,file_create_date,run_id,name,tax_id,code,code type,code description,payer,plan_type,patient_class,gross charge,de-identified minimum negotiated charge,payer-specific negotiated charge,de-identified maximum negotiated charge,discounted cash price
0,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,HMO,O,1881.00,160.85,162.47,936.63,1128.60
1,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,Medicaid,I,3199.87,740.21,1855.92,2543.89,1919.92
2,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,190,ms-drg,Chronic Obstructive Pulmonary Disease With MCC,aetna,EPO,I,21678.10,5783.22,5783.22,12966.75,13006.86
3,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72141,cpt,MRI Scan Of Upper Spinal Canal Without Contrast,aetna,Medicaid,O,2882.19,205.13,1642.85,2291.34,244.57
4,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11044,cpt,Removal Of Skin And Bone First 20 Sq Cm Or Less,aetna,Medicaid,O,3769.31,1215.96,1260.27,2751.80,2261.59
5,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0403,revCode,Other Imaging Services Screening Mammography,aetna,EPO,O,312.75,51.78,104.90,273.24,187.65
6,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna,EPO,O,2144.07,645.60,1279.68,2047.58,1286.44
7,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96361,cpt,"Infusion Into A Vein For Hydration, Each Additional Hour",aetna,POS,O,58.98,10.31,33.62,44.24,35.39
8,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna,Medicare Part B,O,176.96,19.79,96.59,99.98,106.18
9,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36415,cpt,Insertion Of Needle Into Vein For Collection Of Blood Sample,aetna,Medicare Part A,O,29.48,2.94,3.00,22.11,17.69
10,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77412,cpt,Delivery Of Complex Radiation Treatment,aetna,POS,O,933.20,214.04,510.62,666.46,256.85
11,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82565,cpt,Blood Creatinine Level,aetna,Medicare Part A,O,30.08,4.82,17.15,30.08,6.14
12,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83550,cpt,Iron Binding Capacity,aetna,Medicare Part A,O,106.28,8.57,60.58,106.28,10.49
13,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94640,cpt,Respiratory Inhaled Pressure Or Nonpressure Treatment To Relieve Airway Obstruction Or For Sputum Specimen,aetna,Medicaid,O,198.78,56.02,185.11,185.11,119.27
14,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,Medicaid,I,137.36,28.95,90.50,129.04,82.42
15,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,070,ms-drg,Nonspecific Cerebrovascular Disorders With MCC,aetna,Medicaid,I,31953.37,10314.69,10417.64,12207.30,19172.02
16,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78070,cpt,Nuclear Medicine Study Of Parathyroid,aetna,EPO,O,1314.27,400.84,749.13,749.13,788.56
17,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97140,cpt,"Manual (Physical) Therapy Techniques To 1 Or More Regions, Each 15 Minutes",aetna,Medicaid,O,232.41,20.93,103.49,164.45,139.45
18,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1644,cpt,"Injection, Heparin Sodium, Per 1000 Units",aetna,Medicaid,O,7.94,2.07,2.73,61.12,4.76
19,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86850,cpt,Screening Test For Red Blood Cell Antibodies,aetna,EPO,O,93.19,8.25,53.12,67.92,53.95
20,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,PPO,I,1495.87,276.63,903.80,903.80,897.52
21,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1030,cpt,"Injection, Methylprednisolone Acetate, 40 Mg",aetna,PPO,O,93.27,42.90,42.90,65.77,55.96
22,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna,Medicaid,O,490.78,263.76,343.76,352.65,294.47
23,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64450,cpt,Injection Of Anesthetic Agent And/Or Steroid Into Other Peripheral Nerve Or Branch,aetna,EPO,O,1533.00,1587.94,12436.52,12436.52,919.80
24,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71101,cpt,"X-Ray Of Ribs On One Side Of Body Including The Chest, Minimum Of 3 Views",aetna,EPO,O,356.28,61.44,203.08,203.08,115.81
25,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,872,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours Without MCC,aetna,Medicaid,I,20748.35,5256.97,6524.49,9809.76,12449.01
26,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80202,cpt,Vancomycin (Antibiotic) Level,aetna,POS,O,87.53,13.54,49.89,49.89,16.25
27,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76881,cpt,Complete Ultrasound Scan Of Joint,aetna,EPO,O,379.88,96.50,216.53,216.53,227.93
28,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7040,cpt,"Infusion, Normal Saline Solution, Sterile (500 Ml = 1 Unit)",aetna,Medicare Part B,O,157.91,58.43,71.06,157.91,94.75
29,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9035,cpt,"Injection, Bevacizumab, 10 Mg",aetna,EPO,O,282.70,75.76,77.46,77.46,169.62
30,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77280,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 1 Treatment Area",aetna,EPO,O,1037.01,112.36,591.10,733.79,134.83
31,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,812,ms-drg,Red Blood Cell Disorders Without MCC,aetna,Medicare Part B,I,18593.40,4553.02,5996.54,8936.86,11156.04
32,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77386,cpt,"Intensity Modulated Radiation Therapy Delivery, Complex",aetna,POS,O,2383.15,480.50,1303.99,1303.99,576.60
33,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88313,cpt,Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,aetna,POS,O,119.15,45.38,67.92,67.92,71.49
34,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73720,cpt,MRI Scan Of Leg Before And After Contrast,aetna,HMO,O,2882.19,326.01,1671.67,1671.67,1729.31
35,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9263,cpt,"Injection, Oxaliplatin, 0.5 Mg",aetna,PPO,O,7.79,0.10,0.10,1.89,4.67
36,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2997,cpt,"Injection, Alteplase Recombinant, 1 Mg",aetna,PPO,O,318.54,54.09,87.67,232.15,191.12
37,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19120,cpt,"Removal Of 1 Or More Breast Growth, Open Procedure",aetna,PPO,O,19283.58,2826.79,11249.61,11249.61,3355.94
38,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5103,cpt,"Injection, Infliximab-Dyyb, Biosimilar, (Inflectra), 10 Mg",aetna,Medicare Part B,O,114.15,40.05,51.37,114.15,68.49
39,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1335,cpt,"Injection, Ertapenem Sodium, 500 Mg",aetna,EPO,O,93.92,16.77,52.86,52.86,56.35
40,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71046,cpt,"X-Ray Of Chest, 2 Views",aetna,EPO,O,344.48,61.44,188.49,273.86,85.98
41,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0460,revCode,"Pulmonary Function, General",aetna,PPO,O,422.68,52.61,218.19,615.78,253.61
42,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,Medicare Part B,O,83.80,8.07,29.33,89.04,50.28
43,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86769,cpt,Measure Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antibody,aetna,Medicaid,O,89.25,16.93,51.77,66.94,50.56
44,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86334,cpt,Immunologic Analysis Technique On Serum (Immunofixation),aetna,Medicaid,O,132.12,17.37,75.31,99.09,26.81
45,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87510,cpt,"Detection Test For Gardnerella Vaginalis (Bacteria), Direct Probe Technique",aetna,EPO,O,107.59,12.03,58.87,104.55,24.06
46,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28008,cpt,Incision Of Tissues Of Muscle Compartment Of Foot And/Or Toe,aetna,EPO,O,15422.69,8682.40,8682.40,15484.76,9253.61
47,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna,EPO,O,88.82,7.62,50.63,66.62,9.32
48,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84550,cpt,"Uric Acid Level, Blood",aetna,HMO,O,50.01,4.52,29.01,79.60,5.42
49,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64484,cpt,"Injections Of Anesthetic And/Or Steroid Drug Into Lower Or Sacral Spine Nerve Root Using Imaging Guidance, Each Additional Level",aetna,Medicare Part A,O,12936.37,728.40,7904.05,7904.05,7761.82
50,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88172,cpt,Evaluation Of Fine Needle Aspirate,aetna,Medicare Part B,O,416.45,228.18,310.38,310.38,249.87
51,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,47563,cpt,Removal Of Gallbladder With X-Ray Study Of Bile Ducts Using An Endoscope,aetna,EPO,O,25129.00,4481.58,12544.52,12544.52,15077.40
52,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81050,cpt,Urine Volume Measurement,aetna,Medicaid,O,30.08,3.64,17.15,22.56,4.37
53,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86480,cpt,"Tuberculosis Test, Gamma Interferon",aetna,Medicare Part A,O,350.39,35.31,199.72,262.79,74.38
54,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85045,cpt,"Red Blood Count, Automated Test",aetna,Medicare Part A,O,38.92,2.44,3.98,14.01,4.79
55,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87081,cpt,Screening Test For Pathogenic Organisms,aetna,PPO,O,45.06,3.98,25.68,32.84,9.19
56,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73523,cpt,"X-Ray Of Both Hips With Pelvis, Minimum Of 5 Views",aetna,POS,O,636.63,58.51,384.65,536.48,115.81
57,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,885,ms-drg,Psychoses,aetna,PPO,I,17080.81,5566.92,6861.23,9301.98,10248.49
58,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78472,cpt,Nuclear Medicine Study Of Heart Pumping Function By Labeling Red Blood Cells With Measurement Of Internal Blood Volume Ejected With Every Beat Over Multiple Cycles,aetna,HMO,O,2168.12,333.98,333.99,645.81,1300.87
59,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0131,cpt,"Injection, Acetaminophen, 10 Mg",aetna,EPO,O,1.46,0.18,0.65,1.44,0.88
60,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,Medicare Part A,O,212.10,40.75,115.12,253.05,127.26
61,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97597,cpt,"Removal Of Tissue From Wounds Per Session, First 20 Sq Cms Or Less",aetna,Medicaid,O,596.96,89.68,159.02,159.02,358.18
62,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87070,cpt,"Bacterial Culture, Any Other Source Except Urine, Blood Or Stool, Aerobic",aetna,Medicare Part A,O,65.11,8.45,8.58,48.83,10.34
63,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0283,cpt,"Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound Care, As Part Of A Therapy Plan Of Care",aetna,PPO,O,93.19,9.47,40.58,93.19,55.91
64,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9060,cpt,"Injection, Cisplatin, Powder Or Solution, 10 Mg",aetna,Medicare Part A,O,7.79,1.85,1.85,2.82,4.67
65,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2405,cpt,"Injection, Ondansetron Hydrochloride, Per 1 Mg",aetna,EPO,O,19.54,1.76,8.78,19.52,11.72
66,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84703,cpt,Gonadotropin (Reproductive Hormone) Analysis,aetna,Medicaid,O,69.48,7.52,37.26,48.18,9.02
67,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86709,cpt,Measurement Of Hepatitis A Antibody (Igm),aetna,EPO,O,106.28,11.21,60.58,60.58,63.77
68,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna,POS,O,1654.04,96.51,942.80,984.47,115.81
69,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,885,ms-drg,Psychoses,aetna,HMO,I,17080.81,5566.92,6861.23,9301.98,10248.49
70,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7040,cpt,"Infusion, Normal Saline Solution, Sterile (500 Ml = 1 Unit)",aetna,HMO,O,157.91,58.43,71.06,157.91,94.75
71,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86360,cpt,"T Cell Count And Ratio, Including Ratio",aetna,Medicare Part B,O,220.61,31.37,125.75,125.75,132.37
72,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80202,cpt,Vancomycin (Antibiotic) Level,aetna,PPO,O,87.53,13.54,49.89,49.89,16.25
73,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77334,cpt,"Radiation Treatment Devices, Design And Construction, Complex",aetna,Medicare Part A,O,599.32,299.94,327.93,327.93,359.94
74,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88175,cpt,"Pap Test, Automated Thin Layer Preparation; Automated System And Manual Rescreening",aetna,Medicare Part A,O,83.33,0.35,47.50,60.74,31.93
75,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96365,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, 1 Hour Or Less",aetna,Medicaid,O,307.18,64.22,180.23,200.85,184.31
76,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0331,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration - Injection,aetna,HMO,O,270.45,26.27,71.27,513.21,162.27
77,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28008,cpt,Incision Of Tissues Of Muscle Compartment Of Foot And/Or Toe,aetna,Medicare Part A,O,15422.69,8682.40,8682.40,15484.76,9253.61
78,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87181,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Agar Dilution Method",aetna,POS,O,16.51,4.75,9.41,9.41,3.37
79,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,55250,cpt,Removal Of Sperm Duct,aetna,HMO,O,17158.79,1587.89,8468.46,8468.46,10295.27
80,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64635,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Single Facet Joint",aetna,Medicaid,O,7086.24,1523.14,4237.46,4237.46,4251.74
81,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9144,cpt,"Injection, Daratumumab, 10 Mg And Hyaluronidase-Fihj",aetna,Medicaid,O,139.92,43.18,45.07,45.65,83.95
82,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71271,cpt,Low Dose CT Scan Of Chest For Lung Cancer Screening,aetna,HMO,O,331.51,71.65,98.50,234.56,198.91
83,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93571,cpt,"Ultrasound Evaluation Of Heart Blood Vessel During Diagnosis Or Treatment, Initial Vessel",aetna,Medicare Part B,O,31969.64,4389.98,14191.44,14191.44,19181.78
84,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna,PPO,O,148.64,18.79,18.79,22.56,22.55
85,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86200,cpt,Measurement Of Antibody For Rheumatoid Arthritis Assessment,aetna,HMO,O,251.28,12.89,140.36,140.36,15.54
86,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73552,cpt,"X-Ray Of Thigh Bone, Minimum 2 Views",aetna,HMO,O,309.09,42.89,176.18,176.18,185.45
87,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93880,cpt,Ultrasound Scanning Of Blood Flow (Outside The Brain) On Both Sides Of Head And Neck,aetna,EPO,O,711.39,203.81,397.38,397.38,426.83
88,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87045,cpt,Stool Culture,aetna,PPO,O,80.09,9.05,46.05,46.05,11.33
89,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1335,cpt,"Injection, Ertapenem Sodium, 500 Mg",aetna,POS,O,93.92,16.77,52.86,52.86,56.35
90,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,EPO,O,63819.96,8894.43,14191.44,29488.15,38291.98
91,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1439,cpt,"Injection, Ferric Carboxymaltose, 1 Mg",aetna,Medicare Part B,O,4.45,0.79,2.09,2.09,2.67
92,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43450,cpt,Dilation Of Esophagus Unguided,aetna,PPO,O,3778.61,1075.52,1753.96,3815.86,2267.17
93,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49402,cpt,Removal Of Foreign Body From Abdominal Cavity,aetna,Medicaid,O,42363.98,24397.19,24397.19,24397.19,25418.39
94,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86762,cpt,Analysis For Antibody To Rubella (German Measles Virus),aetna,POS,O,50.01,4.42,27.36,37.51,17.10
95,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73560,cpt,"X-Ray Of Knee, 1 Or 2 Views",aetna,Medicare Part B,O,231.22,26.24,126.52,126.52,138.73
96,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73522,cpt,"X-Ray Of Both Hips With Pelvis, 3-4 Views",aetna,EPO,O,355.11,58.62,194.31,194.31,213.07
97,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9443,cpt,"Lactation Classes, Non-Physician Provider, Per Session",aetna,HMO,O,155.82,92.26,92.26,155.82,93.49
98,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84166,cpt,"Protein Measurement, Body Fluid",aetna,HMO,O,57.87,6.77,17.83,17.90,21.40
99,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3480,cpt,"Injection, Potassium Chloride, Per 2 Meq",aetna,Medicare Part B,O,2.35,0.80,1.02,1.02,1.41
100,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,POS,I,268.98,56.00,329.15,795.98,161.39
101,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76801,cpt,Abdominal Ultrasound Of Pregnant Uterus (Less Than 14 Weeks 0 Days) Single Or First Fetus,aetna,Medicare Part A,O,357.27,96.50,217.76,229.19,115.81
102,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7030,cpt,"Infusion, Normal Saline Solution , 1000 Cc",aetna,PPO,O,8.25,3.71,3.71,162.78,4.95
103,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82390,cpt,Ceruloplasmin (Protein) Level,aetna,POS,O,71.96,6.02,39.38,39.38,43.18
104,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17270,cpt,"Destruction Of Malignant Growth (0.5 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,HMO,O,1881.00,159.01,159.94,475.20,1128.60
105,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80307,cpt,"Testing For Presence Of Drug, By Chemistry Analyzers",aetna,EPO,O,197.60,49.05,49.06,62.39,118.56
106,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86778,cpt,Analysis For Antibody (Igm) To Toxoplasma (Parasite),aetna,POS,O,152.18,14.27,86.74,86.74,91.31
107,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,620,ms-drg,O.R. Procedures For Obesity With CC,aetna,Medicare Part A,I,57057.61,10746.01,10746.01,20648.25,34234.57
108,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0942,revCode,Medical Rehabilitation Day Program Education/Training,aetna,Medicaid,O,155.82,64.63,92.26,117.54,93.49
109,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96367,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Additional Sequential Infusion, 1 Hour Or Less",aetna,POS,O,117.97,25.86,64.55,88.48,70.78
110,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83690,cpt,Lipase (Fat Enzyme) Level,aetna,HMO,O,52.60,6.89,18.70,39.45,8.27
111,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84466,cpt,Transferrin (Iron Binding Protein) Level,aetna,Medicare Part A,O,67.24,10.47,36.80,36.80,40.34
112,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88342,cpt,"Special Stained Specimen Slides To Examine Tissue, Initial Procedure",aetna,HMO,O,419.99,33.03,239.39,314.99,251.99
113,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna,Medicaid,O,2535.33,203.81,1416.20,1958.54,244.57
114,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87301,cpt,Detection Test By Immunoassay Technique For Adenovirus Enteric Types 40/41,aetna,PPO,O,60.03,6.75,34.52,34.52,14.38
115,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86706,cpt,Hepatitis B Surface Antibody Measurement,aetna,PPO,O,94.38,6.44,52.72,70.79,12.89
116,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71046,cpt,"X-Ray Of Chest, 2 Views",aetna,POS,O,344.48,61.44,188.49,273.86,85.98
117,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45385,cpt,Removal Of Polyps Or Growths Of Large Bowel Using An Endoscope With Mechanical Snare,aetna,PPO,O,5305.34,938.17,2617.73,5400.89,1653.07
118,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72148,cpt,MRI Scan Of Lower Spinal Canal,aetna,Medicaid,O,2882.19,203.81,1642.85,2039.29,244.57
119,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9035,cpt,"Injection, Bevacizumab, 10 Mg",aetna,HMO,O,282.70,75.76,77.46,77.46,169.62
120,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84480,cpt,"Thyroid Hormone, T3 Measurement, Total",aetna,EPO,O,60.03,11.72,34.82,34.82,17.02
121,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97162,cpt,"Evaluation For Physical Therapy, Typically 30 Minutes",aetna,Medicare Part A,O,224.82,58.86,123.02,136.58,134.89
122,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0444,revCode,Occupational Therapy Evaluation Or Reevaluation,aetna,Medicaid,I,509.00,129.95,286.62,370.63,305.40
123,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83036,cpt,Hemoglobin A1c Level,aetna,PPO,O,76.68,5.83,41.96,57.51,11.65
124,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna,EPO,O,252.47,18.27,143.91,336.23,151.48
125,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45378,cpt,Diagnostic Colonoscopy Of Large Bowel Using A Flexible Endoscope,aetna,Medicaid,O,3131.25,717.01,1860.41,2251.40,861.59
126,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72195,cpt,MRI Scan Of Pelvis Without Contrast,aetna,PPO,O,1763.76,203.81,1005.34,1008.21,1058.26
127,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80306,cpt,"Testing For Presence Of Drug, Read By Instrument Assisted Observation",aetna,Medicare Part A,O,513.19,16.97,292.52,384.89,20.57
128,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2997,cpt,"Injection, Alteplase Recombinant, 1 Mg",aetna,HMO,O,318.54,54.09,87.67,232.15,191.12
129,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83021,cpt,"Hemoglobin Analysis And Measurement, Chromatography",aetna,POS,O,130.95,16.12,71.65,71.65,21.67
130,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86200,cpt,Measurement Of Antibody For Rheumatoid Arthritis Assessment,aetna,PPO,O,251.28,12.89,140.36,140.36,15.54
131,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96375,cpt,"Injection Of Different Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,HMO,O,88.47,19.71,48.41,66.35,53.08
132,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72050,cpt,"X-Ray Of Upper Spine, 4 Or 5 Views",aetna,POS,O,613.48,42.39,349.68,373.40,115.81
133,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93289,cpt,"Evaluation Of Defibrillator Including Connection, Recording And Disconnection",aetna,Medicare Part B,O,206.45,32.90,115.33,115.33,123.87
134,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80069,cpt,Kidney Function Blood Test Panel,aetna,HMO,O,67.58,8.51,38.52,38.52,10.42
135,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97110,cpt,"Therapeutic Exercise To Develop Strength, Endurance, Range Of Motion, And Flexibility, Each 15 Minutes",aetna,PPO,O,173.42,23.35,77.46,114.70,29.09
136,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84155,cpt,"Total Protein Level, Blood",aetna,EPO,O,69.00,3.67,3.67,51.75,4.40
137,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87045,cpt,Stool Culture,aetna,POS,O,80.09,9.05,46.05,46.05,11.33
138,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9299,cpt,"Injection, Nivolumab, 1 Mg",aetna,HMO,O,107.35,13.51,28.82,29.25,64.41
139,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72110,cpt,"X-Ray Of Lower And Sacral Spine, Minimum Of 4 Views",aetna,Medicaid,O,613.48,46.08,335.68,365.14,115.81
140,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9263,cpt,"Injection, Oxaliplatin, 0.5 Mg",aetna,Medicare Part B,O,7.79,0.10,0.10,1.89,4.67
141,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0360,revCode,"Operating Room Services, General",aetna,PPO,O,9825.06,1878.83,4989.15,12996.76,5895.04
142,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0131,cpt,"Injection, Acetaminophen, 10 Mg",aetna,Medicare Part A,O,1.46,0.18,0.65,1.44,0.88
143,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84403,cpt,"Testosterone (Hormone) Level, Total",aetna,Medicare Part B,O,135.66,25.30,77.33,101.75,30.97
144,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88177,cpt,"Pap Test, Evaluation Of Fine Needle Aspirate, Immediate, Each Additional Evaluation Episode",aetna,PPO,O,49.54,26.22,93.48,93.48,29.72
145,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,HMO,I,490.78,103.68,279.74,347.25,294.47
146,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72195,cpt,MRI Scan Of Pelvis Without Contrast,aetna,POS,O,1763.76,203.81,1005.34,1008.21,1058.26
147,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87181,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Agar Dilution Method",aetna,EPO,O,16.51,4.75,9.41,9.41,3.37
148,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S2900,cpt,Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure),aetna,PPO,O,26479.60,4481.58,24397.19,24397.19,15887.76
149,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87660,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Direct Probe Technique",aetna,Medicaid,O,114.43,12.03,62.62,85.82,24.06
150,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49320,cpt,Diagnostic Examination Of The Abdomen Using An Endoscope,aetna,Medicaid,O,23329.13,4381.91,24397.19,24397.19,13997.48
151,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna,Medicaid,O,1956.07,299.94,1070.30,1213.17,359.94
152,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,871,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours With MCC,aetna,POS,I,36297.45,7941.64,11794.58,17432.39,21778.47
153,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7120,cpt,"Ringers Lactate Infusion, Up To 1000 Cc",aetna,POS,O,162.48,32.42,74.74,162.48,97.49
154,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,300,ms-drg,Peripheral Vascular Disorders With CC,aetna,POS,I,19902.20,6642.09,6642.09,11743.17,11941.32
155,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45378,cpt,Diagnostic Colonoscopy Of Large Bowel Using A Flexible Endoscope,aetna,Medicare Part B,O,3131.25,717.01,1860.41,2251.40,861.59
156,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82565,cpt,Blood Creatinine Level,aetna,PPO,O,30.08,4.82,17.15,30.08,6.14
157,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88172,cpt,Evaluation Of Fine Needle Aspirate,aetna,PPO,O,416.45,228.18,310.38,310.38,249.87
158,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2370,cpt,"Injection, Phenylephrine Hcl, Up To 1 Ml",aetna,Medicaid,O,87.77,23.91,40.37,66.01,52.66
159,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96417,cpt,Infusion Of Different Chemotherapy Drug Or Substance Into A Vein Up To 1 Hour,aetna,EPO,O,241.84,54.88,132.33,181.38,145.10
160,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77301,cpt,Management Of Modulation Radiotherapy Planning,aetna,PPO,O,7734.62,1117.80,4232.16,4232.16,1341.41
161,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99204,cpt,"New Patient Office Or Other Outpatient Visit, 45-59 Minutes",aetna,POS,O,634.41,49.54,367.96,475.81,223.37
162,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76700,cpt,"Ultrasound Of Abdomen, Complete",aetna,HMO,O,970.94,96.51,542.36,771.89,116.30
163,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna,Medicare Part B,O,70.06,8.01,39.93,52.55,9.80
164,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96415,cpt,"Administration Of Chemotherapy Into Vein, Each Additional Hour",aetna,HMO,O,110.89,25.40,60.68,83.17,66.53
165,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82375,cpt,Carboxyhemoglobin (Protein) Level,aetna,Medicaid,O,103.50,12.32,60.03,77.63,14.78
166,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88172,cpt,Evaluation Of Fine Needle Aspirate,aetna,HMO,O,416.45,228.18,310.38,310.38,249.87
167,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,P9040,cpt,"Red Blood Cells, Leukocytes Reduced, Irradiated, Each Unit",aetna,POS,O,756.23,260.55,262.76,509.61,453.74
168,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33216,cpt,Insertion Of Electrode For Permanent Pacemaker Or Pacing Defibrillator Device,aetna,PPO,O,31268.54,3610.13,3610.13,3610.13,18761.12
169,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82627,cpt,Dehydroepiandrosterone (Dhea-S) Hormone Level,aetna,PPO,O,119.15,19.46,67.92,67.92,71.49
170,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna,Medicare Part A,O,2535.33,203.81,1416.20,1958.54,244.57
171,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9271,cpt,"Injection, Pembrolizumab, 1 Mg",aetna,Medicare Part A,O,192.29,32.26,52.73,144.22,115.37
172,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76881,cpt,Complete Ultrasound Scan Of Joint,aetna,PPO,O,379.88,96.50,216.53,216.53,227.93
173,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,POS,I,710.22,207.44,407.05,747.97,426.13
174,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,Medicare Part B,O,1881.00,160.85,162.47,936.63,1128.60
175,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9130,cpt,Dacarbazine 100 Mg Inj,aetna,Medicare Part A,O,15.58,5.03,5.03,16.51,9.35
176,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88331,cpt,"Pathology Examination Of Specimen During Surgery, First Tissue Block",aetna,Medicaid,O,438.52,153.98,254.34,254.34,263.11
177,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93308,cpt,Follow-Up Or Limited Ultrasound Examination Of Heart,aetna,PPO,O,415.27,203.81,204.22,403.52,249.16
178,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9579,cpt,"Injection, Gadolinium-Based Magnetic Resonance Contrast Agent, Not Otherwise Specified (Nos), Per Ml",aetna,EPO,O,15.32,0.10,6.89,16.23,9.19
179,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85520,cpt,Heparin Assay,aetna,Medicaid,O,67.89,39.38,39.38,39.38,40.73
180,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1644,cpt,"Injection, Heparin Sodium, Per 1000 Units",aetna,EPO,O,7.94,2.07,2.73,61.12,4.76
181,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0881,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (Non-Esrd Use)",aetna,PPO,O,15.58,2.38,7.43,7.43,9.35
182,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82248,cpt,"Bilirubin Level, Direct",aetna,EPO,O,41.28,4.92,14.47,14.47,6.02
183,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna,EPO,O,289.04,102.81,158.15,158.15,134.83
184,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73721,cpt,MRI Scan Of Leg Joint,aetna,HMO,O,2882.19,141.17,1577.05,2039.29,245.82
185,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3010,cpt,"Injection, Fentanyl Citrate, 0.1 Mg",aetna,PPO,O,82.61,17.19,37.17,85.93,49.57
186,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72197,cpt,MRI Scan Of Pelvis Before And After Contrast,aetna,POS,O,2882.19,326.01,329.84,2161.64,391.22
187,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,Medicaid,I,218.25,67.65,124.40,224.80,130.95
188,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0279,cpt,"Diagnostic Digital Breast Tomosynthesis, Unilateral Or Bilateral (List Separately In Addition To 77065 Or 77066)",aetna,Medicare Part B,O,120.33,22.38,69.79,95.66,72.20
189,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90694,cpt,"Influenza Virus Vaccine, Quadrivalent (Aiiv4), Inactivated, Adjuvanted, Preservative Free, For Injection Into Muscle, 0.5 Ml Dosage",aetna,Medicare Part B,O,193.98,23.39,23.39,61.00,116.39
190,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,58558,cpt,Biopsy Of Lining Of Uterus And/Or Removal Of Polyp Using An Endoscope,aetna,Medicaid,O,22844.35,2323.22,10420.95,10420.95,13706.61
191,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0410,revCode,"Respiratory Services, General",aetna,Medicare Part A,I,205.27,71.94,125.75,182.34,123.16
192,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0371,revCode,Anesthesia Incident To Radiology,aetna,Medicaid,I,47.19,8.72,26.90,26.90,28.31
193,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95819,cpt,"Measurement And Recording Of Brain Wave (Eeg) Activity, Awake And Asleep",aetna,Medicare Part A,O,779.82,234.21,444.50,735.68,467.89
194,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86140,cpt,Measurement C-Reactive Protein For Detection Of Infection Or Inflammation,aetna,EPO,O,67.58,5.08,38.52,50.69,6.22
195,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna,POS,O,67.58,3.47,5.78,47.82,6.94
196,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87177,cpt,Smear For Parasites,aetna,PPO,O,123.87,8.72,70.61,70.61,10.68
197,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43235,cpt,"Diagnostic Examination Of Esophagus, Stomach, And/Or Upper Small Bowel Using An Endoscope",aetna,Medicaid,O,3132.69,724.55,1758.22,2956.79,1171.78
198,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72195,cpt,MRI Scan Of Pelvis Without Contrast,aetna,Medicaid,O,1763.76,203.81,1005.34,1008.21,1058.26
199,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1453,cpt,"Injection, Fosaprepitant, 1 Mg",aetna,EPO,O,6.67,0.28,3.07,7.29,4.00
200,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,POS,O,110.40,7.04,8.00,129.02,66.24
201,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96377,cpt,Application Of On-Body Injector For Under Skin Injection,aetna,EPO,O,44.52,9.67,25.82,25.82,26.71
202,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85520,cpt,Heparin Assay,aetna,HMO,O,67.89,39.38,39.38,39.38,40.73
203,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33216,cpt,Insertion Of Electrode For Permanent Pacemaker Or Pacing Defibrillator Device,aetna,Medicare Part B,O,31268.54,3610.13,3610.13,3610.13,18761.12
204,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80307,cpt,"Testing For Presence Of Drug, By Chemistry Analyzers",aetna,PPO,O,197.60,49.05,49.06,62.39,118.56
205,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97605,cpt,"Negative Pressure Wound Therapy, Surface Area Less Than Or Equal To 50 Square Centimeters, Per Session",aetna,EPO,O,1788.02,425.00,754.73,826.48,1072.81
206,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0243,cpt,"Injection, Casirivimab And Imdevimab, 2400 Mg",aetna,HMO,O,0.03,0.01,0.01,11.63,0.02
207,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87624,cpt,"Detection Test By Nucleic Acid For Human Papillomavirus (Hpv), High-Risk Types",aetna,EPO,O,108.49,21.05,59.36,108.49,42.11
208,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna,HMO,O,108.88,10.16,59.58,77.04,20.33
209,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,Medicare Part B,O,1952.12,97.51,1370.07,1839.56,1171.27
210,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0279,cpt,"Diagnostic Digital Breast Tomosynthesis, Unilateral Or Bilateral (List Separately In Addition To 77065 Or 77066)",aetna,PPO,O,120.33,22.38,69.79,95.66,72.20
211,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88331,cpt,"Pathology Examination Of Specimen During Surgery, First Tissue Block",aetna,Medicare Part A,O,438.52,153.98,254.34,254.34,263.11
212,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82950,cpt,Blood Glucose (Sugar) Level After Receiving Dose Of Glucose,aetna,Medicaid,O,38.92,4.70,21.30,75.94,5.70
213,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0120,revCode,Room And Board Semiprivate (Two Beds) General,aetna,Medicaid,I,1274.16,366.55,685.17,6328.83,764.50
214,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna,Medicare Part A,O,982.00,159.01,162.47,1222.94,589.20
215,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna,POS,O,36.32,4.21,20.29,27.24,5.15
216,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72072,cpt,"X-Ray Of Middle Spine, 3 Views",aetna,PPO,O,356.28,33.86,199.02,249.40,116.30
217,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86769,cpt,Measure Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antibody,aetna,PPO,O,89.25,16.93,51.77,66.94,50.56
218,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9202,cpt,"Goserelin Acetate Implant, Per 3.6 Mg",aetna,Medicaid,O,1210.44,149.56,581.30,581.30,726.26
219,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96523,cpt,Irrigation Of Implanted Venous Access Drug Delivery Device,aetna,Medicaid,O,192.29,49.29,109.61,144.22,115.37
220,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna,POS,O,2535.33,203.81,1416.20,1958.54,244.57
221,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80053,cpt,"Blood Test, Comprehensive Group Of Blood Chemicals",aetna,EPO,O,91.30,10.35,49.96,68.47,12.67
222,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,EPO,O,238.18,42.44,143.91,252.47,142.91
223,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2505,cpt,"Injection, Pegfilgrastim, 6 Mg",aetna,Medicaid,O,17508.60,2251.51,6955.90,6955.90,10505.16
224,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77412,cpt,Delivery Of Complex Radiation Treatment,aetna,Medicaid,O,933.20,214.04,510.62,666.46,256.85
225,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73600,cpt,"X-Ray Of Ankle, 2 Views",aetna,POS,O,252.47,30.86,143.91,143.91,151.48
226,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99282,cpt,Emergency Department Visit For Problem Of Mild To Moderate Severity,aetna,Medicare Part B,E,276.06,99.19,160.11,290.62,165.64
227,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9130,cpt,Dacarbazine 100 Mg Inj,aetna,HMO,O,15.58,5.03,5.03,16.51,9.35
228,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96411,cpt,Administration Of Additional New Drug Or Substance Into Vein Using Push Technique,aetna,POS,O,238.30,49.47,130.40,178.73,142.98
229,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84165,cpt,"Protein Measurement, Serum",aetna,HMO,O,116.79,10.63,10.74,82.64,12.89
230,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76816,cpt,"Ultrasound Re-Evaluation Of Pregnant Uterus, Per Fetus",aetna,Medicare Part B,O,611.12,96.51,348.34,432.40,366.67
231,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17281,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,Medicaid,O,2354.50,306.29,393.96,1345.09,1412.70
232,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87389,cpt,Detection Test By Immunoassay Technique For Hiv-1 Antigen And Hiv-1 And Hiv-2 Antibodies,aetna,EPO,O,101.33,8.97,55.45,76.00,28.90
233,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17280,cpt,"Destruction Of Malignant Growth (0.5 Centimeters Or Less) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,PPO,O,1569.00,159.01,162.47,542.48,941.40
234,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84402,cpt,"Testosterone (Hormone) Level, Free",aetna,Medicaid,O,70.78,13.11,38.73,53.09,30.56
235,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93279,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Single Lead Pacemaker System In One Chamber Of Heart With Qualified Health Care Professional Analysis, Review, And Report",aetna,EPO,O,180.49,32.90,32.90,76.59,108.29
236,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna,PPO,O,251.28,64.70,137.49,266.35,150.77
237,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9306,cpt,"Injection, Pertuzumab, 1 Mg",aetna,EPO,O,44.82,10.05,14.64,424.56,26.89
238,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43244,cpt,Tying Of Dilated Veins Of Stomach And/Or Esophagus Using A Flexible Endoscope,aetna,HMO,O,4323.48,1441.59,1441.59,1469.46,2594.09
239,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82962,cpt,Blood Glucose (Sugar) Test Performed By Hand-Held Instrument,aetna,Medicaid,O,42.58,3.28,24.27,42.58,3.94
240,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86592,cpt,Syphilis Detection Test,aetna,PPO,O,40.11,4.27,22.41,30.08,5.12
241,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72195,cpt,MRI Scan Of Pelvis Without Contrast,aetna,Medicare Part A,O,1763.76,203.81,1005.34,1008.21,1058.26
242,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94729,cpt,Test To Examine How Well The Lungs Exchange Gases,aetna,Medicare Part A,O,218.25,52.60,119.42,119.42,130.95
243,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna,HMO,O,4073.77,814.60,2322.05,3238.64,977.56
244,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92920,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Each Additional Artery Or Branch",aetna,PPO,O,63533.28,4389.98,4389.98,25971.62,38119.97
245,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82731,cpt,Fetal Fibronectin (Protein) Analysis,aetna,POS,O,565.34,60.62,64.37,424.01,115.33
246,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,638,ms-drg,Diabetes With CC,aetna,PPO,I,20621.27,4023.89,8833.24,8833.24,12372.76
247,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92611,cpt,Fluoroscopic And Video Recorded Motion Evaluation Of Swallowing Function,aetna,EPO,O,328.90,87.83,190.76,190.76,197.34
248,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17281,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,Medicare Part B,O,2354.50,306.29,393.96,1345.09,1412.70
249,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97597,cpt,"Removal Of Tissue From Wounds Per Session, First 20 Sq Cms Or Less",aetna,PPO,O,596.96,89.68,159.02,159.02,358.18
250,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2632,cpt,"Post Chmbr Intraocular Lens; Prosthetics, Orthotics, And Supplies",aetna,HMO,O,797.52,202.98,270.86,797.52,478.51
251,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,47563,cpt,Removal Of Gallbladder With X-Ray Study Of Bile Ducts Using An Endoscope,aetna,PPO,O,25129.00,4481.58,12544.52,12544.52,15077.40
252,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna,EPO,O,84.93,5.32,30.50,63.70,15.10
253,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97140,cpt,"Manual (Physical) Therapy Techniques To 1 Or More Regions, Each 15 Minutes",aetna,HMO,O,232.41,20.93,103.49,164.45,139.45
254,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92921,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Single Artery Or Branch",aetna,Medicaid,O,71846.71,8777.72,8894.43,14120.90,43108.03
255,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82746,cpt,"Folic Acid Level, Serum",aetna,EPO,O,65.11,9.14,37.11,37.11,17.64
256,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73720,cpt,MRI Scan Of Leg Before And After Contrast,aetna,Medicare Part A,O,2882.19,326.01,1671.67,1671.67,1729.31
257,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80069,cpt,Kidney Function Blood Test Panel,aetna,Medicare Part A,O,67.58,8.51,38.52,38.52,10.42
258,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,Medicaid,O,3199.87,326.01,1445.14,2637.87,1919.92
259,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82565,cpt,Blood Creatinine Level,aetna,HMO,O,30.08,4.82,17.15,30.08,6.14
260,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11102,cpt,"Biopsy Of Related Skin Growth, First Growth",aetna,PPO,O,1042.00,159.01,160.97,708.35,625.20
261,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90694,cpt,"Influenza Virus Vaccine, Quadrivalent (Aiiv4), Inactivated, Adjuvanted, Preservative Free, For Injection Into Muscle, 0.5 Ml Dosage",aetna,PPO,O,193.98,23.39,23.39,61.00,116.39
262,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,300,ms-drg,Peripheral Vascular Disorders With CC,aetna,HMO,I,19902.20,6642.09,6642.09,11743.17,11941.32
263,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83540,cpt,Iron Level,aetna,Medicaid,O,41.28,6.35,23.53,41.28,7.76
264,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,Medicaid,I,216.65,43.99,86.21,184.92,129.99
265,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87591,cpt,"Detection Test By Nucleic Acid For Neisseria Gonorrhoeae (Gonorrhoeae Bacteria), Amplified Probe Technique",aetna,PPO,O,147.58,21.05,82.44,110.69,42.11
266,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80074,cpt,Acute Hepatitis Panel,aetna,POS,O,213.87,26.66,117.03,117.03,57.16
267,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C8908,cpt,"Magnetic Resonance Imaging Without Contrast Followed By With Contrast, Breast; Bilateral",aetna,Medicare Part B,O,3010.79,326.02,1716.15,1716.15,1806.47
268,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87389,cpt,Detection Test By Immunoassay Technique For Hiv-1 Antigen And Hiv-1 And Hiv-2 Antibodies,aetna,Medicare Part A,O,101.33,8.97,55.45,76.00,28.90
269,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66991,cpt,Extracapsular Removal Of Cataract With Insertion Of Artificial Lens And Insertion Of Drainage Device In Front Chamber Of Eye,aetna,Medicaid,O,8752.90,3729.66,3729.66,3765.43,5251.74
270,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88360,cpt,"Microscopic Genetic Analysis Of Tumor, Manual",aetna,POS,O,331.51,126.27,188.96,188.96,198.91
271,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S2900,cpt,Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure),aetna,POS,O,26479.60,4481.58,24397.19,24397.19,15887.76
272,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,Medicaid,O,238.18,42.44,143.91,252.47,142.91
273,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85379,cpt,"Coagulation Function Measurement, D-Dimer; Quantitative",aetna,Medicare Part B,O,122.56,9.98,71.08,71.08,12.22
274,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93279,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Single Lead Pacemaker System In One Chamber Of Heart With Qualified Health Care Professional Analysis, Review, And Report",aetna,PPO,O,180.49,32.90,32.90,76.59,108.29
275,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96365,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, 1 Hour Or Less",aetna,Medicare Part B,O,307.18,64.22,180.23,200.85,184.31
276,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99283,cpt,Emergency Department Visit For Problem Of Moderate Severity,aetna,Medicare Part B,E,871.53,205.11,459.97,892.25,522.92
277,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11045,cpt,"Removal Of Skin And Tissue, Each Additional 20.0 Sq Cm Or Less",aetna,EPO,O,2875.83,306.28,312.72,3179.32,1725.50
278,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82627,cpt,Dehydroepiandrosterone (Dhea-S) Hormone Level,aetna,Medicaid,O,119.15,19.46,67.92,67.92,71.49
279,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna,Medicare Part A,O,93.19,18.38,53.12,74.09,55.91
280,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,Medicare Part A,I,218.25,67.65,124.40,224.80,130.95
281,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88175,cpt,"Pap Test, Automated Thin Layer Preparation; Automated System And Manual Rescreening",aetna,EPO,O,83.33,0.35,47.50,60.74,31.93
282,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36415,cpt,Insertion Of Needle Into Vein For Collection Of Blood Sample,aetna,HMO,O,29.48,2.94,3.00,22.11,17.69
283,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88173,cpt,Evaluation Of Fine Needle Aspirate With Interpretation And Report,aetna,POS,O,109.71,60.12,81.77,81.77,65.83
284,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87661,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Amplified Probe Technique",aetna,POS,O,151.64,21.05,84.70,113.73,42.11
285,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0312,revCode,Laboratory Pathology Histology,aetna,Medicare Part B,O,419.99,131.76,239.39,419.99,251.99
286,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna,POS,O,88.82,7.62,50.63,66.62,9.32
287,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna,Medicare Part B,O,373.98,199.25,204.64,352.82,359.94
288,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83883,cpt,"Nephelometry, Test Method Using Light",aetna,Medicaid,O,93.19,11.70,13.60,69.89,16.32
289,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17280,cpt,"Destruction Of Malignant Growth (0.5 Centimeters Or Less) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,Medicaid,O,1569.00,159.01,162.47,542.48,941.40
290,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33216,cpt,Insertion Of Electrode For Permanent Pacemaker Or Pacing Defibrillator Device,aetna,Medicaid,O,31268.54,3610.13,3610.13,3610.13,18761.12
291,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0434,revCode,"Occupational Therapy, Evaluation Or Reevaluation",aetna,HMO,I,357.27,76.33,271.01,357.27,214.36
292,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83880,cpt,Natriuretic Peptide (Heart And Blood Vessel Protein) Level,aetna,HMO,O,130.11,25.90,39.26,92.07,47.11
293,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9443,cpt,"Lactation Classes, Non-Physician Provider, Per Session",aetna,Medicaid,O,155.82,92.26,92.26,155.82,93.49
294,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,PPO,I,2452.75,716.49,1897.41,2313.92,1471.65
295,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0521,revCode,Freestanding Clinic Clinic Visit By Member Torhc/Fqhc,aetna,HMO,O,195.00,111.87,111.87,244.91,117.00
296,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85651,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Non-Automated",aetna,Medicare Part B,O,13.00,1.77,4.25,4.68,7.80
297,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,HMO,I,726.73,207.37,642.32,642.32,436.04
298,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86300,cpt,"Immunologic Analysis For Detection Of Tumor Antigen, Quantitative; Ca 15-3",aetna,EPO,O,85.70,20.40,51.78,90.84,24.97
299,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82550,cpt,"Creatine Kinase (Cardiac Enzyme) Level, Total",aetna,POS,O,60.16,6.44,33.61,33.61,7.81
300,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82803,cpt,Blood Gases Measurement,aetna,Medicare Part B,O,158.08,26.07,86.50,86.50,30.97
301,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36598,cpt,Contrast Injections For X-Ray Imaging Procedure To Evaluate Central Venous Access Device,aetna,EPO,O,1156.30,162.25,585.00,585.00,693.78
302,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82950,cpt,Blood Glucose (Sugar) Level After Receiving Dose Of Glucose,aetna,POS,O,38.92,4.70,21.30,75.94,5.70
303,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2469,cpt,"Injection, Palonosetron Hcl, 25 Mcg",aetna,POS,O,90.84,19.36,39.42,85.70,54.50
304,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84439,cpt,"Thyroxine (Thyroid Chemical), Free",aetna,HMO,O,52.60,8.84,28.79,39.45,10.82
305,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66984,cpt,"Removal Of Cataract With Insertion Of Lens, Simple",aetna,POS,O,14664.91,1841.26,3839.82,4337.53,8798.95
306,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77301,cpt,Management Of Modulation Radiotherapy Planning,aetna,Medicaid,O,7734.62,1117.80,4232.16,4232.16,1341.41
307,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71260,cpt,CT Scan Of Chest With Contrast,aetna,Medicare Part B,O,1774.38,129.65,1011.40,1330.79,189.76
308,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,POS,O,58.98,6.19,15.24,1399.28,35.39
309,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0710,revCode,Recovery Room General,aetna,PPO,O,3506.08,933.94,2267.67,2982.15,2103.65
310,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,190,ms-drg,Chronic Obstructive Pulmonary Disease With MCC,aetna,Medicaid,I,21678.10,5783.22,5783.22,12966.75,13006.86
311,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85651,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Non-Automated",aetna,HMO,O,13.00,1.77,4.25,4.68,7.80
312,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,POS,O,238.18,42.44,143.91,252.47,142.91
313,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna,PPO,O,93.19,18.38,53.12,74.09,55.91
314,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,Medicare Part A,I,726.73,207.37,642.32,642.32,436.04
315,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96361,cpt,"Infusion Into A Vein For Hydration, Each Additional Hour",aetna,HMO,O,58.98,10.31,33.62,44.24,35.39
316,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,Medicare Part B,I,973.23,169.01,169.01,1031.60,583.94
317,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,POS,I,281.58,60.08,199.37,281.58,168.95
318,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,271,ms-drg,Other Major Cardiovascular Procedures With CC,aetna,POS,I,68161.35,20934.94,27743.68,28893.46,40896.81
319,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88360,cpt,"Microscopic Genetic Analysis Of Tumor, Manual",aetna,Medicare Part B,O,331.51,126.27,188.96,188.96,198.91
320,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,236,ms-drg,Coronary Bypass Without Cardiac Catheterization Without MCC,aetna,EPO,I,156904.89,23866.31,23891.99,44284.10,94142.93
321,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88341,cpt,"Special Stained Specimen Slides To Examine Tissue, Each Additional Procedure",aetna,Medicaid,O,125.04,25.34,71.27,125.04,75.02
322,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,Medicare Part A,O,711.39,96.53,359.62,479.92,426.83
323,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna,PPO,O,252.47,18.27,143.91,336.23,151.48
324,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna,PPO,O,281.96,102.95,163.54,224.15,123.54
325,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2632,cpt,"Post Chmbr Intraocular Lens; Prosthetics, Orthotics, And Supplies",aetna,Medicaid,O,797.52,202.98,270.86,797.52,478.51
326,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36600,cpt,Arterial Puncture Withdrawal Of Blood For Diagnosis,aetna,HMO,O,179.32,34.87,147.18,147.18,107.59
327,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna,HMO,O,120.33,10.08,65.84,90.25,20.16
328,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73522,cpt,"X-Ray Of Both Hips With Pelvis, 3-4 Views",aetna,PPO,O,355.11,58.62,194.31,194.31,213.07
329,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9271,cpt,"Injection, Pembrolizumab, 1 Mg",aetna,EPO,O,192.29,32.26,52.73,144.22,115.37
330,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87496,cpt,"Detection Test By Nucleic Acid For Cytomegalovirus (Cmv), Amplified Probe Technique",aetna,Medicare Part B,O,191.11,108.93,108.93,108.93,114.67
331,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93452,cpt,Insertion Of Tube In Left Heart Chambers For Diagnosis With Review By Radiologist,aetna,PPO,I,54103.79,7333.25,7333.25,7333.25,32462.27
332,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1170,cpt,"Injection, Hydromorphone, Up To 4 Mg",aetna,PPO,O,82.88,16.96,38.12,82.88,49.73
333,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9171,cpt,"Injection, Docetaxel, 1 Mg",aetna,Medicaid,O,15.58,0.67,0.67,4.17,9.35
334,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83883,cpt,"Nephelometry, Test Method Using Light",aetna,HMO,O,93.19,11.70,13.60,69.89,16.32
335,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74018,cpt,"X-Ray Of Abdomen, 1 View",aetna,POS,O,268.98,61.44,147.18,285.11,85.98
336,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85651,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Non-Automated",aetna,EPO,O,13.00,1.77,4.25,4.68,7.80
337,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,Medicaid,I,973.23,169.01,169.01,1031.60,583.94
338,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,PPO,O,479.00,41.29,159.02,1803.87,287.40
339,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80202,cpt,Vancomycin (Antibiotic) Level,aetna,Medicaid,O,87.53,13.54,49.89,49.89,16.25
340,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9445,cpt,"Patient Education, Not Otherwise Classified, Non-Physician Provider, Individual, Per Session",aetna,HMO,O,104.62,78.47,104.62,114.22,62.77
341,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96411,cpt,Administration Of Additional New Drug Or Substance Into Vein Using Push Technique,aetna,Medicare Part A,O,238.30,49.47,130.40,178.73,142.98
342,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17281,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,PPO,O,2354.50,306.29,393.96,1345.09,1412.70
343,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2632,cpt,"Post Chmbr Intraocular Lens; Prosthetics, Orthotics, And Supplies",aetna,POS,O,797.52,202.98,270.86,797.52,478.51
344,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86334,cpt,Immunologic Analysis Technique On Serum (Immunofixation),aetna,POS,O,132.12,17.37,75.31,99.09,26.81
345,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81050,cpt,Urine Volume Measurement,aetna,POS,O,30.08,3.64,17.15,22.56,4.37
346,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77300,cpt,Calculation Of Radiation Therapy Dose,aetna,Medicaid,O,273.70,47.14,131.71,131.71,134.83
347,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0441,revCode,Occupational Therapy Visit Charge,aetna,PPO,O,328.90,81.87,190.76,190.76,197.34
348,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,070,ms-drg,Nonspecific Cerebrovascular Disorders With MCC,aetna,HMO,I,31953.37,10314.69,10417.64,12207.30,19172.02
349,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85652,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Automated",aetna,EPO,O,38.92,2.65,21.30,29.59,3.24
350,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93280,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Dual Lead Pacemaker System With Physician Analysis, Review, And Report",aetna,POS,O,214.80,32.43,32.51,76.59,128.88
351,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86920,cpt,"Blood Unit Compatibility Test, Immediate Spin Technique",aetna,EPO,O,373.98,33.03,132.10,152.61,79.26
352,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82950,cpt,Blood Glucose (Sugar) Level After Receiving Dose Of Glucose,aetna,Medicare Part A,O,38.92,4.70,21.30,75.94,5.70
353,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77063,cpt,Screening Digital Tomography Of Both Breasts,aetna,POS,O,184.03,20.92,100.70,167.23,110.42
354,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93452,cpt,Insertion Of Tube In Left Heart Chambers For Diagnosis With Review By Radiologist,aetna,Medicaid,I,54103.79,7333.25,7333.25,7333.25,32462.27
355,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna,HMO,O,67.58,3.47,5.78,47.82,6.94
356,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87205,cpt,Special Gram Or Giemsa Stain For Microorganism,aetna,Medicare Part A,O,87.53,4.18,4.25,65.65,5.12
357,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87496,cpt,"Detection Test By Nucleic Acid For Cytomegalovirus (Cmv), Amplified Probe Technique",aetna,HMO,O,191.11,108.93,108.93,108.93,114.67
358,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna,PPO,O,67.58,3.47,5.78,47.82,6.94
359,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90694,cpt,"Influenza Virus Vaccine, Quadrivalent (Aiiv4), Inactivated, Adjuvanted, Preservative Free, For Injection Into Muscle, 0.5 Ml Dosage",aetna,EPO,O,193.98,23.39,23.39,61.00,116.39
360,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9035,cpt,"Injection, Bevacizumab, 10 Mg",aetna,PPO,O,282.70,75.76,77.46,77.46,169.62
361,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82652,cpt,"Dihydroxyvitamin D, 1, 25 Level",aetna,PPO,O,221.79,38.50,126.42,166.34,46.20
362,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71270,cpt,CT Scan Of Chest Before And After Contrast,aetna,PPO,O,2554.21,161.61,161.61,161.61,192.38
363,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86920,cpt,"Blood Unit Compatibility Test, Immediate Spin Technique",aetna,Medicare Part B,O,373.98,33.03,132.10,152.61,79.26
364,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78306,cpt,Nuclear Medicine Study Of Bone And/Or Joint Whole Body,aetna,HMO,O,848.21,330.97,483.48,522.98,400.79
365,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,330,ms-drg,Major Small And Large Bowel Procedures With CC,aetna,PPO,I,58731.07,15126.82,15186.72,23610.09,35238.64
366,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1453,cpt,"Injection, Fosaprepitant, 1 Mg",aetna,PPO,O,6.67,0.28,3.07,7.29,4.00
367,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93280,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Dual Lead Pacemaker System With Physician Analysis, Review, And Report",aetna,EPO,O,214.80,32.43,32.51,76.59,128.88
368,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,Medicaid,O,218.25,35.37,121.91,263.09,130.95
369,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,871,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours With MCC,aetna,Medicare Part B,I,36297.45,7941.64,11794.58,17432.39,21778.47
370,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97530,cpt,"Therapeutic Activities To Improve Function, With One-On-One Contact Between Patient And Provider, Each 15 Minutes",aetna,Medicare Part A,O,166.34,34.57,91.02,91.02,99.80
371,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna,PPO,O,2144.07,645.60,1279.68,2047.58,1286.44
372,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97165,cpt,"Evaluation For Occupational Therapy, Typically 30 Minutes",aetna,POS,O,211.24,71.93,120.41,120.41,126.74
373,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0114,revCode,Room And Board Private (One Bed) Psychiatric,aetna,HMO,I,2200.28,629.26,1203.93,7562.58,1320.17
374,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86780,cpt,"Analysis For Antibody, Treponema Pallidum",aetna,Medicare Part B,O,331.50,12.98,188.96,248.62,198.90
375,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78227,cpt,Nuclear Medicine Study Of Liver And Bile Duct System With Use Of Drugs,aetna,Medicare Part A,O,1528.98,161.81,836.62,1038.75,520.12
376,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0460,revCode,"Pulmonary Function, General",aetna,Medicaid,O,422.68,52.61,218.19,615.78,253.61
377,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90694,cpt,"Influenza Virus Vaccine, Quadrivalent (Aiiv4), Inactivated, Adjuvanted, Preservative Free, For Injection Into Muscle, 0.5 Ml Dosage",aetna,Medicare Part A,O,193.98,23.39,23.39,61.00,116.39
378,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77301,cpt,Management Of Modulation Radiotherapy Planning,aetna,EPO,O,7734.62,1117.80,4232.16,4232.16,1341.41
379,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0942,revCode,Medical Rehabilitation Day Program Education/Training,aetna,Medicare Part A,O,155.82,64.63,92.26,117.54,93.49
380,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0881,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (Non-Esrd Use)",aetna,HMO,O,15.58,2.38,7.43,7.43,9.35
381,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0942,revCode,Medical Rehabilitation Day Program Education/Training,aetna,POS,O,155.82,64.63,92.26,117.54,93.49
382,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0269,cpt,"Placement Of Occlusive Device Into Either A Venous Or Arterial Access Site, Post Surgical Or Interventional Procedure (E.G., Angioseal Plug, Vascular Plug)",aetna,POS,O,67707.99,403.09,4389.98,14226.92,40624.79
383,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,236,ms-drg,Coronary Bypass Without Cardiac Catheterization Without MCC,aetna,PPO,I,156904.89,23866.31,23891.99,44284.10,94142.93
384,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11047,cpt,"Removal Of Bone, Each Additional 20.0 Sq Cm Or Less",aetna,Medicare Part B,O,12247.63,1215.96,1247.54,1273.00,7348.58
385,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9263,cpt,"Injection, Oxaliplatin, 0.5 Mg",aetna,HMO,O,7.79,0.10,0.10,1.89,4.67
386,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0410,revCode,"Respiratory Services, General",aetna,Medicaid,I,205.27,71.94,125.75,182.34,123.16
387,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90686,cpt,"Vaccine For Influenza For Administration Into Muscle, 0.5 Ml Dosage, Quadrivalent, Preservation Free",aetna,Medicaid,O,132.44,13.48,20.93,79.94,79.46
388,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0333,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Radiation Therapy,aetna,HMO,O,933.20,214.04,481.06,1795.20,559.92
389,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,287,ms-drg,"Circulatory Disorders Except Ami, With Cardiac Catheterization Without MCC",aetna,Medicare Part B,I,39655.14,7316.35,7333.25,13218.75,23793.08
390,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9202,cpt,"Goserelin Acetate Implant, Per 3.6 Mg",aetna,HMO,O,1210.44,149.56,581.30,581.30,726.26
391,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36600,cpt,Arterial Puncture Withdrawal Of Blood For Diagnosis,aetna,Medicare Part A,O,179.32,34.87,147.18,147.18,107.59
392,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,371,ms-drg,Major Gastrointestinal Disorders And Peritoneal Infections With MCC,aetna,POS,I,34185.44,8873.88,8873.88,11142.92,20511.26
393,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3010,cpt,"Injection, Fentanyl Citrate, 0.1 Mg",aetna,HMO,O,82.61,17.19,37.17,85.93,49.57
394,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71270,cpt,CT Scan Of Chest Before And After Contrast,aetna,POS,O,2554.21,161.61,161.61,161.61,192.38
