 CPT Outpatient 36703.80 6300.82 Wellcare Wellcare Medicare 0.16 5937.71 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 717001 42820 CPT Outpatient 17232.60 2958.26 Wellcare Wellcare Medicare 0.64 11027.66 0.64 17232.60 0.64 Case Rate 42820 Priced Control throat bleeding 717001 42960 CPT Outpatient 24066.00 4131.33 Wellcare Wellcare Medicare 0.20 4852.02 0.20 24066.00 0.20 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 717001 43235 CPT Outpatient 8856.75 1633.35 Wellcare Wellcare Medicare 0.11 944.67 0.11 8856.75 0.11 Case Rate 43235 Priced Laparoscopy fundoplasty 717001 43280 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 717001 43282 CPT Outpatient 84344.40 14479.12 Wellcare Wellcare Medicare 0.13 10981.07 0.13 84344.40 0.13 Case Rate 43282 Priced Laparoscopy appendectomy 717001 44970 CPT Outpatient 82300.05 14128.18 Wellcare Wellcare Medicare 0.08 6988.44 0.08 82300.05 0.08 Case Rate 44970 Priced Diagnostic sigmoidoscopy 717001 45330 CPT Outpatient 17286.15 542.26 Wellcare Wellcare Medicare 0.11 1880.24 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 717001 47000 CPT Outpatient 10398.15 1225.34 Wellcare Wellcare Medicare 0.20 2101.24 0.20 10398.15 0.20 Case Rate 47000 Priced Removal of gallbladder using an endoscope 717001 47562 CPT Outpatient 58430.40 10030.55 Wellcare Wellcare Medicare 0.10 5965.34 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 717001 47563 CPT Outpatient 71747.55 12316.66 Wellcare Wellcare Medicare 0.09 6769.21 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 717001 49083 CPT Outpatient 6979.35 1113.95 Wellcare Wellcare Medicare 0.14 944.67 0.14 6979.35 0.14 Case Rate 49083 Priced Diag laparo separate proc 717001 49320 CPT Outpatient 31629.15 5429.67 Wellcare Wellcare Medicare 0.42 13201.26 0.42 31629.15 0.42 Case Rate 49320 Priced Laparoscopy biopsy 717001 49321 CPT Outpatient 41892.90 7191.61 Wellcare Wellcare Medicare 0.32 13491.42 0.32 41892.90 0.32 Case Rate 49321 Priced Laparoscopy aspiration 717001 49322 CPT Outpatient 34392.75 5904.09 Wellcare Wellcare Medicare 0.39 13396.33 0.39 34392.75 0.39 Case Rate 49322 Priced Lap insert tunnel ip cath 717001 49324 CPT Outpatient 39264.75 6740.45 Wellcare Wellcare Medicare 0.15 5972.32 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 717001 49329 CPT Outpatient 58696.05 10076.16 Wellcare Wellcare Medicare 0.29 17162.20 0.29 58696.05 0.29 Case Rate 49329 Priced Ins tun ip cath for dial opn 717001 49421 CPT Outpatient 25460.40 3319.30 Wellcare Wellcare Medicare 0.15 3702.67 0.15 25460.40 0.15 Case Rate 49421 Priced Remove tunneled ip cath 717001 49422 CPT Outpatient 25515.00 4380.08 Wellcare Wellcare Medicare 0.13 3342.08 0.13 25515.00 0.13 Case Rate 49422 Priced Rpr ing hernia init reduce 717001 49500 CPT Outpatient 19594.05 3363.65 Wellcare Wellcare Medicare 0.56 11018.31 0.56 19594.05 0.56 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 717001 49505 CPT Outpatient 34915.65 5993.85 Wellcare Wellcare Medicare 0.21 7278.08 0.21 34915.65 0.21 Case Rate 49505 Priced Prp i/hern init block >5 yr 717001 49507 CPT Outpatient 29794.80 5114.77 Wellcare Wellcare Medicare 0.25 7306.28 0.25 29794.80 0.25 Case Rate 49507 Priced Rerepair ing hernia reduce 717001 49520 CPT Outpatient 36940.05 6341.38 Wellcare Wellcare Medicare 0.20 7341.71 0.20 36940.05 0.20 Case Rate 49520 Priced Rpr ventral hern init reduc 717001 49560 CPT Outpatient 53177.25 9128.76 Wellcare Wellcare Medicare 0.18 9686.73 0.18 53177.25 0.18 Case Rate 49560 Priced Rpr ventral hern init block 717001 49561 CPT Outpatient 30755.55 5279.70 Wellcare Wellcare Medicare 0.24 7522.67 0.24 30755.55 0.24 Case Rate 49561 Priced Rerepair ventrl hern reduce 717001 49565 CPT Outpatient 69917.40 12002.49 Wellcare Wellcare Medicare 0.14 10018.26 0.14 69917.40 0.14 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 717001 49585 CPT Outpatient 41806.80 7176.83 Wellcare Wellcare Medicare 0.23 9650.59 0.23 41806.80 0.23 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 717001 49587 CPT Outpatient 37320.15 6406.63 Wellcare Wellcare Medicare 0.20 7369.53 0.20 37320.15 0.20 Case Rate 49587 Priced Lap ing hernia repair init 717001 49650 CPT Outpatient 41932.80 7198.46 Wellcare Wellcare Medicare 0.14 5784.73 0.14 41932.80 0.14 Case Rate 49650 Priced Lap ing hernia repair recur 717001 49651 CPT Outpatient 46915.05 8053.75 Wellcare Wellcare Medicare 0.26 12396.08 0.26 46915.05 0.26 Case Rate 49651 Priced Lap vent/abd hernia repair 717001 49652 CPT Outpatient 51294.60 8805.57 Wellcare Wellcare Medicare 0.12 6001.15 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 717001 49653 CPT Outpatient 46102.35 7914.24 Wellcare Wellcare Medicare 0.13 5907.33 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 717001 49654 CPT Outpatient 47221.65 8106.38 Wellcare Wellcare Medicare 0.22 10246.22 0.22 47221.65 0.22 Case Rate 49654 Priced Lap inc hern repair comp 717001 49655 CPT Outpatient 54590.55 9371.38 Wellcare Wellcare Medicare 0.19 10557.83 0.19 54590.55 0.19 Case Rate 49655 Priced Lap inc hernia repair recur 717001 49656 CPT Outpatient 55443.15 9517.74 Wellcare Wellcare Medicare 0.19 10492.84 0.19 55443.15 0.19 Case Rate 49656 Priced Removal of kidney stone 717001 50080 CPT Outpatient 53165.70 9126.78 Wellcare Wellcare Medicare 0.32 16951.33 0.32 53165.70 0.32 Case Rate 50080 Priced Removal of kidney stone 717001 50081 CPT Outpatient 66931.20 11489.86 Wellcare Wellcare Medicare 0.30 20375.49 0.30 66931.20 0.30 Case Rate 50081 Priced Renal biopsy perq 717001 50200 CPT Outpatient 43096.20 1225.34 Wellcare Wellcare Medicare 0.23 9703.00 0.23 43096.20 0.23 Case Rate 50200 Priced Plmt nephroureteral catheter 717001 50433 CPT Outpatient 64566.60 1424.48 Wellcare Wellcare Medicare 0.27 17570.80 0.27 64566.60 0.27 Case Rate 50433 Priced Laparo radical nephrectomy 717001 50545 CPT Outpatient 43449.00 7458.75 Wellcare Wellcare Medicare 0.03 1190.00 0.03 43449.00 0.03 Case Rate 50545 Priced Laparoscope proc ureter 717001 50949 CPT Outpatient 49986.30 8580.98 Wellcare Wellcare Medicare 0.34 17208.73 0.34 49986.30 0.34 Case Rate 50949 Priced Injection for bladder x-ray 717001 51600 CPT Outpatient 3285.45 89.22 Wellcare Wellcare Medicare 0.08 268.63 0.08 3285.45 0.08 Case Rate 51600 Priced Cystoscopy 717001 52000 CPT Outpatient 22149.75 3802.37 Wellcare Wellcare Medicare 0.36 7975.55 0.36 22149.75 0.36 Case Rate 52000 Priced Cystoscopy & ureter catheter 717001 52005 CPT Outpatient 42529.20 2095.77 Wellcare Wellcare Medicare 0.21 9136.51 0.21 42529.20 0.21 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 717001 52204 CPT Outpatient 31274.25 5368.75 Wellcare Wellcare Medicare 0.18 5745.54 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 717001 52224 CPT Outpatient 13445.25 2308.10 Wellcare Wellcare Medicare 0.54 7303.88 0.54 13445.25 0.54 Case Rate 52224 Priced Cystoscopy and treatment 717001 52234 CPT Outpatient 28510.65 4894.33 Wellcare Wellcare Medicare 0.27 7572.52 0.27 28510.65 0.27 Case Rate 52234 Priced Cystoscopy and treatment 717001 52235 CPT Outpatient 29417.85 5050.06 Wellcare Wellcare Medicare 0.25 7276.20 0.25 29417.85 0.25 Case Rate 52235 Priced Cystoscopy and treatment 717001 52240 CPT Outpatient 33933.90 5825.32 Wellcare Wellcare Medicare 0.27 9046.24 0.27 33933.90 0.27 Case Rate 52240 Priced Cystoscopy and treatment 717001 52281 CPT Outpatient 22159.20 3804.00 Wellcare Wellcare Medicare 0.26 5688.66 0.26 22159.20 0.26 Case Rate 52281 Priced Remove bladder stone 717001 52317 CPT Outpatient 27085.80 4649.73 Wellcare Wellcare Medicare 0.27 7426.56 0.27 27085.80 0.27 Case Rate 52317 Priced Remove bladder stone 717001 52318 CPT Outpatient 26685.75 4581.05 Wellcare Wellcare Medicare 0.28 7361.57 0.28 26685.75 0.28 Case Rate 52318 Priced Cystoscopy and treatment 717001 52332 CPT Outpatient 115306.80 19794.33 Wellcare Wellcare Medicare 0.18 20580.50 0.18 115306.80 0.18 Case Rate 52332 Priced Cystouretero w/stone remove 717001 52352 CPT Outpatient 42420.00 7282.10 Wellcare Wellcare Medicare 0.38 16312.79 0.38 42420.00 0.38 Case Rate 52352 Priced Cystouretero w/lithotripsy 717001 52353 CPT Outpatient 38608.50 6627.79 Wellcare Wellcare Medicare 0.24 9133.86 0.24 38608.50 0.24 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 717001 52356 CPT Outpatient 36255.45 6223.85 Wellcare Wellcare Medicare 0.25 9133.86 0.25 36255.45 0.25 Case Rate 52356 Priced Prostatectomy (turp) 717001 52601 CPT Outpatient 35371.35 6072.08 Wellcare Wellcare Medicare 0.25 8684.69 0.25 35371.35 0.25 Case Rate 52601 Priced Laser surgery of prostate 717001 52648 CPT Outpatient 24264.45 4165.40 Wellcare Wellcare Medicare 0.37 9020.55 0.37 24264.45 0.37 Case Rate 52648 Priced Revision of urethra 717001 53450 CPT Outpatient 16209.90 2782.70 Wellcare Wellcare Medicare 0.35 5679.84 0.35 16209.90 0.35 Case Rate 53450 Priced Urology surgery procedure 717001 53899 CPT Outpatient 25368.00 134.83 Wellcare Wellcare Medicare 0.27 6862.63 0.27 25368.00 0.27 Case Rate 53899 Priced Circumcision w/regionl block 717001 54150 CPT Outpatient 14700.00 2523.50 Wellcare Wellcare Medicare 0.14 2090.37 0.14 14700.00 0.14 Case Rate 54150 Priced Circum 28 days or older 717001 54161 CPT Outpatient 19186.65 3293.71 Wellcare Wellcare Medicare 0.11 2049.61 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 717001 54162 CPT Outpatient 19795.65 3398.25 Wellcare Wellcare Medicare 0.85 16823.10 0.85 19795.65 0.85 Case Rate 54162 Priced Repair of circumcision 717001 54163 CPT Outpatient 16391.55 2813.88 Wellcare Wellcare Medicare 0.24 4010.49 0.24 16391.55 0.24 Case Rate 54163 Priced Reconstruction of urethra 717001 54324 CPT Outpatient 32880.75 5644.53 Wellcare Wellcare Medicare 0.28 9303.52 0.28 32880.75 0.28 Case Rate 54324 Priced Revise penis/urethra 717001 54332 CPT Outpatient 19968.90 3427.99 Wellcare Wellcare Medicare 0.18 3589.47 0.18 19968.90 0.18 Case Rate 54332 Priced Insert self-contd prosthesis 717001 54401 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 717001 54520 CPT Outpatient 35442.75 6084.34 Wellcare Wellcare Medicare 0.34 12158.30 0.34 35442.75 0.34 Case Rate 54520 Priced Reduce testis torsion 717001 54600 CPT Outpatient 55049.40 9450.15 Wellcare Wellcare Medicare 0.28 15402.48 0.28 55049.40 0.28 Case Rate 54600 Priced Suspension of testis 717001 54640 CPT Outpatient 26860.05 4610.98 Wellcare Wellcare Medicare 0.28 7428.84 0.28 26860.05 0.28 Case Rate 54640 Priced Removal of hydrocele 717001 55040 CPT Outpatient 27277.95 4682.71 Wellcare Wellcare Medicare 0.27 7369.91 0.27 27277.95 0.27 Case Rate 55040 Priced Biopsy of prostate gland 717001 55700 CPT Outpatient 28699.65 4926.77 Wellcare Wellcare Medicare 0.13 3731.04 0.13 28699.65 0.13 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 717001 55866 CPT Outpatient 93088.80 15980.24 Wellcare Wellcare Medicare 0.24 22017.24 0.24 93088.80 0.24 Case Rate 55866 Priced Closure of vagina 717001 57120 CPT Outpatient 34369.65 5900.12 Wellcare Wellcare Medicare 0.43 14932.00 0.43 34369.65 0.43 Case Rate 57120 Priced Repair of vagina 717001 57200 CPT Outpatient 25247.25 4334.11 Wellcare Wellcare Medicare 0.31 7732.37 0.31 25247.25 0.31 Case Rate 57200 Priced Anterior colporrhaphy 717001 57240 CPT Outpatient 36210.30 6216.10 Wellcare Wellcare Medicare 0.53 19223.69 0.53 36210.30 0.53 Case Rate 57240 Priced Repair rectum & vagina 717001 57250 CPT Outpatient 40441.80 6942.51 Wellcare Wellcare Medicare 0.56 22691.64 0.56 40441.80 0.56 Case Rate 57250 Priced Cmbn ant pst colprhy 717001 57260 CPT Outpatient 46323.90 7952.27 Wellcare Wellcare Medicare 0.66 30437.82 0.66 46323.90 0.66 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 717001 57265 CPT Outpatient 42586.95 7310.76 Wellcare Wellcare Medicare 0.43 18248.88 0.43 42586.95 0.43 Case Rate 57265 Priced Repair of bowel bulge 717001 57268 CPT Outpatient 36865.50 6328.58 Wellcare Wellcare Medicare 0.49 18090.91 0.49 36865.50 0.49 Case Rate 57268 Priced Colpopexy extraperitoneal 717001 57282 CPT Outpatient 45629.85 7833.12 Wellcare Wellcare Medicare 0.66 30324.80 0.66 45629.85 0.66 Case Rate 57282 Priced Repair bladder defect 717001 57288 CPT Outpatient 43069.95 7393.67 Wellcare Wellcare Medicare 0.56 24109.88 0.56 43069.95 0.56 Case Rate 57288 Priced Bx/curett of cervix w/scope 717001 57454 CPT Outpatient 2888.55 442.93 Wellcare Wellcare Medicare 0.11 329.27 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 717001 57520 CPT Outpatient 26728.80 4588.44 Wellcare Wellcare Medicare 0.16 4211.41 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 717001 57522 CPT Outpatient 22737.75 3903.31 Wellcare Wellcare Medicare 0.15 3411.24 0.15 22737.75 0.15 Case Rate 57522 Priced Biopsy of uterus lining 717001 58100 CPT Outpatient 2371.95 194.80 Wellcare Wellcare Medicare 0.08 198.89 0.08 2371.95 0.08 Case Rate 58100 Priced Catheter for hysterography 717001 58340 CPT Outpatient 6322.05 131.04 Wellcare Wellcare Medicare 0.04 268.63 0.04 6322.05 0.04 Case Rate 58340 Priced Reopen fallopian tube 717001 58350 CPT Outpatient 46507.65 7983.81 Wellcare Wellcare Medicare 0.38 17563.57 0.38 46507.65 0.38 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 717001 58542 CPT Outpatient 64194.90 11020.12 Wellcare Wellcare Medicare 0.37 24060.91 0.37 64194.90 0.37 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 717001 58544 CPT Outpatient 51020.55 8758.53 Wellcare Wellcare Medicare 0.65 33216.81 0.65 51020.55 0.65 Case Rate 58544 Priced Laparoscopic myomectomy 717001 58545 CPT Outpatient 56946.75 9775.86 Wellcare Wellcare Medicare 0.17 9718.98 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 717001 58552 CPT Outpatient 57228.15 9824.17 Wellcare Wellcare Medicare 0.32 18381.02 0.32 57228.15 0.32 Case Rate 58552 Priced Hysteroscopy biopsy 717001 58558 CPT Outpatient 28581.00 2077.02 Wellcare Wellcare Medicare 0.25 7238.81 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 717001 58561 CPT Outpatient 35222.25 6046.49 Wellcare Wellcare Medicare 0.27 9531.42 0.27 35222.25 0.27 Case Rate 58561 Priced Hysteroscopy ablation 717001 58563 CPT Outpatient 38399.55 6591.92 Wellcare Wellcare Medicare 0.51 19555.87 0.51 38399.55 0.51 Case Rate 58563 Priced Tlh uterus 250 g or less 717001 58570 CPT Outpatient 43316.70 7436.03 Wellcare Wellcare Medicare 0.26 11083.71 0.26 43316.70 0.26 Case Rate 58570 Priced Tlh w/t/o 250 g or less 717001 58571 CPT Outpatient 48603.45 8343.59 Wellcare Wellcare Medicare 0.30 14369.35 0.30 48603.45 0.30 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 717001 58573 CPT Outpatient 52905.30 9082.08 Wellcare Wellcare Medicare 0.32 16722.51 0.32 52905.30 0.32 Case Rate 58573 Priced Laparoscopy remove adnexa 717001 58661 CPT Outpatient 47008.50 8069.79 Wellcare Wellcare Medicare 0.18 8686.07 0.18 47008.50 0.18 Case Rate 58661 Priced Laparoscopy excise lesions 717001 58662 CPT Outpatient 45053.40 7734.17 Wellcare Wellcare Medicare 0.38 17220.22 0.38 45053.40 0.38 Case Rate 58662 Priced Treat ectopic pregnancy 717001 59151 CPT Outpatient 74690.70 12821.90 Wellcare Wellcare Medicare 0.09 6630.70 0.09 74690.70 0.09 Case Rate 59151 Priced Treatment of miscarriage 717001 59812 CPT Outpatient 56109.90 9632.20 Wellcare Wellcare Medicare 0.07 4075.96 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 717001 60220 CPT Outpatient 53639.25 9208.07 Wellcare Wellcare Medicare 0.11 6088.34 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 717001 60240 CPT Outpatient 98252.70 16866.71 Wellcare Wellcare Medicare 0.06 5905.23 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 717001 60500 CPT Outpatient 150495.45 25835.05 Wellcare Wellcare Medicare 0.06 9768.16 0.06 150495.45 0.06 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 717001 62322 CPT Outpatient 43709.40 514.24 Wellcare Wellcare Medicare 0.28 12235.33 0.28 43709.40 0.28 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 717001 62323 CPT Outpatient 8304.45 467.31 Wellcare Wellcare Medicare 16.45 136591.28 16.45 8304.45 16.45 Case Rate 62323 Priced Low back disk surgery 717001 63030 CPT Outpatient 50287.65 8632.71 Wellcare Wellcare Medicare 0.30 14893.92 0.30 50287.65 0.30 Case Rate 63030 Priced Inc for vagus n elect impl 717001 64568 CPT Outpatient 124562.55 21383.24 Wellcare Wellcare Medicare 0.27 33814.93 0.27 124562.55 0.27 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 717001 66821 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 717001 66984 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicare 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 48016 216 DRG Inpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 48016 460 DRG Inpatient 416122.79 53834.63 Aetna Better Health Aetna Medicaid 0.18 75759.95 0.18 416122.79 0.18 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 48016 470 DRG Inpatient 167912.19 21723.13 Aetna Better Health Aetna Medicaid 0.15 25592.13 0.15 167912.19 0.15 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 48016 473 DRG Inpatient 100687.91 13026.19 Aetna Better Health Aetna Medicaid 0.25 25076.29 0.25 100687.91 0.25 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 48016 743 DRG Inpatient 102691.67 13285.42 Aetna Better Health Aetna Medicaid 0.13 12981.04 0.13 102691.67 0.13 Case Rate 743 Priced NORMAL NEWBORN 48016 795 DRG Inpatient 6266.93 2335.00 Aetna Better Health Aetna Medicaid 0.29 1793.75 0.29 6266.93 0.29 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 48016 807 DRG Inpatient 116469.59 4193.00 Aetna Better Health Aetna Medicaid 0.05 5499.83 0.05 116469.59 0.05 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 48016 788 DRG Inpatient 76050.77 4538.00 Aetna Better Health Aetna Medicaid 0.11 8267.86 0.11 76050.77 0.11 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 48016 59400 CPT Inpatient 116469.59 4193.00 Aetna Better Health Aetna Medicaid 0.05 5499.83 0.05 116469.59 0.05 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 48016 59510 CPT Inpatient 76050.77 4538.00 Aetna Better Health Aetna Medicaid 0.11 8267.86 0.11 76050.77 0.11 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 48016 59610 CPT Inpatient 116469.59 4193.00 Aetna Better Health Aetna Medicaid 0.05 5499.83 0.05 116469.59 0.05 Case Rate 59610 Priced "Psychotherapy, 30 min" 48016 90832 CPT Outpatient 577.50 91.21 Aetna Better Health Aetna Medicaid 0.03 18.37 0.03 577.50 0.03 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 48016 90834 CPT Outpatient 44134.65 271.96 Aetna Better Health Aetna Medicaid 0.01 642.88 0.01 44134.65 0.01 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 48016 90837 CPT Outpatient 2240.70 442.93 Aetna Better Health Aetna Medicaid 0.02 43.16 0.02 2240.70 0.02 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 48016 90846 CPT Outpatient 0.01 131.50 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 48016 90847 CPT Outpatient 44134.65 369.97 Aetna Better Health Aetna Medicaid 0.01 642.88 0.01 44134.65 0.01 Fee Schedule 90847 Priced Group psychotherapy 48016 90853 CPT Outpatient 44134.65 101.99 Aetna Better Health Aetna Medicaid 0.01 642.88 0.01 44134.65 0.01 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 48016 99203 CPT Outpatient 3480.75 176.07 Aetna Better Health Aetna Medicaid 0.10 332.33 0.10 3480.75 0.10 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 48016 99204 CPT Outpatient 2103.15 233.39 Aetna Better Health Aetna Medicaid 0.10 200.75 0.10 2103.15 0.10 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 48016 99205 CPT Outpatient 4970.70 314.28 Aetna Better Health Aetna Medicaid 0.05 237.28 0.05 4970.70 0.05 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 48016 99243 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 48016 99244 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 48016 99385 CPT Outpatient 1114.05 185.90 Aetna Better Health Aetna Medicaid 0.10 106.32 0.10 1114.05 0.10 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 48016 99386 CPT Outpatient 4877.25 185.90 Aetna Better Health Aetna Medicaid 0.07 349.73 0.07 4877.25 0.07 Fee Schedule 99386 Priced Routine venipuncture 48016 36415 CPT Outpatient 127.05 19.57 Aetna Better Health Aetna Medicaid 0.01 1.85 0.01 127.05 0.01 Fee Schedule 36415 Priced Basic Metabolic Panel 48016 80048 CPT Outpatient 576.45 88.78 Aetna Better Health Aetna Medicaid 0.02 9.53 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 48016 80053 CPT Outpatient 763.35 117.56 Aetna Better Health Aetna Medicaid 0.01 10.76 0.01 763.35 0.01 Fee Schedule 80053 Priced Obstetric blood test panel 48016 80055 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 48016 80061 CPT Outpatient 1349.25 197.77 Aetna Better Health Aetna Medicaid 0.01 15.38 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 48016 80069 CPT Outpatient 716.10 104.95 Aetna Better Health Aetna Medicaid 0.01 9.84 0.01 716.10 0.01 Fee Schedule 80069 Priced Liver function panel test 48016 80076 CPT Outpatient 716.10 104.95 Aetna Better Health Aetna Medicaid 0.01 7.18 0.01 716.10 0.01 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 48016 81000 CPT Outpatient 144.90 21.18 Aetna Better Health Aetna Medicaid 0.01 1.23 0.01 144.90 0.01 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 48016 81001 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 48016 81002 CPT Outpatient 57.75 8.89 Aetna Better Health Aetna Medicaid 0.02 1.03 0.02 57.75 0.02 Fee Schedule 81002 Priced Automated urinalysis test 48016 81003 CPT Outpatient 219.45 33.80 Aetna Better Health Aetna Medicaid 0.01 1.54 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 48016 82306 CPT Outpatient 1880.55 289.62 Aetna Better Health Aetna Medicaid 0.02 30.75 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 48016 83036 CPT Outpatient 494.55 76.17 Aetna Better Health Aetna Medicaid 0.01 6.77 0.01 494.55 0.01 Fee Schedule 83036 Priced PSA (prostate specific antigen) 48016 84153 CPT Outpatient 1177.05 181.28 Aetna Better Health Aetna Medicaid 0.02 25.11 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 48016 84154 CPT Outpatient 598.50 92.17 Aetna Better Health Aetna Medicaid 0.04 25.11 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 48016 84443 CPT Outpatient 519.75 80.05 Aetna Better Health Aetna Medicaid 0.04 18.76 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 48016 84703 CPT Outpatient 785.40 120.96 Aetna Better Health Aetna Medicaid 0.01 3.08 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 48016 85025 CPT Outpatient 635.25 97.83 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 635.25 0.01 Fee Schedule 85025 Priced "Complete blood count, automated" 48016 85027 CPT Outpatient 576.45 88.78 Aetna Better Health Aetna Medicaid 0.01 4.92 0.01 576.45 0.01 Fee Schedule 85027 Priced "Blood test, clotting time" 48016 85610 CPT Outpatient 404.25 62.26 Aetna Better Health Aetna Medicaid 0.01 3.08 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 48016 85730 CPT Outpatient 17.22 2.65 Aetna Better Health Aetna Medicaid 0.18 3.08 0.18 17.22 0.18 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 48016 86003 CPT Outpatient 32.55 5.01 Aetna Better Health Aetna Medicaid 0.13 4.10 0.13 32.55 0.13 Fee Schedule 86003 Priced Tb test cell immun measure 48016 86480 CPT Outpatient 530.25 81.66 Aetna Better Health Aetna Medicaid 0.10 50.82 0.10 530.25 0.10 Fee Schedule 86480 Priced Urine culture/colony count 48016 87086 CPT Outpatient 763.35 117.56 Aetna Better Health Aetna Medicaid 0.01 6.15 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 48016 87338 CPT Outpatient 785.40 120.96 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 785.40 0.01 Fee Schedule 87338 Priced Cytopath eval fna report 48016 88173 CPT Outpatient 750.75 115.62 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 750.75 0.01 Fee Schedule 88173 Priced Tissue exam by pathologist 48016 88302 CPT Outpatient 635.25 97.83 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 635.25 0.01 Fee Schedule 88302 Priced Tissue exam by pathologist 48016 88305 CPT Outpatient 323.40 49.81 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 323.40 0.01 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 48016 11042 CPT Outpatient 2668.05 481.45 Aetna Better Health Aetna Medicaid 0.10 254.74 0.10 2668.05 0.10 Case Rate 11042 Priced Deb subq tissue add-on 48016 11045 CPT Outpatient 4652.55 330.00 Aetna Better Health Aetna Medicaid 0.10 444.22 0.10 4652.55 0.10 Case Rate 11045 Priced Dx bronchoscope/lavage 48016 31624 CPT Outpatient 41223.00 7602.31 Aetna Better Health Aetna Medicaid 0.09 3793.90 0.09 41223.00 0.09 Case Rate 31624 Priced Bronchoscopy/lung bx each 48016 31628 CPT Outpatient 49048.65 9045.51 Aetna Better Health Aetna Medicaid 0.10 4667.65 0.10 49048.65 0.10 Case Rate 31628 Priced Blood transfusion service 48016 36430 CPT Outpatient 9166.50 574.93 Aetna Better Health Aetna Medicaid 0.05 497.40 0.05 9166.50 0.05 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 48016 43235 CPT Outpatient 8856.75 1633.35 Aetna Better Health Aetna Medicaid 0.10 880.41 0.10 8856.75 0.10 Case Rate 43235 Priced Endoscopic us exam esoph 48016 43237 CPT Outpatient 23867.55 4401.63 Aetna Better Health Aetna Medicaid 0.09 2255.64 0.09 23867.55 0.09 Case Rate 43237 Priced Egd us fine needle bx/aspir 48016 43238 CPT Outpatient 30690.45 5659.90 Aetna Better Health Aetna Medicaid 0.09 2818.33 0.09 30690.45 0.09 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 48016 43239 CPT Outpatient 40191.90 7412.15 Aetna Better Health Aetna Medicaid 0.11 4303.11 0.11 40191.90 0.11 Case Rate 43239 Priced Ercp remove duct calculi 48016 43264 CPT Outpatient 34335.00 6332.03 Aetna Better Health Aetna Medicaid 0.10 3323.78 0.10 34335.00 0.10 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 48016 45378 CPT Outpatient 13991.25 889.35 Aetna Better Health Aetna Medicaid 0.10 1338.27 0.10 13991.25 0.10 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 48016 45380 CPT Outpatient 22215.90 4097.04 Aetna Better Health Aetna Medicaid 0.10 2125.88 0.10 22215.90 0.10 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 48016 45385 CPT Outpatient 119569.80 22050.95 Aetna Better Health Aetna Medicaid 0.03 3842.86 0.03 119569.80 0.03 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 48016 45391 CPT Outpatient 24923.85 4596.43 Aetna Better Health Aetna Medicaid 0.10 2380.28 0.10 24923.85 0.10 Case Rate 45391 Priced Fragmenting of kidney stone 48016 50590 CPT Outpatient 40930.05 7548.28 Aetna Better Health Aetna Medicaid 0.10 3922.16 0.10 40930.05 0.10 Case Rate 50590 Priced Fetal non-stress test 48016 59025 CPT Outpatient 3153.15 477.76 Aetna Better Health Aetna Medicaid 0.10 301.06 0.10 3153.15 0.10 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 48016 64483 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 48016 92567 CPT Outpatient 2224.95 98.50 Aetna Better Health Aetna Medicaid 0.10 212.43 0.10 2224.95 0.10 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 48016 93000 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 48016 93017 CPT Outpatient 3076.50 532.96 Aetna Better Health Aetna Medicaid 0.10 293.69 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 48016 93452 CPT Outpatient 55621.65 8611.87 Aetna Better Health Aetna Medicaid 0.09 5122.11 0.09 55621.65 0.09 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 48016 95810 CPT Outpatient 20341.65 3373.48 Aetna Better Health Aetna Medicaid 0.10 1942.19 0.10 20341.65 0.10 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 48016 95811 CPT Outpatient 22491.00 3731.18 Aetna Better Health Aetna Medicaid 0.10 2147.46 0.10 22491.00 0.10 Case Rate 95811 Priced Eeg 41-60 minutes 48016 95812 CPT Outpatient 5578.65 925.83 Aetna Better Health Aetna Medicaid 0.10 532.65 0.10 5578.65 0.10 Case Rate 95812 Priced Genetic counseling 30 min 48016 96040 CPT Outpatient 0.01 102.81 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 48016 96413 CPT Outpatient 4856.25 472.45 Aetna Better Health Aetna Medicaid 0.10 463.60 0.10 4856.25 0.10 Case Rate 96413 Priced Ultrasound therapy 48016 97035 CPT Outpatient 2111.55 134.99 Aetna Better Health Aetna Medicaid 0.10 201.59 0.10 2111.55 0.10 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 48016 97110 CPT Outpatient 6494.25 92.86 Aetna Better Health Aetna Medicaid 0.10 620.02 0.10 6494.25 0.10 Case Rate 97110 Priced Gait training therapy 48016 97116 CPT Outpatient 4723.95 110.61 Aetna Better Health Aetna Medicaid 0.10 450.97 0.10 4723.95 0.10 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 48016 70450 CPT Outpatient 8566.95 835.61 Aetna Better Health Aetna Medicaid 0.10 817.93 0.10 8566.95 0.10 Case Rate 70450 Priced Mri brain stem w/o dye 48016 70551 CPT Outpatient 7861.35 1361.31 Aetna Better Health Aetna Medicaid 0.10 750.56 0.10 7861.35 0.10 Case Rate 70551 Priced MRI scan of brain before and after contrast 48016 70553 CPT Outpatient 10882.20 1625.88 Aetna Better Health Aetna Medicaid 0.10 1038.99 0.10 10882.20 0.10 Case Rate 70553 Priced X-ray exam chest 2 views 48016 71046 CPT Outpatient 859.95 150.37 Aetna Better Health Aetna Medicaid 0.10 82.11 0.10 859.95 0.10 Case Rate 71046 Priced Ct thorax w/o dye 48016 71250 CPT Outpatient 7288.05 1261.63 Aetna Better Health Aetna Medicaid 0.10 695.82 0.10 7288.05 0.10 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 48016 72082 CPT Outpatient 2022.30 253.33 Aetna Better Health Aetna Medicaid 0.11 229.59 0.11 2022.30 0.11 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 48016 72100 CPT Outpatient 1599.15 277.38 Aetna Better Health Aetna Medicaid 0.10 152.64 0.10 1599.15 0.10 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 48016 72110 CPT Outpatient 1389.15 241.04 Aetna Better Health Aetna Medicaid 0.10 132.64 0.10 1389.15 0.10 Case Rate 72110 Priced MRI scan of lower spinal canal 48016 72148 CPT Outpatient 7861.35 1361.31 Aetna Better Health Aetna Medicaid 0.10 750.56 0.10 7861.35 0.10 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 48016 72193 CPT Outpatient 13671.00 1412.01 Aetna Better Health Aetna Medicaid 0.06 778.98 0.06 13671.00 0.06 Case Rate 72193 Priced X-ray exam of shoulder 48016 73030 CPT Outpatient 1452.15 251.43 Aetna Better Health Aetna Medicaid 0.10 138.64 0.10 1452.15 0.10 Case Rate 73030 Priced X-ray exam of elbow 48016 73080 CPT Outpatient 1356.60 235.68 Aetna Better Health Aetna Medicaid 0.10 129.48 0.10 1356.60 0.10 Case Rate 73080 Priced X-ray exam of forearm 48016 73090 CPT Outpatient 1243.20 215.26 Aetna Better Health Aetna Medicaid 0.10 118.63 0.10 1243.20 0.10 Case Rate 73090 Priced X-ray exam of wrist 48016 73110 CPT Outpatient 1243.20 215.26 Aetna Better Health Aetna Medicaid 0.10 118.63 0.10 1243.20 0.10 Case Rate 73110 Priced X-ray exam of hand 48016 73130 CPT Outpatient 1243.20 215.26 Aetna Better Health Aetna Medicaid 0.10 118.63 0.10 1243.20 0.10 Case Rate 73130 Priced X-ray exam hips bi 2 views 48016 73521 CPT Outpatient 970.20 228.41 Aetna Better Health Aetna Medicaid 0.13 125.27 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 48016 73562 CPT Outpatient 802.20 139.12 Aetna Better Health Aetna Medicaid 0.10 76.53 0.10 802.20 0.10 Case Rate 73562 Priced X-ray exam of lower leg 48016 73590 CPT Outpatient 1243.20 215.26 Aetna Better Health Aetna Medicaid 0.10 118.63 0.10 1243.20 0.10 Case Rate 73590 Priced X-ray exam of ankle 48016 73610 CPT Outpatient 1378.65 239.31 Aetna Better Health Aetna Medicaid 0.10 131.59 0.10 1378.65 0.10 Case Rate 73610 Priced X-ray exam of foot 48016 73630 CPT Outpatient 975.45 169.41 Aetna Better Health Aetna Medicaid 0.10 93.06 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 48016 73721 CPT Outpatient 7861.35 1361.31 Aetna Better Health Aetna Medicaid 0.10 750.56 0.10 7861.35 0.10 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 48016 74177 CPT Outpatient 14222.25 1412.01 Aetna Better Health Aetna Medicaid 0.05 778.98 0.05 14222.25 0.05 Case Rate 74177 Priced Contrst x-ray exam of throat 48016 74210 CPT Outpatient 0.01 440.39 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 48016 76098 CPT Outpatient 6141.45 407.86 Aetna Better Health Aetna Medicaid 0.10 586.34 0.10 6141.45 0.10 Case Rate 76098 Priced Us exam of head and neck 48016 76536 CPT Outpatient 5512.50 955.18 Aetna Better Health Aetna Medicaid 0.10 526.34 0.10 5512.50 0.10 Case Rate 76536 Priced Ultrasound breast limited 48016 76642 CPT Outpatient 5777.10 127.70 Aetna Better Health Aetna Medicaid 0.10 551.60 0.10 5777.10 0.10 Case Rate 76642 Priced Ultrasound of abdomen 48016 76700 CPT Outpatient 4917.15 851.88 Aetna Better Health Aetna Medicaid 0.10 469.49 0.10 4917.15 0.10 Case Rate 76700 Priced Echo exam of abdomen 48016 76705 CPT Outpatient 3836.70 665.17 Aetna Better Health Aetna Medicaid 0.10 366.34 0.10 3836.70 0.10 Case Rate 76705 Priced Us exam abdo back wall comp 48016 76770 CPT Outpatient 5171.25 895.48 Aetna Better Health Aetna Medicaid 0.10 493.70 0.10 5171.25 0.10 Case Rate 76770 Priced Us exam abdo back wall lim 48016 76775 CPT Outpatient 3969.00 686.97 Aetna Better Health Aetna Medicaid 0.10 378.96 0.10 3969.00 0.10 Case Rate 76775 Priced Ob us < 14 wks single fetus 48016 76801 CPT Outpatient 2006.55 347.98 Aetna Better Health Aetna Medicaid 0.10 191.58 0.10 2006.55 0.10 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 48016 76805 CPT Outpatient 3969.00 686.97 Aetna Better Health Aetna Medicaid 0.10 378.96 0.10 3969.00 0.10 Case Rate 76805 Priced Ob us detailed sngl fetus 48016 76811 CPT Outpatient 2844.45 492.99 Aetna Better Health Aetna Medicaid 0.10 271.59 0.10 2844.45 0.10 Case Rate 76811 Priced Ob us nuchal meas 1 gest 48016 76813 CPT Outpatient 1044.75 180.83 Aetna Better Health Aetna Medicaid 0.10 99.69 0.10 1044.75 0.10 Case Rate 76813 Priced Ob us limited fetus(s) 48016 76815 CPT Outpatient 6428.10 639.90 Aetna Better Health Aetna Medicaid 0.10 613.71 0.10 6428.10 0.10 Case Rate 76815 Priced Ob us follow-up per fetus 48016 76816 CPT Outpatient 4818.45 833.88 Aetna Better Health Aetna Medicaid 0.10 460.02 0.10 4818.45 0.10 Case Rate 76816 Priced Transvaginal us obstetric 48016 76817 CPT Outpatient 6428.10 476.73 Aetna Better Health Aetna Medicaid 0.10 613.71 0.10 6428.10 0.10 Case Rate 76817 Priced Fetal biophys profil w/o nst 48016 76819 CPT Outpatient 1741.95 302.65 Aetna Better Health Aetna Medicaid 0.10 166.33 0.10 1741.95 0.10 Case Rate 76819 Priced Ultrasound pelvis through vagina 48016 76830 CPT Outpatient 9305.10 806.54 Aetna Better Health Aetna Medicaid 0.10 888.46 0.10 9305.10 0.10 Case Rate 76830 Priced Us exam scrotum 48016 76870 CPT Outpatient 6328.35 1096.55 Aetna Better Health Aetna Medicaid 0.10 604.24 0.10 6328.35 0.10 Case Rate 76870 Priced Us exam infant hips dynamic 48016 76885 CPT Outpatient 3836.70 665.17 Aetna Better Health Aetna Medicaid 0.10 366.34 0.10 3836.70 0.10 Case Rate 76885 Priced Mammography of one breast 48016 77065 CPT Outpatient 3451.35 192.07 Aetna Better Health Aetna Medicaid 0.10 329.49 0.10 3451.35 0.10 Case Rate 77065 Priced Mammography of both breasts 48016 77066 CPT Outpatient 5777.10 235.68 Aetna Better Health Aetna Medicaid 0.10 551.60 0.10 5777.10 0.10 Case Rate 77066 Priced "Mamography, screening bilateral" 48016 77067 CPT Outpatient 1416.45 205.57 Aetna Better Health Aetna Medicaid 0.10 135.17 0.10 1416.45 0.10 Case Rate 77067 Priced X-rays for bone age 48016 77072 CPT Outpatient 2022.30 163.87 Aetna Better Health Aetna Medicaid 0.11 229.59 0.11 2022.30 0.11 Case Rate 77072 Priced Joint survey single view 48016 77077 CPT Outpatient 985.95 171.14 Aetna Better Health Aetna Medicaid 0.10 94.11 0.10 985.95 0.10 Case Rate 77077 Priced Dxa bone density axial 48016 77080 CPT Outpatient 3257.10 319.09 Aetna Better Health Aetna Medicaid 0.10 310.96 0.10 3257.10 0.10 Case Rate 77080 Priced Fna bx w/us gdn 1st les 48016 10005 CPT Outpatient 5512.50 547.24 Aetna Better Health Aetna Medicaid 0.10 526.34 0.10 5512.50 0.10 Case Rate 10005 Priced Fna bx w/us gdn ea addl 48016 10006 CPT Outpatient 10628.10 594.83 Aetna Better Health Aetna Medicaid 0.10 1014.78 0.10 10628.10 0.10 Case Rate 10006 Priced Drainage of hematoma/fluid 48016 10140 CPT Outpatient 23209.20 1081.95 Aetna Better Health Aetna Medicaid 0.08 1807.28 0.08 23209.20 0.08 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 48016 11042 CPT Outpatient 2668.05 481.45 Aetna Better Health Aetna Medicaid 0.10 254.74 0.10 2668.05 0.10 Case Rate 11042 Priced Deb bone 20 sq cm/< 48016 11044 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 48016 11406 CPT Outpatient 19967.85 3427.81 Aetna Better Health Aetna Medicaid 0.09 1764.96 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 48016 11424 CPT Outpatient 0.01 1004.93 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 48016 11770 CPT Outpatient 19173.00 3291.37 Aetna Better Health Aetna Medicaid 0.10 1832.69 0.10 19173.00 0.10 Case Rate 11770 Priced Replace tissue expander 48016 11970 CPT Outpatient 59239.95 10169.52 Aetna Better Health Aetna Medicaid 0.09 5369.92 0.09 59239.95 0.09 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 48016 14020 CPT Outpatient 32166.75 5521.96 Aetna Better Health Aetna Medicaid 0.09 2895.86 0.09 32166.75 0.09 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 48016 14060 CPT Outpatient 25993.80 1374.69 Aetna Better Health Aetna Medicaid 0.10 2512.82 0.10 25993.80 0.10 Case Rate 14060 Priced Wound prep trk/arm/leg 48016 15002 CPT Outpatient 41748.00 1441.73 Aetna Better Health Aetna Medicaid 0.10 4012.86 0.10 41748.00 0.10 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 48016 15271 CPT Outpatient 24343.20 3769.48 Aetna Better Health Aetna Medicaid 0.09 2250.62 0.09 24343.20 0.09 Case Rate 15271 Priced Acellular derm matrix implt 48016 15777 CPT Outpatient 101672.55 17453.79 Aetna Better Health Aetna Medicaid 0.12 11759.07 0.12 101672.55 0.12 Case Rate 15777 Priced Exc skin abd 48016 15830 CPT Outpatient 54696.60 9389.58 Aetna Better Health Aetna Medicaid 0.07 3777.02 0.07 54696.60 0.07 Case Rate 15830 Priced Dressing change not for burn 48016 15852 CPT Outpatient 0.01 290.74 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 48016 15877 CPT Outpatient 63741.30 10942.26 Aetna Better Health Aetna Medicaid 0.10 6097.58 0.10 63741.30 0.10 Case Rate 15877 Priced Suction lipectomy lwr extrem 48016 15879 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 48016 19000 CPT Outpatient 10143.00 594.83 Aetna Better Health Aetna Medicaid 0.10 968.46 0.10 10143.00 0.10 Case Rate 19000 Priced Bx breast 1st lesion strtctc 48016 19081 CPT Outpatient 12341.70 1250.69 Aetna Better Health Aetna Medicaid 0.10 1178.36 0.10 12341.70 0.10 Case Rate 19081 Priced Bx breast add lesion us imag 48016 19084 CPT Outpatient 29058.75 547.24 Aetna Better Health Aetna Medicaid 0.10 2843.72 0.10 29058.75 0.10 Case Rate 19084 Priced Biopsy of breast open 48016 19101 CPT Outpatient 39545.10 2737.82 Aetna Better Health Aetna Medicaid 0.09 3427.01 0.09 39545.10 0.09 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 48016 19120 CPT Outpatient 35761.95 2737.82 Aetna Better Health Aetna Medicaid 0.10 3559.81 0.10 35761.95 0.10 Case Rate 19120 Priced Excision breast lesion 48016 19125 CPT Outpatient 33184.20 0.01 Aetna Better Health Aetna Medicaid 0.09 2978.77 0.09 33184.20 0.09 Case Rate 19125 Priced Perq device breast 1st imag 48016 19281 CPT Outpatient 6141.45 598.61 Aetna Better Health Aetna Medicaid 0.10 586.34 0.10 6141.45 0.10 Case Rate 19281 Priced Perq device breast ea imag 48016 19282 CPT Outpatient 8379.00 319.04 Aetna Better Health Aetna Medicaid 0.10 800.03 0.10 8379.00 0.10 Case Rate 19282 Priced Partial mastectomy 48016 19301 CPT Outpatient 39157.65 6722.06 Aetna Better Health Aetna Medicaid 0.10 3821.87 0.10 39157.65 0.10 Case Rate 19301 Priced Mast simple complete 48016 19303 CPT Outpatient 105389.55 18091.87 Aetna Better Health Aetna Medicaid 0.10 10106.30 0.10 105389.55 0.10 Case Rate 19303 Priced Reduction of large breast 48016 19318 CPT Outpatient 65239.65 11199.47 Aetna Better Health Aetna Medicaid 0.10 6225.18 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 48016 19340 CPT Outpatient 113100.75 19415.63 Aetna Better Health Aetna Medicaid 0.09 10704.11 0.09 113100.75 0.09 Case Rate 19340 Priced Delayed breast prosthesis 48016 19342 CPT Outpatient 56988.75 9783.07 Aetna Better Health Aetna Medicaid 0.09 5348.35 0.09 56988.75 0.09 Case Rate 19342 Priced Breast reconstruction 48016 19357 CPT Outpatient 101672.55 17453.79 Aetna Better Health Aetna Medicaid 0.12 11759.07 0.12 101672.55 0.12 Case Rate 19357 Priced Breast reconstruction 48016 19366 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 48016 19380 CPT Outpatient 61493.25 10556.34 Aetna Better Health Aetna Medicaid 0.10 5956.21 0.10 61493.25 0.10 Case Rate 19380 Priced Removal of support implant 48016 20680 CPT Outpatient 42329.70 7266.60 Aetna Better Health Aetna Medicaid 0.10 4091.71 0.10 42329.70 0.10 Case Rate 20680 Priced Cerv artific diskectomy 48016 22856 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 48016 24538 CPT Outpatient 51237.90 4775.24 Aetna Better Health Aetna Medicaid 0.07 3646.90 0.07 51237.90 0.07 Case Rate 24538 Priced Remove wrist tendon lesion 48016 25111 CPT Outpatient 25855.20 4438.48 Aetna Better Health Aetna Medicaid 0.09 2378.79 0.09 25855.20 0.09 Case Rate 25111 Priced Incise finger tendon sheath 48016 26055 CPT Outpatient 15862.35 2723.04 Aetna Better Health Aetna Medicaid 0.09 1420.52 0.09 15862.35 0.09 Case Rate 26055 Priced Treat finger fracture each 48016 26727 CPT Outpatient 22779.75 2030.47 Aetna Better Health Aetna Medicaid 0.10 2212.37 0.10 22779.75 0.10 Case Rate 26727 Priced Revision of knee joint 48016 27446 CPT Outpatient 67882.50 11653.16 Aetna Better Health Aetna Medicaid 0.09 6189.59 0.09 67882.50 0.09 Case Rate 27446 Priced Total knee arthroplasty 48016 27447 CPT Outpatient 130698.75 22436.62 Aetna Better Health Aetna Medicaid 0.06 7792.10 0.06 130698.75 0.06 Case Rate 27447 Priced Surgery to stop leg growth 48016 27485 CPT Outpatient 43310.40 7434.95 Aetna Better Health Aetna Medicaid 0.09 4043.95 0.09 43310.40 0.09 Case Rate 27485 Priced Repair achilles tendon 48016 27650 CPT Outpatient 38246.25 3762.57 Aetna Better Health Aetna Medicaid 0.09 3390.17 0.09 38246.25 0.09 Case Rate 27650 Priced Treatment of ankle fracture 48016 27792 CPT Outpatient 36101.10 6197.36 Aetna Better Health Aetna Medicaid 0.10 3506.63 0.10 36101.10 0.10 Case Rate 27792 Priced Treatment of ankle fracture 48016 27814 CPT Outpatient 49405.65 8481.30 Aetna Better Health Aetna Medicaid 0.09 4287.10 0.09 49405.65 0.09 Case Rate 27814 Priced Removal of foot lesion 48016 28080 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 48016 28285 CPT Outpatient 68603.85 11776.99 Aetna Better Health Aetna Medicaid 0.08 5801.80 0.08 68603.85 0.08 Case Rate 28285 Priced Correction hallux valgus 48016 28296 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 48016 29823 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 48016 29826 CPT Outpatient 49840.35 8555.93 Aetna Better Health Aetna Medicaid 0.10 4854.27 0.10 49840.35 0.10 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 48016 29881 CPT Outpatient 35556.15 6103.81 Aetna Better Health Aetna Medicaid 0.09 3330.26 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 48016 29882 CPT Outpatient 61099.50 10488.75 Aetna Better Health Aetna Medicaid 0.10 5952.84 0.10 61099.50 0.10 Case Rate 29882 Priced Percut bx lung/mediastinum 48016 32405 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 48016 32555 CPT Outpatient 14597.10 687.29 Aetna Better Health Aetna Medicaid 0.04 642.25 0.04 14597.10 0.04 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 48016 32664 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 48016 35190 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 48016 36478 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 48016 36561 CPT Outpatient 53531.10 3292.99 Aetna Better Health Aetna Medicaid 0.05 2666.42 0.05 53531.10 0.05 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 48016 36569 CPT Outpatient 31421.25 1299.06 Aetna Better Health Aetna Medicaid 0.07 2213.67 0.07 31421.25 0.07 Case Rate 36569 Priced Removal tunneled cv cath 48016 36590 CPT Outpatient 1996.05 273.95 Aetna Better Health Aetna Medicaid 0.10 191.38 0.10 1996.05 0.10 Case Rate 36590 Priced Av fuse uppr arm basilic 48016 36819 CPT Outpatient 56861.70 9761.26 Aetna Better Health Aetna Medicaid 0.10 5606.61 0.10 56861.70 0.10 Case Rate 36819 Priced Av fusion direct any site 48016 36821 CPT Outpatient 42953.40 7373.67 Aetna Better Health Aetna Medicaid 0.09 4057.36 0.09 42953.40 0.09 Case Rate 36821 Priced Artery-vein autograft 48016 36825 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 48016 36830 CPT Outpatient 53656.05 9210.96 Aetna Better Health Aetna Medicaid 0.10 5434.23 0.10 53656.05 0.10 Case Rate 36830 Priced Av fistula revision open 48016 36832 CPT Outpatient 52492.65 9011.24 Aetna Better Health Aetna Medicaid 0.09 4608.27 0.09 52492.65 0.09 Case Rate 36832 Priced Av fistula revision 48016 36833 CPT Outpatient 37098.60 6368.59 Aetna Better Health Aetna Medicaid 0.09 3487.01 0.09 37098.60 0.09 Case Rate 36833 Priced Intro cath dialysis circuit 48016 36903 CPT Outpatient 77541.45 10669.90 Aetna Better Health Aetna Medicaid 0.08 6332.59 0.08 77541.45 0.08 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 48016 36906 CPT Outpatient 96694.50 16175.64 Aetna Better Health Aetna Medicaid 0.09 8800.94 0.09 96694.50 0.09 Case Rate 36906 Priced Fem/popl revas w/tla 48016 37224 CPT Outpatient 200076.45 5139.31 Aetna Better Health Aetna Medicaid 0.09 18303.46 0.09 200076.45 0.09 Case Rate 37224 Priced Fem/popl revasc stnt & ather 48016 37227 CPT Outpatient 117170.55 18045.38 Aetna Better Health Aetna Medicaid 0.10 11746.91 0.10 117170.55 0.10 Case Rate 37227 Priced Revise leg vein 48016 37700 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 48016 37722 CPT Outpatient 27815.55 4775.00 Aetna Better Health Aetna Medicaid 0.10 2689.35 0.10 27815.55 0.10 Case Rate 37722 Priced Stab phleb veins xtr 10-20 48016 37765 CPT Outpatient 26561.85 4559.78 Aetna Better Health Aetna Medicaid 0.10 2575.64 0.10 26561.85 0.10 Case Rate 37765 Priced Biopsy/removal lymph nodes 48016 38500 CPT Outpatient 35955.15 6172.30 Aetna Better Health Aetna Medicaid 0.10 3601.92 0.10 35955.15 0.10 Case Rate 38500 Priced Biopsy/removal lymph nodes 48016 38525 CPT Outpatient 101194.80 17371.77 Aetna Better Health Aetna Medicaid 0.10 9688.89 0.10 101194.80 0.10 Case Rate 38525 Priced Laparoscopy lymph node biop 48016 38570 CPT Outpatient 65631.30 11266.71 Aetna Better Health Aetna Medicaid 0.09 6212.57 0.09 65631.30 0.09 Case Rate 38570 Priced Laparoscopy lymphadenectomy 48016 38571 CPT Outpatient 84031.50 14425.41 Aetna Better Health Aetna Medicaid 0.09 7669.75 0.09 84031.50 0.09 Case Rate 38571 Priced Laparoscopy lymphadenectomy 48016 38572 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 48016 38792 CPT Outpatient 2868.60 432.48 Aetna Better Health Aetna Medicaid 0.10 273.80 0.10 2868.60 0.10 Case Rate 38792 Priced Excision of gum lesion 48016 41825 CPT Outpatient 11580.45 1987.98 Aetna Better Health Aetna Medicaid 0.10 1150.33 0.10 11580.45 0.10 Case Rate 41825 Priced Reconstruct cleft palate 48016 42200 CPT Outpatient 36703.80 6300.82 Aetna Better Health Aetna Medicaid 0.10 3505.00 0.10 36703.80 0.10 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 48016 42820 CPT Outpatient 17232.60 2958.26 Aetna Better Health Aetna Medicaid 0.10 1715.92 0.10 17232.60 0.10 Case Rate 42820 Priced Control throat bleeding 48016 42960 CPT Outpatient 24066.00 4131.33 Aetna Better Health Aetna Medicaid 0.10 2325.00 0.10 24066.00 0.10 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 48016 43235 CPT Outpatient 8856.75 1633.35 Aetna Better Health Aetna Medicaid 0.10 880.41 0.10 8856.75 0.10 Case Rate 43235 Priced Laparoscopy fundoplasty 48016 43280 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 48016 43282 CPT Outpatient 84344.40 14479.12 Aetna Better Health Aetna Medicaid 0.10 8331.45 0.10 84344.40 0.10 Case Rate 43282 Priced Laparoscopy appendectomy 48016 44970 CPT Outpatient 82300.05 14128.18 Aetna Better Health Aetna Medicaid 0.05 4395.83 0.05 82300.05 0.05 Case Rate 44970 Priced Diagnostic sigmoidoscopy 48016 45330 CPT Outpatient 17286.15 542.26 Aetna Better Health Aetna Medicaid 0.09 1608.66 0.09 17286.15 0.09 Case Rate 45330 Priced Needle biopsy of liver 48016 47000 CPT Outpatient 10398.15 1225.34 Aetna Better Health Aetna Medicaid 0.10 992.77 0.10 10398.15 0.10 Case Rate 47000 Priced Removal of gallbladder using an endoscope 48016 47562 CPT Outpatient 58430.40 10030.55 Aetna Better Health Aetna Medicaid 0.05 2824.94 0.05 58430.40 0.05 Case Rate 47562 Priced Laparo cholecystectomy/graph 48016 47563 CPT Outpatient 71747.55 12316.66 Aetna Better Health Aetna Medicaid 0.08 5807.38 0.08 71747.55 0.08 Case Rate 47563 Priced Abd paracentesis w/imaging 48016 49083 CPT Outpatient 6979.35 1113.95 Aetna Better Health Aetna Medicaid 0.10 666.34 0.10 6979.35 0.10 Case Rate 49083 Priced Diag laparo separate proc 48016 49320 CPT Outpatient 31629.15 5429.67 Aetna Better Health Aetna Medicaid 0.10 3006.03 0.10 31629.15 0.10 Case Rate 49320 Priced Laparoscopy biopsy 48016 49321 CPT Outpatient 41892.90 7191.61 Aetna Better Health Aetna Medicaid 0.09 3888.69 0.09 41892.90 0.09 Case Rate 49321 Priced Laparoscopy aspiration 48016 49322 CPT Outpatient 34392.75 5904.09 Aetna Better Health Aetna Medicaid 0.09 3222.10 0.09 34392.75 0.09 Case Rate 49322 Priced Lap insert tunnel ip cath 48016 49324 CPT Outpatient 39264.75 6740.45 Aetna Better Health Aetna Medicaid 0.09 3562.75 0.09 39264.75 0.09 Case Rate 49324 Priced Laparo proc abdm/per/oment 48016 49329 CPT Outpatient 58696.05 10076.16 Aetna Better Health Aetna Medicaid 0.09 5389.70 0.09 58696.05 0.09 Case Rate 49329 Priced Ins tun ip cath for dial opn 48016 49421 CPT Outpatient 25460.40 3319.30 Aetna Better Health Aetna Medicaid 0.09 2346.61 0.09 25460.40 0.09 Case Rate 49421 Priced Remove tunneled ip cath 48016 49422 CPT Outpatient 25515.00 4380.08 Aetna Better Health Aetna Medicaid 0.10 2480.16 0.10 25515.00 0.10 Case Rate 49422 Priced Rpr ing hernia init reduce 48016 49500 CPT Outpatient 19594.05 3363.65 Aetna Better Health Aetna Medicaid 0.10 1915.13 0.10 19594.05 0.10 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 48016 49505 CPT Outpatient 34915.65 5993.85 Aetna Better Health Aetna Medicaid 0.09 3211.75 0.09 34915.65 0.09 Case Rate 49505 Priced Prp i/hern init block >5 yr 48016 49507 CPT Outpatient 29794.80 5114.77 Aetna Better Health Aetna Medicaid 0.10 2840.69 0.10 29794.80 0.10 Case Rate 49507 Priced Rerepair ing hernia reduce 48016 49520 CPT Outpatient 36940.05 6341.38 Aetna Better Health Aetna Medicaid 0.09 3437.18 0.09 36940.05 0.09 Case Rate 49520 Priced Rpr ventral hern init reduc 48016 49560 CPT Outpatient 53177.25 9128.76 Aetna Better Health Aetna Medicaid 0.09 5049.19 0.09 53177.25 0.09 Case Rate 49560 Priced Rpr ventral hern init block 48016 49561 CPT Outpatient 30755.55 5279.70 Aetna Better Health Aetna Medicaid 0.10 2943.37 0.10 30755.55 0.10 Case Rate 49561 Priced Rerepair ventrl hern reduce 48016 49565 CPT Outpatient 69917.40 12002.49 Aetna Better Health Aetna Medicaid 0.09 6438.24 0.09 69917.40 0.09 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 48016 49585 CPT Outpatient 41806.80 7176.83 Aetna Better Health Aetna Medicaid 0.10 3982.46 0.10 41806.80 0.10 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 48016 49587 CPT Outpatient 37320.15 6406.63 Aetna Better Health Aetna Medicaid 0.09 3350.53 0.09 37320.15 0.09 Case Rate 49587 Priced Lap ing hernia repair init 48016 49650 CPT Outpatient 41932.80 7198.46 Aetna Better Health Aetna Medicaid 0.10 4148.64 0.10 41932.80 0.10 Case Rate 49650 Priced Lap ing hernia repair recur 48016 49651 CPT Outpatient 46915.05 8053.75 Aetna Better Health Aetna Medicaid 0.10 4476.23 0.10 46915.05 0.10 Case Rate 49651 Priced Lap vent/abd hernia repair 48016 49652 CPT Outpatient 51294.60 8805.57 Aetna Better Health Aetna Medicaid 0.09 4872.06 0.09 51294.60 0.09 Case Rate 49652 Priced Lap vent/abd hern proc comp 48016 49653 CPT Outpatient 46102.35 7914.24 Aetna Better Health Aetna Medicaid 0.09 4369.15 0.09 46102.35 0.09 Case Rate 49653 Priced Lap inc hernia repair 48016 49654 CPT Outpatient 47221.65 8106.38 Aetna Better Health Aetna Medicaid 0.10 4504.47 0.10 47221.65 0.10 Case Rate 49654 Priced Lap inc hern repair comp 48016 49655 CPT Outpatient 54590.55 9371.38 Aetna Better Health Aetna Medicaid 0.09 5086.79 0.09 54590.55 0.09 Case Rate 49655 Priced Lap inc hernia repair recur 48016 49656 CPT Outpatient 55443.15 9517.74 Aetna Better Health Aetna Medicaid 0.09 5254.08 0.09 55443.15 0.09 Case Rate 49656 Priced Removal of kidney stone 48016 50080 CPT Outpatient 53165.70 9126.78 Aetna Better Health Aetna Medicaid 0.09 4602.08 0.09 53165.70 0.09 Case Rate 50080 Priced Removal of kidney stone 48016 50081 CPT Outpatient 66931.20 11489.86 Aetna Better Health Aetna Medicaid 0.09 5960.00 0.09 66931.20 0.09 Case Rate 50081 Priced Renal biopsy perq 48016 50200 CPT Outpatient 43096.20 1225.34 Aetna Better Health Aetna Medicaid 0.05 2279.75 0.05 43096.20 0.05 Case Rate 50200 Priced Plmt nephroureteral catheter 48016 50433 CPT Outpatient 64566.60 1424.48 Aetna Better Health Aetna Medicaid 0.09 5749.04 0.09 64566.60 0.09 Case Rate 50433 Priced Laparo radical nephrectomy 48016 50545 CPT Outpatient 43449.00 7458.75 Aetna Better Health Aetna Medicaid 0.09 4000.41 0.09 43449.00 0.09 Case Rate 50545 Priced Laparoscope proc ureter 48016 50949 CPT Outpatient 49986.30 8580.98 Aetna Better Health Aetna Medicaid 0.09 4667.96 0.09 49986.30 0.09 Case Rate 50949 Priced Injection for bladder x-ray 48016 51600 CPT Outpatient 3285.45 89.22 Aetna Better Health Aetna Medicaid 0.10 313.70 0.10 3285.45 0.10 Case Rate 51600 Priced Cystoscopy 48016 52000 CPT Outpatient 22149.75 3802.37 Aetna Better Health Aetna Medicaid 0.09 2026.55 0.09 22149.75 0.09 Case Rate 52000 Priced Cystoscopy & ureter catheter 48016 52005 CPT Outpatient 42529.20 2095.77 Aetna Better Health Aetna Medicaid 0.10 4086.28 0.10 42529.20 0.10 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 48016 52204 CPT Outpatient 31274.25 5368.75 Aetna Better Health Aetna Medicaid 0.08 2433.34 0.08 31274.25 0.08 Case Rate 52204 Priced Cystoscopy and treatment 48016 52224 CPT Outpatient 13445.25 2308.10 Aetna Better Health Aetna Medicaid 0.09 1217.97 0.09 13445.25 0.09 Case Rate 52224 Priced Cystoscopy and treatment 48016 52234 CPT Outpatient 28510.65 4894.33 Aetna Better Health Aetna Medicaid 0.08 2287.00 0.08 28510.65 0.08 Case Rate 52234 Priced Cystoscopy and treatment 48016 52235 CPT Outpatient 29417.85 5050.06 Aetna Better Health Aetna Medicaid 0.08 2234.63 0.08 29417.85 0.08 Case Rate 52235 Priced Cystoscopy and treatment 48016 52240 CPT Outpatient 33933.90 5825.32 Aetna Better Health Aetna Medicaid 0.10 3237.86 0.10 33933.90 0.10 Case Rate 52240 Priced Cystoscopy and treatment 48016 52281 CPT Outpatient 22159.20 3804.00 Aetna Better Health Aetna Medicaid 0.09 1917.29 0.09 22159.20 0.09 Case Rate 52281 Priced Remove bladder stone 48016 52317 CPT Outpatient 27085.80 4649.73 Aetna Better Health Aetna Medicaid 0.10 2584.60 0.10 27085.80 0.10 Case Rate 52317 Priced Remove bladder stone 48016 52318 CPT Outpatient 26685.75 4581.05 Aetna Better Health Aetna Medicaid 0.09 2429.12 0.09 26685.75 0.09 Case Rate 52318 Priced Cystoscopy and treatment 48016 52332 CPT Outpatient 115306.80 19794.33 Aetna Better Health Aetna Medicaid 0.05 5472.08 0.05 115306.80 0.05 Case Rate 52332 Priced Cystouretero w/stone remove 48016 52352 CPT Outpatient 42420.00 7282.10 Aetna Better Health Aetna Medicaid 0.09 3954.93 0.09 42420.00 0.09 Case Rate 52352 Priced Cystouretero w/lithotripsy 48016 52353 CPT Outpatient 38608.50 6627.79 Aetna Better Health Aetna Medicaid 0.09 3639.93 0.09 38608.50 0.09 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 48016 52356 CPT Outpatient 36255.45 6223.85 Aetna Better Health Aetna Medicaid 0.09 3402.36 0.09 36255.45 0.09 Case Rate 52356 Priced Prostatectomy (turp) 48016 52601 CPT Outpatient 35371.35 6072.08 Aetna Better Health Aetna Medicaid 0.08 2850.60 0.08 35371.35 0.08 Case Rate 52601 Priced Laser surgery of prostate 48016 52648 CPT Outpatient 24264.45 4165.40 Aetna Better Health Aetna Medicaid 0.10 2485.95 0.10 24264.45 0.10 Case Rate 52648 Priced Revision of urethra 48016 53450 CPT Outpatient 16209.90 2782.70 Aetna Better Health Aetna Medicaid 0.10 1586.86 0.10 16209.90 0.10 Case Rate 53450 Priced Urology surgery procedure 48016 53899 CPT Outpatient 25368.00 134.83 Aetna Better Health Aetna Medicaid 0.09 2368.93 0.09 25368.00 0.09 Case Rate 53899 Priced Circumcision w/regionl block 48016 54150 CPT Outpatient 14700.00 2523.50 Aetna Better Health Aetna Medicaid 0.10 1434.55 0.10 14700.00 0.10 Case Rate 54150 Priced Circum 28 days or older 48016 54161 CPT Outpatient 19186.65 3293.71 Aetna Better Health Aetna Medicaid 0.10 1827.97 0.10 19186.65 0.10 Case Rate 54161 Priced Lysis penil circumic lesion 48016 54162 CPT Outpatient 19795.65 3398.25 Aetna Better Health Aetna Medicaid 0.10 1929.51 0.10 19795.65 0.10 Case Rate 54162 Priced Repair of circumcision 48016 54163 CPT Outpatient 16391.55 2813.88 Aetna Better Health Aetna Medicaid 0.10 1630.62 0.10 16391.55 0.10 Case Rate 54163 Priced Reconstruction of urethra 48016 54324 CPT Outpatient 32880.75 5644.53 Aetna Better Health Aetna Medicaid 0.10 3180.62 0.10 32880.75 0.10 Case Rate 54324 Priced Revise penis/urethra 48016 54332 CPT Outpatient 19968.90 3427.99 Aetna Better Health Aetna Medicaid 0.10 2008.81 0.10 19968.90 0.10 Case Rate 54332 Priced Insert self-contd prosthesis 48016 54401 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 48016 54520 CPT Outpatient 35442.75 6084.34 Aetna Better Health Aetna Medicaid 0.09 3242.34 0.09 35442.75 0.09 Case Rate 54520 Priced Reduce testis torsion 48016 54600 CPT Outpatient 55049.40 9450.15 Aetna Better Health Aetna Medicaid 0.07 3690.12 0.07 55049.40 0.07 Case Rate 54600 Priced Suspension of testis 48016 54640 CPT Outpatient 26860.05 4610.98 Aetna Better Health Aetna Medicaid 0.10 2605.44 0.10 26860.05 0.10 Case Rate 54640 Priced Removal of hydrocele 48016 55040 CPT Outpatient 27277.95 4682.71 Aetna Better Health Aetna Medicaid 0.09 2481.62 0.09 27277.95 0.09 Case Rate 55040 Priced Biopsy of prostate gland 48016 55700 CPT Outpatient 28699.65 4926.77 Aetna Better Health Aetna Medicaid 0.09 2724.96 0.09 28699.65 0.09 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 48016 55866 CPT Outpatient 93088.80 15980.24 Aetna Better Health Aetna Medicaid 0.09 8286.86 0.09 93088.80 0.09 Case Rate 55866 Priced Closure of vagina 48016 57120 CPT Outpatient 34369.65 5900.12 Aetna Better Health Aetna Medicaid 0.09 3225.59 0.09 34369.65 0.09 Case Rate 57120 Priced Repair of vagina 48016 57200 CPT Outpatient 25247.25 4334.11 Aetna Better Health Aetna Medicaid 0.09 2186.34 0.09 25247.25 0.09 Case Rate 57200 Priced Anterior colporrhaphy 48016 57240 CPT Outpatient 36210.30 6216.10 Aetna Better Health Aetna Medicaid 0.10 3764.98 0.10 36210.30 0.10 Case Rate 57240 Priced Repair rectum & vagina 48016 57250 CPT Outpatient 40441.80 6942.51 Aetna Better Health Aetna Medicaid 0.09 3802.83 0.09 40441.80 0.09 Case Rate 57250 Priced Cmbn ant pst colprhy 48016 57260 CPT Outpatient 46323.90 7952.27 Aetna Better Health Aetna Medicaid 0.09 4371.74 0.09 46323.90 0.09 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 48016 57265 CPT Outpatient 42586.95 7310.76 Aetna Better Health Aetna Medicaid 0.08 3283.43 0.08 42586.95 0.08 Case Rate 57265 Priced Repair of bowel bulge 48016 57268 CPT Outpatient 36865.50 6328.58 Aetna Better Health Aetna Medicaid 0.09 3328.82 0.09 36865.50 0.09 Case Rate 57268 Priced Colpopexy extraperitoneal 48016 57282 CPT Outpatient 45629.85 7833.12 Aetna Better Health Aetna Medicaid 0.09 4031.48 0.09 45629.85 0.09 Case Rate 57282 Priced Repair bladder defect 48016 57288 CPT Outpatient 43069.95 7393.67 Aetna Better Health Aetna Medicaid 0.10 4095.31 0.10 43069.95 0.10 Case Rate 57288 Priced Bx/curett of cervix w/scope 48016 57454 CPT Outpatient 2888.55 442.93 Aetna Better Health Aetna Medicaid 0.09 257.82 0.09 2888.55 0.09 Case Rate 57454 Priced Conization of cervix 48016 57520 CPT Outpatient 26728.80 4588.44 Aetna Better Health Aetna Medicaid 0.09 2515.97 0.09 26728.80 0.09 Case Rate 57520 Priced Conization of cervix 48016 57522 CPT Outpatient 22737.75 3903.31 Aetna Better Health Aetna Medicaid 0.10 2293.15 0.10 22737.75 0.10 Case Rate 57522 Priced Biopsy of uterus lining 48016 58100 CPT Outpatient 2371.95 194.80 Aetna Better Health Aetna Medicaid 0.09 208.45 0.09 2371.95 0.09 Case Rate 58100 Priced Catheter for hysterography 48016 58340 CPT Outpatient 6322.05 131.04 Aetna Better Health Aetna Medicaid 0.05 340.43 0.05 6322.05 0.05 Case Rate 58340 Priced Reopen fallopian tube 48016 58350 CPT Outpatient 46507.65 7983.81 Aetna Better Health Aetna Medicaid 0.09 4365.24 0.09 46507.65 0.09 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 48016 58542 CPT Outpatient 64194.90 11020.12 Aetna Better Health Aetna Medicaid 0.09 6090.94 0.09 64194.90 0.09 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 48016 58544 CPT Outpatient 51020.55 8758.53 Aetna Better Health Aetna Medicaid 0.09 4742.85 0.09 51020.55 0.09 Case Rate 58544 Priced Laparoscopic myomectomy 48016 58545 CPT Outpatient 56946.75 9775.86 Aetna Better Health Aetna Medicaid 0.09 5325.56 0.09 56946.75 0.09 Case Rate 58545 Priced Laparo-vag hyst incl t/o 48016 58552 CPT Outpatient 57228.15 9824.17 Aetna Better Health Aetna Medicaid 0.09 5406.15 0.09 57228.15 0.09 Case Rate 58552 Priced Hysteroscopy biopsy 48016 58558 CPT Outpatient 28581.00 2077.02 Aetna Better Health Aetna Medicaid 0.10 2719.86 0.10 28581.00 0.10 Case Rate 58558 Priced Hysteroscopy remove myoma 48016 58561 CPT Outpatient 35222.25 6046.49 Aetna Better Health Aetna Medicaid 0.09 3270.00 0.09 35222.25 0.09 Case Rate 58561 Priced Hysteroscopy ablation 48016 58563 CPT Outpatient 38399.55 6591.92 Aetna Better Health Aetna Medicaid 0.11 4232.16 0.11 38399.55 0.11 Case Rate 58563 Priced Tlh uterus 250 g or less 48016 58570 CPT Outpatient 43316.70 7436.03 Aetna Better Health Aetna Medicaid 0.09 3956.53 0.09 43316.70 0.09 Case Rate 58570 Priced Tlh w/t/o 250 g or less 48016 58571 CPT Outpatient 48603.45 8343.59 Aetna Better Health Aetna Medicaid 0.10 4683.55 0.10 48603.45 0.10 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 48016 58573 CPT Outpatient 52905.30 9082.08 Aetna Better Health Aetna Medicaid 0.09 4911.52 0.09 52905.30 0.09 Case Rate 58573 Priced Laparoscopy remove adnexa 48016 58661 CPT Outpatient 47008.50 8069.79 Aetna Better Health Aetna Medicaid 0.10 4475.42 0.10 47008.50 0.10 Case Rate 58661 Priced Laparoscopy excise lesions 48016 58662 CPT Outpatient 45053.40 7734.17 Aetna Better Health Aetna Medicaid 0.10 4312.40 0.10 45053.40 0.10 Case Rate 58662 Priced Treat ectopic pregnancy 48016 59151 CPT Outpatient 74690.70 12821.90 Aetna Better Health Aetna Medicaid 0.06 4661.07 0.06 74690.70 0.06 Case Rate 59151 Priced Treatment of miscarriage 48016 59812 CPT Outpatient 56109.90 9632.20 Aetna Better Health Aetna Medicaid 0.05 2659.14 0.05 56109.90 0.05 Case Rate 59812 Priced Partial removal of thyroid 48016 60220 CPT Outpatient 53639.25 9208.07 Aetna Better Health Aetna Medicaid 0.11 5806.81 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 48016 60240 CPT Outpatient 98252.70 16866.71 Aetna Better Health Aetna Medicaid 0.07 6443.78 0.07 98252.70 0.07 Case Rate 60240 Priced Explore parathyroid glands 48016 60500 CPT Outpatient 150495.45 25835.05 Aetna Better Health Aetna Medicaid 0.03 5051.13 0.03 150495.45 0.03 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 48016 62322 CPT Outpatient 43709.40 514.24 Aetna Better Health Aetna Medicaid 0.10 4236.24 0.10 43709.40 0.10 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 48016 62323 CPT Outpatient 8304.45 467.31 Aetna Better Health Aetna Medicaid 0.06 473.06 0.06 8304.45 0.06 Case Rate 62323 Priced Low back disk surgery 48016 63030 CPT Outpatient 50287.65 8632.71 Aetna Better Health Aetna Medicaid 0.09 4596.08 0.09 50287.65 0.09 Case Rate 63030 Priced Inc for vagus n elect impl 48016 64568 CPT Outpatient 124562.55 21383.24 Aetna Better Health Aetna Medicaid 0.10 11879.93 0.10 124562.55 0.10 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 48016 66821 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 48016 66984 CPT Outpatient 0.01 0.01 Aetna Better Health Aetna Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 701044 216 DRG Inpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 701044 460 DRG Inpatient 416122.79 53834.63 Wellpoint Mellpoint Medicaid 0.13 54196.94 0.13 416122.79 0.13 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 701044 470 DRG Inpatient 167912.19 21723.13 Wellpoint Mellpoint Medicaid 0.11 18308.03 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 701044 473 DRG Inpatient 100687.91 13026.19 Wellpoint Mellpoint Medicaid 0.18 17939.00 0.18 100687.91 0.18 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 701044 743 DRG Inpatient 102691.67 13285.42 Wellpoint Mellpoint Medicaid 0.09 9286.35 0.09 102691.67 0.09 Case Rate 743 Priced NORMAL NEWBORN 701044 795 DRG Inpatient 6266.93 2335.00 Wellpoint Mellpoint Medicaid 0.18 1130.95 0.18 6266.93 0.18 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 701044 807 DRG Inpatient 116469.59 4193.00 Wellpoint Mellpoint Medicaid 0.03 3934.45 0.03 116469.59 0.03 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 701044 788 DRG Inpatient 76050.77 4538.00 Wellpoint Mellpoint Medicaid 0.08 5914.64 0.08 76050.77 0.08 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 701044 59400 CPT Inpatient 116469.59 4193.00 Wellpoint Mellpoint Medicaid 0.03 3934.45 0.03 116469.59 0.03 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 701044 59510 CPT Inpatient 76050.77 4538.00 Wellpoint Mellpoint Medicaid 0.08 5914.64 0.08 76050.77 0.08 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 701044 59610 CPT Inpatient 116469.59 4193.00 Wellpoint Mellpoint Medicaid 0.03 3934.45 0.03 116469.59 0.03 Case Rate 59610 Priced "Psychotherapy, 30 min" 701044 90832 CPT Outpatient 577.50 91.21 Wellpoint Mellpoint Medicaid 0.13 74.83 0.13 577.50 0.13 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 701044 90834 CPT Outpatient 44134.65 271.96 Wellpoint Mellpoint Medicaid 0.06 2618.88 0.06 44134.65 0.06 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 701044 90837 CPT Outpatient 2240.70 442.93 Wellpoint Mellpoint Medicaid 0.02 47.49 0.02 2240.70 0.02 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 701044 90846 CPT Outpatient 0.01 131.50 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 701044 90847 CPT Outpatient 44134.65 369.97 Wellpoint Mellpoint Medicaid 0.06 2618.88 0.06 44134.65 0.06 Fee Schedule 90847 Priced Group psychotherapy 701044 90853 CPT Outpatient 44134.65 101.99 Wellpoint Mellpoint Medicaid 0.06 2618.88 0.06 44134.65 0.06 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 701044 99203 CPT Outpatient 3480.75 176.07 Wellpoint Mellpoint Medicaid 0.11 365.66 0.11 3480.75 0.11 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 701044 99204 CPT Outpatient 2103.15 233.39 Wellpoint Mellpoint Medicaid 0.11 220.88 0.11 2103.15 0.11 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 701044 99205 CPT Outpatient 4970.70 314.28 Wellpoint Mellpoint Medicaid 0.05 261.07 0.05 4970.70 0.05 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 701044 99243 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 701044 99244 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 701044 99385 CPT Outpatient 1114.05 185.90 Wellpoint Mellpoint Medicaid 0.11 116.98 0.11 1114.05 0.11 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 701044 99386 CPT Outpatient 4877.25 185.90 Wellpoint Mellpoint Medicaid 0.11 512.30 0.11 4877.25 0.11 Fee Schedule 99386 Priced Routine venipuncture 701044 36415 CPT Outpatient 127.05 19.57 Wellpoint Mellpoint Medicaid 0.11 14.01 0.11 127.05 0.11 Fee Schedule 36415 Priced Basic Metabolic Panel 701044 80048 CPT Outpatient 576.45 88.78 Wellpoint Mellpoint Medicaid 0.11 63.59 0.11 576.45 0.11 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 701044 80053 CPT Outpatient 763.35 117.56 Wellpoint Mellpoint Medicaid 0.11 84.20 0.11 763.35 0.11 Fee Schedule 80053 Priced Obstetric blood test panel 701044 80055 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 701044 80061 CPT Outpatient 1349.25 197.77 Wellpoint Mellpoint Medicaid 0.10 141.66 0.10 1349.25 0.10 Fee Schedule 80061 Priced Kidney function panel test 701044 80069 CPT Outpatient 716.10 104.95 Wellpoint Mellpoint Medicaid 0.10 75.17 0.10 716.10 0.10 Fee Schedule 80069 Priced Liver function panel test 701044 80076 CPT Outpatient 716.10 104.95 Wellpoint Mellpoint Medicaid 0.10 75.17 0.10 716.10 0.10 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 701044 81000 CPT Outpatient 144.90 21.18 Wellpoint Mellpoint Medicaid 0.10 15.17 0.10 144.90 0.10 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 701044 81001 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 701044 81002 CPT Outpatient 57.75 8.89 Wellpoint Mellpoint Medicaid 0.11 6.38 0.11 57.75 0.11 Fee Schedule 81002 Priced Automated urinalysis test 701044 81003 CPT Outpatient 219.45 33.80 Wellpoint Mellpoint Medicaid 0.11 24.21 0.11 219.45 0.11 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 701044 82306 CPT Outpatient 1880.55 289.62 Wellpoint Mellpoint Medicaid 0.11 207.44 0.11 1880.55 0.11 Fee Schedule 82306 Priced Glycosylated hemoglobin test 701044 83036 CPT Outpatient 494.55 76.17 Wellpoint Mellpoint Medicaid 0.11 54.55 0.11 494.55 0.11 Fee Schedule 83036 Priced PSA (prostate specific antigen) 701044 84153 CPT Outpatient 1177.05 181.28 Wellpoint Mellpoint Medicaid 0.11 129.84 0.11 1177.05 0.11 Fee Schedule 84153 Priced PSA (prostate specific antigen) 701044 84154 CPT Outpatient 598.50 92.17 Wellpoint Mellpoint Medicaid 0.11 66.02 0.11 598.50 0.11 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 701044 84443 CPT Outpatient 519.75 80.05 Wellpoint Mellpoint Medicaid 0.11 57.34 0.11 519.75 0.11 Fee Schedule 84443 Priced Chorionic gonadotropin assay 701044 84703 CPT Outpatient 785.40 120.96 Wellpoint Mellpoint Medicaid 0.11 86.63 0.11 785.40 0.11 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 701044 85025 CPT Outpatient 635.25 97.83 Wellpoint Mellpoint Medicaid 0.11 70.08 0.11 635.25 0.11 Fee Schedule 85025 Priced "Complete blood count, automated" 701044 85027 CPT Outpatient 576.45 88.78 Wellpoint Mellpoint Medicaid 0.11 63.59 0.11 576.45 0.11 Fee Schedule 85027 Priced "Blood test, clotting time" 701044 85610 CPT Outpatient 404.25 62.26 Wellpoint Mellpoint Medicaid 0.11 44.60 0.11 404.25 0.11 Fee Schedule 85610 Priced Coagulation assessment blood test 701044 85730 CPT Outpatient 17.22 2.65 Wellpoint Mellpoint Medicaid 0.11 1.90 0.11 17.22 0.11 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 701044 86003 CPT Outpatient 32.55 5.01 Wellpoint Mellpoint Medicaid 0.11 3.59 0.11 32.55 0.11 Fee Schedule 86003 Priced Tb test cell immun measure 701044 86480 CPT Outpatient 530.25 81.66 Wellpoint Mellpoint Medicaid 0.11 58.50 0.11 530.25 0.11 Fee Schedule 86480 Priced Urine culture/colony count 701044 87086 CPT Outpatient 763.35 117.56 Wellpoint Mellpoint Medicaid 0.11 84.20 0.11 763.35 0.11 Fee Schedule 87086 Priced Hpylori stool ia 701044 87338 CPT Outpatient 785.40 120.96 Wellpoint Mellpoint Medicaid 0.11 86.63 0.11 785.40 0.11 Fee Schedule 87338 Priced Cytopath eval fna report 701044 88173 CPT Outpatient 750.75 115.62 Wellpoint Mellpoint Medicaid 0.11 82.82 0.11 750.75 0.11 Fee Schedule 88173 Priced Tissue exam by pathologist 701044 88302 CPT Outpatient 635.25 97.83 Wellpoint Mellpoint Medicaid 0.11 70.08 0.11 635.25 0.11 Fee Schedule 88302 Priced Tissue exam by pathologist 701044 88305 CPT Outpatient 323.40 49.81 Wellpoint Mellpoint Medicaid 0.11 35.67 0.11 323.40 0.11 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 701044 11042 CPT Outpatient 2668.05 481.45 Wellpoint Mellpoint Medicaid 0.11 280.30 0.11 2668.05 0.11 Case Rate 11042 Priced Deb subq tissue add-on 701044 11045 CPT Outpatient 4652.55 330.00 Wellpoint Mellpoint Medicaid 0.11 488.78 0.11 4652.55 0.11 Case Rate 11045 Priced Dx bronchoscope/lavage 701044 31624 CPT Outpatient 41223.00 7602.31 Wellpoint Mellpoint Medicaid 0.11 4411.20 0.11 41223.00 0.11 Case Rate 31624 Priced Bronchoscopy/lung bx each 701044 31628 CPT Outpatient 49048.65 9045.51 Wellpoint Mellpoint Medicaid 0.11 5258.92 0.11 49048.65 0.11 Case Rate 31628 Priced Blood transfusion service 701044 36430 CPT Outpatient 9166.50 574.93 Wellpoint Mellpoint Medicaid 0.11 962.97 0.11 9166.50 0.11 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 701044 43235 CPT Outpatient 8856.75 1633.35 Wellpoint Mellpoint Medicaid 0.11 934.01 0.11 8856.75 0.11 Case Rate 43235 Priced Endoscopic us exam esoph 701044 43237 CPT Outpatient 23867.55 4401.63 Wellpoint Mellpoint Medicaid 0.11 2511.90 0.11 23867.55 0.11 Case Rate 43237 Priced Egd us fine needle bx/aspir 701044 43238 CPT Outpatient 30690.45 5659.90 Wellpoint Mellpoint Medicaid 0.10 3076.20 0.10 30690.45 0.10 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 701044 43239 CPT Outpatient 40191.90 7412.15 Wellpoint Mellpoint Medicaid 0.12 4816.12 0.12 40191.90 0.12 Case Rate 43239 Priced Ercp remove duct calculi 701044 43264 CPT Outpatient 34335.00 6332.03 Wellpoint Mellpoint Medicaid 0.11 3622.43 0.11 34335.00 0.11 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 701044 45378 CPT Outpatient 13991.25 889.35 Wellpoint Mellpoint Medicaid 0.11 1472.48 0.11 13991.25 0.11 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 701044 45380 CPT Outpatient 22215.90 4097.04 Wellpoint Mellpoint Medicaid 0.11 2339.09 0.11 22215.90 0.11 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 701044 45385 CPT Outpatient 119569.80 22050.95 Wellpoint Mellpoint Medicaid 0.04 4193.56 0.04 119569.80 0.04 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 701044 45391 CPT Outpatient 24923.85 4596.43 Wellpoint Mellpoint Medicaid 0.11 2623.67 0.11 24923.85 0.11 Case Rate 45391 Priced Fragmenting of kidney stone 701044 50590 CPT Outpatient 40930.05 7548.28 Wellpoint Mellpoint Medicaid 0.11 4315.53 0.11 40930.05 0.11 Case Rate 50590 Priced Fetal non-stress test 701044 59025 CPT Outpatient 3153.15 477.76 Wellpoint Mellpoint Medicaid 0.11 331.26 0.11 3153.15 0.11 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 701044 64483 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 701044 92567 CPT Outpatient 2224.95 98.50 Wellpoint Mellpoint Medicaid 0.11 233.73 0.11 2224.95 0.11 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 701044 93000 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 701044 93017 CPT Outpatient 3076.50 532.96 Wellpoint Mellpoint Medicaid 0.11 323.15 0.11 3076.50 0.11 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 701044 93452 CPT Outpatient 55621.65 8611.87 Wellpoint Mellpoint Medicaid 0.11 5868.74 0.11 55621.65 0.11 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 701044 95810 CPT Outpatient 20341.65 3373.48 Wellpoint Mellpoint Medicaid 0.11 2136.97 0.11 20341.65 0.11 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 701044 95811 CPT Outpatient 22491.00 3731.18 Wellpoint Mellpoint Medicaid 0.11 2362.83 0.11 22491.00 0.11 Case Rate 95811 Priced Eeg 41-60 minutes 701044 95812 CPT Outpatient 5578.65 925.83 Wellpoint Mellpoint Medicaid 0.11 586.07 0.11 5578.65 0.11 Case Rate 95812 Priced Genetic counseling 30 min 701044 96040 CPT Outpatient 0.01 102.81 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 701044 96413 CPT Outpatient 4856.25 472.45 Wellpoint Mellpoint Medicaid 0.11 511.02 0.11 4856.25 0.11 Case Rate 96413 Priced Ultrasound therapy 701044 97035 CPT Outpatient 2111.55 134.99 Wellpoint Mellpoint Medicaid 0.11 221.81 0.11 2111.55 0.11 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 701044 97110 CPT Outpatient 6494.25 92.86 Wellpoint Mellpoint Medicaid 0.11 682.21 0.11 6494.25 0.11 Case Rate 97110 Priced Gait training therapy 701044 97116 CPT Outpatient 4723.95 110.61 Wellpoint Mellpoint Medicaid 0.11 496.19 0.11 4723.95 0.11 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 701044 70450 CPT Outpatient 8566.95 835.61 Wellpoint Mellpoint Medicaid 0.11 899.96 0.11 8566.95 0.11 Case Rate 70450 Priced Mri brain stem w/o dye 701044 70551 CPT Outpatient 7861.35 1361.31 Wellpoint Mellpoint Medicaid 0.11 825.83 0.11 7861.35 0.11 Case Rate 70551 Priced MRI scan of brain before and after contrast 701044 70553 CPT Outpatient 10882.20 1625.88 Wellpoint Mellpoint Medicaid 0.11 1143.19 0.11 10882.20 0.11 Case Rate 70553 Priced X-ray exam chest 2 views 701044 71046 CPT Outpatient 859.95 150.37 Wellpoint Mellpoint Medicaid 0.11 90.34 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 701044 71250 CPT Outpatient 7288.05 1261.63 Wellpoint Mellpoint Medicaid 0.11 765.60 0.11 7288.05 0.11 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 701044 72082 CPT Outpatient 2022.30 253.33 Wellpoint Mellpoint Medicaid 0.12 252.61 0.12 2022.30 0.12 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 701044 72100 CPT Outpatient 1599.15 277.38 Wellpoint Mellpoint Medicaid 0.11 167.95 0.11 1599.15 0.11 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 701044 72110 CPT Outpatient 1389.15 241.04 Wellpoint Mellpoint Medicaid 0.11 145.94 0.11 1389.15 0.11 Case Rate 72110 Priced MRI scan of lower spinal canal 701044 72148 CPT Outpatient 7861.35 1361.31 Wellpoint Mellpoint Medicaid 0.11 825.83 0.11 7861.35 0.11 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 701044 72193 CPT Outpatient 13671.00 1412.01 Wellpoint Mellpoint Medicaid 0.06 857.11 0.06 13671.00 0.06 Case Rate 72193 Priced X-ray exam of shoulder 701044 73030 CPT Outpatient 1452.15 251.43 Wellpoint Mellpoint Medicaid 0.11 152.54 0.11 1452.15 0.11 Case Rate 73030 Priced X-ray exam of elbow 701044 73080 CPT Outpatient 1356.60 235.68 Wellpoint Mellpoint Medicaid 0.11 142.46 0.11 1356.60 0.11 Case Rate 73080 Priced X-ray exam of forearm 701044 73090 CPT Outpatient 1243.20 215.26 Wellpoint Mellpoint Medicaid 0.10 130.53 0.10 1243.20 0.10 Case Rate 73090 Priced X-ray exam of wrist 701044 73110 CPT Outpatient 1243.20 215.26 Wellpoint Mellpoint Medicaid 0.10 130.53 0.10 1243.20 0.10 Case Rate 73110 Priced X-ray exam of hand 701044 73130 CPT Outpatient 1243.20 215.26 Wellpoint Mellpoint Medicaid 0.10 130.53 0.10 1243.20 0.10 Case Rate 73130 Priced X-ray exam hips bi 2 views 701044 73521 CPT Outpatient 970.20 228.41 Wellpoint Mellpoint Medicaid 0.14 137.83 0.14 970.20 0.14 Case Rate 73521 Priced X-ray exam of knee 3 701044 73562 CPT Outpatient 802.20 139.12 Wellpoint Mellpoint Medicaid 0.10 84.20 0.10 802.20 0.10 Case Rate 73562 Priced X-ray exam of lower leg 701044 73590 CPT Outpatient 1243.20 215.26 Wellpoint Mellpoint Medicaid 0.10 130.53 0.10 1243.20 0.10 Case Rate 73590 Priced X-ray exam of ankle 701044 73610 CPT Outpatient 1378.65 239.31 Wellpoint Mellpoint Medicaid 0.11 144.78 0.11 1378.65 0.11 Case Rate 73610 Priced X-ray exam of foot 701044 73630 CPT Outpatient 975.45 169.41 Wellpoint Mellpoint Medicaid 0.10 102.39 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 701044 73721 CPT Outpatient 7861.35 1361.31 Wellpoint Mellpoint Medicaid 0.11 825.83 0.11 7861.35 0.11 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 701044 74177 CPT Outpatient 14222.25 1412.01 Wellpoint Mellpoint Medicaid 0.06 857.11 0.06 14222.25 0.06 Case Rate 74177 Priced Contrst x-ray exam of throat 701044 74210 CPT Outpatient 0.01 440.39 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 701044 76098 CPT Outpatient 6141.45 407.86 Wellpoint Mellpoint Medicaid 0.11 645.15 0.11 6141.45 0.11 Case Rate 76098 Priced Us exam of head and neck 701044 76536 CPT Outpatient 5512.50 955.18 Wellpoint Mellpoint Medicaid 0.11 579.13 0.11 5512.50 0.11 Case Rate 76536 Priced Ultrasound breast limited 701044 76642 CPT Outpatient 5777.10 127.70 Wellpoint Mellpoint Medicaid 0.11 606.92 0.11 5777.10 0.11 Case Rate 76642 Priced Ultrasound of abdomen 701044 76700 CPT Outpatient 4917.15 851.88 Wellpoint Mellpoint Medicaid 0.11 516.58 0.11 4917.15 0.11 Case Rate 76700 Priced Echo exam of abdomen 701044 76705 CPT Outpatient 3836.70 665.17 Wellpoint Mellpoint Medicaid 0.11 403.07 0.11 3836.70 0.11 Case Rate 76705 Priced Us exam abdo back wall comp 701044 76770 CPT Outpatient 5171.25 895.48 Wellpoint Mellpoint Medicaid 0.11 543.22 0.11 5171.25 0.11 Case Rate 76770 Priced Us exam abdo back wall lim 701044 76775 CPT Outpatient 3969.00 686.97 Wellpoint Mellpoint Medicaid 0.11 416.97 0.11 3969.00 0.11 Case Rate 76775 Priced Ob us < 14 wks single fetus 701044 76801 CPT Outpatient 2006.55 347.98 Wellpoint Mellpoint Medicaid 0.11 210.80 0.11 2006.55 0.11 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 701044 76805 CPT Outpatient 3969.00 686.97 Wellpoint Mellpoint Medicaid 0.11 416.97 0.11 3969.00 0.11 Case Rate 76805 Priced Ob us detailed sngl fetus 701044 76811 CPT Outpatient 2844.45 492.99 Wellpoint Mellpoint Medicaid 0.11 298.83 0.11 2844.45 0.11 Case Rate 76811 Priced Ob us nuchal meas 1 gest 701044 76813 CPT Outpatient 1044.75 180.83 Wellpoint Mellpoint Medicaid 0.10 109.69 0.10 1044.75 0.10 Case Rate 76813 Priced Ob us limited fetus(s) 701044 76815 CPT Outpatient 6428.10 639.90 Wellpoint Mellpoint Medicaid 0.11 675.26 0.11 6428.10 0.11 Case Rate 76815 Priced Ob us follow-up per fetus 701044 76816 CPT Outpatient 4818.45 833.88 Wellpoint Mellpoint Medicaid 0.11 506.16 0.11 4818.45 0.11 Case Rate 76816 Priced Transvaginal us obstetric 701044 76817 CPT Outpatient 6428.10 476.73 Wellpoint Mellpoint Medicaid 0.11 675.26 0.11 6428.10 0.11 Case Rate 76817 Priced Fetal biophys profil w/o nst 701044 76819 CPT Outpatient 1741.95 302.65 Wellpoint Mellpoint Medicaid 0.11 183.00 0.11 1741.95 0.11 Case Rate 76819 Priced Ultrasound pelvis through vagina 701044 76830 CPT Outpatient 9305.10 806.54 Wellpoint Mellpoint Medicaid 0.11 977.56 0.11 9305.10 0.11 Case Rate 76830 Priced Us exam scrotum 701044 76870 CPT Outpatient 6328.35 1096.55 Wellpoint Mellpoint Medicaid 0.11 664.84 0.11 6328.35 0.11 Case Rate 76870 Priced Us exam infant hips dynamic 701044 76885 CPT Outpatient 3836.70 665.17 Wellpoint Mellpoint Medicaid 0.11 403.07 0.11 3836.70 0.11 Case Rate 76885 Priced Mammography of one breast 701044 77065 CPT Outpatient 3451.35 192.07 Wellpoint Mellpoint Medicaid 0.11 362.53 0.11 3451.35 0.11 Case Rate 77065 Priced Mammography of both breasts 701044 77066 CPT Outpatient 5777.10 235.68 Wellpoint Mellpoint Medicaid 0.11 606.92 0.11 5777.10 0.11 Case Rate 77066 Priced "Mamography, screening bilateral" 701044 77067 CPT Outpatient 1416.45 205.57 Wellpoint Mellpoint Medicaid 0.10 148.72 0.10 1416.45 0.10 Case Rate 77067 Priced X-rays for bone age 701044 77072 CPT Outpatient 2022.30 163.87 Wellpoint Mellpoint Medicaid 0.12 252.61 0.12 2022.30 0.12 Case Rate 77072 Priced Joint survey single view 701044 77077 CPT Outpatient 985.95 171.14 Wellpoint Mellpoint Medicaid 0.11 103.55 0.11 985.95 0.11 Case Rate 77077 Priced Dxa bone density axial 701044 77080 CPT Outpatient 3257.10 319.09 Wellpoint Mellpoint Medicaid 0.11 342.15 0.11 3257.10 0.11 Case Rate 77080 Priced Fna bx w/us gdn 1st les 701044 10005 CPT Outpatient 5512.50 547.24 Wellpoint Mellpoint Medicaid 0.11 579.13 0.11 5512.50 0.11 Case Rate 10005 Priced Fna bx w/us gdn ea addl 701044 10006 CPT Outpatient 10628.10 594.83 Wellpoint Mellpoint Medicaid 0.11 1116.55 0.11 10628.10 0.11 Case Rate 10006 Priced Drainage of hematoma/fluid 701044 10140 CPT Outpatient 23209.20 1081.95 Wellpoint Mellpoint Medicaid 0.09 2126.20 0.09 23209.20 0.09 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 701044 11042 CPT Outpatient 2668.05 481.45 Wellpoint Mellpoint Medicaid 0.11 280.30 0.11 2668.05 0.11 Case Rate 11042 Priced Deb bone 20 sq cm/< 701044 11044 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 701044 11406 CPT Outpatient 19967.85 3427.81 Wellpoint Mellpoint Medicaid 0.10 2093.42 0.10 19967.85 0.10 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 701044 11424 CPT Outpatient 0.01 1004.93 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 701044 11770 CPT Outpatient 19173.00 3291.37 Wellpoint Mellpoint Medicaid 0.10 2001.57 0.10 19173.00 0.10 Case Rate 11770 Priced Replace tissue expander 701044 11970 CPT Outpatient 59239.95 10169.52 Wellpoint Mellpoint Medicaid 0.11 6422.26 0.11 59239.95 0.11 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 701044 14020 CPT Outpatient 32166.75 5521.96 Wellpoint Mellpoint Medicaid 0.11 3387.88 0.11 32166.75 0.11 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 701044 14060 CPT Outpatient 25993.80 1374.69 Wellpoint Mellpoint Medicaid 0.11 2749.92 0.11 25993.80 0.11 Case Rate 14060 Priced Wound prep trk/arm/leg 701044 15002 CPT Outpatient 41748.00 1441.73 Wellpoint Mellpoint Medicaid 0.11 4594.08 0.11 41748.00 0.11 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 701044 15271 CPT Outpatient 24343.20 3769.48 Wellpoint Mellpoint Medicaid 0.10 2476.34 0.10 24343.20 0.10 Case Rate 15271 Priced Acellular derm matrix implt 701044 15777 CPT Outpatient 101672.55 17453.79 Wellpoint Mellpoint Medicaid 0.06 6491.29 0.06 101672.55 0.06 Case Rate 15777 Priced Exc skin abd 701044 15830 CPT Outpatient 54696.60 9389.58 Wellpoint Mellpoint Medicaid 0.08 4436.79 0.08 54696.60 0.08 Case Rate 15830 Priced Dressing change not for burn 701044 15852 CPT Outpatient 0.01 290.74 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 701044 15877 CPT Outpatient 63741.30 10942.26 Wellpoint Mellpoint Medicaid 0.11 6906.53 0.11 63741.30 0.11 Case Rate 15877 Priced Suction lipectomy lwr extrem 701044 15879 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 701044 19000 CPT Outpatient 10143.00 594.83 Wellpoint Mellpoint Medicaid 0.11 1065.59 0.11 10143.00 0.11 Case Rate 19000 Priced Bx breast 1st lesion strtctc 701044 19081 CPT Outpatient 12341.70 1250.69 Wellpoint Mellpoint Medicaid 0.11 1296.54 0.11 12341.70 0.11 Case Rate 19081 Priced Bx breast add lesion us imag 701044 19084 CPT Outpatient 29058.75 547.24 Wellpoint Mellpoint Medicaid 0.11 3052.80 0.11 29058.75 0.11 Case Rate 19084 Priced Biopsy of breast open 701044 19101 CPT Outpatient 39545.10 2737.82 Wellpoint Mellpoint Medicaid 0.10 3835.78 0.10 39545.10 0.10 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 701044 19120 CPT Outpatient 35761.95 2737.82 Wellpoint Mellpoint Medicaid 0.12 4126.61 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 701044 19125 CPT Outpatient 33184.20 0.01 Wellpoint Mellpoint Medicaid 0.10 3314.73 0.10 33184.20 0.10 Case Rate 19125 Priced Perq device breast 1st imag 701044 19281 CPT Outpatient 6141.45 598.61 Wellpoint Mellpoint Medicaid 0.11 645.15 0.11 6141.45 0.11 Case Rate 19281 Priced Perq device breast ea imag 701044 19282 CPT Outpatient 8379.00 319.04 Wellpoint Mellpoint Medicaid 0.11 880.27 0.11 8379.00 0.11 Case Rate 19282 Priced Partial mastectomy 701044 19301 CPT Outpatient 39157.65 6722.06 Wellpoint Mellpoint Medicaid 0.11 4205.17 0.11 39157.65 0.11 Case Rate 19301 Priced Mast simple complete 701044 19303 CPT Outpatient 105389.55 18091.87 Wellpoint Mellpoint Medicaid 0.09 9216.78 0.09 105389.55 0.09 Case Rate 19303 Priced Reduction of large breast 701044 19318 CPT Outpatient 65239.65 11199.47 Wellpoint Mellpoint Medicaid 0.11 7060.80 0.11 65239.65 0.11 Case Rate 19318 Priced Immediate breast prosthesis 701044 19340 CPT Outpatient 113100.75 19415.63 Wellpoint Mellpoint Medicaid 0.07 7410.94 0.07 113100.75 0.07 Case Rate 19340 Priced Delayed breast prosthesis 701044 19342 CPT Outpatient 56988.75 9783.07 Wellpoint Mellpoint Medicaid 0.11 6242.39 0.11 56988.75 0.11 Case Rate 19342 Priced Breast reconstruction 701044 19357 CPT Outpatient 101672.55 17453.79 Wellpoint Mellpoint Medicaid 0.06 6491.29 0.06 101672.55 0.06 Case Rate 19357 Priced Breast reconstruction 701044 19366 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 701044 19380 CPT Outpatient 61493.25 10556.34 Wellpoint Mellpoint Medicaid 0.11 6683.69 0.11 61493.25 0.11 Case Rate 19380 Priced Removal of support implant 701044 20680 CPT Outpatient 42329.70 7266.60 Wellpoint Mellpoint Medicaid 0.11 4467.37 0.11 42329.70 0.11 Case Rate 20680 Priced Cerv artific diskectomy 701044 22856 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 701044 24538 CPT Outpatient 51237.90 4775.24 Wellpoint Mellpoint Medicaid 0.08 4069.52 0.08 51237.90 0.08 Case Rate 24538 Priced Remove wrist tendon lesion 701044 25111 CPT Outpatient 25855.20 4438.48 Wellpoint Mellpoint Medicaid 0.11 2732.92 0.11 25855.20 0.11 Case Rate 25111 Priced Incise finger tendon sheath 701044 26055 CPT Outpatient 15862.35 2723.04 Wellpoint Mellpoint Medicaid 0.11 1678.54 0.11 15862.35 0.11 Case Rate 26055 Priced Treat finger fracture each 701044 26727 CPT Outpatient 22779.75 2030.47 Wellpoint Mellpoint Medicaid 0.11 2399.55 0.11 22779.75 0.11 Case Rate 26727 Priced Revision of knee joint 701044 27446 CPT Outpatient 67882.50 11653.16 Wellpoint Mellpoint Medicaid 0.11 7396.47 0.11 67882.50 0.11 Case Rate 27446 Priced Total knee arthroplasty 701044 27447 CPT Outpatient 130698.75 22436.62 Wellpoint Mellpoint Medicaid 0.07 9534.04 0.07 130698.75 0.07 Case Rate 27447 Priced Surgery to stop leg growth 701044 27485 CPT Outpatient 43310.40 7434.95 Wellpoint Mellpoint Medicaid 0.10 4432.28 0.10 43310.40 0.10 Case Rate 27485 Priced Repair achilles tendon 701044 27650 CPT Outpatient 38246.25 3762.57 Wellpoint Mellpoint Medicaid 0.10 3855.58 0.10 38246.25 0.10 Case Rate 27650 Priced Treatment of ankle fracture 701044 27792 CPT Outpatient 36101.10 6197.36 Wellpoint Mellpoint Medicaid 0.11 3823.62 0.11 36101.10 0.11 Case Rate 27792 Priced Treatment of ankle fracture 701044 27814 CPT Outpatient 49405.65 8481.30 Wellpoint Mellpoint Medicaid 0.10 4901.48 0.10 49405.65 0.10 Case Rate 27814 Priced Removal of foot lesion 701044 28080 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 701044 28285 CPT Outpatient 68603.85 11776.99 Wellpoint Mellpoint Medicaid 0.10 6702.44 0.10 68603.85 0.10 Case Rate 28285 Priced Correction hallux valgus 701044 28296 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 701044 29823 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 701044 29826 CPT Outpatient 49840.35 8555.93 Wellpoint Mellpoint Medicaid 0.11 5306.40 0.11 49840.35 0.11 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 701044 29881 CPT Outpatient 35556.15 6103.81 Wellpoint Mellpoint Medicaid 0.11 3760.03 0.11 35556.15 0.11 Case Rate 29881 Priced Knee arthroscopy/surgery 701044 29882 CPT Outpatient 61099.50 10488.75 Wellpoint Mellpoint Medicaid 0.11 6572.02 0.11 61099.50 0.11 Case Rate 29882 Priced Percut bx lung/mediastinum 701044 32405 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 701044 32555 CPT Outpatient 14597.10 687.29 Wellpoint Mellpoint Medicaid 0.09 1360.60 0.09 14597.10 0.09 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 701044 32664 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 701044 35190 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 701044 36478 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 701044 36561 CPT Outpatient 53531.10 3292.99 Wellpoint Mellpoint Medicaid 0.05 2933.85 0.05 53531.10 0.05 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 701044 36569 CPT Outpatient 31421.25 1299.06 Wellpoint Mellpoint Medicaid 0.08 2435.91 0.08 31421.25 0.08 Case Rate 36569 Priced Removal tunneled cv cath 701044 36590 CPT Outpatient 1996.05 273.95 Wellpoint Mellpoint Medicaid 0.11 210.57 0.11 1996.05 0.11 Case Rate 36590 Priced Av fuse uppr arm basilic 701044 36819 CPT Outpatient 56861.70 9761.26 Wellpoint Mellpoint Medicaid 0.11 6134.20 0.11 56861.70 0.11 Case Rate 36819 Priced Av fusion direct any site 701044 36821 CPT Outpatient 42953.40 7373.67 Wellpoint Mellpoint Medicaid 0.11 4524.93 0.11 42953.40 0.11 Case Rate 36821 Priced Artery-vein autograft 701044 36825 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 701044 36830 CPT Outpatient 53656.05 9210.96 Wellpoint Mellpoint Medicaid 0.12 6261.50 0.12 53656.05 0.12 Case Rate 36830 Priced Av fistula revision open 701044 36832 CPT Outpatient 52492.65 9011.24 Wellpoint Mellpoint Medicaid 0.11 5568.17 0.11 52492.65 0.11 Case Rate 36832 Priced Av fistula revision 701044 36833 CPT Outpatient 37098.60 6368.59 Wellpoint Mellpoint Medicaid 0.11 3913.73 0.11 37098.60 0.11 Case Rate 36833 Priced Intro cath dialysis circuit 701044 36903 CPT Outpatient 77541.45 10669.90 Wellpoint Mellpoint Medicaid 0.09 7363.46 0.09 77541.45 0.09 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 701044 36906 CPT Outpatient 96694.50 16175.64 Wellpoint Mellpoint Medicaid 0.10 9985.39 0.10 96694.50 0.10 Case Rate 36906 Priced Fem/popl revas w/tla 701044 37224 CPT Outpatient 200076.45 5139.31 Wellpoint Mellpoint Medicaid 0.10 20325.67 0.10 200076.45 0.10 Case Rate 37224 Priced Fem/popl revasc stnt & ather 701044 37227 CPT Outpatient 117170.55 18045.38 Wellpoint Mellpoint Medicaid 0.11 12925.02 0.11 117170.55 0.11 Case Rate 37227 Priced Revise leg vein 701044 37700 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 701044 37722 CPT Outpatient 27815.55 4775.00 Wellpoint Mellpoint Medicaid 0.11 2944.16 0.11 27815.55 0.11 Case Rate 37722 Priced Stab phleb veins xtr 10-20 701044 37765 CPT Outpatient 26561.85 4559.78 Wellpoint Mellpoint Medicaid 0.11 2799.25 0.11 26561.85 0.11 Case Rate 37765 Priced Biopsy/removal lymph nodes 701044 38500 CPT Outpatient 35955.15 6172.30 Wellpoint Mellpoint Medicaid 0.11 3843.88 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 701044 38525 CPT Outpatient 101194.80 17371.77 Wellpoint Mellpoint Medicaid 0.11 11005.80 0.11 101194.80 0.11 Case Rate 38525 Priced Laparoscopy lymph node biop 701044 38570 CPT Outpatient 65631.30 11266.71 Wellpoint Mellpoint Medicaid 0.11 7203.04 0.11 65631.30 0.11 Case Rate 38570 Priced Laparoscopy lymphadenectomy 701044 38571 CPT Outpatient 84031.50 14425.41 Wellpoint Mellpoint Medicaid 0.11 8944.24 0.11 84031.50 0.11 Case Rate 38571 Priced Laparoscopy lymphadenectomy 701044 38572 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 701044 38792 CPT Outpatient 2868.60 432.48 Wellpoint Mellpoint Medicaid 0.11 301.26 0.11 2868.60 0.11 Case Rate 38792 Priced Excision of gum lesion 701044 41825 CPT Outpatient 11580.45 1987.98 Wellpoint Mellpoint Medicaid 0.11 1230.98 0.11 11580.45 0.11 Case Rate 41825 Priced Reconstruct cleft palate 701044 42200 CPT Outpatient 36703.80 6300.82 Wellpoint Mellpoint Medicaid 0.10 3845.19 0.10 36703.80 0.10 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 701044 42820 CPT Outpatient 17232.60 2958.26 Wellpoint Mellpoint Medicaid 0.11 1853.31 0.11 17232.60 0.11 Case Rate 42820 Priced Control throat bleeding 701044 42960 CPT Outpatient 24066.00 4131.33 Wellpoint Mellpoint Medicaid 0.11 2568.30 0.11 24066.00 0.11 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 701044 43235 CPT Outpatient 8856.75 1633.35 Wellpoint Mellpoint Medicaid 0.11 934.01 0.11 8856.75 0.11 Case Rate 43235 Priced Laparoscopy fundoplasty 701044 43280 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 701044 43282 CPT Outpatient 84344.40 14479.12 Wellpoint Mellpoint Medicaid 0.11 9271.90 0.11 84344.40 0.11 Case Rate 43282 Priced Laparoscopy appendectomy 701044 44970 CPT Outpatient 82300.05 14128.18 Wellpoint Mellpoint Medicaid 0.06 5039.48 0.06 82300.05 0.06 Case Rate 44970 Priced Diagnostic sigmoidoscopy 701044 45330 CPT Outpatient 17286.15 542.26 Wellpoint Mellpoint Medicaid 0.11 1819.04 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 701044 47000 CPT Outpatient 10398.15 1225.34 Wellpoint Mellpoint Medicaid 0.11 1092.34 0.11 10398.15 0.11 Case Rate 47000 Priced Removal of gallbladder using an endoscope 701044 47562 CPT Outpatient 58430.40 10030.55 Wellpoint Mellpoint Medicaid 0.05 3093.34 0.05 58430.40 0.05 Case Rate 47562 Priced Laparo cholecystectomy/graph 701044 47563 CPT Outpatient 71747.55 12316.66 Wellpoint Mellpoint Medicaid 0.09 6587.32 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 701044 49083 CPT Outpatient 6979.35 1113.95 Wellpoint Mellpoint Medicaid 0.11 733.17 0.11 6979.35 0.11 Case Rate 49083 Priced Diag laparo separate proc 701044 49320 CPT Outpatient 31629.15 5429.67 Wellpoint Mellpoint Medicaid 0.11 3347.69 0.11 31629.15 0.11 Case Rate 49320 Priced Laparoscopy biopsy 701044 49321 CPT Outpatient 41892.90 7191.61 Wellpoint Mellpoint Medicaid 0.11 4405.52 0.11 41892.90 0.11 Case Rate 49321 Priced Laparoscopy aspiration 701044 49322 CPT Outpatient 34392.75 5904.09 Wellpoint Mellpoint Medicaid 0.11 3632.16 0.11 34392.75 0.11 Case Rate 49322 Priced Lap insert tunnel ip cath 701044 49324 CPT Outpatient 39264.75 6740.45 Wellpoint Mellpoint Medicaid 0.11 4155.80 0.11 39264.75 0.11 Case Rate 49324 Priced Laparo proc abdm/per/oment 701044 49329 CPT Outpatient 58696.05 10076.16 Wellpoint Mellpoint Medicaid 0.10 6045.26 0.10 58696.05 0.10 Case Rate 49329 Priced Ins tun ip cath for dial opn 701044 49421 CPT Outpatient 25460.40 3319.30 Wellpoint Mellpoint Medicaid 0.11 2714.02 0.11 25460.40 0.11 Case Rate 49421 Priced Remove tunneled ip cath 701044 49422 CPT Outpatient 25515.00 4380.08 Wellpoint Mellpoint Medicaid 0.11 2694.20 0.11 25515.00 0.11 Case Rate 49422 Priced Rpr ing hernia init reduce 701044 49500 CPT Outpatient 19594.05 3363.65 Wellpoint Mellpoint Medicaid 0.11 2107.21 0.11 19594.05 0.11 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 701044 49505 CPT Outpatient 34915.65 5993.85 Wellpoint Mellpoint Medicaid 0.11 3700.61 0.11 34915.65 0.11 Case Rate 49505 Priced Prp i/hern init block >5 yr 701044 49507 CPT Outpatient 29794.80 5114.77 Wellpoint Mellpoint Medicaid 0.11 3203.42 0.11 29794.80 0.11 Case Rate 49507 Priced Rerepair ing hernia reduce 701044 49520 CPT Outpatient 36940.05 6341.38 Wellpoint Mellpoint Medicaid 0.11 3913.96 0.11 36940.05 0.11 Case Rate 49520 Priced Rpr ventral hern init reduc 701044 49560 CPT Outpatient 53177.25 9128.76 Wellpoint Mellpoint Medicaid 0.11 5594.93 0.11 53177.25 0.11 Case Rate 49560 Priced Rpr ventral hern init block 701044 49561 CPT Outpatient 30755.55 5279.70 Wellpoint Mellpoint Medicaid 0.11 3280.86 0.11 30755.55 0.11 Case Rate 49561 Priced Rerepair ventrl hern reduce 701044 49565 CPT Outpatient 69917.40 12002.49 Wellpoint Mellpoint Medicaid 0.11 7610.05 0.11 69917.40 0.11 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 701044 49585 CPT Outpatient 41806.80 7176.83 Wellpoint Mellpoint Medicaid 0.11 4424.17 0.11 41806.80 0.11 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 701044 49587 CPT Outpatient 37320.15 6406.63 Wellpoint Mellpoint Medicaid 0.11 4087.74 0.11 37320.15 0.11 Case Rate 49587 Priced Lap ing hernia repair init 701044 49650 CPT Outpatient 41932.80 7198.46 Wellpoint Mellpoint Medicaid 0.11 4530.01 0.11 41932.80 0.11 Case Rate 49650 Priced Lap ing hernia repair recur 701044 49651 CPT Outpatient 46915.05 8053.75 Wellpoint Mellpoint Medicaid 0.11 4992.29 0.11 46915.05 0.11 Case Rate 49651 Priced Lap vent/abd hernia repair 701044 49652 CPT Outpatient 51294.60 8805.57 Wellpoint Mellpoint Medicaid 0.10 5382.85 0.10 51294.60 0.10 Case Rate 49652 Priced Lap vent/abd hern proc comp 701044 49653 CPT Outpatient 46102.35 7914.24 Wellpoint Mellpoint Medicaid 0.10 4827.12 0.10 46102.35 0.10 Case Rate 49653 Priced Lap inc hernia repair 701044 49654 CPT Outpatient 47221.65 8106.38 Wellpoint Mellpoint Medicaid 0.10 4921.52 0.10 47221.65 0.10 Case Rate 49654 Priced Lap inc hern repair comp 701044 49655 CPT Outpatient 54590.55 9371.38 Wellpoint Mellpoint Medicaid 0.11 5761.72 0.11 54590.55 0.11 Case Rate 49655 Priced Lap inc hernia repair recur 701044 49656 CPT Outpatient 55443.15 9517.74 Wellpoint Mellpoint Medicaid 0.10 5803.18 0.10 55443.15 0.10 Case Rate 49656 Priced Removal of kidney stone 701044 50080 CPT Outpatient 53165.70 9126.78 Wellpoint Mellpoint Medicaid 0.10 5408.45 0.10 53165.70 0.10 Case Rate 50080 Priced Removal of kidney stone 701044 50081 CPT Outpatient 66931.20 11489.86 Wellpoint Mellpoint Medicaid 0.11 7224.98 0.11 66931.20 0.11 Case Rate 50081 Priced Renal biopsy perq 701044 50200 CPT Outpatient 43096.20 1225.34 Wellpoint Mellpoint Medicaid 0.10 4521.35 0.10 43096.20 0.10 Case Rate 50200 Priced Plmt nephroureteral catheter 701044 50433 CPT Outpatient 64566.60 1424.48 Wellpoint Mellpoint Medicaid 0.11 7024.44 0.11 64566.60 0.11 Case Rate 50433 Priced Laparo radical nephrectomy 701044 50545 CPT Outpatient 43449.00 7458.75 Wellpoint Mellpoint Medicaid 0.11 4724.85 0.11 43449.00 0.11 Case Rate 50545 Priced Laparoscope proc ureter 701044 50949 CPT Outpatient 49986.30 8580.98 Wellpoint Mellpoint Medicaid 0.10 5229.89 0.10 49986.30 0.10 Case Rate 50949 Priced Injection for bladder x-ray 701044 51600 CPT Outpatient 3285.45 89.22 Wellpoint Mellpoint Medicaid 0.11 345.16 0.11 3285.45 0.11 Case Rate 51600 Priced Cystoscopy 701044 52000 CPT Outpatient 22149.75 3802.37 Wellpoint Mellpoint Medicaid 0.10 2310.60 0.10 22149.75 0.10 Case Rate 52000 Priced Cystoscopy & ureter catheter 701044 52005 CPT Outpatient 42529.20 2095.77 Wellpoint Mellpoint Medicaid 0.11 4530.38 0.11 42529.20 0.11 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 701044 52204 CPT Outpatient 31274.25 5368.75 Wellpoint Mellpoint Medicaid 0.09 2719.68 0.09 31274.25 0.09 Case Rate 52204 Priced Cystoscopy and treatment 701044 52224 CPT Outpatient 13445.25 2308.10 Wellpoint Mellpoint Medicaid 0.11 1417.12 0.11 13445.25 0.11 Case Rate 52224 Priced Cystoscopy and treatment 701044 52234 CPT Outpatient 28510.65 4894.33 Wellpoint Mellpoint Medicaid 0.09 2481.67 0.09 28510.65 0.09 Case Rate 52234 Priced Cystoscopy and treatment 701044 52235 CPT Outpatient 29417.85 5050.06 Wellpoint Mellpoint Medicaid 0.09 2554.53 0.09 29417.85 0.09 Case Rate 52235 Priced Cystoscopy and treatment 701044 52240 CPT Outpatient 33933.90 5825.32 Wellpoint Mellpoint Medicaid 0.11 3699.56 0.11 33933.90 0.11 Case Rate 52240 Priced Cystoscopy and treatment 701044 52281 CPT Outpatient 22159.20 3804.00 Wellpoint Mellpoint Medicaid 0.11 2334.11 0.11 22159.20 0.11 Case Rate 52281 Priced Remove bladder stone 701044 52317 CPT Outpatient 27085.80 4649.73 Wellpoint Mellpoint Medicaid 0.11 2865.97 0.11 27085.80 0.11 Case Rate 52317 Priced Remove bladder stone 701044 52318 CPT Outpatient 26685.75 4581.05 Wellpoint Mellpoint Medicaid 0.11 2830.53 0.11 26685.75 0.11 Case Rate 52318 Priced Cystoscopy and treatment 701044 52332 CPT Outpatient 115306.80 19794.33 Wellpoint Mellpoint