hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|LA,"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.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Morehouse General Hospital,1/1/2025,2.0.0,Morehouse General Hospital,"323 W. Walnut Avenue Bastrop, LA 71220",726011528,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA Plan,AETNA Reimbursement Method,AETNA MEDICAID Plan,AETNA MEDICAID Reimbursement Method,AETNA MEDICAID CHIP Plan,AETNA MEDICAID CHIP Reimbursement Method,AETNA MEDICAID QHP Plan,AETNA MEDICAID QHP Reimbursement Method,AETNA MEDICAL RENTAL NETWORK Plan,AETNA MEDICAL RENTAL NETWORK Reimbursement Method,BCBS HMO Plan,BCBS HMO Reimbursement Method,BCBS PPO Plan,BCBS PPO Reimbursement Method,BCBS TRADITIONAL Plan,BCBS TRADITIONAL Reimbursement Method,HUMANA COMMERCIAL EPO Plan,HUMANA COMMERCIAL EPO Reimbursement Method,HUMANA COMMERCIAL EPOX Plan,HUMANA COMMERCIAL EPOX Reimbursement Method,HUMANA COMMERCIAL HMO Plan,HUMANA COMMERCIAL HMO Reimbursement Method,HUMANA COMMERCIAL HMOX Plan,HUMANA COMMERCIAL HMOX Reimbursement Method,HUMANA COMMERCIAL POS Plan,HUMANA COMMERCIAL POS Reimbursement Method,HUMANA COMMERCIAL PPO Plan,HUMANA COMMERCIAL PPO Reimbursement Method,HUMANA COMMERCIAL PPOX Plan,HUMANA COMMERCIAL PPOX Reimbursement Method,HUMANA MEDICAID Plan,HUMANA MEDICAID Reimbursement Method,UHC Plan,UHC Reimbursement Method,UHC MEDICAID Plan,UHC MEDICAID Reimbursement Method,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE 
Outpatient Medical Services,Ambulatory,36569,PICC INSERTION MID L,761,"$2,307.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,845.60 ",paid @80% Aetna Medical Rental Network rate,$859.82 ,paid @32.27% of BCBS HMO rates,$859.82 ,paid @32.27% of BCBS PPO rates,$859.82 ,paid @32.27% of BCBS rates,"$1,287.52 ",pays @100% MCR OPPS,"$1,287.52 ",pays at 100% MCR OPPS,"$1,287.52 ",pays @100 MCR OPPS,N/A,not separately reimburseable,"$1,287.52 ",pays at 100% MCR OPPS,"$1,287.52 ",pays at 100% MCR OPPS,"$1,287.52 ",pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$922.80 ,pays @40% of UHC MCD billed charges,$859.82 ,"$1,845.60 ","$1,845.60 "
Outpatient Medical Services,Cardiac,93320,Echo with doppler,480,$674.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$539.20 ,paid @80% Aetna Medical Rental Network rate,$251.20 ,paid @32.27% of BCBS HMO rates,$251.20 ,paid @32.27% of BCBS PPO rates,$251.20 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$269.60 ,pays @40% of UHC MCD billed charges,$251.20 ,$539.20 ,$539.20 
Outpatient Medical Services,Delivery & Neonatal,59410,Vaginal delivery with post-delivery care,761,"$2,247.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,797.60 ",paid @80% Aetna Medical Rental Network rate,$837.46 ,paid @32.27% of BCBS HMO rates,$837.46 ,paid @32.27% of BCBS PPO rates,$837.46 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$898.80 ,pays @40% of UHC MCD billed charges,$837.46 ,"$1,797.60 ","$1,797.60 "
Outpatient Medical Services,Emergency Room,99291,CRIT CARE 30-74M W/P,450,"$1,889.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,511.20 ",paid @80% Aetna Medical Rental Network rate,$704.03 ,paid @32.27% of BCBS HMO rates,$704.03 ,paid @32.27% of BCBS PPO rates,$704.03 ,paid @32.27% of BCBS rates,"$1,264.35 ",pays @100% MCR OPPS,"$1,264.35 ",pays at 100% MCR OPPS,"$1,264.35 ",pays @100 MCR OPPS,$600.00 ,pays at 100% MCR OPPS,"$1,264.35 ",pays at 100% MCR OPPS,"$1,264.35 ",pays at 100% MCR OPPS,"$1,264.35 ",pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$755.60 ,pays @40% of UHC MCD billed charges,$600.00 ,"$1,511.20 ","$1,511.20 "
Outpatient Medical Services,Emergency Room,99281,ER CARE LEVEL 1,450,$224.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$179.20 ,paid @80% Aetna Medical Rental Network rate,$83.48 ,paid @32.27% of BCBS HMO rates,$83.48 ,paid @32.27% of BCBS PPO rates,$83.48 ,paid @32.27% of BCBS rates,$664.98 ,pays @100% MCR OPPS,$664.98 ,pays at 100% MCR OPPS,$664.98 ,pays @100 MCR OPPS,$600.00 ,pays at 100% MCR OPPS,$664.98 ,pays at 100% MCR OPPS,$664.98 ,pays at 100% MCR OPPS,$664.98 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$89.60 ,pays @40% of UHC MCD billed charges,$83.48 ,$664.98 ,$179.20 
Outpatient Medical Services,Emergency Room,99282,ER CARE LEVEL 2,450,$365.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$292.00 ,paid @80% Aetna Medical Rental Network rate,$136.04 ,paid @32.27% of BCBS HMO rates,$136.04 ,paid @32.27% of BCBS PPO rates,$136.04 ,paid @32.27% of BCBS rates,$720.88 ,pays @100% MCR OPPS,$720.88 ,pays at 100% MCR OPPS,$720.88 ,pays @100 MCR OPPS,$600.00 ,pays at 100% MCR OPPS,$720.88 ,pays at 100% MCR OPPS,$720.88 ,pays at 100% MCR OPPS,$720.88 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$146.00 ,pays @40% of UHC MCD billed charges,$136.04 ,$720.88 ,$292.00 
Outpatient Medical Services,Emergency Room,99283,"Emergency department visit, moderately severe problem",450,$590.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$472.00 ,paid @80% Aetna Medical Rental Network rate,$219.89 ,paid @32.27% of BCBS HMO rates,$219.89 ,paid @32.27% of BCBS PPO rates,$219.89 ,paid @32.27% of BCBS rates,$812.04 ,pays @100% MCR OPPS,$812.04 ,pays at 100% MCR OPPS,$812.04 ,pays @100 MCR OPPS,$600.00 ,pays at 100% MCR OPPS,$812.04 ,pays at 100% MCR OPPS,$812.04 ,pays at 100% MCR OPPS,$812.04 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$236.00 ,pays @40% of UHC MCD billed charges,$219.89 ,$812.04 ,$472.00 
Outpatient Medical Services,Emergency Room,99284,"Emergency department visit, problem of high severity",450,$785.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$628.00 ,paid @80% Aetna Medical Rental Network rate,$292.57 ,paid @32.27% of BCBS HMO rates,$292.57 ,paid @32.27% of BCBS PPO rates,$292.57 ,paid @32.27% of BCBS rates,$930.23 ,pays @100% MCR OPPS,$930.23 ,pays at 100% MCR OPPS,$930.23 ,pays @100 MCR OPPS,$600.00 ,pays at 100% MCR OPPS,$930.23 ,pays at 100% MCR OPPS,$930.23 ,pays at 100% MCR OPPS,$930.23 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$314.00 ,pays @40% of UHC MCD billed charges,$292.57 ,$930.23 ,$628.00 
Outpatient Medical Services,Emergency Room,99285,"Emergency department visit, problem with significant threat to life or function",450,"$1,122.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$897.60 ,paid @80% Aetna Medical Rental Network rate,$418.17 ,paid @32.27% of BCBS HMO rates,$418.17 ,paid @32.27% of BCBS PPO rates,$418.17 ,paid @32.27% of BCBS rates,"$1,074.31 ",pays @100% MCR OPPS,"$1,074.31 ",pays at 100% MCR OPPS,"$1,074.31 ",pays @100 MCR OPPS,$600.00 ,pays at 100% MCR OPPS,"$1,074.31 ",pays at 100% MCR OPPS,"$1,074.31 ",pays at 100% MCR OPPS,"$1,074.31 ",pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$448.80 ,pays @40% of UHC MCD billed charges,$418.17 ,"$1,074.31 ",$897.60 
Outpatient Medical Services,Lab,83586,17 KETOSTERIODS,301,$176.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$140.80 ,paid @80% Aetna Medical Rental Network rate,$65.60 ,paid @32.27% of BCBS HMO rates,$65.60 ,paid @32.27% of BCBS PPO rates,$65.60 ,paid @32.27% of BCBS rates,$9.60 ,pays @100% MCR OPPS,$9.60 ,pays at 100% MCR OPPS,$12.80 ,pays @100 MCR OPPS,$12.80 ,pays at 100% MCR OPPS,$12.80 ,pays at 100% MCR OPPS,$12.80 ,pays at 100% MCR OPPS,$12.80 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$70.40 ,pays @40% of UHC MCD billed charges,$9.60 ,$140.80 ,$140.80 
Outpatient Medical Services,Lab,84143,17-HYDROXYPREGNEOLON,301,$150.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$120.00 ,paid @80% Aetna Medical Rental Network rate,$55.91 ,paid @32.27% of BCBS HMO rates,$55.91 ,paid @32.27% of BCBS PPO rates,$55.91 ,paid @32.27% of BCBS rates,$17.10 ,pays @100% MCR OPPS,$17.10 ,pays at 100% MCR OPPS,$22.81 ,pays @100 MCR OPPS,$22.81 ,pays at 100% MCR OPPS,$22.81 ,pays at 100% MCR OPPS,$22.81 ,pays at 100% MCR OPPS,$22.81 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$60.00 ,pays @40% of UHC MCD billed charges,$17.10 ,$120.00 ,$120.00 
Outpatient Medical Services,Lab,84060,ACID PHOSPHATASE,301,$42.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$33.60 ,paid @80% Aetna Medical Rental Network rate,$15.65 ,paid @32.27% of BCBS HMO rates,$15.65 ,paid @32.27% of BCBS PPO rates,$15.65 ,paid @32.27% of BCBS rates,$5.73 ,pays @100% MCR OPPS,$5.73 ,pays at 100% MCR OPPS,$7.64 ,pays @100 MCR OPPS,$7.64 ,pays at 100% MCR OPPS,$7.64 ,pays at 100% MCR OPPS,$7.64 ,pays at 100% MCR OPPS,$7.64 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.80 ,pays @40% of UHC MCD billed charges,$5.73 ,$33.60 ,$33.60 
Outpatient Medical Services,Lab,86162,AH50 ALTERNATIVE PAT,301,$132.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$105.60 ,paid @80% Aetna Medical Rental Network rate,$49.20 ,paid @32.27% of BCBS HMO rates,$49.20 ,paid @32.27% of BCBS PPO rates,$49.20 ,paid @32.27% of BCBS rates,$15.24 ,pays @100% MCR OPPS,$15.24 ,pays at 100% MCR OPPS,$20.32 ,pays @100 MCR OPPS,$20.32 ,pays at 100% MCR OPPS,$20.32 ,pays at 100% MCR OPPS,$20.32 ,pays at 100% MCR OPPS,$20.32 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$52.80 ,pays @40% of UHC MCD billed charges,$15.24 ,$105.60 ,$105.60 
Outpatient Medical Services,Lab,84080,ALKALINE PHOSP ISOEZ,301,$91.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.80 ,paid @80% Aetna Medical Rental Network rate,$33.92 ,paid @32.27% of BCBS HMO rates,$33.92 ,paid @32.27% of BCBS PPO rates,$33.92 ,paid @32.27% of BCBS rates,$11.08 ,pays @100% MCR OPPS,$11.08 ,pays at 100% MCR OPPS,$14.78 ,pays @100 MCR OPPS,$14.78 ,pays at 100% MCR OPPS,$14.78 ,pays at 100% MCR OPPS,$14.78 ,pays at 100% MCR OPPS,$14.78 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.40 ,pays @40% of UHC MCD billed charges,$11.08 ,$72.80 ,$72.80 
Outpatient Medical Services,Lab,84075,ALKALINE PHOSPHATASE,301,$28.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.40 ,paid @80% Aetna Medical Rental Network rate,$10.44 ,paid @32.27% of BCBS HMO rates,$10.44 ,paid @32.27% of BCBS PPO rates,$10.44 ,paid @32.27% of BCBS rates,$3.88 ,pays @100% MCR OPPS,$3.88 ,pays at 100% MCR OPPS,$5.18 ,pays @100 MCR OPPS,$5.18 ,pays at 100% MCR OPPS,$5.18 ,pays at 100% MCR OPPS,$5.18 ,pays at 100% MCR OPPS,$5.18 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$11.20 ,pays @40% of UHC MCD billed charges,$3.88 ,$22.40 ,$22.40 
Outpatient Medical Services,Lab,86008,ALLERGEN SPECIFIC IG,305,$24.89 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$19.91 ,paid @80% Aetna Medical Rental Network rate,$9.28 ,paid @32.27% of BCBS HMO rates,$9.28 ,paid @32.27% of BCBS PPO rates,$9.28 ,paid @32.27% of BCBS rates,$13.44 ,pays @100% MCR OPPS,$13.44 ,pays at 100% MCR OPPS,$17.93 ,pays @100 MCR OPPS,$17.93 ,pays at 100% MCR OPPS,$17.93 ,pays at 100% MCR OPPS,$17.93 ,pays at 100% MCR OPPS,$17.93 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$9.96 ,pays @40% of UHC MCD billed charges,$9.28 ,$19.91 ,$19.91 
Outpatient Medical Services,Lab,84081,AMNIOSTAT,301,$108.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$86.40 ,paid @80% Aetna Medical Rental Network rate,$40.25 ,paid @32.27% of BCBS HMO rates,$40.25 ,paid @32.27% of BCBS PPO rates,$40.25 ,paid @32.27% of BCBS rates,$12.39 ,pays @100% MCR OPPS,$12.39 ,pays at 100% MCR OPPS,$16.52 ,pays @100 MCR OPPS,$16.52 ,pays at 100% MCR OPPS,$16.52 ,pays at 100% MCR OPPS,$16.52 ,pays at 100% MCR OPPS,$16.52 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$43.20 ,pays @40% of UHC MCD billed charges,$12.39 ,$86.40 ,$86.40 
Outpatient Medical Services,Lab,86753,ANTI-AMOEBA SEROLOGY,301,$66.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$52.80 ,paid @80% Aetna Medical Rental Network rate,$24.60 ,paid @32.27% of BCBS HMO rates,$24.60 ,paid @32.27% of BCBS PPO rates,$24.60 ,paid @32.27% of BCBS rates,$9.29 ,pays @100% MCR OPPS,$9.29 ,pays at 100% MCR OPPS,$12.39 ,pays @100 MCR OPPS,$12.39 ,pays at 100% MCR OPPS,$12.39 ,pays at 100% MCR OPPS,$12.39 ,pays at 100% MCR OPPS,$12.39 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$26.40 ,pays @40% of UHC MCD billed charges,$9.29 ,$52.80 ,$52.80 
Outpatient Medical Services,Lab,84588,ANTIDIURETIC HORMONE,301,$279.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$223.20 ,paid @80% Aetna Medical Rental Network rate,$103.98 ,paid @32.27% of BCBS HMO rates,$103.98 ,paid @32.27% of BCBS PPO rates,$103.98 ,paid @32.27% of BCBS rates,$25.45 ,pays @100% MCR OPPS,$25.45 ,pays at 100% MCR OPPS,$33.94 ,pays @100 MCR OPPS,$33.94 ,pays at 100% MCR OPPS,$33.94 ,pays at 100% MCR OPPS,$33.94 ,pays at 100% MCR OPPS,$33.94 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$111.60 ,pays @40% of UHC MCD billed charges,$25.45 ,$223.20 ,$223.20 
Outpatient Medical Services,Lab,85300,"ANTI-THROMBIN III, F",305,$241.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$192.80 ,paid @80% Aetna Medical Rental Network rate,$89.82 ,paid @32.27% of BCBS HMO rates,$89.82 ,paid @32.27% of BCBS PPO rates,$89.82 ,paid @32.27% of BCBS rates,$8.88 ,pays @100% MCR OPPS,$8.88 ,pays at 100% MCR OPPS,$11.85 ,pays @100 MCR OPPS,$11.85 ,pays at 100% MCR OPPS,$11.85 ,pays at 100% MCR OPPS,$11.85 ,pays at 100% MCR OPPS,$11.85 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$96.40 ,pays @40% of UHC MCD billed charges,$8.88 ,$192.80 ,$192.80 
Outpatient Medical Services,Lab,86606,ASPERGILLUS FUMIGATU,301,$108.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$86.40 ,paid @80% Aetna Medical Rental Network rate,$40.25 ,paid @32.27% of BCBS HMO rates,$40.25 ,paid @32.27% of BCBS PPO rates,$40.25 ,paid @32.27% of BCBS rates,$11.28 ,pays @100% MCR OPPS,$11.28 ,pays at 100% MCR OPPS,$15.05 ,pays @100 MCR OPPS,$15.05 ,pays at 100% MCR OPPS,$15.05 ,pays at 100% MCR OPPS,$15.05 ,pays at 100% MCR OPPS,$15.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$43.20 ,pays @40% of UHC MCD billed charges,$11.28 ,$86.40 ,$86.40 
Outpatient Medical Services,Lab,86355,B CELLS TOTAL COUNT,301,$200.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$160.00 ,paid @80% Aetna Medical Rental Network rate,$74.54 ,paid @32.27% of BCBS HMO rates,$74.54 ,paid @32.27% of BCBS PPO rates,$74.54 ,paid @32.27% of BCBS rates,$28.29 ,pays @100% MCR OPPS,$28.29 ,pays at 100% MCR OPPS,$37.72 ,pays @100 MCR OPPS,$37.72 ,pays at 100% MCR OPPS,$37.72 ,pays at 100% MCR OPPS,$37.72 ,pays at 100% MCR OPPS,$37.72 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$80.00 ,pays @40% of UHC MCD billed charges,$28.29 ,$160.00 ,$160.00 
Outpatient Medical Services,Lab,83789,BACLOFEN LEVEL,301,$447.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$357.60 ,paid @80% Aetna Medical Rental Network rate,$166.60 ,paid @32.27% of BCBS HMO rates,$166.60 ,paid @32.27% of BCBS PPO rates,$166.60 ,paid @32.27% of BCBS rates,$18.08 ,pays @100% MCR OPPS,$18.08 ,pays at 100% MCR OPPS,$24.11 ,pays @100 MCR OPPS,$24.11 ,pays at 100% MCR OPPS,$24.11 ,pays at 100% MCR OPPS,$24.11 ,pays at 100% MCR OPPS,$24.11 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$178.80 ,pays @40% of UHC MCD billed charges,$18.08 ,$357.60 ,$357.60 
Outpatient Medical Services,Lab,80048,Basic metabolic panel,301,$39.87 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$31.90 ,paid @80% Aetna Medical Rental Network rate,$14.86 ,paid @32.27% of BCBS HMO rates,$14.86 ,paid @32.27% of BCBS PPO rates,$14.86 ,paid @32.27% of BCBS rates,$6.34 ,pays @100% MCR OPPS,$6.34 ,pays at 100% MCR OPPS,$8.46 ,pays @100 MCR OPPS,$8.46 ,pays at 100% MCR OPPS,$8.46 ,pays at 100% MCR OPPS,$8.46 ,pays at 100% MCR OPPS,$8.46 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$15.95 ,pays @40% of UHC MCD billed charges,$6.34 ,$31.90 ,$31.90 
Outpatient Medical Services,Lab,86612,BLASTOMYCES ANTIBODI,301,$69.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$55.20 ,paid @80% Aetna Medical Rental Network rate,$25.72 ,paid @32.27% of BCBS HMO rates,$25.72 ,paid @32.27% of BCBS PPO rates,$25.72 ,paid @32.27% of BCBS rates,$9.67 ,pays @100% MCR OPPS,$9.67 ,pays at 100% MCR OPPS,$12.90 ,pays @100 MCR OPPS,$12.90 ,pays at 100% MCR OPPS,$12.90 ,pays at 100% MCR OPPS,$12.90 ,pays at 100% MCR OPPS,$12.90 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$27.60 ,pays @40% of UHC MCD billed charges,$9.67 ,$55.20 ,$55.20 
Outpatient Medical Services,Lab,82947,Quantitative measure of glucose build up in the blood over time,301,$21.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.80 ,paid @80% Aetna Medical Rental Network rate,$7.83 ,paid @32.27% of BCBS HMO rates,$7.83 ,paid @32.27% of BCBS PPO rates,$7.83 ,paid @32.27% of BCBS rates,$2.94 ,pays @100% MCR OPPS,$2.94 ,pays at 100% MCR OPPS,$3.93 ,pays @100 MCR OPPS,$3.93 ,pays at 100% MCR OPPS,$3.93 ,pays at 100% MCR OPPS,$3.93 ,pays at 100% MCR OPPS,$3.93 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.40 ,pays @40% of UHC MCD billed charges,$2.94 ,$16.80 ,$16.80 
Outpatient Medical Services,Lab,36430,BLOOD TRANSFUSION,391,"$1,034.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$827.20 ,paid @80% Aetna Medical Rental Network rate,$385.37 ,paid @32.27% of BCBS HMO rates,$385.37 ,paid @32.27% of BCBS PPO rates,$385.37 ,paid @32.27% of BCBS rates,$352.85 ,pays @100% MCR OPPS,$352.85 ,pays at 100% MCR OPPS,$352.85 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$352.85 ,pays at 100% MCR OPPS,$352.85 ,pays at 100% MCR OPPS,$352.85 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$413.60 ,pays @40% of UHC MCD billed charges,$352.85 ,$827.20 ,$827.20 
Outpatient Medical Services,Lab,83880,Blood test used to diagnose heart failure,301,$286.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$228.80 ,paid @80% Aetna Medical Rental Network rate,$106.59 ,paid @32.27% of BCBS HMO rates,$106.59 ,paid @32.27% of BCBS PPO rates,$106.59 ,paid @32.27% of BCBS rates,$29.44 ,pays @100% MCR OPPS,$29.44 ,pays at 100% MCR OPPS,$39.26 ,pays @100 MCR OPPS,$39.26 ,pays at 100% MCR OPPS,$39.26 ,pays at 100% MCR OPPS,$39.26 ,pays at 100% MCR OPPS,$39.26 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$114.40 ,pays @40% of UHC MCD billed charges,$29.44 ,$228.80 ,$228.80 
Outpatient Medical Services,Lab,86622,BRUCELLA,301,$43.72 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$34.98 ,paid @80% Aetna Medical Rental Network rate,$16.29 ,paid @32.27% of BCBS HMO rates,$16.29 ,paid @32.27% of BCBS PPO rates,$16.29 ,paid @32.27% of BCBS rates,$6.69 ,pays @100% MCR OPPS,$6.69 ,pays at 100% MCR OPPS,$8.93 ,pays @100 MCR OPPS,$8.93 ,pays at 100% MCR OPPS,$8.93 ,pays at 100% MCR OPPS,$8.93 ,pays at 100% MCR OPPS,$8.93 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$17.49 ,pays @40% of UHC MCD billed charges,$6.69 ,$34.98 ,$34.98 
Outpatient Medical Services,Lab,84520,BUN,301,$21.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.80 ,paid @80% Aetna Medical Rental Network rate,$7.83 ,paid @32.27% of BCBS HMO rates,$7.83 ,paid @32.27% of BCBS PPO rates,$7.83 ,paid @32.27% of BCBS rates,$2.96 ,pays @100% MCR OPPS,$2.96 ,pays at 100% MCR OPPS,$3.95 ,pays @100 MCR OPPS,$3.95 ,pays at 100% MCR OPPS,$3.95 ,pays at 100% MCR OPPS,$3.95 ,pays at 100% MCR OPPS,$3.95 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.40 ,pays @40% of UHC MCD billed charges,$2.96 ,$16.80 ,$16.80 
Outpatient Medical Services,Lab,87481,C ALBICANS C GLABRAT,301,$183.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$146.40 ,paid @80% Aetna Medical Rental Network rate,$68.20 ,paid @32.27% of BCBS HMO rates,$68.20 ,paid @32.27% of BCBS PPO rates,$68.20 ,paid @32.27% of BCBS rates,$26.31 ,pays @100% MCR OPPS,$26.31 ,pays at 100% MCR OPPS,$35.09 ,pays @100 MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$73.20 ,pays @40% of UHC MCD billed charges,$26.31 ,$146.40 ,$146.40 