395,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0500,cpt,"Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care Professional Performing A Gastrointestinal Endoscopic Service That Sedation Supports, Requiring The Presence Of",aetna,HMO,O,47.19,27.14,27.14,47.19,28.31
396,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93452,cpt,Insertion Of Tube In Left Heart Chambers For Diagnosis With Review By Radiologist,aetna,POS,I,54103.79,7333.25,7333.25,7333.25,32462.27
397,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93280,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Dual Lead Pacemaker System With Physician Analysis, Review, And Report",aetna,Medicare Part B,O,214.80,32.43,32.51,76.59,128.88
398,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0333,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Radiation Therapy,aetna,EPO,O,933.20,214.04,481.06,1795.20,559.92
399,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73620,cpt,"X-Ray Of Foot, 2 Views",aetna,Medicare Part A,O,252.47,61.44,143.91,143.91,151.48
400,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86430,cpt,Rheumatoid Factor Analysis,aetna,Medicare Part B,O,42.58,6.10,14.72,31.94,7.37
401,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0482,revCode,"Cardiology, Stress Test",aetna,HMO,O,474.26,84.78,270.33,377.03,284.56
402,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,PPO,O,83.80,8.07,29.33,89.04,50.28
403,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0114,revCode,Room And Board Private (One Bed) Psychiatric,aetna,Medicare Part B,I,2200.28,629.26,1203.93,7562.58,1320.17
404,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86038,cpt,Screening Test For Autoimmune Disorder,aetna,PPO,O,105.06,0.47,36.51,45.12,14.51
405,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,Medicare Part A,I,7.39,2.22,3.59,34.05,4.43
406,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,POS,I,140.26,41.63,88.86,224.92,84.16
407,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0710,revCode,Recovery Room General,aetna,POS,O,3506.08,933.94,2267.67,2982.15,2103.65
408,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,58558,cpt,Biopsy Of Lining Of Uterus And/Or Removal Of Polyp Using An Endoscope,aetna,PPO,O,22844.35,2323.22,10420.95,10420.95,13706.61
409,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0260,revCode,Intravenous (Iv) Therapy,aetna,Medicare Part B,O,325.61,56.09,185.60,1926.96,195.37
410,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna,EPO,O,50.72,5.89,27.75,35.89,7.21
411,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,300,ms-drg,Peripheral Vascular Disorders With CC,aetna,EPO,I,19902.20,6642.09,6642.09,11743.17,11941.32
412,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73600,cpt,"X-Ray Of Ankle, 2 Views",aetna,EPO,O,252.47,30.86,143.91,143.91,151.48
413,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70553,cpt,MRI Scan Of Brain Before And After Contrast,aetna,POS,O,3824.84,25.27,2092.84,3040.75,391.22
414,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49402,cpt,Removal Of Foreign Body From Abdominal Cavity,aetna,EPO,O,42363.98,24397.19,24397.19,24397.19,25418.39
415,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84166,cpt,"Protein Measurement, Body Fluid",aetna,PPO,O,57.87,6.77,17.83,17.90,21.40
416,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36598,cpt,Contrast Injections For X-Ray Imaging Procedure To Evaluate Central Venous Access Device,aetna,POS,O,1156.30,162.25,585.00,585.00,693.78
417,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87045,cpt,Stool Culture,aetna,Medicaid,O,80.09,9.05,46.05,46.05,11.33
418,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,287,ms-drg,"Circulatory Disorders Except Ami, With Cardiac Catheterization Without MCC",aetna,HMO,I,39655.14,7316.35,7333.25,13218.75,23793.08
419,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94726,cpt,Determination Of Lung Volumes Using Plethysmography,aetna,HMO,O,501.40,116.04,274.35,274.35,300.84
420,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna,Medicare Part A,O,252.47,18.27,143.91,336.23,151.48
421,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95819,cpt,"Measurement And Recording Of Brain Wave (Eeg) Activity, Awake And Asleep",aetna,Medicaid,O,779.82,234.21,444.50,735.68,467.89
422,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43244,cpt,Tying Of Dilated Veins Of Stomach And/Or Esophagus Using A Flexible Endoscope,aetna,Medicare Part B,O,4323.48,1441.59,1441.59,1469.46,2594.09
423,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9445,cpt,"Patient Education, Not Otherwise Classified, Non-Physician Provider, Individual, Per Session",aetna,Medicaid,O,104.62,78.47,104.62,114.22,62.77
424,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna,Medicaid,O,289.04,102.81,158.15,158.15,134.83
425,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5101,cpt,"Injection, Filgrastim-Sndz, Biosimilar, (Zarxio), 1 Microgram",aetna,EPO,O,1.85,0.17,0.35,0.35,1.11
426,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,10005,cpt,"Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth",aetna,Medicare Part A,O,2422.63,555.63,1193.41,1567.18,1453.58
427,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,638,ms-drg,Diabetes With CC,aetna,EPO,I,20621.27,4023.89,8833.24,8833.24,12372.76
428,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82375,cpt,Carboxyhemoglobin (Protein) Level,aetna,HMO,O,103.50,12.32,60.03,77.63,14.78
429,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80069,cpt,Kidney Function Blood Test Panel,aetna,POS,O,67.58,8.51,38.52,38.52,10.42
430,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,POS,O,83.80,8.07,29.33,89.04,50.28
431,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93452,cpt,Insertion Of Tube In Left Heart Chambers For Diagnosis With Review By Radiologist,aetna,Medicare Part A,I,54103.79,7333.25,7333.25,7333.25,32462.27
432,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna,PPO,O,1884.10,427.65,1030.93,1413.08,1130.46
433,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna,Medicaid,O,108.88,10.16,59.58,77.04,20.33
434,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77300,cpt,Calculation Of Radiation Therapy Dose,aetna,Medicare Part A,O,273.70,47.14,131.71,131.71,134.83
435,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna,Medicare Part B,O,88.82,7.62,50.63,66.62,9.32
436,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,Medicaid,I,1495.87,276.63,903.80,903.80,897.52
437,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83880,cpt,Natriuretic Peptide (Heart And Blood Vessel Protein) Level,aetna,EPO,O,130.11,25.90,39.26,92.07,47.11
438,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86735,cpt,Analysis For Antibody To Mumps Virus,aetna,POS,O,50.01,7.59,27.36,35.01,30.01
439,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83690,cpt,Lipase (Fat Enzyme) Level,aetna,Medicare Part B,O,52.60,6.89,18.70,39.45,8.27
440,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0463,cpt,Hospital Outpatient Clinic Visit For Assessment And Management Of A Patient,aetna,POS,O,176.96,59.81,102.70,107.50,106.18
441,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0120,revCode,Room And Board Semiprivate (Two Beds) General,aetna,HMO,I,1274.16,366.55,685.17,6328.83,764.50
442,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88360,cpt,"Microscopic Genetic Analysis Of Tumor, Manual",aetna,EPO,O,331.51,126.27,188.96,188.96,198.91
443,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C8908,cpt,"Magnetic Resonance Imaging Without Contrast Followed By With Contrast, Breast; Bilateral",aetna,POS,O,3010.79,326.02,1716.15,1716.15,1806.47
444,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna,Medicare Part A,O,329.15,22.74,190.91,261.67,197.49
445,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97163,cpt,"Evaluation For Physical Therapy, Typically 45 Minutes",aetna,POS,O,281.58,53.70,154.08,154.08,168.95
446,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93280,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Dual Lead Pacemaker System With Physician Analysis, Review, And Report",aetna,PPO,O,214.80,32.43,32.51,76.59,128.88
447,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97165,cpt,"Evaluation For Occupational Therapy, Typically 30 Minutes",aetna,Medicare Part B,O,211.24,71.93,120.41,120.41,126.74
448,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76536,cpt,Ultrasound Scan Of Head And Neck Soft Tissue,aetna,POS,O,491.96,96.50,269.19,391.10,295.18
449,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76999,cpt,Other Ultrasound Procedure,aetna,HMO,O,238.30,71.65,130.40,216.32,142.98
450,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73721,cpt,MRI Scan Of Leg Joint,aetna,Medicaid,O,2882.19,141.17,1577.05,2039.29,245.82
451,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2704,cpt,"Injection, Propofol, 10 Mg",aetna,HMO,O,4.12,0.82,1.89,4.12,2.47
452,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70553,cpt,MRI Scan Of Brain Before And After Contrast,aetna,EPO,O,3824.84,25.27,2092.84,3040.75,391.22
453,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73070,cpt,"X-Ray Of Elbow, 2 Views",aetna,EPO,O,238.30,35.12,143.98,143.98,142.98
454,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0371,revCode,Anesthesia Incident To Radiology,aetna,Medicare Part B,I,47.19,8.72,26.90,26.90,28.31
455,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,Medicare Part B,I,72.54,19.89,124.91,124.91,43.52
456,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27328,cpt,Removal (Less Than 5 Centimeters) Muscle Growth Of Thigh Or Knee,aetna,Medicaid,O,23211.17,12578.62,12578.62,12578.62,13926.70
457,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,POS,O,1952.12,97.51,1370.07,1839.56,1171.27
458,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9171,cpt,"Injection, Docetaxel, 1 Mg",aetna,Medicare Part A,O,15.58,0.67,0.67,4.17,9.35
459,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,064,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With MCC,aetna,POS,I,42514.90,11561.36,11613.14,15935.29,25508.94
460,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96366,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Each Additional Hour",aetna,HMO,O,307.18,19.72,178.16,178.16,184.31
461,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11606,cpt,"Removal Of Malignant Growth (Over 4.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,Medicare Part B,O,17489.70,4901.08,9591.25,9591.25,10493.82
462,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87661,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Amplified Probe Technique",aetna,EPO,O,151.64,21.05,84.70,113.73,42.11
463,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97035,cpt,"Application Of Ultrasound To 1 Or More Areas, Each 15 Minutes",aetna,Medicare Part B,O,106.18,10.67,46.92,46.92,63.71
464,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85014,cpt,Red Blood Cell Concentration Measurement,aetna,HMO,O,28.77,2.35,16.40,21.58,2.84
465,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97163,cpt,"Evaluation For Physical Therapy, Typically 45 Minutes",aetna,PPO,O,281.58,53.70,154.08,154.08,168.95
466,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11104,cpt,Punch Biopsy Of Single Skin Lesion,aetna,PPO,O,2056.68,306.29,1669.70,3042.91,1234.01
467,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0463,cpt,Hospital Outpatient Clinic Visit For Assessment And Management Of A Patient,aetna,Medicare Part A,O,176.96,59.81,102.70,107.50,106.18
468,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76536,cpt,Ultrasound Scan Of Head And Neck Soft Tissue,aetna,Medicare Part A,O,491.96,96.50,269.19,391.10,295.18
469,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0434,revCode,"Occupational Therapy, Evaluation Or Reevaluation",aetna,POS,I,357.27,76.33,271.01,357.27,214.36
470,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74183,cpt,MRI Scan Of Abdomen Before And After Contrast,aetna,Medicare Part B,O,3824.84,326.02,2180.16,2180.16,2294.90
471,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64484,cpt,"Injections Of Anesthetic And/Or Steroid Drug Into Lower Or Sacral Spine Nerve Root Using Imaging Guidance, Each Additional Level",aetna,POS,O,12936.37,728.40,7904.05,7904.05,7761.82
472,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0260,revCode,Intravenous (Iv) Therapy,aetna,PPO,O,325.61,56.09,185.60,1926.96,195.37
473,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96401,cpt,Administration Of Non-Hormonal Anti-Neoplastic Chemotherapy Under Skin Or Into Muscle,aetna,PPO,O,286.67,27.44,27.44,63.97,172.00
474,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0942,revCode,Medical Rehabilitation Day Program Education/Training,aetna,HMO,O,155.82,64.63,92.26,117.54,93.49
475,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70220,cpt,"X-Ray Of Paranasal Sinus, Complete, Minimum Of 3 Views",aetna,HMO,O,342.13,47.22,195.01,271.99,205.28
476,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,Medicare Part A,O,479.00,41.29,159.02,1803.87,287.40
477,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,PPO,I,2882.19,290.04,2229.62,2229.62,1729.31
478,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70220,cpt,"X-Ray Of Paranasal Sinus, Complete, Minimum Of 3 Views",aetna,EPO,O,342.13,47.22,195.01,271.99,205.28
479,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86038,cpt,Screening Test For Autoimmune Disorder,aetna,Medicare Part B,O,105.06,0.47,36.51,45.12,14.51
480,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84703,cpt,Gonadotropin (Reproductive Hormone) Analysis,aetna,POS,O,69.48,7.52,37.26,48.18,9.02
481,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93308,cpt,Follow-Up Or Limited Ultrasound Examination Of Heart,aetna,Medicare Part A,O,415.27,203.81,204.22,403.52,249.16
482,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72146,cpt,MRI Scan Of Middle Spinal Canal Without Contrast,aetna,EPO,O,2882.19,207.32,821.42,821.42,248.82
483,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92920,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Each Additional Artery Or Branch",aetna,Medicare Part A,O,63533.28,4389.98,4389.98,25971.62,38119.97
484,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,776,ms-drg,Postpartum And Post Abortion Diagnoses Without O.R. Procedures,aetna,Medicare Part A,I,14400.00,2525.16,5439.38,9082.13,8640.00
485,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9202,cpt,"Goserelin Acetate Implant, Per 3.6 Mg",aetna,PPO,O,1210.44,149.56,581.30,581.30,726.26
486,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna,Medicare Part B,I,5647.36,1115.96,3413.14,3995.78,3388.42
487,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87340,cpt,Detection Test By Immunoassay Technique For Hepatitis B Surface Antigen,aetna,Medicare Part B,O,80.09,7.09,45.65,60.07,12.40
488,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99214,cpt,"Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes",aetna,HMO,O,423.60,59.52,255.94,255.94,254.16
489,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,271,ms-drg,Other Major Cardiovascular Procedures With CC,aetna,EPO,I,68161.35,20934.94,27743.68,28893.46,40896.81
490,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86696,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 2",aetna,PPO,O,126.23,19.24,69.07,94.67,23.22
491,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna,Medicare Part A,O,50.72,6.48,17.70,38.04,7.78
492,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,070,ms-drg,Nonspecific Cerebrovascular Disorders With MCC,aetna,PPO,I,31953.37,10314.69,10417.64,12207.30,19172.02
493,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,190,ms-drg,Chronic Obstructive Pulmonary Disease With MCC,aetna,Medicare Part B,I,21678.10,5783.22,5783.22,12966.75,13006.86
494,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87186,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or Agar Dilution",aetna,HMO,O,47.53,6.92,8.65,35.65,10.38
495,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71271,cpt,Low Dose CT Scan Of Chest For Lung Cancer Screening,aetna,PPO,O,331.51,71.65,98.50,234.56,198.91
496,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17281,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,EPO,O,2354.50,306.29,393.96,1345.09,1412.70
497,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77280,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 1 Treatment Area",aetna,POS,O,1037.01,112.36,591.10,733.79,134.83
498,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0441,revCode,Occupational Therapy Visit Charge,aetna,POS,O,328.90,81.87,190.76,190.76,197.34
499,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82962,cpt,Blood Glucose (Sugar) Test Performed By Hand-Held Instrument,aetna,EPO,O,42.58,3.28,24.27,42.58,3.94
500,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80069,cpt,Kidney Function Blood Test Panel,aetna,EPO,O,67.58,8.51,38.52,38.52,10.42
501,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83540,cpt,Iron Level,aetna,PPO,O,41.28,6.35,23.53,41.28,7.76
502,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71101,cpt,"X-Ray Of Ribs On One Side Of Body Including The Chest, Minimum Of 3 Views",aetna,HMO,O,356.28,61.44,203.08,203.08,115.81
503,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0882,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (For Esrd On Dialysis)",aetna,Medicaid,O,16.51,7.43,7.43,7.43,9.91
504,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,Medicaid,O,2882.19,203.81,1577.05,2039.29,1729.31
505,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5115,cpt,"Injection, Rituximab-Abbs, Biosimilar, (Truxima), 10 Mg",aetna,HMO,O,218.36,61.56,68.50,163.77,131.02
506,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0710,revCode,Recovery Room General,aetna,Medicare Part B,O,3506.08,933.94,2267.67,2982.15,2103.65
507,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78070,cpt,Nuclear Medicine Study Of Parathyroid,aetna,PPO,O,1314.27,400.84,749.13,749.13,788.56
508,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,Medicaid,O,711.39,96.53,359.62,479.92,426.83
509,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11045,cpt,"Removal Of Skin And Tissue, Each Additional 20.0 Sq Cm Or Less",aetna,Medicaid,O,2875.83,306.28,312.72,3179.32,1725.50
510,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86920,cpt,"Blood Unit Compatibility Test, Immediate Spin Technique",aetna,POS,O,373.98,33.03,132.10,152.61,79.26
511,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83021,cpt,"Hemoglobin Analysis And Measurement, Chromatography",aetna,Medicare Part A,O,130.95,16.12,71.65,71.65,21.67
512,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82652,cpt,"Dihydroxyvitamin D, 1, 25 Level",aetna,EPO,O,221.79,38.50,126.42,166.34,46.20
513,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90694,cpt,"Influenza Virus Vaccine, Quadrivalent (Aiiv4), Inactivated, Adjuvanted, Preservative Free, For Injection Into Muscle, 0.5 Ml Dosage",aetna,HMO,O,193.98,23.39,23.39,61.00,116.39
514,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0330,cpt,"Injection, Succinylcholine Chloride, Up To 20 Mg",aetna,Medicare Part A,O,97.93,26.00,44.25,73.44,58.76
515,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9445,cpt,"Patient Education, Not Otherwise Classified, Non-Physician Provider, Individual, Per Session",aetna,EPO,O,104.62,78.47,104.62,114.22,62.77
516,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96365,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, 1 Hour Or Less",aetna,PPO,O,307.18,64.22,180.23,200.85,184.31
517,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88331,cpt,"Pathology Examination Of Specimen During Surgery, First Tissue Block",aetna,PPO,O,438.52,153.98,254.34,254.34,263.11
518,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27328,cpt,Removal (Less Than 5 Centimeters) Muscle Growth Of Thigh Or Knee,aetna,POS,O,23211.17,12578.62,12578.62,12578.62,13926.70
519,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87491,cpt,"Detection Test By Nucleic Acid For Chlamydia Trachomatis, Amplified Probe Technique",aetna,POS,O,147.58,21.05,82.44,110.69,42.11
520,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0710,revCode,Recovery Room General,aetna,EPO,O,3506.08,933.94,2267.67,2982.15,2103.65
521,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96416,cpt,Prolonged Chemotherapy Infusion Into A Vein By Portable Or Implanted Pump More Than 8 Hours,aetna,POS,O,535.61,119.50,290.78,401.71,321.37
522,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87255,cpt,Virus Isolation,aetna,POS,O,123.87,33.86,67.78,81.80,40.63
523,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0371,revCode,Anesthesia Incident To Radiology,aetna,Medicare Part A,I,47.19,8.72,26.90,26.90,28.31
524,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S2900,cpt,Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure),aetna,EPO,O,26479.60,4481.58,24397.19,24397.19,15887.76
525,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27328,cpt,Removal (Less Than 5 Centimeters) Muscle Growth Of Thigh Or Knee,aetna,Medicare Part B,O,23211.17,12578.62,12578.62,12578.62,13926.70
526,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64484,cpt,"Injections Of Anesthetic And/Or Steroid Drug Into Lower Or Sacral Spine Nerve Root Using Imaging Guidance, Each Additional Level",aetna,EPO,O,12936.37,728.40,7904.05,7904.05,7761.82
527,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,690,ms-drg,Kidney And Urinary Tract Infections Without MCC,aetna,EPO,I,16840.52,3735.53,9339.74,9339.74,10104.31
528,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1644,cpt,"Injection, Heparin Sodium, Per 1000 Units",aetna,HMO,O,7.94,2.07,2.73,61.12,4.76
529,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna,HMO,O,176.96,19.79,96.59,99.98,106.18
530,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11401,cpt,"Removal Of Growth (0.6 To 1.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,HMO,O,4292.00,309.74,309.74,2167.15,2575.20
531,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36598,cpt,Contrast Injections For X-Ray Imaging Procedure To Evaluate Central Venous Access Device,aetna,HMO,O,1156.30,162.25,585.00,585.00,693.78
532,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71101,cpt,"X-Ray Of Ribs On One Side Of Body Including The Chest, Minimum Of 3 Views",aetna,Medicaid,O,356.28,61.44,203.08,203.08,115.81
533,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80306,cpt,"Testing For Presence Of Drug, Read By Instrument Assisted Observation",aetna,EPO,O,513.19,16.97,292.52,384.89,20.57
534,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,Medicare Part B,O,479.00,41.29,159.02,1803.87,287.40
535,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96402,cpt,Hormonal Anti-Neoplastic Chemotherapy Administration Beneath The Skin Or Into Muscle,aetna,Medicare Part A,O,125.04,21.31,71.27,71.27,75.02
536,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78306,cpt,Nuclear Medicine Study Of Bone And/Or Joint Whole Body,aetna,Medicare Part B,O,848.21,330.97,483.48,522.98,400.79
537,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83883,cpt,"Nephelometry, Test Method Using Light",aetna,PPO,O,93.19,11.70,13.60,69.89,16.32
538,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96401,cpt,Administration Of Non-Hormonal Anti-Neoplastic Chemotherapy Under Skin Or Into Muscle,aetna,Medicaid,O,286.67,27.44,27.44,63.97,172.00
539,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97530,cpt,"Therapeutic Activities To Improve Function, With One-On-One Contact Between Patient And Provider, Each 15 Minutes",aetna,EPO,O,166.34,34.57,91.02,91.02,99.80
540,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76536,cpt,Ultrasound Scan Of Head And Neck Soft Tissue,aetna,HMO,O,491.96,96.50,269.19,391.10,295.18
541,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,Medicaid,O,63819.96,8894.43,14191.44,29488.15,38291.98
542,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82962,cpt,Blood Glucose (Sugar) Test Performed By Hand-Held Instrument,aetna,POS,O,42.58,3.28,24.27,42.58,3.94
543,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73070,cpt,"X-Ray Of Elbow, 2 Views",aetna,Medicare Part B,O,238.30,35.12,143.98,143.98,142.98
544,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28080,cpt,Removal Of Fibrous Nerve Growth From Between Toes,aetna,Medicare Part A,O,17456.96,1200.71,9928.29,9928.29,10474.18
545,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73552,cpt,"X-Ray Of Thigh Bone, Minimum 2 Views",aetna,Medicaid,O,309.09,42.89,176.18,176.18,185.45
546,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84702,cpt,"Gonadotropin, Chorionic (Reproductive Hormone) Level",aetna,Medicare Part A,O,67.24,15.05,36.80,47.58,18.06
547,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74018,cpt,"X-Ray Of Abdomen, 1 View",aetna,Medicaid,O,268.98,61.44,147.18,285.11,85.98
548,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84425,cpt,Vitamin B-1 (Thiamine) Level,aetna,Medicare Part B,O,138.03,18.33,75.53,75.53,82.82
549,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87480,cpt,"Detection Test For Candida Species (Yeast), Direct Probe Technique",aetna,Medicaid,O,107.59,12.03,58.87,80.69,24.06
550,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna,Medicaid,O,93.19,18.38,53.12,74.09,55.91
551,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81050,cpt,Urine Volume Measurement,aetna,Medicare Part A,O,30.08,3.64,17.15,22.56,4.37
552,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11045,cpt,"Removal Of Skin And Tissue, Each Additional 20.0 Sq Cm Or Less",aetna,Medicare Part A,O,2875.83,306.28,312.72,3179.32,1725.50
553,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,HMO,I,137.36,28.95,90.50,129.04,82.42
554,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86300,cpt,"Immunologic Analysis For Detection Of Tumor Antigen, Quantitative; Ca 15-3",aetna,POS,O,85.70,20.40,51.78,90.84,24.97
555,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,Medicare Part B,I,1495.87,276.63,903.80,903.80,897.52
556,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85597,cpt,Platelet Function Test,aetna,Medicare Part A,O,89.65,9.41,51.10,67.24,21.58
557,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38505,cpt,Needle Biopsy Or Removal Of Surface Lymph Nodes,aetna,Medicare Part B,O,8266.58,1246.10,7074.31,7074.31,4959.95
558,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73552,cpt,"X-Ray Of Thigh Bone, Minimum 2 Views",aetna,PPO,O,309.09,42.89,176.18,176.18,185.45
559,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78306,cpt,Nuclear Medicine Study Of Bone And/Or Joint Whole Body,aetna,Medicaid,O,848.21,330.97,483.48,522.98,400.79
560,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,40490,cpt,Biopsy Of Lip,aetna,POS,O,1535.00,623.16,642.96,1044.00,921.00
561,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0138,cpt,"Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (Non-Esrd Use)",aetna,HMO,O,4.45,0.69,0.93,1.82,2.67
562,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna,POS,O,50.01,3.11,27.36,66.28,6.22
563,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93880,cpt,Ultrasound Scanning Of Blood Flow (Outside The Brain) On Both Sides Of Head And Neck,aetna,PPO,O,711.39,203.81,397.38,397.38,426.83
564,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1200,cpt,"Injection, Diphenhydramine Hcl, Up To 50 Mg",aetna,Medicare Part A,O,3.52,0.76,18.38,80.35,2.11
565,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7040,cpt,"Infusion, Normal Saline Solution, Sterile (500 Ml = 1 Unit)",aetna,EPO,O,157.91,58.43,71.06,157.91,94.75
566,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85597,cpt,Platelet Function Test,aetna,Medicaid,O,89.65,9.41,51.10,67.24,21.58
567,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3010,cpt,"Injection, Fentanyl Citrate, 0.1 Mg",aetna,Medicaid,O,82.61,17.19,37.17,85.93,49.57
568,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96416,cpt,Prolonged Chemotherapy Infusion Into A Vein By Portable Or Implanted Pump More Than 8 Hours,aetna,Medicare Part B,O,535.61,119.50,290.78,401.71,321.37
569,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1335,cpt,"Injection, Ertapenem Sodium, 500 Mg",aetna,PPO,O,93.92,16.77,52.86,52.86,56.35
570,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82550,cpt,"Creatine Kinase (Cardiac Enzyme) Level, Total",aetna,Medicare Part A,O,60.16,6.44,33.61,33.61,7.81
571,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93225,cpt,Electrocardiogram (Ecg) 2-Day Continuous,aetna,POS,O,251.28,64.70,119.50,199.77,150.77
572,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0114,revCode,Room And Board Private (One Bed) Psychiatric,aetna,PPO,I,2200.28,629.26,1203.93,7562.58,1320.17
573,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna,PPO,O,108.88,10.16,59.58,77.04,20.33
574,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43450,cpt,Dilation Of Esophagus Unguided,aetna,Medicaid,O,3778.61,1075.52,1753.96,3815.86,2267.17
575,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83883,cpt,"Nephelometry, Test Method Using Light",aetna,EPO,O,93.19,11.70,13.60,69.89,16.32
576,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna,Medicaid,O,329.15,22.74,190.91,261.67,197.49
577,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97163,cpt,"Evaluation For Physical Therapy, Typically 45 Minutes",aetna,EPO,O,281.58,53.70,154.08,154.08,168.95
578,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11104,cpt,Punch Biopsy Of Single Skin Lesion,aetna,POS,O,2056.68,306.29,1669.70,3042.91,1234.01
579,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82248,cpt,"Bilirubin Level, Direct",aetna,Medicare Part B,O,41.28,4.92,14.47,14.47,6.02
580,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,287,ms-drg,"Circulatory Disorders Except Ami, With Cardiac Catheterization Without MCC",aetna,POS,I,39655.14,7316.35,7333.25,13218.75,23793.08
581,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11104,cpt,Punch Biopsy Of Single Skin Lesion,aetna,Medicaid,O,2056.68,306.29,1669.70,3042.91,1234.01
582,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,371,ms-drg,Major Gastrointestinal Disorders And Peritoneal Infections With MCC,aetna,Medicare Part B,I,34185.44,8873.88,8873.88,11142.92,20511.26
583,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73610,cpt,"X-Ray Of Ankle, Minimum Of 3 Views",aetna,PPO,O,329.15,46.08,180.10,261.67,197.49
584,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19084,cpt,"Biopsy Of Breast And Placement Of Locating Device Using Ultrasound, Each Additional Growth",aetna,Medicaid,O,12042.88,1246.10,6742.37,6742.37,7225.73
585,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82626,cpt,Dehydroepiandrosterone (Dhea) Hormone Level,aetna,EPO,O,148.02,23.79,85.85,85.85,88.81
586,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72148,cpt,MRI Scan Of Lower Spinal Canal,aetna,POS,O,2882.19,203.81,1642.85,2039.29,244.57
587,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,Medicare Part B,O,218.25,35.37,121.91,263.09,130.95
588,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49402,cpt,Removal Of Foreign Body From Abdominal Cavity,aetna,Medicare Part A,O,42363.98,24397.19,24397.19,24397.19,25418.39
589,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92610,cpt,Evaluation Of Swallowing Function,aetna,Medicare Part B,O,286.43,81.46,166.13,166.13,171.86
590,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna,Medicare Part A,O,95.71,16.18,16.18,21.31,19.42
591,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,Medicare Part B,O,110.40,7.04,8.00,129.02,66.24
592,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87046,cpt,"Stool Culture, Additional Pathogens",aetna,Medicare Part B,O,52.60,5.92,30.25,30.25,11.33
593,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1437,cpt,"Injection, Ferric Derisomaltose, 10 Mg",aetna,Medicare Part A,O,80.56,14.43,25.38,25.82,48.34
594,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93279,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Single Lead Pacemaker System In One Chamber Of Heart With Qualified Health Care Professional Analysis, Review, And Report",aetna,Medicare Part A,O,180.49,32.90,32.90,76.59,108.29
595,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0274,revCode,"Medical/Surgical Supplies And Devices, Prosthetic/Orthotic Devices",aetna,PPO,O,89.04,8.13,2026.64,2026.64,53.42
596,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,POS,O,2882.19,203.81,1577.05,2039.29,1729.31
597,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna,Medicaid,O,4073.77,814.60,2322.05,3238.64,977.56
598,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0441,revCode,Occupational Therapy Visit Charge,aetna,EPO,O,328.90,81.87,190.76,190.76,197.34
599,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87660,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Direct Probe Technique",aetna,EPO,O,114.43,12.03,62.62,85.82,24.06
600,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna,Medicaid,O,52.60,6.47,8.08,42.46,9.70
601,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,811,ms-drg,Red Blood Cell Disorders With MCC,aetna,Medicaid,I,34462.34,8519.29,8897.14,15450.42,20677.40
602,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11045,cpt,"Removal Of Skin And Tissue, Each Additional 20.0 Sq Cm Or Less",aetna,HMO,O,2875.83,306.28,312.72,3179.32,1725.50
603,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49402,cpt,Removal Of Foreign Body From Abdominal Cavity,aetna,PPO,O,42363.98,24397.19,24397.19,24397.19,25418.39
604,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0434,revCode,"Occupational Therapy, Evaluation Or Reevaluation",aetna,Medicaid,I,357.27,76.33,271.01,357.27,214.36
605,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49320,cpt,Diagnostic Examination Of The Abdomen Using An Endoscope,aetna,EPO,O,23329.13,4381.91,24397.19,24397.19,13997.48
606,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,Medicare Part A,O,8.83,1.76,5.12,26.77,5.30
607,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna,EPO,O,148.64,18.79,18.79,22.56,22.55
608,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,POS,I,726.73,207.37,642.32,642.32,436.04
609,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,POS,I,973.23,169.01,169.01,1031.60,583.94
610,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76999,cpt,Other Ultrasound Procedure,aetna,Medicare Part A,O,238.30,71.65,130.40,216.32,142.98
611,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9060,cpt,"Injection, Cisplatin, Powder Or Solution, 10 Mg",aetna,HMO,O,7.79,1.85,1.85,2.82,4.67
612,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78815,cpt,Nuclear Medicine Study From Skull Base To Mid-Thigh With CT Scan,aetna,Medicare Part B,O,7116.42,1311.00,3893.89,5657.55,4269.85
613,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1644,cpt,"Injection, Heparin Sodium, Per 1000 Units",aetna,Medicare Part A,O,7.94,2.07,2.73,61.12,4.76
614,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73600,cpt,"X-Ray Of Ankle, 2 Views",aetna,PPO,O,252.47,30.86,143.91,143.91,151.48
615,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna,POS,O,176.96,19.79,96.59,99.98,106.18
616,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84439,cpt,"Thyroxine (Thyroid Chemical), Free",aetna,EPO,O,52.60,8.84,28.79,39.45,10.82
617,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86765,cpt,Analysis For Antibody To Rubeola (Measles Virus),aetna,HMO,O,50.01,7.69,55.32,55.32,30.01
618,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82652,cpt,"Dihydroxyvitamin D, 1, 25 Level",aetna,Medicare Part A,O,221.79,38.50,126.42,166.34,46.20
619,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74018,cpt,"X-Ray Of Abdomen, 1 View",aetna,EPO,O,268.98,61.44,147.18,285.11,85.98
620,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11606,cpt,"Removal Of Malignant Growth (Over 4.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,POS,O,17489.70,4901.08,9591.25,9591.25,10493.82
621,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82550,cpt,"Creatine Kinase (Cardiac Enzyme) Level, Total",aetna,HMO,O,60.16,6.44,33.61,33.61,7.81
622,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,603,ms-drg,Cellulitis Without MCC,aetna,Medicare Part B,I,19499.58,3283.09,5672.80,12955.93,11699.75
623,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73522,cpt,"X-Ray Of Both Hips With Pelvis, 3-4 Views",aetna,Medicare Part B,O,355.11,58.62,194.31,194.31,213.07
624,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0335,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration -Iv,aetna,PPO,O,487.49,86.82,282.74,11490.04,292.49
625,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C8908,cpt,"Magnetic Resonance Imaging Without Contrast Followed By With Contrast, Breast; Bilateral",aetna,Medicare Part A,O,3010.79,326.02,1716.15,1716.15,1806.47
626,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,M0243,cpt,"Intravenous Infusion, Casirivimab And Imdevimab Includes Infusion And Post Administration Monitoring",aetna,EPO,O,820.47,138.86,502.86,502.86,492.28
627,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96401,cpt,Administration Of Non-Hormonal Anti-Neoplastic Chemotherapy Under Skin Or Into Muscle,aetna,Medicare Part A,O,286.67,27.44,27.44,63.97,172.00
628,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1453,cpt,"Injection, Fosaprepitant, 1 Mg",aetna,Medicaid,O,6.67,0.28,3.07,7.29,4.00
629,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70220,cpt,"X-Ray Of Paranasal Sinus, Complete, Minimum Of 3 Views",aetna,PPO,O,342.13,47.22,195.01,271.99,205.28
630,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,Medicare Part A,O,58.98,6.19,15.24,1399.28,35.39
631,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87255,cpt,Virus Isolation,aetna,Medicaid,O,123.87,33.86,67.78,81.80,40.63
632,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna,EPO,O,50.72,6.48,17.70,38.04,7.78
633,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33235,cpt,Removal Of Dual Electrodes From Right Heart,aetna,HMO,O,21468.71,3610.13,3610.13,3610.13,12881.23
634,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82310,cpt,"Calcium Level, Total",aetna,EPO,O,36.61,5.16,5.16,36.61,21.97
635,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86038,cpt,Screening Test For Autoimmune Disorder,aetna,POS,O,105.06,0.47,36.51,45.12,14.51
636,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73218,cpt,MRI Scan Of Arm Without Contrast,aetna,Medicare Part A,O,2882.19,206.00,1642.85,2719.05,1729.31
637,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83690,cpt,Lipase (Fat Enzyme) Level,aetna,Medicaid,O,52.60,6.89,18.70,39.45,8.27
638,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5103,cpt,"Injection, Infliximab-Dyyb, Biosimilar, (Inflectra), 10 Mg",aetna,PPO,O,114.15,40.05,51.37,114.15,68.49
639,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,811,ms-drg,Red Blood Cell Disorders With MCC,aetna,EPO,I,34462.34,8519.29,8897.14,15450.42,20677.40
640,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,330,ms-drg,Major Small And Large Bowel Procedures With CC,aetna,EPO,I,58731.07,15126.82,15186.72,23610.09,35238.64
641,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna,EPO,O,14.15,0.48,0.89,8.71,8.49
642,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82310,cpt,"Calcium Level, Total",aetna,Medicare Part A,O,36.61,5.16,5.16,36.61,21.97
643,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0343,revCode,"Nuclear Medicine, Diagnostic Radiopharmaceuticals",aetna,Medicare Part B,O,692.52,123.81,394.74,1192.32,415.51
644,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna,Medicare Part A,O,281.96,102.95,163.54,224.15,123.54
645,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92610,cpt,Evaluation Of Swallowing Function,aetna,HMO,O,286.43,81.46,166.13,166.13,171.86
646,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96367,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Additional Sequential Infusion, 1 Hour Or Less",aetna,Medicare Part A,O,117.97,25.86,64.55,88.48,70.78
647,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1200,cpt,"Injection, Diphenhydramine Hcl, Up To 50 Mg",aetna,Medicaid,O,3.52,0.76,18.38,80.35,2.11
648,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73522,cpt,"X-Ray Of Both Hips With Pelvis, 3-4 Views",aetna,HMO,O,355.11,58.62,194.31,194.31,213.07
649,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0612,revCode,Magnetic Resonance Technology (Mrt) Spinal Cord/Spine,aetna,Medicaid,O,2882.19,203.81,1642.85,2100.47,1729.31
650,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1335,cpt,"Injection, Ertapenem Sodium, 500 Mg",aetna,Medicaid,O,93.92,16.77,52.86,52.86,56.35
651,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95811,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab With Continued Pressured Respiratory Assistance By Mask Or Breathing Tube,aetna,PPO,O,3186.58,814.60,1816.35,1816.35,1911.95
652,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73070,cpt,"X-Ray Of Elbow, 2 Views",aetna,POS,O,238.30,35.12,143.98,143.98,142.98
653,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84155,cpt,"Total Protein Level, Blood",aetna,Medicare Part B,O,69.00,3.67,3.67,51.75,4.40
654,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,26055,cpt,Incision Of Tendon Covering Of Finger,aetna,POS,O,16309.48,1233.08,10334.48,10334.48,9785.69
655,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84112,cpt,Cervicovaginal Secretion Of Placenta Protein,aetna,Medicaid,O,243.07,29.33,29.33,243.07,49.58
656,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,236,ms-drg,Coronary Bypass Without Cardiac Catheterization Without MCC,aetna,Medicare Part B,I,156904.89,23866.31,23891.99,44284.10,94142.93
657,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,300,ms-drg,Peripheral Vascular Disorders With CC,aetna,PPO,I,19902.20,6642.09,6642.09,11743.17,11941.32
658,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90694,cpt,"Influenza Virus Vaccine, Quadrivalent (Aiiv4), Inactivated, Adjuvanted, Preservative Free, For Injection Into Muscle, 0.5 Ml Dosage",aetna,Medicaid,O,193.98,23.39,23.39,61.00,116.39
659,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0360,revCode,"Operating Room Services, General",aetna,Medicare Part B,O,9825.06,1878.83,4989.15,12996.76,5895.04
660,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna,PPO,O,50.72,6.48,17.70,38.04,7.78
661,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2175,cpt,"Injection, Meperidine Hydrochloride, Per 100 Mg",aetna,HMO,O,85.94,17.32,39.53,86.60,51.56
662,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82803,cpt,Blood Gases Measurement,aetna,PPO,O,158.08,26.07,86.50,86.50,30.97
663,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87624,cpt,"Detection Test By Nucleic Acid For Human Papillomavirus (Hpv), High-Risk Types",aetna,Medicare Part A,O,108.49,21.05,59.36,108.49,42.11
664,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,596,ms-drg,Major Skin Disorders Without MCC,aetna,HMO,I,17771.27,4749.34,4749.34,8242.06,10662.76
665,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86141,cpt,"Measurement C-Reactive Protein For Detection Of Infection Or Inflammation, High Sensitivity",aetna,POS,O,138.33,7.77,7.77,13.00,15.54
666,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2370,cpt,"Injection, Phenylephrine Hcl, Up To 1 Ml",aetna,Medicare Part B,O,87.77,23.91,40.37,66.01,52.66
667,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83880,cpt,Natriuretic Peptide (Heart And Blood Vessel Protein) Level,aetna,Medicaid,O,130.11,25.90,39.26,92.07,47.11
668,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0640,cpt,"Injection, Leucovorin Calcium, Per 50 Mg",aetna,Medicare Part B,O,17.80,3.56,3.56,14.15,10.68
669,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76536,cpt,Ultrasound Scan Of Head And Neck Soft Tissue,aetna,Medicaid,O,491.96,96.50,269.19,391.10,295.18
670,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93280,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Dual Lead Pacemaker System With Physician Analysis, Review, And Report",aetna,HMO,O,214.80,32.43,32.51,76.59,128.88
671,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2997,cpt,"Injection, Alteplase Recombinant, 1 Mg",aetna,POS,O,318.54,54.09,87.67,232.15,191.12
672,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96365,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, 1 Hour Or Less",aetna,EPO,O,307.18,64.22,180.23,200.85,184.31
673,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna,Medicare Part B,O,251.28,64.70,137.49,266.35,150.77
674,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86300,cpt,"Immunologic Analysis For Detection Of Tumor Antigen, Quantitative; Ca 15-3",aetna,Medicare Part B,O,85.70,20.40,51.78,90.84,24.97
675,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,064,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With MCC,aetna,PPO,I,42514.90,11561.36,11613.14,15935.29,25508.94
676,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0881,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (Non-Esrd Use)",aetna,Medicaid,O,15.58,2.38,7.43,7.43,9.35
677,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82626,cpt,Dehydroepiandrosterone (Dhea) Hormone Level,aetna,Medicare Part B,O,148.02,23.79,85.85,85.85,88.81
678,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna,PPO,O,329.15,22.74,190.91,261.67,197.49
679,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna,Medicare Part A,O,251.28,64.70,137.49,266.35,150.77
680,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80053,cpt,"Blood Test, Comprehensive Group Of Blood Chemicals",aetna,PPO,O,91.30,10.35,49.96,68.47,12.67
681,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45385,cpt,Removal Of Polyps Or Growths Of Large Bowel Using An Endoscope With Mechanical Snare,aetna,EPO,O,5305.34,938.17,2617.73,5400.89,1653.07
682,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0120,revCode,Room And Board Semiprivate (Two Beds) General,aetna,EPO,I,1274.16,366.55,685.17,6328.83,764.50
683,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93452,cpt,Insertion Of Tube In Left Heart Chambers For Diagnosis With Review By Radiologist,aetna,Medicare Part B,I,54103.79,7333.25,7333.25,7333.25,32462.27
684,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82746,cpt,"Folic Acid Level, Serum",aetna,HMO,O,65.11,9.14,37.11,37.11,17.64
685,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86769,cpt,Measure Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antibody,aetna,POS,O,89.25,16.93,51.77,66.94,50.56
686,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38505,cpt,Needle Biopsy Or Removal Of Surface Lymph Nodes,aetna,Medicare Part A,O,8266.58,1246.10,7074.31,7074.31,4959.95
687,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2175,cpt,"Injection, Meperidine Hydrochloride, Per 100 Mg",aetna,Medicaid,O,85.94,17.32,39.53,86.60,51.56
688,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9360,cpt,"Injection, Vinblastine Sulfate, 1 Mg",aetna,Medicaid,O,11.79,2.36,4.08,4.08,7.07
689,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76815,cpt,"Ultrasound Of Pregnant Uterus, 1 Or More Fetus(Es)",aetna,EPO,O,611.12,97.50,348.34,647.78,366.67
690,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0510,revCode,Clinic General,aetna,EPO,O,167.48,51.31,51.31,289.51,100.49
691,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72146,cpt,MRI Scan Of Middle Spinal Canal Without Contrast,aetna,HMO,O,2882.19,207.32,821.42,821.42,248.82
692,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77063,cpt,Screening Digital Tomography Of Both Breasts,aetna,HMO,O,184.03,20.92,100.70,167.23,110.42
693,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0269,cpt,"Placement Of Occlusive Device Into Either A Venous Or Arterial Access Site, Post Surgical Or Interventional Procedure (E.G., Angioseal Plug, Vascular Plug)",aetna,EPO,O,67707.99,403.09,4389.98,14226.92,40624.79
694,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9299,cpt,"Injection, Nivolumab, 1 Mg",aetna,PPO,O,107.35,13.51,28.82,29.25,64.41
695,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66984,cpt,"Removal Of Cataract With Insertion Of Lens, Simple",aetna,HMO,O,14664.91,1841.26,3839.82,4337.53,8798.95
696,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96411,cpt,Administration Of Additional New Drug Or Substance Into Vein Using Push Technique,aetna,Medicare Part B,O,238.30,49.47,130.40,178.73,142.98
697,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,190,ms-drg,Chronic Obstructive Pulmonary Disease With MCC,aetna,PPO,I,21678.10,5783.22,5783.22,12966.75,13006.86
698,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87340,cpt,Detection Test By Immunoassay Technique For Hepatitis B Surface Antigen,aetna,POS,O,80.09,7.09,45.65,60.07,12.40
699,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78070,cpt,Nuclear Medicine Study Of Parathyroid,aetna,POS,O,1314.27,400.84,749.13,749.13,788.56
700,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3380,cpt,"Injection, Vedolizumab, 1 Mg",aetna,Medicare Part B,O,60.64,21.72,28.92,28.92,36.38
701,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna,HMO,O,271.34,80.51,148.47,215.72,96.61
702,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73600,cpt,"X-Ray Of Ankle, 2 Views",aetna,Medicare Part B,O,252.47,30.86,143.91,143.91,151.48
703,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,Medicare Part A,O,344.48,61.44,188.49,273.86,206.69
704,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0243,cpt,"Injection, Casirivimab And Imdevimab, 2400 Mg",aetna,Medicare Part B,O,0.03,0.01,0.01,11.63,0.02
705,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,58558,cpt,Biopsy Of Lining Of Uterus And/Or Removal Of Polyp Using An Endoscope,aetna,EPO,O,22844.35,2323.22,10420.95,10420.95,13706.61
706,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87205,cpt,Special Gram Or Giemsa Stain For Microorganism,aetna,Medicaid,O,87.53,4.18,4.25,65.65,5.12
707,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84165,cpt,"Protein Measurement, Serum",aetna,Medicare Part B,O,116.79,10.63,10.74,82.64,12.89
708,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1335,cpt,"Injection, Ertapenem Sodium, 500 Mg",aetna,HMO,O,93.92,16.77,52.86,52.86,56.35
709,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,HMO,O,8.83,1.76,5.12,26.77,5.30
710,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96401,cpt,Administration Of Non-Hormonal Anti-Neoplastic Chemotherapy Under Skin Or Into Muscle,aetna,EPO,O,286.67,27.44,27.44,63.97,172.00
711,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9190,cpt,"Injection, Fluorouracil, 500 Mg",aetna,POS,O,8.25,1.86,1.89,8.07,4.95
712,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93925,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of Both Legs,aetna,Medicare Part A,O,726.73,203.81,207.32,359.62,436.04
713,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9171,cpt,"Injection, Docetaxel, 1 Mg",aetna,PPO,O,15.58,0.67,0.67,4.17,9.35
714,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49320,cpt,Diagnostic Examination Of The Abdomen Using An Endoscope,aetna,Medicare Part A,O,23329.13,4381.91,24397.19,24397.19,13997.48
715,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,065,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With CC Or Tpa In 24 Hours,aetna,Medicare Part A,I,23737.47,6483.31,6483.31,11599.87,14242.48
716,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94640,cpt,Respiratory Inhaled Pressure Or Nonpressure Treatment To Relieve Airway Obstruction Or For Sputum Specimen,aetna,POS,O,198.78,56.02,185.11,185.11,119.27
717,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64484,cpt,"Injections Of Anesthetic And/Or Steroid Drug Into Lower Or Sacral Spine Nerve Root Using Imaging Guidance, Each Additional Level",aetna,Medicaid,O,12936.37,728.40,7904.05,7904.05,7761.82
718,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17110,cpt,"Destruction Of Skin Growth, 1-14 Growths",aetna,HMO,O,958.00,159.01,159.02,479.00,574.80
719,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna,POS,O,252.47,18.27,143.91,336.23,151.48
720,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0482,revCode,"Cardiology, Stress Test",aetna,Medicaid,O,474.26,84.78,270.33,377.03,284.56
721,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,Medicare Part B,I,2882.19,290.04,2229.62,2229.62,1729.31
722,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73200,cpt,CT Scan Of Arm Without Contrast,aetna,EPO,O,1267.08,96.51,482.16,482.16,760.25
723,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2997,cpt,"Injection, Alteplase Recombinant, 1 Mg",aetna,Medicare Part A,O,318.54,54.09,87.67,232.15,191.12
724,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76870,cpt,Ultrasound Scan Of Scrotum,aetna,EPO,O,528.53,96.50,295.23,396.40,317.12
725,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33430,cpt,Replacement Of Valve Between Left Upper And Lower Chambers On Heart-Lung Machine,aetna,PPO,I,207801.54,46497.02,46497.02,46497.02,124680.92
726,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33430,cpt,Replacement Of Valve Between Left Upper And Lower Chambers On Heart-Lung Machine,aetna,Medicare Part B,I,207801.54,46497.02,46497.02,46497.02,124680.92
727,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,58558,cpt,Biopsy Of Lining Of Uterus And/Or Removal Of Polyp Using An Endoscope,aetna,HMO,O,22844.35,2323.22,10420.95,10420.95,13706.61
728,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95811,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab With Continued Pressured Respiratory Assistance By Mask Or Breathing Tube,aetna,Medicare Part B,O,3186.58,814.60,1816.35,1816.35,1911.95
729,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0341,revCode,"Nuclear Medicine, Diagnostic",aetna,Medicare Part A,O,5568.56,800.20,3046.95,5465.13,3341.14
730,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86334,cpt,Immunologic Analysis Technique On Serum (Immunofixation),aetna,Medicare Part B,O,132.12,17.37,75.31,99.09,26.81
731,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96402,cpt,Hormonal Anti-Neoplastic Chemotherapy Administration Beneath The Skin Or Into Muscle,aetna,EPO,O,125.04,21.31,71.27,71.27,75.02
732,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88331,cpt,"Pathology Examination Of Specimen During Surgery, First Tissue Block",aetna,Medicare Part B,O,438.52,153.98,254.34,254.34,263.11
733,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73700,cpt,CT Scan Of Leg Without Contrast,aetna,Medicaid,O,1395.67,96.50,779.60,809.76,837.40
734,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80048,cpt,"Blood Test, Basic Group Of Blood Chemicals (Calcium, Total)",aetna,Medicaid,O,70.06,8.30,38.34,49.58,10.15
735,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78306,cpt,Nuclear Medicine Study Of Bone And/Or Joint Whole Body,aetna,EPO,O,848.21,330.97,483.48,522.98,400.79
736,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,PPO,O,344.48,61.44,188.49,273.86,206.69
737,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,Medicare Part B,O,1775.23,260.44,1248.81,1902.32,1065.14
738,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,EPO,O,30.08,3.64,57.64,96.59,18.05
739,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna,EPO,O,1884.10,427.65,1030.93,1413.08,1130.46
740,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82962,cpt,Blood Glucose (Sugar) Test Performed By Hand-Held Instrument,aetna,HMO,O,42.58,3.28,24.27,42.58,3.94
741,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96368,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Concurrent With Another Infusion",aetna,Medicare Part A,O,75.68,16.92,43.89,60.16,45.41
742,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,POS,I,1747.84,436.13,970.89,1375.11,1048.70
743,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70220,cpt,"X-Ray Of Paranasal Sinus, Complete, Minimum Of 3 Views",aetna,POS,O,342.13,47.22,195.01,271.99,205.28
744,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,690,ms-drg,Kidney And Urinary Tract Infections Without MCC,aetna,HMO,I,16840.52,3735.53,9339.74,9339.74,10104.31
745,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9360,cpt,"Injection, Vinblastine Sulfate, 1 Mg",aetna,Medicare Part A,O,11.79,2.36,4.08,4.08,7.07
746,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96402,cpt,Hormonal Anti-Neoplastic Chemotherapy Administration Beneath The Skin Or Into Muscle,aetna,POS,O,125.04,21.31,71.27,71.27,75.02
747,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna,HMO,O,95.71,16.18,16.18,21.31,19.42
748,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93925,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of Both Legs,aetna,Medicare Part B,O,726.73,203.81,207.32,359.62,436.04
749,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82525,cpt,Copper Level,aetna,HMO,O,71.96,9.63,39.38,39.38,14.89
750,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87186,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or Agar Dilution",aetna,POS,O,47.53,6.92,8.65,35.65,10.38
751,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37230,cpt,"Insertion Of Stents Into Artery In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna,Medicare Part A,I,262831.76,27743.68,27743.68,27743.68,157699.06
752,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84155,cpt,"Total Protein Level, Blood",aetna,HMO,O,69.00,3.67,3.67,51.75,4.40
753,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82375,cpt,Carboxyhemoglobin (Protein) Level,aetna,Medicare Part B,O,103.50,12.32,60.03,77.63,14.78
754,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74246,cpt,X-Ray Of Upper Digestive Tract With Double Contrast,aetna,HMO,O,484.07,158.13,264.87,284.00,189.76
755,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,Medicaid,O,30.08,3.64,57.64,96.59,18.05
756,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12032,cpt,"Repair Of Wound (2.6 To 7.5 Centimeters) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna,EPO,O,3063.00,309.74,309.74,3849.84,1837.80
757,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81001,cpt,"Manual Urinalysis Test With Examination Using Microscope, Automated",aetna,POS,O,13.80,2.37,7.87,10.35,8.28
758,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95819,cpt,"Measurement And Recording Of Brain Wave (Eeg) Activity, Awake And Asleep",aetna,HMO,O,779.82,234.21,444.50,735.68,467.89
759,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,580,ms-drg,"Other Skin, Subcutaneous Tissue And Breast Procedures With CC",aetna,PPO,I,43871.64,9796.13,9809.77,15064.04,26322.98
760,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80053,cpt,"Blood Test, Comprehensive Group Of Blood Chemicals",aetna,POS,O,91.30,10.35,49.96,68.47,12.67
761,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72146,cpt,MRI Scan Of Middle Spinal Canal Without Contrast,aetna,Medicaid,O,2882.19,207.32,821.42,821.42,248.82
762,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5103,cpt,"Injection, Infliximab-Dyyb, Biosimilar, (Inflectra), 10 Mg",aetna,HMO,O,114.15,40.05,51.37,114.15,68.49
763,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73130,cpt,"X-Ray Of Hand, Minimum Of 3 Views",aetna,POS,O,329.15,46.08,180.10,261.67,197.49
764,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97165,cpt,"Evaluation For Occupational Therapy, Typically 30 Minutes",aetna,Medicare Part A,O,211.24,71.93,120.41,120.41,126.74
765,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73600,cpt,"X-Ray Of Ankle, 2 Views",aetna,HMO,O,252.47,30.86,143.91,143.91,151.48
766,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7121,cpt,"5% Dextrose In Lactated Ringers Infusion, Up To 1000 Cc",aetna,Medicare Part A,O,164.65,75.76,75.76,75.76,98.79
767,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86769,cpt,Measure Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antibody,aetna,Medicare Part A,O,89.25,16.93,51.77,66.94,50.56
768,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna,Medicare Part A,O,176.96,19.79,96.59,99.98,106.18
769,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77300,cpt,Calculation Of Radiation Therapy Dose,aetna,Medicare Part B,O,273.70,47.14,131.71,131.71,134.83
770,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84703,cpt,Gonadotropin (Reproductive Hormone) Analysis,aetna,Medicare Part B,O,69.48,7.52,37.26,48.18,9.02
771,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0441,revCode,Occupational Therapy Visit Charge,aetna,Medicare Part B,O,328.90,81.87,190.76,190.76,197.34
772,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2704,cpt,"Injection, Propofol, 10 Mg",aetna,Medicare Part B,O,4.12,0.82,1.89,4.12,2.47
773,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1885,cpt,"Injection, Ketorolac Tromethamine, Per 15 Mg",aetna,Medicaid,O,39.72,7.88,18.17,40.53,23.83
774,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11103,cpt,"Biopsy Of Related Skin Growth, Each Additional Growth",aetna,Medicare Part B,O,1126.00,160.53,161.01,647.00,675.60
775,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9360,cpt,"Injection, Vinblastine Sulfate, 1 Mg",aetna,EPO,O,11.79,2.36,4.08,4.08,7.07
776,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84425,cpt,Vitamin B-1 (Thiamine) Level,aetna,EPO,O,138.03,18.33,75.53,75.53,82.82
777,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0243,cpt,"Injection, Casirivimab And Imdevimab, 2400 Mg",aetna,Medicaid,O,0.03,0.01,0.01,11.63,0.02
778,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11047,cpt,"Removal Of Bone, Each Additional 20.0 Sq Cm Or Less",aetna,EPO,O,12247.63,1215.96,1247.54,1273.00,7348.58
779,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80202,cpt,Vancomycin (Antibiotic) Level,aetna,Medicare Part A,O,87.53,13.54,49.89,49.89,16.25
780,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86334,cpt,Immunologic Analysis Technique On Serum (Immunofixation),aetna,PPO,O,132.12,17.37,75.31,99.09,26.81
781,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74183,cpt,MRI Scan Of Abdomen Before And After Contrast,aetna,Medicare Part A,O,3824.84,326.02,2180.16,2180.16,2294.90
782,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76815,cpt,"Ultrasound Of Pregnant Uterus, 1 Or More Fetus(Es)",aetna,Medicare Part B,O,611.12,97.50,348.34,647.78,366.67
783,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,Medicare Part B,I,137.36,28.95,90.50,129.04,82.42
784,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,812,ms-drg,Red Blood Cell Disorders Without MCC,aetna,POS,I,18593.40,4553.02,5996.54,8936.86,11156.04
785,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81001,cpt,"Manual Urinalysis Test With Examination Using Microscope, Automated",aetna,Medicare Part A,O,13.80,2.37,7.87,10.35,8.28
786,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17110,cpt,"Destruction Of Skin Growth, 1-14 Growths",aetna,Medicare Part A,O,958.00,159.01,159.02,479.00,574.80
787,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,371,ms-drg,Major Gastrointestinal Disorders And Peritoneal Infections With MCC,aetna,Medicare Part A,I,34185.44,8873.88,8873.88,11142.92,20511.26
788,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76815,cpt,"Ultrasound Of Pregnant Uterus, 1 Or More Fetus(Es)",aetna,Medicare Part A,O,611.12,97.50,348.34,647.78,366.67
789,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70487,cpt,CT Scan Of Face With Contrast,aetna,Medicare Part B,O,1358.47,810.86,810.86,810.86,815.08
790,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85014,cpt,Red Blood Cell Concentration Measurement,aetna,Medicaid,O,28.77,2.35,16.40,21.58,2.84
791,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92920,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Each Additional Artery Or Branch",aetna,POS,O,63533.28,4389.98,4389.98,25971.62,38119.97