Medicaid 0.05 6050.93 0.05 115306.80 0.05 Case Rate 52332 Priced Cystouretero w/stone remove 701044 52352 CPT Outpatient 42420.00 7282.10 Wellpoint Mellpoint Medicaid 0.11 4467.13 0.11 42420.00 0.11 Case Rate 52352 Priced Cystouretero w/lithotripsy 701044 52353 CPT Outpatient 38608.50 6627.79 Wellpoint Mellpoint Medicaid 0.11 4104.14 0.11 38608.50 0.11 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 701044 52356 CPT Outpatient 36255.45 6223.85 Wellpoint Mellpoint Medicaid 0.11 3839.36 0.11 36255.45 0.11 Case Rate 52356 Priced Prostatectomy (turp) 701044 52601 CPT Outpatient 35371.35 6072.08 Wellpoint Mellpoint Medicaid 0.09 3185.54 0.09 35371.35 0.09 Case Rate 52601 Priced Laser surgery of prostate 701044 52648 CPT Outpatient 24264.45 4165.40 Wellpoint Mellpoint Medicaid 0.11 2700.58 0.11 24264.45 0.11 Case Rate 52648 Priced Revision of urethra 701044 53450 CPT Outpatient 16209.90 2782.70 Wellpoint Mellpoint Medicaid 0.11 1711.32 0.11 16209.90 0.11 Case Rate 53450 Priced Urology surgery procedure 701044 53899 CPT Outpatient 25368.00 134.83 Wellpoint Mellpoint Medicaid 0.11 2735.79 0.11 25368.00 0.11 Case Rate 53899 Priced Circumcision w/regionl block 701044 54150 CPT Outpatient 14700.00 2523.50 Wellpoint Mellpoint Medicaid 0.11 1543.71 0.11 14700.00 0.11 Case Rate 54150 Priced Circum 28 days or older 701044 54161 CPT Outpatient 19186.65 3293.71 Wellpoint Mellpoint Medicaid 0.10 2011.31 0.10 19186.65 0.10 Case Rate 54161 Priced Lysis penil circumic lesion 701044 54162 CPT Outpatient 19795.65 3398.25 Wellpoint Mellpoint Medicaid 0.11 2088.32 0.11 19795.65 0.11 Case Rate 54162 Priced Repair of circumcision 701044 54163 CPT Outpatient 16391.55 2813.88 Wellpoint Mellpoint Medicaid 0.11 1723.59 0.11 16391.55 0.11 Case Rate 54163 Priced Reconstruction of urethra 701044 54324 CPT Outpatient 32880.75 5644.53 Wellpoint Mellpoint Medicaid 0.11 3464.91 0.11 32880.75 0.11 Case Rate 54324 Priced Revise penis/urethra 701044 54332 CPT Outpatient 19968.90 3427.99 Wellpoint Mellpoint Medicaid 0.11 2106.16 0.11 19968.90 0.11 Case Rate 54332 Priced Insert self-contd prosthesis 701044 54401 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 701044 54520 CPT Outpatient 35442.75 6084.34 Wellpoint Mellpoint Medicaid 0.10 3715.32 0.10 35442.75 0.10 Case Rate 54520 Priced Reduce testis torsion 701044 54600 CPT Outpatient 55049.40 9450.15 Wellpoint Mellpoint Medicaid 0.08 4134.26 0.08 55049.40 0.08 Case Rate 54600 Priced Suspension of testis 701044 54640 CPT Outpatient 26860.05 4610.98 Wellpoint Mellpoint Medicaid 0.11 2832.03 0.11 26860.05 0.11 Case Rate 54640 Priced Removal of hydrocele 701044 55040 CPT Outpatient 27277.95 4682.71 Wellpoint Mellpoint Medicaid 0.11 2881.96 0.11 27277.95 0.11 Case Rate 55040 Priced Biopsy of prostate gland 701044 55700 CPT Outpatient 28699.65 4926.77 Wellpoint Mellpoint Medicaid 0.10 2898.64 0.10 28699.65 0.10 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 701044 55866 CPT Outpatient 93088.80 15980.24 Wellpoint Mellpoint Medicaid 0.11 10055.51 0.11 93088.80 0.11 Case Rate 55866 Priced Closure of vagina 701044 57120 CPT Outpatient 34369.65 5900.12 Wellpoint Mellpoint Medicaid 0.11 3653.45 0.11 34369.65 0.11 Case Rate 57120 Priced Repair of vagina 701044 57200 CPT Outpatient 25247.25 4334.11 Wellpoint Mellpoint Medicaid 0.11 2698.03 0.11 25247.25 0.11 Case Rate 57200 Priced Anterior colporrhaphy 701044 57240 CPT Outpatient 36210.30 6216.10 Wellpoint Mellpoint Medicaid 0.11 4142.71 0.11 36210.30 0.11 Case Rate 57240 Priced Repair rectum & vagina 701044 57250 CPT Outpatient 40441.80 6942.51 Wellpoint Mellpoint Medicaid 0.11 4429.85 0.11 40441.80 0.11 Case Rate 57250 Priced Cmbn ant pst colprhy 701044 57260 CPT Outpatient 46323.90 7952.27 Wellpoint Mellpoint Medicaid 0.11 4982.44 0.11 46323.90 0.11 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 701044 57265 CPT Outpatient 42586.95 7310.76 Wellpoint Mellpoint Medicaid 0.09 3860.21 0.09 42586.95 0.09 Case Rate 57265 Priced Repair of bowel bulge 701044 57268 CPT Outpatient 36865.50 6328.58 Wellpoint Mellpoint Medicaid 0.11 3930.99 0.11 36865.50 0.11 Case Rate 57268 Priced Colpopexy extraperitoneal 701044 57282 CPT Outpatient 45629.85 7833.12 Wellpoint Mellpoint Medicaid 0.10 4720.10 0.10 45629.85 0.10 Case Rate 57282 Priced Repair bladder defect 701044 57288 CPT Outpatient 43069.95 7393.67 Wellpoint Mellpoint Medicaid 0.11 4698.78 0.11 43069.95 0.11 Case Rate 57288 Priced Bx/curett of cervix w/scope 701044 57454 CPT Outpatient 2888.55 442.93 Wellpoint Mellpoint Medicaid 0.11 303.46 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 701044 57520 CPT Outpatient 26728.80 4588.44 Wellpoint Mellpoint Medicaid 0.11 2821.38 0.11 26728.80 0.11 Case Rate 57520 Priced Conization of cervix 701044 57522 CPT Outpatient 22737.75 3903.31 Wellpoint Mellpoint Medicaid 0.11 2415.19 0.11 22737.75 0.11 Case Rate 57522 Priced Biopsy of uterus lining 701044 58100 CPT Outpatient 2371.95 194.80 Wellpoint Mellpoint Medicaid 0.11 249.14 0.11 2371.95 0.11 Case Rate 58100 Priced Catheter for hysterography 701044 58340 CPT Outpatient 6322.05 131.04 Wellpoint Mellpoint Medicaid 0.11 664.14 0.11 6322.05 0.11 Case Rate 58340 Priced Reopen fallopian tube 701044 58350 CPT Outpatient 46507.65 7983.81 Wellpoint Mellpoint Medicaid 0.10 4843.23 0.10 46507.65 0.10 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 701044 58542 CPT Outpatient 64194.90 11020.12 Wellpoint Mellpoint Medicaid 0.11 7085.53 0.11 64194.90 0.11 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 701044 58544 CPT Outpatient 51020.55 8758.53 Wellpoint Mellpoint Medicaid 0.11 5387.48 0.11 51020.55 0.11 Case Rate 58544 Priced Laparoscopic myomectomy 701044 58545 CPT Outpatient 56946.75 9775.86 Wellpoint Mellpoint Medicaid 0.10 5924.56 0.10 56946.75 0.10 Case Rate 58545 Priced Laparo-vag hyst incl t/o 701044 58552 CPT Outpatient 57228.15 9824.17 Wellpoint Mellpoint Medicaid 0.11 6168.03 0.11 57228.15 0.11 Case Rate 58552 Priced Hysteroscopy biopsy 701044 58558 CPT Outpatient 28581.00 2077.02 Wellpoint Mellpoint Medicaid 0.11 3022.68 0.11 28581.00 0.11 Case Rate 58558 Priced Hysteroscopy remove myoma 701044 58561 CPT Outpatient 35222.25 6046.49 Wellpoint Mellpoint Medicaid 0.10 3693.42 0.10 35222.25 0.10 Case Rate 58561 Priced Hysteroscopy ablation 701044 58563 CPT Outpatient 38399.55 6591.92 Wellpoint Mellpoint Medicaid 0.13 4955.80 0.13 38399.55 0.13 Case Rate 58563 Priced Tlh uterus 250 g or less 701044 58570 CPT Outpatient 43316.70 7436.03 Wellpoint Mellpoint Medicaid 0.10 4458.22 0.10 43316.70 0.10 Case Rate 58570 Priced Tlh w/t/o 250 g or less 701044 58571 CPT Outpatient 48603.45 8343.59 Wellpoint Mellpoint Medicaid 0.11 5183.33 0.11 48603.45 0.11 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 701044 58573 CPT Outpatient 52905.30 9082.08 Wellpoint Mellpoint Medicaid 0.10 5434.16 0.10 52905.30 0.10 Case Rate 58573 Priced Laparoscopy remove adnexa 701044 58661 CPT Outpatient 47008.50 8069.79 Wellpoint Mellpoint Medicaid 0.11 4996.74 0.11 47008.50 0.11 Case Rate 58661 Priced Laparoscopy excise lesions 701044 58662 CPT Outpatient 45053.40 7734.17 Wellpoint Mellpoint Medicaid 0.11 4785.08 0.11 45053.40 0.11 Case Rate 58662 Priced Treat ectopic pregnancy 701044 59151 CPT Outpatient 74690.70 12821.90 Wellpoint Mellpoint Medicaid 0.07 5435.43 0.07 74690.70 0.07 Case Rate 59151 Priced Treatment of miscarriage 701044 59812 CPT Outpatient 56109.90 9632.20 Wellpoint Mellpoint Medicaid 0.06 3442.67 0.06 56109.90 0.06 Case Rate 59812 Priced Partial removal of thyroid 701044 60220 CPT Outpatient 53639.25 9208.07 Wellpoint Mellpoint Medicaid 0.12 6503.57 0.12 53639.25 0.12 Case Rate 60220 Priced Removal of thyroid 701044 60240 CPT Outpatient 98252.70 16866.71 Wellpoint Mellpoint Medicaid 0.08 7648.39 0.08 98252.70 0.08 Case Rate 60240 Priced Explore parathyroid glands 701044 60500 CPT Outpatient 150495.45 25835.05 Wellpoint Mellpoint Medicaid 0.05 6988.99 0.05 150495.45 0.05 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 701044 62322 CPT Outpatient 43709.40 514.24 Wellpoint Mellpoint Medicaid 0.11 4626.40 0.11 43709.40 0.11 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 701044 62323 CPT Outpatient 8304.45 467.31 Wellpoint Mellpoint Medicaid 0.08 646.54 0.08 8304.45 0.08 Case Rate 62323 Priced Low back disk surgery 701044 63030 CPT Outpatient 50287.65 8632.71 Wellpoint Mellpoint Medicaid 0.11 5630.95 0.11 50287.65 0.11 Case Rate 63030 Priced Inc for vagus n elect impl 701044 64568 CPT Outpatient 124562.55 21383.24 Wellpoint Mellpoint Medicaid 0.06 7297.67 0.06 124562.55 0.06 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 701044 66821 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 701044 66984 CPT Outpatient 0.01 0.01 Wellpoint Mellpoint Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 78063 216 DRG Inpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 78063 460 DRG Inpatient 416122.79 53834.63 Amerihealth Amerihealth Commercial 0.15 63436.16 0.15 416122.79 0.15 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 78063 470 DRG Inpatient 167912.19 21723.13 Amerihealth Amerihealth Commercial 0.18 30646.21 0.18 167912.19 0.18 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 78063 473 DRG Inpatient 100687.91 13026.19 Amerihealth Amerihealth Commercial 0.41 40974.52 0.41 100687.91 0.41 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 78063 743 DRG Inpatient 102691.67 13285.42 Amerihealth Amerihealth Commercial 0.18 18264.49 0.18 102691.67 0.18 Case Rate 743 Priced NORMAL NEWBORN 78063 795 DRG Inpatient 6266.93 2335.00 Amerihealth Amerihealth Commercial 0.34 2140.14 0.34 6266.93 0.34 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 78063 807 DRG Inpatient 116469.59 4193.00 Amerihealth Amerihealth Commercial 0.08 9188.08 0.08 116469.59 0.08 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 78063 788 DRG Inpatient 76050.77 4538.00 Amerihealth Amerihealth Commercial 0.17 13189.58 0.17 76050.77 0.17 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 78063 59400 CPT Inpatient 116469.59 4193.00 Amerihealth Amerihealth Commercial 0.08 9188.08 0.08 116469.59 0.08 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 78063 59510 CPT Inpatient 76050.77 4538.00 Amerihealth Amerihealth Commercial 0.17 13189.58 0.17 76050.77 0.17 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 78063 59610 CPT Inpatient 116469.59 4193.00 Amerihealth Amerihealth Commercial 0.08 9188.08 0.08 116469.59 0.08 Case Rate 59610 Priced "Psychotherapy, 30 min" 78063 90832 CPT Outpatient 577.50 91.21 Amerihealth Amerihealth Commercial 0.34 198.22 0.34 577.50 0.34 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 78063 90834 CPT Outpatient 44134.65 271.96 Amerihealth Amerihealth Commercial 0.33 14427.17 0.33 44134.65 0.33 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 78063 90837 CPT Outpatient 2240.70 442.93 Amerihealth Amerihealth Commercial 0.07 147.76 0.07 2240.70 0.07 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 78063 90846 CPT Outpatient 0.01 131.50 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 78063 90847 CPT Outpatient 44134.65 369.97 Amerihealth Amerihealth Commercial 0.33 14427.17 0.33 44134.65 0.33 Fee Schedule 90847 Priced Group psychotherapy 78063 90853 CPT Outpatient 44134.65 101.99 Amerihealth Amerihealth Commercial 0.33 14427.17 0.33 44134.65 0.33 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 78063 99203 CPT Outpatient 3480.75 176.07 Amerihealth Amerihealth Commercial 0.33 1137.78 0.33 3480.75 0.33 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 78063 99204 CPT Outpatient 2103.15 233.39 Amerihealth Amerihealth Commercial 0.33 687.28 0.33 2103.15 0.33 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 78063 99205 CPT Outpatient 4970.70 314.28 Amerihealth Amerihealth Commercial 0.16 812.34 0.16 4970.70 0.16 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 78063 99243 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 78063 99244 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 78063 99385 CPT Outpatient 1114.05 185.90 Amerihealth Amerihealth Commercial 0.33 364.00 0.33 1114.05 0.33 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 78063 99386 CPT Outpatient 4877.25 185.90 Amerihealth Amerihealth Commercial 0.16 790.70 0.16 4877.25 0.16 Fee Schedule 99386 Priced Routine venipuncture 78063 36415 CPT Outpatient 127.05 19.57 Amerihealth Amerihealth Commercial 0.02 2.15 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 78063 80048 CPT Outpatient 576.45 88.78 Amerihealth Amerihealth Commercial 0.04 25.18 0.04 576.45 0.04 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 78063 80053 CPT Outpatient 763.35 117.56 Amerihealth Amerihealth Commercial 0.04 31.42 0.04 763.35 0.04 Fee Schedule 80053 Priced Obstetric blood test panel 78063 80055 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 78063 80061 CPT Outpatient 1349.25 197.77 Amerihealth Amerihealth Commercial 0.03 40.88 0.03 1349.25 0.03 Fee Schedule 80061 Priced Kidney function panel test 78063 80069 CPT Outpatient 716.10 104.95 Amerihealth Amerihealth Commercial 0.04 25.82 0.04 716.10 0.04 Fee Schedule 80069 Priced Liver function panel test 78063 80076 CPT Outpatient 716.10 104.95 Amerihealth Amerihealth Commercial 0.03 24.32 0.03 716.10 0.03 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 78063 81000 CPT Outpatient 144.90 21.18 Amerihealth Amerihealth Commercial 0.07 10.76 0.07 144.90 0.07 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 78063 81001 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 78063 81002 CPT Outpatient 57.75 8.89 Amerihealth Amerihealth Commercial 0.19 10.76 0.19 57.75 0.19 Fee Schedule 81002 Priced Automated urinalysis test 78063 81003 CPT Outpatient 219.45 33.80 Amerihealth Amerihealth Commercial 0.03 7.31 0.03 219.45 0.03 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 78063 82306 CPT Outpatient 1880.55 289.62 Amerihealth Amerihealth Commercial 0.05 96.62 0.05 1880.55 0.05 Fee Schedule 82306 Priced Glycosylated hemoglobin test 78063 83036 CPT Outpatient 494.55 76.17 Amerihealth Amerihealth Commercial 0.06 31.84 0.06 494.55 0.06 Fee Schedule 83036 Priced PSA (prostate specific antigen) 78063 84153 CPT Outpatient 1177.05 181.28 Amerihealth Amerihealth Commercial 0.05 56.16 0.05 1177.05 0.05 Fee Schedule 84153 Priced PSA (prostate specific antigen) 78063 84154 CPT Outpatient 598.50 92.17 Amerihealth Amerihealth Commercial 0.09 54.65 0.09 598.50 0.09 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 78063 84443 CPT Outpatient 519.75 80.05 Amerihealth Amerihealth Commercial 0.11 56.38 0.11 519.75 0.11 Fee Schedule 84443 Priced Chorionic gonadotropin assay 78063 84703 CPT Outpatient 785.40 120.96 Amerihealth Amerihealth Commercial 0.03 24.96 0.03 785.40 0.03 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 78063 85025 CPT Outpatient 635.25 97.83 Amerihealth Amerihealth Commercial 0.04 23.67 0.04 635.25 0.04 Fee Schedule 85025 Priced "Complete blood count, automated" 78063 85027 CPT Outpatient 576.45 88.78 Amerihealth Amerihealth Commercial 0.04 21.52 0.04 576.45 0.04 Fee Schedule 85027 Priced "Blood test, clotting time" 78063 85610 CPT Outpatient 404.25 62.26 Amerihealth Amerihealth Commercial 0.03 12.05 0.03 404.25 0.03 Fee Schedule 85610 Priced Coagulation assessment blood test 78063 85730 CPT Outpatient 17.22 2.65 Amerihealth Amerihealth Commercial 1.01 17.38 1.01 17.22 1.01 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 78063 86003 CPT Outpatient 32.55 5.01 Amerihealth Amerihealth Commercial 0.49 15.92 0.49 32.55 0.49 Fee Schedule 86003 Priced Tb test cell immun measure 78063 86480 CPT Outpatient 530.25 81.66 Amerihealth Amerihealth Commercial 0.39 204.42 0.39 530.25 0.39 Fee Schedule 86480 Priced Urine culture/colony count 78063 87086 CPT Outpatient 763.35 117.56 Amerihealth Amerihealth Commercial 0.04 27.97 0.04 763.35 0.04 Fee Schedule 87086 Priced Hpylori stool ia 78063 87338 CPT Outpatient 785.40 120.96 Amerihealth Amerihealth Commercial 0.04 34.43 0.04 785.40 0.04 Fee Schedule 87338 Priced Cytopath eval fna report 78063 88173 CPT Outpatient 750.75 115.62 Amerihealth Amerihealth Commercial 0.05 37.46 0.05 750.75 0.05 Fee Schedule 88173 Priced Tissue exam by pathologist 78063 88302 CPT Outpatient 635.25 97.83 Amerihealth Amerihealth Commercial 0.07 43.04 0.07 635.25 0.07 Fee Schedule 88302 Priced Tissue exam by pathologist 78063 88305 CPT Outpatient 323.40 49.81 Amerihealth Amerihealth Commercial 0.40 129.11 0.40 323.40 0.40 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 78063 11042 CPT Outpatient 2668.05 481.45 Amerihealth Amerihealth Commercial 0.33 872.17 0.33 2668.05 0.33 Case Rate 11042 Priced Deb subq tissue add-on 78063 11045 CPT Outpatient 4652.55 330.00 Amerihealth Amerihealth Commercial 0.33 1520.89 0.33 4652.55 0.33 Case Rate 11045 Priced Dx bronchoscope/lavage 78063 31624 CPT Outpatient 41223.00 7602.31 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 41223.00 0.17 Case Rate 31624 Priced Bronchoscopy/lung bx each 78063 31628 CPT Outpatient 49048.65 9045.51 Amerihealth Amerihealth Commercial 0.15 7158.18 0.15 49048.65 0.15 Case Rate 31628 Priced Blood transfusion service 78063 36430 CPT Outpatient 9166.50 574.93 Amerihealth Amerihealth Commercial 0.29 2666.75 0.29 9166.50 0.29 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 78063 43235 CPT Outpatient 8856.75 1633.35 Amerihealth Amerihealth Commercial 0.50 4395.43 0.50 8856.75 0.50 Case Rate 43235 Priced Endoscopic us exam esoph 78063 43237 CPT Outpatient 23867.55 4401.63 Amerihealth Amerihealth Commercial 0.30 7158.18 0.30 23867.55 0.30 Case Rate 43237 Priced Egd us fine needle bx/aspir 78063 43238 CPT Outpatient 30690.45 5659.90 Amerihealth Amerihealth Commercial 0.23 7158.18 0.23 30690.45 0.23 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 78063 43239 CPT Outpatient 40191.90 7412.15 Amerihealth Amerihealth Commercial 0.18 7158.18 0.18 40191.90 0.18 Case Rate 43239 Priced Ercp remove duct calculi 78063 43264 CPT Outpatient 34335.00 6332.03 Amerihealth Amerihealth Commercial 0.21 7158.18 0.21 34335.00 0.21 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 78063 45378 CPT Outpatient 13991.25 889.35 Amerihealth Amerihealth Commercial 0.50 6944.16 0.50 13991.25 0.50 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 78063 45380 CPT Outpatient 22215.90 4097.04 Amerihealth Amerihealth Commercial 0.32 7158.18 0.32 22215.90 0.32 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 78063 45385 CPT Outpatient 119569.80 22050.95 Amerihealth Amerihealth Commercial 0.06 7158.18 0.06 119569.80 0.06 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 78063 45391 CPT Outpatient 24923.85 4596.43 Amerihealth Amerihealth Commercial 0.29 7158.18 0.29 24923.85 0.29 Case Rate 45391 Priced Fragmenting of kidney stone 78063 50590 CPT Outpatient 40930.05 7548.28 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 40930.05 0.17 Case Rate 50590 Priced Fetal non-stress test 78063 59025 CPT Outpatient 3153.15 477.76 Amerihealth Amerihealth Commercial 0.33 1030.74 0.33 3153.15 0.33 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 78063 64483 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 78063 92567 CPT Outpatient 2224.95 98.50 Amerihealth Amerihealth Commercial 0.33 727.29 0.33 2224.95 0.33 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 78063 93000 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 78063 93017 CPT Outpatient 3076.50 532.96 Amerihealth Amerihealth Commercial 0.33 1005.52 0.33 3076.50 0.33 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 78063 93452 CPT Outpatient 55621.65 8611.87 Amerihealth Amerihealth Commercial 0.22 12171.98 0.22 55621.65 0.22 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 78063 95810 CPT Outpatient 20341.65 3373.48 Amerihealth Amerihealth Commercial 0.33 6649.38 0.33 20341.65 0.33 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 78063 95811 CPT Outpatient 22491.00 3731.18 Amerihealth Amerihealth Commercial 0.33 7352.16 0.33 22491.00 0.33 Case Rate 95811 Priced Eeg 41-60 minutes 78063 95812 CPT Outpatient 5578.65 925.83 Amerihealth Amerihealth Commercial 0.33 1823.62 0.33 5578.65 0.33 Case Rate 95812 Priced Genetic counseling 30 min 78063 96040 CPT Outpatient 0.01 102.81 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 78063 96413 CPT Outpatient 4856.25 472.45 Amerihealth Amerihealth Commercial 0.33 1587.20 0.33 4856.25 0.33 Case Rate 96413 Priced Ultrasound therapy 78063 97035 CPT Outpatient 2111.55 134.99 Amerihealth Amerihealth Commercial 0.33 690.17 0.33 2111.55 0.33 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 78063 97110 CPT Outpatient 6494.25 92.86 Amerihealth Amerihealth Commercial 0.33 2122.76 0.33 6494.25 0.33 Case Rate 97110 Priced Gait training therapy 78063 97116 CPT Outpatient 4723.95 110.61 Amerihealth Amerihealth Commercial 0.33 1543.95 0.33 4723.95 0.33 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 78063 70450 CPT Outpatient 8566.95 835.61 Amerihealth Amerihealth Commercial 0.15 1322.88 0.15 8566.95 0.15 Case Rate 70450 Priced Mri brain stem w/o dye 78063 70551 CPT Outpatient 7861.35 1361.31 Amerihealth Amerihealth Commercial 0.14 1073.86 0.14 7861.35 0.14 Case Rate 70551 Priced MRI scan of brain before and after contrast 78063 70553 CPT Outpatient 10882.20 1625.88 Amerihealth Amerihealth Commercial 0.20 2227.34 0.20 10882.20 0.20 Case Rate 70553 Priced X-ray exam chest 2 views 78063 71046 CPT Outpatient 859.95 150.37 Amerihealth Amerihealth Commercial 0.09 76.87 0.09 859.95 0.09 Case Rate 71046 Priced Ct thorax w/o dye 78063 71250 CPT Outpatient 7288.05 1261.63 Amerihealth Amerihealth Commercial 0.09 626.24 0.09 7288.05 0.09 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 78063 72082 CPT Outpatient 2022.30 253.33 Amerihealth Amerihealth Commercial 0.07 142.43 0.07 2022.30 0.07 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 78063 72100 CPT Outpatient 1599.15 277.38 Amerihealth Amerihealth Commercial 0.05 83.64 0.05 1599.15 0.05 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 78063 72110 CPT Outpatient 1389.15 241.04 Amerihealth Amerihealth Commercial 0.08 113.04 0.08 1389.15 0.08 Case Rate 72110 Priced MRI scan of lower spinal canal 78063 72148 CPT Outpatient 7861.35 1361.31 Amerihealth Amerihealth Commercial 0.14 1073.86 0.14 7861.35 0.14 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 78063 72193 CPT Outpatient 13671.00 1412.01 Amerihealth Amerihealth Commercial 0.05 703.10 0.05 13671.00 0.05 Case Rate 72193 Priced X-ray exam of shoulder 78063 73030 CPT Outpatient 1452.15 251.43 Amerihealth Amerihealth Commercial 0.05 70.09 0.05 1452.15 0.05 Case Rate 73030 Priced X-ray exam of elbow 78063 73080 CPT Outpatient 1356.60 235.68 Amerihealth Amerihealth Commercial 0.05 67.82 0.05 1356.60 0.05 Case Rate 73080 Priced X-ray exam of forearm 78063 73090 CPT Outpatient 1243.20 215.26 Amerihealth Amerihealth Commercial 0.05 67.82 0.05 1243.20 0.05 Case Rate 73090 Priced X-ray exam of wrist 78063 73110 CPT Outpatient 1243.20 215.26 Amerihealth Amerihealth Commercial 0.05 65.56 0.05 1243.20 0.05 Case Rate 73110 Priced X-ray exam of hand 78063 73130 CPT Outpatient 1243.20 215.26 Amerihealth Amerihealth Commercial 0.05 65.56 0.05 1243.20 0.05 Case Rate 73130 Priced X-ray exam hips bi 2 views 78063 73521 CPT Outpatient 970.20 228.41 Amerihealth Amerihealth Commercial 0.09 88.17 0.09 970.20 0.09 Case Rate 73521 Priced X-ray exam of knee 3 78063 73562 CPT Outpatient 802.20 139.12 Amerihealth Amerihealth Commercial 0.09 70.09 0.09 802.20 0.09 Case Rate 73562 Priced X-ray exam of lower leg 78063 73590 CPT Outpatient 1243.20 215.26 Amerihealth Amerihealth Commercial 0.05 65.56 0.05 1243.20 0.05 Case Rate 73590 Priced X-ray exam of ankle 78063 73610 CPT Outpatient 1378.65 239.31 Amerihealth Amerihealth Commercial 0.05 65.56 0.05 1378.65 0.05 Case Rate 73610 Priced X-ray exam of foot 78063 73630 CPT Outpatient 975.45 169.41 Amerihealth Amerihealth Commercial 0.07 65.56 0.07 975.45 0.07 Case Rate 73630 Priced MRI scan of leg joint 78063 73721 CPT Outpatient 7861.35 1361.31 Amerihealth Amerihealth Commercial 0.14 1073.86 0.14 7861.35 0.14 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 78063 74177 CPT Outpatient 14222.25 1412.01 Amerihealth Amerihealth Commercial 0.05 716.67 0.05 14222.25 0.05 Case Rate 74177 Priced Contrst x-ray exam of throat 78063 74210 CPT Outpatient 0.01 440.39 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 78063 76098 CPT Outpatient 6141.45 407.86 Amerihealth Amerihealth Commercial 0.50 3047.74 0.50 6141.45 0.50 Case Rate 76098 Priced Us exam of head and neck 78063 76536 CPT Outpatient 5512.50 955.18 Amerihealth Amerihealth Commercial 0.03 185.38 0.03 5512.50 0.03 Case Rate 76536 Priced Ultrasound breast limited 78063 76642 CPT Outpatient 5777.10 127.70 Amerihealth Amerihealth Commercial 0.06 354.94 0.06 5777.10 0.06 Case Rate 76642 Priced Ultrasound of abdomen 78063 76700 CPT Outpatient 4917.15 851.88 Amerihealth Amerihealth Commercial 0.05 257.73 0.05 4917.15 0.05 Case Rate 76700 Priced Echo exam of abdomen 78063 76705 CPT Outpatient 3836.70 665.17 Amerihealth Amerihealth Commercial 0.05 187.64 0.05 3836.70 0.05 Case Rate 76705 Priced Us exam abdo back wall comp 78063 76770 CPT Outpatient 5171.25 895.48 Amerihealth Amerihealth Commercial 0.05 250.94 0.05 5171.25 0.05 Case Rate 76770 Priced Us exam abdo back wall lim 78063 76775 CPT Outpatient 3969.00 686.97 Amerihealth Amerihealth Commercial 0.05 187.64 0.05 3969.00 0.05 Case Rate 76775 Priced Ob us < 14 wks single fetus 78063 76801 CPT Outpatient 2006.55 347.98 Amerihealth Amerihealth Commercial 0.11 226.08 0.11 2006.55 0.11 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 78063 76805 CPT Outpatient 3969.00 686.97 Amerihealth Amerihealth Commercial 0.06 226.08 0.06 3969.00 0.06 Case Rate 76805 Priced Ob us detailed sngl fetus 78063 76811 CPT Outpatient 2844.45 492.99 Amerihealth Amerihealth Commercial 0.10 287.89 0.10 2844.45 0.10 Case Rate 76811 Priced Ob us nuchal meas 1 gest 78063 76813 CPT Outpatient 1044.75 180.83 Amerihealth Amerihealth Commercial 0.34 350.41 0.34 1044.75 0.34 Case Rate 76813 Priced Ob us limited fetus(s) 78063 76815 CPT Outpatient 6428.10 639.90 Amerihealth Amerihealth Commercial 0.07 420.50 0.07 6428.10 0.07 Case Rate 76815 Priced Ob us follow-up per fetus 78063 76816 CPT Outpatient 4818.45 833.88 Amerihealth Amerihealth Commercial 0.03 160.52 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 78063 76817 CPT Outpatient 6428.10 476.73 Amerihealth Amerihealth Commercial 0.07 420.50 0.07 6428.10 0.07 Case Rate 76817 Priced Fetal biophys profil w/o nst 78063 76819 CPT Outpatient 1741.95 302.65 Amerihealth Amerihealth Commercial 0.16 282.60 0.16 1741.95 0.16 Case Rate 76819 Priced Ultrasound pelvis through vagina 78063 76830 CPT Outpatient 9305.10 806.54 Amerihealth Amerihealth Commercial 0.05 420.50 0.05 9305.10 0.05 Case Rate 76830 Priced Us exam scrotum 78063 76870 CPT Outpatient 6328.35 1096.55 Amerihealth Amerihealth Commercial 0.03 203.47 0.03 6328.35 0.03 Case Rate 76870 Priced Us exam infant hips dynamic 78063 76885 CPT Outpatient 3836.70 665.17 Amerihealth Amerihealth Commercial 0.06 232.86 0.06 3836.70 0.06 Case Rate 76885 Priced Mammography of one breast 78063 77065 CPT Outpatient 3451.35 192.07 Amerihealth Amerihealth Commercial 0.09 316.51 0.09 3451.35 0.09 Case Rate 77065 Priced Mammography of both breasts 78063 77066 CPT Outpatient 5777.10 235.68 Amerihealth Amerihealth Commercial 0.06 354.94 0.06 5777.10 0.06 Case Rate 77066 Priced "Mamography, screening bilateral" 78063 77067 CPT Outpatient 1416.45 205.57 Amerihealth Amerihealth Commercial 0.11 158.26 0.11 1416.45 0.11 Case Rate 77067 Priced X-rays for bone age 78063 77072 CPT Outpatient 2022.30 163.87 Amerihealth Amerihealth Commercial 0.07 142.43 0.07 2022.30 0.07 Case Rate 77072 Priced Joint survey single view 78063 77077 CPT Outpatient 985.95 171.14 Amerihealth Amerihealth Commercial 0.18 174.08 0.18 985.95 0.18 Case Rate 77077 Priced Dxa bone density axial 78063 77080 CPT Outpatient 3257.10 319.09 Amerihealth Amerihealth Commercial 0.10 332.34 0.10 3257.10 0.10 Case Rate 77080 Priced Fna bx w/us gdn 1st les 78063 10005 CPT Outpatient 5512.50 547.24 Amerihealth Amerihealth Commercial 0.50 2735.86 0.50 5512.50 0.50 Case Rate 10005 Priced Fna bx w/us gdn ea addl 78063 10006 CPT Outpatient 10628.10 594.83 Amerihealth Amerihealth Commercial 0.50 5274.74 0.50 10628.10 0.50 Case Rate 10006 Priced Drainage of hematoma/fluid 78063 10140 CPT Outpatient 23209.20 1081.95 Amerihealth Amerihealth Commercial 0.31 7158.18 0.31 23209.20 0.31 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 78063 11042 CPT Outpatient 2668.05 481.45 Amerihealth Amerihealth Commercial 0.33 872.17 0.33 2668.05 0.33 Case Rate 11042 Priced Deb bone 20 sq cm/< 78063 11044 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 78063 11406 CPT Outpatient 19967.85 3427.81 Amerihealth Amerihealth Commercial 0.36 7158.18 0.36 19967.85 0.36 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 78063 11424 CPT Outpatient 0.01 1004.93 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 78063 11770 CPT Outpatient 19173.00 3291.37 Amerihealth Amerihealth Commercial 0.37 7158.18 0.37 19173.00 0.37 Case Rate 11770 Priced Replace tissue expander 78063 11970 CPT Outpatient 59239.95 10169.52 Amerihealth Amerihealth Commercial 0.12 7158.18 0.12 59239.95 0.12 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 78063 14020 CPT Outpatient 32166.75 5521.96 Amerihealth Amerihealth Commercial 0.22 7158.18 0.22 32166.75 0.22 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 78063 14060 CPT Outpatient 25993.80 1374.69 Amerihealth Amerihealth Commercial 0.28 7158.18 0.28 25993.80 0.28 Case Rate 14060 Priced Wound prep trk/arm/leg 78063 15002 CPT Outpatient 41748.00 1441.73 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 41748.00 0.17 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 78063 15271 CPT Outpatient 24343.20 3769.48 Amerihealth Amerihealth Commercial 0.31 7427.84 0.31 24343.20 0.31 Case Rate 15271 Priced Acellular derm matrix implt 78063 15777 CPT Outpatient 101672.55 17453.79 Amerihealth Amerihealth Commercial 0.07 7158.18 0.07 101672.55 0.07 Case Rate 15777 Priced Exc skin abd 78063 15830 CPT Outpatient 54696.60 9389.58 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 54696.60 0.13 Case Rate 15830 Priced Dressing change not for burn 78063 15852 CPT Outpatient 0.01 290.74 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 78063 15877 CPT Outpatient 63741.30 10942.26 Amerihealth Amerihealth Commercial 0.11 7158.18 0.11 63741.30 0.11 Case Rate 15877 Priced Suction lipectomy lwr extrem 78063 15879 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 78063 19000 CPT Outpatient 10143.00 594.83 Amerihealth Amerihealth Commercial 0.50 5033.98 0.50 10143.00 0.50 Case Rate 19000 Priced Bx breast 1st lesion strtctc 78063 19081 CPT Outpatient 12341.70 1250.69 Amerihealth Amerihealth Commercial 0.48 5889.76 0.48 12341.70 0.48 Case Rate 19081 Priced Bx breast add lesion us imag 78063 19084 CPT Outpatient 29058.75 547.24 Amerihealth Amerihealth Commercial 0.25 7158.18 0.25 29058.75 0.25 Case Rate 19084 Priced Biopsy of breast open 78063 19101 CPT Outpatient 39545.10 2737.82 Amerihealth Amerihealth Commercial 0.18 7158.18 0.18 39545.10 0.18 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 78063 19120 CPT Outpatient 35761.95 2737.82 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 35761.95 0.20 Case Rate 19120 Priced Excision breast lesion 78063 19125 CPT Outpatient 33184.20 0.01 Amerihealth Amerihealth Commercial 0.22 7158.18 0.22 33184.20 0.22 Case Rate 19125 Priced Perq device breast 1st imag 78063 19281 CPT Outpatient 6141.45 598.61 Amerihealth Amerihealth Commercial 0.50 3047.74 0.50 6141.45 0.50 Case Rate 19281 Priced Perq device breast ea imag 78063 19282 CPT Outpatient 8379.00 319.04 Amerihealth Amerihealth Commercial 0.50 4158.51 0.50 8379.00 0.50 Case Rate 19282 Priced Partial mastectomy 78063 19301 CPT Outpatient 39157.65 6722.06 Amerihealth Amerihealth Commercial 0.18 7158.18 0.18 39157.65 0.18 Case Rate 19301 Priced Mast simple complete 78063 19303 CPT Outpatient 105389.55 18091.87 Amerihealth Amerihealth Commercial 0.07 7158.18 0.07 105389.55 0.07 Case Rate 19303 Priced Reduction of large breast 78063 19318 CPT Outpatient 65239.65 11199.47 Amerihealth Amerihealth Commercial 0.11 7158.18 0.11 65239.65 0.11 Case Rate 19318 Priced Immediate breast prosthesis 78063 19340 CPT Outpatient 113100.75 19415.63 Amerihealth Amerihealth Commercial 0.06 7158.18 0.06 113100.75 0.06 Case Rate 19340 Priced Delayed breast prosthesis 78063 19342 CPT Outpatient 56988.75 9783.07 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 56988.75 0.13 Case Rate 19342 Priced Breast reconstruction 78063 19357 CPT Outpatient 101672.55 17453.79 Amerihealth Amerihealth Commercial 0.07 7158.18 0.07 101672.55 0.07 Case Rate 19357 Priced Breast reconstruction 78063 19366 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 78063 19380 CPT Outpatient 61493.25 10556.34 Amerihealth Amerihealth Commercial 0.12 7158.18 0.12 61493.25 0.12 Case Rate 19380 Priced Removal of support implant 78063 20680 CPT Outpatient 42329.70 7266.60 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 42329.70 0.17 Case Rate 20680 Priced Cerv artific diskectomy 78063 22856 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 78063 24538 CPT Outpatient 51237.90 4775.24 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 51237.90 0.14 Case Rate 24538 Priced Remove wrist tendon lesion 78063 25111 CPT Outpatient 25855.20 4438.48 Amerihealth Amerihealth Commercial 0.28 7158.18 0.28 25855.20 0.28 Case Rate 25111 Priced Incise finger tendon sheath 78063 26055 CPT Outpatient 15862.35 2723.04 Amerihealth Amerihealth Commercial 0.45 7158.18 0.45 15862.35 0.45 Case Rate 26055 Priced Treat finger fracture each 78063 26727 CPT Outpatient 22779.75 2030.47 Amerihealth Amerihealth Commercial 0.31 7158.18 0.31 22779.75 0.31 Case Rate 26727 Priced Revision of knee joint 78063 27446 CPT Outpatient 67882.50 11653.16 Amerihealth Amerihealth Commercial 0.29 19985.24 0.29 67882.50 0.29 Case Rate 27446 Priced Total knee arthroplasty 78063 27447 CPT Outpatient 130698.75 22436.62 Amerihealth Amerihealth Commercial 0.15 19985.24 0.15 130698.75 0.15 Case Rate 27447 Priced Surgery to stop leg growth 78063 27485 CPT Outpatient 43310.40 7434.95 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 43310.40 0.17 Case Rate 27485 Priced Repair achilles tendon 78063 27650 CPT Outpatient 38246.25 3762.57 Amerihealth Amerihealth Commercial 0.19 7158.18 0.19 38246.25 0.19 Case Rate 27650 Priced Treatment of ankle fracture 78063 27792 CPT Outpatient 36101.10 6197.36 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 36101.10 0.20 Case Rate 27792 Priced Treatment of ankle fracture 78063 27814 CPT Outpatient 49405.65 8481.30 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 49405.65 0.14 Case Rate 27814 Priced Removal of foot lesion 78063 28080 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 78063 28285 CPT Outpatient 68603.85 11776.99 Amerihealth Amerihealth Commercial 0.10 7158.18 0.10 68603.85 0.10 Case Rate 28285 Priced Correction hallux valgus 78063 28296 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 78063 29823 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 78063 29826 CPT Outpatient 49840.35 8555.93 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 49840.35 0.14 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 78063 29881 CPT Outpatient 35556.15 6103.81 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 35556.15 0.20 Case Rate 29881 Priced Knee arthroscopy/surgery 78063 29882 CPT Outpatient 61099.50 10488.75 Amerihealth Amerihealth Commercial 0.12 7158.18 0.12 61099.50 0.12 Case Rate 29882 Priced Percut bx lung/mediastinum 78063 32405 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 78063 32555 CPT Outpatient 14597.10 687.29 Amerihealth Amerihealth Commercial 0.44 6427.63 0.44 14597.10 0.44 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 78063 32664 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 78063 35190 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 78063 36478 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 78063 36561 CPT Outpatient 53531.10 3292.99 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 53531.10 0.13 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 78063 36569 CPT Outpatient 31421.25 1299.06 Amerihealth Amerihealth Commercial 0.23 7158.18 0.23 31421.25 0.23 Case Rate 36569 Priced Removal tunneled cv cath 78063 36590 CPT Outpatient 1996.05 273.95 Amerihealth Amerihealth Commercial 0.50 994.76 0.50 1996.05 0.50 Case Rate 36590 Priced Av fuse uppr arm basilic 78063 36819 CPT Outpatient 56861.70 9761.26 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 56861.70 0.13 Case Rate 36819 Priced Av fusion direct any site 78063 36821 CPT Outpatient 42953.40 7373.67 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 42953.40 0.17 Case Rate 36821 Priced Artery-vein autograft 78063 36825 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 78063 36830 CPT Outpatient 53656.05 9210.96 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 53656.05 0.13 Case Rate 36830 Priced Av fistula revision open 78063 36832 CPT Outpatient 52492.65 9011.24 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 52492.65 0.14 Case Rate 36832 Priced Av fistula revision 78063 36833 CPT Outpatient 37098.60 6368.59 Amerihealth Amerihealth Commercial 0.19 7158.18 0.19 37098.60 0.19 Case Rate 36833 Priced Intro cath dialysis circuit 78063 36903 CPT Outpatient 77541.45 10669.90 Amerihealth Amerihealth Commercial 0.09 7158.18 0.09 77541.45 0.09 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 78063 36906 CPT Outpatient 96694.50 16175.64 Amerihealth Amerihealth Commercial 0.07 7158.18 0.07 96694.50 0.07 Case Rate 36906 Priced Fem/popl revas w/tla 78063 37224 CPT Outpatient 200076.45 5139.31 Amerihealth Amerihealth Commercial 0.06 12171.98 0.06 200076.45 0.06 Case Rate 37224 Priced Fem/popl revasc stnt & ather 78063 37227 CPT Outpatient 117170.55 18045.38 Amerihealth Amerihealth Commercial 0.10 12171.98 0.10 117170.55 0.10 Case Rate 37227 Priced Revise leg vein 78063 37700 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 78063 37722 CPT Outpatient 27815.55 4775.00 Amerihealth Amerihealth Commercial 0.26 7158.18 0.26 27815.55 0.26 Case Rate 37722 Priced Stab phleb veins xtr 10-20 78063 37765 CPT Outpatient 26561.85 4559.78 Amerihealth Amerihealth Commercial 0.27 7158.18 0.27 26561.85 0.27 Case Rate 37765 Priced Biopsy/removal lymph nodes 78063 38500 CPT Outpatient 35955.15 6172.30 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 35955.15 0.20 Case Rate 38500 Priced Biopsy/removal lymph nodes 78063 38525 CPT Outpatient 101194.80 17371.77 Amerihealth Amerihealth Commercial 0.07 7158.18 0.07 101194.80 0.07 Case Rate 38525 Priced Laparoscopy lymph node biop 78063 38570 CPT Outpatient 65631.30 11266.71 Amerihealth Amerihealth Commercial 0.11 7158.18 0.11 65631.30 0.11 Case Rate 38570 Priced Laparoscopy lymphadenectomy 78063 38571 CPT Outpatient 84031.50 14425.41 Amerihealth Amerihealth Commercial 0.09 7158.18 0.09 84031.50 0.09 Case Rate 38571 Priced Laparoscopy lymphadenectomy 78063 38572 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 78063 38792 CPT Outpatient 2868.60 432.48 Amerihealth Amerihealth Commercial 0.50 1423.20 0.50 2868.60 0.50 Case Rate 38792 Priced Excision of gum lesion 78063 41825 CPT Outpatient 11580.45 1987.98 Amerihealth Amerihealth Commercial 0.50 5763.91 0.50 11580.45 0.50 Case Rate 41825 Priced Reconstruct cleft palate 78063 42200 CPT Outpatient 36703.80 6300.82 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 36703.80 0.20 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 78063 42820 CPT Outpatient 17232.60 2958.26 Amerihealth Amerihealth Commercial 0.42 7158.18 0.42 17232.60 0.42 Case Rate 42820 Priced Control throat bleeding 78063 42960 CPT Outpatient 24066.00 4131.33 Amerihealth Amerihealth Commercial 0.30 7158.18 0.30 24066.00 0.30 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 78063 43235 CPT Outpatient 8856.75 1633.35 Amerihealth Amerihealth Commercial 0.50 4395.43 0.50 8856.75 0.50 Case Rate 43235 Priced Laparoscopy fundoplasty 78063 43280 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 78063 43282 CPT Outpatient 84344.40 14479.12 Amerihealth Amerihealth Commercial 0.08 7158.18 0.08 84344.40 0.08 Case Rate 43282 Priced Laparoscopy appendectomy 78063 44970 CPT Outpatient 82300.05 14128.18 Amerihealth Amerihealth Commercial 0.09 7158.18 0.09 82300.05 0.09 Case Rate 44970 Priced Diagnostic sigmoidoscopy 78063 45330 CPT Outpatient 17286.15 542.26 Amerihealth Amerihealth Commercial 0.41 7158.18 0.41 17286.15 0.41 Case Rate 45330 Priced Needle biopsy of liver 78063 47000 CPT Outpatient 10398.15 1225.34 Amerihealth Amerihealth Commercial 0.50 5160.38 0.50 10398.15 0.50 Case Rate 47000 Priced Removal of gallbladder using an endoscope 78063 47562 CPT Outpatient 58430.40 10030.55 Amerihealth Amerihealth Commercial 0.12 7158.18 0.12 58430.40 0.12 Case Rate 47562 Priced Laparo cholecystectomy/graph 78063 47563 CPT Outpatient 71747.55 12316.66 Amerihealth Amerihealth Commercial 0.10 7158.18 0.10 71747.55 0.10 Case Rate 47563 Priced Abd paracentesis w/imaging 78063 49083 CPT Outpatient 6979.35 1113.95 Amerihealth Amerihealth Commercial 0.50 3463.60 0.50 6979.35 0.50 Case Rate 49083 Priced Diag laparo separate proc 78063 49320 CPT Outpatient 31629.15 5429.67 Amerihealth Amerihealth Commercial 0.23 7158.18 0.23 31629.15 0.23 Case Rate 49320 Priced Laparoscopy biopsy 78063 49321 CPT Outpatient 41892.90 7191.61 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 41892.90 0.17 Case Rate 49321 Priced Laparoscopy aspiration 78063 49322 CPT Outpatient 34392.75 5904.09 Amerihealth Amerihealth Commercial 0.21 7158.18 0.21 34392.75 0.21 Case Rate 49322 Priced Lap insert tunnel ip cath 78063 49324 CPT Outpatient 39264.75 6740.45 Amerihealth Amerihealth Commercial 0.18 7158.18 0.18 39264.75 0.18 Case Rate 49324 Priced Laparo proc abdm/per/oment 78063 49329 CPT Outpatient 58696.05 10076.16 Amerihealth Amerihealth Commercial 0.12 7158.18 0.12 58696.05 0.12 Case Rate 49329 Priced Ins tun ip cath for dial opn 78063 49421 CPT Outpatient 25460.40 3319.30 Amerihealth Amerihealth Commercial 0.28 7158.18 0.28 25460.40 0.28 Case Rate 49421 Priced Remove tunneled ip cath 78063 49422 CPT Outpatient 25515.00 4380.08 Amerihealth Amerihealth Commercial 0.28 7158.18 0.28 25515.00 0.28 Case Rate 49422 Priced Rpr ing hernia init reduce 78063 49500 CPT Outpatient 19594.05 3363.65 Amerihealth Amerihealth Commercial 0.37 7158.18 0.37 19594.05 0.37 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 78063 49505 CPT Outpatient 34915.65 5993.85 Amerihealth Amerihealth Commercial 0.21 7158.18 0.21 34915.65 0.21 Case Rate 49505 Priced Prp i/hern init block >5 yr 78063 49507 CPT Outpatient 29794.80 5114.77 Amerihealth Amerihealth Commercial 0.24 7158.18 0.24 29794.80 0.24 Case Rate 49507 Priced Rerepair ing hernia reduce 78063 49520 CPT Outpatient 36940.05 6341.38 Amerihealth Amerihealth Commercial 0.19 7158.18 0.19 36940.05 0.19 Case Rate 49520 Priced Rpr ventral hern init reduc 78063 49560 CPT Outpatient 53177.25 9128.76 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 53177.25 0.13 Case Rate 49560 Priced Rpr ventral hern init block 78063 49561 CPT Outpatient 30755.55 5279.70 Amerihealth Amerihealth Commercial 0.23 7158.18 0.23 30755.55 0.23 Case Rate 49561 Priced Rerepair ventrl hern reduce 78063 49565 CPT Outpatient 69917.40 12002.49 Amerihealth Amerihealth Commercial 0.10 7158.18 0.10 69917.40 0.10 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 78063 49585 CPT Outpatient 41806.80 7176.83 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 41806.80 0.17 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 78063 49587 CPT Outpatient 37320.15 6406.63 Amerihealth Amerihealth Commercial 0.19 7158.18 0.19 37320.15 0.19 Case Rate 49587 Priced Lap ing hernia repair init 78063 49650 CPT Outpatient 41932.80 7198.46 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 41932.80 0.17 Case Rate 49650 Priced Lap ing hernia repair recur 78063 49651 CPT Outpatient 46915.05 8053.75 Amerihealth Amerihealth Commercial 0.15 7158.18 0.15 46915.05 0.15 Case Rate 49651 Priced Lap vent/abd hernia repair 78063 49652 CPT Outpatient 51294.60 8805.57 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 51294.60 0.14 Case Rate 49652 Priced Lap vent/abd hern proc comp 78063 49653 CPT Outpatient 46102.35 7914.24 Amerihealth Amerihealth Commercial 0.16 7158.18 0.16 46102.35 0.16 Case Rate 49653 Priced Lap inc hernia repair 78063 49654 CPT Outpatient 47221.65 8106.38 Amerihealth Amerihealth Commercial 0.15 7158.18 0.15 47221.65 0.15 Case Rate 49654 Priced Lap inc hern repair comp 78063 49655 CPT Outpatient 54590.55 9371.38 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 54590.55 0.13 Case Rate 49655 Priced Lap inc hernia repair recur 78063 49656 CPT Outpatient 55443.15 9517.74 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 55443.15 0.13 Case Rate 49656 Priced Removal of kidney stone 78063 50080 CPT Outpatient 53165.70 9126.78 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 53165.70 0.13 Case Rate 50080 Priced Removal of kidney stone 78063 50081 CPT Outpatient 66931.20 11489.86 Amerihealth Amerihealth Commercial 0.11 7158.18 0.11 66931.20 0.11 Case Rate 50081 Priced Renal biopsy perq 78063 50200 CPT Outpatient 43096.20 1225.34 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 43096.20 0.17 Case Rate 50200 Priced Plmt nephroureteral catheter 78063 50433 CPT Outpatient 64566.60 1424.48 Amerihealth Amerihealth Commercial 0.11 7158.18 0.11 64566.60 0.11 Case Rate 50433 Priced Laparo radical nephrectomy 78063 50545 CPT Outpatient 43449.00 7458.75 Amerihealth Amerihealth Commercial 0.16 7158.18 0.16 43449.00 0.16 Case Rate 50545 Priced Laparoscope proc ureter 78063 50949 CPT Outpatient 49986.30 8580.98 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 49986.30 0.14 Case Rate 50949 Priced Injection for bladder x-ray 78063 51600 CPT Outpatient 3285.45 89.22 Amerihealth Amerihealth Commercial 0.50 1630.58 0.50 3285.45 0.50 Case Rate 51600 Priced Cystoscopy 78063 52000 CPT Outpatient 22149.75 3802.37 Amerihealth Amerihealth Commercial 0.32 7158.18 0.32 22149.75 0.32 Case Rate 52000 Priced Cystoscopy & ureter catheter 78063 52005 CPT Outpatient 42529.20 2095.77 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 42529.20 0.17 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 78063 52204 CPT Outpatient 31274.25 5368.75 Amerihealth Amerihealth Commercial 0.23 7158.18 0.23 31274.25 0.23 Case Rate 52204 Priced Cystoscopy and treatment 78063 52224 CPT Outpatient 13445.25 2308.10 Amerihealth Amerihealth Commercial 0.50 6672.76 0.50 13445.25 0.50 Case Rate 52224 Priced Cystoscopy and treatment 78063 52234 CPT Outpatient 28510.65 4894.33 Amerihealth Amerihealth Commercial 0.25 7158.18 0.25 28510.65 0.25 Case Rate 52234 Priced Cystoscopy and treatment 78063 52235 CPT Outpatient 29417.85 5050.06 Amerihealth Amerihealth Commercial 0.24 7158.18 0.24 29417.85 0.24 Case Rate 52235 Priced Cystoscopy and treatment 78063 52240 CPT Outpatient 33933.90 5825.32 Amerihealth Amerihealth Commercial 0.21 7158.18 0.21 33933.90 0.21 Case Rate 52240 Priced Cystoscopy and treatment 78063 52281 CPT Outpatient 22159.20 3804.00 Amerihealth Amerihealth Commercial 0.32 7158.18 0.32 22159.20 0.32 Case Rate 52281 Priced Remove bladder stone 78063 52317 CPT Outpatient 27085.80 4649.73 Amerihealth Amerihealth Commercial 0.26 7158.18 0.26 27085.80 0.26 Case Rate 52317 Priced Remove bladder stone 78063 52318 CPT Outpatient 26685.75 4581.05 Amerihealth Amerihealth Commercial 0.27 7158.18 0.27 26685.75 0.27 Case Rate 52318 Priced Cystoscopy and treatment 78063 52332 CPT Outpatient 115306.80 19794.33 Amerihealth Amerihealth Commercial 0.06 7158.18 0.06 115306.80 0.06 Case Rate 52332 Priced Cystouretero w/stone remove 78063 52352 CPT Outpatient 42420.00 7282.10 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 42420.00 0.17 Case Rate 52352 Priced Cystouretero w/lithotripsy 78063 52353 CPT Outpatient 38608.50 6627.79 Amerihealth Amerihealth Commercial 0.19 7158.18 0.19 38608.50 0.19 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 78063 52356 CPT Outpatient 36255.45 6223.85 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 36255.45 0.20 Case Rate 52356 Priced Prostatectomy (turp) 78063 52601 CPT Outpatient 35371.35 6072.08 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 35371.35 0.20 Case Rate 52601 Priced Laser surgery of prostate 78063 52648 CPT Outpatient 24264.45 4165.40 Amerihealth Amerihealth Commercial 0.30 7158.18 0.30 24264.45 0.30 Case Rate 52648 Priced Revision of urethra 78063 53450 CPT Outpatient 16209.90 2782.70 Amerihealth Amerihealth Commercial 0.44 7158.18 0.44 16209.90 0.44 Case Rate 53450 Priced Urology surgery procedure 78063 53899 CPT Outpatient 25368.00 134.83 Amerihealth Amerihealth Commercial 0.28 7158.18 0.28 25368.00 0.28 Case Rate 53899 Priced Circumcision w/regionl block 78063 54150 CPT Outpatient 14700.00 2523.50 Amerihealth Amerihealth Commercial 0.49 7158.18 0.49 14700.00 0.49 Case Rate 54150 Priced Circum 28 days or older 78063 54161 CPT Outpatient 19186.65 3293.71 Amerihealth Amerihealth Commercial 0.37 7158.18 0.37 19186.65 0.37 Case Rate 54161 Priced Lysis penil circumic lesion 78063 54162 CPT Outpatient 19795.65 3398.25 Amerihealth Amerihealth Commercial 0.36 7158.18 0.36 19795.65 0.36 Case Rate 54162 Priced Repair of circumcision 78063 54163 CPT Outpatient 16391.55 2813.88 Amerihealth Amerihealth Commercial 0.44 7158.18 0.44 16391.55 0.44 Case Rate 54163 Priced Reconstruction of urethra 78063 54324 CPT Outpatient 32880.75 5644.53 Amerihealth Amerihealth Commercial 0.22 7158.18 0.22 32880.75 0.22 Case Rate 54324 Priced Revise penis/urethra 78063 54332 CPT Outpatient 19968.90 3427.99 Amerihealth Amerihealth Commercial 0.36 7158.18 0.36 19968.90 0.36 Case Rate 54332 Priced Insert self-contd prosthesis 78063 54401 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 78063 54520 CPT Outpatient 35442.75 6084.34 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 35442.75 0.20 Case Rate 54520 Priced Reduce testis torsion 78063 54600 CPT Outpatient 55049.40 9450.15 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 55049.40 0.13 Case Rate 54600 Priced Suspension of testis 78063 54640 CPT Outpatient 26860.05 4610.98 Amerihealth Amerihealth Commercial 0.27 7158.18 0.27 26860.05 0.27 Case Rate 54640 Priced Removal of hydrocele 78063 55040 CPT Outpatient 27277.95 4682.71 Amerihealth Amerihealth Commercial 0.26 7158.18 0.26 27277.95 0.26 Case Rate 55040 Priced Biopsy of prostate gland 78063 55700 CPT Outpatient 28699.65 4926.77 Amerihealth Amerihealth Commercial 0.25 7158.18 0.25 28699.65 0.25 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 78063 55866 CPT Outpatient 93088.80 15980.24 Amerihealth Amerihealth Commercial 0.08 7158.18 0.08 93088.80 0.08 Case Rate 55866 Priced Closure of vagina 78063 57120 CPT Outpatient 34369.65 5900.12 Amerihealth Amerihealth Commercial 0.21 7158.18 0.21 34369.65 0.21 Case Rate 57120 Priced Repair of vagina 78063 57200 CPT Outpatient 25247.25 4334.11 Amerihealth Amerihealth Commercial 0.28 7158.18 0.28 25247.25 0.28 Case Rate 57200 Priced Anterior colporrhaphy 78063 57240 CPT Outpatient 36210.30 6216.10 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 36210.30 0.20 Case Rate 57240 Priced Repair rectum & vagina 78063 57250 CPT Outpatient 40441.80 6942.51 Amerihealth Amerihealth Commercial 0.18 7158.18 0.18 40441.80 0.18 Case Rate 57250 Priced Cmbn ant pst colprhy 78063 57260 CPT Outpatient 46323.90 7952.27 Amerihealth Amerihealth Commercial 0.15 7158.18 0.15 46323.90 0.15 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 78063 57265 CPT Outpatient 42586.95 7310.76 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 42586.95 0.17 Case Rate 57265 Priced Repair of bowel bulge 78063 57268 CPT Outpatient 36865.50 6328.58 Amerihealth Amerihealth Commercial 0.19 7158.18 0.19 36865.50 0.19 Case Rate 57268 Priced Colpopexy extraperitoneal 78063 57282 CPT Outpatient 45629.85 7833.12 Amerihealth Amerihealth Commercial 0.16 7158.18 0.16 45629.85 0.16 Case Rate 57282 Priced Repair bladder defect 78063 57288 CPT Outpatient 43069.95 7393.67 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 43069.95 0.17 Case Rate 57288 Priced Bx/curett of cervix w/scope 78063 57454 CPT Outpatient 2888.55 442.93 Amerihealth Amerihealth Commercial 0.50 1433.59 0.50 2888.55 0.50 Case Rate 57454 Priced Conization of cervix 78063 57520 CPT Outpatient 26728.80 4588.44 Amerihealth Amerihealth Commercial 0.27 7158.18 0.27 26728.80 0.27 Case Rate 57520 Priced Conization of cervix 78063 57522 CPT Outpatient 22737.75 3903.31 Amerihealth Amerihealth Commercial 0.31 7158.18 0.31 22737.75 0.31 Case Rate 57522 Priced Biopsy of uterus lining 78063 58100 CPT Outpatient 2371.95 194.80 Amerihealth Amerihealth Commercial 0.50 1176.97 0.50 2371.95 0.50 Case Rate 58100 Priced Catheter for hysterography 78063 58340 CPT Outpatient 6322.05 131.04 Amerihealth Amerihealth Commercial 0.28 1769.55 0.28 6322.05 0.28 Case Rate 58340 Priced Reopen fallopian tube 78063 58350 CPT Outpatient 46507.65 7983.81 Amerihealth Amerihealth Commercial 0.15 7158.18 0.15 46507.65 0.15 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 78063 58542 CPT Outpatient 64194.90 11020.12 Amerihealth Amerihealth Commercial 0.11 7158.18 0.11 64194.90 0.11 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 78063 58544 CPT Outpatient 51020.55 8758.53 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 51020.55 0.14 Case Rate 58544 Priced Laparoscopic myomectomy 78063 58545 CPT Outpatient 56946.75 9775.86 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 56946.75 0.13 Case Rate 58545 Priced Laparo-vag hyst incl t/o 78063 58552 CPT Outpatient 57228.15 9824.17 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 57228.15 0.13 Case Rate 58552 Priced Hysteroscopy biopsy 78063 58558 CPT Outpatient 28581.00 2077.02 Amerihealth Amerihealth Commercial 0.25 7158.18 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 78063 58561 CPT Outpatient 35222.25 6046.49 Amerihealth Amerihealth Commercial 0.20 7158.18 0.20 35222.25 0.20 Case Rate 58561 Priced Hysteroscopy ablation 78063 58563 CPT Outpatient 38399.55 6591.92 Amerihealth Amerihealth Commercial 0.19 7158.18 0.19 38399.55 0.19 Case Rate 58563 Priced Tlh uterus 250 g or less 78063 58570 CPT Outpatient 43316.70 7436.03 Amerihealth Amerihealth Commercial 0.17 7158.18 0.17 43316.70 0.17 Case Rate 58570 Priced Tlh w/t/o 250 g or less 78063 58571 CPT Outpatient 48603.45 8343.59 Amerihealth Amerihealth Commercial 0.15 7158.18 0.15 48603.45 0.15 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 78063 58573 CPT Outpatient 52905.30 9082.08 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 52905.30 0.14 Case Rate 58573 Priced Laparoscopy remove adnexa 78063 58661 CPT Outpatient 47008.50 8069.79 Amerihealth Amerihealth Commercial 0.15 7158.18 0.15 47008.50 0.15 Case Rate 58661 Priced Laparoscopy excise lesions 78063 58662 CPT Outpatient 45053.40 7734.17 Amerihealth Amerihealth Commercial 0.16 7158.18 0.16 45053.40 0.16 Case Rate 58662 Priced Treat ectopic pregnancy 78063 59151 CPT Outpatient 74690.70 12821.90 Amerihealth Amerihealth Commercial 0.10 7158.18 0.10 74690.70 0.10 Case Rate 59151 Priced Treatment of miscarriage 78063 59812 CPT Outpatient 56109.90 9632.20 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 56109.90 0.13 Case Rate 59812 Priced Partial removal of thyroid 78063 60220 CPT Outpatient 53639.25 9208.07 Amerihealth Amerihealth Commercial 0.13 7158.18 0.13 53639.25 0.13 Case Rate 60220 Priced Removal of thyroid 78063 60240 CPT Outpatient 98252.70 16866.71 Amerihealth Amerihealth Commercial 0.07 7158.18 0.07 98252.70 0.07 Case Rate 60240 Priced Explore parathyroid glands 78063 60500 CPT Outpatient 150495.45 25835.05 Amerihealth Amerihealth Commercial 0.05 7158.18 0.05 150495.45 0.05 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 78063 62322 CPT Outpatient 43709.40 514.24 Amerihealth Amerihealth Commercial 0.16 7158.18 0.16 43709.40 0.16 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 78063 62323 CPT Outpatient 8304.45 467.31 Amerihealth Amerihealth Commercial 0.37 3054.32 0.37 8304.45 0.37 Case Rate 62323 Priced Low back disk surgery 78063 63030 CPT Outpatient 50287.65 8632.71 Amerihealth Amerihealth Commercial 0.14 7158.18 0.14 50287.65 0.14 Case Rate 63030 Priced Inc for vagus n elect impl 78063 64568 CPT Outpatient 124562.55 21383.24 Amerihealth Amerihealth Commercial 0.06 7158.18 0.06 124562.55 0.06 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 78063 66821 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 78063 66984 CPT Outpatient 0.01 0.01 Amerihealth Amerihealth Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 559001 216 DRG Inpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 559001 460 DRG Inpatient 416122.79 53834.63 CHN CHN Commercial 0.10 40460.00 0.10 416122.79 0.10 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 559001 470 DRG Inpatient 167912.19 21723.13 CHN CHN Commercial 0.02 2890.00 0.02 167912.19 0.02 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 559001 473 DRG Inpatient 100687.91 13026.19 CHN CHN Commercial 0.03 2890.00 0.03 100687.91 0.03 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 559001 743 DRG Inpatient 102691.67 13285.42 CHN CHN Commercial 0.03 2890.00 0.03 102691.67 0.03 Case Rate 743 Priced NORMAL NEWBORN 559001 795 DRG Inpatient 6266.93 2335.00 CHN CHN Commercial 0.17 1075.00 0.17 6266.93 0.17 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 559001 807 DRG Inpatient 116469.59 4193.00 CHN CHN Commercial 0.05 6400.00 0.05 116469.59 0.05 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 559001 788 DRG Inpatient 76050.77 4538.00 CHN CHN Commercial 0.12 9225.00 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 559001 59400 CPT Inpatient 116469.59 4193.00 CHN CHN Commercial 0.05 6400.00 0.05 116469.59 0.05 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 559001 59510 CPT Inpatient 76050.77 4538.00 CHN CHN Commercial 0.12 9225.00 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 559001 59610 CPT Inpatient 116469.59 4193.00 CHN CHN Commercial 0.05 6400.00 0.05 116469.59 0.05 Case Rate 59610 Priced "Psychotherapy, 30 min" 559001 90832 CPT Outpatient 577.50 91.21 CHN CHN Commercial 0.67 385.00 0.67 577.50 0.67 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 559001 90834 CPT Outpatient 44134.65 271.96 CHN CHN Commercial 0.63 28021.70 0.63 44134.65 0.63 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 559001 90837 CPT Outpatient 2240.70 442.93 CHN CHN Commercial 0.13 287.00 0.13 2240.70 0.13 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 559001 90846 CPT Outpatient 0.01 131.50 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 559001 90847 CPT Outpatient 44134.65 369.97 CHN CHN Commercial 0.63 28021.70 0.63 44134.65 0.63 Fee Schedule 90847 Priced Group psychotherapy 559001 90853 CPT Outpatient 44134.65 101.99 CHN CHN Commercial 0.63 28021.70 0.63 44134.65 0.63 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 559001 99203 CPT Outpatient 3480.75 176.07 CHN CHN Commercial 0.63 2209.90 0.63 3480.75 0.63 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 559001 99204 CPT Outpatient 2103.15 233.39 CHN CHN Commercial 0.63 1334.90 0.63 2103.15 0.63 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 559001 99205 CPT Outpatient 4970.70 314.28 CHN CHN Commercial 0.32 1577.80 0.32 4970.70 0.32 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 559001 99243 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 559001 99244 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 559001 99385 CPT Outpatient 1114.05 185.90 CHN CHN Commercial 0.63 707.00 0.63 1114.05 0.63 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 559001 99386 CPT Outpatient 4877.25 185.90 CHN CHN Commercial 0.51 2488.50 0.51 4877.25 0.51 Fee Schedule 99386 Priced Routine venipuncture 559001 36415 CPT Outpatient 127.05 19.57 CHN CHN Commercial 0.67 84.70 0.67 127.05 0.67 Fee Schedule 36415 Priced Basic Metabolic Panel 559001 80048 CPT Outpatient 576.45 88.78 CHN CHN Commercial 0.67 384.30 0.67 576.45 0.67 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 559001 80053 CPT Outpatient 763.35 117.56 CHN CHN Commercial 0.67 508.90 0.67 763.35 0.67 Fee Schedule 80053 Priced Obstetric blood test panel 559001 80055 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 559001 80061 CPT Outpatient 1349.25 197.77 CHN CHN Commercial 0.63 856.10 0.63 1349.25 0.63 Fee Schedule 80061 Priced Kidney function panel test 559001 80069 CPT Outpatient 716.10 104.95 CHN CHN Commercial 0.63 454.30 0.63 716.10 0.63 Fee Schedule 80069 Priced Liver function panel test 559001 80076 CPT Outpatient 716.10 104.95 CHN CHN Commercial 0.63 454.30 0.63 716.10 0.63 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 559001 81000 CPT Outpatient 144.90 21.18 CHN CHN Commercial 0.63 91.70 0.63 144.90 0.63 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 559001 81001 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 559001 81002 CPT Outpatient 57.75 8.89 CHN CHN Commercial 0.67 38.50 0.67 57.75 0.67 Fee Schedule 81002 Priced Automated urinalysis test 559001 81003 CPT Outpatient 219.45 33.80 CHN CHN Commercial 0.67 146.30 0.67 219.45 0.67 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 559001 82306 CPT Outpatient 1880.55 289.62 CHN CHN Commercial 0.67 1253.70 0.67 1880.55 0.67 Fee Schedule 82306 Priced Glycosylated hemoglobin test 559001 83036 CPT Outpatient 494.55 76.17 CHN CHN Commercial 0.67 329.70 0.67 494.55 0.67 Fee Schedule 83036 Priced PSA (prostate specific antigen) 559001 84153 CPT Outpatient 1177.05 181.28 CHN CHN Commercial 0.67 784.70 0.67 1177.05 0.67 Fee Schedule 84153 Priced PSA (prostate specific antigen) 559001 84154 CPT Outpatient 598.50 92.17 CHN CHN Commercial 0.67 399.00 0.67 598.50 0.67 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 559001 84443 CPT Outpatient 519.75 80.05 CHN CHN Commercial 0.67 346.50 0.67 519.75 0.67 Fee Schedule 84443 Priced Chorionic gonadotropin assay 559001 84703 CPT Outpatient 785.40 120.96 CHN CHN Commercial 0.67 523.60 0.67 785.40 0.67 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 559001 85025 CPT Outpatient 635.25 97.83 CHN CHN Commercial 0.67 423.50 0.67 635.25 0.67 Fee Schedule 85025 Priced "Complete blood count, automated" 559001 85027 CPT Outpatient 576.45 88.78 CHN CHN Commercial 0.67 384.30 0.67 576.45 0.67 Fee Schedule 85027 Priced "Blood test, clotting time" 559001 85610 CPT Outpatient 404.25 62.26 CHN CHN Commercial 0.67 269.50 0.67 404.25 0.67 Fee Schedule 85610 Priced Coagulation assessment blood test 559001 85730 CPT Outpatient 17.22 2.65 CHN CHN Commercial 0.67 11.48 0.67 17.22 0.67 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 559001 86003 CPT Outpatient 32.55 5.01 CHN CHN Commercial 0.67 21.70 0.67 32.55 0.67 Fee Schedule 86003 Priced Tb test cell immun measure 559001 86480 CPT Outpatient 530.25 81.66 CHN CHN Commercial 0.67 353.50 0.67 530.25 0.67 Fee Schedule 86480 Priced Urine culture/colony count 559001 87086 CPT Outpatient 763.35 117.56 CHN CHN Commercial 0.67 508.90 0.67 763.35 0.67 Fee Schedule 87086 Priced Hpylori stool ia 559001 87338 CPT Outpatient 785.40 120.96 CHN CHN Commercial 0.67 523.60 0.67 785.40 0.67 Fee Schedule 87338 Priced Cytopath eval fna report 559001 88173 CPT Outpatient 750.75 115.62 CHN CHN Commercial 0.67 500.50 0.67 750.75 0.67 Fee Schedule 88173 Priced Tissue exam by pathologist 559001 88302 CPT Outpatient 635.25 97.83 CHN CHN Commercial 0.67 423.50 0.67 635.25 0.67 Fee Schedule 88302 Priced Tissue exam by pathologist 559001 88305 CPT Outpatient 323.40 49.81 CHN CHN Commercial 0.67 215.60 0.67 323.40 0.67 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 559001 11042 CPT Outpatient 2668.05 481.45 CHN CHN Commercial 0.63 1694.00 0.63 2668.05 0.63 Case Rate 11042 Priced Deb subq tissue add-on 559001 11045 CPT Outpatient 4652.55 330.00 CHN CHN Commercial 0.63 2954.00 0.63 4652.55 0.63 Case Rate 11045 Priced Dx bronchoscope/lavage 559001 31624 CPT Outpatient 41223.00 7602.31 CHN CHN Commercial 0.13 5500.00 0.13 41223.00 0.13 Case Rate 31624 Priced Bronchoscopy/lung bx each 559001 31628 CPT Outpatient 49048.65 9045.51 CHN CHN Commercial 0.11 5500.00 0.11 49048.65 0.11 Case Rate 31628 Priced Blood transfusion service 559001 36430 CPT Outpatient 9166.50 574.93 CHN CHN Commercial 0.63 5819.80 0.63 9166.50 0.63 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 559001 43235 CPT Outpatient 8856.75 1633.35 CHN CHN Commercial 0.62 5500.00 0.62 8856.75 0.62 Case Rate 43235 Priced Endoscopic us exam esoph 559001 43237 CPT Outpatient 23867.55 4401.63 CHN CHN Commercial 0.23 5500.00 0.23 23867.55 0.23 Case Rate 43237 Priced Egd us fine needle bx/aspir 559001 43238 CPT Outpatient 30690.45 5659.90 CHN CHN Commercial 0.18 5500.00 0.18 30690.45 0.18 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 559001 43239 CPT Outpatient 40191.90 7412.15 CHN CHN Commercial 0.14 5500.00 0.14 40191.90 0.14 Case Rate 43239 Priced Ercp remove duct calculi 559001 43264 CPT Outpatient 34335.00 6332.03 CHN CHN Commercial 0.16 5500.00 0.16 34335.00 0.16 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 559001 45378 CPT Outpatient 13991.25 889.35 CHN CHN Commercial 0.39 5500.00 0.39 13991.25 0.39 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 559001 45380 CPT Outpatient 22215.90 4097.04 CHN CHN Commercial 0.25 5500.00 0.25 22215.90 0.25 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 559001 45385 CPT Outpatient 119569.80 22050.95 CHN CHN Commercial 0.05 5500.00 0.05 119569.80 0.05 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 559001 45391 CPT Outpatient 24923.85 4596.43 CHN CHN Commercial 0.22 5500.00 0.22 24923.85 0.22 Case Rate 45391 Priced Fragmenting of kidney stone 559001 50590 CPT Outpatient 40930.05 7548.28 CHN CHN Commercial 0.13 5500.00 0.13 40930.05 0.13 Case Rate 50590 Priced Fetal non-stress test 559001 59025 CPT Outpatient 3153.15 477.76 CHN CHN Commercial 0.63 2002.00 0.63 3153.15 0.63 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 559001 64483 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 559001 92567 CPT Outpatient 2224.95 98.50 CHN CHN Commercial 0.63 1412.60 0.63 2224.95 0.63 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 559001 93000 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 559001 93017 CPT Outpatient 3076.50 532.96 CHN CHN Commercial 0.63 1953.00 0.63 3076.50 0.63 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 559001 93452 CPT Outpatient 55621.65 8611.87 CHN CHN Commercial 0.12 6875.00 0.12 55621.65 0.12 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 559001 95810 CPT Outpatient 20341.65 3373.48 CHN CHN Commercial 0.63 12915.00 0.63 20341.65 0.63 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 559001 95811 CPT Outpatient 22491.00 3731.18 CHN CHN Commercial 0.63 14280.00 0.63 22491.00 0.63 Case Rate 95811 Priced Eeg 41-60 minutes 559001 95812 CPT Outpatient 5578.65 925.83 CHN CHN Commercial 0.63 3542.00 0.63 5578.65 0.63 Case Rate 95812 Priced Genetic counseling 30 min 559001 96040 CPT Outpatient 0.01 102.81 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 559001 96413 CPT Outpatient 4856.25 472.45 CHN CHN Commercial 0.63 3082.80 0.63 4856.25 0.63 Case Rate 96413 Priced Ultrasound therapy 559001 97035 CPT Outpatient 2111.55 134.99 CHN CHN Commercial 0.63 1340.50 0.63 2111.55 0.63 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 559001 97110 CPT Outpatient 6494.25 92.86 CHN CHN Commercial 0.63 4123.00 0.63 6494.25 0.63 Case Rate 97110 Priced Gait training therapy 559001 97116 CPT Outpatient 4723.95 110.61 CHN CHN Commercial 0.63 2998.80 0.63 4723.95 0.63 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 559001 70450 CPT Outpatient 8566.95 835.61 CHN CHN Commercial 0.11 975.00 0.11 8566.95 0.11 Case Rate 70450 Priced Mri brain stem w/o dye 559001 70551 CPT Outpatient 7861.35 1361.31 CHN CHN Commercial 0.63 4991.00 0.63 7861.35 0.63 Case Rate 70551 Priced MRI scan of brain before and after contrast 559001 70553 CPT Outpatient 10882.20 1625.88 CHN CHN Commercial 0.63 6909.00 0.63 10882.20 0.63 Case Rate 70553 Priced X-ray exam chest 2 views 559001 71046 CPT Outpatient 859.95 150.37 CHN CHN Commercial 0.63 546.00 0.63 859.95 0.63 Case Rate 71046 Priced Ct thorax w/o dye 559001 71250 CPT Outpatient 7288.05 1261.63 CHN CHN Commercial 0.63 4627.00 0.63 7288.05 0.63 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 559001 72082 CPT Outpatient 2022.30 253.33 CHN CHN Commercial 0.75 1526.70 0.75 2022.30 0.75 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 559001 72100 CPT Outpatient 1599.15 277.38 CHN CHN Commercial 0.63 1015.00 0.63 1599.15 0.63 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 559001 72110 CPT Outpatient 1389.15 241.04 CHN CHN Commercial 0.63 882.00 0.63 1389.15 0.63 Case Rate 72110 Priced MRI scan of lower spinal canal 559001 72148 CPT Outpatient 7861.35 1361.31 CHN CHN Commercial 0.63 4991.00 0.63 7861.35 0.63 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 559001 72193 CPT Outpatient 13671.00 1412.01 CHN CHN Commercial 0.38 5180.00 0.38 13671.00 0.38 Case Rate 72193 Priced X-ray exam of shoulder 559001 73030 CPT Outpatient 1452.15 251.43 CHN CHN Commercial 0.63 921.90 0.63 1452.15 0.63 Case Rate 73030 Priced X-ray exam of elbow 559001 73080 CPT Outpatient 1356.60 235.68 CHN CHN Commercial 0.63 861.00 0.63 1356.60 0.63 Case Rate 73080 Priced X-ray exam of forearm 559001 73090 CPT Outpatient 1243.20 215.26 CHN CHN Commercial 0.63 788.90 0.63 1243.20 0.63 Case Rate 73090 Priced X-ray exam of wrist 559001 73110 CPT Outpatient 1243.20 215.26 CHN CHN Commercial 0.63 788.90 0.63 1243.20 0.63 Case Rate 73110 Priced X-ray exam of hand 559001 73130 CPT Outpatient 1243.20 215.26 CHN CHN Commercial 0.63 788.90 0.63 1243.20 0.63 Case Rate 73130 Priced X-ray exam hips bi 2 views 559001 73521 CPT Outpatient 970.20 228.41 CHN CHN Commercial 0.86 833.00 0.86 970.20 0.86 Case Rate 73521 Priced X-ray exam of knee 3 559001 73562 CPT Outpatient 802.20 139.12 CHN CHN Commercial 0.63 508.90 0.63 802.20 0.63 Case Rate 73562 Priced X-ray exam of lower leg 559001 73590 CPT Outpatient 1243.20 215.26 CHN CHN Commercial 0.63 788.90 0.63 1243.20 0.63 Case Rate 73590 Priced X-ray exam of ankle 559001 73610 CPT Outpatient 1378.65 239.31 CHN CHN Commercial 0.63 875.00 0.63 1378.65 0.63 Case Rate 73610 Priced X-ray exam of foot 559001 73630 CPT Outpatient 975.45 169.41 CHN CHN Commercial 0.63 618.80 0.63 975.45 0.63 Case Rate 73630 Priced MRI scan of leg joint 559001 73721 CPT Outpatient 7861.35 1361.31 CHN CHN Commercial 0.63 4991.00 0.63 7861.35 0.63 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 559001 74177 CPT Outpatient 14222.25 1412.01 CHN CHN Commercial 0.36 5180.00 0.36 14222.25 0.36 Case Rate 74177 Priced Contrst x-ray exam of throat 559001 74210 CPT Outpatient 0.01 440.39 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 559001 76098 CPT Outpatient 6141.45 407.86 CHN CHN Commercial 0.90 5500.00 0.90 6141.45 0.90 Case Rate 76098 Priced Us exam of head and neck 559001 76536 CPT Outpatient 5512.50 955.18 CHN CHN Commercial 0.63 3500.00 0.63 5512.50 0.63 Case Rate 76536 Priced Ultrasound breast limited 559001 76642 CPT Outpatient 5777.10 127.70 CHN CHN Commercial 0.63 3668.00 0.63 5777.10 0.63 Case Rate 76642 Priced Ultrasound of abdomen 559001 76700 CPT Outpatient 4917.15 851.88 CHN CHN Commercial 0.63 3122.00 0.63 4917.15 0.63 Case Rate 76700 Priced Echo exam of abdomen 559001 76705 CPT Outpatient 3836.70 665.17 CHN CHN Commercial 0.63 2436.00 0.63 3836.70 0.63 Case Rate 76705 Priced Us exam abdo back wall comp 559001 76770 CPT Outpatient 5171.25 895.48 CHN CHN Commercial 0.63 3283.00 0.63 5171.25 0.63 Case Rate 76770 Priced Us exam abdo back wall lim 559001 76775 CPT Outpatient 3969.00 686.97 CHN CHN Commercial 0.63 2520.00 0.63 3969.00 0.63 Case Rate 76775 Priced Ob us < 14 wks single fetus 559001 76801 CPT Outpatient 2006.55 347.98 CHN CHN Commercial 0.63 1274.00 0.63 2006.55 0.63 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 559001 76805 CPT Outpatient 3969.00 686.97 CHN CHN Commercial 0.63 2520.00 0.63 3969.00 0.63 Case Rate 76805 Priced Ob us detailed sngl fetus 559001 76811 CPT Outpatient 2844.45 492.99 CHN CHN Commercial 0.63 1806.00 0.63 2844.45 0.63 Case Rate 76811 Priced Ob us nuchal meas 1 gest 559001 76813 CPT Outpatient 1044.75 180.83 CHN CHN Commercial 0.63 662.90 0.63 1044.75 0.63 Case Rate 76813 Priced Ob us limited fetus(s) 559001 76815 CPT Outpatient 6428.10 639.90 CHN CHN Commercial 0.63 4081.00 0.63 6428.10 0.63 Case Rate 76815 Priced Ob us follow-up per fetus 559001 76816 CPT Outpatient 4818.45 833.88 CHN CHN Commercial 0.63 3059.00 0.63 4818.45 0.63 Case Rate 76816 Priced Transvaginal us obstetric 559001 76817 CPT Outpatient 6428.10 476.73 CHN CHN Commercial 0.63 4081.00 0.63 6428.10 0.63 Case Rate 76817 Priced Fetal biophys profil w/o nst 559001 76819 CPT Outpatient 1741.95 302.65 CHN CHN Commercial 0.63 1106.00 0.63 1741.95 0.63 Case Rate 76819 Priced Ultrasound pelvis through vagina 559001 76830 CPT Outpatient 9305.10 806.54 CHN CHN Commercial 0.63 5908.00 0.63 9305.10 0.63 Case Rate 76830 Priced Us exam scrotum 559001 76870 CPT Outpatient 6328.35 1096.55 CHN CHN Commercial 0.63 4018.00 0.63 6328.35 0.63 Case Rate 76870 Priced Us exam infant hips dynamic 559001 76885 CPT Outpatient 3836.70 665.17 CHN CHN Commercial 0.63 2436.00 0.63 3836.70 0.63 Case Rate 76885 Priced Mammography of one breast 559001 77065 CPT Outpatient 3451.35 192.07 CHN CHN Commercial 0.63 2191.00 0.63 3451.35 0.63 Case Rate 77065 Priced Mammography of both breasts 559001 77066 CPT Outpatient 5777.10 235.68 CHN CHN Commercial 0.63 3668.00 0.63 5777.10 0.63 Case Rate 77066 Priced "Mamography, screening bilateral" 559001 77067 CPT Outpatient 1416.45 205.57 CHN CHN Commercial 0.63 898.80 0.63 1416.45 0.63 Case Rate 77067 Priced X-rays for bone age 559001 77072 CPT Outpatient 2022.30 163.87 CHN CHN Commercial 0.75 1526.70 0.75 2022.30 0.75 Case Rate 77072 Priced Joint survey single view 559001 77077 CPT Outpatient 985.95 171.14 CHN CHN Commercial 0.63 625.80 0.63 985.95 0.63 Case Rate 77077 Priced Dxa bone density axial 559001 77080 CPT Outpatient 3257.10 319.09 CHN CHN Commercial 0.63 2067.80 0.63 3257.10 0.63 Case Rate 77080 Priced Fna bx w/us gdn 1st les 559001 10005 CPT Outpatient 5512.50 547.24 CHN CHN Commercial 0.91 5000.00 0.91 5512.50 0.91 Case Rate 10005 Priced Fna bx w/us gdn ea addl 559001 10006 CPT Outpatient 10628.10 594.83 CHN CHN Commercial 0.52 5500.00 0.52 10628.10 0.52 Case Rate 10006 Priced Drainage of hematoma/fluid 559001 10140 CPT Outpatient 23209.20 1081.95 CHN CHN Commercial 0.24 5500.00 0.24 23209.20 0.24 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 559001 11042 CPT Outpatient 2668.05 481.45 CHN CHN Commercial 0.63 1694.00 0.63 2668.05 0.63 Case Rate 11042 Priced Deb bone 20 sq cm/< 559001 11044 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 559001 11406 CPT Outpatient 19967.85 3427.81 CHN CHN Commercial 0.28 5500.00 0.28 19967.85 0.28 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 559001 11424 CPT Outpatient 0.01 1004.93 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 559001 11770 CPT Outpatient 19173.00 3291.37 CHN CHN Commercial 0.29 5500.00 0.29 19173.00 0.29 Case Rate 11770 Priced Replace tissue expander 559001 11970 CPT Outpatient 59239.95 10169.52 CHN CHN Commercial 0.09 5500.00 0.09 59239.95 0.09 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 559001 14020 CPT Outpatient 32166.75 5521.96 CHN CHN Commercial 0.17 5500.00 0.17 32166.75 0.17 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 559001 14060 CPT Outpatient 25993.80 1374.69 CHN CHN Commercial 0.21 5500.00 0.21 25993.80 0.21 Case Rate 14060 Priced Wound prep trk/arm/leg 559001 15002 CPT Outpatient 41748.00 1441.73 CHN CHN Commercial 0.13 5500.00 0.13 41748.00 0.13 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 559001 15271 CPT Outpatient 24343.20 3769.48 CHN CHN Commercial 0.59 14427.00 0.59 24343.20 0.59 Case Rate 15271 Priced Acellular derm matrix implt 559001 15777 CPT Outpatient 101672.55 17453.79 CHN CHN Commercial 0.05 5500.00 0.05 101672.55 0.05 Case Rate 15777 Priced Exc skin abd 559001 15830 CPT Outpatient 54696.60 9389.58 CHN CHN Commercial 0.10 5500.00 0.10 54696.60 0.10 Case Rate 15830 Priced Dressing change not for burn 559001 15852 CPT Outpatient 0.01 290.74 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 559001 15877 CPT Outpatient 63741.30 10942.26 CHN CHN Commercial 0.09 5500.00 0.09 63741.30 0.09 Case Rate 15877 Priced Suction lipectomy lwr extrem 559001 15879 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 559001 19000 CPT Outpatient 10143.00 594.83 CHN CHN Commercial 0.54 5500.00 0.54 10143.00 0.54 Case Rate 19000 Priced Bx breast 1st lesion strtctc 559001 19081 CPT Outpatient 12341.70 1250.69 CHN CHN Commercial 0.45 5500.00 0.45 12341.70 0.45 Case Rate 19081 Priced Bx breast add lesion us imag 559001 19084 CPT Outpatient 29058.75 547.24 CHN CHN Commercial 0.19 5500.00 0.19 29058.75 0.19 Case Rate 19084 Priced Biopsy of breast open 559001 19101 CPT Outpatient 39545.10 2737.82 CHN CHN Commercial 0.14 5500.00 0.14 39545.10 0.14 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 559001 19120 CPT Outpatient 35761.95 2737.82 CHN CHN Commercial 0.15 5500.00 0.15 35761.95 0.15 Case Rate 19120 Priced Excision breast lesion 559001 19125 CPT Outpatient 33184.20 0.01 CHN CHN Commercial 0.17 5500.00 0.17 33184.20 0.17 Case Rate 19125 Priced Perq device breast 1st imag 559001 19281 CPT Outpatient 6141.45 598.61 CHN CHN Commercial 0.90 5500.00 0.90 6141.45 0.90 Case Rate 19281 Priced Perq device breast ea imag 559001 19282 CPT Outpatient 8379.00 319.04 CHN CHN Commercial 0.66 5500.00 0.66 8379.00 0.66 Case Rate 19282 Priced Partial mastectomy 559001 19301 CPT Outpatient 39157.65 6722.06 CHN CHN Commercial 0.14 5500.00 0.14 39157.65 0.14 Case Rate 19301 Priced Mast simple complete 559001 19303 CPT Outpatient 105389.55 18091.87 CHN CHN Commercial 0.05 5500.00 0.05 105389.55 0.05 Case Rate 19303 Priced Reduction of large breast 559001 19318 CPT Outpatient 65239.65 11199.47 CHN CHN Commercial 0.08 5500.00 0.08 65239.65 0.08 Case Rate 19318 Priced Immediate breast prosthesis 559001 19340 CPT Outpatient 113100.75 19415.63 CHN CHN Commercial 0.05 5500.00 0.05 113100.75 0.05 Case Rate 19340 Priced Delayed breast prosthesis 559001 19342 CPT Outpatient 56988.75 9783.07 CHN CHN Commercial 0.10 5500.00 0.10 56988.75 0.10 Case Rate 19342 Priced Breast reconstruction 559001 19357 CPT Outpatient 101672.55 17453.79 CHN CHN Commercial 0.05 5500.00 0.05 101672.55 0.05 Case Rate 19357 Priced Breast reconstruction 559001 19366 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 559001 19380 CPT Outpatient 61493.25 10556.34 CHN CHN Commercial 0.09 5500.00 0.09 61493.25 0.09 Case Rate 19380 Priced Removal of support implant 559001 20680 CPT Outpatient 42329.70 7266.60 CHN CHN Commercial 0.13 5500.00 0.13 42329.70 0.13 Case Rate 20680 Priced Cerv artific diskectomy 559001 22856 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 559001 24538 CPT Outpatient 51237.90 4775.24 CHN CHN Commercial 0.11 5500.00 0.11 51237.90 0.11 Case Rate 24538 Priced Remove wrist tendon lesion 559001 25111 CPT Outpatient 25855.20 4438.48 CHN CHN Commercial 0.21 5500.00 0.21 25855.20 0.21 Case Rate 25111 Priced Incise finger tendon sheath 559001 26055 CPT Outpatient 15862.35 2723.04 CHN CHN Commercial 0.35 5500.00 0.35 15862.35 0.35 Case Rate 26055 Priced Treat finger fracture each 559001 26727 CPT Outpatient 22779.75 2030.47 CHN CHN Commercial 0.24 5500.00 0.24 22779.75 0.24 Case Rate 26727 Priced Revision of knee joint 559001 27446 CPT Outpatient 67882.50 11653.16 CHN CHN Commercial 0.08 5500.00 0.08 67882.50 0.08 Case Rate 27446 Priced Total knee arthroplasty 559001 27447 CPT Outpatient 130698.75 22436.62 CHN CHN Commercial 0.04 5500.00 0.04 130698.75 0.04 Case Rate 27447 Priced Surgery to stop leg growth 559001 27485 CPT Outpatient 43310.40 7434.95 CHN CHN Commercial 0.13 5500.00 0.13 43310.40 0.13 Case Rate 27485 Priced Repair achilles tendon 559001 27650 CPT Outpatient 38246.25 3762.57 CHN CHN Commercial 0.14 5500.00 0.14 38246.25 0.14 Case Rate 27650 Priced Treatment of ankle fracture 559001 27792 CPT Outpatient 36101.10 6197.36 CHN CHN Commercial 0.15 5500.00 0.15 36101.10 0.15 Case Rate 27792 Priced Treatment of ankle fracture 559001 27814 CPT Outpatient 49405.65 8481.30 CHN CHN Commercial 0.11 5500.00 0.11 49405.65 0.11 Case Rate 27814 Priced Removal of foot lesion 559001 28080 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 559001 28285 CPT Outpatient 68603.85 11776.99 CHN CHN Commercial 0.08 5500.00 0.08 68603.85 0.08 Case Rate 28285 Priced Correction hallux valgus 559001 28296 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 559001 29823 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 559001 29826 CPT Outpatient 49840.35 8555.93 CHN CHN Commercial 0.11 5500.00 0.11 49840.35 0.11 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 559001 29881 CPT Outpatient 35556.15 6103.81 CHN CHN Commercial 0.15 5500.00 0.15 35556.15 0.15 Case Rate 29881 Priced Knee arthroscopy/surgery 559001 29882 CPT Outpatient 61099.50 10488.75 CHN CHN Commercial 0.09 5500.00 0.09 61099.50 0.09 Case Rate 29882 Priced Percut bx lung/mediastinum 559001 32405 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 559001 32555 CPT Outpatient 14597.10 687.29 CHN CHN Commercial 0.38 5500.00 0.38 14597.10 0.38 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 559001 32664 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 559001 35190 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 559001 36478 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 559001 36561 CPT Outpatient 53531.10 3292.99 CHN CHN Commercial 0.10 5500.00 0.10 53531.10 0.10 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 559001 36569 CPT Outpatient 31421.25 1299.06 CHN CHN Commercial 0.18 5500.00 0.18 31421.25 0.18 Case Rate 36569 Priced Removal tunneled cv cath 559001 36590 CPT Outpatient 1996.05 273.95 CHN CHN Commercial 0.91 1818.00 0.91 1996.05 0.91 Case Rate 36590 Priced Av fuse uppr arm basilic 559001 36819 CPT Outpatient 56861.70 9761.26 CHN CHN Commercial 0.10 5500.00 0.10 56861.70 0.10 Case Rate 36819 Priced Av fusion direct any site 559001 36821 CPT Outpatient 42953.40 7373.67 CHN CHN Commercial 0.13 5500.00 0.13 42953.40 0.13 Case Rate 36821 Priced Artery-vein autograft 559001 36825 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 559001 36830 CPT Outpatient 53656.05 9210.96 CHN CHN Commercial 0.10 5500.00 0.10 53656.05 0.10 Case Rate 36830 Priced Av fistula revision open 559001 36832 CPT Outpatient 52492.65 9011.24 CHN CHN Commercial 0.10 5500.00 0.10 52492.65 0.10 Case Rate 36832 Priced Av fistula revision 559001 36833 CPT Outpatient 37098.60 6368.59 CHN CHN Commercial 0.15 5500.00 0.15 37098.60 0.15 Case Rate 36833 Priced Intro cath dialysis circuit 559001 36903 CPT Outpatient 77541.45 10669.90 CHN CHN Commercial 0.07 5500.00 0.07 77541.45 0.07 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 559001 36906 CPT Outpatient 96694.50 16175.64 CHN CHN Commercial 0.06 5500.00 0.06 96694.50 0.06 Case Rate 36906 Priced Fem/popl revas w/tla 559001 37224 CPT Outpatient 200076.45 5139.31 CHN CHN Commercial 0.03 6875.00 0.03 200076.45 0.03 Case Rate 37224 Priced Fem/popl revasc stnt & ather 559001 37227 CPT Outpatient 117170.55 18045.38 CHN CHN Commercial 0.06 6875.00 0.06 117170.55 0.06 Case Rate 37227 Priced Revise leg vein 559001 37700 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 559001 37722 CPT Outpatient 27815.55 4775.00 CHN CHN Commercial 0.20 5500.00 0.20 27815.55 0.20 Case Rate 37722 Priced Stab phleb veins xtr 10-20 559001 37765 CPT Outpatient 26561.85 4559.78 CHN CHN Commercial 0.21 5500.00 0.21 26561.85 0.21 Case Rate 37765 Priced Biopsy/removal lymph nodes 559001 38500 CPT Outpatient 35955.15 6172.30 CHN CHN Commercial 0.15 5500.00 0.15 35955.15 0.15 Case Rate 38500 Priced Biopsy/removal lymph nodes 559001 38525 CPT Outpatient 101194.80 17371.77 CHN CHN Commercial 0.05 5500.00 0.05 101194.80 0.05 Case Rate 38525 Priced Laparoscopy lymph node biop 559001 38570 CPT Outpatient 65631.30 11266.71 CHN CHN Commercial 0.08 5500.00 0.08 65631.30 0.08 Case Rate 38570 Priced Laparoscopy lymphadenectomy 559001 38571 CPT Outpatient 84031.50 14425.41 CHN CHN Commercial 0.07 5500.00 0.07 84031.50 0.07 Case Rate 38571 Priced Laparoscopy lymphadenectomy 559001 38572 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 559001 38792 CPT Outpatient 2868.60 432.48 CHN CHN Commercial 0.91 2601.00 0.91 2868.60 0.91 Case Rate 38792 Priced Excision of gum lesion 559001 41825 CPT Outpatient 11580.45 1987.98 CHN CHN Commercial 0.47 5500.00 0.47 11580.45 0.47 Case Rate 41825 Priced Reconstruct cleft palate 559001 42200 CPT Outpatient 36703.80 6300.82 CHN CHN Commercial 0.15 5500.00 0.15 36703.80 0.15 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 559001 42820 CPT Outpatient 17232.60 2958.26 CHN CHN Commercial 0.32 5500.00 0.32 17232.60 0.32 Case Rate 42820 Priced Control throat bleeding 559001 42960 CPT Outpatient 24066.00 4131.33 CHN CHN Commercial 0.23 5500.00 0.23 24066.00 0.23 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 559001 43235 CPT Outpatient 8856.75 1633.35 CHN CHN Commercial 0.62 5500.00 0.62 8856.75 0.62 Case Rate 43235 Priced Laparoscopy fundoplasty 559001 43280 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 559001 43282 CPT Outpatient 84344.40 14479.12 CHN CHN Commercial 0.07 5500.00 0.07 84344.40 0.07 Case Rate 43282 Priced Laparoscopy appendectomy 559001 44970 CPT Outpatient 82300.05 14128.18 CHN CHN Commercial 0.07 5500.00 0.07 82300.05 0.07 Case Rate 44970 Priced Diagnostic sigmoidoscopy 559001 45330 CPT Outpatient 17286.15 542.26 CHN CHN Commercial 0.32 5500.00 0.32 17286.15 0.32 Case Rate 45330 Priced Needle biopsy of liver 559001 47000 CPT Outpatient 10398.15 1225.34 CHN CHN Commercial 0.53 5500.00 0.53 10398.15 0.53 Case Rate 47000 Priced Removal of gallbladder using an endoscope 559001 47562 CPT Outpatient 58430.40 10030.55 CHN CHN Commercial 0.09 5500.00 0.09 58430.40 0.09 Case Rate 47562 Priced Laparo cholecystectomy/graph 559001 47563 CPT Outpatient 71747.55 12316.66 CHN CHN Commercial 0.08 5500.00 0.08 71747.55 0.08 Case Rate 47563 Priced Abd paracentesis w/imaging 559001 49083 CPT Outpatient 6979.35 1113.95 CHN CHN Commercial 0.79 5500.00 0.79 6979.35 0.79 Case Rate 49083 Priced Diag laparo separate proc 559001 49320 CPT Outpatient 31629.15 5429.67 CHN CHN Commercial 0.17 5500.00 0.17 31629.15 0.17 Case Rate 49320 Priced Laparoscopy biopsy 559001 49321 CPT Outpatient 41892.90 7191.61 CHN CHN Commercial 0.13 5500.00 0.13 41892.90 0.13 Case Rate 49321 Priced Laparoscopy aspiration 559001 49322 CPT Outpatient 34392.75 5904.09 CHN CHN Commercial 0.16 5500.00 0.16 34392.75 0.16 Case Rate 49322 Priced Lap insert tunnel ip cath 559001 49324 CPT Outpatient 39264.75 6740.45 CHN CHN Commercial 0.14 5500.00 0.14 39264.75 0.14 Case Rate 49324 Priced Laparo proc abdm/per/oment 559001 49329 CPT Outpatient 58696.05 10076.16 CHN CHN Commercial 0.09 5500.00 0.09 58696.05 0.09 Case Rate 49329 Priced Ins tun ip cath for dial opn 559001 49421 CPT Outpatient 25460.40 3319.30 CHN CHN Commercial 0.22 5500.00 0.22 25460.40 0.22 Case Rate 49421 Priced Remove tunneled ip cath 559001 49422 CPT Outpatient 25515.00 4380.08 CHN CHN Commercial 0.22 5500.00 0.22 25515.00 0.22 Case Rate 49422 Priced Rpr ing hernia init reduce 559001 49500 CPT Outpatient 19594.05 3363.65 CHN CHN Commercial 0.28 5500.00 0.28 19594.05 0.28 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 559001 49505 CPT Outpatient 34915.65 5993.85 CHN CHN Commercial 0.16 5500.00 0.16 34915.65 0.16 Case Rate 49505 Priced Prp i/hern init block >5 yr 559001 49507 CPT Outpatient 29794.80 5114.77 CHN CHN Commercial 0.18 5500.00 0.18 29794.80 0.18 Case Rate 49507 Priced Rerepair ing hernia reduce 559001 49520 CPT Outpatient 36940.05 6341.38 CHN CHN Commercial 0.15 5500.00 0.15 36940.05 0.15 Case Rate 49520 Priced Rpr ventral hern init reduc 559001 49560 CPT Outpatient 53177.25 9128.76 CHN CHN Commercial 0.10 5500.00 0.10 53177.25 0.10 Case Rate 49560 Priced Rpr ventral hern init block 559001 49561 CPT Outpatient 30755.55 5279.70 CHN CHN Commercial 0.18 5500.00 0.18 30755.55 0.18 Case Rate 49561 Priced Rerepair ventrl hern reduce 559001 49565 CPT Outpatient 69917.40 12002.49 CHN CHN Commercial 0.08 5500.00 0.08 69917.40 0.08 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 559001 49585 CPT Outpatient 41806.80 7176.83 CHN CHN Commercial 0.13 5500.00 0.13 41806.80 0.13 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 559001 49587 CPT Outpatient 37320.15 6406.63 CHN CHN Commercial 0.15 5500.00 0.15 37320.15 0.15 Case Rate 49587 Priced Lap ing hernia repair init 559001 49650 CPT Outpatient 41932.80 7198.46 CHN CHN Commercial 0.13 5500.00 0.13 41932.80 0.13 Case Rate 49650 Priced Lap ing hernia repair recur 559001 49651 CPT Outpatient 46915.05 8053.75 CHN CHN Commercial 0.12 5500.00 0.12 46915.05 0.12 Case Rate 49651 Priced Lap vent/abd hernia repair 559001 49652 CPT Outpatient 51294.60 8805.57 CHN CHN Commercial 0.11 5500.00 0.11 51294.60 0.11 Case Rate 49652 Priced Lap vent/abd hern proc comp 559001 49653 CPT Outpatient 46102.35 7914.24 CHN CHN Commercial 0.12 5500.00 0.12 46102.35 0.12 Case Rate 49653 Priced Lap inc hernia repair 559001 49654 CPT Outpatient 47221.65 8106.38 CHN CHN Commercial 0.12 5500.00 0.12 47221.65 0.12 Case Rate 49654 Priced Lap inc hern repair comp 559001 49655 CPT Outpatient 54590.55 9371.38 CHN CHN Commercial 0.10 5500.00 0.10 54590.55 0.10 Case Rate 49655 Priced Lap inc hernia repair recur 559001 49656 CPT Outpatient 55443.15 9517.74 CHN CHN Commercial 0.10 5500.00 0.10 55443.15 0.10 Case Rate 49656 Priced Removal of kidney stone 559001 50080 CPT Outpatient 53165.70 9126.78 CHN CHN Commercial 0.10 5500.00 0.10 53165.70 0.10 Case Rate 50080 Priced Removal of kidney stone 559001 50081 CPT Outpatient 66931.20 11489.86 CHN CHN Commercial 0.08 5500.00 0.08 66931.20 0.08 Case Rate 50081 Priced Renal biopsy perq 559001 50200 CPT Outpatient 43096.20 1225.34 CHN CHN Commercial 0.13 5500.00 0.13 43096.20 0.13 Case Rate 50200 Priced Plmt nephroureteral catheter 559001 50433 CPT Outpatient 64566.60 1424.48 CHN CHN Commercial 0.09 5500.00 0.09 64566.60 0.09 Case Rate 50433 Priced Laparo radical nephrectomy 559001 50545 CPT Outpatient 43449.00 7458.75 CHN CHN Commercial 0.13 5500.00 0.13 43449.00 0.13 Case Rate 50545 Priced Laparoscope proc ureter 559001 50949 CPT Outpatient 49986.30 8580.98 CHN CHN Commercial 0.11 5500.00 0.11 49986.30 0.11 Case Rate 50949 Priced Injection for bladder x-ray 559001 51600 CPT Outpatient 3285.45 89.22 CHN CHN Commercial 0.91 2980.00 0.91 3285.45 0.91 Case Rate 51600 Priced Cystoscopy 559001 52000 CPT Outpatient 22149.75 3802.37 CHN CHN Commercial 0.25 5500.00 0.25 22149.75 0.25 Case Rate 52000 Priced Cystoscopy & ureter catheter 559001 52005 CPT Outpatient 42529.20 2095.77 CHN CHN Commercial 0.13 5500.00 0.13 42529.20 0.13 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 559001 52204 CPT Outpatient 31274.25 5368.75 CHN CHN Commercial 0.18 5500.00 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 559001 52224 CPT Outpatient 13445.25 2308.10 CHN CHN Commercial 0.41 5500.00 0.41 13445.25 0.41 Case Rate 52224 Priced Cystoscopy and treatment 559001 52234 CPT Outpatient 28510.65 4894.33 CHN CHN Commercial 0.19 5500.00 0.19 28510.65 0.19 Case Rate 52234 Priced Cystoscopy and treatment 559001 52235 CPT Outpatient 29417.85 5050.06 CHN CHN Commercial 0.19 5500.00 0.19 29417.85 0.19 Case Rate 52235 Priced Cystoscopy and treatment 559001 52240 CPT Outpatient 33933.90 5825.32 CHN CHN Commercial 0.16 5500.00 0.16 33933.90 0.16 Case Rate 52240 Priced Cystoscopy and treatment 559001 52281 CPT Outpatient 22159.20 3804.00 CHN CHN Commercial 0.25 5500.00 0.25 22159.20 0.25 Case Rate 52281 Priced Remove bladder stone 559001 52317 CPT Outpatient 27085.80 4649.73 CHN CHN Commercial 0.20 5500.00 0.20 27085.80 0.20 Case Rate 52317 Priced Remove bladder stone 559001 52318 CPT Outpatient 26685.75 4581.05 CHN CHN Commercial 0.21 5500.00 0.21 26685.75 0.21 Case Rate 52318 Priced Cystoscopy and treatment 559001 52332 CPT Outpatient 115306.80 19794.33 CHN CHN Commercial 0.05 5500.00 0.05 115306.80 0.05 Case Rate 52332 Priced Cystouretero w/stone remove 559001 52352 CPT Outpatient 42420.00 7282.10 CHN CHN Commercial 0.13 5500.00 0.13 42420.00 0.13 Case Rate 52352 Priced Cystouretero w/lithotripsy 559001 52353 CPT Outpatient 38608.50 6627.79 CHN CHN Commercial 0.14 5500.00 0.14 38608.50 0.14 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 559001 52356 CPT Outpatient 36255.45 6223.85 CHN CHN Commercial 0.15 5500.00 0.15 36255.45 0.15 Case Rate 52356 Priced Prostatectomy (turp) 559001 52601 CPT Outpatient 35371.35 6072.08 CHN CHN Commercial 0.16 5500.00 0.16 35371.35 0.16 Case Rate 52601 Priced Laser surgery of prostate 559001 52648 CPT Outpatient 24264.45 4165.40 CHN CHN Commercial 0.23 5500.00 0.23 24264.45 0.23 Case Rate 52648 Priced Revision of urethra 559001 53450 CPT Outpatient 16209.90 2782.70 CHN CHN Commercial 0.34 5500.00 0.34 16209.90 0.34 Case Rate 53450 Priced Urology surgery procedure 559001 53899 CPT Outpatient 25368.00 134.83 CHN CHN Commercial 0.22 5500.00 0.22 25368.00 0.22 Case Rate 53899 Priced Circumcision w/regionl block 559001 54150 CPT Outpatient 14700.00 2523.50 CHN CHN Commercial 0.37 5500.00 0.37 14700.00 0.37 Case Rate 54150 Priced Circum 28 days or older 559001 54161 CPT Outpatient 19186.65 3293.71 CHN CHN Commercial 0.29 5500.00 0.29 19186.65 0.29 Case Rate 54161 Priced Lysis penil circumic lesion 559001 54162 CPT Outpatient 19795.65 3398.25 CHN CHN Commercial 0.28 5500.00 0.28 19795.65 0.28 Case Rate 54162 Priced Repair of circumcision 559001 54163 CPT Outpatient 16391.55 2813.88 CHN CHN Commercial 0.34 5500.00 0.34 16391.55 0.34 Case Rate 54163 Priced Reconstruction of urethra 559001 54324 CPT Outpatient 32880.75 5644.53 CHN CHN Commercial 0.17 5500.00 0.17 32880.75 0.17 Case Rate 54324 Priced Revise penis/urethra 559001 54332 CPT Outpatient 19968.90 3427.99 CHN CHN Commercial 0.28 5500.00 0.28 19968.90 0.28 Case Rate 54332 Priced Insert self-contd prosthesis 559001 54401 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 559001 54520 CPT Outpatient 35442.75 6084.34 CHN CHN Commercial 0.16 5500.00 0.16 35442.75 0.16 Case Rate 54520 Priced Reduce testis torsion 559001 54600 CPT Outpatient 55049.40 9450.15 CHN CHN Commercial 0.10 5500.00 0.10 55049.40 0.10 Case Rate 54600 Priced Suspension of testis 559001 54640 CPT Outpatient 26860.05 4610.98 CHN CHN Commercial 0.20 5500.00 0.20 26860.05 0.20 Case Rate 54640 Priced Removal of hydrocele 559001 55040 CPT Outpatient 27277.95 4682.71 CHN CHN Commercial 0.20 5500.00 0.20 27277.95 0.20 Case Rate 55040 Priced Biopsy of prostate gland 559001 55700 CPT Outpatient 28699.65 4926.77 CHN CHN Commercial 0.19 5500.00 0.19 28699.65 0.19 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 559001 55866 CPT Outpatient 93088.80 15980.24 CHN CHN Commercial 0.06 5500.00 0.06 93088.80 0.06 Case Rate 55866 Priced Closure of vagina 559001 57120 CPT Outpatient 34369.65 5900.12 CHN CHN Commercial 0.16 5500.00 0.16 34369.65 0.16 Case Rate 57120 Priced Repair of vagina 559001 57200 CPT Outpatient 25247.25 4334.11 CHN CHN Commercial 0.22 5500.00 0.22 25247.25 0.22 Case Rate 57200 Priced Anterior colporrhaphy 559001 57240 CPT Outpatient 36210.30 6216.10 CHN CHN Commercial 0.15 5500.00 0.15 36210.30 0.15 Case Rate 57240 Priced Repair rectum & vagina 559001 57250 CPT Outpatient 40441.80 6942.51 CHN CHN Commercial 0.14 5500.00 0.14 40441.80 0.14 Case Rate 57250 Priced Cmbn ant pst colprhy 559001 57260 CPT Outpatient 46323.90 7952.27 CHN CHN Commercial 0.12 5500.00 0.12 46323.90 0.12 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 559001 57265 CPT Outpatient 42586.95 7310.76 CHN CHN Commercial 0.13 5500.00 0.13 42586.95 0.13 Case Rate 57265 Priced Repair of bowel bulge 559001 57268 CPT Outpatient 36865.50 6328.58 CHN CHN Commercial 0.15 5500.00 0.15 36865.50 0.15 Case Rate 57268 Priced Colpopexy extraperitoneal 559001 57282 CPT Outpatient 45629.85 7833.12 CHN CHN Commercial 0.12 5500.00 0.12 45629.85 0.12 Case Rate 57282 Priced Repair bladder defect 559001 57288 CPT Outpatient 43069.95 7393.67 CHN CHN Commercial 0.13 5500.00 0.13 43069.95 0.13 Case Rate 57288 Priced Bx/curett of cervix w/scope 559001 57454 CPT Outpatient 2888.55 442.93 CHN CHN Commercial 0.91 2620.00 0.91 2888.55 0.91 Case Rate 57454 Priced Conization of cervix 559001 57520 CPT Outpatient 26728.80 4588.44 CHN CHN Commercial 0.21 5500.00 0.21 26728.80 0.21 Case Rate 57520 Priced Conization of cervix 559001 57522 CPT Outpatient 22737.75 3903.31 CHN CHN Commercial 0.24 5500.00 0.24 22737.75 0.24 Case Rate 57522 Priced Biopsy of uterus lining 559001 58100 CPT Outpatient 2371.95 194.80 CHN CHN Commercial 0.91 2151.00 0.91 2371.95 0.91 Case Rate 58100 Priced Catheter for hysterography 559001 58340 CPT Outpatient 6322.05 131.04 CHN CHN Commercial 0.51 3234.00 0.51 6322.05 0.51 Case Rate 58340 Priced Reopen fallopian tube 559001 58350 CPT Outpatient 46507.65 7983.81 CHN CHN Commercial 0.12 5500.00 0.12 46507.65 0.12 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 559001 58542 CPT Outpatient 64194.90 11020.12 CHN CHN Commercial 0.09 5500.00 0.09 64194.90 0.09 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 559001 58544 CPT Outpatient 51020.55 8758.53 CHN CHN Commercial 0.11 5500.00 0.11 51020.55 0.11 Case Rate 58544 Priced Laparoscopic myomectomy 559001 58545 CPT Outpatient 56946.75 9775.86 CHN CHN Commercial 0.10 5500.00 0.10 56946.75 0.10 Case Rate 58545 Priced Laparo-vag hyst incl t/o 559001 58552 CPT Outpatient 57228.15 9824.17 CHN CHN Commercial 0.10 5500.00 0.10 57228.15 0.10 Case Rate 58552 Priced Hysteroscopy biopsy 559001 58558 CPT Outpatient 28581.00 2077.02 CHN CHN Commercial 0.19 5500.00 0.19 28581.00 0.19 Case Rate 58558 Priced Hysteroscopy remove myoma 559001 58561 CPT Outpatient 35222.25 6046.49 CHN CHN Commercial 0.16 5500.00 0.16 35222.25 0.16 Case Rate 58561 Priced Hysteroscopy ablation 559001 58563 CPT Outpatient 38399.55 6591.92 CHN CHN Commercial 0.14 5500.00 0.14 38399.55 0.14 Case Rate 58563 Priced Tlh uterus 250 g or less 559001 58570 CPT Outpatient 43316.70 7436.03 CHN CHN Commercial 0.13 5500.00 0.13 43316.70 0.13 Case Rate 58570 Priced Tlh w/t/o 250 g or less 559001 58571 CPT Outpatient 48603.45 8343.59 CHN CHN Commercial 0.11 5500.00 0.11 48603.45 0.11 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 559001 58573 CPT Outpatient 52905.30 9082.08 CHN CHN Commercial 0.10 5500.00 0.10 52905.30 0.10 Case Rate 58573 Priced Laparoscopy remove adnexa 559001 58661 CPT Outpatient 47008.50 8069.79 CHN CHN Commercial 0.12 5500.00 0.12 47008.50 0.12 Case Rate 58661 Priced Laparoscopy excise lesions 559001 58662 CPT Outpatient 45053.40 7734.17 CHN CHN Commercial 0.12 5500.00 0.12 45053.40 0.12 Case Rate 58662 Priced Treat ectopic pregnancy 559001 59151 CPT Outpatient 74690.70 12821.90 CHN CHN Commercial 0.07 5500.00 0.07 74690.70 0.07 Case Rate 59151 Priced Treatment of miscarriage 559001 59812 CPT Outpatient 56109.90 9632.20 CHN CHN Commercial 0.10 5500.00 0.10 56109.90 0.10 Case Rate 59812 Priced Partial removal of thyroid 559001 60220 CPT Outpatient 53639.25 9208.07 CHN CHN Commercial 0.10 5500.00 0.10 53639.25 0.10 Case Rate 60220 Priced Removal of thyroid 559001 60240 CPT Outpatient 98252.70 16866.71 CHN CHN Commercial 0.06 5500.00 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 559001 60500 CPT Outpatient 150495.45 25835.05 CHN CHN Commercial 0.04 5500.00 0.04 150495.45 0.04 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 559001 62322 CPT Outpatient 43709.40 514.24 CHN CHN Commercial 0.13 5500.00 0.13 43709.40 0.13 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 559001 62323 CPT Outpatient 8304.45 467.31 CHN CHN Commercial 0.66 5500.00 0.66 8304.45 0.66 Case Rate 62323 Priced Low back disk surgery 559001 63030 CPT Outpatient 50287.65 8632.71 CHN CHN Commercial 0.11 5500.00 0.11 50287.65 0.11 Case Rate 63030 Priced Inc for vagus n elect impl 559001 64568 CPT Outpatient 124562.55 21383.24 CHN CHN Commercial 0.04 5500.00 0.04 124562.55 0.04 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 559001 66821 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 559001 66984 CPT Outpatient 0.01 0.01 CHN CHN Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 740063 216 DRG Inpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 740063 460 DRG Inpatient 416122.79 53834.63 Cigna Cigna Commercial 0.14 59516.11 0.14 416122.79 0.14 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 740063 470 DRG Inpatient 167912.19 21723.13 Cigna Cigna Commercial 0.18 30214.77 0.18 167912.19 0.18 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 740063 473 DRG Inpatient 100687.91 13026.19 Cigna Cigna Commercial 0.40 40063.54 0.40 100687.91 0.40 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 740063 743 DRG Inpatient 102691.67 13285.42 Cigna Cigna Commercial 0.18 18499.61 0.18 102691.67 0.18 Case Rate 743 Priced NORMAL NEWBORN 740063 795 DRG Inpatient 6266.93 2335.00 Cigna Cigna Commercial 0.40 2514.27 0.40 6266.93 0.40 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 740063 807 DRG Inpatient 116469.59 4193.00 Cigna Cigna Commercial 0.08 9392.46 0.08 116469.59 0.08 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 740063 788 DRG Inpatient 76050.77 4538.00 Cigna Cigna Commercial 0.17 12909.93 0.17 76050.77 0.17 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 740063 59400 CPT Inpatient 116469.59 4193.00 Cigna Cigna Commercial 0.08 9392.46 0.08 116469.59 0.08 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 740063 59510 CPT Inpatient 76050.77 4538.00 Cigna Cigna Commercial 0.17 12909.93 0.17 76050.77 0.17 