Outpatient Medical Services,Lab,86361,C04 HELPER/INDUCER,301,$105.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$84.00 ,paid @80% Aetna Medical Rental Network rate,$39.13 ,paid @32.27% of BCBS HMO rates,$39.13 ,paid @32.27% of BCBS PPO rates,$39.13 ,paid @32.27% of BCBS rates,$20.08 ,pays @100% MCR OPPS,$20.08 ,pays at 100% MCR OPPS,$26.78 ,pays @100 MCR OPPS,$26.78 ,pays at 100% MCR OPPS,$26.78 ,pays at 100% MCR OPPS,$26.78 ,pays at 100% MCR OPPS,$26.78 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$42.00 ,pays @40% of UHC MCD billed charges,$20.08 ,$84.00 ,$84.00 
Outpatient Medical Services,Lab,83993,"CALPROTECTIN, FECAL",301,$223.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$178.40 ,paid @80% Aetna Medical Rental Network rate,$83.11 ,paid @32.27% of BCBS HMO rates,$83.11 ,paid @32.27% of BCBS PPO rates,$83.11 ,paid @32.27% of BCBS rates,$14.72 ,pays @100% MCR OPPS,$14.72 ,pays at 100% MCR OPPS,$19.63 ,pays @100 MCR OPPS,$19.63 ,pays at 100% MCR OPPS,$19.63 ,pays at 100% MCR OPPS,$19.63 ,pays at 100% MCR OPPS,$19.63 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$89.20 ,pays @40% of UHC MCD billed charges,$14.72 ,$178.40 ,$178.40 
Outpatient Medical Services,Lab,86628,"CANDIDA IGG,IGA:IGM",301,$349.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$279.20 ,paid @80% Aetna Medical Rental Network rate,$130.07 ,paid @32.27% of BCBS HMO rates,$130.07 ,paid @32.27% of BCBS PPO rates,$130.07 ,paid @32.27% of BCBS rates,$9.00 ,pays @100% MCR OPPS,$9.00 ,pays at 100% MCR OPPS,$12.01 ,pays @100 MCR OPPS,$12.01 ,pays at 100% MCR OPPS,$12.01 ,pays at 100% MCR OPPS,$12.01 ,pays at 100% MCR OPPS,$12.01 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$139.60 ,pays @40% of UHC MCD billed charges,$9.00 ,$279.20 ,$279.20 
Outpatient Medical Services,Lab,85025,"Complete blood cell count, with differential white blood cells, automated",305,$108.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$86.40 ,paid @80% Aetna Medical Rental Network rate,$40.25 ,paid @32.27% of BCBS HMO rates,$40.25 ,paid @32.27% of BCBS PPO rates,$40.25 ,paid @32.27% of BCBS rates,$5.82 ,pays @100% MCR OPPS,$5.82 ,pays at 100% MCR OPPS,$7.77 ,pays @100 MCR OPPS,$7.77 ,pays at 100% MCR OPPS,$7.77 ,pays at 100% MCR OPPS,$7.77 ,pays at 100% MCR OPPS,$7.77 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$43.20 ,pays @40% of UHC MCD billed charges,$5.82 ,$86.40 ,$86.40 
Outpatient Medical Services,Lab,85027,"Complete blood count, automated",305,$30.84 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.67 ,paid @80% Aetna Medical Rental Network rate,$11.49 ,paid @32.27% of BCBS HMO rates,$11.49 ,paid @32.27% of BCBS PPO rates,$11.49 ,paid @32.27% of BCBS rates,$4.85 ,pays @100% MCR OPPS,$4.85 ,pays at 100% MCR OPPS,$6.47 ,pays @100 MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$12.34 ,pays @40% of UHC MCD billed charges,$4.85 ,$24.67 ,$24.67 
Outpatient Medical Services,Lab,86632,CHLAMYDIC TRACH IGM,301,$41.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$32.80 ,paid @80% Aetna Medical Rental Network rate,$15.28 ,paid @32.27% of BCBS HMO rates,$15.28 ,paid @32.27% of BCBS PPO rates,$15.28 ,paid @32.27% of BCBS rates,$9.51 ,pays @100% MCR OPPS,$9.51 ,pays at 100% MCR OPPS,$12.68 ,pays @100 MCR OPPS,$12.68 ,pays at 100% MCR OPPS,$12.68 ,pays at 100% MCR OPPS,$12.68 ,pays at 100% MCR OPPS,$12.68 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.40 ,pays @40% of UHC MCD billed charges,$9.51 ,$32.80 ,$32.80 
Outpatient Medical Services,Lab,86160,CI ESTERASE INHIB SE,301,$64.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$51.20 ,paid @80% Aetna Medical Rental Network rate,$23.85 ,paid @32.27% of BCBS HMO rates,$23.85 ,paid @32.27% of BCBS PPO rates,$23.85 ,paid @32.27% of BCBS rates,$9.00 ,pays @100% MCR OPPS,$9.00 ,pays at 100% MCR OPPS,$12.00 ,pays @100 MCR OPPS,$12.00 ,pays at 100% MCR OPPS,$12.00 ,pays at 100% MCR OPPS,$12.00 ,pays at 100% MCR OPPS,$12.00 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$25.60 ,pays @40% of UHC MCD billed charges,$9.00 ,$51.20 ,$51.20 
Outpatient Medical Services,Lab,84681,C-PEPTIDE,301,$118.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$94.40 ,paid @80% Aetna Medical Rental Network rate,$43.98 ,paid @32.27% of BCBS HMO rates,$43.98 ,paid @32.27% of BCBS PPO rates,$43.98 ,paid @32.27% of BCBS rates,$15.60 ,pays @100% MCR OPPS,$15.60 ,pays at 100% MCR OPPS,$20.81 ,pays @100 MCR OPPS,$20.81 ,pays at 100% MCR OPPS,$20.81 ,pays at 100% MCR OPPS,$20.81 ,pays at 100% MCR OPPS,$20.81 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$47.20 ,pays @40% of UHC MCD billed charges,$15.60 ,$94.40 ,$94.40 
Outpatient Medical Services,Lab,89060,CRYSTAL SYNOVIAL FLU,305,$183.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$146.40 ,paid @80% Aetna Medical Rental Network rate,$68.20 ,paid @32.27% of BCBS HMO rates,$68.20 ,paid @32.27% of BCBS PPO rates,$68.20 ,paid @32.27% of BCBS rates,$5.49 ,pays @100% MCR OPPS,$5.49 ,pays at 100% MCR OPPS,$7.33 ,pays @100 MCR OPPS,$7.33 ,pays at 100% MCR OPPS,$7.33 ,pays at 100% MCR OPPS,$7.33 ,pays at 100% MCR OPPS,$7.33 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$73.20 ,pays @40% of UHC MCD billed charges,$5.49 ,$146.40 ,$146.40 
Outpatient Medical Services,Lab,85379,D-DIMER QUANTATIVE,305,$63.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$50.40 ,paid @80% Aetna Medical Rental Network rate,$23.48 ,paid @32.27% of BCBS HMO rates,$23.48 ,paid @32.27% of BCBS PPO rates,$23.48 ,paid @32.27% of BCBS rates,$7.63 ,pays @100% MCR OPPS,$7.63 ,pays at 100% MCR OPPS,$10.18 ,pays @100 MCR OPPS,$10.18 ,pays at 100% MCR OPPS,$10.18 ,pays at 100% MCR OPPS,$10.18 ,pays at 100% MCR OPPS,$10.18 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$25.20 ,pays @40% of UHC MCD billed charges,$7.63 ,$50.40 ,$50.40 
Outpatient Medical Services,Lab,85613,DILUTE RUSSELL VIPER,305,$108.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$86.40 ,paid @80% Aetna Medical Rental Network rate,$40.25 ,paid @32.27% of BCBS HMO rates,$40.25 ,paid @32.27% of BCBS PPO rates,$40.25 ,paid @32.27% of BCBS rates,$7.18 ,pays @100% MCR OPPS,$7.18 ,pays at 100% MCR OPPS,$9.58 ,pays @100 MCR OPPS,$9.58 ,pays at 100% MCR OPPS,$9.58 ,pays at 100% MCR OPPS,$9.58 ,pays at 100% MCR OPPS,$9.58 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$43.20 ,pays @40% of UHC MCD billed charges,$7.18 ,$86.40 ,$86.40 
Outpatient Medical Services,Lab,G0480,DRUG 1-7 DEFINITIVE,300,$278.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$222.40 ,paid @80% Aetna Medical Rental Network rate,$103.61 ,paid @32.27% of BCBS HMO rates,$103.61 ,paid @32.27% of BCBS PPO rates,$103.61 ,paid @32.27% of BCBS rates,$85.82 ,pays @100% MCR OPPS,$85.82 ,pays at 100% MCR OPPS,$114.43 ,pays @100 MCR OPPS,$114.43 ,pays at 100% MCR OPPS,$114.43 ,pays at 100% MCR OPPS,$114.43 ,pays at 100% MCR OPPS,$114.43 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$111.20 ,pays @40% of UHC MCD billed charges,$85.82 ,$222.40 ,$222.40 
Outpatient Medical Services,Lab,80051,"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",301,$39.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$31.20 ,paid @80% Aetna Medical Rental Network rate,$14.54 ,paid @32.27% of BCBS HMO rates,$14.54 ,paid @32.27% of BCBS PPO rates,$14.54 ,paid @32.27% of BCBS rates,$5.25 ,pays @100% MCR OPPS,$5.25 ,pays at 100% MCR OPPS,$7.01 ,pays @100 MCR OPPS,$7.01 ,pays at 100% MCR OPPS,$7.01 ,pays at 100% MCR OPPS,$7.01 ,pays at 100% MCR OPPS,$7.01 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$15.60 ,pays @40% of UHC MCD billed charges,$5.25 ,$31.20 ,$31.20 
Outpatient Medical Services,Lab,84112,EVAL CERVICOVAG FLUI,301,$307.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$245.60 ,paid @80% Aetna Medical Rental Network rate,$114.42 ,paid @32.27% of BCBS HMO rates,$114.42 ,paid @32.27% of BCBS PPO rates,$114.42 ,paid @32.27% of BCBS rates,$73.58 ,pays @100% MCR OPPS,$73.58 ,pays at 100% MCR OPPS,$98.11 ,pays @100 MCR OPPS,$98.11 ,pays at 100% MCR OPPS,$98.11 ,pays at 100% MCR OPPS,$98.11 ,pays at 100% MCR OPPS,$98.11 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$122.80 ,pays @40% of UHC MCD billed charges,$73.58 ,$245.60 ,$245.60 
Outpatient Medical Services,Lab,80053,"Blood test, comprehensive group of blood chemicals",301,$151.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$120.80 ,paid @80% Aetna Medical Rental Network rate,$56.28 ,paid @32.27% of BCBS HMO rates,$56.28 ,paid @32.27% of BCBS PPO rates,$56.28 ,paid @32.27% of BCBS rates,$7.92 ,pays @100% MCR OPPS,$7.92 ,pays at 100% MCR OPPS,$10.56 ,pays @100 MCR OPPS,$10.56 ,pays at 100% MCR OPPS,$10.56 ,pays at 100% MCR OPPS,$10.56 ,pays at 100% MCR OPPS,$10.56 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$60.40 ,pays @40% of UHC MCD billed charges,$7.92 ,$120.80 ,$120.80 
Outpatient Medical Services,Lab,85335,FACTOR INHIBITOR TES,305,$61.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$48.80 ,paid @80% Aetna Medical Rental Network rate,$22.73 ,paid @32.27% of BCBS HMO rates,$22.73 ,paid @32.27% of BCBS PPO rates,$22.73 ,paid @32.27% of BCBS rates,$9.65 ,pays @100% MCR OPPS,$9.65 ,pays at 100% MCR OPPS,$12.87 ,pays @100 MCR OPPS,$12.87 ,pays at 100% MCR OPPS,$12.87 ,pays at 100% MCR OPPS,$12.87 ,pays at 100% MCR OPPS,$12.87 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.40 ,pays @40% of UHC MCD billed charges,$9.65 ,$48.80 ,$48.80 
Outpatient Medical Services,Lab,85290,FACTOR XIII FUNCTION,305,$242.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$193.60 ,paid @80% Aetna Medical Rental Network rate,$90.19 ,paid @32.27% of BCBS HMO rates,$90.19 ,paid @32.27% of BCBS PPO rates,$90.19 ,paid @32.27% of BCBS rates,$12.25 ,pays @100% MCR OPPS,$12.25 ,pays at 100% MCR OPPS,$16.34 ,pays @100 MCR OPPS,$16.34 ,pays at 100% MCR OPPS,$16.34 ,pays at 100% MCR OPPS,$16.34 ,pays at 100% MCR OPPS,$16.34 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$96.80 ,pays @40% of UHC MCD billed charges,$12.25 ,$193.60 ,$193.60 
Outpatient Medical Services,Lab,83663,FETAL LUNG MATUR SUR,301,$76.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$60.80 ,paid @80% Aetna Medical Rental Network rate,$28.33 ,paid @32.27% of BCBS HMO rates,$28.33 ,paid @32.27% of BCBS PPO rates,$28.33 ,paid @32.27% of BCBS rates,$14.18 ,pays @100% MCR OPPS,$14.18 ,pays at 100% MCR OPPS,$18.91 ,pays @100 MCR OPPS,$18.91 ,pays at 100% MCR OPPS,$18.91 ,pays at 100% MCR OPPS,$18.91 ,pays at 100% MCR OPPS,$18.91 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$30.40 ,pays @40% of UHC MCD billed charges,$14.18 ,$60.80 ,$60.80 
Outpatient Medical Services,Lab,85461,FETAL SCREEN,301,$17.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$13.60 ,paid @80% Aetna Medical Rental Network rate,$6.34 ,paid @32.27% of BCBS HMO rates,$6.34 ,paid @32.27% of BCBS PPO rates,$6.34 ,paid @32.27% of BCBS rates,$7.02 ,pays @100% MCR OPPS,$7.02 ,pays at 100% MCR OPPS,$9.36 ,pays @100 MCR OPPS,$9.36 ,pays at 100% MCR OPPS,$9.36 ,pays at 100% MCR OPPS,$9.36 ,pays at 100% MCR OPPS,$9.36 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$6.80 ,pays @40% of UHC MCD billed charges,$6.34 ,$13.60 ,$13.60 
Outpatient Medical Services,Lab,85362,FIBRIN DEGRADATION P,305,$48.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$38.40 ,paid @80% Aetna Medical Rental Network rate,$17.89 ,paid @32.27% of BCBS HMO rates,$17.89 ,paid @32.27% of BCBS PPO rates,$17.89 ,paid @32.27% of BCBS rates,$5.16 ,pays @100% MCR OPPS,$5.16 ,pays at 100% MCR OPPS,$6.89 ,pays @100 MCR OPPS,$6.89 ,pays at 100% MCR OPPS,$6.89 ,pays at 100% MCR OPPS,$6.89 ,pays at 100% MCR OPPS,$6.89 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$19.20 ,pays @40% of UHC MCD billed charges,$5.16 ,$38.40 ,$38.40 
Outpatient Medical Services,Lab,85385,FIBRINDGEN,305,$50.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$40.00 ,paid @80% Aetna Medical Rental Network rate,$18.64 ,paid @32.27% of BCBS HMO rates,$18.64 ,paid @32.27% of BCBS PPO rates,$18.64 ,paid @32.27% of BCBS rates,$10.84 ,pays @100% MCR OPPS,$10.84 ,pays at 100% MCR OPPS,$14.46 ,pays @100 MCR OPPS,$14.46 ,pays at 100% MCR OPPS,$14.46 ,pays at 100% MCR OPPS,$14.46 ,pays at 100% MCR OPPS,$14.46 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$20.00 ,pays @40% of UHC MCD billed charges,$10.84 ,$40.00 ,$40.00 
Outpatient Medical Services,Lab,85384,FIBRINOGEN ACTIVITY,305,$40.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$32.00 ,paid @80% Aetna Medical Rental Network rate,$14.91 ,paid @32.27% of BCBS HMO rates,$14.91 ,paid @32.27% of BCBS PPO rates,$14.91 ,paid @32.27% of BCBS rates,$7.29 ,pays @100% MCR OPPS,$7.29 ,pays at 100% MCR OPPS,$9.72 ,pays @100 MCR OPPS,$9.72 ,pays at 100% MCR OPPS,$9.72 ,pays at 100% MCR OPPS,$9.72 ,pays at 100% MCR OPPS,$9.72 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.00 ,pays @40% of UHC MCD billed charges,$7.29 ,$32.00 ,$32.00 
Outpatient Medical Services,Lab,84311,FRUCTOSAMINE,301,$59.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$47.20 ,paid @80% Aetna Medical Rental Network rate,$21.99 ,paid @32.27% of BCBS HMO rates,$21.99 ,paid @32.27% of BCBS PPO rates,$21.99 ,paid @32.27% of BCBS rates,$6.07 ,pays @100% MCR OPPS,$6.07 ,pays at 100% MCR OPPS,$8.10 ,pays @100 MCR OPPS,$8.10 ,pays at 100% MCR OPPS,$8.10 ,pays at 100% MCR OPPS,$8.10 ,pays at 100% MCR OPPS,$8.10 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$23.60 ,pays @40% of UHC MCD billed charges,$6.07 ,$47.20 ,$47.20 
Outpatient Medical Services,Lab,87507,GI PROFILE STOOL PCR,301,$400.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$320.00 ,paid @80% Aetna Medical Rental Network rate,$149.08 ,paid @32.27% of BCBS HMO rates,$149.08 ,paid @32.27% of BCBS PPO rates,$149.08 ,paid @32.27% of BCBS rates,$312.58 ,pays @100% MCR OPPS,$312.58 ,pays at 100% MCR OPPS,$416.78 ,pays @100 MCR OPPS,$416.78 ,pays at 100% MCR OPPS,$416.78 ,pays at 100% MCR OPPS,$416.78 ,pays at 100% MCR OPPS,$416.78 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$160.00 ,pays @40% of UHC MCD billed charges,$149.08 ,$416.78 ,$320.00 
Outpatient Medical Services,Lab,82945,GLUCOSE FLUID,301,$21.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.80 ,paid @80% Aetna Medical Rental Network rate,$7.83 ,paid @32.27% of BCBS HMO rates,$7.83 ,paid @32.27% of BCBS PPO rates,$7.83 ,paid @32.27% of BCBS rates,$2.94 ,pays @100% MCR OPPS,$2.94 ,pays at 100% MCR OPPS,$3.93 ,pays @100 MCR OPPS,$3.93 ,pays at 100% MCR OPPS,$3.93 ,pays at 100% MCR OPPS,$3.93 ,pays at 100% MCR OPPS,$3.93 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.40 ,pays @40% of UHC MCD billed charges,$2.94 ,$16.80 ,$16.80 
Outpatient Medical Services,Lab,84703,Blood test to assess for pregnancy,301,$42.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$33.60 ,paid @80% Aetna Medical Rental Network rate,$15.65 ,paid @32.27% of BCBS HMO rates,$15.65 ,paid @32.27% of BCBS PPO rates,$15.65 ,paid @32.27% of BCBS rates,$5.64 ,pays @100% MCR OPPS,$5.64 ,pays at 100% MCR OPPS,$7.52 ,pays @100 MCR OPPS,$7.52 ,pays at 100% MCR OPPS,$7.52 ,pays at 100% MCR OPPS,$7.52 ,pays at 100% MCR OPPS,$7.52 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.80 ,pays @40% of UHC MCD billed charges,$5.64 ,$33.60 ,$33.60 
Outpatient Medical Services,Lab,84702,HCG QUANTITATIVE SER,301,$70.85 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$56.68 ,paid @80% Aetna Medical Rental Network rate,$26.41 ,paid @32.27% of BCBS HMO rates,$26.41 ,paid @32.27% of BCBS PPO rates,$26.41 ,paid @32.27% of BCBS rates,$11.28 ,pays @100% MCR OPPS,$11.28 ,pays at 100% MCR OPPS,$15.05 ,pays @100 MCR OPPS,$15.05 ,pays at 100% MCR OPPS,$15.05 ,pays at 100% MCR OPPS,$15.05 ,pays at 100% MCR OPPS,$15.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$28.34 ,pays @40% of UHC MCD billed charges,$11.28 ,$56.68 ,$56.68 
Outpatient Medical Services,Lab,87521,HCV RNA NAA QL,301,$167.55 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$134.04 ,paid @80% Aetna Medical Rental Network rate,$62.45 ,paid @32.27% of BCBS HMO rates,$62.45 ,paid @32.27% of BCBS PPO rates,$62.45 ,paid @32.27% of BCBS rates,$26.31 ,pays @100% MCR OPPS,$26.31 ,pays at 100% MCR OPPS,$35.09 ,pays @100 MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$67.02 ,pays @40% of UHC MCD billed charges,$26.31 ,$134.04 ,$134.04 
Outpatient Medical Services,Lab,83718,Blood test to measure the level of lipoproteins in the blood,301,$46.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.80 ,paid @80% Aetna Medical Rental Network rate,$17.14 ,paid @32.27% of BCBS HMO rates,$17.14 ,paid @32.27% of BCBS PPO rates,$17.14 ,paid @32.27% of BCBS rates,$6.14 ,pays @100% MCR OPPS,$6.14 ,pays at 100% MCR OPPS,$8.19 ,pays @100 MCR OPPS,$8.19 ,pays at 100% MCR OPPS,$8.19 ,pays at 100% MCR OPPS,$8.19 ,pays at 100% MCR OPPS,$8.19 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$18.40 ,pays @40% of UHC MCD billed charges,$6.14 ,$36.80 ,$36.80 
Outpatient Medical Services,Lab,85014,HEMATOCRIT,305,$11.31 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$9.05 ,paid @80% Aetna Medical Rental Network rate,$4.22 ,paid @32.27% of BCBS HMO rates,$4.22 ,paid @32.27% of BCBS PPO rates,$4.22 ,paid @32.27% of BCBS rates,$1.77 ,pays @100% MCR OPPS,$1.77 ,pays at 100% MCR OPPS,$2.37 ,pays @100 MCR OPPS,$2.37 ,pays at 100% MCR OPPS,$2.37 ,pays at 100% MCR OPPS,$2.37 ,pays at 100% MCR OPPS,$2.37 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$4.52 ,pays @40% of UHC MCD billed charges,$1.77 ,$9.05 ,$9.05 
Outpatient Medical Services,Lab,85018,Blood test to measure levels of hemoglobin,305,$14.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$11.20 ,paid @80% Aetna Medical Rental Network rate,$5.22 ,paid @32.27% of BCBS HMO rates,$5.22 ,paid @32.27% of BCBS PPO rates,$5.22 ,paid @32.27% of BCBS rates,$1.77 ,pays @100% MCR OPPS,$1.77 ,pays at 100% MCR OPPS,$2.37 ,pays @100 MCR OPPS,$2.37 ,pays at 100% MCR OPPS,$2.37 ,pays at 100% MCR OPPS,$2.37 ,pays at 100% MCR OPPS,$2.37 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$5.60 ,pays @40% of UHC MCD billed charges,$1.77 ,$11.20 ,$11.20 
Outpatient Medical Services,Lab,83036,Blood test to measure average blood glucose levels for past 2-3 months,301,$55.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.00 ,paid @80% Aetna Medical Rental Network rate,$20.50 ,paid @32.27% of BCBS HMO rates,$20.50 ,paid @32.27% of BCBS PPO rates,$20.50 ,paid @32.27% of BCBS rates,$7.28 ,pays @100% MCR OPPS,$7.28 ,pays at 100% MCR OPPS,$9.71 ,pays @100 MCR OPPS,$9.71 ,pays at 100% MCR OPPS,$9.71 ,pays at 100% MCR OPPS,$9.71 ,pays at 100% MCR OPPS,$9.71 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.00 ,pays @40% of UHC MCD billed charges,$7.28 ,$44.00 ,$44.00 
Outpatient Medical Services,Lab,80076,Liver function blood test panel,301,$46.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.80 ,paid @80% Aetna Medical Rental Network rate,$17.14 ,paid @32.27% of BCBS HMO rates,$17.14 ,paid @32.27% of BCBS PPO rates,$17.14 ,paid @32.27% of BCBS rates,$6.12 ,pays @100% MCR OPPS,$6.12 ,pays at 100% MCR OPPS,$8.17 ,pays @100 MCR OPPS,$8.17 ,pays at 100% MCR OPPS,$8.17 ,pays at 100% MCR OPPS,$8.17 ,pays at 100% MCR OPPS,$8.17 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$18.40 ,pays @40% of UHC MCD billed charges,$6.12 ,$36.80 ,$36.80 
Outpatient Medical Services,Lab,80074,Acute hepatitis panel,301,$267.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$213.60 ,paid @80% Aetna Medical Rental Network rate,$99.51 ,paid @32.27% of BCBS HMO rates,$99.51 ,paid @32.27% of BCBS PPO rates,$99.51 ,paid @32.27% of BCBS rates,$35.72 ,pays @100% MCR OPPS,$35.72 ,pays at 100% MCR OPPS,$47.63 ,pays @100 MCR OPPS,$47.63 ,pays at 100% MCR OPPS,$47.63 ,pays at 100% MCR OPPS,$47.63 ,pays at 100% MCR OPPS,$47.63 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$106.80 ,pays @40% of UHC MCD billed charges,$35.72 ,$213.60 ,$213.60 