792,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1453,cpt,"Injection, Fosaprepitant, 1 Mg",aetna,Medicare Part B,O,6.67,0.28,3.07,7.29,4.00
793,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0434,revCode,"Occupational Therapy, Evaluation Or Reevaluation",aetna,Medicare Part B,I,357.27,76.33,271.01,357.27,214.36
794,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84165,cpt,"Protein Measurement, Serum",aetna,Medicaid,O,116.79,10.63,10.74,82.64,12.89
795,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83880,cpt,Natriuretic Peptide (Heart And Blood Vessel Protein) Level,aetna,Medicare Part B,O,130.11,25.90,39.26,92.07,47.11
796,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,Medicare Part B,I,1747.84,436.13,970.89,1375.11,1048.70
797,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11047,cpt,"Removal Of Bone, Each Additional 20.0 Sq Cm Or Less",aetna,POS,O,12247.63,1215.96,1247.54,1273.00,7348.58
798,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,Medicare Part B,O,3199.87,326.01,1445.14,2637.87,1919.92
799,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0331,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration - Injection,aetna,PPO,O,270.45,26.27,71.27,513.21,162.27
800,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0740,revCode,"Electroencephalogram (Eeg), General",aetna,POS,O,779.82,234.21,444.50,735.68,467.89
801,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0276,revCode,Medical/Surgical Supplies And Devices Intracular Lens,aetna,POS,O,797.52,202.98,270.86,797.52,478.51
802,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77373,cpt,Stereotactic Body Radiation Therapy 1 Or More Lesions Using Imaging Guidance,aetna,POS,O,4368.52,843.53,2639.46,2639.46,1842.56
803,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72050,cpt,"X-Ray Of Upper Spine, 4 Or 5 Views",aetna,HMO,O,613.48,42.39,349.68,373.40,115.81
804,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82397,cpt,Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,aetna,Medicaid,O,51.39,6.88,29.29,29.29,30.83
805,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77280,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 1 Treatment Area",aetna,HMO,O,1037.01,112.36,591.10,733.79,134.83
806,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2370,cpt,"Injection, Phenylephrine Hcl, Up To 1 Ml",aetna,PPO,O,87.77,23.91,40.37,66.01,52.66
807,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna,Medicare Part A,O,52.60,6.47,8.08,42.46,9.70
808,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,HMO,O,63819.96,8894.43,14191.44,29488.15,38291.98
809,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna,Medicare Part A,O,91.30,14.35,49.96,64.61,54.78
810,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,PPO,O,2882.19,203.81,1577.05,2039.29,1729.31
811,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77301,cpt,Management Of Modulation Radiotherapy Planning,aetna,HMO,O,7734.62,1117.80,4232.16,4232.16,1341.41
812,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88307,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately High Complexity",aetna,EPO,O,298.47,86.80,170.13,298.47,179.08
813,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87491,cpt,"Detection Test By Nucleic Acid For Chlamydia Trachomatis, Amplified Probe Technique",aetna,Medicare Part A,O,147.58,21.05,82.44,110.69,42.11
814,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,EPO,O,490.78,263.76,343.76,353.36,294.47
815,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,58558,cpt,Biopsy Of Lining Of Uterus And/Or Removal Of Polyp Using An Endoscope,aetna,Medicare Part A,O,22844.35,2323.22,10420.95,10420.95,13706.61
816,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna,PPO,I,5647.36,1115.96,3413.14,3995.78,3388.42
817,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84112,cpt,Cervicovaginal Secretion Of Placenta Protein,aetna,POS,O,243.07,29.33,29.33,243.07,49.58
818,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64635,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Single Facet Joint",aetna,POS,O,7086.24,1523.14,4237.46,4237.46,4251.74
819,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0138,cpt,"Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (Non-Esrd Use)",aetna,Medicare Part B,O,4.45,0.69,0.93,1.82,2.67
820,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43450,cpt,Dilation Of Esophagus Unguided,aetna,POS,O,3778.61,1075.52,1753.96,3815.86,2267.17
821,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84550,cpt,"Uric Acid Level, Blood",aetna,PPO,O,50.01,4.52,29.01,79.60,5.42
822,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19120,cpt,"Removal Of 1 Or More Breast Growth, Open Procedure",aetna,Medicaid,O,19283.58,2826.79,11249.61,11249.61,3355.94
823,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1437,cpt,"Injection, Ferric Derisomaltose, 10 Mg",aetna,EPO,O,80.56,14.43,25.38,25.82,48.34
824,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna,Medicare Part B,O,982.00,159.01,162.47,1222.94,589.20
825,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87046,cpt,"Stool Culture, Additional Pathogens",aetna,Medicare Part A,O,52.60,5.92,30.25,30.25,11.33
826,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna,EPO,E,5923.22,592.08,2036.44,2288.99,3553.93
827,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96416,cpt,Prolonged Chemotherapy Infusion Into A Vein By Portable Or Implanted Pump More Than 8 Hours,aetna,PPO,O,535.61,119.50,290.78,401.71,321.37
828,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0131,cpt,"Injection, Acetaminophen, 10 Mg",aetna,POS,O,1.46,0.18,0.65,1.44,0.88
829,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,EPO,I,268.98,56.00,329.15,795.98,161.39
830,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97140,cpt,"Manual (Physical) Therapy Techniques To 1 Or More Regions, Each 15 Minutes",aetna,POS,O,232.41,20.93,103.49,164.45,139.45
831,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97110,cpt,"Therapeutic Exercise To Develop Strength, Endurance, Range Of Motion, And Flexibility, Each 15 Minutes",aetna,Medicaid,O,173.42,23.35,77.46,114.70,29.09
832,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,POS,O,654.73,185.98,323.41,694.53,392.84
833,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84100,cpt,Phosphate Level,aetna,Medicaid,O,40.11,4.74,13.80,13.80,5.69
834,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76817,cpt,Vaginal Ultrasound Of Pregnant Uterus,aetna,Medicaid,O,611.12,96.51,341.37,432.40,115.81
835,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77080,cpt,"Bone Density Measurement Of The Core Or Central Skeleton (E.G., Hips, Pelvis, Spine)",aetna,EPO,O,352.74,96.51,201.06,249.59,115.81
836,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73218,cpt,MRI Scan Of Arm Without Contrast,aetna,Medicare Part B,O,2882.19,206.00,1642.85,2719.05,1729.31
837,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83550,cpt,Iron Binding Capacity,aetna,PPO,O,106.28,8.57,60.58,106.28,10.49
838,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0371,revCode,Anesthesia Incident To Radiology,aetna,HMO,I,47.19,8.72,26.90,26.90,28.31
839,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5106,cpt,"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (For Non-Esrd Use), 1000 Units",aetna,EPO,O,32.27,8.13,8.62,13.29,19.36
840,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43235,cpt,"Diagnostic Examination Of Esophagus, Stomach, And/Or Upper Small Bowel Using An Endoscope",aetna,HMO,O,3132.69,724.55,1758.22,2956.79,1171.78
841,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82627,cpt,Dehydroepiandrosterone (Dhea-S) Hormone Level,aetna,POS,O,119.15,19.46,67.92,67.92,71.49
842,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,673,ms-drg,Other Kidney And Urinary Tract Procedures With MCC,aetna,EPO,I,61701.73,20358.57,20462.06,20647.19,37021.04
843,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0430,revCode,"Occupational Therapy, General",aetna,Medicaid,I,176.32,32.63,91.02,165.50,105.79
844,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73218,cpt,MRI Scan Of Arm Without Contrast,aetna,HMO,O,2882.19,206.00,1642.85,2719.05,1729.31
845,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9045,cpt,"Injection, Carboplatin, 50 Mg",aetna,HMO,O,16.51,2.82,2.82,4.53,9.91
846,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11044,cpt,Removal Of Skin And Bone First 20 Sq Cm Or Less,aetna,EPO,O,3769.31,1215.96,1260.27,2751.80,2261.59
847,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna,POS,O,188.09,38.65,107.21,141.02,112.85
848,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,Medicaid,O,344.48,61.44,188.49,273.86,206.69
849,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77280,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 1 Treatment Area",aetna,PPO,O,1037.01,112.36,591.10,733.79,134.83
850,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73610,cpt,"X-Ray Of Ankle, Minimum Of 3 Views",aetna,Medicare Part A,O,329.15,46.08,180.10,261.67,197.49
851,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2997,cpt,"Injection, Alteplase Recombinant, 1 Mg",aetna,Medicare Part B,O,318.54,54.09,87.67,232.15,191.12
852,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90686,cpt,"Vaccine For Influenza For Administration Into Muscle, 0.5 Ml Dosage, Quadrivalent, Preservation Free",aetna,Medicare Part A,O,132.44,13.48,20.93,79.94,79.46
853,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna,POS,O,3391.86,327.84,1855.92,2543.90,462.44
854,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,300,ms-drg,Peripheral Vascular Disorders With CC,aetna,Medicare Part A,I,19902.20,6642.09,6642.09,11743.17,11941.32
855,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70490,cpt,CT Scan Of Soft Tissue Of Neck Without Contrast,aetna,POS,O,1267.08,96.50,693.31,693.31,760.25
856,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80202,cpt,Vancomycin (Antibiotic) Level,aetna,Medicare Part B,O,87.53,13.54,49.89,49.89,16.25
857,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna,PPO,O,289.04,102.81,158.15,158.15,134.83
858,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9171,cpt,"Injection, Docetaxel, 1 Mg",aetna,HMO,O,15.58,0.67,0.67,4.17,9.35
859,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96365,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, 1 Hour Or Less",aetna,HMO,O,307.18,64.22,180.23,200.85,184.31
860,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0762,revCode,Specialty Services Observation Hours,aetna,Medicare Part A,I,15.11,4.72,10.23,10.23,9.07
861,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94060,cpt,"Measurement And Graphic Recording Of The Amount And Speed Of Breathed Air, Before And Following Medication Administration",aetna,POS,O,422.68,78.29,218.19,239.44,253.61
862,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88342,cpt,"Special Stained Specimen Slides To Examine Tissue, Initial Procedure",aetna,Medicaid,O,419.99,33.03,239.39,314.99,251.99
863,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83883,cpt,"Nephelometry, Test Method Using Light",aetna,Medicare Part B,O,93.19,11.70,13.60,69.89,16.32
864,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85049,cpt,"Platelet Count, Automated Test",aetna,PPO,O,36.32,4.39,4.39,9.15,5.38
865,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0481,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,Medicare Part B,O,315.99,155.10,155.10,156.59,189.59
866,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11401,cpt,"Removal Of Growth (0.6 To 1.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,Medicare Part B,O,4292.00,309.74,309.74,2167.15,2575.20
867,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,HMO,O,58.98,6.19,15.24,1399.28,35.39
868,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97035,cpt,"Application Of Ultrasound To 1 Or More Areas, Each 15 Minutes",aetna,PPO,O,106.18,10.67,46.92,46.92,63.71
869,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,47563,cpt,Removal Of Gallbladder With X-Ray Study Of Bile Ducts Using An Endoscope,aetna,POS,O,25129.00,4481.58,12544.52,12544.52,15077.40
870,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86762,cpt,Analysis For Antibody To Rubella (German Measles Virus),aetna,Medicaid,O,50.01,4.42,27.36,37.51,17.10
871,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93350,cpt,"Ultrasound Examination Of The Heart Performed During Rest, Exercise, And/Or Drug-Induced Stress With Interpretation And Report",aetna,HMO,O,1353.20,427.67,740.43,1075.79,811.92
872,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99213,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes",aetna,HMO,O,270.16,52.43,153.99,211.73,162.10
873,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,872,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours Without MCC,aetna,HMO,I,20748.35,5256.97,6524.49,9809.76,12449.01
874,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87181,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Agar Dilution Method",aetna,Medicaid,O,16.51,4.75,9.41,9.41,3.37
875,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96366,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Each Additional Hour",aetna,Medicaid,O,307.18,19.72,178.16,178.16,184.31
876,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna,POS,I,5647.36,1115.96,3413.14,3995.78,3388.42
877,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86480,cpt,"Tuberculosis Test, Gamma Interferon",aetna,EPO,O,350.39,35.31,199.72,262.79,74.38
878,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,186,ms-drg,Pleural Effusion With MCC,aetna,HMO,I,29279.58,9460.85,9734.76,9734.76,17567.75
879,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19081,cpt,"Biopsy Of Breast And Placement Of Locating Device Using X-Ray With Needle, First Growth",aetna,Medicaid,O,8708.58,1254.46,4315.79,4315.79,5225.15
880,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0260,revCode,Intravenous (Iv) Therapy,aetna,Medicare Part A,O,325.61,56.09,185.60,1926.96,195.37
881,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81003,cpt,Automated Urinalysis Test,aetna,Medicare Part B,O,13.80,2.25,7.55,9.77,2.70
882,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76815,cpt,"Ultrasound Of Pregnant Uterus, 1 Or More Fetus(Es)",aetna,POS,O,611.12,97.50,348.34,647.78,366.67
883,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88313,cpt,Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,aetna,Medicare Part B,O,119.15,45.38,67.92,67.92,71.49
884,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86900,cpt,Blood Group Typing (ABO),aetna,EPO,O,126.23,11.17,71.95,99.15,118.98
885,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77385,cpt,"Intensity Modulated Radiation Therapy Delivery, Simple",aetna,Medicare Part B,O,1786.18,480.50,485.97,729.06,576.60
886,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74175,cpt,CT Scan Of Blood Vessels Of Abdomen With Contrast,aetna,Medicaid,O,1737.39,158.13,158.13,1841.63,1042.43
887,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88313,cpt,Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,aetna,HMO,O,119.15,45.38,67.92,67.92,71.49
888,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71270,cpt,CT Scan Of Chest Before And After Contrast,aetna,HMO,O,2554.21,161.61,161.61,161.61,192.38
889,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74174,cpt,CT Scan Of Blood Vessels Of Abdomen And Pelvis With Contrast,aetna,Medicaid,O,1736.62,326.01,329.84,497.16,391.22
890,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96365,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, 1 Hour Or Less",aetna,POS,O,307.18,64.22,180.23,200.85,184.31
891,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92611,cpt,Fluoroscopic And Video Recorded Motion Evaluation Of Swallowing Function,aetna,Medicare Part B,O,328.90,87.83,190.76,190.76,197.34
892,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,46255,cpt,Removal Of Single External And Internal Hemorrhoid Group,aetna,Medicare Part B,O,17900.37,2210.31,9939.29,9939.29,10740.22
893,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0410,revCode,"Respiratory Services, General",aetna,EPO,I,205.27,71.94,125.75,182.34,123.16
894,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82746,cpt,"Folic Acid Level, Serum",aetna,PPO,O,65.11,9.14,37.11,37.11,17.64
895,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80048,cpt,"Blood Test, Basic Group Of Blood Chemicals (Calcium, Total)",aetna,HMO,O,70.06,8.30,38.34,49.58,10.15
896,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,186,ms-drg,Pleural Effusion With MCC,aetna,Medicare Part B,I,29279.58,9460.85,9734.76,9734.76,17567.75
897,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0740,revCode,"Electroencephalogram (Eeg), General",aetna,Medicare Part A,O,779.82,234.21,444.50,735.68,467.89
898,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84145,cpt,Procalcitonin (Hormone) Level,aetna,Medicaid,O,97.91,20.28,53.57,53.57,32.66
899,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2704,cpt,"Injection, Propofol, 10 Mg",aetna,Medicare Part A,O,4.12,0.82,1.89,4.12,2.47
900,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86376,cpt,Microsomal Antibodies (Autoantibody) Measurement,aetna,Medicare Part A,O,90.15,12.00,21.95,21.95,17.46
901,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87086,cpt,"Bacterial Colony Count, Urine",aetna,Medicare Part A,O,71.96,7.91,39.38,53.97,9.68
902,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76770,cpt,Complete Ultrasound Scan Behind Abdominal Cavity,aetna,EPO,O,747.97,96.51,409.27,409.27,115.81
903,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73522,cpt,"X-Ray Of Both Hips With Pelvis, 3-4 Views",aetna,Medicare Part A,O,355.11,58.62,194.31,194.31,213.07
904,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76816,cpt,"Ultrasound Re-Evaluation Of Pregnant Uterus, Per Fetus",aetna,Medicaid,O,611.12,96.51,348.34,432.40,366.67
905,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88177,cpt,"Pap Test, Evaluation Of Fine Needle Aspirate, Immediate, Each Additional Evaluation Episode",aetna,Medicare Part B,O,49.54,26.22,93.48,93.48,29.72
906,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5111,cpt,"Injection, Pegfilgrastim-Cbqv, Biosimilar, (Udenyca), 0.5 Mg",aetna,Medicaid,O,1901.34,181.58,880.52,880.52,1140.80
907,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,Medicaid,O,490.78,263.76,343.76,353.36,294.47
908,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43239,cpt,"Biopsy Of Esophagus, Stomach, And/Or Upper Small Bowel Using A Flexible Endoscope",aetna,HMO,O,4254.12,439.90,1990.82,4844.32,1282.14
909,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9354,cpt,"Injection, Ado-Trastuzumab Emtansine, 1 Mg",aetna,Medicare Part B,O,123.87,25.63,36.89,41.57,74.32
910,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87661,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Amplified Probe Technique",aetna,Medicaid,O,151.64,21.05,84.70,113.73,42.11
911,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0439,cpt,"Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (Pps), Subsequent Visit",aetna,PPO,O,154.00,125.26,125.26,125.26,92.40
912,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0444,revCode,Occupational Therapy Evaluation Or Reevaluation,aetna,Medicare Part B,I,509.00,129.95,286.62,370.63,305.40
913,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93308,cpt,Follow-Up Or Limited Ultrasound Examination Of Heart,aetna,Medicaid,O,415.27,203.81,204.22,403.52,249.16
914,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72050,cpt,"X-Ray Of Upper Spine, 4 Or 5 Views",aetna,EPO,O,613.48,42.39,349.68,373.40,115.81
915,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76801,cpt,Abdominal Ultrasound Of Pregnant Uterus (Less Than 14 Weeks 0 Days) Single Or First Fetus,aetna,Medicaid,O,357.27,96.50,217.76,229.19,115.81
916,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna,Medicare Part B,O,108.88,10.16,59.58,77.04,20.33
917,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82525,cpt,Copper Level,aetna,PPO,O,71.96,9.63,39.38,39.38,14.89
918,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82310,cpt,"Calcium Level, Total",aetna,Medicaid,O,36.61,5.16,5.16,36.61,21.97
919,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87070,cpt,"Bacterial Culture, Any Other Source Except Urine, Blood Or Stool, Aerobic",aetna,POS,O,65.11,8.45,8.58,48.83,10.34
920,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5111,cpt,"Injection, Pegfilgrastim-Cbqv, Biosimilar, (Udenyca), 0.5 Mg",aetna,POS,O,1901.34,181.58,880.52,880.52,1140.80
921,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,Medicare Part A,I,1884.10,527.05,1030.93,1360.64,1130.46
922,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0612,revCode,Magnetic Resonance Technology (Mrt) Spinal Cord/Spine,aetna,Medicare Part B,O,2882.19,203.81,1642.85,2100.47,1729.31
923,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77295,cpt,"Management Of Radiation Therapy, 3d",aetna,Medicaid,O,1926.57,1003.61,1098.14,1531.62,1341.41
924,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96417,cpt,Infusion Of Different Chemotherapy Drug Or Substance Into A Vein Up To 1 Hour,aetna,Medicare Part A,O,241.84,54.88,132.33,181.38,145.10
925,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,P9040,cpt,"Red Blood Cells, Leukocytes Reduced, Irradiated, Each Unit",aetna,HMO,O,756.23,260.55,262.76,509.61,453.74
926,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2469,cpt,"Injection, Palonosetron Hcl, 25 Mcg",aetna,Medicaid,O,90.84,19.36,39.42,85.70,54.50
927,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9271,cpt,"Injection, Pembrolizumab, 1 Mg",aetna,HMO,O,192.29,32.26,52.73,144.22,115.37
928,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82626,cpt,Dehydroepiandrosterone (Dhea) Hormone Level,aetna,HMO,O,148.02,23.79,85.85,85.85,88.81
929,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73720,cpt,MRI Scan Of Leg Before And After Contrast,aetna,PPO,O,2882.19,326.01,1671.67,1671.67,1729.31
930,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2370,cpt,"Injection, Phenylephrine Hcl, Up To 1 Ml",aetna,EPO,O,87.77,23.91,40.37,66.01,52.66
931,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95811,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab With Continued Pressured Respiratory Assistance By Mask Or Breathing Tube,aetna,EPO,O,3186.58,814.60,1816.35,1816.35,1911.95
932,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97166,cpt,"Evaluation For Occupational Therapy, Typically 45 Minutes",aetna,Medicaid,O,265.44,85.51,151.30,163.25,159.26
933,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5111,cpt,"Injection, Pegfilgrastim-Cbqv, Biosimilar, (Udenyca), 0.5 Mg",aetna,HMO,O,1901.34,181.58,880.52,880.52,1140.80
934,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19084,cpt,"Biopsy Of Breast And Placement Of Locating Device Using Ultrasound, Each Additional Growth",aetna,EPO,O,12042.88,1246.10,6742.37,6742.37,7225.73
935,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93225,cpt,Electrocardiogram (Ecg) 2-Day Continuous,aetna,Medicare Part B,O,251.28,64.70,119.50,199.77,150.77
936,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64635,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Single Facet Joint",aetna,Medicare Part A,O,7086.24,1523.14,4237.46,4237.46,4251.74
937,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0690,cpt,"Injection, Cefazolin Sodium, 500 Mg",aetna,Medicare Part A,O,35.58,12.05,29.43,64.88,21.35
938,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna,Medicare Part B,O,356.28,61.44,194.95,194.95,213.77
939,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0121,cpt,Colorectal Cancer Screening; Colonoscopy On Individual Not Meeting Criteria For High Risk,aetna,Medicaid,O,3036.82,702.86,1604.70,2259.70,1822.09
940,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9552,cpt,"Fluorodeoxyglucose F-18 Fdg, Diagnostic, Per Study Dose, Up To 45 Millicuries",aetna,Medicare Part B,O,1552.58,289.56,849.53,1645.73,931.55
941,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11045,cpt,"Removal Of Skin And Tissue, Each Additional 20.0 Sq Cm Or Less",aetna,PPO,O,2875.83,306.28,312.72,3179.32,1725.50
942,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77080,cpt,"Bone Density Measurement Of The Core Or Central Skeleton (E.G., Hips, Pelvis, Spine)",aetna,HMO,O,352.74,96.51,201.06,249.59,115.81
943,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,690,ms-drg,Kidney And Urinary Tract Infections Without MCC,aetna,POS,I,16840.52,3735.53,9339.74,9339.74,10104.31
944,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76801,cpt,Abdominal Ultrasound Of Pregnant Uterus (Less Than 14 Weeks 0 Days) Single Or First Fetus,aetna,Medicare Part B,O,357.27,96.50,217.76,229.19,115.81
945,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna,HMO,O,14.15,0.48,0.89,8.71,8.49
946,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2250,cpt,"Injection, Midazolam Hydrochloride, Per 1 Mg",aetna,Medicare Part A,O,41.06,10.28,18.48,41.06,24.64
947,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82607,cpt,Cyanocobalamin (Vitamin B-12) Level,aetna,HMO,O,73.83,10.37,42.08,42.08,18.10
948,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64718,cpt,Release And/Or Relocation Of Ulnar Nerve At Elbow,aetna,POS,O,16595.69,1553.71,9876.73,9876.73,9957.41
949,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7050,cpt,"Infusion, Normal Saline Solution, 250 Cc",aetna,HMO,O,157.33,71.59,71.59,118.00,94.40
950,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93880,cpt,Ultrasound Scanning Of Blood Flow (Outside The Brain) On Both Sides Of Head And Neck,aetna,Medicare Part A,O,711.39,203.81,397.38,397.38,426.83
951,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5114,cpt,"Injection, Trastuzumab-Dkst, Biosimilar, (Ogivri), 10 Mg",aetna,Medicaid,O,232.14,60.17,60.17,66.12,139.28
952,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85597,cpt,Platelet Function Test,aetna,Medicare Part B,O,89.65,9.41,51.10,67.24,21.58
953,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,292,ms-drg,Heart Failure And Shock With CC,aetna,Medicaid,I,18032.02,5781.24,12207.78,12207.78,10819.21
954,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,20680,cpt,Removal Of Deep Implant From Bone,aetna,EPO,O,21223.25,2098.90,12436.52,12436.52,12733.95
955,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82607,cpt,Cyanocobalamin (Vitamin B-12) Level,aetna,PPO,O,73.83,10.37,42.08,42.08,18.10
956,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93225,cpt,Electrocardiogram (Ecg) 2-Day Continuous,aetna,PPO,O,251.28,64.70,119.50,199.77,150.77
957,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0274,revCode,"Medical/Surgical Supplies And Devices, Prosthetic/Orthotic Devices",aetna,Medicare Part B,O,89.04,8.13,2026.64,2026.64,53.42
958,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9130,cpt,Dacarbazine 100 Mg Inj,aetna,Medicaid,O,15.58,5.03,5.03,16.51,9.35
959,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,Medicare Part A,O,218.25,35.37,121.91,263.09,130.95
960,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87480,cpt,"Detection Test For Candida Species (Yeast), Direct Probe Technique",aetna,Medicare Part B,O,107.59,12.03,58.87,80.69,24.06
961,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81001,cpt,"Manual Urinalysis Test With Examination Using Microscope, Automated",aetna,HMO,O,13.80,2.37,7.87,10.35,8.28
962,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43239,cpt,"Biopsy Of Esophagus, Stomach, And/Or Upper Small Bowel Using A Flexible Endoscope",aetna,PPO,O,4254.12,439.90,1990.82,4844.32,1282.14
963,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0403,revCode,Other Imaging Services Screening Mammography,aetna,POS,O,312.75,51.78,104.90,273.24,187.65
964,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82784,cpt,Gammaglobulin (Immune System Protein) Measurement,aetna,HMO,O,65.66,9.30,9.30,52.19,11.16
965,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82950,cpt,Blood Glucose (Sugar) Level After Receiving Dose Of Glucose,aetna,Medicare Part B,O,38.92,4.70,21.30,75.94,5.70
966,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,40490,cpt,Biopsy Of Lip,aetna,Medicaid,O,1535.00,623.16,642.96,1044.00,921.00
967,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83540,cpt,Iron Level,aetna,HMO,O,41.28,6.35,23.53,41.28,7.76
968,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73620,cpt,"X-Ray Of Foot, 2 Views",aetna,HMO,O,252.47,61.44,143.91,143.91,151.48
969,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11047,cpt,"Removal Of Bone, Each Additional 20.0 Sq Cm Or Less",aetna,HMO,O,12247.63,1215.96,1247.54,1273.00,7348.58
970,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9552,cpt,"Fluorodeoxyglucose F-18 Fdg, Diagnostic, Per Study Dose, Up To 45 Millicuries",aetna,POS,O,1552.58,289.56,849.53,1645.73,931.55
971,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96416,cpt,Prolonged Chemotherapy Infusion Into A Vein By Portable Or Implanted Pump More Than 8 Hours,aetna,HMO,O,535.61,119.50,290.78,401.71,321.37
972,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87491,cpt,"Detection Test By Nucleic Acid For Chlamydia Trachomatis, Amplified Probe Technique",aetna,PPO,O,147.58,21.05,82.44,110.69,42.11
973,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71275,cpt,CT Scan Of Blood Vessels Of Chest With Contrast,aetna,Medicaid,O,1841.63,158.13,970.89,1464.09,189.76
974,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77385,cpt,"Intensity Modulated Radiation Therapy Delivery, Simple",aetna,HMO,O,1786.18,480.50,485.97,729.06,576.60
975,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86376,cpt,Microsomal Antibodies (Autoantibody) Measurement,aetna,Medicaid,O,90.15,12.00,21.95,21.95,17.46
976,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna,Medicare Part B,O,148.64,18.79,18.79,22.56,22.55
977,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0171,cpt,"Injection, Adrenalin, Epinephrine, 0.1 Mg",aetna,Medicare Part A,O,5.83,0.23,2.68,2.68,3.50
978,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna,POS,O,2144.07,645.60,1279.68,2047.58,1286.44
979,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73070,cpt,"X-Ray Of Elbow, 2 Views",aetna,Medicare Part A,O,238.30,35.12,143.98,143.98,142.98
980,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74178,cpt,CT Scan Of Abdomen And Pelvis Before And After Contrast,aetna,POS,O,4577.54,2.93,2609.20,3536.15,391.22
981,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80069,cpt,Kidney Function Blood Test Panel,aetna,Medicaid,O,67.58,8.51,38.52,38.52,10.42
982,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,186,ms-drg,Pleural Effusion With MCC,aetna,Medicaid,I,29279.58,9460.85,9734.76,9734.76,17567.75
983,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96375,cpt,"Injection Of Different Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,Medicare Part B,O,88.47,19.71,48.41,66.35,53.08
984,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9190,cpt,"Injection, Fluorouracil, 500 Mg",aetna,Medicare Part A,O,8.25,1.86,1.89,8.07,4.95
985,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna,HMO,O,91.30,14.35,49.96,64.61,54.78
986,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna,Medicare Part A,E,5923.22,592.08,2036.44,2288.99,3553.93
987,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,580,ms-drg,"Other Skin, Subcutaneous Tissue And Breast Procedures With CC",aetna,EPO,I,43871.64,9796.13,9809.77,15064.04,26322.98
988,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9060,cpt,"Injection, Cisplatin, Powder Or Solution, 10 Mg",aetna,Medicare Part B,O,7.79,1.85,1.85,2.82,4.67
989,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82310,cpt,"Calcium Level, Total",aetna,PPO,O,36.61,5.16,5.16,36.61,21.97
990,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84480,cpt,"Thyroid Hormone, T3 Measurement, Total",aetna,HMO,O,60.03,11.72,34.82,34.82,17.02
991,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86778,cpt,Analysis For Antibody (Igm) To Toxoplasma (Parasite),aetna,Medicare Part A,O,152.18,14.27,86.74,86.74,91.31
992,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11042,cpt,Removal Of Skin And Tissue First 20 Sq Cm Or Less,aetna,Medicare Part A,O,1315.41,306.28,624.03,3179.32,789.25
993,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38505,cpt,Needle Biopsy Or Removal Of Surface Lymph Nodes,aetna,Medicaid,O,8266.58,1246.10,7074.31,7074.31,4959.95
994,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92610,cpt,Evaluation Of Swallowing Function,aetna,Medicaid,O,286.43,81.46,166.13,166.13,171.86
995,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,596,ms-drg,Major Skin Disorders Without MCC,aetna,EPO,I,17771.27,4749.34,4749.34,8242.06,10662.76
996,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77280,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 1 Treatment Area",aetna,Medicare Part A,O,1037.01,112.36,591.10,733.79,134.83
997,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9354,cpt,"Injection, Ado-Trastuzumab Emtansine, 1 Mg",aetna,Medicaid,O,123.87,25.63,36.89,41.57,74.32
998,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,371,ms-drg,Major Gastrointestinal Disorders And Peritoneal Infections With MCC,aetna,HMO,I,34185.44,8873.88,8873.88,11142.92,20511.26
999,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,292,ms-drg,Heart Failure And Shock With CC,aetna,HMO,I,18032.02,5781.24,12207.78,12207.78,10819.21
1000,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82607,cpt,Cyanocobalamin (Vitamin B-12) Level,aetna,Medicare Part B,O,73.83,10.37,42.08,42.08,18.10
1001,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73620,cpt,"X-Ray Of Foot, 2 Views",aetna,EPO,O,252.47,61.44,143.91,143.91,151.48
1002,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0371,revCode,Anesthesia Incident To Radiology,aetna,EPO,I,47.19,8.72,26.90,26.90,28.31
1003,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83735,cpt,Magnesium Level,aetna,POS,O,65.11,6.70,35.63,46.07,8.04
1004,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87624,cpt,"Detection Test By Nucleic Acid For Human Papillomavirus (Hpv), High-Risk Types",aetna,PPO,O,108.49,21.05,59.36,108.49,42.11
1005,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna,EPO,O,281.96,102.95,163.54,224.15,123.54
1006,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88307,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately High Complexity",aetna,HMO,O,298.47,86.80,170.13,298.47,179.08
1007,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,271,ms-drg,Other Major Cardiovascular Procedures With CC,aetna,Medicare Part B,I,68161.35,20934.94,27743.68,28893.46,40896.81
1008,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87045,cpt,Stool Culture,aetna,EPO,O,80.09,9.05,46.05,46.05,11.33
1009,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna,EPO,O,331.51,82.43,181.40,301.25,102.14
1010,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna,EPO,O,226.51,61.44,126.53,160.27,135.91
1011,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93798,cpt,"Outpatient Heart Rehabilitation With Electrocardiogram (Ecg) Monitoring, Quality Health Care Professional Services",aetna,PPO,O,173.89,102.78,102.79,130.42,123.35
1012,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3010,cpt,"Injection, Fentanyl Citrate, 0.1 Mg",aetna,Medicare Part A,O,82.61,17.19,37.17,85.93,49.57
1013,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,POS,O,479.00,41.29,159.02,1803.87,287.40
1014,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73110,cpt,"X-Ray Of Wrist, Minimum Of 3 Views",aetna,Medicare Part B,O,329.15,51.73,183.86,246.86,197.49
1015,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82140,cpt,Ammonia Level,aetna,Medicare Part B,O,108.53,13.90,59.39,59.39,17.48
1016,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0500,cpt,"Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care Professional Performing A Gastrointestinal Endoscopic Service That Sedation Supports, Requiring The Presence Of",aetna,Medicare Part B,O,47.19,27.14,27.14,47.19,28.31
1017,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0482,revCode,"Cardiology, Stress Test",aetna,POS,O,474.26,84.78,270.33,377.03,284.56
1018,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17280,cpt,"Destruction Of Malignant Growth (0.5 Centimeters Or Less) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,EPO,O,1569.00,159.01,162.47,542.48,941.40
1019,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96413,cpt,"Administration Of Chemotherapy Into Vein, 1 Hour Or Less",aetna,EPO,O,516.73,113.98,282.74,387.55,310.04
1020,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,HMO,O,83.80,8.07,29.33,89.04,50.28
1021,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1100,cpt,"Injection, Dexamethasone Sodium Phosphate, 1 Mg",aetna,PPO,O,7.91,1.12,1.12,7.91,4.75
1022,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2710,cpt,"Injection, Neostigmine Methylsulfate, Up To 0.5 Mg",aetna,PPO,O,4.65,0.15,0.15,4.27,2.79
1023,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0171,cpt,"Injection, Adrenalin, Epinephrine, 0.1 Mg",aetna,EPO,O,5.83,0.23,2.68,2.68,3.50
1024,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97535,cpt,"Training For Self-Care Or Home Management, Each 15 Minutes",aetna,EPO,O,200.56,25.86,84.86,87.79,120.34
1025,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0276,revCode,Medical/Surgical Supplies And Devices Intracular Lens,aetna,Medicaid,O,797.52,202.98,270.86,797.52,478.51
1026,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99282,cpt,Emergency Department Visit For Problem Of Mild To Moderate Severity,aetna,HMO,E,276.06,99.19,160.11,290.62,165.64
1027,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80074,cpt,Acute Hepatitis Panel,aetna,HMO,O,213.87,26.66,117.03,117.03,57.16
1028,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2505,cpt,"Injection, Pegfilgrastim, 6 Mg",aetna,Medicare Part A,O,17508.60,2251.51,6955.90,6955.90,10505.16
1029,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93308,cpt,Follow-Up Or Limited Ultrasound Examination Of Heart,aetna,POS,O,415.27,203.81,204.22,403.52,249.16
1030,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88173,cpt,Evaluation Of Fine Needle Aspirate With Interpretation And Report,aetna,EPO,O,109.71,60.12,81.77,81.77,65.83
1031,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11044,cpt,Removal Of Skin And Bone First 20 Sq Cm Or Less,aetna,Medicare Part A,O,3769.31,1215.96,1260.27,2751.80,2261.59
1032,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5106,cpt,"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (For Non-Esrd Use), 1000 Units",aetna,HMO,O,32.27,8.13,8.62,13.29,19.36
1033,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72202,cpt,"X-Ray Of Joint Between Lower Spine And Hip Bone, 3 Or More Views",aetna,HMO,O,252.47,26.87,145.17,166.73,151.48
1034,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72050,cpt,"X-Ray Of Upper Spine, 4 Or 5 Views",aetna,PPO,O,613.48,42.39,349.68,373.40,115.81
1035,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73600,cpt,"X-Ray Of Ankle, 2 Views",aetna,Medicare Part A,O,252.47,30.86,143.91,143.91,151.48
1036,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2785,cpt,"Injection, Regadenoson, 0.1 Mg",aetna,Medicare Part B,O,154.74,25.67,69.52,154.76,92.84
1037,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72141,cpt,MRI Scan Of Upper Spinal Canal Without Contrast,aetna,POS,O,2882.19,205.13,1642.85,2291.34,244.57
1038,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,638,ms-drg,Diabetes With CC,aetna,Medicaid,I,20621.27,4023.89,8833.24,8833.24,12372.76
1039,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7121,cpt,"5% Dextrose In Lactated Ringers Infusion, Up To 1000 Cc",aetna,PPO,O,164.65,75.76,75.76,75.76,98.79
1040,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna,PPO,O,188.09,38.65,107.21,141.02,112.85
1041,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27328,cpt,Removal (Less Than 5 Centimeters) Muscle Growth Of Thigh Or Knee,aetna,EPO,O,23211.17,12578.62,12578.62,12578.62,13926.70
1042,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86762,cpt,Analysis For Antibody To Rubella (German Measles Virus),aetna,PPO,O,50.01,4.42,27.36,37.51,17.10
1043,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96377,cpt,Application Of On-Body Injector For Under Skin Injection,aetna,Medicaid,O,44.52,9.67,25.82,25.82,26.71
1044,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7040,cpt,"Infusion, Normal Saline Solution, Sterile (500 Ml = 1 Unit)",aetna,POS,O,157.91,58.43,71.06,157.91,94.75
1045,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84144,cpt,Progesterone (Reproductive Hormone) Level,aetna,PPO,O,101.45,17.03,55.51,71.78,25.03
1046,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0335,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration -Iv,aetna,HMO,O,487.49,86.82,282.74,11490.04,292.49
1047,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3480,cpt,"Injection, Potassium Chloride, Per 2 Meq",aetna,Medicaid,O,2.35,0.80,1.02,1.02,1.41
1048,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0740,revCode,"Electroencephalogram (Eeg), General",aetna,Medicare Part B,O,779.82,234.21,444.50,735.68,467.89
1049,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna,Medicaid,O,88.82,7.62,50.63,66.62,9.32
1050,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,784,ms-drg,Cesarean Section With Sterilization With CC,aetna,Medicare Part A,I,14658.24,5823.07,5823.07,10802.78,8794.94
1051,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76642,cpt,Limited Ultrasound Scan Of 1 Breast,aetna,Medicaid,O,305.55,71.65,167.19,242.91,183.33
1052,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,596,ms-drg,Major Skin Disorders Without MCC,aetna,PPO,I,17771.27,4749.34,4749.34,8242.06,10662.76
1053,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,M0243,cpt,"Intravenous Infusion, Casirivimab And Imdevimab Includes Infusion And Post Administration Monitoring",aetna,PPO,O,820.47,138.86,502.86,502.86,492.28
1054,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna,Medicaid,O,14.15,0.48,0.89,8.71,8.49
1055,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0114,revCode,Room And Board Private (One Bed) Psychiatric,aetna,POS,I,2200.28,629.26,1203.93,7562.58,1320.17
1056,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72050,cpt,"X-Ray Of Upper Spine, 4 Or 5 Views",aetna,Medicare Part B,O,613.48,42.39,349.68,373.40,115.81
1057,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76770,cpt,Complete Ultrasound Scan Behind Abdominal Cavity,aetna,Medicaid,O,747.97,96.51,409.27,409.27,115.81
1058,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85018,cpt,"Blood Count, Hemoglobin",aetna,Medicaid,O,33.02,2.35,18.82,24.77,2.84
1059,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A4565,cpt,Slings; Medical And Surgical Supplies - Various Medical Supplies Including Tapes And Surgical Dressings,aetna,POS,O,21.33,6.00,7.91,29.48,12.80
1060,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7030,cpt,"Infusion, Normal Saline Solution , 1000 Cc",aetna,Medicare Part A,O,8.25,3.71,3.71,162.78,4.95
1061,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna,EPO,O,188.09,38.65,107.21,141.02,112.85
1062,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,247,ms-drg,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without MCC,aetna,PPO,I,79628.76,11995.52,12110.64,46153.54,47777.26
1063,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,219,ms-drg,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With MCC,aetna,PPO,I,256090.54,46435.26,46497.02,47950.73,153654.32
1064,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97110,cpt,"Therapeutic Exercise To Develop Strength, Endurance, Range Of Motion, And Flexibility, Each 15 Minutes",aetna,POS,O,173.42,23.35,77.46,114.70,29.09
1065,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,POS,I,2882.19,650.30,2882.19,2882.19,1729.31
1066,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82248,cpt,"Bilirubin Level, Direct",aetna,PPO,O,41.28,4.92,14.47,14.47,6.02
1067,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99283,cpt,Emergency Department Visit For Problem Of Moderate Severity,aetna,Medicaid,E,871.53,205.11,459.97,892.25,522.92
1068,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1885,cpt,"Injection, Ketorolac Tromethamine, Per 15 Mg",aetna,POS,O,39.72,7.88,18.17,40.53,23.83
1069,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38505,cpt,Needle Biopsy Or Removal Of Surface Lymph Nodes,aetna,PPO,O,8266.58,1246.10,7074.31,7074.31,4959.95
1070,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17003,cpt,"Destruction Of Precancer Skin Growth, 2-14 Growths",aetna,EPO,O,982.00,159.01,162.47,1222.94,589.20
1071,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19120,cpt,"Removal Of 1 Or More Breast Growth, Open Procedure",aetna,Medicare Part B,O,19283.58,2826.79,11249.61,11249.61,3355.94
1072,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,Medicare Part B,O,1673.95,97.51,795.53,1330.78,1004.37
1073,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92921,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Single Artery Or Branch",aetna,PPO,O,71846.71,8777.72,8894.43,14120.90,43108.03
1074,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0341,revCode,"Nuclear Medicine, Diagnostic",aetna,POS,O,5568.56,800.20,3046.95,5465.13,3341.14
1075,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86803,cpt,Hepatitis C Antibody Measurement,aetna,Medicare Part B,O,113.25,14.27,64.55,140.68,17.12
1076,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,Medicare Part A,I,45.29,12.02,38.30,59.57,27.17
1077,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2765,cpt,"Injection, Metoclopramide Hcl, Up To 10 Mg",aetna,EPO,O,79.57,18.17,36.60,79.57,47.74
1078,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73523,cpt,"X-Ray Of Both Hips With Pelvis, Minimum Of 5 Views",aetna,EPO,O,636.63,58.51,384.65,536.48,115.81
1079,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,Medicaid,O,212.10,40.75,115.12,253.05,127.26
1080,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82397,cpt,Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,aetna,Medicare Part A,O,51.39,6.88,29.29,29.29,30.83
1081,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87181,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Agar Dilution Method",aetna,Medicare Part B,O,16.51,4.75,9.41,9.41,3.37
1082,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73620,cpt,"X-Ray Of Foot, 2 Views",aetna,Medicare Part B,O,252.47,61.44,143.91,143.91,151.48
1083,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0942,revCode,Medical Rehabilitation Day Program Education/Training,aetna,Medicare Part B,O,155.82,64.63,92.26,117.54,93.49
1084,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna,EPO,O,490.78,263.76,343.76,352.65,294.47
1085,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86800,cpt,Thyroglobulin (Thyroid Protein) Antibody Measurement,aetna,Medicare Part B,O,71.96,14.53,40.56,40.56,19.09
1086,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1439,cpt,"Injection, Ferric Carboxymaltose, 1 Mg",aetna,HMO,O,4.45,0.79,2.09,2.09,2.67
1087,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2599,cpt,Contact Lens/Es Other Type,aetna,Medicare Part A,O,3822.87,1002.34,4045.37,4045.37,2293.72
1088,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87427,cpt,Detection Test By Immunoassay Technique For Shiga-Like Toxin (Bacterial Toxin),aetna,HMO,O,60.03,6.75,34.22,34.22,14.38
1089,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86141,cpt,"Measurement C-Reactive Protein For Detection Of Infection Or Inflammation, High Sensitivity",aetna,Medicare Part A,O,138.33,7.77,7.77,13.00,15.54
1090,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2765,cpt,"Injection, Metoclopramide Hcl, Up To 10 Mg",aetna,POS,O,79.57,18.17,36.60,79.57,47.74
1091,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0360,revCode,"Operating Room Services, General",aetna,Medicaid,O,9825.06,1878.83,4989.15,12996.76,5895.04
1092,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna,Medicaid,E,5923.22,592.08,2036.44,2288.99,3553.93
1093,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,Medicaid,O,332.78,61.44,194.95,261.67,199.67
1094,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1200,cpt,"Injection, Diphenhydramine Hcl, Up To 50 Mg",aetna,HMO,O,3.52,0.76,18.38,80.35,2.11
1095,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,POS,I,218.25,67.65,124.40,224.80,130.95
1096,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93017,cpt,Exercise Or Drug-Induced Heart And Blood Vessel Stress Test With Ekg Tracing And Monitoring,aetna,HMO,O,474.26,84.78,270.33,377.03,284.56
1097,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45385,cpt,Removal Of Polyps Or Growths Of Large Bowel Using An Endoscope With Mechanical Snare,aetna,HMO,O,5305.34,938.17,2617.73,5400.89,1653.07
1098,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64450,cpt,Injection Of Anesthetic Agent And/Or Steroid Into Other Peripheral Nerve Or Branch,aetna,Medicare Part A,O,1533.00,1587.94,12436.52,12436.52,919.80
1099,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,PPO,I,58214.47,42815.71,42815.71,42815.71,34928.68
1100,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82952,cpt,"Blood Glucose (Sugar) Tolerance Test, Each Additional Beyond 3 Specimens",aetna,Medicare Part B,O,48.36,3.92,27.57,36.27,4.70
1101,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19120,cpt,"Removal Of 1 Or More Breast Growth, Open Procedure",aetna,Medicare Part A,O,19283.58,2826.79,11249.61,11249.61,3355.94
1102,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99211,cpt,Office Or Other Outpatient Visit For The Evaluation And Management Of Established Patient That May Not Require Presence Of Healthcare Professional,aetna,Medicaid,O,91.30,29.79,52.04,190.38,54.78
1103,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71260,cpt,CT Scan Of Chest With Contrast,aetna,EPO,O,1774.38,129.65,1011.40,1330.79,189.76
1104,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,32408,cpt,"Core Needle Biopsy Of Lung Or Center Cavity Of Chest (Mediastinum), Accessed Through Skin",aetna,HMO,O,3883.82,638.16,1248.81,1248.81,2330.29
1105,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1200,cpt,"Injection, Diphenhydramine Hcl, Up To 50 Mg",aetna,POS,O,3.52,0.76,18.38,80.35,2.11
1106,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82962,cpt,Blood Glucose (Sugar) Test Performed By Hand-Held Instrument,aetna,Medicare Part B,O,42.58,3.28,24.27,42.58,3.94
1107,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2704,cpt,"Injection, Propofol, 10 Mg",aetna,EPO,O,4.12,0.82,1.89,4.12,2.47
1108,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0482,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,HMO,O,315.99,78.44,78.44,208.68,189.59
1109,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82140,cpt,Ammonia Level,aetna,HMO,O,108.53,13.90,59.39,59.39,17.48
1110,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87661,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Amplified Probe Technique",aetna,HMO,O,151.64,21.05,84.70,113.73,42.11
1111,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52260,cpt,Dilation Of The Bladder Using An Endoscope Under General Or Spinal Anesthesia,aetna,EPO,O,14589.65,1578.66,8790.54,8790.54,8753.79
1112,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna,HMO,O,92.22,24.06,24.60,24.60,55.33
1113,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0330,cpt,"Injection, Succinylcholine Chloride, Up To 20 Mg",aetna,PPO,O,97.93,26.00,44.25,73.44,58.76
1114,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna,POS,O,50.72,5.89,27.75,35.89,7.21
1115,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93017,cpt,Exercise Or Drug-Induced Heart And Blood Vessel Stress Test With Ekg Tracing And Monitoring,aetna,PPO,O,474.26,84.78,270.33,377.03,284.56
1116,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3370,cpt,"Injection, Vancomycin Hcl, 500 Mg",aetna,Medicare Part B,O,75.38,22.33,34.67,34.67,45.23
1117,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87181,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Agar Dilution Method",aetna,PPO,O,16.51,4.75,9.41,9.41,3.37
1118,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97018,cpt,Application Of Hot Wax Bath To 1 Or More Areas,aetna,EPO,O,79.04,3.64,32.08,34.45,47.42
1119,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72050,cpt,"X-Ray Of Upper Spine, 4 Or 5 Views",aetna,Medicare Part A,O,613.48,42.39,349.68,373.40,115.81
1120,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82627,cpt,Dehydroepiandrosterone (Dhea-S) Hormone Level,aetna,EPO,O,119.15,19.46,67.92,67.92,71.49
1121,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86235,cpt,"Measurement Of Antibody For Assessment Of Autoimmune Disorder, Any Method",aetna,HMO,O,43.81,6.19,24.97,30.69,21.52
1122,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0430,revCode,"Occupational Therapy, General",aetna,EPO,I,176.32,32.63,91.02,165.50,105.79
1123,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64635,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Single Facet Joint",aetna,Medicare Part B,O,7086.24,1523.14,4237.46,4237.46,4251.74
1124,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85045,cpt,"Red Blood Count, Automated Test",aetna,POS,O,38.92,2.44,3.98,14.01,4.79
1125,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S2900,cpt,Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure),aetna,Medicare Part B,O,26479.60,4481.58,24397.19,24397.19,15887.76
1126,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84112,cpt,Cervicovaginal Secretion Of Placenta Protein,aetna,Medicare Part A,O,243.07,29.33,29.33,243.07,49.58
1127,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0463,cpt,Hospital Outpatient Clinic Visit For Assessment And Management Of A Patient,aetna,PPO,O,176.96,59.81,102.70,107.50,106.18
1128,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76817,cpt,Vaginal Ultrasound Of Pregnant Uterus,aetna,Medicare Part B,O,611.12,96.51,341.37,432.40,115.81
1129,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0243,cpt,"Injection, Casirivimab And Imdevimab, 2400 Mg",aetna,Medicare Part A,O,0.03,0.01,0.01,11.63,0.02
1130,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0762,revCode,Specialty Services Observation Hours,aetna,PPO,I,15.11,4.72,10.23,10.23,9.07
1131,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88304,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately Low Complexity",aetna,Medicare Part B,O,212.36,44.07,116.20,200.34,127.42
1132,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87635,cpt,Amplifed DNA Or Rna Probe Detection Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antigen,aetna,PPO,O,168.00,50.29,97.44,126.00,61.57
1133,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87255,cpt,Virus Isolation,aetna,EPO,O,123.87,33.86,67.78,81.80,40.63
1134,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83540,cpt,Iron Level,aetna,POS,O,41.28,6.35,23.53,41.28,7.76
1135,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0771,revCode,"Preventive Care Services, Vaccine Administration",aetna,EPO,O,820.44,35.43,512.23,512.23,492.26
1136,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,Medicare Part B,O,576.53,96.50,334.39,562.62,345.92
1137,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85018,cpt,"Blood Count, Hemoglobin",aetna,HMO,O,33.02,2.35,18.82,24.77,2.84
1138,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna,POS,O,142.89,8.03,64.15,113.59,16.07
1139,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1170,cpt,"Injection, Hydromorphone, Up To 4 Mg",aetna,EPO,O,82.88,16.96,38.12,82.88,49.73
1140,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0720,revCode,Labor Room/Delivery General,aetna,Medicare Part B,I,141.69,33.03,82.08,5123.48,85.01
1141,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17280,cpt,"Destruction Of Malignant Growth (0.5 Centimeters Or Less) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,Medicare Part B,O,1569.00,159.01,162.47,542.48,941.40
1142,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,885,ms-drg,Psychoses,aetna,POS,I,17080.81,5566.92,6861.23,9301.98,10248.49
1143,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna,PPO,O,36.32,4.21,20.29,27.24,5.15
1144,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0882,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (For Esrd On Dialysis)",aetna,PPO,O,16.51,7.43,7.43,7.43,9.91
1145,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86769,cpt,Measure Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antibody,aetna,EPO,O,89.25,16.93,51.77,66.94,50.56
1146,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88177,cpt,"Pap Test, Evaluation Of Fine Needle Aspirate, Immediate, Each Additional Evaluation Episode",aetna,POS,O,49.54,26.22,93.48,93.48,29.72
1147,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0690,cpt,"Injection, Cefazolin Sodium, 500 Mg",aetna,Medicare Part B,O,35.58,12.05,29.43,64.88,21.35
1148,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,596,ms-drg,Major Skin Disorders Without MCC,aetna,Medicare Part B,I,17771.27,4749.34,4749.34,8242.06,10662.76
1149,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78070,cpt,Nuclear Medicine Study Of Parathyroid,aetna,Medicare Part A,O,1314.27,400.84,749.13,749.13,788.56
1150,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna,HMO,O,331.51,82.43,181.40,301.25,102.14
1151,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85732,cpt,"Coagulation Assessment Blood Test, Substitution, Plasma Fractions",aetna,Medicaid,O,35.39,3.71,20.17,26.54,7.76
1152,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73610,cpt,"X-Ray Of Ankle, Minimum Of 3 Views",aetna,EPO,O,329.15,46.08,180.10,261.67,197.49
1153,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna,Medicare Part B,E,5923.22,592.08,2036.44,2288.99,3553.93
1154,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9144,cpt,"Injection, Daratumumab, 10 Mg And Hyaluronidase-Fihj",aetna,HMO,O,139.92,43.18,45.07,45.65,83.95
1155,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82746,cpt,"Folic Acid Level, Serum",aetna,Medicare Part A,O,65.11,9.14,37.11,37.11,17.64
1156,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87389,cpt,Detection Test By Immunoassay Technique For Hiv-1 Antigen And Hiv-1 And Hiv-2 Antibodies,aetna,HMO,O,101.33,8.97,55.45,76.00,28.90
1157,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82607,cpt,Cyanocobalamin (Vitamin B-12) Level,aetna,Medicaid,O,73.83,10.37,42.08,42.08,18.10
1158,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93571,cpt,"Ultrasound Evaluation Of Heart Blood Vessel During Diagnosis Or Treatment, Initial Vessel",aetna,Medicare Part A,O,31969.64,4389.98,14191.44,14191.44,19181.78
1159,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7121,cpt,"5% Dextrose In Lactated Ringers Infusion, Up To 1000 Cc",aetna,EPO,O,164.65,75.76,75.76,75.76,98.79
1160,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82784,cpt,Gammaglobulin (Immune System Protein) Measurement,aetna,EPO,O,65.66,9.30,9.30,52.19,11.16
1161,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93970,cpt,Ultrasound Scan Of Veins Of Both Arms Or Legs Including Assessment Of Compression And Functional Maneuvers,aetna,Medicaid,O,1047.64,203.81,415.78,773.81,628.58
1162,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96367,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Additional Sequential Infusion, 1 Hour Or Less",aetna,PPO,O,117.97,25.86,64.55,88.48,70.78
1163,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76999,cpt,Other Ultrasound Procedure,aetna,Medicare Part B,O,238.30,71.65,130.40,216.32,142.98
1164,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,EPO,I,1495.87,276.63,903.80,903.80,897.52
1165,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0431,revCode,Occupational Therapy Visit Charge,aetna,PPO,O,173.42,21.75,80.69,875.96,104.05
1166,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0640,cpt,"Injection, Leucovorin Calcium, Per 50 Mg",aetna,Medicare Part A,O,17.80,3.56,3.56,14.15,10.68
1167,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna,HMO,O,289.04,102.81,158.15,158.15,134.83
1168,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64635,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Single Facet Joint",aetna,HMO,O,7086.24,1523.14,4237.46,4237.46,4251.74
1169,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70487,cpt,CT Scan Of Face With Contrast,aetna,Medicare Part A,O,1358.47,810.86,810.86,810.86,815.08
1170,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88172,cpt,Evaluation Of Fine Needle Aspirate,aetna,Medicare Part A,O,416.45,228.18,310.38,310.38,249.87
1171,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76870,cpt,Ultrasound Scan Of Scrotum,aetna,Medicaid,O,528.53,96.50,295.23,396.40,317.12
1172,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,EPO,O,110.40,7.04,8.00,129.02,66.24
1173,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,PPO,I,137.36,28.95,90.50,129.04,82.42
1174,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,POS,O,30.08,3.64,57.64,96.59,18.05
1175,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36561,cpt,"Insertion Of Central Venous Catheter And Implanted Device For Infusion Beneath The Skin, Patient 5 Years Or Older",aetna,PPO,O,18382.66,2534.31,2589.99,17974.64,11029.60
1176,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9130,cpt,Dacarbazine 100 Mg Inj,aetna,POS,O,15.58,5.03,5.03,16.51,9.35
1177,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19084,cpt,"Biopsy Of Breast And Placement Of Locating Device Using Ultrasound, Each Additional Growth",aetna,POS,O,12042.88,1246.10,6742.37,6742.37,7225.73
1178,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19120,cpt,"Removal Of 1 Or More Breast Growth, Open Procedure",aetna,EPO,O,19283.58,2826.79,11249.61,11249.61,3355.94
1179,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0882,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (For Esrd On Dialysis)",aetna,EPO,O,16.51,7.43,7.43,7.43,9.91
1180,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76819,cpt,Ultrasound Scan Of Fetus,aetna,HMO,O,611.12,96.51,348.34,485.84,366.67
1181,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78472,cpt,Nuclear Medicine Study Of Heart Pumping Function By Labeling Red Blood Cells With Measurement Of Internal Blood Volume Ejected With Every Beat Over Multiple Cycles,aetna,Medicare Part A,O,2168.12,333.98,333.99,645.81,1300.87
1182,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1437,cpt,"Injection, Ferric Derisomaltose, 10 Mg",aetna,HMO,O,80.56,14.43,25.38,25.82,48.34
1183,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,46255,cpt,Removal Of Single External And Internal Hemorrhoid Group,aetna,Medicare Part A,O,17900.37,2210.31,9939.29,9939.29,10740.22
1184,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82728,cpt,Ferritin (Blood Protein) Level,aetna,HMO,O,84.93,11.67,46.48,84.93,16.36
1185,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1437,cpt,"Injection, Ferric Derisomaltose, 10 Mg",aetna,Medicaid,O,80.56,14.43,25.38,25.82,48.34
1186,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0008,cpt,Administration Of Influenza Virus Vaccine,aetna,PPO,O,99.09,11.08,35.43,35.43,42.52
1187,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94640,cpt,Respiratory Inhaled Pressure Or Nonpressure Treatment To Relieve Airway Obstruction Or For Sputum Specimen,aetna,Medicare Part B,O,198.78,56.02,185.11,185.11,119.27