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 740063 59610 CPT Inpatient 116469.59 4193.00 Cigna Cigna Commercial 0.08 9392.46 0.08 116469.59 0.08 Case Rate 59610 Priced "Psychotherapy, 30 min" 740063 90832 CPT Outpatient 577.50 91.21 Cigna Cigna Commercial 0.46 263.24 0.46 577.50 0.46 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 740063 90834 CPT Outpatient 44134.65 271.96 Cigna Cigna Commercial 0.43 19159.24 0.43 44134.65 0.43 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 740063 90837 CPT Outpatient 2240.70 442.93 Cigna Cigna Commercial 0.01 0.01 0.01 2240.70 0.01 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 740063 90846 CPT Outpatient 0.01 131.50 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 740063 90847 CPT Outpatient 44134.65 369.97 Cigna Cigna Commercial 0.43 19159.24 0.43 44134.65 0.43 Fee Schedule 90847 Priced Group psychotherapy 740063 90853 CPT Outpatient 44134.65 101.99 Cigna Cigna Commercial 0.43 19159.24 0.43 44134.65 0.43 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 740063 99203 CPT Outpatient 3480.75 176.07 Cigna Cigna Commercial 0.33 1158.25 0.33 3480.75 0.33 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 740063 99204 CPT Outpatient 2103.15 233.39 Cigna Cigna Commercial 0.21 448.47 0.21 2103.15 0.21 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 740063 99205 CPT Outpatient 4970.70 314.28 Cigna Cigna Commercial 0.09 448.47 0.09 4970.70 0.09 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 740063 99243 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 740063 99244 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 740063 99385 CPT Outpatient 1114.05 185.90 Cigna Cigna Commercial 0.43 483.40 0.43 1114.05 0.43 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 740063 99386 CPT Outpatient 4877.25 185.90 Cigna Cigna Commercial 0.24 1182.91 0.24 4877.25 0.24 Fee Schedule 99386 Priced Routine venipuncture 740063 36415 CPT Outpatient 127.05 19.57 Cigna Cigna Commercial 0.05 5.79 0.05 127.05 0.05 Fee Schedule 36415 Priced Basic Metabolic Panel 740063 80048 CPT Outpatient 576.45 88.78 Cigna Cigna Commercial 0.07 40.18 0.07 576.45 0.07 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 740063 80053 CPT Outpatient 763.35 117.56 Cigna Cigna Commercial 0.07 50.23 0.07 763.35 0.07 Fee Schedule 80053 Priced Obstetric blood test panel 740063 80055 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 740063 80061 CPT Outpatient 1349.25 197.77 Cigna Cigna Commercial 0.07 95.42 0.07 1349.25 0.07 Fee Schedule 80061 Priced Kidney function panel test 740063 80069 CPT Outpatient 716.10 104.95 Cigna Cigna Commercial 0.06 41.43 0.06 716.10 0.06 Fee Schedule 80069 Priced Liver function panel test 740063 80076 CPT Outpatient 716.10 104.95 Cigna Cigna Commercial 0.05 38.93 0.05 716.10 0.05 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 740063 81000 CPT Outpatient 144.90 21.18 Cigna Cigna Commercial 0.10 15.08 0.10 144.90 0.10 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 740063 81001 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 740063 81002 CPT Outpatient 57.75 8.89 Cigna Cigna Commercial 0.22 12.56 0.22 57.75 0.22 Fee Schedule 81002 Priced Automated urinalysis test 740063 81003 CPT Outpatient 219.45 33.80 Cigna Cigna Commercial 0.05 11.31 0.05 219.45 0.05 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 740063 82306 CPT Outpatient 1880.55 289.62 Cigna Cigna Commercial 0.08 141.88 0.08 1880.55 0.08 Fee Schedule 82306 Priced Glycosylated hemoglobin test 740063 83036 CPT Outpatient 494.55 76.17 Cigna Cigna Commercial 0.09 46.46 0.09 494.55 0.09 Fee Schedule 83036 Priced PSA (prostate specific antigen) 740063 84153 CPT Outpatient 1177.05 181.28 Cigna Cigna Commercial 0.07 87.89 0.07 1177.05 0.07 Fee Schedule 84153 Priced PSA (prostate specific antigen) 740063 84154 CPT Outpatient 598.50 92.17 Cigna Cigna Commercial 0.15 87.89 0.15 598.50 0.15 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 740063 84443 CPT Outpatient 519.75 80.05 Cigna Cigna Commercial 0.15 80.36 0.15 519.75 0.15 Fee Schedule 84443 Priced Chorionic gonadotropin assay 740063 84703 CPT Outpatient 785.40 120.96 Cigna Cigna Commercial 0.05 36.42 0.05 785.40 0.05 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 740063 85025 CPT Outpatient 635.25 97.83 Cigna Cigna Commercial 0.06 37.67 0.06 635.25 0.06 Fee Schedule 85025 Priced "Complete blood count, automated" 740063 85027 CPT Outpatient 576.45 88.78 Cigna Cigna Commercial 0.05 31.39 0.05 576.45 0.05 Fee Schedule 85027 Priced "Blood test, clotting time" 740063 85610 CPT Outpatient 404.25 62.26 Cigna Cigna Commercial 0.05 18.83 0.05 404.25 0.05 Fee Schedule 85610 Priced Coagulation assessment blood test 740063 85730 CPT Outpatient 17.22 2.65 Cigna Cigna Commercial 1.00 17.14 1.00 17.22 1.00 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 740063 86003 CPT Outpatient 32.55 5.01 Cigna Cigna Commercial 0.77 25.10 0.77 32.55 0.77 Fee Schedule 86003 Priced Tb test cell immun measure 740063 86480 CPT Outpatient 530.25 81.66 Cigna Cigna Commercial 0.56 297.57 0.56 530.25 0.56 Fee Schedule 86480 Priced Urine culture/colony count 740063 87086 CPT Outpatient 763.35 117.56 Cigna Cigna Commercial 0.05 38.93 0.05 763.35 0.05 Fee Schedule 87086 Priced Hpylori stool ia 740063 87338 CPT Outpatient 785.40 120.96 Cigna Cigna Commercial 0.09 69.05 0.09 785.40 0.09 Fee Schedule 87338 Priced Cytopath eval fna report 740063 88173 CPT Outpatient 750.75 115.62 Cigna Cigna Commercial 0.38 284.66 0.38 750.75 0.38 Fee Schedule 88173 Priced Tissue exam by pathologist 740063 88302 CPT Outpatient 635.25 97.83 Cigna Cigna Commercial 0.13 82.70 0.13 635.25 0.13 Fee Schedule 88302 Priced Tissue exam by pathologist 740063 88305 CPT Outpatient 323.40 49.81 Cigna Cigna Commercial 0.32 104.04 0.32 323.40 0.32 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 740063 11042 CPT Outpatient 2668.05 481.45 Cigna Cigna Commercial 0.43 1158.24 0.43 2668.05 0.43 Case Rate 11042 Priced Deb subq tissue add-on 740063 11045 CPT Outpatient 4652.55 330.00 Cigna Cigna Commercial 0.43 2019.73 0.43 4652.55 0.43 Case Rate 11045 Priced Dx bronchoscope/lavage 740063 31624 CPT Outpatient 41223.00 7602.31 Cigna Cigna Commercial 0.08 3258.31 0.08 41223.00 0.08 Case Rate 31624 Priced Bronchoscopy/lung bx each 740063 31628 CPT Outpatient 49048.65 9045.51 Cigna Cigna Commercial 0.07 3258.31 0.07 49048.65 0.07 Case Rate 31628 Priced Blood transfusion service 740063 36430 CPT Outpatient 9166.50 574.93 Cigna Cigna Commercial 0.39 3584.57 0.39 9166.50 0.39 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 740063 43235 CPT Outpatient 8856.75 1633.35 Cigna Cigna Commercial 0.36 3193.14 0.36 8856.75 0.36 Case Rate 43235 Priced Endoscopic us exam esoph 740063 43237 CPT Outpatient 23867.55 4401.63 Cigna Cigna Commercial 0.14 3258.31 0.14 23867.55 0.14 Case Rate 43237 Priced Egd us fine needle bx/aspir 740063 43238 CPT Outpatient 30690.45 5659.90 Cigna Cigna Commercial 0.11 3258.31 0.11 30690.45 0.11 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 740063 43239 CPT Outpatient 40191.90 7412.15 Cigna Cigna Commercial 0.08 3258.31 0.08 40191.90 0.08 Case Rate 43239 Priced Ercp remove duct calculi 740063 43264 CPT Outpatient 34335.00 6332.03 Cigna Cigna Commercial 0.09 3258.31 0.09 34335.00 0.09 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 740063 45378 CPT Outpatient 13991.25 889.35 Cigna Cigna Commercial 0.23 3258.31 0.23 13991.25 0.23 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 740063 45380 CPT Outpatient 22215.90 4097.04 Cigna Cigna Commercial 0.15 3258.31 0.15 22215.90 0.15 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 740063 45385 CPT Outpatient 119569.80 22050.95 Cigna Cigna Commercial 0.03 3193.14 0.03 119569.80 0.03 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 740063 45391 CPT Outpatient 24923.85 4596.43 Cigna Cigna Commercial 0.13 3258.31 0.13 24923.85 0.13 Case Rate 45391 Priced Fragmenting of kidney stone 740063 50590 CPT Outpatient 40930.05 7548.28 Cigna Cigna Commercial 0.12 5069.30 0.12 40930.05 0.12 Case Rate 50590 Priced Fetal non-stress test 740063 59025 CPT Outpatient 3153.15 477.76 Cigna Cigna Commercial 0.95 2988.70 0.95 3153.15 0.95 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 740063 64483 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 740063 92567 CPT Outpatient 2224.95 98.50 Cigna Cigna Commercial 0.43 965.83 0.43 2224.95 0.43 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 740063 93000 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 740063 93017 CPT Outpatient 3076.50 532.96 Cigna Cigna Commercial 0.43 1335.32 0.43 3076.50 0.43 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 740063 93452 CPT Outpatient 55621.65 8611.87 Cigna Cigna Commercial 0.17 9405.00 0.17 55621.65 0.17 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 740063 95810 CPT Outpatient 20341.65 3373.48 Cigna Cigna Commercial 0.19 3929.19 0.19 20341.65 0.19 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 740063 95811 CPT Outpatient 22491.00 3731.18 Cigna Cigna Commercial 0.17 3765.48 0.17 22491.00 0.17 Case Rate 95811 Priced Eeg 41-60 minutes 740063 95812 CPT Outpatient 5578.65 925.83 Cigna Cigna Commercial 0.59 3274.33 0.59 5578.65 0.59 Case Rate 95812 Priced Genetic counseling 30 min 740063 96040 CPT Outpatient 0.01 102.81 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 740063 96413 CPT Outpatient 4856.25 472.45 Cigna Cigna Commercial 0.34 1643.56 0.34 4856.25 0.34 Case Rate 96413 Priced Ultrasound therapy 740063 97035 CPT Outpatient 2111.55 134.99 Cigna Cigna Commercial 0.13 268.57 0.13 2111.55 0.13 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 740063 97110 CPT Outpatient 6494.25 92.86 Cigna Cigna Commercial 0.21 1342.83 0.21 6494.25 0.21 Case Rate 97110 Priced Gait training therapy 740063 97116 CPT Outpatient 4723.95 110.61 Cigna Cigna Commercial 0.11 537.13 0.11 4723.95 0.11 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 740063 70450 CPT Outpatient 8566.95 835.61 Cigna Cigna Commercial 0.15 1311.48 0.15 8566.95 0.15 Case Rate 70450 Priced Mri brain stem w/o dye 740063 70551 CPT Outpatient 7861.35 1361.31 Cigna Cigna Commercial 0.07 553.54 0.07 7861.35 0.07 Case Rate 70551 Priced MRI scan of brain before and after contrast 740063 70553 CPT Outpatient 10882.20 1625.88 Cigna Cigna Commercial 0.14 1573.64 0.14 10882.20 0.14 Case Rate 70553 Priced X-ray exam chest 2 views 740063 71046 CPT Outpatient 859.95 150.37 Cigna Cigna Commercial 0.43 373.32 0.43 859.95 0.43 Case Rate 71046 Priced Ct thorax w/o dye 740063 71250 CPT Outpatient 7288.05 1261.63 Cigna Cigna Commercial 0.06 456.85 0.06 7288.05 0.06 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 740063 72082 CPT Outpatient 2022.30 253.33 Cigna Cigna Commercial 0.10 210.59 0.10 2022.30 0.10 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 740063 72100 CPT Outpatient 1599.15 277.38 Cigna Cigna Commercial 0.05 83.96 0.05 1599.15 0.05 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 740063 72110 CPT Outpatient 1389.15 241.04 Cigna Cigna Commercial 0.08 116.59 0.08 1389.15 0.08 Case Rate 72110 Priced MRI scan of lower spinal canal 740063 72148 CPT Outpatient 7861.35 1361.31 Cigna Cigna Commercial 0.07 525.92 0.07 7861.35 0.07 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 740063 72193 CPT Outpatient 13671.00 1412.01 Cigna Cigna Commercial 0.04 592.46 0.04 13671.00 0.04 Case Rate 72193 Priced X-ray exam of shoulder 740063 73030 CPT Outpatient 1452.15 251.43 Cigna Cigna Commercial 0.05 68.88 0.05 1452.15 0.05 Case Rate 73030 Priced X-ray exam of elbow 740063 73080 CPT Outpatient 1356.60 235.68 Cigna Cigna Commercial 0.06 78.92 0.06 1356.60 0.06 Case Rate 73080 Priced X-ray exam of forearm 740063 73090 CPT Outpatient 1243.20 215.26 Cigna Cigna Commercial 0.05 61.35 0.05 1243.20 0.05 Case Rate 73090 Priced X-ray exam of wrist 740063 73110 CPT Outpatient 1243.20 215.26 Cigna Cigna Commercial 0.08 93.99 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 740063 73130 CPT Outpatient 1243.20 215.26 Cigna Cigna Commercial 0.06 77.66 0.06 1243.20 0.06 Case Rate 73130 Priced X-ray exam hips bi 2 views 740063 73521 CPT Outpatient 970.20 228.41 Cigna Cigna Commercial 0.10 99.00 0.10 970.20 0.10 Case Rate 73521 Priced X-ray exam of knee 3 740063 73562 CPT Outpatient 802.20 139.12 Cigna Cigna Commercial 0.12 92.73 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 740063 73590 CPT Outpatient 1243.20 215.26 Cigna Cigna Commercial 0.06 71.39 0.06 1243.20 0.06 Case Rate 73590 Priced X-ray exam of ankle 740063 73610 CPT Outpatient 1378.65 239.31 Cigna Cigna Commercial 0.06 80.18 0.06 1378.65 0.06 Case Rate 73610 Priced X-ray exam of foot 740063 73630 CPT Outpatient 975.45 169.41 Cigna Cigna Commercial 0.07 72.65 0.07 975.45 0.07 Case Rate 73630 Priced MRI scan of leg joint 740063 73721 CPT Outpatient 7861.35 1361.31 Cigna Cigna Commercial 0.08 596.06 0.08 7861.35 0.08 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 740063 74177 CPT Outpatient 14222.25 1412.01 Cigna Cigna Commercial 0.05 777.02 0.05 14222.25 0.05 Case Rate 74177 Priced Contrst x-ray exam of throat 740063 74210 CPT Outpatient 0.01 440.39 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 740063 76098 CPT Outpatient 6141.45 407.86 Cigna Cigna Commercial 0.27 1676.38 0.27 6141.45 0.27 Case Rate 76098 Priced Us exam of head and neck 740063 76536 CPT Outpatient 5512.50 955.18 Cigna Cigna Commercial 0.06 314.97 0.06 5512.50 0.06 Case Rate 76536 Priced Ultrasound breast limited 740063 76642 CPT Outpatient 5777.10 127.70 Cigna Cigna Commercial 0.12 707.82 0.12 5777.10 0.12 Case Rate 76642 Priced Ultrasound of abdomen 740063 76700 CPT Outpatient 4917.15 851.88 Cigna Cigna Commercial 0.06 292.37 0.06 4917.15 0.06 Case Rate 76700 Priced Echo exam of abdomen 740063 76705 CPT Outpatient 3836.70 665.17 Cigna Cigna Commercial 0.06 220.81 0.06 3836.70 0.06 Case Rate 76705 Priced Us exam abdo back wall comp 740063 76770 CPT Outpatient 5171.25 895.48 Cigna Cigna Commercial 0.05 272.27 0.05 5171.25 0.05 Case Rate 76770 Priced Us exam abdo back wall lim 740063 76775 CPT Outpatient 3969.00 686.97 Cigna Cigna Commercial 0.03 105.29 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 740063 76801 CPT Outpatient 2006.55 347.98 Cigna Cigna Commercial 0.13 262.25 0.13 2006.55 0.13 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 740063 76805 CPT Outpatient 3969.00 686.97 Cigna Cigna Commercial 0.08 328.79 0.08 3969.00 0.08 Case Rate 76805 Priced Ob us detailed sngl fetus 740063 76811 CPT Outpatient 2844.45 492.99 Cigna Cigna Commercial 0.11 304.75 0.11 2844.45 0.11 Case Rate 76811 Priced Ob us nuchal meas 1 gest 740063 76813 CPT Outpatient 1044.75 180.83 Cigna Cigna Commercial 0.21 218.29 0.21 1044.75 0.21 Case Rate 76813 Priced Ob us limited fetus(s) 740063 76815 CPT Outpatient 6428.10 639.90 Cigna Cigna Commercial 0.06 397.67 0.06 6428.10 0.06 Case Rate 76815 Priced Ob us follow-up per fetus 740063 76816 CPT Outpatient 4818.45 833.88 Cigna Cigna Commercial 0.05 257.22 0.05 4818.45 0.05 Case Rate 76816 Priced Transvaginal us obstetric 740063 76817 CPT Outpatient 6428.10 476.73 Cigna Cigna Commercial 0.06 397.67 0.06 6428.10 0.06 Case Rate 76817 Priced Fetal biophys profil w/o nst 740063 76819 CPT Outpatient 1741.95 302.65 Cigna Cigna Commercial 0.10 181.89 0.10 1741.95 0.10 Case Rate 76819 Priced Ultrasound pelvis through vagina 740063 76830 CPT Outpatient 9305.10 806.54 Cigna Cigna Commercial 0.06 582.23 0.06 9305.10 0.06 Case Rate 76830 Priced Us exam scrotum 740063 76870 CPT Outpatient 6328.35 1096.55 Cigna Cigna Commercial 0.02 127.89 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 740063 76885 CPT Outpatient 3836.70 665.17 Cigna Cigna Commercial 0.10 390.31 0.10 3836.70 0.10 Case Rate 76885 Priced Mammography of one breast 740063 77065 CPT Outpatient 3451.35 192.07 Cigna Cigna Commercial 0.18 614.90 0.18 3451.35 0.18 Case Rate 77065 Priced Mammography of both breasts 740063 77066 CPT Outpatient 5777.10 235.68 Cigna Cigna Commercial 0.12 707.82 0.12 5777.10 0.12 Case Rate 77066 Priced "Mamography, screening bilateral" 740063 77067 CPT Outpatient 1416.45 205.57 Cigna Cigna Commercial 0.31 440.54 0.31 1416.45 0.31 Case Rate 77067 Priced X-rays for bone age 740063 77072 CPT Outpatient 2022.30 163.87 Cigna Cigna Commercial 0.10 210.59 0.10 2022.30 0.10 Case Rate 77072 Priced Joint survey single view 740063 77077 CPT Outpatient 985.95 171.14 Cigna Cigna Commercial 0.07 73.90 0.07 985.95 0.07 Case Rate 77077 Priced Dxa bone density axial 740063 77080 CPT Outpatient 3257.10 319.09 Cigna Cigna Commercial 0.17 549.60 0.17 3257.10 0.17 Case Rate 77080 Priced Fna bx w/us gdn 1st les 740063 10005 CPT Outpatient 5512.50 547.24 Cigna Cigna Commercial 0.37 2028.28 0.37 5512.50 0.37 Case Rate 10005 Priced Fna bx w/us gdn ea addl 740063 10006 CPT Outpatient 10628.10 594.83 Cigna Cigna Commercial 0.37 3884.27 0.37 10628.10 0.37 Case Rate 10006 Priced Drainage of hematoma/fluid 740063 10140 CPT Outpatient 23209.20 1081.95 Cigna Cigna Commercial 0.22 5172.75 0.22 23209.20 0.22 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 740063 11042 CPT Outpatient 2668.05 481.45 Cigna Cigna Commercial 0.43 1158.24 0.43 2668.05 0.43 Case Rate 11042 Priced Deb bone 20 sq cm/< 740063 11044 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 740063 11406 CPT Outpatient 19967.85 3427.81 Cigna Cigna Commercial 0.26 5172.75 0.26 19967.85 0.26 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 740063 11424 CPT Outpatient 0.01 1004.93 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 740063 11770 CPT Outpatient 19173.00 3291.37 Cigna Cigna Commercial 0.27 5172.75 0.27 19173.00 0.27 Case Rate 11770 Priced Replace tissue expander 740063 11970 CPT Outpatient 59239.95 10169.52 Cigna Cigna Commercial 0.09 5069.30 0.09 59239.95 0.09 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 740063 14020 CPT Outpatient 32166.75 5521.96 Cigna Cigna Commercial 0.16 5069.30 0.16 32166.75 0.16 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 740063 14060 CPT Outpatient 25993.80 1374.69 Cigna Cigna Commercial 0.20 5172.75 0.20 25993.80 0.20 Case Rate 14060 Priced Wound prep trk/arm/leg 740063 15002 CPT Outpatient 41748.00 1441.73 Cigna Cigna Commercial 0.12 5172.75 0.12 41748.00 0.12 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 740063 15271 CPT Outpatient 24343.20 3769.48 Cigna Cigna Commercial 0.41 9864.15 0.41 24343.20 0.41 Case Rate 15271 Priced Acellular derm matrix implt 740063 15777 CPT Outpatient 101672.55 17453.79 Cigna Cigna Commercial 0.05 5172.75 0.05 101672.55 0.05 Case Rate 15777 Priced Exc skin abd 740063 15830 CPT Outpatient 54696.60 9389.58 Cigna Cigna Commercial 0.09 5172.75 0.09 54696.60 0.09 Case Rate 15830 Priced Dressing change not for burn 740063 15852 CPT Outpatient 0.01 290.74 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 740063 15877 CPT Outpatient 63741.30 10942.26 Cigna Cigna Commercial 0.08 5172.75 0.08 63741.30 0.08 Case Rate 15877 Priced Suction lipectomy lwr extrem 740063 15879 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 740063 19000 CPT Outpatient 10143.00 594.83 Cigna Cigna Commercial 0.35 3520.06 0.35 10143.00 0.35 Case Rate 19000 Priced Bx breast 1st lesion strtctc 740063 19081 CPT Outpatient 12341.70 1250.69 Cigna Cigna Commercial 0.36 4489.16 0.36 12341.70 0.36 Case Rate 19081 Priced Bx breast add lesion us imag 740063 19084 CPT Outpatient 29058.75 547.24 Cigna Cigna Commercial 0.32 9431.14 0.32 29058.75 0.32 Case Rate 19084 Priced Biopsy of breast open 740063 19101 CPT Outpatient 39545.10 2737.82 Cigna Cigna Commercial 0.13 5172.75 0.13 39545.10 0.13 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 740063 19120 CPT Outpatient 35761.95 2737.82 Cigna Cigna Commercial 0.14 5172.75 0.14 35761.95 0.14 Case Rate 19120 Priced Excision breast lesion 740063 19125 CPT Outpatient 33184.20 0.01 Cigna Cigna Commercial 0.16 5172.75 0.16 33184.20 0.16 Case Rate 19125 Priced Perq device breast 1st imag 740063 19281 CPT Outpatient 6141.45 598.61 Cigna Cigna Commercial 0.27 1676.38 0.27 6141.45 0.27 Case Rate 19281 Priced Perq device breast ea imag 740063 19282 CPT Outpatient 8379.00 319.04 Cigna Cigna Commercial 0.32 2647.96 0.32 8379.00 0.32 Case Rate 19282 Priced Partial mastectomy 740063 19301 CPT Outpatient 39157.65 6722.06 Cigna Cigna Commercial 0.13 5172.75 0.13 39157.65 0.13 Case Rate 19301 Priced Mast simple complete 740063 19303 CPT Outpatient 105389.55 18091.87 Cigna Cigna Commercial 0.05 5172.75 0.05 105389.55 0.05 Case Rate 19303 Priced Reduction of large breast 740063 19318 CPT Outpatient 65239.65 11199.47 Cigna Cigna Commercial 0.08 5172.75 0.08 65239.65 0.08 Case Rate 19318 Priced Immediate breast prosthesis 740063 19340 CPT Outpatient 113100.75 19415.63 Cigna Cigna Commercial 0.04 5069.30 0.04 113100.75 0.04 Case Rate 19340 Priced Delayed breast prosthesis 740063 19342 CPT Outpatient 56988.75 9783.07 Cigna Cigna Commercial 0.09 5172.75 0.09 56988.75 0.09 Case Rate 19342 Priced Breast reconstruction 740063 19357 CPT Outpatient 101672.55 17453.79 Cigna Cigna Commercial 0.05 5172.75 0.05 101672.55 0.05 Case Rate 19357 Priced Breast reconstruction 740063 19366 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 740063 19380 CPT Outpatient 61493.25 10556.34 Cigna Cigna Commercial 0.08 5172.75 0.08 61493.25 0.08 Case Rate 19380 Priced Removal of support implant 740063 20680 CPT Outpatient 42329.70 7266.60 Cigna Cigna Commercial 0.12 5172.75 0.12 42329.70 0.12 Case Rate 20680 Priced Cerv artific diskectomy 740063 22856 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 740063 24538 CPT Outpatient 51237.90 4775.24 Cigna Cigna Commercial 0.10 5172.75 0.10 51237.90 0.10 Case Rate 24538 Priced Remove wrist tendon lesion 740063 25111 CPT Outpatient 25855.20 4438.48 Cigna Cigna Commercial 0.20 5172.75 0.20 25855.20 0.20 Case Rate 25111 Priced Incise finger tendon sheath 740063 26055 CPT Outpatient 15862.35 2723.04 Cigna Cigna Commercial 0.33 5172.75 0.33 15862.35 0.33 Case Rate 26055 Priced Treat finger fracture each 740063 26727 CPT Outpatient 22779.75 2030.47 Cigna Cigna Commercial 0.23 5172.75 0.23 22779.75 0.23 Case Rate 26727 Priced Revision of knee joint 740063 27446 CPT Outpatient 67882.50 11653.16 Cigna Cigna Commercial 0.07 5069.30 0.07 67882.50 0.07 Case Rate 27446 Priced Total knee arthroplasty 740063 27447 CPT Outpatient 130698.75 22436.62 Cigna Cigna Commercial 0.04 5172.75 0.04 130698.75 0.04 Case Rate 27447 Priced Surgery to stop leg growth 740063 27485 CPT Outpatient 43310.40 7434.95 Cigna Cigna Commercial 0.12 5172.75 0.12 43310.40 0.12 Case Rate 27485 Priced Repair achilles tendon 740063 27650 CPT Outpatient 38246.25 3762.57 Cigna Cigna Commercial 0.14 5172.75 0.14 38246.25 0.14 Case Rate 27650 Priced Treatment of ankle fracture 740063 27792 CPT Outpatient 36101.10 6197.36 Cigna Cigna Commercial 0.14 5172.75 0.14 36101.10 0.14 Case Rate 27792 Priced Treatment of ankle fracture 740063 27814 CPT Outpatient 49405.65 8481.30 Cigna Cigna Commercial 0.10 5172.75 0.10 49405.65 0.10 Case Rate 27814 Priced Removal of foot lesion 740063 28080 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 740063 28285 CPT Outpatient 68603.85 11776.99 Cigna Cigna Commercial 0.08 5172.75 0.08 68603.85 0.08 Case Rate 28285 Priced Correction hallux valgus 740063 28296 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 740063 29823 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 740063 29826 CPT Outpatient 49840.35 8555.93 Cigna Cigna Commercial 0.10 5172.75 0.10 49840.35 0.10 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 740063 29881 CPT Outpatient 35556.15 6103.81 Cigna Cigna Commercial 0.15 5172.75 0.15 35556.15 0.15 Case Rate 29881 Priced Knee arthroscopy/surgery 740063 29882 CPT Outpatient 61099.50 10488.75 Cigna Cigna Commercial 0.08 5172.75 0.08 61099.50 0.08 Case Rate 29882 Priced Percut bx lung/mediastinum 740063 32405 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 740063 32555 CPT Outpatient 14597.10 687.29 Cigna Cigna Commercial 0.19 2726.76 0.19 14597.10 0.19 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 740063 32664 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 740063 35190 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 740063 36478 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 740063 36561 CPT Outpatient 53531.10 3292.99 Cigna Cigna Commercial 0.21 10995.10 0.21 53531.10 0.21 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 740063 36569 CPT Outpatient 31421.25 1299.06 Cigna Cigna Commercial 0.14 4476.89 0.14 31421.25 0.14 Case Rate 36569 Priced Removal tunneled cv cath 740063 36590 CPT Outpatient 1996.05 273.95 Cigna Cigna Commercial 0.44 870.11 0.44 1996.05 0.44 Case Rate 36590 Priced Av fuse uppr arm basilic 740063 36819 CPT Outpatient 56861.70 9761.26 Cigna Cigna Commercial 0.09 5069.30 0.09 56861.70 0.09 Case Rate 36819 Priced Av fusion direct any site 740063 36821 CPT Outpatient 42953.40 7373.67 Cigna Cigna Commercial 0.12 5172.75 0.12 42953.40 0.12 Case Rate 36821 Priced Artery-vein autograft 740063 36825 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 740063 36830 CPT Outpatient 53656.05 9210.96 Cigna Cigna Commercial 0.10 5172.75 0.10 53656.05 0.10 Case Rate 36830 Priced Av fistula revision open 740063 36832 CPT Outpatient 52492.65 9011.24 Cigna Cigna Commercial 0.10 5069.30 0.10 52492.65 0.10 Case Rate 36832 Priced Av fistula revision 740063 36833 CPT Outpatient 37098.60 6368.59 Cigna Cigna Commercial 0.14 5069.30 0.14 37098.60 0.14 Case Rate 36833 Priced Intro cath dialysis circuit 740063 36903 CPT Outpatient 77541.45 10669.90 Cigna Cigna Commercial 0.07 5172.75 0.07 77541.45 0.07 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 740063 36906 CPT Outpatient 96694.50 16175.64 Cigna Cigna Commercial 0.05 5069.30 0.05 96694.50 0.05 Case Rate 36906 Priced Fem/popl revas w/tla 740063 37224 CPT Outpatient 200076.45 5139.31 Cigna Cigna Commercial 0.05 9405.00 0.05 200076.45 0.05 Case Rate 37224 Priced Fem/popl revasc stnt & ather 740063 37227 CPT Outpatient 117170.55 18045.38 Cigna Cigna Commercial 0.08 9405.00 0.08 117170.55 0.08 Case Rate 37227 Priced Revise leg vein 740063 37700 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 740063 37722 CPT Outpatient 27815.55 4775.00 Cigna Cigna Commercial 0.19 5172.75 0.19 27815.55 0.19 Case Rate 37722 Priced Stab phleb veins xtr 10-20 740063 37765 CPT Outpatient 26561.85 4559.78 Cigna Cigna Commercial 0.19 5069.30 0.19 26561.85 0.19 Case Rate 37765 Priced Biopsy/removal lymph nodes 740063 38500 CPT Outpatient 35955.15 6172.30 Cigna Cigna Commercial 0.14 5172.75 0.14 35955.15 0.14 Case Rate 38500 Priced Biopsy/removal lymph nodes 740063 38525 CPT Outpatient 101194.80 17371.77 Cigna Cigna Commercial 0.05 5172.75 0.05 101194.80 0.05 Case Rate 38525 Priced Laparoscopy lymph node biop 740063 38570 CPT Outpatient 65631.30 11266.71 Cigna Cigna Commercial 0.08 5172.75 0.08 65631.30 0.08 Case Rate 38570 Priced Laparoscopy lymphadenectomy 740063 38571 CPT Outpatient 84031.50 14425.41 Cigna Cigna Commercial 0.06 5172.75 0.06 84031.50 0.06 Case Rate 38571 Priced Laparoscopy lymphadenectomy 740063 38572 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 740063 38792 CPT Outpatient 2868.60 432.48 Cigna Cigna Commercial 0.43 1244.87 0.43 2868.60 0.43 Case Rate 38792 Priced Excision of gum lesion 740063 41825 CPT Outpatient 11580.45 1987.98 Cigna Cigna Commercial 0.45 5172.75 0.45 11580.45 0.45 Case Rate 41825 Priced Reconstruct cleft palate 740063 42200 CPT Outpatient 36703.80 6300.82 Cigna Cigna Commercial 0.14 5172.75 0.14 36703.80 0.14 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 740063 42820 CPT Outpatient 17232.60 2958.26 Cigna Cigna Commercial 0.30 5172.75 0.30 17232.60 0.30 Case Rate 42820 Priced Control throat bleeding 740063 42960 CPT Outpatient 24066.00 4131.33 Cigna Cigna Commercial 0.21 5172.75 0.21 24066.00 0.21 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 740063 43235 CPT Outpatient 8856.75 1633.35 Cigna Cigna Commercial 0.36 3193.14 0.36 8856.75 0.36 Case Rate 43235 Priced Laparoscopy fundoplasty 740063 43280 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 740063 43282 CPT Outpatient 84344.40 14479.12 Cigna Cigna Commercial 0.06 5172.75 0.06 84344.40 0.06 Case Rate 43282 Priced Laparoscopy appendectomy 740063 44970 CPT Outpatient 82300.05 14128.18 Cigna Cigna Commercial 0.06 5172.75 0.06 82300.05 0.06 Case Rate 44970 Priced Diagnostic sigmoidoscopy 740063 45330 CPT Outpatient 17286.15 542.26 Cigna Cigna Commercial 0.19 3258.31 0.19 17286.15 0.19 Case Rate 45330 Priced Needle biopsy of liver 740063 47000 CPT Outpatient 10398.15 1225.34 Cigna Cigna Commercial 0.43 4486.11 0.43 10398.15 0.43 Case Rate 47000 Priced Removal of gallbladder using an endoscope 740063 47562 CPT Outpatient 58430.40 10030.55 Cigna Cigna Commercial 0.09 5172.75 0.09 58430.40 0.09 Case Rate 47562 Priced Laparo cholecystectomy/graph 740063 47563 CPT Outpatient 71747.55 12316.66 Cigna Cigna Commercial 0.07 5172.75 0.07 71747.55 0.07 Case Rate 47563 Priced Abd paracentesis w/imaging 740063 49083 CPT Outpatient 6979.35 1113.95 Cigna Cigna Commercial 0.43 3029.60 0.43 6979.35 0.43 Case Rate 49083 Priced Diag laparo separate proc 740063 49320 CPT Outpatient 31629.15 5429.67 Cigna Cigna Commercial 0.10 3258.31 0.10 31629.15 0.10 Case Rate 49320 Priced Laparoscopy biopsy 740063 49321 CPT Outpatient 41892.90 7191.61 Cigna Cigna Commercial 0.08 3258.31 0.08 41892.90 0.08 Case Rate 49321 Priced Laparoscopy aspiration 740063 49322 CPT Outpatient 34392.75 5904.09 Cigna Cigna Commercial 0.09 3258.31 0.09 34392.75 0.09 Case Rate 49322 Priced Lap insert tunnel ip cath 740063 49324 CPT Outpatient 39264.75 6740.45 Cigna Cigna Commercial 0.13 5172.75 0.13 39264.75 0.13 Case Rate 49324 Priced Laparo proc abdm/per/oment 740063 49329 CPT Outpatient 58696.05 10076.16 Cigna Cigna Commercial 0.09 5172.75 0.09 58696.05 0.09 Case Rate 49329 Priced Ins tun ip cath for dial opn 740063 49421 CPT Outpatient 25460.40 3319.30 Cigna Cigna Commercial 0.20 5172.75 0.20 25460.40 0.20 Case Rate 49421 Priced Remove tunneled ip cath 740063 49422 CPT Outpatient 25515.00 4380.08 Cigna Cigna Commercial 0.20 5172.75 0.20 25515.00 0.20 Case Rate 49422 Priced Rpr ing hernia init reduce 740063 49500 CPT Outpatient 19594.05 3363.65 Cigna Cigna Commercial 0.26 5172.75 0.26 19594.05 0.26 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 740063 49505 CPT Outpatient 34915.65 5993.85 Cigna Cigna Commercial 0.15 5069.30 0.15 34915.65 0.15 Case Rate 49505 Priced Prp i/hern init block >5 yr 740063 49507 CPT Outpatient 29794.80 5114.77 Cigna Cigna Commercial 0.17 5172.75 0.17 29794.80 0.17 Case Rate 49507 Priced Rerepair ing hernia reduce 740063 49520 CPT Outpatient 36940.05 6341.38 Cigna Cigna Commercial 0.14 5172.75 0.14 36940.05 0.14 Case Rate 49520 Priced Rpr ventral hern init reduc 740063 49560 CPT Outpatient 53177.25 9128.76 Cigna Cigna Commercial 0.10 5172.75 0.10 53177.25 0.10 Case Rate 49560 Priced Rpr ventral hern init block 740063 49561 CPT Outpatient 30755.55 5279.70 Cigna Cigna Commercial 0.17 5172.75 0.17 30755.55 0.17 Case Rate 49561 Priced Rerepair ventrl hern reduce 740063 49565 CPT Outpatient 69917.40 12002.49 Cigna Cigna Commercial 0.07 5069.30 0.07 69917.40 0.07 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 740063 49585 CPT Outpatient 41806.80 7176.83 Cigna Cigna Commercial 0.12 5172.75 0.12 41806.80 0.12 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 740063 49587 CPT Outpatient 37320.15 6406.63 Cigna Cigna Commercial 0.14 5172.75 0.14 37320.15 0.14 Case Rate 49587 Priced Lap ing hernia repair init 740063 49650 CPT Outpatient 41932.80 7198.46 Cigna Cigna Commercial 0.12 5069.30 0.12 41932.80 0.12 Case Rate 49650 Priced Lap ing hernia repair recur 740063 49651 CPT Outpatient 46915.05 8053.75 Cigna Cigna Commercial 0.11 5172.75 0.11 46915.05 0.11 Case Rate 49651 Priced Lap vent/abd hernia repair 740063 49652 CPT Outpatient 51294.60 8805.57 Cigna Cigna Commercial 0.10 5172.75 0.10 51294.60 0.10 Case Rate 49652 Priced Lap vent/abd hern proc comp 740063 49653 CPT Outpatient 46102.35 7914.24 Cigna Cigna Commercial 0.11 5172.75 0.11 46102.35 0.11 Case Rate 49653 Priced Lap inc hernia repair 740063 49654 CPT Outpatient 47221.65 8106.38 Cigna Cigna Commercial 0.11 5172.75 0.11 47221.65 0.11 Case Rate 49654 Priced Lap inc hern repair comp 740063 49655 CPT Outpatient 54590.55 9371.38 Cigna Cigna Commercial 0.09 5172.75 0.09 54590.55 0.09 Case Rate 49655 Priced Lap inc hernia repair recur 740063 49656 CPT Outpatient 55443.15 9517.74 Cigna Cigna Commercial 0.09 5172.75 0.09 55443.15 0.09 Case Rate 49656 Priced Removal of kidney stone 740063 50080 CPT Outpatient 53165.70 9126.78 Cigna Cigna Commercial 0.10 5172.75 0.10 53165.70 0.10 Case Rate 50080 Priced Removal of kidney stone 740063 50081 CPT Outpatient 66931.20 11489.86 Cigna Cigna Commercial 0.05 3258.31 0.05 66931.20 0.05 Case Rate 50081 Priced Renal biopsy perq 740063 50200 CPT Outpatient 43096.20 1225.34 Cigna Cigna Commercial 0.25 10840.34 0.25 43096.20 0.25 Case Rate 50200 Priced Plmt nephroureteral catheter 740063 50433 CPT Outpatient 64566.60 1424.48 Cigna Cigna Commercial 0.08 5172.75 0.08 64566.60 0.08 Case Rate 50433 Priced Laparo radical nephrectomy 740063 50545 CPT Outpatient 43449.00 7458.75 Cigna Cigna Commercial 0.12 5172.75 0.12 43449.00 0.12 Case Rate 50545 Priced Laparoscope proc ureter 740063 50949 CPT Outpatient 49986.30 8580.98 Cigna Cigna Commercial 0.10 5172.75 0.10 49986.30 0.10 Case Rate 50949 Priced Injection for bladder x-ray 740063 51600 CPT Outpatient 3285.45 89.22 Cigna Cigna Commercial 0.13 422.29 0.13 3285.45 0.13 Case Rate 51600 Priced Cystoscopy 740063 52000 CPT Outpatient 22149.75 3802.37 Cigna Cigna Commercial 0.15 3258.31 0.15 22149.75 0.15 Case Rate 52000 Priced Cystoscopy & ureter catheter 740063 52005 CPT Outpatient 42529.20 2095.77 Cigna Cigna Commercial 0.08 3258.31 0.08 42529.20 0.08 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 740063 52204 CPT Outpatient 31274.25 5368.75 Cigna Cigna Commercial 0.10 3193.14 0.10 31274.25 0.10 Case Rate 52204 Priced Cystoscopy and treatment 740063 52224 CPT Outpatient 13445.25 2308.10 Cigna Cigna Commercial 0.24 3193.14 0.24 13445.25 0.24 Case Rate 52224 Priced Cystoscopy and treatment 740063 52234 CPT Outpatient 28510.65 4894.33 Cigna Cigna Commercial 0.11 3258.31 0.11 28510.65 0.11 Case Rate 52234 Priced Cystoscopy and treatment 740063 52235 CPT Outpatient 29417.85 5050.06 Cigna Cigna Commercial 0.11 3258.31 0.11 29417.85 0.11 Case Rate 52235 Priced Cystoscopy and treatment 740063 52240 CPT Outpatient 33933.90 5825.32 Cigna Cigna Commercial 0.09 3193.14 0.09 33933.90 0.09 Case Rate 52240 Priced Cystoscopy and treatment 740063 52281 CPT Outpatient 22159.20 3804.00 Cigna Cigna Commercial 0.14 3193.14 0.14 22159.20 0.14 Case Rate 52281 Priced Remove bladder stone 740063 52317 CPT Outpatient 27085.80 4649.73 Cigna Cigna Commercial 0.12 3258.31 0.12 27085.80 0.12 Case Rate 52317 Priced Remove bladder stone 740063 52318 CPT Outpatient 26685.75 4581.05 Cigna Cigna Commercial 0.12 3258.31 0.12 26685.75 0.12 Case Rate 52318 Priced Cystoscopy and treatment 740063 52332 CPT Outpatient 115306.80 19794.33 Cigna Cigna Commercial 0.03 3258.31 0.03 115306.80 0.03 Case Rate 52332 Priced Cystouretero w/stone remove 740063 52352 CPT Outpatient 42420.00 7282.10 Cigna Cigna Commercial 0.08 3258.31 0.08 42420.00 0.08 Case Rate 52352 Priced Cystouretero w/lithotripsy 740063 52353 CPT Outpatient 38608.50 6627.79 Cigna Cigna Commercial 0.08 3193.14 0.08 38608.50 0.08 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 740063 52356 CPT Outpatient 36255.45 6223.85 Cigna Cigna Commercial 0.09 3193.14 0.09 36255.45 0.09 Case Rate 52356 Priced Prostatectomy (turp) 740063 52601 CPT Outpatient 35371.35 6072.08 Cigna Cigna Commercial 0.09 3258.31 0.09 35371.35 0.09 Case Rate 52601 Priced Laser surgery of prostate 740063 52648 CPT Outpatient 24264.45 4165.40 Cigna Cigna Commercial 0.13 3193.14 0.13 24264.45 0.13 Case Rate 52648 Priced Revision of urethra 740063 53450 CPT Outpatient 16209.90 2782.70 Cigna Cigna Commercial 0.32 5172.75 0.32 16209.90 0.32 Case Rate 53450 Priced Urology surgery procedure 740063 53899 CPT Outpatient 25368.00 134.83 Cigna Cigna Commercial 0.13 3258.31 0.13 25368.00 0.13 Case Rate 53899 Priced Circumcision w/regionl block 740063 54150 CPT Outpatient 14700.00 2523.50 Cigna Cigna Commercial 0.35 5172.75 0.35 14700.00 0.35 Case Rate 54150 Priced Circum 28 days or older 740063 54161 CPT Outpatient 19186.65 3293.71 Cigna Cigna Commercial 0.27 5172.75 0.27 19186.65 0.27 Case Rate 54161 Priced Lysis penil circumic lesion 740063 54162 CPT Outpatient 19795.65 3398.25 Cigna Cigna Commercial 0.26 5172.75 0.26 19795.65 0.26 Case Rate 54162 Priced Repair of circumcision 740063 54163 CPT Outpatient 16391.55 2813.88 Cigna Cigna Commercial 0.32 5172.75 0.32 16391.55 0.32 Case Rate 54163 Priced Reconstruction of urethra 740063 54324 CPT Outpatient 32880.75 5644.53 Cigna Cigna Commercial 0.16 5172.75 0.16 32880.75 0.16 Case Rate 54324 Priced Revise penis/urethra 740063 54332 CPT Outpatient 19968.90 3427.99 Cigna Cigna Commercial 0.26 5172.75 0.26 19968.90 0.26 Case Rate 54332 Priced Insert self-contd prosthesis 740063 54401 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 740063 54520 CPT Outpatient 35442.75 6084.34 Cigna Cigna Commercial 0.15 5172.75 0.15 35442.75 0.15 Case Rate 54520 Priced Reduce testis torsion 740063 54600 CPT Outpatient 55049.40 9450.15 Cigna Cigna Commercial 0.09 5172.75 0.09 55049.40 0.09 Case Rate 54600 Priced Suspension of testis 740063 54640 CPT Outpatient 26860.05 4610.98 Cigna Cigna Commercial 0.19 5172.75 0.19 26860.05 0.19 Case Rate 54640 Priced Removal of hydrocele 740063 55040 CPT Outpatient 27277.95 4682.71 Cigna Cigna Commercial 0.19 5172.75 0.19 27277.95 0.19 Case Rate 55040 Priced Biopsy of prostate gland 740063 55700 CPT Outpatient 28699.65 4926.77 Cigna Cigna Commercial 0.18 5172.75 0.18 28699.65 0.18 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 740063 55866 CPT Outpatient 93088.80 15980.24 Cigna Cigna Commercial 0.06 5172.75 0.06 93088.80 0.06 Case Rate 55866 Priced Closure of vagina 740063 57120 CPT Outpatient 34369.65 5900.12 Cigna Cigna Commercial 0.15 5069.30 0.15 34369.65 0.15 Case Rate 57120 Priced Repair of vagina 740063 57200 CPT Outpatient 25247.25 4334.11 Cigna Cigna Commercial 0.20 5172.75 0.20 25247.25 0.20 Case Rate 57200 Priced Anterior colporrhaphy 740063 57240 CPT Outpatient 36210.30 6216.10 Cigna Cigna Commercial 0.09 3258.31 0.09 36210.30 0.09 Case Rate 57240 Priced Repair rectum & vagina 740063 57250 CPT Outpatient 40441.80 6942.51 Cigna Cigna Commercial 0.13 5172.75 0.13 40441.80 0.13 Case Rate 57250 Priced Cmbn ant pst colprhy 740063 57260 CPT Outpatient 46323.90 7952.27 Cigna Cigna Commercial 0.11 5172.75 0.11 46323.90 0.11 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 740063 57265 CPT Outpatient 42586.95 7310.76 Cigna Cigna Commercial 0.12 5172.75 0.12 42586.95 0.12 Case Rate 57265 Priced Repair of bowel bulge 740063 57268 CPT Outpatient 36865.50 6328.58 Cigna Cigna Commercial 0.09 3258.31 0.09 36865.50 0.09 Case Rate 57268 Priced Colpopexy extraperitoneal 740063 57282 CPT Outpatient 45629.85 7833.12 Cigna Cigna Commercial 0.11 5172.75 0.11 45629.85 0.11 Case Rate 57282 Priced Repair bladder defect 740063 57288 CPT Outpatient 43069.95 7393.67 Cigna Cigna Commercial 0.12 5069.30 0.12 43069.95 0.12 Case Rate 57288 Priced Bx/curett of cervix w/scope 740063 57454 CPT Outpatient 2888.55 442.93 Cigna Cigna Commercial 0.95 2737.90 0.95 2888.55 0.95 Case Rate 57454 Priced Conization of cervix 740063 57520 CPT Outpatient 26728.80 4588.44 Cigna Cigna Commercial 0.19 5172.75 0.19 26728.80 0.19 Case Rate 57520 Priced Conization of cervix 740063 57522 CPT Outpatient 22737.75 3903.31 Cigna Cigna Commercial 0.23 5172.75 0.23 22737.75 0.23 Case Rate 57522 Priced Biopsy of uterus lining 740063 58100 CPT Outpatient 2371.95 194.80 Cigna Cigna Commercial 0.27 646.12 0.27 2371.95 0.27 Case Rate 58100 Priced Catheter for hysterography 740063 58340 CPT Outpatient 6322.05 131.04 Cigna Cigna Commercial 0.09 581.75 0.09 6322.05 0.09 Case Rate 58340 Priced Reopen fallopian tube 740063 58350 CPT Outpatient 46507.65 7983.81 Cigna Cigna Commercial 0.11 5172.75 0.11 46507.65 0.11 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 740063 58542 CPT Outpatient 64194.90 11020.12 Cigna Cigna Commercial 0.08 5172.75 0.08 64194.90 0.08 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 740063 58544 CPT Outpatient 51020.55 8758.53 Cigna Cigna Commercial 0.10 5172.75 0.10 51020.55 0.10 Case Rate 58544 Priced Laparoscopic myomectomy 740063 58545 CPT Outpatient 56946.75 9775.86 Cigna Cigna Commercial 0.06 3258.31 0.06 56946.75 0.06 Case Rate 58545 Priced Laparo-vag hyst incl t/o 740063 58552 CPT Outpatient 57228.15 9824.17 Cigna Cigna Commercial 0.09 5172.75 0.09 57228.15 0.09 Case Rate 58552 Priced Hysteroscopy biopsy 740063 58558 CPT Outpatient 28581.00 2077.02 Cigna Cigna Commercial 0.11 3258.31 0.11 28581.00 0.11 Case Rate 58558 Priced Hysteroscopy remove myoma 740063 58561 CPT Outpatient 35222.25 6046.49 Cigna Cigna Commercial 0.09 3258.31 0.09 35222.25 0.09 Case Rate 58561 Priced Hysteroscopy ablation 740063 58563 CPT Outpatient 38399.55 6591.92 Cigna Cigna Commercial 0.08 3258.31 0.08 38399.55 0.08 Case Rate 58563 Priced Tlh uterus 250 g or less 740063 58570 CPT Outpatient 43316.70 7436.03 Cigna Cigna Commercial 0.12 5172.75 0.12 43316.70 0.12 Case Rate 58570 Priced Tlh w/t/o 250 g or less 740063 58571 CPT Outpatient 48603.45 8343.59 Cigna Cigna Commercial 0.11 5172.75 0.11 48603.45 0.11 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 740063 58573 CPT Outpatient 52905.30 9082.08 Cigna Cigna Commercial 0.10 5172.75 0.10 52905.30 0.10 Case Rate 58573 Priced Laparoscopy remove adnexa 740063 58661 CPT Outpatient 47008.50 8069.79 Cigna Cigna Commercial 0.07 3258.31 0.07 47008.50 0.07 Case Rate 58661 Priced Laparoscopy excise lesions 740063 58662 CPT Outpatient 45053.40 7734.17 Cigna Cigna Commercial 0.11 5172.75 0.11 45053.40 0.11 Case Rate 58662 Priced Treat ectopic pregnancy 740063 59151 CPT Outpatient 74690.70 12821.90 Cigna Cigna Commercial 0.07 5172.75 0.07 74690.70 0.07 Case Rate 59151 Priced Treatment of miscarriage 740063 59812 CPT Outpatient 56109.90 9632.20 Cigna Cigna Commercial 0.09 5172.75 0.09 56109.90 0.09 Case Rate 59812 Priced Partial removal of thyroid 740063 60220 CPT Outpatient 53639.25 9208.07 Cigna Cigna Commercial 0.10 5172.75 0.10 53639.25 0.10 Case Rate 60220 Priced Removal of thyroid 740063 60240 CPT Outpatient 98252.70 16866.71 Cigna Cigna Commercial 0.05 5172.75 0.05 98252.70 0.05 Case Rate 60240 Priced Explore parathyroid glands 740063 60500 CPT Outpatient 150495.45 25835.05 Cigna Cigna Commercial 0.03 5172.75 0.03 150495.45 0.03 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 740063 62322 CPT Outpatient 43709.40 514.24 Cigna Cigna Commercial 0.12 5172.75 0.12 43709.40 0.12 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 740063 62323 CPT Outpatient 8304.45 467.31 Cigna Cigna Commercial 0.24 2025.84 0.24 8304.45 0.24 Case Rate 62323 Priced Low back disk surgery 740063 63030 CPT Outpatient 50287.65 8632.71 Cigna Cigna Commercial 0.10 5172.75 0.10 50287.65 0.10 Case Rate 63030 Priced Inc for vagus n elect impl 740063 64568 CPT Outpatient 124562.55 21383.24 Cigna Cigna Commercial 0.04 5172.75 0.04 124562.55 0.04 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 740063 66821 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 740063 66984 CPT Outpatient 0.01 0.01 Cigna Cigna Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 199049 216 DRG Inpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 199049 460 DRG Inpatient 416122.79 53834.63 Emblem Emblem Commercial 0.11 46209.23 0.11 416122.79 0.11 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 199049 470 DRG Inpatient 167912.19 21723.13 Emblem Emblem Commercial 0.13 22323.83 0.13 167912.19 0.13 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 199049 473 DRG Inpatient 100687.91 13026.19 Emblem Emblem Commercial 0.30 29847.35 0.30 100687.91 0.30 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 199049 743 DRG Inpatient 102691.67 13285.42 Emblem Emblem Commercial 0.13 13304.53 0.13 102691.67 0.13 Case Rate 743 Priced NORMAL NEWBORN 199049 795 DRG Inpatient 6266.93 2335.00 Emblem Emblem Commercial 0.20 1275.00 0.20 6266.93 0.20 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 199049 807 DRG Inpatient 116469.59 4193.00 Emblem Emblem Commercial 0.07 7700.00 0.07 116469.59 0.07 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 199049 788 DRG Inpatient 76050.77 4538.00 Emblem Emblem Commercial 0.14 11000.00 0.14 76050.77 0.14 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 199049 59400 CPT Inpatient 116469.59 4193.00 Emblem Emblem Commercial 0.07 7700.00 0.07 116469.59 0.07 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 199049 59510 CPT Inpatient 76050.77 4538.00 Emblem Emblem Commercial 0.14 11000.00 0.14 76050.77 0.14 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 199049 59610 CPT Inpatient 116469.59 4193.00 Emblem Emblem Commercial 0.07 7700.00 0.07 116469.59 0.07 Case Rate 59610 Priced "Psychotherapy, 30 min" 199049 90832 CPT Outpatient 577.50 91.21 Emblem Emblem Commercial 0.52 302.50 0.52 577.50 0.52 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 199049 90834 CPT Outpatient 44134.65 271.96 Emblem Emblem Commercial 0.50 22017.05 0.50 44134.65 0.50 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 199049 90837 CPT Outpatient 2240.70 442.93 Emblem Emblem Commercial 0.10 225.50 0.10 2240.70 0.10 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 199049 90846 CPT Outpatient 0.01 131.50 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 199049 90847 CPT Outpatient 44134.65 369.97 Emblem Emblem Commercial 0.50 22017.05 0.50 44134.65 0.50 Fee Schedule 90847 Priced Group psychotherapy 199049 90853 CPT Outpatient 44134.65 101.99 Emblem Emblem Commercial 0.50 22017.05 0.50 44134.65 0.50 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 199049 99203 CPT Outpatient 3480.75 176.07 Emblem Emblem Commercial 0.50 1736.35 0.50 3480.75 0.50 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 199049 99204 CPT Outpatient 2103.15 233.39 Emblem Emblem Commercial 0.50 1048.85 0.50 2103.15 0.50 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 199049 99205 CPT Outpatient 4970.70 314.28 Emblem Emblem Commercial 0.25 1239.70 0.25 4970.70 0.25 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 199049 99243 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 199049 99244 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 199049 99385 CPT Outpatient 1114.05 185.90 Emblem Emblem Commercial 0.50 555.50 0.50 1114.05 0.50 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 199049 99386 CPT Outpatient 4877.25 185.90 Emblem Emblem Commercial 0.50 2432.65 0.50 4877.25 0.50 Fee Schedule 99386 Priced Routine venipuncture 199049 36415 CPT Outpatient 127.05 19.57 Emblem Emblem Commercial 0.52 66.55 0.52 127.05 0.52 Fee Schedule 36415 Priced Basic Metabolic Panel 199049 80048 CPT Outpatient 576.45 88.78 Emblem Emblem Commercial 0.52 301.95 0.52 576.45 0.52 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 199049 80053 CPT Outpatient 763.35 117.56 Emblem Emblem Commercial 0.52 399.85 0.52 763.35 0.52 Fee Schedule 80053 Priced Obstetric blood test panel 199049 80055 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 199049 80061 CPT Outpatient 1349.25 197.77 Emblem Emblem Commercial 0.50 672.65 0.50 1349.25 0.50 Fee Schedule 80061 Priced Kidney function panel test 199049 80069 CPT Outpatient 716.10 104.95 Emblem Emblem Commercial 0.50 356.95 0.50 716.10 0.50 Fee Schedule 80069 Priced Liver function panel test 199049 80076 CPT Outpatient 716.10 104.95 Emblem Emblem Commercial 0.50 356.95 0.50 716.10 0.50 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 199049 81000 CPT Outpatient 144.90 21.18 Emblem Emblem Commercial 0.50 72.05 0.50 144.90 0.50 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 199049 81001 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 199049 81002 CPT Outpatient 57.75 8.89 Emblem Emblem Commercial 0.52 30.25 0.52 57.75 0.52 Fee Schedule 81002 Priced Automated urinalysis test 199049 81003 CPT Outpatient 219.45 33.80 Emblem Emblem Commercial 0.52 114.95 0.52 219.45 0.52 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 199049 82306 CPT Outpatient 1880.55 289.62 Emblem Emblem Commercial 0.52 985.05 0.52 1880.55 0.52 Fee Schedule 82306 Priced Glycosylated hemoglobin test 199049 83036 CPT Outpatient 494.55 76.17 Emblem Emblem Commercial 0.52 259.05 0.52 494.55 0.52 Fee Schedule 83036 Priced PSA (prostate specific antigen) 199049 84153 CPT Outpatient 1177.05 181.28 Emblem Emblem Commercial 0.52 616.55 0.52 1177.05 0.52 Fee Schedule 84153 Priced PSA (prostate specific antigen) 199049 84154 CPT Outpatient 598.50 92.17 Emblem Emblem Commercial 0.52 313.50 0.52 598.50 0.52 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 199049 84443 CPT Outpatient 519.75 80.05 Emblem Emblem Commercial 0.52 272.25 0.52 519.75 0.52 Fee Schedule 84443 Priced Chorionic gonadotropin assay 199049 84703 CPT Outpatient 785.40 120.96 Emblem Emblem Commercial 0.52 411.40 0.52 785.40 0.52 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 199049 85025 CPT Outpatient 635.25 97.83 Emblem Emblem Commercial 0.52 332.75 0.52 635.25 0.52 Fee Schedule 85025 Priced "Complete blood count, automated" 199049 85027 CPT Outpatient 576.45 88.78 Emblem Emblem Commercial 0.52 301.95 0.52 576.45 0.52 Fee Schedule 85027 Priced "Blood test, clotting time" 199049 85610 CPT Outpatient 404.25 62.26 Emblem Emblem Commercial 0.52 211.75 0.52 404.25 0.52 Fee Schedule 85610 Priced Coagulation assessment blood test 199049 85730 CPT Outpatient 17.22 2.65 Emblem Emblem Commercial 0.52 9.02 0.52 17.22 0.52 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 199049 86003 CPT Outpatient 32.55 5.01 Emblem Emblem Commercial 0.52 17.05 0.52 32.55 0.52 Fee Schedule 86003 Priced Tb test cell immun measure 199049 86480 CPT Outpatient 530.25 81.66 Emblem Emblem Commercial 0.52 277.75 0.52 530.25 0.52 Fee Schedule 86480 Priced Urine culture/colony count 199049 87086 CPT Outpatient 763.35 117.56 Emblem Emblem Commercial 0.52 399.85 0.52 763.35 0.52 Fee Schedule 87086 Priced Hpylori stool ia 199049 87338 CPT Outpatient 785.40 120.96 Emblem Emblem Commercial 0.52 411.40 0.52 785.40 0.52 Fee Schedule 87338 Priced Cytopath eval fna report 199049 88173 CPT Outpatient 750.75 115.62 Emblem Emblem Commercial 0.52 393.25 0.52 750.75 0.52 Fee Schedule 88173 Priced Tissue exam by pathologist 199049 88302 CPT Outpatient 635.25 97.83 Emblem Emblem Commercial 0.52 332.75 0.52 635.25 0.52 Fee Schedule 88302 Priced Tissue exam by pathologist 199049 88305 CPT Outpatient 323.40 49.81 Emblem Emblem Commercial 0.52 169.40 0.52 323.40 0.52 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 199049 11042 CPT Outpatient 2668.05 481.45 Emblem Emblem Commercial 0.50 1331.00 0.50 2668.05 0.50 Case Rate 11042 Priced Deb subq tissue add-on 199049 11045 CPT Outpatient 4652.55 330.00 Emblem Emblem Commercial 0.50 2321.00 0.50 4652.55 0.50 Case Rate 11045 Priced Dx bronchoscope/lavage 199049 31624 CPT Outpatient 41223.00 7602.31 Emblem Emblem Commercial 0.10 4093.00 0.10 41223.00 0.10 Case Rate 31624 Priced Bronchoscopy/lung bx each 199049 31628 CPT Outpatient 49048.65 9045.51 Emblem Emblem Commercial 0.08 4093.00 0.08 49048.65 0.08 Case Rate 31628 Priced Blood transfusion service 199049 36430 CPT Outpatient 9166.50 574.93 Emblem Emblem Commercial 0.50 4572.70 0.50 9166.50 0.50 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 199049 43235 CPT Outpatient 8856.75 1633.35 Emblem Emblem Commercial 0.46 4032.00 0.46 8856.75 0.46 Case Rate 43235 Priced Endoscopic us exam esoph 199049 43237 CPT Outpatient 23867.55 4401.63 Emblem Emblem Commercial 0.17 4093.00 0.17 23867.55 0.17 Case Rate 43237 Priced Egd us fine needle bx/aspir 199049 43238 CPT Outpatient 30690.45 5659.90 Emblem Emblem Commercial 0.13 4093.00 0.13 30690.45 0.13 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 199049 43239 CPT Outpatient 40191.90 7412.15 Emblem Emblem Commercial 0.10 4093.00 0.10 40191.90 0.10 Case Rate 43239 Priced Ercp remove duct calculi 199049 43264 CPT Outpatient 34335.00 6332.03 Emblem Emblem Commercial 0.12 4093.00 0.12 34335.00 0.12 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 199049 45378 CPT Outpatient 13991.25 889.35 Emblem Emblem Commercial 0.29 4093.00 0.29 13991.25 0.29 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 199049 45380 CPT Outpatient 22215.90 4097.04 Emblem Emblem Commercial 0.18 4093.00 0.18 22215.90 0.18 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 199049 45385 CPT Outpatient 119569.80 22050.95 Emblem Emblem Commercial 0.03 4093.00 0.03 119569.80 0.03 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 199049 45391 CPT Outpatient 24923.85 4596.43 Emblem Emblem Commercial 0.16 4093.00 0.16 24923.85 0.16 Case Rate 45391 Priced Fragmenting of kidney stone 199049 50590 CPT Outpatient 40930.05 7548.28 Emblem Emblem Commercial 0.10 4093.00 0.10 40930.05 0.10 Case Rate 50590 Priced Fetal non-stress test 199049 59025 CPT Outpatient 3153.15 477.76 Emblem Emblem Commercial 0.50 1573.00 0.50 3153.15 0.50 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 199049 64483 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 199049 92567 CPT Outpatient 2224.95 98.50 Emblem Emblem Commercial 0.50 1109.90 0.50 2224.95 0.50 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 199049 93000 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 199049 93017 CPT Outpatient 3076.50 532.96 Emblem Emblem Commercial 0.50 1534.50 0.50 3076.50 0.50 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 199049 93452 CPT Outpatient 55621.65 8611.87 Emblem Emblem Commercial 0.10 5750.00 0.10 55621.65 0.10 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 199049 95810 CPT Outpatient 20341.65 3373.48 Emblem Emblem Commercial 0.50 10147.50 0.50 20341.65 0.50 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 199049 95811 CPT Outpatient 22491.00 3731.18 Emblem Emblem Commercial 0.50 11220.00 0.50 22491.00 0.50 Case Rate 95811 Priced Eeg 41-60 minutes 199049 95812 CPT Outpatient 5578.65 925.83 Emblem Emblem Commercial 0.50 2783.00 0.50 5578.65 0.50 Case Rate 95812 Priced Genetic counseling 30 min 199049 96040 CPT Outpatient 0.01 102.81 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 199049 96413 CPT Outpatient 4856.25 472.45 Emblem Emblem Commercial 0.10 475.00 0.10 4856.25 0.10 Case Rate 96413 Priced Ultrasound therapy 199049 97035 CPT Outpatient 2111.55 134.99 Emblem Emblem Commercial 0.08 175.00 0.08 2111.55 0.08 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 199049 97110 CPT Outpatient 6494.25 92.86 Emblem Emblem Commercial 0.13 875.00 0.13 6494.25 0.13 Case Rate 97110 Priced Gait training therapy 199049 97116 CPT Outpatient 4723.95 110.61 Emblem Emblem Commercial 0.07 350.00 0.07 4723.95 0.07 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 199049 70450 CPT Outpatient 8566.95 835.61 Emblem Emblem Commercial 0.09 775.00 0.09 8566.95 0.09 Case Rate 70450 Priced Mri brain stem w/o dye 199049 70551 CPT Outpatient 7861.35 1361.31 Emblem Emblem Commercial 0.50 3921.50 0.50 7861.35 0.50 Case Rate 70551 Priced MRI scan of brain before and after contrast 199049 70553 CPT Outpatient 10882.20 1625.88 Emblem Emblem Commercial 0.50 5428.50 0.50 10882.20 0.50 Case Rate 70553 Priced X-ray exam chest 2 views 199049 71046 CPT Outpatient 859.95 150.37 Emblem Emblem Commercial 0.50 429.00 0.50 859.95 0.50 Case Rate 71046 Priced Ct thorax w/o dye 199049 71250 CPT Outpatient 7288.05 1261.63 Emblem Emblem Commercial 0.50 3635.50 0.50 7288.05 0.50 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 199049 72082 CPT Outpatient 2022.30 253.33 Emblem Emblem Commercial 0.59 1199.55 0.59 2022.30 0.59 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 199049 72100 CPT Outpatient 1599.15 277.38 Emblem Emblem Commercial 0.50 797.50 0.50 1599.15 0.50 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 199049 72110 CPT Outpatient 1389.15 241.04 Emblem Emblem Commercial 0.50 693.00 0.50 1389.15 0.50 Case Rate 72110 Priced MRI scan of lower spinal canal 199049 72148 CPT Outpatient 7861.35 1361.31 Emblem Emblem Commercial 0.50 3921.50 0.50 7861.35 0.50 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 199049 72193 CPT Outpatient 13671.00 1412.01 Emblem Emblem Commercial 0.30 4070.00 0.30 13671.00 0.30 Case Rate 72193 Priced X-ray exam of shoulder 199049 73030 CPT Outpatient 1452.15 251.43 Emblem Emblem Commercial 0.50 724.35 0.50 1452.15 0.50 Case Rate 73030 Priced X-ray exam of elbow 199049 73080 CPT Outpatient 1356.60 235.68 Emblem Emblem Commercial 0.50 676.50 0.50 1356.60 0.50 Case Rate 73080 Priced X-ray exam of forearm 199049 73090 CPT Outpatient 1243.20 215.26 Emblem Emblem Commercial 0.50 619.85 0.50 1243.20 0.50 Case Rate 73090 Priced X-ray exam of wrist 199049 73110 CPT Outpatient 1243.20 215.26 Emblem Emblem Commercial 0.50 619.85 0.50 1243.20 0.50 Case Rate 73110 Priced X-ray exam of hand 199049 73130 CPT Outpatient 1243.20 215.26 Emblem Emblem Commercial 0.50 619.85 0.50 1243.20 0.50 Case Rate 73130 Priced X-ray exam hips bi 2 views 199049 73521 CPT Outpatient 970.20 228.41 Emblem Emblem Commercial 0.67 654.50 0.67 970.20 0.67 Case Rate 73521 Priced X-ray exam of knee 3 199049 73562 CPT Outpatient 802.20 139.12 Emblem Emblem Commercial 0.50 399.85 0.50 802.20 0.50 Case Rate 73562 Priced X-ray exam of lower leg 199049 73590 CPT Outpatient 1243.20 215.26 Emblem Emblem Commercial 0.50 619.85 0.50 1243.20 0.50 Case Rate 73590 Priced X-ray exam of ankle 199049 73610 CPT Outpatient 1378.65 239.31 Emblem Emblem Commercial 0.50 687.50 0.50 1378.65 0.50 Case Rate 73610 Priced X-ray exam of foot 199049 73630 CPT Outpatient 975.45 169.41 Emblem Emblem Commercial 0.50 486.20 0.50 975.45 0.50 Case Rate 73630 Priced MRI scan of leg joint 199049 73721 CPT Outpatient 7861.35 1361.31 Emblem Emblem Commercial 0.50 3921.50 0.50 7861.35 0.50 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 199049 74177 CPT Outpatient 14222.25 1412.01 Emblem Emblem Commercial 0.29 4070.00 0.29 14222.25 0.29 Case Rate 74177 Priced Contrst x-ray exam of throat 199049 74210 CPT Outpatient 0.01 440.39 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 199049 76098 CPT Outpatient 6141.45 407.86 Emblem Emblem Commercial 0.45 2785.00 0.45 6141.45 0.45 Case Rate 76098 Priced Us exam of head and neck 199049 76536 CPT Outpatient 5512.50 955.18 Emblem Emblem Commercial 0.50 2750.00 0.50 5512.50 0.50 Case Rate 76536 Priced Ultrasound breast limited 199049 76642 CPT Outpatient 5777.10 127.70 Emblem Emblem Commercial 0.50 2882.00 0.50 5777.10 0.50 Case Rate 76642 Priced Ultrasound of abdomen 199049 76700 CPT Outpatient 4917.15 851.88 Emblem Emblem Commercial 0.50 2453.00 0.50 4917.15 0.50 Case Rate 76700 Priced Echo exam of abdomen 199049 76705 CPT Outpatient 3836.70 665.17 Emblem Emblem Commercial 0.50 1914.00 0.50 3836.70 0.50 Case Rate 76705 Priced Us exam abdo back wall comp 199049 76770 CPT Outpatient 5171.25 895.48 Emblem Emblem Commercial 0.50 2579.50 0.50 5171.25 0.50 Case Rate 76770 Priced Us exam abdo back wall lim 199049 76775 CPT Outpatient 3969.00 686.97 Emblem Emblem Commercial 0.50 1980.00 0.50 3969.00 0.50 Case Rate 76775 Priced Ob us < 14 wks single fetus 199049 76801 CPT Outpatient 2006.55 347.98 Emblem Emblem Commercial 0.50 1001.00 0.50 2006.55 0.50 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 199049 76805 CPT Outpatient 3969.00 686.97 Emblem Emblem Commercial 0.50 1980.00 0.50 3969.00 0.50 Case Rate 76805 Priced Ob us detailed sngl fetus 199049 76811 CPT Outpatient 2844.45 492.99 Emblem Emblem Commercial 0.50 1419.00 0.50 2844.45 0.50 Case Rate 76811 Priced Ob us nuchal meas 1 gest 199049 76813 CPT Outpatient 1044.75 180.83 Emblem Emblem Commercial 0.50 520.85 0.50 1044.75 0.50 Case Rate 76813 Priced Ob us limited fetus(s) 199049 76815 CPT Outpatient 6428.10 639.90 Emblem Emblem Commercial 0.50 3206.50 0.50 6428.10 0.50 Case Rate 76815 Priced Ob us follow-up per fetus 199049 76816 CPT Outpatient 4818.45 833.88 Emblem Emblem Commercial 0.50 2403.50 0.50 4818.45 0.50 Case Rate 76816 Priced Transvaginal us obstetric 199049 76817 CPT Outpatient 6428.10 476.73 Emblem Emblem Commercial 0.50 3206.50 0.50 6428.10 0.50 Case Rate 76817 Priced Fetal biophys profil w/o nst 199049 76819 CPT Outpatient 1741.95 302.65 Emblem Emblem Commercial 0.50 869.00 0.50 1741.95 0.50 Case Rate 76819 Priced Ultrasound pelvis through vagina 199049 76830 CPT Outpatient 9305.10 806.54 Emblem Emblem Commercial 0.50 4642.00 0.50 9305.10 0.50 Case Rate 76830 Priced Us exam scrotum 199049 76870 CPT Outpatient 6328.35 1096.55 Emblem Emblem Commercial 0.50 3157.00 0.50 6328.35 0.50 Case Rate 76870 Priced Us exam infant hips dynamic 199049 76885 CPT Outpatient 3836.70 665.17 Emblem Emblem Commercial 0.50 1914.00 0.50 3836.70 0.50 Case Rate 76885 Priced Mammography of one breast 199049 77065 CPT Outpatient 3451.35 192.07 Emblem Emblem Commercial 0.50 1721.50 0.50 3451.35 0.50 Case Rate 77065 Priced Mammography of both breasts 199049 77066 CPT Outpatient 5777.10 235.68 Emblem Emblem Commercial 0.50 2882.00 0.50 5777.10 0.50 Case Rate 77066 Priced "Mamography, screening bilateral" 199049 77067 CPT Outpatient 1416.45 205.57 Emblem Emblem Commercial 0.50 706.20 0.50 1416.45 0.50 Case Rate 77067 Priced X-rays for bone age 199049 77072 CPT Outpatient 2022.30 163.87 Emblem Emblem Commercial 0.59 1199.55 0.59 2022.30 0.59 Case Rate 77072 Priced Joint survey single view 199049 77077 CPT Outpatient 985.95 171.14 Emblem Emblem Commercial 0.50 491.70 0.50 985.95 0.50 Case Rate 77077 Priced Dxa bone density axial 199049 77080 CPT Outpatient 3257.10 319.09 Emblem Emblem Commercial 0.50 1624.70 0.50 3257.10 0.50 Case Rate 77080 Priced Fna bx w/us gdn 1st les 199049 10005 CPT Outpatient 5512.50 547.24 Emblem Emblem Commercial 0.45 2500.00 0.45 5512.50 0.45 Case Rate 10005 Priced Fna bx w/us gdn ea addl 199049 10006 CPT Outpatient 10628.10 594.83 Emblem Emblem Commercial 0.39 4093.00 0.39 10628.10 0.39 Case Rate 10006 Priced Drainage of hematoma/fluid 199049 10140 CPT Outpatient 23209.20 1081.95 Emblem Emblem Commercial 0.18 4093.00 0.18 23209.20 0.18 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 199049 11042 CPT Outpatient 2668.05 481.45 Emblem Emblem Commercial 0.50 1331.00 0.50 2668.05 0.50 Case Rate 11042 Priced Deb bone 20 sq cm/< 199049 11044 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 199049 11406 CPT Outpatient 19967.85 3427.81 Emblem Emblem Commercial 0.20 4093.00 0.20 19967.85 0.20 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 199049 11424 CPT Outpatient 0.01 1004.93 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 199049 11770 CPT Outpatient 19173.00 3291.37 Emblem Emblem Commercial 0.21 4093.00 0.21 19173.00 0.21 Case Rate 11770 Priced Replace tissue expander 199049 11970 CPT Outpatient 59239.95 10169.52 Emblem Emblem Commercial 0.07 4093.00 0.07 59239.95 0.07 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 199049 14020 CPT Outpatient 32166.75 5521.96 Emblem Emblem Commercial 0.13 4093.00 0.13 32166.75 0.13 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 199049 14060 CPT Outpatient 25993.80 1374.69 Emblem Emblem Commercial 0.16 4093.00 0.16 25993.80 0.16 Case Rate 14060 Priced Wound prep trk/arm/leg 199049 15002 CPT Outpatient 41748.00 1441.73 Emblem Emblem Commercial 0.10 4093.00 0.10 41748.00 0.10 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 199049 15271 CPT Outpatient 24343.20 3769.48 Emblem Emblem Commercial 0.48 11759.00 0.48 24343.20 0.48 Case Rate 15271 Priced Acellular derm matrix implt 199049 15777 CPT Outpatient 101672.55 17453.79 Emblem Emblem Commercial 0.04 4093.00 0.04 101672.55 0.04 Case Rate 15777 Priced Exc skin abd 199049 15830 CPT Outpatient 54696.60 9389.58 Emblem Emblem Commercial 0.07 4093.00 0.07 54696.60 0.07 Case Rate 15830 Priced Dressing change not for burn 199049 15852 CPT Outpatient 0.01 290.74 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 199049 15877 CPT Outpatient 63741.30 10942.26 Emblem Emblem Commercial 0.06 4093.00 0.06 63741.30 0.06 Case Rate 15877 Priced Suction lipectomy lwr extrem 199049 15879 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 199049 19000 CPT Outpatient 10143.00 594.83 Emblem Emblem Commercial 0.40 4093.00 0.40 10143.00 0.40 Case Rate 19000 Priced Bx breast 1st lesion strtctc 199049 19081 CPT Outpatient 12341.70 1250.69 Emblem Emblem Commercial 0.33 4093.00 0.33 12341.70 0.33 Case Rate 19081 Priced Bx breast add lesion us imag 199049 19084 CPT Outpatient 29058.75 547.24 Emblem Emblem Commercial 0.14 4093.00 0.14 29058.75 0.14 Case Rate 19084 Priced Biopsy of breast open 199049 19101 CPT Outpatient 39545.10 2737.82 Emblem Emblem Commercial 0.10 4093.00 0.10 39545.10 0.10 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 199049 19120 CPT Outpatient 35761.95 2737.82 Emblem Emblem Commercial 0.11 4093.00 0.11 35761.95 0.11 Case Rate 19120 Priced Excision breast lesion 199049 19125 CPT Outpatient 33184.20 0.01 Emblem Emblem Commercial 0.12 4093.00 0.12 33184.20 0.12 Case Rate 19125 Priced Perq device breast 1st imag 199049 19281 CPT Outpatient 6141.45 598.61 Emblem Emblem Commercial 0.45 2785.00 0.45 6141.45 0.45 Case Rate 19281 Priced Perq device breast ea imag 199049 19282 CPT Outpatient 8379.00 319.04 Emblem Emblem Commercial 0.45 3800.00 0.45 8379.00 0.45 Case Rate 19282 Priced Partial mastectomy 199049 19301 CPT Outpatient 39157.65 6722.06 Emblem Emblem Commercial 0.10 4093.00 0.10 39157.65 0.10 Case Rate 19301 Priced Mast simple complete 199049 19303 CPT Outpatient 105389.55 18091.87 Emblem Emblem Commercial 0.04 4093.00 0.04 105389.55 0.04 Case Rate 19303 Priced Reduction of large breast 199049 19318 CPT Outpatient 65239.65 11199.47 Emblem Emblem Commercial 0.06 4093.00 0.06 65239.65 0.06 Case Rate 19318 Priced Immediate breast prosthesis 199049 19340 CPT Outpatient 113100.75 19415.63 Emblem Emblem Commercial 0.04 4093.00 0.04 113100.75 0.04 Case Rate 19340 Priced Delayed breast prosthesis 199049 19342 CPT Outpatient 56988.75 9783.07 Emblem Emblem Commercial 0.07 4093.00 0.07 56988.75 0.07 Case Rate 19342 Priced Breast reconstruction 199049 19357 CPT Outpatient 101672.55 17453.79 Emblem Emblem Commercial 0.04 4093.00 0.04 101672.55 0.04 Case Rate 19357 Priced Breast reconstruction 199049 19366 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 199049 19380 CPT Outpatient 61493.25 10556.34 Emblem Emblem Commercial 0.07 4093.00 0.07 61493.25 0.07 Case Rate 19380 Priced Removal of support implant 199049 20680 CPT Outpatient 42329.70 7266.60 Emblem Emblem Commercial 0.10 4093.00 0.10 42329.70 0.10 Case Rate 20680 Priced Cerv artific diskectomy 199049 22856 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 199049 24538 CPT Outpatient 51237.90 4775.24 Emblem Emblem Commercial 0.08 4093.00 0.08 51237.90 0.08 Case Rate 24538 Priced Remove wrist tendon lesion 199049 25111 CPT Outpatient 25855.20 4438.48 Emblem Emblem Commercial 0.16 4093.00 0.16 25855.20 0.16 Case Rate 25111 Priced Incise finger tendon sheath 199049 26055 CPT Outpatient 15862.35 2723.04 Emblem Emblem Commercial 0.26 4093.00 0.26 15862.35 0.26 Case Rate 26055 Priced Treat finger fracture each 199049 26727 CPT Outpatient 22779.75 2030.47 Emblem Emblem Commercial 0.18 4093.00 0.18 22779.75 0.18 Case Rate 26727 Priced Revision of knee joint 199049 27446 CPT Outpatient 67882.50 11653.16 Emblem Emblem Commercial 0.23 15500.00 0.23 67882.50 0.23 Case Rate 27446 Priced Total knee arthroplasty 199049 27447 CPT Outpatient 130698.75 22436.62 Emblem Emblem Commercial 0.12 15500.00 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 199049 27485 CPT Outpatient 43310.40 7434.95 Emblem Emblem Commercial 0.09 4093.00 0.09 43310.40 0.09 Case Rate 27485 Priced Repair achilles tendon 199049 27650 CPT Outpatient 38246.25 3762.57 Emblem Emblem Commercial 0.11 4093.00 0.11 38246.25 0.11 Case Rate 27650 Priced Treatment of ankle fracture 199049 27792 CPT Outpatient 36101.10 6197.36 Emblem Emblem Commercial 0.11 4093.00 0.11 36101.10 0.11 Case Rate 27792 Priced Treatment of ankle fracture 199049 27814 CPT Outpatient 49405.65 8481.30 Emblem Emblem Commercial 0.08 4093.00 0.08 49405.65 0.08 Case Rate 27814 Priced Removal of foot lesion 199049 28080 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 199049 28285 CPT Outpatient 68603.85 11776.99 Emblem Emblem Commercial 0.06 4093.00 0.06 68603.85 0.06 Case Rate 28285 Priced Correction hallux valgus 199049 28296 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 199049 29823 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 199049 29826 CPT Outpatient 49840.35 8555.93 Emblem Emblem Commercial 0.08 4093.00 0.08 49840.35 0.08 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 199049 29881 CPT Outpatient 35556.15 6103.81 Emblem Emblem Commercial 0.12 4093.00 0.12 35556.15 0.12 Case Rate 29881 Priced Knee arthroscopy/surgery 199049 29882 CPT Outpatient 61099.50 10488.75 Emblem Emblem Commercial 0.07 4093.00 0.07 61099.50 0.07 Case Rate 29882 Priced Percut bx lung/mediastinum 199049 32405 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 199049 32555 CPT Outpatient 14597.10 687.29 Emblem Emblem Commercial 0.28 4093.00 0.28 14597.10 0.28 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 199049 32664 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 199049 35190 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 199049 36478 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 199049 36561 CPT Outpatient 53531.10 3292.99 Emblem Emblem Commercial 0.08 4093.00 0.08 53531.10 0.08 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 199049 36569 CPT Outpatient 31421.25 1299.06 Emblem Emblem Commercial 0.13 4093.00 0.13 31421.25 0.13 Case Rate 36569 Priced Removal tunneled cv cath 199049 36590 CPT Outpatient 1996.05 273.95 Emblem Emblem Commercial 0.46 909.00 0.46 1996.05 0.46 Case Rate 36590 Priced Av fuse uppr arm basilic 199049 36819 CPT Outpatient 56861.70 9761.26 Emblem Emblem Commercial 0.07 4093.00 0.07 56861.70 0.07 Case Rate 36819 Priced Av fusion direct any site 199049 36821 CPT Outpatient 42953.40 7373.67 Emblem Emblem Commercial 0.10 4093.00 0.10 42953.40 0.10 Case Rate 36821 Priced Artery-vein autograft 199049 36825 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 199049 36830 CPT Outpatient 53656.05 9210.96 Emblem Emblem Commercial 0.08 4093.00 0.08 53656.05 0.08 Case Rate 36830 Priced Av fistula revision open 199049 36832 CPT Outpatient 52492.65 9011.24 Emblem Emblem Commercial 0.08 4093.00 0.08 52492.65 0.08 Case Rate 36832 Priced Av fistula revision 199049 36833 CPT Outpatient 37098.60 6368.59 Emblem Emblem Commercial 0.11 4093.00 0.11 37098.60 0.11 Case Rate 36833 Priced Intro cath dialysis circuit 199049 36903 CPT Outpatient 77541.45 10669.90 Emblem Emblem Commercial 0.05 4093.00 0.05 77541.45 0.05 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 199049 36906 CPT Outpatient 96694.50 16175.64 Emblem Emblem Commercial 0.04 4093.00 0.04 96694.50 0.04 Case Rate 36906 Priced Fem/popl revas w/tla 199049 37224 CPT Outpatient 200076.45 5139.31 Emblem Emblem Commercial 0.03 5750.00 0.03 200076.45 0.03 Case Rate 37224 Priced Fem/popl revasc stnt & ather 199049 37227 CPT Outpatient 117170.55 18045.38 Emblem Emblem Commercial 0.05 5750.00 0.05 117170.55 0.05 Case Rate 37227 Priced Revise leg vein 199049 37700 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 199049 37722 CPT Outpatient 27815.55 4775.00 Emblem Emblem Commercial 0.15 4093.00 0.15 27815.55 0.15 Case Rate 37722 Priced Stab phleb veins xtr 10-20 199049 37765 CPT Outpatient 26561.85 4559.78 Emblem Emblem Commercial 0.15 4093.00 0.15 26561.85 0.15 Case Rate 37765 Priced Biopsy/removal lymph nodes 199049 38500 CPT Outpatient 35955.15 6172.30 Emblem Emblem Commercial 0.11 4093.00 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 199049 38525 CPT Outpatient 101194.80 17371.77 Emblem Emblem Commercial 0.04 4093.00 0.04 101194.80 0.04 Case Rate 38525 Priced Laparoscopy lymph node biop 199049 38570 CPT Outpatient 65631.30 11266.71 Emblem Emblem Commercial 0.06 4093.00 0.06 65631.30 0.06 Case Rate 38570 Priced Laparoscopy lymphadenectomy 199049 38571 CPT Outpatient 84031.50 14425.41 Emblem Emblem Commercial 0.05 4093.00 0.05 84031.50 0.05 Case Rate 38571 Priced Laparoscopy lymphadenectomy 199049 38572 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 199049 38792 CPT Outpatient 2868.60 432.48 Emblem Emblem Commercial 0.45 1300.50 0.45 2868.60 0.45 Case Rate 38792 Priced Excision of gum lesion 199049 41825 CPT Outpatient 11580.45 1987.98 Emblem Emblem Commercial 0.35 4093.00 0.35 11580.45 0.35 Case Rate 41825 Priced Reconstruct cleft palate 199049 42200 CPT Outpatient 36703.80 6300.82 Emblem Emblem Commercial 0.11 4093.00 0.11 36703.80 0.11 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 199049 42820 CPT Outpatient 17232.60 2958.26 Emblem Emblem Commercial 0.24 4093.00 0.24 17232.60 0.24 Case Rate 42820 Priced Control throat bleeding 199049 42960 CPT Outpatient 24066.00 4131.33 Emblem Emblem Commercial 0.17 4093.00 0.17 24066.00 0.17 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 199049 43235 CPT Outpatient 8856.75 1633.35 Emblem Emblem Commercial 0.46 4032.00 0.46 8856.75 0.46 Case Rate 43235 Priced Laparoscopy fundoplasty 199049 43280 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 199049 43282 CPT Outpatient 84344.40 14479.12 Emblem Emblem Commercial 0.05 4093.00 0.05 84344.40 0.05 Case Rate 43282 Priced Laparoscopy appendectomy 199049 44970 CPT Outpatient 82300.05 14128.18 Emblem Emblem Commercial 0.05 4093.00 0.05 82300.05 0.05 Case Rate 44970 Priced Diagnostic sigmoidoscopy 199049 45330 CPT Outpatient 17286.15 542.26 Emblem Emblem Commercial 0.24 4093.00 0.24 17286.15 0.24 Case Rate 45330 Priced Needle biopsy of liver 199049 47000 CPT Outpatient 10398.15 1225.34 Emblem Emblem Commercial 0.39 4093.00 0.39 10398.15 0.39 Case Rate 47000 Priced Removal of gallbladder using an endoscope 199049 47562 CPT Outpatient 58430.40 10030.55 Emblem Emblem Commercial 0.07 4093.00 0.07 58430.40 0.07 Case Rate 47562 Priced Laparo cholecystectomy/graph 199049 47563 CPT Outpatient 71747.55 12316.66 Emblem Emblem Commercial 0.06 4093.00 0.06 71747.55 0.06 Case Rate 47563 Priced Abd paracentesis w/imaging 199049 49083 CPT Outpatient 6979.35 1113.95 Emblem Emblem Commercial 0.45 3165.00 0.45 6979.35 0.45 Case Rate 49083 Priced Diag laparo separate proc 199049 49320 CPT Outpatient 31629.15 5429.67 Emblem Emblem Commercial 0.13 4093.00 0.13 31629.15 0.13 Case Rate 49320 Priced Laparoscopy biopsy 199049 49321 CPT Outpatient 41892.90 7191.61 Emblem Emblem Commercial 0.10 4093.00 0.10 41892.90 0.10 Case Rate 49321 Priced Laparoscopy aspiration 199049 49322 CPT Outpatient 34392.75 5904.09 Emblem Emblem Commercial 0.12 4093.00 0.12 34392.75 0.12 Case Rate 49322 Priced Lap insert tunnel ip cath 199049 49324 CPT Outpatient 39264.75 6740.45 Emblem Emblem Commercial 0.10 4093.00 0.10 39264.75 0.10 Case Rate 49324 Priced Laparo proc abdm/per/oment 199049 49329 CPT Outpatient 58696.05 10076.16 Emblem Emblem Commercial 0.07 4093.00 0.07 58696.05 0.07 Case Rate 49329 Priced Ins tun ip cath for dial opn 199049 49421 CPT Outpatient 25460.40 3319.30 Emblem Emblem Commercial 0.16 4093.00 0.16 25460.40 0.16 Case Rate 49421 Priced Remove tunneled ip cath 199049 49422 CPT Outpatient 25515.00 4380.08 Emblem Emblem Commercial 0.16 4093.00 0.16 25515.00 0.16 Case Rate 49422 Priced Rpr ing hernia init reduce 199049 49500 CPT Outpatient 19594.05 3363.65 Emblem Emblem Commercial 0.21 4093.00 0.21 19594.05 0.21 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 199049 49505 CPT Outpatient 34915.65 5993.85 Emblem Emblem Commercial 0.12 4093.00 0.12 34915.65 0.12 Case Rate 49505 Priced Prp i/hern init block >5 yr 199049 49507 CPT Outpatient 29794.80 5114.77 Emblem Emblem Commercial 0.14 4093.00 0.14 29794.80 0.14 Case Rate 49507 Priced Rerepair ing hernia reduce 199049 49520 CPT Outpatient 36940.05 6341.38 Emblem Emblem Commercial 0.11 4093.00 0.11 36940.05 0.11 Case Rate 49520 Priced Rpr ventral hern init reduc 199049 49560 CPT Outpatient 53177.25 9128.76 Emblem Emblem Commercial 0.08 4093.00 0.08 53177.25 0.08 Case Rate 49560 Priced Rpr ventral hern init block 199049 49561 CPT Outpatient 30755.55 5279.70 Emblem Emblem Commercial 0.13 4093.00 0.13 30755.55 0.13 Case Rate 49561 Priced Rerepair ventrl hern reduce 199049 49565 CPT Outpatient 69917.40 12002.49 Emblem Emblem Commercial 0.06 4093.00 0.06 69917.40 0.06 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 199049 49585 CPT Outpatient 41806.80 7176.83 Emblem Emblem Commercial 0.10 4093.00 0.10 41806.80 0.10 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 199049 49587 CPT Outpatient 37320.15 6406.63 Emblem Emblem Commercial 0.11 4093.00 0.11 37320.15 0.11 Case Rate 49587 Priced Lap ing hernia repair init 199049 49650 CPT Outpatient 41932.80 7198.46 Emblem Emblem Commercial 0.10 4093.00 0.10 41932.80 0.10 Case Rate 49650 Priced Lap ing hernia repair recur 199049 49651 CPT Outpatient 46915.05 8053.75 Emblem Emblem Commercial 0.09 4093.00 0.09 46915.05 0.09 Case Rate 49651 Priced Lap vent/abd hernia repair 199049 49652 CPT Outpatient 51294.60 8805.57 Emblem Emblem Commercial 0.08 4093.00 0.08 51294.60 0.08 Case Rate 49652 Priced Lap vent/abd hern proc comp 199049 49653 CPT Outpatient 46102.35 7914.24 Emblem Emblem Commercial 0.09 4093.00 0.09 46102.35 0.09 Case Rate 49653 Priced Lap inc hernia repair 199049 49654 CPT Outpatient 47221.65 8106.38 Emblem Emblem Commercial 0.09 4093.00 0.09 47221.65 0.09 Case Rate 49654 Priced Lap inc hern repair comp 199049 49655 CPT Outpatient 54590.55 9371.38 Emblem Emblem Commercial 0.07 4093.00 0.07 54590.55 0.07 Case Rate 49655 Priced Lap inc hernia repair recur 199049 49656 CPT Outpatient 55443.15 9517.74 Emblem Emblem Commercial 0.07 4093.00 0.07 55443.15 0.07 Case Rate 49656 Priced Removal of kidney stone 199049 50080 CPT Outpatient 53165.70 9126.78 Emblem Emblem Commercial 0.08 4093.00 0.08 53165.70 0.08 Case Rate 50080 Priced Removal of kidney stone 199049 50081 CPT Outpatient 66931.20 11489.86 Emblem Emblem Commercial 0.06 4093.00 0.06 66931.20 0.06 Case Rate 50081 Priced Renal biopsy perq 199049 50200 CPT Outpatient 43096.20 1225.34 Emblem Emblem Commercial 0.09 4093.00 0.09 43096.20 0.09 Case Rate 50200 Priced Plmt nephroureteral catheter 199049 50433 CPT Outpatient 64566.60 1424.48 Emblem Emblem Commercial 0.06 4093.00 0.06 64566.60 0.06 Case Rate 50433 Priced Laparo radical nephrectomy 199049 50545 CPT Outpatient 43449.00 7458.75 Emblem Emblem Commercial 0.09 4093.00 0.09 43449.00 0.09 Case Rate 50545 Priced Laparoscope proc ureter 199049 50949 CPT Outpatient 49986.30 8580.98 Emblem Emblem Commercial 0.08 4093.00 0.08 49986.30 0.08 Case Rate 50949 Priced Injection for bladder x-ray 199049 51600 CPT Outpatient 3285.45 89.22 Emblem Emblem Commercial 0.45 1490.00 0.45 3285.45 0.45 Case Rate 51600 Priced Cystoscopy 199049 52000 CPT Outpatient 22149.75 3802.37 Emblem Emblem Commercial 0.18 4093.00 0.18 22149.75 0.18 Case Rate 52000 Priced Cystoscopy & ureter catheter 199049 52005 CPT Outpatient 42529.20 2095.77 Emblem Emblem Commercial 0.10 4093.00 0.10 42529.20 0.10 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 199049 52204 CPT Outpatient 31274.25 5368.75 Emblem Emblem Commercial 0.13 4093.00 0.13 31274.25 0.13 Case Rate 52204 Priced Cystoscopy and treatment 199049 52224 CPT Outpatient 13445.25 2308.10 Emblem Emblem Commercial 0.30 4093.00 0.30 13445.25 0.30 Case Rate 52224 Priced Cystoscopy and treatment 199049 52234 CPT Outpatient 28510.65 4894.33 Emblem Emblem Commercial 0.14 4093.00 0.14 28510.65 0.14 Case Rate 52234 Priced Cystoscopy and treatment 199049 52235 CPT Outpatient 29417.85 5050.06 Emblem Emblem Commercial 0.14 4093.00 0.14 29417.85 0.14 Case Rate 52235 Priced Cystoscopy and treatment 199049 52240 CPT Outpatient 33933.90 5825.32 Emblem Emblem Commercial 0.12 4093.00 0.12 33933.90 0.12 Case Rate 52240 Priced Cystoscopy and treatment 199049 52281 CPT Outpatient 22159.20 3804.00 Emblem Emblem Commercial 0.18 4093.00 0.18 22159.20 0.18 Case Rate 52281 Priced Remove bladder stone 199049 52317 CPT Outpatient 27085.80 4649.73 Emblem Emblem Commercial 0.15 4093.00 0.15 27085.80 0.15 Case Rate 52317 Priced Remove bladder stone 199049 52318 CPT Outpatient 26685.75 4581.05 Emblem Emblem Commercial 0.15 4093.00 0.15 26685.75 0.15 Case Rate 52318 Priced Cystoscopy and treatment 199049 52332 CPT Outpatient 115306.80 19794.33 Emblem Emblem Commercial 0.04 4093.00 0.04 115306.80 0.04 Case Rate 52332 Priced Cystouretero w/stone remove 199049 52352 CPT Outpatient 42420.00 7282.10 Emblem Emblem Commercial 0.10 4093.00 0.10 42420.00 0.10 Case Rate 52352 Priced Cystouretero w/lithotripsy 199049 52353 CPT Outpatient 38608.50 6627.79 Emblem Emblem Commercial 0.11 4093.00 0.11 38608.50 0.11 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 199049 52356 CPT Outpatient 36255.45 6223.85 Emblem Emblem Commercial 0.11 4093.00 0.11 36255.45 0.11 Case Rate 52356 Priced Prostatectomy (turp) 199049 52601 CPT Outpatient 35371.35 6072.08 Emblem Emblem Commercial 0.12 4093.00 0.12 35371.35 0.12 Case Rate 52601 Priced Laser surgery of prostate 199049 52648 CPT Outpatient 24264.45 4165.40 Emblem Emblem Commercial 0.17 4093.00 0.17 24264.45 0.17 Case Rate 52648 Priced Revision of urethra 199049 53450 CPT Outpatient 16209.90 2782.70 Emblem Emblem Commercial 0.25 4093.00 0.25 16209.90 0.25 Case Rate 53450 Priced Urology surgery procedure 199049 53899 CPT Outpatient 25368.00 134.83 Emblem Emblem Commercial 0.16 4093.00 0.16 25368.00 0.16 Case Rate 53899 Priced Circumcision w/regionl block 199049 54150 CPT Outpatient 14700.00 2523.50 Emblem Emblem Commercial 0.28 4093.00 0.28 14700.00 0.28 Case Rate 54150 Priced Circum 28 days or older 199049 54161 CPT Outpatient 19186.65 3293.71 Emblem Emblem Commercial 0.21 4093.00 0.21 19186.65 0.21 Case Rate 54161 Priced Lysis penil circumic lesion 199049 54162 CPT Outpatient 19795.65 3398.25 Emblem Emblem Commercial 0.21 4093.00 0.21 19795.65 0.21 Case Rate 54162 Priced Repair of circumcision 199049 54163 CPT Outpatient 16391.55 2813.88 Emblem Emblem Commercial 0.25 4093.00 0.25 16391.55 0.25 Case Rate 54163 Priced Reconstruction of urethra 199049 54324 CPT Outpatient 32880.75 5644.53 Emblem Emblem Commercial 0.12 4093.00 0.12 32880.75 0.12 Case Rate 54324 Priced Revise penis/urethra 199049 54332 CPT Outpatient 19968.90 3427.99 Emblem Emblem Commercial 0.20 4093.00 0.20 19968.90 0.20 Case Rate 54332 Priced Insert self-contd prosthesis 199049 54401 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 199049 54520 CPT Outpatient 35442.75 6084.34 Emblem Emblem Commercial 0.12 4093.00 0.12 35442.75 0.12 Case Rate 54520 Priced Reduce testis torsion 199049 54600 CPT Outpatient 55049.40 9450.15 Emblem Emblem Commercial 0.07 4093.00 0.07 55049.40 0.07 Case Rate 54600 Priced Suspension of testis 199049 54640 CPT Outpatient 26860.05 4610.98 Emblem Emblem Commercial 0.15 4093.00 0.15 26860.05 0.15 Case Rate 54640 Priced Removal of hydrocele 199049 55040 CPT Outpatient 27277.95 4682.71 Emblem Emblem Commercial 0.15 4093.00 0.15 27277.95 0.15 Case Rate 55040 Priced Biopsy of prostate gland 199049 55700 CPT Outpatient 28699.65 4926.77 Emblem Emblem Commercial 0.14 4093.00 0.14 28699.65 0.14 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 199049 55866 CPT Outpatient 93088.80 15980.24 Emblem Emblem Commercial 0.04 4093.00 0.04 93088.80 0.04 Case Rate 55866 Priced Closure of vagina 199049 57120 CPT Outpatient 34369.65 5900.12 Emblem Emblem Commercial 0.12 4093.00 0.12 34369.65 0.12 Case Rate 57120 Priced Repair of vagina 199049 57200 CPT Outpatient 25247.25 4334.11 Emblem Emblem Commercial 0.16 4093.00 0.16 25247.25 0.16 Case Rate 57200 Priced Anterior colporrhaphy 199049 57240 CPT Outpatient 36210.30 6216.10 Emblem Emblem Commercial 0.11 4093.00 0.11 36210.30 0.11 Case Rate 57240 Priced Repair rectum & vagina 199049 57250 CPT Outpatient 40441.80 6942.51 Emblem Emblem Commercial 0.10 4093.00 0.10 40441.80 0.10 Case Rate 57250 Priced Cmbn ant pst colprhy 199049 57260 CPT Outpatient 46323.90 7952.27 Emblem Emblem Commercial 0.09 4093.00 0.09 46323.90 0.09 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 199049 57265 CPT Outpatient 42586.95 7310.76 Emblem Emblem Commercial 0.10 4093.00 0.10 42586.95 0.10 Case Rate 57265 Priced Repair of bowel bulge 199049 57268 CPT Outpatient 36865.50 6328.58 Emblem Emblem Commercial 0.11 4093.00 0.11 36865.50 0.11 Case Rate 57268 Priced Colpopexy extraperitoneal 199049 57282 CPT Outpatient 45629.85 7833.12 Emblem Emblem Commercial 0.09 4093.00 0.09 45629.85 0.09 Case Rate 57282 Priced Repair bladder defect 199049 57288 CPT Outpatient 43069.95 7393.67 Emblem Emblem Commercial 0.10 4093.00 0.10 43069.95 0.10 Case Rate 57288 Priced Bx/curett of cervix w/scope 199049 57454 CPT Outpatient 2888.55 442.93 Emblem Emblem Commercial 0.45 1310.00 0.45 2888.55 0.45 Case Rate 57454 Priced Conization of cervix 199049 57520 CPT Outpatient 26728.80 4588.44 Emblem Emblem Commercial 0.15 4093.00 0.15 26728.80 0.15 Case Rate 57520 Priced Conization of cervix 199049 57522 CPT Outpatient 22737.75 3903.31 Emblem Emblem Commercial 0.18 4093.00 0.18 22737.75 0.18 Case Rate 57522 Priced Biopsy of uterus lining 199049 58100 CPT Outpatient 2371.95 194.80 Emblem Emblem Commercial 0.45 1075.50 0.45 2371.95 0.45 Case Rate 58100 Priced Catheter for hysterography 199049 58340 CPT Outpatient 6322.05 131.04 Emblem Emblem Commercial 0.45 2867.00 0.45 6322.05 0.45 Case Rate 58340 Priced Reopen fallopian tube 199049 58350 CPT Outpatient 46507.65 7983.81 Emblem Emblem Commercial 0.09 4093.00 0.09 46507.65 0.09 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 199049 58542 CPT Outpatient 64194.90 11020.12 Emblem Emblem Commercial 0.06 4093.00 0.06 64194.90 0.06 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 199049 58544 CPT Outpatient 51020.55 8758.53 Emblem Emblem Commercial 0.08 4093.00 0.08 51020.55 0.08 Case Rate 58544 Priced Laparoscopic myomectomy 199049 58545 CPT Outpatient 56946.75 9775.86 Emblem Emblem Commercial 0.07 4093.00 0.07 56946.75 0.07 Case Rate 58545 Priced Laparo-vag hyst incl t/o 199049 58552 CPT Outpatient 57228.15 9824.17 Emblem Emblem Commercial 0.07 4093.00 0.07 57228.15 0.07 Case Rate 58552 Priced Hysteroscopy biopsy 199049 58558 CPT Outpatient 28581.00 2077.02 Emblem Emblem Commercial 0.14 4093.00 0.14 28581.00 0.14 Case Rate 58558 Priced Hysteroscopy remove myoma 199049 58561 CPT Outpatient 35222.25 6046.49 Emblem Emblem Commercial 0.12 4093.00 0.12 35222.25 0.12 Case Rate 58561 Priced Hysteroscopy ablation 199049 58563 CPT Outpatient 38399.55 6591.92 Emblem Emblem Commercial 0.11 4093.00 0.11 38399.55 0.11 Case Rate 58563 Priced Tlh uterus 250 g or less 199049 58570 CPT Outpatient 43316.70 7436.03 Emblem Emblem Commercial 0.09 4093.00 0.09 43316.70 0.09 Case Rate 58570 Priced Tlh w/t/o 250 g or less 199049 58571 CPT Outpatient 48603.45 8343.59 Emblem Emblem Commercial 0.08 4093.00 0.08 48603.45 0.08 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 199049 58573 CPT Outpatient 52905.30 9082.08 Emblem Emblem Commercial 0.08 4093.00 0.08 52905.30 0.08 Case Rate 58573 Priced Laparoscopy remove adnexa 199049 58661 CPT Outpatient 47008.50 8069.79 Emblem Emblem Commercial 0.09 4093.00 0.09 47008.50 0.09 Case Rate 58661 Priced Laparoscopy excise lesions 199049 58662 CPT Outpatient 45053.40 7734.17 Emblem Emblem Commercial 0.09 4093.00 0.09 45053.40 0.09 Case Rate 58662 Priced Treat ectopic pregnancy 199049 59151 CPT Outpatient 74690.70 12821.90 Emblem Emblem Commercial 0.05 4093.00 0.05 74690.70 0.05 Case Rate 59151 Priced Treatment of miscarriage 199049 59812 CPT Outpatient 56109.90 9632.20 Emblem Emblem Commercial 0.07 4093.00 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 199049 60220 CPT Outpatient 53639.25 9208.07 Emblem Emblem Commercial 0.08 4093.00 0.08 53639.25 0.08 Case Rate 60220 Priced Removal of thyroid 199049 60240 CPT Outpatient 98252.70 16866.71 Emblem Emblem Commercial 0.04 4093.00 0.04 98252.70 0.04 Case Rate 60240 Priced Explore parathyroid glands 199049 60500 CPT Outpatient 150495.45 25835.05 Emblem Emblem Commercial 0.03 4093.00 0.03 150495.45 0.03 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 199049 62322 CPT Outpatient 43709.40 514.24 Emblem Emblem Commercial 0.09 4093.00 0.09 43709.40 0.09 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 199049 62323 CPT Outpatient 8304.45 467.31 Emblem Emblem Commercial 0.34 2791.00 0.34 8304.45 0.34 Case Rate 62323 Priced Low back disk surgery 199049 63030 CPT Outpatient 50287.65 8632.71 Emblem Emblem Commercial 0.08 4093.00 0.08 50287.65 0.08 Case Rate 63030 Priced Inc for vagus n elect impl 199049 64568 CPT Outpatient 124562.55 21383.24 Emblem Emblem Commercial 0.03 4093.00 0.03 124562.55 0.03 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 199049 66821 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 199049 66984 CPT Outpatient 0.01 0.01 Emblem Emblem Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 280043 216 DRG Inpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 280043 460 DRG Inpatient 416122.79 53834.63 Horizon BCBS Horizon HMO 0.19 77752.48 0.19 416122.79 0.19 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 280043 470 DRG Inpatient 167912.19 21723.13 Horizon BCBS Horizon HMO 0.22 37589.76 0.22 167912.19 0.22 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 280043 473 DRG Inpatient 100687.91 13026.19 Horizon BCBS Horizon HMO 0.50 50223.68 0.50 100687.91 0.50 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 280043 743 DRG Inpatient 102691.67 13285.42 Horizon BCBS Horizon HMO 0.22 22407.84 0.22 102691.67 0.22 Case Rate 743 Priced NORMAL NEWBORN 280043 795 DRG Inpatient 6266.93 2335.00 Horizon BCBS Horizon HMO 0.32 2005.12 0.32 6266.93 0.32 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 280043 807 DRG Inpatient 116469.59 4193.00 Horizon BCBS Horizon HMO 0.08 8802.56 0.08 116469.59 0.08 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 280043 788 DRG Inpatient 76050.77 4538.00 Horizon BCBS Horizon HMO 0.23 17120.48 0.23 76050.77 0.23 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 280043 59400 CPT Inpatient 116469.59 4193.00 Horizon BCBS Horizon HMO 0.08 8802.56 0.08 116469.59 0.08 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 280043 59510 CPT Inpatient 76050.77 4538.00 Horizon BCBS Horizon HMO 0.23 17120.48 0.23 76050.77 0.23 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 280043 59610 CPT Inpatient 116469.59 4193.00 Horizon BCBS Horizon HMO 0.08 8802.56 0.08 116469.59 0.08 Case Rate 59610 Priced "Psychotherapy, 30 min" 280043 90832 CPT Outpatient 577.50 91.21 Horizon BCBS Horizon HMO 0.33 190.70 0.33 577.50 0.33 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 280043 90834 CPT Outpatient 44134.65 271.96 Horizon BCBS Horizon HMO 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 280043 90837 CPT Outpatient 2240.70 442.93 Horizon BCBS Horizon HMO 0.06 142.16 0.06 2240.70 0.06 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 280043 90846 CPT Outpatient 0.01 131.50 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 280043 90847 CPT Outpatient 44134.65 369.97 Horizon BCBS Horizon HMO 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90847 Priced Group psychotherapy 280043 90853 CPT Outpatient 44134.65 101.99 Horizon BCBS Horizon HMO 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 280043 99203 CPT Outpatient 3480.75 176.07 Horizon BCBS Horizon HMO 0.31 1094.64 0.31 3480.75 0.31 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 280043 99204 CPT Outpatient 2103.15 233.39 Horizon BCBS Horizon HMO 0.31 661.22 0.31 2103.15 0.31 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 280043 99205 CPT Outpatient 4970.70 314.28 Horizon BCBS Horizon HMO 0.16 781.54 0.16 4970.70 0.16 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 280043 99243 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 280043 99244 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 280043 99385 CPT Outpatient 1114.05 185.90 Horizon BCBS Horizon HMO 0.31 350.20 0.31 1114.05 0.31 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 280043 99386 CPT Outpatient 4877.25 185.90 Horizon BCBS Horizon HMO 0.31 1533.31 0.31 4877.25 0.31 Fee Schedule 99386 Priced Routine venipuncture 280043 36415 CPT Outpatient 127.05 19.57 Horizon BCBS Horizon HMO 0.33 41.95 0.33 127.05 0.33 Fee Schedule 36415 Priced Basic Metabolic Panel 280043 80048 CPT Outpatient 576.45 88.78 Horizon BCBS Horizon HMO 0.33 190.36 0.33 576.45 0.33 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 280043 80053 CPT Outpatient 763.35 117.56 Horizon BCBS Horizon HMO 0.33 252.08 0.33 763.35 0.33 Fee Schedule 80053 Priced Obstetric blood test panel 280043 80055 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 280043 80061 CPT Outpatient 1349.25 197.77 Horizon BCBS Horizon HMO 0.31 424.06 0.31 1349.25 0.31 Fee Schedule 80061 Priced Kidney function panel test 280043 80069 CPT Outpatient 716.10 104.95 Horizon BCBS Horizon HMO 0.31 225.04 0.31 716.10 0.31 Fee Schedule 80069 Priced Liver function panel test 280043 80076 CPT Outpatient 716.10 104.95 Horizon BCBS Horizon HMO 0.31 225.04 0.31 716.10 0.31 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 280043 81000 CPT Outpatient 144.90 21.18 Horizon BCBS Horizon HMO 0.31 45.43 0.31 144.90 0.31 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 280043 81001 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 280043 81002 CPT Outpatient 57.75 8.89 Horizon BCBS Horizon HMO 0.33 19.07 0.33 57.75 0.33 Fee Schedule 81002 Priced Automated urinalysis test 280043 81003 CPT Outpatient 219.45 33.80 Horizon BCBS Horizon HMO 0.33 72.47 0.33 219.45 0.33 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 280043 82306 CPT Outpatient 1880.55 289.62 Horizon BCBS Horizon HMO 0.33 621.00 0.33 1880.55 0.33 Fee Schedule 82306 Priced Glycosylated hemoglobin test 280043 83036 CPT Outpatient 494.55 76.17 Horizon BCBS Horizon HMO 0.33 163.31 0.33 494.55 0.33 Fee Schedule 83036 Priced PSA (prostate specific antigen) 280043 84153 CPT Outpatient 1177.05 181.28 Horizon BCBS Horizon HMO 0.33 388.69 0.33 1177.05 0.33 Fee Schedule 84153 Priced PSA (prostate specific antigen) 280043 84154 CPT Outpatient 598.50 92.17 Horizon BCBS Horizon HMO 0.33 197.64 0.33 598.50 0.33 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 280043 84443 CPT Outpatient 519.75 80.05 Horizon BCBS Horizon HMO 0.33 171.63 0.33 519.75 0.33 Fee Schedule 84443 Priced Chorionic gonadotropin assay 280043 84703 CPT Outpatient 785.40 120.96 Horizon BCBS Horizon HMO 0.33 259.36 0.33 785.40 0.33 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 280043 85025 CPT Outpatient 635.25 97.83 Horizon BCBS Horizon HMO 0.33 209.78 0.33 635.25 0.33 Fee Schedule 85025 Priced "Complete blood count, automated" 280043 85027 CPT Outpatient 576.45 88.78 Horizon BCBS Horizon HMO 0.33 190.36 0.33 576.45 0.33 Fee Schedule 85027 Priced "Blood test, clotting time" 280043 85610 CPT Outpatient 404.25 62.26 Horizon BCBS Horizon HMO 0.33 133.49 0.33 404.25 0.33 Fee Schedule 85610 Priced Coagulation assessment blood test 280043 85730 CPT Outpatient 17.22 2.65 Horizon BCBS Horizon HMO 0.33 5.69 0.33 17.22 0.33 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 280043 86003 CPT Outpatient 32.55 5.01 Horizon BCBS Horizon HMO 0.33 10.75 0.33 32.55 0.33 Fee Schedule 86003 Priced Tb test cell immun measure 280043 86480 CPT Outpatient 530.25 81.66 Horizon BCBS Horizon HMO 0.33 175.10 0.33 530.25 0.33 Fee Schedule 86480 Priced Urine culture/colony count 280043 87086 CPT Outpatient 763.35 117.56 Horizon BCBS Horizon HMO 0.33 252.08 0.33 763.35 0.33 Fee Schedule 87086 Priced Hpylori stool ia 280043 87338 CPT Outpatient 785.40 120.96 Horizon BCBS Horizon HMO 0.33 259.36 0.33 785.40 0.33 Fee Schedule 87338 Priced Cytopath eval fna report 280043 88173 CPT Outpatient 750.75 115.62 Horizon BCBS Horizon HMO 0.33 247.92 0.33 750.75 0.33 Fee Schedule 88173 Priced Tissue exam by pathologist 280043 88302 CPT Outpatient 635.25 97.83 Horizon BCBS Horizon HMO 0.33 209.78 0.33 635.25 0.33 Fee Schedule 88302 Priced Tissue exam by pathologist 280043 88305 CPT Outpatient 323.40 49.81 Horizon BCBS Horizon HMO 0.33 106.80 0.33 323.40 0.33 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 280043 11042 CPT Outpatient 2668.05 481.45 Horizon BCBS Horizon HMO 0.31 839.10 0.31 2668.05 0.31 Case Rate 11042 Priced Deb subq tissue add-on 280043 11045 CPT Outpatient 4652.55 330.00 Horizon BCBS Horizon HMO 0.31 1463.23 0.31 4652.55 0.31 Case Rate 11045 Priced Dx bronchoscope/lavage 280043 31624 CPT Outpatient 41223.00 7602.31 Horizon BCBS Horizon HMO 0.14 5642.00 0.14 41223.00 0.14 Case Rate 31624 Priced Bronchoscopy/lung bx each 280043 31628 CPT Outpatient 49048.65 9045.51 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 49048.65 0.12 Case Rate 31628 Priced Blood transfusion service 280043 36430 CPT Outpatient 9166.50 574.93 Horizon BCBS Horizon HMO 0.31 2882.77 0.31 9166.50 0.31 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 280043 43235 CPT Outpatient 8856.75 1633.35 Horizon BCBS Horizon HMO 0.32 2796.08 0.32 8856.75 0.32 Case Rate 43235 Priced Endoscopic us exam esoph 280043 43237 CPT Outpatient 23867.55 4401.63 Horizon BCBS Horizon HMO 0.24 5642.00 0.24 23867.55 0.24 Case Rate 43237 Priced Egd us fine needle bx/aspir 280043 43238 CPT Outpatient 30690.45 5659.90 Horizon BCBS Horizon HMO 0.18 5642.00 0.18 30690.45 0.18 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 280043 43239 CPT Outpatient 40191.90 7412.15 Horizon BCBS Horizon HMO 0.14 5642.00 0.14 40191.90 0.14 Case Rate 43239 Priced Ercp remove duct calculi 280043 43264 CPT Outpatient 34335.00 6332.03 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 34335.00 0.16 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 280043 45378 CPT Outpatient 13991.25 889.35 Horizon BCBS Horizon HMO 0.32 4408.05 0.32 13991.25 0.32 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 280043 45380 CPT Outpatient 22215.90 4097.04 Horizon BCBS Horizon HMO 0.25 5642.00 0.25 22215.90 0.25 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 280043 45385 CPT Outpatient 119569.80 22050.95 Horizon BCBS Horizon HMO 0.05 5642.00 0.05 119569.80 0.05 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 280043 45391 CPT Outpatient 24923.85 4596.43 Horizon BCBS Horizon HMO 0.23 5642.00 0.23 24923.85 0.23 Case Rate 45391 Priced Fragmenting of kidney stone 280043 50590 CPT Outpatient 40930.05 7548.28 Horizon BCBS Horizon HMO 0.14 5642.00 0.14 40930.05 0.14 Case Rate 50590 Priced Fetal non-stress test 280043 59025 CPT Outpatient 3153.15 477.76 Horizon BCBS Horizon HMO 0.31 991.66 0.31 3153.15 0.31 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 280043 64483 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 280043 92567 CPT Outpatient 2224.95 98.50 Horizon BCBS Horizon HMO 0.31 699.71 0.31 2224.95 0.31 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 280043 93000 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 280043 93017 CPT Outpatient 3076.50 532.96 Horizon BCBS Horizon HMO 0.31 967.40 0.31 3076.50 0.31 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 280043 93452 CPT Outpatient 55621.65 8611.87 Horizon BCBS Horizon HMO 0.17 9210.24 0.17 55621.65 0.17 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 280043 95810 CPT Outpatient 20341.65 3373.48 Horizon BCBS Horizon HMO 0.31 6397.28 0.31 20341.65 0.31 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 280043 95811 CPT Outpatient 22491.00 3731.18 Horizon BCBS Horizon HMO 0.31 7073.41 0.31 22491.00 0.31 Case Rate 95811 Priced Eeg 41-60 minutes 280043 95812 CPT Outpatient 5578.65 925.83 Horizon BCBS Horizon HMO 0.31 1754.48 0.31 5578.65 0.31 Case Rate 95812 Priced Genetic counseling 30 min 280043 96040 CPT Outpatient 0.01 102.81 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 280043 96413 CPT Outpatient 4856.25 472.45 Horizon BCBS Horizon HMO 0.76 3712.97 0.76 4856.25 0.76 Case Rate 96413 Priced Ultrasound therapy 280043 97035 CPT Outpatient 2111.55 134.99 Horizon BCBS Horizon HMO 0.17 358.49 0.17 2111.55 0.17 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 280043 97110 CPT Outpatient 6494.25 92.86 Horizon BCBS Horizon HMO 0.17 1102.61 0.17 6494.25 0.17 Case Rate 97110 Priced Gait training therapy 280043 97116 CPT Outpatient 4723.95 110.61 Horizon BCBS Horizon HMO 0.17 801.96 0.17 4723.95 0.17 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 280043 70450 CPT Outpatient 8566.95 835.61 Horizon BCBS Horizon HMO 0.16 1375.92 0.16 8566.95 0.16 Case Rate 70450 Priced Mri brain stem w/o dye 280043 70551 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon HMO 0.31 2472.23 0.31 7861.35 0.31 Case Rate 70551 Priced MRI scan of brain before and after contrast 280043 70553 CPT Outpatient 10882.20 1625.88 Horizon BCBS Horizon HMO 0.31 3422.29 0.31 10882.20 0.31 Case Rate 70553 Priced X-ray exam chest 2 views 280043 71046 CPT Outpatient 859.95 150.37 Horizon BCBS Horizon HMO 0.31 270.45 0.31 859.95 0.31 Case Rate 71046 Priced Ct thorax w/o dye 280043 71250 CPT Outpatient 7288.05 1261.63 Horizon BCBS Horizon HMO 0.31 2291.92 0.31 7288.05 0.31 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 280043 72082 CPT Outpatient 2022.30 253.33 Horizon BCBS Horizon HMO 0.37 756.24 0.37 2022.30 0.37 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 280043 72100 CPT Outpatient 1599.15 277.38 Horizon BCBS Horizon HMO 0.31 502.77 0.31 1599.15 0.31 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 280043 72110 CPT Outpatient 1389.15 241.04 Horizon BCBS Horizon HMO 0.31 436.88 0.31 1389.15 0.31 Case Rate 72110 Priced MRI scan of lower spinal canal 280043 72148 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon HMO 0.31 2472.23 0.31 7861.35 0.31 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 280043 72193 CPT Outpatient 13671.00 1412.01 Horizon BCBS Horizon HMO 0.31 4299.53 0.31 13671.00 0.31 Case Rate 72193 Priced X-ray exam of shoulder 280043 73030 CPT Outpatient 1452.15 251.43 Horizon BCBS