Outpatient Medical Services,Lab,86790,HEPATITIS E IGM,301,$389.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$311.20 ,paid @80% Aetna Medical Rental Network rate,$144.98 ,paid @32.27% of BCBS HMO rates,$144.98 ,paid @32.27% of BCBS PPO rates,$144.98 ,paid @32.27% of BCBS rates,$9.66 ,pays @100% MCR OPPS,$9.66 ,pays at 100% MCR OPPS,$12.88 ,pays @100 MCR OPPS,$12.88 ,pays at 100% MCR OPPS,$12.88 ,pays at 100% MCR OPPS,$12.88 ,pays at 100% MCR OPPS,$12.88 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$155.60 ,pays @40% of UHC MCD billed charges,$9.66 ,$311.20 ,$311.20 
Outpatient Medical Services,Lab,86141,HIGH SENSITIVITY CRP,301,$62.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$49.60 ,paid @80% Aetna Medical Rental Network rate,$23.11 ,paid @32.27% of BCBS HMO rates,$23.11 ,paid @32.27% of BCBS PPO rates,$23.11 ,paid @32.27% of BCBS rates,$9.71 ,pays @100% MCR OPPS,$9.71 ,pays at 100% MCR OPPS,$12.95 ,pays @100 MCR OPPS,$12.95 ,pays at 100% MCR OPPS,$12.95 ,pays at 100% MCR OPPS,$12.95 ,pays at 100% MCR OPPS,$12.95 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.80 ,pays @40% of UHC MCD billed charges,$9.71 ,$49.60 ,$49.60 
Outpatient Medical Services,Lab,87903,HIV INTH INHB RES,301,"$2,327.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,861.60 ",paid @80% Aetna Medical Rental Network rate,$867.27 ,paid @32.27% of BCBS HMO rates,$867.27 ,paid @32.27% of BCBS PPO rates,$867.27 ,paid @32.27% of BCBS rates,$366.49 ,pays @100% MCR OPPS,$366.49 ,pays at 100% MCR OPPS,$488.66 ,pays @100 MCR OPPS,$488.66 ,pays at 100% MCR OPPS,$488.66 ,pays at 100% MCR OPPS,$488.66 ,pays at 100% MCR OPPS,$488.66 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$930.80 ,pays @40% of UHC MCD billed charges,$366.49 ,"$1,861.60 ","$1,861.60 "
Outpatient Medical Services,Lab,87536,HIV1 RNA PCR VIRAL,301,$405.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$324.00 ,paid @80% Aetna Medical Rental Network rate,$150.94 ,paid @32.27% of BCBS HMO rates,$150.94 ,paid @32.27% of BCBS PPO rates,$150.94 ,paid @32.27% of BCBS rates,$63.82 ,pays @100% MCR OPPS,$63.82 ,pays at 100% MCR OPPS,$85.10 ,pays @100 MCR OPPS,$85.10 ,pays at 100% MCR OPPS,$85.10 ,pays at 100% MCR OPPS,$85.10 ,pays at 100% MCR OPPS,$85.10 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$162.00 ,pays @40% of UHC MCD billed charges,$63.82 ,$324.00 ,$324.00 
Outpatient Medical Services,Lab,86352,IMMUKNOW,301,$721.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.80 ,paid @80% Aetna Medical Rental Network rate,$268.72 ,paid @32.27% of BCBS HMO rates,$268.72 ,paid @32.27% of BCBS PPO rates,$268.72 ,paid @32.27% of BCBS rates,$101.89 ,pays @100% MCR OPPS,$101.89 ,pays at 100% MCR OPPS,$135.86 ,pays @100 MCR OPPS,$135.86 ,pays at 100% MCR OPPS,$135.86 ,pays at 100% MCR OPPS,$135.86 ,pays at 100% MCR OPPS,$135.86 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.40 ,pays @40% of UHC MCD billed charges,$101.89 ,$576.80 ,$576.80 
Outpatient Medical Services,Lab,83525,INSULIN SERUM,301,$54.50 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$43.60 ,paid @80% Aetna Medical Rental Network rate,$20.31 ,paid @32.27% of BCBS HMO rates,$20.31 ,paid @32.27% of BCBS PPO rates,$20.31 ,paid @32.27% of BCBS rates,$8.57 ,pays @100% MCR OPPS,$8.57 ,pays at 100% MCR OPPS,$11.43 ,pays @100 MCR OPPS,$11.43 ,pays at 100% MCR OPPS,$11.43 ,pays at 100% MCR OPPS,$11.43 ,pays at 100% MCR OPPS,$11.43 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$21.80 ,pays @40% of UHC MCD billed charges,$8.57 ,$43.60 ,$43.60 
Outpatient Medical Services,Lab,83550,Blood test that measures the amount of iron carried in the blood,301,$49.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$39.20 ,paid @80% Aetna Medical Rental Network rate,$18.26 ,paid @32.27% of BCBS HMO rates,$18.26 ,paid @32.27% of BCBS PPO rates,$18.26 ,paid @32.27% of BCBS rates,$6.55 ,pays @100% MCR OPPS,$6.55 ,pays at 100% MCR OPPS,$8.74 ,pays @100 MCR OPPS,$8.74 ,pays at 100% MCR OPPS,$8.74 ,pays at 100% MCR OPPS,$8.74 ,pays at 100% MCR OPPS,$8.74 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$19.60 ,pays @40% of UHC MCD billed charges,$6.55 ,$39.20 ,$39.20 
Outpatient Medical Services,Lab,83540,Blood test to measure the amount of iron that is in transit in the body,301,$43.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$34.40 ,paid @80% Aetna Medical Rental Network rate,$16.03 ,paid @32.27% of BCBS HMO rates,$16.03 ,paid @32.27% of BCBS PPO rates,$16.03 ,paid @32.27% of BCBS rates,$4.85 ,pays @100% MCR OPPS,$4.85 ,pays at 100% MCR OPPS,$6.47 ,pays @100 MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$17.20 ,pays @40% of UHC MCD billed charges,$4.85 ,$34.40 ,$34.40 
Outpatient Medical Services,Lab,86341,ISLET CELL ANITBODY,301,$105.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$84.00 ,paid @80% Aetna Medical Rental Network rate,$39.13 ,paid @32.27% of BCBS HMO rates,$39.13 ,paid @32.27% of BCBS PPO rates,$39.13 ,paid @32.27% of BCBS rates,$17.67 ,pays @100% MCR OPPS,$17.67 ,pays at 100% MCR OPPS,$23.57 ,pays @100 MCR OPPS,$23.57 ,pays at 100% MCR OPPS,$23.57 ,pays at 100% MCR OPPS,$23.57 ,pays at 100% MCR OPPS,$23.57 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$42.00 ,pays @40% of UHC MCD billed charges,$17.67 ,$84.00 ,$84.00 
Outpatient Medical Services,Lab,85460,KLEIHAUER BETKE QUAN,301,$73.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$58.40 ,paid @80% Aetna Medical Rental Network rate,$27.21 ,paid @32.27% of BCBS HMO rates,$27.21 ,paid @32.27% of BCBS PPO rates,$27.21 ,paid @32.27% of BCBS rates,$5.79 ,pays @100% MCR OPPS,$5.79 ,pays at 100% MCR OPPS,$7.73 ,pays @100 MCR OPPS,$7.73 ,pays at 100% MCR OPPS,$7.73 ,pays at 100% MCR OPPS,$7.73 ,pays at 100% MCR OPPS,$7.73 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$29.20 ,pays @40% of UHC MCD billed charges,$5.79 ,$58.40 ,$58.40 
Outpatient Medical Services,Lab,83605,LACTIC ACID,301,$94.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$75.20 ,paid @80% Aetna Medical Rental Network rate,$35.03 ,paid @32.27% of BCBS HMO rates,$35.03 ,paid @32.27% of BCBS PPO rates,$35.03 ,paid @32.27% of BCBS rates,$8.67 ,pays @100% MCR OPPS,$8.67 ,pays at 100% MCR OPPS,$11.57 ,pays @100 MCR OPPS,$11.57 ,pays at 100% MCR OPPS,$11.57 ,pays at 100% MCR OPPS,$11.57 ,pays at 100% MCR OPPS,$11.57 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$37.60 ,pays @40% of UHC MCD billed charges,$8.67 ,$75.20 ,$75.20 
Outpatient Medical Services,Lab,83631,LACTOFERRIN QUANT,301,$94.26 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$75.41 ,paid @80% Aetna Medical Rental Network rate,$35.13 ,paid @32.27% of BCBS HMO rates,$35.13 ,paid @32.27% of BCBS PPO rates,$35.13 ,paid @32.27% of BCBS rates,$14.72 ,pays @100% MCR OPPS,$14.72 ,pays at 100% MCR OPPS,$19.63 ,pays @100 MCR OPPS,$19.63 ,pays at 100% MCR OPPS,$19.63 ,pays at 100% MCR OPPS,$19.63 ,pays at 100% MCR OPPS,$19.63 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$37.70 ,pays @40% of UHC MCD billed charges,$14.72 ,$75.41 ,$75.41 
Outpatient Medical Services,Lab,83630,"LACTOFERRIN, FECAL",301,$64.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$51.20 ,paid @80% Aetna Medical Rental Network rate,$23.85 ,paid @32.27% of BCBS HMO rates,$23.85 ,paid @32.27% of BCBS PPO rates,$23.85 ,paid @32.27% of BCBS rates,$14.77 ,pays @100% MCR OPPS,$14.77 ,pays at 100% MCR OPPS,$19.70 ,pays @100 MCR OPPS,$19.70 ,pays at 100% MCR OPPS,$19.70 ,pays at 100% MCR OPPS,$19.70 ,pays at 100% MCR OPPS,$19.70 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$25.60 ,pays @40% of UHC MCD billed charges,$14.77 ,$51.20 ,$51.20 
Outpatient Medical Services,Lab,83615,LDH,301,$34.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$27.20 ,paid @80% Aetna Medical Rental Network rate,$12.67 ,paid @32.27% of BCBS HMO rates,$12.67 ,paid @32.27% of BCBS PPO rates,$12.67 ,paid @32.27% of BCBS rates,$4.53 ,pays @100% MCR OPPS,$4.53 ,pays at 100% MCR OPPS,$6.04 ,pays @100 MCR OPPS,$6.04 ,pays at 100% MCR OPPS,$6.04 ,pays at 100% MCR OPPS,$6.04 ,pays at 100% MCR OPPS,$6.04 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$13.60 ,pays @40% of UHC MCD billed charges,$4.53 ,$27.20 ,$27.20 
Outpatient Medical Services,Lab,83625,LDH FLUID,301,$52.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$41.60 ,paid @80% Aetna Medical Rental Network rate,$19.38 ,paid @32.27% of BCBS HMO rates,$19.38 ,paid @32.27% of BCBS PPO rates,$19.38 ,paid @32.27% of BCBS rates,$9.59 ,pays @100% MCR OPPS,$9.59 ,pays at 100% MCR OPPS,$12.79 ,pays @100 MCR OPPS,$12.79 ,pays at 100% MCR OPPS,$12.79 ,pays at 100% MCR OPPS,$12.79 ,pays at 100% MCR OPPS,$12.79 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$20.80 ,pays @40% of UHC MCD billed charges,$9.59 ,$41.60 ,$41.60 
Outpatient Medical Services,Lab,83721,LDL CHOLESTEROL,301,$83.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$66.40 ,paid @80% Aetna Medical Rental Network rate,$30.93 ,paid @32.27% of BCBS HMO rates,$30.93 ,paid @32.27% of BCBS PPO rates,$30.93 ,paid @32.27% of BCBS rates,$7.87 ,pays @100% MCR OPPS,$7.87 ,pays at 100% MCR OPPS,$10.50 ,pays @100 MCR OPPS,$10.50 ,pays at 100% MCR OPPS,$10.50 ,pays at 100% MCR OPPS,$10.50 ,pays at 100% MCR OPPS,$10.50 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$33.20 ,pays @40% of UHC MCD billed charges,$7.87 ,$66.40 ,$66.40 
Outpatient Medical Services,Lab,83655,Blood test to determine the concentration of lead in the blood,301,$67.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$53.60 ,paid @80% Aetna Medical Rental Network rate,$24.97 ,paid @32.27% of BCBS HMO rates,$24.97 ,paid @32.27% of BCBS PPO rates,$24.97 ,paid @32.27% of BCBS rates,$9.08 ,pays @100% MCR OPPS,$9.08 ,pays at 100% MCR OPPS,$12.11 ,pays @100 MCR OPPS,$12.11 ,pays at 100% MCR OPPS,$12.11 ,pays at 100% MCR OPPS,$12.11 ,pays at 100% MCR OPPS,$12.11 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$26.80 ,pays @40% of UHC MCD billed charges,$9.08 ,$53.60 ,$53.60 
Outpatient Medical Services,Lab,83664,LECITHIN SPHINGOMYEL,301,$211.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$168.80 ,paid @80% Aetna Medical Rental Network rate,$78.64 ,paid @32.27% of BCBS HMO rates,$78.64 ,paid @32.27% of BCBS PPO rates,$78.64 ,paid @32.27% of BCBS rates,$14.49 ,pays @100% MCR OPPS,$14.49 ,pays at 100% MCR OPPS,$19.32 ,pays @100 MCR OPPS,$19.32 ,pays at 100% MCR OPPS,$19.32 ,pays at 100% MCR OPPS,$19.32 ,pays at 100% MCR OPPS,$19.32 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$84.40 ,pays @40% of UHC MCD billed charges,$14.49 ,$168.80 ,$168.80 
Outpatient Medical Services,Lab,85345,LEE WHITE CLOTTING,305,$24.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$19.20 ,paid @80% Aetna Medical Rental Network rate,$8.94 ,paid @32.27% of BCBS HMO rates,$8.94 ,paid @32.27% of BCBS PPO rates,$8.94 ,paid @32.27% of BCBS rates,$3.51 ,pays @100% MCR OPPS,$3.51 ,pays at 100% MCR OPPS,$4.69 ,pays @100 MCR OPPS,$4.69 ,pays at 100% MCR OPPS,$4.69 ,pays at 100% MCR OPPS,$4.69 ,pays at 100% MCR OPPS,$4.69 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$9.60 ,pays @40% of UHC MCD billed charges,$3.51 ,$19.20 ,$19.20 
Outpatient Medical Services,Lab,86720,LEPTOSPIRA,301,$63.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$50.40 ,paid @80% Aetna Medical Rental Network rate,$23.48 ,paid @32.27% of BCBS HMO rates,$23.48 ,paid @32.27% of BCBS PPO rates,$23.48 ,paid @32.27% of BCBS rates,$12.15 ,pays @100% MCR OPPS,$12.15 ,pays at 100% MCR OPPS,$16.20 ,pays @100 MCR OPPS,$16.20 ,pays at 100% MCR OPPS,$16.20 ,pays at 100% MCR OPPS,$16.20 ,pays at 100% MCR OPPS,$16.20 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$25.20 ,pays @40% of UHC MCD billed charges,$12.15 ,$50.40 ,$50.40 
Outpatient Medical Services,Lab,85540,LEUKOCYTE ALKALINE,305,$50.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$40.00 ,paid @80% Aetna Medical Rental Network rate,$18.64 ,paid @32.27% of BCBS HMO rates,$18.64 ,paid @32.27% of BCBS PPO rates,$18.64 ,paid @32.27% of BCBS rates,$6.45 ,pays @100% MCR OPPS,$6.45 ,pays at 100% MCR OPPS,$8.60 ,pays @100 MCR OPPS,$8.60 ,pays at 100% MCR OPPS,$8.60 ,pays at 100% MCR OPPS,$8.60 ,pays at 100% MCR OPPS,$8.60 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$20.00 ,pays @40% of UHC MCD billed charges,$6.45 ,$40.00 ,$40.00 
Outpatient Medical Services,Lab,83690,LIPASE,301,$39.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$31.20 ,paid @80% Aetna Medical Rental Network rate,$14.54 ,paid @32.27% of BCBS HMO rates,$14.54 ,paid @32.27% of BCBS PPO rates,$14.54 ,paid @32.27% of BCBS rates,$5.16 ,pays @100% MCR OPPS,$5.16 ,pays at 100% MCR OPPS,$6.89 ,pays @100 MCR OPPS,$6.89 ,pays at 100% MCR OPPS,$6.89 ,pays at 100% MCR OPPS,$6.89 ,pays at 100% MCR OPPS,$6.89 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$15.60 ,pays @40% of UHC MCD billed charges,$5.16 ,$31.20 ,$31.20 
Outpatient Medical Services,Lab,80061,"Blood test, lipids (cholesterol and triglycerides)",301,$67.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$53.60 ,paid @80% Aetna Medical Rental Network rate,$24.97 ,paid @32.27% of BCBS HMO rates,$24.97 ,paid @32.27% of BCBS PPO rates,$24.97 ,paid @32.27% of BCBS rates,$10.04 ,pays @100% MCR OPPS,$10.04 ,pays at 100% MCR OPPS,$13.39 ,pays @100 MCR OPPS,$13.39 ,pays at 100% MCR OPPS,$13.39 ,pays at 100% MCR OPPS,$13.39 ,pays at 100% MCR OPPS,$13.39 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$26.80 ,pays @40% of UHC MCD billed charges,$10.04 ,$53.60 ,$53.60 
Outpatient Medical Services,Lab,83698,LIPOPRO W/PHOS A2,301,$186.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$148.80 ,paid @80% Aetna Medical Rental Network rate,$69.32 ,paid @32.27% of BCBS HMO rates,$69.32 ,paid @32.27% of BCBS PPO rates,$69.32 ,paid @32.27% of BCBS rates,$34.73 ,pays @100% MCR OPPS,$34.73 ,pays at 100% MCR OPPS,$46.31 ,pays @100 MCR OPPS,$46.31 ,pays at 100% MCR OPPS,$46.31 ,pays at 100% MCR OPPS,$46.31 ,pays at 100% MCR OPPS,$46.31 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$74.40 ,pays @40% of UHC MCD billed charges,$34.73 ,$148.80 ,$148.80 
Outpatient Medical Services,Lab,83695,LIPOPROTEIN A,301,$94.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$75.20 ,paid @80% Aetna Medical Rental Network rate,$35.03 ,paid @32.27% of BCBS HMO rates,$35.03 ,paid @32.27% of BCBS PPO rates,$35.03 ,paid @32.27% of BCBS rates,$10.74 ,pays @100% MCR OPPS,$10.74 ,pays at 100% MCR OPPS,$14.32 ,pays @100 MCR OPPS,$14.32 ,pays at 100% MCR OPPS,$14.32 ,pays at 100% MCR OPPS,$14.32 ,pays at 100% MCR OPPS,$14.32 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$37.60 ,pays @40% of UHC MCD billed charges,$10.74 ,$75.20 ,$75.20 
Outpatient Medical Services,Lab,83704,LIPOPROTEIN QUANTITA,301,$172.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$137.60 ,paid @80% Aetna Medical Rental Network rate,$64.10 ,paid @32.27% of BCBS HMO rates,$64.10 ,paid @32.27% of BCBS PPO rates,$64.10 ,paid @32.27% of BCBS rates,$25.64 ,pays @100% MCR OPPS,$25.64 ,pays at 100% MCR OPPS,$34.19 ,pays @100 MCR OPPS,$34.19 ,pays at 100% MCR OPPS,$34.19 ,pays at 100% MCR OPPS,$34.19 ,pays at 100% MCR OPPS,$34.19 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$68.80 ,pays @40% of UHC MCD billed charges,$25.64 ,$137.60 ,$137.60 
Outpatient Medical Services,Lab,85597,"LUPUS ANTICOAG,PLT N",305,$77.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$61.60 ,paid @80% Aetna Medical Rental Network rate,$28.70 ,paid @32.27% of BCBS HMO rates,$28.70 ,paid @32.27% of BCBS PPO rates,$28.70 ,paid @32.27% of BCBS rates,$13.48 ,pays @100% MCR OPPS,$13.48 ,pays at 100% MCR OPPS,$17.98 ,pays @100 MCR OPPS,$17.98 ,pays at 100% MCR OPPS,$17.98 ,pays at 100% MCR OPPS,$17.98 ,pays at 100% MCR OPPS,$17.98 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$30.80 ,pays @40% of UHC MCD billed charges,$13.48 ,$61.60 ,$61.60 
Outpatient Medical Services,Lab,86617,LYMES WESTERN BLOT,301,$73.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$58.40 ,paid @80% Aetna Medical Rental Network rate,$27.21 ,paid @32.27% of BCBS HMO rates,$27.21 ,paid @32.27% of BCBS PPO rates,$27.21 ,paid @32.27% of BCBS rates,$11.61 ,pays @100% MCR OPPS,$11.61 ,pays at 100% MCR OPPS,$15.49 ,pays @100 MCR OPPS,$15.49 ,pays at 100% MCR OPPS,$15.49 ,pays at 100% MCR OPPS,$15.49 ,pays at 100% MCR OPPS,$15.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$29.20 ,pays @40% of UHC MCD billed charges,$11.61 ,$58.40 ,$58.40 
Outpatient Medical Services,Lab,85549,LYSOZYME,305,$105.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$84.00 ,paid @80% Aetna Medical Rental Network rate,$39.13 ,paid @32.27% of BCBS HMO rates,$39.13 ,paid @32.27% of BCBS PPO rates,$39.13 ,paid @32.27% of BCBS rates,$14.06 ,pays @100% MCR OPPS,$14.06 ,pays at 100% MCR OPPS,$18.75 ,pays @100 MCR OPPS,$18.75 ,pays at 100% MCR OPPS,$18.75 ,pays at 100% MCR OPPS,$18.75 ,pays at 100% MCR OPPS,$18.75 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$42.00 ,pays @40% of UHC MCD billed charges,$14.06 ,$84.00 ,$84.00 
Outpatient Medical Services,Lab,83735,"MAGNESIUM, RBC",301,$91.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.80 ,paid @80% Aetna Medical Rental Network rate,$33.92 ,paid @32.27% of BCBS HMO rates,$33.92 ,paid @32.27% of BCBS PPO rates,$33.92 ,paid @32.27% of BCBS rates,$5.02 ,pays @100% MCR OPPS,$5.02 ,pays at 100% MCR OPPS,$6.70 ,pays @100 MCR OPPS,$6.70 ,pays at 100% MCR OPPS,$6.70 ,pays at 100% MCR OPPS,$6.70 ,pays at 100% MCR OPPS,$6.70 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.40 ,pays @40% of UHC MCD billed charges,$5.02 ,$72.80 ,$72.80 
Outpatient Medical Services,Lab,83785,MANGANESE,301,$120.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$96.00 ,paid @80% Aetna Medical Rental Network rate,$44.72 ,paid @32.27% of BCBS HMO rates,$44.72 ,paid @32.27% of BCBS PPO rates,$44.72 ,paid @32.27% of BCBS rates,$19.98 ,pays @100% MCR OPPS,$19.98 ,pays at 100% MCR OPPS,$26.65 ,pays @100 MCR OPPS,$26.65 ,pays at 100% MCR OPPS,$26.65 ,pays at 100% MCR OPPS,$26.65 ,pays at 100% MCR OPPS,$26.65 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$48.00 ,pays @40% of UHC MCD billed charges,$19.98 ,$96.00 ,$96.00 
Outpatient Medical Services,Lab,83825,"MERCURY LEVEL,BLD/UR",301,$91.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.80 ,paid @80% Aetna Medical Rental Network rate,$33.92 ,paid @32.27% of BCBS HMO rates,$33.92 ,paid @32.27% of BCBS PPO rates,$33.92 ,paid @32.27% of BCBS rates,$12.19 ,pays @100% MCR OPPS,$12.19 ,pays at 100% MCR OPPS,$16.26 ,pays @100 MCR OPPS,$16.26 ,pays at 100% MCR OPPS,$16.26 ,pays at 100% MCR OPPS,$16.26 ,pays at 100% MCR OPPS,$16.26 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.40 ,pays @40% of UHC MCD billed charges,$12.19 ,$72.80 ,$72.80 
Outpatient Medical Services,Lab,83835,"METANEPHRINES, FRACT",301,$134.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$107.20 ,paid @80% Aetna Medical Rental Network rate,$49.94 ,paid @32.27% of BCBS HMO rates,$49.94 ,paid @32.27% of BCBS PPO rates,$49.94 ,paid @32.27% of BCBS rates,$12.70 ,pays @100% MCR OPPS,$12.70 ,pays at 100% MCR OPPS,$16.94 ,pays @100 MCR OPPS,$16.94 ,pays at 100% MCR OPPS,$16.94 ,pays at 100% MCR OPPS,$16.94 ,pays at 100% MCR OPPS,$16.94 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$53.60 ,pays @40% of UHC MCD billed charges,$12.70 ,$107.20 ,$107.20 
Outpatient Medical Services,Lab,83921,METHYLMALONIC ACID,301,$92.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$73.60 ,paid @80% Aetna Medical Rental Network rate,$34.29 ,paid @32.27% of BCBS HMO rates,$34.29 ,paid @32.27% of BCBS PPO rates,$34.29 ,paid @32.27% of BCBS rates,$15.90 ,pays @100% MCR OPPS,$15.90 ,pays at 100% MCR OPPS,$21.21 ,pays @100 MCR OPPS,$21.21 ,pays at 100% MCR OPPS,$21.21 ,pays at 100% MCR OPPS,$21.21 ,pays at 100% MCR OPPS,$21.21 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.80 ,pays @40% of UHC MCD billed charges,$15.90 ,$73.60 ,$73.60 