1188,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36598,cpt,Contrast Injections For X-Ray Imaging Procedure To Evaluate Central Venous Access Device,aetna,Medicare Part B,O,1156.30,162.25,585.00,585.00,693.78
1189,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83690,cpt,Lipase (Fat Enzyme) Level,aetna,PPO,O,52.60,6.89,18.70,39.45,8.27
1190,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0882,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (For Esrd On Dialysis)",aetna,POS,O,16.51,7.43,7.43,7.43,9.91
1191,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97165,cpt,"Evaluation For Occupational Therapy, Typically 30 Minutes",aetna,PPO,O,211.24,71.93,120.41,120.41,126.74
1192,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna,Medicare Part A,O,116.31,19.19,63.64,84.77,23.26
1193,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97113,cpt,"Water Pool Therapy With Therapeutic Exercises To 1 Or More Areas, Each 15 Minutes",aetna,PPO,O,132.12,28.83,54.93,62.54,79.27
1194,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88331,cpt,"Pathology Examination Of Specimen During Surgery, First Tissue Block",aetna,EPO,O,438.52,153.98,254.34,254.34,263.11
1195,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71275,cpt,CT Scan Of Blood Vessels Of Chest With Contrast,aetna,PPO,O,1841.63,158.13,970.89,1464.09,189.76
1196,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84166,cpt,"Protein Measurement, Body Fluid",aetna,POS,O,57.87,6.77,17.83,17.90,21.40
1197,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88172,cpt,Evaluation Of Fine Needle Aspirate,aetna,EPO,O,416.45,228.18,310.38,310.38,249.87
1198,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36010,cpt,Introduction Of Catheter Into The Upper Or Lower Major Vein (Vena Cava),aetna,PPO,I,37979.62,17796.08,17796.08,17796.08,22787.77
1199,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84153,cpt,"PSA (Prostate Specific Antigen) Measurement, Total",aetna,Medicare Part B,O,91.30,18.03,51.00,60.30,22.07
1200,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94060,cpt,"Measurement And Graphic Recording Of The Amount And Speed Of Breathed Air, Before And Following Medication Administration",aetna,HMO,O,422.68,78.29,218.19,239.44,253.61
1201,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna,HMO,O,50.72,6.48,17.70,38.04,7.78
1202,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0946,revCode,Medical Rehabilitation Day Program Complex Medical Equipment - Routine,aetna,HMO,I,144.44,64.00,258.21,258.21,86.66
1203,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37230,cpt,"Insertion Of Stents Into Artery In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna,POS,I,262831.76,27743.68,27743.68,27743.68,157699.06
1204,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99204,cpt,"New Patient Office Or Other Outpatient Visit, 45-59 Minutes",aetna,PPO,O,634.41,49.54,367.96,475.81,223.37
1205,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96374,cpt,"Injection Of Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,Medicaid,O,218.25,39.35,154.75,181.39,130.95
1206,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna,EPO,O,982.00,159.01,162.47,1222.94,589.20
1207,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93279,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Single Lead Pacemaker System In One Chamber Of Heart With Qualified Health Care Professional Analysis, Review, And Report",aetna,Medicaid,O,180.49,32.90,32.90,76.59,108.29
1208,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66984,cpt,"Removal Of Cataract With Insertion Of Lens, Simple",aetna,EPO,O,14664.91,1841.26,3839.82,4337.53,8798.95
1209,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88172,cpt,Evaluation Of Fine Needle Aspirate,aetna,POS,O,416.45,228.18,310.38,310.38,249.87
1210,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,673,ms-drg,Other Kidney And Urinary Tract Procedures With MCC,aetna,HMO,I,61701.73,20358.57,20462.06,20647.19,37021.04
1211,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0330,cpt,"Injection, Succinylcholine Chloride, Up To 20 Mg",aetna,Medicare Part B,O,97.93,26.00,44.25,73.44,58.76
1212,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1453,cpt,"Injection, Fosaprepitant, 1 Mg",aetna,Medicare Part A,O,6.67,0.28,3.07,7.29,4.00
1213,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77063,cpt,Screening Digital Tomography Of Both Breasts,aetna,Medicaid,O,184.03,20.92,100.70,167.23,110.42
1214,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11042,cpt,Removal Of Skin And Tissue First 20 Sq Cm Or Less,aetna,Medicaid,O,1315.41,306.28,624.03,3179.32,789.25
1215,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77338,cpt,Design And Construction Of Radiation Treatment Device For High Precision Radiation Therapy,aetna,Medicare Part B,O,2028.03,299.94,1109.68,1109.68,359.94
1216,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0243,cpt,"Injection, Casirivimab And Imdevimab, 2400 Mg",aetna,EPO,O,0.03,0.01,0.01,11.63,0.02
1217,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3370,cpt,"Injection, Vancomycin Hcl, 500 Mg",aetna,PPO,O,75.38,22.33,34.67,34.67,45.23
1218,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76642,cpt,Limited Ultrasound Scan Of 1 Breast,aetna,POS,O,305.55,71.65,167.19,242.91,183.33
1219,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,P9040,cpt,"Red Blood Cells, Leukocytes Reduced, Irradiated, Each Unit",aetna,Medicaid,O,756.23,260.55,262.76,509.61,453.74
1220,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96375,cpt,"Injection Of Different Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,POS,O,88.47,19.71,48.41,66.35,53.08
1221,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna,HMO,O,4055.15,194.15,2179.00,3854.73,1125.84
1222,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87493,cpt,"Detection Test By Nucleic Acid For Clostridium Difficile, Amplified Probe Technique",aetna,EPO,O,100.03,11.59,58.02,58.02,44.72
1223,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82390,cpt,Ceruloplasmin (Protein) Level,aetna,Medicare Part A,O,71.96,6.02,39.38,39.38,43.18
1224,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86235,cpt,"Measurement Of Antibody For Assessment Of Autoimmune Disorder, Any Method",aetna,POS,O,43.81,6.19,24.97,30.69,21.52
1225,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna,HMO,O,50.72,5.89,27.75,35.89,7.21
1226,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9360,cpt,"Injection, Vinblastine Sulfate, 1 Mg",aetna,HMO,O,11.79,2.36,4.08,4.08,7.07
1227,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,HMO,O,1775.23,260.44,1248.81,1902.32,1065.14
1228,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17110,cpt,"Destruction Of Skin Growth, 1-14 Growths",aetna,EPO,O,958.00,159.01,159.02,479.00,574.80
1229,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76805,cpt,"Ultrasound Scan Of Pregnant Uterus (14 Weeks Or More), Single Or First Fetus",aetna,POS,O,442.41,49.86,252.17,292.16,117.01
1230,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85018,cpt,"Blood Count, Hemoglobin",aetna,POS,O,33.02,2.35,18.82,24.77,2.84
1231,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2599,cpt,Contact Lens/Es Other Type,aetna,POS,O,3822.87,1002.34,4045.37,4045.37,2293.72
1232,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97018,cpt,Application Of Hot Wax Bath To 1 Or More Areas,aetna,HMO,O,79.04,3.64,32.08,34.45,47.42
1233,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5101,cpt,"Injection, Filgrastim-Sndz, Biosimilar, (Zarxio), 1 Microgram",aetna,HMO,O,1.85,0.17,0.35,0.35,1.11
1234,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,Medicaid,O,83.80,8.07,29.33,89.04,50.28
1235,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87340,cpt,Detection Test By Immunoassay Technique For Hepatitis B Surface Antigen,aetna,Medicaid,O,80.09,7.09,45.65,60.07,12.40
1236,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0897,cpt,"Injection, Denosumab, 1 Mg",aetna,EPO,O,62.32,12.82,18.35,21.26,37.39
1237,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76816,cpt,"Ultrasound Re-Evaluation Of Pregnant Uterus, Per Fetus",aetna,HMO,O,611.12,96.51,348.34,432.40,366.67
1238,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92611,cpt,Fluoroscopic And Video Recorded Motion Evaluation Of Swallowing Function,aetna,Medicare Part A,O,328.90,87.83,190.76,190.76,197.34
1239,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11047,cpt,"Removal Of Bone, Each Additional 20.0 Sq Cm Or Less",aetna,Medicare Part A,O,12247.63,1215.96,1247.54,1273.00,7348.58
1240,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87070,cpt,"Bacterial Culture, Any Other Source Except Urine, Blood Or Stool, Aerobic",aetna,HMO,O,65.11,8.45,8.58,48.83,10.34
1241,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0421,revCode,Physical Therapy Visit Charge,aetna,Medicare Part B,O,173.42,23.17,76.68,1195.53,104.05
1242,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86920,cpt,"Blood Unit Compatibility Test, Immediate Spin Technique",aetna,PPO,O,373.98,33.03,132.10,152.61,79.26
1243,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74178,cpt,CT Scan Of Abdomen And Pelvis Before And After Contrast,aetna,Medicaid,O,4577.54,2.93,2609.20,3536.15,391.22
1244,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86778,cpt,Analysis For Antibody (Igm) To Toxoplasma (Parasite),aetna,HMO,O,152.18,14.27,86.74,86.74,91.31
1245,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,47563,cpt,Removal Of Gallbladder With X-Ray Study Of Bile Ducts Using An Endoscope,aetna,Medicare Part A,O,25129.00,4481.58,12544.52,12544.52,15077.40
1246,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5117,cpt,"Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg",aetna,Medicare Part A,O,285.60,38.03,46.31,88.21,171.36
1247,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66984,cpt,"Removal Of Cataract With Insertion Of Lens, Simple",aetna,Medicare Part A,O,14664.91,1841.26,3839.82,4337.53,8798.95
1248,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93017,cpt,Exercise Or Drug-Induced Heart And Blood Vessel Stress Test With Ekg Tracing And Monitoring,aetna,POS,O,474.26,84.78,270.33,377.03,284.56
1249,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87493,cpt,"Detection Test By Nucleic Acid For Clostridium Difficile, Amplified Probe Technique",aetna,Medicare Part B,O,100.03,11.59,58.02,58.02,44.72
1250,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7120,cpt,"Ringers Lactate Infusion, Up To 1000 Cc",aetna,Medicaid,O,162.48,32.42,74.74,162.48,97.49
1251,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1100,cpt,"Injection, Dexamethasone Sodium Phosphate, 1 Mg",aetna,EPO,O,7.91,1.12,1.12,7.91,4.75
1252,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,EPO,O,576.53,96.50,334.39,562.62,345.92
1253,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64450,cpt,Injection Of Anesthetic Agent And/Or Steroid Into Other Peripheral Nerve Or Branch,aetna,Medicare Part B,O,1533.00,1587.94,12436.52,12436.52,919.80
1254,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73130,cpt,"X-Ray Of Hand, Minimum Of 3 Views",aetna,Medicare Part B,O,329.15,46.08,180.10,261.67,197.49
1255,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87493,cpt,"Detection Test By Nucleic Acid For Clostridium Difficile, Amplified Probe Technique",aetna,Medicaid,O,100.03,11.59,58.02,58.02,44.72
1256,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17270,cpt,"Destruction Of Malignant Growth (0.5 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,POS,O,1881.00,159.01,159.94,475.20,1128.60
1257,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,Medicare Part A,O,1952.12,97.51,1370.07,1839.56,1171.27
1258,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97605,cpt,"Negative Pressure Wound Therapy, Surface Area Less Than Or Equal To 50 Square Centimeters, Per Session",aetna,POS,O,1788.02,425.00,754.73,826.48,1072.81
1259,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64484,cpt,"Injections Of Anesthetic And/Or Steroid Drug Into Lower Or Sacral Spine Nerve Root Using Imaging Guidance, Each Additional Level",aetna,HMO,O,12936.37,728.40,7904.05,7904.05,7761.82
1260,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0280,revCode,Oncology General,aetna,HMO,O,192.29,49.29,109.61,144.22,115.37
1261,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93350,cpt,"Ultrasound Examination Of The Heart Performed During Rest, Exercise, And/Or Drug-Induced Stress With Interpretation And Report",aetna,Medicare Part A,O,1353.20,427.67,740.43,1075.79,811.92
1262,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84425,cpt,Vitamin B-1 (Thiamine) Level,aetna,Medicaid,O,138.03,18.33,75.53,75.53,82.82
1263,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36593,cpt,Declotting Infusion Of Implanted Central Venous Access Device Or Catheter,aetna,PPO,O,18177.79,1282.65,9002.79,20624.05,10906.67
1264,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87205,cpt,Special Gram Or Giemsa Stain For Microorganism,aetna,EPO,O,87.53,4.18,4.25,65.65,5.12
1265,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82951,cpt,"Blood Glucose (Sugar) Tolerance Test, 3 Specimens",aetna,Medicaid,O,117.61,12.87,39.96,84.59,15.44
1266,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,189,ms-drg,Pulmonary Edema And Respiratory Failure,aetna,PPO,I,29155.17,7655.58,9502.30,14063.21,17493.10
1267,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94060,cpt,"Measurement And Graphic Recording Of The Amount And Speed Of Breathed Air, Before And Following Medication Administration",aetna,Medicare Part A,O,422.68,78.29,218.19,239.44,253.61
1268,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36010,cpt,Introduction Of Catheter Into The Upper Or Lower Major Vein (Vena Cava),aetna,HMO,I,37979.62,17796.08,17796.08,17796.08,22787.77
1269,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna,EPO,O,108.88,10.16,59.58,77.04,20.33
1270,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86147,cpt,Cardiolipin Antibody (Tissue Antibody) Measurement,aetna,Medicare Part A,O,330.33,25.55,188.29,247.75,30.54
1271,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,Medicaid,O,1884.10,207.52,1030.93,11598.92,1130.46
1272,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1442,cpt,"Injection, Filgrastim (G-Csf), Excludes Biosimilars, 1 Microgram",aetna,EPO,O,4.45,0.72,0.93,1.48,2.67
1273,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0331,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration - Injection,aetna,Medicare Part A,O,270.45,26.27,71.27,513.21,162.27
1274,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86787,cpt,Analysis For Antibody To Varicella-Zoster Virus (Chicken Pox),aetna,Medicaid,O,53.08,6.47,29.05,39.81,15.46
1275,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0171,cpt,"Injection, Adrenalin, Epinephrine, 0.1 Mg",aetna,POS,O,5.83,0.23,2.68,2.68,3.50
1276,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0882,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (For Esrd On Dialysis)",aetna,HMO,O,16.51,7.43,7.43,7.43,9.91
1277,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,10005,cpt,"Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth",aetna,POS,O,2422.63,555.63,1193.41,1567.18,1453.58
1278,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85027,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test",aetna,EPO,O,56.26,6.34,30.79,39.81,7.76
1279,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,EPO,I,490.78,103.68,279.74,347.25,294.47
1280,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,371,ms-drg,Major Gastrointestinal Disorders And Peritoneal Infections With MCC,aetna,PPO,I,34185.44,8873.88,8873.88,11142.92,20511.26
1281,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64721,cpt,Release And/Or Relocation Of Median Nerve Of Hand,aetna,PPO,O,15304.77,1553.71,8031.11,8031.11,9182.86
1282,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99212,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 10 Minutes",aetna,Medicaid,O,180.14,52.17,102.68,135.10,108.08
1283,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93798,cpt,"Outpatient Heart Rehabilitation With Electrocardiogram (Ecg) Monitoring, Quality Health Care Professional Services",aetna,Medicare Part A,O,173.89,102.78,102.79,130.42,123.35
1284,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74174,cpt,CT Scan Of Blood Vessels Of Abdomen And Pelvis With Contrast,aetna,PPO,O,1736.62,326.01,329.84,497.16,391.22
1285,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5101,cpt,"Injection, Filgrastim-Sndz, Biosimilar, (Zarxio), 1 Microgram",aetna,Medicare Part A,O,1.85,0.17,0.35,0.35,1.11
1286,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94060,cpt,"Measurement And Graphic Recording Of The Amount And Speed Of Breathed Air, Before And Following Medication Administration",aetna,PPO,O,422.68,78.29,218.19,239.44,253.61
1287,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27328,cpt,Removal (Less Than 5 Centimeters) Muscle Growth Of Thigh Or Knee,aetna,Medicare Part A,O,23211.17,12578.62,12578.62,12578.62,13926.70
1288,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80306,cpt,"Testing For Presence Of Drug, Read By Instrument Assisted Observation",aetna,POS,O,513.19,16.97,292.52,384.89,20.57
1289,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2370,cpt,"Injection, Phenylephrine Hcl, Up To 1 Ml",aetna,POS,O,87.77,23.91,40.37,66.01,52.66
1290,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17261,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Trunk, Arms, Or Legs",aetna,Medicare Part B,O,1857.00,159.01,159.02,543.72,1114.20
1291,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna,Medicare Part B,I,25207.44,6812.39,8243.81,14290.40,15124.46
1292,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78227,cpt,Nuclear Medicine Study Of Liver And Bile Duct System With Use Of Drugs,aetna,PPO,O,1528.98,161.81,836.62,1038.75,520.12
1293,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,PPO,I,216.65,43.99,86.21,184.92,129.99
1294,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99213,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes",aetna,Medicaid,O,270.16,52.43,153.99,211.73,162.10
1295,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0278,revCode,Medical/Surgical Supplies And Devices Other Implants,aetna,POS,I,12498.86,118.53,1501.07,6933.25,7499.32
1296,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87147,cpt,"Identification Of Organisms By Immunologic Analysis, Other Than Immunofluorescence Method",aetna,EPO,O,25.94,5.18,5.18,19.46,6.22
1297,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0403,revCode,Other Imaging Services Screening Mammography,aetna,HMO,O,312.75,51.78,104.90,273.24,187.65
1298,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83735,cpt,Magnesium Level,aetna,Medicaid,O,65.11,6.70,35.63,46.07,8.04
1299,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87389,cpt,Detection Test By Immunoassay Technique For Hiv-1 Antigen And Hiv-1 And Hiv-2 Antibodies,aetna,Medicare Part B,O,101.33,8.97,55.45,76.00,28.90
1300,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43244,cpt,Tying Of Dilated Veins Of Stomach And/Or Esophagus Using A Flexible Endoscope,aetna,EPO,O,4323.48,1441.59,1441.59,1469.46,2594.09
1301,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17003,cpt,"Destruction Of Precancer Skin Growth, 2-14 Growths",aetna,PPO,O,982.00,159.01,162.47,1222.94,589.20
1302,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,292,ms-drg,Heart Failure And Shock With CC,aetna,EPO,I,18032.02,5781.24,12207.78,12207.78,10819.21
1303,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9228,cpt,"Injection, Ipilimumab, 1 Mg",aetna,Medicare Part B,O,588.70,104.49,157.23,157.23,353.22
1304,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,PPO,I,145.10,44.06,100.82,507.29,87.06
1305,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0510,revCode,Clinic General,aetna,Medicaid,O,167.48,51.31,51.31,289.51,100.49
1306,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84439,cpt,"Thyroxine (Thyroid Chemical), Free",aetna,Medicaid,O,52.60,8.84,28.79,39.45,10.82
1307,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82746,cpt,"Folic Acid Level, Serum",aetna,Medicare Part B,O,65.11,9.14,37.11,37.11,17.64
1308,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73610,cpt,"X-Ray Of Ankle, Minimum Of 3 Views",aetna,Medicaid,O,329.15,46.08,180.10,261.67,197.49
1309,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0403,revCode,Other Imaging Services Screening Mammography,aetna,PPO,O,312.75,51.78,104.90,273.24,187.65
1310,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna,Medicaid,O,70.06,8.01,39.93,52.55,9.80
1311,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73523,cpt,"X-Ray Of Both Hips With Pelvis, Minimum Of 5 Views",aetna,Medicare Part A,O,636.63,58.51,384.65,536.48,115.81
1312,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88307,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately High Complexity",aetna,Medicaid,O,298.47,86.80,170.13,298.47,179.08
1313,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85027,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test",aetna,Medicaid,O,56.26,6.34,30.79,39.81,7.76
1314,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,784,ms-drg,Cesarean Section With Sterilization With CC,aetna,POS,I,14658.24,5823.07,5823.07,10802.78,8794.94
1315,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna,Medicaid,O,2882.19,203.81,1577.05,2291.34,244.57
1316,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73221,cpt,MRI Scan Of Arm Joint Without Contrast,aetna,HMO,O,2882.19,203.81,1577.05,1715.45,245.82
1317,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99214,cpt,"Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes",aetna,PPO,O,423.60,59.52,255.94,255.94,254.16
1318,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88162,cpt,"Screening Examination Of Specimen Cells, Extended Study",aetna,Medicaid,O,303.20,44.07,44.07,97.64,181.92
1319,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,603,ms-drg,Cellulitis Without MCC,aetna,Medicaid,I,19499.58,3283.09,5672.80,12955.93,11699.75
1320,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72202,cpt,"X-Ray Of Joint Between Lower Spine And Hip Bone, 3 Or More Views",aetna,POS,O,252.47,26.87,145.17,166.73,151.48
1321,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,POS,O,1881.00,160.85,162.47,936.63,1128.60
1322,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna,Medicaid,O,84.93,5.32,30.50,63.70,15.10
1323,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93308,cpt,Follow-Up Or Limited Ultrasound Examination Of Heart,aetna,EPO,O,415.27,203.81,204.22,403.52,249.16
1324,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77295,cpt,"Management Of Radiation Therapy, 3d",aetna,HMO,O,1926.57,1003.61,1098.14,1531.62,1341.41
1325,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74220,cpt,X-Ray Of Esophagus With Single Contrast,aetna,PPO,O,552.13,55.19,320.24,320.24,193.72
1326,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82731,cpt,Fetal Fibronectin (Protein) Analysis,aetna,PPO,O,565.34,60.62,64.37,424.01,115.33
1327,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7120,cpt,"Ringers Lactate Infusion, Up To 1000 Cc",aetna,Medicare Part A,O,162.48,32.42,74.74,162.48,97.49
1328,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87535,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Amplified Probe Technique",aetna,EPO,O,376.19,56.83,218.19,299.07,225.71
1329,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna,EPO,O,251.28,64.70,137.49,266.35,150.77
1330,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0312,revCode,Laboratory Pathology Histology,aetna,PPO,O,419.99,131.76,239.39,419.99,251.99
1331,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna,HMO,O,2144.07,645.60,1279.68,2047.58,1286.44
1332,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43450,cpt,Dilation Of Esophagus Unguided,aetna,Medicare Part B,O,3778.61,1075.52,1753.96,3815.86,2267.17
1333,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3480,cpt,"Injection, Potassium Chloride, Per 2 Meq",aetna,POS,O,2.35,0.80,1.02,1.02,1.41
1334,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna,HMO,O,84.93,5.32,30.50,63.70,15.10
1335,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82248,cpt,"Bilirubin Level, Direct",aetna,Medicaid,O,41.28,4.92,14.47,14.47,6.02
1336,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87147,cpt,"Identification Of Organisms By Immunologic Analysis, Other Than Immunofluorescence Method",aetna,Medicaid,O,25.94,5.18,5.18,19.46,6.22
1337,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86777,cpt,Analysis For Antibody To Toxoplasma (Parasite),aetna,Medicare Part A,O,152.18,14.25,86.74,86.74,91.31
1338,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna,PPO,I,25207.44,6812.39,8243.81,14290.40,15124.46
1339,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna,POS,O,135.07,18.96,76.99,121.94,81.04
1340,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna,POS,O,120.33,10.08,65.84,90.25,20.16
1341,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2250,cpt,"Injection, Midazolam Hydrochloride, Per 1 Mg",aetna,EPO,O,41.06,10.28,18.48,41.06,24.64
1342,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86200,cpt,Measurement Of Antibody For Rheumatoid Arthritis Assessment,aetna,Medicare Part B,O,251.28,12.89,140.36,140.36,15.54
1343,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84145,cpt,Procalcitonin (Hormone) Level,aetna,Medicare Part B,O,97.91,20.28,53.57,53.57,32.66
1344,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82375,cpt,Carboxyhemoglobin (Protein) Level,aetna,POS,O,103.50,12.32,60.03,77.63,14.78
1345,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,Medicare Part B,O,332.78,61.44,194.95,261.67,199.67
1346,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,872,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours Without MCC,aetna,Medicare Part B,I,20748.35,5256.97,6524.49,9809.76,12449.01
1347,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33430,cpt,Replacement Of Valve Between Left Upper And Lower Chambers On Heart-Lung Machine,aetna,HMO,I,207801.54,46497.02,46497.02,46497.02,124680.92
1348,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77412,cpt,Delivery Of Complex Radiation Treatment,aetna,Medicare Part B,O,933.20,214.04,510.62,666.46,256.85
1349,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88307,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately High Complexity",aetna,PPO,O,298.47,86.80,170.13,298.47,179.08
1350,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0444,revCode,Occupational Therapy Evaluation Or Reevaluation,aetna,Medicare Part A,I,509.00,129.95,286.62,370.63,305.40
1351,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94729,cpt,Test To Examine How Well The Lungs Exchange Gases,aetna,PPO,O,218.25,52.60,119.42,119.42,130.95
1352,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99214,cpt,"Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes",aetna,POS,O,423.60,59.52,255.94,255.94,254.16
1353,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88341,cpt,"Special Stained Specimen Slides To Examine Tissue, Each Additional Procedure",aetna,POS,O,125.04,25.34,71.27,125.04,75.02
1354,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87301,cpt,Detection Test By Immunoassay Technique For Adenovirus Enteric Types 40/41,aetna,POS,O,60.03,6.75,34.52,34.52,14.38
1355,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73523,cpt,"X-Ray Of Both Hips With Pelvis, Minimum Of 5 Views",aetna,PPO,O,636.63,58.51,384.65,536.48,115.81
1356,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,46255,cpt,Removal Of Single External And Internal Hemorrhoid Group,aetna,EPO,O,17900.37,2210.31,9939.29,9939.29,10740.22
1357,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna,PPO,E,3350.06,336.55,1455.60,2095.51,2010.04
1358,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0481,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,HMO,O,315.99,155.10,155.10,156.59,189.59
1359,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,Medicare Part B,I,218.25,67.65,124.40,224.80,130.95
1360,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86900,cpt,Blood Group Typing (ABO),aetna,POS,O,126.23,11.17,71.95,99.15,118.98
1361,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73560,cpt,"X-Ray Of Knee, 1 Or 2 Views",aetna,POS,O,231.22,26.24,126.52,126.52,138.73
1362,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97605,cpt,"Negative Pressure Wound Therapy, Surface Area Less Than Or Equal To 50 Square Centimeters, Per Session",aetna,Medicare Part B,O,1788.02,425.00,754.73,826.48,1072.81
1363,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1030,cpt,"Injection, Methylprednisolone Acetate, 40 Mg",aetna,Medicaid,O,93.27,42.90,42.90,65.77,55.96
1364,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,673,ms-drg,Other Kidney And Urinary Tract Procedures With MCC,aetna,Medicare Part A,I,61701.73,20358.57,20462.06,20647.19,37021.04
1365,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78816,cpt,Nuclear Medicine Study With CT Imaging Whole Body,aetna,EPO,O,7556.48,1311.05,1311.05,2704.61,4533.89
1366,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70543,cpt,"MRI Scan Of Bone Of Eye Socket, Face, And/Or Neck Before And After Contrast",aetna,Medicare Part A,O,2110.61,326.01,1213.60,1213.60,1266.37
1367,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,219,ms-drg,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With MCC,aetna,Medicare Part A,I,256090.54,46435.26,46497.02,47950.73,153654.32
1368,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87046,cpt,"Stool Culture, Additional Pathogens",aetna,PPO,O,52.60,5.92,30.25,30.25,11.33
1369,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94726,cpt,Determination Of Lung Volumes Using Plethysmography,aetna,PPO,O,501.40,116.04,274.35,274.35,300.84
1370,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0690,cpt,"Injection, Cefazolin Sodium, 500 Mg",aetna,Medicaid,O,35.58,12.05,29.43,64.88,21.35
1371,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85520,cpt,Heparin Assay,aetna,PPO,O,67.89,39.38,39.38,39.38,40.73
1372,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1439,cpt,"Injection, Ferric Carboxymaltose, 1 Mg",aetna,PPO,O,4.45,0.79,2.09,2.09,2.67
1373,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87081,cpt,Screening Test For Pathogenic Organisms,aetna,Medicare Part A,O,45.06,3.98,25.68,32.84,9.19
1374,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11401,cpt,"Removal Of Growth (0.6 To 1.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,EPO,O,4292.00,309.74,309.74,2167.15,2575.20
1375,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81001,cpt,"Manual Urinalysis Test With Examination Using Microscope, Automated",aetna,EPO,O,13.80,2.37,7.87,10.35,8.28
1376,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87070,cpt,"Bacterial Culture, Any Other Source Except Urine, Blood Or Stool, Aerobic",aetna,Medicaid,O,65.11,8.45,8.58,48.83,10.34
1377,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna,Medicaid,I,1307.77,398.79,745.43,8974.67,784.66
1378,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72197,cpt,MRI Scan Of Pelvis Before And After Contrast,aetna,Medicaid,O,2882.19,326.01,329.84,2161.64,391.22
1379,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72141,cpt,MRI Scan Of Upper Spinal Canal Without Contrast,aetna,EPO,O,2882.19,205.13,1642.85,2291.34,244.57
1380,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73522,cpt,"X-Ray Of Both Hips With Pelvis, 3-4 Views",aetna,POS,O,355.11,58.62,194.31,194.31,213.07
1381,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84439,cpt,"Thyroxine (Thyroid Chemical), Free",aetna,Medicare Part A,O,52.60,8.84,28.79,39.45,10.82
1382,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna,EPO,O,3391.86,327.84,1855.92,2543.90,462.44
1383,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83516,cpt,"Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",aetna,EPO,O,51.31,8.70,30.43,41.58,13.84
1384,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33235,cpt,Removal Of Dual Electrodes From Right Heart,aetna,PPO,O,21468.71,3610.13,3610.13,3610.13,12881.23
1385,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84145,cpt,Procalcitonin (Hormone) Level,aetna,Medicare Part A,O,97.91,20.28,53.57,53.57,32.66
1386,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86147,cpt,Cardiolipin Antibody (Tissue Antibody) Measurement,aetna,POS,O,330.33,25.55,188.29,247.75,30.54
1387,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9228,cpt,"Injection, Ipilimumab, 1 Mg",aetna,EPO,O,588.70,104.49,157.23,157.23,353.22
1388,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86430,cpt,Rheumatoid Factor Analysis,aetna,PPO,O,42.58,6.10,14.72,31.94,7.37
1389,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9500,cpt,"Technetium Tc-99m Sestamibi, Diagnostic, Per Study Dose",aetna,POS,O,692.52,114.53,394.74,734.07,415.51
1390,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,271,ms-drg,Other Major Cardiovascular Procedures With CC,aetna,PPO,I,68161.35,20934.94,27743.68,28893.46,40896.81
1391,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70450,cpt,CT Of Head Without Contrast,aetna,HMO,O,2452.75,96.51,1398.07,1839.56,115.81
1392,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38505,cpt,Needle Biopsy Or Removal Of Surface Lymph Nodes,aetna,HMO,O,8266.58,1246.10,7074.31,7074.31,4959.95
1393,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0138,cpt,"Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (Non-Esrd Use)",aetna,Medicaid,O,4.45,0.69,0.93,1.82,2.67
1394,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72148,cpt,MRI Scan Of Lower Spinal Canal,aetna,Medicare Part A,O,2882.19,203.81,1642.85,2039.29,244.57
1395,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19083,cpt,"Biopsy Of Breast Accessed Through The Skin With Ultrasound Guidance, First Lesion",aetna,PPO,O,8391.01,1246.10,6742.37,6742.37,5034.61
1396,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19081,cpt,"Biopsy Of Breast And Placement Of Locating Device Using X-Ray With Needle, First Growth",aetna,EPO,O,8708.58,1254.46,4315.79,4315.79,5225.15
1397,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,EPO,O,8.83,1.76,5.12,26.77,5.30
1398,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82951,cpt,"Blood Glucose (Sugar) Tolerance Test, 3 Specimens",aetna,Medicare Part B,O,117.61,12.87,39.96,84.59,15.44
1399,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5115,cpt,"Injection, Rituximab-Abbs, Biosimilar, (Truxima), 10 Mg",aetna,POS,O,218.36,61.56,68.50,163.77,131.02
1400,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3475,cpt,"Injection, Magnesium Sulfate, Per 500 Mg",aetna,Medicare Part B,O,4.45,1.00,2.05,2.05,2.67
1401,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0430,revCode,"Occupational Therapy, General",aetna,Medicare Part A,I,176.32,32.63,91.02,165.50,105.79
1402,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76819,cpt,Ultrasound Scan Of Fetus,aetna,POS,O,611.12,96.51,348.34,485.84,366.67
1403,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9503,cpt,"Technetium Tc-99m Medronate, Diagnostic, Per Study Dose, Up To 30 Millicuries",aetna,POS,O,212.36,61.08,121.05,130.93,127.42
1404,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99282,cpt,Emergency Department Visit For Problem Of Mild To Moderate Severity,aetna,POS,E,276.06,99.19,160.11,290.62,165.64
1405,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0640,cpt,"Injection, Leucovorin Calcium, Per 50 Mg",aetna,EPO,O,17.80,3.56,3.56,14.15,10.68
1406,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9445,cpt,"Patient Education, Not Otherwise Classified, Non-Physician Provider, Individual, Per Session",aetna,PPO,O,104.62,78.47,104.62,114.22,62.77
1407,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0371,revCode,Anesthesia Incident To Radiology,aetna,PPO,I,47.19,8.72,26.90,26.90,28.31
1408,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85379,cpt,"Coagulation Function Measurement, D-Dimer; Quantitative",aetna,EPO,O,122.56,9.98,71.08,71.08,12.22
1409,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,689,ms-drg,Kidney And Urinary Tract Infections With MCC,aetna,POS,I,22796.06,6348.25,8547.01,9085.55,13677.64
1410,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93350,cpt,"Ultrasound Examination Of The Heart Performed During Rest, Exercise, And/Or Drug-Induced Stress With Interpretation And Report",aetna,POS,O,1353.20,427.67,740.43,1075.79,811.92
1411,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11047,cpt,"Removal Of Bone, Each Additional 20.0 Sq Cm Or Less",aetna,PPO,O,12247.63,1215.96,1247.54,1273.00,7348.58
1412,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0431,revCode,Occupational Therapy Visit Charge,aetna,POS,O,173.42,21.75,80.69,875.96,104.05
1413,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11102,cpt,"Biopsy Of Related Skin Growth, First Growth",aetna,EPO,O,1042.00,159.01,160.97,708.35,625.20
1414,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36561,cpt,"Insertion Of Central Venous Catheter And Implanted Device For Infusion Beneath The Skin, Patient 5 Years Or Older",aetna,Medicaid,O,18382.66,2534.31,2589.99,17974.64,11029.60
1415,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9443,cpt,"Lactation Classes, Non-Physician Provider, Per Session",aetna,Medicare Part B,O,155.82,92.26,92.26,155.82,93.49
1416,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1442,cpt,"Injection, Filgrastim (G-Csf), Excludes Biosimilars, 1 Microgram",aetna,POS,O,4.45,0.72,0.93,1.48,2.67
1417,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77280,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 1 Treatment Area",aetna,Medicaid,O,1037.01,112.36,591.10,733.79,134.83
1418,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7030,cpt,"Infusion, Normal Saline Solution , 1000 Cc",aetna,EPO,O,8.25,3.71,3.71,162.78,4.95
1419,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9354,cpt,"Injection, Ado-Trastuzumab Emtansine, 1 Mg",aetna,PPO,O,123.87,25.63,36.89,41.57,74.32
1420,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77338,cpt,Design And Construction Of Radiation Treatment Device For High Precision Radiation Therapy,aetna,Medicaid,O,2028.03,299.94,1109.68,1109.68,359.94
1421,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11606,cpt,"Removal Of Malignant Growth (Over 4.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,HMO,O,17489.70,4901.08,9591.25,9591.25,10493.82
1422,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0521,revCode,Freestanding Clinic Clinic Visit By Member Torhc/Fqhc,aetna,Medicare Part B,O,195.00,111.87,111.87,244.91,117.00
1423,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna,Medicaid,O,91.30,14.35,49.96,64.61,54.78
1424,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85520,cpt,Heparin Assay,aetna,Medicare Part A,O,67.89,39.38,39.38,39.38,40.73
1425,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0401,revCode,Other Imaging Services Diagnostic Mammography,aetna,HMO,O,266.00,50.09,79.04,224.15,159.60
1426,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,POS,I,1884.10,527.05,1030.93,1360.64,1130.46
1427,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5103,cpt,"Injection, Infliximab-Dyyb, Biosimilar, (Inflectra), 10 Mg",aetna,EPO,O,114.15,40.05,51.37,114.15,68.49
1428,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74220,cpt,X-Ray Of Esophagus With Single Contrast,aetna,POS,O,552.13,55.19,320.24,320.24,193.72
1429,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2785,cpt,"Injection, Regadenoson, 0.1 Mg",aetna,POS,O,154.74,25.67,69.52,154.76,92.84
1430,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43235,cpt,"Diagnostic Examination Of Esophagus, Stomach, And/Or Upper Small Bowel Using An Endoscope",aetna,Medicare Part A,O,3132.69,724.55,1758.22,2956.79,1171.78
1431,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna,Medicaid,O,50.72,6.48,17.70,38.04,7.78
1432,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88304,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately Low Complexity",aetna,EPO,O,212.36,44.07,116.20,200.34,127.42
1433,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86850,cpt,Screening Test For Red Blood Cell Antibodies,aetna,Medicaid,O,93.19,8.25,53.12,67.92,53.95
1434,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9443,cpt,"Lactation Classes, Non-Physician Provider, Per Session",aetna,Medicare Part A,O,155.82,92.26,92.26,155.82,93.49
1435,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3370,cpt,"Injection, Vancomycin Hcl, 500 Mg",aetna,Medicaid,O,75.38,22.33,34.67,34.67,45.23
1436,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84112,cpt,Cervicovaginal Secretion Of Placenta Protein,aetna,PPO,O,243.07,29.33,29.33,243.07,49.58
1437,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73110,cpt,"X-Ray Of Wrist, Minimum Of 3 Views",aetna,Medicare Part A,O,329.15,51.73,183.86,246.86,197.49
1438,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1030,cpt,"Injection, Methylprednisolone Acetate, 40 Mg",aetna,Medicare Part B,O,93.27,42.90,42.90,65.77,55.96
1439,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0441,revCode,Occupational Therapy Visit Charge,aetna,HMO,O,328.90,81.87,190.76,190.76,197.34
1440,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0276,revCode,Medical/Surgical Supplies And Devices Intracular Lens,aetna,HMO,O,797.52,202.98,270.86,797.52,478.51
1441,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0690,cpt,"Injection, Cefazolin Sodium, 500 Mg",aetna,EPO,O,35.58,12.05,29.43,64.88,21.35
1442,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96368,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Concurrent With Another Infusion",aetna,Medicare Part B,O,75.68,16.92,43.89,60.16,45.41
1443,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85018,cpt,"Blood Count, Hemoglobin",aetna,PPO,O,33.02,2.35,18.82,24.77,2.84
1444,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86765,cpt,Analysis For Antibody To Rubeola (Measles Virus),aetna,EPO,O,50.01,7.69,55.32,55.32,30.01
1445,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,Medicaid,I,726.73,207.37,642.32,642.32,436.04
1446,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85597,cpt,Platelet Function Test,aetna,PPO,O,89.65,9.41,51.10,67.24,21.58
1447,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,Medicare Part B,I,145.10,44.06,100.82,507.29,87.06
1448,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0463,cpt,Hospital Outpatient Clinic Visit For Assessment And Management Of A Patient,aetna,HMO,O,176.96,59.81,102.70,107.50,106.18
1449,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0330,cpt,"Injection, Succinylcholine Chloride, Up To 20 Mg",aetna,HMO,O,97.93,26.00,44.25,73.44,58.76
1450,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2710,cpt,"Injection, Neostigmine Methylsulfate, Up To 0.5 Mg",aetna,POS,O,4.65,0.15,0.15,4.27,2.79
1451,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9306,cpt,"Injection, Pertuzumab, 1 Mg",aetna,Medicare Part A,O,44.82,10.05,14.64,424.56,26.89
1452,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84153,cpt,"PSA (Prostate Specific Antigen) Measurement, Total",aetna,EPO,O,91.30,18.03,51.00,60.30,22.07
1453,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0278,revCode,Medical/Surgical Supplies And Devices Other Implants,aetna,Medicaid,I,12498.86,118.53,1501.07,6933.25,7499.32
1454,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,PPO,O,8.83,1.76,5.12,26.77,5.30
1455,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0269,cpt,"Placement Of Occlusive Device Into Either A Venous Or Arterial Access Site, Post Surgical Or Interventional Procedure (E.G., Angioseal Plug, Vascular Plug)",aetna,Medicare Part A,O,67707.99,403.09,4389.98,14226.92,40624.79
1456,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95819,cpt,"Measurement And Recording Of Brain Wave (Eeg) Activity, Awake And Asleep",aetna,EPO,O,779.82,234.21,444.50,735.68,467.89
1457,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna,POS,O,329.15,22.74,190.91,261.67,197.49
1458,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0260,revCode,Intravenous (Iv) Therapy,aetna,Medicaid,O,325.61,56.09,185.60,1926.96,195.37
1459,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70220,cpt,"X-Ray Of Paranasal Sinus, Complete, Minimum Of 3 Views",aetna,Medicaid,O,342.13,47.22,195.01,271.99,205.28
1460,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2704,cpt,"Injection, Propofol, 10 Mg",aetna,POS,O,4.12,0.82,1.89,4.12,2.47
1461,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72195,cpt,MRI Scan Of Pelvis Without Contrast,aetna,Medicare Part B,O,1763.76,203.81,1005.34,1008.21,1058.26
1462,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74018,cpt,"X-Ray Of Abdomen, 1 View",aetna,Medicare Part B,O,268.98,61.44,147.18,285.11,85.98
1463,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0482,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,Medicare Part A,O,315.99,78.44,78.44,208.68,189.59
1464,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2785,cpt,"Injection, Regadenoson, 0.1 Mg",aetna,Medicare Part A,O,154.74,25.67,69.52,154.76,92.84
1465,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,Medicaid,I,140.26,41.63,88.86,224.92,84.16
1466,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0434,revCode,"Occupational Therapy, Evaluation Or Reevaluation",aetna,EPO,I,357.27,76.33,271.01,357.27,214.36
1467,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,070,ms-drg,Nonspecific Cerebrovascular Disorders With MCC,aetna,EPO,I,31953.37,10314.69,10417.64,12207.30,19172.02
1468,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0279,cpt,"Diagnostic Digital Breast Tomosynthesis, Unilateral Or Bilateral (List Separately In Addition To 77065 Or 77066)",aetna,Medicare Part A,O,120.33,22.38,69.79,95.66,72.20
1469,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83540,cpt,Iron Level,aetna,EPO,O,41.28,6.35,23.53,41.28,7.76
1470,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80307,cpt,"Testing For Presence Of Drug, By Chemistry Analyzers",aetna,POS,O,197.60,49.05,49.06,62.39,118.56
1471,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77301,cpt,Management Of Modulation Radiotherapy Planning,aetna,Medicare Part A,O,7734.62,1117.80,4232.16,4232.16,1341.41
1472,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,Medicaid,I,281.58,60.08,199.37,281.58,168.95
1473,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,26055,cpt,Incision Of Tendon Covering Of Finger,aetna,EPO,O,16309.48,1233.08,10334.48,10334.48,9785.69
1474,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83002,cpt,"Gonadotropin, Luteinizing (Reproductive Hormone) Level",aetna,Medicaid,O,250.10,18.52,142.56,187.58,22.22
1475,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86901,cpt,Blood Typing For Rh (D) Antigen,aetna,Medicare Part A,O,83.76,7.41,47.74,83.76,17.09
1476,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11044,cpt,Removal Of Skin And Bone First 20 Sq Cm Or Less,aetna,PPO,O,3769.31,1215.96,1260.27,2751.80,2261.59
1477,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71046,cpt,"X-Ray Of Chest, 2 Views",aetna,Medicare Part A,O,344.48,61.44,188.49,273.86,85.98
1478,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87536,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Quantification",aetna,POS,O,519.10,67.96,295.89,295.89,311.46
1479,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,PPO,O,1673.95,97.51,795.53,1330.78,1004.37
1480,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,EPO,O,344.48,61.44,188.49,273.86,206.69
1481,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,M0243,cpt,"Intravenous Infusion, Casirivimab And Imdevimab Includes Infusion And Post Administration Monitoring",aetna,HMO,O,820.47,138.86,502.86,502.86,492.28
1482,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9035,cpt,"Injection, Bevacizumab, 10 Mg",aetna,Medicare Part B,O,282.70,75.76,77.46,77.46,169.62
1483,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9445,cpt,"Patient Education, Not Otherwise Classified, Non-Physician Provider, Individual, Per Session",aetna,POS,O,104.62,78.47,104.62,114.22,62.77
1484,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19084,cpt,"Biopsy Of Breast And Placement Of Locating Device Using Ultrasound, Each Additional Growth",aetna,Medicare Part A,O,12042.88,1246.10,6742.37,6742.37,7225.73
1485,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna,EPO,O,95.71,16.18,16.18,21.31,19.42
1486,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna,HMO,O,281.96,102.95,163.54,224.15,123.54
1487,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86038,cpt,Screening Test For Autoimmune Disorder,aetna,HMO,O,105.06,0.47,36.51,45.12,14.51
1488,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0421,revCode,Physical Therapy Visit Charge,aetna,Medicaid,O,173.42,23.17,76.68,1195.53,104.05
1489,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,55250,cpt,Removal Of Sperm Duct,aetna,Medicare Part A,O,17158.79,1587.89,8468.46,8468.46,10295.27
1490,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,638,ms-drg,Diabetes With CC,aetna,HMO,I,20621.27,4023.89,8833.24,8833.24,12372.76
1491,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,Medicare Part A,O,1775.23,260.44,1248.81,1902.32,1065.14
1492,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84403,cpt,"Testosterone (Hormone) Level, Total",aetna,Medicaid,O,135.66,25.30,77.33,101.75,30.97
1493,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87641,cpt,"Detection Test By Nucleic Acid For Staphylococcus Aureus, Methicillin Resistant (Mrsa Bacteria), Amplified Probe Technique",aetna,Medicare Part A,O,90.84,13.32,51.78,64.28,42.11
1494,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82525,cpt,Copper Level,aetna,Medicare Part B,O,71.96,9.63,39.38,39.38,14.89
1495,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82248,cpt,"Bilirubin Level, Direct",aetna,POS,O,41.28,4.92,14.47,14.47,6.02
1496,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70487,cpt,CT Scan Of Face With Contrast,aetna,POS,O,1358.47,810.86,810.86,810.86,815.08
1497,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84439,cpt,"Thyroxine (Thyroid Chemical), Free",aetna,POS,O,52.60,8.84,28.79,39.45,10.82
1498,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0279,cpt,"Diagnostic Digital Breast Tomosynthesis, Unilateral Or Bilateral (List Separately In Addition To 77065 Or 77066)",aetna,EPO,O,120.33,22.38,69.79,95.66,72.20
1499,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9190,cpt,"Injection, Fluorouracil, 500 Mg",aetna,EPO,O,8.25,1.86,1.89,8.07,4.95
1500,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97605,cpt,"Negative Pressure Wound Therapy, Surface Area Less Than Or Equal To 50 Square Centimeters, Per Session",aetna,Medicaid,O,1788.02,425.00,754.73,826.48,1072.81
1501,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87081,cpt,Screening Test For Pathogenic Organisms,aetna,POS,O,45.06,3.98,25.68,32.84,9.19
1502,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64718,cpt,Release And/Or Relocation Of Ulnar Nerve At Elbow,aetna,EPO,O,16595.69,1553.71,9876.73,9876.73,9957.41
1503,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93279,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Single Lead Pacemaker System In One Chamber Of Heart With Qualified Health Care Professional Analysis, Review, And Report",aetna,POS,O,180.49,32.90,32.90,76.59,108.29
1504,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99153,cpt,"Use Of A Drug To Induce Depression Of Consciousness By Physician Performing A Procedure, Each Additional 15 Minutes",aetna,POS,O,47.19,6.59,27.37,47.19,28.31
1505,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9145,cpt,"Injection, Daratumumab, 10 Mg",aetna,Medicaid,O,87.92,56.29,56.29,56.29,52.75
1506,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,070,ms-drg,Nonspecific Cerebrovascular Disorders With MCC,aetna,POS,I,31953.37,10314.69,10417.64,12207.30,19172.02
1507,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3475,cpt,"Injection, Magnesium Sulfate, Per 500 Mg",aetna,PPO,O,4.45,1.00,2.05,2.05,2.67
1508,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99282,cpt,Emergency Department Visit For Problem Of Mild To Moderate Severity,aetna,Medicaid,E,276.06,99.19,160.11,290.62,165.64
1509,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93289,cpt,"Evaluation Of Defibrillator Including Connection, Recording And Disconnection",aetna,EPO,O,206.45,32.90,115.33,115.33,123.87
1510,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84144,cpt,Progesterone (Reproductive Hormone) Level,aetna,Medicare Part B,O,101.45,17.03,55.51,71.78,25.03
1511,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85014,cpt,Red Blood Cell Concentration Measurement,aetna,EPO,O,28.77,2.35,16.40,21.58,2.84
1512,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84166,cpt,"Protein Measurement, Body Fluid",aetna,EPO,O,57.87,6.77,17.83,17.90,21.40
1513,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87147,cpt,"Identification Of Organisms By Immunologic Analysis, Other Than Immunofluorescence Method",aetna,Medicare Part A,O,25.94,5.18,5.18,19.46,6.22
1514,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna,PPO,O,373.98,199.25,204.64,352.82,359.94
1515,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80053,cpt,"Blood Test, Comprehensive Group Of Blood Chemicals",aetna,HMO,O,91.30,10.35,49.96,68.47,12.67
1516,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9202,cpt,"Goserelin Acetate Implant, Per 3.6 Mg",aetna,Medicare Part A,O,1210.44,149.56,581.30,581.30,726.26
1517,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77386,cpt,"Intensity Modulated Radiation Therapy Delivery, Complex",aetna,PPO,O,2383.15,480.50,1303.99,1303.99,576.60
1518,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11045,cpt,"Removal Of Skin And Tissue, Each Additional 20.0 Sq Cm Or Less",aetna,Medicare Part B,O,2875.83,306.28,312.72,3179.32,1725.50
1519,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna,HMO,O,252.47,18.27,143.91,336.23,151.48
1520,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna,Medicare Part A,O,148.64,18.79,18.79,22.56,22.55
1521,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82550,cpt,"Creatine Kinase (Cardiac Enzyme) Level, Total",aetna,Medicare Part B,O,60.16,6.44,33.61,33.61,7.81
1522,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,10005,cpt,"Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth",aetna,Medicare Part B,O,2422.63,555.63,1193.41,1567.18,1453.58
1523,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,812,ms-drg,Red Blood Cell Disorders Without MCC,aetna,Medicaid,I,18593.40,4553.02,5996.54,8936.86,11156.04
1524,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna,PPO,O,88.82,7.62,50.63,66.62,9.32
1525,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84439,cpt,"Thyroxine (Thyroid Chemical), Free",aetna,PPO,O,52.60,8.84,28.79,39.45,10.82
1526,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84484,cpt,"Troponin (Protein) Analysis, Quantitative",aetna,Medicare Part A,O,80.09,12.47,29.46,56.67,14.96
1527,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,EPO,I,2882.19,290.04,2229.62,2229.62,1729.31
1528,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0942,revCode,Medical Rehabilitation Day Program Education/Training,aetna,PPO,O,155.82,64.63,92.26,117.54,93.49
1529,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87301,cpt,Detection Test By Immunoassay Technique For Adenovirus Enteric Types 40/41,aetna,EPO,O,60.03,6.75,34.52,34.52,14.38
1530,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27328,cpt,Removal (Less Than 5 Centimeters) Muscle Growth Of Thigh Or Knee,aetna,PPO,O,23211.17,12578.62,12578.62,12578.62,13926.70
1531,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83001,cpt,"Gonadotropin, Follicle Stimulating (Reproductive Hormone) Level",aetna,POS,O,103.81,18.58,56.81,77.86,22.30
1532,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82310,cpt,"Calcium Level, Total",aetna,HMO,O,36.61,5.16,5.16,36.61,21.97
1533,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95811,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab With Continued Pressured Respiratory Assistance By Mask Or Breathing Tube,aetna,Medicare Part A,O,3186.58,814.60,1816.35,1816.35,1911.95
1534,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96375,cpt,"Injection Of Different Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,PPO,O,88.47,19.71,48.41,66.35,53.08
1535,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78816,cpt,Nuclear Medicine Study With CT Imaging Whole Body,aetna,Medicare Part A,O,7556.48,1311.05,1311.05,2704.61,4533.89
1536,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86803,cpt,Hepatitis C Antibody Measurement,aetna,EPO,O,113.25,14.27,64.55,140.68,17.12
1537,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87480,cpt,"Detection Test For Candida Species (Yeast), Direct Probe Technique",aetna,PPO,O,107.59,12.03,58.87,80.69,24.06
1538,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,Medicaid,O,654.73,185.98,323.41,694.53,392.84
1539,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97530,cpt,"Therapeutic Activities To Improve Function, With One-On-One Contact Between Patient And Provider, Each 15 Minutes",aetna,Medicaid,O,166.34,34.57,91.02,91.02,99.80
1540,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87493,cpt,"Detection Test By Nucleic Acid For Clostridium Difficile, Amplified Probe Technique",aetna,POS,O,100.03,11.59,58.02,58.02,44.72
1541,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,26055,cpt,Incision Of Tendon Covering Of Finger,aetna,PPO,O,16309.48,1233.08,10334.48,10334.48,9785.69
1542,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88342,cpt,"Special Stained Specimen Slides To Examine Tissue, Initial Procedure",aetna,EPO,O,419.99,33.03,239.39,314.99,251.99
1543,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,596,ms-drg,Major Skin Disorders Without MCC,aetna,POS,I,17771.27,4749.34,4749.34,8242.06,10662.76
1544,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2710,cpt,"Injection, Neostigmine Methylsulfate, Up To 0.5 Mg",aetna,Medicaid,O,4.65,0.15,0.15,4.27,2.79
1545,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70487,cpt,CT Scan Of Face With Contrast,aetna,EPO,O,1358.47,810.86,810.86,810.86,815.08
1546,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11103,cpt,"Biopsy Of Related Skin Growth, Each Additional Growth",aetna,Medicaid,O,1126.00,160.53,161.01,647.00,675.60
1547,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna,POS,O,108.88,10.16,59.58,77.04,20.33
1548,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0882,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (For Esrd On Dialysis)",aetna,Medicare Part A,O,16.51,7.43,7.43,7.43,9.91
1549,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9306,cpt,"Injection, Pertuzumab, 1 Mg",aetna,Medicare Part B,O,44.82,10.05,14.64,424.56,26.89
1550,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97535,cpt,"Training For Self-Care Or Home Management, Each 15 Minutes",aetna,HMO,O,200.56,25.86,84.86,87.79,120.34
1551,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3380,cpt,"Injection, Vedolizumab, 1 Mg",aetna,HMO,O,60.64,21.72,28.92,28.92,36.38
1552,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,59025,cpt,Fetal Non-Stress Test,aetna,Medicare Part B,O,250.10,17.49,145.06,176.96,150.06
1553,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83516,cpt,"Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",aetna,POS,O,51.31,8.70,30.43,41.58,13.84
1554,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76830,cpt,Ultrasound Pelvis Through Vagina,aetna,HMO,O,795.16,96.50,435.09,632.15,115.81
1555,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84466,cpt,Transferrin (Iron Binding Protein) Level,aetna,Medicaid,O,67.24,10.47,36.80,36.80,40.34
1556,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna,HMO,I,5647.36,1115.96,3413.14,3995.78,3388.42
1557,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84145,cpt,Procalcitonin (Hormone) Level,aetna,PPO,O,97.91,20.28,53.57,53.57,32.66
1558,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna,Medicare Part A,O,2144.07,645.60,1279.68,2047.58,1286.44
1559,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85520,cpt,Heparin Assay,aetna,EPO,O,67.89,39.38,39.38,39.38,40.73
1560,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9552,cpt,"Fluorodeoxyglucose F-18 Fdg, Diagnostic, Per Study Dose, Up To 45 Millicuries",aetna,HMO,O,1552.58,289.56,849.53,1645.73,931.55
1561,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86695,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 1",aetna,PPO,O,89.65,13.19,49.06,67.24,15.83
1562,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87301,cpt,Detection Test By Immunoassay Technique For Adenovirus Enteric Types 40/41,aetna,Medicaid,O,60.03,6.75,34.52,34.52,14.38
1563,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90686,cpt,"Vaccine For Influenza For Administration Into Muscle, 0.5 Ml Dosage, Quadrivalent, Preservation Free",aetna,POS,O,132.44,13.48,20.93,79.94,79.46
1564,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0214,revCode,Coronary Care Unit Intermediate Ccu,aetna,Medicare Part B,I,3917.76,854.59,2252.72,11926.72,2350.66
1565,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87046,cpt,"Stool Culture, Additional Pathogens",aetna,HMO,O,52.60,5.92,30.25,30.25,11.33
1566,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87147,cpt,"Identification Of Organisms By Immunologic Analysis, Other Than Immunofluorescence Method",aetna,PPO,O,25.94,5.18,5.18,19.46,6.22
1567,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82140,cpt,Ammonia Level,aetna,Medicare Part A,O,108.53,13.90,59.39,59.39,17.48
1568,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82652,cpt,"Dihydroxyvitamin D, 1, 25 Level",aetna,Medicaid,O,221.79,38.50,126.42,166.34,46.20
1569,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43239,cpt,"Biopsy Of Esophagus, Stomach, And/Or Upper Small Bowel Using A Flexible Endoscope",aetna,EPO,O,4254.12,439.90,1990.82,4844.32,1282.14
1570,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73200,cpt,CT Scan Of Arm Without Contrast,aetna,HMO,O,1267.08,96.51,482.16,482.16,760.25
1571,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87510,cpt,"Detection Test For Gardnerella Vaginalis (Bacteria), Direct Probe Technique",aetna,POS,O,107.59,12.03,58.87,104.55,24.06
1572,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76770,cpt,Complete Ultrasound Scan Behind Abdominal Cavity,aetna,HMO,O,747.97,96.51,409.27,409.27,115.81
1573,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,620,ms-drg,O.R. Procedures For Obesity With CC,aetna,PPO,I,57057.61,10746.01,10746.01,20648.25,34234.57
1574,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna,Medicare Part B,O,120.33,10.08,65.84,90.25,20.16
1575,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83516,cpt,"Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",aetna,Medicaid,O,51.31,8.70,30.43,41.58,13.84
1576,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna,PPO,O,70.06,8.01,39.93,52.55,9.80
1577,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0450,revCode,"Emergency Room, General",aetna,PPO,I,891.51,282.04,810.79,6159.07,534.91
1578,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,23472,cpt,"Prosthetic Repair Of Shoulder Joint, Total Shoulder",aetna,Medicaid,I,123346.27,14814.57,14814.57,14814.57,74007.76