Horizon HMO 0.31 456.65 0.31 1452.15 0.31 Case Rate 73030 Priced X-ray exam of elbow 280043 73080 CPT Outpatient 1356.60 235.68 Horizon BCBS Horizon HMO 0.31 426.48 0.31 1356.60 0.31 Case Rate 73080 Priced X-ray exam of forearm 280043 73090 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon HMO 0.31 390.77 0.31 1243.20 0.31 Case Rate 73090 Priced X-ray exam of wrist 280043 73110 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon HMO 0.31 390.77 0.31 1243.20 0.31 Case Rate 73110 Priced X-ray exam of hand 280043 73130 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon HMO 0.31 390.77 0.31 1243.20 0.31 Case Rate 73130 Priced X-ray exam hips bi 2 views 280043 73521 CPT Outpatient 970.20 228.41 Horizon BCBS Horizon HMO 0.43 412.62 0.43 970.20 0.43 Case Rate 73521 Priced X-ray exam of knee 3 280043 73562 CPT Outpatient 802.20 139.12 Horizon BCBS Horizon HMO 0.31 252.08 0.31 802.20 0.31 Case Rate 73562 Priced X-ray exam of lower leg 280043 73590 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon HMO 0.31 390.77 0.31 1243.20 0.31 Case Rate 73590 Priced X-ray exam of ankle 280043 73610 CPT Outpatient 1378.65 239.31 Horizon BCBS Horizon HMO 0.31 433.42 0.31 1378.65 0.31 Case Rate 73610 Priced X-ray exam of foot 280043 73630 CPT Outpatient 975.45 169.41 Horizon BCBS Horizon HMO 0.31 306.52 0.31 975.45 0.31 Case Rate 73630 Priced MRI scan of leg joint 280043 73721 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon HMO 0.31 2472.23 0.31 7861.35 0.31 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 280043 74177 CPT Outpatient 14222.25 1412.01 Horizon BCBS Horizon HMO 0.31 4472.89 0.31 14222.25 0.31 Case Rate 74177 Priced Contrst x-ray exam of throat 280043 74210 CPT Outpatient 0.01 440.39 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 280043 76098 CPT Outpatient 6141.45 407.86 Horizon BCBS Horizon HMO 0.31 1931.32 0.31 6141.45 0.31 Case Rate 76098 Priced Us exam of head and neck 280043 76536 CPT Outpatient 5512.50 955.18 Horizon BCBS Horizon HMO 0.31 1733.68 0.31 5512.50 0.31 Case Rate 76536 Priced Ultrasound breast limited 280043 76642 CPT Outpatient 5777.10 127.70 Horizon BCBS Horizon HMO 0.31 1816.90 0.31 5777.10 0.31 Case Rate 76642 Priced Ultrasound of abdomen 280043 76700 CPT Outpatient 4917.15 851.88 Horizon BCBS Horizon HMO 0.31 1546.44 0.31 4917.15 0.31 Case Rate 76700 Priced Echo exam of abdomen 280043 76705 CPT Outpatient 3836.70 665.17 Horizon BCBS Horizon HMO 0.31 1206.64 0.31 3836.70 0.31 Case Rate 76705 Priced Us exam abdo back wall comp 280043 76770 CPT Outpatient 5171.25 895.48 Horizon BCBS Horizon HMO 0.31 1626.20 0.31 5171.25 0.31 Case Rate 76770 Priced Us exam abdo back wall lim 280043 76775 CPT Outpatient 3969.00 686.97 Horizon BCBS Horizon HMO 0.31 1248.25 0.31 3969.00 0.31 Case Rate 76775 Priced Ob us < 14 wks single fetus 280043 76801 CPT Outpatient 2006.55 347.98 Horizon BCBS Horizon HMO 0.31 631.06 0.31 2006.55 0.31 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 280043 76805 CPT Outpatient 3969.00 686.97 Horizon BCBS Horizon HMO 0.31 1248.25 0.31 3969.00 0.31 Case Rate 76805 Priced Ob us detailed sngl fetus 280043 76811 CPT Outpatient 2844.45 492.99 Horizon BCBS Horizon HMO 0.31 894.58 0.31 2844.45 0.31 Case Rate 76811 Priced Ob us nuchal meas 1 gest 280043 76813 CPT Outpatient 1044.75 180.83 Horizon BCBS Horizon HMO 0.31 328.36 0.31 1044.75 0.31 Case Rate 76813 Priced Ob us limited fetus(s) 280043 76815 CPT Outpatient 6428.10 639.90 Horizon BCBS Horizon HMO 0.31 2021.47 0.31 6428.10 0.31 Case Rate 76815 Priced Ob us follow-up per fetus 280043 76816 CPT Outpatient 4818.45 833.88 Horizon BCBS Horizon HMO 0.31 1515.24 0.31 4818.45 0.31 Case Rate 76816 Priced Transvaginal us obstetric 280043 76817 CPT Outpatient 6428.10 476.73 Horizon BCBS Horizon HMO 0.31 2021.47 0.31 6428.10 0.31 Case Rate 76817 Priced Fetal biophys profil w/o nst 280043 76819 CPT Outpatient 1741.95 302.65 Horizon BCBS Horizon HMO 0.31 547.84 0.31 1741.95 0.31 Case Rate 76819 Priced Ultrasound pelvis through vagina 280043 76830 CPT Outpatient 9305.10 806.54 Horizon BCBS Horizon HMO 0.31 2926.46 0.31 9305.10 0.31 Case Rate 76830 Priced Us exam scrotum 280043 76870 CPT Outpatient 6328.35 1096.55 Horizon BCBS Horizon HMO 0.31 1990.27 0.31 6328.35 0.31 Case Rate 76870 Priced Us exam infant hips dynamic 280043 76885 CPT Outpatient 3836.70 665.17 Horizon BCBS Horizon HMO 0.31 1206.64 0.31 3836.70 0.31 Case Rate 76885 Priced Mammography of one breast 280043 77065 CPT Outpatient 3451.35 192.07 Horizon BCBS Horizon HMO 0.31 1085.28 0.31 3451.35 0.31 Case Rate 77065 Priced Mammography of both breasts 280043 77066 CPT Outpatient 5777.10 235.68 Horizon BCBS Horizon HMO 0.31 1816.90 0.31 5777.10 0.31 Case Rate 77066 Priced "Mamography, screening bilateral" 280043 77067 CPT Outpatient 1416.45 205.57 Horizon BCBS Horizon HMO 0.31 445.21 0.31 1416.45 0.31 Case Rate 77067 Priced X-rays for bone age 280043 77072 CPT Outpatient 2022.30 163.87 Horizon BCBS Horizon HMO 0.37 756.24 0.37 2022.30 0.37 Case Rate 77072 Priced Joint survey single view 280043 77077 CPT Outpatient 985.95 171.14 Horizon BCBS Horizon HMO 0.31 309.98 0.31 985.95 0.31 Case Rate 77077 Priced Dxa bone density axial 280043 77080 CPT Outpatient 3257.10 319.09 Horizon BCBS Horizon HMO 0.31 1024.25 0.31 3257.10 0.31 Case Rate 77080 Priced Fna bx w/us gdn 1st les 280043 10005 CPT Outpatient 5512.50 547.24 Horizon BCBS Horizon HMO 0.31 1733.68 0.31 5512.50 0.31 Case Rate 10005 Priced Fna bx w/us gdn ea addl 280043 10006 CPT Outpatient 10628.10 594.83 Horizon BCBS Horizon HMO 0.31 3342.54 0.31 10628.10 0.31 Case Rate 10006 Priced Drainage of hematoma/fluid 280043 10140 CPT Outpatient 23209.20 1081.95 Horizon BCBS Horizon HMO 0.24 5642.00 0.24 23209.20 0.24 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 280043 11042 CPT Outpatient 2668.05 481.45 Horizon BCBS Horizon HMO 0.31 839.10 0.31 2668.05 0.31 Case Rate 11042 Priced Deb bone 20 sq cm/< 280043 11044 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 280043 11406 CPT Outpatient 19967.85 3427.81 Horizon BCBS Horizon HMO 0.28 5642.00 0.28 19967.85 0.28 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 280043 11424 CPT Outpatient 0.01 1004.93 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 280043 11770 CPT Outpatient 19173.00 3291.37 Horizon BCBS Horizon HMO 0.29 5642.00 0.29 19173.00 0.29 Case Rate 11770 Priced Replace tissue expander 280043 11970 CPT Outpatient 59239.95 10169.52 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 59239.95 0.10 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 280043 14020 CPT Outpatient 32166.75 5521.96 Horizon BCBS Horizon HMO 0.18 5642.00 0.18 32166.75 0.18 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 280043 14060 CPT Outpatient 25993.80 1374.69 Horizon BCBS Horizon HMO 0.22 5642.00 0.22 25993.80 0.22 Case Rate 14060 Priced Wound prep trk/arm/leg 280043 15002 CPT Outpatient 41748.00 1441.73 Horizon BCBS Horizon HMO 0.14 5642.00 0.14 41748.00 0.14 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 280043 15271 CPT Outpatient 24343.20 3769.48 Horizon BCBS Horizon HMO 0.30 7413.21 0.30 24343.20 0.30 Case Rate 15271 Priced Acellular derm matrix implt 280043 15777 CPT Outpatient 101672.55 17453.79 Horizon BCBS Horizon HMO 0.06 5642.00 0.06 101672.55 0.06 Case Rate 15777 Priced Exc skin abd 280043 15830 CPT Outpatient 54696.60 9389.58 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 54696.60 0.10 Case Rate 15830 Priced Dressing change not for burn 280043 15852 CPT Outpatient 0.01 290.74 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 280043 15877 CPT Outpatient 63741.30 10942.26 Horizon BCBS Horizon HMO 0.09 5642.00 0.09 63741.30 0.09 Case Rate 15877 Priced Suction lipectomy lwr extrem 280043 15879 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 280043 19000 CPT Outpatient 10143.00 594.83 Horizon BCBS Horizon HMO 0.31 3189.97 0.31 10143.00 0.31 Case Rate 19000 Priced Bx breast 1st lesion strtctc 280043 19081 CPT Outpatient 12341.70 1250.69 Horizon BCBS Horizon HMO 0.31 3881.36 0.31 12341.70 0.31 Case Rate 19081 Priced Bx breast add lesion us imag 280043 19084 CPT Outpatient 29058.75 547.24 Horizon BCBS Horizon HMO 0.19 5642.00 0.19 29058.75 0.19 Case Rate 19084 Priced Biopsy of breast open 280043 19101 CPT Outpatient 39545.10 2737.82 Horizon BCBS Horizon HMO 0.14 5642.00 0.14 39545.10 0.14 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 280043 19120 CPT Outpatient 35761.95 2737.82 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 35761.95 0.16 Case Rate 19120 Priced Excision breast lesion 280043 19125 CPT Outpatient 33184.20 0.01 Horizon BCBS Horizon HMO 0.17 5642.00 0.17 33184.20 0.17 Case Rate 19125 Priced Perq device breast 1st imag 280043 19281 CPT Outpatient 6141.45 598.61 Horizon BCBS Horizon HMO 0.31 1931.32 0.31 6141.45 0.31 Case Rate 19281 Priced Perq device breast ea imag 280043 19282 CPT Outpatient 8379.00 319.04 Horizon BCBS Horizon HMO 0.31 2635.19 0.31 8379.00 0.31 Case Rate 19282 Priced Partial mastectomy 280043 19301 CPT Outpatient 39157.65 6722.06 Horizon BCBS Horizon HMO 0.14 5642.00 0.14 39157.65 0.14 Case Rate 19301 Priced Mast simple complete 280043 19303 CPT Outpatient 105389.55 18091.87 Horizon BCBS Horizon HMO 0.05 5642.00 0.05 105389.55 0.05 Case Rate 19303 Priced Reduction of large breast 280043 19318 CPT Outpatient 65239.65 11199.47 Horizon BCBS Horizon HMO 0.09 5642.00 0.09 65239.65 0.09 Case Rate 19318 Priced Immediate breast prosthesis 280043 19340 CPT Outpatient 113100.75 19415.63 Horizon BCBS Horizon HMO 0.05 5642.00 0.05 113100.75 0.05 Case Rate 19340 Priced Delayed breast prosthesis 280043 19342 CPT Outpatient 56988.75 9783.07 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 56988.75 0.10 Case Rate 19342 Priced Breast reconstruction 280043 19357 CPT Outpatient 101672.55 17453.79 Horizon BCBS Horizon HMO 0.06 5642.00 0.06 101672.55 0.06 Case Rate 19357 Priced Breast reconstruction 280043 19366 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 280043 19380 CPT Outpatient 61493.25 10556.34 Horizon BCBS Horizon HMO 0.09 5642.00 0.09 61493.25 0.09 Case Rate 19380 Priced Removal of support implant 280043 20680 CPT Outpatient 42329.70 7266.60 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 42329.70 0.13 Case Rate 20680 Priced Cerv artific diskectomy 280043 22856 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 280043 24538 CPT Outpatient 51237.90 4775.24 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 51237.90 0.11 Case Rate 24538 Priced Remove wrist tendon lesion 280043 25111 CPT Outpatient 25855.20 4438.48 Horizon BCBS Horizon HMO 0.22 5642.00 0.22 25855.20 0.22 Case Rate 25111 Priced Incise finger tendon sheath 280043 26055 CPT Outpatient 15862.35 2723.04 Horizon BCBS Horizon HMO 0.32 5024.90 0.32 15862.35 0.32 Case Rate 26055 Priced Treat finger fracture each 280043 26727 CPT Outpatient 22779.75 2030.47 Horizon BCBS Horizon HMO 0.25 5642.00 0.25 22779.75 0.25 Case Rate 26727 Priced Revision of knee joint 280043 27446 CPT Outpatient 67882.50 11653.16 Horizon BCBS Horizon HMO 0.24 16406.00 0.24 67882.50 0.24 Case Rate 27446 Priced Total knee arthroplasty 280043 27447 CPT Outpatient 130698.75 22436.62 Horizon BCBS Horizon HMO 0.13 16406.00 0.13 130698.75 0.13 Case Rate 27447 Priced Surgery to stop leg growth 280043 27485 CPT Outpatient 43310.40 7434.95 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 43310.40 0.13 Case Rate 27485 Priced Repair achilles tendon 280043 27650 CPT Outpatient 38246.25 3762.57 Horizon BCBS Horizon HMO 0.15 5642.00 0.15 38246.25 0.15 Case Rate 27650 Priced Treatment of ankle fracture 280043 27792 CPT Outpatient 36101.10 6197.36 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 36101.10 0.16 Case Rate 27792 Priced Treatment of ankle fracture 280043 27814 CPT Outpatient 49405.65 8481.30 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 49405.65 0.11 Case Rate 27814 Priced Removal of foot lesion 280043 28080 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 280043 28285 CPT Outpatient 68603.85 11776.99 Horizon BCBS Horizon HMO 0.08 5642.00 0.08 68603.85 0.08 Case Rate 28285 Priced Correction hallux valgus 280043 28296 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 280043 29823 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 280043 29826 CPT Outpatient 49840.35 8555.93 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 49840.35 0.11 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 280043 29881 CPT Outpatient 35556.15 6103.81 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 35556.15 0.16 Case Rate 29881 Priced Knee arthroscopy/surgery 280043 29882 CPT Outpatient 61099.50 10488.75 Horizon BCBS Horizon HMO 0.09 5642.00 0.09 61099.50 0.09 Case Rate 29882 Priced Percut bx lung/mediastinum 280043 32405 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 280043 32555 CPT Outpatient 14597.10 687.29 Horizon BCBS Horizon HMO 0.28 4073.11 0.28 14597.10 0.28 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 280043 32664 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 280043 35190 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 280043 36478 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 280043 36561 CPT Outpatient 53531.10 3292.99 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 53531.10 0.11 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 280043 36569 CPT Outpatient 31421.25 1299.06 Horizon BCBS Horizon HMO 0.18 5642.00 0.18 31421.25 0.18 Case Rate 36569 Priced Removal tunneled cv cath 280043 36590 CPT Outpatient 1996.05 273.95 Horizon BCBS Horizon HMO 0.32 630.36 0.32 1996.05 0.32 Case Rate 36590 Priced Av fuse uppr arm basilic 280043 36819 CPT Outpatient 56861.70 9761.26 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 56861.70 0.10 Case Rate 36819 Priced Av fusion direct any site 280043 36821 CPT Outpatient 42953.40 7373.67 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 42953.40 0.13 Case Rate 36821 Priced Artery-vein autograft 280043 36825 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 280043 36830 CPT Outpatient 53656.05 9210.96 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 53656.05 0.11 Case Rate 36830 Priced Av fistula revision open 280043 36832 CPT Outpatient 52492.65 9011.24 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 52492.65 0.11 Case Rate 36832 Priced Av fistula revision 280043 36833 CPT Outpatient 37098.60 6368.59 Horizon BCBS Horizon HMO 0.15 5642.00 0.15 37098.60 0.15 Case Rate 36833 Priced Intro cath dialysis circuit 280043 36903 CPT Outpatient 77541.45 10669.90 Horizon BCBS Horizon HMO 0.07 5642.00 0.07 77541.45 0.07 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 280043 36906 CPT Outpatient 96694.50 16175.64 Horizon BCBS Horizon HMO 0.06 5642.00 0.06 96694.50 0.06 Case Rate 36906 Priced Fem/popl revas w/tla 280043 37224 CPT Outpatient 200076.45 5139.31 Horizon BCBS Horizon HMO 0.05 9210.24 0.05 200076.45 0.05 Case Rate 37224 Priced Fem/popl revasc stnt & ather 280043 37227 CPT Outpatient 117170.55 18045.38 Horizon BCBS Horizon HMO 0.08 9210.24 0.08 117170.55 0.08 Case Rate 37227 Priced Revise leg vein 280043 37700 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 280043 37722 CPT Outpatient 27815.55 4775.00 Horizon BCBS Horizon HMO 0.20 5642.00 0.20 27815.55 0.20 Case Rate 37722 Priced Stab phleb veins xtr 10-20 280043 37765 CPT Outpatient 26561.85 4559.78 Horizon BCBS Horizon HMO 0.21 5642.00 0.21 26561.85 0.21 Case Rate 37765 Priced Biopsy/removal lymph nodes 280043 38500 CPT Outpatient 35955.15 6172.30 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 35955.15 0.16 Case Rate 38500 Priced Biopsy/removal lymph nodes 280043 38525 CPT Outpatient 101194.80 17371.77 Horizon BCBS Horizon HMO 0.06 5642.00 0.06 101194.80 0.06 Case Rate 38525 Priced Laparoscopy lymph node biop 280043 38570 CPT Outpatient 65631.30 11266.71 Horizon BCBS Horizon HMO 0.09 5642.00 0.09 65631.30 0.09 Case Rate 38570 Priced Laparoscopy lymphadenectomy 280043 38571 CPT Outpatient 84031.50 14425.41 Horizon BCBS Horizon HMO 0.07 5642.00 0.07 84031.50 0.07 Case Rate 38571 Priced Laparoscopy lymphadenectomy 280043 38572 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 280043 38792 CPT Outpatient 2868.60 432.48 Horizon BCBS Horizon HMO 0.31 901.86 0.31 2868.60 0.31 Case Rate 38792 Priced Excision of gum lesion 280043 41825 CPT Outpatient 11580.45 1987.98 Horizon BCBS Horizon HMO 0.32 3685.12 0.32 11580.45 0.32 Case Rate 41825 Priced Reconstruct cleft palate 280043 42200 CPT Outpatient 36703.80 6300.82 Horizon BCBS Horizon HMO 0.15 5642.00 0.15 36703.80 0.15 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 280043 42820 CPT Outpatient 17232.60 2958.26 Horizon BCBS Horizon HMO 0.32 5548.12 0.32 17232.60 0.32 Case Rate 42820 Priced Control throat bleeding 280043 42960 CPT Outpatient 24066.00 4131.33 Horizon BCBS Horizon HMO 0.23 5642.00 0.23 24066.00 0.23 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 280043 43235 CPT Outpatient 8856.75 1633.35 Horizon BCBS Horizon HMO 0.32 2796.08 0.32 8856.75 0.32 Case Rate 43235 Priced Laparoscopy fundoplasty 280043 43280 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 280043 43282 CPT Outpatient 84344.40 14479.12 Horizon BCBS Horizon HMO 0.07 5642.00 0.07 84344.40 0.07 Case Rate 43282 Priced Laparoscopy appendectomy 280043 44970 CPT Outpatient 82300.05 14128.18 Horizon BCBS Horizon HMO 0.07 5642.00 0.07 82300.05 0.07 Case Rate 44970 Priced Diagnostic sigmoidoscopy 280043 45330 CPT Outpatient 17286.15 542.26 Horizon BCBS Horizon HMO 0.32 5445.49 0.32 17286.15 0.32 Case Rate 45330 Priced Needle biopsy of liver 280043 47000 CPT Outpatient 10398.15 1225.34 Horizon BCBS Horizon HMO 0.31 3270.07 0.31 10398.15 0.31 Case Rate 47000 Priced Removal of gallbladder using an endoscope 280043 47562 CPT Outpatient 58430.40 10030.55 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 280043 47563 CPT Outpatient 71747.55 12316.66 Horizon BCBS Horizon HMO 0.08 5642.00 0.08 71747.55 0.08 Case Rate 47563 Priced Abd paracentesis w/imaging 280043 49083 CPT Outpatient 6979.35 1113.95 Horizon BCBS Horizon HMO 0.31 2194.84 0.31 6979.35 0.31 Case Rate 49083 Priced Diag laparo separate proc 280043 49320 CPT Outpatient 31629.15 5429.67 Horizon BCBS Horizon HMO 0.18 5642.00 0.18 31629.15 0.18 Case Rate 49320 Priced Laparoscopy biopsy 280043 49321 CPT Outpatient 41892.90 7191.61 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 41892.90 0.13 Case Rate 49321 Priced Laparoscopy aspiration 280043 49322 CPT Outpatient 34392.75 5904.09 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 34392.75 0.16 Case Rate 49322 Priced Lap insert tunnel ip cath 280043 49324 CPT Outpatient 39264.75 6740.45 Horizon BCBS Horizon HMO 0.14 5642.00 0.14 39264.75 0.14 Case Rate 49324 Priced Laparo proc abdm/per/oment 280043 49329 CPT Outpatient 58696.05 10076.16 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 58696.05 0.10 Case Rate 49329 Priced Ins tun ip cath for dial opn 280043 49421 CPT Outpatient 25460.40 3319.30 Horizon BCBS Horizon HMO 0.22 5642.00 0.22 25460.40 0.22 Case Rate 49421 Priced Remove tunneled ip cath 280043 49422 CPT Outpatient 25515.00 4380.08 Horizon BCBS Horizon HMO 0.22 5642.00 0.22 25515.00 0.22 Case Rate 49422 Priced Rpr ing hernia init reduce 280043 49500 CPT Outpatient 19594.05 3363.65 Horizon BCBS Horizon HMO 0.29 5642.00 0.29 19594.05 0.29 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 280043 49505 CPT Outpatient 34915.65 5993.85 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 34915.65 0.16 Case Rate 49505 Priced Prp i/hern init block >5 yr 280043 49507 CPT Outpatient 29794.80 5114.77 Horizon BCBS Horizon HMO 0.19 5642.00 0.19 29794.80 0.19 Case Rate 49507 Priced Rerepair ing hernia reduce 280043 49520 CPT Outpatient 36940.05 6341.38 Horizon BCBS Horizon HMO 0.15 5642.00 0.15 36940.05 0.15 Case Rate 49520 Priced Rpr ventral hern init reduc 280043 49560 CPT Outpatient 53177.25 9128.76 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 53177.25 0.11 Case Rate 49560 Priced Rpr ventral hern init block 280043 49561 CPT Outpatient 30755.55 5279.70 Horizon BCBS Horizon HMO 0.18 5642.00 0.18 30755.55 0.18 Case Rate 49561 Priced Rerepair ventrl hern reduce 280043 49565 CPT Outpatient 69917.40 12002.49 Horizon BCBS Horizon HMO 0.08 5642.00 0.08 69917.40 0.08 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 280043 49585 CPT Outpatient 41806.80 7176.83 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 41806.80 0.13 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 280043 49587 CPT Outpatient 37320.15 6406.63 Horizon BCBS Horizon HMO 0.15 5642.00 0.15 37320.15 0.15 Case Rate 49587 Priced Lap ing hernia repair init 280043 49650 CPT Outpatient 41932.80 7198.46 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 41932.80 0.13 Case Rate 49650 Priced Lap ing hernia repair recur 280043 49651 CPT Outpatient 46915.05 8053.75 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 46915.05 0.12 Case Rate 49651 Priced Lap vent/abd hernia repair 280043 49652 CPT Outpatient 51294.60 8805.57 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 51294.60 0.11 Case Rate 49652 Priced Lap vent/abd hern proc comp 280043 49653 CPT Outpatient 46102.35 7914.24 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 46102.35 0.12 Case Rate 49653 Priced Lap inc hernia repair 280043 49654 CPT Outpatient 47221.65 8106.38 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 47221.65 0.12 Case Rate 49654 Priced Lap inc hern repair comp 280043 49655 CPT Outpatient 54590.55 9371.38 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 54590.55 0.10 Case Rate 49655 Priced Lap inc hernia repair recur 280043 49656 CPT Outpatient 55443.15 9517.74 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 55443.15 0.10 Case Rate 49656 Priced Removal of kidney stone 280043 50080 CPT Outpatient 53165.70 9126.78 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 53165.70 0.11 Case Rate 50080 Priced Removal of kidney stone 280043 50081 CPT Outpatient 66931.20 11489.86 Horizon BCBS Horizon HMO 0.08 5642.00 0.08 66931.20 0.08 Case Rate 50081 Priced Renal biopsy perq 280043 50200 CPT Outpatient 43096.20 1225.34 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 43096.20 0.13 Case Rate 50200 Priced Plmt nephroureteral catheter 280043 50433 CPT Outpatient 64566.60 1424.48 Horizon BCBS Horizon HMO 0.09 5642.00 0.09 64566.60 0.09 Case Rate 50433 Priced Laparo radical nephrectomy 280043 50545 CPT Outpatient 43449.00 7458.75 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 43449.00 0.13 Case Rate 50545 Priced Laparoscope proc ureter 280043 50949 CPT Outpatient 49986.30 8580.98 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 49986.30 0.11 Case Rate 50949 Priced Injection for bladder x-ray 280043 51600 CPT Outpatient 3285.45 89.22 Horizon BCBS Horizon HMO 0.31 1033.27 0.31 3285.45 0.31 Case Rate 51600 Priced Cystoscopy 280043 52000 CPT Outpatient 22149.75 3802.37 Horizon BCBS Horizon HMO 0.25 5642.00 0.25 22149.75 0.25 Case Rate 52000 Priced Cystoscopy & ureter catheter 280043 52005 CPT Outpatient 42529.20 2095.77 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 42529.20 0.13 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 280043 52204 CPT Outpatient 31274.25 5368.75 Horizon BCBS Horizon HMO 0.18 5642.00 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 280043 52224 CPT Outpatient 13445.25 2308.10 Horizon BCBS Horizon HMO 0.32 4242.32 0.32 13445.25 0.32 Case Rate 52224 Priced Cystoscopy and treatment 280043 52234 CPT Outpatient 28510.65 4894.33 Horizon BCBS Horizon HMO 0.20 5642.00 0.20 28510.65 0.20 Case Rate 52234 Priced Cystoscopy and treatment 280043 52235 CPT Outpatient 29417.85 5050.06 Horizon BCBS Horizon HMO 0.19 5642.00 0.19 29417.85 0.19 Case Rate 52235 Priced Cystoscopy and treatment 280043 52240 CPT Outpatient 33933.90 5825.32 Horizon BCBS Horizon HMO 0.17 5642.00 0.17 33933.90 0.17 Case Rate 52240 Priced Cystoscopy and treatment 280043 52281 CPT Outpatient 22159.20 3804.00 Horizon BCBS Horizon HMO 0.25 5642.00 0.25 22159.20 0.25 Case Rate 52281 Priced Remove bladder stone 280043 52317 CPT Outpatient 27085.80 4649.73 Horizon BCBS Horizon HMO 0.21 5642.00 0.21 27085.80 0.21 Case Rate 52317 Priced Remove bladder stone 280043 52318 CPT Outpatient 26685.75 4581.05 Horizon BCBS Horizon HMO 0.21 5642.00 0.21 26685.75 0.21 Case Rate 52318 Priced Cystoscopy and treatment 280043 52332 CPT Outpatient 115306.80 19794.33 Horizon BCBS Horizon HMO 0.05 5642.00 0.05 115306.80 0.05 Case Rate 52332 Priced Cystouretero w/stone remove 280043 52352 CPT Outpatient 42420.00 7282.10 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 42420.00 0.13 Case Rate 52352 Priced Cystouretero w/lithotripsy 280043 52353 CPT Outpatient 38608.50 6627.79 Horizon BCBS Horizon HMO 0.15 5642.00 0.15 38608.50 0.15 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 280043 52356 CPT Outpatient 36255.45 6223.85 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 36255.45 0.16 Case Rate 52356 Priced Prostatectomy (turp) 280043 52601 CPT Outpatient 35371.35 6072.08 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 35371.35 0.16 Case Rate 52601 Priced Laser surgery of prostate 280043 52648 CPT Outpatient 24264.45 4165.40 Horizon BCBS Horizon HMO 0.23 5642.00 0.23 24264.45 0.23 Case Rate 52648 Priced Revision of urethra 280043 53450 CPT Outpatient 16209.90 2782.70 Horizon BCBS Horizon HMO 0.32 5123.03 0.32 16209.90 0.32 Case Rate 53450 Priced Urology surgery procedure 280043 53899 CPT Outpatient 25368.00 134.83 Horizon BCBS Horizon HMO 0.22 5642.00 0.22 25368.00 0.22 Case Rate 53899 Priced Circumcision w/regionl block 280043 54150 CPT Outpatient 14700.00 2523.50 Horizon BCBS Horizon HMO 0.31 4621.30 0.31 14700.00 0.31 Case Rate 54150 Priced Circum 28 days or older 280043 54161 CPT Outpatient 19186.65 3293.71 Horizon BCBS Horizon HMO 0.29 5642.00 0.29 19186.65 0.29 Case Rate 54161 Priced Lysis penil circumic lesion 280043 54162 CPT Outpatient 19795.65 3398.25 Horizon BCBS Horizon HMO 0.29 5642.00 0.29 19795.65 0.29 Case Rate 54162 Priced Repair of circumcision 280043 54163 CPT Outpatient 16391.55 2813.88 Horizon BCBS Horizon HMO 0.31 5159.78 0.31 16391.55 0.31 Case Rate 54163 Priced Reconstruction of urethra 280043 54324 CPT Outpatient 32880.75 5644.53 Horizon BCBS Horizon HMO 0.17 5642.00 0.17 32880.75 0.17 Case Rate 54324 Priced Revise penis/urethra 280043 54332 CPT Outpatient 19968.90 3427.99 Horizon BCBS Horizon HMO 0.28 5642.00 0.28 19968.90 0.28 Case Rate 54332 Priced Insert self-contd prosthesis 280043 54401 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 280043 54520 CPT Outpatient 35442.75 6084.34 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 35442.75 0.16 Case Rate 54520 Priced Reduce testis torsion 280043 54600 CPT Outpatient 55049.40 9450.15 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 55049.40 0.10 Case Rate 54600 Priced Suspension of testis 280043 54640 CPT Outpatient 26860.05 4610.98 Horizon BCBS Horizon HMO 0.21 5642.00 0.21 26860.05 0.21 Case Rate 54640 Priced Removal of hydrocele 280043 55040 CPT Outpatient 27277.95 4682.71 Horizon BCBS Horizon HMO 0.21 5642.00 0.21 27277.95 0.21 Case Rate 55040 Priced Biopsy of prostate gland 280043 55700 CPT Outpatient 28699.65 4926.77 Horizon BCBS Horizon HMO 0.20 5642.00 0.20 28699.65 0.20 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 280043 55866 CPT Outpatient 93088.80 15980.24 Horizon BCBS Horizon HMO 0.06 5642.00 0.06 93088.80 0.06 Case Rate 55866 Priced Closure of vagina 280043 57120 CPT Outpatient 34369.65 5900.12 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 34369.65 0.16 Case Rate 57120 Priced Repair of vagina 280043 57200 CPT Outpatient 25247.25 4334.11 Horizon BCBS Horizon HMO 0.22 5642.00 0.22 25247.25 0.22 Case Rate 57200 Priced Anterior colporrhaphy 280043 57240 CPT Outpatient 36210.30 6216.10 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 36210.30 0.16 Case Rate 57240 Priced Repair rectum & vagina 280043 57250 CPT Outpatient 40441.80 6942.51 Horizon BCBS Horizon HMO 0.14 5642.00 0.14 40441.80 0.14 Case Rate 57250 Priced Cmbn ant pst colprhy 280043 57260 CPT Outpatient 46323.90 7952.27 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 46323.90 0.12 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 280043 57265 CPT Outpatient 42586.95 7310.76 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 42586.95 0.13 Case Rate 57265 Priced Repair of bowel bulge 280043 57268 CPT Outpatient 36865.50 6328.58 Horizon BCBS Horizon HMO 0.15 5642.00 0.15 36865.50 0.15 Case Rate 57268 Priced Colpopexy extraperitoneal 280043 57282 CPT Outpatient 45629.85 7833.12 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 45629.85 0.12 Case Rate 57282 Priced Repair bladder defect 280043 57288 CPT Outpatient 43069.95 7393.67 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 43069.95 0.13 Case Rate 57288 Priced Bx/curett of cervix w/scope 280043 57454 CPT Outpatient 2888.55 442.93 Horizon BCBS Horizon HMO 0.31 908.45 0.31 2888.55 0.31 Case Rate 57454 Priced Conization of cervix 280043 57520 CPT Outpatient 26728.80 4588.44 Horizon BCBS Horizon HMO 0.21 5642.00 0.21 26728.80 0.21 Case Rate 57520 Priced Conization of cervix 280043 57522 CPT Outpatient 22737.75 3903.31 Horizon BCBS Horizon HMO 0.25 5642.00 0.25 22737.75 0.25 Case Rate 57522 Priced Biopsy of uterus lining 280043 58100 CPT Outpatient 2371.95 194.80 Horizon BCBS Horizon HMO 0.31 745.83 0.31 2371.95 0.31 Case Rate 58100 Priced Catheter for hysterography 280043 58340 CPT Outpatient 6322.05 131.04 Horizon BCBS Horizon HMO 0.31 1988.19 0.31 6322.05 0.31 Case Rate 58340 Priced Reopen fallopian tube 280043 58350 CPT Outpatient 46507.65 7983.81 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 46507.65 0.12 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 280043 58542 CPT Outpatient 64194.90 11020.12 Horizon BCBS Horizon HMO 0.09 5642.00 0.09 64194.90 0.09 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 280043 58544 CPT Outpatient 51020.55 8758.53 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 51020.55 0.11 Case Rate 58544 Priced Laparoscopic myomectomy 280043 58545 CPT Outpatient 56946.75 9775.86 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 56946.75 0.10 Case Rate 58545 Priced Laparo-vag hyst incl t/o 280043 58552 CPT Outpatient 57228.15 9824.17 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 57228.15 0.10 Case Rate 58552 Priced Hysteroscopy biopsy 280043 58558 CPT Outpatient 28581.00 2077.02 Horizon BCBS Horizon HMO 0.20 5642.00 0.20 28581.00 0.20 Case Rate 58558 Priced Hysteroscopy remove myoma 280043 58561 CPT Outpatient 35222.25 6046.49 Horizon BCBS Horizon HMO 0.16 5642.00 0.16 35222.25 0.16 Case Rate 58561 Priced Hysteroscopy ablation 280043 58563 CPT Outpatient 38399.55 6591.92 Horizon BCBS Horizon HMO 0.15 5642.00 0.15 38399.55 0.15 Case Rate 58563 Priced Tlh uterus 250 g or less 280043 58570 CPT Outpatient 43316.70 7436.03 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 43316.70 0.13 Case Rate 58570 Priced Tlh w/t/o 250 g or less 280043 58571 CPT Outpatient 48603.45 8343.59 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 48603.45 0.12 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 280043 58573 CPT Outpatient 52905.30 9082.08 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 52905.30 0.11 Case Rate 58573 Priced Laparoscopy remove adnexa 280043 58661 CPT Outpatient 47008.50 8069.79 Horizon BCBS Horizon HMO 0.12 5642.00 0.12 47008.50 0.12 Case Rate 58661 Priced Laparoscopy excise lesions 280043 58662 CPT Outpatient 45053.40 7734.17 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 45053.40 0.13 Case Rate 58662 Priced Treat ectopic pregnancy 280043 59151 CPT Outpatient 74690.70 12821.90 Horizon BCBS Horizon HMO 0.08 5642.00 0.08 74690.70 0.08 Case Rate 59151 Priced Treatment of miscarriage 280043 59812 CPT Outpatient 56109.90 9632.20 Horizon BCBS Horizon HMO 0.10 5642.00 0.10 56109.90 0.10 Case Rate 59812 Priced Partial removal of thyroid 280043 60220 CPT Outpatient 53639.25 9208.07 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 280043 60240 CPT Outpatient 98252.70 16866.71 Horizon BCBS Horizon HMO 0.06 5642.00 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 280043 60500 CPT Outpatient 150495.45 25835.05 Horizon BCBS Horizon HMO 0.04 5642.00 0.04 150495.45 0.04 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 280043 62322 CPT Outpatient 43709.40 514.24 Horizon BCBS Horizon HMO 0.13 5642.00 0.13 43709.40 0.13 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 280043 62323 CPT Outpatient 8304.45 467.31 Horizon BCBS Horizon HMO 0.68 5642.00 0.68 8304.45 0.68 Case Rate 62323 Priced Low back disk surgery 280043 63030 CPT Outpatient 50287.65 8632.71 Horizon BCBS Horizon HMO 0.11 5642.00 0.11 50287.65 0.11 Case Rate 63030 Priced Inc for vagus n elect impl 280043 64568 CPT Outpatient 124562.55 21383.24 Horizon BCBS Horizon HMO 0.05 5642.00 0.05 124562.55 0.05 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 280043 66821 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 280043 66984 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon HMO 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 280063 216 DRG Inpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 280063 460 DRG Inpatient 416122.79 53834.63 Horizon BCBS Horizon PPO 0.19 77752.48 0.19 416122.79 0.19 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 280063 470 DRG Inpatient 167912.19 21723.13 Horizon BCBS Horizon PPO 0.22 37589.76 0.22 167912.19 0.22 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 280063 473 DRG Inpatient 100687.91 13026.19 Horizon BCBS Horizon PPO 0.50 50223.68 0.50 100687.91 0.50 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 280063 743 DRG Inpatient 102691.67 13285.42 Horizon BCBS Horizon PPO 0.22 22407.84 0.22 102691.67 0.22 Case Rate 743 Priced NORMAL NEWBORN 280063 795 DRG Inpatient 6266.93 2335.00 Horizon BCBS Horizon PPO 0.32 2005.12 0.32 6266.93 0.32 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 280063 807 DRG Inpatient 116469.59 4193.00 Horizon BCBS Horizon PPO 0.09 10063.04 0.09 116469.59 0.09 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 280063 788 DRG Inpatient 76050.77 4538.00 Horizon BCBS Horizon PPO 0.25 18796.96 0.25 76050.77 0.25 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 280063 59400 CPT Inpatient 116469.59 4193.00 Horizon BCBS Horizon PPO 0.09 10063.04 0.09 116469.59 0.09 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 280063 59510 CPT Inpatient 76050.77 4538.00 Horizon BCBS Horizon PPO 0.25 18796.96 0.25 76050.77 0.25 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 280063 59610 CPT Inpatient 116469.59 4193.00 Horizon BCBS Horizon PPO 0.09 10063.04 0.09 116469.59 0.09 Case Rate 59610 Priced "Psychotherapy, 30 min" 280063 90832 CPT Outpatient 577.50 91.21 Horizon BCBS Horizon PPO 0.33 190.70 0.33 577.50 0.33 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 280063 90834 CPT Outpatient 44134.65 271.96 Horizon BCBS Horizon PPO 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 280063 90837 CPT Outpatient 2240.70 442.93 Horizon BCBS Horizon PPO 0.06 142.16 0.06 2240.70 0.06 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 280063 90846 CPT Outpatient 0.01 131.50 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 280063 90847 CPT Outpatient 44134.65 369.97 Horizon BCBS Horizon PPO 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90847 Priced Group psychotherapy 280063 90853 CPT Outpatient 44134.65 101.99 Horizon BCBS Horizon PPO 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 280063 99203 CPT Outpatient 3480.75 176.07 Horizon BCBS Horizon PPO 0.31 1094.64 0.31 3480.75 0.31 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 280063 99204 CPT Outpatient 2103.15 233.39 Horizon BCBS Horizon PPO 0.31 661.22 0.31 2103.15 0.31 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 280063 99205 CPT Outpatient 4970.70 314.28 Horizon BCBS Horizon PPO 0.16 781.54 0.16 4970.70 0.16 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 280063 99243 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 280063 99244 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 280063 99385 CPT Outpatient 1114.05 185.90 Horizon BCBS Horizon PPO 0.31 350.20 0.31 1114.05 0.31 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 280063 99386 CPT Outpatient 4877.25 185.90 Horizon BCBS Horizon PPO 0.31 1533.31 0.31 4877.25 0.31 Fee Schedule 99386 Priced Routine venipuncture 280063 36415 CPT Outpatient 127.05 19.57 Horizon BCBS Horizon PPO 0.33 41.95 0.33 127.05 0.33 Fee Schedule 36415 Priced Basic Metabolic Panel 280063 80048 CPT Outpatient 576.45 88.78 Horizon BCBS Horizon PPO 0.33 190.36 0.33 576.45 0.33 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 280063 80053 CPT Outpatient 763.35 117.56 Horizon BCBS Horizon PPO 0.33 252.08 0.33 763.35 0.33 Fee Schedule 80053 Priced Obstetric blood test panel 280063 80055 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 280063 80061 CPT Outpatient 1349.25 197.77 Horizon BCBS Horizon PPO 0.31 424.06 0.31 1349.25 0.31 Fee Schedule 80061 Priced Kidney function panel test 280063 80069 CPT Outpatient 716.10 104.95 Horizon BCBS Horizon PPO 0.31 225.04 0.31 716.10 0.31 Fee Schedule 80069 Priced Liver function panel test 280063 80076 CPT Outpatient 716.10 104.95 Horizon BCBS Horizon PPO 0.31 225.04 0.31 716.10 0.31 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 280063 81000 CPT Outpatient 144.90 21.18 Horizon BCBS Horizon PPO 0.31 45.43 0.31 144.90 0.31 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 280063 81001 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 280063 81002 CPT Outpatient 57.75 8.89 Horizon BCBS Horizon PPO 0.33 19.07 0.33 57.75 0.33 Fee Schedule 81002 Priced Automated urinalysis test 280063 81003 CPT Outpatient 219.45 33.80 Horizon BCBS Horizon PPO 0.33 72.47 0.33 219.45 0.33 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 280063 82306 CPT Outpatient 1880.55 289.62 Horizon BCBS Horizon PPO 0.33 621.00 0.33 1880.55 0.33 Fee Schedule 82306 Priced Glycosylated hemoglobin test 280063 83036 CPT Outpatient 494.55 76.17 Horizon BCBS Horizon PPO 0.33 163.31 0.33 494.55 0.33 Fee Schedule 83036 Priced PSA (prostate specific antigen) 280063 84153 CPT Outpatient 1177.05 181.28 Horizon BCBS Horizon PPO 0.33 388.69 0.33 1177.05 0.33 Fee Schedule 84153 Priced PSA (prostate specific antigen) 280063 84154 CPT Outpatient 598.50 92.17 Horizon BCBS Horizon PPO 0.33 197.64 0.33 598.50 0.33 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 280063 84443 CPT Outpatient 519.75 80.05 Horizon BCBS Horizon PPO 0.33 171.63 0.33 519.75 0.33 Fee Schedule 84443 Priced Chorionic gonadotropin assay 280063 84703 CPT Outpatient 785.40 120.96 Horizon BCBS Horizon PPO 0.33 259.36 0.33 785.40 0.33 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 280063 85025 CPT Outpatient 635.25 97.83 Horizon BCBS Horizon PPO 0.33 209.78 0.33 635.25 0.33 Fee Schedule 85025 Priced "Complete blood count, automated" 280063 85027 CPT Outpatient 576.45 88.78 Horizon BCBS Horizon PPO 0.33 190.36 0.33 576.45 0.33 Fee Schedule 85027 Priced "Blood test, clotting time" 280063 85610 CPT Outpatient 404.25 62.26 Horizon BCBS Horizon PPO 0.33 133.49 0.33 404.25 0.33 Fee Schedule 85610 Priced Coagulation assessment blood test 280063 85730 CPT Outpatient 17.22 2.65 Horizon BCBS Horizon PPO 0.33 5.69 0.33 17.22 0.33 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 280063 86003 CPT Outpatient 32.55 5.01 Horizon BCBS Horizon PPO 0.33 10.75 0.33 32.55 0.33 Fee Schedule 86003 Priced Tb test cell immun measure 280063 86480 CPT Outpatient 530.25 81.66 Horizon BCBS Horizon PPO 0.33 175.10 0.33 530.25 0.33 Fee Schedule 86480 Priced Urine culture/colony count 280063 87086 CPT Outpatient 763.35 117.56 Horizon BCBS Horizon PPO 0.33 252.08 0.33 763.35 0.33 Fee Schedule 87086 Priced Hpylori stool ia 280063 87338 CPT Outpatient 785.40 120.96 Horizon BCBS Horizon PPO 0.33 259.36 0.33 785.40 0.33 Fee Schedule 87338 Priced Cytopath eval fna report 280063 88173 CPT Outpatient 750.75 115.62 Horizon BCBS Horizon PPO 0.33 247.92 0.33 750.75 0.33 Fee Schedule 88173 Priced Tissue exam by pathologist 280063 88302 CPT Outpatient 635.25 97.83 Horizon BCBS Horizon PPO 0.33 209.78 0.33 635.25 0.33 Fee Schedule 88302 Priced Tissue exam by pathologist 280063 88305 CPT Outpatient 323.40 49.81 Horizon BCBS Horizon PPO 0.33 106.80 0.33 323.40 0.33 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 280063 11042 CPT Outpatient 2668.05 481.45 Horizon BCBS Horizon PPO 0.31 839.10 0.31 2668.05 0.31 Case Rate 11042 Priced Deb subq tissue add-on 280063 11045 CPT Outpatient 4652.55 330.00 Horizon BCBS Horizon PPO 0.31 1463.23 0.31 4652.55 0.31 Case Rate 11045 Priced Dx bronchoscope/lavage 280063 31624 CPT Outpatient 41223.00 7602.31 Horizon BCBS Horizon PPO 0.14 5642.00 0.14 41223.00 0.14 Case Rate 31624 Priced Bronchoscopy/lung bx each 280063 31628 CPT Outpatient 49048.65 9045.51 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 49048.65 0.12 Case Rate 31628 Priced Blood transfusion service 280063 36430 CPT Outpatient 9166.50 574.93 Horizon BCBS Horizon PPO 0.31 2882.77 0.31 9166.50 0.31 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 280063 43235 CPT Outpatient 8856.75 1633.35 Horizon BCBS Horizon PPO 0.32 2796.08 0.32 8856.75 0.32 Case Rate 43235 Priced Endoscopic us exam esoph 280063 43237 CPT Outpatient 23867.55 4401.63 Horizon BCBS Horizon PPO 0.24 5642.00 0.24 23867.55 0.24 Case Rate 43237 Priced Egd us fine needle bx/aspir 280063 43238 CPT Outpatient 30690.45 5659.90 Horizon BCBS Horizon PPO 0.18 5642.00 0.18 30690.45 0.18 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 280063 43239 CPT Outpatient 40191.90 7412.15 Horizon BCBS Horizon PPO 0.14 5642.00 0.14 40191.90 0.14 Case Rate 43239 Priced Ercp remove duct calculi 280063 43264 CPT Outpatient 34335.00 6332.03 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 34335.00 0.16 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 280063 45378 CPT Outpatient 13991.25 889.35 Horizon BCBS Horizon PPO 0.32 4408.05 0.32 13991.25 0.32 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 280063 45380 CPT Outpatient 22215.90 4097.04 Horizon BCBS Horizon PPO 0.25 5642.00 0.25 22215.90 0.25 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 280063 45385 CPT Outpatient 119569.80 22050.95 Horizon BCBS Horizon PPO 0.05 5642.00 0.05 119569.80 0.05 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 280063 45391 CPT Outpatient 24923.85 4596.43 Horizon BCBS Horizon PPO 0.23 5642.00 0.23 24923.85 0.23 Case Rate 45391 Priced Fragmenting of kidney stone 280063 50590 CPT Outpatient 40930.05 7548.28 Horizon BCBS Horizon PPO 0.14 5642.00 0.14 40930.05 0.14 Case Rate 50590 Priced Fetal non-stress test 280063 59025 CPT Outpatient 3153.15 477.76 Horizon BCBS Horizon PPO 0.31 991.66 0.31 3153.15 0.31 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 280063 64483 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 280063 92567 CPT Outpatient 2224.95 98.50 Horizon BCBS Horizon PPO 0.31 699.71 0.31 2224.95 0.31 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 280063 93000 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 280063 93017 CPT Outpatient 3076.50 532.96 Horizon BCBS Horizon PPO 0.31 967.40 0.31 3076.50 0.31 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 280063 93452 CPT Outpatient 55621.65 8611.87 Horizon BCBS Horizon PPO 0.17 9210.24 0.17 55621.65 0.17 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 280063 95810 CPT Outpatient 20341.65 3373.48 Horizon BCBS Horizon PPO 0.31 6397.28 0.31 20341.65 0.31 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 280063 95811 CPT Outpatient 22491.00 3731.18 Horizon BCBS Horizon PPO 0.31 7073.41 0.31 22491.00 0.31 Case Rate 95811 Priced Eeg 41-60 minutes 280063 95812 CPT Outpatient 5578.65 925.83 Horizon BCBS Horizon PPO 0.31 1754.48 0.31 5578.65 0.31 Case Rate 95812 Priced Genetic counseling 30 min 280063 96040 CPT Outpatient 0.01 102.81 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 280063 96413 CPT Outpatient 4856.25 472.45 Horizon BCBS Horizon PPO 0.76 3712.97 0.76 4856.25 0.76 Case Rate 96413 Priced Ultrasound therapy 280063 97035 CPT Outpatient 2111.55 134.99 Horizon BCBS Horizon PPO 0.17 358.49 0.17 2111.55 0.17 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 280063 97110 CPT Outpatient 6494.25 92.86 Horizon BCBS Horizon PPO 0.17 1102.61 0.17 6494.25 0.17 Case Rate 97110 Priced Gait training therapy 280063 97116 CPT Outpatient 4723.95 110.61 Horizon BCBS Horizon PPO 0.17 801.96 0.17 4723.95 0.17 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 280063 70450 CPT Outpatient 8566.95 835.61 Horizon BCBS Horizon PPO 0.18 1526.72 0.18 8566.95 0.18 Case Rate 70450 Priced Mri brain stem w/o dye 280063 70551 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon PPO 0.31 2472.23 0.31 7861.35 0.31 Case Rate 70551 Priced MRI scan of brain before and after contrast 280063 70553 CPT Outpatient 10882.20 1625.88 Horizon BCBS Horizon PPO 0.31 3422.29 0.31 10882.20 0.31 Case Rate 70553 Priced X-ray exam chest 2 views 280063 71046 CPT Outpatient 859.95 150.37 Horizon BCBS Horizon PPO 0.31 270.45 0.31 859.95 0.31 Case Rate 71046 Priced Ct thorax w/o dye 280063 71250 CPT Outpatient 7288.05 1261.63 Horizon BCBS Horizon PPO 0.31 2291.92 0.31 7288.05 0.31 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 280063 72082 CPT Outpatient 2022.30 253.33 Horizon BCBS Horizon PPO 0.37 756.24 0.37 2022.30 0.37 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 280063 72100 CPT Outpatient 1599.15 277.38 Horizon BCBS Horizon PPO 0.31 502.77 0.31 1599.15 0.31 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 280063 72110 CPT Outpatient 1389.15 241.04 Horizon BCBS Horizon PPO 0.31 436.88 0.31 1389.15 0.31 Case Rate 72110 Priced MRI scan of lower spinal canal 280063 72148 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon PPO 0.31 2472.23 0.31 7861.35 0.31 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 280063 72193 CPT Outpatient 13671.00 1412.01 Horizon BCBS Horizon PPO 0.31 4299.53 0.31 13671.00 0.31 Case Rate 72193 Priced X-ray exam of shoulder 280063 73030 CPT Outpatient 1452.15 251.43 Horizon BCBS Horizon PPO 0.31 456.65 0.31 1452.15 0.31 Case Rate 73030 Priced X-ray exam of elbow 280063 73080 CPT Outpatient 1356.60 235.68 Horizon BCBS Horizon PPO 0.31 426.48 0.31 1356.60 0.31 Case Rate 73080 Priced X-ray exam of forearm 280063 73090 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon PPO 0.31 390.77 0.31 1243.20 0.31 Case Rate 73090 Priced X-ray exam of wrist 280063 73110 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon PPO 0.31 390.77 0.31 1243.20 0.31 Case Rate 73110 Priced X-ray exam of hand 280063 73130 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon PPO 0.31 390.77 0.31 1243.20 0.31 Case Rate 73130 Priced X-ray exam hips bi 2 views 280063 73521 CPT Outpatient 970.20 228.41 Horizon BCBS Horizon PPO 0.43 412.62 0.43 970.20 0.43 Case Rate 73521 Priced X-ray exam of knee 3 280063 73562 CPT Outpatient 802.20 139.12 Horizon BCBS Horizon PPO 0.31 252.08 0.31 802.20 0.31 Case Rate 73562 Priced X-ray exam of lower leg 280063 73590 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon PPO 0.31 390.77 0.31 1243.20 0.31 Case Rate 73590 Priced X-ray exam of ankle 280063 73610 CPT Outpatient 1378.65 239.31 Horizon BCBS Horizon PPO 0.31 433.42 0.31 1378.65 0.31 Case Rate 73610 Priced X-ray exam of foot 280063 73630 CPT Outpatient 975.45 169.41 Horizon BCBS Horizon PPO 0.31 306.52 0.31 975.45 0.31 Case Rate 73630 Priced MRI scan of leg joint 280063 73721 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon PPO 0.31 2472.23 0.31 7861.35 0.31 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 280063 74177 CPT Outpatient 14222.25 1412.01 Horizon BCBS Horizon PPO 0.31 4472.89 0.31 14222.25 0.31 Case Rate 74177 Priced Contrst x-ray exam of throat 280063 74210 CPT Outpatient 0.01 440.39 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 280063 76098 CPT Outpatient 6141.45 407.86 Horizon BCBS Horizon PPO 0.31 1931.32 0.31 6141.45 0.31 Case Rate 76098 Priced Us exam of head and neck 280063 76536 CPT Outpatient 5512.50 955.18 Horizon BCBS Horizon PPO 0.31 1733.68 0.31 5512.50 0.31 Case Rate 76536 Priced Ultrasound breast limited 280063 76642 CPT Outpatient 5777.10 127.70 Horizon BCBS Horizon PPO 0.31 1816.90 0.31 5777.10 0.31 Case Rate 76642 Priced Ultrasound of abdomen 280063 76700 CPT Outpatient 4917.15 851.88 Horizon BCBS Horizon PPO 0.31 1546.44 0.31 4917.15 0.31 Case Rate 76700 Priced Echo exam of abdomen 280063 76705 CPT Outpatient 3836.70 665.17 Horizon BCBS Horizon PPO 0.31 1206.64 0.31 3836.70 0.31 Case Rate 76705 Priced Us exam abdo back wall comp 280063 76770 CPT Outpatient 5171.25 895.48 Horizon BCBS Horizon PPO 0.31 1626.20 0.31 5171.25 0.31 Case Rate 76770 Priced Us exam abdo back wall lim 280063 76775 CPT Outpatient 3969.00 686.97 Horizon BCBS Horizon PPO 0.31 1248.25 0.31 3969.00 0.31 Case Rate 76775 Priced Ob us < 14 wks single fetus 280063 76801 CPT Outpatient 2006.55 347.98 Horizon BCBS Horizon PPO 0.31 631.06 0.31 2006.55 0.31 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 280063 76805 CPT Outpatient 3969.00 686.97 Horizon BCBS Horizon PPO 0.31 1248.25 0.31 3969.00 0.31 Case Rate 76805 Priced Ob us detailed sngl fetus 280063 76811 CPT Outpatient 2844.45 492.99 Horizon BCBS Horizon PPO 0.31 894.58 0.31 2844.45 0.31 Case Rate 76811 Priced Ob us nuchal meas 1 gest 280063 76813 CPT Outpatient 1044.75 180.83 Horizon BCBS Horizon PPO 0.31 328.36 0.31 1044.75 0.31 Case Rate 76813 Priced Ob us limited fetus(s) 280063 76815 CPT Outpatient 6428.10 639.90 Horizon BCBS Horizon PPO 0.31 2021.47 0.31 6428.10 0.31 Case Rate 76815 Priced Ob us follow-up per fetus 280063 76816 CPT Outpatient 4818.45 833.88 Horizon BCBS Horizon PPO 0.31 1515.24 0.31 4818.45 0.31 Case Rate 76816 Priced Transvaginal us obstetric 280063 76817 CPT Outpatient 6428.10 476.73 Horizon BCBS Horizon PPO 0.31 2021.47 0.31 6428.10 0.31 Case Rate 76817 Priced Fetal biophys profil w/o nst 280063 76819 CPT Outpatient 1741.95 302.65 Horizon BCBS Horizon PPO 0.31 547.84 0.31 1741.95 0.31 Case Rate 76819 Priced Ultrasound pelvis through vagina 280063 76830 CPT Outpatient 9305.10 806.54 Horizon BCBS Horizon PPO 0.31 2926.46 0.31 9305.10 0.31 Case Rate 76830 Priced Us exam scrotum 280063 76870 CPT Outpatient 6328.35 1096.55 Horizon BCBS Horizon PPO 0.31 1990.27 0.31 6328.35 0.31 Case Rate 76870 Priced Us exam infant hips dynamic 280063 76885 CPT Outpatient 3836.70 665.17 Horizon BCBS Horizon PPO 0.31 1206.64 0.31 3836.70 0.31 Case Rate 76885 Priced Mammography of one breast 280063 77065 CPT Outpatient 3451.35 192.07 Horizon BCBS Horizon PPO 0.31 1085.28 0.31 3451.35 0.31 Case Rate 77065 Priced Mammography of both breasts 280063 77066 CPT Outpatient 5777.10 235.68 Horizon BCBS Horizon PPO 0.31 1816.90 0.31 5777.10 0.31 Case Rate 77066 Priced "Mamography, screening bilateral" 280063 77067 CPT Outpatient 1416.45 205.57 Horizon BCBS Horizon PPO 0.31 445.21 0.31 1416.45 0.31 Case Rate 77067 Priced X-rays for bone age 280063 77072 CPT Outpatient 2022.30 163.87 Horizon BCBS Horizon PPO 0.37 756.24 0.37 2022.30 0.37 Case Rate 77072 Priced Joint survey single view 280063 77077 CPT Outpatient 985.95 171.14 Horizon BCBS Horizon PPO 0.31 309.98 0.31 985.95 0.31 Case Rate 77077 Priced Dxa bone density axial 280063 77080 CPT Outpatient 3257.10 319.09 Horizon BCBS Horizon PPO 0.31 1024.25 0.31 3257.10 0.31 Case Rate 77080 Priced Fna bx w/us gdn 1st les 280063 10005 CPT Outpatient 5512.50 547.24 Horizon BCBS Horizon PPO 0.31 1733.68 0.31 5512.50 0.31 Case Rate 10005 Priced Fna bx w/us gdn ea addl 280063 10006 CPT Outpatient 10628.10 594.83 Horizon BCBS Horizon PPO 0.31 3342.54 0.31 10628.10 0.31 Case Rate 10006 Priced Drainage of hematoma/fluid 280063 10140 CPT Outpatient 23209.20 1081.95 Horizon BCBS Horizon PPO 0.24 5642.00 0.24 23209.20 0.24 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 280063 11042 CPT Outpatient 2668.05 481.45 Horizon BCBS Horizon PPO 0.31 839.10 0.31 2668.05 0.31 Case Rate 11042 Priced Deb bone 20 sq cm/< 280063 11044 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 280063 11406 CPT Outpatient 19967.85 3427.81 Horizon BCBS Horizon PPO 0.28 5642.00 0.28 19967.85 0.28 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 280063 11424 CPT Outpatient 0.01 1004.93 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 280063 11770 CPT Outpatient 19173.00 3291.37 Horizon BCBS Horizon PPO 0.29 5642.00 0.29 19173.00 0.29 Case Rate 11770 Priced Replace tissue expander 280063 11970 CPT Outpatient 59239.95 10169.52 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 59239.95 0.10 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 280063 14020 CPT Outpatient 32166.75 5521.96 Horizon BCBS Horizon PPO 0.18 5642.00 0.18 32166.75 0.18 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 280063 14060 CPT Outpatient 25993.80 1374.69 Horizon BCBS Horizon PPO 0.22 5642.00 0.22 25993.80 0.22 Case Rate 14060 Priced Wound prep trk/arm/leg 280063 15002 CPT Outpatient 41748.00 1441.73 Horizon BCBS Horizon PPO 0.14 5642.00 0.14 41748.00 0.14 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 280063 15271 CPT Outpatient 24343.20 3769.48 Horizon BCBS Horizon PPO 0.30 7413.21 0.30 24343.20 0.30 Case Rate 15271 Priced Acellular derm matrix implt 280063 15777 CPT Outpatient 101672.55 17453.79 Horizon BCBS Horizon PPO 0.06 5642.00 0.06 101672.55 0.06 Case Rate 15777 Priced Exc skin abd 280063 15830 CPT Outpatient 54696.60 9389.58 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 54696.60 0.10 Case Rate 15830 Priced Dressing change not for burn 280063 15852 CPT Outpatient 0.01 290.74 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 280063 15877 CPT Outpatient 63741.30 10942.26 Horizon BCBS Horizon PPO 0.09 5642.00 0.09 63741.30 0.09 Case Rate 15877 Priced Suction lipectomy lwr extrem 280063 15879 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 280063 19000 CPT Outpatient 10143.00 594.83 Horizon BCBS Horizon PPO 0.31 3189.97 0.31 10143.00 0.31 Case Rate 19000 Priced Bx breast 1st lesion strtctc 280063 19081 CPT Outpatient 12341.70 1250.69 Horizon BCBS Horizon PPO 0.31 3881.36 0.31 12341.70 0.31 Case Rate 19081 Priced Bx breast add lesion us imag 280063 19084 CPT Outpatient 29058.75 547.24 Horizon BCBS Horizon PPO 0.19 5642.00 0.19 29058.75 0.19 Case Rate 19084 Priced Biopsy of breast open 280063 19101 CPT Outpatient 39545.10 2737.82 Horizon BCBS Horizon PPO 0.14 5642.00 0.14 39545.10 0.14 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 280063 19120 CPT Outpatient 35761.95 2737.82 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 35761.95 0.16 Case Rate 19120 Priced Excision breast lesion 280063 19125 CPT Outpatient 33184.20 0.01 Horizon BCBS Horizon PPO 0.17 5642.00 0.17 33184.20 0.17 Case Rate 19125 Priced Perq device breast 1st imag 280063 19281 CPT Outpatient 6141.45 598.61 Horizon BCBS Horizon PPO 0.31 1931.32 0.31 6141.45 0.31 Case Rate 19281 Priced Perq device breast ea imag 280063 19282 CPT Outpatient 8379.00 319.04 Horizon BCBS Horizon PPO 0.31 2635.19 0.31 8379.00 0.31 Case Rate 19282 Priced Partial mastectomy 280063 19301 CPT Outpatient 39157.65 6722.06 Horizon BCBS Horizon PPO 0.14 5642.00 0.14 39157.65 0.14 Case Rate 19301 Priced Mast simple complete 280063 19303 CPT Outpatient 105389.55 18091.87 Horizon BCBS Horizon PPO 0.05 5642.00 0.05 105389.55 0.05 Case Rate 19303 Priced Reduction of large breast 280063 19318 CPT Outpatient 65239.65 11199.47 Horizon BCBS Horizon PPO 0.09 5642.00 0.09 65239.65 0.09 Case Rate 19318 Priced Immediate breast prosthesis 280063 19340 CPT Outpatient 113100.75 19415.63 Horizon BCBS Horizon PPO 0.05 5642.00 0.05 113100.75 0.05 Case Rate 19340 Priced Delayed breast prosthesis 280063 19342 CPT Outpatient 56988.75 9783.07 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 56988.75 0.10 Case Rate 19342 Priced Breast reconstruction 280063 19357 CPT Outpatient 101672.55 17453.79 Horizon BCBS Horizon PPO 0.06 5642.00 0.06 101672.55 0.06 Case Rate 19357 Priced Breast reconstruction 280063 19366 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 280063 19380 CPT Outpatient 61493.25 10556.34 Horizon BCBS Horizon PPO 0.09 5642.00 0.09 61493.25 0.09 Case Rate 19380 Priced Removal of support implant 280063 20680 CPT Outpatient 42329.70 7266.60 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 42329.70 0.13 Case Rate 20680 Priced Cerv artific diskectomy 280063 22856 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 280063 24538 CPT Outpatient 51237.90 4775.24 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 51237.90 0.11 Case Rate 24538 Priced Remove wrist tendon lesion 280063 25111 CPT Outpatient 25855.20 4438.48 Horizon BCBS Horizon PPO 0.22 5642.00 0.22 25855.20 0.22 Case Rate 25111 Priced Incise finger tendon sheath 280063 26055 CPT Outpatient 15862.35 2723.04 Horizon BCBS Horizon PPO 0.32 5024.90 0.32 15862.35 0.32 Case Rate 26055 Priced Treat finger fracture each 280063 26727 CPT Outpatient 22779.75 2030.47 Horizon BCBS Horizon PPO 0.25 5642.00 0.25 22779.75 0.25 Case Rate 26727 Priced Revision of knee joint 280063 27446 CPT Outpatient 67882.50 11653.16 Horizon BCBS Horizon PPO 0.24 16406.00 0.24 67882.50 0.24 Case Rate 27446 Priced Total knee arthroplasty 280063 27447 CPT Outpatient 130698.75 22436.62 Horizon BCBS Horizon PPO 0.13 16406.00 0.13 130698.75 0.13 Case Rate 27447 Priced Surgery to stop leg growth 280063 27485 CPT Outpatient 43310.40 7434.95 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 43310.40 0.13 Case Rate 27485 Priced Repair achilles tendon 280063 27650 CPT Outpatient 38246.25 3762.57 Horizon BCBS Horizon PPO 0.15 5642.00 0.15 38246.25 0.15 Case Rate 27650 Priced Treatment of ankle fracture 280063 27792 CPT Outpatient 36101.10 6197.36 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 36101.10 0.16 Case Rate 27792 Priced Treatment of ankle fracture 280063 27814 CPT Outpatient 49405.65 8481.30 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 49405.65 0.11 Case Rate 27814 Priced Removal of foot lesion 280063 28080 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 280063 28285 CPT Outpatient 68603.85 11776.99 Horizon BCBS Horizon PPO 0.08 5642.00 0.08 68603.85 0.08 Case Rate 28285 Priced Correction hallux valgus 280063 28296 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 280063 29823 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 280063 29826 CPT Outpatient 49840.35 8555.93 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 49840.35 0.11 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 280063 29881 CPT Outpatient 35556.15 6103.81 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 35556.15 0.16 Case Rate 29881 Priced Knee arthroscopy/surgery 280063 29882 CPT Outpatient 61099.50 10488.75 Horizon BCBS Horizon PPO 0.09 5642.00 0.09 61099.50 0.09 Case Rate 29882 Priced Percut bx lung/mediastinum 280063 32405 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 280063 32555 CPT Outpatient 14597.10 687.29 Horizon BCBS Horizon PPO 0.28 4073.11 0.28 14597.10 0.28 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 280063 32664 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 280063 35190 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 280063 36478 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 280063 36561 CPT Outpatient 53531.10 3292.99 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 53531.10 0.11 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 280063 36569 CPT Outpatient 31421.25 1299.06 Horizon BCBS Horizon PPO 0.18 5642.00 0.18 31421.25 0.18 Case Rate 36569 Priced Removal tunneled cv cath 280063 36590 CPT Outpatient 1996.05 273.95 Horizon BCBS Horizon PPO 0.32 630.36 0.32 1996.05 0.32 Case Rate 36590 Priced Av fuse uppr arm basilic 280063 36819 CPT Outpatient 56861.70 9761.26 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 56861.70 0.10 Case Rate 36819 Priced Av fusion direct any site 280063 36821 CPT Outpatient 42953.40 7373.67 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 42953.40 0.13 Case Rate 36821 Priced Artery-vein autograft 280063 36825 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 280063 36830 CPT Outpatient 53656.05 9210.96 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 53656.05 0.11 Case Rate 36830 Priced Av fistula revision open 280063 36832 CPT Outpatient 52492.65 9011.24 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 52492.65 0.11 Case Rate 36832 Priced Av fistula revision 280063 36833 CPT Outpatient 37098.60 6368.59 Horizon BCBS Horizon PPO 0.15 5642.00 0.15 37098.60 0.15 Case Rate 36833 Priced Intro cath dialysis circuit 280063 36903 CPT Outpatient 77541.45 10669.90 Horizon BCBS Horizon PPO 0.07 5642.00 0.07 77541.45 0.07 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 280063 36906 CPT Outpatient 96694.50 16175.64 Horizon BCBS Horizon PPO 0.06 5642.00 0.06 96694.50 0.06 Case Rate 36906 Priced Fem/popl revas w/tla 280063 37224 CPT Outpatient 200076.45 5139.31 Horizon BCBS Horizon PPO 0.05 9210.24 0.05 200076.45 0.05 Case Rate 37224 Priced Fem/popl revasc stnt & ather 280063 37227 CPT Outpatient 117170.55 18045.38 Horizon BCBS Horizon PPO 0.08 9210.24 0.08 117170.55 0.08 Case Rate 37227 Priced Revise leg vein 280063 37700 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 280063 37722 CPT Outpatient 27815.55 4775.00 Horizon BCBS Horizon PPO 0.20 5642.00 0.20 27815.55 0.20 Case Rate 37722 Priced Stab phleb veins xtr 10-20 280063 37765 CPT Outpatient 26561.85 4559.78 Horizon BCBS Horizon PPO 0.21 5642.00 0.21 26561.85 0.21 Case Rate 37765 Priced Biopsy/removal lymph nodes 280063 38500 CPT Outpatient 35955.15 6172.30 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 35955.15 0.16 Case Rate 38500 Priced Biopsy/removal lymph nodes 280063 38525 CPT Outpatient 101194.80 17371.77 Horizon BCBS Horizon PPO 0.06 5642.00 0.06 101194.80 0.06 Case Rate 38525 Priced Laparoscopy lymph node biop 280063 38570 CPT Outpatient 65631.30 11266.71 Horizon BCBS Horizon PPO 0.09 5642.00 0.09 65631.30 0.09 Case Rate 38570 Priced Laparoscopy lymphadenectomy 280063 38571 CPT Outpatient 84031.50 14425.41 Horizon BCBS Horizon PPO 0.07 5642.00 0.07 84031.50 0.07 Case Rate 38571 Priced Laparoscopy lymphadenectomy 280063 38572 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 280063 38792 CPT Outpatient 2868.60 432.48 Horizon BCBS Horizon PPO 0.31 901.86 0.31 2868.60 0.31 Case Rate 38792 Priced Excision of gum lesion 280063 41825 CPT Outpatient 11580.45 1987.98 Horizon BCBS Horizon PPO 0.32 3685.12 0.32 11580.45 0.32 Case Rate 41825 Priced Reconstruct cleft palate 280063 42200 CPT Outpatient 36703.80 6300.82 Horizon BCBS Horizon PPO 0.15 5642.00 0.15 36703.80 0.15 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 280063 42820 CPT Outpatient 17232.60 2958.26 Horizon BCBS Horizon PPO 0.32 5548.12 0.32 17232.60 0.32 Case Rate 42820 Priced Control throat bleeding 280063 42960 CPT Outpatient 24066.00 4131.33 Horizon BCBS Horizon PPO 0.23 5642.00 0.23 24066.00 0.23 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 280063 43235 CPT Outpatient 8856.75 1633.35 Horizon BCBS Horizon PPO 0.32 2796.08 0.32 8856.75 0.32 Case Rate 43235 Priced Laparoscopy fundoplasty 280063 43280 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 280063 43282 CPT Outpatient 84344.40 14479.12 Horizon BCBS Horizon PPO 0.07 5642.00 0.07 84344.40 0.07 Case Rate 43282 Priced Laparoscopy appendectomy 280063 44970 CPT Outpatient 82300.05 14128.18 Horizon BCBS Horizon PPO 0.07 5642.00 0.07 82300.05 0.07 Case Rate 44970 Priced Diagnostic sigmoidoscopy 280063 45330 CPT Outpatient 17286.15 542.26 Horizon BCBS Horizon PPO 0.32 5445.49 0.32 17286.15 0.32 Case Rate 45330 Priced Needle biopsy of liver 280063 47000 CPT Outpatient 10398.15 1225.34 Horizon BCBS Horizon PPO 0.31 3270.07 0.31 10398.15 0.31 Case Rate 47000 Priced Removal of gallbladder using an endoscope 280063 47562 CPT Outpatient 58430.40 10030.55 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 280063 47563 CPT Outpatient 71747.55 12316.66 Horizon BCBS Horizon PPO 0.08 5642.00 0.08 71747.55 0.08 Case Rate 47563 Priced Abd paracentesis w/imaging 280063 49083 CPT Outpatient 6979.35 1113.95 Horizon BCBS Horizon PPO 0.31 2194.84 0.31 6979.35 0.31 Case Rate 49083 Priced Diag laparo separate proc 280063 49320 CPT Outpatient 31629.15 5429.67 Horizon BCBS Horizon PPO 0.18 5642.00 0.18 31629.15 0.18 Case Rate 49320 Priced Laparoscopy biopsy 280063 49321 CPT Outpatient 41892.90 7191.61 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 41892.90 0.13 Case Rate 49321 Priced Laparoscopy aspiration 280063 49322 CPT Outpatient 34392.75 5904.09 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 34392.75 0.16 Case Rate 49322 Priced Lap insert tunnel ip cath 280063 49324 CPT Outpatient 39264.75 6740.45 Horizon BCBS Horizon PPO 0.14 5642.00 0.14 39264.75 0.14 Case Rate 49324 Priced Laparo proc abdm/per/oment 280063 49329 CPT Outpatient 58696.05 10076.16 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 58696.05 0.10 Case Rate 49329 Priced Ins tun ip cath for dial opn 280063 49421 CPT Outpatient 25460.40 3319.30 Horizon BCBS Horizon PPO 0.22 5642.00 0.22 25460.40 0.22 Case Rate 49421 Priced Remove tunneled ip cath 280063 49422 CPT Outpatient 25515.00 4380.08 Horizon BCBS Horizon PPO 0.22 5642.00 0.22 25515.00 0.22 Case Rate 49422 Priced Rpr ing hernia init reduce 280063 49500 CPT Outpatient 19594.05 3363.65 Horizon BCBS Horizon PPO 0.29 5642.00 0.29 19594.05 0.29 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 280063 49505 CPT Outpatient 34915.65 5993.85 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 34915.65 0.16 Case Rate 49505 Priced Prp i/hern init block >5 yr 280063 49507 CPT Outpatient 29794.80 5114.77 Horizon BCBS Horizon PPO 0.19 5642.00 0.19 29794.80 0.19 Case Rate 49507 Priced Rerepair ing hernia reduce 280063 49520 CPT Outpatient 36940.05 6341.38 Horizon BCBS Horizon PPO 0.15 5642.00 0.15 36940.05 0.15 Case Rate 49520 Priced Rpr ventral hern init reduc 280063 49560 CPT Outpatient 53177.25 9128.76 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 53177.25 0.11 Case Rate 49560 Priced Rpr ventral hern init block 280063 49561 CPT Outpatient 30755.55 5279.70 Horizon BCBS Horizon PPO 0.18 5642.00 0.18 30755.55 0.18 Case Rate 49561 Priced Rerepair ventrl hern reduce 280063 49565 CPT Outpatient 69917.40 12002.49 Horizon BCBS Horizon PPO 0.08 5642.00 0.08 69917.40 0.08 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 280063 49585 CPT Outpatient 41806.80 7176.83 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 41806.80 0.13 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 280063 49587 CPT Outpatient 37320.15 6406.63 Horizon BCBS Horizon PPO 0.15 5642.00 0.15 37320.15 0.15 Case Rate 49587 Priced Lap ing hernia repair init 280063 49650 CPT Outpatient 41932.80 7198.46 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 41932.80 0.13 Case Rate 49650 Priced Lap ing hernia repair recur 280063 49651 CPT Outpatient 46915.05 8053.75 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 46915.05 0.12 Case Rate 49651 Priced Lap vent/abd hernia repair 280063 49652 CPT Outpatient 51294.60 8805.57 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 51294.60 0.11 Case Rate 49652 Priced Lap vent/abd hern proc comp 280063 49653 CPT Outpatient 46102.35 7914.24 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 46102.35 0.12 Case Rate 49653 Priced Lap inc hernia repair 280063 49654 CPT Outpatient 47221.65 8106.38 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 47221.65 0.12 Case Rate 49654 Priced Lap inc hern repair comp 280063 49655 CPT Outpatient 54590.55 9371.38 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 54590.55 0.10 Case Rate 49655 Priced Lap inc hernia repair recur 280063 49656 CPT Outpatient 55443.15 9517.74 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 55443.15 0.10 Case Rate 49656 Priced Removal of kidney stone 280063 50080 CPT Outpatient 53165.70 9126.78 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 53165.70 0.11 Case Rate 50080 Priced Removal of kidney stone 280063 50081 CPT Outpatient 66931.20 11489.86 Horizon BCBS Horizon PPO 0.08 5642.00 0.08 66931.20 0.08 Case Rate 50081 Priced Renal biopsy perq 280063 50200 CPT Outpatient 43096.20 1225.34 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 43096.20 0.13 Case Rate 50200 Priced Plmt nephroureteral catheter 280063 50433 CPT Outpatient 64566.60 1424.48 Horizon BCBS Horizon PPO 0.09 5642.00 0.09 64566.60 0.09 Case Rate 50433 Priced Laparo radical nephrectomy 280063 50545 CPT Outpatient 43449.00 7458.75 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 43449.00 0.13 Case Rate 50545 Priced Laparoscope proc ureter 280063 50949 CPT Outpatient 49986.30 8580.98 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 49986.30 0.11 Case Rate 50949 Priced Injection for bladder x-ray 280063 51600 CPT Outpatient 3285.45 89.22 Horizon BCBS Horizon PPO 0.31 1033.27 0.31 3285.45 0.31 Case Rate 51600 Priced Cystoscopy 280063 52000 CPT Outpatient 22149.75 3802.37 Horizon BCBS Horizon PPO 0.25 5642.00 0.25 22149.75 0.25 Case Rate 52000 Priced Cystoscopy & ureter catheter 280063 52005 CPT Outpatient 42529.20 2095.77 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 42529.20 0.13 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 280063 52204 CPT Outpatient 31274.25 5368.75 Horizon BCBS Horizon PPO 0.18 5642.00 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 280063 52224 CPT Outpatient 13445.25 2308.10 Horizon BCBS Horizon PPO 0.32 4242.32 0.32 13445.25 0.32 Case Rate 52224 Priced Cystoscopy and treatment 280063 52234 CPT Outpatient 28510.65 4894.33 Horizon BCBS Horizon PPO 0.20 5642.00 0.20 28510.65 0.20 Case Rate 52234 Priced Cystoscopy and treatment 280063 52235 CPT Outpatient 29417.85 5050.06 Horizon BCBS Horizon PPO 0.19 5642.00 0.19 29417.85 0.19 Case Rate 52235 Priced Cystoscopy and treatment 280063 52240 CPT Outpatient 33933.90 5825.32 Horizon BCBS Horizon PPO 0.17 5642.00 0.17 33933.90 0.17 Case Rate 52240 Priced Cystoscopy and treatment 280063 52281 CPT Outpatient 22159.20 3804.00 Horizon BCBS Horizon PPO 0.25 5642.00 0.25 22159.20 0.25 Case Rate 52281 Priced Remove bladder stone 280063 52317 CPT Outpatient 27085.80 4649.73 Horizon BCBS Horizon PPO 0.21 5642.00 0.21 27085.80 0.21 Case Rate 52317 Priced Remove bladder stone 280063 52318 CPT Outpatient 26685.75 4581.05 Horizon BCBS Horizon PPO 0.21 5642.00 0.21 26685.75 0.21 Case Rate 52318 Priced Cystoscopy and treatment 280063 52332 CPT Outpatient 115306.80 19794.33 Horizon BCBS Horizon PPO 0.05 5642.00 0.05 115306.80 0.05 Case Rate 52332 Priced Cystouretero w/stone remove 280063 52352 CPT Outpatient 42420.00 7282.10 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 42420.00 0.13 Case Rate 52352 Priced Cystouretero w/lithotripsy 280063 52353 CPT Outpatient 38608.50 6627.79 Horizon BCBS Horizon PPO 0.15 5642.00 0.15 38608.50 0.15 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 280063 52356 CPT Outpatient 36255.45 6223.85 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 36255.45 0.16 Case Rate 52356 Priced Prostatectomy (turp) 280063 52601 CPT Outpatient 35371.35 6072.08 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 35371.35 0.16 Case Rate 52601 Priced Laser surgery of prostate 280063 52648 CPT Outpatient 24264.45 4165.40 Horizon BCBS Horizon PPO 0.23 5642.00 0.23 24264.45 0.23 Case Rate 52648 Priced Revision of urethra 280063 53450 CPT Outpatient 16209.90 2782.70 Horizon BCBS Horizon PPO 0.32 5123.03 0.32 16209.90 0.32 Case Rate 53450 Priced Urology surgery procedure 280063 53899 CPT Outpatient 25368.00 134.83 Horizon BCBS Horizon PPO 0.22 5642.00 0.22 25368.00 0.22 Case Rate 53899 Priced Circumcision w/regionl block 280063 54150 CPT Outpatient 14700.00 2523.50 Horizon BCBS Horizon PPO 0.31 4621.30 0.31 14700.00 0.31 Case Rate 54150 Priced Circum 28 days or older 280063 54161 CPT Outpatient 19186.65 3293.71 Horizon BCBS Horizon PPO 0.29 5642.00 0.29 19186.65 0.29 Case Rate 54161 Priced Lysis penil circumic lesion 280063 54162 CPT Outpatient 19795.65 3398.25 Horizon BCBS Horizon PPO 0.29 5642.00 0.29 19795.65 0.29 Case Rate 54162 Priced Repair of circumcision 280063 54163 CPT Outpatient 16391.55 2813.88 Horizon BCBS Horizon PPO 0.31 5159.78 0.31 16391.55 0.31 Case Rate 54163 Priced Reconstruction of urethra 280063 54324 CPT Outpatient 32880.75 5644.53 Horizon BCBS Horizon PPO 0.17 5642.00 0.17 32880.75 0.17 Case Rate 54324 Priced Revise penis/urethra 280063 54332 CPT Outpatient 19968.90 3427.99 Horizon BCBS Horizon PPO 0.28 5642.00 0.28 19968.90 0.28 Case Rate 54332 Priced Insert self-contd prosthesis 280063 54401 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 280063 54520 CPT Outpatient 35442.75 6084.34 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 35442.75 0.16 Case Rate 54520 Priced Reduce testis torsion 280063 54600 CPT Outpatient 55049.40 9450.15 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 55049.40 0.10 Case Rate 54600 Priced Suspension of testis 280063 54640 CPT Outpatient 26860.05 4610.98 Horizon BCBS Horizon PPO 0.21 5642.00 0.21 26860.05 0.21 Case Rate 54640 Priced Removal of hydrocele 280063 55040 CPT Outpatient 27277.95 4682.71 Horizon BCBS Horizon PPO 0.21 5642.00 0.21 27277.95 0.21 Case Rate 55040 Priced Biopsy of prostate gland 280063 55700 CPT Outpatient 28699.65 4926.77 Horizon BCBS Horizon PPO 0.20 5642.00 0.20 28699.65 0.20 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 280063 55866 CPT Outpatient 93088.80 15980.24 Horizon BCBS Horizon PPO 0.06 5642.00 0.06 93088.80 0.06 Case Rate 55866 Priced Closure of vagina 280063 57120 CPT Outpatient 34369.65 5900.12 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 34369.65 0.16 Case Rate 57120 Priced Repair of vagina 280063 57200 CPT Outpatient 25247.25 4334.11 Horizon BCBS Horizon PPO 0.22 5642.00 0.22 25247.25 0.22 Case Rate 57200 Priced Anterior colporrhaphy 280063 57240 CPT Outpatient 36210.30 6216.10 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 36210.30 0.16 Case Rate 57240 Priced Repair rectum & vagina 280063 57250 CPT Outpatient 40441.80 6942.51 Horizon BCBS Horizon PPO 0.14 5642.00 0.14 40441.80 0.14 Case Rate 57250 Priced Cmbn ant pst colprhy 280063 57260 CPT Outpatient 46323.90 7952.27 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 46323.90 0.12 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 280063 57265 CPT Outpatient 42586.95 7310.76 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 42586.95 0.13 Case Rate 57265 Priced Repair of bowel bulge 280063 57268 CPT Outpatient 36865.50 6328.58 Horizon BCBS Horizon PPO 0.15 5642.00 0.15 36865.50 0.15 Case Rate 57268 Priced Colpopexy extraperitoneal 280063 57282 CPT Outpatient 45629.85 7833.12 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 45629.85 0.12 Case Rate 57282 Priced Repair bladder defect 280063 57288 CPT Outpatient 43069.95 7393.67 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 43069.95 0.13 Case Rate 57288 Priced Bx/curett of cervix w/scope 280063 57454 CPT Outpatient 2888.55 442.93 Horizon BCBS Horizon PPO 0.31 908.45 0.31 2888.55 0.31 Case Rate 57454 Priced Conization of cervix 280063 57520 CPT Outpatient 26728.80 4588.44 Horizon BCBS Horizon PPO 0.21 5642.00 0.21 26728.80 0.21 Case Rate 57520 Priced Conization of cervix 280063 57522 CPT Outpatient 22737.75 3903.31 Horizon BCBS Horizon PPO 0.25 5642.00 0.25 22737.75 0.25 Case Rate 57522 Priced Biopsy of uterus lining 280063 58100 CPT Outpatient 2371.95 194.80 Horizon BCBS Horizon PPO 0.31 745.83 0.31 2371.95 0.31 Case Rate 58100 Priced Catheter for hysterography 280063 58340 CPT Outpatient 6322.05 131.04 Horizon BCBS Horizon PPO 0.31 1988.19 0.31 6322.05 0.31 Case Rate 58340 Priced Reopen fallopian tube 280063 58350 CPT Outpatient 46507.65 7983.81 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 46507.65 0.12 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 280063 58542 CPT Outpatient 64194.90 11020.12 Horizon BCBS Horizon PPO 0.09 5642.00 0.09 64194.90 0.09 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 280063 58544 CPT Outpatient 51020.55 8758.53 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 51020.55 0.11 Case Rate 58544 Priced Laparoscopic myomectomy 280063 58545 CPT Outpatient 56946.75 9775.86 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 56946.75 0.10 Case Rate 58545 Priced Laparo-vag hyst incl t/o 280063 58552 CPT Outpatient 57228.15 9824.17 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 57228.15 0.10 Case Rate 58552 Priced Hysteroscopy biopsy 280063 58558 CPT Outpatient 28581.00 2077.02 Horizon BCBS Horizon PPO 0.20 5642.00 0.20 28581.00 0.20 Case Rate 58558 Priced Hysteroscopy remove myoma 280063 58561 CPT Outpatient 35222.25 6046.49 Horizon BCBS Horizon PPO 0.16 5642.00 0.16 35222.25 0.16 Case Rate 58561 Priced Hysteroscopy ablation 280063 58563 CPT Outpatient 38399.55 6591.92 Horizon BCBS Horizon PPO 0.15 5642.00 0.15 38399.55 0.15 Case Rate 58563 Priced Tlh uterus 250 g or less 280063 58570 CPT Outpatient 43316.70 7436.03 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 43316.70 0.13 Case Rate 58570 Priced Tlh w/t/o 250 g or less 280063 58571 CPT Outpatient 48603.45 8343.59 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 48603.45 0.12 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 280063 58573 CPT Outpatient 52905.30 9082.08 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 52905.30 0.11 Case Rate 58573 Priced Laparoscopy remove adnexa 280063 58661 CPT Outpatient 47008.50 8069.79 Horizon BCBS Horizon PPO 0.12 5642.00 0.12 47008.50 0.12 Case Rate 58661 Priced Laparoscopy excise lesions 280063 58662 CPT Outpatient 45053.40 7734.17 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 45053.40 0.13 Case Rate 58662 Priced Treat ectopic pregnancy 280063 59151 CPT Outpatient 74690.70 12821.90 Horizon BCBS Horizon PPO 0.08 5642.00 0.08 74690.70 0.08 Case Rate 59151 Priced Treatment of miscarriage 280063 59812 CPT Outpatient 56109.90 9632.20 Horizon BCBS Horizon PPO 0.10 5642.00 0.10 56109.90 0.10 Case Rate 59812 Priced Partial removal of thyroid 280063 60220 CPT Outpatient 53639.25 9208.07 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 280063 60240 CPT Outpatient 98252.70 16866.71 Horizon BCBS Horizon PPO 0.06 5642.00 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 280063 60500 CPT Outpatient 150495.45 25835.05 Horizon BCBS Horizon PPO 0.04 5642.00 0.04 150495.45 0.04 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 280063 62322 CPT Outpatient 43709.40 514.24 Horizon BCBS Horizon PPO 0.13 5642.00 0.13 43709.40 0.13 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 280063 62323 CPT Outpatient 8304.45 467.31 Horizon BCBS Horizon PPO 0.68 5642.00 0.68 8304.45 0.68 Case Rate 62323 Priced Low back disk surgery 280063 63030 CPT Outpatient 50287.65 8632.71 Horizon BCBS Horizon PPO 0.11 5642.00 0.11 50287.65 0.11 Case Rate 63030 Priced Inc for vagus n elect impl 280063 64568 CPT Outpatient 124562.55 21383.24 Horizon BCBS Horizon PPO 0.05 5642.00 0.05 124562.55 0.05 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 280063 66821 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 280063 66984 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 280013 216 DRG Inpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 280013 460 DRG Inpatient 416122.79 53834.63 Horizon BCBS Horizon Indemnity 0.29 119171.52 0.29 416122.79 0.29 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 280013 470 DRG Inpatient 167912.19 21723.13 Horizon BCBS Horizon Indemnity 0.34 57613.92 0.34 167912.19 0.34 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 280013 473 DRG Inpatient 100687.91 13026.19 Horizon BCBS Horizon Indemnity 0.76 76977.68 0.76 100687.91 0.76 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 280013 743 DRG Inpatient 102691.67 13285.42 Horizon BCBS Horizon Indemnity 0.33 34343.92 0.33 102691.67 0.33 Case Rate 743 Priced NORMAL NEWBORN 280013 795 DRG Inpatient 6266.93 2335.00 Horizon BCBS Horizon Indemnity 0.37 2316.08 0.37 6266.93 0.37 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 280013 807 DRG Inpatient 116469.59 4193.00 Horizon BCBS Horizon Indemnity 0.14 16715.92 0.14 116469.59 0.14 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 280013 788 DRG Inpatient 76050.77 4538.00 Horizon BCBS Horizon Indemnity 0.38 28745.60 0.38 76050.77 0.38 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 280013 59400 CPT Inpatient 116469.59 4193.00 Horizon BCBS Horizon Indemnity 0.14 16715.92 0.14 116469.59 0.14 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 280013 59510 CPT Inpatient 76050.77 4538.00 Horizon BCBS Horizon Indemnity 0.38 28745.60 0.38 76050.77 0.38 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 280013 59610 CPT Inpatient 116469.59 4193.00 Horizon BCBS Horizon Indemnity 0.14 16715.92 0.14 116469.59 0.14 Case Rate 59610 Priced "Psychotherapy, 30 min" 280013 90832 CPT Outpatient 577.50 91.21 Horizon BCBS Horizon Indemnity 0.33 190.70 0.33 577.50 0.33 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 280013 90834 CPT Outpatient 44134.65 271.96 Horizon BCBS Horizon Indemnity 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 280013 90837 CPT Outpatient 2240.70 442.93 Horizon BCBS Horizon Indemnity 0.06 142.16 0.06 2240.70 0.06 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 280013 90846 CPT Outpatient 0.01 131.50 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 280013 90847 CPT Outpatient 44134.65 369.97 Horizon BCBS Horizon Indemnity 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90847 Priced Group psychotherapy 280013 90853 CPT Outpatient 44134.65 101.99 Horizon BCBS Horizon Indemnity 0.31 13880.19 0.31 44134.65 0.31 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 280013 99203 CPT Outpatient 3480.75 176.07 Horizon BCBS Horizon Indemnity 0.31 1094.64 0.31 3480.75 0.31 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 280013 99204 CPT Outpatient 2103.15 233.39 Horizon BCBS Horizon Indemnity 0.31 661.22 0.31 2103.15 0.31 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 280013 99205 CPT Outpatient 4970.70 314.28 Horizon BCBS Horizon Indemnity 0.16 781.54 0.16 4970.70 0.16 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 280013 99243 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 280013 99244 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 280013 99385 CPT Outpatient 1114.05 185.90 Horizon BCBS Horizon Indemnity 0.31 350.20 0.31 1114.05 0.31 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 280013 99386 CPT Outpatient 4877.25 185.90 Horizon BCBS Horizon Indemnity 0.31 1533.31 0.31 4877.25 0.31 Fee Schedule 99386 Priced Routine venipuncture 280013 36415 CPT Outpatient 127.05 19.57 Horizon BCBS Horizon Indemnity 0.33 41.95 0.33 127.05 0.33 Fee Schedule 36415 Priced Basic Metabolic Panel 280013 80048 CPT Outpatient 576.45 88.78 Horizon BCBS Horizon Indemnity 0.33 190.36 0.33 576.45 0.33 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 280013 80053 CPT Outpatient 763.35 117.56 Horizon BCBS Horizon Indemnity 0.33 252.08 0.33 763.35 0.33 Fee Schedule 80053 Priced Obstetric blood test panel 280013 80055 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 280013 80061 CPT Outpatient 1349.25 197.77 Horizon BCBS Horizon Indemnity 0.31 424.06 0.31 1349.25 0.31 Fee Schedule 80061 Priced Kidney function panel test 280013 80069 CPT Outpatient 716.10 104.95 Horizon BCBS Horizon Indemnity 0.31 225.04 0.31 716.10 0.31 Fee Schedule 80069 Priced Liver function panel test 280013 80076 CPT Outpatient 716.10 104.95 Horizon BCBS Horizon Indemnity 0.31 225.04 0.31 716.10 0.31 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 280013 81000 CPT Outpatient 144.90 21.18 Horizon BCBS Horizon Indemnity 0.31 45.43 0.31 144.90 0.31 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 280013 81001 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 280013 81002 CPT Outpatient 57.75 8.89 Horizon BCBS Horizon Indemnity 0.33 19.07 0.33 57.75 0.33 Fee Schedule 81002 Priced Automated urinalysis test 280013 81003 CPT Outpatient 219.45 33.80 Horizon BCBS Horizon Indemnity 0.33 72.47 0.33 219.45 0.33 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 280013 82306 CPT Outpatient 1880.55 289.62 Horizon BCBS Horizon Indemnity 0.33 621.00 0.33 1880.55 0.33 Fee Schedule 82306 Priced Glycosylated hemoglobin test 280013 83036 CPT Outpatient 494.55 76.17 Horizon BCBS Horizon Indemnity 0.33 163.31 0.33 494.55 0.33 Fee Schedule 83036 Priced PSA (prostate specific antigen) 280013 84153 CPT Outpatient 1177.05 181.28 Horizon BCBS Horizon Indemnity 0.33 388.69 0.33 1177.05 0.33 Fee Schedule 84153 Priced PSA (prostate specific antigen) 280013 84154 CPT Outpatient 598.50 92.17 Horizon BCBS Horizon Indemnity 0.33 197.64 0.33 598.50 0.33 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 280013 84443 CPT Outpatient 519.75 80.05 Horizon BCBS Horizon Indemnity 0.33 171.63 0.33 519.75 0.33 Fee Schedule 84443 Priced Chorionic gonadotropin assay 280013 84703 CPT Outpatient 785.40 120.96 Horizon BCBS Horizon Indemnity 0.33 259.36 0.33 785.40 0.33 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 280013 85025 CPT Outpatient 635.25 97.83 Horizon BCBS Horizon Indemnity 0.33 209.78 0.33 635.25 0.33 Fee Schedule 85025 Priced "Complete blood count, automated" 280013 85027 CPT Outpatient 576.45 88.78 Horizon BCBS Horizon Indemnity 0.33 190.36 0.33 576.45 0.33 Fee Schedule 85027 Priced "Blood test, clotting time" 280013 85610 CPT Outpatient 404.25 62.26 Horizon BCBS Horizon Indemnity 0.33 133.49 0.33 404.25 0.33 Fee Schedule 85610 Priced Coagulation assessment blood test 280013 85730 CPT Outpatient 17.22 2.65 Horizon BCBS Horizon Indemnity 0.33 5.69 0.33 17.22 0.33 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 280013 86003 CPT Outpatient 32.55 5.01 Horizon BCBS Horizon Indemnity 0.33 10.75 0.33 32.55 0.33 Fee Schedule 86003 Priced Tb test cell immun measure 280013 86480 CPT Outpatient 530.25 81.66 Horizon BCBS Horizon Indemnity 0.33 175.10 0.33 530.25 0.33 Fee Schedule 86480 Priced Urine culture/colony count 280013 87086 CPT Outpatient 763.35 117.56 Horizon BCBS Horizon Indemnity 0.33 252.08 0.33 763.35 0.33 Fee Schedule 87086 Priced Hpylori stool ia 280013 87338 CPT Outpatient 785.40 120.96 Horizon BCBS Horizon Indemnity 0.33 259.36 0.33 785.40 0.33 Fee Schedule 87338 Priced Cytopath eval fna report 280013 88173 CPT Outpatient 750.75 115.62 Horizon BCBS Horizon Indemnity 0.33 247.92 0.33 750.75 0.33 Fee Schedule 88173 Priced Tissue exam by pathologist 280013 88302 CPT Outpatient 635.25 97.83 Horizon BCBS Horizon Indemnity 0.33 209.78 0.33 635.25 0.33 Fee Schedule 88302 Priced Tissue exam by pathologist 280013 88305 CPT Outpatient 323.40 49.81 Horizon BCBS Horizon Indemnity 0.33 106.80 0.33 323.40 0.33 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 280013 11042 CPT Outpatient 2668.05 481.45 Horizon BCBS Horizon Indemnity 0.31 839.10 0.31 2668.05 0.31 Case Rate 11042 Priced Deb subq tissue add-on 280013 11045 CPT Outpatient 4652.55 330.00 Horizon BCBS Horizon Indemnity 0.31 1463.23 0.31 4652.55 0.31 Case Rate 11045 Priced Dx bronchoscope/lavage 280013 31624 CPT Outpatient 41223.00 7602.31 Horizon BCBS Horizon Indemnity 0.14 5642.00 0.14 41223.00 0.14 Case Rate 31624 Priced Bronchoscopy/lung bx each 280013 31628 CPT Outpatient 49048.65 9045.51 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 49048.65 0.12 Case Rate 31628 Priced Blood transfusion service 280013 36430 CPT Outpatient 9166.50 574.93 Horizon BCBS Horizon Indemnity 0.31 2882.77 0.31 9166.50 0.31 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 280013 43235 CPT Outpatient 8856.75 1633.35 Horizon BCBS Horizon Indemnity 0.32 2796.08 0.32 8856.75 0.32 Case Rate 43235 Priced Endoscopic us exam esoph 280013 43237 CPT Outpatient 23867.55 4401.63 Horizon BCBS Horizon Indemnity 0.24 5642.00 0.24 23867.55 0.24 Case Rate 43237 Priced Egd us fine needle bx/aspir 280013 43238 CPT Outpatient 30690.45 5659.90 Horizon BCBS Horizon Indemnity 0.18 5642.00 0.18 30690.45 0.18 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 280013 43239 CPT Outpatient 40191.90 7412.15 Horizon BCBS Horizon Indemnity 0.14 5642.00 0.14 40191.90 0.14 Case Rate 43239 Priced Ercp remove duct calculi 280013 43264 CPT Outpatient 34335.00 6332.03 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 34335.00 0.16 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 280013 45378 CPT Outpatient 13991.25 889.35 Horizon BCBS Horizon Indemnity 0.32 4408.05 0.32 13991.25 0.32 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 280013 45380 CPT Outpatient 22215.90 4097.04 Horizon BCBS Horizon Indemnity 0.25 5642.00 0.25 22215.90 0.25 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 280013 45385 CPT Outpatient 119569.80 22050.95 Horizon BCBS Horizon Indemnity 0.05 5642.00 0.05 119569.80 0.05 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 280013 45391 CPT Outpatient 24923.85 4596.43 Horizon BCBS Horizon Indemnity 0.23 5642.00 0.23 24923.85 0.23 Case Rate 45391 Priced Fragmenting of kidney stone 280013 50590 CPT Outpatient 40930.05 7548.28 Horizon BCBS Horizon Indemnity 0.14 5642.00 0.14 40930.05 0.14 Case Rate 50590 Priced Fetal non-stress test 280013 59025 CPT Outpatient 3153.15 477.76 Horizon BCBS Horizon Indemnity 0.31 991.66 0.31 3153.15 0.31 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 280013 64483 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 280013 92567 CPT Outpatient 2224.95 98.50 Horizon BCBS Horizon Indemnity 0.31 699.71 0.31 2224.95 0.31 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 280013 93000 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 280013 93017 CPT Outpatient 3076.50 532.96 Horizon BCBS Horizon Indemnity 0.31 967.40 0.31 3076.50 0.31 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 280013 93452 CPT Outpatient 55621.65 8611.87 Horizon BCBS Horizon Indemnity 0.17 9210.24 0.17 55621.65 0.17 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 280013 95810 CPT Outpatient 20341.65 3373.48 Horizon BCBS Horizon Indemnity 0.31 6397.28 0.31 20341.65 0.31 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 280013 95811 CPT Outpatient 22491.00 3731.18 Horizon BCBS Horizon Indemnity 0.31 7073.41 0.31 22491.00 0.31 Case Rate 95811 Priced Eeg 41-60 minutes 280013 95812 CPT Outpatient 5578.65 925.83 Horizon BCBS Horizon Indemnity 0.31 1754.48 0.31 5578.65 0.31 Case Rate 95812 Priced Genetic counseling 30 min 280013 96040 CPT Outpatient 0.01 102.81 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 280013 96413 CPT Outpatient 4856.25 472.45 Horizon BCBS Horizon Indemnity 0.76 3712.97 0.76 4856.25 0.76 Case Rate 96413 Priced Ultrasound therapy 280013 97035 CPT Outpatient 2111.55 134.99 Horizon BCBS Horizon Indemnity 0.17 358.49 0.17 2111.55 0.17 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 280013 97110 CPT Outpatient 6494.25 92.86 Horizon BCBS Horizon Indemnity 0.17 1102.61 0.17 6494.25 0.17 Case Rate 97110 Priced Gait training therapy 280013 97116 CPT Outpatient 4723.95 110.61 Horizon BCBS Horizon Indemnity 0.17 801.96 0.17 4723.95 0.17 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 280013 70450 CPT Outpatient 8566.95 835.61 Horizon BCBS Horizon Indemnity 0.19 1608.88 0.19 8566.95 0.19 Case Rate 70450 Priced Mri brain stem w/o dye 280013 70551 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon Indemnity 0.31 2472.23 0.31 7861.35 0.31 Case Rate 70551 Priced MRI scan of brain before and after contrast 280013 70553 CPT Outpatient 10882.20 1625.88 Horizon BCBS Horizon Indemnity 0.31 3422.29 0.31 10882.20 0.31 Case Rate 70553 Priced X-ray exam chest 2 views 280013 71046 CPT Outpatient 859.95 150.37 Horizon BCBS Horizon Indemnity 0.31 270.45 0.31 859.95 0.31 Case Rate 71046 Priced Ct thorax w/o dye 280013 71250 CPT Outpatient 7288.05 1261.63 Horizon BCBS Horizon Indemnity 0.31 2291.92 0.31 7288.05 0.31 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 280013 72082 CPT Outpatient 2022.30 253.33 Horizon BCBS Horizon Indemnity 0.37 756.24 0.37 2022.30 0.37 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 280013 72100 CPT Outpatient 1599.15 277.38 Horizon BCBS Horizon Indemnity 0.31 502.77 0.31 1599.15 0.31 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 280013 72110 CPT Outpatient 1389.15 241.04 Horizon BCBS Horizon Indemnity 0.31 436.88 0.31 1389.15 0.31 Case Rate 72110 Priced MRI scan of lower spinal canal 280013 72148 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon Indemnity 0.31 2472.23 0.31 7861.35 0.31 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 280013 72193 CPT Outpatient 13671.00 1412.01 Horizon BCBS Horizon Indemnity 0.31 4299.53 0.31 13671.00 0.31 Case Rate 72193 Priced X-ray exam of shoulder 280013 73030 CPT Outpatient 1452.15 251.43 Horizon BCBS Horizon Indemnity 0.31 456.65 0.31 1452.15 0.31 Case Rate 73030 Priced X-ray exam of elbow 280013 73080 CPT Outpatient 1356.60 235.68 Horizon BCBS Horizon Indemnity 0.31 426.48 0.31 1356.60 0.31 Case Rate 73080 Priced X-ray exam of forearm 280013 73090 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon Indemnity 0.31 390.77 0.31 1243.20 0.31 Case Rate 73090 Priced X-ray exam of wrist 280013 73110 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon Indemnity 0.31 390.77 0.31 1243.20 0.31 Case Rate 73110 Priced X-ray exam of hand 280013 73130 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon Indemnity 0.31 390.77 0.31 1243.20 0.31 Case Rate 73130 Priced X-ray exam hips bi 2 views 280013 73521 CPT Outpatient 970.20 228.41 Horizon BCBS Horizon Indemnity 0.43 412.62 0.43 970.20 0.43 Case Rate 73521 Priced X-ray exam of knee 3 280013 73562 CPT Outpatient 802.20 139.12 Horizon BCBS Horizon Indemnity 0.31 252.08 0.31 802.20 0.31 Case Rate 73562 Priced X-ray exam of lower leg 280013 73590 CPT Outpatient 1243.20 215.26 Horizon BCBS Horizon Indemnity 0.31 390.77 0.31 1243.20 0.31 Case Rate 73590 Priced X-ray exam of ankle 280013 73610 CPT Outpatient 1378.65 239.31 Horizon BCBS Horizon Indemnity 0.31 433.42 0.31 1378.65 0.31 Case Rate 73610 Priced X-ray exam of foot 280013 73630 CPT Outpatient 975.45 169.41 Horizon BCBS Horizon Indemnity 0.31 306.52 0.31 975.45 0.31 Case Rate 73630 Priced MRI scan of leg joint 280013 73721 CPT Outpatient 7861.35 1361.31 Horizon BCBS Horizon Indemnity 0.31 2472.23 0.31 7861.35 0.31 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 280013 74177 CPT Outpatient 14222.25 1412.01 Horizon BCBS Horizon Indemnity 0.31 4472.89 0.31 14222.25 0.31 Case Rate 74177 Priced Contrst x-ray exam of throat 280013 74210 CPT Outpatient 0.01 440.39 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 280013 76098 CPT Outpatient 6141.45 407.86 Horizon BCBS Horizon Indemnity 0.31 1931.32 0.31 6141.45 0.31 Case Rate 76098 Priced Us exam of head and neck 280013 76536 CPT Outpatient 5512.50 955.18 Horizon BCBS Horizon Indemnity 0.31 1733.68 0.31 5512.50 0.31 Case Rate 76536 Priced Ultrasound breast limited 280013 76642 CPT Outpatient 5777.10 127.70 Horizon BCBS Horizon Indemnity 0.31 1816.90 0.31 5777.10 0.31 Case Rate 76642 Priced Ultrasound of abdomen 280013 76700 CPT Outpatient 4917.15 851.88 Horizon BCBS Horizon Indemnity 0.31 1546.44 0.31 4917.15 0.31 Case Rate 76700 Priced Echo exam of abdomen 280013 76705 CPT Outpatient 3836.70 665.17 Horizon BCBS Horizon Indemnity 0.31 1206.64 0.31 3836.70 0.31 Case Rate 76705 Priced Us exam abdo back wall comp 280013 76770 CPT Outpatient 5171.25 895.48 Horizon BCBS Horizon Indemnity 0.31 1626.20 0.31 5171.25 0.31 Case Rate 76770 Priced Us exam abdo back wall lim 280013 76775 CPT Outpatient 3969.00 686.97 Horizon BCBS Horizon Indemnity 0.31 1248.25 0.31 3969.00 0.31 Case Rate 76775 Priced Ob us < 14 wks single fetus 280013 76801 CPT Outpatient 2006.55 347.98 Horizon BCBS Horizon Indemnity 0.31 631.06 0.31 2006.55 0.31 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 280013 76805 CPT Outpatient 3969.00 686.97 Horizon BCBS Horizon Indemnity 0.31 1248.25 0.31 3969.00 0.31 Case Rate 76805 Priced Ob us detailed sngl fetus 280013 76811 CPT Outpatient 2844.45 492.99 Horizon BCBS Horizon Indemnity 0.31 894.58 0.31 2844.45 0.31 Case Rate 76811 Priced Ob us nuchal meas 1 gest 280013 76813 CPT Outpatient 1044.75 180.83 Horizon BCBS Horizon Indemnity 0.31 328.36 0.31 1044.75 0.31 Case Rate 76813 Priced Ob us limited fetus(s) 280013 76815 CPT Outpatient 6428.10 639.90 Horizon BCBS Horizon Indemnity 0.31 2021.47 0.31 6428.10 0.31 Case Rate 76815 Priced Ob us follow-up per fetus 280013 76816 CPT Outpatient 4818.45 833.88 Horizon BCBS Horizon Indemnity 0.31 1515.24 0.31 4818.45 0.31 Case Rate 76816 Priced Transvaginal us obstetric 280013 76817 CPT Outpatient 6428.10 476.73 Horizon BCBS Horizon Indemnity 0.31 2021.47 0.31 6428.10 0.31 Case Rate 76817 Priced Fetal biophys profil w/o nst 280013 76819 CPT Outpatient 1741.95 302.65 Horizon BCBS Horizon Indemnity 0.31 547.84 0.31 1741.95 0.31 Case Rate 76819 Priced Ultrasound pelvis through vagina 280013 76830 CPT Outpatient 9305.10 806.54 Horizon BCBS Horizon Indemnity 0.31 2926.46 0.31 9305.10 0.31 Case Rate 76830 Priced Us exam scrotum 280013 76870 CPT Outpatient 6328.35 1096.55 Horizon BCBS Horizon Indemnity 0.31 1990.27 0.31 6328.35 0.31 Case Rate 76870 Priced Us exam infant hips dynamic 280013 76885 CPT Outpatient 3836.70 665.17 Horizon BCBS Horizon Indemnity 0.31 1206.64 0.31 3836.70 0.31 Case Rate 76885 Priced Mammography of one breast 280013 77065 CPT Outpatient 3451.35 192.07 Horizon BCBS Horizon Indemnity 0.31 1085.28 0.31 3451.35 0.31 Case Rate 77065 Priced Mammography of both breasts 280013 77066 CPT Outpatient 5777.10 235.68 Horizon BCBS Horizon Indemnity 0.31 1816.90 0.31 5777.10 0.31 Case Rate 77066 Priced "Mamography, screening bilateral" 280013 77067 CPT Outpatient 1416.45 205.57 Horizon BCBS Horizon Indemnity 0.31 445.21 0.31 1416.45 0.31 Case Rate 77067 Priced X-rays for bone age 280013 77072 CPT Outpatient 2022.30 163.87 Horizon BCBS Horizon Indemnity 0.37 756.24 0.37 2022.30 0.37 Case Rate 77072 Priced Joint survey single view 280013 77077 CPT Outpatient 985.95 171.14 Horizon BCBS Horizon Indemnity 0.31 309.98 0.31 985.95 0.31 Case Rate 77077 Priced Dxa bone density axial 280013 77080 CPT Outpatient 3257.10 319.09 Horizon BCBS Horizon Indemnity 0.31 1024.25 0.31 3257.10 0.31 Case Rate 77080 Priced Fna bx w/us gdn 1st les 280013 10005 CPT Outpatient 5512.50 547.24 Horizon BCBS Horizon Indemnity 0.31 1733.68 0.31 5512.50 0.31 Case Rate 10005 Priced Fna bx w/us gdn ea addl 280013 10006 CPT Outpatient 10628.10 594.83 Horizon BCBS Horizon Indemnity 0.31 3342.54 0.31 10628.10 0.31 Case Rate 10006 Priced Drainage of hematoma/fluid 280013 10140 CPT Outpatient 23209.20 1081.95 Horizon BCBS Horizon Indemnity 0.24 5642.00 0.24 23209.20 0.24 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 280013 11042 CPT Outpatient 2668.05 481.45 Horizon BCBS Horizon Indemnity 0.31 839.10 0.31 2668.05 0.31 Case Rate 11042 Priced Deb bone 20 sq cm/< 280013 11044 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 280013 11406 CPT Outpatient 19967.85 3427.81 Horizon BCBS Horizon Indemnity 0.28 5642.00 0.28 19967.85 0.28 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 280013 11424 CPT Outpatient 0.01 1004.93 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 280013 11770 CPT Outpatient 19173.00 3291.37 Horizon BCBS Horizon Indemnity 0.29 5642.00 0.29 19173.00 0.29 Case Rate 11770 Priced Replace tissue expander 280013 11970 CPT Outpatient 59239.95 10169.52 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 59239.95 0.10 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 280013 14020 CPT Outpatient 32166.75 5521.96 Horizon BCBS Horizon Indemnity 0.18 5642.00 0.18 32166.75 0.18 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 280013 14060 CPT Outpatient 25993.80 1374.69 Horizon BCBS Horizon Indemnity 0.22 5642.00 0.22 25993.80 0.22 Case Rate 14060 Priced Wound prep trk/arm/leg 280013 15002 CPT Outpatient 41748.00 1441.73 Horizon BCBS Horizon Indemnity 0.14 5642.00 0.14 41748.00 0.14 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 280013 15271 CPT Outpatient 24343.20 3769.48 Horizon BCBS Horizon Indemnity 0.30 7413.21 0.30 24343.20 0.30 Case Rate 15271 Priced Acellular derm matrix implt 280013 15777 CPT Outpatient 101672.55 17453.79 Horizon BCBS Horizon Indemnity 0.06 5642.00 0.06 101672.55 0.06 Case Rate 15777 Priced Exc skin abd 280013 15830 CPT Outpatient 54696.60 9389.58 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 54696.60 0.10 Case Rate 15830 Priced Dressing change not for burn 280013 15852 CPT Outpatient 0.01 290.74 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 280013 15877 CPT Outpatient 63741.30 10942.26 Horizon BCBS Horizon Indemnity 0.09 5642.00 0.09 63741.30 0.09 Case Rate 15877 Priced Suction lipectomy lwr extrem 280013 15879 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 280013 19000 CPT Outpatient 10143.00 594.83 Horizon BCBS Horizon Indemnity 0.31 3189.97 0.31 10143.00 0.31 Case Rate 19000 Priced Bx breast 1st lesion strtctc 280013 19081 CPT Outpatient 12341.70 1250.69 Horizon BCBS Horizon Indemnity 0.31 3881.36 0.31 12341.70 0.31 Case Rate 19081 Priced Bx breast add lesion us imag 280013 19084 CPT Outpatient 29058.75 547.24 Horizon BCBS Horizon Indemnity 0.19 5642.00 0.19 29058.75 0.19 Case Rate 19084 Priced Biopsy of breast open 280013 19101 CPT Outpatient 39545.10 2737.82 Horizon BCBS Horizon Indemnity 0.14 5642.00 0.14 39545.10 0.14 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 280013 19120 CPT Outpatient 35761.95 2737.82 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 35761.95 0.16 Case Rate 19120 Priced Excision breast lesion 280013 19125 CPT Outpatient 33184.20 0.01 Horizon BCBS Horizon Indemnity 0.17 5642.00 0.17 33184.20 0.17 Case Rate 19125 Priced Perq device breast 1st imag 280013 19281 CPT Outpatient 6141.45 598.61 Horizon BCBS Horizon Indemnity 0.31 1931.32 0.31 6141.45 0.31 Case Rate 19281 Priced Perq device breast ea imag 280013 19282 CPT Outpatient 8379.00 319.04 Horizon BCBS Horizon Indemnity 0.31 2635.19 0.31 8379.00 0.31 Case Rate 19282 Priced Partial mastectomy 280013 19301 CPT Outpatient 39157.65 6722.06 Horizon BCBS Horizon Indemnity 0.14 5642.00 0.14 39157.65 0.14 Case Rate 19301 Priced Mast simple complete 280013 19303 CPT Outpatient 105389.55 18091.87 