Outpatient Medical Services,Lab,83900,MOLE AMP TARGET 1-2,301,$185.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$148.00 ,paid @80% Aetna Medical Rental Network rate,$68.95 ,paid @32.27% of BCBS HMO rates,$68.95 ,paid @32.27% of BCBS PPO rates,$68.95 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$74.00 ,pays @40% of UHC MCD billed charges,$68.95 ,$148.00 ,$148.00 
Outpatient Medical Services,Lab,83898,MOLE AMPLI TARGET,301,$92.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$73.60 ,paid @80% Aetna Medical Rental Network rate,$34.29 ,paid @32.27% of BCBS HMO rates,$34.29 ,paid @32.27% of BCBS PPO rates,$34.29 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.80 ,pays @40% of UHC MCD billed charges,$34.29 ,$73.60 ,$73.60 
Outpatient Medical Services,Lab,83891,MOLE ISO/EXT PURIFIE,301,$22.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$17.60 ,paid @80% Aetna Medical Rental Network rate,$8.20 ,paid @32.27% of BCBS HMO rates,$8.20 ,paid @32.27% of BCBS PPO rates,$8.20 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.80 ,pays @40% of UHC MCD billed charges,$8.20 ,$17.60 ,$17.60 
Outpatient Medical Services,Lab,83897,MOLE NUCLEIC AC TRAN,301,$22.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$17.60 ,paid @80% Aetna Medical Rental Network rate,$8.20 ,paid @32.27% of BCBS HMO rates,$8.20 ,paid @32.27% of BCBS PPO rates,$8.20 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.80 ,pays @40% of UHC MCD billed charges,$8.20 ,$17.60 ,$17.60 
Outpatient Medical Services,Lab,83912,MOLECULAR INTERPRETA,301,$90.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.00 ,paid @80% Aetna Medical Rental Network rate,$33.54 ,paid @32.27% of BCBS HMO rates,$33.54 ,paid @32.27% of BCBS PPO rates,$33.54 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.00 ,pays @40% of UHC MCD billed charges,$33.54 ,$72.00 ,$72.00 
Outpatient Medical Services,Lab,83894,MOLECULAR SEPARATION,301,$90.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.00 ,paid @80% Aetna Medical Rental Network rate,$33.54 ,paid @32.27% of BCBS HMO rates,$33.54 ,paid @32.27% of BCBS PPO rates,$33.54 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.00 ,pays @40% of UHC MCD billed charges,$33.54 ,$72.00 ,$72.00 
Outpatient Medical Services,Lab,83873,MYELIN BASIC PROTEIN,301,$90.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.00 ,paid @80% Aetna Medical Rental Network rate,$33.54 ,paid @32.27% of BCBS HMO rates,$33.54 ,paid @32.27% of BCBS PPO rates,$33.54 ,paid @32.27% of BCBS rates,$12.90 ,pays @100% MCR OPPS,$12.90 ,pays at 100% MCR OPPS,$17.20 ,pays @100 MCR OPPS,$17.20 ,pays at 100% MCR OPPS,$17.20 ,pays at 100% MCR OPPS,$17.20 ,pays at 100% MCR OPPS,$17.20 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.00 ,pays @40% of UHC MCD billed charges,$12.90 ,$72.00 ,$72.00 
Outpatient Medical Services,Lab,83874,"MYOGLOBIN, SERUM",301,$158.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$126.40 ,paid @80% Aetna Medical Rental Network rate,$58.89 ,paid @32.27% of BCBS HMO rates,$58.89 ,paid @32.27% of BCBS PPO rates,$58.89 ,paid @32.27% of BCBS rates,$9.69 ,pays @100% MCR OPPS,$9.69 ,pays at 100% MCR OPPS,$12.92 ,pays @100 MCR OPPS,$12.92 ,pays at 100% MCR OPPS,$12.92 ,pays at 100% MCR OPPS,$12.92 ,pays at 100% MCR OPPS,$12.92 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$63.20 ,pays @40% of UHC MCD billed charges,$9.69 ,$126.40 ,$126.40 
Outpatient Medical Services,Lab,84437,NEONATAL T4,301,$36.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$28.80 ,paid @80% Aetna Medical Rental Network rate,$13.42 ,paid @32.27% of BCBS HMO rates,$13.42 ,paid @32.27% of BCBS PPO rates,$13.42 ,paid @32.27% of BCBS rates,$4.85 ,pays @100% MCR OPPS,$4.85 ,pays at 100% MCR OPPS,$6.47 ,pays @100 MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$14.40 ,pays @40% of UHC MCD billed charges,$4.85 ,$28.80 ,$28.80 
Outpatient Medical Services,Lab,83883,NEPHELOMETRY,301,$211.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$168.80 ,paid @80% Aetna Medical Rental Network rate,$78.64 ,paid @32.27% of BCBS HMO rates,$78.64 ,paid @32.27% of BCBS PPO rates,$78.64 ,paid @32.27% of BCBS rates,$10.20 ,pays @100% MCR OPPS,$10.20 ,pays at 100% MCR OPPS,$13.60 ,pays @100 MCR OPPS,$13.60 ,pays at 100% MCR OPPS,$13.60 ,pays at 100% MCR OPPS,$13.60 ,pays at 100% MCR OPPS,$13.60 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$84.40 ,pays @40% of UHC MCD billed charges,$10.20 ,$168.80 ,$168.80 
Outpatient Medical Services,Lab,83915,NUCLEOTIDASE,301,$80.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$64.00 ,paid @80% Aetna Medical Rental Network rate,$29.82 ,paid @32.27% of BCBS HMO rates,$29.82 ,paid @32.27% of BCBS PPO rates,$29.82 ,paid @32.27% of BCBS rates,$8.36 ,pays @100% MCR OPPS,$8.36 ,pays at 100% MCR OPPS,$11.15 ,pays @100 MCR OPPS,$11.15 ,pays at 100% MCR OPPS,$11.15 ,pays at 100% MCR OPPS,$11.15 ,pays at 100% MCR OPPS,$11.15 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$32.00 ,pays @40% of UHC MCD billed charges,$8.36 ,$64.00 ,$64.00 
Outpatient Medical Services,Lab,87529,NUSWAB FOR HSV 1 & 2,301,$445.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$356.00 ,paid @80% Aetna Medical Rental Network rate,$165.85 ,paid @32.27% of BCBS HMO rates,$165.85 ,paid @32.27% of BCBS PPO rates,$165.85 ,paid @32.27% of BCBS rates,$26.31 ,pays @100% MCR OPPS,$26.31 ,pays at 100% MCR OPPS,$35.09 ,pays @100 MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$178.00 ,pays @40% of UHC MCD billed charges,$26.31 ,$356.00 ,$356.00 
Outpatient Medical Services,Lab,80081,"Blood test panel for obstetrics (cbc, differential wbc count, hepatitis b, hiv, rubella, syphilis, antibody screening, rbc, blood typing)",300,$356.90 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$285.52 ,paid @80% Aetna Medical Rental Network rate,$133.02 ,paid @32.27% of BCBS HMO rates,$133.02 ,paid @32.27% of BCBS PPO rates,$133.02 ,paid @32.27% of BCBS rates,$56.14 ,pays @100% MCR OPPS,$56.14 ,pays at 100% MCR OPPS,$74.86 ,pays @100 MCR OPPS,$74.86 ,pays at 100% MCR OPPS,$74.86 ,pays at 100% MCR OPPS,$74.86 ,pays at 100% MCR OPPS,$74.86 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$142.76 ,pays @40% of UHC MCD billed charges,$56.14 ,$285.52 ,$285.52 
Outpatient Medical Services,Lab,83916,OLIGOCLONAL SER& CSF,301,$116.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$92.80 ,paid @80% Aetna Medical Rental Network rate,$43.23 ,paid @32.27% of BCBS HMO rates,$43.23 ,paid @32.27% of BCBS PPO rates,$43.23 ,paid @32.27% of BCBS rates,$20.54 ,pays @100% MCR OPPS,$20.54 ,pays at 100% MCR OPPS,$27.39 ,pays @100 MCR OPPS,$27.39 ,pays at 100% MCR OPPS,$27.39 ,pays at 100% MCR OPPS,$27.39 ,pays at 100% MCR OPPS,$27.39 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$46.40 ,pays @40% of UHC MCD billed charges,$20.54 ,$92.80 ,$92.80 
Outpatient Medical Services,Lab,83918,ORGANIC ACID QUAL UR,301,$109.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$87.20 ,paid @80% Aetna Medical Rental Network rate,$40.62 ,paid @32.27% of BCBS HMO rates,$40.62 ,paid @32.27% of BCBS PPO rates,$40.62 ,paid @32.27% of BCBS rates,$17.70 ,pays @100% MCR OPPS,$17.70 ,pays at 100% MCR OPPS,$23.60 ,pays @100 MCR OPPS,$23.60 ,pays at 100% MCR OPPS,$23.60 ,pays at 100% MCR OPPS,$23.60 ,pays at 100% MCR OPPS,$23.60 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$43.60 ,pays @40% of UHC MCD billed charges,$17.70 ,$87.20 ,$87.20 
Outpatient Medical Services,Lab,83935,OSMOLALITY,301,$46.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.80 ,paid @80% Aetna Medical Rental Network rate,$17.14 ,paid @32.27% of BCBS HMO rates,$17.14 ,paid @32.27% of BCBS PPO rates,$17.14 ,paid @32.27% of BCBS rates,$5.11 ,pays @100% MCR OPPS,$5.11 ,pays at 100% MCR OPPS,$6.82 ,pays @100 MCR OPPS,$6.82 ,pays at 100% MCR OPPS,$6.82 ,pays at 100% MCR OPPS,$6.82 ,pays at 100% MCR OPPS,$6.82 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$18.40 ,pays @40% of UHC MCD billed charges,$5.11 ,$36.80 ,$36.80 
Outpatient Medical Services,Lab,83930,OSMOLALITY SERUM,301,$39.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$31.20 ,paid @80% Aetna Medical Rental Network rate,$14.54 ,paid @32.27% of BCBS HMO rates,$14.54 ,paid @32.27% of BCBS PPO rates,$14.54 ,paid @32.27% of BCBS rates,$4.95 ,pays @100% MCR OPPS,$4.95 ,pays at 100% MCR OPPS,$6.61 ,pays @100 MCR OPPS,$6.61 ,pays at 100% MCR OPPS,$6.61 ,pays at 100% MCR OPPS,$6.61 ,pays at 100% MCR OPPS,$6.61 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$15.60 ,pays @40% of UHC MCD billed charges,$4.95 ,$31.20 ,$31.20 
Outpatient Medical Services,Lab,83945,OXALATE AS OXALIC AC,301,$108.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$86.40 ,paid @80% Aetna Medical Rental Network rate,$40.25 ,paid @32.27% of BCBS HMO rates,$40.25 ,paid @32.27% of BCBS PPO rates,$40.25 ,paid @32.27% of BCBS rates,$10.83 ,pays @100% MCR OPPS,$10.83 ,pays at 100% MCR OPPS,$14.45 ,pays @100 MCR OPPS,$14.45 ,pays at 100% MCR OPPS,$14.45 ,pays at 100% MCR OPPS,$14.45 ,pays at 100% MCR OPPS,$14.45 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$43.20 ,pays @40% of UHC MCD billed charges,$10.83 ,$86.40 ,$86.40 
Outpatient Medical Services,Lab,83970,PARATHYROID HORMONE-,301,$231.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$184.80 ,paid @80% Aetna Medical Rental Network rate,$86.09 ,paid @32.27% of BCBS HMO rates,$86.09 ,paid @32.27% of BCBS PPO rates,$86.09 ,paid @32.27% of BCBS rates,$30.96 ,pays @100% MCR OPPS,$30.96 ,pays at 100% MCR OPPS,$41.28 ,pays @100 MCR OPPS,$41.28 ,pays at 100% MCR OPPS,$41.28 ,pays at 100% MCR OPPS,$41.28 ,pays at 100% MCR OPPS,$41.28 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$92.40 ,pays @40% of UHC MCD billed charges,$30.96 ,$184.80 ,$184.80 
Outpatient Medical Services,Lab,83992,PCP CONFIRMATION UA,301,$50.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$40.00 ,paid @80% Aetna Medical Rental Network rate,$18.64 ,paid @32.27% of BCBS HMO rates,$18.64 ,paid @32.27% of BCBS PPO rates,$18.64 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$20.00 ,pays @40% of UHC MCD billed charges,$18.64 ,$40.00 ,$40.00 
Outpatient Medical Services,Lab,86800,PEDI MICROSOMAL,301,$75.95 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$60.76 ,paid @80% Aetna Medical Rental Network rate,$28.31 ,paid @32.27% of BCBS HMO rates,$28.31 ,paid @32.27% of BCBS PPO rates,$28.31 ,paid @32.27% of BCBS rates,$11.93 ,pays @100% MCR OPPS,$11.93 ,pays at 100% MCR OPPS,$15.91 ,pays @100 MCR OPPS,$15.91 ,pays at 100% MCR OPPS,$15.91 ,pays at 100% MCR OPPS,$15.91 ,pays at 100% MCR OPPS,$15.91 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$30.38 ,pays @40% of UHC MCD billed charges,$11.93 ,$60.76 ,$60.76 
Outpatient Medical Services,Lab,86376,PEDI THYROGLOBULIN,301,$69.48 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$55.58 ,paid @80% Aetna Medical Rental Network rate,$25.90 ,paid @32.27% of BCBS HMO rates,$25.90 ,paid @32.27% of BCBS PPO rates,$25.90 ,paid @32.27% of BCBS rates,$10.91 ,pays @100% MCR OPPS,$10.91 ,pays at 100% MCR OPPS,$14.55 ,pays @100 MCR OPPS,$14.55 ,pays at 100% MCR OPPS,$14.55 ,pays at 100% MCR OPPS,$14.55 ,pays at 100% MCR OPPS,$14.55 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$27.79 ,pays @40% of UHC MCD billed charges,$10.91 ,$55.58 ,$55.58 
Outpatient Medical Services,Lab,84105,PHOSPHORUS URINE,301,$28.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.40 ,paid @80% Aetna Medical Rental Network rate,$10.44 ,paid @32.27% of BCBS HMO rates,$10.44 ,paid @32.27% of BCBS PPO rates,$10.44 ,paid @32.27% of BCBS rates,$4.33 ,pays @100% MCR OPPS,$4.33 ,pays at 100% MCR OPPS,$5.78 ,pays @100 MCR OPPS,$5.78 ,pays at 100% MCR OPPS,$5.78 ,pays at 100% MCR OPPS,$5.78 ,pays at 100% MCR OPPS,$5.78 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$11.20 ,pays @40% of UHC MCD billed charges,$4.33 ,$22.40 ,$22.40 
Outpatient Medical Services,Lab,84100,"PHOSPHORUS, SERUM",301,$27.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$21.60 ,paid @80% Aetna Medical Rental Network rate,$10.06 ,paid @32.27% of BCBS HMO rates,$10.06 ,paid @32.27% of BCBS PPO rates,$10.06 ,paid @32.27% of BCBS rates,$3.55 ,pays @100% MCR OPPS,$3.55 ,pays at 100% MCR OPPS,$4.74 ,pays @100 MCR OPPS,$4.74 ,pays at 100% MCR OPPS,$4.74 ,pays at 100% MCR OPPS,$4.74 ,pays at 100% MCR OPPS,$4.74 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.80 ,pays @40% of UHC MCD billed charges,$3.55 ,$21.60 ,$21.60 
Outpatient Medical Services,Lab,84030,"PKU, PHENYLALANINE B",301,$31.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.80 ,paid @80% Aetna Medical Rental Network rate,$11.55 ,paid @32.27% of BCBS HMO rates,$11.55 ,paid @32.27% of BCBS PPO rates,$11.55 ,paid @32.27% of BCBS rates,$4.12 ,pays @100% MCR OPPS,$4.12 ,pays at 100% MCR OPPS,$5.50 ,pays @100 MCR OPPS,$5.50 ,pays at 100% MCR OPPS,$5.50 ,pays at 100% MCR OPPS,$5.50 ,pays at 100% MCR OPPS,$5.50 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$12.40 ,pays @40% of UHC MCD billed charges,$4.12 ,$24.80 ,$24.80 
Outpatient Medical Services,Lab,85420,PLASMINOGEN,305,$133.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$106.40 ,paid @80% Aetna Medical Rental Network rate,$49.57 ,paid @32.27% of BCBS HMO rates,$49.57 ,paid @32.27% of BCBS PPO rates,$49.57 ,paid @32.27% of BCBS rates,$4.89 ,pays @100% MCR OPPS,$4.89 ,pays at 100% MCR OPPS,$6.53 ,pays @100 MCR OPPS,$6.53 ,pays at 100% MCR OPPS,$6.53 ,pays at 100% MCR OPPS,$6.53 ,pays at 100% MCR OPPS,$6.53 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$53.20 ,pays @40% of UHC MCD billed charges,$4.89 ,$106.40 ,$106.40 
Outpatient Medical Services,Lab,87798,PLASMODIUM SPECIES P,301,$186.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$148.80 ,paid @80% Aetna Medical Rental Network rate,$69.32 ,paid @32.27% of BCBS HMO rates,$69.32 ,paid @32.27% of BCBS PPO rates,$69.32 ,paid @32.27% of BCBS rates,$26.31 ,pays @100% MCR OPPS,$26.31 ,pays at 100% MCR OPPS,$35.09 ,pays @100 MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,$35.09 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$74.40 ,pays @40% of UHC MCD billed charges,$26.31 ,$148.80 ,$148.80 
Outpatient Medical Services,Lab,85415,PLATELET ACTIVATOR H,305,$328.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$262.40 ,paid @80% Aetna Medical Rental Network rate,$122.25 ,paid @32.27% of BCBS HMO rates,$122.25 ,paid @32.27% of BCBS PPO rates,$122.25 ,paid @32.27% of BCBS rates,$12.89 ,pays @100% MCR OPPS,$12.89 ,pays at 100% MCR OPPS,$17.19 ,pays @100 MCR OPPS,$17.19 ,pays at 100% MCR OPPS,$17.19 ,pays at 100% MCR OPPS,$17.19 ,pays at 100% MCR OPPS,$17.19 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$131.20 ,pays @40% of UHC MCD billed charges,$12.89 ,$262.40 ,$262.40 
Outpatient Medical Services,Lab,85576,PLATELET FUNCT ASSAY,301,$181.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$144.80 ,paid @80% Aetna Medical Rental Network rate,$67.46 ,paid @32.27% of BCBS HMO rates,$67.46 ,paid @32.27% of BCBS PPO rates,$67.46 ,paid @32.27% of BCBS rates,$18.68 ,pays @100% MCR OPPS,$18.68 ,pays at 100% MCR OPPS,$24.91 ,pays @100 MCR OPPS,$24.91 ,pays at 100% MCR OPPS,$24.91 ,pays at 100% MCR OPPS,$24.91 ,pays at 100% MCR OPPS,$24.91 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.40 ,pays @40% of UHC MCD billed charges,$18.68 ,$144.80 ,$144.80 
Outpatient Medical Services,Lab,84110,PORPHOBILINOGEN,301,$55.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.00 ,paid @80% Aetna Medical Rental Network rate,$20.50 ,paid @32.27% of BCBS HMO rates,$20.50 ,paid @32.27% of BCBS PPO rates,$20.50 ,paid @32.27% of BCBS rates,$6.33 ,pays @100% MCR OPPS,$6.33 ,pays at 100% MCR OPPS,$8.44 ,pays @100 MCR OPPS,$8.44 ,pays at 100% MCR OPPS,$8.44 ,pays at 100% MCR OPPS,$8.44 ,pays at 100% MCR OPPS,$8.44 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.00 ,pays @40% of UHC MCD billed charges,$6.33 ,$44.00 ,$44.00 
Outpatient Medical Services,Lab,84119,PORPHYRIN SCREEN URI,301,$120.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$96.00 ,paid @80% Aetna Medical Rental Network rate,$44.72 ,paid @32.27% of BCBS HMO rates,$44.72 ,paid @32.27% of BCBS PPO rates,$44.72 ,paid @32.27% of BCBS rates,$10.02 ,pays @100% MCR OPPS,$10.02 ,pays at 100% MCR OPPS,$13.36 ,pays @100 MCR OPPS,$13.36 ,pays at 100% MCR OPPS,$13.36 ,pays at 100% MCR OPPS,$13.36 ,pays at 100% MCR OPPS,$13.36 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$48.00 ,pays @40% of UHC MCD billed charges,$10.02 ,$96.00 ,$96.00 
Outpatient Medical Services,Lab,84120,"PORPHYRINS, FRACT, U",301,$132.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$105.60 ,paid @80% Aetna Medical Rental Network rate,$49.20 ,paid @32.27% of BCBS HMO rates,$49.20 ,paid @32.27% of BCBS PPO rates,$49.20 ,paid @32.27% of BCBS rates,$11.03 ,pays @100% MCR OPPS,$11.03 ,pays at 100% MCR OPPS,$14.71 ,pays @100 MCR OPPS,$14.71 ,pays at 100% MCR OPPS,$14.71 ,pays at 100% MCR OPPS,$14.71 ,pays at 100% MCR OPPS,$14.71 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$52.80 ,pays @40% of UHC MCD billed charges,$11.03 ,$105.60 ,$105.60 
Outpatient Medical Services,Lab,84132,"POTASSIUM, SERUM",301,$25.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$20.00 ,paid @80% Aetna Medical Rental Network rate,$9.32 ,paid @32.27% of BCBS HMO rates,$9.32 ,paid @32.27% of BCBS PPO rates,$9.32 ,paid @32.27% of BCBS rates,$3.57 ,pays @100% MCR OPPS,$3.57 ,pays at 100% MCR OPPS,$4.76 ,pays @100 MCR OPPS,$4.76 ,pays at 100% MCR OPPS,$4.76 ,pays at 100% MCR OPPS,$4.76 ,pays at 100% MCR OPPS,$4.76 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.00 ,pays @40% of UHC MCD billed charges,$3.57 ,$20.00 ,$20.00 
Outpatient Medical Services,Lab,84133,"POTASSIUM, URINE",301,$24.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$19.20 ,paid @80% Aetna Medical Rental Network rate,$8.94 ,paid @32.27% of BCBS HMO rates,$8.94 ,paid @32.27% of BCBS PPO rates,$8.94 ,paid @32.27% of BCBS rates,$3.54 ,pays @100% MCR OPPS,$3.54 ,pays at 100% MCR OPPS,$4.73 ,pays @100 MCR OPPS,$4.73 ,pays at 100% MCR OPPS,$4.73 ,pays at 100% MCR OPPS,$4.73 ,pays at 100% MCR OPPS,$4.73 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$9.60 ,pays @40% of UHC MCD billed charges,$3.54 ,$19.20 ,$19.20 
Outpatient Medical Services,Lab,84134,Blood test to measure level of prealbumin,301,$62.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$49.60 ,paid @80% Aetna Medical Rental Network rate,$23.11 ,paid @32.27% of BCBS HMO rates,$23.11 ,paid @32.27% of BCBS PPO rates,$23.11 ,paid @32.27% of BCBS rates,$10.94 ,pays @100% MCR OPPS,$10.94 ,pays at 100% MCR OPPS,$14.59 ,pays @100 MCR OPPS,$14.59 ,pays at 100% MCR OPPS,$14.59 ,pays at 100% MCR OPPS,$14.59 ,pays at 100% MCR OPPS,$14.59 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.80 ,pays @40% of UHC MCD billed charges,$10.94 ,$49.60 ,$49.60 
Outpatient Medical Services,Lab,84140,PREGNENOLONE,301,$141.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$112.80 ,paid @80% Aetna Medical Rental Network rate,$52.55 ,paid @32.27% of BCBS HMO rates,$52.55 ,paid @32.27% of BCBS PPO rates,$52.55 ,paid @32.27% of BCBS rates,$15.50 ,pays @100% MCR OPPS,$15.50 ,pays at 100% MCR OPPS,$20.67 ,pays @100 MCR OPPS,$20.67 ,pays at 100% MCR OPPS,$20.67 ,pays at 100% MCR OPPS,$20.67 ,pays at 100% MCR OPPS,$20.67 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$56.40 ,pays @40% of UHC MCD billed charges,$15.50 ,$112.80 ,$112.80 