1579,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93660,cpt,Evaluation Of Heart Function Using Tilt Table,aetna,Medicare Part B,O,1139.65,276.48,649.60,649.60,683.79
1580,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93350,cpt,"Ultrasound Examination Of The Heart Performed During Rest, Exercise, And/Or Drug-Induced Stress With Interpretation And Report",aetna,Medicare Part B,O,1353.20,427.67,740.43,1075.79,811.92
1581,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76830,cpt,Ultrasound Pelvis Through Vagina,aetna,POS,O,795.16,96.50,435.09,632.15,115.81
1582,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96374,cpt,"Injection Of Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,HMO,O,218.25,39.35,154.75,181.39,130.95
1583,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84156,cpt,"Total Protein Level, Urine",aetna,Medicaid,O,80.24,3.60,46.54,53.04,4.40
1584,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna,Medicare Part B,O,145.10,26.57,41.28,89.17,49.54
1585,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73110,cpt,"X-Ray Of Wrist, Minimum Of 3 Views",aetna,Medicaid,O,329.15,51.73,183.86,246.86,197.49
1586,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74220,cpt,X-Ray Of Esophagus With Single Contrast,aetna,Medicare Part B,O,552.13,55.19,320.24,320.24,193.72
1587,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna,Medicaid,O,148.64,18.79,18.79,22.56,22.55
1588,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84466,cpt,Transferrin (Iron Binding Protein) Level,aetna,HMO,O,67.24,10.47,36.80,36.80,40.34
1589,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,EPO,I,710.22,207.44,407.05,747.97,426.13
1590,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87070,cpt,"Bacterial Culture, Any Other Source Except Urine, Blood Or Stool, Aerobic",aetna,EPO,O,65.11,8.45,8.58,48.83,10.34
1591,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0008,cpt,Administration Of Influenza Virus Vaccine,aetna,Medicaid,O,99.09,11.08,35.43,35.43,42.52
1592,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5107,cpt,"Injection, Bevacizumab-Awwb, Biosimilar, (Mvasi), 10 Mg",aetna,HMO,O,219.45,31.72,60.94,74.56,131.67
1593,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36415,cpt,Insertion Of Needle Into Vein For Collection Of Blood Sample,aetna,Medicare Part B,O,29.48,2.94,3.00,22.11,17.69
1594,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2250,cpt,"Injection, Midazolam Hydrochloride, Per 1 Mg",aetna,POS,O,41.06,10.28,18.48,41.06,24.64
1595,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna,PPO,O,142.89,8.03,64.15,113.59,16.07
1596,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,Medicaid,O,576.53,96.50,334.39,562.62,345.92
1597,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna,EPO,O,1956.07,299.94,1070.30,1213.17,359.94
1598,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7121,cpt,"5% Dextrose In Lactated Ringers Infusion, Up To 1000 Cc",aetna,Medicare Part B,O,164.65,75.76,75.76,75.76,98.79
1599,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,32408,cpt,"Core Needle Biopsy Of Lung Or Center Cavity Of Chest (Mediastinum), Accessed Through Skin",aetna,POS,O,3883.82,638.16,1248.81,1248.81,2330.29
1600,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76817,cpt,Vaginal Ultrasound Of Pregnant Uterus,aetna,POS,O,611.12,96.51,341.37,432.40,115.81
1601,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76830,cpt,Ultrasound Pelvis Through Vagina,aetna,Medicare Part B,O,795.16,96.50,435.09,632.15,115.81
1602,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93308,cpt,Follow-Up Or Limited Ultrasound Examination Of Heart,aetna,Medicare Part B,O,415.27,203.81,204.22,403.52,249.16
1603,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77412,cpt,Delivery Of Complex Radiation Treatment,aetna,EPO,O,933.20,214.04,510.62,666.46,256.85
1604,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88162,cpt,"Screening Examination Of Specimen Cells, Extended Study",aetna,Medicare Part A,O,303.20,44.07,44.07,97.64,181.92
1605,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5106,cpt,"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (For Non-Esrd Use), 1000 Units",aetna,Medicare Part B,O,32.27,8.13,8.62,13.29,19.36
1606,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A4565,cpt,Slings; Medical And Surgical Supplies - Various Medical Supplies Including Tapes And Surgical Dressings,aetna,HMO,O,21.33,6.00,7.91,29.48,12.80
1607,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0121,cpt,Colorectal Cancer Screening; Colonoscopy On Individual Not Meeting Criteria For High Risk,aetna,Medicare Part A,O,3036.82,702.86,1604.70,2259.70,1822.09
1608,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36561,cpt,"Insertion Of Central Venous Catheter And Implanted Device For Infusion Beneath The Skin, Patient 5 Years Or Older",aetna,POS,O,18382.66,2534.31,2589.99,17974.64,11029.60
1609,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0312,revCode,Laboratory Pathology Histology,aetna,HMO,O,419.99,131.76,239.39,419.99,251.99
1610,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74420,cpt,Imaging Of Urinary Tract Following Injection Of A Contrast Agent,aetna,HMO,O,1007.53,278.97,574.29,574.29,253.90
1611,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82390,cpt,Ceruloplasmin (Protein) Level,aetna,HMO,O,71.96,6.02,39.38,39.38,43.18
1612,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87147,cpt,"Identification Of Organisms By Immunologic Analysis, Other Than Immunofluorescence Method",aetna,Medicare Part B,O,25.94,5.18,5.18,19.46,6.22
1613,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,189,ms-drg,Pulmonary Edema And Respiratory Failure,aetna,EPO,I,29155.17,7655.58,9502.30,14063.21,17493.10
1614,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45385,cpt,Removal Of Polyps Or Growths Of Large Bowel Using An Endoscope With Mechanical Snare,aetna,Medicare Part A,O,5305.34,938.17,2617.73,5400.89,1653.07
1615,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,59025,cpt,Fetal Non-Stress Test,aetna,EPO,O,250.10,17.49,145.06,176.96,150.06
1616,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5117,cpt,"Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg",aetna,POS,O,285.60,38.03,46.31,88.21,171.36
1617,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84156,cpt,"Total Protein Level, Urine",aetna,HMO,O,80.24,3.60,46.54,53.04,4.40
1618,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9299,cpt,"Injection, Nivolumab, 1 Mg",aetna,Medicare Part A,O,107.35,13.51,28.82,29.25,64.41
1619,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,PPO,I,45.29,12.02,38.30,59.57,27.17
1620,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88162,cpt,"Screening Examination Of Specimen Cells, Extended Study",aetna,Medicare Part B,O,303.20,44.07,44.07,97.64,181.92
1621,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,P9040,cpt,"Red Blood Cells, Leukocytes Reduced, Irradiated, Each Unit",aetna,Medicare Part A,O,756.23,260.55,262.76,509.61,453.74
1622,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84702,cpt,"Gonadotropin, Chorionic (Reproductive Hormone) Level",aetna,HMO,O,67.24,15.05,36.80,47.58,18.06
1623,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna,Medicare Part B,O,1956.07,299.94,1070.30,1213.17,359.94
1624,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,PPO,I,490.78,103.68,279.74,347.25,294.47
1625,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0274,revCode,"Medical/Surgical Supplies And Devices, Prosthetic/Orthotic Devices",aetna,Medicare Part A,O,89.04,8.13,2026.64,2026.64,53.42
1626,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9360,cpt,"Injection, Vinblastine Sulfate, 1 Mg",aetna,Medicare Part B,O,11.79,2.36,4.08,4.08,7.07
1627,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77338,cpt,Design And Construction Of Radiation Treatment Device For High Precision Radiation Therapy,aetna,PPO,O,2028.03,299.94,1109.68,1109.68,359.94
1628,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna,Medicare Part B,O,92.22,24.06,24.60,24.60,55.33
1629,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72197,cpt,MRI Scan Of Pelvis Before And After Contrast,aetna,Medicare Part A,O,2882.19,326.01,329.84,2161.64,391.22
1630,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna,PPO,O,84.93,5.32,30.50,63.70,15.10
1631,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71260,cpt,CT Scan Of Chest With Contrast,aetna,POS,O,1774.38,129.65,1011.40,1330.79,189.76
1632,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76642,cpt,Limited Ultrasound Scan Of 1 Breast,aetna,PPO,O,305.55,71.65,167.19,242.91,183.33
1633,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,32408,cpt,"Core Needle Biopsy Of Lung Or Center Cavity Of Chest (Mediastinum), Accessed Through Skin",aetna,Medicare Part A,O,3883.82,638.16,1248.81,1248.81,2330.29
1634,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna,Medicare Part A,O,84.93,5.32,30.50,63.70,15.10
1635,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,219,ms-drg,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With MCC,aetna,HMO,I,256090.54,46435.26,46497.02,47950.73,153654.32
1636,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77412,cpt,Delivery Of Complex Radiation Treatment,aetna,Medicare Part A,O,933.20,214.04,510.62,666.46,256.85
1637,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2370,cpt,"Injection, Phenylephrine Hcl, Up To 1 Ml",aetna,HMO,O,87.77,23.91,40.37,66.01,52.66
1638,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71275,cpt,CT Scan Of Blood Vessels Of Chest With Contrast,aetna,Medicare Part B,O,1841.63,158.13,970.89,1464.09,189.76
1639,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,689,ms-drg,Kidney And Urinary Tract Infections With MCC,aetna,PPO,I,22796.06,6348.25,8547.01,9085.55,13677.64
1640,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna,Medicare Part B,O,2882.19,203.81,1577.05,2291.34,244.57
1641,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93005,cpt,Routine Electrocardiogram (Ekg) With Tracing Using At Least 12 Leads,aetna,Medicare Part A,O,218.25,35.36,121.91,154.43,130.95
1642,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,M0243,cpt,"Intravenous Infusion, Casirivimab And Imdevimab Includes Infusion And Post Administration Monitoring",aetna,Medicare Part B,O,820.47,138.86,502.86,502.86,492.28
1643,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna,PPO,O,490.78,263.76,343.76,352.65,294.47
1644,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85384,cpt,Fibrinogen (Factor 1) Activity Measurement,aetna,PPO,O,89.70,9.63,54.20,54.20,11.66
1645,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86376,cpt,Microsomal Antibodies (Autoantibody) Measurement,aetna,Medicare Part B,O,90.15,12.00,21.95,21.95,17.46
1646,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86140,cpt,Measurement C-Reactive Protein For Detection Of Infection Or Inflammation,aetna,Medicare Part B,O,67.58,5.08,38.52,50.69,6.22
1647,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17261,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Trunk, Arms, Or Legs",aetna,Medicaid,O,1857.00,159.01,159.02,543.72,1114.20
1648,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87635,cpt,Amplifed DNA Or Rna Probe Detection Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antigen,aetna,POS,O,168.00,50.29,97.44,126.00,61.57
1649,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna,Medicare Part A,O,356.28,61.44,194.95,194.95,213.77
1650,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0121,cpt,Colorectal Cancer Screening; Colonoscopy On Individual Not Meeting Criteria For High Risk,aetna,PPO,O,3036.82,702.86,1604.70,2259.70,1822.09
1651,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,EPO,O,332.78,61.44,194.95,261.67,199.67
1652,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97018,cpt,Application Of Hot Wax Bath To 1 Or More Areas,aetna,PPO,O,79.04,3.64,32.08,34.45,47.42
1653,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84484,cpt,"Troponin (Protein) Analysis, Quantitative",aetna,Medicare Part B,O,80.09,12.47,29.46,56.67,14.96
1654,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5107,cpt,"Injection, Bevacizumab-Awwb, Biosimilar, (Mvasi), 10 Mg",aetna,Medicare Part B,O,219.45,31.72,60.94,74.56,131.67
1655,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0343,revCode,"Nuclear Medicine, Diagnostic Radiopharmaceuticals",aetna,POS,O,692.52,123.81,394.74,1192.32,415.51
1656,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9552,cpt,"Fluorodeoxyglucose F-18 Fdg, Diagnostic, Per Study Dose, Up To 45 Millicuries",aetna,Medicaid,O,1552.58,289.56,849.53,1645.73,931.55
1657,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77385,cpt,"Intensity Modulated Radiation Therapy Delivery, Simple",aetna,Medicaid,O,1786.18,480.50,485.97,729.06,576.60
1658,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88173,cpt,Evaluation Of Fine Needle Aspirate With Interpretation And Report,aetna,Medicare Part A,O,109.71,60.12,81.77,81.77,65.83
1659,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97113,cpt,"Water Pool Therapy With Therapeutic Exercises To 1 Or More Areas, Each 15 Minutes",aetna,Medicare Part B,O,132.12,28.83,54.93,62.54,79.27
1660,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,853,ms-drg,Infectious And Parasitic Diseases With O.R. Procedures With MCC,aetna,Medicare Part A,I,131887.09,28277.35,28277.35,59129.81,79132.25
1661,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43450,cpt,Dilation Of Esophagus Unguided,aetna,HMO,O,3778.61,1075.52,1753.96,3815.86,2267.17
1662,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94729,cpt,Test To Examine How Well The Lungs Exchange Gases,aetna,HMO,O,218.25,52.60,119.42,119.42,130.95
1663,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88309,cpt,"Pathology Examination Of Tissue Using A Microscope, High Complexity",aetna,Medicare Part A,O,696.07,273.94,396.76,396.76,417.64
1664,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,191,ms-drg,Chronic Obstructive Pulmonary Disease With CC,aetna,Medicaid,I,15955.32,4343.49,5733.83,7724.36,9573.19
1665,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82390,cpt,Ceruloplasmin (Protein) Level,aetna,Medicare Part B,O,71.96,6.02,39.38,39.38,43.18
1666,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87660,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Direct Probe Technique",aetna,HMO,O,114.43,12.03,62.62,85.82,24.06
1667,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,57522,cpt,Removal Or Destruction Of Cervix With Electrical Cautery,aetna,POS,O,18168.39,2323.14,10911.60,10911.60,10901.03
1668,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86141,cpt,"Measurement C-Reactive Protein For Detection Of Infection Or Inflammation, High Sensitivity",aetna,HMO,O,138.33,7.77,7.77,13.00,15.54
1669,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83036,cpt,Hemoglobin A1c Level,aetna,Medicaid,O,76.68,5.83,41.96,57.51,11.65
1670,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45378,cpt,Diagnostic Colonoscopy Of Large Bowel Using A Flexible Endoscope,aetna,Medicare Part A,O,3131.25,717.01,1860.41,2251.40,861.59
1671,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76817,cpt,Vaginal Ultrasound Of Pregnant Uterus,aetna,EPO,O,611.12,96.51,341.37,432.40,115.81
1672,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna,HMO,O,1956.07,299.94,1070.30,1213.17,359.94
1673,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84144,cpt,Progesterone (Reproductive Hormone) Level,aetna,POS,O,101.45,17.03,55.51,71.78,25.03
1674,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0278,revCode,Medical/Surgical Supplies And Devices Other Implants,aetna,PPO,I,12498.86,118.53,1501.07,6933.25,7499.32
1675,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9130,cpt,Dacarbazine 100 Mg Inj,aetna,Medicare Part B,O,15.58,5.03,5.03,16.51,9.35
1676,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84702,cpt,"Gonadotropin, Chorionic (Reproductive Hormone) Level",aetna,Medicaid,O,67.24,15.05,36.80,47.58,18.06
1677,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0946,revCode,Medical Rehabilitation Day Program Complex Medical Equipment - Routine,aetna,PPO,I,144.44,64.00,258.21,258.21,86.66
1678,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84155,cpt,"Total Protein Level, Blood",aetna,PPO,O,69.00,3.67,3.67,51.75,4.40
1679,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86592,cpt,Syphilis Detection Test,aetna,Medicaid,O,40.11,4.27,22.41,30.08,5.12
1680,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64636,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Each Additional Facet Joint",aetna,PPO,O,7088.87,1523.14,4237.46,4237.46,4253.32
1681,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93350,cpt,"Ultrasound Examination Of The Heart Performed During Rest, Exercise, And/Or Drug-Induced Stress With Interpretation And Report",aetna,PPO,O,1353.20,427.67,740.43,1075.79,811.92
1682,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna,HMO,O,251.28,64.70,137.49,266.36,150.77
1683,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99153,cpt,"Use Of A Drug To Induce Depression Of Consciousness By Physician Performing A Procedure, Each Additional 15 Minutes",aetna,EPO,O,47.19,6.59,27.37,47.19,28.31
1684,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0897,cpt,"Injection, Denosumab, 1 Mg",aetna,Medicaid,O,62.32,12.82,18.35,21.26,37.39
1685,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86777,cpt,Analysis For Antibody To Toxoplasma (Parasite),aetna,Medicaid,O,152.18,14.25,86.74,86.74,91.31
1686,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna,Medicaid,O,3391.86,327.84,1855.92,2543.90,462.44
1687,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9354,cpt,"Injection, Ado-Trastuzumab Emtansine, 1 Mg",aetna,POS,O,123.87,25.63,36.89,41.57,74.32
1688,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73560,cpt,"X-Ray Of Knee, 1 Or 2 Views",aetna,PPO,O,231.22,26.24,126.52,126.52,138.73
1689,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36593,cpt,Declotting Infusion Of Implanted Central Venous Access Device Or Catheter,aetna,POS,O,18177.79,1282.65,9002.79,20624.05,10906.67
1690,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17270,cpt,"Destruction Of Malignant Growth (0.5 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,EPO,O,1881.00,159.01,159.94,475.20,1128.60
1691,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,191,ms-drg,Chronic Obstructive Pulmonary Disease With CC,aetna,Medicare Part A,I,15955.32,4343.49,5733.83,7724.36,9573.19
1692,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64483,cpt,"Injection Of Anesthetic And/Or Steroid Drug Into Sacral Spine Nerve Root Using Imaging Guidance, Single Level",aetna,PPO,O,2134.28,1064.77,4498.33,4498.33,1311.13
1693,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna,EPO,E,3350.06,336.55,1455.60,2095.51,2010.04
1694,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,55250,cpt,Removal Of Sperm Duct,aetna,Medicare Part B,O,17158.79,1587.89,8468.46,8468.46,10295.27
1695,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7050,cpt,"Infusion, Normal Saline Solution, 250 Cc",aetna,PPO,O,157.33,71.59,71.59,118.00,94.40
1696,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,Medicare Part B,I,1884.10,527.05,1030.93,1360.64,1130.46
1697,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,HMO,I,145.10,44.06,100.82,507.29,87.06
1698,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0510,revCode,Clinic General,aetna,Medicare Part A,O,167.48,51.31,51.31,289.51,100.49
1699,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73200,cpt,CT Scan Of Arm Without Contrast,aetna,PPO,O,1267.08,96.51,482.16,482.16,760.25
1700,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73221,cpt,MRI Scan Of Arm Joint Without Contrast,aetna,Medicare Part B,O,2882.19,203.81,1577.05,1715.45,245.82
1701,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1100,cpt,"Injection, Dexamethasone Sodium Phosphate, 1 Mg",aetna,Medicaid,O,7.91,1.12,1.12,7.91,4.75
1702,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86140,cpt,Measurement C-Reactive Protein For Detection Of Infection Or Inflammation,aetna,HMO,O,67.58,5.08,38.52,50.69,6.22
1703,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76770,cpt,Complete Ultrasound Scan Behind Abdominal Cavity,aetna,Medicare Part A,O,747.97,96.51,409.27,409.27,115.81
1704,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93350,cpt,"Ultrasound Examination Of The Heart Performed During Rest, Exercise, And/Or Drug-Induced Stress With Interpretation And Report",aetna,Medicaid,O,1353.20,427.67,740.43,1075.79,811.92
1705,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93798,cpt,"Outpatient Heart Rehabilitation With Electrocardiogram (Ecg) Monitoring, Quality Health Care Professional Services",aetna,Medicaid,O,173.89,102.78,102.79,130.42,123.35
1706,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83516,cpt,"Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",aetna,HMO,O,51.31,8.70,30.43,41.58,13.84
1707,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97166,cpt,"Evaluation For Occupational Therapy, Typically 45 Minutes",aetna,EPO,O,265.44,85.51,151.30,163.25,159.26
1708,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0401,revCode,Other Imaging Services Diagnostic Mammography,aetna,PPO,O,266.00,50.09,79.04,224.15,159.60
1709,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna,HMO,O,135.07,18.96,76.99,121.94,81.04
1710,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna,Medicaid,O,120.33,10.08,65.84,90.25,20.16
1711,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9060,cpt,"Injection, Cisplatin, Powder Or Solution, 10 Mg",aetna,PPO,O,7.79,1.85,1.85,2.82,4.67
1712,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74246,cpt,X-Ray Of Upper Digestive Tract With Double Contrast,aetna,Medicare Part A,O,484.07,158.13,264.87,284.00,189.76
1713,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76801,cpt,Abdominal Ultrasound Of Pregnant Uterus (Less Than 14 Weeks 0 Days) Single Or First Fetus,aetna,HMO,O,357.27,96.50,217.76,229.19,115.81
1714,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0280,revCode,Oncology General,aetna,Medicare Part B,O,192.29,49.29,109.61,144.22,115.37
1715,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,189,ms-drg,Pulmonary Edema And Respiratory Failure,aetna,Medicare Part A,I,29155.17,7655.58,9502.30,14063.21,17493.10
1716,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12032,cpt,"Repair Of Wound (2.6 To 7.5 Centimeters) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna,PPO,O,3063.00,309.74,309.74,3849.84,1837.80
1717,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2469,cpt,"Injection, Palonosetron Hcl, 25 Mcg",aetna,EPO,O,90.84,19.36,39.42,85.70,54.50
1718,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87177,cpt,Smear For Parasites,aetna,POS,O,123.87,8.72,70.61,70.61,10.68
1719,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,603,ms-drg,Cellulitis Without MCC,aetna,Medicare Part A,I,19499.58,3283.09,5672.80,12955.93,11699.75
1720,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,853,ms-drg,Infectious And Parasitic Diseases With O.R. Procedures With MCC,aetna,POS,I,131887.09,28277.35,28277.35,59129.81,79132.25
1721,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0403,revCode,Other Imaging Services Screening Mammography,aetna,Medicaid,O,312.75,51.78,104.90,273.24,187.65
1722,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1442,cpt,"Injection, Filgrastim (G-Csf), Excludes Biosimilars, 1 Microgram",aetna,PPO,O,4.45,0.72,0.93,1.48,2.67
1723,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,Medicare Part B,I,45.29,12.02,38.30,59.57,27.17
1724,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87301,cpt,Detection Test By Immunoassay Technique For Adenovirus Enteric Types 40/41,aetna,Medicare Part A,O,60.03,6.75,34.52,34.52,14.38
1725,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88172,cpt,Evaluation Of Fine Needle Aspirate,aetna,Medicaid,O,416.45,228.18,310.38,310.38,249.87
1726,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96415,cpt,"Administration Of Chemotherapy Into Vein, Each Additional Hour",aetna,Medicare Part B,O,110.89,25.40,60.68,83.17,66.53
1727,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72148,cpt,MRI Scan Of Lower Spinal Canal,aetna,EPO,O,2882.19,203.81,1642.85,2039.29,244.57
1728,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78227,cpt,Nuclear Medicine Study Of Liver And Bile Duct System With Use Of Drugs,aetna,POS,O,1528.98,161.81,836.62,1038.75,520.12
1729,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,EPO,I,216.65,43.99,86.21,184.92,129.99
1730,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84466,cpt,Transferrin (Iron Binding Protein) Level,aetna,PPO,O,67.24,10.47,36.80,36.80,40.34
1731,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96375,cpt,"Injection Of Different Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,EPO,O,88.47,19.71,48.41,66.35,53.08
1732,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92610,cpt,Evaluation Of Swallowing Function,aetna,Medicare Part A,O,286.43,81.46,166.13,166.13,171.86
1733,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64718,cpt,Release And/Or Relocation Of Ulnar Nerve At Elbow,aetna,HMO,O,16595.69,1553.71,9876.73,9876.73,9957.41
1734,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77385,cpt,"Intensity Modulated Radiation Therapy Delivery, Simple",aetna,EPO,O,1786.18,480.50,485.97,729.06,576.60
1735,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5117,cpt,"Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg",aetna,Medicaid,O,285.60,38.03,46.31,88.21,171.36
1736,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93458,cpt,Insertion Of Catheter In Left Heart For Imaging Of Blood Vessels And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna,POS,O,25037.36,2421.03,5730.96,15138.17,15022.42
1737,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87046,cpt,"Stool Culture, Additional Pathogens",aetna,Medicaid,O,52.60,5.92,30.25,30.25,11.33
1738,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2599,cpt,Contact Lens/Es Other Type,aetna,Medicaid,O,3822.87,1002.34,4045.37,4045.37,2293.72
1739,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2765,cpt,"Injection, Metoclopramide Hcl, Up To 10 Mg",aetna,PPO,O,79.57,18.17,36.60,79.57,47.74
1740,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96415,cpt,"Administration Of Chemotherapy Into Vein, Each Additional Hour",aetna,POS,O,110.89,25.40,60.68,83.17,66.53
1741,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11042,cpt,Removal Of Skin And Tissue First 20 Sq Cm Or Less,aetna,EPO,O,1315.41,306.28,624.03,3179.32,789.25
1742,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85652,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Automated",aetna,Medicare Part B,O,38.92,2.65,21.30,29.59,3.24
1743,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9228,cpt,"Injection, Ipilimumab, 1 Mg",aetna,Medicaid,O,588.70,104.49,157.23,157.23,353.22
1744,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9579,cpt,"Injection, Gadolinium-Based Magnetic Resonance Contrast Agent, Not Otherwise Specified (Nos), Per Ml",aetna,Medicare Part B,O,15.32,0.10,6.89,16.23,9.19
1745,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84156,cpt,"Total Protein Level, Urine",aetna,Medicare Part B,O,80.24,3.60,46.54,53.04,4.40
1746,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,483,ms-drg,Major Joint Or Limb Reattachment Procedures Of Upper Extremities,aetna,Medicare Part A,I,77640.79,14258.73,14814.57,23206.53,46584.47
1747,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97162,cpt,"Evaluation For Physical Therapy, Typically 30 Minutes",aetna,Medicaid,O,224.82,58.86,123.02,136.58,134.89
1748,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,871,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours With MCC,aetna,EPO,I,36297.45,7941.64,11794.58,17432.39,21778.47
1749,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0421,revCode,Physical Therapy Visit Charge,aetna,EPO,O,173.42,23.17,76.68,1195.53,104.05
1750,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72110,cpt,"X-Ray Of Lower And Sacral Spine, Minimum Of 4 Views",aetna,POS,O,613.48,46.08,335.68,365.14,115.81
1751,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87536,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Quantification",aetna,Medicaid,O,519.10,67.96,295.89,295.89,311.46
1752,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,Medicaid,O,1881.00,160.85,162.47,936.63,1128.60
1753,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72110,cpt,"X-Ray Of Lower And Sacral Spine, Minimum Of 4 Views",aetna,Medicare Part A,O,613.48,46.08,335.68,365.14,115.81
1754,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84480,cpt,"Thyroid Hormone, T3 Measurement, Total",aetna,Medicaid,O,60.03,11.72,34.82,34.82,17.02
1755,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85379,cpt,"Coagulation Function Measurement, D-Dimer; Quantitative",aetna,HMO,O,122.56,9.98,71.08,71.08,12.22
1756,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82952,cpt,"Blood Glucose (Sugar) Tolerance Test, Each Additional Beyond 3 Specimens",aetna,Medicare Part A,O,48.36,3.92,27.57,36.27,4.70
1757,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93660,cpt,Evaluation Of Heart Function Using Tilt Table,aetna,EPO,O,1139.65,276.48,649.60,649.60,683.79
1758,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78816,cpt,Nuclear Medicine Study With CT Imaging Whole Body,aetna,Medicare Part B,O,7556.48,1311.05,1311.05,2704.61,4533.89
1759,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0124,revCode,Room And Board Semiprivate (Two Beds) Psychiatric,aetna,EPO,I,2075.74,728.48,728.48,1347.17,1245.44
1760,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19083,cpt,"Biopsy Of Breast Accessed Through The Skin With Ultrasound Guidance, First Lesion",aetna,EPO,O,8391.01,1246.10,6742.37,6742.37,5034.61
1761,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7030,cpt,"Infusion, Normal Saline Solution , 1000 Cc",aetna,POS,O,8.25,3.71,3.71,162.78,4.95
1762,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83001,cpt,"Gonadotropin, Follicle Stimulating (Reproductive Hormone) Level",aetna,PPO,O,103.81,18.58,56.81,77.86,22.30
1763,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86800,cpt,Thyroglobulin (Thyroid Protein) Antibody Measurement,aetna,Medicaid,O,71.96,14.53,40.56,40.56,19.09
1764,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0720,revCode,Labor Room/Delivery General,aetna,Medicaid,I,141.69,33.03,82.08,5123.48,85.01
1765,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,483,ms-drg,Major Joint Or Limb Reattachment Procedures Of Upper Extremities,aetna,Medicare Part B,I,77640.79,14258.73,14814.57,23206.53,46584.47
1766,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84153,cpt,"PSA (Prostate Specific Antigen) Measurement, Total",aetna,PPO,O,91.30,18.03,51.00,60.30,22.07
1767,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19083,cpt,"Biopsy Of Breast Accessed Through The Skin With Ultrasound Guidance, First Lesion",aetna,Medicare Part B,O,8391.01,1246.10,6742.37,6742.37,5034.61
1768,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76819,cpt,Ultrasound Scan Of Fetus,aetna,Medicare Part B,O,611.12,96.51,348.34,485.84,366.67
1769,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87591,cpt,"Detection Test By Nucleic Acid For Neisseria Gonorrhoeae (Gonorrhoeae Bacteria), Amplified Probe Technique",aetna,POS,O,147.58,21.05,82.44,110.69,42.11
1770,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0343,revCode,"Nuclear Medicine, Diagnostic Radiopharmaceuticals",aetna,Medicaid,O,692.52,123.81,394.74,1192.32,415.51
1771,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80307,cpt,"Testing For Presence Of Drug, By Chemistry Analyzers",aetna,Medicare Part B,O,197.60,49.05,49.06,62.39,118.56
1772,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76700,cpt,"Ultrasound Of Abdomen, Complete",aetna,PPO,O,970.94,96.51,542.36,771.89,116.30
1773,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,191,ms-drg,Chronic Obstructive Pulmonary Disease With CC,aetna,HMO,I,15955.32,4343.49,5733.83,7724.36,9573.19
1774,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17261,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Trunk, Arms, Or Legs",aetna,EPO,O,1857.00,159.01,159.02,543.72,1114.20
1775,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0431,revCode,Occupational Therapy Visit Charge,aetna,Medicaid,O,173.42,21.75,80.69,875.96,104.05
1776,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93660,cpt,Evaluation Of Heart Function Using Tilt Table,aetna,PPO,O,1139.65,276.48,649.60,649.60,683.79
1777,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52260,cpt,Dilation Of The Bladder Using An Endoscope Under General Or Spinal Anesthesia,aetna,HMO,O,14589.65,1578.66,8790.54,8790.54,8753.79
1778,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99214,cpt,"Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes",aetna,Medicare Part B,O,423.60,59.52,255.94,255.94,254.16
1779,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77280,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 1 Treatment Area",aetna,Medicare Part B,O,1037.01,112.36,591.10,733.79,134.83
1780,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92610,cpt,Evaluation Of Swallowing Function,aetna,POS,O,286.43,81.46,166.13,166.13,171.86
1781,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36593,cpt,Declotting Infusion Of Implanted Central Venous Access Device Or Catheter,aetna,Medicare Part A,O,18177.79,1282.65,9002.79,20624.05,10906.67
1782,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87635,cpt,Amplifed DNA Or Rna Probe Detection Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antigen,aetna,Medicare Part B,O,168.00,50.29,97.44,126.00,61.57
1783,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,Medicare Part A,I,3199.87,740.21,1855.92,2543.89,1919.92
1784,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0243,cpt,"Injection, Casirivimab And Imdevimab, 2400 Mg",aetna,POS,O,0.03,0.01,0.01,11.63,0.02
1785,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2785,cpt,"Injection, Regadenoson, 0.1 Mg",aetna,Medicaid,O,154.74,25.67,69.52,154.76,92.84
1786,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17261,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Trunk, Arms, Or Legs",aetna,HMO,O,1857.00,159.01,159.02,543.72,1114.20
1787,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93005,cpt,Routine Electrocardiogram (Ekg) With Tracing Using At Least 12 Leads,aetna,PPO,O,218.25,35.36,121.91,154.43,130.95
1788,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86480,cpt,"Tuberculosis Test, Gamma Interferon",aetna,Medicaid,O,350.39,35.31,199.72,262.79,74.38
1789,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0124,revCode,Room And Board Semiprivate (Two Beds) Psychiatric,aetna,Medicaid,I,2075.74,728.48,728.48,1347.17,1245.44
1790,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,620,ms-drg,O.R. Procedures For Obesity With CC,aetna,Medicaid,I,57057.61,10746.01,10746.01,20648.25,34234.57
1791,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86592,cpt,Syphilis Detection Test,aetna,EPO,O,40.11,4.27,22.41,30.08,5.12
1792,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82731,cpt,Fetal Fibronectin (Protein) Analysis,aetna,HMO,O,565.34,60.62,64.37,424.01,115.33
1793,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna,POS,O,70.06,8.01,39.93,52.55,9.80
1794,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0312,revCode,Laboratory Pathology Histology,aetna,Medicaid,O,419.99,131.76,239.39,419.99,251.99
1795,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96368,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Concurrent With Another Infusion",aetna,Medicaid,O,75.68,16.92,43.89,60.16,45.41
1796,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,26055,cpt,Incision Of Tendon Covering Of Finger,aetna,HMO,O,16309.48,1233.08,10334.48,10334.48,9785.69
1797,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84100,cpt,Phosphate Level,aetna,HMO,O,40.11,4.74,13.80,13.80,5.69
1798,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,784,ms-drg,Cesarean Section With Sterilization With CC,aetna,EPO,I,14658.24,5823.07,5823.07,10802.78,8794.94
1799,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96415,cpt,"Administration Of Chemotherapy Into Vein, Each Additional Hour",aetna,Medicare Part A,O,110.89,25.40,60.68,83.17,66.53
1800,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,673,ms-drg,Other Kidney And Urinary Tract Procedures With MCC,aetna,Medicare Part B,I,61701.73,20358.57,20462.06,20647.19,37021.04
1801,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,885,ms-drg,Psychoses,aetna,EPO,I,17080.81,5566.92,6861.23,9301.98,10248.49
1802,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna,PPO,O,4055.15,194.15,2179.00,3854.73,1125.84
1803,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97597,cpt,"Removal Of Tissue From Wounds Per Session, First 20 Sq Cms Or Less",aetna,EPO,O,596.96,89.68,159.02,159.02,358.18
1804,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna,EPO,O,135.07,18.96,76.99,121.94,81.04
1805,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,620,ms-drg,O.R. Procedures For Obesity With CC,aetna,Medicare Part B,I,57057.61,10746.01,10746.01,20648.25,34234.57
1806,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86709,cpt,Measurement Of Hepatitis A Antibody (Igm),aetna,HMO,O,106.28,11.21,60.58,60.58,63.77
1807,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96415,cpt,"Administration Of Chemotherapy Into Vein, Each Additional Hour",aetna,EPO,O,110.89,25.40,60.68,83.17,66.53
1808,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,247,ms-drg,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without MCC,aetna,Medicare Part B,I,79628.76,11995.52,12110.64,46153.54,47777.26
1809,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9601,cpt,"Percutaneous Transcatheter Placement Of Drug-Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery (List Separately In Addition To",aetna,Medicare Part A,O,71354.64,14191.44,14191.44,14191.44,42812.78
1810,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64483,cpt,"Injection Of Anesthetic And/Or Steroid Drug Into Sacral Spine Nerve Root Using Imaging Guidance, Single Level",aetna,HMO,O,2134.28,1064.77,4498.33,4498.33,1311.13
1811,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84550,cpt,"Uric Acid Level, Blood",aetna,POS,O,50.01,4.52,29.01,79.60,5.42
1812,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66991,cpt,Extracapsular Removal Of Cataract With Insertion Of Artificial Lens And Insertion Of Drainage Device In Front Chamber Of Eye,aetna,PPO,O,8752.90,3729.66,3729.66,3765.43,5251.74
1813,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2150,cpt,"Injection, Mannitol, 25% In 50 Ml",aetna,EPO,O,8.02,2.82,3.58,3.58,4.81
1814,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96377,cpt,Application Of On-Body Injector For Under Skin Injection,aetna,Medicare Part B,O,44.52,9.67,25.82,25.82,26.71
1815,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9579,cpt,"Injection, Gadolinium-Based Magnetic Resonance Contrast Agent, Not Otherwise Specified (Nos), Per Ml",aetna,PPO,O,15.32,0.10,6.89,16.23,9.19
1816,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19083,cpt,"Biopsy Of Breast Accessed Through The Skin With Ultrasound Guidance, First Lesion",aetna,POS,O,8391.01,1246.10,6742.37,6742.37,5034.61
1817,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87427,cpt,Detection Test By Immunoassay Technique For Shiga-Like Toxin (Bacterial Toxin),aetna,POS,O,60.03,6.75,34.22,34.22,14.38
1818,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83550,cpt,Iron Binding Capacity,aetna,EPO,O,106.28,8.57,60.58,106.28,10.49
1819,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76830,cpt,Ultrasound Pelvis Through Vagina,aetna,Medicare Part A,O,795.16,96.50,435.09,632.15,115.81
1820,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78472,cpt,Nuclear Medicine Study Of Heart Pumping Function By Labeling Red Blood Cells With Measurement Of Internal Blood Volume Ejected With Every Beat Over Multiple Cycles,aetna,EPO,O,2168.12,333.98,333.99,645.81,1300.87
1821,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,Medicare Part A,I,216.65,43.99,86.21,184.92,129.99
1822,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna,Medicare Part A,O,92.22,24.06,24.60,24.60,55.33
1823,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99212,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 10 Minutes",aetna,PPO,O,180.14,52.17,102.68,135.10,108.08
1824,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87177,cpt,Smear For Parasites,aetna,Medicaid,O,123.87,8.72,70.61,70.61,10.68
1825,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0450,revCode,"Emergency Room, General",aetna,Medicaid,I,891.51,282.04,810.79,6159.07,534.91
1826,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,POS,O,212.10,40.75,115.12,253.05,127.26
1827,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,247,ms-drg,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without MCC,aetna,POS,I,79628.76,11995.52,12110.64,46153.54,47777.26
1828,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82390,cpt,Ceruloplasmin (Protein) Level,aetna,PPO,O,71.96,6.02,39.38,39.38,43.18
1829,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88360,cpt,"Microscopic Genetic Analysis Of Tumor, Manual",aetna,Medicaid,O,331.51,126.27,188.96,188.96,198.91
1830,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86762,cpt,Analysis For Antibody To Rubella (German Measles Virus),aetna,EPO,O,50.01,4.42,27.36,37.51,17.10
1831,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,HMO,O,1673.95,97.51,795.53,1330.78,1004.37
1832,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76815,cpt,"Ultrasound Of Pregnant Uterus, 1 Or More Fetus(Es)",aetna,Medicaid,O,611.12,97.50,348.34,647.78,366.67
1833,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0430,revCode,"Occupational Therapy, General",aetna,POS,I,176.32,32.63,91.02,165.50,105.79
1834,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85045,cpt,"Red Blood Count, Automated Test",aetna,Medicare Part B,O,38.92,2.44,3.98,14.01,4.79
1835,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna,HMO,O,148.64,18.79,18.79,22.56,22.55
1836,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93660,cpt,Evaluation Of Heart Function Using Tilt Table,aetna,Medicaid,O,1139.65,276.48,649.60,649.60,683.79
1837,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70450,cpt,CT Of Head Without Contrast,aetna,Medicare Part B,O,2452.75,96.51,1398.07,1839.56,115.81
1838,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85027,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test",aetna,POS,O,56.26,6.34,30.79,39.81,7.76
1839,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0269,cpt,"Placement Of Occlusive Device Into Either A Venous Or Arterial Access Site, Post Surgical Or Interventional Procedure (E.G., Angioseal Plug, Vascular Plug)",aetna,Medicaid,O,67707.99,403.09,4389.98,14226.92,40624.79
1840,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,871,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours With MCC,aetna,Medicaid,I,36297.45,7941.64,11794.58,17432.39,21778.47
1841,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99212,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 10 Minutes",aetna,POS,O,180.14,52.17,102.68,135.10,108.08
1842,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,596,ms-drg,Major Skin Disorders Without MCC,aetna,Medicare Part A,I,17771.27,4749.34,4749.34,8242.06,10662.76
1843,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0269,cpt,"Placement Of Occlusive Device Into Either A Venous Or Arterial Access Site, Post Surgical Or Interventional Procedure (E.G., Angioseal Plug, Vascular Plug)",aetna,PPO,O,67707.99,403.09,4389.98,14226.92,40624.79
1844,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84702,cpt,"Gonadotropin, Chorionic (Reproductive Hormone) Level",aetna,Medicare Part B,O,67.24,15.05,36.80,47.58,18.06
1845,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0401,revCode,Other Imaging Services Diagnostic Mammography,aetna,POS,O,266.00,50.09,79.04,224.15,159.60
1846,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99153,cpt,"Use Of A Drug To Induce Depression Of Consciousness By Physician Performing A Procedure, Each Additional 15 Minutes",aetna,HMO,O,47.19,6.59,27.37,47.19,28.31
1847,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9360,cpt,"Injection, Vinblastine Sulfate, 1 Mg",aetna,POS,O,11.79,2.36,4.08,4.08,7.07
1848,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96367,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Additional Sequential Infusion, 1 Hour Or Less",aetna,Medicaid,O,117.97,25.86,64.55,88.48,70.78
1849,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,292,ms-drg,Heart Failure And Shock With CC,aetna,PPO,I,18032.02,5781.24,12207.78,12207.78,10819.21
1850,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73110,cpt,"X-Ray Of Wrist, Minimum Of 3 Views",aetna,PPO,O,329.15,51.73,183.86,246.86,197.49
1851,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84484,cpt,"Troponin (Protein) Analysis, Quantitative",aetna,EPO,O,80.09,12.47,29.46,56.67,14.96
1852,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna,POS,O,92.22,24.06,24.60,24.60,55.33
1853,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna,POS,O,982.00,159.01,162.47,1222.94,589.20
1854,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64721,cpt,Release And/Or Relocation Of Median Nerve Of Hand,aetna,Medicare Part A,O,15304.77,1553.71,8031.11,8031.11,9182.86
1855,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86850,cpt,Screening Test For Red Blood Cell Antibodies,aetna,POS,O,93.19,8.25,53.12,67.92,53.95
1856,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76815,cpt,"Ultrasound Of Pregnant Uterus, 1 Or More Fetus(Es)",aetna,HMO,O,611.12,97.50,348.34,647.78,366.67
1857,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83735,cpt,Magnesium Level,aetna,Medicare Part A,O,65.11,6.70,35.63,46.07,8.04
1858,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0762,revCode,Specialty Services Observation Hours,aetna,Medicare Part B,I,15.11,4.72,10.23,10.23,9.07
1859,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96402,cpt,Hormonal Anti-Neoplastic Chemotherapy Administration Beneath The Skin Or Into Muscle,aetna,Medicare Part B,O,125.04,21.31,71.27,71.27,75.02
1860,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna,EPO,O,145.10,26.57,41.28,89.17,49.54
1861,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0269,cpt,"Placement Of Occlusive Device Into Either A Venous Or Arterial Access Site, Post Surgical Or Interventional Procedure (E.G., Angioseal Plug, Vascular Plug)",aetna,HMO,O,67707.99,403.09,4389.98,14226.92,40624.79
1862,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78815,cpt,Nuclear Medicine Study From Skull Base To Mid-Thigh With CT Scan,aetna,Medicare Part A,O,7116.42,1311.00,3893.89,5657.55,4269.85
1863,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87591,cpt,"Detection Test By Nucleic Acid For Neisseria Gonorrhoeae (Gonorrhoeae Bacteria), Amplified Probe Technique",aetna,Medicare Part B,O,147.58,21.05,82.44,110.69,42.11
1864,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,186,ms-drg,Pleural Effusion With MCC,aetna,POS,I,29279.58,9460.85,9734.76,9734.76,17567.75
1865,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9503,cpt,"Technetium Tc-99m Medronate, Diagnostic, Per Study Dose, Up To 30 Millicuries",aetna,PPO,O,212.36,61.08,121.05,130.93,127.42
1866,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77334,cpt,"Radiation Treatment Devices, Design And Construction, Complex",aetna,PPO,O,599.32,299.94,327.93,327.93,359.94
1867,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78815,cpt,Nuclear Medicine Study From Skull Base To Mid-Thigh With CT Scan,aetna,EPO,O,7116.42,1311.00,3893.89,5657.55,4269.85
1868,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna,Medicare Part B,E,3350.06,336.55,1455.60,2095.51,2010.04
1869,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,193,ms-drg,Simple Pneumonia And Pleurisy With MCC,aetna,POS,I,28945.31,6804.78,18583.72,18583.72,17367.19
1870,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80069,cpt,Kidney Function Blood Test Panel,aetna,PPO,O,67.58,8.51,38.52,38.52,10.42
1871,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5117,cpt,"Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg",aetna,HMO,O,285.60,38.03,46.31,88.21,171.36
1872,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna,HMO,O,1654.04,96.51,942.80,984.47,115.81
1873,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82652,cpt,"Dihydroxyvitamin D, 1, 25 Level",aetna,POS,O,221.79,38.50,126.42,166.34,46.20
1874,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,Medicare Part A,O,1881.00,160.85,162.47,936.63,1128.60
1875,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99153,cpt,"Use Of A Drug To Induce Depression Of Consciousness By Physician Performing A Procedure, Each Additional 15 Minutes",aetna,Medicare Part B,O,47.19,6.59,27.37,47.19,28.31
1876,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna,Medicare Part A,O,2882.19,203.81,1577.05,2291.34,244.57
1877,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88304,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately Low Complexity",aetna,PPO,O,212.36,44.07,116.20,200.34,127.42
1878,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9306,cpt,"Injection, Pertuzumab, 1 Mg",aetna,HMO,O,44.82,10.05,14.64,424.56,26.89
1879,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2710,cpt,"Injection, Neostigmine Methylsulfate, Up To 0.5 Mg",aetna,Medicare Part A,O,4.65,0.15,0.15,4.27,2.79
1880,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80048,cpt,"Blood Test, Basic Group Of Blood Chemicals (Calcium, Total)",aetna,EPO,O,70.06,8.30,38.34,49.58,10.15
1881,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94640,cpt,Respiratory Inhaled Pressure Or Nonpressure Treatment To Relieve Airway Obstruction Or For Sputum Specimen,aetna,Medicare Part A,O,198.78,56.02,185.11,185.11,119.27
1882,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9443,cpt,"Lactation Classes, Non-Physician Provider, Per Session",aetna,POS,O,155.82,92.26,92.26,155.82,93.49
1883,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85597,cpt,Platelet Function Test,aetna,POS,O,89.65,9.41,51.10,67.24,21.58
1884,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73523,cpt,"X-Ray Of Both Hips With Pelvis, Minimum Of 5 Views",aetna,Medicaid,O,636.63,58.51,384.65,536.48,115.81
1885,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,Medicaid,I,2882.19,650.30,2882.19,2882.19,1729.31
1886,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna,EPO,O,271.34,80.51,148.47,215.72,96.61
1887,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2370,cpt,"Injection, Phenylephrine Hcl, Up To 1 Ml",aetna,Medicare Part A,O,87.77,23.91,40.37,66.01,52.66
1888,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86235,cpt,"Measurement Of Antibody For Assessment Of Autoimmune Disorder, Any Method",aetna,Medicare Part B,O,43.81,6.19,24.97,30.69,21.52
1889,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0330,cpt,"Injection, Succinylcholine Chloride, Up To 20 Mg",aetna,Medicaid,O,97.93,26.00,44.25,73.44,58.76
1890,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna,Medicare Part A,O,188.09,38.65,107.21,141.02,112.85
1891,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43239,cpt,"Biopsy Of Esophagus, Stomach, And/Or Upper Small Bowel Using A Flexible Endoscope",aetna,POS,O,4254.12,439.90,1990.82,4844.32,1282.14
1892,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93458,cpt,Insertion Of Catheter In Left Heart For Imaging Of Blood Vessels And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna,HMO,O,25037.36,2421.03,5730.96,15138.17,15022.42
1893,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5117,cpt,"Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg",aetna,PPO,O,285.60,38.03,46.31,88.21,171.36
1894,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86709,cpt,Measurement Of Hepatitis A Antibody (Igm),aetna,Medicare Part A,O,106.28,11.21,60.58,60.58,63.77
1895,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0343,revCode,"Nuclear Medicine, Diagnostic Radiopharmaceuticals",aetna,PPO,O,692.52,123.81,394.74,1192.32,415.51
1896,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9552,cpt,"Fluorodeoxyglucose F-18 Fdg, Diagnostic, Per Study Dose, Up To 45 Millicuries",aetna,EPO,O,1552.58,289.56,849.53,1645.73,931.55
1897,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11102,cpt,"Biopsy Of Related Skin Growth, First Growth",aetna,POS,O,1042.00,159.01,160.97,708.35,625.20
1898,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96361,cpt,"Infusion Into A Vein For Hydration, Each Additional Hour",aetna,EPO,O,58.98,10.31,33.62,44.24,35.39
1899,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72072,cpt,"X-Ray Of Middle Spine, 3 Views",aetna,Medicaid,O,356.28,33.86,199.02,249.40,116.30
1900,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0882,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (For Esrd On Dialysis)",aetna,Medicare Part B,O,16.51,7.43,7.43,7.43,9.91
1901,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77373,cpt,Stereotactic Body Radiation Therapy 1 Or More Lesions Using Imaging Guidance,aetna,Medicaid,O,4368.52,843.53,2639.46,2639.46,1842.56
1902,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna,EPO,O,2882.19,203.81,1577.05,2291.34,244.57
1903,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,PPO,I,1884.10,527.05,1030.93,1360.64,1130.46
1904,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77417,cpt,Therapeutic Radiology Port Films,aetna,Medicare Part A,O,37.84,21.95,21.95,28.66,9.54
1905,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86376,cpt,Microsomal Antibodies (Autoantibody) Measurement,aetna,POS,O,90.15,12.00,21.95,21.95,17.46
1906,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,HMO,O,479.00,41.29,159.02,1803.87,287.40
1907,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0138,cpt,"Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (Non-Esrd Use)",aetna,EPO,O,4.45,0.69,0.93,1.82,2.67
1908,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92611,cpt,Fluoroscopic And Video Recorded Motion Evaluation Of Swallowing Function,aetna,POS,O,328.90,87.83,190.76,190.76,197.34
1909,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9503,cpt,"Technetium Tc-99m Medronate, Diagnostic, Per Study Dose, Up To 30 Millicuries",aetna,Medicaid,O,212.36,61.08,121.05,130.93,127.42
1910,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84484,cpt,"Troponin (Protein) Analysis, Quantitative",aetna,Medicaid,O,80.09,12.47,29.46,56.67,14.96
1911,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87147,cpt,"Identification Of Organisms By Immunologic Analysis, Other Than Immunofluorescence Method",aetna,HMO,O,25.94,5.18,5.18,19.46,6.22
1912,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84403,cpt,"Testosterone (Hormone) Level, Total",aetna,PPO,O,135.66,25.30,77.33,101.75,30.97
1913,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87510,cpt,"Detection Test For Gardnerella Vaginalis (Bacteria), Direct Probe Technique",aetna,Medicare Part B,O,107.59,12.03,58.87,104.55,24.06
1914,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86147,cpt,Cardiolipin Antibody (Tissue Antibody) Measurement,aetna,Medicaid,O,330.33,25.55,188.29,247.75,30.54
1915,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96417,cpt,Infusion Of Different Chemotherapy Drug Or Substance Into A Vein Up To 1 Hour,aetna,Medicaid,O,241.84,54.88,132.33,181.38,145.10
1916,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11042,cpt,Removal Of Skin And Tissue First 20 Sq Cm Or Less,aetna,POS,O,1315.41,306.28,624.03,3179.32,789.25
1917,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93571,cpt,"Ultrasound Evaluation Of Heart Blood Vessel During Diagnosis Or Treatment, Initial Vessel",aetna,Medicaid,O,31969.64,4389.98,14191.44,14191.44,19181.78
1918,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64484,cpt,"Injections Of Anesthetic And/Or Steroid Drug Into Lower Or Sacral Spine Nerve Root Using Imaging Guidance, Each Additional Level",aetna,Medicare Part B,O,12936.37,728.40,7904.05,7904.05,7761.82
1919,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0482,revCode,"Cardiology, Stress Test",aetna,Medicare Part B,O,474.26,84.78,270.33,377.03,284.56
1920,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85027,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test",aetna,Medicare Part A,O,56.26,6.34,30.79,39.81,7.76
1921,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74174,cpt,CT Scan Of Blood Vessels Of Abdomen And Pelvis With Contrast,aetna,Medicare Part B,O,1736.62,326.01,329.84,497.16,391.22
1922,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna,POS,O,356.28,61.44,194.95,194.95,213.77
1923,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0481,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,Medicare Part A,O,315.99,155.10,155.10,156.59,189.59
1924,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86695,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 1",aetna,EPO,O,89.65,13.19,49.06,67.24,15.83
1925,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86147,cpt,Cardiolipin Antibody (Tissue Antibody) Measurement,aetna,Medicare Part B,O,330.33,25.55,188.29,247.75,30.54
1926,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85379,cpt,"Coagulation Function Measurement, D-Dimer; Quantitative",aetna,Medicare Part A,O,122.56,9.98,71.08,71.08,12.22
1927,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,812,ms-drg,Red Blood Cell Disorders Without MCC,aetna,Medicare Part A,I,18593.40,4553.02,5996.54,8936.86,11156.04
1928,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5103,cpt,"Injection, Infliximab-Dyyb, Biosimilar, (Inflectra), 10 Mg",aetna,Medicare Part A,O,114.15,40.05,51.37,114.15,68.49
1929,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86800,cpt,Thyroglobulin (Thyroid Protein) Antibody Measurement,aetna,HMO,O,71.96,14.53,40.56,40.56,19.09
1930,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81003,cpt,Automated Urinalysis Test,aetna,POS,O,13.80,2.25,7.55,9.77,2.70
1931,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87427,cpt,Detection Test By Immunoassay Technique For Shiga-Like Toxin (Bacterial Toxin),aetna,PPO,O,60.03,6.75,34.22,34.22,14.38
1932,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,872,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours Without MCC,aetna,PPO,I,20748.35,5256.97,6524.49,9809.76,12449.01
1933,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86787,cpt,Analysis For Antibody To Varicella-Zoster Virus (Chicken Pox),aetna,EPO,O,53.08,6.47,29.05,39.81,15.46
1934,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82728,cpt,Ferritin (Blood Protein) Level,aetna,Medicaid,O,84.93,11.67,46.48,84.93,16.36
1935,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0121,cpt,Colorectal Cancer Screening; Colonoscopy On Individual Not Meeting Criteria For High Risk,aetna,Medicare Part B,O,3036.82,702.86,1604.70,2259.70,1822.09
1936,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70543,cpt,"MRI Scan Of Bone Of Eye Socket, Face, And/Or Neck Before And After Contrast",aetna,Medicaid,O,2110.61,326.01,1213.60,1213.60,1266.37
1937,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12032,cpt,"Repair Of Wound (2.6 To 7.5 Centimeters) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna,Medicare Part A,O,3063.00,309.74,309.74,3849.84,1837.80
1938,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A4565,cpt,Slings; Medical And Surgical Supplies - Various Medical Supplies Including Tapes And Surgical Dressings,aetna,Medicare Part B,O,21.33,6.00,7.91,29.48,12.80
1939,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97140,cpt,"Manual (Physical) Therapy Techniques To 1 Or More Regions, Each 15 Minutes",aetna,Medicare Part A,O,232.41,20.93,103.49,164.45,139.45
1940,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86706,cpt,Hepatitis B Surface Antibody Measurement,aetna,Medicare Part A,O,94.38,6.44,52.72,70.79,12.89
1941,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1030,cpt,"Injection, Methylprednisolone Acetate, 40 Mg",aetna,EPO,O,93.27,42.90,42.90,65.77,55.96
1942,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3480,cpt,"Injection, Potassium Chloride, Per 2 Meq",aetna,PPO,O,2.35,0.80,1.02,1.02,1.41
1943,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,287,ms-drg,"Circulatory Disorders Except Ami, With Cardiac Catheterization Without MCC",aetna,Medicaid,I,39655.14,7316.35,7333.25,13218.75,23793.08
1944,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80074,cpt,Acute Hepatitis Panel,aetna,PPO,O,213.87,26.66,117.03,117.03,57.16
1945,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84100,cpt,Phosphate Level,aetna,POS,O,40.11,4.74,13.80,13.80,5.69
1946,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna,PPO,O,120.33,10.08,65.84,90.25,20.16
1947,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna,POS,O,91.30,14.35,49.96,64.61,54.78
1948,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84112,cpt,Cervicovaginal Secretion Of Placenta Protein,aetna,Medicare Part B,O,243.07,29.33,29.33,243.07,49.58
1949,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76536,cpt,Ultrasound Scan Of Head And Neck Soft Tissue,aetna,Medicare Part B,O,491.96,96.50,269.19,391.10,295.18
1950,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80053,cpt,"Blood Test, Comprehensive Group Of Blood Chemicals",aetna,Medicaid,O,91.30,10.35,49.96,68.47,12.67
1951,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83498,cpt,"Hydroxyprogesterone, 17-D (Synthetic Hormone) Level",aetna,POS,O,126.23,20.54,69.07,69.07,75.74
1952,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,HMO,I,218.25,67.65,124.40,224.80,130.95
1953,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9045,cpt,"Injection, Carboplatin, 50 Mg",aetna,Medicare Part B,O,16.51,2.82,2.82,4.53,9.91
1954,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,59025,cpt,Fetal Non-Stress Test,aetna,POS,O,250.10,17.49,145.06,176.96,150.06
1955,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,193,ms-drg,Simple Pneumonia And Pleurisy With MCC,aetna,EPO,I,28945.31,6804.78,18583.72,18583.72,17367.19
1956,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36600,cpt,Arterial Puncture Withdrawal Of Blood For Diagnosis,aetna,POS,O,179.32,34.87,147.18,147.18,107.59
1957,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83880,cpt,Natriuretic Peptide (Heart And Blood Vessel Protein) Level,aetna,POS,O,130.11,25.90,39.26,92.07,47.11
1958,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9045,cpt,"Injection, Carboplatin, 50 Mg",aetna,EPO,O,16.51,2.82,2.82,4.53,9.91
1959,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64636,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Each Additional Facet Joint",aetna,HMO,O,7088.87,1523.14,4237.46,4237.46,4253.32
1960,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna,Medicare Part B,O,1654.04,96.51,942.80,984.47,115.81
1961,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96366,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Each Additional Hour",aetna,Medicare Part B,O,307.18,19.72,178.16,178.16,184.31
1962,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64721,cpt,Release And/Or Relocation Of Median Nerve Of Hand,aetna,POS,O,15304.77,1553.71,8031.11,8031.11,9182.86
1963,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19120,cpt,"Removal Of 1 Or More Breast Growth, Open Procedure",aetna,HMO,O,19283.58,2826.79,11249.61,11249.61,3355.94