Horizon BCBS Horizon Indemnity 0.05 5642.00 0.05 105389.55 0.05 Case Rate 19303 Priced Reduction of large breast 280013 19318 CPT Outpatient 65239.65 11199.47 Horizon BCBS Horizon Indemnity 0.09 5642.00 0.09 65239.65 0.09 Case Rate 19318 Priced Immediate breast prosthesis 280013 19340 CPT Outpatient 113100.75 19415.63 Horizon BCBS Horizon Indemnity 0.05 5642.00 0.05 113100.75 0.05 Case Rate 19340 Priced Delayed breast prosthesis 280013 19342 CPT Outpatient 56988.75 9783.07 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 56988.75 0.10 Case Rate 19342 Priced Breast reconstruction 280013 19357 CPT Outpatient 101672.55 17453.79 Horizon BCBS Horizon Indemnity 0.06 5642.00 0.06 101672.55 0.06 Case Rate 19357 Priced Breast reconstruction 280013 19366 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 280013 19380 CPT Outpatient 61493.25 10556.34 Horizon BCBS Horizon Indemnity 0.09 5642.00 0.09 61493.25 0.09 Case Rate 19380 Priced Removal of support implant 280013 20680 CPT Outpatient 42329.70 7266.60 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 42329.70 0.13 Case Rate 20680 Priced Cerv artific diskectomy 280013 22856 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 280013 24538 CPT Outpatient 51237.90 4775.24 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 51237.90 0.11 Case Rate 24538 Priced Remove wrist tendon lesion 280013 25111 CPT Outpatient 25855.20 4438.48 Horizon BCBS Horizon Indemnity 0.22 5642.00 0.22 25855.20 0.22 Case Rate 25111 Priced Incise finger tendon sheath 280013 26055 CPT Outpatient 15862.35 2723.04 Horizon BCBS Horizon Indemnity 0.32 5024.90 0.32 15862.35 0.32 Case Rate 26055 Priced Treat finger fracture each 280013 26727 CPT Outpatient 22779.75 2030.47 Horizon BCBS Horizon Indemnity 0.25 5642.00 0.25 22779.75 0.25 Case Rate 26727 Priced Revision of knee joint 280013 27446 CPT Outpatient 67882.50 11653.16 Horizon BCBS Horizon Indemnity 0.24 16406.00 0.24 67882.50 0.24 Case Rate 27446 Priced Total knee arthroplasty 280013 27447 CPT Outpatient 130698.75 22436.62 Horizon BCBS Horizon Indemnity 0.13 16406.00 0.13 130698.75 0.13 Case Rate 27447 Priced Surgery to stop leg growth 280013 27485 CPT Outpatient 43310.40 7434.95 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 43310.40 0.13 Case Rate 27485 Priced Repair achilles tendon 280013 27650 CPT Outpatient 38246.25 3762.57 Horizon BCBS Horizon Indemnity 0.15 5642.00 0.15 38246.25 0.15 Case Rate 27650 Priced Treatment of ankle fracture 280013 27792 CPT Outpatient 36101.10 6197.36 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 36101.10 0.16 Case Rate 27792 Priced Treatment of ankle fracture 280013 27814 CPT Outpatient 49405.65 8481.30 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 49405.65 0.11 Case Rate 27814 Priced Removal of foot lesion 280013 28080 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 280013 28285 CPT Outpatient 68603.85 11776.99 Horizon BCBS Horizon Indemnity 0.08 5642.00 0.08 68603.85 0.08 Case Rate 28285 Priced Correction hallux valgus 280013 28296 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 280013 29823 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 280013 29826 CPT Outpatient 49840.35 8555.93 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 49840.35 0.11 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 280013 29881 CPT Outpatient 35556.15 6103.81 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 35556.15 0.16 Case Rate 29881 Priced Knee arthroscopy/surgery 280013 29882 CPT Outpatient 61099.50 10488.75 Horizon BCBS Horizon Indemnity 0.09 5642.00 0.09 61099.50 0.09 Case Rate 29882 Priced Percut bx lung/mediastinum 280013 32405 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 280013 32555 CPT Outpatient 14597.10 687.29 Horizon BCBS Horizon Indemnity 0.28 4073.11 0.28 14597.10 0.28 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 280013 32664 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 280013 35190 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 280013 36478 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 280013 36561 CPT Outpatient 53531.10 3292.99 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 53531.10 0.11 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 280013 36569 CPT Outpatient 31421.25 1299.06 Horizon BCBS Horizon Indemnity 0.18 5642.00 0.18 31421.25 0.18 Case Rate 36569 Priced Removal tunneled cv cath 280013 36590 CPT Outpatient 1996.05 273.95 Horizon BCBS Horizon Indemnity 0.32 630.36 0.32 1996.05 0.32 Case Rate 36590 Priced Av fuse uppr arm basilic 280013 36819 CPT Outpatient 56861.70 9761.26 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 56861.70 0.10 Case Rate 36819 Priced Av fusion direct any site 280013 36821 CPT Outpatient 42953.40 7373.67 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 42953.40 0.13 Case Rate 36821 Priced Artery-vein autograft 280013 36825 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 280013 36830 CPT Outpatient 53656.05 9210.96 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 53656.05 0.11 Case Rate 36830 Priced Av fistula revision open 280013 36832 CPT Outpatient 52492.65 9011.24 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 52492.65 0.11 Case Rate 36832 Priced Av fistula revision 280013 36833 CPT Outpatient 37098.60 6368.59 Horizon BCBS Horizon Indemnity 0.15 5642.00 0.15 37098.60 0.15 Case Rate 36833 Priced Intro cath dialysis circuit 280013 36903 CPT Outpatient 77541.45 10669.90 Horizon BCBS Horizon Indemnity 0.07 5642.00 0.07 77541.45 0.07 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 280013 36906 CPT Outpatient 96694.50 16175.64 Horizon BCBS Horizon Indemnity 0.06 5642.00 0.06 96694.50 0.06 Case Rate 36906 Priced Fem/popl revas w/tla 280013 37224 CPT Outpatient 200076.45 5139.31 Horizon BCBS Horizon Indemnity 0.05 9210.24 0.05 200076.45 0.05 Case Rate 37224 Priced Fem/popl revasc stnt & ather 280013 37227 CPT Outpatient 117170.55 18045.38 Horizon BCBS Horizon Indemnity 0.08 9210.24 0.08 117170.55 0.08 Case Rate 37227 Priced Revise leg vein 280013 37700 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 280013 37722 CPT Outpatient 27815.55 4775.00 Horizon BCBS Horizon Indemnity 0.20 5642.00 0.20 27815.55 0.20 Case Rate 37722 Priced Stab phleb veins xtr 10-20 280013 37765 CPT Outpatient 26561.85 4559.78 Horizon BCBS Horizon Indemnity 0.21 5642.00 0.21 26561.85 0.21 Case Rate 37765 Priced Biopsy/removal lymph nodes 280013 38500 CPT Outpatient 35955.15 6172.30 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 35955.15 0.16 Case Rate 38500 Priced Biopsy/removal lymph nodes 280013 38525 CPT Outpatient 101194.80 17371.77 Horizon BCBS Horizon Indemnity 0.06 5642.00 0.06 101194.80 0.06 Case Rate 38525 Priced Laparoscopy lymph node biop 280013 38570 CPT Outpatient 65631.30 11266.71 Horizon BCBS Horizon Indemnity 0.09 5642.00 0.09 65631.30 0.09 Case Rate 38570 Priced Laparoscopy lymphadenectomy 280013 38571 CPT Outpatient 84031.50 14425.41 Horizon BCBS Horizon Indemnity 0.07 5642.00 0.07 84031.50 0.07 Case Rate 38571 Priced Laparoscopy lymphadenectomy 280013 38572 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 280013 38792 CPT Outpatient 2868.60 432.48 Horizon BCBS Horizon Indemnity 0.31 901.86 0.31 2868.60 0.31 Case Rate 38792 Priced Excision of gum lesion 280013 41825 CPT Outpatient 11580.45 1987.98 Horizon BCBS Horizon Indemnity 0.32 3685.12 0.32 11580.45 0.32 Case Rate 41825 Priced Reconstruct cleft palate 280013 42200 CPT Outpatient 36703.80 6300.82 Horizon BCBS Horizon Indemnity 0.15 5642.00 0.15 36703.80 0.15 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 280013 42820 CPT Outpatient 17232.60 2958.26 Horizon BCBS Horizon Indemnity 0.32 5548.12 0.32 17232.60 0.32 Case Rate 42820 Priced Control throat bleeding 280013 42960 CPT Outpatient 24066.00 4131.33 Horizon BCBS Horizon Indemnity 0.23 5642.00 0.23 24066.00 0.23 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 280013 43235 CPT Outpatient 8856.75 1633.35 Horizon BCBS Horizon Indemnity 0.32 2796.08 0.32 8856.75 0.32 Case Rate 43235 Priced Laparoscopy fundoplasty 280013 43280 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 280013 43282 CPT Outpatient 84344.40 14479.12 Horizon BCBS Horizon Indemnity 0.07 5642.00 0.07 84344.40 0.07 Case Rate 43282 Priced Laparoscopy appendectomy 280013 44970 CPT Outpatient 82300.05 14128.18 Horizon BCBS Horizon Indemnity 0.07 5642.00 0.07 82300.05 0.07 Case Rate 44970 Priced Diagnostic sigmoidoscopy 280013 45330 CPT Outpatient 17286.15 542.26 Horizon BCBS Horizon Indemnity 0.32 5445.49 0.32 17286.15 0.32 Case Rate 45330 Priced Needle biopsy of liver 280013 47000 CPT Outpatient 10398.15 1225.34 Horizon BCBS Horizon Indemnity 0.31 3270.07 0.31 10398.15 0.31 Case Rate 47000 Priced Removal of gallbladder using an endoscope 280013 47562 CPT Outpatient 58430.40 10030.55 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 280013 47563 CPT Outpatient 71747.55 12316.66 Horizon BCBS Horizon Indemnity 0.08 5642.00 0.08 71747.55 0.08 Case Rate 47563 Priced Abd paracentesis w/imaging 280013 49083 CPT Outpatient 6979.35 1113.95 Horizon BCBS Horizon Indemnity 0.31 2194.84 0.31 6979.35 0.31 Case Rate 49083 Priced Diag laparo separate proc 280013 49320 CPT Outpatient 31629.15 5429.67 Horizon BCBS Horizon Indemnity 0.18 5642.00 0.18 31629.15 0.18 Case Rate 49320 Priced Laparoscopy biopsy 280013 49321 CPT Outpatient 41892.90 7191.61 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 41892.90 0.13 Case Rate 49321 Priced Laparoscopy aspiration 280013 49322 CPT Outpatient 34392.75 5904.09 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 34392.75 0.16 Case Rate 49322 Priced Lap insert tunnel ip cath 280013 49324 CPT Outpatient 39264.75 6740.45 Horizon BCBS Horizon Indemnity 0.14 5642.00 0.14 39264.75 0.14 Case Rate 49324 Priced Laparo proc abdm/per/oment 280013 49329 CPT Outpatient 58696.05 10076.16 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 58696.05 0.10 Case Rate 49329 Priced Ins tun ip cath for dial opn 280013 49421 CPT Outpatient 25460.40 3319.30 Horizon BCBS Horizon Indemnity 0.22 5642.00 0.22 25460.40 0.22 Case Rate 49421 Priced Remove tunneled ip cath 280013 49422 CPT Outpatient 25515.00 4380.08 Horizon BCBS Horizon Indemnity 0.22 5642.00 0.22 25515.00 0.22 Case Rate 49422 Priced Rpr ing hernia init reduce 280013 49500 CPT Outpatient 19594.05 3363.65 Horizon BCBS Horizon Indemnity 0.29 5642.00 0.29 19594.05 0.29 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 280013 49505 CPT Outpatient 34915.65 5993.85 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 34915.65 0.16 Case Rate 49505 Priced Prp i/hern init block >5 yr 280013 49507 CPT Outpatient 29794.80 5114.77 Horizon BCBS Horizon Indemnity 0.19 5642.00 0.19 29794.80 0.19 Case Rate 49507 Priced Rerepair ing hernia reduce 280013 49520 CPT Outpatient 36940.05 6341.38 Horizon BCBS Horizon Indemnity 0.15 5642.00 0.15 36940.05 0.15 Case Rate 49520 Priced Rpr ventral hern init reduc 280013 49560 CPT Outpatient 53177.25 9128.76 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 53177.25 0.11 Case Rate 49560 Priced Rpr ventral hern init block 280013 49561 CPT Outpatient 30755.55 5279.70 Horizon BCBS Horizon Indemnity 0.18 5642.00 0.18 30755.55 0.18 Case Rate 49561 Priced Rerepair ventrl hern reduce 280013 49565 CPT Outpatient 69917.40 12002.49 Horizon BCBS Horizon Indemnity 0.08 5642.00 0.08 69917.40 0.08 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 280013 49585 CPT Outpatient 41806.80 7176.83 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 41806.80 0.13 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 280013 49587 CPT Outpatient 37320.15 6406.63 Horizon BCBS Horizon Indemnity 0.15 5642.00 0.15 37320.15 0.15 Case Rate 49587 Priced Lap ing hernia repair init 280013 49650 CPT Outpatient 41932.80 7198.46 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 41932.80 0.13 Case Rate 49650 Priced Lap ing hernia repair recur 280013 49651 CPT Outpatient 46915.05 8053.75 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 46915.05 0.12 Case Rate 49651 Priced Lap vent/abd hernia repair 280013 49652 CPT Outpatient 51294.60 8805.57 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 51294.60 0.11 Case Rate 49652 Priced Lap vent/abd hern proc comp 280013 49653 CPT Outpatient 46102.35 7914.24 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 46102.35 0.12 Case Rate 49653 Priced Lap inc hernia repair 280013 49654 CPT Outpatient 47221.65 8106.38 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 47221.65 0.12 Case Rate 49654 Priced Lap inc hern repair comp 280013 49655 CPT Outpatient 54590.55 9371.38 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 54590.55 0.10 Case Rate 49655 Priced Lap inc hernia repair recur 280013 49656 CPT Outpatient 55443.15 9517.74 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 55443.15 0.10 Case Rate 49656 Priced Removal of kidney stone 280013 50080 CPT Outpatient 53165.70 9126.78 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 53165.70 0.11 Case Rate 50080 Priced Removal of kidney stone 280013 50081 CPT Outpatient 66931.20 11489.86 Horizon BCBS Horizon Indemnity 0.08 5642.00 0.08 66931.20 0.08 Case Rate 50081 Priced Renal biopsy perq 280013 50200 CPT Outpatient 43096.20 1225.34 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 43096.20 0.13 Case Rate 50200 Priced Plmt nephroureteral catheter 280013 50433 CPT Outpatient 64566.60 1424.48 Horizon BCBS Horizon Indemnity 0.09 5642.00 0.09 64566.60 0.09 Case Rate 50433 Priced Laparo radical nephrectomy 280013 50545 CPT Outpatient 43449.00 7458.75 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 43449.00 0.13 Case Rate 50545 Priced Laparoscope proc ureter 280013 50949 CPT Outpatient 49986.30 8580.98 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 49986.30 0.11 Case Rate 50949 Priced Injection for bladder x-ray 280013 51600 CPT Outpatient 3285.45 89.22 Horizon BCBS Horizon Indemnity 0.31 1033.27 0.31 3285.45 0.31 Case Rate 51600 Priced Cystoscopy 280013 52000 CPT Outpatient 22149.75 3802.37 Horizon BCBS Horizon Indemnity 0.25 5642.00 0.25 22149.75 0.25 Case Rate 52000 Priced Cystoscopy & ureter catheter 280013 52005 CPT Outpatient 42529.20 2095.77 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 42529.20 0.13 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 280013 52204 CPT Outpatient 31274.25 5368.75 Horizon BCBS Horizon Indemnity 0.18 5642.00 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 280013 52224 CPT Outpatient 13445.25 2308.10 Horizon BCBS Horizon Indemnity 0.32 4242.32 0.32 13445.25 0.32 Case Rate 52224 Priced Cystoscopy and treatment 280013 52234 CPT Outpatient 28510.65 4894.33 Horizon BCBS Horizon Indemnity 0.20 5642.00 0.20 28510.65 0.20 Case Rate 52234 Priced Cystoscopy and treatment 280013 52235 CPT Outpatient 29417.85 5050.06 Horizon BCBS Horizon Indemnity 0.19 5642.00 0.19 29417.85 0.19 Case Rate 52235 Priced Cystoscopy and treatment 280013 52240 CPT Outpatient 33933.90 5825.32 Horizon BCBS Horizon Indemnity 0.17 5642.00 0.17 33933.90 0.17 Case Rate 52240 Priced Cystoscopy and treatment 280013 52281 CPT Outpatient 22159.20 3804.00 Horizon BCBS Horizon Indemnity 0.25 5642.00 0.25 22159.20 0.25 Case Rate 52281 Priced Remove bladder stone 280013 52317 CPT Outpatient 27085.80 4649.73 Horizon BCBS Horizon Indemnity 0.21 5642.00 0.21 27085.80 0.21 Case Rate 52317 Priced Remove bladder stone 280013 52318 CPT Outpatient 26685.75 4581.05 Horizon BCBS Horizon Indemnity 0.21 5642.00 0.21 26685.75 0.21 Case Rate 52318 Priced Cystoscopy and treatment 280013 52332 CPT Outpatient 115306.80 19794.33 Horizon BCBS Horizon Indemnity 0.05 5642.00 0.05 115306.80 0.05 Case Rate 52332 Priced Cystouretero w/stone remove 280013 52352 CPT Outpatient 42420.00 7282.10 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 42420.00 0.13 Case Rate 52352 Priced Cystouretero w/lithotripsy 280013 52353 CPT Outpatient 38608.50 6627.79 Horizon BCBS Horizon Indemnity 0.15 5642.00 0.15 38608.50 0.15 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 280013 52356 CPT Outpatient 36255.45 6223.85 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 36255.45 0.16 Case Rate 52356 Priced Prostatectomy (turp) 280013 52601 CPT Outpatient 35371.35 6072.08 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 35371.35 0.16 Case Rate 52601 Priced Laser surgery of prostate 280013 52648 CPT Outpatient 24264.45 4165.40 Horizon BCBS Horizon Indemnity 0.23 5642.00 0.23 24264.45 0.23 Case Rate 52648 Priced Revision of urethra 280013 53450 CPT Outpatient 16209.90 2782.70 Horizon BCBS Horizon Indemnity 0.32 5123.03 0.32 16209.90 0.32 Case Rate 53450 Priced Urology surgery procedure 280013 53899 CPT Outpatient 25368.00 134.83 Horizon BCBS Horizon Indemnity 0.22 5642.00 0.22 25368.00 0.22 Case Rate 53899 Priced Circumcision w/regionl block 280013 54150 CPT Outpatient 14700.00 2523.50 Horizon BCBS Horizon Indemnity 0.31 4621.30 0.31 14700.00 0.31 Case Rate 54150 Priced Circum 28 days or older 280013 54161 CPT Outpatient 19186.65 3293.71 Horizon BCBS Horizon Indemnity 0.29 5642.00 0.29 19186.65 0.29 Case Rate 54161 Priced Lysis penil circumic lesion 280013 54162 CPT Outpatient 19795.65 3398.25 Horizon BCBS Horizon Indemnity 0.29 5642.00 0.29 19795.65 0.29 Case Rate 54162 Priced Repair of circumcision 280013 54163 CPT Outpatient 16391.55 2813.88 Horizon BCBS Horizon Indemnity 0.31 5159.78 0.31 16391.55 0.31 Case Rate 54163 Priced Reconstruction of urethra 280013 54324 CPT Outpatient 32880.75 5644.53 Horizon BCBS Horizon Indemnity 0.17 5642.00 0.17 32880.75 0.17 Case Rate 54324 Priced Revise penis/urethra 280013 54332 CPT Outpatient 19968.90 3427.99 Horizon BCBS Horizon Indemnity 0.28 5642.00 0.28 19968.90 0.28 Case Rate 54332 Priced Insert self-contd prosthesis 280013 54401 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 280013 54520 CPT Outpatient 35442.75 6084.34 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 35442.75 0.16 Case Rate 54520 Priced Reduce testis torsion 280013 54600 CPT Outpatient 55049.40 9450.15 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 55049.40 0.10 Case Rate 54600 Priced Suspension of testis 280013 54640 CPT Outpatient 26860.05 4610.98 Horizon BCBS Horizon Indemnity 0.21 5642.00 0.21 26860.05 0.21 Case Rate 54640 Priced Removal of hydrocele 280013 55040 CPT Outpatient 27277.95 4682.71 Horizon BCBS Horizon Indemnity 0.21 5642.00 0.21 27277.95 0.21 Case Rate 55040 Priced Biopsy of prostate gland 280013 55700 CPT Outpatient 28699.65 4926.77 Horizon BCBS Horizon Indemnity 0.20 5642.00 0.20 28699.65 0.20 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 280013 55866 CPT Outpatient 93088.80 15980.24 Horizon BCBS Horizon Indemnity 0.06 5642.00 0.06 93088.80 0.06 Case Rate 55866 Priced Closure of vagina 280013 57120 CPT Outpatient 34369.65 5900.12 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 34369.65 0.16 Case Rate 57120 Priced Repair of vagina 280013 57200 CPT Outpatient 25247.25 4334.11 Horizon BCBS Horizon Indemnity 0.22 5642.00 0.22 25247.25 0.22 Case Rate 57200 Priced Anterior colporrhaphy 280013 57240 CPT Outpatient 36210.30 6216.10 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 36210.30 0.16 Case Rate 57240 Priced Repair rectum & vagina 280013 57250 CPT Outpatient 40441.80 6942.51 Horizon BCBS Horizon Indemnity 0.14 5642.00 0.14 40441.80 0.14 Case Rate 57250 Priced Cmbn ant pst colprhy 280013 57260 CPT Outpatient 46323.90 7952.27 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 46323.90 0.12 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 280013 57265 CPT Outpatient 42586.95 7310.76 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 42586.95 0.13 Case Rate 57265 Priced Repair of bowel bulge 280013 57268 CPT Outpatient 36865.50 6328.58 Horizon BCBS Horizon Indemnity 0.15 5642.00 0.15 36865.50 0.15 Case Rate 57268 Priced Colpopexy extraperitoneal 280013 57282 CPT Outpatient 45629.85 7833.12 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 45629.85 0.12 Case Rate 57282 Priced Repair bladder defect 280013 57288 CPT Outpatient 43069.95 7393.67 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 43069.95 0.13 Case Rate 57288 Priced Bx/curett of cervix w/scope 280013 57454 CPT Outpatient 2888.55 442.93 Horizon BCBS Horizon Indemnity 0.31 908.45 0.31 2888.55 0.31 Case Rate 57454 Priced Conization of cervix 280013 57520 CPT Outpatient 26728.80 4588.44 Horizon BCBS Horizon Indemnity 0.21 5642.00 0.21 26728.80 0.21 Case Rate 57520 Priced Conization of cervix 280013 57522 CPT Outpatient 22737.75 3903.31 Horizon BCBS Horizon Indemnity 0.25 5642.00 0.25 22737.75 0.25 Case Rate 57522 Priced Biopsy of uterus lining 280013 58100 CPT Outpatient 2371.95 194.80 Horizon BCBS Horizon Indemnity 0.31 745.83 0.31 2371.95 0.31 Case Rate 58100 Priced Catheter for hysterography 280013 58340 CPT Outpatient 6322.05 131.04 Horizon BCBS Horizon Indemnity 0.31 1988.19 0.31 6322.05 0.31 Case Rate 58340 Priced Reopen fallopian tube 280013 58350 CPT Outpatient 46507.65 7983.81 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 46507.65 0.12 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 280013 58542 CPT Outpatient 64194.90 11020.12 Horizon BCBS Horizon Indemnity 0.09 5642.00 0.09 64194.90 0.09 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 280013 58544 CPT Outpatient 51020.55 8758.53 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 51020.55 0.11 Case Rate 58544 Priced Laparoscopic myomectomy 280013 58545 CPT Outpatient 56946.75 9775.86 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 56946.75 0.10 Case Rate 58545 Priced Laparo-vag hyst incl t/o 280013 58552 CPT Outpatient 57228.15 9824.17 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 57228.15 0.10 Case Rate 58552 Priced Hysteroscopy biopsy 280013 58558 CPT Outpatient 28581.00 2077.02 Horizon BCBS Horizon Indemnity 0.20 5642.00 0.20 28581.00 0.20 Case Rate 58558 Priced Hysteroscopy remove myoma 280013 58561 CPT Outpatient 35222.25 6046.49 Horizon BCBS Horizon Indemnity 0.16 5642.00 0.16 35222.25 0.16 Case Rate 58561 Priced Hysteroscopy ablation 280013 58563 CPT Outpatient 38399.55 6591.92 Horizon BCBS Horizon Indemnity 0.15 5642.00 0.15 38399.55 0.15 Case Rate 58563 Priced Tlh uterus 250 g or less 280013 58570 CPT Outpatient 43316.70 7436.03 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 43316.70 0.13 Case Rate 58570 Priced Tlh w/t/o 250 g or less 280013 58571 CPT Outpatient 48603.45 8343.59 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 48603.45 0.12 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 280013 58573 CPT Outpatient 52905.30 9082.08 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 52905.30 0.11 Case Rate 58573 Priced Laparoscopy remove adnexa 280013 58661 CPT Outpatient 47008.50 8069.79 Horizon BCBS Horizon Indemnity 0.12 5642.00 0.12 47008.50 0.12 Case Rate 58661 Priced Laparoscopy excise lesions 280013 58662 CPT Outpatient 45053.40 7734.17 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 45053.40 0.13 Case Rate 58662 Priced Treat ectopic pregnancy 280013 59151 CPT Outpatient 74690.70 12821.90 Horizon BCBS Horizon Indemnity 0.08 5642.00 0.08 74690.70 0.08 Case Rate 59151 Priced Treatment of miscarriage 280013 59812 CPT Outpatient 56109.90 9632.20 Horizon BCBS Horizon Indemnity 0.10 5642.00 0.10 56109.90 0.10 Case Rate 59812 Priced Partial removal of thyroid 280013 60220 CPT Outpatient 53639.25 9208.07 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 280013 60240 CPT Outpatient 98252.70 16866.71 Horizon BCBS Horizon Indemnity 0.06 5642.00 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 280013 60500 CPT Outpatient 150495.45 25835.05 Horizon BCBS Horizon Indemnity 0.04 5642.00 0.04 150495.45 0.04 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 280013 62322 CPT Outpatient 43709.40 514.24 Horizon BCBS Horizon Indemnity 0.13 5642.00 0.13 43709.40 0.13 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 280013 62323 CPT Outpatient 8304.45 467.31 Horizon BCBS Horizon Indemnity 0.68 5642.00 0.68 8304.45 0.68 Case Rate 62323 Priced Low back disk surgery 280013 63030 CPT Outpatient 50287.65 8632.71 Horizon BCBS Horizon Indemnity 0.11 5642.00 0.11 50287.65 0.11 Case Rate 63030 Priced Inc for vagus n elect impl 280013 64568 CPT Outpatient 124562.55 21383.24 Horizon BCBS Horizon Indemnity 0.05 5642.00 0.05 124562.55 0.05 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 280013 66821 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 280013 66984 CPT Outpatient 0.01 0.01 Horizon BCBS Horizon Indemnity 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 711044 216 DRG Inpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 711044 460 DRG Inpatient 416122.79 53834.63 Horizon NJ Health Horizon Medicaid 0.07 27717.00 0.07 416122.79 0.07 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 711044 470 DRG Inpatient 167912.19 21723.13 Horizon NJ Health Horizon Medicaid 0.08 13660.00 0.08 167912.19 0.08 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 711044 473 DRG Inpatient 100687.91 13026.19 Horizon NJ Health Horizon Medicaid 0.16 16290.00 0.16 100687.91 0.16 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 711044 743 DRG Inpatient 102691.67 13285.42 Horizon NJ Health Horizon Medicaid 0.07 7659.00 0.07 102691.67 0.07 Case Rate 743 Priced NORMAL NEWBORN 711044 795 DRG Inpatient 6266.93 2335.00 Horizon NJ Health Horizon Medicaid 0.18 1103.00 0.18 6266.93 0.18 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 711044 807 DRG Inpatient 116469.59 4193.00 Horizon NJ Health Horizon Medicaid 0.04 5213.00 0.04 116469.59 0.04 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 711044 788 DRG Inpatient 76050.77 4538.00 Horizon NJ Health Horizon Medicaid 0.10 7254.00 0.10 76050.77 0.10 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 711044 59400 CPT Inpatient 116469.59 4193.00 Horizon NJ Health Horizon Medicaid 0.04 5213.00 0.04 116469.59 0.04 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 711044 59510 CPT Inpatient 76050.77 4538.00 Horizon NJ Health Horizon Medicaid 0.10 7254.00 0.10 76050.77 0.10 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 711044 59610 CPT Inpatient 116469.59 4193.00 Horizon NJ Health Horizon Medicaid 0.04 5213.00 0.04 116469.59 0.04 Case Rate 59610 Priced "Psychotherapy, 30 min" 711044 90832 CPT Outpatient 577.50 91.21 Horizon NJ Health Horizon Medicaid 0.95 550.00 0.95 577.50 0.95 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 711044 90834 CPT Outpatient 44134.65 271.96 Horizon NJ Health Horizon Medicaid 0.01 485.44 0.01 44134.65 0.01 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 711044 90837 CPT Outpatient 2240.70 442.93 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 2240.70 0.01 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 711044 90846 CPT Outpatient 0.01 131.50 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 711044 90847 CPT Outpatient 44134.65 369.97 Horizon NJ Health Horizon Medicaid 0.01 485.44 0.01 44134.65 0.01 Fee Schedule 90847 Priced Group psychotherapy 711044 90853 CPT Outpatient 44134.65 101.99 Horizon NJ Health Horizon Medicaid 0.01 485.44 0.01 44134.65 0.01 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 711044 99203 CPT Outpatient 3480.75 176.07 Horizon NJ Health Horizon Medicaid 0.01 42.94 0.01 3480.75 0.01 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 711044 99204 CPT Outpatient 2103.15 233.39 Horizon NJ Health Horizon Medicaid 0.02 46.21 0.02 2103.15 0.02 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 711044 99205 CPT Outpatient 4970.70 314.28 Horizon NJ Health Horizon Medicaid 0.01 46.21 0.01 4970.70 0.01 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 711044 99243 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 711044 99244 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 711044 99385 CPT Outpatient 1114.05 185.90 Horizon NJ Health Horizon Medicaid 0.03 35.53 0.03 1114.05 0.03 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 711044 99386 CPT Outpatient 4877.25 185.90 Horizon NJ Health Horizon Medicaid 0.05 234.35 0.05 4877.25 0.05 Fee Schedule 99386 Priced Routine venipuncture 711044 36415 CPT Outpatient 127.05 19.57 Horizon NJ Health Horizon Medicaid 0.03 3.80 0.03 127.05 0.03 Fee Schedule 36415 Priced Basic Metabolic Panel 711044 80048 CPT Outpatient 576.45 88.78 Horizon NJ Health Horizon Medicaid 0.02 14.32 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 711044 80053 CPT Outpatient 763.35 117.56 Horizon NJ Health Horizon Medicaid 0.03 22.18 0.03 763.35 0.03 Fee Schedule 80053 Priced Obstetric blood test panel 711044 80055 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 711044 80061 CPT Outpatient 1349.25 197.77 Horizon NJ Health Horizon Medicaid 0.02 23.10 0.02 1349.25 0.02 Fee Schedule 80061 Priced Kidney function panel test 711044 80069 CPT Outpatient 716.10 104.95 Horizon NJ Health Horizon Medicaid 0.01 7.58 0.01 716.10 0.01 Fee Schedule 80069 Priced Liver function panel test 711044 80076 CPT Outpatient 716.10 104.95 Horizon NJ Health Horizon Medicaid 0.02 10.78 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 711044 81000 CPT Outpatient 144.90 21.18 Horizon NJ Health Horizon Medicaid 0.01 1.85 0.01 144.90 0.01 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 711044 81001 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 711044 81002 CPT Outpatient 57.75 8.89 Horizon NJ Health Horizon Medicaid 0.03 1.54 0.03 57.75 0.03 Fee Schedule 81002 Priced Automated urinalysis test 711044 81003 CPT Outpatient 219.45 33.80 Horizon NJ Health Horizon Medicaid 0.01 2.31 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 711044 82306 CPT Outpatient 1880.55 289.62 Horizon NJ Health Horizon Medicaid 0.02 46.20 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 711044 83036 CPT Outpatient 494.55 76.17 Horizon NJ Health Horizon Medicaid 0.02 10.16 0.02 494.55 0.02 Fee Schedule 83036 Priced PSA (prostate specific antigen) 711044 84153 CPT Outpatient 1177.05 181.28 Horizon NJ Health Horizon Medicaid 0.03 37.73 0.03 1177.05 0.03 Fee Schedule 84153 Priced PSA (prostate specific antigen) 711044 84154 CPT Outpatient 598.50 92.17 Horizon NJ Health Horizon Medicaid 0.03 16.05 0.03 598.50 0.03 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 711044 84443 CPT Outpatient 519.75 80.05 Horizon NJ Health Horizon Medicaid 0.07 38.50 0.07 519.75 0.07 Fee Schedule 84443 Priced Chorionic gonadotropin assay 711044 84703 CPT Outpatient 785.40 120.96 Horizon NJ Health Horizon Medicaid 0.01 4.62 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 711044 85025 CPT Outpatient 635.25 97.83 Horizon NJ Health Horizon Medicaid 0.01 7.70 0.01 635.25 0.01 Fee Schedule 85025 Priced "Complete blood count, automated" 711044 85027 CPT Outpatient 576.45 88.78 Horizon NJ Health Horizon Medicaid 0.01 7.39 0.01 576.45 0.01 Fee Schedule 85027 Priced "Blood test, clotting time" 711044 85610 CPT Outpatient 404.25 62.26 Horizon NJ Health Horizon Medicaid 0.01 4.62 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 711044 85730 CPT Outpatient 17.22 2.65 Horizon NJ Health Horizon Medicaid 0.27 4.62 0.27 17.22 0.27 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 711044 86003 CPT Outpatient 32.55 5.01 Horizon NJ Health Horizon Medicaid 0.95 30.80 0.95 32.55 0.95 Fee Schedule 86003 Priced Tb test cell immun measure 711044 86480 CPT Outpatient 530.25 81.66 Horizon NJ Health Horizon Medicaid 0.12 62.29 0.12 530.25 0.12 Fee Schedule 86480 Priced Urine culture/colony count 711044 87086 CPT Outpatient 763.35 117.56 Horizon NJ Health Horizon Medicaid 0.01 9.24 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 711044 87338 CPT Outpatient 785.40 120.96 Horizon NJ Health Horizon Medicaid 0.02 12.55 0.02 785.40 0.02 Fee Schedule 87338 Priced Cytopath eval fna report 711044 88173 CPT Outpatient 750.75 115.62 Horizon NJ Health Horizon Medicaid 0.05 38.50 0.05 750.75 0.05 Fee Schedule 88173 Priced Tissue exam by pathologist 711044 88302 CPT Outpatient 635.25 97.83 Horizon NJ Health Horizon Medicaid 0.05 32.34 0.05 635.25 0.05 Fee Schedule 88302 Priced Tissue exam by pathologist 711044 88305 CPT Outpatient 323.40 49.81 Horizon NJ Health Horizon Medicaid 0.19 61.60 0.19 323.40 0.19 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 711044 11042 CPT Outpatient 2668.05 481.45 Horizon NJ Health Horizon Medicaid 0.02 42.93 0.02 2668.05 0.02 Case Rate 11042 Priced Deb subq tissue add-on 711044 11045 CPT Outpatient 4652.55 330.00 Horizon NJ Health Horizon Medicaid 0.01 62.31 0.01 4652.55 0.01 Case Rate 11045 Priced Dx bronchoscope/lavage 711044 31624 CPT Outpatient 41223.00 7602.31 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 41223.00 0.05 Case Rate 31624 Priced Bronchoscopy/lung bx each 711044 31628 CPT Outpatient 49048.65 9045.51 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 49048.65 0.05 Case Rate 31628 Priced Blood transfusion service 711044 36430 CPT Outpatient 9166.50 574.93 Horizon NJ Health Horizon Medicaid 0.05 457.55 0.05 9166.50 0.05 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 711044 43235 CPT Outpatient 8856.75 1633.35 Horizon NJ Health Horizon Medicaid 0.25 2211.00 0.25 8856.75 0.25 Case Rate 43235 Priced Endoscopic us exam esoph 711044 43237 CPT Outpatient 23867.55 4401.63 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 23867.55 0.09 Case Rate 43237 Priced Egd us fine needle bx/aspir 711044 43238 CPT Outpatient 30690.45 5659.90 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 30690.45 0.07 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 711044 43239 CPT Outpatient 40191.90 7412.15 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 40191.90 0.06 Case Rate 43239 Priced Ercp remove duct calculi 711044 43264 CPT Outpatient 34335.00 6332.03 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 34335.00 0.06 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 711044 45378 CPT Outpatient 13991.25 889.35 Horizon NJ Health Horizon Medicaid 0.16 2211.00 0.16 13991.25 0.16 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 711044 45380 CPT Outpatient 22215.90 4097.04 Horizon NJ Health Horizon Medicaid 0.10 2211.00 0.10 22215.90 0.10 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 711044 45385 CPT Outpatient 119569.80 22050.95 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 119569.80 0.02 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 711044 45391 CPT Outpatient 24923.85 4596.43 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 24923.85 0.09 Case Rate 45391 Priced Fragmenting of kidney stone 711044 50590 CPT Outpatient 40930.05 7548.28 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 40930.05 0.05 Case Rate 50590 Priced Fetal non-stress test 711044 59025 CPT Outpatient 3153.15 477.76 Horizon NJ Health Horizon Medicaid 0.16 497.00 0.16 3153.15 0.16 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 711044 64483 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 711044 92567 CPT Outpatient 2224.95 98.50 Horizon NJ Health Horizon Medicaid 0.11 240.90 0.11 2224.95 0.11 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 711044 93000 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 711044 93017 CPT Outpatient 3076.50 532.96 Horizon NJ Health Horizon Medicaid 0.11 336.60 0.11 3076.50 0.11 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 711044 93452 CPT Outpatient 55621.65 8611.87 Horizon NJ Health Horizon Medicaid 0.08 4367.00 0.08 55621.65 0.08 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 711044 95810 CPT Outpatient 20341.65 3373.48 Horizon NJ Health Horizon Medicaid 0.05 1103.00 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 711044 95811 CPT Outpatient 22491.00 3731.18 Horizon NJ Health Horizon Medicaid 0.05 1103.00 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 711044 95812 CPT Outpatient 5578.65 925.83 Horizon NJ Health Horizon Medicaid 0.05 273.90 0.05 5578.65 0.05 Case Rate 95812 Priced Genetic counseling 30 min 711044 96040 CPT Outpatient 0.01 102.81 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 711044 96413 CPT Outpatient 4856.25 472.45 Horizon NJ Health Horizon Medicaid 0.55 2667.29 0.55 4856.25 0.55 Case Rate 96413 Priced Ultrasound therapy 711044 97035 CPT Outpatient 2111.55 134.99 Horizon NJ Health Horizon Medicaid 0.03 60.00 0.03 2111.55 0.03 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 711044 97110 CPT Outpatient 6494.25 92.86 Horizon NJ Health Horizon Medicaid 0.05 300.00 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 711044 97116 CPT Outpatient 4723.95 110.61 Horizon NJ Health Horizon Medicaid 0.03 120.00 0.03 4723.95 0.03 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 711044 70450 CPT Outpatient 8566.95 835.61 Horizon NJ Health Horizon Medicaid 0.05 440.00 0.05 8566.95 0.05 Case Rate 70450 Priced Mri brain stem w/o dye 711044 70551 CPT Outpatient 7861.35 1361.31 Horizon NJ Health Horizon Medicaid 0.08 633.60 0.08 7861.35 0.08 Case Rate 70551 Priced MRI scan of brain before and after contrast 711044 70553 CPT Outpatient 10882.20 1625.88 Horizon NJ Health Horizon Medicaid 0.10 1046.90 0.10 10882.20 0.10 Case Rate 70553 Priced X-ray exam chest 2 views 711044 71046 CPT Outpatient 859.95 150.37 Horizon NJ Health Horizon Medicaid 0.03 23.83 0.03 859.95 0.03 Case Rate 71046 Priced Ct thorax w/o dye 711044 71250 CPT Outpatient 7288.05 1261.63 Horizon NJ Health Horizon Medicaid 0.04 280.26 0.04 7288.05 0.04 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 711044 72082 CPT Outpatient 2022.30 253.33 Horizon NJ Health Horizon Medicaid 0.05 97.39 0.05 2022.30 0.05 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 711044 72100 CPT Outpatient 1599.15 277.38 Horizon NJ Health Horizon Medicaid 0.03 42.24 0.03 1599.15 0.03 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 711044 72110 CPT Outpatient 1389.15 241.04 Horizon NJ Health Horizon Medicaid 0.04 52.80 0.04 1389.15 0.04 Case Rate 72110 Priced MRI scan of lower spinal canal 711044 72148 CPT Outpatient 7861.35 1361.31 Horizon NJ Health Horizon Medicaid 0.08 633.60 0.08 7861.35 0.08 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 711044 72193 CPT Outpatient 13671.00 1412.01 Horizon NJ Health Horizon Medicaid 0.02 327.05 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 711044 73030 CPT Outpatient 1452.15 251.43 Horizon NJ Health Horizon Medicaid 0.02 31.68 0.02 1452.15 0.02 Case Rate 73030 Priced X-ray exam of elbow 711044 73080 CPT Outpatient 1356.60 235.68 Horizon NJ Health Horizon Medicaid 0.02 31.68 0.02 1356.60 0.02 Case Rate 73080 Priced X-ray exam of forearm 711044 73090 CPT Outpatient 1243.20 215.26 Horizon NJ Health Horizon Medicaid 0.02 26.88 0.02 1243.20 0.02 Case Rate 73090 Priced X-ray exam of wrist 711044 73110 CPT Outpatient 1243.20 215.26 Horizon NJ Health Horizon Medicaid 0.03 31.68 0.03 1243.20 0.03 Case Rate 73110 Priced X-ray exam of hand 711044 73130 CPT Outpatient 1243.20 215.26 Horizon NJ Health Horizon Medicaid 0.03 31.68 0.03 1243.20 0.03 Case Rate 73130 Priced X-ray exam hips bi 2 views 711044 73521 CPT Outpatient 970.20 228.41 Horizon NJ Health Horizon Medicaid 0.04 42.14 0.04 970.20 0.04 Case Rate 73521 Priced X-ray exam of knee 3 711044 73562 CPT Outpatient 802.20 139.12 Horizon NJ Health Horizon Medicaid 0.04 31.68 0.04 802.20 0.04 Case Rate 73562 Priced X-ray exam of lower leg 711044 73590 CPT Outpatient 1243.20 215.26 Horizon NJ Health Horizon Medicaid 0.03 31.68 0.03 1243.20 0.03 Case Rate 73590 Priced X-ray exam of ankle 711044 73610 CPT Outpatient 1378.65 239.31 Horizon NJ Health Horizon Medicaid 0.02 29.18 0.02 1378.65 0.02 Case Rate 73610 Priced X-ray exam of foot 711044 73630 CPT Outpatient 975.45 169.41 Horizon NJ Health Horizon Medicaid 0.03 29.18 0.03 975.45 0.03 Case Rate 73630 Priced MRI scan of leg joint 711044 73721 CPT Outpatient 7861.35 1361.31 Horizon NJ Health Horizon Medicaid 0.08 633.60 0.08 7861.35 0.08 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 711044 74177 CPT Outpatient 14222.25 1412.01 Horizon NJ Health Horizon Medicaid 0.02 230.43 0.02 14222.25 0.02 Case Rate 74177 Priced Contrst x-ray exam of throat 711044 74210 CPT Outpatient 0.01 440.39 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 711044 76098 CPT Outpatient 6141.45 407.86 Horizon NJ Health Horizon Medicaid 0.36 2211.00 0.36 6141.45 0.36 Case Rate 76098 Priced Us exam of head and neck 711044 76536 CPT Outpatient 5512.50 955.18 Horizon NJ Health Horizon Medicaid 0.01 78.60 0.01 5512.50 0.01 Case Rate 76536 Priced Ultrasound breast limited 711044 76642 CPT Outpatient 5777.10 127.70 Horizon NJ Health Horizon Medicaid 0.03 186.57 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 711044 76700 CPT Outpatient 4917.15 851.88 Horizon NJ Health Horizon Medicaid 0.03 126.72 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 711044 76705 CPT Outpatient 3836.70 665.17 Horizon NJ Health Horizon Medicaid 0.02 84.48 0.02 3836.70 0.02 Case Rate 76705 Priced Us exam abdo back wall comp 711044 76770 CPT Outpatient 5171.25 895.48 Horizon NJ Health Horizon Medicaid 0.02 126.72 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 711044 76775 CPT Outpatient 3969.00 686.97 Horizon NJ Health Horizon Medicaid 0.03 126.72 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 711044 76801 CPT Outpatient 2006.55 347.98 Horizon NJ Health Horizon Medicaid 0.05 105.60 0.05 2006.55 0.05 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 711044 76805 CPT Outpatient 3969.00 686.97 Horizon NJ Health Horizon Medicaid 0.03 124.03 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 711044 76811 CPT Outpatient 2844.45 492.99 Horizon NJ Health Horizon Medicaid 0.14 391.68 0.14 2844.45 0.14 Case Rate 76811 Priced Ob us nuchal meas 1 gest 711044 76813 CPT Outpatient 1044.75 180.83 Horizon NJ Health Horizon Medicaid 0.06 67.35 0.06 1044.75 0.06 Case Rate 76813 Priced Ob us limited fetus(s) 711044 76815 CPT Outpatient 6428.10 639.90 Horizon NJ Health Horizon Medicaid 0.03 222.72 0.03 6428.10 0.03 Case Rate 76815 Priced Ob us follow-up per fetus 711044 76816 CPT Outpatient 4818.45 833.88 Horizon NJ Health Horizon Medicaid 0.01 67.20 0.01 4818.45 0.01 Case Rate 76816 Priced Transvaginal us obstetric 711044 76817 CPT Outpatient 6428.10 476.73 Horizon NJ Health Horizon Medicaid 0.03 222.72 0.03 6428.10 0.03 Case Rate 76817 Priced Fetal biophys profil w/o nst 711044 76819 CPT Outpatient 1741.95 302.65 Horizon NJ Health Horizon Medicaid 0.06 105.60 0.06 1741.95 0.06 Case Rate 76819 Priced Ultrasound pelvis through vagina 711044 76830 CPT Outpatient 9305.10 806.54 Horizon NJ Health Horizon Medicaid 0.03 268.22 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 711044 76870 CPT Outpatient 6328.35 1096.55 Horizon NJ Health Horizon Medicaid 0.02 99.26 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 711044 76885 CPT Outpatient 3836.70 665.17 Horizon NJ Health Horizon Medicaid 0.02 71.04 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 711044 77065 CPT Outpatient 3451.35 192.07 Horizon NJ Health Horizon Medicaid 0.05 162.23 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 711044 77066 CPT Outpatient 5777.10 235.68 Horizon NJ Health Horizon Medicaid 0.03 186.57 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 711044 77067 CPT Outpatient 1416.45 205.57 Horizon NJ Health Horizon Medicaid 0.08 119.62 0.08 1416.45 0.08 Case Rate 77067 Priced X-rays for bone age 711044 77072 CPT Outpatient 2022.30 163.87 Horizon NJ Health Horizon Medicaid 0.05 97.39 0.05 2022.30 0.05 Case Rate 77072 Priced Joint survey single view 711044 77077 CPT Outpatient 985.95 171.14 Horizon NJ Health Horizon Medicaid 0.03 33.33 0.03 985.95 0.03 Case Rate 77077 Priced Dxa bone density axial 711044 77080 CPT Outpatient 3257.10 319.09 Horizon NJ Health Horizon Medicaid 0.08 244.42 0.08 3257.10 0.08 Case Rate 77080 Priced Fna bx w/us gdn 1st les 711044 10005 CPT Outpatient 5512.50 547.24 Horizon NJ Health Horizon Medicaid 0.40 2211.00 0.40 5512.50 0.40 Case Rate 10005 Priced Fna bx w/us gdn ea addl 711044 10006 CPT Outpatient 10628.10 594.83 Horizon NJ Health Horizon Medicaid 0.21 2211.00 0.21 10628.10 0.21 Case Rate 10006 Priced Drainage of hematoma/fluid 711044 10140 CPT Outpatient 23209.20 1081.95 Horizon NJ Health Horizon Medicaid 0.10 2211.00 0.10 23209.20 0.10 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 711044 11042 CPT Outpatient 2668.05 481.45 Horizon NJ Health Horizon Medicaid 0.02 42.93 0.02 2668.05 0.02 Case Rate 11042 Priced Deb bone 20 sq cm/< 711044 11044 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 711044 11406 CPT Outpatient 19967.85 3427.81 Horizon NJ Health Horizon Medicaid 0.11 2211.00 0.11 19967.85 0.11 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 711044 11424 CPT Outpatient 0.01 1004.93 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 711044 11770 CPT Outpatient 19173.00 3291.37 Horizon NJ Health Horizon Medicaid 0.12 2211.00 0.12 19173.00 0.12 Case Rate 11770 Priced Replace tissue expander 711044 11970 CPT Outpatient 59239.95 10169.52 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 59239.95 0.04 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 711044 14020 CPT Outpatient 32166.75 5521.96 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 32166.75 0.07 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 711044 14060 CPT Outpatient 25993.80 1374.69 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 25993.80 0.09 Case Rate 14060 Priced Wound prep trk/arm/leg 711044 15002 CPT Outpatient 41748.00 1441.73 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 41748.00 0.05 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 711044 15271 CPT Outpatient 24343.20 3769.48 Horizon NJ Health Horizon Medicaid 0.01 89.50 0.01 24343.20 0.01 Case Rate 15271 Priced Acellular derm matrix implt 711044 15777 CPT Outpatient 101672.55 17453.79 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 101672.55 0.02 Case Rate 15777 Priced Exc skin abd 711044 15830 CPT Outpatient 54696.60 9389.58 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 54696.60 0.04 Case Rate 15830 Priced Dressing change not for burn 711044 15852 CPT Outpatient 0.01 290.74 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 711044 15877 CPT Outpatient 63741.30 10942.26 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 63741.30 0.03 Case Rate 15877 Priced Suction lipectomy lwr extrem 711044 15879 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 711044 19000 CPT Outpatient 10143.00 594.83 Horizon NJ Health Horizon Medicaid 0.22 2211.00 0.22 10143.00 0.22 Case Rate 19000 Priced Bx breast 1st lesion strtctc 711044 19081 CPT Outpatient 12341.70 1250.69 Horizon NJ Health Horizon Medicaid 0.18 2211.00 0.18 12341.70 0.18 Case Rate 19081 Priced Bx breast add lesion us imag 711044 19084 CPT Outpatient 29058.75 547.24 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 29058.75 0.08 Case Rate 19084 Priced Biopsy of breast open 711044 19101 CPT Outpatient 39545.10 2737.82 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 39545.10 0.06 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 711044 19120 CPT Outpatient 35761.95 2737.82 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 35761.95 0.06 Case Rate 19120 Priced Excision breast lesion 711044 19125 CPT Outpatient 33184.20 0.01 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 33184.20 0.07 Case Rate 19125 Priced Perq device breast 1st imag 711044 19281 CPT Outpatient 6141.45 598.61 Horizon NJ Health Horizon Medicaid 0.36 2211.00 0.36 6141.45 0.36 Case Rate 19281 Priced Perq device breast ea imag 711044 19282 CPT Outpatient 8379.00 319.04 Horizon NJ Health Horizon Medicaid 0.26 2211.00 0.26 8379.00 0.26 Case Rate 19282 Priced Partial mastectomy 711044 19301 CPT Outpatient 39157.65 6722.06 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 39157.65 0.06 Case Rate 19301 Priced Mast simple complete 711044 19303 CPT Outpatient 105389.55 18091.87 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 105389.55 0.02 Case Rate 19303 Priced Reduction of large breast 711044 19318 CPT Outpatient 65239.65 11199.47 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 65239.65 0.03 Case Rate 19318 Priced Immediate breast prosthesis 711044 19340 CPT Outpatient 113100.75 19415.63 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 113100.75 0.02 Case Rate 19340 Priced Delayed breast prosthesis 711044 19342 CPT Outpatient 56988.75 9783.07 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 56988.75 0.04 Case Rate 19342 Priced Breast reconstruction 711044 19357 CPT Outpatient 101672.55 17453.79 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 101672.55 0.02 Case Rate 19357 Priced Breast reconstruction 711044 19366 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 711044 19380 CPT Outpatient 61493.25 10556.34 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 61493.25 0.04 Case Rate 19380 Priced Removal of support implant 711044 20680 CPT Outpatient 42329.70 7266.60 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 42329.70 0.05 Case Rate 20680 Priced Cerv artific diskectomy 711044 22856 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 711044 24538 CPT Outpatient 51237.90 4775.24 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 51237.90 0.04 Case Rate 24538 Priced Remove wrist tendon lesion 711044 25111 CPT Outpatient 25855.20 4438.48 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 25855.20 0.09 Case Rate 25111 Priced Incise finger tendon sheath 711044 26055 CPT Outpatient 15862.35 2723.04 Horizon NJ Health Horizon Medicaid 0.14 2211.00 0.14 15862.35 0.14 Case Rate 26055 Priced Treat finger fracture each 711044 26727 CPT Outpatient 22779.75 2030.47 Horizon NJ Health Horizon Medicaid 0.10 2211.00 0.10 22779.75 0.10 Case Rate 26727 Priced Revision of knee joint 711044 27446 CPT Outpatient 67882.50 11653.16 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 67882.50 0.03 Case Rate 27446 Priced Total knee arthroplasty 711044 27447 CPT Outpatient 130698.75 22436.62 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 130698.75 0.02 Case Rate 27447 Priced Surgery to stop leg growth 711044 27485 CPT Outpatient 43310.40 7434.95 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 43310.40 0.05 Case Rate 27485 Priced Repair achilles tendon 711044 27650 CPT Outpatient 38246.25 3762.57 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 38246.25 0.06 Case Rate 27650 Priced Treatment of ankle fracture 711044 27792 CPT Outpatient 36101.10 6197.36 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 36101.10 0.06 Case Rate 27792 Priced Treatment of ankle fracture 711044 27814 CPT Outpatient 49405.65 8481.30 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 49405.65 0.04 Case Rate 27814 Priced Removal of foot lesion 711044 28080 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 711044 28285 CPT Outpatient 68603.85 11776.99 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 68603.85 0.03 Case Rate 28285 Priced Correction hallux valgus 711044 28296 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 711044 29823 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 711044 29826 CPT Outpatient 49840.35 8555.93 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 49840.35 0.04 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 711044 29881 CPT Outpatient 35556.15 6103.81 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 35556.15 0.06 Case Rate 29881 Priced Knee arthroscopy/surgery 711044 29882 CPT Outpatient 61099.50 10488.75 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 61099.50 0.04 Case Rate 29882 Priced Percut bx lung/mediastinum 711044 32405 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 711044 32555 CPT Outpatient 14597.10 687.29 Horizon NJ Health Horizon Medicaid 0.15 2211.00 0.15 14597.10 0.15 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 711044 32664 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 711044 35190 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 711044 36478 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 711044 36561 CPT Outpatient 53531.10 3292.99 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 53531.10 0.04 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 711044 36569 CPT Outpatient 31421.25 1299.06 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 31421.25 0.07 Case Rate 36569 Priced Removal tunneled cv cath 711044 36590 CPT Outpatient 1996.05 273.95 Horizon NJ Health Horizon Medicaid 0.91 1818.00 0.91 1996.05 0.91 Case Rate 36590 Priced Av fuse uppr arm basilic 711044 36819 CPT Outpatient 56861.70 9761.26 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 56861.70 0.04 Case Rate 36819 Priced Av fusion direct any site 711044 36821 CPT Outpatient 42953.40 7373.67 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 42953.40 0.05 Case Rate 36821 Priced Artery-vein autograft 711044 36825 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 711044 36830 CPT Outpatient 53656.05 9210.96 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 53656.05 0.04 Case Rate 36830 Priced Av fistula revision open 711044 36832 CPT Outpatient 52492.65 9011.24 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 52492.65 0.04 Case Rate 36832 Priced Av fistula revision 711044 36833 CPT Outpatient 37098.60 6368.59 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 37098.60 0.06 Case Rate 36833 Priced Intro cath dialysis circuit 711044 36903 CPT Outpatient 77541.45 10669.90 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 77541.45 0.03 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 711044 36906 CPT Outpatient 96694.50 16175.64 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 96694.50 0.02 Case Rate 36906 Priced Fem/popl revas w/tla 711044 37224 CPT Outpatient 200076.45 5139.31 Horizon NJ Health Horizon Medicaid 0.02 4367.00 0.02 200076.45 0.02 Case Rate 37224 Priced Fem/popl revasc stnt & ather 711044 37227 CPT Outpatient 117170.55 18045.38 Horizon NJ Health Horizon Medicaid 0.04 4367.00 0.04 117170.55 0.04 Case Rate 37227 Priced Revise leg vein 711044 37700 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 711044 37722 CPT Outpatient 27815.55 4775.00 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 27815.55 0.08 Case Rate 37722 Priced Stab phleb veins xtr 10-20 711044 37765 CPT Outpatient 26561.85 4559.78 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 26561.85 0.08 Case Rate 37765 Priced Biopsy/removal lymph nodes 711044 38500 CPT Outpatient 35955.15 6172.30 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 35955.15 0.06 Case Rate 38500 Priced Biopsy/removal lymph nodes 711044 38525 CPT Outpatient 101194.80 17371.77 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 101194.80 0.02 Case Rate 38525 Priced Laparoscopy lymph node biop 711044 38570 CPT Outpatient 65631.30 11266.71 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 65631.30 0.03 Case Rate 38570 Priced Laparoscopy lymphadenectomy 711044 38571 CPT Outpatient 84031.50 14425.41 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 84031.50 0.03 Case Rate 38571 Priced Laparoscopy lymphadenectomy 711044 38572 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 711044 38792 CPT Outpatient 2868.60 432.48 Horizon NJ Health Horizon Medicaid 0.77 2211.00 0.77 2868.60 0.77 Case Rate 38792 Priced Excision of gum lesion 711044 41825 CPT Outpatient 11580.45 1987.98 Horizon NJ Health Horizon Medicaid 0.19 2211.00 0.19 11580.45 0.19 Case Rate 41825 Priced Reconstruct cleft palate 711044 42200 CPT Outpatient 36703.80 6300.82 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 36703.80 0.06 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 711044 42820 CPT Outpatient 17232.60 2958.26 Horizon NJ Health Horizon Medicaid 0.13 2211.00 0.13 17232.60 0.13 Case Rate 42820 Priced Control throat bleeding 711044 42960 CPT Outpatient 24066.00 4131.33 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 24066.00 0.09 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 711044 43235 CPT Outpatient 8856.75 1633.35 Horizon NJ Health Horizon Medicaid 0.25 2211.00 0.25 8856.75 0.25 Case Rate 43235 Priced Laparoscopy fundoplasty 711044 43280 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 711044 43282 CPT Outpatient 84344.40 14479.12 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 84344.40 0.03 Case Rate 43282 Priced Laparoscopy appendectomy 711044 44970 CPT Outpatient 82300.05 14128.18 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 82300.05 0.03 Case Rate 44970 Priced Diagnostic sigmoidoscopy 711044 45330 CPT Outpatient 17286.15 542.26 Horizon NJ Health Horizon Medicaid 0.13 2211.00 0.13 17286.15 0.13 Case Rate 45330 Priced Needle biopsy of liver 711044 47000 CPT Outpatient 10398.15 1225.34 Horizon NJ Health Horizon Medicaid 0.21 2211.00 0.21 10398.15 0.21 Case Rate 47000 Priced Removal of gallbladder using an endoscope 711044 47562 CPT Outpatient 58430.40 10030.55 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 58430.40 0.04 Case Rate 47562 Priced Laparo cholecystectomy/graph 711044 47563 CPT Outpatient 71747.55 12316.66 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 71747.55 0.03 Case Rate 47563 Priced Abd paracentesis w/imaging 711044 49083 CPT Outpatient 6979.35 1113.95 Horizon NJ Health Horizon Medicaid 0.32 2211.00 0.32 6979.35 0.32 Case Rate 49083 Priced Diag laparo separate proc 711044 49320 CPT Outpatient 31629.15 5429.67 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 31629.15 0.07 Case Rate 49320 Priced Laparoscopy biopsy 711044 49321 CPT Outpatient 41892.90 7191.61 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 41892.90 0.05 Case Rate 49321 Priced Laparoscopy aspiration 711044 49322 CPT Outpatient 34392.75 5904.09 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 34392.75 0.06 Case Rate 49322 Priced Lap insert tunnel ip cath 711044 49324 CPT Outpatient 39264.75 6740.45 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 39264.75 0.06 Case Rate 49324 Priced Laparo proc abdm/per/oment 711044 49329 CPT Outpatient 58696.05 10076.16 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 58696.05 0.04 Case Rate 49329 Priced Ins tun ip cath for dial opn 711044 49421 CPT Outpatient 25460.40 3319.30 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 25460.40 0.09 Case Rate 49421 Priced Remove tunneled ip cath 711044 49422 CPT Outpatient 25515.00 4380.08 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 25515.00 0.09 Case Rate 49422 Priced Rpr ing hernia init reduce 711044 49500 CPT Outpatient 19594.05 3363.65 Horizon NJ Health Horizon Medicaid 0.11 2211.00 0.11 19594.05 0.11 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 711044 49505 CPT Outpatient 34915.65 5993.85 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 34915.65 0.06 Case Rate 49505 Priced Prp i/hern init block >5 yr 711044 49507 CPT Outpatient 29794.80 5114.77 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 29794.80 0.07 Case Rate 49507 Priced Rerepair ing hernia reduce 711044 49520 CPT Outpatient 36940.05 6341.38 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 36940.05 0.06 Case Rate 49520 Priced Rpr ventral hern init reduc 711044 49560 CPT Outpatient 53177.25 9128.76 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 53177.25 0.04 Case Rate 49560 Priced Rpr ventral hern init block 711044 49561 CPT Outpatient 30755.55 5279.70 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 30755.55 0.07 Case Rate 49561 Priced Rerepair ventrl hern reduce 711044 49565 CPT Outpatient 69917.40 12002.49 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 69917.40 0.03 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 711044 49585 CPT Outpatient 41806.80 7176.83 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 41806.80 0.05 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 711044 49587 CPT Outpatient 37320.15 6406.63 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 37320.15 0.06 Case Rate 49587 Priced Lap ing hernia repair init 711044 49650 CPT Outpatient 41932.80 7198.46 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 41932.80 0.05 Case Rate 49650 Priced Lap ing hernia repair recur 711044 49651 CPT Outpatient 46915.05 8053.75 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 46915.05 0.05 Case Rate 49651 Priced Lap vent/abd hernia repair 711044 49652 CPT Outpatient 51294.60 8805.57 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 51294.60 0.04 Case Rate 49652 Priced Lap vent/abd hern proc comp 711044 49653 CPT Outpatient 46102.35 7914.24 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 46102.35 0.05 Case Rate 49653 Priced Lap inc hernia repair 711044 49654 CPT Outpatient 47221.65 8106.38 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 47221.65 0.05 Case Rate 49654 Priced Lap inc hern repair comp 711044 49655 CPT Outpatient 54590.55 9371.38 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 54590.55 0.04 Case Rate 49655 Priced Lap inc hernia repair recur 711044 49656 CPT Outpatient 55443.15 9517.74 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 55443.15 0.04 Case Rate 49656 Priced Removal of kidney stone 711044 50080 CPT Outpatient 53165.70 9126.78 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 53165.70 0.04 Case Rate 50080 Priced Removal of kidney stone 711044 50081 CPT Outpatient 66931.20 11489.86 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 66931.20 0.03 Case Rate 50081 Priced Renal biopsy perq 711044 50200 CPT Outpatient 43096.20 1225.34 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 43096.20 0.05 Case Rate 50200 Priced Plmt nephroureteral catheter 711044 50433 CPT Outpatient 64566.60 1424.48 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 64566.60 0.03 Case Rate 50433 Priced Laparo radical nephrectomy 711044 50545 CPT Outpatient 43449.00 7458.75 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 43449.00 0.05 Case Rate 50545 Priced Laparoscope proc ureter 711044 50949 CPT Outpatient 49986.30 8580.98 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 49986.30 0.04 Case Rate 50949 Priced Injection for bladder x-ray 711044 51600 CPT Outpatient 3285.45 89.22 Horizon NJ Health Horizon Medicaid 0.67 2211.00 0.67 3285.45 0.67 Case Rate 51600 Priced Cystoscopy 711044 52000 CPT Outpatient 22149.75 3802.37 Horizon NJ Health Horizon Medicaid 0.10 2211.00 0.10 22149.75 0.10 Case Rate 52000 Priced Cystoscopy & ureter catheter 711044 52005 CPT Outpatient 42529.20 2095.77 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 42529.20 0.05 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 711044 52204 CPT Outpatient 31274.25 5368.75 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 31274.25 0.07 Case Rate 52204 Priced Cystoscopy and treatment 711044 52224 CPT Outpatient 13445.25 2308.10 Horizon NJ Health Horizon Medicaid 0.16 2211.00 0.16 13445.25 0.16 Case Rate 52224 Priced Cystoscopy and treatment 711044 52234 CPT Outpatient 28510.65 4894.33 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 28510.65 0.08 Case Rate 52234 Priced Cystoscopy and treatment 711044 52235 CPT Outpatient 29417.85 5050.06 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 29417.85 0.08 Case Rate 52235 Priced Cystoscopy and treatment 711044 52240 CPT Outpatient 33933.90 5825.32 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 33933.90 0.07 Case Rate 52240 Priced Cystoscopy and treatment 711044 52281 CPT Outpatient 22159.20 3804.00 Horizon NJ Health Horizon Medicaid 0.10 2211.00 0.10 22159.20 0.10 Case Rate 52281 Priced Remove bladder stone 711044 52317 CPT Outpatient 27085.80 4649.73 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 27085.80 0.08 Case Rate 52317 Priced Remove bladder stone 711044 52318 CPT Outpatient 26685.75 4581.05 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 26685.75 0.08 Case Rate 52318 Priced Cystoscopy and treatment 711044 52332 CPT Outpatient 115306.80 19794.33 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 115306.80 0.02 Case Rate 52332 Priced Cystouretero w/stone remove 711044 52352 CPT Outpatient 42420.00 7282.10 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 42420.00 0.05 Case Rate 52352 Priced Cystouretero w/lithotripsy 711044 52353 CPT Outpatient 38608.50 6627.79 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 38608.50 0.06 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 711044 52356 CPT Outpatient 36255.45 6223.85 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 36255.45 0.06 Case Rate 52356 Priced Prostatectomy (turp) 711044 52601 CPT Outpatient 35371.35 6072.08 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 35371.35 0.06 Case Rate 52601 Priced Laser surgery of prostate 711044 52648 CPT Outpatient 24264.45 4165.40 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 24264.45 0.09 Case Rate 52648 Priced Revision of urethra 711044 53450 CPT Outpatient 16209.90 2782.70 Horizon NJ Health Horizon Medicaid 0.14 2211.00 0.14 16209.90 0.14 Case Rate 53450 Priced Urology surgery procedure 711044 53899 CPT Outpatient 25368.00 134.83 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 25368.00 0.09 Case Rate 53899 Priced Circumcision w/regionl block 711044 54150 CPT Outpatient 14700.00 2523.50 Horizon NJ Health Horizon Medicaid 0.15 2211.00 0.15 14700.00 0.15 Case Rate 54150 Priced Circum 28 days or older 711044 54161 CPT Outpatient 19186.65 3293.71 Horizon NJ Health Horizon Medicaid 0.12 2211.00 0.12 19186.65 0.12 Case Rate 54161 Priced Lysis penil circumic lesion 711044 54162 CPT Outpatient 19795.65 3398.25 Horizon NJ Health Horizon Medicaid 0.11 2211.00 0.11 19795.65 0.11 Case Rate 54162 Priced Repair of circumcision 711044 54163 CPT Outpatient 16391.55 2813.88 Horizon NJ Health Horizon Medicaid 0.13 2211.00 0.13 16391.55 0.13 Case Rate 54163 Priced Reconstruction of urethra 711044 54324 CPT Outpatient 32880.75 5644.53 Horizon NJ Health Horizon Medicaid 0.07 2211.00 0.07 32880.75 0.07 Case Rate 54324 Priced Revise penis/urethra 711044 54332 CPT Outpatient 19968.90 3427.99 Horizon NJ Health Horizon Medicaid 0.11 2211.00 0.11 19968.90 0.11 Case Rate 54332 Priced Insert self-contd prosthesis 711044 54401 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 711044 54520 CPT Outpatient 35442.75 6084.34 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 35442.75 0.06 Case Rate 54520 Priced Reduce testis torsion 711044 54600 CPT Outpatient 55049.40 9450.15 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 55049.40 0.04 Case Rate 54600 Priced Suspension of testis 711044 54640 CPT Outpatient 26860.05 4610.98 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 26860.05 0.08 Case Rate 54640 Priced Removal of hydrocele 711044 55040 CPT Outpatient 27277.95 4682.71 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 27277.95 0.08 Case Rate 55040 Priced Biopsy of prostate gland 711044 55700 CPT Outpatient 28699.65 4926.77 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 28699.65 0.08 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 711044 55866 CPT Outpatient 93088.80 15980.24 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 93088.80 0.02 Case Rate 55866 Priced Closure of vagina 711044 57120 CPT Outpatient 34369.65 5900.12 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 34369.65 0.06 Case Rate 57120 Priced Repair of vagina 711044 57200 CPT Outpatient 25247.25 4334.11 Horizon NJ Health Horizon Medicaid 0.09 2211.00 0.09 25247.25 0.09 Case Rate 57200 Priced Anterior colporrhaphy 711044 57240 CPT Outpatient 36210.30 6216.10 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 36210.30 0.06 Case Rate 57240 Priced Repair rectum & vagina 711044 57250 CPT Outpatient 40441.80 6942.51 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 40441.80 0.05 Case Rate 57250 Priced Cmbn ant pst colprhy 711044 57260 CPT Outpatient 46323.90 7952.27 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 46323.90 0.05 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 711044 57265 CPT Outpatient 42586.95 7310.76 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 42586.95 0.05 Case Rate 57265 Priced Repair of bowel bulge 711044 57268 CPT Outpatient 36865.50 6328.58 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 36865.50 0.06 Case Rate 57268 Priced Colpopexy extraperitoneal 711044 57282 CPT Outpatient 45629.85 7833.12 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 45629.85 0.05 Case Rate 57282 Priced Repair bladder defect 711044 57288 CPT Outpatient 43069.95 7393.67 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 43069.95 0.05 Case Rate 57288 Priced Bx/curett of cervix w/scope 711044 57454 CPT Outpatient 2888.55 442.93 Horizon NJ Health Horizon Medicaid 0.77 2211.00 0.77 2888.55 0.77 Case Rate 57454 Priced Conization of cervix 711044 57520 CPT Outpatient 26728.80 4588.44 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 26728.80 0.08 Case Rate 57520 Priced Conization of cervix 711044 57522 CPT Outpatient 22737.75 3903.31 Horizon NJ Health Horizon Medicaid 0.10 2211.00 0.10 22737.75 0.10 Case Rate 57522 Priced Biopsy of uterus lining 711044 58100 CPT Outpatient 2371.95 194.80 Horizon NJ Health Horizon Medicaid 0.91 2151.00 0.91 2371.95 0.91 Case Rate 58100 Priced Catheter for hysterography 711044 58340 CPT Outpatient 6322.05 131.04 Horizon NJ Health Horizon Medicaid 0.35 2211.00 0.35 6322.05 0.35 Case Rate 58340 Priced Reopen fallopian tube 711044 58350 CPT Outpatient 46507.65 7983.81 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 46507.65 0.05 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 711044 58542 CPT Outpatient 64194.90 11020.12 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 64194.90 0.03 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 711044 58544 CPT Outpatient 51020.55 8758.53 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 51020.55 0.04 Case Rate 58544 Priced Laparoscopic myomectomy 711044 58545 CPT Outpatient 56946.75 9775.86 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 56946.75 0.04 Case Rate 58545 Priced Laparo-vag hyst incl t/o 711044 58552 CPT Outpatient 57228.15 9824.17 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 57228.15 0.04 Case Rate 58552 Priced Hysteroscopy biopsy 711044 58558 CPT Outpatient 28581.00 2077.02 Horizon NJ Health Horizon Medicaid 0.08 2211.00 0.08 28581.00 0.08 Case Rate 58558 Priced Hysteroscopy remove myoma 711044 58561 CPT Outpatient 35222.25 6046.49 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 35222.25 0.06 Case Rate 58561 Priced Hysteroscopy ablation 711044 58563 CPT Outpatient 38399.55 6591.92 Horizon NJ Health Horizon Medicaid 0.06 2211.00 0.06 38399.55 0.06 Case Rate 58563 Priced Tlh uterus 250 g or less 711044 58570 CPT Outpatient 43316.70 7436.03 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 43316.70 0.05 Case Rate 58570 Priced Tlh w/t/o 250 g or less 711044 58571 CPT Outpatient 48603.45 8343.59 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 48603.45 0.05 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 711044 58573 CPT Outpatient 52905.30 9082.08 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 52905.30 0.04 Case Rate 58573 Priced Laparoscopy remove adnexa 711044 58661 CPT Outpatient 47008.50 8069.79 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 47008.50 0.05 Case Rate 58661 Priced Laparoscopy excise lesions 711044 58662 CPT Outpatient 45053.40 7734.17 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 45053.40 0.05 Case Rate 58662 Priced Treat ectopic pregnancy 711044 59151 CPT Outpatient 74690.70 12821.90 Horizon NJ Health Horizon Medicaid 0.03 2211.00 0.03 74690.70 0.03 Case Rate 59151 Priced Treatment of miscarriage 711044 59812 CPT Outpatient 56109.90 9632.20 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 56109.90 0.04 Case Rate 59812 Priced Partial removal of thyroid 711044 60220 CPT Outpatient 53639.25 9208.07 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 53639.25 0.04 Case Rate 60220 Priced Removal of thyroid 711044 60240 CPT Outpatient 98252.70 16866.71 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 98252.70 0.02 Case Rate 60240 Priced Explore parathyroid glands 711044 60500 CPT Outpatient 150495.45 25835.05 Horizon NJ Health Horizon Medicaid 0.01 2211.00 0.01 150495.45 0.01 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 711044 62322 CPT Outpatient 43709.40 514.24 Horizon NJ Health Horizon Medicaid 0.05 2211.00 0.05 43709.40 0.05 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 711044 62323 CPT Outpatient 8304.45 467.31 Horizon NJ Health Horizon Medicaid 0.27 2211.00 0.27 8304.45 0.27 Case Rate 62323 Priced Low back disk surgery 711044 63030 CPT Outpatient 50287.65 8632.71 Horizon NJ Health Horizon Medicaid 0.04 2211.00 0.04 50287.65 0.04 Case Rate 63030 Priced Inc for vagus n elect impl 711044 64568 CPT Outpatient 124562.55 21383.24 Horizon NJ Health Horizon Medicaid 0.02 2211.00 0.02 124562.55 0.02 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 711044 66821 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 711044 66984 CPT Outpatient 0.01 0.01 Horizon NJ Health Horizon Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 173047 216 DRG Inpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 173047 460 DRG Inpatient 416122.79 53834.63 Longevity Longevity PPO 0.09 35617.13 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 173047 470 DRG Inpatient 167912.19 21723.13 Longevity Longevity PPO 0.11 18107.36 0.11 167912.19 0.11 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 173047 473 DRG Inpatient 100687.91 13026.19 Longevity Longevity PPO 0.24 23833.77 0.24 100687.91 0.24 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 173047 743 DRG Inpatient 102691.67 13285.42 Longevity Longevity PPO 0.11 11234.17 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 173047 795 DRG Inpatient 6266.93 2335.00 Longevity Longevity PPO 0.48 3018.86 0.48 6266.93 0.48 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 173047 807 DRG Inpatient 116469.59 4193.00 Longevity Longevity PPO 0.06 6949.69 0.06 116469.59 0.06 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 173047 788 DRG Inpatient 76050.77 4538.00 Longevity Longevity PPO 0.12 9157.94 0.12 76050.77 0.12 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 173047 59400 CPT Inpatient 116469.59 4193.00 Longevity Longevity PPO 0.06 6949.69 0.06 116469.59 0.06 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 173047 59510 CPT Inpatient 76050.77 4538.00 Longevity Longevity PPO 0.12 9157.94 0.12 76050.77 0.12 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 173047 59610 CPT Inpatient 116469.59 4193.00 Longevity Longevity PPO 0.06 6949.69 0.06 116469.59 0.06 Case Rate 59610 Priced "Psychotherapy, 30 min" 173047 90832 CPT Outpatient 577.50 91.21 Longevity Longevity PPO 0.28 162.49 0.28 577.50 0.28 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 173047 90834 CPT Outpatient 44134.65 271.96 Longevity Longevity PPO 0.07 3167.98 0.07 44134.65 0.07 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 173047 90837 CPT Outpatient 2240.70 442.93 Longevity Longevity PPO 0.18 410.00 0.18 2240.70 0.18 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 173047 90846 CPT Outpatient 0.01 131.50 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 173047 90847 CPT Outpatient 44134.65 369.97 Longevity Longevity PPO 0.07 3167.98 0.07 44134.65 0.07 Fee Schedule 90847 Priced Group psychotherapy 173047 90853 CPT Outpatient 44134.65 101.99 Longevity Longevity PPO 0.07 3167.98 0.07 44134.65 0.07 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 173047 99203 CPT Outpatient 3480.75 176.07 Longevity Longevity PPO 0.11 400.08 0.11 3480.75 0.11 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 173047 99204 CPT Outpatient 2103.15 233.39 Longevity Longevity PPO 0.91 1907.00 0.91 2103.15 0.91 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 173047 99205 CPT Outpatient 4970.70 314.28 Longevity Longevity PPO 0.45 2254.00 0.45 4970.70 0.45 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 173047 99243 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 173047 99244 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 173047 99385 CPT Outpatient 1114.05 185.90 Longevity Longevity PPO 0.91 1010.00 0.91 1114.05 0.91 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 173047 99386 CPT Outpatient 4877.25 185.90 Longevity Longevity PPO 0.02 98.03 0.02 4877.25 0.02 Fee Schedule 99386 Priced Routine venipuncture 173047 36415 CPT Outpatient 127.05 19.57 Longevity Longevity PPO 0.02 3.00 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 173047 80048 CPT Outpatient 576.45 88.78 Longevity Longevity PPO 0.02 11.60 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 173047 80053 CPT Outpatient 763.35 117.56 Longevity Longevity PPO 0.02 13.11 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 173047 80055 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 173047 80061 CPT Outpatient 1349.25 197.77 Longevity Longevity PPO 0.01 18.37 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 173047 80069 CPT Outpatient 716.10 104.95 Longevity Longevity PPO 0.02 11.91 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 173047 80076 CPT Outpatient 716.10 104.95 Longevity Longevity PPO 0.02 11.21 0.02 716.10 0.02 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 173047 81000 CPT Outpatient 144.90 21.18 Longevity Longevity PPO 0.03 4.35 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 173047 81001 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 173047 81002 CPT Outpatient 57.75 8.89 Longevity Longevity PPO 0.06 3.50 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 173047 81003 CPT Outpatient 219.45 33.80 Longevity Longevity PPO 0.01 3.08 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 173047 82306 CPT Outpatient 1880.55 289.62 Longevity Longevity PPO 0.02 40.61 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 173047 83036 CPT Outpatient 494.55 76.17 Longevity Longevity PPO 0.03 13.32 0.03 494.55 0.03 Fee Schedule 83036 Priced PSA (prostate specific antigen) 173047 84153 CPT Outpatient 1177.05 181.28 Longevity Longevity PPO 0.02 25.23 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 173047 84154 CPT Outpatient 598.50 92.17 Longevity Longevity PPO 0.04 25.23 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 173047 84443 CPT Outpatient 519.75 80.05 Longevity Longevity PPO 0.04 23.05 0.04 519.75 0.04 Fee Schedule 84443 Priced Chorionic gonadotropin assay 173047 84703 CPT Outpatient 785.40 120.96 Longevity Longevity PPO 0.01 10.32 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 173047 85025 CPT Outpatient 635.25 97.83 Longevity Longevity PPO 0.02 10.66 0.02 635.25 0.02 Fee Schedule 85025 Priced "Complete blood count, automated" 173047 85027 CPT Outpatient 576.45 88.78 Longevity Longevity PPO 0.02 8.87 0.02 576.45 0.02 Fee Schedule 85027 Priced "Blood test, clotting time" 173047 85610 CPT Outpatient 404.25 62.26 Longevity Longevity PPO 0.01 5.39 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 173047 85730 CPT Outpatient 17.22 2.65 Longevity Longevity PPO 0.48 8.24 0.48 17.22 0.48 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 173047 86003 CPT Outpatient 32.55 5.01 Longevity Longevity PPO 0.22 7.16 0.22 32.55 0.22 Fee Schedule 86003 Priced Tb test cell immun measure 173047 86480 CPT Outpatient 530.25 81.66 Longevity Longevity PPO 0.16 85.02 0.16 530.25 0.16 Fee Schedule 86480 Priced Urine culture/colony count 173047 87086 CPT Outpatient 763.35 117.56 Longevity Longevity PPO 0.01 11.07 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 173047 87338 CPT Outpatient 785.40 120.96 Longevity Longevity PPO 0.03 19.73 0.03 785.40 0.03 Fee Schedule 87338 Priced Cytopath eval fna report 173047 88173 CPT Outpatient 750.75 115.62 Longevity Longevity PPO 0.08 56.83 0.08 750.75 0.08 Fee Schedule 88173 Priced Tissue exam by pathologist 173047 88302 CPT Outpatient 635.25 97.83 Longevity Longevity PPO 0.04 28.29 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 173047 88305 CPT Outpatient 323.40 49.81 Longevity Longevity PPO 0.18 56.83 0.18 323.40 0.18 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 173047 11042 CPT Outpatient 2668.05 481.45 Longevity Longevity PPO 0.15 393.68 0.15 2668.05 0.15 Case Rate 11042 Priced Deb subq tissue add-on 173047 11045 CPT Outpatient 4652.55 330.00 Longevity Longevity PPO 0.09 400.08 0.09 4652.55 0.09 Case Rate 11045 Priced Dx bronchoscope/lavage 173047 31624 CPT Outpatient 41223.00 7602.31 Longevity Longevity PPO 0.19 7738.97 0.19 41223.00 0.19 Case Rate 31624 Priced Bronchoscopy/lung bx each 173047 31628 CPT Outpatient 49048.65 9045.51 Longevity Longevity PPO 0.25 12187.69 0.25 49048.65 0.25 Case Rate 31628 Priced Blood transfusion service 173047 36430 CPT Outpatient 9166.50 574.93 Longevity Longevity PPO 0.08 713.86 0.08 9166.50 0.08 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 173047 43235 CPT Outpatient 8856.75 1633.35 Longevity Longevity PPO 0.10 921.63 0.10 8856.75 0.10 Case Rate 43235 Priced Endoscopic us exam esoph 173047 43237 CPT Outpatient 23867.55 4401.63 Longevity Longevity PPO 0.12 2816.68 0.12 23867.55 0.12 Case Rate 43237 Priced Egd us fine needle bx/aspir 173047 43238 CPT Outpatient 30690.45 5659.90 Longevity Longevity PPO 0.06 1898.16 0.06 30690.45 0.06 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 173047 43239 CPT Outpatient 40191.90 7412.15 Longevity Longevity PPO 0.07 2675.69 0.07 40191.90 0.07 Case Rate 43239 Priced Ercp remove duct calculi 173047 43264 CPT Outpatient 34335.00 6332.03 Longevity Longevity PPO 0.20 6983.41 0.20 34335.00 0.20 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 173047 45378 CPT Outpatient 13991.25 889.35 Longevity Longevity PPO 0.07 918.58 0.07 13991.25 0.07 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 173047 45380 CPT Outpatient 22215.90 4097.04 Longevity Longevity PPO 0.08 1800.48 0.08 22215.90 0.08 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 173047 45385 CPT Outpatient 119569.80 22050.95 Longevity Longevity PPO 0.01 1607.92 0.01 119569.80 0.01 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 173047 45391 CPT Outpatient 24923.85 4596.43 Longevity Longevity PPO 0.07 1762.90 0.07 24923.85 0.07 Case Rate 45391 Priced Fragmenting of kidney stone 173047 50590 CPT Outpatient 40930.05 7548.28 Longevity Longevity PPO 0.09 3594.05 0.09 40930.05 0.09 Case Rate 50590 Priced Fetal non-stress test 173047 59025 CPT Outpatient 3153.15 477.76 Longevity Longevity PPO 0.06 197.20 0.06 3153.15 0.06 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 173047 64483 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 173047 92567 CPT Outpatient 2224.95 98.50 Longevity Longevity PPO 0.14 306.34 0.14 2224.95 0.14 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 173047 93000 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 173047 93017 CPT Outpatient 3076.50 532.96 Longevity Longevity PPO 0.10 306.34 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 173047 93452 CPT Outpatient 55621.65 8611.87 Longevity Longevity PPO 0.06 3356.53 0.06 55621.65 0.06 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 173047 95810 CPT Outpatient 20341.65 3373.48 Longevity Longevity PPO 0.05 1064.94 0.05 20341.65 0.05 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 173047 95811 CPT Outpatient 22491.00 3731.18 Longevity Longevity PPO 0.05 1064.94 0.05 22491.00 0.05 Case Rate 95811 Priced Eeg 41-60 minutes 173047 95812 CPT Outpatient 5578.65 925.83 Longevity Longevity PPO 0.05 306.34 0.05 5578.65 0.05 Case Rate 95812 Priced Genetic counseling 30 min 173047 96040 CPT Outpatient 0.01 102.81 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 173047 96413 CPT Outpatient 4856.25 472.45 Longevity Longevity PPO 0.54 2631.44 0.54 4856.25 0.54 Case Rate 96413 Priced Ultrasound therapy 173047 97035 CPT Outpatient 2111.55 134.99 Longevity Longevity PPO 0.04 84.56 0.04 2111.55 0.04 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 173047 97110 CPT Outpatient 6494.25 92.86 Longevity Longevity PPO 0.05 352.10 0.05 6494.25 0.05 Case Rate 97110 Priced Gait training therapy 173047 97116 CPT Outpatient 4723.95 110.61 Longevity Longevity PPO 0.06 286.74 0.06 4723.95 0.06 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 173047 70450 CPT Outpatient 8566.95 835.61 Longevity Longevity PPO 0.06 547.09 0.06 8566.95 0.06 Case Rate 70450 Priced Mri brain stem w/o dye 173047 70551 CPT Outpatient 7861.35 1361.31 Longevity Longevity PPO 0.03 266.34 0.03 7861.35 0.03 Case Rate 70551 Priced MRI scan of brain before and after contrast 173047 70553 CPT Outpatient 10882.20 1625.88 Longevity Longevity PPO 0.04 426.25 0.04 10882.20 0.04 Case Rate 70553 Priced X-ray exam chest 2 views 173047 71046 CPT Outpatient 859.95 150.37 Longevity Longevity PPO 0.11 93.63 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 173047 71250 CPT Outpatient 7288.05 1261.63 Longevity Longevity PPO 0.02 126.02 0.02 7288.05 0.02 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 173047 72082 CPT Outpatient 2022.30 253.33 Longevity Longevity PPO 0.12 252.04 0.12 2022.30 0.12 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 173047 72100 CPT Outpatient 1599.15 277.38 Longevity Longevity PPO 0.08 126.02 0.08 1599.15 0.08 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 173047 72110 CPT Outpatient 1389.15 241.04 Longevity Longevity PPO 0.09 126.02 0.09 1389.15 0.09 Case Rate 72110 Priced MRI scan of lower spinal canal 173047 72148 CPT Outpatient 7861.35 1361.31 Longevity Longevity PPO 0.03 266.34 0.03 7861.35 0.03 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 173047 72193 CPT Outpatient 13671.00 1412.01 Longevity Longevity PPO 0.02 206.76 0.02 13671.00 0.02 Case Rate 72193 Priced X-ray exam of shoulder 173047 73030 CPT Outpatient 1452.15 251.43 Longevity Longevity PPO 0.06 93.63 0.06 1452.15 0.06 Case Rate 73030 Priced X-ray exam of elbow 173047 73080 CPT Outpatient 1356.60 235.68 Longevity Longevity PPO 0.07 93.63 0.07 1356.60 0.07 Case Rate 73080 Priced X-ray exam of forearm 173047 73090 CPT Outpatient 1243.20 215.26 Longevity Longevity PPO 0.08 93.63 0.08 1243.20 0.08 Case Rate 73090 Priced X-ray exam of wrist 173047 73110 CPT Outpatient 1243.20 215.26 Longevity Longevity PPO 0.08 93.63 0.08 1243.20 0.08 Case Rate 73110 Priced X-ray exam of hand 173047 73130 CPT Outpatient 1243.20 215.26 Longevity Longevity PPO 0.08 93.63 0.08 1243.20 0.08 Case Rate 73130 Priced X-ray exam hips bi 2 views 173047 73521 CPT Outpatient 970.20 228.41 Longevity Longevity PPO 0.13 126.02 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 173047 73562 CPT Outpatient 802.20 139.12 Longevity Longevity PPO 0.12 93.63 0.12 802.20 0.12 Case Rate 73562 Priced X-ray exam of lower leg 173047 73590 CPT Outpatient 1243.20 215.26 Longevity Longevity PPO 0.08 93.63 0.08 1243.20 0.08 Case Rate 73590 Priced X-ray exam of ankle 173047 73610 CPT Outpatient 1378.65 239.31 Longevity Longevity PPO 0.07 93.63 0.07 1378.65 0.07 Case Rate 73610 Priced X-ray exam of foot 173047 73630 CPT Outpatient 975.45 169.41 Longevity Longevity PPO 0.10 93.63 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 173047 73721 CPT Outpatient 7861.35 1361.31 Longevity Longevity PPO 0.03 266.34 0.03 7861.35 0.03 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 173047 74177 CPT Outpatient 14222.25 1412.01 Longevity Longevity PPO 0.03 426.25 0.03 14222.25 0.03 Case Rate 74177 Priced Contrst x-ray exam of throat 173047 74210 CPT Outpatient 0.01 440.39 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 173047 76098 CPT Outpatient 6141.45 407.86 Longevity Longevity PPO 0.21 1259.13 0.21 6141.45 0.21 Case Rate 76098 Priced Us exam of head and neck 173047 76536 CPT Outpatient 5512.50 955.18 Longevity Longevity PPO 0.02 126.02 0.02 5512.50 0.02 Case Rate 76536 Priced Ultrasound breast limited 173047 76642 CPT Outpatient 5777.10 127.70 Longevity Longevity PPO 0.03 156.98 0.03 5777.10 0.03 Case Rate 76642 Priced Ultrasound of abdomen 173047 76700 CPT Outpatient 4917.15 851.88 Longevity Longevity PPO 0.03 126.02 0.03 4917.15 0.03 Case Rate 76700 Priced Echo exam of abdomen 173047 76705 CPT Outpatient 3836.70 665.17 Longevity Longevity PPO 0.03 126.02 0.03 3836.70 0.03 Case Rate 76705 Priced Us exam abdo back wall comp 173047 76770 CPT Outpatient 5171.25 895.48 Longevity Longevity PPO 0.02 126.02 0.02 5171.25 0.02 Case Rate 76770 Priced Us exam abdo back wall lim 173047 76775 CPT Outpatient 3969.00 686.97 Longevity Longevity PPO 0.03 126.02 0.03 3969.00 0.03 Case Rate 76775 Priced Ob us < 14 wks single fetus 173047 76801 CPT Outpatient 2006.55 347.98 Longevity Longevity PPO 0.06 126.02 0.06 2006.55 0.06 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 173047 76805 CPT Outpatient 3969.00 686.97 Longevity Longevity PPO 0.03 126.02 0.03 3969.00 0.03 Case Rate 76805 Priced Ob us detailed sngl fetus 173047 76811 CPT Outpatient 2844.45 492.99 Longevity Longevity PPO 0.09 266.34 0.09 2844.45 0.09 Case Rate 76811 Priced Ob us nuchal meas 1 gest 173047 76813 CPT Outpatient 1044.75 180.83 Longevity Longevity PPO 0.12 126.02 0.12 1044.75 0.12 Case Rate 76813 Priced Ob us limited fetus(s) 173047 76815 CPT Outpatient 6428.10 639.90 Longevity Longevity PPO 0.04 252.04 0.04 6428.10 0.04 Case Rate 76815 Priced Ob us follow-up per fetus 173047 76816 CPT Outpatient 4818.45 833.88 Longevity Longevity PPO 0.03 126.02 0.03 4818.45 0.03 Case Rate 76816 Priced Transvaginal us obstetric 173047 76817 CPT Outpatient 6428.10 476.73 Longevity Longevity PPO 0.04 252.04 0.04 6428.10 0.04 Case Rate 76817 Priced Fetal biophys profil w/o nst 173047 76819 CPT Outpatient 1741.95 302.65 Longevity Longevity PPO 0.07 126.02 0.07 1741.95 0.07 Case Rate 76819 Priced Ultrasound pelvis through vagina 173047 76830 CPT Outpatient 9305.10 806.54 Longevity Longevity PPO 0.03 252.04 0.03 9305.10 0.03 Case Rate 76830 Priced Us exam scrotum 173047 76870 CPT Outpatient 6328.35 1096.55 Longevity Longevity PPO 0.02 126.02 0.02 6328.35 0.02 Case Rate 76870 Priced Us exam infant hips dynamic 173047 76885 CPT Outpatient 3836.70 665.17 Longevity Longevity PPO 0.02 93.63 0.02 3836.70 0.02 Case Rate 76885 Priced Mammography of one breast 173047 77065 CPT Outpatient 3451.35 192.07 Longevity Longevity PPO 0.05 156.98 0.05 3451.35 0.05 Case Rate 77065 Priced Mammography of both breasts 173047 77066 CPT Outpatient 5777.10 235.68 Longevity Longevity PPO 0.03 156.98 0.03 5777.10 0.03 Case Rate 77066 Priced "Mamography, screening bilateral" 173047 77067 CPT Outpatient 1416.45 205.57 Longevity Longevity PPO 0.04 63.35 0.04 1416.45 0.04 Case Rate 77067 Priced X-rays for bone age 173047 77072 CPT Outpatient 2022.30 163.87 Longevity Longevity PPO 0.12 252.04 0.12 2022.30 0.12 Case Rate 77072 Priced Joint survey single view 173047 77077 CPT Outpatient 985.95 171.14 Longevity Longevity PPO 0.13 123.50 0.13 985.95 0.13 Case Rate 77077 Priced Dxa bone density axial 173047 77080 CPT Outpatient 3257.10 319.09 Longevity Longevity PPO 0.06 189.37 0.06 3257.10 0.06 Case Rate 77080 Priced Fna bx w/us gdn 1st les 173047 10005 CPT Outpatient 5512.50 547.24 Longevity Longevity PPO 0.13 720.31 0.13 5512.50 0.13 Case Rate 10005 Priced Fna bx w/us gdn ea addl 173047 10006 CPT Outpatient 10628.10 594.83 Longevity Longevity PPO 0.07 720.31 0.07 10628.10 0.07 Case Rate 10006 Priced Drainage of hematoma/fluid 173047 10140 CPT Outpatient 23209.20 1081.95 Longevity Longevity PPO 0.26 6128.73 0.26 23209.20 0.26 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 173047 11042 CPT Outpatient 2668.05 481.45 Longevity Longevity PPO 0.15 393.68 0.15 2668.05 0.15 Case Rate 11042 Priced Deb bone 20 sq cm/< 173047 11044 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 173047 11406 CPT Outpatient 19967.85 3427.81 Longevity Longevity PPO 0.08 1685.71 0.08 19967.85 0.08 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 173047 11424 CPT Outpatient 0.01 1004.93 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 173047 11770 CPT Outpatient 19173.00 3291.37 Longevity Longevity PPO 0.15 2802.06 0.15 19173.00 0.15 Case Rate 11770 Priced Replace tissue expander 173047 11970 CPT Outpatient 59239.95 10169.52 Longevity Longevity PPO 0.51 30234.14 0.51 59239.95 0.51 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 173047 14020 CPT Outpatient 32166.75 5521.96 Longevity Longevity PPO 0.06 1950.86 0.06 32166.75 0.06 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 173047 14060 CPT Outpatient 25993.80 1374.69 Longevity Longevity PPO 0.30 7869.66 0.30 25993.80 0.30 Case Rate 14060 Priced Wound prep trk/arm/leg 173047 15002 CPT Outpatient 41748.00 1441.73 Longevity Longevity PPO 0.21 8749.92 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 173047 15271 CPT Outpatient 24343.20 3769.48 Longevity Longevity PPO 0.08 1950.86 0.08 24343.20 0.08 Case Rate 15271 Priced Acellular derm matrix implt 173047 15777 CPT Outpatient 101672.55 17453.79 Longevity Longevity PPO 0.23 23367.82 0.23 101672.55 0.23 Case Rate 15777 Priced Exc skin abd 173047 15830 CPT Outpatient 54696.60 9389.58 Longevity Longevity PPO 0.11 6272.06 0.11 54696.60 0.11 Case Rate 15830 Priced Dressing change not for burn 173047 15852 CPT Outpatient 0.01 290.74 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 173047 15877 CPT Outpatient 63741.30 10942.26 Longevity Longevity PPO 0.17 10784.98 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 173047 15879 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 173047 19000 CPT Outpatient 10143.00 594.83 Longevity Longevity PPO 0.08 783.66 0.08 10143.00 0.08 Case Rate 19000 Priced Bx breast 1st lesion strtctc 173047 19081 CPT Outpatient 12341.70 1250.69 Longevity Longevity PPO 0.14 1743.69 0.14 12341.70 0.14 Case Rate 19081 Priced Bx breast add lesion us imag 173047 19084 CPT Outpatient 29058.75 547.24 Longevity Longevity PPO 0.07 1958.19 0.07 29058.75 0.07 Case Rate 19084 Priced Biopsy of breast open 173047 19101 CPT Outpatient 39545.10 2737.82 Longevity Longevity PPO 0.23 8912.10 0.23 39545.10 0.23 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 173047 19120 CPT Outpatient 35761.95 2737.82 Longevity Longevity PPO 0.12 4261.38 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 173047 19125 CPT Outpatient 33184.20 0.01 Longevity Longevity PPO 0.26 8587.25 0.26 33184.20 0.26 Case Rate 19125 Priced Perq device breast 1st imag 173047 19281 CPT Outpatient 6141.45 598.61 Longevity Longevity PPO 0.21 1259.13 0.21 6141.45 0.21 Case Rate 19281 Priced Perq device breast ea imag 173047 19282 CPT Outpatient 8379.00 319.04 Longevity Longevity PPO 0.15 1259.13 0.15 8379.00 0.15 Case Rate 19282 Priced Partial mastectomy 173047 19301 CPT Outpatient 39157.65 6722.06 Longevity Longevity PPO 0.20 7779.57 0.20 39157.65 0.20 Case Rate 19301 Priced Mast simple complete 173047 19303 CPT Outpatient 105389.55 18091.87 Longevity Longevity PPO 0.27 28951.17 0.27 105389.55 0.27 Case Rate 19303 Priced Reduction of large breast 173047 19318 CPT Outpatient 65239.65 11199.47 Longevity Longevity PPO 0.10 6521.02 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 173047 19340 CPT Outpatient 113100.75 19415.63 Longevity Longevity PPO 0.13 14461.43 0.13 113100.75 0.13 Case Rate 19340 Priced Delayed breast prosthesis 173047 19342 CPT Outpatient 56988.75 9783.07 Longevity Longevity PPO 0.35 20073.57 0.35 56988.75 0.35 Case Rate 19342 Priced Breast reconstruction 173047 19357 CPT Outpatient 101672.55 17453.79 Longevity Longevity PPO 0.23 23367.82 0.23 101672.55 0.23 Case Rate 19357 Priced Breast reconstruction 173047 19366 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 173047 19380 CPT Outpatient 61493.25 10556.34 Longevity Longevity PPO 0.21 13099.63 0.21 61493.25 0.21 Case Rate 19380 Priced Removal of support implant 173047 20680 CPT Outpatient 42329.70 7266.60 Longevity Longevity PPO 0.14 5755.42 0.14 42329.70 0.14 Case Rate 20680 Priced Cerv artific diskectomy 173047 22856 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 173047 24538 CPT Outpatient 51237.90 4775.24 Longevity Longevity PPO 0.19 9733.27 0.19 51237.90 0.19 Case Rate 24538 Priced Remove wrist tendon lesion 173047 25111 CPT Outpatient 25855.20 4438.48 Longevity Longevity PPO 0.06 1640.84 0.06 25855.20 0.06 Case Rate 25111 Priced Incise finger tendon sheath 173047 26055 CPT Outpatient 15862.35 2723.04 Longevity Longevity PPO 0.12 1914.66 0.12 15862.35 0.12 Case Rate 26055 Priced Treat finger fracture each 173047 26727 CPT Outpatient 22779.75 2030.47 Longevity Longevity PPO 0.16 3544.40 0.16 22779.75 0.16 Case Rate 26727 Priced Revision of knee joint 173047 27446 CPT Outpatient 67882.50 11653.16 Longevity Longevity PPO 0.22 15187.78 0.22 67882.50 0.22 Case Rate 27446 Priced Total knee arthroplasty 173047 27447 CPT Outpatient 130698.75 22436.62 Longevity Longevity PPO 0.12 15471.35 0.12 130698.75 0.12 Case Rate 27447 Priced Surgery to stop leg growth 173047 27485 CPT Outpatient 43310.40 7434.95 Longevity Longevity PPO 0.25 10969.41 0.25 43310.40 0.25 Case Rate 27485 Priced Repair achilles tendon 173047 27650 CPT Outpatient 38246.25 3762.57 Longevity Longevity PPO 0.29 10947.71 0.29 38246.25 0.29 Case Rate 27650 Priced Treatment of ankle fracture 173047 27792 CPT Outpatient 36101.10 6197.36 Longevity Longevity PPO 0.21 7516.63 0.21 36101.10 0.21 Case Rate 27792 Priced Treatment of ankle fracture 173047 27814 CPT Outpatient 49405.65 8481.30 Longevity Longevity PPO 0.16 7700.27 0.16 49405.65 0.16 Case Rate 27814 Priced Removal of foot lesion 173047 28080 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 173047 28285 CPT Outpatient 68603.85 11776.99 Longevity Longevity PPO 0.20 13867.24 0.20 68603.85 0.20 Case Rate 28285 Priced Correction hallux valgus 173047 28296 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 173047 29823 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 173047 29826 CPT Outpatient 49840.35 8555.93 Longevity Longevity PPO 0.15 7250.29 0.15 49840.35 0.15 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 173047 29881 CPT Outpatient 35556.15 6103.81 Longevity Longevity PPO 0.09 3278.05 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 173047 29882 CPT Outpatient 61099.50 10488.75 Longevity Longevity PPO 0.19 11479.03 0.19 61099.50 0.19 Case Rate 29882 Priced Percut bx lung/mediastinum 173047 32405 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 173047 32555 CPT Outpatient 14597.10 687.29 Longevity Longevity PPO 0.05 694.26 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 173047 32664 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 173047 35190 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 173047 36478 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 173047 36561 CPT Outpatient 53531.10 3292.99 Longevity Longevity PPO 0.06 3313.58 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 173047 36569 CPT Outpatient 31421.25 1299.06 Longevity Longevity PPO 0.06 1767.32 0.06 31421.25 0.06 Case Rate 36569 Priced Removal tunneled cv cath 173047 36590 CPT Outpatient 1996.05 273.95 Longevity Longevity PPO 0.80 1601.67 0.80 1996.05 0.80 Case Rate 36590 Priced Av fuse uppr arm basilic 173047 36819 CPT Outpatient 56861.70 9761.26 Longevity Longevity PPO 0.16 9229.09 0.16 56861.70 0.16 Case Rate 36819 Priced Av fusion direct any site 173047 36821 CPT Outpatient 42953.40 7373.67 Longevity Longevity PPO 0.16 6996.33 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 173047 36825 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 173047 36830 CPT Outpatient 53656.05 9210.96 Longevity Longevity PPO 0.17 9267.02 0.17 53656.05 0.17 Case Rate 36830 Priced Av fistula revision open 173047 36832 CPT Outpatient 52492.65 9011.24 Longevity Longevity PPO 0.22 11752.20 0.22 52492.65 0.22 Case Rate 36832 Priced Av fistula revision 173047 36833 CPT Outpatient 37098.60 6368.59 Longevity Longevity PPO 0.27 9992.97 0.27 37098.60 0.27 Case Rate 36833 Priced Intro cath dialysis circuit 173047 36903 CPT Outpatient 77541.45 10669.90 Longevity Longevity PPO 0.24 18296.91 0.24 77541.45 0.24 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 173047 36906 CPT Outpatient 96694.50 16175.64 Longevity Longevity PPO 0.26 25577.26 0.26 96694.50 0.26 Case Rate 36906 Priced Fem/popl revas w/tla 173047 37224 CPT Outpatient 200076.45 5139.31 Longevity Longevity PPO 0.14 27198.43 0.14 200076.45 0.14 Case Rate 37224 Priced Fem/popl revasc stnt & ather 173047 37227 CPT Outpatient 117170.55 18045.38 Longevity Longevity PPO 0.16 19157.25 0.16 117170.55 0.16 Case Rate 37227 Priced Revise leg vein 173047 37700 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 173047 37722 CPT Outpatient 27815.55 4775.00 Longevity Longevity PPO 0.37 10309.92 0.37 27815.55 0.37 Case Rate 37722 Priced Stab phleb veins xtr 10-20 173047 37765 CPT Outpatient 26561.85 4559.78 Longevity Longevity PPO 0.50 13405.52 0.50 26561.85 0.50 Case Rate 37765 Priced Biopsy/removal lymph nodes 173047 38500 CPT Outpatient 35955.15 6172.30 Longevity Longevity PPO 0.11 3885.31 0.11 35955.15 0.11 Case Rate 38500 Priced Biopsy/removal lymph nodes 173047 38525 CPT Outpatient 101194.80 17371.77 Longevity Longevity PPO 0.18 18690.41 0.18 101194.80 0.18 Case Rate 38525 Priced Laparoscopy lymph node biop 173047 38570 CPT Outpatient 65631.30 11266.71 Longevity Longevity PPO 0.27 17935.41 0.27 65631.30 0.27 Case Rate 38570 Priced Laparoscopy lymphadenectomy 173047 38571 CPT Outpatient 84031.50 14425.41 Longevity Longevity PPO 0.26 22005.13 0.26 84031.50 0.26 Case Rate 38571 Priced Laparoscopy lymphadenectomy 173047 38572 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 173047 38792 CPT Outpatient 2868.60 432.48 Longevity Longevity PPO 0.15 436.34 0.15 2868.60 0.15 Case Rate 38792 Priced Excision of gum lesion 173047 41825 CPT Outpatient 11580.45 1987.98 Longevity Longevity PPO 0.29 3411.53 0.29 11580.45 0.29 Case Rate 41825 Priced Reconstruct cleft palate 173047 42200 CPT Outpatient 36703.80 6300.82 Longevity Longevity PPO 0.16 5887.08 0.16 36703.80 0.16 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 173047 42820 CPT Outpatient 17232.60 2958.26 Longevity Longevity PPO 0.63 10933.63 0.63 17232.60 0.63 Case Rate 42820 Priced Control throat bleeding 173047 42960 CPT Outpatient 24066.00 4131.33 Longevity Longevity PPO 0.20 4810.65 0.20 24066.00 0.20 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 173047 43235 CPT Outpatient 8856.75 1633.35 Longevity Longevity PPO 0.10 921.63 0.10 8856.75 0.10 Case Rate 43235 Priced Laparoscopy fundoplasty 173047 43280 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 173047 43282 CPT Outpatient 84344.40 14479.12 Longevity Longevity PPO 0.13 10887.44 0.13 84344.40 0.13 Case Rate 43282 Priced