Outpatient Medical Services,Lab,84206,PRO INSULIN LEVEL,301,$84.91 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$67.93 ,paid @80% Aetna Medical Rental Network rate,$31.65 ,paid @32.27% of BCBS HMO rates,$31.65 ,paid @32.27% of BCBS PPO rates,$31.65 ,paid @32.27% of BCBS rates,$20.01 ,pays @100% MCR OPPS,$20.01 ,pays at 100% MCR OPPS,$26.69 ,pays @100 MCR OPPS,$26.69 ,pays at 100% MCR OPPS,$26.69 ,pays at 100% MCR OPPS,$26.69 ,pays at 100% MCR OPPS,$26.69 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$33.96 ,pays @40% of UHC MCD billed charges,$20.01 ,$67.93 ,$67.93 
Outpatient Medical Services,Lab,84145,PROCALCITONIN,301,$110.25 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$88.20 ,paid @80% Aetna Medical Rental Network rate,$41.09 ,paid @32.27% of BCBS HMO rates,$41.09 ,paid @32.27% of BCBS PPO rates,$41.09 ,paid @32.27% of BCBS rates,$20.41 ,pays @100% MCR OPPS,$20.41 ,pays at 100% MCR OPPS,$27.22 ,pays @100 MCR OPPS,$27.22 ,pays at 100% MCR OPPS,$27.22 ,pays at 100% MCR OPPS,$27.22 ,pays at 100% MCR OPPS,$27.22 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.10 ,pays @40% of UHC MCD billed charges,$20.41 ,$88.20 ,$88.20 
Outpatient Medical Services,Lab,84144,PROGESTERONE,301,$118.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$94.40 ,paid @80% Aetna Medical Rental Network rate,$43.98 ,paid @32.27% of BCBS HMO rates,$43.98 ,paid @32.27% of BCBS PPO rates,$43.98 ,paid @32.27% of BCBS rates,$15.64 ,pays @100% MCR OPPS,$15.64 ,pays at 100% MCR OPPS,$20.86 ,pays @100 MCR OPPS,$20.86 ,pays at 100% MCR OPPS,$20.86 ,pays at 100% MCR OPPS,$20.86 ,pays at 100% MCR OPPS,$20.86 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$47.20 ,pays @40% of UHC MCD billed charges,$15.64 ,$94.40 ,$94.40 
Outpatient Medical Services,Lab,84146,PROLACTIN SERUM,301,$109.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$87.20 ,paid @80% Aetna Medical Rental Network rate,$40.62 ,paid @32.27% of BCBS HMO rates,$40.62 ,paid @32.27% of BCBS PPO rates,$40.62 ,paid @32.27% of BCBS rates,$14.53 ,pays @100% MCR OPPS,$14.53 ,pays at 100% MCR OPPS,$19.38 ,pays @100 MCR OPPS,$19.38 ,pays at 100% MCR OPPS,$19.38 ,pays at 100% MCR OPPS,$19.38 ,pays at 100% MCR OPPS,$19.38 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$43.60 ,pays @40% of UHC MCD billed charges,$14.53 ,$87.20 ,$87.20 
Outpatient Medical Services,Lab,84066,PROSTATIC ACID PHOS,301,$56.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.80 ,paid @80% Aetna Medical Rental Network rate,$20.87 ,paid @32.27% of BCBS HMO rates,$20.87 ,paid @32.27% of BCBS PPO rates,$20.87 ,paid @32.27% of BCBS rates,$7.24 ,pays @100% MCR OPPS,$7.24 ,pays at 100% MCR OPPS,$9.66 ,pays @100 MCR OPPS,$9.66 ,pays at 100% MCR OPPS,$9.66 ,pays at 100% MCR OPPS,$9.66 ,pays at 100% MCR OPPS,$9.66 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.40 ,pays @40% of UHC MCD billed charges,$7.24 ,$44.80 ,$44.80 
Outpatient Medical Services,Lab,G0103,Prostate cancer screening; prostate specific antigen test (psa),300,$102.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$81.60 ,paid @80% Aetna Medical Rental Network rate,$38.02 ,paid @32.27% of BCBS HMO rates,$38.02 ,paid @32.27% of BCBS PPO rates,$38.02 ,paid @32.27% of BCBS rates,$14.48 ,pays @100% MCR OPPS,$14.48 ,pays at 100% MCR OPPS,$19.30 ,pays @100 MCR OPPS,$19.30 ,pays at 100% MCR OPPS,$19.30 ,pays at 100% MCR OPPS,$19.30 ,pays at 100% MCR OPPS,$19.30 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$40.80 ,pays @40% of UHC MCD billed charges,$14.48 ,$81.60 ,$81.60 
Outpatient Medical Services,Lab,85303,PROTEIN C ACTIVITYY,305,$196.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$156.80 ,paid @80% Aetna Medical Rental Network rate,$73.05 ,paid @32.27% of BCBS HMO rates,$73.05 ,paid @32.27% of BCBS PPO rates,$73.05 ,paid @32.27% of BCBS rates,$10.38 ,pays @100% MCR OPPS,$10.38 ,pays at 100% MCR OPPS,$13.84 ,pays @100 MCR OPPS,$13.84 ,pays at 100% MCR OPPS,$13.84 ,pays at 100% MCR OPPS,$13.84 ,pays at 100% MCR OPPS,$13.84 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$78.40 ,pays @40% of UHC MCD billed charges,$10.38 ,$156.80 ,$156.80 
Outpatient Medical Services,Lab,85302,PROTEIN C ANTIGEN,305,$218.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$174.40 ,paid @80% Aetna Medical Rental Network rate,$81.25 ,paid @32.27% of BCBS HMO rates,$81.25 ,paid @32.27% of BCBS PPO rates,$81.25 ,paid @32.27% of BCBS rates,$9.00 ,pays @100% MCR OPPS,$9.00 ,pays at 100% MCR OPPS,$12.01 ,pays @100 MCR OPPS,$12.01 ,pays at 100% MCR OPPS,$12.01 ,pays at 100% MCR OPPS,$12.01 ,pays at 100% MCR OPPS,$12.01 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$87.20 ,pays @40% of UHC MCD billed charges,$9.00 ,$174.40 ,$174.40 
Outpatient Medical Services,Lab,85307,PROTEIN C RESISTANCE,305,$172.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$137.60 ,paid @80% Aetna Medical Rental Network rate,$64.10 ,paid @32.27% of BCBS HMO rates,$64.10 ,paid @32.27% of BCBS PPO rates,$64.10 ,paid @32.27% of BCBS rates,$11.49 ,pays @100% MCR OPPS,$11.49 ,pays at 100% MCR OPPS,$15.32 ,pays @100 MCR OPPS,$15.32 ,pays at 100% MCR OPPS,$15.32 ,pays at 100% MCR OPPS,$15.32 ,pays at 100% MCR OPPS,$15.32 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$68.80 ,pays @40% of UHC MCD billed charges,$11.49 ,$137.60 ,$137.60 
Outpatient Medical Services,Lab,84165,PROTEIN ELECTROPH S,301,$60.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$48.00 ,paid @80% Aetna Medical Rental Network rate,$22.36 ,paid @32.27% of BCBS HMO rates,$22.36 ,paid @32.27% of BCBS PPO rates,$22.36 ,paid @32.27% of BCBS rates,$8.05 ,pays @100% MCR OPPS,$8.05 ,pays at 100% MCR OPPS,$10.74 ,pays @100 MCR OPPS,$10.74 ,pays at 100% MCR OPPS,$10.74 ,pays at 100% MCR OPPS,$10.74 ,pays at 100% MCR OPPS,$10.74 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.00 ,pays @40% of UHC MCD billed charges,$8.05 ,$48.00 ,$48.00 
Outpatient Medical Services,Lab,84166,PROTEIN ELECTROPH UR,301,$90.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.00 ,paid @80% Aetna Medical Rental Network rate,$33.54 ,paid @32.27% of BCBS HMO rates,$33.54 ,paid @32.27% of BCBS PPO rates,$33.54 ,paid @32.27% of BCBS rates,$13.37 ,pays @100% MCR OPPS,$13.37 ,pays at 100% MCR OPPS,$17.82 ,pays @100 MCR OPPS,$17.82 ,pays at 100% MCR OPPS,$17.82 ,pays at 100% MCR OPPS,$17.82 ,pays at 100% MCR OPPS,$17.82 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.00 ,pays @40% of UHC MCD billed charges,$13.37 ,$72.00 ,$72.00 
Outpatient Medical Services,Lab,84157,PROTEIN FLUID,301,$27.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$21.60 ,paid @80% Aetna Medical Rental Network rate,$10.06 ,paid @32.27% of BCBS HMO rates,$10.06 ,paid @32.27% of BCBS PPO rates,$10.06 ,paid @32.27% of BCBS rates,$3.00 ,pays @100% MCR OPPS,$3.00 ,pays at 100% MCR OPPS,$4.00 ,pays @100 MCR OPPS,$4.00 ,pays at 100% MCR OPPS,$4.00 ,pays at 100% MCR OPPS,$4.00 ,pays at 100% MCR OPPS,$4.00 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.80 ,pays @40% of UHC MCD billed charges,$3.00 ,$21.60 ,$21.60 
Outpatient Medical Services,Lab,85306,PROTEIN S ACTIVITY,305,$203.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$162.40 ,paid @80% Aetna Medical Rental Network rate,$75.66 ,paid @32.27% of BCBS HMO rates,$75.66 ,paid @32.27% of BCBS PPO rates,$75.66 ,paid @32.27% of BCBS rates,$11.49 ,pays @100% MCR OPPS,$11.49 ,pays at 100% MCR OPPS,$15.32 ,pays @100 MCR OPPS,$15.32 ,pays at 100% MCR OPPS,$15.32 ,pays at 100% MCR OPPS,$15.32 ,pays at 100% MCR OPPS,$15.32 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$81.20 ,pays @40% of UHC MCD billed charges,$11.49 ,$162.40 ,$162.40 
Outpatient Medical Services,Lab,85305,PROTEIN S ANTIGEN,305,$259.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$207.20 ,paid @80% Aetna Medical Rental Network rate,$96.53 ,paid @32.27% of BCBS HMO rates,$96.53 ,paid @32.27% of BCBS PPO rates,$96.53 ,paid @32.27% of BCBS rates,$8.70 ,pays @100% MCR OPPS,$8.70 ,pays at 100% MCR OPPS,$11.61 ,pays @100 MCR OPPS,$11.61 ,pays at 100% MCR OPPS,$11.61 ,pays at 100% MCR OPPS,$11.61 ,pays at 100% MCR OPPS,$11.61 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$103.60 ,pays @40% of UHC MCD billed charges,$8.70 ,$207.20 ,$207.20 
Outpatient Medical Services,Lab,84156,PROTEIN TOTAL 24 URI,301,$27.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$21.60 ,paid @80% Aetna Medical Rental Network rate,$10.06 ,paid @32.27% of BCBS HMO rates,$10.06 ,paid @32.27% of BCBS PPO rates,$10.06 ,paid @32.27% of BCBS rates,$2.75 ,pays @100% MCR OPPS,$2.75 ,pays at 100% MCR OPPS,$3.67 ,pays @100 MCR OPPS,$3.67 ,pays at 100% MCR OPPS,$3.67 ,pays at 100% MCR OPPS,$3.67 ,pays at 100% MCR OPPS,$3.67 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.80 ,pays @40% of UHC MCD billed charges,$2.75 ,$21.60 ,$21.60 
Outpatient Medical Services,Lab,85610,"Blood test, clotting time",305,$21.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.80 ,paid @80% Aetna Medical Rental Network rate,$7.83 ,paid @32.27% of BCBS HMO rates,$7.83 ,paid @32.27% of BCBS PPO rates,$7.83 ,paid @32.27% of BCBS rates,$3.21 ,pays @100% MCR OPPS,$3.21 ,pays at 100% MCR OPPS,$4.29 ,pays @100 MCR OPPS,$4.29 ,pays at 100% MCR OPPS,$4.29 ,pays at 100% MCR OPPS,$4.29 ,pays at 100% MCR OPPS,$4.29 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.40 ,pays @40% of UHC MCD billed charges,$3.21 ,$16.80 ,$16.80 
Outpatient Medical Services,Lab,84152,PSA COMPLEXED,301,$134.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$107.20 ,paid @80% Aetna Medical Rental Network rate,$49.94 ,paid @32.27% of BCBS HMO rates,$49.94 ,paid @32.27% of BCBS PPO rates,$49.94 ,paid @32.27% of BCBS rates,$13.79 ,pays @100% MCR OPPS,$13.79 ,pays at 100% MCR OPPS,$18.39 ,pays @100 MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$53.60 ,pays @40% of UHC MCD billed charges,$13.79 ,$107.20 ,$107.20 
Outpatient Medical Services,Lab,84153,PSA (prostate specific antigen),301,$155.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$124.00 ,paid @80% Aetna Medical Rental Network rate,$57.77 ,paid @32.27% of BCBS HMO rates,$57.77 ,paid @32.27% of BCBS PPO rates,$57.77 ,paid @32.27% of BCBS rates,$13.79 ,pays @100% MCR OPPS,$13.79 ,pays at 100% MCR OPPS,$18.39 ,pays @100 MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$62.00 ,pays @40% of UHC MCD billed charges,$13.79 ,$124.00 ,$124.00 
Outpatient Medical Services,Lab,84154,PSA (prostate specific antigen) measurement,301,$181.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$144.80 ,paid @80% Aetna Medical Rental Network rate,$67.46 ,paid @32.27% of BCBS HMO rates,$67.46 ,paid @32.27% of BCBS PPO rates,$67.46 ,paid @32.27% of BCBS rates,$13.79 ,pays @100% MCR OPPS,$13.79 ,pays at 100% MCR OPPS,$18.39 ,pays @100 MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,$18.39 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.40 ,pays @40% of UHC MCD billed charges,$13.79 ,$144.80 ,$144.80 
Outpatient Medical Services,Lab,85730,Coagulation assessment blood test,305,$34.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$27.20 ,paid @80% Aetna Medical Rental Network rate,$12.67 ,paid @32.27% of BCBS HMO rates,$12.67 ,paid @32.27% of BCBS PPO rates,$12.67 ,paid @32.27% of BCBS rates,$4.50 ,pays @100% MCR OPPS,$4.50 ,pays at 100% MCR OPPS,$6.01 ,pays @100 MCR OPPS,$6.01 ,pays at 100% MCR OPPS,$6.01 ,pays at 100% MCR OPPS,$6.01 ,pays at 100% MCR OPPS,$6.01 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$13.60 ,pays @40% of UHC MCD billed charges,$4.50 ,$27.20 ,$27.20 
Outpatient Medical Services,Lab,84244,RENIN ACTIVITY,301,$181.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$144.80 ,paid @80% Aetna Medical Rental Network rate,$67.46 ,paid @32.27% of BCBS HMO rates,$67.46 ,paid @32.27% of BCBS PPO rates,$67.46 ,paid @32.27% of BCBS rates,$16.49 ,pays @100% MCR OPPS,$16.49 ,pays at 100% MCR OPPS,$21.99 ,pays @100 MCR OPPS,$21.99 ,pays at 100% MCR OPPS,$21.99 ,pays at 100% MCR OPPS,$21.99 ,pays at 100% MCR OPPS,$21.99 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.40 ,pays @40% of UHC MCD billed charges,$16.49 ,$144.80 ,$144.80 
Outpatient Medical Services,Lab,85635,REPTILASE,305,$252.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$201.60 ,paid @80% Aetna Medical Rental Network rate,$93.92 ,paid @32.27% of BCBS HMO rates,$93.92 ,paid @32.27% of BCBS PPO rates,$93.92 ,paid @32.27% of BCBS rates,$7.38 ,pays @100% MCR OPPS,$7.38 ,pays at 100% MCR OPPS,$9.85 ,pays @100 MCR OPPS,$9.85 ,pays at 100% MCR OPPS,$9.85 ,pays at 100% MCR OPPS,$9.85 ,pays at 100% MCR OPPS,$9.85 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$100.80 ,pays @40% of UHC MCD billed charges,$7.38 ,$201.60 ,$201.60 
Outpatient Medical Services,Lab,86431,RHEUMATOID FACTOR QU,301,$27.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$21.60 ,paid @80% Aetna Medical Rental Network rate,$10.06 ,paid @32.27% of BCBS HMO rates,$10.06 ,paid @32.27% of BCBS PPO rates,$10.06 ,paid @32.27% of BCBS rates,$4.25 ,pays @100% MCR OPPS,$4.25 ,pays at 100% MCR OPPS,$5.67 ,pays @100 MCR OPPS,$5.67 ,pays at 100% MCR OPPS,$5.67 ,pays at 100% MCR OPPS,$5.67 ,pays at 100% MCR OPPS,$5.67 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.80 ,pays @40% of UHC MCD billed charges,$4.25 ,$21.60 ,$21.60 
Outpatient Medical Services,Lab,85651,SEDIMENTATION RATE,305,$20.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.00 ,paid @80% Aetna Medical Rental Network rate,$7.45 ,paid @32.27% of BCBS HMO rates,$7.45 ,paid @32.27% of BCBS PPO rates,$7.45 ,paid @32.27% of BCBS rates,$3.20 ,pays @100% MCR OPPS,$3.20 ,pays at 100% MCR OPPS,$4.26 ,pays @100 MCR OPPS,$4.26 ,pays at 100% MCR OPPS,$4.26 ,pays at 100% MCR OPPS,$4.26 ,pays at 100% MCR OPPS,$4.26 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.00 ,pays @40% of UHC MCD billed charges,$3.20 ,$16.00 ,$16.00 
Outpatient Medical Services,Lab,84260,"SEROTONIN, SERUM",301,$461.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$368.80 ,paid @80% Aetna Medical Rental Network rate,$171.81 ,paid @32.27% of BCBS HMO rates,$171.81 ,paid @32.27% of BCBS PPO rates,$171.81 ,paid @32.27% of BCBS rates,$23.23 ,pays @100% MCR OPPS,$23.23 ,pays at 100% MCR OPPS,$30.98 ,pays @100 MCR OPPS,$30.98 ,pays at 100% MCR OPPS,$30.98 ,pays at 100% MCR OPPS,$30.98 ,pays at 100% MCR OPPS,$30.98 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$184.40 ,pays @40% of UHC MCD billed charges,$23.23 ,$368.80 ,$368.80 
Outpatient Medical Services,Lab,84270,SEX HORMONE BINDING,301,$139.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$111.20 ,paid @80% Aetna Medical Rental Network rate,$51.81 ,paid @32.27% of BCBS HMO rates,$51.81 ,paid @32.27% of BCBS PPO rates,$51.81 ,paid @32.27% of BCBS rates,$16.29 ,pays @100% MCR OPPS,$16.29 ,pays at 100% MCR OPPS,$21.73 ,pays @100 MCR OPPS,$21.73 ,pays at 100% MCR OPPS,$21.73 ,pays at 100% MCR OPPS,$21.73 ,pays at 100% MCR OPPS,$21.73 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$55.60 ,pays @40% of UHC MCD billed charges,$16.29 ,$111.20 ,$111.20 
Outpatient Medical Services,Lab,84450,SGOT,301,$28.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.40 ,paid @80% Aetna Medical Rental Network rate,$10.44 ,paid @32.27% of BCBS HMO rates,$10.44 ,paid @32.27% of BCBS PPO rates,$10.44 ,paid @32.27% of BCBS rates,$3.88 ,pays @100% MCR OPPS,$3.88 ,pays at 100% MCR OPPS,$5.18 ,pays @100 MCR OPPS,$5.18 ,pays at 100% MCR OPPS,$5.18 ,pays at 100% MCR OPPS,$5.18 ,pays at 100% MCR OPPS,$5.18 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$11.20 ,pays @40% of UHC MCD billed charges,$3.88 ,$22.40 ,$22.40 
Outpatient Medical Services,Lab,84460,Blood test to evaluate liver function,301,$29.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$23.20 ,paid @80% Aetna Medical Rental Network rate,$10.81 ,paid @32.27% of BCBS HMO rates,$10.81 ,paid @32.27% of BCBS PPO rates,$10.81 ,paid @32.27% of BCBS rates,$3.97 ,pays @100% MCR OPPS,$3.97 ,pays at 100% MCR OPPS,$5.30 ,pays @100 MCR OPPS,$5.30 ,pays at 100% MCR OPPS,$5.30 ,pays at 100% MCR OPPS,$5.30 ,pays at 100% MCR OPPS,$5.30 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$11.60 ,pays @40% of UHC MCD billed charges,$3.97 ,$23.20 ,$23.20 
Outpatient Medical Services,Lab,85660,SICKLEDEX,305,$31.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.80 ,paid @80% Aetna Medical Rental Network rate,$11.55 ,paid @32.27% of BCBS HMO rates,$11.55 ,paid @32.27% of BCBS PPO rates,$11.55 ,paid @32.27% of BCBS rates,$4.13 ,pays @100% MCR OPPS,$4.13 ,pays at 100% MCR OPPS,$5.51 ,pays @100 MCR OPPS,$5.51 ,pays at 100% MCR OPPS,$5.51 ,pays at 100% MCR OPPS,$5.51 ,pays at 100% MCR OPPS,$5.51 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$12.40 ,pays @40% of UHC MCD billed charges,$4.13 ,$24.80 ,$24.80 
Outpatient Medical Services,Lab,84295,"SODIUM, SERUM",301,$27.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$21.60 ,paid @80% Aetna Medical Rental Network rate,$10.06 ,paid @32.27% of BCBS HMO rates,$10.06 ,paid @32.27% of BCBS PPO rates,$10.06 ,paid @32.27% of BCBS rates,$3.60 ,pays @100% MCR OPPS,$3.60 ,pays at 100% MCR OPPS,$4.80 ,pays @100 MCR OPPS,$4.80 ,pays at 100% MCR OPPS,$4.80 ,pays at 100% MCR OPPS,$4.80 ,pays at 100% MCR OPPS,$4.80 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.80 ,pays @40% of UHC MCD billed charges,$3.60 ,$21.60 ,$21.60 
Outpatient Medical Services,Lab,84300,"SODIUM, URINE",301,$27.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$21.60 ,paid @80% Aetna Medical Rental Network rate,$10.06 ,paid @32.27% of BCBS HMO rates,$10.06 ,paid @32.27% of BCBS PPO rates,$10.06 ,paid @32.27% of BCBS rates,$3.79 ,pays @100% MCR OPPS,$3.79 ,pays at 100% MCR OPPS,$5.05 ,pays @100 MCR OPPS,$5.05 ,pays at 100% MCR OPPS,$5.05 ,pays at 100% MCR OPPS,$5.05 ,pays at 100% MCR OPPS,$5.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.80 ,pays @40% of UHC MCD billed charges,$3.79 ,$21.60 ,$21.60 
Outpatient Medical Services,Lab,84305,SOMATOMEDIN,301,$93.63 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$74.90 ,paid @80% Aetna Medical Rental Network rate,$34.90 ,paid @32.27% of BCBS HMO rates,$34.90 ,paid @32.27% of BCBS PPO rates,$34.90 ,paid @32.27% of BCBS rates,$15.94 ,pays @100% MCR OPPS,$15.94 ,pays at 100% MCR OPPS,$21.26 ,pays @100 MCR OPPS,$21.26 ,pays at 100% MCR OPPS,$21.26 ,pays at 100% MCR OPPS,$21.26 ,pays at 100% MCR OPPS,$21.26 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$37.45 ,pays @40% of UHC MCD billed charges,$15.94 ,$74.90 ,$74.90 
Outpatient Medical Services,Lab,81002,Manual urinalysis test with examination without using microscope,307,$14.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$11.20 ,paid @80% Aetna Medical Rental Network rate,$5.22 ,paid @32.27% of BCBS HMO rates,$5.22 ,paid @32.27% of BCBS PPO rates,$5.22 ,paid @32.27% of BCBS rates,$2.61 ,pays @100% MCR OPPS,$2.61 ,pays at 100% MCR OPPS,$3.48 ,pays @100 MCR OPPS,$3.48 ,pays at 100% MCR OPPS,$3.48 ,pays at 100% MCR OPPS,$3.48 ,pays at 100% MCR OPPS,$3.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$5.60 ,pays @40% of UHC MCD billed charges,$2.61 ,$11.20 ,$11.20 
Outpatient Medical Services,Lab,84315,SPECIFIC GRAVITY FLU,301,$14.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$11.20 ,paid @80% Aetna Medical Rental Network rate,$5.22 ,paid @32.27% of BCBS HMO rates,$5.22 ,paid @32.27% of BCBS PPO rates,$5.22 ,paid @32.27% of BCBS rates,$2.45 ,pays @100% MCR OPPS,$2.45 ,pays at 100% MCR OPPS,$3.28 ,pays @100 MCR OPPS,$3.28 ,pays at 100% MCR OPPS,$3.28 ,pays at 100% MCR OPPS,$3.28 ,pays at 100% MCR OPPS,$3.28 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$5.60 ,pays @40% of UHC MCD billed charges,$2.45 ,$11.20 ,$11.20 
Outpatient Medical Services,Lab,83986,STOOL PH,301,$20.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.00 ,paid @80% Aetna Medical Rental Network rate,$7.45 ,paid @32.27% of BCBS HMO rates,$7.45 ,paid @32.27% of BCBS PPO rates,$7.45 ,paid @32.27% of BCBS rates,$2.68 ,pays @100% MCR OPPS,$2.68 ,pays at 100% MCR OPPS,$3.58 ,pays @100 MCR OPPS,$3.58 ,pays at 100% MCR OPPS,$3.58 ,pays at 100% MCR OPPS,$3.58 ,pays at 100% MCR OPPS,$3.58 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.00 ,pays @40% of UHC MCD billed charges,$2.68 ,$16.00 ,$16.00 