1964,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9299,cpt,"Injection, Nivolumab, 1 Mg",aetna,Medicaid,O,107.35,13.51,28.82,29.25,64.41
1965,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9228,cpt,"Injection, Ipilimumab, 1 Mg",aetna,HMO,O,588.70,104.49,157.23,157.23,353.22
1966,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87086,cpt,"Bacterial Colony Count, Urine",aetna,POS,O,71.96,7.91,39.38,53.97,9.68
1967,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82550,cpt,"Creatine Kinase (Cardiac Enzyme) Level, Total",aetna,EPO,O,60.16,6.44,33.61,33.61,7.81
1968,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97162,cpt,"Evaluation For Physical Therapy, Typically 30 Minutes",aetna,PPO,O,224.82,58.86,123.02,136.58,134.89
1969,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36010,cpt,Introduction Of Catheter Into The Upper Or Lower Major Vein (Vena Cava),aetna,Medicaid,I,37979.62,17796.08,17796.08,17796.08,22787.77
1970,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9601,cpt,"Percutaneous Transcatheter Placement Of Drug-Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery (List Separately In Addition To",aetna,Medicaid,O,71354.64,14191.44,14191.44,14191.44,42812.78
1971,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna,Medicare Part A,O,36.32,4.21,20.29,27.24,5.15
1972,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86376,cpt,Microsomal Antibodies (Autoantibody) Measurement,aetna,PPO,O,90.15,12.00,21.95,21.95,17.46
1973,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,32408,cpt,"Core Needle Biopsy Of Lung Or Center Cavity Of Chest (Mediastinum), Accessed Through Skin",aetna,PPO,O,3883.82,638.16,1248.81,1248.81,2330.29
1974,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86900,cpt,Blood Group Typing (ABO),aetna,Medicaid,O,126.23,11.17,71.95,99.15,118.98
1975,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83615,cpt,Lactate Dehydrogenase (Enzyme) Level,aetna,PPO,O,50.72,6.04,28.91,70.62,7.25
1976,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9299,cpt,"Injection, Nivolumab, 1 Mg",aetna,POS,O,107.35,13.51,28.82,29.25,64.41
1977,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64450,cpt,Injection Of Anesthetic Agent And/Or Steroid Into Other Peripheral Nerve Or Branch,aetna,Medicaid,O,1533.00,1587.94,12436.52,12436.52,919.80
1978,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87205,cpt,Special Gram Or Giemsa Stain For Microorganism,aetna,HMO,O,87.53,4.18,4.25,65.65,5.12
1979,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83735,cpt,Magnesium Level,aetna,PPO,O,65.11,6.70,35.63,46.07,8.04
1980,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,46255,cpt,Removal Of Single External And Internal Hemorrhoid Group,aetna,POS,O,17900.37,2210.31,9939.29,9939.29,10740.22
1981,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85384,cpt,Fibrinogen (Factor 1) Activity Measurement,aetna,Medicare Part A,O,89.70,9.63,54.20,54.20,11.66
1982,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77417,cpt,Therapeutic Radiology Port Films,aetna,EPO,O,37.84,21.95,21.95,28.66,9.54
1983,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0331,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration - Injection,aetna,Medicaid,O,270.45,26.27,71.27,513.21,162.27
1984,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0341,revCode,"Nuclear Medicine, Diagnostic",aetna,EPO,O,5568.56,800.20,3046.95,5465.13,3341.14
1985,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77386,cpt,"Intensity Modulated Radiation Therapy Delivery, Complex",aetna,HMO,O,2383.15,480.50,1303.99,1303.99,576.60
1986,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72110,cpt,"X-Ray Of Lower And Sacral Spine, Minimum Of 4 Views",aetna,HMO,O,613.48,46.08,335.68,365.14,115.81
1987,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87186,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or Agar Dilution",aetna,Medicare Part A,O,47.53,6.92,8.65,35.65,10.38
1988,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,885,ms-drg,Psychoses,aetna,Medicaid,I,17080.81,5566.92,6861.23,9301.98,10248.49
1989,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83036,cpt,Hemoglobin A1c Level,aetna,POS,O,76.68,5.83,41.96,57.51,11.65
1990,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0943,revCode,Medical Rehabilitation Day Program Cardiac Rehabilitation,aetna,PPO,O,173.89,102.78,102.79,369.10,104.33
1991,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85652,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Automated",aetna,HMO,O,38.92,2.65,21.30,29.59,3.24
1992,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86709,cpt,Measurement Of Hepatitis A Antibody (Igm),aetna,Medicaid,O,106.28,11.21,60.58,60.58,63.77
1993,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9060,cpt,"Injection, Cisplatin, Powder Or Solution, 10 Mg",aetna,Medicaid,O,7.79,1.85,1.85,2.82,4.67
1994,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna,POS,O,95.71,16.18,16.18,21.31,19.42
1995,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0612,revCode,Magnetic Resonance Technology (Mrt) Spinal Cord/Spine,aetna,Medicare Part A,O,2882.19,203.81,1642.85,2100.47,1729.31
1996,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88177,cpt,"Pap Test, Evaluation Of Fine Needle Aspirate, Immediate, Each Additional Evaluation Episode",aetna,Medicaid,O,49.54,26.22,93.48,93.48,29.72
1997,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0131,cpt,"Injection, Acetaminophen, 10 Mg",aetna,PPO,O,1.46,0.18,0.65,1.44,0.88
1998,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,P9040,cpt,"Red Blood Cells, Leukocytes Reduced, Irradiated, Each Unit",aetna,EPO,O,756.23,260.55,262.76,509.61,453.74
1999,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97035,cpt,"Application Of Ultrasound To 1 Or More Areas, Each 15 Minutes",aetna,EPO,O,106.18,10.67,46.92,46.92,63.71
2000,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87641,cpt,"Detection Test By Nucleic Acid For Staphylococcus Aureus, Methicillin Resistant (Mrsa Bacteria), Amplified Probe Technique",aetna,EPO,O,90.84,13.32,51.78,64.28,42.11
2001,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78816,cpt,Nuclear Medicine Study With CT Imaging Whole Body,aetna,HMO,O,7556.48,1311.05,1311.05,2704.61,4533.89
2002,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72202,cpt,"X-Ray Of Joint Between Lower Spine And Hip Bone, 3 Or More Views",aetna,Medicare Part B,O,252.47,26.87,145.17,166.73,151.48
2003,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99213,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes",aetna,EPO,O,270.16,52.43,153.99,211.73,162.10
2004,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna,EPO,O,120.33,10.08,65.84,90.25,20.16
2005,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna,POS,I,25207.44,6812.39,8243.81,14290.40,15124.46
2006,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83615,cpt,Lactate Dehydrogenase (Enzyme) Level,aetna,HMO,O,50.72,6.04,28.91,70.62,7.25
2007,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83880,cpt,Natriuretic Peptide (Heart And Blood Vessel Protein) Level,aetna,PPO,O,130.11,25.90,39.26,92.07,47.11
2008,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,Medicare Part A,I,490.78,103.68,279.74,347.25,294.47
2009,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7050,cpt,"Infusion, Normal Saline Solution, 250 Cc",aetna,Medicare Part B,O,157.33,71.59,71.59,118.00,94.40
2010,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,EPO,I,45.29,12.02,38.30,59.57,27.17
2011,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9145,cpt,"Injection, Daratumumab, 10 Mg",aetna,HMO,O,87.92,56.29,56.29,56.29,52.75
2012,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82652,cpt,"Dihydroxyvitamin D, 1, 25 Level",aetna,HMO,O,221.79,38.50,126.42,166.34,46.20
2013,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna,HMO,I,1307.77,398.79,745.43,8974.67,784.66
2014,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64635,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Single Facet Joint",aetna,EPO,O,7086.24,1523.14,4237.46,4237.46,4251.74
2015,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0720,revCode,Labor Room/Delivery General,aetna,EPO,I,141.69,33.03,82.08,5123.48,85.01
2016,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87301,cpt,Detection Test By Immunoassay Technique For Adenovirus Enteric Types 40/41,aetna,Medicare Part B,O,60.03,6.75,34.52,34.52,14.38
2017,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99211,cpt,Office Or Other Outpatient Visit For The Evaluation And Management Of Established Patient That May Not Require Presence Of Healthcare Professional,aetna,Medicare Part A,O,91.30,29.79,52.04,190.38,54.78
2018,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99212,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 10 Minutes",aetna,Medicare Part B,O,180.14,52.17,102.68,135.10,108.08
2019,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73140,cpt,"X-Ray Of Fingers, Minimum Of 2 Views",aetna,Medicare Part B,O,226.51,61.44,131.38,131.38,85.98
2020,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna,POS,O,1956.07,299.94,1070.30,1213.17,359.94
2021,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36561,cpt,"Insertion Of Central Venous Catheter And Implanted Device For Infusion Beneath The Skin, Patient 5 Years Or Older",aetna,Medicare Part B,O,18382.66,2534.31,2589.99,17974.64,11029.60
2022,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84100,cpt,Phosphate Level,aetna,PPO,O,40.11,4.74,13.80,13.80,5.69
2023,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33235,cpt,Removal Of Dual Electrodes From Right Heart,aetna,EPO,O,21468.71,3610.13,3610.13,3610.13,12881.23
2024,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2250,cpt,"Injection, Midazolam Hydrochloride, Per 1 Mg",aetna,Medicaid,O,41.06,10.28,18.48,41.06,24.64
2025,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85732,cpt,"Coagulation Assessment Blood Test, Substitution, Plasma Fractions",aetna,Medicare Part A,O,35.39,3.71,20.17,26.54,7.76
2026,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86480,cpt,"Tuberculosis Test, Gamma Interferon",aetna,Medicare Part B,O,350.39,35.31,199.72,262.79,74.38
2027,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93571,cpt,"Ultrasound Evaluation Of Heart Blood Vessel During Diagnosis Or Treatment, Initial Vessel",aetna,EPO,O,31969.64,4389.98,14191.44,14191.44,19181.78
2028,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7040,cpt,"Infusion, Normal Saline Solution, Sterile (500 Ml = 1 Unit)",aetna,Medicaid,O,157.91,58.43,71.06,157.91,94.75
2029,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna,HMO,O,70.06,8.01,39.93,52.55,9.80
2030,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84550,cpt,"Uric Acid Level, Blood",aetna,Medicaid,O,50.01,4.52,29.01,79.60,5.42
2031,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna,EPO,O,116.31,19.19,63.64,84.77,23.26
2032,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,20680,cpt,Removal Of Deep Implant From Bone,aetna,HMO,O,21223.25,2098.90,12436.52,12436.52,12733.95
2033,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,Medicaid,I,268.98,56.00,329.15,795.98,161.39
2034,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82310,cpt,"Calcium Level, Total",aetna,Medicare Part B,O,36.61,5.16,5.16,36.61,21.97
2035,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0283,cpt,"Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound Care, As Part Of A Therapy Plan Of Care",aetna,POS,O,93.19,9.47,40.58,93.19,55.91
2036,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96413,cpt,"Administration Of Chemotherapy Into Vein, 1 Hour Or Less",aetna,Medicaid,O,516.73,113.98,282.74,387.55,310.04
2037,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97113,cpt,"Water Pool Therapy With Therapeutic Exercises To 1 Or More Areas, Each 15 Minutes",aetna,EPO,O,132.12,28.83,54.93,62.54,79.27
2038,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86141,cpt,"Measurement C-Reactive Protein For Detection Of Infection Or Inflammation, High Sensitivity",aetna,Medicare Part B,O,138.33,7.77,7.77,13.00,15.54
2039,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85027,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test",aetna,Medicare Part B,O,56.26,6.34,30.79,39.81,7.76
2040,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71270,cpt,CT Scan Of Chest Before And After Contrast,aetna,EPO,O,2554.21,161.61,161.61,161.61,192.38
2041,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0421,revCode,Physical Therapy Visit Charge,aetna,POS,O,173.42,23.17,76.68,1195.53,104.05
2042,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,689,ms-drg,Kidney And Urinary Tract Infections With MCC,aetna,HMO,I,22796.06,6348.25,8547.01,9085.55,13677.64
2043,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0260,revCode,Intravenous (Iv) Therapy,aetna,EPO,O,325.61,56.09,185.60,1926.96,195.37
2044,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna,Medicare Part B,I,1307.77,398.79,745.43,8974.67,784.66
2045,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52260,cpt,Dilation Of The Bladder Using An Endoscope Under General Or Spinal Anesthesia,aetna,Medicare Part B,O,14589.65,1578.66,8790.54,8790.54,8753.79
2046,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9306,cpt,"Injection, Pertuzumab, 1 Mg",aetna,POS,O,44.82,10.05,14.64,424.56,26.89
2047,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,PPO,I,710.22,207.44,407.05,747.97,426.13
2048,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0341,revCode,"Nuclear Medicine, Diagnostic",aetna,HMO,O,5568.56,800.20,3046.95,5465.13,3341.14
2049,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83002,cpt,"Gonadotropin, Luteinizing (Reproductive Hormone) Level",aetna,HMO,O,250.10,18.52,142.56,187.58,22.22
2050,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77386,cpt,"Intensity Modulated Radiation Therapy Delivery, Complex",aetna,Medicare Part A,O,2383.15,480.50,1303.99,1303.99,576.60
2051,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,300,ms-drg,Peripheral Vascular Disorders With CC,aetna,Medicaid,I,19902.20,6642.09,6642.09,11743.17,11941.32
2052,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0138,cpt,"Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (Non-Esrd Use)",aetna,POS,O,4.45,0.69,0.93,1.82,2.67
2053,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11042,cpt,Removal Of Skin And Tissue First 20 Sq Cm Or Less,aetna,PPO,O,1315.41,306.28,624.03,3179.32,789.25
2054,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,Medicare Part B,I,58214.47,42815.71,42815.71,42815.71,34928.68
2055,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83002,cpt,"Gonadotropin, Luteinizing (Reproductive Hormone) Level",aetna,Medicare Part B,O,250.10,18.52,142.56,187.58,22.22
2056,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97162,cpt,"Evaluation For Physical Therapy, Typically 30 Minutes",aetna,Medicare Part B,O,224.82,58.86,123.02,136.58,134.89
2057,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0331,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration - Injection,aetna,POS,O,270.45,26.27,71.27,513.21,162.27
2058,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0771,revCode,"Preventive Care Services, Vaccine Administration",aetna,Medicare Part B,O,820.44,35.43,512.23,512.23,492.26
2059,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84402,cpt,"Testosterone (Hormone) Level, Free",aetna,HMO,O,70.78,13.11,38.73,53.09,30.56
2060,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0279,cpt,"Diagnostic Digital Breast Tomosynthesis, Unilateral Or Bilateral (List Separately In Addition To 77065 Or 77066)",aetna,Medicaid,O,120.33,22.38,69.79,95.66,72.20
2061,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0124,revCode,Room And Board Semiprivate (Two Beds) Psychiatric,aetna,HMO,I,2075.74,728.48,728.48,1347.17,1245.44
2062,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7120,cpt,"Ringers Lactate Infusion, Up To 1000 Cc",aetna,PPO,O,162.48,32.42,74.74,162.48,97.49
2063,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna,Medicaid,O,2144.07,645.60,1279.68,2047.58,1286.44
2064,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77373,cpt,Stereotactic Body Radiation Therapy 1 Or More Lesions Using Imaging Guidance,aetna,Medicare Part B,O,4368.52,843.53,2639.46,2639.46,1842.56
2065,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,812,ms-drg,Red Blood Cell Disorders Without MCC,aetna,EPO,I,18593.40,4553.02,5996.54,8936.86,11156.04
2066,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,HMO,I,2452.75,716.49,1897.41,2313.92,1471.65
2067,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93225,cpt,Electrocardiogram (Ecg) 2-Day Continuous,aetna,EPO,O,251.28,64.70,119.50,199.77,150.77
2068,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83498,cpt,"Hydroxyprogesterone, 17-D (Synthetic Hormone) Level",aetna,Medicare Part A,O,126.23,20.54,69.07,69.07,75.74
2069,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97110,cpt,"Therapeutic Exercise To Develop Strength, Endurance, Range Of Motion, And Flexibility, Each 15 Minutes",aetna,EPO,O,173.42,23.35,77.46,114.70,29.09
2070,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0171,cpt,"Injection, Adrenalin, Epinephrine, 0.1 Mg",aetna,Medicare Part B,O,5.83,0.23,2.68,2.68,3.50
2071,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70490,cpt,CT Scan Of Soft Tissue Of Neck Without Contrast,aetna,PPO,O,1267.08,96.50,693.31,693.31,760.25
2072,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,Medicare Part A,O,30.08,3.64,57.64,96.59,18.05
2073,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0283,cpt,"Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound Care, As Part Of A Therapy Plan Of Care",aetna,HMO,O,93.19,9.47,40.58,93.19,55.91
2074,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2250,cpt,"Injection, Midazolam Hydrochloride, Per 1 Mg",aetna,PPO,O,41.06,10.28,18.48,41.06,24.64
2075,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5101,cpt,"Injection, Filgrastim-Sndz, Biosimilar, (Zarxio), 1 Microgram",aetna,Medicare Part B,O,1.85,0.17,0.35,0.35,1.11
2076,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73030,cpt,"X-Ray Of Shoulder, Minimum Of 2 Views",aetna,HMO,O,252.47,45.52,143.91,176.73,151.48
2077,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82525,cpt,Copper Level,aetna,POS,O,71.96,9.63,39.38,39.38,14.89
2078,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna,PPO,O,226.51,61.44,126.53,160.27,135.91
2079,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2405,cpt,"Injection, Ondansetron Hydrochloride, Per 1 Mg",aetna,Medicaid,O,19.54,1.76,8.78,19.52,11.72
2080,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86900,cpt,Blood Group Typing (ABO),aetna,PPO,O,126.23,11.17,71.95,99.15,118.98
2081,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,690,ms-drg,Kidney And Urinary Tract Infections Without MCC,aetna,PPO,I,16840.52,3735.53,9339.74,9339.74,10104.31
2082,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82746,cpt,"Folic Acid Level, Serum",aetna,Medicaid,O,65.11,9.14,37.11,37.11,17.64
2083,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna,Medicaid,E,3350.06,336.55,1455.60,2095.51,2010.04
2084,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,Medicare Part B,O,30.08,3.64,57.64,96.59,18.05
2085,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33430,cpt,Replacement Of Valve Between Left Upper And Lower Chambers On Heart-Lung Machine,aetna,Medicaid,I,207801.54,46497.02,46497.02,46497.02,124680.92
2086,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1200,cpt,"Injection, Diphenhydramine Hcl, Up To 50 Mg",aetna,EPO,O,3.52,0.76,18.38,80.35,2.11
2087,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74018,cpt,"X-Ray Of Abdomen, 1 View",aetna,Medicare Part A,O,268.98,61.44,147.18,285.11,85.98
2088,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86709,cpt,Measurement Of Hepatitis A Antibody (Igm),aetna,POS,O,106.28,11.21,60.58,60.58,63.77
2089,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97018,cpt,Application Of Hot Wax Bath To 1 Or More Areas,aetna,Medicaid,O,79.04,3.64,32.08,34.45,47.42
2090,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94060,cpt,"Measurement And Graphic Recording Of The Amount And Speed Of Breathed Air, Before And Following Medication Administration",aetna,EPO,O,422.68,78.29,218.19,239.44,253.61
2091,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9601,cpt,"Percutaneous Transcatheter Placement Of Drug-Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery (List Separately In Addition To",aetna,EPO,O,71354.64,14191.44,14191.44,14191.44,42812.78
2092,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64484,cpt,"Injections Of Anesthetic And/Or Steroid Drug Into Lower Or Sacral Spine Nerve Root Using Imaging Guidance, Each Additional Level",aetna,PPO,O,12936.37,728.40,7904.05,7904.05,7761.82
2093,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52260,cpt,Dilation Of The Bladder Using An Endoscope Under General Or Spinal Anesthesia,aetna,Medicare Part A,O,14589.65,1578.66,8790.54,8790.54,8753.79
2094,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77080,cpt,"Bone Density Measurement Of The Core Or Central Skeleton (E.G., Hips, Pelvis, Spine)",aetna,PPO,O,352.74,96.51,201.06,249.59,115.81
2095,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna,EPO,O,1654.04,96.51,942.80,984.47,115.81
2096,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36591,cpt,Collection Of Blood Specimen From A Completely Implantable Venous Access Device,aetna,HMO,O,172.23,13.59,102.02,102.02,103.34
2097,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78070,cpt,Nuclear Medicine Study Of Parathyroid,aetna,HMO,O,1314.27,400.84,749.13,749.13,788.56
2098,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,Medicare Part A,I,268.98,56.00,329.15,795.98,161.39
2099,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,HMO,I,2882.19,290.04,2229.62,2229.62,1729.31
2100,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,PPO,O,1775.23,260.44,1248.81,1902.32,1065.14
2101,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88300,cpt,"Pathology Examination Of Tissue Using A Microscope, Limited Examination",aetna,Medicare Part A,O,93.19,27.95,50.99,50.99,55.91
2102,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74178,cpt,CT Scan Of Abdomen And Pelvis Before And After Contrast,aetna,EPO,O,4577.54,2.93,2609.20,3536.15,391.22
2103,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0510,revCode,Clinic General,aetna,PPO,O,167.48,51.31,51.31,289.51,100.49
2104,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76881,cpt,Complete Ultrasound Scan Of Joint,aetna,Medicare Part B,O,379.88,96.50,216.53,216.53,227.93
2105,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84403,cpt,"Testosterone (Hormone) Level, Total",aetna,EPO,O,135.66,25.30,77.33,101.75,30.97
2106,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45378,cpt,Diagnostic Colonoscopy Of Large Bowel Using A Flexible Endoscope,aetna,POS,O,3131.25,717.01,1860.41,2251.40,861.59
2107,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82784,cpt,Gammaglobulin (Immune System Protein) Measurement,aetna,Medicare Part A,O,65.66,9.30,9.30,52.19,11.16
2108,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86780,cpt,"Analysis For Antibody, Treponema Pallidum",aetna,Medicare Part A,O,331.50,12.98,188.96,248.62,198.90
2109,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5115,cpt,"Injection, Rituximab-Abbs, Biosimilar, (Truxima), 10 Mg",aetna,Medicare Part A,O,218.36,61.56,68.50,163.77,131.02
2110,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84166,cpt,"Protein Measurement, Body Fluid",aetna,Medicare Part B,O,57.87,6.77,17.83,17.90,21.40
2111,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,638,ms-drg,Diabetes With CC,aetna,Medicare Part A,I,20621.27,4023.89,8833.24,8833.24,12372.76
2112,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9144,cpt,"Injection, Daratumumab, 10 Mg And Hyaluronidase-Fihj",aetna,POS,O,139.92,43.18,45.07,45.65,83.95
2113,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82140,cpt,Ammonia Level,aetna,EPO,O,108.53,13.90,59.39,59.39,17.48
2114,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97166,cpt,"Evaluation For Occupational Therapy, Typically 45 Minutes",aetna,Medicare Part A,O,265.44,85.51,151.30,163.25,159.26
2115,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,236,ms-drg,Coronary Bypass Without Cardiac Catheterization Without MCC,aetna,POS,I,156904.89,23866.31,23891.99,44284.10,94142.93
2116,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88300,cpt,"Pathology Examination Of Tissue Using A Microscope, Limited Examination",aetna,Medicare Part B,O,93.19,27.95,50.99,50.99,55.91
2117,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0482,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,Medicare Part B,O,315.99,78.44,78.44,208.68,189.59
2118,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43235,cpt,"Diagnostic Examination Of Esophagus, Stomach, And/Or Upper Small Bowel Using An Endoscope",aetna,POS,O,3132.69,724.55,1758.22,2956.79,1171.78
2119,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86480,cpt,"Tuberculosis Test, Gamma Interferon",aetna,HMO,O,350.39,35.31,199.72,262.79,74.38
2120,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94729,cpt,Test To Examine How Well The Lungs Exchange Gases,aetna,Medicare Part B,O,218.25,52.60,119.42,119.42,130.95
2121,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77334,cpt,"Radiation Treatment Devices, Design And Construction, Complex",aetna,POS,O,599.32,299.94,327.93,327.93,359.94
2122,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86735,cpt,Analysis For Antibody To Mumps Virus,aetna,Medicare Part B,O,50.01,7.59,27.36,35.01,30.01
2123,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96411,cpt,Administration Of Additional New Drug Or Substance Into Vein Using Push Technique,aetna,Medicaid,O,238.30,49.47,130.40,178.73,142.98
2124,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,812,ms-drg,Red Blood Cell Disorders Without MCC,aetna,HMO,I,18593.40,4553.02,5996.54,8936.86,11156.04
2125,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,EPO,I,1747.84,436.13,970.89,1375.11,1048.70
2126,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86765,cpt,Analysis For Antibody To Rubeola (Measles Virus),aetna,POS,O,50.01,7.69,55.32,55.32,30.01
2127,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93970,cpt,Ultrasound Scan Of Veins Of Both Arms Or Legs Including Assessment Of Compression And Functional Maneuvers,aetna,POS,O,1047.64,203.81,415.78,773.81,628.58
2128,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna,PPO,O,982.00,159.01,162.47,1222.94,589.20
2129,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86850,cpt,Screening Test For Red Blood Cell Antibodies,aetna,Medicare Part B,O,93.19,8.25,53.12,67.92,53.95
2130,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43244,cpt,Tying Of Dilated Veins Of Stomach And/Or Esophagus Using A Flexible Endoscope,aetna,Medicare Part A,O,4323.48,1441.59,1441.59,1469.46,2594.09
2131,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88331,cpt,"Pathology Examination Of Specimen During Surgery, First Tissue Block",aetna,POS,O,438.52,153.98,254.34,254.34,263.11
2132,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0710,revCode,Recovery Room General,aetna,HMO,O,3506.08,933.94,2267.67,2982.15,2103.65
2133,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64450,cpt,Injection Of Anesthetic Agent And/Or Steroid Into Other Peripheral Nerve Or Branch,aetna,POS,O,1533.00,1587.94,12436.52,12436.52,919.80
2134,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,811,ms-drg,Red Blood Cell Disorders With MCC,aetna,Medicare Part B,I,34462.34,8519.29,8897.14,15450.42,20677.40
2135,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0612,revCode,Magnetic Resonance Technology (Mrt) Spinal Cord/Spine,aetna,EPO,O,2882.19,203.81,1642.85,2100.47,1729.31
2136,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71270,cpt,CT Scan Of Chest Before And After Contrast,aetna,Medicare Part A,O,2554.21,161.61,161.61,161.61,192.38
2137,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5115,cpt,"Injection, Rituximab-Abbs, Biosimilar, (Truxima), 10 Mg",aetna,Medicaid,O,218.36,61.56,68.50,163.77,131.02
2138,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna,HMO,O,50.01,3.11,27.36,66.28,6.22
2139,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,Medicare Part B,O,490.78,263.76,343.76,353.36,294.47
2140,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36598,cpt,Contrast Injections For X-Ray Imaging Procedure To Evaluate Central Venous Access Device,aetna,PPO,O,1156.30,162.25,585.00,585.00,693.78
2141,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0771,revCode,"Preventive Care Services, Vaccine Administration",aetna,POS,O,820.44,35.43,512.23,512.23,492.26
2142,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49402,cpt,Removal Of Foreign Body From Abdominal Cavity,aetna,Medicare Part B,O,42363.98,24397.19,24397.19,24397.19,25418.39
2143,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88175,cpt,"Pap Test, Automated Thin Layer Preparation; Automated System And Manual Rescreening",aetna,POS,O,83.33,0.35,47.50,60.74,31.93
2144,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,HMO,O,2882.19,207.14,1577.05,2666.05,1729.31
2145,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9500,cpt,"Technetium Tc-99m Sestamibi, Diagnostic, Per Study Dose",aetna,Medicaid,O,692.52,114.53,394.74,734.07,415.51
2146,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83540,cpt,Iron Level,aetna,Medicare Part A,O,41.28,6.35,23.53,41.28,7.76
2147,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0120,revCode,Room And Board Semiprivate (Two Beds) General,aetna,Medicare Part B,I,1274.16,366.55,685.17,6328.83,764.50
2148,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95811,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab With Continued Pressured Respiratory Assistance By Mask Or Breathing Tube,aetna,POS,O,3186.58,814.60,1816.35,1816.35,1911.95
2149,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82728,cpt,Ferritin (Blood Protein) Level,aetna,POS,O,84.93,11.67,46.48,84.93,16.36
2150,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84165,cpt,"Protein Measurement, Serum",aetna,Medicare Part A,O,116.79,10.63,10.74,82.64,12.89
2151,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77080,cpt,"Bone Density Measurement Of The Core Or Central Skeleton (E.G., Hips, Pelvis, Spine)",aetna,Medicare Part B,O,352.74,96.51,201.06,249.59,115.81
2152,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85049,cpt,"Platelet Count, Automated Test",aetna,Medicaid,O,36.32,4.39,4.39,9.15,5.38
2153,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna,POS,O,148.64,18.79,18.79,22.56,22.55
2154,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86696,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 2",aetna,Medicaid,O,126.23,19.24,69.07,94.67,23.22
2155,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94726,cpt,Determination Of Lung Volumes Using Plethysmography,aetna,Medicare Part B,O,501.40,116.04,274.35,274.35,300.84
2156,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9145,cpt,"Injection, Daratumumab, 10 Mg",aetna,POS,O,87.92,56.29,56.29,56.29,52.75
2157,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87480,cpt,"Detection Test For Candida Species (Yeast), Direct Probe Technique",aetna,POS,O,107.59,12.03,58.87,80.69,24.06
2158,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna,EPO,O,2535.33,203.81,1416.20,1958.54,244.57
2159,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76999,cpt,Other Ultrasound Procedure,aetna,EPO,O,238.30,71.65,130.40,216.32,142.98
2160,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87536,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Quantification",aetna,HMO,O,519.10,67.96,295.89,295.89,311.46
2161,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5101,cpt,"Injection, Filgrastim-Sndz, Biosimilar, (Zarxio), 1 Microgram",aetna,Medicaid,O,1.85,0.17,0.35,0.35,1.11
2162,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,HMO,O,33.76,8.03,18.27,694.79,20.26
2163,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,190,ms-drg,Chronic Obstructive Pulmonary Disease With MCC,aetna,HMO,I,21678.10,5783.22,5783.22,12966.75,13006.86
2164,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82306,cpt,Vitamin D-3 Level,aetna,EPO,O,101.33,21.15,57.76,63.19,35.52
2165,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84144,cpt,Progesterone (Reproductive Hormone) Level,aetna,Medicare Part A,O,101.45,17.03,55.51,71.78,25.03
2166,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87491,cpt,"Detection Test By Nucleic Acid For Chlamydia Trachomatis, Amplified Probe Technique",aetna,EPO,O,147.58,21.05,82.44,110.69,42.11
2167,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,EPO,I,218.25,67.65,124.40,224.80,130.95
2168,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43235,cpt,"Diagnostic Examination Of Esophagus, Stomach, And/Or Upper Small Bowel Using An Endoscope",aetna,PPO,O,3132.69,724.55,1758.22,2956.79,1171.78
2169,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36598,cpt,Contrast Injections For X-Ray Imaging Procedure To Evaluate Central Venous Access Device,aetna,Medicaid,O,1156.30,162.25,585.00,585.00,693.78
2170,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17003,cpt,"Destruction Of Precancer Skin Growth, 2-14 Growths",aetna,Medicaid,O,982.00,159.01,162.47,1222.94,589.20
2171,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3475,cpt,"Injection, Magnesium Sulfate, Per 500 Mg",aetna,HMO,O,4.45,1.00,2.05,2.05,2.67
2172,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66991,cpt,Extracapsular Removal Of Cataract With Insertion Of Artificial Lens And Insertion Of Drainage Device In Front Chamber Of Eye,aetna,Medicare Part A,O,8752.90,3729.66,3729.66,3765.43,5251.74
2173,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A4565,cpt,Slings; Medical And Surgical Supplies - Various Medical Supplies Including Tapes And Surgical Dressings,aetna,PPO,O,21.33,6.00,7.91,29.48,12.80
2174,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73720,cpt,MRI Scan Of Leg Before And After Contrast,aetna,Medicaid,O,2882.19,326.01,1671.67,1671.67,1729.31
2175,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76830,cpt,Ultrasound Pelvis Through Vagina,aetna,Medicaid,O,795.16,96.50,435.09,632.15,115.81
2176,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,57522,cpt,Removal Or Destruction Of Cervix With Electrical Cautery,aetna,HMO,O,18168.39,2323.14,10911.60,10911.60,10901.03
2177,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64483,cpt,"Injection Of Anesthetic And/Or Steroid Drug Into Sacral Spine Nerve Root Using Imaging Guidance, Single Level",aetna,Medicare Part B,O,2134.28,1064.77,4498.33,4498.33,1311.13
2178,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11044,cpt,Removal Of Skin And Bone First 20 Sq Cm Or Less,aetna,HMO,O,3769.31,1215.96,1260.27,2751.80,2261.59
2179,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,10005,cpt,"Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth",aetna,Medicaid,O,2422.63,555.63,1193.41,1567.18,1453.58
2180,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,PPO,I,268.98,56.00,329.15,795.98,161.39
2181,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43244,cpt,Tying Of Dilated Veins Of Stomach And/Or Esophagus Using A Flexible Endoscope,aetna,PPO,O,4323.48,1441.59,1441.59,1469.46,2594.09
2182,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86480,cpt,"Tuberculosis Test, Gamma Interferon",aetna,PPO,O,350.39,35.31,199.72,262.79,74.38
2183,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99282,cpt,Emergency Department Visit For Problem Of Mild To Moderate Severity,aetna,PPO,E,276.06,99.19,160.11,290.62,165.64
2184,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87181,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Agar Dilution Method",aetna,HMO,O,16.51,4.75,9.41,9.41,3.37
2185,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2765,cpt,"Injection, Metoclopramide Hcl, Up To 10 Mg",aetna,Medicare Part A,O,79.57,18.17,36.60,79.57,47.74
2186,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,EPO,O,58.98,6.19,15.24,1399.28,35.39
2187,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88309,cpt,"Pathology Examination Of Tissue Using A Microscope, High Complexity",aetna,EPO,O,696.07,273.94,396.76,396.76,417.64
2188,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1170,cpt,"Injection, Hydromorphone, Up To 4 Mg",aetna,Medicare Part B,O,82.88,16.96,38.12,82.88,49.73
2189,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna,POS,E,3350.06,336.55,1455.60,2095.51,2010.04
2190,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85651,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Non-Automated",aetna,POS,O,13.00,1.77,4.25,4.68,7.80
2191,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C8908,cpt,"Magnetic Resonance Imaging Without Contrast Followed By With Contrast, Breast; Bilateral",aetna,HMO,O,3010.79,326.02,1716.15,1716.15,1806.47
2192,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73720,cpt,MRI Scan Of Leg Before And After Contrast,aetna,POS,O,2882.19,326.01,1671.67,1671.67,1729.31
2193,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88175,cpt,"Pap Test, Automated Thin Layer Preparation; Automated System And Manual Rescreening",aetna,PPO,O,83.33,0.35,47.50,60.74,31.93
2194,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,POS,O,1775.23,260.44,1248.81,1902.32,1065.14
2195,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97140,cpt,"Manual (Physical) Therapy Techniques To 1 Or More Regions, Each 15 Minutes",aetna,PPO,O,232.41,20.93,103.49,164.45,139.45
2196,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73218,cpt,MRI Scan Of Arm Without Contrast,aetna,EPO,O,2882.19,206.00,1642.85,2719.05,1729.31
2197,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83880,cpt,Natriuretic Peptide (Heart And Blood Vessel Protein) Level,aetna,Medicare Part A,O,130.11,25.90,39.26,92.07,47.11
2198,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2505,cpt,"Injection, Pegfilgrastim, 6 Mg",aetna,PPO,O,17508.60,2251.51,6955.90,6955.90,10505.16
2199,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82652,cpt,"Dihydroxyvitamin D, 1, 25 Level",aetna,Medicare Part B,O,221.79,38.50,126.42,166.34,46.20
2200,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11103,cpt,"Biopsy Of Related Skin Growth, Each Additional Growth",aetna,Medicare Part A,O,1126.00,160.53,161.01,647.00,675.60
2201,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86787,cpt,Analysis For Antibody To Varicella-Zoster Virus (Chicken Pox),aetna,POS,O,53.08,6.47,29.05,39.81,15.46
2202,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71101,cpt,"X-Ray Of Ribs On One Side Of Body Including The Chest, Minimum Of 3 Views",aetna,Medicare Part A,O,356.28,61.44,203.08,203.08,115.81
2203,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86780,cpt,"Analysis For Antibody, Treponema Pallidum",aetna,Medicaid,O,331.50,12.98,188.96,248.62,198.90
2204,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86360,cpt,"T Cell Count And Ratio, Including Ratio",aetna,PPO,O,220.61,31.37,125.75,125.75,132.37
2205,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11401,cpt,"Removal Of Growth (0.6 To 1.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,PPO,O,4292.00,309.74,309.74,2167.15,2575.20
2206,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83550,cpt,Iron Binding Capacity,aetna,Medicare Part B,O,106.28,8.57,60.58,106.28,10.49
2207,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36600,cpt,Arterial Puncture Withdrawal Of Blood For Diagnosis,aetna,PPO,O,179.32,34.87,147.18,147.18,107.59
2208,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna,Medicare Part A,O,271.34,80.51,148.47,215.72,96.61
2209,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna,HMO,O,142.89,8.03,64.15,113.59,16.07
2210,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96413,cpt,"Administration Of Chemotherapy Into Vein, 1 Hour Or Less",aetna,Medicare Part B,O,516.73,113.98,282.74,387.55,310.04
2211,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9202,cpt,"Goserelin Acetate Implant, Per 3.6 Mg",aetna,Medicare Part B,O,1210.44,149.56,581.30,581.30,726.26
2212,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,EPO,I,281.58,60.08,199.37,281.58,168.95
2213,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82950,cpt,Blood Glucose (Sugar) Level After Receiving Dose Of Glucose,aetna,EPO,O,38.92,4.70,21.30,75.94,5.70
2214,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87081,cpt,Screening Test For Pathogenic Organisms,aetna,Medicaid,O,45.06,3.98,25.68,32.84,9.19
2215,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82962,cpt,Blood Glucose (Sugar) Test Performed By Hand-Held Instrument,aetna,Medicare Part A,O,42.58,3.28,24.27,42.58,3.94
2216,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,POS,O,8.83,1.76,5.12,26.77,5.30
2217,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0333,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Radiation Therapy,aetna,POS,O,933.20,214.04,481.06,1795.20,559.92
2218,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64483,cpt,"Injection Of Anesthetic And/Or Steroid Drug Into Sacral Spine Nerve Root Using Imaging Guidance, Single Level",aetna,Medicaid,O,2134.28,1064.77,4498.33,4498.33,1311.13
2219,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74175,cpt,CT Scan Of Blood Vessels Of Abdomen With Contrast,aetna,HMO,O,1737.39,158.13,158.13,1841.63,1042.43
2220,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70220,cpt,"X-Ray Of Paranasal Sinus, Complete, Minimum Of 3 Views",aetna,Medicare Part B,O,342.13,47.22,195.01,271.99,205.28
2221,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94729,cpt,Test To Examine How Well The Lungs Exchange Gases,aetna,Medicaid,O,218.25,52.60,119.42,119.42,130.95
2222,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2150,cpt,"Injection, Mannitol, 25% In 50 Ml",aetna,POS,O,8.02,2.82,3.58,3.58,4.81
2223,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85027,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test",aetna,HMO,O,56.26,6.34,30.79,39.81,7.76
2224,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,Medicare Part B,O,33.76,8.03,18.27,694.79,20.26
2225,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11042,cpt,Removal Of Skin And Tissue First 20 Sq Cm Or Less,aetna,HMO,O,1315.41,306.28,624.03,3179.32,789.25
2226,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72110,cpt,"X-Ray Of Lower And Sacral Spine, Minimum Of 4 Views",aetna,PPO,O,613.48,46.08,335.68,365.14,115.81
2227,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0771,revCode,"Preventive Care Services, Vaccine Administration",aetna,PPO,O,820.44,35.43,512.23,512.23,492.26
2228,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74420,cpt,Imaging Of Urinary Tract Following Injection Of A Contrast Agent,aetna,POS,O,1007.53,278.97,574.29,574.29,253.90
2229,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0500,cpt,"Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care Professional Performing A Gastrointestinal Endoscopic Service That Sedation Supports, Requiring The Presence Of",aetna,POS,O,47.19,27.14,27.14,47.19,28.31
2230,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna,PPO,O,145.10,26.57,41.28,89.17,49.54
2231,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87205,cpt,Special Gram Or Giemsa Stain For Microorganism,aetna,POS,O,87.53,4.18,4.25,65.65,5.12
2232,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,871,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours With MCC,aetna,HMO,I,36297.45,7941.64,11794.58,17432.39,21778.47
2233,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17110,cpt,"Destruction Of Skin Growth, 1-14 Growths",aetna,Medicare Part B,O,958.00,159.01,159.02,479.00,574.80
2234,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82550,cpt,"Creatine Kinase (Cardiac Enzyme) Level, Total",aetna,Medicaid,O,60.16,6.44,33.61,33.61,7.81
2235,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73080,cpt,"X-Ray Of Elbow, Minimum Of 3 Views",aetna,Medicare Part A,O,294.94,49.66,168.12,168.12,176.96
2236,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,776,ms-drg,Postpartum And Post Abortion Diagnoses Without O.R. Procedures,aetna,POS,I,14400.00,2525.16,5439.38,9082.13,8640.00
2237,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86777,cpt,Analysis For Antibody To Toxoplasma (Parasite),aetna,POS,O,152.18,14.25,86.74,86.74,91.31
2238,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9354,cpt,"Injection, Ado-Trastuzumab Emtansine, 1 Mg",aetna,Medicare Part A,O,123.87,25.63,36.89,41.57,74.32
2239,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73030,cpt,"X-Ray Of Shoulder, Minimum Of 2 Views",aetna,Medicare Part B,O,252.47,45.52,143.91,176.73,151.48
2240,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0283,cpt,"Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound Care, As Part Of A Therapy Plan Of Care",aetna,Medicaid,O,93.19,9.47,40.58,93.19,55.91
2241,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82390,cpt,Ceruloplasmin (Protein) Level,aetna,Medicaid,O,71.96,6.02,39.38,39.38,43.18
2242,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70553,cpt,MRI Scan Of Brain Before And After Contrast,aetna,HMO,O,3824.84,25.27,2092.84,3040.75,391.22
2243,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17110,cpt,"Destruction Of Skin Growth, 1-14 Growths",aetna,POS,O,958.00,159.01,159.02,479.00,574.80
2244,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86780,cpt,"Analysis For Antibody, Treponema Pallidum",aetna,HMO,O,331.50,12.98,188.96,248.62,198.90
2245,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,064,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With MCC,aetna,Medicare Part B,I,42514.90,11561.36,11613.14,15935.29,25508.94
2246,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97035,cpt,"Application Of Ultrasound To 1 Or More Areas, Each 15 Minutes",aetna,HMO,O,106.18,10.67,46.92,46.92,63.71
2247,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17270,cpt,"Destruction Of Malignant Growth (0.5 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,PPO,O,1881.00,159.01,159.94,475.20,1128.60
2248,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna,EPO,O,176.96,19.79,96.59,99.98,106.18
2249,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,330,ms-drg,Major Small And Large Bowel Procedures With CC,aetna,POS,I,58731.07,15126.82,15186.72,23610.09,35238.64
2250,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2150,cpt,"Injection, Mannitol, 25% In 50 Ml",aetna,PPO,O,8.02,2.82,3.58,3.58,4.81
2251,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74178,cpt,CT Scan Of Abdomen And Pelvis Before And After Contrast,aetna,PPO,O,4577.54,2.93,2609.20,3536.15,391.22
2252,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17280,cpt,"Destruction Of Malignant Growth (0.5 Centimeters Or Less) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,HMO,O,1569.00,159.01,162.47,542.48,941.40
2253,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43450,cpt,Dilation Of Esophagus Unguided,aetna,EPO,O,3778.61,1075.52,1753.96,3815.86,2267.17
2254,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74175,cpt,CT Scan Of Blood Vessels Of Abdomen With Contrast,aetna,EPO,O,1737.39,158.13,158.13,1841.63,1042.43
2255,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87340,cpt,Detection Test By Immunoassay Technique For Hepatitis B Surface Antigen,aetna,Medicare Part A,O,80.09,7.09,45.65,60.07,12.40
2256,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66984,cpt,"Removal Of Cataract With Insertion Of Lens, Simple",aetna,PPO,O,14664.91,1841.26,3839.82,4337.53,8798.95
2257,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86147,cpt,Cardiolipin Antibody (Tissue Antibody) Measurement,aetna,EPO,O,330.33,25.55,188.29,247.75,30.54
2258,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77338,cpt,Design And Construction Of Radiation Treatment Device For High Precision Radiation Therapy,aetna,HMO,O,2028.03,299.94,1109.68,1109.68,359.94
2259,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70450,cpt,CT Of Head Without Contrast,aetna,EPO,O,2452.75,96.51,1398.07,1839.56,115.81
2260,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85014,cpt,Red Blood Cell Concentration Measurement,aetna,Medicare Part B,O,28.77,2.35,16.40,21.58,2.84
2261,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0124,revCode,Room And Board Semiprivate (Two Beds) Psychiatric,aetna,Medicare Part A,I,2075.74,728.48,728.48,1347.17,1245.44
2262,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0276,revCode,Medical/Surgical Supplies And Devices Intracular Lens,aetna,Medicare Part A,O,797.52,202.98,270.86,797.52,478.51
2263,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11102,cpt,"Biopsy Of Related Skin Growth, First Growth",aetna,Medicaid,O,1042.00,159.01,160.97,708.35,625.20
2264,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92921,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Single Artery Or Branch",aetna,Medicare Part A,O,71846.71,8777.72,8894.43,14120.90,43108.03
2265,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna,Medicare Part A,O,70.06,8.01,39.93,52.55,9.80
2266,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76816,cpt,"Ultrasound Re-Evaluation Of Pregnant Uterus, Per Fetus",aetna,POS,O,611.12,96.51,348.34,432.40,366.67
2267,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna,PPO,O,52.60,6.47,8.08,42.46,9.70
2268,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86300,cpt,"Immunologic Analysis For Detection Of Tumor Antigen, Quantitative; Ca 15-3",aetna,PPO,O,85.70,20.40,51.78,90.84,24.97
2269,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0881,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (Non-Esrd Use)",aetna,EPO,O,15.58,2.38,7.43,7.43,9.35
2270,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99211,cpt,Office Or Other Outpatient Visit For The Evaluation And Management Of Established Patient That May Not Require Presence Of Healthcare Professional,aetna,Medicare Part B,O,91.30,29.79,52.04,190.38,54.78
2271,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0114,revCode,Room And Board Private (One Bed) Psychiatric,aetna,Medicaid,I,2200.28,629.26,1203.93,7562.58,1320.17
2272,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76700,cpt,"Ultrasound Of Abdomen, Complete",aetna,Medicare Part B,O,970.94,96.51,542.36,771.89,116.30
2273,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95811,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab With Continued Pressured Respiratory Assistance By Mask Or Breathing Tube,aetna,HMO,O,3186.58,814.60,1816.35,1816.35,1911.95
2274,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,483,ms-drg,Major Joint Or Limb Reattachment Procedures Of Upper Extremities,aetna,Medicaid,I,77640.79,14258.73,14814.57,23206.53,46584.47
2275,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86430,cpt,Rheumatoid Factor Analysis,aetna,Medicaid,O,42.58,6.10,14.72,31.94,7.37
2276,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88313,cpt,Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,aetna,Medicaid,O,119.15,45.38,67.92,67.92,71.49
2277,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70543,cpt,"MRI Scan Of Bone Of Eye Socket, Face, And/Or Neck Before And After Contrast",aetna,PPO,O,2110.61,326.01,1213.60,1213.60,1266.37
2278,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85018,cpt,"Blood Count, Hemoglobin",aetna,Medicare Part A,O,33.02,2.35,18.82,24.77,2.84
2279,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,POS,I,2882.19,290.04,2229.62,2229.62,1729.31
2280,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86141,cpt,"Measurement C-Reactive Protein For Detection Of Infection Or Inflammation, High Sensitivity",aetna,EPO,O,138.33,7.77,7.77,13.00,15.54
2281,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,603,ms-drg,Cellulitis Without MCC,aetna,HMO,I,19499.58,3283.09,5672.80,12955.93,11699.75
2282,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96361,cpt,"Infusion Into A Vein For Hydration, Each Additional Hour",aetna,PPO,O,58.98,10.31,33.62,44.24,35.39
2283,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76816,cpt,"Ultrasound Re-Evaluation Of Pregnant Uterus, Per Fetus",aetna,Medicare Part A,O,611.12,96.51,348.34,432.40,366.67
2284,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87510,cpt,"Detection Test For Gardnerella Vaginalis (Bacteria), Direct Probe Technique",aetna,Medicare Part A,O,107.59,12.03,58.87,104.55,24.06
2285,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87480,cpt,"Detection Test For Candida Species (Yeast), Direct Probe Technique",aetna,EPO,O,107.59,12.03,58.87,80.69,24.06
2286,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73522,cpt,"X-Ray Of Both Hips With Pelvis, 3-4 Views",aetna,Medicaid,O,355.11,58.62,194.31,194.31,213.07
2287,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96523,cpt,Irrigation Of Implanted Venous Access Drug Delivery Device,aetna,HMO,O,192.29,49.29,109.61,144.22,115.37
2288,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86850,cpt,Screening Test For Red Blood Cell Antibodies,aetna,HMO,O,93.19,8.25,53.12,67.92,53.95
2289,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0114,revCode,Room And Board Private (One Bed) Psychiatric,aetna,EPO,I,2200.28,629.26,1203.93,7562.58,1320.17
2290,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73502,cpt,"X-Ray Of Hip With Pelvis, 2-3 Views",aetna,Medicare Part B,O,213.53,40.67,121.71,169.76,85.98
2291,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87186,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or Agar Dilution",aetna,Medicaid,O,47.53,6.92,8.65,35.65,10.38
2292,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86430,cpt,Rheumatoid Factor Analysis,aetna,Medicare Part A,O,42.58,6.10,14.72,31.94,7.37
2293,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73502,cpt,"X-Ray Of Hip With Pelvis, 2-3 Views",aetna,Medicaid,O,213.53,40.67,121.71,169.76,85.98
2294,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82375,cpt,Carboxyhemoglobin (Protein) Level,aetna,PPO,O,103.50,12.32,60.03,77.63,14.78
2295,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82306,cpt,Vitamin D-3 Level,aetna,Medicaid,O,101.33,21.15,57.76,63.19,35.52
2296,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2632,cpt,"Post Chmbr Intraocular Lens; Prosthetics, Orthotics, And Supplies",aetna,Medicare Part A,O,797.52,202.98,270.86,797.52,478.51
2297,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77295,cpt,"Management Of Radiation Therapy, 3d",aetna,Medicare Part B,O,1926.57,1003.61,1098.14,1531.62,1341.41
2298,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81050,cpt,Urine Volume Measurement,aetna,EPO,O,30.08,3.64,17.15,22.56,4.37
2299,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82627,cpt,Dehydroepiandrosterone (Dhea-S) Hormone Level,aetna,Medicare Part A,O,119.15,19.46,67.92,67.92,71.49
2300,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93970,cpt,Ultrasound Scan Of Veins Of Both Arms Or Legs Including Assessment Of Compression And Functional Maneuvers,aetna,EPO,O,1047.64,203.81,415.78,773.81,628.58
2301,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1437,cpt,"Injection, Ferric Derisomaltose, 10 Mg",aetna,PPO,O,80.56,14.43,25.38,25.82,48.34
2302,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84466,cpt,Transferrin (Iron Binding Protein) Level,aetna,POS,O,67.24,10.47,36.80,36.80,40.34
2303,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0942,revCode,Medical Rehabilitation Day Program Education/Training,aetna,EPO,O,155.82,64.63,92.26,117.54,93.49
2304,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80074,cpt,Acute Hepatitis Panel,aetna,Medicare Part B,O,213.87,26.66,117.03,117.03,57.16
2305,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96374,cpt,"Injection Of Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,POS,O,218.25,39.35,154.75,181.39,130.95
2306,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11103,cpt,"Biopsy Of Related Skin Growth, Each Additional Growth",aetna,POS,O,1126.00,160.53,161.01,647.00,675.60
2307,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27328,cpt,Removal (Less Than 5 Centimeters) Muscle Growth Of Thigh Or Knee,aetna,HMO,O,23211.17,12578.62,12578.62,12578.62,13926.70
2308,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36600,cpt,Arterial Puncture Withdrawal Of Blood For Diagnosis,aetna,Medicare Part B,O,179.32,34.87,147.18,147.18,107.59
2309,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3480,cpt,"Injection, Potassium Chloride, Per 2 Meq",aetna,Medicare Part A,O,2.35,0.80,1.02,1.02,1.41
2310,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95811,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab With Continued Pressured Respiratory Assistance By Mask Or Breathing Tube,aetna,Medicaid,O,3186.58,814.60,1816.35,1816.35,1911.95
2311,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81003,cpt,Automated Urinalysis Test,aetna,HMO,O,13.80,2.25,7.55,9.77,2.70
2312,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,POS,O,63819.96,8894.43,14191.44,29488.15,38291.98
2313,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,POS,O,218.25,35.37,121.91,263.09,130.95
2314,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73130,cpt,"X-Ray Of Hand, Minimum Of 3 Views",aetna,Medicare Part A,O,329.15,46.08,180.10,261.67,197.49
2315,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83021,cpt,"Hemoglobin Analysis And Measurement, Chromatography",aetna,EPO,O,130.95,16.12,71.65,71.65,21.67
2316,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82565,cpt,Blood Creatinine Level,aetna,EPO,O,30.08,4.82,17.15,30.08,6.14
2317,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,HMO,O,654.73,185.98,323.41,694.53,392.84
2318,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83550,cpt,Iron Binding Capacity,aetna,Medicaid,O,106.28,8.57,60.58,106.28,10.49
2319,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28080,cpt,Removal Of Fibrous Nerve Growth From Between Toes,aetna,EPO,O,17456.96,1200.71,9928.29,9928.29,10474.18
2320,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86778,cpt,Analysis For Antibody (Igm) To Toxoplasma (Parasite),aetna,Medicaid,O,152.18,14.27,86.74,86.74,91.31
2321,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,23472,cpt,"Prosthetic Repair Of Shoulder Joint, Total Shoulder",aetna,PPO,I,123346.27,14814.57,14814.57,14814.57,74007.76
2322,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,Medicaid,I,2882.19,290.04,2229.62,2229.62,1729.31
2323,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83021,cpt,"Hemoglobin Analysis And Measurement, Chromatography",aetna,HMO,O,130.95,16.12,71.65,71.65,21.67
2324,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,Medicare Part A,I,1495.87,276.63,903.80,903.80,897.52
2325,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72197,cpt,MRI Scan Of Pelvis Before And After Contrast,aetna,PPO,O,2882.19,326.01,329.84,2161.64,391.22
2326,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86038,cpt,Screening Test For Autoimmune Disorder,aetna,EPO,O,105.06,0.47,36.51,45.12,14.51
2327,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,EPO,I,2452.75,716.49,1897.41,2313.92,1471.65
2328,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97597,cpt,"Removal Of Tissue From Wounds Per Session, First 20 Sq Cms Or Less",aetna,Medicare Part A,O,596.96,89.68,159.02,159.02,358.18
2329,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93452,cpt,Insertion Of Tube In Left Heart Chambers For Diagnosis With Review By Radiologist,aetna,EPO,I,54103.79,7333.25,7333.25,7333.25,32462.27
2330,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna,Medicaid,O,1884.10,427.65,1030.93,1413.08,1130.46
2331,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0500,cpt,"Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care Professional Performing A Gastrointestinal Endoscopic Service That Sedation Supports, Requiring The Presence Of",aetna,PPO,O,47.19,27.14,27.14,47.19,28.31
2332,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,Medicare Part B,I,216.65,43.99,86.21,184.92,129.99
2333,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73070,cpt,"X-Ray Of Elbow, 2 Views",aetna,Medicaid,O,238.30,35.12,143.98,143.98,142.98
2334,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84550,cpt,"Uric Acid Level, Blood",aetna,Medicare Part A,O,50.01,4.52,29.01,79.60,5.42
2335,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0008,cpt,Administration Of Influenza Virus Vaccine,aetna,Medicare Part A,O,99.09,11.08,35.43,35.43,42.52
2336,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87641,cpt,"Detection Test By Nucleic Acid For Staphylococcus Aureus, Methicillin Resistant (Mrsa Bacteria), Amplified Probe Technique",aetna,Medicare Part B,O,90.84,13.32,51.78,64.28,42.11
2337,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37230,cpt,"Insertion Of Stents Into Artery In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna,Medicare Part B,I,262831.76,27743.68,27743.68,27743.68,157699.06
2338,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11104,cpt,Punch Biopsy Of Single Skin Lesion,aetna,Medicare Part B,O,2056.68,306.29,1669.70,3042.91,1234.01
2339,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99204,cpt,"New Patient Office Or Other Outpatient Visit, 45-59 Minutes",aetna,Medicaid,O,634.41,49.54,367.96,475.81,223.37
2340,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12032,cpt,"Repair Of Wound (2.6 To 7.5 Centimeters) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna,HMO,O,3063.00,309.74,309.74,3849.84,1837.80
2341,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna,Medicare Part B,O,4073.77,814.60,2322.05,3238.64,977.56
2342,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73502,cpt,"X-Ray Of Hip With Pelvis, 2-3 Views",aetna,POS,O,213.53,40.67,121.71,169.76,85.98
2343,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86334,cpt,Immunologic Analysis Technique On Serum (Immunofixation),aetna,EPO,O,132.12,17.37,75.31,99.09,26.81
2344,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84480,cpt,"Thyroid Hormone, T3 Measurement, Total",aetna,PPO,O,60.03,11.72,34.82,34.82,17.02
2345,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85045,cpt,"Red Blood Count, Automated Test",aetna,HMO,O,38.92,2.44,3.98,14.01,4.79
2346,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,20680,cpt,Removal Of Deep Implant From Bone,aetna,PPO,O,21223.25,2098.90,12436.52,12436.52,12733.95
2347,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87491,cpt,"Detection Test By Nucleic Acid For Chlamydia Trachomatis, Amplified Probe Technique",aetna,Medicaid,O,147.58,21.05,82.44,110.69,42.11
2348,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71046,cpt,"X-Ray Of Chest, 2 Views",aetna,HMO,O,344.48,61.44,188.49,273.86,85.98
2349,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82803,cpt,Blood Gases Measurement,aetna,EPO,O,158.08,26.07,86.50,86.50,30.97
2350,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83516,cpt,"Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",aetna,PPO,O,51.31,8.70,30.43,41.58,13.84
2351,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,HMO,I,281.58,60.08,199.37,281.58,168.95
2352,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86762,cpt,Analysis For Antibody To Rubella (German Measles Virus),aetna,HMO,O,50.01,4.42,27.36,37.51,17.10
2353,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9190,cpt,"Injection, Fluorouracil, 500 Mg",aetna,Medicare Part B,O,8.25,1.86,1.89,8.07,4.95