Laparoscopy appendectomy 173047 44970 CPT Outpatient 82300.05 14128.18 Longevity Longevity PPO 0.08 6928.85 0.08 82300.05 0.08 Case Rate 44970 Priced Diagnostic sigmoidoscopy 173047 45330 CPT Outpatient 17286.15 542.26 Longevity Longevity PPO 0.11 1864.21 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 173047 47000 CPT Outpatient 10398.15 1225.34 Longevity Longevity PPO 0.20 2083.32 0.20 10398.15 0.20 Case Rate 47000 Priced Removal of gallbladder using an endoscope 173047 47562 CPT Outpatient 58430.40 10030.55 Longevity Longevity PPO 0.10 5914.48 0.10 58430.40 0.10 Case Rate 47562 Priced Laparo cholecystectomy/graph 173047 47563 CPT Outpatient 71747.55 12316.66 Longevity Longevity PPO 0.09 6711.49 0.09 71747.55 0.09 Case Rate 47563 Priced Abd paracentesis w/imaging 173047 49083 CPT Outpatient 6979.35 1113.95 Longevity Longevity PPO 0.13 936.61 0.13 6979.35 0.13 Case Rate 49083 Priced Diag laparo separate proc 173047 49320 CPT Outpatient 31629.15 5429.67 Longevity Longevity PPO 0.41 13088.70 0.41 31629.15 0.41 Case Rate 49320 Priced Laparoscopy biopsy 173047 49321 CPT Outpatient 41892.90 7191.61 Longevity Longevity PPO 0.32 13376.38 0.32 41892.90 0.32 Case Rate 49321 Priced Laparoscopy aspiration 173047 49322 CPT Outpatient 34392.75 5904.09 Longevity Longevity PPO 0.39 13282.10 0.39 34392.75 0.39 Case Rate 49322 Priced Lap insert tunnel ip cath 173047 49324 CPT Outpatient 39264.75 6740.45 Longevity Longevity PPO 0.15 5921.39 0.15 39264.75 0.15 Case Rate 49324 Priced Laparo proc abdm/per/oment 173047 49329 CPT Outpatient 58696.05 10076.16 Longevity Longevity PPO 0.29 17015.86 0.29 58696.05 0.29 Case Rate 49329 Priced Ins tun ip cath for dial opn 173047 49421 CPT Outpatient 25460.40 3319.30 Longevity Longevity PPO 0.14 3671.10 0.14 25460.40 0.14 Case Rate 49421 Priced Remove tunneled ip cath 173047 49422 CPT Outpatient 25515.00 4380.08 Longevity Longevity PPO 0.13 3313.58 0.13 25515.00 0.13 Case Rate 49422 Priced Rpr ing hernia init reduce 173047 49500 CPT Outpatient 19594.05 3363.65 Longevity Longevity PPO 0.56 10924.36 0.56 19594.05 0.56 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 173047 49505 CPT Outpatient 34915.65 5993.85 Longevity Longevity PPO 0.20 7100.57 0.20 34915.65 0.20 Case Rate 49505 Priced Prp i/hern init block >5 yr 173047 49507 CPT Outpatient 29794.80 5114.77 Longevity Longevity PPO 0.24 7243.99 0.24 29794.80 0.24 Case Rate 49507 Priced Rerepair ing hernia reduce 173047 49520 CPT Outpatient 36940.05 6341.38 Longevity Longevity PPO 0.20 7279.11 0.20 36940.05 0.20 Case Rate 49520 Priced Rpr ventral hern init reduc 173047 49560 CPT Outpatient 53177.25 9128.76 Longevity Longevity PPO 0.18 9604.14 0.18 53177.25 0.18 Case Rate 49560 Priced Rpr ventral hern init block 173047 49561 CPT Outpatient 30755.55 5279.70 Longevity Longevity PPO 0.24 7458.52 0.24 30755.55 0.24 Case Rate 49561 Priced Rerepair ventrl hern reduce 173047 49565 CPT Outpatient 69917.40 12002.49 Longevity Longevity PPO 0.14 9773.91 0.14 69917.40 0.14 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 173047 49585 CPT Outpatient 41806.80 7176.83 Longevity Longevity PPO 0.23 9568.30 0.23 41806.80 0.23 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 173047 49587 CPT Outpatient 37320.15 6406.63 Longevity Longevity PPO 0.20 7306.70 0.20 37320.15 0.20 Case Rate 49587 Priced Lap ing hernia repair init 173047 49650 CPT Outpatient 41932.80 7198.46 Longevity Longevity PPO 0.13 5643.64 0.13 41932.80 0.13 Case Rate 49650 Priced Lap ing hernia repair recur 173047 49651 CPT Outpatient 46915.05 8053.75 Longevity Longevity PPO 0.26 12290.38 0.26 46915.05 0.26 Case Rate 49651 Priced Lap vent/abd hernia repair 173047 49652 CPT Outpatient 51294.60 8805.57 Longevity Longevity PPO 0.12 5949.98 0.12 51294.60 0.12 Case Rate 49652 Priced Lap vent/abd hern proc comp 173047 49653 CPT Outpatient 46102.35 7914.24 Longevity Longevity PPO 0.13 5856.96 0.13 46102.35 0.13 Case Rate 49653 Priced Lap inc hernia repair 173047 49654 CPT Outpatient 47221.65 8106.38 Longevity Longevity PPO 0.22 10158.85 0.22 47221.65 0.22 Case Rate 49654 Priced Lap inc hern repair comp 173047 49655 CPT Outpatient 54590.55 9371.38 Longevity Longevity PPO 0.19 10467.81 0.19 54590.55 0.19 Case Rate 49655 Priced Lap inc hernia repair recur 173047 49656 CPT Outpatient 55443.15 9517.74 Longevity Longevity PPO 0.19 10403.37 0.19 55443.15 0.19 Case Rate 49656 Priced Removal of kidney stone 173047 50080 CPT Outpatient 53165.70 9126.78 Longevity Longevity PPO 0.32 16806.79 0.32 53165.70 0.32 Case Rate 50080 Priced Removal of kidney stone 173047 50081 CPT Outpatient 66931.20 11489.86 Longevity Longevity PPO 0.30 20201.76 0.30 66931.20 0.30 Case Rate 50081 Priced Renal biopsy perq 173047 50200 CPT Outpatient 43096.20 1225.34 Longevity Longevity PPO 0.22 9620.27 0.22 43096.20 0.22 Case Rate 50200 Priced Plmt nephroureteral catheter 173047 50433 CPT Outpatient 64566.60 1424.48 Longevity Longevity PPO 0.27 17420.98 0.27 64566.60 0.27 Case Rate 50433 Priced Laparo radical nephrectomy 173047 50545 CPT Outpatient 43449.00 7458.75 Longevity Longevity PPO 0.03 1179.86 0.03 43449.00 0.03 Case Rate 50545 Priced Laparoscope proc ureter 173047 50949 CPT Outpatient 49986.30 8580.98 Longevity Longevity PPO 0.34 17061.99 0.34 49986.30 0.34 Case Rate 50949 Priced Injection for bladder x-ray 173047 51600 CPT Outpatient 3285.45 89.22 Longevity Longevity PPO 0.08 266.34 0.08 3285.45 0.08 Case Rate 51600 Priced Cystoscopy 173047 52000 CPT Outpatient 22149.75 3802.37 Longevity Longevity PPO 0.36 7907.54 0.36 22149.75 0.36 Case Rate 52000 Priced Cystoscopy & ureter catheter 173047 52005 CPT Outpatient 42529.20 2095.77 Longevity Longevity PPO 0.21 9058.61 0.21 42529.20 0.21 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 173047 52204 CPT Outpatient 31274.25 5368.75 Longevity Longevity PPO 0.18 5605.40 0.18 31274.25 0.18 Case Rate 52204 Priced Cystoscopy and treatment 173047 52224 CPT Outpatient 13445.25 2308.10 Longevity Longevity PPO 0.53 7125.74 0.53 13445.25 0.53 Case Rate 52224 Priced Cystoscopy and treatment 173047 52234 CPT Outpatient 28510.65 4894.33 Longevity Longevity PPO 0.26 7507.95 0.26 28510.65 0.26 Case Rate 52234 Priced Cystoscopy and treatment 173047 52235 CPT Outpatient 29417.85 5050.06 Longevity Longevity PPO 0.25 7214.16 0.25 29417.85 0.25 Case Rate 52235 Priced Cystoscopy and treatment 173047 52240 CPT Outpatient 33933.90 5825.32 Longevity Longevity PPO 0.26 8825.60 0.26 33933.90 0.26 Case Rate 52240 Priced Cystoscopy and treatment 173047 52281 CPT Outpatient 22159.20 3804.00 Longevity Longevity PPO 0.25 5549.91 0.25 22159.20 0.25 Case Rate 52281 Priced Remove bladder stone 173047 52317 CPT Outpatient 27085.80 4649.73 Longevity Longevity PPO 0.27 7363.23 0.27 27085.80 0.27 Case Rate 52317 Priced Remove bladder stone 173047 52318 CPT Outpatient 26685.75 4581.05 Longevity Longevity PPO 0.27 7298.80 0.27 26685.75 0.27 Case Rate 52318 Priced Cystoscopy and treatment 173047 52332 CPT Outpatient 115306.80 19794.33 Longevity Longevity PPO 0.18 20405.02 0.18 115306.80 0.18 Case Rate 52332 Priced Cystouretero w/stone remove 173047 52352 CPT Outpatient 42420.00 7282.10 Longevity Longevity PPO 0.38 16173.70 0.38 42420.00 0.38 Case Rate 52352 Priced Cystouretero w/lithotripsy 173047 52353 CPT Outpatient 38608.50 6627.79 Longevity Longevity PPO 0.23 8911.08 0.23 38608.50 0.23 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 173047 52356 CPT Outpatient 36255.45 6223.85 Longevity Longevity PPO 0.25 8911.08 0.25 36255.45 0.25 Case Rate 52356 Priced Prostatectomy (turp) 173047 52601 CPT Outpatient 35371.35 6072.08 Longevity Longevity PPO 0.24 8610.64 0.24 35371.35 0.24 Case Rate 52601 Priced Laser surgery of prostate 173047 52648 CPT Outpatient 24264.45 4165.40 Longevity Longevity PPO 0.36 8800.54 0.36 24264.45 0.36 Case Rate 52648 Priced Revision of urethra 173047 53450 CPT Outpatient 16209.90 2782.70 Longevity Longevity PPO 0.35 5631.41 0.35 16209.90 0.35 Case Rate 53450 Priced Urology surgery procedure 173047 53899 CPT Outpatient 25368.00 134.83 Longevity Longevity PPO 0.27 6804.11 0.27 25368.00 0.27 Case Rate 53899 Priced Circumcision w/regionl block 173047 54150 CPT Outpatient 14700.00 2523.50 Longevity Longevity PPO 0.14 2072.56 0.14 14700.00 0.14 Case Rate 54150 Priced Circum 28 days or older 173047 54161 CPT Outpatient 19186.65 3293.71 Longevity Longevity PPO 0.11 2032.14 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 173047 54162 CPT Outpatient 19795.65 3398.25 Longevity Longevity PPO 0.84 16679.66 0.84 19795.65 0.84 Case Rate 54162 Priced Repair of circumcision 173047 54163 CPT Outpatient 16391.55 2813.88 Longevity Longevity PPO 0.24 3976.29 0.24 16391.55 0.24 Case Rate 54163 Priced Reconstruction of urethra 173047 54324 CPT Outpatient 32880.75 5644.53 Longevity Longevity PPO 0.28 9224.18 0.28 32880.75 0.28 Case Rate 54324 Priced Revise penis/urethra 173047 54332 CPT Outpatient 19968.90 3427.99 Longevity Longevity PPO 0.18 3558.86 0.18 19968.90 0.18 Case Rate 54332 Priced Insert self-contd prosthesis 173047 54401 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 173047 54520 CPT Outpatient 35442.75 6084.34 Longevity Longevity PPO 0.34 12054.63 0.34 35442.75 0.34 Case Rate 54520 Priced Reduce testis torsion 173047 54600 CPT Outpatient 55049.40 9450.15 Longevity Longevity PPO 0.28 15271.15 0.28 55049.40 0.28 Case Rate 54600 Priced Suspension of testis 173047 54640 CPT Outpatient 26860.05 4610.98 Longevity Longevity PPO 0.27 7365.50 0.27 26860.05 0.27 Case Rate 54640 Priced Removal of hydrocele 173047 55040 CPT Outpatient 27277.95 4682.71 Longevity Longevity PPO 0.27 7307.07 0.27 27277.95 0.27 Case Rate 55040 Priced Biopsy of prostate gland 173047 55700 CPT Outpatient 28699.65 4926.77 Longevity Longevity PPO 0.13 3699.23 0.13 28699.65 0.13 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 173047 55866 CPT Outpatient 93088.80 15980.24 Longevity Longevity PPO 0.23 21829.50 0.23 93088.80 0.23 Case Rate 55866 Priced Closure of vagina 173047 57120 CPT Outpatient 34369.65 5900.12 Longevity Longevity PPO 0.42 14567.80 0.42 34369.65 0.42 Case Rate 57120 Priced Repair of vagina 173047 57200 CPT Outpatient 25247.25 4334.11 Longevity Longevity PPO 0.30 7666.44 0.30 25247.25 0.30 Case Rate 57200 Priced Anterior colporrhaphy 173047 57240 CPT Outpatient 36210.30 6216.10 Longevity Longevity PPO 0.53 19059.78 0.53 36210.30 0.53 Case Rate 57240 Priced Repair rectum & vagina 173047 57250 CPT Outpatient 40441.80 6942.51 Longevity Longevity PPO 0.56 22498.16 0.56 40441.80 0.56 Case Rate 57250 Priced Cmbn ant pst colprhy 173047 57260 CPT Outpatient 46323.90 7952.27 Longevity Longevity PPO 0.65 30178.28 0.65 46323.90 0.65 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 173047 57265 CPT Outpatient 42586.95 7310.76 Longevity Longevity PPO 0.42 18093.28 0.42 42586.95 0.42 Case Rate 57265 Priced Repair of bowel bulge 173047 57268 CPT Outpatient 36865.50 6328.58 Longevity Longevity PPO 0.49 17936.65 0.49 36865.50 0.49 Case Rate 57268 Priced Colpopexy extraperitoneal 173047 57282 CPT Outpatient 45629.85 7833.12 Longevity Longevity PPO 0.66 30066.23 0.66 45629.85 0.66 Case Rate 57282 Priced Repair bladder defect 173047 57288 CPT Outpatient 43069.95 7393.67 Longevity Longevity PPO 0.55 23521.83 0.55 43069.95 0.55 Case Rate 57288 Priced Bx/curett of cervix w/scope 173047 57454 CPT Outpatient 2888.55 442.93 Longevity Longevity PPO 0.11 326.46 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 173047 57520 CPT Outpatient 26728.80 4588.44 Longevity Longevity PPO 0.16 4175.50 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 173047 57522 CPT Outpatient 22737.75 3903.31 Longevity Longevity PPO 0.15 3382.15 0.15 22737.75 0.15 Case Rate 57522 Priced Biopsy of uterus lining 173047 58100 CPT Outpatient 2371.95 194.80 Longevity Longevity PPO 0.08 197.20 0.08 2371.95 0.08 Case Rate 58100 Priced Catheter for hysterography 173047 58340 CPT Outpatient 6322.05 131.04 Longevity Longevity PPO 0.04 266.34 0.04 6322.05 0.04 Case Rate 58340 Priced Reopen fallopian tube 173047 58350 CPT Outpatient 46507.65 7983.81 Longevity Longevity PPO 0.37 17413.81 0.37 46507.65 0.37 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 173047 58542 CPT Outpatient 64194.90 11020.12 Longevity Longevity PPO 0.37 23855.76 0.37 64194.90 0.37 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 173047 58544 CPT Outpatient 51020.55 8758.53 Longevity Longevity PPO 0.65 32933.57 0.65 51020.55 0.65 Case Rate 58544 Priced Laparoscopic myomectomy 173047 58545 CPT Outpatient 56946.75 9775.86 Longevity Longevity PPO 0.17 9636.11 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 173047 58552 CPT Outpatient 57228.15 9824.17 Longevity Longevity PPO 0.32 18224.29 0.32 57228.15 0.32 Case Rate 58552 Priced Hysteroscopy biopsy 173047 58558 CPT Outpatient 28581.00 2077.02 Longevity Longevity PPO 0.25 7177.08 0.25 28581.00 0.25 Case Rate 58558 Priced Hysteroscopy remove myoma 173047 58561 CPT Outpatient 35222.25 6046.49 Longevity Longevity PPO 0.27 9450.16 0.27 35222.25 0.27 Case Rate 58561 Priced Hysteroscopy ablation 173047 58563 CPT Outpatient 38399.55 6591.92 Longevity Longevity PPO 0.50 19389.13 0.50 38399.55 0.50 Case Rate 58563 Priced Tlh uterus 250 g or less 173047 58570 CPT Outpatient 43316.70 7436.03 Longevity Longevity PPO 0.25 10989.21 0.25 43316.70 0.25 Case Rate 58570 Priced Tlh w/t/o 250 g or less 173047 58571 CPT Outpatient 48603.45 8343.59 Longevity Longevity PPO 0.29 14246.82 0.29 48603.45 0.29 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 173047 58573 CPT Outpatient 52905.30 9082.08 Longevity Longevity PPO 0.31 16579.92 0.31 52905.30 0.31 Case Rate 58573 Priced Laparoscopy remove adnexa 173047 58661 CPT Outpatient 47008.50 8069.79 Longevity Longevity PPO 0.18 8612.00 0.18 47008.50 0.18 Case Rate 58661 Priced Laparoscopy excise lesions 173047 58662 CPT Outpatient 45053.40 7734.17 Longevity Longevity PPO 0.38 17073.38 0.38 45053.40 0.38 Case Rate 58662 Priced Treat ectopic pregnancy 173047 59151 CPT Outpatient 74690.70 12821.90 Longevity Longevity PPO 0.09 6574.17 0.09 74690.70 0.09 Case Rate 59151 Priced Treatment of miscarriage 173047 59812 CPT Outpatient 56109.90 9632.20 Longevity Longevity PPO 0.07 4041.21 0.07 56109.90 0.07 Case Rate 59812 Priced Partial removal of thyroid 173047 60220 CPT Outpatient 53639.25 9208.07 Longevity Longevity PPO 0.11 6036.43 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 173047 60240 CPT Outpatient 98252.70 16866.71 Longevity Longevity PPO 0.06 5854.88 0.06 98252.70 0.06 Case Rate 60240 Priced Explore parathyroid glands 173047 60500 CPT Outpatient 150495.45 25835.05 Longevity Longevity PPO 0.06 9684.87 0.06 150495.45 0.06 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 173047 62322 CPT Outpatient 43709.40 514.24 Longevity Longevity PPO 0.28 12131.01 0.28 43709.40 0.28 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 173047 62323 CPT Outpatient 8304.45 467.31 Longevity Longevity PPO 16.31 135426.62 16.31 8304.45 16.31 Case Rate 62323 Priced Low back disk surgery 173047 63030 CPT Outpatient 50287.65 8632.71 Longevity Longevity PPO 0.29 14766.92 0.29 50287.65 0.29 Case Rate 63030 Priced Inc for vagus n elect impl 173047 64568 CPT Outpatient 124562.55 21383.24 Longevity Longevity PPO 0.27 33526.60 0.27 124562.55 0.27 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 173047 66821 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 173047 66984 CPT Outpatient 0.01 0.01 Longevity Longevity PPO 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 554063 216 DRG Inpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 554063 460 DRG Inpatient 416122.79 53834.63 MagnaCare MagnaCare Commercial 0.09 36414.00 0.09 416122.79 0.09 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 554063 470 DRG Inpatient 167912.19 21723.13 MagnaCare MagnaCare Commercial 0.02 2601.00 0.02 167912.19 0.02 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 554063 473 DRG Inpatient 100687.91 13026.19 MagnaCare MagnaCare Commercial 0.03 2601.00 0.03 100687.91 0.03 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 554063 743 DRG Inpatient 102691.67 13285.42 MagnaCare MagnaCare Commercial 0.03 2601.00 0.03 102691.67 0.03 Case Rate 743 Priced NORMAL NEWBORN 554063 795 DRG Inpatient 6266.93 2335.00 MagnaCare MagnaCare Commercial 0.12 780.30 0.12 6266.93 0.12 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 554063 807 DRG Inpatient 116469.59 4193.00 MagnaCare MagnaCare Commercial 0.04 5202.00 0.04 116469.59 0.04 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 554063 788 DRG Inpatient 76050.77 4538.00 MagnaCare MagnaCare Commercial 0.07 5462.10 0.07 76050.77 0.07 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 554063 59400 CPT Inpatient 116469.59 4193.00 MagnaCare MagnaCare Commercial 0.04 5202.00 0.04 116469.59 0.04 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 554063 59510 CPT Inpatient 76050.77 4538.00 MagnaCare MagnaCare Commercial 0.07 5462.10 0.07 76050.77 0.07 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 554063 59610 CPT Inpatient 116469.59 4193.00 MagnaCare MagnaCare Commercial 0.04 5202.00 0.04 116469.59 0.04 Case Rate 59610 Priced "Psychotherapy, 30 min" 554063 90832 CPT Outpatient 577.50 91.21 MagnaCare MagnaCare Commercial 0.81 467.50 0.81 577.50 0.81 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 554063 90834 CPT Outpatient 44134.65 271.96 MagnaCare MagnaCare Commercial 0.77 34026.35 0.77 44134.65 0.77 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 554063 90837 CPT Outpatient 2240.70 442.93 MagnaCare MagnaCare Commercial 0.16 348.50 0.16 2240.70 0.16 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 554063 90846 CPT Outpatient 0.01 131.50 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 554063 90847 CPT Outpatient 44134.65 369.97 MagnaCare MagnaCare Commercial 0.77 34026.35 0.77 44134.65 0.77 Fee Schedule 90847 Priced Group psychotherapy 554063 90853 CPT Outpatient 44134.65 101.99 MagnaCare MagnaCare Commercial 0.77 34026.35 0.77 44134.65 0.77 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 554063 99203 CPT Outpatient 3480.75 176.07 MagnaCare MagnaCare Commercial 0.77 2683.45 0.77 3480.75 0.77 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 554063 99204 CPT Outpatient 2103.15 233.39 MagnaCare MagnaCare Commercial 0.77 1620.95 0.77 2103.15 0.77 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 554063 99205 CPT Outpatient 4970.70 314.28 MagnaCare MagnaCare Commercial 0.39 1915.90 0.39 4970.70 0.39 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 554063 99243 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 554063 99244 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 554063 99385 CPT Outpatient 1114.05 185.90 MagnaCare MagnaCare Commercial 0.77 858.50 0.77 1114.05 0.77 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 554063 99386 CPT Outpatient 4877.25 185.90 MagnaCare MagnaCare Commercial 0.62 3021.75 0.62 4877.25 0.62 Fee Schedule 99386 Priced Routine venipuncture 554063 36415 CPT Outpatient 127.05 19.57 MagnaCare MagnaCare Commercial 0.81 102.85 0.81 127.05 0.81 Fee Schedule 36415 Priced Basic Metabolic Panel 554063 80048 CPT Outpatient 576.45 88.78 MagnaCare MagnaCare Commercial 0.81 466.65 0.81 576.45 0.81 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 554063 80053 CPT Outpatient 763.35 117.56 MagnaCare MagnaCare Commercial 0.81 617.95 0.81 763.35 0.81 Fee Schedule 80053 Priced Obstetric blood test panel 554063 80055 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 554063 80061 CPT Outpatient 1349.25 197.77 MagnaCare MagnaCare Commercial 0.77 1039.55 0.77 1349.25 0.77 Fee Schedule 80061 Priced Kidney function panel test 554063 80069 CPT Outpatient 716.10 104.95 MagnaCare MagnaCare Commercial 0.77 551.65 0.77 716.10 0.77 Fee Schedule 80069 Priced Liver function panel test 554063 80076 CPT Outpatient 716.10 104.95 MagnaCare MagnaCare Commercial 0.77 551.65 0.77 716.10 0.77 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 554063 81000 CPT Outpatient 144.90 21.18 MagnaCare MagnaCare Commercial 0.77 111.35 0.77 144.90 0.77 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 554063 81001 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 554063 81002 CPT Outpatient 57.75 8.89 MagnaCare MagnaCare Commercial 0.81 46.75 0.81 57.75 0.81 Fee Schedule 81002 Priced Automated urinalysis test 554063 81003 CPT Outpatient 219.45 33.80 MagnaCare MagnaCare Commercial 0.81 177.65 0.81 219.45 0.81 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 554063 82306 CPT Outpatient 1880.55 289.62 MagnaCare MagnaCare Commercial 0.81 1522.35 0.81 1880.55 0.81 Fee Schedule 82306 Priced Glycosylated hemoglobin test 554063 83036 CPT Outpatient 494.55 76.17 MagnaCare MagnaCare Commercial 0.81 400.35 0.81 494.55 0.81 Fee Schedule 83036 Priced PSA (prostate specific antigen) 554063 84153 CPT Outpatient 1177.05 181.28 MagnaCare MagnaCare Commercial 0.81 952.85 0.81 1177.05 0.81 Fee Schedule 84153 Priced PSA (prostate specific antigen) 554063 84154 CPT Outpatient 598.50 92.17 MagnaCare MagnaCare Commercial 0.81 484.50 0.81 598.50 0.81 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 554063 84443 CPT Outpatient 519.75 80.05 MagnaCare MagnaCare Commercial 0.81 420.75 0.81 519.75 0.81 Fee Schedule 84443 Priced Chorionic gonadotropin assay 554063 84703 CPT Outpatient 785.40 120.96 MagnaCare MagnaCare Commercial 0.81 635.80 0.81 785.40 0.81 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 554063 85025 CPT Outpatient 635.25 97.83 MagnaCare MagnaCare Commercial 0.81 514.25 0.81 635.25 0.81 Fee Schedule 85025 Priced "Complete blood count, automated" 554063 85027 CPT Outpatient 576.45 88.78 MagnaCare MagnaCare Commercial 0.81 466.65 0.81 576.45 0.81 Fee Schedule 85027 Priced "Blood test, clotting time" 554063 85610 CPT Outpatient 404.25 62.26 MagnaCare MagnaCare Commercial 0.81 327.25 0.81 404.25 0.81 Fee Schedule 85610 Priced Coagulation assessment blood test 554063 85730 CPT Outpatient 17.22 2.65 MagnaCare MagnaCare Commercial 0.81 13.94 0.81 17.22 0.81 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 554063 86003 CPT Outpatient 32.55 5.01 MagnaCare MagnaCare Commercial 0.81 26.35 0.81 32.55 0.81 Fee Schedule 86003 Priced Tb test cell immun measure 554063 86480 CPT Outpatient 530.25 81.66 MagnaCare MagnaCare Commercial 0.81 429.25 0.81 530.25 0.81 Fee Schedule 86480 Priced Urine culture/colony count 554063 87086 CPT Outpatient 763.35 117.56 MagnaCare MagnaCare Commercial 0.81 617.95 0.81 763.35 0.81 Fee Schedule 87086 Priced Hpylori stool ia 554063 87338 CPT Outpatient 785.40 120.96 MagnaCare MagnaCare Commercial 0.81 635.80 0.81 785.40 0.81 Fee Schedule 87338 Priced Cytopath eval fna report 554063 88173 CPT Outpatient 750.75 115.62 MagnaCare MagnaCare Commercial 0.81 607.75 0.81 750.75 0.81 Fee Schedule 88173 Priced Tissue exam by pathologist 554063 88302 CPT Outpatient 635.25 97.83 MagnaCare MagnaCare Commercial 0.81 514.25 0.81 635.25 0.81 Fee Schedule 88302 Priced Tissue exam by pathologist 554063 88305 CPT Outpatient 323.40 49.81 MagnaCare MagnaCare Commercial 0.81 261.80 0.81 323.40 0.81 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 554063 11042 CPT Outpatient 2668.05 481.45 MagnaCare MagnaCare Commercial 0.77 2057.00 0.77 2668.05 0.77 Case Rate 11042 Priced Deb subq tissue add-on 554063 11045 CPT Outpatient 4652.55 330.00 MagnaCare MagnaCare Commercial 0.77 3587.00 0.77 4652.55 0.77 Case Rate 11045 Priced Dx bronchoscope/lavage 554063 31624 CPT Outpatient 41223.00 7602.31 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 41223.00 0.10 Case Rate 31624 Priced Bronchoscopy/lung bx each 554063 31628 CPT Outpatient 49048.65 9045.51 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 49048.65 0.09 Case Rate 31628 Priced Blood transfusion service 554063 36430 CPT Outpatient 9166.50 574.93 MagnaCare MagnaCare Commercial 0.77 7066.90 0.77 9166.50 0.77 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 554063 43235 CPT Outpatient 8856.75 1633.35 MagnaCare MagnaCare Commercial 0.48 4251.00 0.48 8856.75 0.48 Case Rate 43235 Priced Endoscopic us exam esoph 554063 43237 CPT Outpatient 23867.55 4401.63 MagnaCare MagnaCare Commercial 0.18 4251.00 0.18 23867.55 0.18 Case Rate 43237 Priced Egd us fine needle bx/aspir 554063 43238 CPT Outpatient 30690.45 5659.90 MagnaCare MagnaCare Commercial 0.14 4251.00 0.14 30690.45 0.14 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 554063 43239 CPT Outpatient 40191.90 7412.15 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 40191.90 0.11 Case Rate 43239 Priced Ercp remove duct calculi 554063 43264 CPT Outpatient 34335.00 6332.03 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 34335.00 0.12 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 554063 45378 CPT Outpatient 13991.25 889.35 MagnaCare MagnaCare Commercial 0.30 4251.00 0.30 13991.25 0.30 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 554063 45380 CPT Outpatient 22215.90 4097.04 MagnaCare MagnaCare Commercial 0.19 4251.00 0.19 22215.90 0.19 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 554063 45385 CPT Outpatient 119569.80 22050.95 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 119569.80 0.04 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 554063 45391 CPT Outpatient 24923.85 4596.43 MagnaCare MagnaCare Commercial 0.17 4251.00 0.17 24923.85 0.17 Case Rate 45391 Priced Fragmenting of kidney stone 554063 50590 CPT Outpatient 40930.05 7548.28 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 40930.05 0.10 Case Rate 50590 Priced Fetal non-stress test 554063 59025 CPT Outpatient 3153.15 477.76 MagnaCare MagnaCare Commercial 0.77 2431.00 0.77 3153.15 0.77 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 554063 64483 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 554063 92567 CPT Outpatient 2224.95 98.50 MagnaCare MagnaCare Commercial 0.77 1715.30 0.77 2224.95 0.77 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 554063 93000 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 554063 93017 CPT Outpatient 3076.50 532.96 MagnaCare MagnaCare Commercial 0.77 2371.50 0.77 3076.50 0.77 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 554063 93452 CPT Outpatient 55621.65 8611.87 MagnaCare MagnaCare Commercial 0.11 6196.00 0.11 55621.65 0.11 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 554063 95810 CPT Outpatient 20341.65 3373.48 MagnaCare MagnaCare Commercial 0.77 15682.50 0.77 20341.65 0.77 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 554063 95811 CPT Outpatient 22491.00 3731.18 MagnaCare MagnaCare Commercial 0.77 17340.00 0.77 22491.00 0.77 Case Rate 95811 Priced Eeg 41-60 minutes 554063 95812 CPT Outpatient 5578.65 925.83 MagnaCare MagnaCare Commercial 0.77 4301.00 0.77 5578.65 0.77 Case Rate 95812 Priced Genetic counseling 30 min 554063 96040 CPT Outpatient 0.01 102.81 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 554063 96413 CPT Outpatient 4856.25 472.45 MagnaCare MagnaCare Commercial 0.77 3743.40 0.77 4856.25 0.77 Case Rate 96413 Priced Ultrasound therapy 554063 97035 CPT Outpatient 2111.55 134.99 MagnaCare MagnaCare Commercial 0.77 1627.75 0.77 2111.55 0.77 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 554063 97110 CPT Outpatient 6494.25 92.86 MagnaCare MagnaCare Commercial 0.77 5006.50 0.77 6494.25 0.77 Case Rate 97110 Priced Gait training therapy 554063 97116 CPT Outpatient 4723.95 110.61 MagnaCare MagnaCare Commercial 0.77 3641.40 0.77 4723.95 0.77 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 554063 70450 CPT Outpatient 8566.95 835.61 MagnaCare MagnaCare Commercial 0.77 6604.50 0.77 8566.95 0.77 Case Rate 70450 Priced Mri brain stem w/o dye 554063 70551 CPT Outpatient 7861.35 1361.31 MagnaCare MagnaCare Commercial 0.77 6060.50 0.77 7861.35 0.77 Case Rate 70551 Priced MRI scan of brain before and after contrast 554063 70553 CPT Outpatient 10882.20 1625.88 MagnaCare MagnaCare Commercial 0.77 8389.50 0.77 10882.20 0.77 Case Rate 70553 Priced X-ray exam chest 2 views 554063 71046 CPT Outpatient 859.95 150.37 MagnaCare MagnaCare Commercial 0.77 663.00 0.77 859.95 0.77 Case Rate 71046 Priced Ct thorax w/o dye 554063 71250 CPT Outpatient 7288.05 1261.63 MagnaCare MagnaCare Commercial 0.77 5618.50 0.77 7288.05 0.77 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 554063 72082 CPT Outpatient 2022.30 253.33 MagnaCare MagnaCare Commercial 0.92 1853.85 0.92 2022.30 0.92 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 554063 72100 CPT Outpatient 1599.15 277.38 MagnaCare MagnaCare Commercial 0.77 1232.50 0.77 1599.15 0.77 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 554063 72110 CPT Outpatient 1389.15 241.04 MagnaCare MagnaCare Commercial 0.77 1071.00 0.77 1389.15 0.77 Case Rate 72110 Priced MRI scan of lower spinal canal 554063 72148 CPT Outpatient 7861.35 1361.31 MagnaCare MagnaCare Commercial 0.77 6060.50 0.77 7861.35 0.77 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 554063 72193 CPT Outpatient 13671.00 1412.01 MagnaCare MagnaCare Commercial 0.46 6290.00 0.46 13671.00 0.46 Case Rate 72193 Priced X-ray exam of shoulder 554063 73030 CPT Outpatient 1452.15 251.43 MagnaCare MagnaCare Commercial 0.77 1119.45 0.77 1452.15 0.77 Case Rate 73030 Priced X-ray exam of elbow 554063 73080 CPT Outpatient 1356.60 235.68 MagnaCare MagnaCare Commercial 0.77 1045.50 0.77 1356.60 0.77 Case Rate 73080 Priced X-ray exam of forearm 554063 73090 CPT Outpatient 1243.20 215.26 MagnaCare MagnaCare Commercial 0.77 957.95 0.77 1243.20 0.77 Case Rate 73090 Priced X-ray exam of wrist 554063 73110 CPT Outpatient 1243.20 215.26 MagnaCare MagnaCare Commercial 0.77 957.95 0.77 1243.20 0.77 Case Rate 73110 Priced X-ray exam of hand 554063 73130 CPT Outpatient 1243.20 215.26 MagnaCare MagnaCare Commercial 0.77 957.95 0.77 1243.20 0.77 Case Rate 73130 Priced X-ray exam hips bi 2 views 554063 73521 CPT Outpatient 970.20 228.41 MagnaCare MagnaCare Commercial 1.04 1011.50 1.04 970.20 1.04 Case Rate 73521 Priced X-ray exam of knee 3 554063 73562 CPT Outpatient 802.20 139.12 MagnaCare MagnaCare Commercial 0.77 617.95 0.77 802.20 0.77 Case Rate 73562 Priced X-ray exam of lower leg 554063 73590 CPT Outpatient 1243.20 215.26 MagnaCare MagnaCare Commercial 0.77 957.95 0.77 1243.20 0.77 Case Rate 73590 Priced X-ray exam of ankle 554063 73610 CPT Outpatient 1378.65 239.31 MagnaCare MagnaCare Commercial 0.77 1062.50 0.77 1378.65 0.77 Case Rate 73610 Priced X-ray exam of foot 554063 73630 CPT Outpatient 975.45 169.41 MagnaCare MagnaCare Commercial 0.77 751.40 0.77 975.45 0.77 Case Rate 73630 Priced MRI scan of leg joint 554063 73721 CPT Outpatient 7861.35 1361.31 MagnaCare MagnaCare Commercial 0.77 6060.50 0.77 7861.35 0.77 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 554063 74177 CPT Outpatient 14222.25 1412.01 MagnaCare MagnaCare Commercial 0.44 6290.00 0.44 14222.25 0.44 Case Rate 74177 Priced Contrst x-ray exam of throat 554063 74210 CPT Outpatient 0.01 440.39 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 554063 76098 CPT Outpatient 6141.45 407.86 MagnaCare MagnaCare Commercial 0.69 4251.00 0.69 6141.45 0.69 Case Rate 76098 Priced Us exam of head and neck 554063 76536 CPT Outpatient 5512.50 955.18 MagnaCare MagnaCare Commercial 0.77 4250.00 0.77 5512.50 0.77 Case Rate 76536 Priced Ultrasound breast limited 554063 76642 CPT Outpatient 5777.10 127.70 MagnaCare MagnaCare Commercial 0.77 4454.00 0.77 5777.10 0.77 Case Rate 76642 Priced Ultrasound of abdomen 554063 76700 CPT Outpatient 4917.15 851.88 MagnaCare MagnaCare Commercial 0.77 3791.00 0.77 4917.15 0.77 Case Rate 76700 Priced Echo exam of abdomen 554063 76705 CPT Outpatient 3836.70 665.17 MagnaCare MagnaCare Commercial 0.77 2958.00 0.77 3836.70 0.77 Case Rate 76705 Priced Us exam abdo back wall comp 554063 76770 CPT Outpatient 5171.25 895.48 MagnaCare MagnaCare Commercial 0.77 3986.50 0.77 5171.25 0.77 Case Rate 76770 Priced Us exam abdo back wall lim 554063 76775 CPT Outpatient 3969.00 686.97 MagnaCare MagnaCare Commercial 0.77 3060.00 0.77 3969.00 0.77 Case Rate 76775 Priced Ob us < 14 wks single fetus 554063 76801 CPT Outpatient 2006.55 347.98 MagnaCare MagnaCare Commercial 0.77 1547.00 0.77 2006.55 0.77 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 554063 76805 CPT Outpatient 3969.00 686.97 MagnaCare MagnaCare Commercial 0.77 3060.00 0.77 3969.00 0.77 Case Rate 76805 Priced Ob us detailed sngl fetus 554063 76811 CPT Outpatient 2844.45 492.99 MagnaCare MagnaCare Commercial 0.77 2193.00 0.77 2844.45 0.77 Case Rate 76811 Priced Ob us nuchal meas 1 gest 554063 76813 CPT Outpatient 1044.75 180.83 MagnaCare MagnaCare Commercial 0.77 804.95 0.77 1044.75 0.77 Case Rate 76813 Priced Ob us limited fetus(s) 554063 76815 CPT Outpatient 6428.10 639.90 MagnaCare MagnaCare Commercial 0.77 4955.50 0.77 6428.10 0.77 Case Rate 76815 Priced Ob us follow-up per fetus 554063 76816 CPT Outpatient 4818.45 833.88 MagnaCare MagnaCare Commercial 0.77 3714.50 0.77 4818.45 0.77 Case Rate 76816 Priced Transvaginal us obstetric 554063 76817 CPT Outpatient 6428.10 476.73 MagnaCare MagnaCare Commercial 0.77 4955.50 0.77 6428.10 0.77 Case Rate 76817 Priced Fetal biophys profil w/o nst 554063 76819 CPT Outpatient 1741.95 302.65 MagnaCare MagnaCare Commercial 0.77 1343.00 0.77 1741.95 0.77 Case Rate 76819 Priced Ultrasound pelvis through vagina 554063 76830 CPT Outpatient 9305.10 806.54 MagnaCare MagnaCare Commercial 0.77 7174.00 0.77 9305.10 0.77 Case Rate 76830 Priced Us exam scrotum 554063 76870 CPT Outpatient 6328.35 1096.55 MagnaCare MagnaCare Commercial 0.77 4879.00 0.77 6328.35 0.77 Case Rate 76870 Priced Us exam infant hips dynamic 554063 76885 CPT Outpatient 3836.70 665.17 MagnaCare MagnaCare Commercial 0.77 2958.00 0.77 3836.70 0.77 Case Rate 76885 Priced Mammography of one breast 554063 77065 CPT Outpatient 3451.35 192.07 MagnaCare MagnaCare Commercial 0.77 2660.50 0.77 3451.35 0.77 Case Rate 77065 Priced Mammography of both breasts 554063 77066 CPT Outpatient 5777.10 235.68 MagnaCare MagnaCare Commercial 0.77 4454.00 0.77 5777.10 0.77 Case Rate 77066 Priced "Mamography, screening bilateral" 554063 77067 CPT Outpatient 1416.45 205.57 MagnaCare MagnaCare Commercial 0.77 1091.40 0.77 1416.45 0.77 Case Rate 77067 Priced X-rays for bone age 554063 77072 CPT Outpatient 2022.30 163.87 MagnaCare MagnaCare Commercial 0.92 1853.85 0.92 2022.30 0.92 Case Rate 77072 Priced Joint survey single view 554063 77077 CPT Outpatient 985.95 171.14 MagnaCare MagnaCare Commercial 0.77 759.90 0.77 985.95 0.77 Case Rate 77077 Priced Dxa bone density axial 554063 77080 CPT Outpatient 3257.10 319.09 MagnaCare MagnaCare Commercial 0.77 2510.90 0.77 3257.10 0.77 Case Rate 77080 Priced Fna bx w/us gdn 1st les 554063 10005 CPT Outpatient 5512.50 547.24 MagnaCare MagnaCare Commercial 0.77 4250.00 0.77 5512.50 0.77 Case Rate 10005 Priced Fna bx w/us gdn ea addl 554063 10006 CPT Outpatient 10628.10 594.83 MagnaCare MagnaCare Commercial 0.40 4251.00 0.40 10628.10 0.40 Case Rate 10006 Priced Drainage of hematoma/fluid 554063 10140 CPT Outpatient 23209.20 1081.95 MagnaCare MagnaCare Commercial 0.18 4251.00 0.18 23209.20 0.18 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 554063 11042 CPT Outpatient 2668.05 481.45 MagnaCare MagnaCare Commercial 0.77 2057.00 0.77 2668.05 0.77 Case Rate 11042 Priced Deb bone 20 sq cm/< 554063 11044 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 554063 11406 CPT Outpatient 19967.85 3427.81 MagnaCare MagnaCare Commercial 0.21 4251.00 0.21 19967.85 0.21 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 554063 11424 CPT Outpatient 0.01 1004.93 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 554063 11770 CPT Outpatient 19173.00 3291.37 MagnaCare MagnaCare Commercial 0.22 4251.00 0.22 19173.00 0.22 Case Rate 11770 Priced Replace tissue expander 554063 11970 CPT Outpatient 59239.95 10169.52 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 59239.95 0.07 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 554063 14020 CPT Outpatient 32166.75 5521.96 MagnaCare MagnaCare Commercial 0.13 4251.00 0.13 32166.75 0.13 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 554063 14060 CPT Outpatient 25993.80 1374.69 MagnaCare MagnaCare Commercial 0.16 4251.00 0.16 25993.80 0.16 Case Rate 14060 Priced Wound prep trk/arm/leg 554063 15002 CPT Outpatient 41748.00 1441.73 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 41748.00 0.10 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 554063 15271 CPT Outpatient 24343.20 3769.48 MagnaCare MagnaCare Commercial 0.72 17518.50 0.72 24343.20 0.72 Case Rate 15271 Priced Acellular derm matrix implt 554063 15777 CPT Outpatient 101672.55 17453.79 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 101672.55 0.04 Case Rate 15777 Priced Exc skin abd 554063 15830 CPT Outpatient 54696.60 9389.58 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 54696.60 0.08 Case Rate 15830 Priced Dressing change not for burn 554063 15852 CPT Outpatient 0.01 290.74 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 554063 15877 CPT Outpatient 63741.30 10942.26 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 63741.30 0.07 Case Rate 15877 Priced Suction lipectomy lwr extrem 554063 15879 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 554063 19000 CPT Outpatient 10143.00 594.83 MagnaCare MagnaCare Commercial 0.42 4251.00 0.42 10143.00 0.42 Case Rate 19000 Priced Bx breast 1st lesion strtctc 554063 19081 CPT Outpatient 12341.70 1250.69 MagnaCare MagnaCare Commercial 0.34 4251.00 0.34 12341.70 0.34 Case Rate 19081 Priced Bx breast add lesion us imag 554063 19084 CPT Outpatient 29058.75 547.24 MagnaCare MagnaCare Commercial 0.15 4251.00 0.15 29058.75 0.15 Case Rate 19084 Priced Biopsy of breast open 554063 19101 CPT Outpatient 39545.10 2737.82 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 39545.10 0.11 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 554063 19120 CPT Outpatient 35761.95 2737.82 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 35761.95 0.12 Case Rate 19120 Priced Excision breast lesion 554063 19125 CPT Outpatient 33184.20 0.01 MagnaCare MagnaCare Commercial 0.13 4251.00 0.13 33184.20 0.13 Case Rate 19125 Priced Perq device breast 1st imag 554063 19281 CPT Outpatient 6141.45 598.61 MagnaCare MagnaCare Commercial 0.69 4251.00 0.69 6141.45 0.69 Case Rate 19281 Priced Perq device breast ea imag 554063 19282 CPT Outpatient 8379.00 319.04 MagnaCare MagnaCare Commercial 0.51 4251.00 0.51 8379.00 0.51 Case Rate 19282 Priced Partial mastectomy 554063 19301 CPT Outpatient 39157.65 6722.06 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 39157.65 0.11 Case Rate 19301 Priced Mast simple complete 554063 19303 CPT Outpatient 105389.55 18091.87 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 105389.55 0.04 Case Rate 19303 Priced Reduction of large breast 554063 19318 CPT Outpatient 65239.65 11199.47 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 65239.65 0.07 Case Rate 19318 Priced Immediate breast prosthesis 554063 19340 CPT Outpatient 113100.75 19415.63 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 113100.75 0.04 Case Rate 19340 Priced Delayed breast prosthesis 554063 19342 CPT Outpatient 56988.75 9783.07 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 56988.75 0.07 Case Rate 19342 Priced Breast reconstruction 554063 19357 CPT Outpatient 101672.55 17453.79 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 101672.55 0.04 Case Rate 19357 Priced Breast reconstruction 554063 19366 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 554063 19380 CPT Outpatient 61493.25 10556.34 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 61493.25 0.07 Case Rate 19380 Priced Removal of support implant 554063 20680 CPT Outpatient 42329.70 7266.60 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 42329.70 0.10 Case Rate 20680 Priced Cerv artific diskectomy 554063 22856 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 554063 24538 CPT Outpatient 51237.90 4775.24 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 51237.90 0.08 Case Rate 24538 Priced Remove wrist tendon lesion 554063 25111 CPT Outpatient 25855.20 4438.48 MagnaCare MagnaCare Commercial 0.16 4251.00 0.16 25855.20 0.16 Case Rate 25111 Priced Incise finger tendon sheath 554063 26055 CPT Outpatient 15862.35 2723.04 MagnaCare MagnaCare Commercial 0.27 4251.00 0.27 15862.35 0.27 Case Rate 26055 Priced Treat finger fracture each 554063 26727 CPT Outpatient 22779.75 2030.47 MagnaCare MagnaCare Commercial 0.19 4251.00 0.19 22779.75 0.19 Case Rate 26727 Priced Revision of knee joint 554063 27446 CPT Outpatient 67882.50 11653.16 MagnaCare MagnaCare Commercial 0.06 4251.00 0.06 67882.50 0.06 Case Rate 27446 Priced Total knee arthroplasty 554063 27447 CPT Outpatient 130698.75 22436.62 MagnaCare MagnaCare Commercial 0.03 4251.00 0.03 130698.75 0.03 Case Rate 27447 Priced Surgery to stop leg growth 554063 27485 CPT Outpatient 43310.40 7434.95 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 43310.40 0.10 Case Rate 27485 Priced Repair achilles tendon 554063 27650 CPT Outpatient 38246.25 3762.57 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 38246.25 0.11 Case Rate 27650 Priced Treatment of ankle fracture 554063 27792 CPT Outpatient 36101.10 6197.36 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 36101.10 0.12 Case Rate 27792 Priced Treatment of ankle fracture 554063 27814 CPT Outpatient 49405.65 8481.30 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 49405.65 0.09 Case Rate 27814 Priced Removal of foot lesion 554063 28080 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 554063 28285 CPT Outpatient 68603.85 11776.99 MagnaCare MagnaCare Commercial 0.06 4251.00 0.06 68603.85 0.06 Case Rate 28285 Priced Correction hallux valgus 554063 28296 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 554063 29823 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 554063 29826 CPT Outpatient 49840.35 8555.93 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 49840.35 0.09 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 554063 29881 CPT Outpatient 35556.15 6103.81 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 35556.15 0.12 Case Rate 29881 Priced Knee arthroscopy/surgery 554063 29882 CPT Outpatient 61099.50 10488.75 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 61099.50 0.07 Case Rate 29882 Priced Percut bx lung/mediastinum 554063 32405 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 554063 32555 CPT Outpatient 14597.10 687.29 MagnaCare MagnaCare Commercial 0.29 4251.00 0.29 14597.10 0.29 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 554063 32664 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 554063 35190 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 554063 36478 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 554063 36561 CPT Outpatient 53531.10 3292.99 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 53531.10 0.08 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 554063 36569 CPT Outpatient 31421.25 1299.06 MagnaCare MagnaCare Commercial 0.14 4251.00 0.14 31421.25 0.14 Case Rate 36569 Priced Removal tunneled cv cath 554063 36590 CPT Outpatient 1996.05 273.95 MagnaCare MagnaCare Commercial 0.77 1545.30 0.77 1996.05 0.77 Case Rate 36590 Priced Av fuse uppr arm basilic 554063 36819 CPT Outpatient 56861.70 9761.26 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 56861.70 0.07 Case Rate 36819 Priced Av fusion direct any site 554063 36821 CPT Outpatient 42953.40 7373.67 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 42953.40 0.10 Case Rate 36821 Priced Artery-vein autograft 554063 36825 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 554063 36830 CPT Outpatient 53656.05 9210.96 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 53656.05 0.08 Case Rate 36830 Priced Av fistula revision open 554063 36832 CPT Outpatient 52492.65 9011.24 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 52492.65 0.08 Case Rate 36832 Priced Av fistula revision 554063 36833 CPT Outpatient 37098.60 6368.59 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 37098.60 0.11 Case Rate 36833 Priced Intro cath dialysis circuit 554063 36903 CPT Outpatient 77541.45 10669.90 MagnaCare MagnaCare Commercial 0.05 4251.00 0.05 77541.45 0.05 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 554063 36906 CPT Outpatient 96694.50 16175.64 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 96694.50 0.04 Case Rate 36906 Priced Fem/popl revas w/tla 554063 37224 CPT Outpatient 200076.45 5139.31 MagnaCare MagnaCare Commercial 0.03 6196.00 0.03 200076.45 0.03 Case Rate 37224 Priced Fem/popl revasc stnt & ather 554063 37227 CPT Outpatient 117170.55 18045.38 MagnaCare MagnaCare Commercial 0.05 6196.00 0.05 117170.55 0.05 Case Rate 37227 Priced Revise leg vein 554063 37700 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 554063 37722 CPT Outpatient 27815.55 4775.00 MagnaCare MagnaCare Commercial 0.15 4251.00 0.15 27815.55 0.15 Case Rate 37722 Priced Stab phleb veins xtr 10-20 554063 37765 CPT Outpatient 26561.85 4559.78 MagnaCare MagnaCare Commercial 0.16 4251.00 0.16 26561.85 0.16 Case Rate 37765 Priced Biopsy/removal lymph nodes 554063 38500 CPT Outpatient 35955.15 6172.30 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 35955.15 0.12 Case Rate 38500 Priced Biopsy/removal lymph nodes 554063 38525 CPT Outpatient 101194.80 17371.77 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 101194.80 0.04 Case Rate 38525 Priced Laparoscopy lymph node biop 554063 38570 CPT Outpatient 65631.30 11266.71 MagnaCare MagnaCare Commercial 0.06 4251.00 0.06 65631.30 0.06 Case Rate 38570 Priced Laparoscopy lymphadenectomy 554063 38571 CPT Outpatient 84031.50 14425.41 MagnaCare MagnaCare Commercial 0.05 4251.00 0.05 84031.50 0.05 Case Rate 38571 Priced Laparoscopy lymphadenectomy 554063 38572 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 554063 38792 CPT Outpatient 2868.60 432.48 MagnaCare MagnaCare Commercial 0.77 2210.85 0.77 2868.60 0.77 Case Rate 38792 Priced Excision of gum lesion 554063 41825 CPT Outpatient 11580.45 1987.98 MagnaCare MagnaCare Commercial 0.37 4251.00 0.37 11580.45 0.37 Case Rate 41825 Priced Reconstruct cleft palate 554063 42200 CPT Outpatient 36703.80 6300.82 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 36703.80 0.12 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 554063 42820 CPT Outpatient 17232.60 2958.26 MagnaCare MagnaCare Commercial 0.25 4251.00 0.25 17232.60 0.25 Case Rate 42820 Priced Control throat bleeding 554063 42960 CPT Outpatient 24066.00 4131.33 MagnaCare MagnaCare Commercial 0.18 4251.00 0.18 24066.00 0.18 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 554063 43235 CPT Outpatient 8856.75 1633.35 MagnaCare MagnaCare Commercial 0.48 4251.00 0.48 8856.75 0.48 Case Rate 43235 Priced Laparoscopy fundoplasty 554063 43280 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 554063 43282 CPT Outpatient 84344.40 14479.12 MagnaCare MagnaCare Commercial 0.05 4251.00 0.05 84344.40 0.05 Case Rate 43282 Priced Laparoscopy appendectomy 554063 44970 CPT Outpatient 82300.05 14128.18 MagnaCare MagnaCare Commercial 0.05 4251.00 0.05 82300.05 0.05 Case Rate 44970 Priced Diagnostic sigmoidoscopy 554063 45330 CPT Outpatient 17286.15 542.26 MagnaCare MagnaCare Commercial 0.25 4251.00 0.25 17286.15 0.25 Case Rate 45330 Priced Needle biopsy of liver 554063 47000 CPT Outpatient 10398.15 1225.34 MagnaCare MagnaCare Commercial 0.41 4251.00 0.41 10398.15 0.41 Case Rate 47000 Priced Removal of gallbladder using an endoscope 554063 47562 CPT Outpatient 58430.40 10030.55 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 58430.40 0.07 Case Rate 47562 Priced Laparo cholecystectomy/graph 554063 47563 CPT Outpatient 71747.55 12316.66 MagnaCare MagnaCare Commercial 0.06 4251.00 0.06 71747.55 0.06 Case Rate 47563 Priced Abd paracentesis w/imaging 554063 49083 CPT Outpatient 6979.35 1113.95 MagnaCare MagnaCare Commercial 0.61 4251.00 0.61 6979.35 0.61 Case Rate 49083 Priced Diag laparo separate proc 554063 49320 CPT Outpatient 31629.15 5429.67 MagnaCare MagnaCare Commercial 0.13 4251.00 0.13 31629.15 0.13 Case Rate 49320 Priced Laparoscopy biopsy 554063 49321 CPT Outpatient 41892.90 7191.61 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 41892.90 0.10 Case Rate 49321 Priced Laparoscopy aspiration 554063 49322 CPT Outpatient 34392.75 5904.09 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 34392.75 0.12 Case Rate 49322 Priced Lap insert tunnel ip cath 554063 49324 CPT Outpatient 39264.75 6740.45 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 39264.75 0.11 Case Rate 49324 Priced Laparo proc abdm/per/oment 554063 49329 CPT Outpatient 58696.05 10076.16 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 58696.05 0.07 Case Rate 49329 Priced Ins tun ip cath for dial opn 554063 49421 CPT Outpatient 25460.40 3319.30 MagnaCare MagnaCare Commercial 0.17 4251.00 0.17 25460.40 0.17 Case Rate 49421 Priced Remove tunneled ip cath 554063 49422 CPT Outpatient 25515.00 4380.08 MagnaCare MagnaCare Commercial 0.17 4251.00 0.17 25515.00 0.17 Case Rate 49422 Priced Rpr ing hernia init reduce 554063 49500 CPT Outpatient 19594.05 3363.65 MagnaCare MagnaCare Commercial 0.22 4251.00 0.22 19594.05 0.22 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 554063 49505 CPT Outpatient 34915.65 5993.85 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 34915.65 0.12 Case Rate 49505 Priced Prp i/hern init block >5 yr 554063 49507 CPT Outpatient 29794.80 5114.77 MagnaCare MagnaCare Commercial 0.14 4251.00 0.14 29794.80 0.14 Case Rate 49507 Priced Rerepair ing hernia reduce 554063 49520 CPT Outpatient 36940.05 6341.38 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 36940.05 0.12 Case Rate 49520 Priced Rpr ventral hern init reduc 554063 49560 CPT Outpatient 53177.25 9128.76 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 53177.25 0.08 Case Rate 49560 Priced Rpr ventral hern init block 554063 49561 CPT Outpatient 30755.55 5279.70 MagnaCare MagnaCare Commercial 0.14 4251.00 0.14 30755.55 0.14 Case Rate 49561 Priced Rerepair ventrl hern reduce 554063 49565 CPT Outpatient 69917.40 12002.49 MagnaCare MagnaCare Commercial 0.06 4251.00 0.06 69917.40 0.06 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 554063 49585 CPT Outpatient 41806.80 7176.83 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 41806.80 0.10 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 554063 49587 CPT Outpatient 37320.15 6406.63 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 37320.15 0.11 Case Rate 49587 Priced Lap ing hernia repair init 554063 49650 CPT Outpatient 41932.80 7198.46 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 41932.80 0.10 Case Rate 49650 Priced Lap ing hernia repair recur 554063 49651 CPT Outpatient 46915.05 8053.75 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 46915.05 0.09 Case Rate 49651 Priced Lap vent/abd hernia repair 554063 49652 CPT Outpatient 51294.60 8805.57 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 51294.60 0.08 Case Rate 49652 Priced Lap vent/abd hern proc comp 554063 49653 CPT Outpatient 46102.35 7914.24 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 46102.35 0.09 Case Rate 49653 Priced Lap inc hernia repair 554063 49654 CPT Outpatient 47221.65 8106.38 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 47221.65 0.09 Case Rate 49654 Priced Lap inc hern repair comp 554063 49655 CPT Outpatient 54590.55 9371.38 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 54590.55 0.08 Case Rate 49655 Priced Lap inc hernia repair recur 554063 49656 CPT Outpatient 55443.15 9517.74 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 55443.15 0.08 Case Rate 49656 Priced Removal of kidney stone 554063 50080 CPT Outpatient 53165.70 9126.78 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 53165.70 0.08 Case Rate 50080 Priced Removal of kidney stone 554063 50081 CPT Outpatient 66931.20 11489.86 MagnaCare MagnaCare Commercial 0.06 4251.00 0.06 66931.20 0.06 Case Rate 50081 Priced Renal biopsy perq 554063 50200 CPT Outpatient 43096.20 1225.34 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 43096.20 0.10 Case Rate 50200 Priced Plmt nephroureteral catheter 554063 50433 CPT Outpatient 64566.60 1424.48 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 64566.60 0.07 Case Rate 50433 Priced Laparo radical nephrectomy 554063 50545 CPT Outpatient 43449.00 7458.75 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 43449.00 0.10 Case Rate 50545 Priced Laparoscope proc ureter 554063 50949 CPT Outpatient 49986.30 8580.98 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 49986.30 0.09 Case Rate 50949 Priced Injection for bladder x-ray 554063 51600 CPT Outpatient 3285.45 89.22 MagnaCare MagnaCare Commercial 0.77 2533.00 0.77 3285.45 0.77 Case Rate 51600 Priced Cystoscopy 554063 52000 CPT Outpatient 22149.75 3802.37 MagnaCare MagnaCare Commercial 0.19 4251.00 0.19 22149.75 0.19 Case Rate 52000 Priced Cystoscopy & ureter catheter 554063 52005 CPT Outpatient 42529.20 2095.77 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 42529.20 0.10 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 554063 52204 CPT Outpatient 31274.25 5368.75 MagnaCare MagnaCare Commercial 0.14 4251.00 0.14 31274.25 0.14 Case Rate 52204 Priced Cystoscopy and treatment 554063 52224 CPT Outpatient 13445.25 2308.10 MagnaCare MagnaCare Commercial 0.32 4251.00 0.32 13445.25 0.32 Case Rate 52224 Priced Cystoscopy and treatment 554063 52234 CPT Outpatient 28510.65 4894.33 MagnaCare MagnaCare Commercial 0.15 4251.00 0.15 28510.65 0.15 Case Rate 52234 Priced Cystoscopy and treatment 554063 52235 CPT Outpatient 29417.85 5050.06 MagnaCare MagnaCare Commercial 0.14 4251.00 0.14 29417.85 0.14 Case Rate 52235 Priced Cystoscopy and treatment 554063 52240 CPT Outpatient 33933.90 5825.32 MagnaCare MagnaCare Commercial 0.13 4251.00 0.13 33933.90 0.13 Case Rate 52240 Priced Cystoscopy and treatment 554063 52281 CPT Outpatient 22159.20 3804.00 MagnaCare MagnaCare Commercial 0.19 4251.00 0.19 22159.20 0.19 Case Rate 52281 Priced Remove bladder stone 554063 52317 CPT Outpatient 27085.80 4649.73 MagnaCare MagnaCare Commercial 0.16 4251.00 0.16 27085.80 0.16 Case Rate 52317 Priced Remove bladder stone 554063 52318 CPT Outpatient 26685.75 4581.05 MagnaCare MagnaCare Commercial 0.16 4251.00 0.16 26685.75 0.16 Case Rate 52318 Priced Cystoscopy and treatment 554063 52332 CPT Outpatient 115306.80 19794.33 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 115306.80 0.04 Case Rate 52332 Priced Cystouretero w/stone remove 554063 52352 CPT Outpatient 42420.00 7282.10 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 42420.00 0.10 Case Rate 52352 Priced Cystouretero w/lithotripsy 554063 52353 CPT Outpatient 38608.50 6627.79 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 38608.50 0.11 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 554063 52356 CPT Outpatient 36255.45 6223.85 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 36255.45 0.12 Case Rate 52356 Priced Prostatectomy (turp) 554063 52601 CPT Outpatient 35371.35 6072.08 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 35371.35 0.12 Case Rate 52601 Priced Laser surgery of prostate 554063 52648 CPT Outpatient 24264.45 4165.40 MagnaCare MagnaCare Commercial 0.18 4251.00 0.18 24264.45 0.18 Case Rate 52648 Priced Revision of urethra 554063 53450 CPT Outpatient 16209.90 2782.70 MagnaCare MagnaCare Commercial 0.26 4251.00 0.26 16209.90 0.26 Case Rate 53450 Priced Urology surgery procedure 554063 53899 CPT Outpatient 25368.00 134.83 MagnaCare MagnaCare Commercial 0.17 4251.00 0.17 25368.00 0.17 Case Rate 53899 Priced Circumcision w/regionl block 554063 54150 CPT Outpatient 14700.00 2523.50 MagnaCare MagnaCare Commercial 0.29 4251.00 0.29 14700.00 0.29 Case Rate 54150 Priced Circum 28 days or older 554063 54161 CPT Outpatient 19186.65 3293.71 MagnaCare MagnaCare Commercial 0.22 4251.00 0.22 19186.65 0.22 Case Rate 54161 Priced Lysis penil circumic lesion 554063 54162 CPT Outpatient 19795.65 3398.25 MagnaCare MagnaCare Commercial 0.21 4251.00 0.21 19795.65 0.21 Case Rate 54162 Priced Repair of circumcision 554063 54163 CPT Outpatient 16391.55 2813.88 MagnaCare MagnaCare Commercial 0.26 4251.00 0.26 16391.55 0.26 Case Rate 54163 Priced Reconstruction of urethra 554063 54324 CPT Outpatient 32880.75 5644.53 MagnaCare MagnaCare Commercial 0.13 4251.00 0.13 32880.75 0.13 Case Rate 54324 Priced Revise penis/urethra 554063 54332 CPT Outpatient 19968.90 3427.99 MagnaCare MagnaCare Commercial 0.21 4251.00 0.21 19968.90 0.21 Case Rate 54332 Priced Insert self-contd prosthesis 554063 54401 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 554063 54520 CPT Outpatient 35442.75 6084.34 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 35442.75 0.12 Case Rate 54520 Priced Reduce testis torsion 554063 54600 CPT Outpatient 55049.40 9450.15 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 55049.40 0.08 Case Rate 54600 Priced Suspension of testis 554063 54640 CPT Outpatient 26860.05 4610.98 MagnaCare MagnaCare Commercial 0.16 4251.00 0.16 26860.05 0.16 Case Rate 54640 Priced Removal of hydrocele 554063 55040 CPT Outpatient 27277.95 4682.71 MagnaCare MagnaCare Commercial 0.16 4251.00 0.16 27277.95 0.16 Case Rate 55040 Priced Biopsy of prostate gland 554063 55700 CPT Outpatient 28699.65 4926.77 MagnaCare MagnaCare Commercial 0.15 4251.00 0.15 28699.65 0.15 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 554063 55866 CPT Outpatient 93088.80 15980.24 MagnaCare MagnaCare Commercial 0.05 4251.00 0.05 93088.80 0.05 Case Rate 55866 Priced Closure of vagina 554063 57120 CPT Outpatient 34369.65 5900.12 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 34369.65 0.12 Case Rate 57120 Priced Repair of vagina 554063 57200 CPT Outpatient 25247.25 4334.11 MagnaCare MagnaCare Commercial 0.17 4251.00 0.17 25247.25 0.17 Case Rate 57200 Priced Anterior colporrhaphy 554063 57240 CPT Outpatient 36210.30 6216.10 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 36210.30 0.12 Case Rate 57240 Priced Repair rectum & vagina 554063 57250 CPT Outpatient 40441.80 6942.51 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 40441.80 0.11 Case Rate 57250 Priced Cmbn ant pst colprhy 554063 57260 CPT Outpatient 46323.90 7952.27 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 46323.90 0.09 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 554063 57265 CPT Outpatient 42586.95 7310.76 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 42586.95 0.10 Case Rate 57265 Priced Repair of bowel bulge 554063 57268 CPT Outpatient 36865.50 6328.58 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 36865.50 0.12 Case Rate 57268 Priced Colpopexy extraperitoneal 554063 57282 CPT Outpatient 45629.85 7833.12 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 45629.85 0.09 Case Rate 57282 Priced Repair bladder defect 554063 57288 CPT Outpatient 43069.95 7393.67 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 43069.95 0.10 Case Rate 57288 Priced Bx/curett of cervix w/scope 554063 57454 CPT Outpatient 2888.55 442.93 MagnaCare MagnaCare Commercial 0.77 2227.00 0.77 2888.55 0.77 Case Rate 57454 Priced Conization of cervix 554063 57520 CPT Outpatient 26728.80 4588.44 MagnaCare MagnaCare Commercial 0.16 4251.00 0.16 26728.80 0.16 Case Rate 57520 Priced Conization of cervix 554063 57522 CPT Outpatient 22737.75 3903.31 MagnaCare MagnaCare Commercial 0.19 4251.00 0.19 22737.75 0.19 Case Rate 57522 Priced Biopsy of uterus lining 554063 58100 CPT Outpatient 2371.95 194.80 MagnaCare MagnaCare Commercial 0.77 1828.35 0.77 2371.95 0.77 Case Rate 58100 Priced Catheter for hysterography 554063 58340 CPT Outpatient 6322.05 131.04 MagnaCare MagnaCare Commercial 0.43 2748.90 0.43 6322.05 0.43 Case Rate 58340 Priced Reopen fallopian tube 554063 58350 CPT Outpatient 46507.65 7983.81 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 46507.65 0.09 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 554063 58542 CPT Outpatient 64194.90 11020.12 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 64194.90 0.07 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 554063 58544 CPT Outpatient 51020.55 8758.53 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 51020.55 0.08 Case Rate 58544 Priced Laparoscopic myomectomy 554063 58545 CPT Outpatient 56946.75 9775.86 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 56946.75 0.07 Case Rate 58545 Priced Laparo-vag hyst incl t/o 554063 58552 CPT Outpatient 57228.15 9824.17 MagnaCare MagnaCare Commercial 0.07 4251.00 0.07 57228.15 0.07 Case Rate 58552 Priced Hysteroscopy biopsy 554063 58558 CPT Outpatient 28581.00 2077.02 MagnaCare MagnaCare Commercial 0.15 4251.00 0.15 28581.00 0.15 Case Rate 58558 Priced Hysteroscopy remove myoma 554063 58561 CPT Outpatient 35222.25 6046.49 MagnaCare MagnaCare Commercial 0.12 4251.00 0.12 35222.25 0.12 Case Rate 58561 Priced Hysteroscopy ablation 554063 58563 CPT Outpatient 38399.55 6591.92 MagnaCare MagnaCare Commercial 0.11 4251.00 0.11 38399.55 0.11 Case Rate 58563 Priced Tlh uterus 250 g or less 554063 58570 CPT Outpatient 43316.70 7436.03 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 43316.70 0.10 Case Rate 58570 Priced Tlh w/t/o 250 g or less 554063 58571 CPT Outpatient 48603.45 8343.59 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 48603.45 0.09 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 554063 58573 CPT Outpatient 52905.30 9082.08 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 52905.30 0.08 Case Rate 58573 Priced Laparoscopy remove adnexa 554063 58661 CPT Outpatient 47008.50 8069.79 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 47008.50 0.09 Case Rate 58661 Priced Laparoscopy excise lesions 554063 58662 CPT Outpatient 45053.40 7734.17 MagnaCare MagnaCare Commercial 0.09 4251.00 0.09 45053.40 0.09 Case Rate 58662 Priced Treat ectopic pregnancy 554063 59151 CPT Outpatient 74690.70 12821.90 MagnaCare MagnaCare Commercial 0.06 4251.00 0.06 74690.70 0.06 Case Rate 59151 Priced Treatment of miscarriage 554063 59812 CPT Outpatient 56109.90 9632.20 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 56109.90 0.08 Case Rate 59812 Priced Partial removal of thyroid 554063 60220 CPT Outpatient 53639.25 9208.07 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 53639.25 0.08 Case Rate 60220 Priced Removal of thyroid 554063 60240 CPT Outpatient 98252.70 16866.71 MagnaCare MagnaCare Commercial 0.04 4251.00 0.04 98252.70 0.04 Case Rate 60240 Priced Explore parathyroid glands 554063 60500 CPT Outpatient 150495.45 25835.05 MagnaCare MagnaCare Commercial 0.03 4251.00 0.03 150495.45 0.03 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 554063 62322 CPT Outpatient 43709.40 514.24 MagnaCare MagnaCare Commercial 0.10 4251.00 0.10 43709.40 0.10 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 554063 62323 CPT Outpatient 8304.45 467.31 MagnaCare MagnaCare Commercial 0.51 4251.00 0.51 8304.45 0.51 Case Rate 62323 Priced Low back disk surgery 554063 63030 CPT Outpatient 50287.65 8632.71 MagnaCare MagnaCare Commercial 0.08 4251.00 0.08 50287.65 0.08 Case Rate 63030 Priced Inc for vagus n elect impl 554063 64568 CPT Outpatient 124562.55 21383.24 MagnaCare MagnaCare Commercial 0.03 4251.00 0.03 124562.55 0.03 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 554063 66821 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 554063 66984 CPT Outpatient 0.01 0.01 MagnaCare MagnaCare Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 580063 216 DRG Inpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 580063 460 DRG Inpatient 416122.79 53834.63 Multiplan Multiplan Commercial 0.73 302345.76 0.73 416122.79 0.73 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 580063 470 DRG Inpatient 167912.19 21723.13 Multiplan Multiplan Commercial 0.36 59993.60 0.36 167912.19 0.36 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 580063 473 DRG Inpatient 100687.91 13026.19 Multiplan Multiplan Commercial 0.60 60104.00 0.60 100687.91 0.60 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 580063 743 DRG Inpatient 102691.67 13285.42 Multiplan Multiplan Commercial 0.74 75825.60 0.74 102691.67 0.74 Case Rate 743 Priced NORMAL NEWBORN 580063 795 DRG Inpatient 6266.93 2335.00 Multiplan Multiplan Commercial 0.77 4820.00 0.77 6266.93 0.77 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 580063 807 DRG Inpatient 116469.59 4193.00 Multiplan Multiplan Commercial 0.35 41084.80 0.35 116469.59 0.35 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 580063 788 DRG Inpatient 76050.77 4538.00 Multiplan Multiplan Commercial 0.72 54756.00 0.72 76050.77 0.72 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 580063 59400 CPT Inpatient 116469.59 4193.00 Multiplan Multiplan Commercial 0.35 41084.80 0.35 116469.59 0.35 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 580063 59510 CPT Inpatient 76050.77 4538.00 Multiplan Multiplan Commercial 0.72 54756.00 0.72 76050.77 0.72 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 580063 59610 CPT Inpatient 116469.59 4193.00 Multiplan Multiplan Commercial 0.35 41084.80 0.35 116469.59 0.35 Case Rate 59610 Priced "Psychotherapy, 30 min" 580063 90832 CPT Outpatient 577.50 91.21 Multiplan Multiplan Commercial 0.76 440.00 0.76 577.50 0.76 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 580063 90834 CPT Outpatient 44134.65 271.96 Multiplan Multiplan Commercial 0.73 32024.80 0.73 44134.65 0.73 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 580063 90837 CPT Outpatient 2240.70 442.93 Multiplan Multiplan Commercial 0.15 328.00 0.15 2240.70 0.15 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 580063 90846 CPT Outpatient 0.01 131.50 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 580063 90847 CPT Outpatient 44134.65 369.97 Multiplan Multiplan Commercial 0.73 32024.80 0.73 44134.65 0.73 Fee Schedule 90847 Priced Group psychotherapy 580063 90853 CPT Outpatient 44134.65 101.99 Multiplan Multiplan Commercial 0.73 32024.80 0.73 44134.65 0.73 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 580063 99203 CPT Outpatient 3480.75 176.07 Multiplan Multiplan Commercial 0.73 2525.60 0.73 3480.75 0.73 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 580063 99204 CPT Outpatient 2103.15 233.39 Multiplan Multiplan Commercial 0.73 1525.60 0.73 2103.15 0.73 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 580063 99205 CPT Outpatient 4970.70 314.28 Multiplan Multiplan Commercial 0.36 1803.20 0.36 4970.70 0.36 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 580063 99243 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 580063 99244 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 580063 99385 CPT Outpatient 1114.05 185.90 Multiplan Multiplan Commercial 0.73 808.00 0.73 1114.05 0.73 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 580063 99386 CPT Outpatient 4877.25 185.90 Multiplan Multiplan Commercial 0.73 3538.40 0.73 4877.25 0.73 Fee Schedule 99386 Priced Routine venipuncture 580063 36415 CPT Outpatient 127.05 19.57 Multiplan Multiplan Commercial 0.76 96.80 0.76 127.05 0.76 Fee Schedule 36415 Priced Basic Metabolic Panel 580063 80048 CPT Outpatient 576.45 88.78 Multiplan Multiplan Commercial 0.76 439.20 0.76 576.45 0.76 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 580063 80053 CPT Outpatient 763.35 117.56 Multiplan Multiplan Commercial 0.76 581.60 0.76 763.35 0.76 Fee Schedule 80053 Priced Obstetric blood test panel 580063 80055 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 580063 80061 CPT Outpatient 1349.25 197.77 Multiplan Multiplan Commercial 0.73 978.40 0.73 1349.25 0.73 Fee Schedule 80061 Priced Kidney function panel test 580063 80069 CPT Outpatient 716.10 104.95 Multiplan Multiplan Commercial 0.73 519.20 0.73 716.10 0.73 Fee Schedule 80069 Priced Liver function panel test 580063 80076 CPT Outpatient 716.10 104.95 Multiplan Multiplan Commercial 0.73 519.20 0.73 716.10 0.73 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 580063 81000 CPT Outpatient 144.90 21.18 Multiplan Multiplan Commercial 0.72 104.80 0.72 144.90 0.72 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 580063 81001 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 580063 81002 CPT Outpatient 57.75 8.89 Multiplan Multiplan Commercial 0.76 44.00 0.76 57.75 0.76 Fee Schedule 81002 Priced Automated urinalysis test 580063 81003 CPT Outpatient 219.45 33.80 Multiplan Multiplan Commercial 0.76 167.20 0.76 219.45 0.76 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 580063 82306 CPT Outpatient 1880.55 289.62 Multiplan Multiplan Commercial 0.76 1432.80 0.76 1880.55 0.76 Fee Schedule 82306 Priced Glycosylated hemoglobin test 580063 83036 CPT Outpatient 494.55 76.17 Multiplan Multiplan Commercial 0.76 376.80 0.76 494.55 0.76 Fee Schedule 83036 Priced PSA (prostate specific antigen) 580063 84153 CPT Outpatient 1177.05 181.28 Multiplan Multiplan Commercial 0.76 896.80 0.76 1177.05 0.76 Fee Schedule 84153 Priced PSA (prostate specific antigen) 580063 84154 CPT Outpatient 598.50 92.17 Multiplan Multiplan Commercial 0.76 456.00 0.76 598.50 0.76 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 580063 84443 CPT Outpatient 519.75 80.05 Multiplan Multiplan Commercial 0.76 396.00 0.76 519.75 0.76 Fee Schedule 84443 Priced Chorionic gonadotropin assay 580063 84703 CPT Outpatient 785.40 120.96 Multiplan Multiplan Commercial 0.76 598.40 0.76 785.40 0.76 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 580063 85025 CPT Outpatient 635.25 97.83 Multiplan Multiplan Commercial 0.76 484.00 0.76 635.25 0.76 Fee Schedule 85025 Priced "Complete blood count, automated" 580063 85027 CPT Outpatient 576.45 88.78 Multiplan Multiplan Commercial 0.76 439.20 0.76 576.45 0.76 Fee Schedule 85027 Priced "Blood test, clotting time" 580063 85610 CPT Outpatient 404.25 62.26 Multiplan Multiplan Commercial 0.76 308.00 0.76 404.25 0.76 Fee Schedule 85610 Priced Coagulation assessment blood test 580063 85730 CPT Outpatient 17.22 2.65 Multiplan Multiplan Commercial 0.76 13.12 0.76 17.22 0.76 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 580063 86003 CPT Outpatient 32.55 5.01 Multiplan Multiplan Commercial 0.76 24.80 0.76 32.55 0.76 Fee Schedule 86003 Priced Tb test cell immun measure 580063 86480 CPT Outpatient 530.25 81.66 Multiplan Multiplan Commercial 0.76 404.00 0.76 530.25 0.76 Fee Schedule 86480 Priced Urine culture/colony count 580063 87086 CPT Outpatient 763.35 117.56 Multiplan Multiplan Commercial 0.76 581.60 0.76 763.35 0.76 Fee Schedule 87086 Priced Hpylori stool ia 580063 87338 CPT Outpatient 785.40 120.96 Multiplan Multiplan Commercial 0.76 598.40 0.76 785.40 0.76 Fee Schedule 87338 Priced Cytopath eval fna report 580063 88173 CPT Outpatient 750.75 115.62 Multiplan Multiplan Commercial 0.76 572.00 0.76 750.75 0.76 Fee Schedule 88173 Priced Tissue exam by pathologist 580063 88302 CPT Outpatient 635.25 97.83 Multiplan Multiplan Commercial 0.76 484.00 0.76 635.25 0.76 Fee Schedule 88302 Priced Tissue exam by pathologist 580063 88305 CPT Outpatient 323.40 49.81 Multiplan Multiplan Commercial 0.76 246.40 0.76 323.40 0.76 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 580063 11042 CPT Outpatient 2668.05 481.45 Multiplan Multiplan Commercial 0.73 1936.00 0.73 2668.05 0.73 Case Rate 11042 Priced Deb subq tissue add-on 580063 11045 CPT Outpatient 4652.55 330.00 Multiplan Multiplan Commercial 0.73 3376.00 0.73 4652.55 0.73 Case Rate 11045 Priced Dx bronchoscope/lavage 580063 31624 CPT Outpatient 41223.00 7602.31 Multiplan Multiplan Commercial 0.74 30468.00 0.74 41223.00 0.74 Case Rate 31624 Priced Bronchoscopy/lung bx each 580063 31628 CPT Outpatient 49048.65 9045.51 Multiplan Multiplan Commercial 0.74 36323.20 0.74 49048.65 0.74 Case Rate 31628 Priced Blood transfusion service 580063 36430 CPT Outpatient 9166.50 574.93 Multiplan Multiplan Commercial 0.73 6651.20 0.73 9166.50 0.73 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 580063 43235 CPT Outpatient 8856.75 1633.35 Multiplan Multiplan Commercial 0.73 6451.20 0.73 8856.75 0.73 Case Rate 43235 Priced Endoscopic us exam esoph 580063 43237 CPT Outpatient 23867.55 4401.63 Multiplan Multiplan Commercial 0.73 17349.60 0.73 23867.55 0.73 Case Rate 43237 Priced Egd us fine needle bx/aspir 580063 43238 CPT Outpatient 30690.45 5659.90 Multiplan Multiplan Commercial 0.69 21247.20 0.69 30690.45 0.69 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 580063 43239 CPT Outpatient 40191.90 7412.15 Multiplan Multiplan Commercial 0.83 33264.80 0.83 40191.90 0.83 Case Rate 43239 Priced Ercp remove duct calculi 580063 43264 CPT Outpatient 34335.00 6332.03 Multiplan Multiplan Commercial 0.73 25020.00 0.73 34335.00 0.73 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 580063 45378 CPT Outpatient 13991.25 889.35 Multiplan Multiplan Commercial 0.73 10170.40 0.73 13991.25 0.73 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 580063 45380 CPT Outpatient 22215.90 4097.04 Multiplan Multiplan Commercial 0.73 16156.00 0.73 22215.90 0.73 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 580063 45385 CPT Outpatient 119569.80 22050.95 Multiplan Multiplan Commercial 0.24 28964.80 0.24 119569.80 0.24 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 580063 45391 CPT Outpatient 24923.85 4596.43 Multiplan Multiplan Commercial 0.73 18121.60 0.73 24923.85 0.73 Case Rate 45391 Priced Fragmenting of kidney stone 580063 50590 CPT Outpatient 40930.05 7548.28 Multiplan Multiplan Commercial 0.73 29807.20 0.73 40930.05 0.73 Case Rate 50590 Priced Fetal non-stress test 580063 59025 CPT Outpatient 3153.15 477.76 Multiplan Multiplan Commercial 0.73 2288.00 0.73 3153.15 0.73 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 580063 64483 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 580063 92567 CPT Outpatient 2224.95 98.50 Multiplan Multiplan Commercial 0.73 1614.40 0.73 2224.95 0.73 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 580063 93000 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 580063 93017 CPT Outpatient 3076.50 532.96 Multiplan Multiplan Commercial 0.73 2232.00 0.73 3076.50 0.73 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 580063 93452 CPT Outpatient 55621.65 8611.87 Multiplan Multiplan Commercial 0.73 40535.20 0.73 55621.65 0.73 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 580063 95810 CPT Outpatient 20341.65 3373.48 Multiplan Multiplan Commercial 0.73 14760.00 0.73 20341.65 0.73 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 580063 95811 CPT Outpatient 22491.00 3731.18 Multiplan Multiplan Commercial 0.73 16320.00 0.73 22491.00 0.73 Case Rate 95811 Priced Eeg 41-60 minutes 580063 95812 CPT Outpatient 5578.65 925.83 Multiplan Multiplan Commercial 0.73 4048.00 0.73 5578.65 0.73 Case Rate 95812 Priced Genetic counseling 30 min 580063 96040 CPT Outpatient 0.01 102.81 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 580063 96413 CPT Outpatient 4856.25 472.45 Multiplan Multiplan Commercial 3.02 14665.60 3.02 4856.25 3.02 Case Rate 96413 Priced Ultrasound therapy 580063 97035 CPT Outpatient 2111.55 134.99 Multiplan Multiplan Commercial 0.73 1532.00 0.73 2111.55 0.73 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 580063 97110 CPT Outpatient 6494.25 92.86 Multiplan Multiplan Commercial 0.73 4712.00 0.73 6494.25 0.73 Case Rate 97110 Priced Gait training therapy 580063 97116 CPT Outpatient 4723.95 110.61 Multiplan Multiplan Commercial 0.73 3427.20 0.73 4723.95 0.73 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 580063 70450 CPT Outpatient 8566.95 835.61 Multiplan Multiplan Commercial 0.73 6216.00 0.73 8566.95 0.73 Case Rate 70450 Priced Mri brain stem w/o dye 580063 70551 CPT Outpatient 7861.35 1361.31 Multiplan Multiplan Commercial 0.73 5704.00 0.73 7861.35 0.73 Case Rate 70551 Priced MRI scan of brain before and after contrast 580063 70553 CPT Outpatient 10882.20 1625.88 Multiplan Multiplan Commercial 0.73 7896.00 0.73 10882.20 0.73 Case Rate 70553 Priced X-ray exam chest 2 views 580063 71046 CPT Outpatient 859.95 150.37 Multiplan Multiplan Commercial 0.73 624.00 0.73 859.95 0.73 Case Rate 71046 Priced Ct thorax w/o dye 580063 71250 CPT Outpatient 7288.05 1261.63 Multiplan Multiplan Commercial 0.73 5288.00 0.73 7288.05 0.73 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 580063 72082 CPT Outpatient 2022.30 253.33 Multiplan Multiplan Commercial 0.86 1744.80 0.86 2022.30 0.86 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 580063 72100 CPT Outpatient 1599.15 277.38 Multiplan Multiplan Commercial 0.73 1160.00 0.73 1599.15 0.73 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 580063 72110 CPT Outpatient 1389.15 241.04 Multiplan Multiplan Commercial 0.73 1008.00 0.73 1389.15 0.73 Case Rate 72110 Priced MRI scan of lower spinal canal 580063 72148 CPT Outpatient 7861.35 1361.31 Multiplan Multiplan Commercial 0.73 5704.00 0.73 7861.35 0.73 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 580063 72193 CPT Outpatient 13671.00 1412.01 Multiplan Multiplan Commercial 0.73 9920.00 0.73 13671.00 0.73 Case Rate 72193 Priced X-ray exam of shoulder 580063 73030 CPT Outpatient 1452.15 251.43 Multiplan Multiplan Commercial 0.73 1053.60 0.73 1452.15 0.73 Case Rate 73030 Priced X-ray exam of elbow 580063 73080 CPT Outpatient 1356.60 235.68 Multiplan Multiplan Commercial 0.73 984.00 0.73 1356.60 0.73 Case Rate 73080 Priced X-ray exam of forearm 580063 73090 CPT Outpatient 1243.20 215.26 Multiplan Multiplan Commercial 0.73 901.60 0.73 1243.20 0.73 Case Rate 73090 Priced X-ray exam of wrist 580063 73110 CPT Outpatient 1243.20 215.26 Multiplan Multiplan Commercial 0.73 901.60 0.73 1243.20 0.73 Case Rate 73110 Priced X-ray exam of hand 580063 73130 CPT Outpatient 1243.20 215.26 Multiplan Multiplan Commercial 0.73 901.60 0.73 1243.20 0.73 Case Rate 73130 Priced X-ray exam hips bi 2 views 580063 73521 CPT Outpatient 970.20 228.41 Multiplan Multiplan Commercial 0.98 952.00 0.98 970.20 0.98 Case Rate 73521 Priced X-ray exam of knee 3 580063 73562 CPT Outpatient 802.20 139.12 Multiplan Multiplan Commercial 0.73 581.60 0.73 802.20 0.73 Case Rate 73562 Priced X-ray exam of lower leg 580063 73590 CPT Outpatient 1243.20 215.26 Multiplan Multiplan Commercial 0.73 901.60 0.73 1243.20 0.73 Case Rate 73590 Priced X-ray exam of ankle 580063 73610 CPT Outpatient 1378.65 239.31 Multiplan Multiplan Commercial 0.73 1000.00 0.73 1378.65 0.73 Case Rate 73610 Priced X-ray exam of foot 580063 73630 CPT Outpatient 975.45 169.41 Multiplan Multiplan Commercial 0.72 707.20 0.72 975.45 0.72 Case Rate 73630 Priced MRI scan of leg joint 580063 73721 CPT Outpatient 7861.35 1361.31 Multiplan Multiplan Commercial 0.73 5704.00 0.73 7861.35 0.73 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 580063 74177 CPT Outpatient 14222.25 1412.01 Multiplan Multiplan Commercial 0.73 10320.00 0.73 14222.25 0.73 Case Rate 74177 Priced Contrst x-ray exam of throat 580063 74210 CPT Outpatient 0.01 440.39 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 580063 76098 CPT Outpatient 6141.45 407.86 Multiplan Multiplan Commercial 0.73 4456.00 0.73 6141.45 0.73 Case Rate 76098 Priced Us exam of head and neck 580063 76536 CPT Outpatient 5512.50 955.18 Multiplan Multiplan Commercial 0.73 4000.00 0.73 5512.50 0.73 Case Rate 76536 Priced Ultrasound breast limited 580063 76642 CPT Outpatient 5777.10 127.70 Multiplan Multiplan Commercial 0.73 4192.00 0.73 5777.10 0.73 Case Rate 76642 Priced Ultrasound of abdomen 580063 76700 CPT Outpatient 4917.15 851.88 Multiplan Multiplan Commercial 0.73 3568.00 0.73 4917.15 0.73 Case Rate 76700 Priced Echo exam of abdomen 580063 76705 CPT Outpatient 3836.70 665.17 Multiplan Multiplan Commercial 0.73 2784.00 0.73 3836.70 0.73 Case Rate 76705 Priced Us exam abdo back wall comp 580063 76770 CPT Outpatient 5171.25 895.48 Multiplan Multiplan Commercial 0.73 3752.00 0.73 5171.25 0.73 Case Rate 76770 Priced Us exam abdo back wall lim 580063 76775 CPT Outpatient 3969.00 686.97 Multiplan Multiplan Commercial 0.73 2880.00 0.73 3969.00 0.73 Case Rate 76775 Priced Ob us < 14 wks single fetus 580063 76801 CPT Outpatient 2006.55 347.98 Multiplan Multiplan Commercial 0.73 1456.00 0.73 2006.55 0.73 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 580063 76805 CPT Outpatient 3969.00 686.97 Multiplan Multiplan Commercial 0.73 2880.00 0.73 3969.00 0.73 Case Rate 76805 Priced Ob us detailed sngl fetus 580063 76811 CPT Outpatient 2844.45 492.99 Multiplan Multiplan Commercial 0.73 2064.00 0.73 2844.45 0.73 Case Rate 76811 Priced Ob us nuchal meas 1 gest 580063 76813 CPT Outpatient 1044.75 180.83 Multiplan Multiplan Commercial 0.73 757.60 0.73 1044.75 0.73 Case Rate 76813 Priced Ob us limited fetus(s) 580063 76815 CPT Outpatient 6428.10 639.90 Multiplan Multiplan Commercial 0.73 4664.00 0.73 6428.10 0.73 Case Rate 76815 Priced Ob us follow-up per fetus 580063 76816 CPT Outpatient 4818.45 833.88 Multiplan Multiplan Commercial 0.73 3496.00 0.73 4818.45 0.73 Case Rate 76816 Priced Transvaginal us obstetric 580063 76817 CPT Outpatient 6428.10 476.73 Multiplan Multiplan Commercial 0.73 4664.00 0.73 6428.10 0.73 Case Rate 76817 Priced Fetal biophys profil w/o nst 580063 76819 CPT Outpatient 1741.95 302.65 Multiplan Multiplan Commercial 0.73 1264.00 0.73 1741.95 0.73 Case Rate 76819 Priced Ultrasound pelvis through vagina 580063 76830 CPT Outpatient 9305.10 806.54 Multiplan Multiplan Commercial 0.73 6752.00 0.73 9305.10 0.73 Case Rate 76830 Priced Us exam scrotum 580063 76870 CPT Outpatient 6328.35 1096.55 Multiplan Multiplan Commercial 0.73 4592.00 0.73 6328.35 0.73 Case Rate 76870 Priced Us exam infant hips dynamic 580063 76885 CPT Outpatient 3836.70 665.17 Multiplan Multiplan Commercial 0.73 2784.00 0.73 3836.70 0.73 Case Rate 76885 Priced Mammography of one breast 580063 77065 CPT Outpatient 3451.35 192.07 Multiplan Multiplan Commercial 0.73 2504.00 0.73 3451.35 0.73 Case Rate 77065 Priced Mammography of both breasts 580063 77066 CPT Outpatient 5777.10 235.68 Multiplan Multiplan Commercial 0.73 4192.00 0.73 5777.10 0.73 Case Rate 77066 Priced "Mamography, screening bilateral" 580063 77067 CPT Outpatient 1416.45 205.57 Multiplan Multiplan Commercial 0.73 1027.20 0.73 1416.45 0.73 Case Rate 77067 Priced X-rays for bone age 580063 77072 CPT Outpatient 2022.30 163.87 Multiplan Multiplan Commercial 0.86 1744.80 0.86 2022.30 0.86 Case Rate 77072 Priced Joint survey single view 580063 77077 CPT Outpatient 985.95 171.14 Multiplan Multiplan Commercial 0.73 715.20 0.73 985.95 0.73 Case Rate 77077 Priced Dxa bone density axial 580063 77080 CPT Outpatient 3257.10 319.09 Multiplan Multiplan Commercial 0.73 2363.20 0.73 3257.10 0.73 Case Rate 77080 Priced Fna bx w/us gdn 1st les 580063 10005 CPT Outpatient 5512.50 547.24 Multiplan Multiplan Commercial 0.73 4000.00 0.73 5512.50 0.73 Case Rate 10005 Priced Fna bx w/us gdn ea addl 580063 10006 CPT Outpatient 10628.10 594.83 Multiplan Multiplan Commercial 0.73 7712.00 0.73 10628.10 0.73 Case Rate 10006 Priced Drainage of hematoma/fluid 580063 10140 CPT Outpatient 23209.20 1081.95 Multiplan Multiplan Commercial 0.63 14685.60 0.63 23209.20 0.63 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 580063 11042 CPT Outpatient 2668.05 481.45 Multiplan Multiplan Commercial 0.73 1936.00 0.73 2668.05 0.73 Case Rate 11042 Priced Deb bone 20 sq cm/< 580063 11044 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 580063 11406 CPT Outpatient 19967.85 3427.81 Multiplan Multiplan Commercial 0.72 14459.20 0.72 19967.85 0.72 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 580063 11424 CPT Outpatient 0.01 1004.93 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 580063 11770 CPT Outpatient 19173.00 3291.37 Multiplan Multiplan Commercial 0.72 13824.80 0.72 19173.00 0.72 Case Rate 11770 Priced Replace tissue expander 580063 11970 CPT Outpatient 59239.95 10169.52 Multiplan Multiplan Commercial 0.75 44358.40 0.75 59239.95 0.75 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 580063 14020 CPT Outpatient 32166.75 5521.96 Multiplan Multiplan Commercial 0.73 23400.00 0.73 32166.75 0.73 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 580063 14060 CPT Outpatient 25993.80 1374.69 Multiplan Multiplan Commercial 0.73 18993.60 0.73 25993.80 0.73 Case Rate 14060 Priced Wound prep trk/arm/leg 580063 15002 CPT Outpatient 41748.00 1441.73 Multiplan Multiplan Commercial 0.76 31731.20 0.76 41748.00 0.76 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 580063 15271 CPT Outpatient 24343.20 3769.48 Multiplan Multiplan Commercial 0.70 17104.00 0.70 24343.20 0.70 Case Rate 15271 Priced Acellular derm matrix implt 580063 15777 CPT Outpatient 101672.55 17453.79 Multiplan Multiplan Commercial 0.89 90915.20 0.89 101672.55 0.89 Case Rate 15777 Priced Exc skin abd 580063 15830 CPT Outpatient 54696.60 9389.58 Multiplan Multiplan Commercial 0.56 30644.80 0.56 54696.60 0.56 Case Rate 15830 Priced Dressing change not for burn 580063 15852 CPT Outpatient 0.01 290.74 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 580063 15877 CPT Outpatient 63741.30 10942.26 Multiplan Multiplan Commercial 0.75 47703.20 0.75 63741.30 0.75 Case Rate 15877 Priced Suction lipectomy lwr extrem 580063 15879 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 580063 19000 CPT Outpatient 10143.00 594.83 Multiplan Multiplan Commercial 0.73 7360.00 0.73 10143.00 0.73 Case Rate 19000 Priced Bx breast 1st lesion strtctc 580063 19081 CPT Outpatient 12341.70 1250.69 Multiplan Multiplan Commercial 0.73 8955.20 0.73 12341.70 0.73 Case Rate 19081 Priced Bx breast add lesion us imag 580063 19084 CPT Outpatient 29058.75 547.24 Multiplan Multiplan Commercial 0.73 21085.60 0.73 29058.75 0.73 Case Rate 19084 Priced Biopsy of breast open 580063 19101 CPT Outpatient 39545.10 2737.82 Multiplan Multiplan Commercial 0.67 26493.60 0.67 39545.10 0.67 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 580063 19120 CPT Outpatient 35761.95 2737.82 Multiplan Multiplan Commercial 0.80 28502.40 0.80 35761.95 0.80 Case Rate 19120 Priced Excision breast lesion 580063 19125 CPT Outpatient 33184.20 0.01 Multiplan Multiplan Commercial 0.69 22894.72 0.69 33184.20 0.69 Case Rate 19125 Priced Perq device breast 1st imag 580063 19281 CPT Outpatient 6141.45 598.61 Multiplan Multiplan Commercial 0.73 4456.00 0.73 6141.45 0.73 Case Rate 19281 Priced Perq device breast ea imag 580063 19282 CPT Outpatient 8379.00 319.04 Multiplan Multiplan Commercial 0.73 6080.00 0.73 8379.00 0.73 Case Rate 19282 Priced Partial mastectomy 580063 19301 CPT Outpatient 39157.65 6722.06 Multiplan Multiplan Commercial 0.74 29044.96 0.74 39157.65 0.74 Case Rate 19301 Priced Mast simple complete 580063 19303 CPT Outpatient 105389.55 18091.87 Multiplan Multiplan Commercial 0.75 79020.00 0.75 105389.55 0.75 Case Rate 19303 Priced Reduction of large breast 580063 19318 CPT Outpatient 65239.65 11199.47 Multiplan Multiplan Commercial 0.75 48768.80 0.75 65239.65 0.75 Case Rate 19318 Priced Immediate breast prosthesis 580063 19340 CPT Outpatient 113100.75 19415.63 Multiplan Multiplan Commercial 0.74 84019.20 0.74 113100.75 0.74 Case Rate 19340 Priced Delayed breast prosthesis 580063 19342 CPT Outpatient 56988.75 9783.07 Multiplan Multiplan Commercial 0.76 43116.00 0.76 56988.75 0.76 Case Rate 19342 Priced Breast reconstruction 580063 19357 CPT Outpatient 101672.55 17453.79 Multiplan Multiplan Commercial 0.89 90915.20 0.89 101672.55 0.89 Case Rate 19357 Priced Breast reconstruction 580063 19366 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 580063 19380 CPT Outpatient 61493.25 10556.34 Multiplan Multiplan Commercial 0.75 46164.00 0.75 61493.25 0.75 Case Rate 19380 Priced Removal of support implant 580063 20680 CPT Outpatient 42329.70 7266.60 Multiplan Multiplan Commercial 0.73 30856.00 0.73 42329.70 0.73 Case Rate 20680 Priced Cerv artific diskectomy 580063 22856 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 580063 24538 CPT Outpatient 51237.90 4775.24 Multiplan Multiplan Commercial 0.55 28108.00 0.55 51237.90 0.55 Case Rate 24538 Priced Remove wrist tendon lesion 580063 25111 CPT Outpatient 25855.20 4438.48 Multiplan Multiplan Commercial 0.73 18876.16 0.73 25855.20 0.73 Case Rate 25111 Priced Incise finger tendon sheath 580063 26055 CPT Outpatient 15862.35 2723.04 Multiplan Multiplan Commercial 0.73 11593.60 0.73 15862.35 0.73 Case Rate 26055 Priced Treat finger fracture each 580063 26727 CPT Outpatient 22779.75 2030.47 Multiplan Multiplan Commercial 0.73 16573.60 0.73 22779.75 0.73 Case Rate 26727 Priced Revision of knee joint 580063 27446 CPT Outpatient 67882.50 11653.16 Multiplan Multiplan Commercial 0.75 51087.20 0.75 67882.50 0.75 Case Rate 27446 Priced Total knee arthroplasty 580063 27447 CPT Outpatient 130698.75 22436.62 Multiplan Multiplan Commercial 0.50 65851.36 0.50 130698.75 0.50 Case Rate 27447 Priced Surgery to stop leg growth 580063 27485 CPT Outpatient 43310.40 7434.95 Multiplan Multiplan Commercial 0.71 30613.68 0.71 43310.40 0.71 Case Rate 27485 Priced Repair achilles tendon 580063 27650 CPT Outpatient 38246.25 3762.57 Multiplan Multiplan Commercial 0.70 26630.40 0.70 38246.25 0.70 Case Rate 27650 Priced Treatment of ankle fracture 580063 27792 CPT Outpatient 36101.10 6197.36 Multiplan Multiplan Commercial 0.73 26409.60 0.73 36101.10 0.73 Case Rate 27792 Priced Treatment of ankle fracture 580063 27814 CPT Outpatient 49405.65 8481.30 Multiplan Multiplan Commercial 0.69 33854.40 0.69 49405.65 0.69 Case Rate 27814 Priced Removal of foot lesion 580063 28080 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 580063 28285 CPT Outpatient 68603.85 11776.99 Multiplan Multiplan Commercial 0.67 46293.60 0.67 68603.85 0.67 Case Rate 28285 Priced Correction hallux valgus 580063 28296 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 580063 29823 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 580063 29826 CPT Outpatient 49840.35 8555.93 Multiplan Multiplan Commercial 0.74 36651.20 0.74 49840.35 0.74 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 580063 29881 CPT Outpatient 35556.15 6103.81 Multiplan Multiplan Commercial 0.73 25970.40 0.73 35556.15 0.73 Case Rate 29881 Priced Knee arthroscopy/surgery 580063 29882 CPT Outpatient 61099.50 10488.75 Multiplan Multiplan Commercial 0.74 45392.80 0.74 61099.50 0.74 Case Rate 29882 Priced Percut bx lung/mediastinum 580063 32405 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 580063 32555 CPT Outpatient 14597.10 687.29 Multiplan Multiplan Commercial 0.64 9397.60 0.64 14597.10 0.64 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 580063 32664 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 580063 35190 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 580063 36478 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 580063 36561 CPT Outpatient 53531.10 3292.99 Multiplan Multiplan Commercial 0.38 20264.00 0.38 53531.10 0.38 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 580063 36569 CPT Outpatient 31421.25 1299.06 Multiplan Multiplan Commercial 0.73 22824.80 0.73 31421.25 0.73 Case Rate 36569 Priced Removal tunneled cv cath 580063 36590 CPT Outpatient 1996.05 273.95 Multiplan Multiplan Commercial 0.73 1454.40 0.73 1996.05 0.73 Case Rate 36590 Priced Av fuse uppr arm basilic 580063 36819 CPT Outpatient 56861.70 9761.26 Multiplan Multiplan Commercial 0.75 42368.80 0.75 56861.70 0.75 Case Rate 36819 Priced Av fusion direct any site 580063 36821 CPT Outpatient 42953.40 7373.67 Multiplan Multiplan Commercial 0.73 31253.60 0.73 42953.40 0.73 Case Rate 36821 Priced Artery-vein autograft 580063 36825 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 580063 36830 CPT Outpatient 53656.05 9210.96 Multiplan Multiplan Commercial 0.81 43248.00 0.81 53656.05 0.81 Case Rate 36830 Priced Av fistula revision open 580063 36832 CPT Outpatient 52492.65 9011.24 Multiplan Multiplan Commercial 0.73 38459.20 0.73 52492.65 0.73 Case Rate 36832 Priced Av fistula revision 580063 36833 CPT Outpatient 37098.60 6368.59 Multiplan Multiplan Commercial 0.73 27032.00 0.73 37098.60 0.73 Case Rate 36833 Priced Intro cath dialysis circuit 580063 36903 CPT Outpatient 77541.45 10669.90 Multiplan Multiplan Commercial 0.71 54859.20 0.71 77541.45 0.71 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 580063 36906 CPT Outpatient 96694.50 16175.64 Multiplan Multiplan Commercial 0.71 68968.80 0.71 96694.50 0.71 Case Rate 36906 Priced Fem/popl revas w/tla 580063 37224 CPT Outpatient 200076.45 5139.31 Multiplan Multiplan Commercial 0.73 145588.80 0.73 200076.45 0.73 Case Rate 37224 Priced Fem/popl revasc stnt & ather 580063 37227 CPT Outpatient 117170.55 18045.38 Multiplan Multiplan Commercial 0.76 89272.80 0.76 117170.55 0.76 Case Rate 37227 Priced Revise leg vein 580063 37700 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 580063 37722 CPT Outpatient 27815.55 4775.00 Multiplan Multiplan Commercial 0.73 20335.20 0.73 27815.55 0.73 Case Rate 37722 Priced Stab phleb veins xtr 10-20 580063 37765 CPT Outpatient 26561.85 4559.78 Multiplan Multiplan Commercial 0.73 19334.40 0.73 26561.85 0.73 Case Rate 37765 Priced Biopsy/removal lymph nodes 580063 38500 CPT Outpatient 35955.15 6172.30 Multiplan Multiplan Commercial 0.74 26549.60 0.74 35955.15 0.74 Case Rate 38500 Priced Biopsy/removal lymph nodes 580063 38525 CPT Outpatient 101194.80 17371.77 Multiplan Multiplan Commercial 0.75 76016.80 0.75 101194.80 0.75 Case Rate 38525 Priced Laparoscopy lymph node biop 580063 38570 CPT Outpatient 65631.30 11266.71 Multiplan Multiplan Commercial 0.76 49751.20 0.76 65631.30 0.76 Case Rate 38570 Priced Laparoscopy lymphadenectomy 580063 38571 CPT Outpatient 84031.50 14425.41 Multiplan Multiplan Commercial 0.74 61777.60 0.74 84031.50 0.74 Case Rate 38571 Priced Laparoscopy lymphadenectomy 580063 38572 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 580063 38792 CPT Outpatient 2868.60 432.48 Multiplan Multiplan Commercial 0.73 2080.80 0.73 2868.60 0.73 Case Rate 38792 Priced Excision of gum lesion 580063 41825 CPT Outpatient 11580.45 1987.98 Multiplan Multiplan Commercial 0.73 8502.40 0.73 11580.45 0.73 Case Rate 41825 Priced Reconstruct cleft palate 580063 42200 CPT Outpatient 36703.80 6300.82 Multiplan Multiplan Commercial 0.72 26558.61 0.72 36703.80 0.72 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 580063 42820 CPT Outpatient 17232.60 2958.26 Multiplan Multiplan Commercial 0.74 12800.80 0.74 17232.60 0.74 Case Rate 42820 Priced Control throat bleeding 580063 42960 CPT Outpatient 24066.00 4131.33 Multiplan Multiplan Commercial 0.74 17739.20 0.74 24066.00 0.74 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 580063 43235 CPT Outpatient 8856.75 1633.35 Multiplan Multiplan Commercial 0.73 6451.20 0.73 8856.75 0.73 Case Rate 43235 Priced Laparoscopy fundoplasty 580063 43280 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 580063 43282 CPT Outpatient 84344.40 14479.12 Multiplan Multiplan Commercial 0.76 64040.80 0.76 84344.40 0.76 Case Rate 43282 Priced Laparoscopy appendectomy 580063 44970 CPT Outpatient 82300.05 14128.18 Multiplan Multiplan Commercial 0.42 34807.60 0.42 82300.05 0.42 Case Rate 44970 Priced Diagnostic sigmoidoscopy 580063 45330 CPT Outpatient 17286.15 542.26 Multiplan Multiplan Commercial 0.73 12564.00 0.73 17286.15 0.73 Case Rate 45330 Priced Needle biopsy of liver 580063 47000 CPT Outpatient 10398.15 1225.34 Multiplan Multiplan Commercial 0.73 7544.80 0.73 10398.15 0.73 Case Rate 47000 Priced Removal of gallbladder using an endoscope 580063 47562 CPT Outpatient 58430.40 10030.55 Multiplan Multiplan Commercial 0.37 21365.60 0.37 58430.40 0.37 Case Rate 47562 Priced Laparo cholecystectomy/graph 580063 47563 CPT Outpatient 71747.55 12316.66 Multiplan Multiplan Commercial 0.63 45498.40 0.63 71747.55 0.63 Case Rate 47563 Priced Abd paracentesis w/imaging 580063 49083 CPT Outpatient 6979.35 1113.95 Multiplan Multiplan Commercial 0.73 5064.00 0.73 6979.35 0.73 Case Rate 49083 Priced Diag laparo separate proc 580063 49320 CPT Outpatient 31629.15 5429.67 Multiplan Multiplan Commercial 0.73 23122.40 0.73 31629.15 0.73 Case Rate 49320 Priced Laparoscopy biopsy 580063 49321 CPT Outpatient 41892.90 7191.61 Multiplan Multiplan Commercial 0.73 30428.80 0.73 41892.90 0.73 Case Rate 49321 Priced Laparoscopy aspiration 580063 49322 CPT Outpatient 34392.75 5904.09 Multiplan Multiplan Commercial 0.73 25087.20 0.73 34392.75 0.73 Case Rate 49322 Priced Lap insert tunnel ip cath 580063 49324 CPT Outpatient 39264.75 6740.45 Multiplan Multiplan Commercial 0.73 28704.00 0.73 39264.75 0.73 Case Rate 49324 Priced Laparo proc abdm/per/oment 580063 49329 CPT Outpatient 58696.05 10076.16 Multiplan Multiplan Commercial 0.71 41754.40 0.71 58696.05 0.71 Case Rate 49329 Priced Ins tun ip cath for dial opn 580063 49421 CPT Outpatient 25460.40 3319.30 Multiplan Multiplan Commercial 0.74 18745.60 0.74 25460.40 0.74 Case Rate 49421 Priced Remove tunneled ip cath 580063 49422 CPT Outpatient 25515.00 4380.08 Multiplan Multiplan Commercial 0.73 18608.80 0.73 25515.00 0.73 Case Rate 49422 Priced Rpr ing hernia init reduce 580063 49500 CPT Outpatient 19594.05 3363.65 Multiplan Multiplan Commercial 0.74 14554.40 0.74 19594.05 0.74 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 580063 49505 CPT Outpatient 34915.65 5993.85 Multiplan Multiplan Commercial 0.73 25560.00 0.73 34915.65 0.73 Case Rate 49505 Priced Prp i/hern init block >5 yr 580063 49507 CPT Outpatient 29794.80 5114.77 Multiplan Multiplan Commercial 0.74 22125.92 0.74 29794.80 0.74 Case Rate 49507 Priced Rerepair ing hernia reduce 580063 49520 CPT Outpatient 36940.05 6341.38 Multiplan Multiplan Commercial 0.73 27033.60 0.73 36940.05 0.73 Case Rate 49520 Priced Rpr ventral hern init reduc 580063 49560 CPT Outpatient 53177.25 9128.76 Multiplan Multiplan Commercial 0.73 38644.00 0.73 53177.25 0.73 Case Rate 49560 Priced Rpr ventral hern init block 580063 49561 CPT Outpatient 30755.55 5279.70 Multiplan Multiplan Commercial 0.74 22660.80 0.74 30755.55 0.74 Case Rate 49561 Priced Rerepair ventrl hern reduce 580063 49565 CPT Outpatient 69917.40 12002.49 Multiplan Multiplan Commercial 0.75 52562.40 0.75 69917.40 0.75 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 580063 49585 CPT Outpatient 41806.80 7176.83 Multiplan Multiplan Commercial 0.73 30557.60 0.73 41806.80 0.73 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 580063 49587 CPT Outpatient 37320.15 6406.63 Multiplan Multiplan Commercial 0.76 28233.92 0.76 37320.15 0.76 Case Rate 49587 Priced Lap ing hernia repair init 580063 49650 CPT Outpatient 41932.80 7198.46 Multiplan Multiplan Commercial 0.75 31288.64 0.75 41932.80 0.75 Case Rate 49650 Priced Lap ing hernia repair recur 580063 49651 CPT Outpatient 46915.05 8053.75 Multiplan Multiplan Commercial 0.73 34481.60 0.73 46915.05 0.73 Case Rate 49651 Priced Lap vent/abd hernia repair 580063 49652 CPT Outpatient 51294.60 8805.57 Multiplan Multiplan Commercial 0.72 37179.20 0.72 51294.60 0.72 Case Rate 49652 Priced Lap vent/abd hern proc comp 580063 49653 CPT Outpatient 46102.35 7914.24 Multiplan Multiplan Commercial 0.72 33340.80 0.72 46102.35 0.72 Case Rate 49653 Priced Lap inc hernia repair 580063 49654 CPT Outpatient 47221.65 8106.38 Multiplan Multiplan Commercial 0.72 33992.80 0.72 47221.65 0.72 Case Rate 49654 Priced Lap inc hern repair comp 580063 49655 CPT Outpatient 54590.55 9371.38 Multiplan Multiplan Commercial 0.73 39796.00 0.73 54590.55 0.73 Case Rate 49655 Priced Lap inc hernia repair recur 580063 49656 CPT Outpatient 55443.15 9517.74 Multiplan Multiplan Commercial 0.72 40082.40 0.72 55443.15 0.72 Case Rate 49656 Priced Removal of kidney stone 580063 50080 CPT Outpatient 53165.70 9126.78 Multiplan Multiplan Commercial 0.78 41356.00 0.78 53165.70 0.78 Case Rate 50080 Priced Removal of kidney stone 580063 50081 CPT Outpatient 66931.20 11489.86 Multiplan Multiplan Commercial 0.75 49902.72 0.75 66931.20 0.75 Case Rate 50081 Priced Renal biopsy perq 580063 50200 CPT Outpatient 43096.20 1225.34 Multiplan Multiplan Commercial 0.72 31228.80 0.72 43096.20 0.72 Case Rate 50200 Priced Plmt nephroureteral catheter 580063 50433 CPT Outpatient 64566.60 1424.48 Multiplan Multiplan Commercial 0.75 48517.60 0.75 64566.60 0.75 Case Rate 50433 Priced Laparo radical nephrectomy 580063 50545 CPT Outpatient 43449.00 7458.75 Multiplan Multiplan Commercial 0.75 32634.40 0.75 43449.00 0.75 Case Rate 50545 Priced Laparoscope proc ureter 580063 50949 CPT Outpatient 49986.30 8580.98 Multiplan Multiplan Commercial 0.72 36122.72 0.72 49986.30 0.72 Case Rate 50949 Priced Injection for bladder x-ray 580063 51600 CPT Outpatient 3285.45 89.22 Multiplan Multiplan Commercial 0.73 2384.00 0.73 3285.45 0.73 Case Rate 51600 Priced Cystoscopy 580063 52000 CPT Outpatient 22149.75 3802.37 Multiplan Multiplan Commercial 0.72 15959.20 0.72 22149.75 0.72 Case Rate 52000 Priced Cystoscopy & ureter catheter 580063 52005 CPT Outpatient 42529.20 2095.77 Multiplan Multiplan Commercial 0.74 31291.20 0.74 42529.20 0.74 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 580063 52204 CPT Outpatient 31274.25 5368.75 Multiplan Multiplan Commercial 0.60 18784.80 0.60 31274.25 0.60 Case Rate 52204 Priced Cystoscopy and treatment 580063 52224 CPT Outpatient 13445.25 2308.10 Multiplan Multiplan Commercial 0.73 9788.00 0.73 13445.25 0.73 Case Rate 52224 Priced Cystoscopy and treatment 580063 52234 CPT Outpatient 28510.65 4894.33 Multiplan Multiplan Commercial 0.60 17140.80 0.60 28510.65 0.60 Case Rate 52234 Priced Cystoscopy and treatment 580063 52235 CPT Outpatient 29417.85 5050.06 Multiplan Multiplan Commercial 0.60 17644.00 0.60 29417.85 0.60 Case Rate 52235 Priced Cystoscopy and treatment 580063 52240 CPT Outpatient 33933.90 5825.32 Multiplan Multiplan Commercial 0.75 25552.80 0.75 33933.90 0.75 Case Rate 52240 Priced Cystoscopy and treatment 580063 52281 CPT Outpatient 22159.20 3804.00 Multiplan Multiplan Commercial 0.73 16121.60 0.73 22159.20 0.73 Case Rate 52281 Priced Remove bladder stone 580063 52317 CPT Outpatient 27085.80 4649.73 Multiplan Multiplan Commercial 0.73 19795.20 0.73 27085.80 0.73 Case Rate 52317 Priced Remove bladder stone 580063 52318 CPT Outpatient 26685.75 4581.05 Multiplan Multiplan Commercial 0.73 19550.40 0.73 26685.75 0.73 Case Rate 52318 Priced Cystoscopy and treatment 580063 52332 CPT Outpatient 115306.80 19794.33 Multiplan Multiplan Commercial 0.36 41793.60 0.36 115306.80 0.36 Case Rate 52332 Priced Cystouretero w/stone remove 580063 52352 CPT Outpatient 42420.00 7282.10 Multiplan Multiplan Commercial 0.73 30854.40 0.73 42420.00 0.73 Case Rate 52352 Priced Cystouretero w/lithotripsy 580063 