Outpatient Medical Services,Lab,85732,SUBS PLASMA FRACTION,301,$31.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.80 ,paid @80% Aetna Medical Rental Network rate,$11.55 ,paid @32.27% of BCBS HMO rates,$11.55 ,paid @32.27% of BCBS PPO rates,$11.55 ,paid @32.27% of BCBS rates,$4.85 ,pays @100% MCR OPPS,$4.85 ,pays at 100% MCR OPPS,$6.47 ,pays @100 MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,$6.47 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$12.40 ,pays @40% of UHC MCD billed charges,$4.85 ,$24.80 ,$24.80 
Outpatient Medical Services,Lab,85611,SUBST PLASMA FRACTIO,305,$18.50 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$14.80 ,paid @80% Aetna Medical Rental Network rate,$6.89 ,paid @32.27% of BCBS HMO rates,$6.89 ,paid @32.27% of BCBS PPO rates,$6.89 ,paid @32.27% of BCBS rates,$2.95 ,pays @100% MCR OPPS,$2.95 ,pays at 100% MCR OPPS,$3.94 ,pays @100 MCR OPPS,$3.94 ,pays at 100% MCR OPPS,$3.94 ,pays at 100% MCR OPPS,$3.94 ,pays at 100% MCR OPPS,$3.94 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$7.40 ,pays @40% of UHC MCD billed charges,$2.95 ,$14.80 ,$14.80 
Outpatient Medical Services,Lab,86360,T CELL ABS COUNT/RAT,301,$214.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$171.20 ,paid @80% Aetna Medical Rental Network rate,$79.76 ,paid @32.27% of BCBS HMO rates,$79.76 ,paid @32.27% of BCBS PPO rates,$79.76 ,paid @32.27% of BCBS rates,$35.23 ,pays @100% MCR OPPS,$35.23 ,pays at 100% MCR OPPS,$46.98 ,pays @100 MCR OPPS,$46.98 ,pays at 100% MCR OPPS,$46.98 ,pays at 100% MCR OPPS,$46.98 ,pays at 100% MCR OPPS,$46.98 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$85.60 ,pays @40% of UHC MCD billed charges,$35.23 ,$171.20 ,$171.20 
Outpatient Medical Services,Lab,84480,Blood test to evaluate thyroid function,301,$55.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.00 ,paid @80% Aetna Medical Rental Network rate,$20.50 ,paid @32.27% of BCBS HMO rates,$20.50 ,paid @32.27% of BCBS PPO rates,$20.50 ,paid @32.27% of BCBS rates,$10.63 ,pays @100% MCR OPPS,$10.63 ,pays at 100% MCR OPPS,$14.18 ,pays @100 MCR OPPS,$14.18 ,pays at 100% MCR OPPS,$14.18 ,pays at 100% MCR OPPS,$14.18 ,pays at 100% MCR OPPS,$14.18 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.00 ,pays @40% of UHC MCD billed charges,$10.63 ,$44.00 ,$44.00 
Outpatient Medical Services,Lab,84481,T3 FREE,301,$133.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$106.40 ,paid @80% Aetna Medical Rental Network rate,$49.57 ,paid @32.27% of BCBS HMO rates,$49.57 ,paid @32.27% of BCBS PPO rates,$49.57 ,paid @32.27% of BCBS rates,$12.70 ,pays @100% MCR OPPS,$12.70 ,pays at 100% MCR OPPS,$16.94 ,pays @100 MCR OPPS,$16.94 ,pays at 100% MCR OPPS,$16.94 ,pays at 100% MCR OPPS,$16.94 ,pays at 100% MCR OPPS,$16.94 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$53.20 ,pays @40% of UHC MCD billed charges,$12.70 ,$106.40 ,$106.40 
Outpatient Medical Services,Lab,84482,T3 REVERSE,301,$53.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$42.40 ,paid @80% Aetna Medical Rental Network rate,$19.75 ,paid @32.27% of BCBS HMO rates,$19.75 ,paid @32.27% of BCBS PPO rates,$19.75 ,paid @32.27% of BCBS rates,$11.82 ,pays @100% MCR OPPS,$11.82 ,pays at 100% MCR OPPS,$15.76 ,pays @100 MCR OPPS,$15.76 ,pays at 100% MCR OPPS,$15.76 ,pays at 100% MCR OPPS,$15.76 ,pays at 100% MCR OPPS,$15.76 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$21.20 ,pays @40% of UHC MCD billed charges,$11.82 ,$42.40 ,$42.40 
Outpatient Medical Services,Lab,84436,Blood test to measure a type of thyroid hormone,301,$55.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.00 ,paid @80% Aetna Medical Rental Network rate,$20.50 ,paid @32.27% of BCBS HMO rates,$20.50 ,paid @32.27% of BCBS PPO rates,$20.50 ,paid @32.27% of BCBS rates,$5.15 ,pays @100% MCR OPPS,$5.15 ,pays at 100% MCR OPPS,$6.87 ,pays @100 MCR OPPS,$6.87 ,pays at 100% MCR OPPS,$6.87 ,pays at 100% MCR OPPS,$6.87 ,pays at 100% MCR OPPS,$6.87 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.00 ,pays @40% of UHC MCD billed charges,$5.15 ,$44.00 ,$44.00 
Outpatient Medical Services,Lab,84439,Blood test to evaluate thyroid function,301,$56.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.80 ,paid @80% Aetna Medical Rental Network rate,$20.87 ,paid @32.27% of BCBS HMO rates,$20.87 ,paid @32.27% of BCBS PPO rates,$20.87 ,paid @32.27% of BCBS rates,$6.76 ,pays @100% MCR OPPS,$6.76 ,pays at 100% MCR OPPS,$9.02 ,pays @100 MCR OPPS,$9.02 ,pays at 100% MCR OPPS,$9.02 ,pays at 100% MCR OPPS,$9.02 ,pays at 100% MCR OPPS,$9.02 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.40 ,pays @40% of UHC MCD billed charges,$6.76 ,$44.80 ,$44.80 
Outpatient Medical Services,Lab,84402,"TESTOSTERONE, FREE",301,$143.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$114.40 ,paid @80% Aetna Medical Rental Network rate,$53.30 ,paid @32.27% of BCBS HMO rates,$53.30 ,paid @32.27% of BCBS PPO rates,$53.30 ,paid @32.27% of BCBS rates,$19.10 ,pays @100% MCR OPPS,$19.10 ,pays at 100% MCR OPPS,$25.47 ,pays @100 MCR OPPS,$25.47 ,pays at 100% MCR OPPS,$25.47 ,pays at 100% MCR OPPS,$25.47 ,pays at 100% MCR OPPS,$25.47 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$57.20 ,pays @40% of UHC MCD billed charges,$19.10 ,$114.40 ,$114.40 
Outpatient Medical Services,Lab,84403,"TESTOSTERONE, TOTAL",301,$144.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$115.20 ,paid @80% Aetna Medical Rental Network rate,$53.67 ,paid @32.27% of BCBS HMO rates,$53.67 ,paid @32.27% of BCBS PPO rates,$53.67 ,paid @32.27% of BCBS rates,$19.35 ,pays @100% MCR OPPS,$19.35 ,pays at 100% MCR OPPS,$25.81 ,pays @100 MCR OPPS,$25.81 ,pays at 100% MCR OPPS,$25.81 ,pays at 100% MCR OPPS,$25.81 ,pays at 100% MCR OPPS,$25.81 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$57.60 ,pays @40% of UHC MCD billed charges,$19.35 ,$115.20 ,$115.20 
Outpatient Medical Services,Lab,85670,THROMBIN TIME,305,$67.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$53.60 ,paid @80% Aetna Medical Rental Network rate,$24.97 ,paid @32.27% of BCBS HMO rates,$24.97 ,paid @32.27% of BCBS PPO rates,$24.97 ,paid @32.27% of BCBS rates,$4.32 ,pays @100% MCR OPPS,$4.32 ,pays at 100% MCR OPPS,$5.77 ,pays @100 MCR OPPS,$5.77 ,pays at 100% MCR OPPS,$5.77 ,pays at 100% MCR OPPS,$5.77 ,pays at 100% MCR OPPS,$5.77 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$26.80 ,pays @40% of UHC MCD billed charges,$4.32 ,$53.60 ,$53.60 
Outpatient Medical Services,Lab,85705,THROMBOPLASTIN INHIB,305,$38.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$30.40 ,paid @80% Aetna Medical Rental Network rate,$14.16 ,paid @32.27% of BCBS HMO rates,$14.16 ,paid @32.27% of BCBS PPO rates,$14.16 ,paid @32.27% of BCBS rates,$7.22 ,pays @100% MCR OPPS,$7.22 ,pays at 100% MCR OPPS,$9.63 ,pays @100 MCR OPPS,$9.63 ,pays at 100% MCR OPPS,$9.63 ,pays at 100% MCR OPPS,$9.63 ,pays at 100% MCR OPPS,$9.63 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$15.20 ,pays @40% of UHC MCD billed charges,$7.22 ,$30.40 ,$30.40 
Outpatient Medical Services,Lab,84432,THYROGLOBULIN,301,$129.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$103.20 ,paid @80% Aetna Medical Rental Network rate,$48.08 ,paid @32.27% of BCBS HMO rates,$48.08 ,paid @32.27% of BCBS PPO rates,$48.08 ,paid @32.27% of BCBS rates,$12.04 ,pays @100% MCR OPPS,$12.04 ,pays at 100% MCR OPPS,$16.05 ,pays @100 MCR OPPS,$16.05 ,pays at 100% MCR OPPS,$16.05 ,pays at 100% MCR OPPS,$16.05 ,pays at 100% MCR OPPS,$16.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$51.60 ,pays @40% of UHC MCD billed charges,$12.04 ,$103.20 ,$103.20 
Outpatient Medical Services,Lab,84442,THYROID BINDING GLOB,301,$101.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$80.80 ,paid @80% Aetna Medical Rental Network rate,$37.64 ,paid @32.27% of BCBS HMO rates,$37.64 ,paid @32.27% of BCBS PPO rates,$37.64 ,paid @32.27% of BCBS rates,$11.08 ,pays @100% MCR OPPS,$11.08 ,pays at 100% MCR OPPS,$14.78 ,pays @100 MCR OPPS,$14.78 ,pays at 100% MCR OPPS,$14.78 ,pays at 100% MCR OPPS,$14.78 ,pays at 100% MCR OPPS,$14.78 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$40.40 ,pays @40% of UHC MCD billed charges,$11.08 ,$80.80 ,$80.80 
Outpatient Medical Services,Lab,84445,THYROID STIMULATING,301,$153.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$122.40 ,paid @80% Aetna Medical Rental Network rate,$57.02 ,paid @32.27% of BCBS HMO rates,$57.02 ,paid @32.27% of BCBS PPO rates,$57.02 ,paid @32.27% of BCBS rates,$38.14 ,pays @100% MCR OPPS,$38.14 ,pays at 100% MCR OPPS,$50.86 ,pays @100 MCR OPPS,$50.86 ,pays at 100% MCR OPPS,$50.86 ,pays at 100% MCR OPPS,$50.86 ,pays at 100% MCR OPPS,$50.86 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$61.20 ,pays @40% of UHC MCD billed charges,$38.14 ,$122.40 ,$122.40 
Outpatient Medical Services,Lab,84155,TOTAL PROTEIN,301,$20.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$16.00 ,paid @80% Aetna Medical Rental Network rate,$7.45 ,paid @32.27% of BCBS HMO rates,$7.45 ,paid @32.27% of BCBS PPO rates,$7.45 ,paid @32.27% of BCBS rates,$2.75 ,pays @100% MCR OPPS,$2.75 ,pays at 100% MCR OPPS,$3.67 ,pays @100 MCR OPPS,$3.67 ,pays at 100% MCR OPPS,$3.67 ,pays at 100% MCR OPPS,$3.67 ,pays at 100% MCR OPPS,$3.67 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$8.00 ,pays @40% of UHC MCD billed charges,$2.75 ,$16.00 ,$16.00 
Outpatient Medical Services,Lab,84466,TRANSFERRIN,301,$71.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$56.80 ,paid @80% Aetna Medical Rental Network rate,$26.46 ,paid @32.27% of BCBS HMO rates,$26.46 ,paid @32.27% of BCBS PPO rates,$26.46 ,paid @32.27% of BCBS rates,$9.57 ,pays @100% MCR OPPS,$9.57 ,pays at 100% MCR OPPS,$12.76 ,pays @100 MCR OPPS,$12.76 ,pays at 100% MCR OPPS,$12.76 ,pays at 100% MCR OPPS,$12.76 ,pays at 100% MCR OPPS,$12.76 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$28.40 ,pays @40% of UHC MCD billed charges,$9.57 ,$56.80 ,$56.80 
Outpatient Medical Services,Lab,86780,Blood test to determine existence of certain bacterium that causes syphilis,301,$70.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$56.00 ,paid @80% Aetna Medical Rental Network rate,$26.09 ,paid @32.27% of BCBS HMO rates,$26.09 ,paid @32.27% of BCBS PPO rates,$26.09 ,paid @32.27% of BCBS rates,$9.93 ,pays @100% MCR OPPS,$9.93 ,pays at 100% MCR OPPS,$13.24 ,pays @100 MCR OPPS,$13.24 ,pays at 100% MCR OPPS,$13.24 ,pays at 100% MCR OPPS,$13.24 ,pays at 100% MCR OPPS,$13.24 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$28.00 ,pays @40% of UHC MCD billed charges,$9.93 ,$56.00 ,$56.00 
Outpatient Medical Services,Lab,84600,TRICHLORO ACID BLD,301,$214.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$171.20 ,paid @80% Aetna Medical Rental Network rate,$79.76 ,paid @32.27% of BCBS HMO rates,$79.76 ,paid @32.27% of BCBS PPO rates,$79.76 ,paid @32.27% of BCBS rates,$12.83 ,pays @100% MCR OPPS,$12.83 ,pays at 100% MCR OPPS,$17.11 ,pays @100 MCR OPPS,$17.11 ,pays at 100% MCR OPPS,$17.11 ,pays at 100% MCR OPPS,$17.11 ,pays at 100% MCR OPPS,$17.11 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$85.60 ,pays @40% of UHC MCD billed charges,$12.83 ,$171.20 ,$171.20 
Outpatient Medical Services,Lab,84478,TRIGLYCERIDES,301,$32.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$25.60 ,paid @80% Aetna Medical Rental Network rate,$11.93 ,paid @32.27% of BCBS HMO rates,$11.93 ,paid @32.27% of BCBS PPO rates,$11.93 ,paid @32.27% of BCBS rates,$4.30 ,pays @100% MCR OPPS,$4.30 ,pays at 100% MCR OPPS,$5.74 ,pays @100 MCR OPPS,$5.74 ,pays at 100% MCR OPPS,$5.74 ,pays at 100% MCR OPPS,$5.74 ,pays at 100% MCR OPPS,$5.74 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$12.80 ,pays @40% of UHC MCD billed charges,$4.30 ,$25.60 ,$25.60 
Outpatient Medical Services,Lab,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,301,$63.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$50.40 ,paid @80% Aetna Medical Rental Network rate,$23.48 ,paid @32.27% of BCBS HMO rates,$23.48 ,paid @32.27% of BCBS PPO rates,$23.48 ,paid @32.27% of BCBS rates,$9.35 ,pays @100% MCR OPPS,$9.35 ,pays at 100% MCR OPPS,$12.47 ,pays @100 MCR OPPS,$12.47 ,pays at 100% MCR OPPS,$12.47 ,pays at 100% MCR OPPS,$12.47 ,pays at 100% MCR OPPS,$12.47 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$25.20 ,pays @40% of UHC MCD billed charges,$9.35 ,$50.40 ,$50.40 
Outpatient Medical Services,Lab,84488,TRYPSIN FECAL,301,$183.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$146.40 ,paid @80% Aetna Medical Rental Network rate,$68.20 ,paid @32.27% of BCBS HMO rates,$68.20 ,paid @32.27% of BCBS PPO rates,$68.20 ,paid @32.27% of BCBS rates,$5.47 ,pays @100% MCR OPPS,$5.47 ,pays at 100% MCR OPPS,$7.30 ,pays @100 MCR OPPS,$7.30 ,pays at 100% MCR OPPS,$7.30 ,pays at 100% MCR OPPS,$7.30 ,pays at 100% MCR OPPS,$7.30 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$73.20 ,pays @40% of UHC MCD billed charges,$5.47 ,$146.40 ,$146.40 
Outpatient Medical Services,Lab,84443,"Blood test, thyroid stimulating hormone (TSH)",301,$94.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$75.20 ,paid @80% Aetna Medical Rental Network rate,$35.03 ,paid @32.27% of BCBS HMO rates,$35.03 ,paid @32.27% of BCBS PPO rates,$35.03 ,paid @32.27% of BCBS rates,$12.60 ,pays @100% MCR OPPS,$12.60 ,pays at 100% MCR OPPS,$16.80 ,pays @100 MCR OPPS,$16.80 ,pays at 100% MCR OPPS,$16.80 ,pays at 100% MCR OPPS,$16.80 ,pays at 100% MCR OPPS,$16.80 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$37.60 ,pays @40% of UHC MCD billed charges,$12.60 ,$75.20 ,$75.20 
Outpatient Medical Services,Lab,84235,TSH RECEPTOR ANTIBOD,301,$293.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$234.40 ,paid @80% Aetna Medical Rental Network rate,$109.20 ,paid @32.27% of BCBS HMO rates,$109.20 ,paid @32.27% of BCBS PPO rates,$109.20 ,paid @32.27% of BCBS rates,$53.42 ,pays @100% MCR OPPS,$53.42 ,pays at 100% MCR OPPS,$71.23 ,pays @100 MCR OPPS,$71.23 ,pays at 100% MCR OPPS,$71.23 ,pays at 100% MCR OPPS,$71.23 ,pays at 100% MCR OPPS,$71.23 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$117.20 ,pays @40% of UHC MCD billed charges,$53.42 ,$234.40 ,$234.40 
Outpatient Medical Services,Lab,84545,UREA CLEARANCE,301,$67.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$53.60 ,paid @80% Aetna Medical Rental Network rate,$24.97 ,paid @32.27% of BCBS HMO rates,$24.97 ,paid @32.27% of BCBS PPO rates,$24.97 ,paid @32.27% of BCBS rates,$5.40 ,pays @100% MCR OPPS,$5.40 ,pays at 100% MCR OPPS,$7.20 ,pays @100 MCR OPPS,$7.20 ,pays at 100% MCR OPPS,$7.20 ,pays at 100% MCR OPPS,$7.20 ,pays at 100% MCR OPPS,$7.20 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$26.80 ,pays @40% of UHC MCD billed charges,$5.40 ,$53.60 ,$53.60 
Outpatient Medical Services,Lab,84540,UREA NITROGEN-URINE,301,$50.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$40.00 ,paid @80% Aetna Medical Rental Network rate,$18.64 ,paid @32.27% of BCBS HMO rates,$18.64 ,paid @32.27% of BCBS PPO rates,$18.64 ,paid @32.27% of BCBS rates,$4.16 ,pays @100% MCR OPPS,$4.16 ,pays at 100% MCR OPPS,$5.56 ,pays @100 MCR OPPS,$5.56 ,pays at 100% MCR OPPS,$5.56 ,pays at 100% MCR OPPS,$5.56 ,pays at 100% MCR OPPS,$5.56 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$20.00 ,pays @40% of UHC MCD billed charges,$4.16 ,$40.00 ,$40.00 
Outpatient Medical Services,Lab,84550,"URIC ACID, SERUM",301,$25.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$20.00 ,paid @80% Aetna Medical Rental Network rate,$9.32 ,paid @32.27% of BCBS HMO rates,$9.32 ,paid @32.27% of BCBS PPO rates,$9.32 ,paid @32.27% of BCBS rates,$3.38 ,pays @100% MCR OPPS,$3.38 ,pays at 100% MCR OPPS,$4.51 ,pays @100 MCR OPPS,$4.51 ,pays at 100% MCR OPPS,$4.51 ,pays at 100% MCR OPPS,$4.51 ,pays at 100% MCR OPPS,$4.51 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.00 ,pays @40% of UHC MCD billed charges,$3.38 ,$20.00 ,$20.00 
Outpatient Medical Services,Lab,84560,"URIC ACID, URINE",301,$32.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$25.60 ,paid @80% Aetna Medical Rental Network rate,$11.93 ,paid @32.27% of BCBS HMO rates,$11.93 ,paid @32.27% of BCBS PPO rates,$11.93 ,paid @32.27% of BCBS rates,$3.81 ,pays @100% MCR OPPS,$3.81 ,pays at 100% MCR OPPS,$5.08 ,pays @100 MCR OPPS,$5.08 ,pays at 100% MCR OPPS,$5.08 ,pays at 100% MCR OPPS,$5.08 ,pays at 100% MCR OPPS,$5.08 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$12.80 ,pays @40% of UHC MCD billed charges,$3.81 ,$25.60 ,$25.60 
Outpatient Medical Services,Lab,81001,Manual urinalysis test with examination with or without using microscope,307,$24.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$19.20 ,paid @80% Aetna Medical Rental Network rate,$8.94 ,paid @32.27% of BCBS HMO rates,$8.94 ,paid @32.27% of BCBS PPO rates,$8.94 ,paid @32.27% of BCBS rates,$2.37 ,pays @100% MCR OPPS,$2.37 ,pays at 100% MCR OPPS,$3.17 ,pays @100 MCR OPPS,$3.17 ,pays at 100% MCR OPPS,$3.17 ,pays at 100% MCR OPPS,$3.17 ,pays at 100% MCR OPPS,$3.17 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$9.60 ,pays @40% of UHC MCD billed charges,$2.37 ,$19.20 ,$19.20 
Outpatient Medical Services,Lab,83701,VAP LIPOPROTEIN SUB,301,$325.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$260.00 ,paid @80% Aetna Medical Rental Network rate,$121.13 ,paid @32.27% of BCBS HMO rates,$121.13 ,paid @32.27% of BCBS PPO rates,$121.13 ,paid @32.27% of BCBS rates,$25.39 ,pays @100% MCR OPPS,$25.39 ,pays at 100% MCR OPPS,$33.86 ,pays @100 MCR OPPS,$33.86 ,pays at 100% MCR OPPS,$33.86 ,pays at 100% MCR OPPS,$33.86 ,pays at 100% MCR OPPS,$33.86 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$130.00 ,pays @40% of UHC MCD billed charges,$25.39 ,$260.00 ,$260.00 
Outpatient Medical Services,Lab,36415,Collection of venous blood by venipuncture,300,$25.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$20.00 ,paid @80% Aetna Medical Rental Network rate,$9.32 ,paid @32.27% of BCBS HMO rates,$9.32 ,paid @32.27% of BCBS PPO rates,$9.32 ,paid @32.27% of BCBS rates,$6.42 ,pays @100% MCR OPPS,$6.42 ,pays at 100% MCR OPPS,$8.57 ,pays @100 MCR OPPS,$8.57 ,pays at 100% MCR OPPS,$8.57 ,pays at 100% MCR OPPS,$8.57 ,pays at 100% MCR OPPS,$8.57 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$10.00 ,pays @40% of UHC MCD billed charges,$6.42 ,$20.00 ,$20.00 
Outpatient Medical Services,Lab,84590,VITAMIN A,301,$77.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$61.60 ,paid @80% Aetna Medical Rental Network rate,$28.70 ,paid @32.27% of BCBS HMO rates,$28.70 ,paid @32.27% of BCBS PPO rates,$28.70 ,paid @32.27% of BCBS rates,$8.70 ,pays @100% MCR OPPS,$8.70 ,pays at 100% MCR OPPS,$11.61 ,pays @100 MCR OPPS,$11.61 ,pays at 100% MCR OPPS,$11.61 ,pays at 100% MCR OPPS,$11.61 ,pays at 100% MCR OPPS,$11.61 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$30.80 ,pays @40% of UHC MCD billed charges,$8.70 ,$61.60 ,$61.60 
Outpatient Medical Services,Lab,84425,VITAMIN B1,301,$90.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$72.00 ,paid @80% Aetna Medical Rental Network rate,$33.54 ,paid @32.27% of BCBS HMO rates,$33.54 ,paid @32.27% of BCBS PPO rates,$33.54 ,paid @32.27% of BCBS rates,$15.92 ,pays @100% MCR OPPS,$15.92 ,pays at 100% MCR OPPS,$21.23 ,pays @100 MCR OPPS,$21.23 ,pays at 100% MCR OPPS,$21.23 ,pays at 100% MCR OPPS,$21.23 ,pays at 100% MCR OPPS,$21.23 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$36.00 ,pays @40% of UHC MCD billed charges,$15.92 ,$72.00 ,$72.00 