2354,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,853,ms-drg,Infectious And Parasitic Diseases With O.R. Procedures With MCC,aetna,Medicaid,I,131887.09,28277.35,28277.35,59129.81,79132.25
2355,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,Medicaid,I,45.29,12.02,38.30,59.57,27.17
2356,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71046,cpt,"X-Ray Of Chest, 2 Views",aetna,Medicaid,O,344.48,61.44,188.49,273.86,85.98
2357,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12032,cpt,"Repair Of Wound (2.6 To 7.5 Centimeters) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna,Medicaid,O,3063.00,309.74,309.74,3849.84,1837.80
2358,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73620,cpt,"X-Ray Of Foot, 2 Views",aetna,PPO,O,252.47,61.44,143.91,143.91,151.48
2359,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86787,cpt,Analysis For Antibody To Varicella-Zoster Virus (Chicken Pox),aetna,PPO,O,53.08,6.47,29.05,39.81,15.46
2360,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0710,revCode,Recovery Room General,aetna,Medicaid,O,3506.08,933.94,2267.67,2982.15,2103.65
2361,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83540,cpt,Iron Level,aetna,Medicare Part B,O,41.28,6.35,23.53,41.28,7.76
2362,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84480,cpt,"Thyroid Hormone, T3 Measurement, Total",aetna,POS,O,60.03,11.72,34.82,34.82,17.02
2363,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0312,revCode,Laboratory Pathology Histology,aetna,Medicare Part A,O,419.99,131.76,239.39,419.99,251.99
2364,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93458,cpt,Insertion Of Catheter In Left Heart For Imaging Of Blood Vessels And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna,PPO,O,25037.36,2421.03,5730.96,15138.17,15022.42
2365,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88304,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately Low Complexity",aetna,Medicare Part A,O,212.36,44.07,116.20,200.34,127.42
2366,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76816,cpt,"Ultrasound Re-Evaluation Of Pregnant Uterus, Per Fetus",aetna,EPO,O,611.12,96.51,348.34,432.40,366.67
2367,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,300,ms-drg,Peripheral Vascular Disorders With CC,aetna,Medicare Part B,I,19902.20,6642.09,6642.09,11743.17,11941.32
2368,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96375,cpt,"Injection Of Different Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,Medicare Part A,O,88.47,19.71,48.41,66.35,53.08
2369,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92526,cpt,Treatment Of Swallowing And/Or Oral Feeding Function,aetna,Medicaid,O,407.71,81.63,232.39,232.39,244.63
2370,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,Medicare Part A,I,137.36,28.95,90.50,129.04,82.42
2371,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0330,cpt,"Injection, Succinylcholine Chloride, Up To 20 Mg",aetna,EPO,O,97.93,26.00,44.25,73.44,58.76
2372,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0897,cpt,"Injection, Denosumab, 1 Mg",aetna,HMO,O,62.32,12.82,18.35,21.26,37.39
2373,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36010,cpt,Introduction Of Catheter Into The Upper Or Lower Major Vein (Vena Cava),aetna,POS,I,37979.62,17796.08,17796.08,17796.08,22787.77
2374,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93925,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of Both Legs,aetna,HMO,O,726.73,203.81,207.32,359.62,436.04
2375,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5114,cpt,"Injection, Trastuzumab-Dkst, Biosimilar, (Ogivri), 10 Mg",aetna,EPO,O,232.14,60.17,60.17,66.12,139.28
2376,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,Medicaid,O,2882.19,207.14,1577.05,2666.05,1729.31
2377,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43239,cpt,"Biopsy Of Esophagus, Stomach, And/Or Upper Small Bowel Using A Flexible Endoscope",aetna,Medicare Part A,O,4254.12,439.90,1990.82,4844.32,1282.14
2378,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86901,cpt,Blood Typing For Rh (D) Antigen,aetna,EPO,O,83.76,7.41,47.74,83.76,17.09
2379,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,871,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours With MCC,aetna,PPO,I,36297.45,7941.64,11794.58,17432.39,21778.47
2380,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,20680,cpt,Removal Of Deep Implant From Bone,aetna,Medicaid,O,21223.25,2098.90,12436.52,12436.52,12733.95
2381,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93880,cpt,Ultrasound Scanning Of Blood Flow (Outside The Brain) On Both Sides Of Head And Neck,aetna,Medicare Part B,O,711.39,203.81,397.38,397.38,426.83
2382,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,638,ms-drg,Diabetes With CC,aetna,Medicare Part B,I,20621.27,4023.89,8833.24,8833.24,12372.76
2383,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66984,cpt,"Removal Of Cataract With Insertion Of Lens, Simple",aetna,Medicare Part B,O,14664.91,1841.26,3839.82,4337.53,8798.95
2384,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84402,cpt,"Testosterone (Hormone) Level, Free",aetna,Medicare Part A,O,70.78,13.11,38.73,53.09,30.56
2385,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87496,cpt,"Detection Test By Nucleic Acid For Cytomegalovirus (Cmv), Amplified Probe Technique",aetna,Medicare Part A,O,191.11,108.93,108.93,108.93,114.67
2386,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99283,cpt,Emergency Department Visit For Problem Of Moderate Severity,aetna,HMO,E,871.53,205.11,459.97,892.25,522.92
2387,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96374,cpt,"Injection Of Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,Medicare Part B,O,218.25,39.35,154.75,181.39,130.95
2388,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87255,cpt,Virus Isolation,aetna,HMO,O,123.87,33.86,67.78,81.80,40.63
2389,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70450,cpt,CT Of Head Without Contrast,aetna,PPO,O,2452.75,96.51,1398.07,1839.56,115.81
2390,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74246,cpt,X-Ray Of Upper Digestive Tract With Double Contrast,aetna,PPO,O,484.07,158.13,264.87,284.00,189.76
2391,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2405,cpt,"Injection, Ondansetron Hydrochloride, Per 1 Mg",aetna,HMO,O,19.54,1.76,8.78,19.52,11.72
2392,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90686,cpt,"Vaccine For Influenza For Administration Into Muscle, 0.5 Ml Dosage, Quadrivalent, Preservation Free",aetna,HMO,O,132.44,13.48,20.93,79.94,79.46
2393,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,247,ms-drg,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without MCC,aetna,HMO,I,79628.76,11995.52,12110.64,46153.54,47777.26
2394,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9190,cpt,"Injection, Fluorouracil, 500 Mg",aetna,Medicaid,O,8.25,1.86,1.89,8.07,4.95
2395,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0008,cpt,Administration Of Influenza Virus Vaccine,aetna,HMO,O,99.09,11.08,35.43,35.43,42.52
2396,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96366,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Each Additional Hour",aetna,POS,O,307.18,19.72,178.16,178.16,184.31
2397,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73502,cpt,"X-Ray Of Hip With Pelvis, 2-3 Views",aetna,HMO,O,213.53,40.67,121.71,169.76,85.98
2398,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2505,cpt,"Injection, Pegfilgrastim, 6 Mg",aetna,EPO,O,17508.60,2251.51,6955.90,6955.90,10505.16
2399,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97535,cpt,"Training For Self-Care Or Home Management, Each 15 Minutes",aetna,Medicare Part B,O,200.56,25.86,84.86,87.79,120.34
2400,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna,EPO,O,52.60,6.47,8.08,42.46,9.70
2401,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11044,cpt,Removal Of Skin And Bone First 20 Sq Cm Or Less,aetna,POS,O,3769.31,1215.96,1260.27,2751.80,2261.59
2402,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85651,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Non-Automated",aetna,Medicaid,O,13.00,1.77,4.25,4.68,7.80
2403,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73610,cpt,"X-Ray Of Ankle, Minimum Of 3 Views",aetna,Medicare Part B,O,329.15,46.08,180.10,261.67,197.49
2404,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87641,cpt,"Detection Test By Nucleic Acid For Staphylococcus Aureus, Methicillin Resistant (Mrsa Bacteria), Amplified Probe Technique",aetna,POS,O,90.84,13.32,51.78,64.28,42.11
2405,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70490,cpt,CT Scan Of Soft Tissue Of Neck Without Contrast,aetna,Medicare Part B,O,1267.08,96.50,693.31,693.31,760.25
2406,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,HMO,O,711.39,96.53,359.62,479.92,426.83
2407,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92610,cpt,Evaluation Of Swallowing Function,aetna,PPO,O,286.43,81.46,166.13,166.13,171.86
2408,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2765,cpt,"Injection, Metoclopramide Hcl, Up To 10 Mg",aetna,Medicaid,O,79.57,18.17,36.60,79.57,47.74
2409,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3380,cpt,"Injection, Vedolizumab, 1 Mg",aetna,EPO,O,60.64,21.72,28.92,28.92,36.38
2410,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76881,cpt,Complete Ultrasound Scan Of Joint,aetna,Medicaid,O,379.88,96.50,216.53,216.53,227.93
2411,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93289,cpt,"Evaluation Of Defibrillator Including Connection, Recording And Disconnection",aetna,PPO,O,206.45,32.90,115.33,115.33,123.87
2412,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96366,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Each Additional Hour",aetna,PPO,O,307.18,19.72,178.16,178.16,184.31
2413,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna,EPO,O,93.19,18.38,53.12,74.09,55.91
2414,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7050,cpt,"Infusion, Normal Saline Solution, 250 Cc",aetna,Medicare Part A,O,157.33,71.59,71.59,118.00,94.40
2415,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86901,cpt,Blood Typing For Rh (D) Antigen,aetna,POS,O,83.76,7.41,47.74,83.76,17.09
2416,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0640,cpt,"Injection, Leucovorin Calcium, Per 50 Mg",aetna,HMO,O,17.80,3.56,3.56,14.15,10.68
2417,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0401,revCode,Other Imaging Services Diagnostic Mammography,aetna,EPO,O,266.00,50.09,79.04,224.15,159.60
2418,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,POS,O,576.53,96.50,334.39,562.62,345.92
2419,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9171,cpt,"Injection, Docetaxel, 1 Mg",aetna,EPO,O,15.58,0.67,0.67,4.17,9.35
2420,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0124,revCode,Room And Board Semiprivate (Two Beds) Psychiatric,aetna,Medicare Part B,I,2075.74,728.48,728.48,1347.17,1245.44
2421,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,PPO,I,7.39,2.22,3.59,34.05,4.43
2422,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0341,revCode,"Nuclear Medicine, Diagnostic",aetna,PPO,O,5568.56,800.20,3046.95,5465.13,3341.14
2423,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64483,cpt,"Injection Of Anesthetic And/Or Steroid Drug Into Sacral Spine Nerve Root Using Imaging Guidance, Single Level",aetna,Medicare Part A,O,2134.28,1064.77,4498.33,4498.33,1311.13
2424,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86803,cpt,Hepatitis C Antibody Measurement,aetna,Medicare Part A,O,113.25,14.27,64.55,140.68,17.12
2425,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,Medicaid,O,33.76,8.03,18.27,694.79,20.26
2426,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86735,cpt,Analysis For Antibody To Mumps Virus,aetna,HMO,O,50.01,7.59,27.36,35.01,30.01
2427,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,Medicare Part A,I,72.54,19.89,124.91,124.91,43.52
2428,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70487,cpt,CT Scan Of Face With Contrast,aetna,PPO,O,1358.47,810.86,810.86,810.86,815.08
2429,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93970,cpt,Ultrasound Scan Of Veins Of Both Arms Or Legs Including Assessment Of Compression And Functional Maneuvers,aetna,HMO,O,1047.64,203.81,415.78,773.81,628.58
2430,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92610,cpt,Evaluation Of Swallowing Function,aetna,EPO,O,286.43,81.46,166.13,166.13,171.86
2431,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78306,cpt,Nuclear Medicine Study Of Bone And/Or Joint Whole Body,aetna,Medicare Part A,O,848.21,330.97,483.48,522.98,400.79
2432,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0278,revCode,Medical/Surgical Supplies And Devices Other Implants,aetna,Medicare Part A,I,12498.86,118.53,1501.07,6933.25,7499.32
2433,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9579,cpt,"Injection, Gadolinium-Based Magnetic Resonance Contrast Agent, Not Otherwise Specified (Nos), Per Ml",aetna,Medicaid,O,15.32,0.10,6.89,16.23,9.19
2434,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9445,cpt,"Patient Education, Not Otherwise Classified, Non-Physician Provider, Individual, Per Session",aetna,Medicare Part A,O,104.62,78.47,104.62,114.22,62.77
2435,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna,Medicaid,O,251.28,64.70,137.49,266.35,150.77
2436,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,59025,cpt,Fetal Non-Stress Test,aetna,HMO,O,250.10,17.49,145.06,176.96,150.06
2437,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2997,cpt,"Injection, Alteplase Recombinant, 1 Mg",aetna,Medicaid,O,318.54,54.09,87.67,232.15,191.12
2438,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72148,cpt,MRI Scan Of Lower Spinal Canal,aetna,PPO,O,2882.19,203.81,1642.85,2039.29,244.57
2439,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna,Medicaid,O,135.07,18.96,76.99,121.94,81.04
2440,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna,POS,E,5923.22,592.08,2036.44,2288.99,3553.93
2441,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87496,cpt,"Detection Test By Nucleic Acid For Cytomegalovirus (Cmv), Amplified Probe Technique",aetna,POS,O,191.11,108.93,108.93,108.93,114.67
2442,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84402,cpt,"Testosterone (Hormone) Level, Free",aetna,Medicare Part B,O,70.78,13.11,38.73,53.09,30.56
2443,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86777,cpt,Analysis For Antibody To Toxoplasma (Parasite),aetna,HMO,O,152.18,14.25,86.74,86.74,91.31
2444,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5101,cpt,"Injection, Filgrastim-Sndz, Biosimilar, (Zarxio), 1 Microgram",aetna,POS,O,1.85,0.17,0.35,0.35,1.11
2445,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0943,revCode,Medical Rehabilitation Day Program Cardiac Rehabilitation,aetna,HMO,O,173.89,102.78,102.79,369.10,104.33
2446,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0276,revCode,Medical/Surgical Supplies And Devices Intracular Lens,aetna,EPO,O,797.52,202.98,270.86,797.52,478.51
2447,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,292,ms-drg,Heart Failure And Shock With CC,aetna,POS,I,18032.02,5781.24,12207.78,12207.78,10819.21
2448,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna,Medicare Part B,O,490.78,263.76,343.76,352.65,294.47
2449,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna,Medicaid,O,188.09,38.65,107.21,141.02,112.85
2450,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83036,cpt,Hemoglobin A1c Level,aetna,Medicare Part A,O,76.68,5.83,41.96,57.51,11.65
2451,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64450,cpt,Injection Of Anesthetic Agent And/Or Steroid Into Other Peripheral Nerve Or Branch,aetna,PPO,O,1533.00,1587.94,12436.52,12436.52,919.80
2452,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81050,cpt,Urine Volume Measurement,aetna,Medicare Part B,O,30.08,3.64,17.15,22.56,4.37
2453,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93458,cpt,Insertion Of Catheter In Left Heart For Imaging Of Blood Vessels And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna,EPO,O,25037.36,2421.03,5730.96,15138.17,15022.42
2454,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna,Medicare Part B,O,2535.33,203.81,1416.20,1958.54,244.57
2455,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73552,cpt,"X-Ray Of Thigh Bone, Minimum 2 Views",aetna,Medicare Part B,O,309.09,42.89,176.18,176.18,185.45
2456,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45385,cpt,Removal Of Polyps Or Growths Of Large Bowel Using An Endoscope With Mechanical Snare,aetna,Medicaid,O,5305.34,938.17,2617.73,5400.89,1653.07
2457,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87177,cpt,Smear For Parasites,aetna,EPO,O,123.87,8.72,70.61,70.61,10.68
2458,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82565,cpt,Blood Creatinine Level,aetna,Medicaid,O,30.08,4.82,17.15,30.08,6.14
2459,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82140,cpt,Ammonia Level,aetna,POS,O,108.53,13.90,59.39,59.39,17.48
2460,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,603,ms-drg,Cellulitis Without MCC,aetna,EPO,I,19499.58,3283.09,5672.80,12955.93,11699.75
2461,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0640,cpt,"Injection, Leucovorin Calcium, Per 50 Mg",aetna,Medicaid,O,17.80,3.56,3.56,14.15,10.68
2462,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72195,cpt,MRI Scan Of Pelvis Without Contrast,aetna,EPO,O,1763.76,203.81,1005.34,1008.21,1058.26
2463,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73700,cpt,CT Scan Of Leg Without Contrast,aetna,EPO,O,1395.67,96.50,779.60,809.76,837.40
2464,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1170,cpt,"Injection, Hydromorphone, Up To 4 Mg",aetna,Medicare Part A,O,82.88,16.96,38.12,82.88,49.73
2465,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna,Medicaid,O,50.72,5.89,27.75,35.89,7.21
2466,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88341,cpt,"Special Stained Specimen Slides To Examine Tissue, Each Additional Procedure",aetna,Medicare Part A,O,125.04,25.34,71.27,125.04,75.02
2467,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,Medicare Part B,O,344.48,61.44,188.49,273.86,206.69
2468,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0430,revCode,"Occupational Therapy, General",aetna,HMO,I,176.32,32.63,91.02,165.50,105.79
2469,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70543,cpt,"MRI Scan Of Bone Of Eye Socket, Face, And/Or Neck Before And After Contrast",aetna,Medicare Part B,O,2110.61,326.01,1213.60,1213.60,1266.37
2470,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77300,cpt,Calculation Of Radiation Therapy Dose,aetna,EPO,O,273.70,47.14,131.71,131.71,134.83
2471,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94640,cpt,Respiratory Inhaled Pressure Or Nonpressure Treatment To Relieve Airway Obstruction Or For Sputum Specimen,aetna,PPO,O,198.78,56.02,185.11,185.11,119.27
2472,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0274,revCode,"Medical/Surgical Supplies And Devices, Prosthetic/Orthotic Devices",aetna,EPO,O,89.04,8.13,2026.64,2026.64,53.42
2473,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82803,cpt,Blood Gases Measurement,aetna,Medicaid,O,158.08,26.07,86.50,86.50,30.97
2474,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82951,cpt,"Blood Glucose (Sugar) Tolerance Test, 3 Specimens",aetna,PPO,O,117.61,12.87,39.96,84.59,15.44
2475,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna,PPO,O,135.07,18.96,76.99,121.94,81.04
2476,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0403,revCode,Other Imaging Services Screening Mammography,aetna,Medicare Part A,O,312.75,51.78,104.90,273.24,187.65
2477,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9443,cpt,"Lactation Classes, Non-Physician Provider, Per Session",aetna,PPO,O,155.82,92.26,92.26,155.82,93.49
2478,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,HMO,O,332.78,61.44,194.95,261.67,199.67
2479,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2405,cpt,"Injection, Ondansetron Hydrochloride, Per 1 Mg",aetna,Medicare Part B,O,19.54,1.76,8.78,19.52,11.72
2480,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2710,cpt,"Injection, Neostigmine Methylsulfate, Up To 0.5 Mg",aetna,Medicare Part B,O,4.65,0.15,0.15,4.27,2.79
2481,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,885,ms-drg,Psychoses,aetna,Medicare Part B,I,17080.81,5566.92,6861.23,9301.98,10248.49
2482,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0740,revCode,"Electroencephalogram (Eeg), General",aetna,PPO,O,779.82,234.21,444.50,735.68,467.89
2483,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna,HMO,O,356.28,61.44,194.95,194.95,213.77
2484,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74183,cpt,MRI Scan Of Abdomen Before And After Contrast,aetna,HMO,O,3824.84,326.02,2180.16,2180.16,2294.90
2485,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87641,cpt,"Detection Test By Nucleic Acid For Staphylococcus Aureus, Methicillin Resistant (Mrsa Bacteria), Amplified Probe Technique",aetna,PPO,O,90.84,13.32,51.78,64.28,42.11
2486,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0720,revCode,Labor Room/Delivery General,aetna,Medicare Part A,I,141.69,33.03,82.08,5123.48,85.01
2487,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,POS,O,1673.95,97.51,795.53,1330.78,1004.37
2488,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9271,cpt,"Injection, Pembrolizumab, 1 Mg",aetna,POS,O,192.29,32.26,52.73,144.22,115.37
2489,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93017,cpt,Exercise Or Drug-Induced Heart And Blood Vessel Stress Test With Ekg Tracing And Monitoring,aetna,Medicaid,O,474.26,84.78,270.33,377.03,284.56
2490,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0276,revCode,Medical/Surgical Supplies And Devices Intracular Lens,aetna,Medicare Part B,O,797.52,202.98,270.86,797.52,478.51
2491,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,Medicare Part B,I,225.33,71.10,128.44,225.33,135.20
2492,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86147,cpt,Cardiolipin Antibody (Tissue Antibody) Measurement,aetna,PPO,O,330.33,25.55,188.29,247.75,30.54
2493,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,Medicaid,I,72.54,19.89,124.91,124.91,43.52
2494,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,59025,cpt,Fetal Non-Stress Test,aetna,Medicaid,O,250.10,17.49,145.06,176.96,150.06
2495,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96416,cpt,Prolonged Chemotherapy Infusion Into A Vein By Portable Or Implanted Pump More Than 8 Hours,aetna,Medicare Part A,O,535.61,119.50,290.78,401.71,321.37
2496,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna,HMO,O,490.78,263.76,343.76,352.65,294.47
2497,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73140,cpt,"X-Ray Of Fingers, Minimum Of 2 Views",aetna,POS,O,226.51,61.44,131.38,131.38,85.98
2498,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0343,revCode,"Nuclear Medicine, Diagnostic Radiopharmaceuticals",aetna,Medicare Part A,O,692.52,123.81,394.74,1192.32,415.51
2499,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83516,cpt,"Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",aetna,Medicare Part A,O,51.31,8.70,30.43,41.58,13.84
2500,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,193,ms-drg,Simple Pneumonia And Pleurisy With MCC,aetna,PPO,I,28945.31,6804.78,18583.72,18583.72,17367.19
2501,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87427,cpt,Detection Test By Immunoassay Technique For Shiga-Like Toxin (Bacterial Toxin),aetna,Medicare Part A,O,60.03,6.75,34.22,34.22,14.38
2502,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17281,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,POS,O,2354.50,306.29,393.96,1345.09,1412.70
2503,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64721,cpt,Release And/Or Relocation Of Median Nerve Of Hand,aetna,EPO,O,15304.77,1553.71,8031.11,8031.11,9182.86
2504,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7040,cpt,"Infusion, Normal Saline Solution, Sterile (500 Ml = 1 Unit)",aetna,Medicare Part A,O,157.91,58.43,71.06,157.91,94.75
2505,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49402,cpt,Removal Of Foreign Body From Abdominal Cavity,aetna,POS,O,42363.98,24397.19,24397.19,24397.19,25418.39
2506,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95819,cpt,"Measurement And Recording Of Brain Wave (Eeg) Activity, Awake And Asleep",aetna,POS,O,779.82,234.21,444.50,735.68,467.89
2507,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,Medicare Part B,I,726.73,207.37,642.32,642.32,436.04
2508,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93880,cpt,Ultrasound Scanning Of Blood Flow (Outside The Brain) On Both Sides Of Head And Neck,aetna,Medicaid,O,711.39,203.81,397.38,397.38,426.83
2509,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88300,cpt,"Pathology Examination Of Tissue Using A Microscope, Limited Examination",aetna,PPO,O,93.19,27.95,50.99,50.99,55.91
2510,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86430,cpt,Rheumatoid Factor Analysis,aetna,EPO,O,42.58,6.10,14.72,31.94,7.37
2511,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74246,cpt,X-Ray Of Upper Digestive Tract With Double Contrast,aetna,POS,O,484.07,158.13,264.87,284.00,189.76
2512,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5115,cpt,"Injection, Rituximab-Abbs, Biosimilar, (Truxima), 10 Mg",aetna,EPO,O,218.36,61.56,68.50,163.77,131.02
2513,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87591,cpt,"Detection Test By Nucleic Acid For Neisseria Gonorrhoeae (Gonorrhoeae Bacteria), Amplified Probe Technique",aetna,Medicaid,O,147.58,21.05,82.44,110.69,42.11
2514,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2405,cpt,"Injection, Ondansetron Hydrochloride, Per 1 Mg",aetna,POS,O,19.54,1.76,8.78,19.52,11.72
2515,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,689,ms-drg,Kidney And Urinary Tract Infections With MCC,aetna,EPO,I,22796.06,6348.25,8547.01,9085.55,13677.64
2516,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0278,revCode,Medical/Surgical Supplies And Devices Other Implants,aetna,HMO,I,12498.86,118.53,1501.07,6933.25,7499.32
2517,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna,HMO,O,145.10,26.57,41.28,89.17,49.54
2518,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88342,cpt,"Special Stained Specimen Slides To Examine Tissue, Initial Procedure",aetna,Medicare Part B,O,419.99,33.03,239.39,314.99,251.99
2519,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,POS,O,1884.10,207.52,1030.93,11598.92,1130.46
2520,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna,HMO,O,188.09,38.65,107.21,141.02,112.85
2521,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70450,cpt,CT Of Head Without Contrast,aetna,POS,O,2452.75,96.51,1398.07,1839.56,115.81
2522,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73221,cpt,MRI Scan Of Arm Joint Without Contrast,aetna,EPO,O,2882.19,203.81,1577.05,1715.45,245.82
2523,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76881,cpt,Complete Ultrasound Scan Of Joint,aetna,HMO,O,379.88,96.50,216.53,216.53,227.93
2524,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,HMO,I,7.39,2.22,3.59,34.05,4.43
2525,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73080,cpt,"X-Ray Of Elbow, Minimum Of 3 Views",aetna,PPO,O,294.94,49.66,168.12,168.12,176.96
2526,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88341,cpt,"Special Stained Specimen Slides To Examine Tissue, Each Additional Procedure",aetna,Medicare Part B,O,125.04,25.34,71.27,125.04,75.02
2527,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,186,ms-drg,Pleural Effusion With MCC,aetna,PPO,I,29279.58,9460.85,9734.76,9734.76,17567.75
2528,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7040,cpt,"Infusion, Normal Saline Solution, Sterile (500 Ml = 1 Unit)",aetna,PPO,O,157.91,58.43,71.06,157.91,94.75
2529,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97035,cpt,"Application Of Ultrasound To 1 Or More Areas, Each 15 Minutes",aetna,POS,O,106.18,10.67,46.92,46.92,63.71
2530,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80074,cpt,Acute Hepatitis Panel,aetna,Medicaid,O,213.87,26.66,117.03,117.03,57.16
2531,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86696,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 2",aetna,HMO,O,126.23,19.24,69.07,94.67,23.22
2532,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,Medicare Part B,I,140.26,41.63,88.86,224.92,84.16
2533,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77417,cpt,Therapeutic Radiology Port Films,aetna,PPO,O,37.84,21.95,21.95,28.66,9.54
2534,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,PPO,I,726.73,207.37,642.32,642.32,436.04
2535,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna,POS,O,93.19,18.38,53.12,74.09,55.91
2536,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5106,cpt,"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (For Non-Esrd Use), 1000 Units",aetna,POS,O,32.27,8.13,8.62,13.29,19.36
2537,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72195,cpt,MRI Scan Of Pelvis Without Contrast,aetna,HMO,O,1763.76,203.81,1005.34,1008.21,1058.26
2538,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71270,cpt,CT Scan Of Chest Before And After Contrast,aetna,Medicaid,O,2554.21,161.61,161.61,161.61,192.38
2539,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96377,cpt,Application Of On-Body Injector For Under Skin Injection,aetna,POS,O,44.52,9.67,25.82,25.82,26.71
2540,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96366,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Each Additional Hour",aetna,Medicare Part A,O,307.18,19.72,178.16,178.16,184.31
2541,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36591,cpt,Collection Of Blood Specimen From A Completely Implantable Venous Access Device,aetna,Medicare Part A,O,172.23,13.59,102.02,102.02,103.34
2542,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna,PPO,O,92.22,24.06,24.60,24.60,55.33
2543,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,Medicare Part A,I,973.23,169.01,169.01,1031.60,583.94
2544,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86850,cpt,Screening Test For Red Blood Cell Antibodies,aetna,Medicare Part A,O,93.19,8.25,53.12,67.92,53.95
2545,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9500,cpt,"Technetium Tc-99m Sestamibi, Diagnostic, Per Study Dose",aetna,Medicare Part B,O,692.52,114.53,394.74,734.07,415.51
2546,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87635,cpt,Amplifed DNA Or Rna Probe Detection Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antigen,aetna,EPO,O,168.00,50.29,97.44,126.00,61.57
2547,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99153,cpt,"Use Of A Drug To Induce Depression Of Consciousness By Physician Performing A Procedure, Each Additional 15 Minutes",aetna,PPO,O,47.19,6.59,27.37,47.19,28.31
2548,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77063,cpt,Screening Digital Tomography Of Both Breasts,aetna,Medicare Part A,O,184.03,20.92,100.70,167.23,110.42
2549,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,776,ms-drg,Postpartum And Post Abortion Diagnoses Without O.R. Procedures,aetna,Medicaid,I,14400.00,2525.16,5439.38,9082.13,8640.00
2550,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94726,cpt,Determination Of Lung Volumes Using Plethysmography,aetna,POS,O,501.40,116.04,274.35,274.35,300.84
2551,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,EPO,O,1775.23,260.44,1248.81,1902.32,1065.14
2552,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1644,cpt,"Injection, Heparin Sodium, Per 1000 Units",aetna,PPO,O,7.94,2.07,2.73,61.12,4.76
2553,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93880,cpt,Ultrasound Scanning Of Blood Flow (Outside The Brain) On Both Sides Of Head And Neck,aetna,POS,O,711.39,203.81,397.38,397.38,426.83
2554,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36593,cpt,Declotting Infusion Of Implanted Central Venous Access Device Or Catheter,aetna,Medicare Part B,O,18177.79,1282.65,9002.79,20624.05,10906.67
2555,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78306,cpt,Nuclear Medicine Study Of Bone And/Or Joint Whole Body,aetna,POS,O,848.21,330.97,483.48,522.98,400.79
2556,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna,Medicaid,O,92.22,24.06,24.60,24.60,55.33
2557,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76815,cpt,"Ultrasound Of Pregnant Uterus, 1 Or More Fetus(Es)",aetna,PPO,O,611.12,97.50,348.34,647.78,366.67
2558,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0943,revCode,Medical Rehabilitation Day Program Cardiac Rehabilitation,aetna,POS,O,173.89,102.78,102.79,369.10,104.33
2559,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9445,cpt,"Patient Education, Not Otherwise Classified, Non-Physician Provider, Individual, Per Session",aetna,Medicare Part B,O,104.62,78.47,104.62,114.22,62.77
2560,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80306,cpt,"Testing For Presence Of Drug, Read By Instrument Assisted Observation",aetna,Medicaid,O,513.19,16.97,292.52,384.89,20.57
2561,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87535,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Amplified Probe Technique",aetna,HMO,O,376.19,56.83,218.19,299.07,225.71
2562,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0171,cpt,"Injection, Adrenalin, Epinephrine, 0.1 Mg",aetna,HMO,O,5.83,0.23,2.68,2.68,3.50
2563,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0431,revCode,Occupational Therapy Visit Charge,aetna,Medicare Part B,O,173.42,21.75,80.69,875.96,104.05
2564,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83690,cpt,Lipase (Fat Enzyme) Level,aetna,EPO,O,52.60,6.89,18.70,39.45,8.27
2565,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0762,revCode,Specialty Services Observation Hours,aetna,POS,I,15.11,4.72,10.23,10.23,9.07
2566,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84550,cpt,"Uric Acid Level, Blood",aetna,EPO,O,50.01,4.52,29.01,79.60,5.42
2567,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86706,cpt,Hepatitis B Surface Antibody Measurement,aetna,POS,O,94.38,6.44,52.72,70.79,12.89
2568,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86769,cpt,Measure Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antibody,aetna,Medicare Part B,O,89.25,16.93,51.77,66.94,50.56
2569,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86900,cpt,Blood Group Typing (ABO),aetna,HMO,O,126.23,11.17,71.95,99.15,118.98
2570,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76881,cpt,Complete Ultrasound Scan Of Joint,aetna,POS,O,379.88,96.50,216.53,216.53,227.93
2571,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96368,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Concurrent With Another Infusion",aetna,EPO,O,75.68,16.92,43.89,60.16,45.41
2572,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85014,cpt,Red Blood Cell Concentration Measurement,aetna,POS,O,28.77,2.35,16.40,21.58,2.84
2573,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9360,cpt,"Injection, Vinblastine Sulfate, 1 Mg",aetna,PPO,O,11.79,2.36,4.08,4.08,7.07
2574,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71101,cpt,"X-Ray Of Ribs On One Side Of Body Including The Chest, Minimum Of 3 Views",aetna,PPO,O,356.28,61.44,203.08,203.08,115.81
2575,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0441,revCode,Occupational Therapy Visit Charge,aetna,Medicaid,O,328.90,81.87,190.76,190.76,197.34
2576,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,Medicare Part A,O,576.53,96.50,334.39,562.62,345.92
2577,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,070,ms-drg,Nonspecific Cerebrovascular Disorders With MCC,aetna,Medicare Part A,I,31953.37,10314.69,10417.64,12207.30,19172.02
2578,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2632,cpt,"Post Chmbr Intraocular Lens; Prosthetics, Orthotics, And Supplies",aetna,Medicare Part B,O,797.52,202.98,270.86,797.52,478.51
2579,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86800,cpt,Thyroglobulin (Thyroid Protein) Antibody Measurement,aetna,POS,O,71.96,14.53,40.56,40.56,19.09
2580,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,673,ms-drg,Other Kidney And Urinary Tract Procedures With MCC,aetna,Medicaid,I,61701.73,20358.57,20462.06,20647.19,37021.04
2581,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73502,cpt,"X-Ray Of Hip With Pelvis, 2-3 Views",aetna,Medicare Part A,O,213.53,40.67,121.71,169.76,85.98
2582,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70220,cpt,"X-Ray Of Paranasal Sinus, Complete, Minimum Of 3 Views",aetna,Medicare Part A,O,342.13,47.22,195.01,271.99,205.28
2583,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96365,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, 1 Hour Or Less",aetna,Medicare Part A,O,307.18,64.22,180.23,200.85,184.31
2584,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96417,cpt,Infusion Of Different Chemotherapy Drug Or Substance Into A Vein Up To 1 Hour,aetna,POS,O,241.84,54.88,132.33,181.38,145.10
2585,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,HMO,O,2882.19,203.81,1577.05,2039.29,1729.31
2586,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87635,cpt,Amplifed DNA Or Rna Probe Detection Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antigen,aetna,Medicare Part A,O,168.00,50.29,97.44,126.00,61.57
2587,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86787,cpt,Analysis For Antibody To Varicella-Zoster Virus (Chicken Pox),aetna,Medicare Part A,O,53.08,6.47,29.05,39.81,15.46
2588,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,HMO,O,238.18,42.44,143.91,252.47,142.91
2589,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87536,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Quantification",aetna,EPO,O,519.10,67.96,295.89,295.89,311.46
2590,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna,Medicare Part A,O,289.04,102.81,158.15,158.15,134.83
2591,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99212,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 10 Minutes",aetna,HMO,O,180.14,52.17,102.68,135.10,108.08
2592,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,236,ms-drg,Coronary Bypass Without Cardiac Catheterization Without MCC,aetna,Medicaid,I,156904.89,23866.31,23891.99,44284.10,94142.93
2593,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97166,cpt,"Evaluation For Occupational Therapy, Typically 45 Minutes",aetna,POS,O,265.44,85.51,151.30,163.25,159.26
2594,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72146,cpt,MRI Scan Of Middle Spinal Canal Without Contrast,aetna,PPO,O,2882.19,207.32,821.42,821.42,248.82
2595,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,776,ms-drg,Postpartum And Post Abortion Diagnoses Without O.R. Procedures,aetna,HMO,I,14400.00,2525.16,5439.38,9082.13,8640.00
2596,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43235,cpt,"Diagnostic Examination Of Esophagus, Stomach, And/Or Upper Small Bowel Using An Endoscope",aetna,Medicare Part B,O,3132.69,724.55,1758.22,2956.79,1171.78
2597,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,Medicare Part A,O,63819.96,8894.43,14191.44,29488.15,38291.98
2598,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73130,cpt,"X-Ray Of Hand, Minimum Of 3 Views",aetna,EPO,O,329.15,46.08,180.10,261.67,197.49
2599,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73140,cpt,"X-Ray Of Fingers, Minimum Of 2 Views",aetna,EPO,O,226.51,61.44,131.38,131.38,85.98
2600,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,PPO,O,1884.10,207.52,1030.93,11598.92,1130.46
2601,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92921,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Single Artery Or Branch",aetna,HMO,O,71846.71,8777.72,8894.43,14120.90,43108.03
2602,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73030,cpt,"X-Ray Of Shoulder, Minimum Of 2 Views",aetna,EPO,O,252.47,45.52,143.91,176.73,151.48
2603,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87081,cpt,Screening Test For Pathogenic Organisms,aetna,HMO,O,45.06,3.98,25.68,32.84,9.19
2604,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,070,ms-drg,Nonspecific Cerebrovascular Disorders With MCC,aetna,Medicare Part B,I,31953.37,10314.69,10417.64,12207.30,19172.02
2605,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0482,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,PPO,O,315.99,78.44,78.44,208.68,189.59
2606,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,690,ms-drg,Kidney And Urinary Tract Infections Without MCC,aetna,Medicare Part A,I,16840.52,3735.53,9339.74,9339.74,10104.31
2607,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9500,cpt,"Technetium Tc-99m Sestamibi, Diagnostic, Per Study Dose",aetna,Medicare Part A,O,692.52,114.53,394.74,734.07,415.51
2608,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77063,cpt,Screening Digital Tomography Of Both Breasts,aetna,Medicare Part B,O,184.03,20.92,100.70,167.23,110.42
2609,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,EPO,O,3199.87,326.01,1445.14,2637.87,1919.92
2610,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,47563,cpt,Removal Of Gallbladder With X-Ray Study Of Bile Ducts Using An Endoscope,aetna,HMO,O,25129.00,4481.58,12544.52,12544.52,15077.40
2611,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna,Medicare Part B,O,331.51,82.43,181.40,301.25,102.14
2612,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83021,cpt,"Hemoglobin Analysis And Measurement, Chromatography",aetna,Medicare Part B,O,130.95,16.12,71.65,71.65,21.67
2613,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73620,cpt,"X-Ray Of Foot, 2 Views",aetna,Medicaid,O,252.47,61.44,143.91,143.91,151.48
2614,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85379,cpt,"Coagulation Function Measurement, D-Dimer; Quantitative",aetna,POS,O,122.56,9.98,71.08,71.08,12.22
2615,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82607,cpt,Cyanocobalamin (Vitamin B-12) Level,aetna,EPO,O,73.83,10.37,42.08,42.08,18.10
2616,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37230,cpt,"Insertion Of Stents Into Artery In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna,HMO,I,262831.76,27743.68,27743.68,27743.68,157699.06
2617,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76870,cpt,Ultrasound Scan Of Scrotum,aetna,POS,O,528.53,96.50,295.23,396.40,317.12
2618,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92526,cpt,Treatment Of Swallowing And/Or Oral Feeding Function,aetna,Medicare Part A,O,407.71,81.63,232.39,232.39,244.63
2619,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82565,cpt,Blood Creatinine Level,aetna,POS,O,30.08,4.82,17.15,30.08,6.14
2620,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88175,cpt,"Pap Test, Automated Thin Layer Preparation; Automated System And Manual Rescreening",aetna,Medicaid,O,83.33,0.35,47.50,60.74,31.93
2621,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9000,cpt,"Injection, Doxorubicin Hydrochloride, 10 Mg",aetna,HMO,O,10.61,1.82,2.81,2.81,6.37
2622,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64718,cpt,Release And/Or Relocation Of Ulnar Nerve At Elbow,aetna,Medicare Part A,O,16595.69,1553.71,9876.73,9876.73,9957.41
2623,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2175,cpt,"Injection, Meperidine Hydrochloride, Per 100 Mg",aetna,EPO,O,85.94,17.32,39.53,86.60,51.56
2624,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9306,cpt,"Injection, Pertuzumab, 1 Mg",aetna,Medicaid,O,44.82,10.05,14.64,424.56,26.89
2625,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73130,cpt,"X-Ray Of Hand, Minimum Of 3 Views",aetna,HMO,O,329.15,46.08,180.10,261.67,197.49
2626,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82397,cpt,Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,aetna,HMO,O,51.39,6.88,29.29,29.29,30.83
2627,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5115,cpt,"Injection, Rituximab-Abbs, Biosimilar, (Truxima), 10 Mg",aetna,PPO,O,218.36,61.56,68.50,163.77,131.02
2628,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna,HMO,O,329.15,22.74,190.91,261.67,197.49
2629,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0482,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,Medicaid,O,315.99,78.44,78.44,208.68,189.59
2630,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0740,revCode,"Electroencephalogram (Eeg), General",aetna,HMO,O,779.82,234.21,444.50,735.68,467.89
2631,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76817,cpt,Vaginal Ultrasound Of Pregnant Uterus,aetna,PPO,O,611.12,96.51,341.37,432.40,115.81
2632,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72072,cpt,"X-Ray Of Middle Spine, 3 Views",aetna,POS,O,356.28,33.86,199.02,249.40,116.30
2633,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87186,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or Agar Dilution",aetna,Medicare Part B,O,47.53,6.92,8.65,35.65,10.38
2634,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0740,revCode,"Electroencephalogram (Eeg), General",aetna,EPO,O,779.82,234.21,444.50,735.68,467.89
2635,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,32408,cpt,"Core Needle Biopsy Of Lung Or Center Cavity Of Chest (Mediastinum), Accessed Through Skin",aetna,Medicare Part B,O,3883.82,638.16,1248.81,1248.81,2330.29
2636,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80162,cpt,"Digoxin Level, Total",aetna,PPO,O,101.33,13.28,13.28,18.31,15.94
2637,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88341,cpt,"Special Stained Specimen Slides To Examine Tissue, Each Additional Procedure",aetna,EPO,O,125.04,25.34,71.27,125.04,75.02
2638,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76999,cpt,Other Ultrasound Procedure,aetna,Medicaid,O,238.30,71.65,130.40,216.32,142.98
2639,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88360,cpt,"Microscopic Genetic Analysis Of Tumor, Manual",aetna,Medicare Part A,O,331.51,126.27,188.96,188.96,198.91
2640,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82728,cpt,Ferritin (Blood Protein) Level,aetna,PPO,O,84.93,11.67,46.48,84.93,16.36
2641,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92921,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Single Artery Or Branch",aetna,Medicare Part B,O,71846.71,8777.72,8894.43,14120.90,43108.03
2642,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82565,cpt,Blood Creatinine Level,aetna,Medicare Part B,O,30.08,4.82,17.15,30.08,6.14
2643,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0434,revCode,"Occupational Therapy, Evaluation Or Reevaluation",aetna,PPO,I,357.27,76.33,271.01,357.27,214.36
2644,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85014,cpt,Red Blood Cell Concentration Measurement,aetna,Medicare Part A,O,28.77,2.35,16.40,21.58,2.84
2645,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76700,cpt,"Ultrasound Of Abdomen, Complete",aetna,Medicare Part A,O,970.94,96.51,542.36,771.89,116.30
2646,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,247,ms-drg,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without MCC,aetna,EPO,I,79628.76,11995.52,12110.64,46153.54,47777.26
2647,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33235,cpt,Removal Of Dual Electrodes From Right Heart,aetna,Medicare Part B,O,21468.71,3610.13,3610.13,3610.13,12881.23
2648,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0463,cpt,Hospital Outpatient Clinic Visit For Assessment And Management Of A Patient,aetna,Medicaid,O,176.96,59.81,102.70,107.50,106.18
2649,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92920,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Each Additional Artery Or Branch",aetna,Medicaid,O,63533.28,4389.98,4389.98,25971.62,38119.97
2650,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,POS,I,137.36,28.95,90.50,129.04,82.42
2651,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,Medicare Part A,O,238.18,42.44,143.91,252.47,142.91
2652,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11104,cpt,Punch Biopsy Of Single Skin Lesion,aetna,Medicare Part A,O,2056.68,306.29,1669.70,3042.91,1234.01
2653,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna,EPO,O,50.01,3.11,27.36,66.28,6.22
2654,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9500,cpt,"Technetium Tc-99m Sestamibi, Diagnostic, Per Study Dose",aetna,PPO,O,692.52,114.53,394.74,734.07,415.51
2655,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna,Medicare Part B,O,142.89,8.03,64.15,113.59,16.07
2656,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0481,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,Medicaid,O,315.99,155.10,155.10,156.59,189.59
2657,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,236,ms-drg,Coronary Bypass Without Cardiac Catheterization Without MCC,aetna,Medicare Part A,I,156904.89,23866.31,23891.99,44284.10,94142.93
2658,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,Medicare Part A,O,332.78,61.44,194.95,261.67,199.67
2659,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,Medicare Part A,I,1747.84,436.13,970.89,1375.11,1048.70
2660,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna,POS,O,4073.77,814.60,2322.05,3238.64,977.56
2661,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9263,cpt,"Injection, Oxaliplatin, 0.5 Mg",aetna,EPO,O,7.79,0.10,0.10,1.89,4.67
2662,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70553,cpt,MRI Scan Of Brain Before And After Contrast,aetna,Medicaid,O,3824.84,25.27,2092.84,3040.75,391.22
2663,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,Medicare Part B,O,2882.19,207.14,1577.05,2666.05,1729.31
2664,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,271,ms-drg,Other Major Cardiovascular Procedures With CC,aetna,HMO,I,68161.35,20934.94,27743.68,28893.46,40896.81
2665,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna,Medicare Part B,O,50.01,3.11,27.36,66.28,6.22
2666,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73130,cpt,"X-Ray Of Hand, Minimum Of 3 Views",aetna,PPO,O,329.15,46.08,180.10,261.67,197.49
2667,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,Medicaid,O,58.98,6.19,15.24,1399.28,35.39
2668,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33235,cpt,Removal Of Dual Electrodes From Right Heart,aetna,Medicare Part A,O,21468.71,3610.13,3610.13,3610.13,12881.23
2669,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86735,cpt,Analysis For Antibody To Mumps Virus,aetna,Medicare Part A,O,50.01,7.59,27.36,35.01,30.01
2670,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86901,cpt,Blood Typing For Rh (D) Antigen,aetna,Medicare Part B,O,83.76,7.41,47.74,83.76,17.09
2671,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77301,cpt,Management Of Modulation Radiotherapy Planning,aetna,Medicare Part B,O,7734.62,1117.80,4232.16,4232.16,1341.41
2672,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94060,cpt,"Measurement And Graphic Recording Of The Amount And Speed Of Breathed Air, Before And Following Medication Administration",aetna,Medicare Part B,O,422.68,78.29,218.19,239.44,253.61
2673,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76870,cpt,Ultrasound Scan Of Scrotum,aetna,HMO,O,528.53,96.50,295.23,396.40,317.12
2674,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,Medicaid,I,1747.84,436.13,970.89,1375.11,1048.70
2675,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36598,cpt,Contrast Injections For X-Ray Imaging Procedure To Evaluate Central Venous Access Device,aetna,Medicare Part A,O,1156.30,162.25,585.00,585.00,693.78
2676,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96366,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Each Additional Hour",aetna,EPO,O,307.18,19.72,178.16,178.16,184.31
2677,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0410,revCode,"Respiratory Services, General",aetna,Medicare Part B,I,205.27,71.94,125.75,182.34,123.16
2678,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71271,cpt,Low Dose CT Scan Of Chest For Lung Cancer Screening,aetna,Medicaid,O,331.51,71.65,98.50,234.56,198.91
2679,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9202,cpt,"Goserelin Acetate Implant, Per 3.6 Mg",aetna,POS,O,1210.44,149.56,581.30,581.30,726.26
2680,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96361,cpt,"Infusion Into A Vein For Hydration, Each Additional Hour",aetna,Medicare Part A,O,58.98,10.31,33.62,44.24,35.39
2681,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,287,ms-drg,"Circulatory Disorders Except Ami, With Cardiac Catheterization Without MCC",aetna,Medicare Part A,I,39655.14,7316.35,7333.25,13218.75,23793.08
2682,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87340,cpt,Detection Test By Immunoassay Technique For Hepatitis B Surface Antigen,aetna,EPO,O,80.09,7.09,45.65,60.07,12.40
2683,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna,PPO,O,1654.04,96.51,942.80,984.47,115.81
2684,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,Medicaid,I,2452.75,716.49,1897.41,2313.92,1471.65
2685,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1335,cpt,"Injection, Ertapenem Sodium, 500 Mg",aetna,Medicare Part A,O,93.92,16.77,52.86,52.86,56.35
2686,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0434,revCode,"Occupational Therapy, Evaluation Or Reevaluation",aetna,Medicare Part A,I,357.27,76.33,271.01,357.27,214.36
2687,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96523,cpt,Irrigation Of Implanted Venous Access Drug Delivery Device,aetna,Medicare Part B,O,192.29,49.29,109.61,144.22,115.37
2688,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72072,cpt,"X-Ray Of Middle Spine, 3 Views",aetna,Medicare Part B,O,356.28,33.86,199.02,249.40,116.30
2689,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2150,cpt,"Injection, Mannitol, 25% In 50 Ml",aetna,Medicaid,O,8.02,2.82,3.58,3.58,4.81
2690,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78306,cpt,Nuclear Medicine Study Of Bone And/Or Joint Whole Body,aetna,PPO,O,848.21,330.97,483.48,522.98,400.79
2691,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86038,cpt,Screening Test For Autoimmune Disorder,aetna,Medicaid,O,105.06,0.47,36.51,45.12,14.51
2692,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72202,cpt,"X-Ray Of Joint Between Lower Spine And Hip Bone, 3 Or More Views",aetna,PPO,O,252.47,26.87,145.17,166.73,151.48
2693,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73140,cpt,"X-Ray Of Fingers, Minimum Of 2 Views",aetna,Medicaid,O,226.51,61.44,131.38,131.38,85.98
2694,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna,Medicaid,O,271.34,80.51,148.47,215.72,96.61
2695,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,193,ms-drg,Simple Pneumonia And Pleurisy With MCC,aetna,Medicaid,I,28945.31,6804.78,18583.72,18583.72,17367.19
2696,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9000,cpt,"Injection, Doxorubicin Hydrochloride, 10 Mg",aetna,Medicare Part B,O,10.61,1.82,2.81,2.81,6.37
2697,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna,HMO,O,2535.33,203.81,1416.20,1958.54,244.57
2698,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna,EPO,I,25207.44,6812.39,8243.81,14290.40,15124.46
2699,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96402,cpt,Hormonal Anti-Neoplastic Chemotherapy Administration Beneath The Skin Or Into Muscle,aetna,Medicaid,O,125.04,21.31,71.27,71.27,75.02
2700,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna,POS,O,52.60,6.47,8.08,42.46,9.70
2701,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0214,revCode,Coronary Care Unit Intermediate Ccu,aetna,PPO,I,3917.76,854.59,2252.72,11926.72,2350.66
2702,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95819,cpt,"Measurement And Recording Of Brain Wave (Eeg) Activity, Awake And Asleep",aetna,Medicare Part B,O,779.82,234.21,444.50,735.68,467.89
2703,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84166,cpt,"Protein Measurement, Body Fluid",aetna,Medicaid,O,57.87,6.77,17.83,17.90,21.40
2704,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,EPO,I,973.23,169.01,169.01,1031.60,583.94
2705,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74183,cpt,MRI Scan Of Abdomen Before And After Contrast,aetna,Medicaid,O,3824.84,326.02,2180.16,2180.16,2294.90
2706,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11401,cpt,"Removal Of Growth (0.6 To 1.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,POS,O,4292.00,309.74,309.74,2167.15,2575.20
2707,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0612,revCode,Magnetic Resonance Technology (Mrt) Spinal Cord/Spine,aetna,POS,O,2882.19,203.81,1642.85,2100.47,1729.31
2708,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna,HMO,O,36.32,4.21,20.29,27.24,5.15
2709,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33216,cpt,Insertion Of Electrode For Permanent Pacemaker Or Pacing Defibrillator Device,aetna,EPO,O,31268.54,3610.13,3610.13,3610.13,18761.12
2710,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,580,ms-drg,"Other Skin, Subcutaneous Tissue And Breast Procedures With CC",aetna,Medicare Part A,I,43871.64,9796.13,9809.77,15064.04,26322.98
2711,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2150,cpt,"Injection, Mannitol, 25% In 50 Ml",aetna,Medicare Part A,O,8.02,2.82,3.58,3.58,4.81
2712,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78227,cpt,Nuclear Medicine Study Of Liver And Bile Duct System With Use Of Drugs,aetna,Medicare Part B,O,1528.98,161.81,836.62,1038.75,520.12
2713,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82784,cpt,Gammaglobulin (Immune System Protein) Measurement,aetna,Medicaid,O,65.66,9.30,9.30,52.19,11.16
2714,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9271,cpt,"Injection, Pembrolizumab, 1 Mg",aetna,Medicaid,O,192.29,32.26,52.73,144.22,115.37
2715,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76536,cpt,Ultrasound Scan Of Head And Neck Soft Tissue,aetna,PPO,O,491.96,96.50,269.19,391.10,295.18
2716,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,Medicare Part B,O,58.98,6.19,15.24,1399.28,35.39
2717,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92921,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Single Artery Or Branch",aetna,EPO,O,71846.71,8777.72,8894.43,14120.90,43108.03
2718,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0460,revCode,"Pulmonary Function, General",aetna,EPO,O,422.68,52.61,218.19,615.78,253.61
2719,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93280,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Dual Lead Pacemaker System With Physician Analysis, Review, And Report",aetna,Medicare Part A,O,214.80,32.43,32.51,76.59,128.88
2720,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,Medicare Part A,I,2882.19,290.04,2229.62,2229.62,1729.31
2721,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0283,cpt,"Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound Care, As Part Of A Therapy Plan Of Care",aetna,Medicare Part A,O,93.19,9.47,40.58,93.19,55.91
2722,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,689,ms-drg,Kidney And Urinary Tract Infections With MCC,aetna,Medicaid,I,22796.06,6348.25,8547.01,9085.55,13677.64
2723,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85651,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Non-Automated",aetna,Medicare Part A,O,13.00,1.77,4.25,4.68,7.80
2724,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87624,cpt,"Detection Test By Nucleic Acid For Human Papillomavirus (Hpv), High-Risk Types",aetna,HMO,O,108.49,21.05,59.36,108.49,42.11
2725,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0360,revCode,"Operating Room Services, General",aetna,EPO,O,9825.06,1878.83,4989.15,12996.76,5895.04
2726,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86334,cpt,Immunologic Analysis Technique On Serum (Immunofixation),aetna,HMO,O,132.12,17.37,75.31,99.09,26.81
2727,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2710,cpt,"Injection, Neostigmine Methylsulfate, Up To 0.5 Mg",aetna,EPO,O,4.65,0.15,0.15,4.27,2.79
2728,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96401,cpt,Administration Of Non-Hormonal Anti-Neoplastic Chemotherapy Under Skin Or Into Muscle,aetna,Medicare Part B,O,286.67,27.44,27.44,63.97,172.00
2729,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,190,ms-drg,Chronic Obstructive Pulmonary Disease With MCC,aetna,Medicare Part A,I,21678.10,5783.22,5783.22,12966.75,13006.86
2730,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80202,cpt,Vancomycin (Antibiotic) Level,aetna,HMO,O,87.53,13.54,49.89,49.89,16.25
2731,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,23472,cpt,"Prosthetic Repair Of Shoulder Joint, Total Shoulder",aetna,EPO,I,123346.27,14814.57,14814.57,14814.57,74007.76
2732,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17270,cpt,"Destruction Of Malignant Growth (0.5 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,Medicare Part A,O,1881.00,159.01,159.94,475.20,1128.60
2733,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83498,cpt,"Hydroxyprogesterone, 17-D (Synthetic Hormone) Level",aetna,Medicare Part B,O,126.23,20.54,69.07,69.07,75.74
2734,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,Medicare Part B,O,711.39,96.53,359.62,479.92,426.83
2735,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74018,cpt,"X-Ray Of Abdomen, 1 View",aetna,PPO,O,268.98,61.44,147.18,285.11,85.98
2736,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84155,cpt,"Total Protein Level, Blood",aetna,POS,O,69.00,3.67,3.67,51.75,4.40
2737,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87624,cpt,"Detection Test By Nucleic Acid For Human Papillomavirus (Hpv), High-Risk Types",aetna,Medicaid,O,108.49,21.05,59.36,108.49,42.11
2738,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0131,cpt,"Injection, Acetaminophen, 10 Mg",aetna,HMO,O,1.46,0.18,0.65,1.44,0.88
2739,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88300,cpt,"Pathology Examination Of Tissue Using A Microscope, Limited Examination",aetna,HMO,O,93.19,27.95,50.99,50.99,55.91
2740,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83498,cpt,"Hydroxyprogesterone, 17-D (Synthetic Hormone) Level",aetna,EPO,O,126.23,20.54,69.07,69.07,75.74
2741,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna,PPO,O,95.71,16.18,16.18,21.31,19.42
2742,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,47563,cpt,Removal Of Gallbladder With X-Ray Study Of Bile Ducts Using An Endoscope,aetna,Medicare Part B,O,25129.00,4481.58,12544.52,12544.52,15077.40
2743,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9035,cpt,"Injection, Bevacizumab, 10 Mg",aetna,Medicaid,O,282.70,75.76,77.46,77.46,169.62
2744,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83883,cpt,"Nephelometry, Test Method Using Light",aetna,POS,O,93.19,11.70,13.60,69.89,16.32
2745,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0131,cpt,"Injection, Acetaminophen, 10 Mg",aetna,Medicaid,O,1.46,0.18,0.65,1.44,0.88
2746,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0460,revCode,"Pulmonary Function, General",aetna,POS,O,422.68,52.61,218.19,615.78,253.61
2747,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73080,cpt,"X-Ray Of Elbow, Minimum Of 3 Views",aetna,POS,O,294.94,49.66,168.12,168.12,176.96
2748,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93005,cpt,Routine Electrocardiogram (Ekg) With Tracing Using At Least 12 Leads,aetna,Medicaid,O,218.25,35.36,121.91,154.43,130.95
2749,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90686,cpt,"Vaccine For Influenza For Administration Into Muscle, 0.5 Ml Dosage, Quadrivalent, Preservation Free",aetna,EPO,O,132.44,13.48,20.93,79.94,79.46
2750,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,Medicare Part A,O,2882.19,203.81,1577.05,2039.29,1729.31
2751,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71046,cpt,"X-Ray Of Chest, 2 Views",aetna,PPO,O,344.48,61.44,188.49,273.86,85.98
2752,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5111,cpt,"Injection, Pegfilgrastim-Cbqv, Biosimilar, (Udenyca), 0.5 Mg",aetna,Medicare Part B,O,1901.34,181.58,880.52,880.52,1140.80