52353 CPT Outpatient 38608.50 6627.79 Multiplan Multiplan Commercial 0.73 28347.20 0.73 38608.50 0.73 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 580063 52356 CPT Outpatient 36255.45 6223.85 Multiplan Multiplan Commercial 0.73 26518.40 0.73 36255.45 0.73 Case Rate 52356 Priced Prostatectomy (turp) 580063 52601 CPT Outpatient 35371.35 6072.08 Multiplan Multiplan Commercial 0.62 22002.40 0.62 35371.35 0.62 Case Rate 52601 Priced Laser surgery of prostate 580063 52648 CPT Outpatient 24264.45 4165.40 Multiplan Multiplan Commercial 0.77 18652.80 0.77 24264.45 0.77 Case Rate 52648 Priced Revision of urethra 580063 53450 CPT Outpatient 16209.90 2782.70 Multiplan Multiplan Commercial 0.73 11820.00 0.73 16209.90 0.73 Case Rate 53450 Priced Urology surgery procedure 580063 53899 CPT Outpatient 25368.00 134.83 Multiplan Multiplan Commercial 0.94 23872.00 0.94 25368.00 0.94 Case Rate 53899 Priced Circumcision w/regionl block 580063 54150 CPT Outpatient 14700.00 2523.50 Multiplan Multiplan Commercial 0.73 10662.40 0.73 14700.00 0.73 Case Rate 54150 Priced Circum 28 days or older 580063 54161 CPT Outpatient 19186.65 3293.71 Multiplan Multiplan Commercial 0.72 13892.00 0.72 19186.65 0.72 Case Rate 54161 Priced Lysis penil circumic lesion 580063 54162 CPT Outpatient 19795.65 3398.25 Multiplan Multiplan Commercial 0.73 14424.00 0.73 19795.65 0.73 Case Rate 54162 Priced Repair of circumcision 580063 54163 CPT Outpatient 16391.55 2813.88 Multiplan Multiplan Commercial 0.73 11904.80 0.73 16391.55 0.73 Case Rate 54163 Priced Reconstruction of urethra 580063 54324 CPT Outpatient 32880.75 5644.53 Multiplan Multiplan Commercial 0.73 23932.00 0.73 32880.75 0.73 Case Rate 54324 Priced Revise penis/urethra 580063 54332 CPT Outpatient 19968.90 3427.99 Multiplan Multiplan Commercial 0.73 14547.20 0.73 19968.90 0.73 Case Rate 54332 Priced Insert self-contd prosthesis 580063 54401 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 580063 54520 CPT Outpatient 35442.75 6084.34 Multiplan Multiplan Commercial 0.72 25661.60 0.72 35442.75 0.72 Case Rate 54520 Priced Reduce testis torsion 580063 54600 CPT Outpatient 55049.40 9450.15 Multiplan Multiplan Commercial 0.52 28555.20 0.52 55049.40 0.52 Case Rate 54600 Priced Suspension of testis 580063 54640 CPT Outpatient 26860.05 4610.98 Multiplan Multiplan Commercial 0.73 19560.80 0.73 26860.05 0.73 Case Rate 54640 Priced Removal of hydrocele 580063 55040 CPT Outpatient 27277.95 4682.71 Multiplan Multiplan Commercial 0.73 19905.60 0.73 27277.95 0.73 Case Rate 55040 Priced Biopsy of prostate gland 580063 55700 CPT Outpatient 28699.65 4926.77 Multiplan Multiplan Commercial 0.70 20020.80 0.70 28699.65 0.70 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 580063 55866 CPT Outpatient 93088.80 15980.24 Multiplan Multiplan Commercial 0.75 69453.12 0.75 93088.80 0.75 Case Rate 55866 Priced Closure of vagina 580063 57120 CPT Outpatient 34369.65 5900.12 Multiplan Multiplan Commercial 0.73 25234.24 0.73 34369.65 0.73 Case Rate 57120 Priced Repair of vagina 580063 57200 CPT Outpatient 25247.25 4334.11 Multiplan Multiplan Commercial 0.74 18635.20 0.74 25247.25 0.74 Case Rate 57200 Priced Anterior colporrhaphy 580063 57240 CPT Outpatient 36210.30 6216.10 Multiplan Multiplan Commercial 0.79 28613.60 0.79 36210.30 0.79 Case Rate 57240 Priced Repair rectum & vagina 580063 57250 CPT Outpatient 40441.80 6942.51 Multiplan Multiplan Commercial 0.76 30596.80 0.76 40441.80 0.76 Case Rate 57250 Priced Cmbn ant pst colprhy 580063 57260 CPT Outpatient 46323.90 7952.27 Multiplan Multiplan Commercial 0.74 34413.60 0.74 46323.90 0.74 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 580063 57265 CPT Outpatient 42586.95 7310.76 Multiplan Multiplan Commercial 0.63 26662.40 0.63 42586.95 0.63 Case Rate 57265 Priced Repair of bowel bulge 580063 57268 CPT Outpatient 36865.50 6328.58 Multiplan Multiplan Commercial 0.87 32127.20 0.87 36865.50 0.87 Case Rate 57268 Priced Colpopexy extraperitoneal 580063 57282 CPT Outpatient 45629.85 7833.12 Multiplan Multiplan Commercial 0.71 32601.60 0.71 45629.85 0.71 Case Rate 57282 Priced Repair bladder defect 580063 57288 CPT Outpatient 43069.95 7393.67 Multiplan Multiplan Commercial 0.75 32454.40 0.75 43069.95 0.75 Case Rate 57288 Priced Bx/curett of cervix w/scope 580063 57454 CPT Outpatient 2888.55 442.93 Multiplan Multiplan Commercial 0.73 2096.00 0.73 2888.55 0.73 Case Rate 57454 Priced Conization of cervix 580063 57520 CPT Outpatient 26728.80 4588.44 Multiplan Multiplan Commercial 0.73 19487.20 0.73 26728.80 0.73 Case Rate 57520 Priced Conization of cervix 580063 57522 CPT Outpatient 22737.75 3903.31 Multiplan Multiplan Commercial 0.73 16681.60 0.73 22737.75 0.73 Case Rate 57522 Priced Biopsy of uterus lining 580063 58100 CPT Outpatient 2371.95 194.80 Multiplan Multiplan Commercial 0.73 1720.80 0.73 2371.95 0.73 Case Rate 58100 Priced Catheter for hysterography 580063 58340 CPT Outpatient 6322.05 131.04 Multiplan Multiplan Commercial 0.73 4587.20 0.73 6322.05 0.73 Case Rate 58340 Priced Reopen fallopian tube 580063 58350 CPT Outpatient 46507.65 7983.81 Multiplan Multiplan Commercial 0.72 33452.00 0.72 46507.65 0.72 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 580063 58542 CPT Outpatient 64194.90 11020.12 Multiplan Multiplan Commercial 0.76 48939.52 0.76 64194.90 0.76 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 580063 58544 CPT Outpatient 51020.55 8758.53 Multiplan Multiplan Commercial 0.73 37211.20 0.73 51020.55 0.73 Case Rate 58544 Priced Laparoscopic myomectomy 580063 58545 CPT Outpatient 56946.75 9775.86 Multiplan Multiplan Commercial 0.72 40920.80 0.72 56946.75 0.72 Case Rate 58545 Priced Laparo-vag hyst incl t/o 580063 58552 CPT Outpatient 57228.15 9824.17 Multiplan Multiplan Commercial 0.74 42602.40 0.74 57228.15 0.74 Case Rate 58552 Priced Hysteroscopy biopsy 580063 58558 CPT Outpatient 28581.00 2077.02 Multiplan Multiplan Commercial 0.73 20877.60 0.73 28581.00 0.73 Case Rate 58558 Priced Hysteroscopy remove myoma 580063 58561 CPT Outpatient 35222.25 6046.49 Multiplan Multiplan Commercial 0.72 25510.40 0.72 35222.25 0.72 Case Rate 58561 Priced Hysteroscopy ablation 580063 58563 CPT Outpatient 38399.55 6591.92 Multiplan Multiplan Commercial 0.89 34229.60 0.89 38399.55 0.89 Case Rate 58563 Priced Tlh uterus 250 g or less 580063 58570 CPT Outpatient 43316.70 7436.03 Multiplan Multiplan Commercial 0.71 30792.80 0.71 43316.70 0.71 Case Rate 58570 Priced Tlh w/t/o 250 g or less 580063 58571 CPT Outpatient 48603.45 8343.59 Multiplan Multiplan Commercial 0.74 35801.12 0.74 48603.45 0.74 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 580063 58573 CPT Outpatient 52905.30 9082.08 Multiplan Multiplan Commercial 0.71 37533.60 0.71 52905.30 0.71 Case Rate 58573 Priced Laparoscopy remove adnexa 580063 58661 CPT Outpatient 47008.50 8069.79 Multiplan Multiplan Commercial 0.73 34512.32 0.73 47008.50 0.73 Case Rate 58661 Priced Laparoscopy excise lesions 580063 58662 CPT Outpatient 45053.40 7734.17 Multiplan Multiplan Commercial 0.73 33050.40 0.73 45053.40 0.73 Case Rate 58662 Priced Treat ectopic pregnancy 580063 59151 CPT Outpatient 74690.70 12821.90 Multiplan Multiplan Commercial 0.50 37542.40 0.50 74690.70 0.50 Case Rate 59151 Priced Treatment of miscarriage 580063 59812 CPT Outpatient 56109.90 9632.20 Multiplan Multiplan Commercial 0.42 23778.40 0.42 56109.90 0.42 Case Rate 59812 Priced Partial removal of thyroid 580063 60220 CPT Outpatient 53639.25 9208.07 Multiplan Multiplan Commercial 0.84 44920.00 0.84 53639.25 0.84 Case Rate 60220 Priced Removal of thyroid 580063 60240 CPT Outpatient 98252.70 16866.71 Multiplan Multiplan Commercial 0.54 52827.20 0.54 98252.70 0.54 Case Rate 60240 Priced Explore parathyroid glands 580063 60500 CPT Outpatient 150495.45 25835.05 Multiplan Multiplan Commercial 0.32 48272.80 0.32 150495.45 0.32 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 580063 62322 CPT Outpatient 43709.40 514.24 Multiplan Multiplan Commercial 0.73 31954.40 0.73 43709.40 0.73 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 580063 62323 CPT Outpatient 8304.45 467.31 Multiplan Multiplan Commercial 61.95 514465.60 61.95 8304.45 61.95 Case Rate 62323 Priced Low back disk surgery 580063 63030 CPT Outpatient 50287.65 8632.71 Multiplan Multiplan Commercial 0.77 38892.80 0.77 50287.65 0.77 Case Rate 63030 Priced Inc for vagus n elect impl 580063 64568 CPT Outpatient 124562.55 21383.24 Multiplan Multiplan Commercial 0.73 90436.80 0.73 124562.55 0.73 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 580063 66821 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 580063 66984 CPT Outpatient 0.01 0.01 Multiplan Multiplan Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 72063 216 DRG Inpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 72063 460 DRG Inpatient 416122.79 53834.63 Oxford Health Oxford Commercial 0.19 78357.32 0.19 416122.79 0.19 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 72063 470 DRG Inpatient 167912.19 21723.13 Oxford Health Oxford Commercial 0.04 7182.90 0.04 167912.19 0.04 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 72063 473 DRG Inpatient 100687.91 13026.19 Oxford Health Oxford Commercial 0.07 7182.90 0.07 100687.91 0.07 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 72063 743 DRG Inpatient 102691.67 13285.42 Oxford Health Oxford Commercial 0.07 7182.90 0.07 102691.67 0.07 Case Rate 743 Priced NORMAL NEWBORN 72063 795 DRG Inpatient 6266.93 2335.00 Oxford Health Oxford Commercial 0.28 1753.29 0.28 6266.93 0.28 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 72063 807 DRG Inpatient 116469.59 4193.00 Oxford Health Oxford Commercial 0.09 10710.18 0.09 116469.59 0.09 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 72063 788 DRG Inpatient 76050.77 4538.00 Oxford Health Oxford Commercial 0.19 14488.97 0.19 76050.77 0.19 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 72063 59400 CPT Inpatient 116469.59 4193.00 Oxford Health Oxford Commercial 0.09 10710.18 0.09 116469.59 0.09 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 72063 59510 CPT Inpatient 76050.77 4538.00 Oxford Health Oxford Commercial 0.19 14488.97 0.19 76050.77 0.19 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 72063 59610 CPT Inpatient 116469.59 4193.00 Oxford Health Oxford Commercial 0.09 10710.18 0.09 116469.59 0.09 Case Rate 59610 Priced "Psychotherapy, 30 min" 72063 90832 CPT Outpatient 577.50 91.21 Oxford Health Oxford Commercial 0.99 569.25 0.99 577.50 0.99 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 72063 90834 CPT Outpatient 44134.65 271.96 Oxford Health Oxford Commercial 0.94 41432.09 0.94 44134.65 0.94 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 72063 90837 CPT Outpatient 2240.70 442.93 Oxford Health Oxford Commercial 0.14 321.23 0.14 2240.70 0.14 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 72063 90846 CPT Outpatient 0.01 131.50 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 72063 90847 CPT Outpatient 44134.65 369.97 Oxford Health Oxford Commercial 0.94 41432.09 0.94 44134.65 0.94 Fee Schedule 90847 Priced Group psychotherapy 72063 90853 CPT Outpatient 44134.65 101.99 Oxford Health Oxford Commercial 0.94 41432.09 0.94 44134.65 0.94 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 72063 99203 CPT Outpatient 3480.75 176.07 Oxford Health Oxford Commercial 0.71 2473.49 0.71 3480.75 0.71 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 72063 99204 CPT Outpatient 2103.15 233.39 Oxford Health Oxford Commercial 0.38 801.09 0.38 2103.15 0.38 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 72063 99205 CPT Outpatient 4970.70 314.28 Oxford Health Oxford Commercial 0.16 801.09 0.16 4970.70 0.16 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 72063 99243 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 72063 99244 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 72063 99385 CPT Outpatient 1114.05 185.90 Oxford Health Oxford Commercial 0.71 791.33 0.71 1114.05 0.71 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 72063 99386 CPT Outpatient 4877.25 185.90 Oxford Health Oxford Commercial 0.05 267.55 0.05 4877.25 0.05 Fee Schedule 99386 Priced Routine venipuncture 72063 36415 CPT Outpatient 127.05 19.57 Oxford Health Oxford Commercial 0.02 3.11 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 72063 80048 CPT Outpatient 576.45 88.78 Oxford Health Oxford Commercial 0.02 8.76 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 72063 80053 CPT Outpatient 763.35 117.56 Oxford Health Oxford Commercial 0.01 10.93 0.01 763.35 0.01 Fee Schedule 80053 Priced Obstetric blood test panel 72063 80055 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 72063 80061 CPT Outpatient 1349.25 197.77 Oxford Health Oxford Commercial 0.01 13.86 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 72063 80069 CPT Outpatient 716.10 104.95 Oxford Health Oxford Commercial 0.01 8.98 0.01 716.10 0.01 Fee Schedule 80069 Priced Liver function panel test 72063 80076 CPT Outpatient 716.10 104.95 Oxford Health Oxford Commercial 0.01 8.46 0.01 716.10 0.01 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 72063 81000 CPT Outpatient 144.90 21.18 Oxford Health Oxford Commercial 0.03 4.16 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 72063 81001 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 72063 81002 CPT Outpatient 57.75 8.89 Oxford Health Oxford Commercial 0.06 3.60 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 72063 81003 CPT Outpatient 219.45 33.80 Oxford Health Oxford Commercial 0.01 2.33 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 72063 82306 CPT Outpatient 1880.55 289.62 Oxford Health Oxford Commercial 0.02 30.64 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 72063 83036 CPT Outpatient 494.55 76.17 Oxford Health Oxford Commercial 0.02 10.05 0.02 494.55 0.02 Fee Schedule 83036 Priced PSA (prostate specific antigen) 72063 84153 CPT Outpatient 1177.05 181.28 Oxford Health Oxford Commercial 0.02 19.03 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 72063 84154 CPT Outpatient 598.50 92.17 Oxford Health Oxford Commercial 0.03 19.03 0.03 598.50 0.03 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 72063 84443 CPT Outpatient 519.75 80.05 Oxford Health Oxford Commercial 0.03 17.39 0.03 519.75 0.03 Fee Schedule 84443 Priced Chorionic gonadotropin assay 72063 84703 CPT Outpatient 785.40 120.96 Oxford Health Oxford Commercial 0.01 7.78 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 72063 85025 CPT Outpatient 635.25 97.83 Oxford Health Oxford Commercial 0.01 8.04 0.01 635.25 0.01 Fee Schedule 85025 Priced "Complete blood count, automated" 72063 85027 CPT Outpatient 576.45 88.78 Oxford Health Oxford Commercial 0.01 6.70 0.01 576.45 0.01 Fee Schedule 85027 Priced "Blood test, clotting time" 72063 85610 CPT Outpatient 404.25 62.26 Oxford Health Oxford Commercial 0.01 4.44 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 72063 85730 CPT Outpatient 17.22 2.65 Oxford Health Oxford Commercial 0.36 6.22 0.36 17.22 0.36 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 72063 86003 CPT Outpatient 32.55 5.01 Oxford Health Oxford Commercial 0.17 5.40 0.17 32.55 0.17 Fee Schedule 86003 Priced Tb test cell immun measure 72063 86480 CPT Outpatient 530.25 81.66 Oxford Health Oxford Commercial 0.12 64.15 0.12 530.25 0.12 Fee Schedule 86480 Priced Urine culture/colony count 72063 87086 CPT Outpatient 763.35 117.56 Oxford Health Oxford Commercial 0.01 8.35 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 72063 87338 CPT Outpatient 785.40 120.96 Oxford Health Oxford Commercial 0.02 14.88 0.02 785.40 0.02 Fee Schedule 87338 Priced Cytopath eval fna report 72063 88173 CPT Outpatient 750.75 115.62 Oxford Health Oxford Commercial 0.07 52.53 0.07 750.75 0.07 Fee Schedule 88173 Priced Tissue exam by pathologist 72063 88302 CPT Outpatient 635.25 97.83 Oxford Health Oxford Commercial 0.04 26.11 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 72063 88305 CPT Outpatient 323.40 49.81 Oxford Health Oxford Commercial 0.16 52.53 0.16 323.40 0.16 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 72063 11042 CPT Outpatient 2668.05 481.45 Oxford Health Oxford Commercial 0.71 1896.06 0.71 2668.05 0.71 Case Rate 11042 Priced Deb subq tissue add-on 72063 11045 CPT Outpatient 4652.55 330.00 Oxford Health Oxford Commercial 0.71 3306.35 0.71 4652.55 0.71 Case Rate 11045 Priced Dx bronchoscope/lavage 72063 31624 CPT Outpatient 41223.00 7602.31 Oxford Health Oxford Commercial 0.24 10055.28 0.24 41223.00 0.24 Case Rate 31624 Priced Bronchoscopy/lung bx each 72063 31628 CPT Outpatient 49048.65 9045.51 Oxford Health Oxford Commercial 0.21 10055.28 0.21 49048.65 0.21 Case Rate 31628 Priced Blood transfusion service 72063 36430 CPT Outpatient 9166.50 574.93 Oxford Health Oxford Commercial 0.04 410.92 0.04 9166.50 0.04 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 72063 43235 CPT Outpatient 8856.75 1633.35 Oxford Health Oxford Commercial 0.53 4721.57 0.53 8856.75 0.53 Case Rate 43235 Priced Endoscopic us exam esoph 72063 43237 CPT Outpatient 23867.55 4401.63 Oxford Health Oxford Commercial 0.30 7226.89 0.30 23867.55 0.30 Case Rate 43237 Priced Egd us fine needle bx/aspir 72063 43238 CPT Outpatient 30690.45 5659.90 Oxford Health Oxford Commercial 0.16 4817.93 0.16 30690.45 0.16 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 72063 43239 CPT Outpatient 40191.90 7412.15 Oxford Health Oxford Commercial 0.21 8431.37 0.21 40191.90 0.21 Case Rate 43239 Priced Ercp remove duct calculi 72063 43264 CPT Outpatient 34335.00 6332.03 Oxford Health Oxford Commercial 0.28 9662.76 0.28 34335.00 0.28 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 72063 45378 CPT Outpatient 13991.25 889.35 Oxford Health Oxford Commercial 0.34 4817.93 0.34 13991.25 0.34 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 72063 45380 CPT Outpatient 22215.90 4097.04 Oxford Health Oxford Commercial 0.33 7226.89 0.33 22215.90 0.33 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 72063 45385 CPT Outpatient 119569.80 22050.95 Oxford Health Oxford Commercial 0.06 7082.35 0.06 119569.80 0.06 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 72063 45391 CPT Outpatient 24923.85 4596.43 Oxford Health Oxford Commercial 0.29 7226.89 0.29 24923.85 0.29 Case Rate 45391 Priced Fragmenting of kidney stone 72063 50590 CPT Outpatient 40930.05 7548.28 Oxford Health Oxford Commercial 0.19 7590.01 0.19 40930.05 0.19 Case Rate 50590 Priced Fetal non-stress test 72063 59025 CPT Outpatient 3153.15 477.76 Oxford Health Oxford Commercial 0.20 619.97 0.20 3153.15 0.20 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 72063 64483 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 72063 92567 CPT Outpatient 2224.95 98.50 Oxford Health Oxford Commercial 0.49 1099.17 0.49 2224.95 0.49 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 72063 93000 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 72063 93017 CPT Outpatient 3076.50 532.96 Oxford Health Oxford Commercial 0.20 619.97 0.20 3076.50 0.20 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 72063 93452 CPT Outpatient 55621.65 8611.87 Oxford Health Oxford Commercial 0.12 6441.84 0.12 55621.65 0.12 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 72063 95810 CPT Outpatient 20341.65 3373.48 Oxford Health Oxford Commercial 0.21 4341.83 0.21 20341.65 0.21 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 72063 95811 CPT Outpatient 22491.00 3731.18 Oxford Health Oxford Commercial 0.19 4341.83 0.19 22491.00 0.19 Case Rate 95811 Priced Eeg 41-60 minutes 72063 95812 CPT Outpatient 5578.65 925.83 Oxford Health Oxford Commercial 0.06 340.52 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 72063 96040 CPT Outpatient 0.01 102.81 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 72063 96413 CPT Outpatient 4856.25 472.45 Oxford Health Oxford Commercial 0.83 4053.07 0.83 4856.25 0.83 Case Rate 96413 Priced Ultrasound therapy 72063 97035 CPT Outpatient 2111.55 134.99 Oxford Health Oxford Commercial 0.57 1207.85 0.57 2111.55 0.57 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 72063 97110 CPT Outpatient 6494.25 92.86 Oxford Health Oxford Commercial 0.62 4026.15 0.62 6494.25 0.62 Case Rate 97110 Priced Gait training therapy 72063 97116 CPT Outpatient 4723.95 110.61 Oxford Health Oxford Commercial 0.68 3220.92 0.68 4723.95 0.68 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 72063 70450 CPT Outpatient 8566.95 835.61 Oxford Health Oxford Commercial 0.13 1150.92 0.13 8566.95 0.13 Case Rate 70450 Priced Mri brain stem w/o dye 72063 70551 CPT Outpatient 7861.35 1361.31 Oxford Health Oxford Commercial 0.07 547.26 0.07 7861.35 0.07 Case Rate 70551 Priced MRI scan of brain before and after contrast 72063 70553 CPT Outpatient 10882.20 1625.88 Oxford Health Oxford Commercial 0.08 875.82 0.08 10882.20 0.08 Case Rate 70553 Priced X-ray exam chest 2 views 72063 71046 CPT Outpatient 859.95 150.37 Oxford Health Oxford Commercial 0.22 192.38 0.22 859.95 0.22 Case Rate 71046 Priced Ct thorax w/o dye 72063 71250 CPT Outpatient 7288.05 1261.63 Oxford Health Oxford Commercial 0.04 258.94 0.04 7288.05 0.04 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 72063 72082 CPT Outpatient 2022.30 253.33 Oxford Health Oxford Commercial 0.26 517.87 0.26 2022.30 0.26 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 72063 72100 CPT Outpatient 1599.15 277.38 Oxford Health Oxford Commercial 0.16 258.94 0.16 1599.15 0.16 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 72063 72110 CPT Outpatient 1389.15 241.04 Oxford Health Oxford Commercial 0.19 258.94 0.19 1389.15 0.19 Case Rate 72110 Priced MRI scan of lower spinal canal 72063 72148 CPT Outpatient 7861.35 1361.31 Oxford Health Oxford Commercial 0.07 547.26 0.07 7861.35 0.07 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 72063 72193 CPT Outpatient 13671.00 1412.01 Oxford Health Oxford Commercial 0.03 425.87 0.03 13671.00 0.03 Case Rate 72193 Priced X-ray exam of shoulder 72063 73030 CPT Outpatient 1452.15 251.43 Oxford Health Oxford Commercial 0.13 192.38 0.13 1452.15 0.13 Case Rate 73030 Priced X-ray exam of elbow 72063 73080 CPT Outpatient 1356.60 235.68 Oxford Health Oxford Commercial 0.14 192.38 0.14 1356.60 0.14 Case Rate 73080 Priced X-ray exam of forearm 72063 73090 CPT Outpatient 1243.20 215.26 Oxford Health Oxford Commercial 0.15 192.38 0.15 1243.20 0.15 Case Rate 73090 Priced X-ray exam of wrist 72063 73110 CPT Outpatient 1243.20 215.26 Oxford Health Oxford Commercial 0.15 192.38 0.15 1243.20 0.15 Case Rate 73110 Priced X-ray exam of hand 72063 73130 CPT Outpatient 1243.20 215.26 Oxford Health Oxford Commercial 0.15 192.38 0.15 1243.20 0.15 Case Rate 73130 Priced X-ray exam hips bi 2 views 72063 73521 CPT Outpatient 970.20 228.41 Oxford Health Oxford Commercial 0.27 258.94 0.27 970.20 0.27 Case Rate 73521 Priced X-ray exam of knee 3 72063 73562 CPT Outpatient 802.20 139.12 Oxford Health Oxford Commercial 0.24 192.38 0.24 802.20 0.24 Case Rate 73562 Priced X-ray exam of lower leg 72063 73590 CPT Outpatient 1243.20 215.26 Oxford Health Oxford Commercial 0.15 192.38 0.15 1243.20 0.15 Case Rate 73590 Priced X-ray exam of ankle 72063 73610 CPT Outpatient 1378.65 239.31 Oxford Health Oxford Commercial 0.14 192.38 0.14 1378.65 0.14 Case Rate 73610 Priced X-ray exam of foot 72063 73630 CPT Outpatient 975.45 169.41 Oxford Health Oxford Commercial 0.20 192.38 0.20 975.45 0.20 Case Rate 73630 Priced MRI scan of leg joint 72063 73721 CPT Outpatient 7861.35 1361.31 Oxford Health Oxford Commercial 0.07 547.26 0.07 7861.35 0.07 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 72063 74177 CPT Outpatient 14222.25 1412.01 Oxford Health Oxford Commercial 0.06 876.96 0.06 14222.25 0.06 Case Rate 74177 Priced Contrst x-ray exam of throat 72063 74210 CPT Outpatient 0.01 440.39 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 72063 76098 CPT Outpatient 6141.45 407.86 Oxford Health Oxford Commercial 0.77 4721.57 0.77 6141.45 0.77 Case Rate 76098 Priced Us exam of head and neck 72063 76536 CPT Outpatient 5512.50 955.18 Oxford Health Oxford Commercial 0.05 258.94 0.05 5512.50 0.05 Case Rate 76536 Priced Ultrasound breast limited 72063 76642 CPT Outpatient 5777.10 127.70 Oxford Health Oxford Commercial 0.09 517.95 0.09 5777.10 0.09 Case Rate 76642 Priced Ultrasound of abdomen 72063 76700 CPT Outpatient 4917.15 851.88 Oxford Health Oxford Commercial 0.05 258.94 0.05 4917.15 0.05 Case Rate 76700 Priced Echo exam of abdomen 72063 76705 CPT Outpatient 3836.70 665.17 Oxford Health Oxford Commercial 0.07 258.94 0.07 3836.70 0.07 Case Rate 76705 Priced Us exam abdo back wall comp 72063 76770 CPT Outpatient 5171.25 895.48 Oxford Health Oxford Commercial 0.05 258.94 0.05 5171.25 0.05 Case Rate 76770 Priced Us exam abdo back wall lim 72063 76775 CPT Outpatient 3969.00 686.97 Oxford Health Oxford Commercial 0.07 258.94 0.07 3969.00 0.07 Case Rate 76775 Priced Ob us < 14 wks single fetus 72063 76801 CPT Outpatient 2006.55 347.98 Oxford Health Oxford Commercial 0.13 258.94 0.13 2006.55 0.13 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 72063 76805 CPT Outpatient 3969.00 686.97 Oxford Health Oxford Commercial 0.07 258.94 0.07 3969.00 0.07 Case Rate 76805 Priced Ob us detailed sngl fetus 72063 76811 CPT Outpatient 2844.45 492.99 Oxford Health Oxford Commercial 0.19 547.26 0.19 2844.45 0.19 Case Rate 76811 Priced Ob us nuchal meas 1 gest 72063 76813 CPT Outpatient 1044.75 180.83 Oxford Health Oxford Commercial 0.25 258.94 0.25 1044.75 0.25 Case Rate 76813 Priced Ob us limited fetus(s) 72063 76815 CPT Outpatient 6428.10 639.90 Oxford Health Oxford Commercial 0.08 517.87 0.08 6428.10 0.08 Case Rate 76815 Priced Ob us follow-up per fetus 72063 76816 CPT Outpatient 4818.45 833.88 Oxford Health Oxford Commercial 0.05 258.94 0.05 4818.45 0.05 Case Rate 76816 Priced Transvaginal us obstetric 72063 76817 CPT Outpatient 6428.10 476.73 Oxford Health Oxford Commercial 0.08 517.87 0.08 6428.10 0.08 Case Rate 76817 Priced Fetal biophys profil w/o nst 72063 76819 CPT Outpatient 1741.95 302.65 Oxford Health Oxford Commercial 0.15 258.94 0.15 1741.95 0.15 Case Rate 76819 Priced Ultrasound pelvis through vagina 72063 76830 CPT Outpatient 9305.10 806.54 Oxford Health Oxford Commercial 0.06 517.87 0.06 9305.10 0.06 Case Rate 76830 Priced Us exam scrotum 72063 76870 CPT Outpatient 6328.35 1096.55 Oxford Health Oxford Commercial 0.04 258.94 0.04 6328.35 0.04 Case Rate 76870 Priced Us exam infant hips dynamic 72063 76885 CPT Outpatient 3836.70 665.17 Oxford Health Oxford Commercial 0.05 192.38 0.05 3836.70 0.05 Case Rate 76885 Priced Mammography of one breast 72063 77065 CPT Outpatient 3451.35 192.07 Oxford Health Oxford Commercial 0.13 459.93 0.13 3451.35 0.13 Case Rate 77065 Priced Mammography of both breasts 72063 77066 CPT Outpatient 5777.10 235.68 Oxford Health Oxford Commercial 0.09 517.95 0.09 5777.10 0.09 Case Rate 77066 Priced "Mamography, screening bilateral" 72063 77067 CPT Outpatient 1416.45 205.57 Oxford Health Oxford Commercial 0.20 278.83 0.20 1416.45 0.20 Case Rate 77067 Priced X-rays for bone age 72063 77072 CPT Outpatient 2022.30 163.87 Oxford Health Oxford Commercial 0.26 517.87 0.26 2022.30 0.26 Case Rate 77072 Priced Joint survey single view 72063 77077 CPT Outpatient 985.95 171.14 Oxford Health Oxford Commercial 0.26 258.94 0.26 985.95 0.26 Case Rate 77077 Priced Dxa bone density axial 72063 77080 CPT Outpatient 3257.10 319.09 Oxford Health Oxford Commercial 0.17 537.77 0.17 3257.10 0.17 Case Rate 77080 Priced Fna bx w/us gdn 1st les 72063 10005 CPT Outpatient 5512.50 547.24 Oxford Health Oxford Commercial 0.87 4817.93 0.87 5512.50 0.87 Case Rate 10005 Priced Fna bx w/us gdn ea addl 72063 10006 CPT Outpatient 10628.10 594.83 Oxford Health Oxford Commercial 0.91 9635.85 0.91 10628.10 0.91 Case Rate 10006 Priced Drainage of hematoma/fluid 72063 10140 CPT Outpatient 23209.20 1081.95 Oxford Health Oxford Commercial 0.49 11259.77 0.49 23209.20 0.49 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 72063 11042 CPT Outpatient 2668.05 481.45 Oxford Health Oxford Commercial 0.71 1896.06 0.71 2668.05 0.71 Case Rate 11042 Priced Deb bone 20 sq cm/< 72063 11044 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 72063 11406 CPT Outpatient 19967.85 3427.81 Oxford Health Oxford Commercial 0.24 4817.93 0.24 19967.85 0.24 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 72063 11424 CPT Outpatient 0.01 1004.93 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 72063 11770 CPT Outpatient 19173.00 3291.37 Oxford Health Oxford Commercial 0.30 5697.68 0.30 19173.00 0.30 Case Rate 11770 Priced Replace tissue expander 72063 11970 CPT Outpatient 59239.95 10169.52 Oxford Health Oxford Commercial 0.31 18637.76 0.31 59239.95 0.31 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 72063 14020 CPT Outpatient 32166.75 5521.96 Oxford Health Oxford Commercial 0.15 4721.57 0.15 32166.75 0.15 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 72063 14060 CPT Outpatient 25993.80 1374.69 Oxford Health Oxford Commercial 0.34 8850.80 0.34 25993.80 0.34 Case Rate 14060 Priced Wound prep trk/arm/leg 72063 15002 CPT Outpatient 41748.00 1441.73 Oxford Health Oxford Commercial 0.21 8850.80 0.21 41748.00 0.21 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 72063 15271 CPT Outpatient 24343.20 3769.48 Oxford Health Oxford Commercial 0.01 0.11 0.01 24343.20 0.01 Case Rate 15271 Priced Acellular derm matrix implt 72063 15777 CPT Outpatient 101672.55 17453.79 Oxford Health Oxford Commercial 0.12 12170.31 0.12 101672.55 0.12 Case Rate 15777 Priced Exc skin abd 72063 15830 CPT Outpatient 54696.60 9389.58 Oxford Health Oxford Commercial 0.16 8850.80 0.16 54696.60 0.16 Case Rate 15830 Priced Dressing change not for burn 72063 15852 CPT Outpatient 0.01 290.74 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 72063 15877 CPT Outpatient 63741.30 10942.26 Oxford Health Oxford Commercial 0.17 10867.24 0.17 63741.30 0.17 Case Rate 15877 Priced Suction lipectomy lwr extrem 72063 15879 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 72063 19000 CPT Outpatient 10143.00 594.83 Oxford Health Oxford Commercial 0.48 4817.93 0.48 10143.00 0.48 Case Rate 19000 Priced Bx breast 1st lesion strtctc 72063 19081 CPT Outpatient 12341.70 1250.69 Oxford Health Oxford Commercial 0.39 4817.93 0.39 12341.70 0.39 Case Rate 19081 Priced Bx breast add lesion us imag 72063 19084 CPT Outpatient 29058.75 547.24 Oxford Health Oxford Commercial 0.33 9635.85 0.33 29058.75 0.33 Case Rate 19084 Priced Biopsy of breast open 72063 19101 CPT Outpatient 39545.10 2737.82 Oxford Health Oxford Commercial 0.43 16957.44 0.43 39545.10 0.43 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 72063 19120 CPT Outpatient 35761.95 2737.82 Oxford Health Oxford Commercial 0.23 8106.64 0.23 35761.95 0.23 Case Rate 19120 Priced Excision breast lesion 72063 19125 CPT Outpatient 33184.20 0.01 Oxford Health Oxford Commercial 0.51 16957.44 0.51 33184.20 0.51 Case Rate 19125 Priced Perq device breast 1st imag 72063 19281 CPT Outpatient 6141.45 598.61 Oxford Health Oxford Commercial 0.77 4721.57 0.77 6141.45 0.77 Case Rate 19281 Priced Perq device breast ea imag 72063 19282 CPT Outpatient 8379.00 319.04 Oxford Health Oxford Commercial 1.13 9443.13 1.13 8379.00 1.13 Case Rate 19282 Priced Partial mastectomy 72063 19301 CPT Outpatient 39157.65 6722.06 Oxford Health Oxford Commercial 0.43 16957.44 0.43 39157.65 0.43 Case Rate 19301 Priced Mast simple complete 72063 19303 CPT Outpatient 105389.55 18091.87 Oxford Health Oxford Commercial 0.16 17208.17 0.16 105389.55 0.16 Case Rate 19303 Priced Reduction of large breast 72063 19318 CPT Outpatient 65239.65 11199.47 Oxford Health Oxford Commercial 0.10 6441.84 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 72063 19340 CPT Outpatient 113100.75 19415.63 Oxford Health Oxford Commercial 0.09 10649.90 0.09 113100.75 0.09 Case Rate 19340 Priced Delayed breast prosthesis 72063 19342 CPT Outpatient 56988.75 9783.07 Oxford Health Oxford Commercial 0.22 12576.29 0.22 56988.75 0.22 Case Rate 19342 Priced Breast reconstruction 72063 19357 CPT Outpatient 101672.55 17453.79 Oxford Health Oxford Commercial 0.12 12170.31 0.12 101672.55 0.12 Case Rate 19357 Priced Breast reconstruction 72063 19366 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 72063 19380 CPT Outpatient 61493.25 10556.34 Oxford Health Oxford Commercial 0.16 9662.76 0.16 61493.25 0.16 Case Rate 19380 Priced Removal of support implant 72063 20680 CPT Outpatient 42329.70 7266.60 Oxford Health Oxford Commercial 0.20 8546.51 0.20 42329.70 0.20 Case Rate 20680 Priced Cerv artific diskectomy 72063 22856 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 72063 24538 CPT Outpatient 51237.90 4775.24 Oxford Health Oxford Commercial 0.16 8106.64 0.16 51237.90 0.16 Case Rate 24538 Priced Remove wrist tendon lesion 72063 25111 CPT Outpatient 25855.20 4438.48 Oxford Health Oxford Commercial 0.22 5697.68 0.22 25855.20 0.22 Case Rate 25111 Priced Incise finger tendon sheath 72063 26055 CPT Outpatient 15862.35 2723.04 Oxford Health Oxford Commercial 0.46 7226.89 0.46 15862.35 0.46 Case Rate 26055 Priced Treat finger fracture each 72063 26727 CPT Outpatient 22779.75 2030.47 Oxford Health Oxford Commercial 0.25 5697.68 0.25 22779.75 0.25 Case Rate 26727 Priced Revision of knee joint 72063 27446 CPT Outpatient 67882.50 11653.16 Oxford Health Oxford Commercial 0.25 16797.02 0.25 67882.50 0.25 Case Rate 27446 Priced Total knee arthroplasty 72063 27447 CPT Outpatient 130698.75 22436.62 Oxford Health Oxford Commercial 0.13 16797.02 0.13 130698.75 0.13 Case Rate 27447 Priced Surgery to stop leg growth 72063 27485 CPT Outpatient 43310.40 7434.95 Oxford Health Oxford Commercial 0.39 16797.02 0.39 43310.40 0.39 Case Rate 27485 Priced Repair achilles tendon 72063 27650 CPT Outpatient 38246.25 3762.57 Oxford Health Oxford Commercial 0.44 16797.02 0.44 38246.25 0.44 Case Rate 27650 Priced Treatment of ankle fracture 72063 27792 CPT Outpatient 36101.10 6197.36 Oxford Health Oxford Commercial 0.47 16797.02 0.47 36101.10 0.47 Case Rate 27792 Priced Treatment of ankle fracture 72063 27814 CPT Outpatient 49405.65 8481.30 Oxford Health Oxford Commercial 0.34 16797.02 0.34 49405.65 0.34 Case Rate 27814 Priced Removal of foot lesion 72063 28080 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 72063 28285 CPT Outpatient 68603.85 11776.99 Oxford Health Oxford Commercial 0.24 16797.02 0.24 68603.85 0.24 Case Rate 28285 Priced Correction hallux valgus 72063 28296 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 72063 29823 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 72063 29826 CPT Outpatient 49840.35 8555.93 Oxford Health Oxford Commercial 0.20 10153.87 0.20 49840.35 0.20 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 72063 29881 CPT Outpatient 35556.15 6103.81 Oxford Health Oxford Commercial 0.18 6441.84 0.18 35556.15 0.18 Case Rate 29881 Priced Knee arthroscopy/surgery 72063 29882 CPT Outpatient 61099.50 10488.75 Oxford Health Oxford Commercial 0.20 12170.31 0.20 61099.50 0.20 Case Rate 29882 Priced Percut bx lung/mediastinum 72063 32405 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 72063 32555 CPT Outpatient 14597.10 687.29 Oxford Health Oxford Commercial 0.32 4721.57 0.32 14597.10 0.32 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 72063 32664 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 72063 35190 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 72063 36478 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 72063 36561 CPT Outpatient 53531.10 3292.99 Oxford Health Oxford Commercial 0.12 6441.84 0.12 53531.10 0.12 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 72063 36569 CPT Outpatient 31421.25 1299.06 Oxford Health Oxford Commercial 0.15 4721.57 0.15 31421.25 0.15 Case Rate 36569 Priced Removal tunneled cv cath 72063 36590 CPT Outpatient 1996.05 273.95 Oxford Health Oxford Commercial 2.37 4721.57 2.37 1996.05 2.37 Case Rate 36590 Priced Av fuse uppr arm basilic 72063 36819 CPT Outpatient 56861.70 9761.26 Oxford Health Oxford Commercial 0.24 13903.01 0.24 56861.70 0.24 Case Rate 36819 Priced Av fusion direct any site 72063 36821 CPT Outpatient 42953.40 7373.67 Oxford Health Oxford Commercial 0.15 6441.84 0.15 42953.40 0.15 Case Rate 36821 Priced Artery-vein autograft 72063 36825 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 72063 36830 CPT Outpatient 53656.05 9210.96 Oxford Health Oxford Commercial 0.26 14186.75 0.26 53656.05 0.26 Case Rate 36830 Priced Av fistula revision open 72063 36832 CPT Outpatient 52492.65 9011.24 Oxford Health Oxford Commercial 0.31 16263.79 0.31 52492.65 0.31 Case Rate 36832 Priced Av fistula revision 72063 36833 CPT Outpatient 37098.60 6368.59 Oxford Health Oxford Commercial 0.44 16263.79 0.44 37098.60 0.44 Case Rate 36833 Priced Intro cath dialysis circuit 72063 36903 CPT Outpatient 77541.45 10669.90 Oxford Health Oxford Commercial 0.18 14186.75 0.18 77541.45 0.18 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 72063 36906 CPT Outpatient 96694.50 16175.64 Oxford Health Oxford Commercial 0.14 13903.01 0.14 96694.50 0.14 Case Rate 36906 Priced Fem/popl revas w/tla 72063 37224 CPT Outpatient 200076.45 5139.31 Oxford Health Oxford Commercial 0.10 19901.58 0.10 200076.45 0.10 Case Rate 37224 Priced Fem/popl revasc stnt & ather 72063 37227 CPT Outpatient 117170.55 18045.38 Oxford Health Oxford Commercial 0.07 7744.91 0.07 117170.55 0.07 Case Rate 37227 Priced Revise leg vein 72063 37700 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 72063 37722 CPT Outpatient 27815.55 4775.00 Oxford Health Oxford Commercial 0.35 9662.76 0.35 27815.55 0.35 Case Rate 37722 Priced Stab phleb veins xtr 10-20 72063 37765 CPT Outpatient 26561.85 4559.78 Oxford Health Oxford Commercial 0.40 10649.90 0.40 26561.85 0.40 Case Rate 37765 Priced Biopsy/removal lymph nodes 72063 38500 CPT Outpatient 35955.15 6172.30 Oxford Health Oxford Commercial 0.16 5697.68 0.16 35955.15 0.16 Case Rate 38500 Priced Biopsy/removal lymph nodes 72063 38525 CPT Outpatient 101194.80 17371.77 Oxford Health Oxford Commercial 0.11 11087.18 0.11 101194.80 0.11 Case Rate 38525 Priced Laparoscopy lymph node biop 72063 38570 CPT Outpatient 65631.30 11266.71 Oxford Health Oxford Commercial 0.18 11617.36 0.18 65631.30 0.18 Case Rate 38570 Priced Laparoscopy lymphadenectomy 72063 38571 CPT Outpatient 84031.50 14425.41 Oxford Health Oxford Commercial 0.14 11617.36 0.14 84031.50 0.14 Case Rate 38571 Priced Laparoscopy lymphadenectomy 72063 38572 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 72063 38792 CPT Outpatient 2868.60 432.48 Oxford Health Oxford Commercial 0.94 2692.04 0.94 2868.60 0.94 Case Rate 38792 Priced Excision of gum lesion 72063 41825 CPT Outpatient 11580.45 1987.98 Oxford Health Oxford Commercial 0.62 7226.89 0.62 11580.45 0.62 Case Rate 41825 Priced Reconstruct cleft palate 72063 42200 CPT Outpatient 36703.80 6300.82 Oxford Health Oxford Commercial 0.18 6441.84 0.18 36703.80 0.18 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 72063 42820 CPT Outpatient 17232.60 2958.26 Oxford Health Oxford Commercial 0.84 14548.48 0.84 17232.60 0.84 Case Rate 42820 Priced Control throat bleeding 72063 42960 CPT Outpatient 24066.00 4131.33 Oxford Health Oxford Commercial 0.47 11259.77 0.47 24066.00 0.47 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 72063 43235 CPT Outpatient 8856.75 1633.35 Oxford Health Oxford Commercial 0.53 4721.57 0.53 8856.75 0.53 Case Rate 43235 Priced Laparoscopy fundoplasty 72063 43280 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 72063 43282 CPT Outpatient 84344.40 14479.12 Oxford Health Oxford Commercial 0.09 7744.91 0.09 84344.40 0.09 Case Rate 43282 Priced Laparoscopy appendectomy 72063 44970 CPT Outpatient 82300.05 14128.18 Oxford Health Oxford Commercial 0.09 7744.91 0.09 82300.05 0.09 Case Rate 44970 Priced Diagnostic sigmoidoscopy 72063 45330 CPT Outpatient 17286.15 542.26 Oxford Health Oxford Commercial 0.49 8431.37 0.49 17286.15 0.49 Case Rate 45330 Priced Needle biopsy of liver 72063 47000 CPT Outpatient 10398.15 1225.34 Oxford Health Oxford Commercial 0.46 4817.93 0.46 10398.15 0.46 Case Rate 47000 Priced Removal of gallbladder using an endoscope 72063 47562 CPT Outpatient 58430.40 10030.55 Oxford Health Oxford Commercial 0.13 7744.91 0.13 58430.40 0.13 Case Rate 47562 Priced Laparo cholecystectomy/graph 72063 47563 CPT Outpatient 71747.55 12316.66 Oxford Health Oxford Commercial 0.11 7744.91 0.11 71747.55 0.11 Case Rate 47563 Priced Abd paracentesis w/imaging 72063 49083 CPT Outpatient 6979.35 1113.95 Oxford Health Oxford Commercial 0.69 4817.93 0.69 6979.35 0.69 Case Rate 49083 Priced Diag laparo separate proc 72063 49320 CPT Outpatient 31629.15 5429.67 Oxford Health Oxford Commercial 0.50 15732.52 0.50 31629.15 0.50 Case Rate 49320 Priced Laparoscopy biopsy 72063 49321 CPT Outpatient 41892.90 7191.61 Oxford Health Oxford Commercial 0.38 15732.52 0.38 41892.90 0.38 Case Rate 49321 Priced Laparoscopy aspiration 72063 49322 CPT Outpatient 34392.75 5904.09 Oxford Health Oxford Commercial 0.46 15732.52 0.46 34392.75 0.46 Case Rate 49322 Priced Lap insert tunnel ip cath 72063 49324 CPT Outpatient 39264.75 6740.45 Oxford Health Oxford Commercial 0.16 6441.84 0.16 39264.75 0.16 Case Rate 49324 Priced Laparo proc abdm/per/oment 72063 49329 CPT Outpatient 58696.05 10076.16 Oxford Health Oxford Commercial 0.19 10965.83 0.19 58696.05 0.19 Case Rate 49329 Priced Ins tun ip cath for dial opn 72063 49421 CPT Outpatient 25460.40 3319.30 Oxford Health Oxford Commercial 0.25 6441.84 0.25 25460.40 0.25 Case Rate 49421 Priced Remove tunneled ip cath 72063 49422 CPT Outpatient 25515.00 4380.08 Oxford Health Oxford Commercial 0.25 6441.84 0.25 25515.00 0.25 Case Rate 49422 Priced Rpr ing hernia init reduce 72063 49500 CPT Outpatient 19594.05 3363.65 Oxford Health Oxford Commercial 0.58 11273.22 0.58 19594.05 0.58 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 72063 49505 CPT Outpatient 34915.65 5993.85 Oxford Health Oxford Commercial 0.18 6313.00 0.18 34915.65 0.18 Case Rate 49505 Priced Prp i/hern init block >5 yr 72063 49507 CPT Outpatient 29794.80 5114.77 Oxford Health Oxford Commercial 0.22 6441.84 0.22 29794.80 0.22 Case Rate 49507 Priced Rerepair ing hernia reduce 72063 49520 CPT Outpatient 36940.05 6341.38 Oxford Health Oxford Commercial 0.17 6441.84 0.17 36940.05 0.17 Case Rate 49520 Priced Rpr ventral hern init reduc 72063 49560 CPT Outpatient 53177.25 9128.76 Oxford Health Oxford Commercial 0.15 7744.91 0.15 53177.25 0.15 Case Rate 49560 Priced Rpr ventral hern init block 72063 49561 CPT Outpatient 30755.55 5279.70 Oxford Health Oxford Commercial 0.21 6441.84 0.21 30755.55 0.21 Case Rate 49561 Priced Rerepair ventrl hern reduce 72063 49565 CPT Outpatient 69917.40 12002.49 Oxford Health Oxford Commercial 0.09 6313.00 0.09 69917.40 0.09 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 72063 49585 CPT Outpatient 41806.80 7176.83 Oxford Health Oxford Commercial 0.19 7744.91 0.19 41806.80 0.19 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 72063 49587 CPT Outpatient 37320.15 6406.63 Oxford Health Oxford Commercial 0.17 6441.84 0.17 37320.15 0.17 Case Rate 49587 Priced Lap ing hernia repair init 72063 49650 CPT Outpatient 41932.80 7198.46 Oxford Health Oxford Commercial 0.18 7590.01 0.18 41932.80 0.18 Case Rate 49650 Priced Lap ing hernia repair recur 72063 49651 CPT Outpatient 46915.05 8053.75 Oxford Health Oxford Commercial 0.25 11617.36 0.25 46915.05 0.25 Case Rate 49651 Priced Lap vent/abd hernia repair 72063 49652 CPT Outpatient 51294.60 8805.57 Oxford Health Oxford Commercial 0.09 4817.93 0.09 51294.60 0.09 Case Rate 49652 Priced Lap vent/abd hern proc comp 72063 49653 CPT Outpatient 46102.35 7914.24 Oxford Health Oxford Commercial 0.10 4817.93 0.10 46102.35 0.10 Case Rate 49653 Priced Lap inc hernia repair 72063 49654 CPT Outpatient 47221.65 8106.38 Oxford Health Oxford Commercial 0.10 4817.93 0.10 47221.65 0.10 Case Rate 49654 Priced Lap inc hern repair comp 72063 49655 CPT Outpatient 54590.55 9371.38 Oxford Health Oxford Commercial 0.09 4817.93 0.09 54590.55 0.09 Case Rate 49655 Priced Lap inc hernia repair recur 72063 49656 CPT Outpatient 55443.15 9517.74 Oxford Health Oxford Commercial 0.09 4817.93 0.09 55443.15 0.09 Case Rate 49656 Priced Removal of kidney stone 72063 50080 CPT Outpatient 53165.70 9126.78 Oxford Health Oxford Commercial 0.35 18581.36 0.35 53165.70 0.35 Case Rate 50080 Priced Removal of kidney stone 72063 50081 CPT Outpatient 66931.20 11489.86 Oxford Health Oxford Commercial 0.24 15732.52 0.24 66931.20 0.24 Case Rate 50081 Priced Renal biopsy perq 72063 50200 CPT Outpatient 43096.20 1225.34 Oxford Health Oxford Commercial 0.11 4817.93 0.11 43096.20 0.11 Case Rate 50200 Priced Plmt nephroureteral catheter 72063 50433 CPT Outpatient 64566.60 1424.48 Oxford Health Oxford Commercial 0.29 18581.36 0.29 64566.60 0.29 Case Rate 50433 Priced Laparo radical nephrectomy 72063 50545 CPT Outpatient 43449.00 7458.75 Oxford Health Oxford Commercial 0.11 4817.93 0.11 43449.00 0.11 Case Rate 50545 Priced Laparoscope proc ureter 72063 50949 CPT Outpatient 49986.30 8580.98 Oxford Health Oxford Commercial 0.22 10965.83 0.22 49986.30 0.22 Case Rate 50949 Priced Injection for bladder x-ray 72063 51600 CPT Outpatient 3285.45 89.22 Oxford Health Oxford Commercial 0.94 3084.30 0.94 3285.45 0.94 Case Rate 51600 Priced Cystoscopy 72063 52000 CPT Outpatient 22149.75 3802.37 Oxford Health Oxford Commercial 0.75 16595.71 0.75 22149.75 0.75 Case Rate 52000 Priced Cystoscopy & ureter catheter 72063 52005 CPT Outpatient 42529.20 2095.77 Oxford Health Oxford Commercial 0.35 14988.35 0.35 42529.20 0.35 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 72063 52204 CPT Outpatient 31274.25 5368.75 Oxford Health Oxford Commercial 0.38 11896.72 0.38 31274.25 0.38 Case Rate 52204 Priced Cystoscopy and treatment 72063 52224 CPT Outpatient 13445.25 2308.10 Oxford Health Oxford Commercial 0.88 11896.72 0.88 13445.25 0.88 Case Rate 52224 Priced Cystoscopy and treatment 72063 52234 CPT Outpatient 28510.65 4894.33 Oxford Health Oxford Commercial 0.51 14548.48 0.51 28510.65 0.51 Case Rate 52234 Priced Cystoscopy and treatment 72063 52235 CPT Outpatient 29417.85 5050.06 Oxford Health Oxford Commercial 0.41 12139.52 0.41 29417.85 0.41 Case Rate 52235 Priced Cystoscopy and treatment 72063 52240 CPT Outpatient 33933.90 5825.32 Oxford Health Oxford Commercial 0.35 11896.72 0.35 33933.90 0.35 Case Rate 52240 Priced Cystoscopy and treatment 72063 52281 CPT Outpatient 22159.20 3804.00 Oxford Health Oxford Commercial 0.50 11034.57 0.50 22159.20 0.50 Case Rate 52281 Priced Remove bladder stone 72063 52317 CPT Outpatient 27085.80 4649.73 Oxford Health Oxford Commercial 0.45 12139.52 0.45 27085.80 0.45 Case Rate 52317 Priced Remove bladder stone 72063 52318 CPT Outpatient 26685.75 4581.05 Oxford Health Oxford Commercial 0.45 12139.52 0.45 26685.75 0.45 Case Rate 52318 Priced Cystoscopy and treatment 72063 52332 CPT Outpatient 115306.80 19794.33 Oxford Health Oxford Commercial 0.11 13041.78 0.11 115306.80 0.11 Case Rate 52332 Priced Cystouretero w/stone remove 72063 52352 CPT Outpatient 42420.00 7282.10 Oxford Health Oxford Commercial 0.40 17156.94 0.40 42420.00 0.40 Case Rate 52352 Priced Cystouretero w/lithotripsy 72063 52353 CPT Outpatient 38608.50 6627.79 Oxford Health Oxford Commercial 0.33 12626.01 0.33 38608.50 0.33 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 72063 52356 CPT Outpatient 36255.45 6223.85 Oxford Health Oxford Commercial 0.35 12626.01 0.35 36255.45 0.35 Case Rate 52356 Priced Prostatectomy (turp) 72063 52601 CPT Outpatient 35371.35 6072.08 Oxford Health Oxford Commercial 0.36 12883.68 0.36 35371.35 0.36 Case Rate 52601 Priced Laser surgery of prostate 72063 52648 CPT Outpatient 24264.45 4165.40 Oxford Health Oxford Commercial 0.52 12626.01 0.52 24264.45 0.52 Case Rate 52648 Priced Revision of urethra 72063 53450 CPT Outpatient 16209.90 2782.70 Oxford Health Oxford Commercial 0.57 9290.68 0.57 16209.90 0.57 Case Rate 53450 Priced Urology surgery procedure 72063 53899 CPT Outpatient 25368.00 134.83 Oxford Health Oxford Commercial 0.40 10055.28 0.40 25368.00 0.40 Case Rate 53899 Priced Circumcision w/regionl block 72063 54150 CPT Outpatient 14700.00 2523.50 Oxford Health Oxford Commercial 0.39 5697.68 0.39 14700.00 0.39 Case Rate 54150 Priced Circum 28 days or older 72063 54161 CPT Outpatient 19186.65 3293.71 Oxford Health Oxford Commercial 0.30 5697.68 0.30 19186.65 0.30 Case Rate 54161 Priced Lysis penil circumic lesion 72063 54162 CPT Outpatient 19795.65 3398.25 Oxford Health Oxford Commercial 0.56 11087.18 0.56 19795.65 0.56 Case Rate 54162 Priced Repair of circumcision 72063 54163 CPT Outpatient 16391.55 2813.88 Oxford Health Oxford Commercial 0.49 8106.64 0.49 16391.55 0.49 Case Rate 54163 Priced Reconstruction of urethra 72063 54324 CPT Outpatient 32880.75 5644.53 Oxford Health Oxford Commercial 0.47 15292.64 0.47 32880.75 0.47 Case Rate 54324 Priced Revise penis/urethra 72063 54332 CPT Outpatient 19968.90 3427.99 Oxford Health Oxford Commercial 0.32 6441.84 0.32 19968.90 0.32 Case Rate 54332 Priced Insert self-contd prosthesis 72063 54401 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 72063 54520 CPT Outpatient 35442.75 6084.34 Oxford Health Oxford Commercial 0.27 9662.76 0.27 35442.75 0.27 Case Rate 54520 Priced Reduce testis torsion 72063 54600 CPT Outpatient 55049.40 9450.15 Oxford Health Oxford Commercial 0.19 10715.10 0.19 55049.40 0.19 Case Rate 54600 Priced Suspension of testis 72063 54640 CPT Outpatient 26860.05 4610.98 Oxford Health Oxford Commercial 0.24 6441.84 0.24 26860.05 0.24 Case Rate 54640 Priced Removal of hydrocele 72063 55040 CPT Outpatient 27277.95 4682.71 Oxford Health Oxford Commercial 0.24 6441.84 0.24 27277.95 0.24 Case Rate 55040 Priced Biopsy of prostate gland 72063 55700 CPT Outpatient 28699.65 4926.77 Oxford Health Oxford Commercial 0.17 4817.93 0.17 28699.65 0.17 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 72063 55866 CPT Outpatient 93088.80 15980.24 Oxford Health Oxford Commercial 0.12 11617.36 0.12 93088.80 0.12 Case Rate 55866 Priced Closure of vagina 72063 57120 CPT Outpatient 34369.65 5900.12 Oxford Health Oxford Commercial 0.28 9469.50 0.28 34369.65 0.28 Case Rate 57120 Priced Repair of vagina 72063 57200 CPT Outpatient 25247.25 4334.11 Oxford Health Oxford Commercial 0.48 12139.52 0.48 25247.25 0.48 Case Rate 57200 Priced Anterior colporrhaphy 72063 57240 CPT Outpatient 36210.30 6216.10 Oxford Health Oxford Commercial 0.31 11087.18 0.31 36210.30 0.31 Case Rate 57240 Priced Repair rectum & vagina 72063 57250 CPT Outpatient 40441.80 6942.51 Oxford Health Oxford Commercial 0.28 11273.22 0.28 40441.80 0.28 Case Rate 57250 Priced Cmbn ant pst colprhy 72063 57260 CPT Outpatient 46323.90 7952.27 Oxford Health Oxford Commercial 0.38 17715.06 0.38 46323.90 0.38 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 72063 57265 CPT Outpatient 42586.95 7310.76 Oxford Health Oxford Commercial 0.26 11273.22 0.26 42586.95 0.26 Case Rate 57265 Priced Repair of bowel bulge 72063 57268 CPT Outpatient 36865.50 6328.58 Oxford Health Oxford Commercial 0.29 10715.10 0.29 36865.50 0.29 Case Rate 57268 Priced Colpopexy extraperitoneal 72063 57282 CPT Outpatient 45629.85 7833.12 Oxford Health Oxford Commercial 0.25 11273.22 0.25 45629.85 0.25 Case Rate 57282 Priced Repair bladder defect 72063 57288 CPT Outpatient 43069.95 7393.67 Oxford Health Oxford Commercial 0.26 11047.76 0.26 43069.95 0.26 Case Rate 57288 Priced Bx/curett of cervix w/scope 72063 57454 CPT Outpatient 2888.55 442.93 Oxford Health Oxford Commercial 0.94 2711.70 0.94 2888.55 0.94 Case Rate 57454 Priced Conization of cervix 72063 57520 CPT Outpatient 26728.80 4588.44 Oxford Health Oxford Commercial 0.21 5697.68 0.21 26728.80 0.21 Case Rate 57520 Priced Conization of cervix 72063 57522 CPT Outpatient 22737.75 3903.31 Oxford Health Oxford Commercial 0.25 5697.68 0.25 22737.75 0.25 Case Rate 57522 Priced Biopsy of uterus lining 72063 58100 CPT Outpatient 2371.95 194.80 Oxford Health Oxford Commercial 0.94 2226.29 0.94 2371.95 0.94 Case Rate 58100 Priced Catheter for hysterography 72063 58340 CPT Outpatient 6322.05 131.04 Oxford Health Oxford Commercial 0.76 4817.93 0.76 6322.05 0.76 Case Rate 58340 Priced Reopen fallopian tube 72063 58350 CPT Outpatient 46507.65 7983.81 Oxford Health Oxford Commercial 0.27 12576.29 0.27 46507.65 0.27 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 72063 58542 CPT Outpatient 64194.90 11020.12 Oxford Health Oxford Commercial 0.20 12576.29 0.20 64194.90 0.20 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 72063 58544 CPT Outpatient 51020.55 8758.53 Oxford Health Oxford Commercial 0.26 13227.82 0.26 51020.55 0.26 Case Rate 58544 Priced Laparoscopic myomectomy 72063 58545 CPT Outpatient 56946.75 9775.86 Oxford Health Oxford Commercial 0.16 9290.68 0.16 56946.75 0.16 Case Rate 58545 Priced Laparo-vag hyst incl t/o 72063 58552 CPT Outpatient 57228.15 9824.17 Oxford Health Oxford Commercial 0.19 10593.74 0.19 57228.15 0.19 Case Rate 58552 Priced Hysteroscopy biopsy 72063 58558 CPT Outpatient 28581.00 2077.02 Oxford Health Oxford Commercial 0.51 14548.48 0.51 28581.00 0.51 Case Rate 58558 Priced Hysteroscopy remove myoma 72063 58561 CPT Outpatient 35222.25 6046.49 Oxford Health Oxford Commercial 0.18 6441.84 0.18 35222.25 0.18 Case Rate 58561 Priced Hysteroscopy ablation 72063 58563 CPT Outpatient 38399.55 6591.92 Oxford Health Oxford Commercial 0.29 11273.22 0.29 38399.55 0.29 Case Rate 58563 Priced Tlh uterus 250 g or less 72063 58570 CPT Outpatient 43316.70 7436.03 Oxford Health Oxford Commercial 0.18 7744.91 0.18 43316.70 0.18 Case Rate 58570 Priced Tlh w/t/o 250 g or less 72063 58571 CPT Outpatient 48603.45 8343.59 Oxford Health Oxford Commercial 0.23 10965.83 0.23 48603.45 0.23 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 72063 58573 CPT Outpatient 52905.30 9082.08 Oxford Health Oxford Commercial 0.22 11617.36 0.22 52905.30 0.22 Case Rate 58573 Priced Laparoscopy remove adnexa 72063 58661 CPT Outpatient 47008.50 8069.79 Oxford Health Oxford Commercial 0.23 10593.74 0.23 47008.50 0.23 Case Rate 58661 Priced Laparoscopy excise lesions 72063 58662 CPT Outpatient 45053.40 7734.17 Oxford Health Oxford Commercial 0.26 11617.36 0.26 45053.40 0.26 Case Rate 58662 Priced Treat ectopic pregnancy 72063 59151 CPT Outpatient 74690.70 12821.90 Oxford Health Oxford Commercial 0.10 7744.91 0.10 74690.70 0.10 Case Rate 59151 Priced Treatment of miscarriage 72063 59812 CPT Outpatient 56109.90 9632.20 Oxford Health Oxford Commercial 0.10 5697.68 0.10 56109.90 0.10 Case Rate 59812 Priced Partial removal of thyroid 72063 60220 CPT Outpatient 53639.25 9208.07 Oxford Health Oxford Commercial 0.14 7744.91 0.14 53639.25 0.14 Case Rate 60220 Priced Removal of thyroid 72063 60240 CPT Outpatient 98252.70 16866.71 Oxford Health Oxford Commercial 0.08 7744.91 0.08 98252.70 0.08 Case Rate 60240 Priced Explore parathyroid glands 72063 60500 CPT Outpatient 150495.45 25835.05 Oxford Health Oxford Commercial 0.09 12883.68 0.09 150495.45 0.09 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 72063 62322 CPT Outpatient 43709.40 514.24 Oxford Health Oxford Commercial 0.23 10055.28 0.23 43709.40 0.23 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 72063 62323 CPT Outpatient 8304.45 467.31 Oxford Health Oxford Commercial 0.58 4817.93 0.58 8304.45 0.58 Case Rate 62323 Priced Low back disk surgery 72063 63030 CPT Outpatient 50287.65 8632.71 Oxford Health Oxford Commercial 0.23 11617.36 0.23 50287.65 0.23 Case Rate 63030 Priced Inc for vagus n elect impl 72063 64568 CPT Outpatient 124562.55 21383.24 Oxford Health Oxford Commercial 0.06 7744.91 0.06 124562.55 0.06 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 72063 66821 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 72063 66984 CPT Outpatient 0.01 0.01 Oxford Health Oxford Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 562043 216 DRG Inpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 562043 460 DRG Inpatient 416122.79 53834.63 United Health Care United Commercial 0.19 79852.77 0.19 416122.79 0.19 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 562043 470 DRG Inpatient 167912.19 21723.13 United Health Care United Commercial 0.04 7323.66 0.04 167912.19 0.04 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 562043 473 DRG Inpatient 100687.91 13026.19 United Health Care United Commercial 0.07 7323.66 0.07 100687.91 0.07 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 562043 743 DRG Inpatient 102691.67 13285.42 United Health Care United Commercial 0.07 7323.66 0.07 102691.67 0.07 Case Rate 743 Priced NORMAL NEWBORN 562043 795 DRG Inpatient 6266.93 2335.00 United Health Care United Commercial 0.28 1782.27 0.28 6266.93 0.28 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 562043 807 DRG Inpatient 116469.59 4193.00 United Health Care United Commercial 0.09 10914.08 0.09 116469.59 0.09 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 562043 788 DRG Inpatient 76050.77 4538.00 United Health Care United Commercial 0.19 14766.35 0.19 76050.77 0.19 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 562043 59400 CPT Inpatient 116469.59 4193.00 United Health Care United Commercial 0.09 10914.08 0.09 116469.59 0.09 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 562043 59510 CPT Inpatient 76050.77 4538.00 United Health Care United Commercial 0.19 14766.35 0.19 76050.77 0.19 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 562043 59610 CPT Inpatient 116469.59 4193.00 United Health Care United Commercial 0.09 10914.08 0.09 116469.59 0.09 Case Rate 59610 Priced "Psychotherapy, 30 min" 562043 90832 CPT Outpatient 577.50 91.21 United Health Care United Commercial 0.99 569.25 0.99 577.50 0.99 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 562043 90834 CPT Outpatient 44134.65 271.96 United Health Care United Commercial 0.94 41432.09 0.94 44134.65 0.94 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 562043 90837 CPT Outpatient 2240.70 442.93 United Health Care United Commercial 0.14 321.23 0.14 2240.70 0.14 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 562043 90846 CPT Outpatient 0.01 131.50 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 562043 90847 CPT Outpatient 44134.65 369.97 United Health Care United Commercial 0.94 41432.09 0.94 44134.65 0.94 Fee Schedule 90847 Priced Group psychotherapy 562043 90853 CPT Outpatient 44134.65 101.99 United Health Care United Commercial 0.94 41432.09 0.94 44134.65 0.94 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 562043 99203 CPT Outpatient 3480.75 176.07 United Health Care United Commercial 0.71 2473.49 0.71 3480.75 0.71 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 562043 99204 CPT Outpatient 2103.15 233.39 United Health Care United Commercial 0.40 838.35 0.40 2103.15 0.40 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 562043 99205 CPT Outpatient 4970.70 314.28 United Health Care United Commercial 0.17 838.35 0.17 4970.70 0.17 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 562043 99243 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 562043 99244 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 562043 99385 CPT Outpatient 1114.05 185.90 United Health Care United Commercial 0.71 791.33 0.71 1114.05 0.71 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 562043 99386 CPT Outpatient 4877.25 185.90 United Health Care United Commercial 0.06 273.76 0.06 4877.25 0.06 Fee Schedule 99386 Priced Routine venipuncture 562043 36415 CPT Outpatient 127.05 19.57 United Health Care United Commercial 0.02 3.11 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 562043 80048 CPT Outpatient 576.45 88.78 United Health Care United Commercial 0.02 8.76 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 562043 80053 CPT Outpatient 763.35 117.56 United Health Care United Commercial 0.01 10.93 0.01 763.35 0.01 Fee Schedule 80053 Priced Obstetric blood test panel 562043 80055 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 562043 80061 CPT Outpatient 1349.25 197.77 United Health Care United Commercial 0.01 13.86 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 562043 80069 CPT Outpatient 716.10 104.95 United Health Care United Commercial 0.01 8.98 0.01 716.10 0.01 Fee Schedule 80069 Priced Liver function panel test 562043 80076 CPT Outpatient 716.10 104.95 United Health Care United Commercial 0.01 8.46 0.01 716.10 0.01 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 562043 81000 CPT Outpatient 144.90 21.18 United Health Care United Commercial 0.03 4.16 0.03 144.90 0.03 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 562043 81001 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 562043 81002 CPT Outpatient 57.75 8.89 United Health Care United Commercial 0.06 3.60 0.06 57.75 0.06 Fee Schedule 81002 Priced Automated urinalysis test 562043 81003 CPT Outpatient 219.45 33.80 United Health Care United Commercial 0.01 2.33 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 562043 82306 CPT Outpatient 1880.55 289.62 United Health Care United Commercial 0.02 30.64 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 562043 83036 CPT Outpatient 494.55 76.17 United Health Care United Commercial 0.02 10.05 0.02 494.55 0.02 Fee Schedule 83036 Priced PSA (prostate specific antigen) 562043 84153 CPT Outpatient 1177.05 181.28 United Health Care United Commercial 0.02 19.03 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 562043 84154 CPT Outpatient 598.50 92.17 United Health Care United Commercial 0.03 19.03 0.03 598.50 0.03 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 562043 84443 CPT Outpatient 519.75 80.05 United Health Care United Commercial 0.03 17.39 0.03 519.75 0.03 Fee Schedule 84443 Priced Chorionic gonadotropin assay 562043 84703 CPT Outpatient 785.40 120.96 United Health Care United Commercial 0.01 7.78 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 562043 85025 CPT Outpatient 635.25 97.83 United Health Care United Commercial 0.01 8.04 0.01 635.25 0.01 Fee Schedule 85025 Priced "Complete blood count, automated" 562043 85027 CPT Outpatient 576.45 88.78 United Health Care United Commercial 0.01 6.70 0.01 576.45 0.01 Fee Schedule 85027 Priced "Blood test, clotting time" 562043 85610 CPT Outpatient 404.25 62.26 United Health Care United Commercial 0.01 4.44 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 562043 85730 CPT Outpatient 17.22 2.65 United Health Care United Commercial 0.36 6.22 0.36 17.22 0.36 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 562043 86003 CPT Outpatient 32.55 5.01 United Health Care United Commercial 0.17 5.40 0.17 32.55 0.17 Fee Schedule 86003 Priced Tb test cell immun measure 562043 86480 CPT Outpatient 530.25 81.66 United Health Care United Commercial 0.12 64.15 0.12 530.25 0.12 Fee Schedule 86480 Priced Urine culture/colony count 562043 87086 CPT Outpatient 763.35 117.56 United Health Care United Commercial 0.01 8.35 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 562043 87338 CPT Outpatient 785.40 120.96 United Health Care United Commercial 0.02 14.88 0.02 785.40 0.02 Fee Schedule 87338 Priced Cytopath eval fna report 562043 88173 CPT Outpatient 750.75 115.62 United Health Care United Commercial 0.07 52.53 0.07 750.75 0.07 Fee Schedule 88173 Priced Tissue exam by pathologist 562043 88302 CPT Outpatient 635.25 97.83 United Health Care United Commercial 0.04 26.11 0.04 635.25 0.04 Fee Schedule 88302 Priced Tissue exam by pathologist 562043 88305 CPT Outpatient 323.40 49.81 United Health Care United Commercial 0.16 52.53 0.16 323.40 0.16 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 562043 11042 CPT Outpatient 2668.05 481.45 United Health Care United Commercial 0.71 1896.06 0.71 2668.05 0.71 Case Rate 11042 Priced Deb subq tissue add-on 562043 11045 CPT Outpatient 4652.55 330.00 United Health Care United Commercial 0.71 3306.35 0.71 4652.55 0.71 Case Rate 11045 Priced Dx bronchoscope/lavage 562043 31624 CPT Outpatient 41223.00 7602.31 United Health Care United Commercial 0.23 9668.19 0.23 41223.00 0.23 Case Rate 31624 Priced Bronchoscopy/lung bx each 562043 31628 CPT Outpatient 49048.65 9045.51 United Health Care United Commercial 0.20 9668.19 0.20 49048.65 0.20 Case Rate 31628 Priced Blood transfusion service 562043 36430 CPT Outpatient 9166.50 574.93 United Health Care United Commercial 0.05 431.62 0.05 9166.50 0.05 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 562043 43235 CPT Outpatient 8856.75 1633.35 United Health Care United Commercial 0.55 4908.20 0.55 8856.75 0.55 Case Rate 43235 Priced Endoscopic us exam esoph 562043 43237 CPT Outpatient 23867.55 4401.63 United Health Care United Commercial 0.31 7512.55 0.31 23867.55 0.31 Case Rate 43237 Priced Egd us fine needle bx/aspir 562043 43238 CPT Outpatient 30690.45 5659.90 United Health Care United Commercial 0.16 5008.37 0.16 30690.45 0.16 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 562043 43239 CPT Outpatient 40191.90 7412.15 United Health Care United Commercial 0.22 8764.64 0.22 40191.90 0.22 Case Rate 43239 Priced Ercp remove duct calculi 562043 43264 CPT Outpatient 34335.00 6332.03 United Health Care United Commercial 0.26 8867.88 0.26 34335.00 0.26 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 562043 45378 CPT Outpatient 13991.25 889.35 United Health Care United Commercial 0.36 5008.37 0.36 13991.25 0.36 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 562043 45380 CPT Outpatient 22215.90 4097.04 United Health Care United Commercial 0.34 7512.55 0.34 22215.90 0.34 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 562043 45385 CPT Outpatient 119569.80 22050.95 United Health Care United Commercial 0.06 7362.30 0.06 119569.80 0.06 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 562043 45391 CPT Outpatient 24923.85 4596.43 United Health Care United Commercial 0.30 7512.55 0.30 24923.85 0.30 Case Rate 45391 Priced Fragmenting of kidney stone 562043 50590 CPT Outpatient 40930.05 7548.28 United Health Care United Commercial 0.20 8188.44 0.20 40930.05 0.20 Case Rate 50590 Priced Fetal non-stress test 562043 59025 CPT Outpatient 3153.15 477.76 United Health Care United Commercial 0.21 649.98 0.21 3153.15 0.21 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 562043 64483 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 562043 92567 CPT Outpatient 2224.95 98.50 United Health Care United Commercial 0.52 1148.85 0.52 2224.95 0.52 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 562043 93000 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 562043 93017 CPT Outpatient 3076.50 532.96 United Health Care United Commercial 0.21 649.98 0.21 3076.50 0.21 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 562043 93452 CPT Outpatient 55621.65 8611.87 United Health Care United Commercial 0.12 6684.03 0.12 55621.65 0.12 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 562043 95810 CPT Outpatient 20341.65 3373.48 United Health Care United Commercial 0.22 4549.86 0.22 20341.65 0.22 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 562043 95811 CPT Outpatient 22491.00 3731.18 United Health Care United Commercial 0.20 4549.86 0.20 22491.00 0.20 Case Rate 95811 Priced Eeg 41-60 minutes 562043 95812 CPT Outpatient 5578.65 925.83 United Health Care United Commercial 0.06 358.11 0.06 5578.65 0.06 Case Rate 95812 Priced Genetic counseling 30 min 562043 96040 CPT Outpatient 0.01 102.81 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 562043 96413 CPT Outpatient 4856.25 472.45 United Health Care United Commercial 0.84 4088.26 0.84 4856.25 0.84 Case Rate 96413 Priced Ultrasound therapy 562043 97035 CPT Outpatient 2111.55 134.99 United Health Care United Commercial 0.60 1266.84 0.60 2111.55 0.60 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 562043 97110 CPT Outpatient 6494.25 92.86 United Health Care United Commercial 0.65 4222.80 0.65 6494.25 0.65 Case Rate 97110 Priced Gait training therapy 562043 97116 CPT Outpatient 4723.95 110.61 United Health Care United Commercial 0.72 3378.24 0.72 4723.95 0.72 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 562043 70450 CPT Outpatient 8566.95 835.61 United Health Care United Commercial 0.14 1206.81 0.14 8566.95 0.14 Case Rate 70450 Priced Mri brain stem w/o dye 562043 70551 CPT Outpatient 7861.35 1361.31 United Health Care United Commercial 0.07 547.26 0.07 7861.35 0.07 Case Rate 70551 Priced MRI scan of brain before and after contrast 562043 70553 CPT Outpatient 10882.20 1625.88 United Health Care United Commercial 0.08 875.82 0.08 10882.20 0.08 Case Rate 70553 Priced X-ray exam chest 2 views 562043 71046 CPT Outpatient 859.95 150.37 United Health Care United Commercial 0.22 192.38 0.22 859.95 0.22 Case Rate 71046 Priced Ct thorax w/o dye 562043 71250 CPT Outpatient 7288.05 1261.63 United Health Care United Commercial 0.04 258.94 0.04 7288.05 0.04 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 562043 72082 CPT Outpatient 2022.30 253.33 United Health Care United Commercial 0.26 517.87 0.26 2022.30 0.26 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 562043 72100 CPT Outpatient 1599.15 277.38 United Health Care United Commercial 0.16 258.94 0.16 1599.15 0.16 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 562043 72110 CPT Outpatient 1389.15 241.04 United Health Care United Commercial 0.19 258.94 0.19 1389.15 0.19 Case Rate 72110 Priced MRI scan of lower spinal canal 562043 72148 CPT Outpatient 7861.35 1361.31 United Health Care United Commercial 0.07 547.26 0.07 7861.35 0.07 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 562043 72193 CPT Outpatient 13671.00 1412.01 United Health Care United Commercial 0.03 425.87 0.03 13671.00 0.03 Case Rate 72193 Priced X-ray exam of shoulder 562043 73030 CPT Outpatient 1452.15 251.43 United Health Care United Commercial 0.13 192.38 0.13 1452.15 0.13 Case Rate 73030 Priced X-ray exam of elbow 562043 73080 CPT Outpatient 1356.60 235.68 United Health Care United Commercial 0.14 192.38 0.14 1356.60 0.14 Case Rate 73080 Priced X-ray exam of forearm 562043 73090 CPT Outpatient 1243.20 215.26 United Health Care United Commercial 0.15 192.38 0.15 1243.20 0.15 Case Rate 73090 Priced X-ray exam of wrist 562043 73110 CPT Outpatient 1243.20 215.26 United Health Care United Commercial 0.15 192.38 0.15 1243.20 0.15 Case Rate 73110 Priced X-ray exam of hand 562043 73130 CPT Outpatient 1243.20 215.26 United Health Care United Commercial 0.15 192.38 0.15 1243.20 0.15 Case Rate 73130 Priced X-ray exam hips bi 2 views 562043 73521 CPT Outpatient 970.20 228.41 United Health Care United Commercial 0.27 258.94 0.27 970.20 0.27 Case Rate 73521 Priced X-ray exam of knee 3 562043 73562 CPT Outpatient 802.20 139.12 United Health Care United Commercial 0.24 192.38 0.24 802.20 0.24 Case Rate 73562 Priced X-ray exam of lower leg 562043 73590 CPT Outpatient 1243.20 215.26 United Health Care United Commercial 0.15 192.38 0.15 1243.20 0.15 Case Rate 73590 Priced X-ray exam of ankle 562043 73610 CPT Outpatient 1378.65 239.31 United Health Care United Commercial 0.14 192.38 0.14 1378.65 0.14 Case Rate 73610 Priced X-ray exam of foot 562043 73630 CPT Outpatient 975.45 169.41 United Health Care United Commercial 0.20 192.38 0.20 975.45 0.20 Case Rate 73630 Priced MRI scan of leg joint 562043 73721 CPT Outpatient 7861.35 1361.31 United Health Care United Commercial 0.07 547.26 0.07 7861.35 0.07 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 562043 74177 CPT Outpatient 14222.25 1412.01 United Health Care United Commercial 0.06 876.96 0.06 14222.25 0.06 Case Rate 74177 Priced Contrst x-ray exam of throat 562043 74210 CPT Outpatient 0.01 440.39 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 562043 76098 CPT Outpatient 6141.45 407.86 United Health Care United Commercial 0.80 4908.20 0.80 6141.45 0.80 Case Rate 76098 Priced Us exam of head and neck 562043 76536 CPT Outpatient 5512.50 955.18 United Health Care United Commercial 0.05 258.94 0.05 5512.50 0.05 Case Rate 76536 Priced Ultrasound breast limited 562043 76642 CPT Outpatient 5777.10 127.70 United Health Care United Commercial 0.09 517.95 0.09 5777.10 0.09 Case Rate 76642 Priced Ultrasound of abdomen 562043 76700 CPT Outpatient 4917.15 851.88 United Health Care United Commercial 0.05 258.94 0.05 4917.15 0.05 Case Rate 76700 Priced Echo exam of abdomen 562043 76705 CPT Outpatient 3836.70 665.17 United Health Care United Commercial 0.07 258.94 0.07 3836.70 0.07 Case Rate 76705 Priced Us exam abdo back wall comp 562043 76770 CPT Outpatient 5171.25 895.48 United Health Care United Commercial 0.05 258.94 0.05 5171.25 0.05 Case Rate 76770 Priced Us exam abdo back wall lim 562043 76775 CPT Outpatient 3969.00 686.97 United Health Care United Commercial 0.07 258.94 0.07 3969.00 0.07 Case Rate 76775 Priced Ob us < 14 wks single fetus 562043 76801 CPT Outpatient 2006.55 347.98 United Health Care United Commercial 0.13 258.94 0.13 2006.55 0.13 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 562043 76805 CPT Outpatient 3969.00 686.97 United Health Care United Commercial 0.07 258.94 0.07 3969.00 0.07 Case Rate 76805 Priced Ob us detailed sngl fetus 562043 76811 CPT Outpatient 2844.45 492.99 United Health Care United Commercial 0.19 547.26 0.19 2844.45 0.19 Case Rate 76811 Priced Ob us nuchal meas 1 gest 562043 76813 CPT Outpatient 1044.75 180.83 United Health Care United Commercial 0.25 258.94 0.25 1044.75 0.25 Case Rate 76813 Priced Ob us limited fetus(s) 562043 76815 CPT Outpatient 6428.10 639.90 United Health Care United Commercial 0.08 517.87 0.08 6428.10 0.08 Case Rate 76815 Priced Ob us follow-up per fetus 562043 76816 CPT Outpatient 4818.45 833.88 United Health Care United Commercial 0.05 258.94 0.05 4818.45 0.05 Case Rate 76816 Priced Transvaginal us obstetric 562043 76817 CPT Outpatient 6428.10 476.73 United Health Care United Commercial 0.08 517.87 0.08 6428.10 0.08 Case Rate 76817 Priced Fetal biophys profil w/o nst 562043 76819 CPT Outpatient 1741.95 302.65 United Health Care United Commercial 0.15 258.94 0.15 1741.95 0.15 Case Rate 76819 Priced Ultrasound pelvis through vagina 562043 76830 CPT Outpatient 9305.10 806.54 United Health Care United Commercial 0.06 517.87 0.06 9305.10 0.06 Case Rate 76830 Priced Us exam scrotum 562043 76870 CPT Outpatient 6328.35 1096.55 United Health Care United Commercial 0.04 258.94 0.04 6328.35 0.04 Case Rate 76870 Priced Us exam infant hips dynamic 562043 76885 CPT Outpatient 3836.70 665.17 United Health Care United Commercial 0.05 192.38 0.05 3836.70 0.05 Case Rate 76885 Priced Mammography of one breast 562043 77065 CPT Outpatient 3451.35 192.07 United Health Care United Commercial 0.13 459.93 0.13 3451.35 0.13 Case Rate 77065 Priced Mammography of both breasts 562043 77066 CPT Outpatient 5777.10 235.68 United Health Care United Commercial 0.09 517.95 0.09 5777.10 0.09 Case Rate 77066 Priced "Mamography, screening bilateral" 562043 77067 CPT Outpatient 1416.45 205.57 United Health Care United Commercial 0.20 278.83 0.20 1416.45 0.20 Case Rate 77067 Priced X-rays for bone age 562043 77072 CPT Outpatient 2022.30 163.87 United Health Care United Commercial 0.26 517.87 0.26 2022.30 0.26 Case Rate 77072 Priced Joint survey single view 562043 77077 CPT Outpatient 985.95 171.14 United Health Care United Commercial 0.26 258.94 0.26 985.95 0.26 Case Rate 77077 Priced Dxa bone density axial 562043 77080 CPT Outpatient 3257.10 319.09 United Health Care United Commercial 0.17 537.77 0.17 3257.10 0.17 Case Rate 77080 Priced Fna bx w/us gdn 1st les 562043 10005 CPT Outpatient 5512.50 547.24 United Health Care United Commercial 0.91 5008.37 0.91 5512.50 0.91 Case Rate 10005 Priced Fna bx w/us gdn ea addl 562043 10006 CPT Outpatient 10628.10 594.83 United Health Care United Commercial 0.94 9977.40 0.94 10628.10 0.94 Case Rate 10006 Priced Drainage of hematoma/fluid 562043 10140 CPT Outpatient 23209.20 1081.95 United Health Care United Commercial 0.50 11692.40 0.50 23209.20 0.50 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 562043 11042 CPT Outpatient 2668.05 481.45 United Health Care United Commercial 0.71 1896.06 0.71 2668.05 0.71 Case Rate 11042 Priced Deb bone 20 sq cm/< 562043 11044 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 562043 11406 CPT Outpatient 19967.85 3427.81 United Health Care United Commercial 0.25 5008.37 0.25 19967.85 0.25 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 562043 11424 CPT Outpatient 0.01 1004.93 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 562043 11770 CPT Outpatient 19173.00 3291.37 United Health Care United Commercial 0.31 5911.92 0.31 19173.00 0.31 Case Rate 11770 Priced Replace tissue expander 562043 11970 CPT Outpatient 59239.95 10169.52 United Health Care United Commercial 0.33 19651.56 0.33 59239.95 0.33 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 562043 14020 CPT Outpatient 32166.75 5521.96 United Health Care United Commercial 0.15 4908.20 0.15 32166.75 0.15 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 562043 14060 CPT Outpatient 25993.80 1374.69 United Health Care United Commercial 0.35 9188.21 0.35 25993.80 0.35 Case Rate 14060 Priced Wound prep trk/arm/leg 562043 15002 CPT Outpatient 41748.00 1441.73 United Health Care United Commercial 0.22 9188.21 0.22 41748.00 0.22 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 562043 15271 CPT Outpatient 24343.20 3769.48 United Health Care United Commercial 0.01 0.11 0.01 24343.20 0.01 Case Rate 15271 Priced Acellular derm matrix implt 562043 15777 CPT Outpatient 101672.55 17453.79 United Health Care United Commercial 0.13 12949.66 0.13 101672.55 0.13 Case Rate 15777 Priced Exc skin abd 562043 15830 CPT Outpatient 54696.60 9389.58 United Health Care United Commercial 0.17 9188.21 0.17 54696.60 0.17 Case Rate 15830 Priced Dressing change not for burn 562043 15852 CPT Outpatient 0.01 290.74 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 562043 15877 CPT Outpatient 63741.30 10942.26 United Health Care United Commercial 0.18 11278.14 0.18 63741.30 0.18 Case Rate 15877 Priced Suction lipectomy lwr extrem 562043 15879 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 562043 19000 CPT Outpatient 10143.00 594.83 United Health Care United Commercial 0.49 5008.37 0.49 10143.00 0.49 Case Rate 19000 Priced Bx breast 1st lesion strtctc 562043 19081 CPT Outpatient 12341.70 1250.69 United Health Care United Commercial 0.41 5008.37 0.41 12341.70 0.41 Case Rate 19081 Priced Bx breast add lesion us imag 562043 19084 CPT Outpatient 29058.75 547.24 United Health Care United Commercial 0.34 10016.73 0.34 29058.75 0.34 Case Rate 19084 Priced Biopsy of breast open 562043 19101 CPT Outpatient 39545.10 2737.82 United Health Care United Commercial 0.45 17604.32 0.45 39545.10 0.45 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 562043 19120 CPT Outpatient 35761.95 2737.82 United Health Care United Commercial 0.24 8416.10 0.24 35761.95 0.24 Case Rate 19120 Priced Excision breast lesion 562043 19125 CPT Outpatient 33184.20 0.01 United Health Care United Commercial 0.53 17604.32 0.53 33184.20 0.53 Case Rate 19125 Priced Perq device breast 1st imag 562043 19281 CPT Outpatient 6141.45 598.61 United Health Care United Commercial 0.80 4908.20 0.80 6141.45 0.80 Case Rate 19281 Priced Perq device breast ea imag 562043 19282 CPT Outpatient 8379.00 319.04 United Health Care United Commercial 1.17 9816.40 1.17 8379.00 1.17 Case Rate 19282 Priced Partial mastectomy 562043 19301 CPT Outpatient 39157.65 6722.06 United Health Care United Commercial 0.45 17604.32 0.45 39157.65 0.45 Case Rate 19301 Priced Mast simple complete 562043 19303 CPT Outpatient 105389.55 18091.87 United Health Care United Commercial 0.17 18183.92 0.17 105389.55 0.17 Case Rate 19303 Priced Reduction of large breast 562043 19318 CPT Outpatient 65239.65 11199.47 United Health Care United Commercial 0.10 6684.03 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 562043 19340 CPT Outpatient 113100.75 19415.63 United Health Care United Commercial 0.10 11052.58 0.10 113100.75 0.10 Case Rate 19340 Priced Delayed breast prosthesis 562043 19342 CPT Outpatient 56988.75 9783.07 United Health Care United Commercial 0.23 13368.58 0.23 56988.75 0.23 Case Rate 19342 Priced Breast reconstruction 562043 19357 CPT Outpatient 101672.55 17453.79 United Health Care United Commercial 0.13 12949.66 0.13 101672.55 0.13 Case Rate 19357 Priced Breast reconstruction 562043 19366 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 562043 19380 CPT Outpatient 61493.25 10556.34 United Health Care United Commercial 0.16 10026.05 0.16 61493.25 0.16 Case Rate 19380 Priced Removal of support implant 562043 20680 CPT Outpatient 42329.70 7266.60 United Health Care United Commercial 0.21 8867.88 0.21 42329.70 0.21 Case Rate 20680 Priced Cerv artific diskectomy 562043 22856 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 562043 24538 CPT Outpatient 51237.90 4775.24 United Health Care United Commercial 0.16 8416.10 0.16 51237.90 0.16 Case Rate 24538 Priced Remove wrist tendon lesion 562043 25111 CPT Outpatient 25855.20 4438.48 United Health Care United Commercial 0.23 5911.92 0.23 25855.20 0.23 Case Rate 25111 Priced Incise finger tendon sheath 562043 26055 CPT Outpatient 15862.35 2723.04 United Health Care United Commercial 0.47 7512.55 0.47 15862.35 0.47 Case Rate 26055 Priced Treat finger fracture each 562043 26727 CPT Outpatient 22779.75 2030.47 United Health Care United Commercial 0.26 5911.92 0.26 22779.75 0.26 Case Rate 26727 Priced Revision of knee joint 562043 27446 CPT Outpatient 67882.50 11653.16 United Health Care United Commercial 0.26 17637.44 0.26 67882.50 0.26 Case Rate 27446 Priced Total knee arthroplasty 562043 27447 CPT Outpatient 130698.75 22436.62 United Health Care United Commercial 0.13 17637.44 0.13 130698.75 0.13 Case Rate 27447 Priced Surgery to stop leg growth 562043 27485 CPT Outpatient 43310.40 7434.95 United Health Care United Commercial 0.41 17637.44 0.41 43310.40 0.41 Case Rate 27485 Priced Repair achilles tendon 562043 27650 CPT Outpatient 38246.25 3762.57 United Health Care United Commercial 0.46 17637.44 0.46 38246.25 0.46 Case Rate 27650 Priced Treatment of ankle fracture 562043 27792 CPT Outpatient 36101.10 6197.36 United Health Care United Commercial 0.49 17637.44 0.49 36101.10 0.49 Case Rate 27792 Priced Treatment of ankle fracture 562043 27814 CPT Outpatient 49405.65 8481.30 United Health Care United Commercial 0.36 17637.44 0.36 49405.65 0.36 Case Rate 27814 Priced Removal of foot lesion 562043 28080 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 562043 28285 CPT Outpatient 68603.85 11776.99 United Health Care United Commercial 0.26 17637.44 0.26 68603.85 0.26 Case Rate 28285 Priced Correction hallux valgus 562043 28296 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 562043 29823 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 562043 29826 CPT Outpatient 49840.35 8555.93 United Health Care United Commercial 0.22 10859.74 0.22 49840.35 0.22 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 562043 29881 CPT Outpatient 35556.15 6103.81 United Health Care United Commercial 0.19 6684.03 0.19 35556.15 0.19 Case Rate 29881 Priced Knee arthroscopy/surgery 562043 29882 CPT Outpatient 61099.50 10488.75 United Health Care United Commercial 0.21 12949.66 0.21 61099.50 0.21 Case Rate 29882 Priced Percut bx lung/mediastinum 562043 32405 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 562043 32555 CPT Outpatient 14597.10 687.29 United Health Care United Commercial 0.34 4908.20 0.34 14597.10 0.34 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 562043 32664 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 562043 35190 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 562043 36478 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 562043 36561 CPT Outpatient 53531.10 3292.99 United Health Care United Commercial 0.12 6684.03 0.12 53531.10 0.12 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 562043 36569 CPT Outpatient 31421.25 1299.06 United Health Care United Commercial 0.16 4908.20 0.16 31421.25 0.16 Case Rate 36569 Priced Removal tunneled cv cath 562043 36590 CPT Outpatient 1996.05 273.95 United Health Care United Commercial 2.46 4908.20 2.46 1996.05 2.46 Case Rate 36590 Priced Av fuse uppr arm basilic 562043 36819 CPT Outpatient 56861.70 9761.26 United Health Care United Commercial 0.26 14738.79 0.26 56861.70 0.26 Case Rate 36819 Priced Av fusion direct any site 562043 36821 CPT Outpatient 42953.40 7373.67 United Health Care United Commercial 0.16 6684.03 0.16 42953.40 0.16 Case Rate 36821 Priced Artery-vein autograft 562043 36825 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 562043 36830 CPT Outpatient 53656.05 9210.96 United Health Care United Commercial 0.28 15039.59 0.28 53656.05 0.28 Case Rate 36830 Priced Av fistula revision open 562043 36832 CPT Outpatient 52492.65 9011.24 United Health Care United Commercial 0.33 17192.89 0.33 52492.65 0.33 Case Rate 36832 Priced Av fistula revision 562043 36833 CPT Outpatient 37098.60 6368.59 United Health Care United Commercial 0.46 17192.89 0.46 37098.60 0.46 Case Rate 36833 Priced Intro cath dialysis circuit 562043 36903 CPT Outpatient 77541.45 10669.90 United Health Care United Commercial 0.19 15039.59 0.19 77541.45 0.19 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 562043 36906 CPT Outpatient 96694.50 16175.64 United Health Care United Commercial 0.15 14738.79 0.15 96694.50 0.15 Case Rate 36906 Priced Fem/popl revas w/tla 562043 37224 CPT Outpatient 200076.45 5139.31 United Health Care United Commercial 0.11 21285.09 0.11 200076.45 0.11 Case Rate 37224 Priced Fem/popl revasc stnt & ather 562043 37227 CPT Outpatient 117170.55 18045.38 United Health Care United Commercial 0.07 8355.56 0.07 117170.55 0.07 Case Rate 37227 Priced Revise leg vein 562043 37700 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 562043 37722 CPT Outpatient 27815.55 4775.00 United Health Care United Commercial 0.36 10026.05 0.36 27815.55 0.36 Case Rate 37722 Priced Stab phleb veins xtr 10-20 562043 37765 CPT Outpatient 26561.85 4559.78 United Health Care United Commercial 0.42 11052.58 0.42 26561.85 0.42 Case Rate 37765 Priced Biopsy/removal lymph nodes 562043 38500 CPT Outpatient 35955.15 6172.30 United Health Care United Commercial 0.16 5911.92 0.16 35955.15 0.16 Case Rate 38500 Priced Biopsy/removal lymph nodes 562043 38525 CPT Outpatient 101194.80 17371.77 United Health Care United Commercial 0.11 11504.03 0.11 101194.80 0.11 Case Rate 38525 Priced Laparoscopy lymph node biop 562043 38570 CPT Outpatient 65631.30 11266.71 United Health Care United Commercial 0.19 12533.33 0.19 65631.30 0.19 Case Rate 38570 Priced Laparoscopy lymphadenectomy 562043 38571 CPT Outpatient 84031.50 14425.41 United Health Care United Commercial 0.15 12533.33 0.15 84031.50 0.15 Case Rate 38571 Priced Laparoscopy lymphadenectomy 562043 38572 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 562043 38792 CPT Outpatient 2868.60 432.48 United Health Care United Commercial 0.94 2692.04 0.94 2868.60 0.94 Case Rate 38792 Priced Excision of gum lesion 562043 41825 CPT Outpatient 11580.45 1987.98 United Health Care United Commercial 0.65 7512.55 0.65 11580.45 0.65 Case Rate 41825 Priced Reconstruct cleft palate 562043 42200 CPT Outpatient 36703.80 6300.82 United Health Care United Commercial 0.18 6684.03 0.18 36703.80 0.18 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 562043 42820 CPT Outpatient 17232.60 2958.26 United Health Care United Commercial 0.88 15100.13 0.88 17232.60 0.88 Case Rate 42820 Priced Control throat bleeding 562043 42960 CPT Outpatient 24066.00 4131.33 United Health Care United Commercial 0.49 11692.40 0.49 24066.00 0.49 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 562043 43235 CPT Outpatient 8856.75 1633.35 United Health Care United Commercial 0.55 4908.20 0.55 8856.75 0.55 Case Rate 43235 Priced Laparoscopy fundoplasty 562043 43280 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 562043 43282 CPT Outpatient 84344.40 14479.12 United Health Care United Commercial 0.10 8355.56 0.10 84344.40 0.10 Case Rate 43282 Priced Laparoscopy appendectomy 562043 44970 CPT Outpatient 82300.05 14128.18 United Health Care United Commercial 0.10 8355.56 0.10 82300.05 0.10 Case Rate 44970 Priced Diagnostic sigmoidoscopy 562043 45330 CPT Outpatient 17286.15 542.26 United Health Care United Commercial 0.51 8764.64 0.51 17286.15 0.51 Case Rate 45330 Priced Needle biopsy of liver 562043 47000 CPT Outpatient 10398.15 1225.34 United Health Care United Commercial 0.48 5008.37 0.48 10398.15 0.48 Case Rate 47000 Priced Removal of gallbladder using an endoscope 562043 47562 CPT Outpatient 58430.40 10030.55 United Health Care United Commercial 0.14 8355.56 0.14 58430.40 0.14 Case Rate 47562 Priced Laparo cholecystectomy/graph 562043 47563 CPT Outpatient 71747.55 12316.66 United Health Care United Commercial 0.12 8355.56 0.12 71747.55 0.12 Case Rate 47563 Priced Abd paracentesis w/imaging 562043 49083 CPT Outpatient 6979.35 1113.95 United Health Care United Commercial 0.72 5008.37 0.72 6979.35 0.72 Case Rate 49083 Priced Diag laparo separate proc 562043 49320 CPT Outpatient 31629.15 5429.67 United Health Care United Commercial 0.52 16324.02 0.52 31629.15 0.52 Case Rate 49320 Priced Laparoscopy biopsy 562043 49321 CPT Outpatient 41892.90 7191.61 United Health Care United Commercial 0.39 16324.02 0.39 41892.90 0.39 Case Rate 49321 Priced Laparoscopy aspiration 562043 49322 CPT Outpatient 34392.75 5904.09 United Health Care United Commercial 0.47 16324.02 0.47 34392.75 0.47 Case Rate 49322 Priced Lap insert tunnel ip cath 562043 49324 CPT Outpatient 39264.75 6740.45 United Health Care United Commercial 0.17 6684.03 0.17 39264.75 0.17 Case Rate 49324 Priced Laparo proc abdm/per/oment 562043 49329 CPT Outpatient 58696.05 10076.16 United Health Care United Commercial 0.20 11697.57 0.20 58696.05 0.20 Case Rate 49329 Priced Ins tun ip cath for dial opn 562043 49421 CPT Outpatient 25460.40 3319.30 United Health Care United Commercial 0.26 6684.03 0.26 25460.40 0.26 Case Rate 49421 Priced Remove tunneled ip cath 562043 49422 CPT Outpatient 25515.00 4380.08 United Health Care United Commercial 0.26 6684.03 0.26 25515.00 0.26 Case Rate 49422 Priced Rpr ing hernia init reduce 562043 49500 CPT Outpatient 19594.05 3363.65 United Health Care United Commercial 0.59 11504.03 0.59 19594.05 0.59 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 562043 49505 CPT Outpatient 34915.65 5993.85 United Health Care United Commercial 0.19 6550.35 0.19 34915.65 0.19 Case Rate 49505 Priced Prp i/hern init block >5 yr 562043 49507 CPT Outpatient 29794.80 5114.77 United Health Care United Commercial 0.22 6684.03 0.22 29794.80 0.22 Case Rate 49507 Priced Rerepair ing hernia reduce 562043 49520 CPT Outpatient 36940.05 6341.38 United Health Care United Commercial 0.18 6684.03 0.18 36940.05 0.18 Case Rate 49520 Priced Rpr ventral hern init reduc 562043 49560 CPT Outpatient 53177.25 9128.76 United Health Care United Commercial 0.16 8355.56 0.16 53177.25 0.16 Case Rate 49560 Priced Rpr ventral hern init block 562043 49561 CPT Outpatient 30755.55 5279.70 United Health Care United Commercial 0.22 6684.03 0.22 30755.55 0.22 Case Rate 49561 Priced Rerepair ventrl hern reduce 562043 49565 CPT Outpatient 69917.40 12002.49 United Health Care United Commercial 0.09 6550.35 0.09 69917.40 0.09 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 562043 49585 CPT Outpatient 41806.80 7176.83 United Health Care United Commercial 0.20 8355.56 0.20 41806.80 0.20 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 562043 49587 CPT Outpatient 37320.15 6406.63 United Health Care United Commercial 0.18 6684.03 0.18 37320.15 0.18 Case Rate 49587 Priced Lap ing hernia repair init 562043 49650 CPT Outpatient 41932.80 7198.46 United Health Care United Commercial 0.20 8188.44 0.20 41932.80 0.20 Case Rate 49650 Priced Lap ing hernia repair recur 562043 49651 CPT Outpatient 46915.05 8053.75 United Health Care United Commercial 0.27 12533.33 0.27 46915.05 0.27 Case Rate 49651 Priced Lap vent/abd hernia repair 562043 49652 CPT Outpatient 51294.60 8805.57 United Health Care United Commercial 0.10 5008.37 0.10 51294.60 0.10 Case Rate 49652 Priced Lap vent/abd hern proc comp 562043 49653 CPT Outpatient 46102.35 7914.24 United Health Care United Commercial 0.11 5008.37 0.11 46102.35 0.11 Case Rate 49653 Priced Lap inc hernia repair 562043 49654 CPT Outpatient 47221.65 8106.38 United Health Care United Commercial 0.11 5008.37 0.11 47221.65 0.11 Case Rate 49654 Priced Lap inc hern repair comp 562043 49655 CPT Outpatient 54590.55 9371.38 United Health Care United Commercial 0.09 5008.37 0.09 54590.55 0.09 Case Rate 49655 Priced Lap inc hernia repair recur 562043 49656 CPT Outpatient 55443.15 9517.74 United Health Care United Commercial 0.09 5008.37 0.09 55443.15 0.09 Case Rate 49656 Priced Removal of kidney stone 562043 50080 CPT Outpatient 53165.70 9126.78 United Health Care United Commercial 0.36 19279.98 0.36 53165.70 0.36 Case Rate 50080 Priced Removal of kidney stone 562043 50081 CPT Outpatient 66931.20 11489.86 United Health Care United Commercial 0.24 16324.02 0.24 66931.20 0.24 Case Rate 50081 Priced Renal biopsy perq 562043 50200 CPT Outpatient 43096.20 1225.34 United Health Care United Commercial 0.12 5008.37 0.12 43096.20 0.12 Case Rate 50200 Priced Plmt nephroureteral catheter 562043 50433 CPT Outpatient 64566.60 1424.48 United Health Care United Commercial 0.30 19279.98 0.30 64566.60 0.30 Case Rate 50433 Priced Laparo radical nephrectomy 562043 50545 CPT Outpatient 43449.00 7458.75 United Health Care United Commercial 0.12 5008.37 0.12 43449.00 0.12 Case Rate 50545 Priced Laparoscope proc ureter 562043 50949 CPT Outpatient 49986.30 8580.98 United Health Care United Commercial 0.23 11697.57 0.23 49986.30 0.23 Case Rate 50949 Priced Injection for bladder x-ray 562043 51600 CPT Outpatient 3285.45 89.22 United Health Care United Commercial 0.94 3084.30 0.94 3285.45 0.94 Case Rate 51600 Priced Cystoscopy 562043 52000 CPT Outpatient 22149.75 3802.37 United Health Care United Commercial 0.79 17543.77 0.79 22149.75 0.79 Case Rate 52000 Priced Cystoscopy & ureter catheter 562043 52005 CPT Outpatient 42529.20 2095.77 United Health Care United Commercial 0.37 15551.91 0.37 42529.20 0.37 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 562043 52204 CPT Outpatient 31274.25 5368.75 United Health Care United Commercial 0.39 12344.03 0.39 31274.25 0.39 Case Rate 52204 Priced Cystoscopy and treatment 562043 52224 CPT Outpatient 13445.25 2308.10 United Health Care United Commercial 0.92 12344.03 0.92 13445.25 0.92 Case Rate 52224 Priced Cystoscopy and treatment 562043 52234 CPT Outpatient 28510.65 4894.33 United Health Care United Commercial 0.53 15100.13 0.53 28510.65 0.53 Case Rate 52234 Priced Cystoscopy and treatment 562043 52235 CPT Outpatient 29417.85 5050.06 United Health Care United Commercial 0.43 12595.95 0.43 29417.85 0.43 Case Rate 52235 Priced Cystoscopy and treatment 562043 52240 CPT Outpatient 33933.90 5825.32 United Health Care United Commercial 0.36 12344.03 0.36 33933.90 0.36 Case Rate 52240 Priced Cystoscopy and treatment 562043 52281 CPT Outpatient 22159.20 3804.00 United Health Care United Commercial 0.52 11458.55 0.52 22159.20 0.52 Case Rate 52281 Priced Remove bladder stone 562043 52317 CPT Outpatient 27085.80 4649.73 United Health Care United Commercial 0.47 12595.95 0.47 27085.80 0.47 Case Rate 52317 Priced Remove bladder stone 562043 52318 CPT Outpatient 26685.75 4581.05 United Health Care United Commercial 0.47 12595.95 0.47 26685.75 0.47 Case Rate 52318 Priced Cystoscopy and treatment 562043 52332 CPT Outpatient 115306.80 19794.33 United Health Care United Commercial 0.12 14011.31 0.12 115306.80 0.12 Case Rate 52332 Priced Cystouretero w/stone remove 562043 52352 CPT Outpatient 42420.00 7282.10 United Health Care United Commercial 0.42 17802.00 0.42 42420.00 0.42 Case Rate 52352 Priced Cystouretero w/lithotripsy 562043 52353 CPT Outpatient 38608.50 6627.79 United Health Care United Commercial 0.34 13100.70 0.34 38608.50 0.34 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 562043 52356 CPT Outpatient 36255.45 6223.85 United Health Care United Commercial 0.36 13100.70 0.36 36255.45 0.36 Case Rate 52356 Priced Prostatectomy (turp) 562043 52601 CPT Outpatient 35371.35 6072.08 United Health Care United Commercial 0.38 13368.06 0.38 35371.35 0.38 Case Rate 52601 Priced Laser surgery of prostate 562043 52648 CPT Outpatient 24264.45 4165.40 United Health Care United Commercial 0.54 13100.70 0.54 24264.45 0.54 Case Rate 52648 Priced Revision of urethra 562043 53450 CPT Outpatient 16209.90 2782.70 United Health Care United Commercial 0.59 9639.99 0.59 16209.90 0.59 Case Rate 53450 Priced Urology surgery procedure 562043 53899 CPT Outpatient 25368.00 134.83 United Health Care United Commercial 0.41 10440.30 0.41 25368.00 0.41 Case Rate 53899 Priced Circumcision w/regionl block 562043 54150 CPT Outpatient 14700.00 2523.50 United Health Care United Commercial 0.40 5911.92 0.40 14700.00 0.40 Case Rate 54150 Priced Circum 28 days or older 562043 54161 CPT Outpatient 19186.65 3293.71 United Health Care United Commercial 0.31 5911.92 0.31 19186.65 0.31 Case Rate 54161 Priced Lysis penil circumic lesion 562043 54162 CPT Outpatient 19795.65 3398.25 United Health Care United Commercial 0.58 11504.03 0.58 19795.65 0.58 Case Rate 54162 Priced Repair of circumcision 562043 54163 CPT Outpatient 16391.55 2813.88 United Health Care United Commercial 0.51 8416.10 0.51 16391.55 0.51 Case Rate 54163 Priced Reconstruction of urethra 562043 54324 CPT Outpatient 32880.75 5644.53 United Health Care United Commercial 0.48 15872.24 0.48 32880.75 0.48 Case Rate 54324 Priced Revise penis/urethra 562043 54332 CPT Outpatient 19968.90 3427.99 United Health Care United Commercial 0.33 6684.03 0.33 19968.90 0.33 Case Rate 54332 Priced Insert self-contd prosthesis 562043 54401 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 562043 54520 CPT Outpatient 35442.75 6084.34 United Health Care United Commercial 0.28 10026.05 0.28 35442.75 0.28 Case Rate 54520 Priced Reduce testis torsion 562043 54600 CPT Outpatient 55049.40 9450.15 United Health Care United Commercial 0.20 11117.97 0.20 55049.40 0.20 Case Rate 54600 Priced Suspension of testis 562043 54640 CPT Outpatient 26860.05 4610.98 United Health Care United Commercial 0.25 6684.03 0.25 26860.05 0.25 Case Rate 54640 Priced Removal of hydrocele 562043 55040 CPT Outpatient 27277.95 4682.71 United Health Care United Commercial 0.25 6684.03 0.25 27277.95 0.25 Case Rate 55040 Priced Biopsy of prostate gland 562043 55700 CPT Outpatient 28699.65 4926.77 United Health Care United Commercial 0.17 5008.37 0.17 28699.65 0.17 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 562043 55866 CPT Outpatient 93088.80 15980.24 United Health Care United Commercial 0.13 12533.33 0.13 93088.80 0.13 Case Rate 55866 Priced Closure of vagina 562043 57120 CPT Outpatient 34369.65 5900.12 United Health Care United Commercial 0.29 9825.52 0.29 34369.65 0.29 Case Rate 57120 Priced Repair of vagina 562043 57200 CPT Outpatient 25247.25 4334.11 United Health Care United Commercial 0.50 12595.95 0.50 25247.25 0.50 Case Rate 57200 Priced Anterior colporrhaphy 562043 57240 CPT Outpatient 36210.30 6216.10 United Health Care United Commercial 0.32 11504.03 0.32 36210.30 0.32 Case Rate 57240 Priced Repair rectum & vagina 562043 57250 CPT Outpatient 40441.80 6942.51 United Health Care United Commercial 0.29 11697.05 0.29 40441.80 0.29 Case Rate 57250 Priced Cmbn ant pst colprhy 562043 57260 CPT Outpatient 46323.90 7952.27 United Health Care United Commercial 0.40 18381.08 0.40 46323.90 0.40 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 562043 57265 CPT Outpatient 42586.95 7310.76 United Health Care United Commercial 0.27 11697.05 0.27 42586.95 0.27 Case Rate 57265 Priced Repair of bowel bulge 562043 57268 CPT Outpatient 36865.50 6328.58 United Health Care United Commercial 0.30 11117.97 0.30 36865.50 0.30 Case Rate 57268 Priced Colpopexy extraperitoneal 562043 57282 CPT Outpatient 45629.85 7833.12 United Health Care United Commercial 0.26 11697.05 0.26 45629.85 0.26 Case Rate 57282 Priced Repair bladder defect 562043 57288 CPT Outpatient 43069.95 7393.67 United Health Care United Commercial 0.27 11463.11 0.27 43069.95 0.27 Case Rate 57288 Priced Bx/curett of cervix w/scope 562043 57454 CPT Outpatient 2888.55 442.93 United Health Care United Commercial 0.94 2711.70 0.94 2888.55 0.94 Case Rate 57454 Priced Conization of cervix 562043 57520 CPT Outpatient 26728.80 4588.44 United Health Care United Commercial 0.22 5911.92 0.22 26728.80 0.22 Case Rate 57520 Priced Conization of cervix 562043 57522 CPT Outpatient 22737.75 3903.31 United Health Care United Commercial 0.26 5911.92 0.26 22737.75 0.26 Case Rate 57522 Priced Biopsy of uterus lining 562043 58100 CPT Outpatient 2371.95 194.80 United Health Care United Commercial 0.94 2226.29 0.94 2371.95 0.94 Case Rate 58100 Priced Catheter for hysterography 562043 58340 CPT Outpatient 6322.05 131.04 United Health Care United Commercial 0.79 5008.37 0.79 6322.05 0.79 Case Rate 58340 Priced Reopen fallopian tube 562043 58350 CPT Outpatient 46507.65 7983.81 United Health Care United Commercial 0.29 13368.58 0.29 46507.65 0.29 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 562043 58542 CPT Outpatient 64194.90 11020.12 United Health Care United Commercial 0.21 13368.58 0.21 64194.90 0.21 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 562043 58544 CPT Outpatient 51020.55 8758.53 United Health Care United Commercial 0.28 14204.34 0.28 51020.55 0.28 Case Rate 58544 Priced Laparoscopic myomectomy 562043 58545 CPT Outpatient 56946.75 9775.86 United Health Care United Commercial 0.17 9639.99 0.17 56946.75 0.17 Case Rate 58545 Priced Laparo-vag hyst incl t/o 562043 58552 CPT Outpatient 57228.15 9824.17 United Health Care United Commercial 0.20 11311.52 0.20 57228.15 0.20 Case Rate 58552 Priced Hysteroscopy biopsy 562043 58558 CPT Outpatient 28581.00 2077.02 United Health Care United Commercial 0.53 15100.13 0.53 28581.00 0.53 Case Rate 58558 Priced Hysteroscopy remove myoma 562043 58561 CPT Outpatient 35222.25 6046.49 United Health Care United Commercial 0.19 6684.03 0.19 35222.25 0.19 Case Rate 58561 Priced Hysteroscopy ablation 