Outpatient Medical Services,Lab,84207,VITAMIN B6,301,$80.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$64.00 ,paid @80% Aetna Medical Rental Network rate,$29.82 ,paid @32.27% of BCBS HMO rates,$29.82 ,paid @32.27% of BCBS PPO rates,$29.82 ,paid @32.27% of BCBS rates,$21.07 ,pays @100% MCR OPPS,$21.07 ,pays at 100% MCR OPPS,$28.10 ,pays @100 MCR OPPS,$28.10 ,pays at 100% MCR OPPS,$28.10 ,pays at 100% MCR OPPS,$28.10 ,pays at 100% MCR OPPS,$28.10 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$32.00 ,pays @40% of UHC MCD billed charges,$21.07 ,$64.00 ,$64.00 
Outpatient Medical Services,Lab,82306,Blood test to monitor vitamin D levels,301,$216.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$172.80 ,paid @80% Aetna Medical Rental Network rate,$80.50 ,paid @32.27% of BCBS HMO rates,$80.50 ,paid @32.27% of BCBS PPO rates,$80.50 ,paid @32.27% of BCBS rates,$22.20 ,pays @100% MCR OPPS,$22.20 ,pays at 100% MCR OPPS,$29.60 ,pays @100 MCR OPPS,$29.60 ,pays at 100% MCR OPPS,$29.60 ,pays at 100% MCR OPPS,$29.60 ,pays at 100% MCR OPPS,$29.60 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$86.40 ,pays @40% of UHC MCD billed charges,$22.20 ,$172.80 ,$172.80 
Outpatient Medical Services,Lab,84446,VITAMIN E,301,$84.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$67.20 ,paid @80% Aetna Medical Rental Network rate,$31.31 ,paid @32.27% of BCBS HMO rates,$31.31 ,paid @32.27% of BCBS PPO rates,$31.31 ,paid @32.27% of BCBS rates,$10.63 ,pays @100% MCR OPPS,$10.63 ,pays at 100% MCR OPPS,$14.18 ,pays @100 MCR OPPS,$14.18 ,pays at 100% MCR OPPS,$14.18 ,pays at 100% MCR OPPS,$14.18 ,pays at 100% MCR OPPS,$14.18 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$33.60 ,pays @40% of UHC MCD billed charges,$10.63 ,$67.20 ,$67.20 
Outpatient Medical Services,Lab,84591,VITAMIN NOT OTH SPEC,301,$55.34 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.27 ,paid @80% Aetna Medical Rental Network rate,$20.63 ,paid @32.27% of BCBS HMO rates,$20.63 ,paid @32.27% of BCBS PPO rates,$20.63 ,paid @32.27% of BCBS rates,$12.79 ,pays @100% MCR OPPS,$12.79 ,pays at 100% MCR OPPS,$17.05 ,pays @100 MCR OPPS,$17.05 ,pays at 100% MCR OPPS,$17.05 ,pays at 100% MCR OPPS,$17.05 ,pays at 100% MCR OPPS,$17.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$22.14 ,pays @40% of UHC MCD billed charges,$12.79 ,$44.27 ,$44.27 
Outpatient Medical Services,Lab,84585,VMA (VANILLYLMANDELI,301,$132.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$105.60 ,paid @80% Aetna Medical Rental Network rate,$49.20 ,paid @32.27% of BCBS HMO rates,$49.20 ,paid @32.27% of BCBS PPO rates,$49.20 ,paid @32.27% of BCBS rates,$11.62 ,pays @100% MCR OPPS,$11.62 ,pays at 100% MCR OPPS,$15.50 ,pays @100 MCR OPPS,$15.50 ,pays at 100% MCR OPPS,$15.50 ,pays at 100% MCR OPPS,$15.50 ,pays at 100% MCR OPPS,$15.50 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$52.80 ,pays @40% of UHC MCD billed charges,$11.62 ,$105.60 ,$105.60 
Outpatient Medical Services,Lab,89055,"WBC, STOOL",305,$14.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$11.20 ,paid @80% Aetna Medical Rental Network rate,$5.22 ,paid @32.27% of BCBS HMO rates,$5.22 ,paid @32.27% of BCBS PPO rates,$5.22 ,paid @32.27% of BCBS rates,$3.20 ,pays @100% MCR OPPS,$3.20 ,pays at 100% MCR OPPS,$4.26 ,pays @100 MCR OPPS,$4.26 ,pays at 100% MCR OPPS,$4.26 ,pays at 100% MCR OPPS,$4.26 ,pays at 100% MCR OPPS,$4.26 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$5.60 ,pays @40% of UHC MCD billed charges,$3.20 ,$11.20 ,$11.20 
Outpatient Medical Services,Lab,84630,ZINC LEVEL,301,$94.13 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$75.30 ,paid @80% Aetna Medical Rental Network rate,$35.08 ,paid @32.27% of BCBS HMO rates,$35.08 ,paid @32.27% of BCBS PPO rates,$35.08 ,paid @32.27% of BCBS rates,$8.54 ,pays @100% MCR OPPS,$8.54 ,pays at 100% MCR OPPS,$11.39 ,pays @100 MCR OPPS,$11.39 ,pays at 100% MCR OPPS,$11.39 ,pays at 100% MCR OPPS,$11.39 ,pays at 100% MCR OPPS,$11.39 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$37.65 ,pays @40% of UHC MCD billed charges,$8.54 ,$75.30 ,$75.30 
Outpatient Medical Services,Radiology,76376,3D RENDERING,350,$159.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$127.20 ,paid @80% Aetna Medical Rental Network rate,$59.26 ,paid @32.27% of BCBS HMO rates,$59.26 ,paid @32.27% of BCBS PPO rates,$59.26 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$63.60 ,pays @40% of UHC MCD billed charges,$59.26 ,$127.20 ,$127.20 
Outpatient Medical Services,Radiology,93922,Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,402,$266.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$212.80 ,paid @80% Aetna Medical Rental Network rate,$99.14 ,paid @32.27% of BCBS HMO rates,$99.14 ,paid @32.27% of BCBS PPO rates,$99.14 ,paid @32.27% of BCBS rates,$100.47 ,pays @100% MCR OPPS,$100.47 ,pays at 100% MCR OPPS,$100.47 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$100.47 ,pays at 100% MCR OPPS,$100.47 ,pays at 100% MCR OPPS,$100.47 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$106.40 ,pays @40% of UHC MCD billed charges,$99.14 ,$212.80 ,$212.80 
Outpatient Medical Services,Radiology,74177,CT scan of abdomen and pelvis with contrast,350,"$3,290.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$2,632.00 ",paid @80% Aetna Medical Rental Network rate,"$1,226.18 ",paid @32.27% of BCBS HMO rates,"$1,226.18 ",paid @32.27% of BCBS PPO rates,"$1,226.18 ",paid @32.27% of BCBS rates,$318.82 ,pays @100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",pays @40% of UHC MCD billed charges,$318.82 ,"$2,632.00 ","$2,632.00 "
Outpatient Medical Services,Radiology,74176,CT of abdomen and pelvis without dye,350,"$3,016.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$2,412.80 ",paid @80% Aetna Medical Rental Network rate,"$1,124.06 ",paid @32.27% of BCBS HMO rates,"$1,124.06 ",paid @32.27% of BCBS PPO rates,"$1,124.06 ",paid @32.27% of BCBS rates,$202.07 ,pays @100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,206.40 ",pays @40% of UHC MCD billed charges,$202.07 ,"$2,412.80 ","$2,412.80 "
Outpatient Medical Services,Radiology,74178,"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",350,"$3,564.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$2,851.20 ",paid @80% Aetna Medical Rental Network rate,"$1,328.30 ",paid @32.27% of BCBS HMO rates,"$1,328.30 ",paid @32.27% of BCBS PPO rates,"$1,328.30 ",paid @32.27% of BCBS rates,$318.82 ,pays @100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,425.60 ",pays @40% of UHC MCD billed charges,$318.82 ,"$2,851.20 ","$2,851.20 "
Outpatient Medical Services,Radiology,74160,CT of abdomen with dye,350,"$2,124.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,699.20 ",paid @80% Aetna Medical Rental Network rate,$791.61 ,paid @32.27% of BCBS HMO rates,$791.61 ,paid @32.27% of BCBS PPO rates,$791.61 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$849.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,699.20 ","$1,699.20 "
Outpatient Medical Services,Radiology,74170,CT of abdomen with and without dye,350,"$2,399.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,919.20 ",paid @80% Aetna Medical Rental Network rate,$894.11 ,paid @32.27% of BCBS HMO rates,$894.11 ,paid @32.27% of BCBS PPO rates,$894.11 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$959.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,919.20 ","$1,919.20 "
Outpatient Medical Services,Radiology,74150,CT of abdomen without dye,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,72125,CT CERV SPINE WO,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,72127,CT CERVICAL SP WOW,350,"$2,399.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,919.20 ",paid @80% Aetna Medical Rental Network rate,$894.11 ,paid @32.27% of BCBS HMO rates,$894.11 ,paid @32.27% of BCBS PPO rates,$894.11 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$959.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,919.20 ","$1,919.20 "
Outpatient Medical Services,Radiology,73701,CT EXTREM LOWER (W),350,"$2,124.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,699.20 ",paid @80% Aetna Medical Rental Network rate,$791.61 ,paid @32.27% of BCBS HMO rates,$791.61 ,paid @32.27% of BCBS PPO rates,$791.61 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$849.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,699.20 ","$1,699.20 "
Outpatient Medical Services,Radiology,73700,CT scan of leg without dye,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,73201,CT EXTREM UPPER (W),350,"$2,124.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,699.20 ",paid @80% Aetna Medical Rental Network rate,$791.61 ,paid @32.27% of BCBS HMO rates,$791.61 ,paid @32.27% of BCBS PPO rates,$791.61 ,paid @32.27% of BCBS rates,$318.82 ,pays @100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$849.60 ,pays @40% of UHC MCD billed charges,$318.82 ,"$1,699.20 ","$1,699.20 "
Outpatient Medical Services,Radiology,73200,CT EXTREM UPPER WO,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,77012,CT GUIDED NEEDLE PLC,350,"$1,596.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,276.80 ",paid @80% Aetna Medical Rental Network rate,$594.83 ,paid @32.27% of BCBS HMO rates,$594.83 ,paid @32.27% of BCBS PPO rates,$594.83 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$638.40 ,pays @40% of UHC MCD billed charges,$594.83 ,"$1,276.80 ","$1,276.80 "
Outpatient Medical Services,Radiology,70470,CT HEAD (WO&W),351,"$1,440.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,152.00 ",paid @80% Aetna Medical Rental Network rate,$536.69 ,paid @32.27% of BCBS HMO rates,$536.69 ,paid @32.27% of BCBS PPO rates,$536.69 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,152.00 ","$1,152.00 "
Outpatient Medical Services,Radiology,70460,CT HEAD W,351,"$2,124.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,699.20 ",paid @80% Aetna Medical Rental Network rate,$791.61 ,paid @32.27% of BCBS HMO rates,$791.61 ,paid @32.27% of BCBS PPO rates,$791.61 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$849.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,699.20 ","$1,699.20 "
Outpatient Medical Services,Radiology,70450,CT scan head or brain without dye,351,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,72131,CT scan of lower spine without dye,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,72133,CT LUMBAR SP WOW,350,"$2,399.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,919.20 ",paid @80% Aetna Medical Rental Network rate,$894.11 ,paid @32.27% of BCBS HMO rates,$894.11 ,paid @32.27% of BCBS PPO rates,$894.11 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$959.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,919.20 ","$1,919.20 "
Outpatient Medical Services,Radiology,70491,CT scan of neck with dye,350,"$2,124.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,699.20 ",paid @80% Aetna Medical Rental Network rate,$791.61 ,paid @32.27% of BCBS HMO rates,$791.61 ,paid @32.27% of BCBS PPO rates,$791.61 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$849.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,699.20 ","$1,699.20 "
Outpatient Medical Services,Radiology,70490,CT NECK (WO),350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,70492,CT NECK SFT TIS WO/W,350,"$2,399.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,919.20 ",paid @80% Aetna Medical Rental Network rate,$894.11 ,paid @32.27% of BCBS HMO rates,$894.11 ,paid @32.27% of BCBS PPO rates,$894.11 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$959.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,919.20 ","$1,919.20 "
Outpatient Medical Services,Radiology,72193,"CT scan, pelvis, with contrast",350,"$2,124.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,699.20 ",paid @80% Aetna Medical Rental Network rate,$791.61 ,paid @32.27% of BCBS HMO rates,$791.61 ,paid @32.27% of BCBS PPO rates,$791.61 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$849.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,699.20 ","$1,699.20 "
Outpatient Medical Services,Radiology,72194,CT PELVIS (WO&W),350,"$2,399.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,919.20 ",paid @80% Aetna Medical Rental Network rate,$894.11 ,paid @32.27% of BCBS HMO rates,$894.11 ,paid @32.27% of BCBS PPO rates,$894.11 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$959.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,919.20 ","$1,919.20 "
Outpatient Medical Services,Radiology,72192,CT of pelvis without dye,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,70480,CT SELLA/IAC/ORB/WO,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,70482,CT SELLA/IAC/ORB/WOW,350,"$2,399.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,919.20 ",paid @80% Aetna Medical Rental Network rate,$894.11 ,paid @32.27% of BCBS HMO rates,$894.11 ,paid @32.27% of BCBS PPO rates,$894.11 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$959.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,919.20 ","$1,919.20 "
Outpatient Medical Services,Radiology,70486,CT Scan of the face and jaw without dye,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,72128,CT THOR SPINE WO,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,72130,CT THORACIC SP W/WO,350,"$2,399.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,919.20 ",paid @80% Aetna Medical Rental Network rate,$894.11 ,paid @32.27% of BCBS HMO rates,$894.11 ,paid @32.27% of BCBS PPO rates,$894.11 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$959.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,919.20 ","$1,919.20 "
Outpatient Medical Services,Radiology,71260,CT scan of the thorax with dye,350,"$2,124.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,699.20 ",paid @80% Aetna Medical Rental Network rate,$791.61 ,paid @32.27% of BCBS HMO rates,$791.61 ,paid @32.27% of BCBS PPO rates,$791.61 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$849.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,699.20 ","$1,699.20 "
Outpatient Medical Services,Radiology,71270,CT THORAX (WO&W),350,"$2,399.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,919.20 ",paid @80% Aetna Medical Rental Network rate,$894.11 ,paid @32.27% of BCBS HMO rates,$894.11 ,paid @32.27% of BCBS PPO rates,$894.11 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$959.60 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,919.20 ","$1,919.20 "
Outpatient Medical Services,Radiology,71250,CT scan of the thorax without dye,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$92.49 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,74175,CTA ABD WO/W,350,"$3,016.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$2,412.80 ",paid @80% Aetna Medical Rental Network rate,"$1,124.06 ",paid @32.27% of BCBS HMO rates,"$1,124.06 ",paid @32.27% of BCBS PPO rates,"$1,124.06 ",paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,206.40 ",pays @40% of UHC MCD billed charges,$156.05 ,"$2,412.80 ","$2,412.80 "
Outpatient Medical Services,Radiology,74174,CTA ABD&PELVIS W/WO,350,"$3,016.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$2,412.80 ",paid @80% Aetna Medical Rental Network rate,"$1,124.06 ",paid @32.27% of BCBS HMO rates,"$1,124.06 ",paid @32.27% of BCBS PPO rates,"$1,124.06 ",paid @32.27% of BCBS rates,$318.82 ,pays @100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,206.40 ",pays @40% of UHC MCD billed charges,$318.82 ,"$2,412.80 ","$2,412.80 "
Outpatient Medical Services,Radiology,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,70496,CTA HEAD W/WO CONT,350,$632.50 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$506.00 ,paid @80% Aetna Medical Rental Network rate,$235.73 ,paid @32.27% of BCBS HMO rates,$235.73 ,paid @32.27% of BCBS PPO rates,$235.73 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$253.00 ,pays @40% of UHC MCD billed charges,$156.05 ,$506.00 ,$506.00 
Outpatient Medical Services,Radiology,73706,CTA LOWER EXT W/WO,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,70498,CTA NECK W/WO,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,72191,CTA PELVIS W/WO,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,73206,CTA UPPER EXT W/WO,350,"$1,645.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,316.00 ",paid @80% Aetna Medical Rental Network rate,$613.09 ,paid @32.27% of BCBS HMO rates,$613.09 ,paid @32.27% of BCBS PPO rates,$613.09 ,paid @32.27% of BCBS rates,$156.05 ,pays @100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,$156.05 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$658.00 ,pays @40% of UHC MCD billed charges,$156.05 ,"$1,316.00 ","$1,316.00 "
Outpatient Medical Services,Radiology,76818,Fetal biophysical profile with non-stress test,402,$300.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$240.00 ,paid @80% Aetna Medical Rental Network rate,$111.81 ,paid @32.27% of BCBS HMO rates,$111.81 ,paid @32.27% of BCBS PPO rates,$111.81 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$120.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$240.00 ,$240.00 
Outpatient Medical Services,Radiology,76819,Fetal biophysical profile without non-stress test,402,$300.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$240.00 ,paid @80% Aetna Medical Rental Network rate,$111.81 ,paid @32.27% of BCBS HMO rates,$111.81 ,paid @32.27% of BCBS PPO rates,$111.81 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$120.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$240.00 ,$240.00 
Outpatient Medical Services,Radiology,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,$428.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$342.40 ,paid @80% Aetna Medical Rental Network rate,$159.52 ,paid @32.27% of BCBS HMO rates,$159.52 ,paid @32.27% of BCBS PPO rates,$159.52 ,paid @32.27% of BCBS rates,$143.88 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$143.88 ,pays at 100% MCR OPPS,$143.88 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$171.20 ,pays @40% of UHC MCD billed charges,$143.88 ,$342.40 ,$342.40 
Outpatient Medical Services,Radiology,77067,Mammography of both breasts-2 or more views,403,$393.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$314.40 ,paid @80% Aetna Medical Rental Network rate,$146.47 ,paid @32.27% of BCBS HMO rates,$146.47 ,paid @32.27% of BCBS PPO rates,$146.47 ,paid @32.27% of BCBS rates,$119.35 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$119.35 ,pays at 100% MCR OPPS,$119.35 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$157.20 ,pays @40% of UHC MCD billed charges,$119.35 ,$314.40 ,$314.40 
Outpatient Medical Services,Radiology,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,$286.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$228.80 ,paid @80% Aetna Medical Rental Network rate,$106.59 ,paid @32.27% of BCBS HMO rates,$106.59 ,paid @32.27% of BCBS PPO rates,$106.59 ,paid @32.27% of BCBS rates,$112.90 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$112.90 ,pays at 100% MCR OPPS,$112.90 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$114.40 ,pays @40% of UHC MCD billed charges,$106.59 ,$228.80 ,$228.80 
Outpatient Medical Services,Radiology,74183,MRI of abdomen without and with dye,610,"$3,564.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$2,851.20 ",paid @80% Aetna Medical Rental Network rate,"$1,328.30 ",paid @32.27% of BCBS HMO rates,"$1,328.30 ",paid @32.27% of BCBS PPO rates,"$1,328.30 ",paid @32.27% of BCBS rates,$318.82 ,pays @100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,$318.82 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,425.60 ",pays @40% of UHC MCD billed charges,$318.82 ,"$2,851.20 ","$2,851.20 "
Outpatient Medical Services,Radiology,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$3,016.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$2,412.80 ",paid @80% Aetna Medical Rental Network rate,"$1,124.06 ",paid @32.27% of BCBS HMO rates,"$1,124.06 ",paid @32.27% of BCBS PPO rates,"$1,124.06 ",paid @32.27% of BCBS rates,$202.07 ,pays @100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,206.40 ",pays @40% of UHC MCD billed charges,$202.07 ,"$2,412.80 ","$2,412.80 "
Outpatient Medical Services,Radiology,72148,MRI scan of lower spinal canal,612,"$3,016.00 ",N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,"$2,412.80 ",paid @80% Aetna Medical Rental Network rate,"$1,124.06 ",paid @32.27% of BCBS HMO rates,"$1,124.06 ",paid @32.27% of BCBS PPO rates,"$1,124.06 ",paid @32.27% of BCBS rates,$202.07 ,pays @100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,"$1,206.40 ",pays @40% of UHC MCD billed charges,$202.07 ,"$2,412.80 ","$2,412.80 "
Outpatient Medical Services,Radiology,73590,Radiologic examination of the lower leg,320,$330.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$264.00 ,paid @80% Aetna Medical Rental Network rate,$122.99 ,paid @32.27% of BCBS HMO rates,$122.99 ,paid @32.27% of BCBS PPO rates,$122.99 ,paid @32.27% of BCBS rates,$75.18 ,pays @100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$132.00 ,pays @40% of UHC MCD billed charges,$75.18 ,$264.00 ,$264.00 
Outpatient Medical Services,Radiology,76801,Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,361,$370.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$296.00 ,paid @80% Aetna Medical Rental Network rate,$137.90 ,paid @32.27% of BCBS HMO rates,$137.90 ,paid @32.27% of BCBS PPO rates,$137.90 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$148.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$296.00 ,$296.00 
Outpatient Medical Services,Radiology,76700,Ultrasound of abdomen with all areas scanned,402,$325.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$260.00 ,paid @80% Aetna Medical Rental Network rate,$121.13 ,paid @32.27% of BCBS HMO rates,$121.13 ,paid @32.27% of BCBS PPO rates,$121.13 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$130.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$260.00 ,$260.00 
Outpatient Medical Services,Radiology,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,$575.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$460.00 ,paid @80% Aetna Medical Rental Network rate,$214.30 ,paid @32.27% of BCBS HMO rates,$214.30 ,paid @32.27% of BCBS PPO rates,$214.30 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$230.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$460.00 ,$460.00 
Outpatient Medical Services,Radiology,76810,US ADDTNL GESTATION,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$268.34 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76946,US AMNIOCENTESIS,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$268.34 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76706,US AORTA SCREENING,402,$262.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$209.60 ,paid @80% Aetna Medical Rental Network rate,$97.65 ,paid @32.27% of BCBS HMO rates,$97.65 ,paid @32.27% of BCBS PPO rates,$97.65 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$104.80 ,pays @40% of UHC MCD billed charges,$92.49 ,$209.60 ,$209.60 
Outpatient Medical Services,Radiology,51798,Ultrasound of bladder to measure urine capacity,402,$140.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$112.00 ,paid @80% Aetna Medical Rental Network rate,$52.18 ,paid @32.27% of BCBS HMO rates,$52.18 ,paid @32.27% of BCBS PPO rates,$52.18 ,paid @32.27% of BCBS rates,$49.74 ,pays @100% MCR OPPS,$49.74 ,pays at 100% MCR OPPS,$49.74 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$49.74 ,pays at 100% MCR OPPS,$49.74 ,pays at 100% MCR OPPS,$49.74 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$56.00 ,pays @40% of UHC MCD billed charges,$49.74 ,$112.00 ,$112.00 
Outpatient Medical Services,Radiology,76641,US BREAST COMPLETE,402,$428.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$342.40 ,paid @80% Aetna Medical Rental Network rate,$159.52 ,paid @32.27% of BCBS HMO rates,$159.52 ,paid @32.27% of BCBS PPO rates,$159.52 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$171.20 ,pays @40% of UHC MCD billed charges,$92.48 ,$342.40 ,$342.40 
Outpatient Medical Services,Radiology,76642,Limited ultrasound of the breast,402,$428.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$342.40 ,paid @80% Aetna Medical Rental Network rate,$159.52 ,paid @32.27% of BCBS HMO rates,$159.52 ,paid @32.27% of BCBS PPO rates,$159.52 ,paid @32.27% of BCBS rates,$75.18 ,pays @100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$171.20 ,pays @40% of UHC MCD billed charges,$75.18 ,$342.40 ,$342.40 
Outpatient Medical Services,Radiology,76604,US CHEST,402,$428.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$342.40 ,paid @80% Aetna Medical Rental Network rate,$159.52 ,paid @32.27% of BCBS HMO rates,$159.52 ,paid @32.27% of BCBS PPO rates,$159.52 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$171.20 ,pays @40% of UHC MCD billed charges,$92.48 ,$342.40 ,$342.40 
Outpatient Medical Services,Radiology,76506,US ECHOENCPHALOGRPHY,402,$286.15 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$228.92 ,paid @80% Aetna Medical Rental Network rate,$106.65 ,paid @32.27% of BCBS HMO rates,$106.65 ,paid @32.27% of BCBS PPO rates,$106.65 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$114.46 ,pays @40% of UHC MCD billed charges,$92.48 ,$228.92 ,$228.92 
Outpatient Medical Services,Radiology,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76815,Ultrasound of fetus with limited views,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$92.48 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76942,US GUIDED NEEDLE PLC,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$268.34 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76885,US INFANT HIPS,402,$226.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$180.80 ,paid @80% Aetna Medical Rental Network rate,$84.23 ,paid @32.27% of BCBS HMO rates,$84.23 ,paid @32.27% of BCBS PPO rates,$84.23 ,paid @32.27% of BCBS rates,$75.18 ,pays @100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,$75.18 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$90.40 ,pays @40% of UHC MCD billed charges,$75.18 ,$180.80 ,$180.80 
Outpatient Medical Services,Radiology,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",972,$286.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,N/A,$228.80 
Outpatient Medical Services,Radiology,76881,US NONVASC EXT COMPL,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76856,Complete ultrasound of the pelvis,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76814,US PREG UTR ADD GEST,402,$286.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$228.80 ,paid @80% Aetna Medical Rental Network rate,$106.59 ,paid @32.27% of BCBS HMO rates,$106.59 ,paid @32.27% of BCBS PPO rates,$106.59 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$114.40 ,pays @40% of UHC MCD billed charges,$106.59 ,$228.80 ,$228.80 
Outpatient Medical Services,Radiology,93975,US RENAL ARTY DOPPLE,402,$580.78 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$464.62 ,paid @80% Aetna Medical Rental Network rate,$216.46 ,paid @32.27% of BCBS HMO rates,$216.46 ,paid @32.27% of BCBS PPO rates,$216.46 ,paid @32.27% of BCBS rates,$202.07 ,pays @100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,$202.07 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$232.31 ,pays @40% of UHC MCD billed charges,$202.07 ,$464.62 ,$464.62 
Outpatient Medical Services,Radiology,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,$325.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$260.00 ,paid @80% Aetna Medical Rental Network rate,$121.13 ,paid @32.27% of BCBS HMO rates,$121.13 ,paid @32.27% of BCBS PPO rates,$121.13 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$130.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$260.00 ,$260.00 
Outpatient Medical Services,Radiology,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,$575.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$460.00 ,paid @80% Aetna Medical Rental Network rate,$214.30 ,paid @32.27% of BCBS HMO rates,$214.30 ,paid @32.27% of BCBS PPO rates,$214.30 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$230.00 ,pays @40% of UHC MCD billed charges,$92.48 ,$460.00 ,$460.00 
Outpatient Medical Services,Radiology,76870,Ultrasound of the scrotum,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$92.48 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76800,US SPINAL CANAL,402,$348.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$278.40 ,paid @80% Aetna Medical Rental Network rate,$129.70 ,paid @32.27% of BCBS HMO rates,$129.70 ,paid @32.27% of BCBS PPO rates,$129.70 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$139.20 ,pays @40% of UHC MCD billed charges,$92.48 ,$278.40 ,$278.40 
Outpatient Medical Services,Radiology,76536,Ultrasound of head and neck,402,$428.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$342.40 ,paid @80% Aetna Medical Rental Network rate,$159.52 ,paid @32.27% of BCBS HMO rates,$159.52 ,paid @32.27% of BCBS PPO rates,$159.52 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$171.20 ,pays @40% of UHC MCD billed charges,$92.48 ,$342.40 ,$342.40 
Outpatient Medical Services,Radiology,76802,US TRANS/ABDOM <14WK,402,$75.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$60.00 ,paid @80% Aetna Medical Rental Network rate,$27.95 ,paid @32.27% of BCBS HMO rates,$27.95 ,paid @32.27% of BCBS PPO rates,$27.95 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$30.00 ,pays @40% of UHC MCD billed charges,$27.95 ,$60.00 ,$60.00 
Outpatient Medical Services,Radiology,76817,Transvaginal ultrasound of uterus,402,$565.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$452.00 ,paid @80% Aetna Medical Rental Network rate,$210.58 ,paid @32.27% of BCBS HMO rates,$210.58 ,paid @32.27% of BCBS PPO rates,$210.58 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$226.00 ,pays @40% of UHC MCD billed charges,$92.48 ,$452.00 ,$452.00 
Outpatient Medical Services,Radiology,76820,US UMBILICAL ARTERY,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,$92.48 ,pays @100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,$92.48 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$92.48 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76830,Ultrasound of the pelvis through vagina,402,$720.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$576.00 ,paid @80% Aetna Medical Rental Network rate,$268.34 ,paid @32.27% of BCBS HMO rates,$268.34 ,paid @32.27% of BCBS PPO rates,$268.34 ,paid @32.27% of BCBS rates,$92.49 ,pays @100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays @100 MCR OPPS,N/A,not separately reimburseable,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,$92.49 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,pays @40% of UHC MCD billed charges,$92.49 ,$576.00 ,$576.00 
Outpatient Medical Services,Radiology,76937,US VASC ACCESS GUIDA,402,$428.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$342.40 ,paid @80% Aetna Medical Rental Network rate,$159.52 ,paid @32.27% of BCBS HMO rates,$159.52 ,paid @32.27% of BCBS PPO rates,$159.52 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$171.20 ,pays @40% of UHC MCD billed charges,$159.52 ,$342.40 ,$342.40 
Outpatient Medical Services,Therapy,97165,OT EVAL LOW COMPLEXI,434,$312.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$249.60 ,paid @80% Aetna Medical Rental Network rate,$116.28 ,paid @32.27% of BCBS HMO rates,$116.28 ,paid @32.27% of BCBS PPO rates,$116.28 ,paid @32.27% of BCBS rates,$139.03 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$139.03 ,pays at 100% MCR OPPS,$139.03 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$124.80 ,pays @40% of UHC MCD billed charges,$116.28 ,$249.60 ,$249.60 
Outpatient Medical Services,Therapy,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",430,$119.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$95.20 ,paid @80% Aetna Medical Rental Network rate,$44.35 ,paid @32.27% of BCBS HMO rates,$44.35 ,paid @32.27% of BCBS PPO rates,$44.35 ,paid @32.27% of BCBS rates,$40.75 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$40.75 ,pays at 100% MCR OPPS,$40.75 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$47.60 ,pays @40% of UHC MCD billed charges,$40.75 ,$95.20 ,$95.20 
Outpatient Medical Services,Therapy,97150,OT THERA ¬RPC GROUP,430,$268.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$214.40 ,paid @80% Aetna Medical Rental Network rate,$99.88 ,paid @32.27% of BCBS HMO rates,$99.88 ,paid @32.27% of BCBS PPO rates,$99.88 ,paid @32.27% of BCBS rates,$24.71 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$24.71 ,pays at 100% MCR OPPS,$24.71 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$107.20 ,pays @40% of UHC MCD billed charges,$24.71 ,$214.40 ,$214.40 
Outpatient Medical Services,Therapy,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",430,$112.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$89.60 ,paid @80% Aetna Medical Rental Network rate,$41.74 ,paid @32.27% of BCBS HMO rates,$41.74 ,paid @32.27% of BCBS PPO rates,$41.74 ,paid @32.27% of BCBS rates,$50.59 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$50.59 ,pays at 100% MCR OPPS,$50.59 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$44.80 ,pays @40% of UHC MCD billed charges,$41.74 ,$89.60 ,$89.60 
Outpatient Medical Services,Therapy,97161,PT EVAL LOW COMPLEXI,424,$304.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$243.20 ,paid @80% Aetna Medical Rental Network rate,$113.30 ,paid @32.27% of BCBS HMO rates,$113.30 ,paid @32.27% of BCBS PPO rates,$113.30 ,paid @32.27% of BCBS rates,$139.03 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$139.03 ,pays at 100% MCR OPPS,$139.03 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$121.60 ,pays @40% of UHC MCD billed charges,$113.30 ,$243.20 ,$243.20 
Outpatient Medical Services,Therapy,92507,Therapy for speech or hearing,440,$220.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$176.00 ,paid @80% Aetna Medical Rental Network rate,$81.99 ,paid @32.27% of BCBS HMO rates,$81.99 ,paid @32.27% of BCBS PPO rates,$81.99 ,paid @32.27% of BCBS rates,$106.58 ,pays @100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$106.58 ,pays at 100% MCR OPPS,$106.58 ,pays at 100% MCR OPPS,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$88.00 ,pays @40% of UHC MCD billed charges,$81.99 ,$176.00 ,$176.00 
Outpatient Medical Services,Visit,99244,"Patient office consultation, typically 60 min",987,$304.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,N/A,$243.20 
Outpatient Medical Services,Visit,99243,"Patient office consultation, typically 40 min",987,$206.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,N/A,$164.80 
Outpatient Medical Services,Visit,99245,OP CONSULT (SEV),987,$377.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,N/A,$301.60 
Outpatient Medical Services,Visit,99213,"Established patient office or other outpatient visit, typically 15 minutes",761,$219.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$175.20 ,paid @80% Aetna Medical Rental Network rate,$81.62 ,paid @32.27% of BCBS HMO rates,$81.62 ,paid @32.27% of BCBS PPO rates,$81.62 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$87.60 ,pays @40% of UHC MCD billed charges,$81.62 ,$175.20 ,$175.20 
Outpatient Medical Services,Visit,99214,"Established patient office or other outpatient visit, typically 25 minutes",761,$279.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$223.20 ,paid @80% Aetna Medical Rental Network rate,$103.98 ,paid @32.27% of BCBS HMO rates,$103.98 ,paid @32.27% of BCBS PPO rates,$103.98 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$111.60 ,pays @40% of UHC MCD billed charges,$103.98 ,$223.20 ,$223.20 
Outpatient Medical Services,Visit,99215,"Established patient office or other outpatient, visit typically 40 minutes",761,$360.00 ,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$288.00 ,paid @80% Aetna Medical Rental Network rate,$134.17 ,paid @32.27% of BCBS HMO rates,$134.17 ,paid @32.27% of BCBS PPO rates,$134.17 ,paid @32.27% of BCBS rates,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,N/A,not separately reimburseable,$144.00 ,pays @40% of UHC MCD billed charges,$134.17 ,$288.00 ,$288.00 
Outpatient Medical Services,BEHAVIORAL,90832,"Psychotherapy, 30 minute",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90834,"Psychotherapy, 45 minutes",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90837,"Psychotherapy, 60 minutes",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90846,"Family psychotherapy, not including patient, 50 minutes",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90847,"Family psychotherapy, including patient, 50 min",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90853,Group psychotherapy,900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99203,"New patient office or other outpatient visit, typically 30 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99204,"New patient office of other outpatient visit, typically 45 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99205,"New patient office of other outpatient visit, typically 60 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99385,"Initial new patient preventive medicine evaluation, for those ages 18 to 39",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99386,"Initial new patient preventive medicine evaluation, for those ages 40 to 64",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,LAB,80055,Obstetric blood test panel,300,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,LAB,80069,Kidney function panel tes,300,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,LAB,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,LAB,81003,Prostate specific antigen,300,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,610,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,RADIOLOGY,72110,"X-Ray, lower back, minimum four views",320,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,RADIOLOGY,19120,"Removal of 1 or more breast growth, open procedure",360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,29826,Shaving of shoulder bone using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,29881,Removal of one knee cartilage using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscop",360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,45378,Diagnostic examination of large bowel using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,45380,Biopsy of large bowel using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,45385,Removal of polyps or growths of large bowel using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,45391,Ultrasound examination of lower large bowel using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,47562,Removal of gallbladder using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,49505,Repair of groin hernia patient age 5 or older,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,55700,Biopsy of prostate gland,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,66821,Removal of recurring cataract in lens capsule using laser,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,66984,Removal of cataract with insertion of lens,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,ECCG,93000,"Electrocardiogram, routine, with interpretation and report",730,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,CARDIOLOGY,93452,Insertion of catheter into left heart for diagnosis,480,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,SLEEP STUDY,95810,Sleep study,920,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,470,Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A