562043 58563 CPT Outpatient 38399.55 6591.92 United Health Care United Commercial 0.30 11697.05 0.30 38399.55 0.30 Case Rate 58563 Priced Tlh uterus 250 g or less 562043 58570 CPT Outpatient 43316.70 7436.03 United Health Care United Commercial 0.19 8355.56 0.19 43316.70 0.19 Case Rate 58570 Priced Tlh w/t/o 250 g or less 562043 58571 CPT Outpatient 48603.45 8343.59 United Health Care United Commercial 0.24 11697.57 0.24 48603.45 0.24 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 562043 58573 CPT Outpatient 52905.30 9082.08 United Health Care United Commercial 0.24 12533.33 0.24 52905.30 0.24 Case Rate 58573 Priced Laparoscopy remove adnexa 562043 58661 CPT Outpatient 47008.50 8069.79 United Health Care United Commercial 0.24 11311.52 0.24 47008.50 0.24 Case Rate 58661 Priced Laparoscopy excise lesions 562043 58662 CPT Outpatient 45053.40 7734.17 United Health Care United Commercial 0.28 12533.33 0.28 45053.40 0.28 Case Rate 58662 Priced Treat ectopic pregnancy 562043 59151 CPT Outpatient 74690.70 12821.90 United Health Care United Commercial 0.11 8355.56 0.11 74690.70 0.11 Case Rate 59151 Priced Treatment of miscarriage 562043 59812 CPT Outpatient 56109.90 9632.20 United Health Care United Commercial 0.11 5911.92 0.11 56109.90 0.11 Case Rate 59812 Priced Partial removal of thyroid 562043 60220 CPT Outpatient 53639.25 9208.07 United Health Care United Commercial 0.16 8355.56 0.16 53639.25 0.16 Case Rate 60220 Priced Removal of thyroid 562043 60240 CPT Outpatient 98252.70 16866.71 United Health Care United Commercial 0.09 8355.56 0.09 98252.70 0.09 Case Rate 60240 Priced Explore parathyroid glands 562043 60500 CPT Outpatient 150495.45 25835.05 United Health Care United Commercial 0.09 13368.06 0.09 150495.45 0.09 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 562043 62322 CPT Outpatient 43709.40 514.24 United Health Care United Commercial 0.24 10440.30 0.24 43709.40 0.24 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 562043 62323 CPT Outpatient 8304.45 467.31 United Health Care United Commercial 0.60 5008.37 0.60 8304.45 0.60 Case Rate 62323 Priced Low back disk surgery 562043 63030 CPT Outpatient 50287.65 8632.71 United Health Care United Commercial 0.25 12533.33 0.25 50287.65 0.25 Case Rate 63030 Priced Inc for vagus n elect impl 562043 64568 CPT Outpatient 124562.55 21383.24 United Health Care United Commercial 0.07 8355.56 0.07 124562.55 0.07 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 562043 66821 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 562043 66984 CPT Outpatient 0.01 0.01 United Health Care United Commercial 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 710044 216 DRG Inpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 710044 460 DRG Inpatient 416122.79 53834.63 United Community and State United Medicaid 0.16 66289.96 0.16 416122.79 0.16 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 710044 470 DRG Inpatient 167912.19 21723.13 United Community and State United Medicaid 0.13 22393.11 0.13 167912.19 0.13 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 710044 473 DRG Inpatient 100687.91 13026.19 United Community and State United Medicaid 0.22 21941.74 0.22 100687.91 0.22 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 710044 743 DRG Inpatient 102691.67 13285.42 United Community and State United Medicaid 0.11 11358.41 0.11 102691.67 0.11 Case Rate 743 Priced NORMAL NEWBORN 710044 795 DRG Inpatient 6266.93 2335.00 United Community and State United Medicaid 0.22 1383.30 0.22 6266.93 0.22 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 710044 807 DRG Inpatient 116469.59 4193.00 United Community and State United Medicaid 0.04 4812.35 0.04 116469.59 0.04 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 710044 788 DRG Inpatient 76050.77 4538.00 United Community and State United Medicaid 0.10 7234.38 0.10 76050.77 0.10 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 710044 59400 CPT Inpatient 116469.59 4193.00 United Community and State United Medicaid 0.04 4812.35 0.04 116469.59 0.04 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 710044 59510 CPT Inpatient 76050.77 4538.00 United Community and State United Medicaid 0.10 7234.38 0.10 76050.77 0.10 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 710044 59610 CPT Inpatient 116469.59 4193.00 United Community and State United Medicaid 0.04 4812.35 0.04 116469.59 0.04 Case Rate 59610 Priced "Psychotherapy, 30 min" 710044 90832 CPT Outpatient 577.50 91.21 United Community and State United Medicaid 0.03 18.37 0.03 577.50 0.03 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 710044 90834 CPT Outpatient 44134.65 271.96 United Community and State United Medicaid 0.01 642.88 0.01 44134.65 0.01 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 710044 90837 CPT Outpatient 2240.70 442.93 United Community and State United Medicaid 0.02 43.16 0.02 2240.70 0.02 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 710044 90846 CPT Outpatient 0.01 131.50 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 710044 90847 CPT Outpatient 44134.65 369.97 United Community and State United Medicaid 0.01 642.88 0.01 44134.65 0.01 Fee Schedule 90847 Priced Group psychotherapy 710044 90853 CPT Outpatient 44134.65 101.99 United Community and State United Medicaid 0.01 642.88 0.01 44134.65 0.01 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 710044 99203 CPT Outpatient 3480.75 176.07 United Community and State United Medicaid 0.10 332.33 0.10 3480.75 0.10 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 710044 99204 CPT Outpatient 2103.15 233.39 United Community and State United Medicaid 0.10 200.75 0.10 2103.15 0.10 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 710044 99205 CPT Outpatient 4970.70 314.28 United Community and State United Medicaid 0.05 237.28 0.05 4970.70 0.05 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 710044 99243 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 710044 99244 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 710044 99385 CPT Outpatient 1114.05 185.90 United Community and State United Medicaid 0.10 106.32 0.10 1114.05 0.10 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 710044 99386 CPT Outpatient 4877.25 185.90 United Community and State United Medicaid 0.08 365.93 0.08 4877.25 0.08 Fee Schedule 99386 Priced Routine venipuncture 710044 36415 CPT Outpatient 127.05 19.57 United Community and State United Medicaid 0.02 1.94 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 710044 80048 CPT Outpatient 576.45 88.78 United Community and State United Medicaid 0.02 10.01 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 710044 80053 CPT Outpatient 763.35 117.56 United Community and State United Medicaid 0.01 11.31 0.01 763.35 0.01 Fee Schedule 80053 Priced Obstetric blood test panel 710044 80055 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 710044 80061 CPT Outpatient 1349.25 197.77 United Community and State United Medicaid 0.01 16.14 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 710044 80069 CPT Outpatient 716.10 104.95 United Community and State United Medicaid 0.01 10.33 0.01 716.10 0.01 Fee Schedule 80069 Priced Liver function panel test 710044 80076 CPT Outpatient 716.10 104.95 United Community and State United Medicaid 0.01 7.53 0.01 716.10 0.01 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 710044 81000 CPT Outpatient 144.90 21.18 United Community and State United Medicaid 0.01 1.29 0.01 144.90 0.01 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 710044 81001 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 710044 81002 CPT Outpatient 57.75 8.89 United Community and State United Medicaid 0.02 1.08 0.02 57.75 0.02 Fee Schedule 81002 Priced Automated urinalysis test 710044 81003 CPT Outpatient 219.45 33.80 United Community and State United Medicaid 0.01 1.62 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 710044 82306 CPT Outpatient 1880.55 289.62 United Community and State United Medicaid 0.02 32.29 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 710044 83036 CPT Outpatient 494.55 76.17 United Community and State United Medicaid 0.01 7.10 0.01 494.55 0.01 Fee Schedule 83036 Priced PSA (prostate specific antigen) 710044 84153 CPT Outpatient 1177.05 181.28 United Community and State United Medicaid 0.02 26.37 0.02 1177.05 0.02 Fee Schedule 84153 Priced PSA (prostate specific antigen) 710044 84154 CPT Outpatient 598.50 92.17 United Community and State United Medicaid 0.04 26.37 0.04 598.50 0.04 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 710044 84443 CPT Outpatient 519.75 80.05 United Community and State United Medicaid 0.05 24.75 0.05 519.75 0.05 Fee Schedule 84443 Priced Chorionic gonadotropin assay 710044 84703 CPT Outpatient 785.40 120.96 United Community and State United Medicaid 0.01 3.23 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 710044 85025 CPT Outpatient 635.25 97.83 United Community and State United Medicaid 0.10 63.68 0.10 635.25 0.10 Fee Schedule 85025 Priced "Complete blood count, automated" 710044 85027 CPT Outpatient 576.45 88.78 United Community and State United Medicaid 0.01 5.17 0.01 576.45 0.01 Fee Schedule 85027 Priced "Blood test, clotting time" 710044 85610 CPT Outpatient 404.25 62.26 United Community and State United Medicaid 0.01 3.23 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 710044 85730 CPT Outpatient 17.22 2.65 United Community and State United Medicaid 0.19 3.23 0.19 17.22 0.19 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 710044 86003 CPT Outpatient 32.55 5.01 United Community and State United Medicaid 0.13 4.31 0.13 32.55 0.13 Fee Schedule 86003 Priced Tb test cell immun measure 710044 86480 CPT Outpatient 530.25 81.66 United Community and State United Medicaid 0.14 73.21 0.14 530.25 0.14 Fee Schedule 86480 Priced Urine culture/colony count 710044 87086 CPT Outpatient 763.35 117.56 United Community and State United Medicaid 0.01 6.46 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 710044 87338 CPT Outpatient 785.40 120.96 United Community and State United Medicaid 0.10 78.74 0.10 785.40 0.10 Fee Schedule 87338 Priced Cytopath eval fna report 710044 88173 CPT Outpatient 750.75 115.62 United Community and State United Medicaid 0.10 75.27 0.10 750.75 0.10 Fee Schedule 88173 Priced Tissue exam by pathologist 710044 88302 CPT Outpatient 635.25 97.83 United Community and State United Medicaid 0.10 63.68 0.10 635.25 0.10 Fee Schedule 88302 Priced Tissue exam by pathologist 710044 88305 CPT Outpatient 323.40 49.81 United Community and State United Medicaid 0.10 32.42 0.10 323.40 0.10 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 710044 11042 CPT Outpatient 2668.05 481.45 United Community and State United Medicaid 0.10 254.74 0.10 2668.05 0.10 Case Rate 11042 Priced Deb subq tissue add-on 710044 11045 CPT Outpatient 4652.55 330.00 United Community and State United Medicaid 0.10 444.22 0.10 4652.55 0.10 Case Rate 11045 Priced Dx bronchoscope/lavage 710044 31624 CPT Outpatient 41223.00 7602.31 United Community and State United Medicaid 0.09 3674.18 0.09 41223.00 0.09 Case Rate 31624 Priced Bronchoscopy/lung bx each 710044 31628 CPT Outpatient 49048.65 9045.51 United Community and State United Medicaid 0.09 4488.96 0.09 49048.65 0.09 Case Rate 31628 Priced Blood transfusion service 710044 36430 CPT Outpatient 9166.50 574.93 United Community and State United Medicaid 0.05 499.12 0.05 9166.50 0.05 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 710044 43235 CPT Outpatient 8856.75 1633.35 United Community and State United Medicaid 0.10 848.87 0.10 8856.75 0.10 Case Rate 43235 Priced Endoscopic us exam esoph 710044 43237 CPT Outpatient 23867.55 4401.63 United Community and State United Medicaid 0.09 2237.80 0.09 23867.55 0.09 Case Rate 43237 Priced Egd us fine needle bx/aspir 710044 43238 CPT Outpatient 30690.45 5659.90 United Community and State United Medicaid 0.09 2782.50 0.09 30690.45 0.09 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 710044 43239 CPT Outpatient 40191.90 7412.15 United Community and State United Medicaid 0.11 4303.91 0.11 40191.90 0.11 Case Rate 43239 Priced Ercp remove duct calculi 710044 43264 CPT Outpatient 34335.00 6332.03 United Community and State United Medicaid 0.10 3292.24 0.10 34335.00 0.10 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 710044 45378 CPT Outpatient 13991.25 889.35 United Community and State United Medicaid 0.10 1338.27 0.10 13991.25 0.10 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 710044 45380 CPT Outpatient 22215.90 4097.04 United Community and State United Medicaid 0.10 2125.88 0.10 22215.90 0.10 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 710044 45385 CPT Outpatient 119569.80 22050.95 United Community and State United Medicaid 0.03 3811.32 0.03 119569.80 0.03 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 710044 45391 CPT Outpatient 24923.85 4596.43 United Community and State United Medicaid 0.09 2308.69 0.09 24923.85 0.09 Case Rate 45391 Priced Fragmenting of kidney stone 710044 50590 CPT Outpatient 40930.05 7548.28 United Community and State United Medicaid 0.10 3922.16 0.10 40930.05 0.10 Case Rate 50590 Priced Fetal non-stress test 710044 59025 CPT Outpatient 3153.15 477.76 United Community and State United Medicaid 0.10 301.06 0.10 3153.15 0.10 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 710044 64483 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 710044 92567 CPT Outpatient 2224.95 98.50 United Community and State United Medicaid 0.10 212.43 0.10 2224.95 0.10 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 710044 93000 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 710044 93017 CPT Outpatient 3076.50 532.96 United Community and State United Medicaid 0.10 293.69 0.10 3076.50 0.10 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 710044 93452 CPT Outpatient 55621.65 8611.87 United Community and State United Medicaid 0.10 5333.80 0.10 55621.65 0.10 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 710044 95810 CPT Outpatient 20341.65 3373.48 United Community and State United Medicaid 0.10 1942.19 0.10 20341.65 0.10 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 710044 95811 CPT Outpatient 22491.00 3731.18 United Community and State United Medicaid 0.10 2147.46 0.10 22491.00 0.10 Case Rate 95811 Priced Eeg 41-60 minutes 710044 95812 CPT Outpatient 5578.65 925.83 United Community and State United Medicaid 0.10 532.65 0.10 5578.65 0.10 Case Rate 95812 Priced Genetic counseling 30 min 710044 96040 CPT Outpatient 0.01 102.81 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 710044 96413 CPT Outpatient 4856.25 472.45 United Community and State United Medicaid 0.40 1929.77 0.40 4856.25 0.40 Case Rate 96413 Priced Ultrasound therapy 710044 97035 CPT Outpatient 2111.55 134.99 United Community and State United Medicaid 0.10 201.59 0.10 2111.55 0.10 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 710044 97110 CPT Outpatient 6494.25 92.86 United Community and State United Medicaid 0.10 620.02 0.10 6494.25 0.10 Case Rate 97110 Priced Gait training therapy 710044 97116 CPT Outpatient 4723.95 110.61 United Community and State United Medicaid 0.10 450.97 0.10 4723.95 0.10 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 710044 70450 CPT Outpatient 8566.95 835.61 United Community and State United Medicaid 0.10 817.93 0.10 8566.95 0.10 Case Rate 70450 Priced Mri brain stem w/o dye 710044 70551 CPT Outpatient 7861.35 1361.31 United Community and State United Medicaid 0.10 750.56 0.10 7861.35 0.10 Case Rate 70551 Priced MRI scan of brain before and after contrast 710044 70553 CPT Outpatient 10882.20 1625.88 United Community and State United Medicaid 0.10 1038.99 0.10 10882.20 0.10 Case Rate 70553 Priced X-ray exam chest 2 views 710044 71046 CPT Outpatient 859.95 150.37 United Community and State United Medicaid 0.10 82.11 0.10 859.95 0.10 Case Rate 71046 Priced Ct thorax w/o dye 710044 71250 CPT Outpatient 7288.05 1261.63 United Community and State United Medicaid 0.10 695.82 0.10 7288.05 0.10 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 710044 72082 CPT Outpatient 2022.30 253.33 United Community and State United Medicaid 0.11 229.59 0.11 2022.30 0.11 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 710044 72100 CPT Outpatient 1599.15 277.38 United Community and State United Medicaid 0.10 152.64 0.10 1599.15 0.10 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 710044 72110 CPT Outpatient 1389.15 241.04 United Community and State United Medicaid 0.10 132.64 0.10 1389.15 0.10 Case Rate 72110 Priced MRI scan of lower spinal canal 710044 72148 CPT Outpatient 7861.35 1361.31 United Community and State United Medicaid 0.10 750.56 0.10 7861.35 0.10 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 710044 72193 CPT Outpatient 13671.00 1412.01 United Community and State United Medicaid 0.10 1305.32 0.10 13671.00 0.10 Case Rate 72193 Priced X-ray exam of shoulder 710044 73030 CPT Outpatient 1452.15 251.43 United Community and State United Medicaid 0.10 138.64 0.10 1452.15 0.10 Case Rate 73030 Priced X-ray exam of elbow 710044 73080 CPT Outpatient 1356.60 235.68 United Community and State United Medicaid 0.10 129.48 0.10 1356.60 0.10 Case Rate 73080 Priced X-ray exam of forearm 710044 73090 CPT Outpatient 1243.20 215.26 United Community and State United Medicaid 0.10 118.63 0.10 1243.20 0.10 Case Rate 73090 Priced X-ray exam of wrist 710044 73110 CPT Outpatient 1243.20 215.26 United Community and State United Medicaid 0.10 118.63 0.10 1243.20 0.10 Case Rate 73110 Priced X-ray exam of hand 710044 73130 CPT Outpatient 1243.20 215.26 United Community and State United Medicaid 0.10 118.63 0.10 1243.20 0.10 Case Rate 73130 Priced X-ray exam hips bi 2 views 710044 73521 CPT Outpatient 970.20 228.41 United Community and State United Medicaid 0.13 125.27 0.13 970.20 0.13 Case Rate 73521 Priced X-ray exam of knee 3 710044 73562 CPT Outpatient 802.20 139.12 United Community and State United Medicaid 0.10 76.53 0.10 802.20 0.10 Case Rate 73562 Priced X-ray exam of lower leg 710044 73590 CPT Outpatient 1243.20 215.26 United Community and State United Medicaid 0.10 118.63 0.10 1243.20 0.10 Case Rate 73590 Priced X-ray exam of ankle 710044 73610 CPT Outpatient 1378.65 239.31 United Community and State United Medicaid 0.10 131.59 0.10 1378.65 0.10 Case Rate 73610 Priced X-ray exam of foot 710044 73630 CPT Outpatient 975.45 169.41 United Community and State United Medicaid 0.10 93.06 0.10 975.45 0.10 Case Rate 73630 Priced MRI scan of leg joint 710044 73721 CPT Outpatient 7861.35 1361.31 United Community and State United Medicaid 0.10 750.56 0.10 7861.35 0.10 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 710044 74177 CPT Outpatient 14222.25 1412.01 United Community and State United Medicaid 0.10 1357.95 0.10 14222.25 0.10 Case Rate 74177 Priced Contrst x-ray exam of throat 710044 74210 CPT Outpatient 0.01 440.39 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 710044 76098 CPT Outpatient 6141.45 407.86 United Community and State United Medicaid 0.10 586.34 0.10 6141.45 0.10 Case Rate 76098 Priced Us exam of head and neck 710044 76536 CPT Outpatient 5512.50 955.18 United Community and State United Medicaid 0.10 526.34 0.10 5512.50 0.10 Case Rate 76536 Priced Ultrasound breast limited 710044 76642 CPT Outpatient 5777.10 127.70 United Community and State United Medicaid 0.10 551.60 0.10 5777.10 0.10 Case Rate 76642 Priced Ultrasound of abdomen 710044 76700 CPT Outpatient 4917.15 851.88 United Community and State United Medicaid 0.10 469.49 0.10 4917.15 0.10 Case Rate 76700 Priced Echo exam of abdomen 710044 76705 CPT Outpatient 3836.70 665.17 United Community and State United Medicaid 0.10 366.34 0.10 3836.70 0.10 Case Rate 76705 Priced Us exam abdo back wall comp 710044 76770 CPT Outpatient 5171.25 895.48 United Community and State United Medicaid 0.10 493.70 0.10 5171.25 0.10 Case Rate 76770 Priced Us exam abdo back wall lim 710044 76775 CPT Outpatient 3969.00 686.97 United Community and State United Medicaid 0.10 378.96 0.10 3969.00 0.10 Case Rate 76775 Priced Ob us < 14 wks single fetus 710044 76801 CPT Outpatient 2006.55 347.98 United Community and State United Medicaid 0.10 191.58 0.10 2006.55 0.10 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 710044 76805 CPT Outpatient 3969.00 686.97 United Community and State United Medicaid 0.10 378.96 0.10 3969.00 0.10 Case Rate 76805 Priced Ob us detailed sngl fetus 710044 76811 CPT Outpatient 2844.45 492.99 United Community and State United Medicaid 0.10 271.59 0.10 2844.45 0.10 Case Rate 76811 Priced Ob us nuchal meas 1 gest 710044 76813 CPT Outpatient 1044.75 180.83 United Community and State United Medicaid 0.10 99.69 0.10 1044.75 0.10 Case Rate 76813 Priced Ob us limited fetus(s) 710044 76815 CPT Outpatient 6428.10 639.90 United Community and State United Medicaid 0.10 613.71 0.10 6428.10 0.10 Case Rate 76815 Priced Ob us follow-up per fetus 710044 76816 CPT Outpatient 4818.45 833.88 United Community and State United Medicaid 0.10 460.02 0.10 4818.45 0.10 Case Rate 76816 Priced Transvaginal us obstetric 710044 76817 CPT Outpatient 6428.10 476.73 United Community and State United Medicaid 0.10 613.71 0.10 6428.10 0.10 Case Rate 76817 Priced Fetal biophys profil w/o nst 710044 76819 CPT Outpatient 1741.95 302.65 United Community and State United Medicaid 0.10 166.33 0.10 1741.95 0.10 Case Rate 76819 Priced Ultrasound pelvis through vagina 710044 76830 CPT Outpatient 9305.10 806.54 United Community and State United Medicaid 0.10 888.46 0.10 9305.10 0.10 Case Rate 76830 Priced Us exam scrotum 710044 76870 CPT Outpatient 6328.35 1096.55 United Community and State United Medicaid 0.10 604.24 0.10 6328.35 0.10 Case Rate 76870 Priced Us exam infant hips dynamic 710044 76885 CPT Outpatient 3836.70 665.17 United Community and State United Medicaid 0.10 366.34 0.10 3836.70 0.10 Case Rate 76885 Priced Mammography of one breast 710044 77065 CPT Outpatient 3451.35 192.07 United Community and State United Medicaid 0.10 329.49 0.10 3451.35 0.10 Case Rate 77065 Priced Mammography of both breasts 710044 77066 CPT Outpatient 5777.10 235.68 United Community and State United Medicaid 0.10 551.60 0.10 5777.10 0.10 Case Rate 77066 Priced "Mamography, screening bilateral" 710044 77067 CPT Outpatient 1416.45 205.57 United Community and State United Medicaid 0.10 135.17 0.10 1416.45 0.10 Case Rate 77067 Priced X-rays for bone age 710044 77072 CPT Outpatient 2022.30 163.87 United Community and State United Medicaid 0.11 229.59 0.11 2022.30 0.11 Case Rate 77072 Priced Joint survey single view 710044 77077 CPT Outpatient 985.95 171.14 United Community and State United Medicaid 0.10 94.11 0.10 985.95 0.10 Case Rate 77077 Priced Dxa bone density axial 710044 77080 CPT Outpatient 3257.10 319.09 United Community and State United Medicaid 0.10 310.96 0.10 3257.10 0.10 Case Rate 77080 Priced Fna bx w/us gdn 1st les 710044 10005 CPT Outpatient 5512.50 547.24 United Community and State United Medicaid 0.10 526.34 0.10 5512.50 0.10 Case Rate 10005 Priced Fna bx w/us gdn ea addl 710044 10006 CPT Outpatient 10628.10 594.83 United Community and State United Medicaid 0.10 1014.78 0.10 10628.10 0.10 Case Rate 10006 Priced Drainage of hematoma/fluid 710044 10140 CPT Outpatient 23209.20 1081.95 United Community and State United Medicaid 0.08 1776.94 0.08 23209.20 0.08 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 710044 11042 CPT Outpatient 2668.05 481.45 United Community and State United Medicaid 0.10 254.74 0.10 2668.05 0.10 Case Rate 11042 Priced Deb bone 20 sq cm/< 710044 11044 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 710044 11406 CPT Outpatient 19967.85 3427.81 United Community and State United Medicaid 0.09 1734.44 0.09 19967.85 0.09 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 710044 11424 CPT Outpatient 0.01 1004.93 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 710044 11770 CPT Outpatient 19173.00 3291.37 United Community and State United Medicaid 0.09 1801.30 0.09 19173.00 0.09 Case Rate 11770 Priced Replace tissue expander 710044 11970 CPT Outpatient 59239.95 10169.52 United Community and State United Medicaid 0.09 5545.13 0.09 59239.95 0.09 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 710044 14020 CPT Outpatient 32166.75 5521.96 United Community and State United Medicaid 0.09 2865.72 0.09 32166.75 0.09 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 710044 14060 CPT Outpatient 25993.80 1374.69 United Community and State United Medicaid 0.10 2481.43 0.10 25993.80 0.10 Case Rate 14060 Priced Wound prep trk/arm/leg 710044 15002 CPT Outpatient 41748.00 1441.73 United Community and State United Medicaid 0.10 4175.33 0.10 41748.00 0.10 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 710044 15271 CPT Outpatient 24343.20 3769.48 United Community and State United Medicaid 0.09 2250.62 0.09 24343.20 0.09 Case Rate 15271 Priced Acellular derm matrix implt 710044 15777 CPT Outpatient 101672.55 17453.79 United Community and State United Medicaid 0.12 11894.09 0.12 101672.55 0.12 Case Rate 15777 Priced Exc skin abd 710044 15830 CPT Outpatient 54696.60 9389.58 United Community and State United Medicaid 0.07 4015.60 0.07 54696.60 0.07 Case Rate 15830 Priced Dressing change not for burn 710044 15852 CPT Outpatient 0.01 290.74 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 710044 15877 CPT Outpatient 63741.30 10942.26 United Community and State United Medicaid 0.10 6277.00 0.10 63741.30 0.10 Case Rate 15877 Priced Suction lipectomy lwr extrem 710044 15879 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 710044 19000 CPT Outpatient 10143.00 594.83 United Community and State United Medicaid 0.10 968.46 0.10 10143.00 0.10 Case Rate 19000 Priced Bx breast 1st lesion strtctc 710044 19081 CPT Outpatient 12341.70 1250.69 United Community and State United Medicaid 0.10 1178.36 0.10 12341.70 0.10 Case Rate 19081 Priced Bx breast add lesion us imag 710044 19084 CPT Outpatient 29058.75 547.24 United Community and State United Medicaid 0.09 2682.47 0.09 29058.75 0.09 Case Rate 19084 Priced Biopsy of breast open 710044 19101 CPT Outpatient 39545.10 2737.82 United Community and State United Medicaid 0.08 3253.23 0.08 39545.10 0.08 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 710044 19120 CPT Outpatient 35761.95 2737.82 United Community and State United Medicaid 0.10 3732.65 0.10 35761.95 0.10 Case Rate 19120 Priced Excision breast lesion 710044 19125 CPT Outpatient 33184.20 0.01 United Community and State United Medicaid 0.09 2946.35 0.09 33184.20 0.09 Case Rate 19125 Priced Perq device breast 1st imag 710044 19281 CPT Outpatient 6141.45 598.61 United Community and State United Medicaid 0.10 586.34 0.10 6141.45 0.10 Case Rate 19281 Priced Perq device breast ea imag 710044 19282 CPT Outpatient 8379.00 319.04 United Community and State United Medicaid 0.10 800.03 0.10 8379.00 0.10 Case Rate 19282 Priced Partial mastectomy 710044 19301 CPT Outpatient 39157.65 6722.06 United Community and State United Medicaid 0.10 3821.87 0.10 39157.65 0.10 Case Rate 19301 Priced Mast simple complete 710044 19303 CPT Outpatient 105389.55 18091.87 United Community and State United Medicaid 0.10 10379.97 0.10 105389.55 0.10 Case Rate 19303 Priced Reduction of large breast 710044 19318 CPT Outpatient 65239.65 11199.47 United Community and State United Medicaid 0.10 6399.38 0.10 65239.65 0.10 Case Rate 19318 Priced Immediate breast prosthesis 710044 19340 CPT Outpatient 113100.75 19415.63 United Community and State United Medicaid 0.10 10985.80 0.10 113100.75 0.10 Case Rate 19340 Priced Delayed breast prosthesis 710044 19342 CPT Outpatient 56988.75 9783.07 United Community and State United Medicaid 0.10 5515.94 0.10 56988.75 0.10 Case Rate 19342 Priced Breast reconstruction 710044 19357 CPT Outpatient 101672.55 17453.79 United Community and State United Medicaid 0.12 11894.09 0.12 101672.55 0.12 Case Rate 19357 Priced Breast reconstruction 710044 19366 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 710044 19380 CPT Outpatient 61493.25 10556.34 United Community and State United Medicaid 0.10 6013.08 0.10 61493.25 0.10 Case Rate 19380 Priced Removal of support implant 710044 20680 CPT Outpatient 42329.70 7266.60 United Community and State United Medicaid 0.10 4060.17 0.10 42329.70 0.10 Case Rate 20680 Priced Cerv artific diskectomy 710044 22856 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 710044 24538 CPT Outpatient 51237.90 4775.24 United Community and State United Medicaid 0.07 3647.47 0.07 51237.90 0.07 Case Rate 24538 Priced Remove wrist tendon lesion 710044 25111 CPT Outpatient 25855.20 4438.48 United Community and State United Medicaid 0.09 2348.29 0.09 25855.20 0.09 Case Rate 25111 Priced Incise finger tendon sheath 710044 26055 CPT Outpatient 15862.35 2723.04 United Community and State United Medicaid 0.09 1390.01 0.09 15862.35 0.09 Case Rate 26055 Priced Treat finger fracture each 710044 26727 CPT Outpatient 22779.75 2030.47 United Community and State United Medicaid 0.10 2180.83 0.10 22779.75 0.10 Case Rate 26727 Priced Revision of knee joint 710044 27446 CPT Outpatient 67882.50 11653.16 United Community and State United Medicaid 0.09 6378.20 0.09 67882.50 0.09 Case Rate 27446 Priced Total knee arthroplasty 710044 27447 CPT Outpatient 130698.75 22436.62 United Community and State United Medicaid 0.06 8020.09 0.06 130698.75 0.06 Case Rate 27447 Priced Surgery to stop leg growth 710044 27485 CPT Outpatient 43310.40 7434.95 United Community and State United Medicaid 0.09 4011.51 0.09 43310.40 0.09 Case Rate 27485 Priced Repair achilles tendon 710044 27650 CPT Outpatient 38246.25 3762.57 United Community and State United Medicaid 0.09 3390.91 0.09 38246.25 0.09 Case Rate 27650 Priced Treatment of ankle fracture 710044 27792 CPT Outpatient 36101.10 6197.36 United Community and State United Medicaid 0.10 3475.09 0.10 36101.10 0.10 Case Rate 27792 Priced Treatment of ankle fracture 710044 27814 CPT Outpatient 49405.65 8481.30 United Community and State United Medicaid 0.09 4256.90 0.09 49405.65 0.09 Case Rate 27814 Priced Removal of foot lesion 710044 28080 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 710044 28285 CPT Outpatient 68603.85 11776.99 United Community and State United Medicaid 0.09 5992.16 0.09 68603.85 0.09 Case Rate 28285 Priced Correction hallux valgus 710044 28296 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 710044 29823 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 710044 29826 CPT Outpatient 49840.35 8555.93 United Community and State United Medicaid 0.10 4822.73 0.10 49840.35 0.10 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 710044 29881 CPT Outpatient 35556.15 6103.81 United Community and State United Medicaid 0.09 3299.60 0.09 35556.15 0.09 Case Rate 29881 Priced Knee arthroscopy/surgery 710044 29882 CPT Outpatient 61099.50 10488.75 United Community and State United Medicaid 0.10 5921.88 0.10 61099.50 0.10 Case Rate 29882 Priced Percut bx lung/mediastinum 710044 32405 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 710044 32555 CPT Outpatient 14597.10 687.29 United Community and State United Medicaid 0.04 613.69 0.04 14597.10 0.04 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 710044 32664 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 710044 35190 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 710044 36478 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 710044 36561 CPT Outpatient 53531.10 3292.99 United Community and State United Medicaid 0.05 2666.42 0.05 53531.10 0.05 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 710044 36569 CPT Outpatient 31421.25 1299.06 United Community and State United Medicaid 0.10 3003.38 0.10 31421.25 0.10 Case Rate 36569 Priced Removal tunneled cv cath 710044 36590 CPT Outpatient 1996.05 273.95 United Community and State United Medicaid 0.10 191.38 0.10 1996.05 0.10 Case Rate 36590 Priced Av fuse uppr arm basilic 710044 36819 CPT Outpatient 56861.70 9761.26 United Community and State United Medicaid 0.10 5575.07 0.10 56861.70 0.10 Case Rate 36819 Priced Av fusion direct any site 710044 36821 CPT Outpatient 42953.40 7373.67 United Community and State United Medicaid 0.09 4026.48 0.09 42953.40 0.09 Case Rate 36821 Priced Artery-vein autograft 710044 36825 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 710044 36830 CPT Outpatient 53656.05 9210.96 United Community and State United Medicaid 0.10 5403.98 0.10 53656.05 0.10 Case Rate 36830 Priced Av fistula revision open 710044 36832 CPT Outpatient 52492.65 9011.24 United Community and State United Medicaid 0.09 4581.00 0.09 52492.65 0.09 Case Rate 36832 Priced Av fistula revision 710044 36833 CPT Outpatient 37098.60 6368.59 United Community and State United Medicaid 0.09 3487.17 0.09 37098.60 0.09 Case Rate 36833 Priced Intro cath dialysis circuit 710044 36903 CPT Outpatient 77541.45 10669.90 United Community and State United Medicaid 0.09 6834.55 0.09 77541.45 0.09 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 710044 36906 CPT Outpatient 96694.50 16175.64 United Community and State United Medicaid 0.09 8771.02 0.09 96694.50 0.09 Case Rate 36906 Priced Fem/popl revas w/tla 710044 37224 CPT Outpatient 200076.45 5139.31 United Community and State United Medicaid 0.09 19006.08 0.09 200076.45 0.09 Case Rate 37224 Priced Fem/popl revasc stnt & ather 710044 37227 CPT Outpatient 117170.55 18045.38 United Community and State United Medicaid 0.10 11746.91 0.10 117170.55 0.10 Case Rate 37227 Priced Revise leg vein 710044 37700 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 710044 37722 CPT Outpatient 27815.55 4775.00 United Community and State United Medicaid 0.10 2657.97 0.10 27815.55 0.10 Case Rate 37722 Priced Stab phleb veins xtr 10-20 710044 37765 CPT Outpatient 26561.85 4559.78 United Community and State United Medicaid 0.10 2544.10 0.10 26561.85 0.10 Case Rate 37765 Priced Biopsy/removal lymph nodes 710044 38500 CPT Outpatient 35955.15 6172.30 United Community and State United Medicaid 0.09 3391.21 0.09 35955.15 0.09 Case Rate 38500 Priced Biopsy/removal lymph nodes 710044 38525 CPT Outpatient 101194.80 17371.77 United Community and State United Medicaid 0.10 9846.53 0.10 101194.80 0.10 Case Rate 38525 Priced Laparoscopy lymph node biop 710044 38570 CPT Outpatient 65631.30 11266.71 United Community and State United Medicaid 0.10 6411.68 0.10 65631.30 0.10 Case Rate 38570 Priced Laparoscopy lymphadenectomy 710044 38571 CPT Outpatient 84031.50 14425.41 United Community and State United Medicaid 0.09 7847.41 0.09 84031.50 0.09 Case Rate 38571 Priced Laparoscopy lymphadenectomy 710044 38572 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 710044 38792 CPT Outpatient 2868.60 432.48 United Community and State United Medicaid 0.10 273.80 0.10 2868.60 0.10 Case Rate 38792 Priced Excision of gum lesion 710044 41825 CPT Outpatient 11580.45 1987.98 United Community and State United Medicaid 0.10 1118.79 0.10 11580.45 0.10 Case Rate 41825 Priced Reconstruct cleft palate 710044 42200 CPT Outpatient 36703.80 6300.82 United Community and State United Medicaid 0.09 3473.61 0.09 36703.80 0.09 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 710044 42820 CPT Outpatient 17232.60 2958.26 United Community and State United Medicaid 0.10 1684.38 0.10 17232.60 0.10 Case Rate 42820 Priced Control throat bleeding 710044 42960 CPT Outpatient 24066.00 4131.33 United Community and State United Medicaid 0.10 2325.09 0.10 24066.00 0.10 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 710044 43235 CPT Outpatient 8856.75 1633.35 United Community and State United Medicaid 0.10 848.87 0.10 8856.75 0.10 Case Rate 43235 Priced Laparoscopy fundoplasty 710044 43280 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 710044 43282 CPT Outpatient 84344.40 14479.12 United Community and State United Medicaid 0.10 8301.31 0.10 84344.40 0.10 Case Rate 43282 Priced Laparoscopy appendectomy 710044 44970 CPT Outpatient 82300.05 14128.18 United Community and State United Medicaid 0.05 4397.10 0.05 82300.05 0.05 Case Rate 44970 Priced Diagnostic sigmoidoscopy 710044 45330 CPT Outpatient 17286.15 542.26 United Community and State United Medicaid 0.09 1577.52 0.09 17286.15 0.09 Case Rate 45330 Priced Needle biopsy of liver 710044 47000 CPT Outpatient 10398.15 1225.34 United Community and State United Medicaid 0.10 992.77 0.10 10398.15 0.10 Case Rate 47000 Priced Removal of gallbladder using an endoscope 710044 47562 CPT Outpatient 58430.40 10030.55 United Community and State United Medicaid 0.05 2793.56 0.05 58430.40 0.05 Case Rate 47562 Priced Laparo cholecystectomy/graph 710044 47563 CPT Outpatient 71747.55 12316.66 United Community and State United Medicaid 0.08 5777.56 0.08 71747.55 0.08 Case Rate 47563 Priced Abd paracentesis w/imaging 710044 49083 CPT Outpatient 6979.35 1113.95 United Community and State United Medicaid 0.10 666.34 0.10 6979.35 0.10 Case Rate 49083 Priced Diag laparo separate proc 710044 49320 CPT Outpatient 31629.15 5429.67 United Community and State United Medicaid 0.09 2975.18 0.09 31629.15 0.09 Case Rate 49320 Priced Laparoscopy biopsy 710044 49321 CPT Outpatient 41892.90 7191.61 United Community and State United Medicaid 0.09 3858.43 0.09 41892.90 0.09 Case Rate 49321 Priced Laparoscopy aspiration 710044 49322 CPT Outpatient 34392.75 5904.09 United Community and State United Medicaid 0.09 3191.73 0.09 34392.75 0.09 Case Rate 49322 Priced Lap insert tunnel ip cath 710044 49324 CPT Outpatient 39264.75 6740.45 United Community and State United Medicaid 0.09 3532.56 0.09 39264.75 0.09 Case Rate 49324 Priced Laparo proc abdm/per/oment 710044 49329 CPT Outpatient 58696.05 10076.16 United Community and State United Medicaid 0.09 5359.43 0.09 58696.05 0.09 Case Rate 49329 Priced Ins tun ip cath for dial opn 710044 49421 CPT Outpatient 25460.40 3319.30 United Community and State United Medicaid 0.09 2284.58 0.09 25460.40 0.09 Case Rate 49421 Priced Remove tunneled ip cath 710044 49422 CPT Outpatient 25515.00 4380.08 United Community and State United Medicaid 0.10 2448.62 0.10 25515.00 0.10 Case Rate 49422 Priced Rpr ing hernia init reduce 710044 49500 CPT Outpatient 19594.05 3363.65 United Community and State United Medicaid 0.10 1915.13 0.10 19594.05 0.10 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 710044 49505 CPT Outpatient 34915.65 5993.85 United Community and State United Medicaid 0.09 3181.25 0.09 34915.65 0.09 Case Rate 49505 Priced Prp i/hern init block >5 yr 710044 49507 CPT Outpatient 29794.80 5114.77 United Community and State United Medicaid 0.09 2809.86 0.09 29794.80 0.09 Case Rate 49507 Priced Rerepair ing hernia reduce 710044 49520 CPT Outpatient 36940.05 6341.38 United Community and State United Medicaid 0.09 3375.15 0.09 36940.05 0.09 Case Rate 49520 Priced Rpr ventral hern init reduc 710044 49560 CPT Outpatient 53177.25 9128.76 United Community and State United Medicaid 0.09 5018.29 0.09 53177.25 0.09 Case Rate 49560 Priced Rpr ventral hern init block 710044 49561 CPT Outpatient 30755.55 5279.70 United Community and State United Medicaid 0.09 2911.99 0.09 30755.55 0.09 Case Rate 49561 Priced Rerepair ventrl hern reduce 710044 49565 CPT Outpatient 69917.40 12002.49 United Community and State United Medicaid 0.09 6613.72 0.09 69917.40 0.09 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 710044 49585 CPT Outpatient 41806.80 7176.83 United Community and State United Medicaid 0.09 3951.09 0.09 41806.80 0.09 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 710044 49587 CPT Outpatient 37320.15 6406.63 United Community and State United Medicaid 0.10 3633.97 0.10 37320.15 0.10 Case Rate 49587 Priced Lap ing hernia repair init 710044 49650 CPT Outpatient 41932.80 7198.46 United Community and State United Medicaid 0.10 4117.10 0.10 41932.80 0.10 Case Rate 49650 Priced Lap ing hernia repair recur 710044 49651 CPT Outpatient 46915.05 8053.75 United Community and State United Medicaid 0.09 4445.70 0.09 46915.05 0.09 Case Rate 49651 Priced Lap vent/abd hernia repair 710044 49652 CPT Outpatient 51294.60 8805.57 United Community and State United Medicaid 0.09 4841.10 0.09 51294.60 0.09 Case Rate 49652 Priced Lap vent/abd hern proc comp 710044 49653 CPT Outpatient 46102.35 7914.24 United Community and State United Medicaid 0.09 4369.31 0.09 46102.35 0.09 Case Rate 49653 Priced Lap inc hernia repair 710044 49654 CPT Outpatient 47221.65 8106.38 United Community and State United Medicaid 0.09 4472.93 0.09 47221.65 0.09 Case Rate 49654 Priced Lap inc hern repair comp 710044 49655 CPT Outpatient 54590.55 9371.38 United Community and State United Medicaid 0.09 5056.44 0.09 54590.55 0.09 Case Rate 49655 Priced Lap inc hernia repair recur 710044 49656 CPT Outpatient 55443.15 9517.74 United Community and State United Medicaid 0.09 5223.11 0.09 55443.15 0.09 Case Rate 49656 Priced Removal of kidney stone 710044 50080 CPT Outpatient 53165.70 9126.78 United Community and State United Medicaid 0.10 5177.59 0.10 53165.70 0.10 Case Rate 50080 Priced Removal of kidney stone 710044 50081 CPT Outpatient 66931.20 11489.86 United Community and State United Medicaid 0.09 6222.17 0.09 66931.20 0.09 Case Rate 50081 Priced Renal biopsy perq 710044 50200 CPT Outpatient 43096.20 1225.34 United Community and State United Medicaid 0.05 2287.39 0.05 43096.20 0.05 Case Rate 50200 Priced Plmt nephroureteral catheter 710044 50433 CPT Outpatient 64566.60 1424.48 United Community and State United Medicaid 0.09 6018.24 0.09 64566.60 0.09 Case Rate 50433 Priced Laparo radical nephrectomy 710044 50545 CPT Outpatient 43449.00 7458.75 United Community and State United Medicaid 0.09 3900.22 0.09 43449.00 0.09 Case Rate 50545 Priced Laparoscope proc ureter 710044 50949 CPT Outpatient 49986.30 8580.98 United Community and State United Medicaid 0.09 4584.10 0.09 49986.30 0.09 Case Rate 50949 Priced Injection for bladder x-ray 710044 51600 CPT Outpatient 3285.45 89.22 United Community and State United Medicaid 0.10 313.70 0.10 3285.45 0.10 Case Rate 51600 Priced Cystoscopy 710044 52000 CPT Outpatient 22149.75 3802.37 United Community and State United Medicaid 0.09 1995.25 0.09 22149.75 0.09 Case Rate 52000 Priced Cystoscopy & ureter catheter 710044 52005 CPT Outpatient 42529.20 2095.77 United Community and State United Medicaid 0.10 4055.04 0.10 42529.20 0.10 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 710044 52204 CPT Outpatient 31274.25 5368.75 United Community and State United Medicaid 0.08 2401.96 0.08 31274.25 0.08 Case Rate 52204 Priced Cystoscopy and treatment 710044 52224 CPT Outpatient 13445.25 2308.10 United Community and State United Medicaid 0.09 1218.13 0.09 13445.25 0.09 Case Rate 52224 Priced Cystoscopy and treatment 710044 52234 CPT Outpatient 28510.65 4894.33 United Community and State United Medicaid 0.08 2255.46 0.08 28510.65 0.08 Case Rate 52234 Priced Cystoscopy and treatment 710044 52235 CPT Outpatient 29417.85 5050.06 United Community and State United Medicaid 0.07 2203.98 0.07 29417.85 0.07 Case Rate 52235 Priced Cystoscopy and treatment 710044 52240 CPT Outpatient 33933.90 5825.32 United Community and State United Medicaid 0.09 3207.54 0.09 33933.90 0.09 Case Rate 52240 Priced Cystoscopy and treatment 710044 52281 CPT Outpatient 22159.20 3804.00 United Community and State United Medicaid 0.08 1855.92 0.08 22159.20 0.08 Case Rate 52281 Priced Remove bladder stone 710044 52317 CPT Outpatient 27085.80 4649.73 United Community and State United Medicaid 0.09 2553.63 0.09 27085.80 0.09 Case Rate 52317 Priced Remove bladder stone 710044 52318 CPT Outpatient 26685.75 4581.05 United Community and State United Medicaid 0.09 2397.99 0.09 26685.75 0.09 Case Rate 52318 Priced Cystoscopy and treatment 710044 52332 CPT Outpatient 115306.80 19794.33 United Community and State United Medicaid 0.05 5441.13 0.05 115306.80 0.05 Case Rate 52332 Priced Cystouretero w/stone remove 710044 52352 CPT Outpatient 42420.00 7282.10 United Community and State United Medicaid 0.09 3924.43 0.09 42420.00 0.09 Case Rate 52352 Priced Cystouretero w/lithotripsy 710044 52353 CPT Outpatient 38608.50 6627.79 United Community and State United Medicaid 0.09 3609.13 0.09 38608.50 0.09 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 710044 52356 CPT Outpatient 36255.45 6223.85 United Community and State United Medicaid 0.09 3371.71 0.09 36255.45 0.09 Case Rate 52356 Priced Prostatectomy (turp) 710044 52601 CPT Outpatient 35371.35 6072.08 United Community and State United Medicaid 0.08 2819.46 0.08 35371.35 0.08 Case Rate 52601 Priced Laser surgery of prostate 710044 52648 CPT Outpatient 24264.45 4165.40 United Community and State United Medicaid 0.10 2454.41 0.10 24264.45 0.10 Case Rate 52648 Priced Revision of urethra 710044 53450 CPT Outpatient 16209.90 2782.70 United Community and State United Medicaid 0.10 1555.32 0.10 16209.90 0.10 Case Rate 53450 Priced Urology surgery procedure 710044 53899 CPT Outpatient 25368.00 134.83 United Community and State United Medicaid 0.12 3000.51 0.12 25368.00 0.12 Case Rate 53899 Priced Circumcision w/regionl block 710044 54150 CPT Outpatient 14700.00 2523.50 United Community and State United Medicaid 0.10 1403.01 0.10 14700.00 0.10 Case Rate 54150 Priced Circum 28 days or older 710044 54161 CPT Outpatient 19186.65 3293.71 United Community and State United Medicaid 0.10 1827.97 0.10 19186.65 0.10 Case Rate 54161 Priced Lysis penil circumic lesion 710044 54162 CPT Outpatient 19795.65 3398.25 United Community and State United Medicaid 0.10 1897.97 0.10 19795.65 0.10 Case Rate 54162 Priced Repair of circumcision 710044 54163 CPT Outpatient 16391.55 2813.88 United Community and State United Medicaid 0.10 1566.49 0.10 16391.55 0.10 Case Rate 54163 Priced Reconstruction of urethra 710044 54324 CPT Outpatient 32880.75 5644.53 United Community and State United Medicaid 0.10 3149.08 0.10 32880.75 0.10 Case Rate 54324 Priced Revise penis/urethra 710044 54332 CPT Outpatient 19968.90 3427.99 United Community and State United Medicaid 0.10 1914.19 0.10 19968.90 0.10 Case Rate 54332 Priced Insert self-contd prosthesis 710044 54401 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 710044 54520 CPT Outpatient 35442.75 6084.34 United Community and State United Medicaid 0.09 3212.09 0.09 35442.75 0.09 Case Rate 54520 Priced Reduce testis torsion 710044 54600 CPT Outpatient 55049.40 9450.15 United Community and State United Medicaid 0.07 3690.76 0.07 55049.40 0.07 Case Rate 54600 Priced Suspension of testis 710044 54640 CPT Outpatient 26860.05 4610.98 United Community and State United Medicaid 0.10 2573.90 0.10 26860.05 0.10 Case Rate 54640 Priced Removal of hydrocele 710044 55040 CPT Outpatient 27277.95 4682.71 United Community and State United Medicaid 0.09 2451.10 0.09 27277.95 0.09 Case Rate 55040 Priced Biopsy of prostate gland 710044 55700 CPT Outpatient 28699.65 4926.77 United Community and State United Medicaid 0.09 2557.85 0.09 28699.65 0.09 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 710044 55866 CPT Outpatient 93088.80 15980.24 United Community and State United Medicaid 0.09 8361.39 0.09 93088.80 0.09 Case Rate 55866 Priced Closure of vagina 710044 57120 CPT Outpatient 34369.65 5900.12 United Community and State United Medicaid 0.09 3195.15 0.09 34369.65 0.09 Case Rate 57120 Priced Repair of vagina 710044 57200 CPT Outpatient 25247.25 4334.11 United Community and State United Medicaid 0.08 2121.05 0.08 25247.25 0.08 Case Rate 57200 Priced Anterior colporrhaphy 710044 57240 CPT Outpatient 36210.30 6216.10 United Community and State United Medicaid 0.10 3733.79 0.10 36210.30 0.10 Case Rate 57240 Priced Repair rectum & vagina 710044 57250 CPT Outpatient 40441.80 6942.51 United Community and State United Medicaid 0.09 3773.49 0.09 40441.80 0.09 Case Rate 57250 Priced Cmbn ant pst colprhy 710044 57260 CPT Outpatient 46323.90 7952.27 United Community and State United Medicaid 0.09 4341.34 0.09 46323.90 0.09 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 710044 57265 CPT Outpatient 42586.95 7310.76 United Community and State United Medicaid 0.08 3285.51 0.08 42586.95 0.08 Case Rate 57265 Priced Repair of bowel bulge 710044 57268 CPT Outpatient 36865.50 6328.58 United Community and State United Medicaid 0.11 3988.42 0.11 36865.50 0.11 Case Rate 57268 Priced Colpopexy extraperitoneal 710044 57282 CPT Outpatient 45629.85 7833.12 United Community and State United Medicaid 0.09 4033.73 0.09 45629.85 0.09 Case Rate 57282 Priced Repair bladder defect 710044 57288 CPT Outpatient 43069.95 7393.67 United Community and State United Medicaid 0.09 4065.50 0.09 43069.95 0.09 Case Rate 57288 Priced Bx/curett of cervix w/scope 710044 57454 CPT Outpatient 2888.55 442.93 United Community and State United Medicaid 0.09 257.97 0.09 2888.55 0.09 Case Rate 57454 Priced Conization of cervix 710044 57520 CPT Outpatient 26728.80 4588.44 United Community and State United Medicaid 0.09 2413.93 0.09 26728.80 0.09 Case Rate 57520 Priced Conization of cervix 710044 57522 CPT Outpatient 22737.75 3903.31 United Community and State United Medicaid 0.09 2064.68 0.09 22737.75 0.09 Case Rate 57522 Priced Biopsy of uterus lining 710044 58100 CPT Outpatient 2371.95 194.80 United Community and State United Medicaid 0.09 208.61 0.09 2371.95 0.09 Case Rate 58100 Priced Catheter for hysterography 710044 58340 CPT Outpatient 6322.05 131.04 United Community and State United Medicaid 0.10 603.60 0.10 6322.05 0.10 Case Rate 58340 Priced Reopen fallopian tube 710044 58350 CPT Outpatient 46507.65 7983.81 United Community and State United Medicaid 0.09 4334.39 0.09 46507.65 0.09 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 710044 58542 CPT Outpatient 64194.90 11020.12 United Community and State United Medicaid 0.09 6061.67 0.09 64194.90 0.09 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 710044 58544 CPT Outpatient 51020.55 8758.53 United Community and State United Medicaid 0.09 4713.34 0.09 51020.55 0.09 Case Rate 58544 Priced Laparoscopic myomectomy 710044 58545 CPT Outpatient 56946.75 9775.86 United Community and State United Medicaid 0.09 5294.97 0.09 56946.75 0.09 Case Rate 58545 Priced Laparo-vag hyst incl t/o 710044 58552 CPT Outpatient 57228.15 9824.17 United Community and State United Medicaid 0.09 5376.44 0.09 57228.15 0.09 Case Rate 58552 Priced Hysteroscopy biopsy 710044 58558 CPT Outpatient 28581.00 2077.02 United Community and State United Medicaid 0.09 2688.91 0.09 28581.00 0.09 Case Rate 58558 Priced Hysteroscopy remove myoma 710044 58561 CPT Outpatient 35222.25 6046.49 United Community and State United Medicaid 0.09 3238.76 0.09 35222.25 0.09 Case Rate 58561 Priced Hysteroscopy ablation 710044 58563 CPT Outpatient 38399.55 6591.92 United Community and State United Medicaid 0.11 4202.73 0.11 38399.55 0.11 Case Rate 58563 Priced Tlh uterus 250 g or less 710044 58570 CPT Outpatient 43316.70 7436.03 United Community and State United Medicaid 0.09 3926.17 0.09 43316.70 0.09 Case Rate 58570 Priced Tlh w/t/o 250 g or less 710044 58571 CPT Outpatient 48603.45 8343.59 United Community and State United Medicaid 0.10 4652.61 0.10 48603.45 0.10 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 710044 58573 CPT Outpatient 52905.30 9082.08 United Community and State United Medicaid 0.09 4880.58 0.09 52905.30 0.09 Case Rate 58573 Priced Laparoscopy remove adnexa 710044 58661 CPT Outpatient 47008.50 8069.79 United Community and State United Medicaid 0.09 4444.91 0.09 47008.50 0.09 Case Rate 58661 Priced Laparoscopy excise lesions 710044 58662 CPT Outpatient 45053.40 7734.17 United Community and State United Medicaid 0.10 4281.55 0.10 45053.40 0.10 Case Rate 58662 Priced Treat ectopic pregnancy 710044 59151 CPT Outpatient 74690.70 12821.90 United Community and State United Medicaid 0.06 4632.29 0.06 74690.70 0.06 Case Rate 59151 Priced Treatment of miscarriage 710044 59812 CPT Outpatient 56109.90 9632.20 United Community and State United Medicaid 0.05 2627.12 0.05 56109.90 0.05 Case Rate 59812 Priced Partial removal of thyroid 710044 60220 CPT Outpatient 53639.25 9208.07 United Community and State United Medicaid 0.11 5690.95 0.11 53639.25 0.11 Case Rate 60220 Priced Removal of thyroid 710044 60240 CPT Outpatient 98252.70 16866.71 United Community and State United Medicaid 0.07 6451.53 0.07 98252.70 0.07 Case Rate 60240 Priced Explore parathyroid glands 710044 60500 CPT Outpatient 150495.45 25835.05 United Community and State United Medicaid 0.03 5035.95 0.03 150495.45 0.03 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 710044 62322 CPT Outpatient 43709.40 514.24 United Community and State United Medicaid 0.10 4204.70 0.10 43709.40 0.10 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 710044 62323 CPT Outpatient 8304.45 467.31 United Community and State United Medicaid 8.13 67550.28 8.13 8304.45 8.13 Case Rate 62323 Priced Low back disk surgery 710044 63030 CPT Outpatient 50287.65 8632.71 United Community and State United Medicaid 0.09 4776.76 0.09 50287.65 0.09 Case Rate 63030 Priced Inc for vagus n elect impl 710044 64568 CPT Outpatient 124562.55 21383.24 United Community and State United Medicaid 0.10 11848.97 0.10 124562.55 0.10 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 710044 66821 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 710044 66984 CPT Outpatient 0.01 0.01 United Community and State United Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced Cardiac valve and other major cardiothoracic procedures with cardiac catherization with major complications or comorbidities 717002 216 DRG Inpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 216 Priced Spinal fusion except cervical without major comorbid conditions or complicaitons (MCC) 717002 460 DRG Inpatient 416122.79 53834.63 Wellcare Wellcare Medicaid 0.18 75759.95 0.18 416122.79 0.18 Case Rate 460 Priced Major joint replacement or reattachment of lower extremity withour major comorbid conditions or complications (MCC) 717002 470 DRG Inpatient 167912.19 21723.13 Wellcare Wellcare Medicaid 0.15 25592.13 0.15 167912.19 0.15 Case Rate 470 Priced Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 717002 473 DRG Inpatient 100687.91 13026.19 Wellcare Wellcare Medicaid 0.25 25076.29 0.25 100687.91 0.25 Case Rate 473 Priced Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid 717002 743 DRG Inpatient 102691.67 13285.42 Wellcare Wellcare Medicaid 0.13 12981.04 0.13 102691.67 0.13 Case Rate 743 Priced NORMAL NEWBORN 717002 795 DRG Inpatient 6266.93 2335.00 Wellcare Wellcare Medicaid 0.25 1580.92 0.25 6266.93 0.25 Per Diem 795 Priced VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 717002 807 DRG Inpatient 116469.59 4193.00 Wellcare Wellcare Medicaid 0.05 5499.83 0.05 116469.59 0.05 Case Rate 807 Priced CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 717002 788 DRG Inpatient 76050.77 4538.00 Wellcare Wellcare Medicaid 0.11 8267.86 0.11 76050.77 0.11 Case Rate 788 Priced Routine obstetric care for vaginal delivery including pre- and post delivery 717002 59400 CPT Inpatient 116469.59 4193.00 Wellcare Wellcare Medicaid 0.05 5499.83 0.05 116469.59 0.05 Case Rate 59400 Priced Routine obstetric careror cesarean deliver including pre and post delivery care 717002 59510 CPT Inpatient 76050.77 4538.00 Wellcare Wellcare Medicaid 0.11 8267.86 0.11 76050.77 0.11 Case Rate 59510 Priced Routine osbstetric care for vaginal delivery after prior cesarean section delivery including pre and post delivery care 717002 59610 CPT Inpatient 116469.59 4193.00 Wellcare Wellcare Medicaid 0.05 5499.83 0.05 116469.59 0.05 Case Rate 59610 Priced "Psychotherapy, 30 min" 717002 90832 CPT Outpatient 577.50 91.21 Wellcare Wellcare Medicaid 0.12 69.45 0.12 577.50 0.12 Fee Schedule 90832 Priced "Psychotherapy, 45 min" 717002 90834 CPT Outpatient 44134.65 271.96 Wellcare Wellcare Medicaid 0.11 5055.12 0.11 44134.65 0.11 Fee Schedule 90834 Priced "Psychotherapy, 60 min" 717002 90837 CPT Outpatient 2240.70 442.93 Wellcare Wellcare Medicaid 0.02 51.77 0.02 2240.70 0.02 Fee Schedule 90837 Priced "Family psychotherapy, not including patient, 50 min" 717002 90846 CPT Outpatient 0.01 131.50 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 90846 Priced "Family psychotherapy, including patient, 50 min" 717002 90847 CPT Outpatient 44134.65 369.97 Wellcare Wellcare Medicaid 0.11 5055.12 0.11 44134.65 0.11 Fee Schedule 90847 Priced Group psychotherapy 717002 90853 CPT Outpatient 44134.65 101.99 Wellcare Wellcare Medicaid 0.11 5055.12 0.11 44134.65 0.11 Fee Schedule 90853 Priced "New Patient office or other outpatient visit, typically 30 min" 717002 99203 CPT Outpatient 3480.75 176.07 Wellcare Wellcare Medicaid 0.11 398.66 0.11 3480.75 0.11 Fee Schedule 99203 Priced "New Patient office or other outpatient visit, typically 45 min" 717002 99204 CPT Outpatient 2103.15 233.39 Wellcare Wellcare Medicaid 0.11 240.81 0.11 2103.15 0.11 Fee Schedule 99204 Priced "New Patient office or other outpatient visit, typically 60 min" 717002 99205 CPT Outpatient 4970.70 314.28 Wellcare Wellcare Medicaid 0.06 284.63 0.06 4970.70 0.06 Fee Schedule 99205 Priced "Patient office consultation, typically 40 min" 717002 99243 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99243 Priced "Patient office consultation, typically 60 min" 717002 99244 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 99244 Priced Initial new patient preventative medicine evaluation (18-39 years) 717002 99385 CPT Outpatient 1114.05 185.90 Wellcare Wellcare Medicaid 0.11 127.54 0.11 1114.05 0.11 Fee Schedule 99385 Priced Initial new patient preventative medicine evaluation (40-64 years) 717002 99386 CPT Outpatient 4877.25 185.90 Wellcare Wellcare Medicaid 0.09 419.57 0.09 4877.25 0.09 Fee Schedule 99386 Priced Routine venipuncture 717002 36415 CPT Outpatient 127.05 19.57 Wellcare Wellcare Medicaid 0.02 2.21 0.02 127.05 0.02 Fee Schedule 36415 Priced Basic Metabolic Panel 717002 80048 CPT Outpatient 576.45 88.78 Wellcare Wellcare Medicaid 0.02 11.44 0.02 576.45 0.02 Fee Schedule 80048 Priced "Blood test, comprehensive group of blood chemicals" 717002 80053 CPT Outpatient 763.35 117.56 Wellcare Wellcare Medicaid 0.02 12.92 0.02 763.35 0.02 Fee Schedule 80053 Priced Obstetric blood test panel 717002 80055 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 80055 Priced "Blood test, lipids(cholesterol and triglycerides)" 717002 80061 CPT Outpatient 1349.25 197.77 Wellcare Wellcare Medicaid 0.01 18.45 0.01 1349.25 0.01 Fee Schedule 80061 Priced Kidney function panel test 717002 80069 CPT Outpatient 716.10 104.95 Wellcare Wellcare Medicaid 0.02 11.81 0.02 716.10 0.02 Fee Schedule 80069 Priced Liver function panel test 717002 80076 CPT Outpatient 716.10 104.95 Wellcare Wellcare Medicaid 0.01 8.61 0.01 716.10 0.01 Fee Schedule 80076 Priced Manual urinalysis test with examination using microscope 717002 81000 CPT Outpatient 144.90 21.18 Wellcare Wellcare Medicaid 0.01 1.48 0.01 144.90 0.01 Fee Schedule 81000 Priced Manual urinalysis test with examination using microscope 717002 81001 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Fee Schedule 81001 Priced Automated urinalysis test 717002 81002 CPT Outpatient 57.75 8.89 Wellcare Wellcare Medicaid 0.02 1.23 0.02 57.75 0.02 Fee Schedule 81002 Priced Automated urinalysis test 717002 81003 CPT Outpatient 219.45 33.80 Wellcare Wellcare Medicaid 0.01 1.85 0.01 219.45 0.01 Fee Schedule 81003 Priced Vitamin d 25 hydroxy 717002 82306 CPT Outpatient 1880.55 289.62 Wellcare Wellcare Medicaid 0.02 36.90 0.02 1880.55 0.02 Fee Schedule 82306 Priced Glycosylated hemoglobin test 717002 83036 CPT Outpatient 494.55 76.17 Wellcare Wellcare Medicaid 0.02 8.12 0.02 494.55 0.02 Fee Schedule 83036 Priced PSA (prostate specific antigen) 717002 84153 CPT Outpatient 1177.05 181.28 Wellcare Wellcare Medicaid 0.03 30.14 0.03 1177.05 0.03 Fee Schedule 84153 Priced PSA (prostate specific antigen) 717002 84154 CPT Outpatient 598.50 92.17 Wellcare Wellcare Medicaid 0.05 30.14 0.05 598.50 0.05 Fee Schedule 84154 Priced "Blood test, thyroid stimulating hormone (TSH)" 717002 84443 CPT Outpatient 519.75 80.05 Wellcare Wellcare Medicaid 0.05 28.29 0.05 519.75 0.05 Fee Schedule 84443 Priced Chorionic gonadotropin assay 717002 84703 CPT Outpatient 785.40 120.96 Wellcare Wellcare Medicaid 0.01 3.69 0.01 785.40 0.01 Fee Schedule 84703 Priced "Complete blood cell count, with diffferential white blood cells, automated" 717002 85025 CPT Outpatient 635.25 97.83 Wellcare Wellcare Medicaid 0.12 76.40 0.12 635.25 0.12 Fee Schedule 85025 Priced "Complete blood count, automated" 717002 85027 CPT Outpatient 576.45 88.78 Wellcare Wellcare Medicaid 0.01 5.90 0.01 576.45 0.01 Fee Schedule 85027 Priced "Blood test, clotting time" 717002 85610 CPT Outpatient 404.25 62.26 Wellcare Wellcare Medicaid 0.01 3.69 0.01 404.25 0.01 Fee Schedule 85610 Priced Coagulation assessment blood test 717002 85730 CPT Outpatient 17.22 2.65 Wellcare Wellcare Medicaid 0.21 3.69 0.21 17.22 0.21 Fee Schedule 85730 Priced Allg spec ige crude xtrc ea 717002 86003 CPT Outpatient 32.55 5.01 Wellcare Wellcare Medicaid 0.15 4.92 0.15 32.55 0.15 Fee Schedule 86003 Priced Tb test cell immun measure 717002 86480 CPT Outpatient 530.25 81.66 Wellcare Wellcare Medicaid 0.12 60.99 0.12 530.25 0.12 Fee Schedule 86480 Priced Urine culture/colony count 717002 87086 CPT Outpatient 763.35 117.56 Wellcare Wellcare Medicaid 0.01 7.38 0.01 763.35 0.01 Fee Schedule 87086 Priced Hpylori stool ia 717002 87338 CPT Outpatient 785.40 120.96 Wellcare Wellcare Medicaid 0.12 94.45 0.12 785.40 0.12 Fee Schedule 87338 Priced Cytopath eval fna report 717002 88173 CPT Outpatient 750.75 115.62 Wellcare Wellcare Medicaid 0.12 90.29 0.12 750.75 0.12 Fee Schedule 88173 Priced Tissue exam by pathologist 717002 88302 CPT Outpatient 635.25 97.83 Wellcare Wellcare Medicaid 0.12 76.40 0.12 635.25 0.12 Fee Schedule 88302 Priced Tissue exam by pathologist 717002 88305 CPT Outpatient 323.40 49.81 Wellcare Wellcare Medicaid 0.12 38.90 0.12 323.40 0.12 Fee Schedule 88305 Priced Deb subq tissue 20 sq cm/< 717002 11042 CPT Outpatient 2668.05 481.45 Wellcare Wellcare Medicaid 0.11 305.59 0.11 2668.05 0.11 Case Rate 11042 Priced Deb subq tissue add-on 717002 11045 CPT Outpatient 4652.55 330.00 Wellcare Wellcare Medicaid 0.11 532.90 0.11 4652.55 0.11 Case Rate 11045 Priced Dx bronchoscope/lavage 717002 31624 CPT Outpatient 41223.00 7602.31 Wellcare Wellcare Medicaid 0.11 4551.39 0.11 41223.00 0.11 Case Rate 31624 Priced Bronchoscopy/lung bx each 717002 31628 CPT Outpatient 49048.65 9045.51 Wellcare Wellcare Medicaid 0.11 5599.68 0.11 49048.65 0.11 Case Rate 31628 Priced Blood transfusion service 717002 36430 CPT Outpatient 9166.50 574.93 Wellcare Wellcare Medicaid 0.07 596.70 0.07 9166.50 0.07 Case Rate 36430 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 717002 43235 CPT Outpatient 8856.75 1633.35 Wellcare Wellcare Medicaid 0.12 1056.17 0.12 8856.75 0.12 Case Rate 43235 Priced Endoscopic us exam esoph 717002 43237 CPT Outpatient 23867.55 4401.63 Wellcare Wellcare Medicaid 0.11 2705.92 0.11 23867.55 0.11 Case Rate 43237 Priced Egd us fine needle bx/aspir 717002 43238 CPT Outpatient 30690.45 5659.90 Wellcare Wellcare Medicaid 0.11 3380.96 0.11 30690.45 0.11 Case Rate 43238 Priced "Biopsy of the esophagus, stomach and or upper small bowel using an endocsope" 717002 43239 CPT Outpatient 40191.90 7412.15 Wellcare Wellcare Medicaid 0.13 5162.07 0.13 40191.90 0.13 Case Rate 43239 Priced Ercp remove duct calculi 717002 43264 CPT Outpatient 34335.00 6332.03 Wellcare Wellcare Medicaid 0.12 3987.26 0.12 34335.00 0.12 Case Rate 43264 Priced Diagnotistic examination of large bowel using an endoscope 717002 45378 CPT Outpatient 13991.25 889.35 Wellcare Wellcare Medicaid 0.11 1605.40 0.11 13991.25 0.11 Case Rate 45378 Priced Biopsy of large bowel using an endoscope 717002 45380 CPT Outpatient 22215.90 4097.04 Wellcare Wellcare Medicaid 0.11 2550.22 0.11 22215.90 0.11 Case Rate 45380 Priced Removal of polyps or growths of large bowel using an endoscope 717002 45385 CPT Outpatient 119569.80 22050.95 Wellcare Wellcare Medicaid 0.04 4609.95 0.04 119569.80 0.04 Case Rate 45385 Priced Ultrasound examination of lower large bowel using an endoscope 717002 45391 CPT Outpatient 24923.85 4596.43 Wellcare Wellcare Medicaid 0.11 2855.53 0.11 24923.85 0.11 Case Rate 45391 Priced Fragmenting of kidney stone 717002 50590 CPT Outpatient 40930.05 7548.28 Wellcare Wellcare Medicaid 0.11 4705.07 0.11 40930.05 0.11 Case Rate 50590 Priced Fetal non-stress test 717002 59025 CPT Outpatient 3153.15 477.76 Wellcare Wellcare Medicaid 0.11 361.16 0.11 3153.15 0.11 Case Rate 59025 Priced Injection of anesthetic and or steriod drug into lower or sacral spine nerve root using imaging guidance 717002 64483 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 64483 Priced Tympanometry 717002 92567 CPT Outpatient 2224.95 98.50 Wellcare Wellcare Medicaid 0.11 254.84 0.11 2224.95 0.11 Case Rate 92567 Priced "Electrocardiogram, routine, with interpretation and report" 717002 93000 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 93000 Priced Cardiovascular stress test 717002 93017 CPT Outpatient 3076.50 532.96 Wellcare Wellcare Medicaid 0.11 352.32 0.11 3076.50 0.11 Case Rate 93017 Priced Insertion of catheter into left heart for diagnosis 717002 93452 CPT Outpatient 55621.65 8611.87 Wellcare Wellcare Medicaid 0.12 6398.48 0.12 55621.65 0.12 Case Rate 93452 Priced Polysom 6/> yrs 4/> param 717002 95810 CPT Outpatient 20341.65 3373.48 Wellcare Wellcare Medicaid 0.11 2329.87 0.11 20341.65 0.11 Case Rate 95810 Priced Polysom 6/>yrs cpap 4/> parm 717002 95811 CPT Outpatient 22491.00 3731.18 Wellcare Wellcare Medicaid 0.11 2576.11 0.11 22491.00 0.11 Case Rate 95811 Priced Eeg 41-60 minutes 717002 95812 CPT Outpatient 5578.65 925.83 Wellcare Wellcare Medicaid 0.11 638.97 0.11 5578.65 0.11 Case Rate 95812 Priced Genetic counseling 30 min 717002 96040 CPT Outpatient 0.01 102.81 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 96040 Priced Chemo iv infusion 1 hr 717002 96413 CPT Outpatient 4856.25 472.45 Wellcare Wellcare Medicaid 0.48 2314.96 0.48 4856.25 0.48 Case Rate 96413 Priced Ultrasound therapy 717002 97035 CPT Outpatient 2111.55 134.99 Wellcare Wellcare Medicaid 0.11 241.83 0.11 2111.55 0.11 Case Rate 97035 Priced "Physical Therapy, therapeutic exercise" 717002 97110 CPT Outpatient 6494.25 92.86 Wellcare Wellcare Medicaid 0.11 743.79 0.11 6494.25 0.11 Case Rate 97110 Priced Gait training therapy 717002 97116 CPT Outpatient 4723.95 110.61 Wellcare Wellcare Medicaid 0.11 540.98 0.11 4723.95 0.11 Case Rate 97116 Priced "CT scan, head or brain, without contrast" 717002 70450 CPT Outpatient 8566.95 835.61 Wellcare Wellcare Medicaid 0.05 461.25 0.05 8566.95 0.05 Case Rate 70450 Priced Mri brain stem w/o dye 717002 70551 CPT Outpatient 7861.35 1361.31 Wellcare Wellcare Medicaid 0.11 900.38 0.11 7861.35 0.11 Case Rate 70551 Priced MRI scan of brain before and after contrast 717002 70553 CPT Outpatient 10882.20 1625.88 Wellcare Wellcare Medicaid 0.11 1246.38 0.11 10882.20 0.11 Case Rate 70553 Priced X-ray exam chest 2 views 717002 71046 CPT Outpatient 859.95 150.37 Wellcare Wellcare Medicaid 0.11 98.50 0.11 859.95 0.11 Case Rate 71046 Priced Ct thorax w/o dye 717002 71250 CPT Outpatient 7288.05 1261.63 Wellcare Wellcare Medicaid 0.11 834.71 0.11 7288.05 0.11 Case Rate 71250 Priced X-ray exam entire spi 2/3 vw 717002 72082 CPT Outpatient 2022.30 253.33 Wellcare Wellcare Medicaid 0.14 275.42 0.14 2022.30 0.14 Case Rate 72082 Priced X-ray exam l-s spine 2/3 vws 717002 72100 CPT Outpatient 1599.15 277.38 Wellcare Wellcare Medicaid 0.11 183.11 0.11 1599.15 0.11 Case Rate 72100 Priced "X-Ray, lower back, minimum 4 views" 717002 72110 CPT Outpatient 1389.15 241.04 Wellcare Wellcare Medicaid 0.11 159.11 0.11 1389.15 0.11 Case Rate 72110 Priced MRI scan of lower spinal canal 717002 72148 CPT Outpatient 7861.35 1361.31 Wellcare Wellcare Medicaid 0.11 900.38 0.11 7861.35 0.11 Case Rate 72148 Priced "CT Scan, pelvis, with contrast" 717002 72193 CPT Outpatient 13671.00 1412.01 Wellcare Wellcare Medicaid 0.11 1565.87 0.11 13671.00 0.11 Case Rate 72193 Priced X-ray exam of shoulder 717002 73030 CPT Outpatient 1452.15 251.43 Wellcare Wellcare Medicaid 0.11 166.31 0.11 1452.15 0.11 Case Rate 73030 Priced X-ray exam of elbow 717002 73080 CPT Outpatient 1356.60 235.68 Wellcare Wellcare Medicaid 0.11 155.33 0.11 1356.60 0.11 Case Rate 73080 Priced X-ray exam of forearm 717002 73090 CPT Outpatient 1243.20 215.26 Wellcare Wellcare Medicaid 0.11 142.32 0.11 1243.20 0.11 Case Rate 73090 Priced X-ray exam of wrist 717002 73110 CPT Outpatient 1243.20 215.26 Wellcare Wellcare Medicaid 0.11 142.32 0.11 1243.20 0.11 Case Rate 73110 Priced X-ray exam of hand 717002 73130 CPT Outpatient 1243.20 215.26 Wellcare Wellcare Medicaid 0.11 142.32 0.11 1243.20 0.11 Case Rate 73130 Priced X-ray exam hips bi 2 views 717002 73521 CPT Outpatient 970.20 228.41 Wellcare Wellcare Medicaid 0.15 150.28 0.15 970.20 0.15 Case Rate 73521 Priced X-ray exam of knee 3 717002 73562 CPT Outpatient 802.20 139.12 Wellcare Wellcare Medicaid 0.11 91.81 0.11 802.20 0.11 Case Rate 73562 Priced X-ray exam of lower leg 717002 73590 CPT Outpatient 1243.20 215.26 Wellcare Wellcare Medicaid 0.11 142.32 0.11 1243.20 0.11 Case Rate 73590 Priced X-ray exam of ankle 717002 73610 CPT Outpatient 1378.65 239.31 Wellcare Wellcare Medicaid 0.11 157.85 0.11 1378.65 0.11 Case Rate 73610 Priced X-ray exam of foot 717002 73630 CPT Outpatient 975.45 169.41 Wellcare Wellcare Medicaid 0.11 111.63 0.11 975.45 0.11 Case Rate 73630 Priced MRI scan of leg joint 717002 73721 CPT Outpatient 7861.35 1361.31 Wellcare Wellcare Medicaid 0.11 900.38 0.11 7861.35 0.11 Case Rate 73721 Priced CT Scan of abdomen and pelvis with contrast 717002 74177 CPT Outpatient 14222.25 1412.01 Wellcare Wellcare Medicaid 0.11 1629.01 0.11 14222.25 0.11 Case Rate 74177 Priced Contrst x-ray exam of throat 717002 74210 CPT Outpatient 0.01 440.39 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 74210 Priced X-ray exam surgical specimen 717002 76098 CPT Outpatient 6141.45 407.86 Wellcare Wellcare Medicaid 0.11 703.38 0.11 6141.45 0.11 Case Rate 76098 Priced Us exam of head and neck 717002 76536 CPT Outpatient 5512.50 955.18 Wellcare Wellcare Medicaid 0.11 631.40 0.11 5512.50 0.11 Case Rate 76536 Priced Ultrasound breast limited 717002 76642 CPT Outpatient 5777.10 127.70 Wellcare Wellcare Medicaid 0.11 661.71 0.11 5777.10 0.11 Case Rate 76642 Priced Ultrasound of abdomen 717002 76700 CPT Outpatient 4917.15 851.88 Wellcare Wellcare Medicaid 0.11 563.21 0.11 4917.15 0.11 Case Rate 76700 Priced Echo exam of abdomen 717002 76705 CPT Outpatient 3836.70 665.17 Wellcare Wellcare Medicaid 0.11 439.46 0.11 3836.70 0.11 Case Rate 76705 Priced Us exam abdo back wall comp 717002 76770 CPT Outpatient 5171.25 895.48 Wellcare Wellcare Medicaid 0.11 592.26 0.11 5171.25 0.11 Case Rate 76770 Priced Us exam abdo back wall lim 717002 76775 CPT Outpatient 3969.00 686.97 Wellcare Wellcare Medicaid 0.11 454.61 0.11 3969.00 0.11 Case Rate 76775 Priced Ob us < 14 wks single fetus 717002 76801 CPT Outpatient 2006.55 347.98 Wellcare Wellcare Medicaid 0.11 229.83 0.11 2006.55 0.11 Case Rate 76801 Priced Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 717002 76805 CPT Outpatient 3969.00 686.97 Wellcare Wellcare Medicaid 0.11 454.61 0.11 3969.00 0.11 Case Rate 76805 Priced Ob us detailed sngl fetus 717002 76811 CPT Outpatient 2844.45 492.99 Wellcare Wellcare Medicaid 0.11 325.81 0.11 2844.45 0.11 Case Rate 76811 Priced Ob us nuchal meas 1 gest 717002 76813 CPT Outpatient 1044.75 180.83 Wellcare Wellcare Medicaid 0.11 119.59 0.11 1044.75 0.11 Case Rate 76813 Priced Ob us limited fetus(s) 717002 76815 CPT Outpatient 6428.10 639.90 Wellcare Wellcare Medicaid 0.11 736.22 0.11 6428.10 0.11 Case Rate 76815 Priced Ob us follow-up per fetus 717002 76816 CPT Outpatient 4818.45 833.88 Wellcare Wellcare Medicaid 0.11 551.84 0.11 4818.45 0.11 Case Rate 76816 Priced Transvaginal us obstetric 717002 76817 CPT Outpatient 6428.10 476.73 Wellcare Wellcare Medicaid 0.11 736.22 0.11 6428.10 0.11 Case Rate 76817 Priced Fetal biophys profil w/o nst 717002 76819 CPT Outpatient 1741.95 302.65 Wellcare Wellcare Medicaid 0.11 199.53 0.11 1741.95 0.11 Case Rate 76819 Priced Ultrasound pelvis through vagina 717002 76830 CPT Outpatient 9305.10 806.54 Wellcare Wellcare Medicaid 0.11 1065.81 0.11 9305.10 0.11 Case Rate 76830 Priced Us exam scrotum 717002 76870 CPT Outpatient 6328.35 1096.55 Wellcare Wellcare Medicaid 0.11 724.85 0.11 6328.35 0.11 Case Rate 76870 Priced Us exam infant hips dynamic 717002 76885 CPT Outpatient 3836.70 665.17 Wellcare Wellcare Medicaid 0.11 439.46 0.11 3836.70 0.11 Case Rate 76885 Priced Mammography of one breast 717002 77065 CPT Outpatient 3451.35 192.07 Wellcare Wellcare Medicaid 0.11 395.26 0.11 3451.35 0.11 Case Rate 77065 Priced Mammography of both breasts 717002 77066 CPT Outpatient 5777.10 235.68 Wellcare Wellcare Medicaid 0.11 661.71 0.11 5777.10 0.11 Case Rate 77066 Priced "Mamography, screening bilateral" 717002 77067 CPT Outpatient 1416.45 205.57 Wellcare Wellcare Medicaid 0.11 162.14 0.11 1416.45 0.11 Case Rate 77067 Priced X-rays for bone age 717002 77072 CPT Outpatient 2022.30 163.87 Wellcare Wellcare Medicaid 0.14 275.42 0.14 2022.30 0.14 Case Rate 77072 Priced Joint survey single view 717002 77077 CPT Outpatient 985.95 171.14 Wellcare Wellcare Medicaid 0.11 112.89 0.11 985.95 0.11 Case Rate 77077 Priced Dxa bone density axial 717002 77080 CPT Outpatient 3257.10 319.09 Wellcare Wellcare Medicaid 0.11 373.03 0.11 3257.10 0.11 Case Rate 77080 Priced Fna bx w/us gdn 1st les 717002 10005 CPT Outpatient 5512.50 547.24 Wellcare Wellcare Medicaid 0.11 631.40 0.11 5512.50 0.11 Case Rate 10005 Priced Fna bx w/us gdn ea addl 717002 10006 CPT Outpatient 10628.10 594.83 Wellcare Wellcare Medicaid 0.11 1217.34 0.11 10628.10 0.11 Case Rate 10006 Priced Drainage of hematoma/fluid 717002 10140 CPT Outpatient 23209.20 1081.95 Wellcare Wellcare Medicaid 0.09 2168.06 0.09 23209.20 0.09 Case Rate 10140 Priced Deb subq tissue 20 sq cm/< 717002 11042 CPT Outpatient 2668.05 481.45 Wellcare Wellcare Medicaid 0.11 305.59 0.11 2668.05 0.11 Case Rate 11042 Priced Deb bone 20 sq cm/< 717002 11044 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11044 Priced Removal of skin tags 4.0 cm 717002 11406 CPT Outpatient 19967.85 3427.81 Wellcare Wellcare Medicaid 0.11 2117.29 0.11 19967.85 0.11 Case Rate 11406 Priced Exc h-f-nk-sp b9+marg 3.1-4 717002 11424 CPT Outpatient 0.01 1004.93 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 11424 Priced Remove pilonidal cyst simple 717002 11770 CPT Outpatient 19173.00 3291.37 Wellcare Wellcare Medicaid 0.11 2198.53 0.11 19173.00 0.11 Case Rate 11770 Priced Replace tissue expander 717002 11970 CPT Outpatient 59239.95 10169.52 Wellcare Wellcare Medicaid 0.11 6688.09 0.11 59239.95 0.11 Case Rate 11970 Priced Tis trnfr s/a/l 10 sq cm/< 717002 14020 CPT Outpatient 32166.75 5521.96 Wellcare Wellcare Medicaid 0.11 3473.93 0.11 32166.75 0.11 Case Rate 14020 Priced Tis trnfr e/n/e/l 10 sq cm/< 717002 14060 CPT Outpatient 25993.80 1374.69 Wellcare Wellcare Medicaid 0.12 3014.42 0.12 25993.80 0.12 Case Rate 14060 Priced Wound prep trk/arm/leg 717002 15002 CPT Outpatient 41748.00 1441.73 Wellcare Wellcare Medicaid 0.12 5046.62 0.12 41748.00 0.12 Case Rate 15002 Priced Skin sub graft trnk/arm/leg 717002 15271 CPT Outpatient 24343.20 3769.48 Wellcare Wellcare Medicaid 0.11 2699.87 0.11 24343.20 0.11 Case Rate 15271 Priced Acellular derm matrix implt 717002 15777 CPT Outpatient 101672.55 17453.79 Wellcare Wellcare Medicaid 0.14 14343.11 0.14 101672.55 0.14 Case Rate 15777 Priced Exc skin abd 717002 15830 CPT Outpatient 54696.60 9389.58 Wellcare Wellcare Medicaid 0.09 4816.98 0.09 54696.60 0.09 Case Rate 15830 Priced Dressing change not for burn 717002 15852 CPT Outpatient 0.01 290.74 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15852 Priced Suction lipectomy trunk 717002 15877 CPT Outpatient 63741.30 10942.26 Wellcare Wellcare Medicaid 0.12 7567.80 0.12 63741.30 0.12 Case Rate 15877 Priced Suction lipectomy lwr extrem 717002 15879 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 15879 Priced Drainage of breast lesion 717002 19000 CPT Outpatient 10143.00 594.83 Wellcare Wellcare Medicaid 0.11 1161.78 0.11 10143.00 0.11 Case Rate 19000 Priced Bx breast 1st lesion strtctc 717002 19081 CPT Outpatient 12341.70 1250.69 Wellcare Wellcare Medicaid 0.11 1413.58 0.11 12341.70 0.11 Case Rate 19081 Priced Bx breast add lesion us imag 717002 19084 CPT Outpatient 29058.75 547.24 Wellcare Wellcare Medicaid 0.12 3411.64 0.12 29058.75 0.12 Case Rate 19084 Priced Biopsy of breast open 717002 19101 CPT Outpatient 39545.10 2737.82 Wellcare Wellcare Medicaid 0.10 4111.35 0.10 39545.10 0.10 Case Rate 19101 Priced "Removal of 1 or more breast growth, open procedure" 717002 19120 CPT Outpatient 35761.95 2737.82 Wellcare Wellcare Medicaid 0.13 4515.39 0.13 35761.95 0.13 Case Rate 19120 Priced Excision breast lesion 717002 19125 CPT Outpatient 33184.20 0.01 Wellcare Wellcare Medicaid 0.11 3573.40 0.11 33184.20 0.11 Case Rate 19125 Priced Perq device breast 1st imag 717002 19281 CPT Outpatient 6141.45 598.61 Wellcare Wellcare Medicaid 0.11 703.38 0.11 6141.45 0.11 Case Rate 19281 Priced Perq device breast ea imag 717002 19282 CPT Outpatient 8379.00 319.04 Wellcare Wellcare Medicaid 0.11 959.73 0.11 8379.00 0.11 Case Rate 19282 Priced Partial mastectomy 717002 19301 CPT Outpatient 39157.65 6722.06 Wellcare Wellcare Medicaid 0.12 4584.74 0.12 39157.65 0.12 Case Rate 19301 Priced Mast simple complete 717002 19303 CPT Outpatient 105389.55 18091.87 Wellcare Wellcare Medicaid 0.12 12489.59 0.12 105389.55 0.12 Case Rate 19303 Priced Reduction of large breast 717002 19318 CPT Outpatient 65239.65 11199.47 Wellcare Wellcare Medicaid 0.12 7714.45 0.12 65239.65 0.12 Case Rate 19318 Priced Immediate breast prosthesis 717002 19340 CPT Outpatient 113100.75 19415.63 Wellcare Wellcare Medicaid 0.12 13216.34 0.12 113100.75 0.12 Case Rate 19340 Priced Delayed breast prosthesis 717002 19342 CPT Outpatient 56988.75 9783.07 Wellcare Wellcare Medicaid 0.12 6654.25 0.12 56988.75 0.12 Case Rate 19342 Priced Breast reconstruction 717002 19357 CPT Outpatient 101672.55 17453.79 Wellcare Wellcare Medicaid 0.14 14343.11 0.14 101672.55 0.14 Case Rate 19357 Priced Breast reconstruction 717002 19366 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 19366 Priced Revise breast reconstruction 717002 19380 CPT Outpatient 61493.25 10556.34 Wellcare Wellcare Medicaid 0.12 7380.36 0.12 61493.25 0.12 Case Rate 19380 Priced Removal of support implant 717002 20680 CPT Outpatient 42329.70 7266.60 Wellcare Wellcare Medicaid 0.12 4908.47 0.12 42329.70 0.12 Case Rate 20680 Priced Cerv artific diskectomy 717002 22856 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 22856 Priced Treat humerus fracture 717002 24538 CPT Outpatient 51237.90 4775.24 Wellcare Wellcare Medicaid 0.09 4374.86 0.09 51237.90 0.09 Case Rate 24538 Priced Remove wrist tendon lesion 717002 25111 CPT Outpatient 25855.20 4438.48 Wellcare Wellcare Medicaid 0.11 2853.64 0.11 25855.20 0.11 Case Rate 25111 Priced Incise finger tendon sheath 717002 26055 CPT Outpatient 15862.35 2723.04 Wellcare Wellcare Medicaid 0.11 1704.09 0.11 15862.35 0.11 Case Rate 26055 Priced Treat finger fracture each 717002 26727 CPT Outpatient 22779.75 2030.47 Wellcare Wellcare Medicaid 0.12 2653.99 0.12 22779.75 0.12 Case Rate 26727 Priced Revision of knee joint 717002 27446 CPT Outpatient 67882.50 11653.16 Wellcare Wellcare Medicaid 0.11 7686.40 0.11 67882.50 0.11 Case Rate 27446 Priced Total knee arthroplasty 717002 27447 CPT Outpatient 130698.75 22436.62 Wellcare Wellcare Medicaid 0.07 9654.67 0.07 130698.75 0.07 Case Rate 27447 Priced Surgery to stop leg growth 717002 27485 CPT Outpatient 43310.40 7434.95 Wellcare Wellcare Medicaid 0.11 4851.18 0.11 43310.40 0.11 Case Rate 27485 Priced Repair achilles tendon 717002 27650 CPT Outpatient 38246.25 3762.57 Wellcare Wellcare Medicaid 0.11 4066.89 0.11 38246.25 0.11 Case Rate 27650 Priced Treatment of ankle fracture 717002 27792 CPT Outpatient 36101.10 6197.36 Wellcare Wellcare Medicaid 0.12 4206.61 0.12 36101.10 0.12 Case Rate 27792 Priced Treatment of ankle fracture 717002 27814 CPT Outpatient 49405.65 8481.30 Wellcare Wellcare Medicaid 0.10 5142.89 0.10 49405.65 0.10 Case Rate 27814 Priced Removal of foot lesion 717002 28080 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28080 Priced Repair of hammertoe 717002 28285 CPT Outpatient 68603.85 11776.99 Wellcare Wellcare Medicaid 0.10 7187.97 0.10 68603.85 0.10 Case Rate 28285 Priced Correction hallux valgus 717002 28296 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 28296 Priced Shoulder arthroscopy/surgery 717002 29823 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 29823 Priced Shaving of shoulder bone using endoscope 717002 29826 CPT Outpatient 49840.35 8555.93 Wellcare Wellcare Medicaid 0.12 5823.24 0.12 49840.35 0.12 Case Rate 29826 Priced Removal of one knee cartilageusing an endoscope 717002 29881 CPT Outpatient 35556.15 6103.81 Wellcare Wellcare Medicaid 0.11 3995.03 0.11 35556.15 0.11 Case Rate 29881 Priced Knee arthroscopy/surgery 717002 29882 CPT Outpatient 61099.50 10488.75 Wellcare Wellcare Medicaid 0.12 7141.11 0.12 61099.50 0.12 Case Rate 29882 Priced Percut bx lung/mediastinum 717002 32405 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32405 Priced Aspirate pleura w/ imaging 717002 32555 CPT Outpatient 14597.10 687.29 Wellcare Wellcare Medicaid 0.05 770.50 0.05 14597.10 0.05 Case Rate 32555 Priced Thoracoscopy w/ th nrv exc 717002 32664 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 32664 Priced Repair blood vessel lesion 717002 35190 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 35190 Priced Endovenous laser 1st vein 717002 36478 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36478 Priced Insert tunneled cv cath 717002 36561 CPT Outpatient 53531.10 3292.99 Wellcare Wellcare Medicaid 0.06 3198.68 0.06 53531.10 0.06 Case Rate 36561 Priced Insj picc 5 yr+ w/o imaging 717002 36569 CPT Outpatient 31421.25 1299.06 Wellcare Wellcare Medicaid 0.11 3602.90 0.11 31421.25 0.11 Case Rate 36569 Priced Removal tunneled cv cath 717002 36590 CPT Outpatient 1996.05 273.95 Wellcare Wellcare Medicaid 0.12 229.58 0.12 1996.05 0.12 Case Rate 36590 Priced Av fuse uppr arm basilic 717002 36819 CPT Outpatient 56861.70 9761.26 Wellcare Wellcare Medicaid 0.12 6725.77 0.12 56861.70 0.12 Case Rate 36819 Priced Av fusion direct any site 717002 36821 CPT Outpatient 42953.40 7373.67 Wellcare Wellcare Medicaid 0.11 4867.27 0.11 42953.40 0.11 Case Rate 36821 Priced Artery-vein autograft 717002 36825 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 36825 Priced Artery-vein nonautograft 717002 36830 CPT Outpatient 53656.05 9210.96 Wellcare Wellcare Medicaid 0.12 6519.00 0.12 53656.05 0.12 Case Rate 36830 Priced Av fistula revision open 717002 36832 CPT Outpatient 52492.65 9011.24 Wellcare Wellcare Medicaid 0.11 5528.18 0.11 52492.65 0.11 Case Rate 36832 Priced Av fistula revision 717002 36833 CPT Outpatient 37098.60 6368.59 Wellcare Wellcare Medicaid 0.11 4183.06 0.11 37098.60 0.11 Case Rate 36833 Priced Intro cath dialysis circuit 717002 36903 CPT Outpatient 77541.45 10669.90 Wellcare Wellcare Medicaid 0.11 8234.65 0.11 77541.45 0.11 Case Rate 36903 Priced Thrmbc/nfs dialysis circuit 717002 36906 CPT Outpatient 96694.50 16175.64 Wellcare Wellcare Medicaid 0.11 10557.73 0.11 96694.50 0.11 Case Rate 36906 Priced Fem/popl revas w/tla 717002 37224 CPT Outpatient 200076.45 5139.31 Wellcare Wellcare Medicaid 0.11 22798.18 0.11 200076.45 0.11 Case Rate 37224 Priced Fem/popl revasc stnt & ather 717002 37227 CPT Outpatient 117170.55 18045.38 Wellcare Wellcare Medicaid 0.12 14091.71 0.12 117170.55 0.12 Case Rate 37227 Priced Revise leg vein 717002 37700 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 37700 Priced Ligate/strip long leg vein 717002 37722 CPT Outpatient 27815.55 4775.00 Wellcare Wellcare Medicaid 0.12 3226.20 0.12 27815.55 0.12 Case Rate 37722 Priced Stab phleb veins xtr 10-20 717002 37765 CPT Outpatient 26561.85 4559.78 Wellcare Wellcare Medicaid 0.12 3089.79 0.12 26561.85 0.12 Case Rate 37765 Priced Biopsy/removal lymph nodes 717002 38500 CPT Outpatient 35955.15 6172.30 Wellcare Wellcare Medicaid 0.12 4321.24 0.12 35955.15 0.12 Case Rate 38500 Priced Biopsy/removal lymph nodes 717002 38525 CPT Outpatient 101194.80 17371.77 Wellcare Wellcare Medicaid 0.12 11999.59 0.12 101194.80 0.12 Case Rate 38525 Priced Laparoscopy lymph node biop 717002 38570 CPT Outpatient 65631.30 11266.71 Wellcare Wellcare Medicaid 0.12 7825.38 0.12 65631.30 0.12 Case Rate 38570 Priced Laparoscopy lymphadenectomy 717002 38571 CPT Outpatient 84031.50 14425.41 Wellcare Wellcare Medicaid 0.11 9448.62 0.11 84031.50 0.11 Case Rate 38571 Priced Laparoscopy lymphadenectomy 717002 38572 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 38572 Priced Ra tracer id of sentinl node 717002 38792 CPT Outpatient 2868.60 432.48 Wellcare Wellcare Medicaid 0.11 328.45 0.11 2868.60 0.11 Case Rate 38792 Priced Excision of gum lesion 717002 41825 CPT Outpatient 11580.45 1987.98 Wellcare Wellcare Medicaid 0.12 1379.96 0.12 11580.45 0.12 Case Rate 41825 Priced Reconstruct cleft palate 717002 42200 CPT Outpatient 36703.80 6300.82 Wellcare Wellcare Medicaid 0.11 4204.65 0.11 36703.80 0.11 Case Rate 42200 Priced Removal of tonsils and adenoid glands patient younger than 12 717002 42820 CPT Outpatient 17232.60 2958.26 Wellcare Wellcare Medicaid 0.12 2058.46 0.12 17232.60 0.12 Case Rate 42820 Priced Control throat bleeding 717002 42960 CPT Outpatient 24066.00 4131.33 Wellcare Wellcare Medicaid 0.12 2789.09 0.12 24066.00 0.12 Case Rate 42960 Priced "Diagnostic examinationof esophagus, stomach, and or upper small bowel using and endoscope" 717002 43235 CPT Outpatient 8856.75 1633.35 Wellcare Wellcare Medicaid 0.12 1056.17 0.12 8856.75 0.12 Case Rate 43235 Priced Laparoscopy fundoplasty 717002 43280 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 43280 Priced Lap paraesoph her rpr w/mesh 717002 43282 CPT Outpatient 84344.40 14479.12 Wellcare Wellcare Medicaid 0.12 9994.52 0.12 84344.40 0.12 Case Rate 43282 Priced Laparoscopy appendectomy 717002 44970 CPT Outpatient 82300.05 14128.18 Wellcare Wellcare Medicaid 0.06 5273.29 0.06 82300.05 0.06 Case Rate 44970 Priced Diagnostic sigmoidoscopy 717002 45330 CPT Outpatient 17286.15 542.26 Wellcare Wellcare Medicaid 0.11 1929.78 0.11 17286.15 0.11 Case Rate 45330 Priced Needle biopsy of liver 717002 47000 CPT Outpatient 10398.15 1225.34 Wellcare Wellcare Medicaid 0.11 1190.95 0.11 10398.15 0.11 Case Rate 47000 Priced Removal of gallbladder using an endoscope 717002 47562 CPT Outpatient 58430.40 10030.55 Wellcare Wellcare Medicaid 0.06 3388.84 0.06 58430.40 0.06 Case Rate 47562 Priced Laparo cholecystectomy/graph 717002 47563 CPT Outpatient 71747.55 12316.66 Wellcare Wellcare Medicaid 0.10 6966.64 0.10 71747.55 0.10 Case Rate 47563 Priced Abd paracentesis w/imaging 717002 49083 CPT Outpatient 6979.35 1113.95 Wellcare Wellcare Medicaid 0.11 799.36 0.11 6979.35 0.11 Case Rate 49083 Priced Diag laparo separate proc 717002 49320 CPT Outpatient 31629.15 5429.67 Wellcare Wellcare Medicaid 0.11 3606.08 0.11 31629.15 0.11 Case Rate 49320 Priced Laparoscopy biopsy 717002 49321 CPT Outpatient 41892.90 7191.61 Wellcare Wellcare Medicaid 0.11 4664.94 0.11 41892.90 0.11 Case Rate 49321 Priced Laparoscopy aspiration 717002 49322 CPT Outpatient 34392.75 5904.09 Wellcare Wellcare Medicaid 0.11 3865.29 0.11 34392.75 0.11 Case Rate 49322 Priced Lap insert tunnel ip cath 717002 49324 CPT Outpatient 39264.75 6740.45 Wellcare Wellcare Medicaid 0.11 4273.94 0.11 39264.75 0.11 Case Rate 49324 Priced Laparo proc abdm/per/oment 717002 49329 CPT Outpatient 58696.05 10076.16 Wellcare Wellcare Medicaid 0.11 6465.57 0.11 58696.05 0.11 Case Rate 49329 Priced Ins tun ip cath for dial opn 717002 49421 CPT Outpatient 25460.40 3319.30 Wellcare Wellcare Medicaid 0.11 2815.07 0.11 25460.40 0.11 Case Rate 49421 Priced Remove tunneled ip cath 717002 49422 CPT Outpatient 25515.00 4380.08 Wellcare Wellcare Medicaid 0.12 2975.26 0.12 25515.00 0.12 Case Rate 49422 Priced Rpr ing hernia init reduce 717002 49500 CPT Outpatient 19594.05 3363.65 Wellcare Wellcare Medicaid 0.12 2297.41 0.12 19594.05 0.12 Case Rate 49500 Priced Repair of groin hernia patient age 5 years or older 717002 49505 CPT Outpatient 34915.65 5993.85 Wellcare Wellcare Medicaid 0.11 3852.86 0.11 34915.65 0.11 Case Rate 49505 Priced Prp i/hern init block >5 yr 717002 49507 CPT Outpatient 29794.80 5114.77 Wellcare Wellcare Medicaid 0.11 3407.74 0.11 29794.80 0.11 Case Rate 49507 Priced Rerepair ing hernia reduce 717002 49520 CPT Outpatient 36940.05 6341.38 Wellcare Wellcare Medicaid 0.11 4123.33 0.11 36940.05 0.11 Case Rate 49520 Priced Rpr ventral hern init reduc 717002 49560 CPT Outpatient 53177.25 9128.76 Wellcare Wellcare Medicaid 0.11 6057.09 0.11 53177.25 0.11 Case Rate 49560 Priced Rpr ventral hern init block 717002 49561 CPT Outpatient 30755.55 5279.70 Wellcare Wellcare Medicaid 0.11 3530.91 0.11 30755.55 0.11 Case Rate 49561 Priced Rerepair ventrl hern reduce 717002 49565 CPT Outpatient 69917.40 12002.49 Wellcare Wellcare Medicaid 0.11 7969.66 0.11 69917.40 0.11 Case Rate 49565 Priced Rpr umbil hern reduc > 5 yr 717002 49585 CPT Outpatient 41806.80 7176.83 Wellcare Wellcare Medicaid 0.11 4777.42 0.11 41806.80 0.11 Case Rate 49585 Priced Rpr umbil hern block > 5 yr 717002 49587 CPT Outpatient 37320.15 6406.63 Wellcare Wellcare Medicaid 0.12 4397.69 0.12 37320.15 0.12 Case Rate 49587 Priced Lap ing hernia repair init 717002 49650 CPT Outpatient 41932.80 7198.46 Wellcare Wellcare Medicaid 0.12 4976.76 0.12 41932.80 0.12 Case Rate 49650 Priced Lap ing hernia repair recur 717002 49651 CPT Outpatient 46915.05 8053.75 Wellcare Wellcare Medicaid 0.11 5369.76 0.11 46915.05 0.11 Case Rate 49651 Priced Lap vent/abd hernia repair 717002 49652 CPT Outpatient 51294.60 8805.57 Wellcare Wellcare Medicaid 0.11 5844.60 0.11 51294.60 0.11 Case Rate 49652 Priced Lap vent/abd hern proc comp 717002 49653 CPT Outpatient 46102.35 7914.24 Wellcare Wellcare Medicaid 0.11 5241.28 0.11 46102.35 0.11 Case Rate 49653 Priced Lap inc hernia repair 717002 49654 CPT Outpatient 47221.65 8106.38 Wellcare Wellcare Medicaid 0.11 5403.62 0.11 47221.65 0.11 Case Rate 49654 Priced Lap inc hern repair comp 717002 49655 CPT Outpatient 54590.55 9371.38 Wellcare Wellcare Medicaid 0.11 6102.19 0.11 54590.55 0.11 Case Rate 49655 Priced Lap inc hernia repair recur 717002 49656 CPT Outpatient 55443.15 9517.74 Wellcare Wellcare Medicaid 0.11 6302.87 0.11 55443.15 0.11 Case Rate 49656 Priced Removal of kidney stone 717002 50080 CPT Outpatient 53165.70 9126.78 Wellcare Wellcare Medicaid 0.12 6246.22 0.12 53165.70 0.12 Case Rate 50080 Priced Removal of kidney stone 717002 50081 CPT Outpatient 66931.20 11489.86 Wellcare Wellcare Medicaid 0.11 7499.14 0.11 66931.20 0.11 Case Rate 50081 Priced Renal biopsy perq 717002 50200 CPT Outpatient 43096.20 1225.34 Wellcare Wellcare Medicaid 0.06 2735.13 0.06 43096.20 0.06 Case Rate 50200 Priced Plmt nephroureteral catheter 717002 50433 CPT Outpatient 64566.60 1424.48 Wellcare Wellcare Medicaid 0.11 7253.64 0.11 64566.60 0.11 Case Rate 50433 Priced Laparo radical nephrectomy 717002 50545 CPT Outpatient 43449.00 7458.75 Wellcare Wellcare Medicaid 0.11 4799.10 0.11 43449.00 0.11 Case Rate 50545 Priced Laparoscope proc ureter 717002 50949 CPT Outpatient 49986.30 8580.98 Wellcare Wellcare Medicaid 0.11 5599.86 0.11 49986.30 0.11 Case Rate 50949 Priced Injection for bladder x-ray 717002 51600 CPT Outpatient 3285.45 89.22 Wellcare Wellcare Medicaid 0.11 376.32 0.11 3285.45 0.11 Case Rate 51600 Priced Cystoscopy 717002 52000 CPT Outpatient 22149.75 3802.37 Wellcare Wellcare Medicaid 0.11 2431.10 0.11 22149.75 0.11 Case Rate 52000 Priced Cystoscopy & ureter catheter 717002 52005 CPT Outpatient 42529.20 2095.77 Wellcare Wellcare Medicaid 0.12 4901.96 0.12 42529.20 0.12 Case Rate 52005 Priced Cystoscopy w/biopsy(s) 717002 52204 CPT Outpatient 31274.25 5368.75 Wellcare Wellcare Medicaid 0.09 2919.09 0.09 31274.25 0.09 Case Rate 52204 Priced Cystoscopy and treatment 717002 52224 CPT Outpatient 13445.25 2308.10 Wellcare Wellcare Medicaid 0.11 1461.09 0.11 13445.25 0.11 Case Rate 52224 Priced Cystoscopy and treatment 717002 52234 CPT Outpatient 28510.65 4894.33 Wellcare Wellcare Medicaid 0.10 2743.53 0.10 28510.65 0.10 Case Rate 52234 Priced Cystoscopy and treatment 717002 52235 CPT Outpatient 29417.85 5050.06 Wellcare Wellcare Medicaid 0.09 2680.71 0.09 29417.85 0.09 Case Rate 52235 Priced Cystoscopy and treatment 717002 52240 CPT Outpatient 33933.90 5825.32 Wellcare Wellcare Medicaid 0.11 3884.20 0.11 33933.90 0.11 Case Rate 52240 Priced Cystoscopy and treatment 717002 52281 CPT Outpatient 22159.20 3804.00 Wellcare Wellcare Medicaid 0.10 2300.06 0.10 22159.20 0.10 Case Rate 52281 Priced Remove bladder stone 717002 52317 CPT Outpatient 27085.80 4649.73 Wellcare Wellcare Medicaid 0.11 3100.53 0.11 27085.80 0.11 Case Rate 52317 Priced Remove bladder stone 717002 52318 CPT Outpatient 26685.75 4581.05 Wellcare Wellcare Medicaid 0.11 2914.01 0.11 26685.75 0.11 Case Rate 52318 Priced Cystoscopy and treatment 717002 52332 CPT Outpatient 115306.80 19794.33 Wellcare Wellcare Medicaid 0.06 6564.38 0.06 115306.80 0.06 Case Rate 52332 Priced Cystouretero w/stone remove 717002 52352 CPT Outpatient 42420.00 7282.10 Wellcare Wellcare Medicaid 0.11 4744.41 0.11 42420.00 0.11 Case Rate 52352 Priced Cystouretero w/lithotripsy 717002 52353 CPT Outpatient 38608.50 6627.79 Wellcare Wellcare Medicaid 0.11 4366.52 0.11 38608.50 0.11 Case Rate 52353 Priced Cysto/uretero w/lithotripsy 717002 52356 CPT Outpatient 36255.45 6223.85 Wellcare Wellcare Medicaid 0.11 4081.54 0.11 36255.45 0.11 Case Rate 52356 Priced Prostatectomy (turp) 717002 52601 CPT Outpatient 35371.35 6072.08 Wellcare Wellcare Medicaid 0.10 3419.63 0.10 35371.35 0.10 Case Rate 52601 Priced Laser surgery of prostate 717002 52648 CPT Outpatient 24264.45 4165.40 Wellcare Wellcare Medicaid 0.12 2982.20 0.12 24264.45 0.12 Case Rate 52648 Priced Revision of urethra 717002 53450 CPT Outpatient 16209.90 2782.70 Wellcare Wellcare Medicaid 0.12 1903.64 0.12 16209.90 0.12 Case Rate 53450 Priced Urology surgery procedure 717002 53899 CPT Outpatient 25368.00 134.83 Wellcare Wellcare Medicaid 0.14 3635.49 0.14 25368.00 0.14 Case Rate 53899 Priced Circumcision w/regionl block 717002 54150 CPT Outpatient 14700.00 2523.50 Wellcare Wellcare Medicaid 0.12 1720.91 0.12 14700.00 0.12 Case Rate 54150 Priced Circum 28 days or older 717002 54161 CPT Outpatient 19186.65 3293.71 Wellcare Wellcare Medicaid 0.11 2192.85 0.11 19186.65 0.11 Case Rate 54161 Priced Lysis penil circumic lesion 717002 54162 CPT Outpatient 19795.65 3398.25 Wellcare Wellcare Medicaid 0.12 2314.69 0.12 19795.65 0.12 Case Rate 54162 Priced Repair of circumcision 717002 54163 CPT Outpatient 16391.55 2813.88 Wellcare Wellcare Medicaid 0.12 1956.14 0.12 16391.55 0.12 Case Rate 54163 Priced Reconstruction of urethra 717002 54324 CPT Outpatient 32880.75 5644.53 Wellcare Wellcare Medicaid 0.12 3815.52 0.12 32880.75 0.12 Case Rate 54324 Priced Revise penis/urethra 717002 54332 CPT Outpatient 19968.90 3427.99 Wellcare Wellcare Medicaid 0.12 2409.84 0.12 19968.90 0.12 Case Rate 54332 Priced Insert self-contd prosthesis 717002 54401 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 54401 Priced Removal of testis 717002 54520 CPT Outpatient 35442.75 6084.34 Wellcare Wellcare Medicaid 0.11 3889.58 0.11 35442.75 0.11 Case Rate 54520 Priced Reduce testis torsion 717002 54600 CPT Outpatient 55049.40 9450.15 Wellcare Wellcare Medicaid 0.08 4426.72 0.08 55049.40 0.08 Case Rate 54600 Priced Suspension of testis 717002 54640 CPT Outpatient 26860.05 4610.98 Wellcare Wellcare Medicaid 0.12 3125.52 0.12 26860.05 0.12 Case Rate 54640 Priced Removal of hydrocele 717002 55040 CPT Outpatient 27277.95 4682.71 Wellcare Wellcare Medicaid 0.11 2977.00 0.11 27277.95 0.11 Case Rate 55040 Priced Biopsy of prostate gland 717002 55700 CPT Outpatient 28699.65 4926.77 Wellcare Wellcare Medicaid 0.11 3269.10 0.11 28699.65 0.11 Case Rate 55700 Priced Surgical removal of prostate and surrounding lymph nodes using an endoscope 717002 55866 CPT Outpatient 93088.80 15980.24 Wellcare Wellcare Medicaid 0.11 10235.93 0.11 93088.80 0.11 Case Rate 55866 Priced Closure of vagina 717002 57120 CPT Outpatient 34369.65 5900.12 Wellcare Wellcare Medicaid 0.11 3869.48 0.11 34369.65 0.11 Case Rate 57120 Priced Repair of vagina 717002 57200 CPT Outpatient 25247.25 4334.11 Wellcare Wellcare Medicaid 0.10 2622.81 0.10 25247.25 0.10 Case Rate 57200 Priced Anterior colporrhaphy 717002 57240 CPT Outpatient 36210.30 6216.10 Wellcare Wellcare Medicaid 0.12 4516.53 0.12 36210.30 0.12 Case Rate 57240 Priced Repair rectum & vagina 717002 57250 CPT Outpatient 40441.80 6942.51 Wellcare Wellcare Medicaid 0.11 4561.95 0.11 40441.80 0.11 Case Rate 57250 Priced Cmbn ant pst colprhy 717002 57260 CPT Outpatient 46323.90 7952.27 Wellcare Wellcare Medicaid 0.11 5244.41 0.11 46323.90 0.11 Case Rate 57260 Priced Cmbn ap colprhy w/ntrcl rpr 717002 57265 CPT Outpatient 42586.95 7310.76 Wellcare Wellcare Medicaid 0.09 3938.86 0.09 42586.95 0.09 Case Rate 57265 Priced Repair of bowel bulge 717002 57268 CPT Outpatient 36865.50 6328.58 Wellcare Wellcare Medicaid 0.13 4819.58 0.13 36865.50 0.13 Case Rate 57268 Priced Colpopexy extraperitoneal 717002 57282 CPT Outpatient 45629.85 7833.12 Wellcare Wellcare Medicaid 0.11 4836.23 0.11 45629.85 0.11 Case Rate 57282 Priced Repair bladder defect 717002 57288 CPT Outpatient 43069.95 7393.67 Wellcare Wellcare Medicaid 0.11 4912.79 0.11 43069.95 0.11 Case Rate 57288 Priced Bx/curett of cervix w/scope 717002 57454 CPT Outpatient 2888.55 442.93 Wellcare Wellcare Medicaid 0.11 309.28 0.11 2888.55 0.11 Case Rate 57454 Priced Conization of cervix 717002 57520 CPT Outpatient 26728.80 4588.44 Wellcare Wellcare Medicaid 0.11 3018.34 0.11 26728.80 0.11 Case Rate 57520 Priced Conization of cervix 717002 57522 CPT Outpatient 22737.75 3903.31 Wellcare Wellcare Medicaid 0.12 2751.26 0.12 22737.75 0.12 Case Rate 57522 Priced Biopsy of uterus lining 717002 58100 CPT Outpatient 2371.95 194.80 Wellcare Wellcare Medicaid 0.11 250.06 0.11 2371.95 0.11 Case Rate 58100 Priced Catheter for hysterography 717002 58340 CPT Outpatient 6322.05 131.04 Wellcare Wellcare Medicaid 0.11 724.09 0.11 6322.05 0.11 Case Rate 58340 Priced Reopen fallopian tube 717002 58350 CPT Outpatient 46507.65 7983.81 Wellcare Wellcare Medicaid 0.11 5236.61 0.11 46507.65 0.11 Case Rate 58350 Priced Lsh w/t/o ut 250 g or less 717002 58542 CPT Outpatient 64194.90 11020.12 Wellcare Wellcare Medicaid 0.11 7306.79 0.11 64194.90 0.11 Case Rate 58542 Priced Lsh w/t/o uterus above 250 g 717002 58544 CPT Outpatient 51020.55 8758.53 Wellcare Wellcare Medicaid 0.11 5689.61 0.11 51020.55 0.11 Case Rate 58544 Priced Laparoscopic myomectomy 717002 58545 CPT Outpatient 56946.75 9775.86 Wellcare Wellcare Medicaid 0.11 6388.63 0.11 56946.75 0.11 Case Rate 58545 Priced Laparo-vag hyst incl t/o 717002 58552 CPT Outpatient 57228.15 9824.17 Wellcare Wellcare Medicaid 0.11 6485.31 0.11 57228.15 0.11 Case Rate 58552 Priced Hysteroscopy biopsy 717002 58558 CPT Outpatient 28581.00 2077.02 Wellcare Wellcare Medicaid 0.11 3262.79 0.11 28581.00 0.11 Case Rate 58558 Priced Hysteroscopy remove myoma 717002 58561 CPT Outpatient 35222.25 6046.49 Wellcare Wellcare Medicaid 0.11 3922.75 0.11 35222.25 0.11 Case Rate 58561 Priced Hysteroscopy ablation 717002 58563 CPT Outpatient 38399.55 6591.92 Wellcare Wellcare Medicaid 0.13 5076.99 0.13 38399.55 0.13 Case Rate 58563 Priced Tlh uterus 250 g or less 717002 58570 CPT Outpatient 43316.70 7436.03 Wellcare Wellcare Medicaid 0.11 4746.32 0.11 43316.70 0.11 Case Rate 58570 Priced Tlh w/t/o 250 g or less 717002 58571 CPT Outpatient 48603.45 8343.59 Wellcare Wellcare Medicaid 0.12 5618.47 0.12 48603.45 0.12 Case Rate 58571 Priced Tlh w/t/o uterus over 250 g 717002 58573 CPT Outpatient 52905.30 9082.08 Wellcare Wellcare Medicaid 0.11 5891.94 0.11 52905.30 0.11 Case Rate 58573 Priced Laparoscopy remove adnexa 717002 58661 CPT Outpatient 47008.50 8069.79 Wellcare Wellcare Medicaid 0.11 5368.79 0.11 47008.50 0.11 Case Rate 58661 Priced Laparoscopy excise lesions 717002 58662 CPT Outpatient 45053.40 7734.17 Wellcare Wellcare Medicaid 0.11 5173.23 0.11 45053.40 0.11 Case Rate 58662 Priced Treat ectopic pregnancy 717002 59151 CPT Outpatient 74690.70 12821.90 Wellcare Wellcare Medicaid 0.07 5591.52 0.07 74690.70 0.07 Case Rate 59151 Priced Treatment of miscarriage 717002 59812 CPT Outpatient 56109.90 9632.20 Wellcare Wellcare Medicaid 0.06 3189.98 0.06 56109.90 0.06 Case Rate 59812 Priced Partial removal of thyroid 717002 60220 CPT Outpatient 53639.25 9208.07 Wellcare Wellcare Medicaid 0.13 6966.04 0.13 53639.25 0.13 Case Rate 60220 Priced Removal of thyroid 717002 60240 CPT Outpatient 98252.70 16866.71 Wellcare Wellcare Medicaid 0.08 7730.08 0.08 98252.70 0.08 Case Rate 60240 Priced Explore parathyroid glands 717002 60500 CPT Outpatient 150495.45 25835.05 Wellcare Wellcare Medicaid 0.04 6059.53 0.04 150495.45 0.04 Case Rate 60500 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 717002 62322 CPT Outpatient 43709.40 514.24 Wellcare Wellcare Medicaid 0.12 5081.86 0.12 43709.40 0.12 Case Rate 62322 Priced Injection of substance into spinal canal of lower back or sacrum using imaging guidance 717002 62323 CPT Outpatient 8304.45 467.31 Wellcare Wellcare Medicaid 9.76 81071.01 9.76 8304.45 9.76 Case Rate 62323 Priced Low back disk surgery 717002 63030 CPT Outpatient 50287.65 8632.71 Wellcare Wellcare Medicaid 0.11 5750.58 0.11 50287.65 0.11 Case Rate 63030 Priced Inc for vagus n elect impl 717002 64568 CPT Outpatient 124562.55 21383.24 Wellcare Wellcare Medicaid 0.11 14251.31 0.11 124562.55 0.11 Case Rate 64568 Priced Removal of recurring cataract in lens capsule using laser 717002 66821 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66821 Priced Removal of cataract with insertion of lens 717002 66984 CPT Outpatient 0.01 0.01 Wellcare Wellcare Medicaid 0.01 0.01 0.01 0.01 0.01 Case Rate 66984 Priced