2753,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0500,cpt,"Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care Professional Performing A Gastrointestinal Endoscopic Service That Sedation Supports, Requiring The Presence Of",aetna,Medicare Part A,O,47.19,27.14,27.14,47.19,28.31
2754,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1885,cpt,"Injection, Ketorolac Tromethamine, Per 15 Mg",aetna,HMO,O,39.72,7.88,18.17,40.53,23.83
2755,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87045,cpt,Stool Culture,aetna,Medicare Part A,O,80.09,9.05,46.05,46.05,11.33
2756,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11103,cpt,"Biopsy Of Related Skin Growth, Each Additional Growth",aetna,HMO,O,1126.00,160.53,161.01,647.00,675.60
2757,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66984,cpt,"Removal Of Cataract With Insertion Of Lens, Simple",aetna,Medicaid,O,14664.91,1841.26,3839.82,4337.53,8798.95
2758,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86901,cpt,Blood Typing For Rh (D) Antigen,aetna,HMO,O,83.76,7.41,47.74,83.76,17.09
2759,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,064,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With MCC,aetna,HMO,I,42514.90,11561.36,11613.14,15935.29,25508.94
2760,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna,Medicaid,O,50.01,3.11,27.36,66.28,6.22
2761,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76816,cpt,"Ultrasound Re-Evaluation Of Pregnant Uterus, Per Fetus",aetna,PPO,O,611.12,96.51,348.34,432.40,366.67
2762,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,POS,O,711.39,96.53,359.62,479.92,426.83
2763,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88162,cpt,"Screening Examination Of Specimen Cells, Extended Study",aetna,EPO,O,303.20,44.07,44.07,97.64,181.92
2764,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97165,cpt,"Evaluation For Occupational Therapy, Typically 30 Minutes",aetna,HMO,O,211.24,71.93,120.41,120.41,126.74
2765,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C8908,cpt,"Magnetic Resonance Imaging Without Contrast Followed By With Contrast, Breast; Bilateral",aetna,Medicaid,O,3010.79,326.02,1716.15,1716.15,1806.47
2766,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80048,cpt,"Blood Test, Basic Group Of Blood Chemicals (Calcium, Total)",aetna,Medicare Part B,O,70.06,8.30,38.34,49.58,10.15
2767,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87661,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Amplified Probe Technique",aetna,PPO,O,151.64,21.05,84.70,113.73,42.11
2768,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83021,cpt,"Hemoglobin Analysis And Measurement, Chromatography",aetna,Medicaid,O,130.95,16.12,71.65,71.65,21.67
2769,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78070,cpt,Nuclear Medicine Study Of Parathyroid,aetna,Medicaid,O,1314.27,400.84,749.13,749.13,788.56
2770,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87496,cpt,"Detection Test By Nucleic Acid For Cytomegalovirus (Cmv), Amplified Probe Technique",aetna,EPO,O,191.11,108.93,108.93,108.93,114.67
2771,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99204,cpt,"New Patient Office Or Other Outpatient Visit, 45-59 Minutes",aetna,HMO,O,634.41,49.54,367.96,475.81,223.37
2772,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76805,cpt,"Ultrasound Scan Of Pregnant Uterus (14 Weeks Or More), Single Or First Fetus",aetna,Medicare Part B,O,442.41,49.86,252.17,292.16,117.01
2773,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,HMO,O,490.78,263.76,343.76,353.36,294.47
2774,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82962,cpt,Blood Glucose (Sugar) Test Performed By Hand-Held Instrument,aetna,PPO,O,42.58,3.28,24.27,42.58,3.94
2775,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87491,cpt,"Detection Test By Nucleic Acid For Chlamydia Trachomatis, Amplified Probe Technique",aetna,HMO,O,147.58,21.05,82.44,110.69,42.11
2776,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11103,cpt,"Biopsy Of Related Skin Growth, Each Additional Growth",aetna,EPO,O,1126.00,160.53,161.01,647.00,675.60
2777,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1335,cpt,"Injection, Ertapenem Sodium, 500 Mg",aetna,Medicare Part B,O,93.92,16.77,52.86,52.86,56.35
2778,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,330,ms-drg,Major Small And Large Bowel Procedures With CC,aetna,Medicaid,I,58731.07,15126.82,15186.72,23610.09,35238.64
2779,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2469,cpt,"Injection, Palonosetron Hcl, 25 Mcg",aetna,Medicare Part B,O,90.84,19.36,39.42,85.70,54.50
2780,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna,EPO,O,92.22,24.06,24.60,24.60,55.33
2781,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82306,cpt,Vitamin D-3 Level,aetna,PPO,O,101.33,21.15,57.76,63.19,35.52
2782,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,P9040,cpt,"Red Blood Cells, Leukocytes Reduced, Irradiated, Each Unit",aetna,Medicare Part B,O,756.23,260.55,262.76,509.61,453.74
2783,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96417,cpt,Infusion Of Different Chemotherapy Drug Or Substance Into A Vein Up To 1 Hour,aetna,PPO,O,241.84,54.88,132.33,181.38,145.10
2784,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36591,cpt,Collection Of Blood Specimen From A Completely Implantable Venous Access Device,aetna,POS,O,172.23,13.59,102.02,102.02,103.34
2785,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2505,cpt,"Injection, Pegfilgrastim, 6 Mg",aetna,Medicare Part B,O,17508.60,2251.51,6955.90,6955.90,10505.16
2786,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S2900,cpt,Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure),aetna,Medicare Part A,O,26479.60,4481.58,24397.19,24397.19,15887.76
2787,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73552,cpt,"X-Ray Of Thigh Bone, Minimum 2 Views",aetna,EPO,O,309.09,42.89,176.18,176.18,185.45
2788,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73700,cpt,CT Scan Of Leg Without Contrast,aetna,HMO,O,1395.67,96.50,779.60,809.76,837.40
2789,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72146,cpt,MRI Scan Of Middle Spinal Canal Without Contrast,aetna,POS,O,2882.19,207.32,821.42,821.42,248.82
2790,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,Medicaid,O,1952.12,97.51,1370.07,1839.56,1171.27
2791,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93925,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of Both Legs,aetna,PPO,O,726.73,203.81,207.32,359.62,436.04
2792,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,Medicare Part A,O,83.80,8.07,29.33,89.04,50.28
2793,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna,Medicare Part A,O,490.78,263.76,343.76,352.65,294.47
2794,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77417,cpt,Therapeutic Radiology Port Films,aetna,HMO,O,37.84,21.95,21.95,28.66,9.54
2795,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87340,cpt,Detection Test By Immunoassay Technique For Hepatitis B Surface Antigen,aetna,HMO,O,80.09,7.09,45.65,60.07,12.40
2796,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86696,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 2",aetna,POS,O,126.23,19.24,69.07,94.67,23.22
2797,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99282,cpt,Emergency Department Visit For Problem Of Mild To Moderate Severity,aetna,Medicare Part A,E,276.06,99.19,160.11,290.62,165.64
2798,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0460,revCode,"Pulmonary Function, General",aetna,Medicare Part B,O,422.68,52.61,218.19,615.78,253.61
2799,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72072,cpt,"X-Ray Of Middle Spine, 3 Views",aetna,EPO,O,356.28,33.86,199.02,249.40,116.30
2800,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82306,cpt,Vitamin D-3 Level,aetna,POS,O,101.33,21.15,57.76,63.19,35.52
2801,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9263,cpt,"Injection, Oxaliplatin, 0.5 Mg",aetna,Medicaid,O,7.79,0.10,0.10,1.89,4.67
2802,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84156,cpt,"Total Protein Level, Urine",aetna,Medicare Part A,O,80.24,3.60,46.54,53.04,4.40
2803,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,Medicaid,O,1775.23,260.44,1248.81,1902.32,1065.14
2804,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87624,cpt,"Detection Test By Nucleic Acid For Human Papillomavirus (Hpv), High-Risk Types",aetna,POS,O,108.49,21.05,59.36,108.49,42.11
2805,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna,Medicare Part A,O,14.15,0.48,0.89,8.71,8.49
2806,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,287,ms-drg,"Circulatory Disorders Except Ami, With Cardiac Catheterization Without MCC",aetna,PPO,I,39655.14,7316.35,7333.25,13218.75,23793.08
2807,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0120,revCode,Room And Board Semiprivate (Two Beds) General,aetna,POS,I,1274.16,366.55,685.17,6328.83,764.50
2808,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45385,cpt,Removal Of Polyps Or Growths Of Large Bowel Using An Endoscope With Mechanical Snare,aetna,Medicare Part B,O,5305.34,938.17,2617.73,5400.89,1653.07
2809,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,PPO,O,1952.12,97.51,1370.07,1839.56,1171.27
2810,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,PPO,O,490.78,263.76,343.76,353.36,294.47
2811,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95819,cpt,"Measurement And Recording Of Brain Wave (Eeg) Activity, Awake And Asleep",aetna,PPO,O,779.82,234.21,444.50,735.68,467.89
2812,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92920,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Each Additional Artery Or Branch",aetna,EPO,O,63533.28,4389.98,4389.98,25971.62,38119.97
2813,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3370,cpt,"Injection, Vancomycin Hcl, 500 Mg",aetna,Medicare Part A,O,75.38,22.33,34.67,34.67,45.23
2814,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86780,cpt,"Analysis For Antibody, Treponema Pallidum",aetna,POS,O,331.50,12.98,188.96,248.62,198.90
2815,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,Medicaid,I,490.78,103.68,279.74,347.25,294.47
2816,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3475,cpt,"Injection, Magnesium Sulfate, Per 500 Mg",aetna,Medicaid,O,4.45,1.00,2.05,2.05,2.67
2817,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17281,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,HMO,O,2354.50,306.29,393.96,1345.09,1412.70
2818,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,EPO,I,72.54,19.89,124.91,124.91,43.52
2819,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86765,cpt,Analysis For Antibody To Rubeola (Measles Virus),aetna,Medicaid,O,50.01,7.69,55.32,55.32,30.01
2820,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85652,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Automated",aetna,PPO,O,38.92,2.65,21.30,29.59,3.24
2821,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0460,revCode,"Pulmonary Function, General",aetna,Medicare Part A,O,422.68,52.61,218.19,615.78,253.61
2822,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77301,cpt,Management Of Modulation Radiotherapy Planning,aetna,POS,O,7734.62,1117.80,4232.16,4232.16,1341.41
2823,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,EPO,O,218.25,35.37,121.91,263.09,130.95
2824,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28080,cpt,Removal Of Fibrous Nerve Growth From Between Toes,aetna,HMO,O,17456.96,1200.71,9928.29,9928.29,10474.18
2825,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0343,revCode,"Nuclear Medicine, Diagnostic Radiopharmaceuticals",aetna,EPO,O,692.52,123.81,394.74,1192.32,415.51
2826,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33216,cpt,Insertion Of Electrode For Permanent Pacemaker Or Pacing Defibrillator Device,aetna,Medicare Part A,O,31268.54,3610.13,3610.13,3610.13,18761.12
2827,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0360,revCode,"Operating Room Services, General",aetna,POS,O,9825.06,1878.83,4989.15,12996.76,5895.04
2828,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76705,cpt,Limited Ultrasound Scan Of Abdomen,aetna,Medicaid,O,710.22,96.50,404.83,564.62,115.81
2829,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87624,cpt,"Detection Test By Nucleic Acid For Human Papillomavirus (Hpv), High-Risk Types",aetna,Medicare Part B,O,108.49,21.05,59.36,108.49,42.11
2830,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna,Medicare Part B,O,252.47,18.27,143.91,336.23,151.48
2831,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,POS,O,33.76,8.03,18.27,694.79,20.26
2832,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71271,cpt,Low Dose CT Scan Of Chest For Lung Cancer Screening,aetna,Medicare Part B,O,331.51,71.65,98.50,234.56,198.91
2833,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97530,cpt,"Therapeutic Activities To Improve Function, With One-On-One Contact Between Patient And Provider, Each 15 Minutes",aetna,HMO,O,166.34,34.57,91.02,91.02,99.80
2834,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0881,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (Non-Esrd Use)",aetna,Medicare Part B,O,15.58,2.38,7.43,7.43,9.35
2835,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86038,cpt,Screening Test For Autoimmune Disorder,aetna,Medicare Part A,O,105.06,0.47,36.51,45.12,14.51
2836,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85652,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Automated",aetna,POS,O,38.92,2.65,21.30,29.59,3.24
2837,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0331,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration - Injection,aetna,EPO,O,270.45,26.27,71.27,513.21,162.27
2838,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76801,cpt,Abdominal Ultrasound Of Pregnant Uterus (Less Than 14 Weeks 0 Days) Single Or First Fetus,aetna,POS,O,357.27,96.50,217.76,229.19,115.81
2839,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96416,cpt,Prolonged Chemotherapy Infusion Into A Vein By Portable Or Implanted Pump More Than 8 Hours,aetna,Medicaid,O,535.61,119.50,290.78,401.71,321.37
2840,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0521,revCode,Freestanding Clinic Clinic Visit By Member Torhc/Fqhc,aetna,PPO,O,195.00,111.87,111.87,244.91,117.00
2841,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna,Medicare Part B,O,14.15,0.48,0.89,8.71,8.49
2842,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,PPO,O,3199.87,326.01,1445.14,2637.87,1919.92
2843,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87635,cpt,Amplifed DNA Or Rna Probe Detection Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antigen,aetna,HMO,O,168.00,50.29,97.44,126.00,61.57
2844,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0260,revCode,Intravenous (Iv) Therapy,aetna,HMO,O,325.61,56.09,185.60,1926.96,195.37
2845,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,580,ms-drg,"Other Skin, Subcutaneous Tissue And Breast Procedures With CC",aetna,Medicare Part B,I,43871.64,9796.13,9809.77,15064.04,26322.98
2846,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,EPO,I,7.39,2.22,3.59,34.05,4.43
2847,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84403,cpt,"Testosterone (Hormone) Level, Total",aetna,HMO,O,135.66,25.30,77.33,101.75,30.97
2848,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,271,ms-drg,Other Major Cardiovascular Procedures With CC,aetna,Medicare Part A,I,68161.35,20934.94,27743.68,28893.46,40896.81
2849,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,690,ms-drg,Kidney And Urinary Tract Infections Without MCC,aetna,Medicare Part B,I,16840.52,3735.53,9339.74,9339.74,10104.31
2850,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0690,cpt,"Injection, Cefazolin Sodium, 500 Mg",aetna,PPO,O,35.58,12.05,29.43,64.88,21.35
2851,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93279,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Single Lead Pacemaker System In One Chamber Of Heart With Qualified Health Care Professional Analysis, Review, And Report",aetna,Medicare Part B,O,180.49,32.90,32.90,76.59,108.29
2852,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36600,cpt,Arterial Puncture Withdrawal Of Blood For Diagnosis,aetna,EPO,O,179.32,34.87,147.18,147.18,107.59
2853,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,POS,I,1495.87,276.63,903.80,903.80,897.52
2854,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna,Medicare Part B,O,93.19,18.38,53.12,74.09,55.91
2855,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3010,cpt,"Injection, Fentanyl Citrate, 0.1 Mg",aetna,Medicare Part B,O,82.61,17.19,37.17,85.93,49.57
2856,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43235,cpt,"Diagnostic Examination Of Esophagus, Stomach, And/Or Upper Small Bowel Using An Endoscope",aetna,EPO,O,3132.69,724.55,1758.22,2956.79,1171.78
2857,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna,HMO,I,1495.87,276.63,903.80,903.80,897.52
2858,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86735,cpt,Analysis For Antibody To Mumps Virus,aetna,Medicaid,O,50.01,7.59,27.36,35.01,30.01
2859,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna,HMO,O,88.82,7.62,50.63,66.62,9.32
2860,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0460,revCode,"Pulmonary Function, General",aetna,HMO,O,422.68,52.61,218.19,615.78,253.61
2861,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86765,cpt,Analysis For Antibody To Rubeola (Measles Virus),aetna,PPO,O,50.01,7.69,55.32,55.32,30.01
2862,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81001,cpt,"Manual Urinalysis Test With Examination Using Microscope, Automated",aetna,Medicaid,O,13.80,2.37,7.87,10.35,8.28
2863,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73218,cpt,MRI Scan Of Arm Without Contrast,aetna,PPO,O,2882.19,206.00,1642.85,2719.05,1729.31
2864,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3380,cpt,"Injection, Vedolizumab, 1 Mg",aetna,POS,O,60.64,21.72,28.92,28.92,36.38
2865,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87255,cpt,Virus Isolation,aetna,PPO,O,123.87,33.86,67.78,81.80,40.63
2866,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,689,ms-drg,Kidney And Urinary Tract Infections With MCC,aetna,Medicare Part A,I,22796.06,6348.25,8547.01,9085.55,13677.64
2867,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86800,cpt,Thyroglobulin (Thyroid Protein) Antibody Measurement,aetna,EPO,O,71.96,14.53,40.56,40.56,19.09
2868,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76805,cpt,"Ultrasound Scan Of Pregnant Uterus (14 Weeks Or More), Single Or First Fetus",aetna,HMO,O,442.41,49.86,252.17,292.16,117.01
2869,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna,POS,O,1884.10,427.65,1030.93,1413.08,1130.46
2870,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71270,cpt,CT Scan Of Chest Before And After Contrast,aetna,Medicare Part B,O,2554.21,161.61,161.61,161.61,192.38
2871,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17280,cpt,"Destruction Of Malignant Growth (0.5 Centimeters Or Less) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,Medicare Part A,O,1569.00,159.01,162.47,542.48,941.40
2872,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88341,cpt,"Special Stained Specimen Slides To Examine Tissue, Each Additional Procedure",aetna,HMO,O,125.04,25.34,71.27,125.04,75.02
2873,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93571,cpt,"Ultrasound Evaluation Of Heart Blood Vessel During Diagnosis Or Treatment, Initial Vessel",aetna,PPO,O,31969.64,4389.98,14191.44,14191.44,19181.78
2874,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0335,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration -Iv,aetna,EPO,O,487.49,86.82,282.74,11490.04,292.49
2875,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna,Medicare Part A,O,108.88,10.16,59.58,77.04,20.33
2876,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86780,cpt,"Analysis For Antibody, Treponema Pallidum",aetna,PPO,O,331.50,12.98,188.96,248.62,198.90
2877,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82784,cpt,Gammaglobulin (Immune System Protein) Measurement,aetna,Medicare Part B,O,65.66,9.30,9.30,52.19,11.16
2878,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,811,ms-drg,Red Blood Cell Disorders With MCC,aetna,POS,I,34462.34,8519.29,8897.14,15450.42,20677.40
2879,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,HMO,O,30.08,3.64,57.64,96.59,18.05
2880,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11045,cpt,"Removal Of Skin And Tissue, Each Additional 20.0 Sq Cm Or Less",aetna,POS,O,2875.83,306.28,312.72,3179.32,1725.50
2881,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9579,cpt,"Injection, Gadolinium-Based Magnetic Resonance Contrast Agent, Not Otherwise Specified (Nos), Per Ml",aetna,POS,O,15.32,0.10,6.89,16.23,9.19
2882,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85597,cpt,Platelet Function Test,aetna,HMO,O,89.65,9.41,51.10,67.24,21.58
2883,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84425,cpt,Vitamin B-1 (Thiamine) Level,aetna,HMO,O,138.03,18.33,75.53,75.53,82.82
2884,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,Medicare Part B,O,2882.19,203.81,1577.05,2039.29,1729.31
2885,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0521,revCode,Freestanding Clinic Clinic Visit By Member Torhc/Fqhc,aetna,Medicaid,O,195.00,111.87,111.87,244.91,117.00
2886,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87427,cpt,Detection Test By Immunoassay Technique For Shiga-Like Toxin (Bacterial Toxin),aetna,Medicaid,O,60.03,6.75,34.22,34.22,14.38
2887,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0482,revCode,"Cardiology, Stress Test",aetna,PPO,O,474.26,84.78,270.33,377.03,284.56
2888,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93925,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of Both Legs,aetna,Medicaid,O,726.73,203.81,207.32,359.62,436.04
2889,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,POS,O,490.78,263.76,343.76,353.36,294.47
2890,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85014,cpt,Red Blood Cell Concentration Measurement,aetna,PPO,O,28.77,2.35,16.40,21.58,2.84
2891,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna,Medicare Part B,O,329.15,22.74,190.91,261.67,197.49
2892,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11102,cpt,"Biopsy Of Related Skin Growth, First Growth",aetna,HMO,O,1042.00,159.01,160.97,708.35,625.20
2893,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86735,cpt,Analysis For Antibody To Mumps Virus,aetna,PPO,O,50.01,7.59,27.36,35.01,30.01
2894,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,330,ms-drg,Major Small And Large Bowel Procedures With CC,aetna,Medicare Part B,I,58731.07,15126.82,15186.72,23610.09,35238.64
2895,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96416,cpt,Prolonged Chemotherapy Infusion Into A Vein By Portable Or Implanted Pump More Than 8 Hours,aetna,EPO,O,535.61,119.50,290.78,401.71,321.37
2896,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92920,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Each Additional Artery Or Branch",aetna,HMO,O,63533.28,4389.98,4389.98,25971.62,38119.97
2897,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11047,cpt,"Removal Of Bone, Each Additional 20.0 Sq Cm Or Less",aetna,Medicaid,O,12247.63,1215.96,1247.54,1273.00,7348.58
2898,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0360,revCode,"Operating Room Services, General",aetna,Medicare Part A,O,9825.06,1878.83,4989.15,12996.76,5895.04
2899,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna,POS,O,289.04,102.81,158.15,158.15,134.83
2900,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3370,cpt,"Injection, Vancomycin Hcl, 500 Mg",aetna,EPO,O,75.38,22.33,34.67,34.67,45.23
2901,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72141,cpt,MRI Scan Of Upper Spinal Canal Without Contrast,aetna,Medicare Part B,O,2882.19,205.13,1642.85,2291.34,244.57
2902,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0482,revCode,"Cardiology, Stress Test",aetna,EPO,O,474.26,84.78,270.33,377.03,284.56
2903,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,POS,I,2452.75,716.49,1897.41,2313.92,1471.65
2904,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97535,cpt,"Training For Self-Care Or Home Management, Each 15 Minutes",aetna,Medicare Part A,O,200.56,25.86,84.86,87.79,120.34
2905,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70487,cpt,CT Scan Of Face With Contrast,aetna,Medicaid,O,1358.47,810.86,810.86,810.86,815.08
2906,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72202,cpt,"X-Ray Of Joint Between Lower Spine And Hip Bone, 3 Or More Views",aetna,Medicare Part A,O,252.47,26.87,145.17,166.73,151.48
2907,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,065,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With CC Or Tpa In 24 Hours,aetna,PPO,I,23737.47,6483.31,6483.31,11599.87,14242.48
2908,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,46255,cpt,Removal Of Single External And Internal Hemorrhoid Group,aetna,Medicaid,O,17900.37,2210.31,9939.29,9939.29,10740.22
2909,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83690,cpt,Lipase (Fat Enzyme) Level,aetna,POS,O,52.60,6.89,18.70,39.45,8.27
2910,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86696,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 2",aetna,EPO,O,126.23,19.24,69.07,94.67,23.22
2911,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,776,ms-drg,Postpartum And Post Abortion Diagnoses Without O.R. Procedures,aetna,EPO,I,14400.00,2525.16,5439.38,9082.13,8640.00
2912,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76705,cpt,Limited Ultrasound Scan Of Abdomen,aetna,HMO,O,710.22,96.50,404.83,564.62,115.81
2913,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82550,cpt,"Creatine Kinase (Cardiac Enzyme) Level, Total",aetna,PPO,O,60.16,6.44,33.61,33.61,7.81
2914,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna,Medicaid,O,36.32,4.21,20.29,27.24,5.15
2915,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86695,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 1",aetna,POS,O,89.65,13.19,49.06,67.24,15.83
2916,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,853,ms-drg,Infectious And Parasitic Diseases With O.R. Procedures With MCC,aetna,Medicare Part B,I,131887.09,28277.35,28277.35,59129.81,79132.25
2917,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,638,ms-drg,Diabetes With CC,aetna,POS,I,20621.27,4023.89,8833.24,8833.24,12372.76
2918,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0333,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Radiation Therapy,aetna,Medicaid,O,933.20,214.04,481.06,1795.20,559.92
2919,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3475,cpt,"Injection, Magnesium Sulfate, Per 500 Mg",aetna,EPO,O,4.45,1.00,2.05,2.05,2.67
2920,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,HMO,O,1952.12,97.51,1370.07,1839.56,1171.27
2921,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80048,cpt,"Blood Test, Basic Group Of Blood Chemicals (Calcium, Total)",aetna,POS,O,70.06,8.30,38.34,49.58,10.15
2922,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93925,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of Both Legs,aetna,POS,O,726.73,203.81,207.32,359.62,436.04
2923,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36415,cpt,Insertion Of Needle Into Vein For Collection Of Blood Sample,aetna,EPO,O,29.48,2.94,3.00,22.11,17.69
2924,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88360,cpt,"Microscopic Genetic Analysis Of Tumor, Manual",aetna,HMO,O,331.51,126.27,188.96,188.96,198.91
2925,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84165,cpt,"Protein Measurement, Serum",aetna,POS,O,116.79,10.63,10.74,82.64,12.89
2926,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72146,cpt,MRI Scan Of Middle Spinal Canal Without Contrast,aetna,Medicare Part A,O,2882.19,207.32,821.42,821.42,248.82
2927,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86735,cpt,Analysis For Antibody To Mumps Virus,aetna,EPO,O,50.01,7.59,27.36,35.01,30.01
2928,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82140,cpt,Ammonia Level,aetna,Medicaid,O,108.53,13.90,59.39,59.39,17.48
2929,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86235,cpt,"Measurement Of Antibody For Assessment Of Autoimmune Disorder, Any Method",aetna,Medicare Part A,O,43.81,6.19,24.97,30.69,21.52
2930,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86334,cpt,Immunologic Analysis Technique On Serum (Immunofixation),aetna,Medicare Part A,O,132.12,17.37,75.31,99.09,26.81
2931,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96401,cpt,Administration Of Non-Hormonal Anti-Neoplastic Chemotherapy Under Skin Or Into Muscle,aetna,HMO,O,286.67,27.44,27.44,63.97,172.00
2932,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1885,cpt,"Injection, Ketorolac Tromethamine, Per 15 Mg",aetna,Medicare Part A,O,39.72,7.88,18.17,40.53,23.83
2933,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17281,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,Medicare Part A,O,2354.50,306.29,393.96,1345.09,1412.70
2934,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94640,cpt,Respiratory Inhaled Pressure Or Nonpressure Treatment To Relieve Airway Obstruction Or For Sputum Specimen,aetna,HMO,O,198.78,56.02,185.11,185.11,119.27
2935,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2704,cpt,"Injection, Propofol, 10 Mg",aetna,PPO,O,4.12,0.82,1.89,4.12,2.47
2936,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84703,cpt,Gonadotropin (Reproductive Hormone) Analysis,aetna,PPO,O,69.48,7.52,37.26,48.18,9.02
2937,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64721,cpt,Release And/Or Relocation Of Median Nerve Of Hand,aetna,Medicare Part B,O,15304.77,1553.71,8031.11,8031.11,9182.86
2938,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97163,cpt,"Evaluation For Physical Therapy, Typically 45 Minutes",aetna,Medicare Part A,O,281.58,53.70,154.08,154.08,168.95
2939,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82306,cpt,Vitamin D-3 Level,aetna,HMO,O,101.33,21.15,57.76,63.19,35.52
2940,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,EPO,O,479.00,41.29,159.02,1803.87,287.40
2941,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna,Medicare Part B,O,36.32,4.21,20.29,27.24,5.15
2942,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77386,cpt,"Intensity Modulated Radiation Therapy Delivery, Complex",aetna,Medicaid,O,2383.15,480.50,1303.99,1303.99,576.60
2943,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88360,cpt,"Microscopic Genetic Analysis Of Tumor, Manual",aetna,PPO,O,331.51,126.27,188.96,188.96,198.91
2944,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11044,cpt,Removal Of Skin And Bone First 20 Sq Cm Or Less,aetna,Medicare Part B,O,3769.31,1215.96,1260.27,2751.80,2261.59
2945,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86430,cpt,Rheumatoid Factor Analysis,aetna,POS,O,42.58,6.10,14.72,31.94,7.37
2946,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93571,cpt,"Ultrasound Evaluation Of Heart Blood Vessel During Diagnosis Or Treatment, Initial Vessel",aetna,HMO,O,31969.64,4389.98,14191.44,14191.44,19181.78
2947,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0710,revCode,Recovery Room General,aetna,Medicare Part A,O,3506.08,933.94,2267.67,2982.15,2103.65
2948,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87427,cpt,Detection Test By Immunoassay Technique For Shiga-Like Toxin (Bacterial Toxin),aetna,EPO,O,60.03,6.75,34.22,34.22,14.38
2949,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11104,cpt,Punch Biopsy Of Single Skin Lesion,aetna,EPO,O,2056.68,306.29,1669.70,3042.91,1234.01
2950,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84165,cpt,"Protein Measurement, Serum",aetna,EPO,O,116.79,10.63,10.74,82.64,12.89
2951,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76999,cpt,Other Ultrasound Procedure,aetna,POS,O,238.30,71.65,130.40,216.32,142.98
2952,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78070,cpt,Nuclear Medicine Study Of Parathyroid,aetna,Medicare Part B,O,1314.27,400.84,749.13,749.13,788.56
2953,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86300,cpt,"Immunologic Analysis For Detection Of Tumor Antigen, Quantitative; Ca 15-3",aetna,Medicaid,O,85.70,20.40,51.78,90.84,24.97
2954,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87480,cpt,"Detection Test For Candida Species (Yeast), Direct Probe Technique",aetna,Medicare Part A,O,107.59,12.03,58.87,80.69,24.06
2955,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0138,cpt,"Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (Non-Esrd Use)",aetna,Medicare Part A,O,4.45,0.69,0.93,1.82,2.67
2956,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99211,cpt,Office Or Other Outpatient Visit For The Evaluation And Management Of Established Patient That May Not Require Presence Of Healthcare Professional,aetna,PPO,O,91.30,29.79,52.04,190.38,54.78
2957,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94726,cpt,Determination Of Lung Volumes Using Plethysmography,aetna,Medicare Part A,O,501.40,116.04,274.35,274.35,300.84
2958,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73140,cpt,"X-Ray Of Fingers, Minimum Of 2 Views",aetna,Medicare Part A,O,226.51,61.44,131.38,131.38,85.98
2959,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0612,revCode,Magnetic Resonance Technology (Mrt) Spinal Cord/Spine,aetna,PPO,O,2882.19,203.81,1642.85,2100.47,1729.31
2960,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,PPO,I,281.58,60.08,199.37,281.58,168.95
2961,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82728,cpt,Ferritin (Blood Protein) Level,aetna,Medicare Part A,O,84.93,11.67,46.48,84.93,16.36
2962,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82784,cpt,Gammaglobulin (Immune System Protein) Measurement,aetna,PPO,O,65.66,9.30,9.30,52.19,11.16
2963,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0343,revCode,"Nuclear Medicine, Diagnostic Radiopharmaceuticals",aetna,HMO,O,692.52,123.81,394.74,1192.32,415.51
2964,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,40490,cpt,Biopsy Of Lip,aetna,PPO,O,1535.00,623.16,642.96,1044.00,921.00
2965,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49320,cpt,Diagnostic Examination Of The Abdomen Using An Endoscope,aetna,Medicare Part B,O,23329.13,4381.91,24397.19,24397.19,13997.48
2966,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72141,cpt,MRI Scan Of Upper Spinal Canal Without Contrast,aetna,HMO,O,2882.19,205.13,1642.85,2291.34,244.57
2967,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9045,cpt,"Injection, Carboplatin, 50 Mg",aetna,Medicare Part A,O,16.51,2.82,2.82,4.53,9.91
2968,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1453,cpt,"Injection, Fosaprepitant, 1 Mg",aetna,HMO,O,6.67,0.28,3.07,7.29,4.00
2969,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2599,cpt,Contact Lens/Es Other Type,aetna,Medicare Part B,O,3822.87,1002.34,4045.37,4045.37,2293.72
2970,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83498,cpt,"Hydroxyprogesterone, 17-D (Synthetic Hormone) Level",aetna,HMO,O,126.23,20.54,69.07,69.07,75.74
2971,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77300,cpt,Calculation Of Radiation Therapy Dose,aetna,PPO,O,273.70,47.14,131.71,131.71,134.83
2972,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93880,cpt,Ultrasound Scanning Of Blood Flow (Outside The Brain) On Both Sides Of Head And Neck,aetna,HMO,O,711.39,203.81,397.38,397.38,426.83
2973,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73140,cpt,"X-Ray Of Fingers, Minimum Of 2 Views",aetna,HMO,O,226.51,61.44,131.38,131.38,85.98
2974,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,40490,cpt,Biopsy Of Lip,aetna,EPO,O,1535.00,623.16,642.96,1044.00,921.00
2975,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,PPO,O,1881.00,160.85,162.47,936.63,1128.60
2976,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,Medicare Part A,O,3199.87,326.01,1445.14,2637.87,1919.92
2977,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna,EPO,O,4055.15,194.15,2179.00,3854.73,1125.84
2978,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49402,cpt,Removal Of Foreign Body From Abdominal Cavity,aetna,HMO,O,42363.98,24397.19,24397.19,24397.19,25418.39
2979,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97110,cpt,"Therapeutic Exercise To Develop Strength, Endurance, Range Of Motion, And Flexibility, Each 15 Minutes",aetna,Medicare Part B,O,173.42,23.35,77.46,114.70,29.09
2980,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna,Medicare Part A,O,50.01,3.11,27.36,66.28,6.22
2981,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0120,revCode,Room And Board Semiprivate (Two Beds) General,aetna,PPO,I,1274.16,366.55,685.17,6328.83,764.50
2982,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76642,cpt,Limited Ultrasound Scan Of 1 Breast,aetna,Medicare Part A,O,305.55,71.65,167.19,242.91,183.33
2983,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0463,cpt,Hospital Outpatient Clinic Visit For Assessment And Management Of A Patient,aetna,EPO,O,176.96,59.81,102.70,107.50,106.18
2984,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,47563,cpt,Removal Of Gallbladder With X-Ray Study Of Bile Ducts Using An Endoscope,aetna,Medicaid,O,25129.00,4481.58,12544.52,12544.52,15077.40
2985,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,PPO,O,238.18,42.44,143.91,252.47,142.91
2986,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82310,cpt,"Calcium Level, Total",aetna,POS,O,36.61,5.16,5.16,36.61,21.97
2987,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88331,cpt,"Pathology Examination Of Specimen During Surgery, First Tissue Block",aetna,HMO,O,438.52,153.98,254.34,254.34,263.11
2988,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna,POS,O,2882.19,203.81,1577.05,2291.34,244.57
2989,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82306,cpt,Vitamin D-3 Level,aetna,Medicare Part B,O,101.33,21.15,57.76,63.19,35.52
2990,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0500,cpt,"Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care Professional Performing A Gastrointestinal Endoscopic Service That Sedation Supports, Requiring The Presence Of",aetna,Medicaid,O,47.19,27.14,27.14,47.19,28.31
2991,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83550,cpt,Iron Binding Capacity,aetna,POS,O,106.28,8.57,60.58,106.28,10.49
2992,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84403,cpt,"Testosterone (Hormone) Level, Total",aetna,POS,O,135.66,25.30,77.33,101.75,30.97
2993,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93280,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Dual Lead Pacemaker System With Physician Analysis, Review, And Report",aetna,Medicaid,O,214.80,32.43,32.51,76.59,128.88
2994,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71271,cpt,Low Dose CT Scan Of Chest For Lung Cancer Screening,aetna,EPO,O,331.51,71.65,98.50,234.56,198.91
2995,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19083,cpt,"Biopsy Of Breast Accessed Through The Skin With Ultrasound Guidance, First Lesion",aetna,HMO,O,8391.01,1246.10,6742.37,6742.37,5034.61
2996,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99211,cpt,Office Or Other Outpatient Visit For The Evaluation And Management Of Established Patient That May Not Require Presence Of Healthcare Professional,aetna,HMO,O,91.30,29.79,52.04,190.38,54.78
2997,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99283,cpt,Emergency Department Visit For Problem Of Moderate Severity,aetna,Medicare Part A,E,871.53,205.11,459.97,892.25,522.92
2998,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81001,cpt,"Manual Urinalysis Test With Examination Using Microscope, Automated",aetna,PPO,O,13.80,2.37,7.87,10.35,8.28
2999,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43239,cpt,"Biopsy Of Esophagus, Stomach, And/Or Upper Small Bowel Using A Flexible Endoscope",aetna,Medicaid,O,4254.12,439.90,1990.82,4844.32,1282.14
3000,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85597,cpt,Platelet Function Test,aetna,EPO,O,89.65,9.41,51.10,67.24,21.58
3001,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87255,cpt,Virus Isolation,aetna,Medicare Part A,O,123.87,33.86,67.78,81.80,40.63
3002,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,580,ms-drg,"Other Skin, Subcutaneous Tissue And Breast Procedures With CC",aetna,HMO,I,43871.64,9796.13,9809.77,15064.04,26322.98
3003,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92921,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Single Artery Or Branch",aetna,POS,O,71846.71,8777.72,8894.43,14120.90,43108.03
3004,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,776,ms-drg,Postpartum And Post Abortion Diagnoses Without O.R. Procedures,aetna,Medicare Part B,I,14400.00,2525.16,5439.38,9082.13,8640.00
3005,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97530,cpt,"Therapeutic Activities To Improve Function, With One-On-One Contact Between Patient And Provider, Each 15 Minutes",aetna,PPO,O,166.34,34.57,91.02,91.02,99.80
3006,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0943,revCode,Medical Rehabilitation Day Program Cardiac Rehabilitation,aetna,Medicare Part B,O,173.89,102.78,102.79,369.10,104.33
3007,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna,Medicare Part A,O,1884.10,427.65,1030.93,1413.08,1130.46
3008,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70553,cpt,MRI Scan Of Brain Before And After Contrast,aetna,PPO,O,3824.84,25.27,2092.84,3040.75,391.22
3009,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73110,cpt,"X-Ray Of Wrist, Minimum Of 3 Views",aetna,HMO,O,329.15,51.73,183.86,246.86,197.49
3010,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82950,cpt,Blood Glucose (Sugar) Level After Receiving Dose Of Glucose,aetna,PPO,O,38.92,4.70,21.30,75.94,5.70
3011,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28080,cpt,Removal Of Fibrous Nerve Growth From Between Toes,aetna,Medicaid,O,17456.96,1200.71,9928.29,9928.29,10474.18
3012,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna,Medicare Part A,O,88.82,7.62,50.63,66.62,9.32
3013,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,58558,cpt,Biopsy Of Lining Of Uterus And/Or Removal Of Polyp Using An Endoscope,aetna,POS,O,22844.35,2323.22,10420.95,10420.95,13706.61
3014,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82375,cpt,Carboxyhemoglobin (Protein) Level,aetna,EPO,O,103.50,12.32,60.03,77.63,14.78
3015,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,EPO,O,711.39,96.53,359.62,479.92,426.83
3016,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0131,cpt,"Injection, Acetaminophen, 10 Mg",aetna,Medicare Part B,O,1.46,0.18,0.65,1.44,0.88
3017,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0333,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Radiation Therapy,aetna,Medicare Part A,O,933.20,214.04,481.06,1795.20,559.92
3018,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,PPO,O,63819.96,8894.43,14191.44,29488.15,38291.98
3019,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,PPO,O,218.25,35.37,121.91,263.09,130.95
3020,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2632,cpt,"Post Chmbr Intraocular Lens; Prosthetics, Orthotics, And Supplies",aetna,EPO,O,797.52,202.98,270.86,797.52,478.51
3021,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99204,cpt,"New Patient Office Or Other Outpatient Visit, 45-59 Minutes",aetna,Medicare Part A,O,634.41,49.54,367.96,475.81,223.37
3022,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82728,cpt,Ferritin (Blood Protein) Level,aetna,EPO,O,84.93,11.67,46.48,84.93,16.36
3023,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,690,ms-drg,Kidney And Urinary Tract Infections Without MCC,aetna,Medicaid,I,16840.52,3735.53,9339.74,9339.74,10104.31
3024,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45378,cpt,Diagnostic Colonoscopy Of Large Bowel Using A Flexible Endoscope,aetna,PPO,O,3131.25,717.01,1860.41,2251.40,861.59
3025,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna,EPO,O,4073.77,814.60,2322.05,3238.64,977.56
3026,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93970,cpt,Ultrasound Scan Of Veins Of Both Arms Or Legs Including Assessment Of Compression And Functional Maneuvers,aetna,Medicare Part B,O,1047.64,203.81,415.78,773.81,628.58
3027,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,10005,cpt,"Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth",aetna,PPO,O,2422.63,555.63,1193.41,1567.18,1453.58
3028,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76805,cpt,"Ultrasound Scan Of Pregnant Uterus (14 Weeks Or More), Single Or First Fetus",aetna,Medicaid,O,442.41,49.86,252.17,292.16,117.01
3029,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,190,ms-drg,Chronic Obstructive Pulmonary Disease With MCC,aetna,POS,I,21678.10,5783.22,5783.22,12966.75,13006.86
3030,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,292,ms-drg,Heart Failure And Shock With CC,aetna,Medicare Part A,I,18032.02,5781.24,12207.78,12207.78,10819.21
3031,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,811,ms-drg,Red Blood Cell Disorders With MCC,aetna,PPO,I,34462.34,8519.29,8897.14,15450.42,20677.40
3032,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49320,cpt,Diagnostic Examination Of The Abdomen Using An Endoscope,aetna,PPO,O,23329.13,4381.91,24397.19,24397.19,13997.48
3033,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38505,cpt,Needle Biopsy Or Removal Of Surface Lymph Nodes,aetna,POS,O,8266.58,1246.10,7074.31,7074.31,4959.95
3034,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28080,cpt,Removal Of Fibrous Nerve Growth From Between Toes,aetna,PPO,O,17456.96,1200.71,9928.29,9928.29,10474.18
3035,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0120,revCode,Room And Board Semiprivate (Two Beds) General,aetna,Medicare Part A,I,1274.16,366.55,685.17,6328.83,764.50
3036,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49320,cpt,Diagnostic Examination Of The Abdomen Using An Endoscope,aetna,HMO,O,23329.13,4381.91,24397.19,24397.19,13997.48
3037,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9271,cpt,"Injection, Pembrolizumab, 1 Mg",aetna,PPO,O,192.29,32.26,52.73,144.22,115.37
3038,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,PPO,I,1747.84,436.13,970.89,1375.11,1048.70
3039,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,POS,I,72.54,19.89,124.91,124.91,43.52
3040,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86300,cpt,"Immunologic Analysis For Detection Of Tumor Antigen, Quantitative; Ca 15-3",aetna,Medicare Part A,O,85.70,20.40,51.78,90.84,24.97
3041,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0943,revCode,Medical Rehabilitation Day Program Cardiac Rehabilitation,aetna,Medicare Part A,O,173.89,102.78,102.79,369.10,104.33
3042,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,PPO,O,30.08,3.64,57.64,96.59,18.05
3043,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3380,cpt,"Injection, Vedolizumab, 1 Mg",aetna,PPO,O,60.64,21.72,28.92,28.92,36.38
3044,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0441,revCode,Occupational Therapy Visit Charge,aetna,Medicare Part A,O,328.90,81.87,190.76,190.76,197.34
3045,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82248,cpt,"Bilirubin Level, Direct",aetna,Medicare Part A,O,41.28,4.92,14.47,14.47,6.02
3046,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0333,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Radiation Therapy,aetna,Medicare Part B,O,933.20,214.04,481.06,1795.20,559.92
3047,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64450,cpt,Injection Of Anesthetic Agent And/Or Steroid Into Other Peripheral Nerve Or Branch,aetna,HMO,O,1533.00,1587.94,12436.52,12436.52,919.80
3048,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,55250,cpt,Removal Of Sperm Duct,aetna,PPO,O,17158.79,1587.89,8468.46,8468.46,10295.27
3049,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S9443,cpt,"Lactation Classes, Non-Physician Provider, Per Session",aetna,EPO,O,155.82,92.26,92.26,155.82,93.49
3050,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,Medicaid,I,7.39,2.22,3.59,34.05,4.43
3051,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96417,cpt,Infusion Of Different Chemotherapy Drug Or Substance Into A Vein Up To 1 Hour,aetna,HMO,O,241.84,54.88,132.33,181.38,145.10
3052,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0335,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration -Iv,aetna,Medicare Part B,O,487.49,86.82,282.74,11490.04,292.49
3053,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C8908,cpt,"Magnetic Resonance Imaging Without Contrast Followed By With Contrast, Breast; Bilateral",aetna,PPO,O,3010.79,326.02,1716.15,1716.15,1806.47
3054,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2150,cpt,"Injection, Mannitol, 25% In 50 Ml",aetna,HMO,O,8.02,2.82,3.58,3.58,4.81
3055,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3475,cpt,"Injection, Magnesium Sulfate, Per 500 Mg",aetna,POS,O,4.45,1.00,2.05,2.05,2.67
3056,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0138,cpt,"Injection, Ferumoxytol, For Treatment Of Iron Deficiency Anemia, 1 Mg (Non-Esrd Use)",aetna,PPO,O,4.45,0.69,0.93,1.82,2.67
3057,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,10005,cpt,"Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth",aetna,EPO,O,2422.63,555.63,1193.41,1567.18,1453.58
3058,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0260,revCode,Intravenous (Iv) Therapy,aetna,POS,O,325.61,56.09,185.60,1926.96,195.37
3059,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97110,cpt,"Therapeutic Exercise To Develop Strength, Endurance, Range Of Motion, And Flexibility, Each 15 Minutes",aetna,Medicare Part A,O,173.42,23.35,77.46,114.70,29.09
3060,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,40490,cpt,Biopsy Of Lip,aetna,Medicare Part A,O,1535.00,623.16,642.96,1044.00,921.00
3061,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,Medicare Part A,I,2452.75,716.49,1897.41,2313.92,1471.65
3062,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73080,cpt,"X-Ray Of Elbow, Minimum Of 3 Views",aetna,Medicaid,O,294.94,49.66,168.12,168.12,176.96
3063,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82375,cpt,Carboxyhemoglobin (Protein) Level,aetna,Medicare Part A,O,103.50,12.32,60.03,77.63,14.78
3064,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna,Medicare Part B,O,271.34,80.51,148.47,215.72,96.61
3065,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,PPO,I,140.26,41.63,88.86,224.92,84.16
3066,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5114,cpt,"Injection, Trastuzumab-Dkst, Biosimilar, (Ogivri), 10 Mg",aetna,HMO,O,232.14,60.17,60.17,66.12,139.28
3067,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84425,cpt,Vitamin B-1 (Thiamine) Level,aetna,POS,O,138.03,18.33,75.53,75.53,82.82
3068,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2150,cpt,"Injection, Mannitol, 25% In 50 Ml",aetna,Medicare Part B,O,8.02,2.82,3.58,3.58,4.81
3069,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna,Medicare Part A,O,4073.77,814.60,2322.05,3238.64,977.56
3070,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna,Medicare Part A,O,331.51,82.43,181.40,301.25,102.14
3071,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,40490,cpt,Biopsy Of Lip,aetna,HMO,O,1535.00,623.16,642.96,1044.00,921.00
3072,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81050,cpt,Urine Volume Measurement,aetna,PPO,O,30.08,3.64,17.15,22.56,4.37
3073,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82803,cpt,Blood Gases Measurement,aetna,POS,O,158.08,26.07,86.50,86.50,30.97
3074,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna,Medicare Part B,O,2144.07,645.60,1279.68,2047.58,1286.44
3075,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83498,cpt,"Hydroxyprogesterone, 17-D (Synthetic Hormone) Level",aetna,PPO,O,126.23,20.54,69.07,69.07,75.74
3076,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1644,cpt,"Injection, Heparin Sodium, Per 1000 Units",aetna,Medicare Part B,O,7.94,2.07,2.73,61.12,4.76
3077,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna,EPO,O,70.06,8.01,39.93,52.55,9.80
3078,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna,POS,O,490.78,263.76,343.76,352.65,294.47
3079,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73610,cpt,"X-Ray Of Ankle, Minimum Of 3 Views",aetna,POS,O,329.15,46.08,180.10,261.67,197.49
3080,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87591,cpt,"Detection Test By Nucleic Acid For Neisseria Gonorrhoeae (Gonorrhoeae Bacteria), Amplified Probe Technique",aetna,EPO,O,147.58,21.05,82.44,110.69,42.11
3081,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84402,cpt,"Testosterone (Hormone) Level, Free",aetna,EPO,O,70.78,13.11,38.73,53.09,30.56
3082,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96402,cpt,Hormonal Anti-Neoplastic Chemotherapy Administration Beneath The Skin Or Into Muscle,aetna,HMO,O,125.04,21.31,71.27,71.27,75.02
3083,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78227,cpt,Nuclear Medicine Study Of Liver And Bile Duct System With Use Of Drugs,aetna,Medicaid,O,1528.98,161.81,836.62,1038.75,520.12
3084,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97163,cpt,"Evaluation For Physical Therapy, Typically 45 Minutes",aetna,Medicare Part B,O,281.58,53.70,154.08,154.08,168.95
3085,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0943,revCode,Medical Rehabilitation Day Program Cardiac Rehabilitation,aetna,Medicaid,O,173.89,102.78,102.79,369.10,104.33
3086,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64721,cpt,Release And/Or Relocation Of Median Nerve Of Hand,aetna,Medicaid,O,15304.77,1553.71,8031.11,8031.11,9182.86
3087,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11102,cpt,"Biopsy Of Related Skin Growth, First Growth",aetna,Medicare Part A,O,1042.00,159.01,160.97,708.35,625.20
3088,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86706,cpt,Hepatitis B Surface Antibody Measurement,aetna,HMO,O,94.38,6.44,52.72,70.79,12.89
3089,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna,EPO,O,91.30,14.35,49.96,64.61,54.78
3090,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72141,cpt,MRI Scan Of Upper Spinal Canal Without Contrast,aetna,Medicare Part A,O,2882.19,205.13,1642.85,2291.34,244.57
3091,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna,PPO,O,91.30,14.35,49.96,64.61,54.78
3092,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76870,cpt,Ultrasound Scan Of Scrotum,aetna,Medicare Part B,O,528.53,96.50,295.23,396.40,317.12
3093,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96361,cpt,"Infusion Into A Vein For Hydration, Each Additional Hour",aetna,Medicare Part B,O,58.98,10.31,33.62,44.24,35.39
3094,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77295,cpt,"Management Of Radiation Therapy, 3d",aetna,PPO,O,1926.57,1003.61,1098.14,1531.62,1341.41
3095,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87255,cpt,Virus Isolation,aetna,Medicare Part B,O,123.87,33.86,67.78,81.80,40.63
3096,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99204,cpt,"New Patient Office Or Other Outpatient Visit, 45-59 Minutes",aetna,EPO,O,634.41,49.54,367.96,475.81,223.37
3097,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0640,cpt,"Injection, Leucovorin Calcium, Per 50 Mg",aetna,POS,O,17.80,3.56,3.56,14.15,10.68
3098,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna,Medicare Part A,E,3350.06,336.55,1455.60,2095.51,2010.04
3099,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,POS,I,7.39,2.22,3.59,34.05,4.43
3100,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,Medicare Part B,O,238.18,42.44,143.91,252.47,142.91
3101,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna,EPO,O,36.32,4.21,20.29,27.24,5.15
3102,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84165,cpt,"Protein Measurement, Serum",aetna,PPO,O,116.79,10.63,10.74,82.64,12.89
3103,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96367,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Additional Sequential Infusion, 1 Hour Or Less",aetna,EPO,O,117.97,25.86,64.55,88.48,70.78
3104,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92920,cpt,"Balloon Dilation Of Narrowed Or Blocked Major Coronary Artery Or Branch (Accessed Through The Skin), Each Additional Artery Or Branch",aetna,Medicare Part B,O,63533.28,4389.98,4389.98,25971.62,38119.97
3105,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70450,cpt,CT Of Head Without Contrast,aetna,Medicaid,O,2452.75,96.51,1398.07,1839.56,115.81
3106,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,580,ms-drg,"Other Skin, Subcutaneous Tissue And Breast Procedures With CC",aetna,POS,I,43871.64,9796.13,9809.77,15064.04,26322.98
3107,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0943,revCode,Medical Rehabilitation Day Program Cardiac Rehabilitation,aetna,EPO,O,173.89,102.78,102.79,369.10,104.33
3108,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,811,ms-drg,Red Blood Cell Disorders With MCC,aetna,HMO,I,34462.34,8519.29,8897.14,15450.42,20677.40
3109,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86901,cpt,Blood Typing For Rh (D) Antigen,aetna,Medicaid,O,83.76,7.41,47.74,83.76,17.09
3110,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna,Medicare Part B,O,67.58,3.47,5.78,47.82,6.94
3111,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0283,cpt,"Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound Care, As Part Of A Therapy Plan Of Care",aetna,EPO,O,93.19,9.47,40.58,93.19,55.91
3112,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,065,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With CC Or Tpa In 24 Hours,aetna,EPO,I,23737.47,6483.31,6483.31,11599.87,14242.48
3113,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0740,revCode,"Electroencephalogram (Eeg), General",aetna,Medicaid,O,779.82,234.21,444.50,735.68,467.89
3114,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86780,cpt,"Analysis For Antibody, Treponema Pallidum",aetna,EPO,O,331.50,12.98,188.96,248.62,198.90
3115,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna,Medicaid,O,331.51,82.43,181.40,301.25,102.14
3116,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna,HMO,O,52.60,6.47,8.08,42.46,9.70
3117,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77300,cpt,Calculation Of Radiation Therapy Dose,aetna,HMO,O,273.70,47.14,131.71,131.71,134.83
3118,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna,Medicaid,O,145.10,26.57,41.28,89.17,49.54
3119,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87491,cpt,"Detection Test By Nucleic Acid For Chlamydia Trachomatis, Amplified Probe Technique",aetna,Medicare Part B,O,147.58,21.05,82.44,110.69,42.11
3120,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna,Medicaid,O,252.47,18.27,143.91,336.23,151.48
3121,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,065,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With CC Or Tpa In 24 Hours,aetna,POS,I,23737.47,6483.31,6483.31,11599.87,14242.48
3122,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1644,cpt,"Injection, Heparin Sodium, Per 1000 Units",aetna,POS,O,7.94,2.07,2.73,61.12,4.76
3123,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76700,cpt,"Ultrasound Of Abdomen, Complete",aetna,Medicaid,O,970.94,96.51,542.36,771.89,116.30
3124,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71101,cpt,"X-Ray Of Ribs On One Side Of Body Including The Chest, Minimum Of 3 Views",aetna,Medicare Part B,O,356.28,61.44,203.08,203.08,115.81
3125,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0482,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,POS,O,315.99,78.44,78.44,208.68,189.59
3126,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86430,cpt,Rheumatoid Factor Analysis,aetna,HMO,O,42.58,6.10,14.72,31.94,7.37
3127,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84402,cpt,"Testosterone (Hormone) Level, Free",aetna,POS,O,70.78,13.11,38.73,53.09,30.56
3128,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73502,cpt,"X-Ray Of Hip With Pelvis, 2-3 Views",aetna,EPO,O,213.53,40.67,121.71,169.76,85.98
3129,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36600,cpt,Arterial Puncture Withdrawal Of Blood For Diagnosis,aetna,Medicaid,O,179.32,34.87,147.18,147.18,107.59
3130,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,PPO,I,2882.19,650.30,2882.19,2882.19,1729.31
3131,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38505,cpt,Needle Biopsy Or Removal Of Surface Lymph Nodes,aetna,EPO,O,8266.58,1246.10,7074.31,7074.31,4959.95
3132,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93458,cpt,Insertion Of Catheter In Left Heart For Imaging Of Blood Vessels And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna,Medicare Part B,O,25037.36,2421.03,5730.96,15138.17,15022.42
3133,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1453,cpt,"Injection, Fosaprepitant, 1 Mg",aetna,POS,O,6.67,0.28,3.07,7.29,4.00
3134,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0330,cpt,"Injection, Succinylcholine Chloride, Up To 20 Mg",aetna,POS,O,97.93,26.00,44.25,73.44,58.76
3135,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,HMO,I,72.54,19.89,124.91,124.91,43.52
3136,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9503,cpt,"Technetium Tc-99m Medronate, Diagnostic, Per Study Dose, Up To 30 Millicuries",aetna,Medicare Part A,O,212.36,61.08,121.05,130.93,127.42
3137,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,HMO,I,973.23,169.01,169.01,1031.60,583.94
3138,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86706,cpt,Hepatitis B Surface Antibody Measurement,aetna,Medicaid,O,94.38,6.44,52.72,70.79,12.89
3139,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11102,cpt,"Biopsy Of Related Skin Growth, First Growth",aetna,Medicare Part B,O,1042.00,159.01,160.97,708.35,625.20
3140,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96417,cpt,Infusion Of Different Chemotherapy Drug Or Substance Into A Vein Up To 1 Hour,aetna,Medicare Part B,O,241.84,54.88,132.33,181.38,145.10
3141,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93925,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of Both Legs,aetna,EPO,O,726.73,203.81,207.32,359.62,436.04
3142,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,Medicare Part A,O,2882.19,207.14,1577.05,2666.05,1729.31
3143,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73502,cpt,"X-Ray Of Hip With Pelvis, 2-3 Views",aetna,PPO,O,213.53,40.67,121.71,169.76,85.98
3144,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72072,cpt,"X-Ray Of Middle Spine, 3 Views",aetna,Medicare Part A,O,356.28,33.86,199.02,249.40,116.30
3145,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82784,cpt,Gammaglobulin (Immune System Protein) Measurement,aetna,POS,O,65.66,9.30,9.30,52.19,11.16
3146,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86920,cpt,"Blood Unit Compatibility Test, Immediate Spin Technique",aetna,HMO,O,373.98,33.03,132.10,152.61,79.26
3147,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77373,cpt,Stereotactic Body Radiation Therapy 1 Or More Lesions Using Imaging Guidance,aetna,Medicare Part A,O,4368.52,843.53,2639.46,2639.46,1842.56
3148,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,PPO,O,711.39,96.53,359.62,479.92,426.83
3149,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5103,cpt,"Injection, Infliximab-Dyyb, Biosimilar, (Inflectra), 10 Mg",aetna,Medicaid,O,114.15,40.05,51.37,114.15,68.49
3150,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86920,cpt,"Blood Unit Compatibility Test, Immediate Spin Technique",aetna,Medicaid,O,373.98,33.03,132.10,152.61,79.26
3151,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73080,cpt,"X-Ray Of Elbow, Minimum Of 3 Views",aetna,EPO,O,294.94,49.66,168.12,168.12,176.96
3152,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97530,cpt,"Therapeutic Activities To Improve Function, With One-On-One Contact Between Patient And Provider, Each 15 Minutes",aetna,POS,O,166.34,34.57,91.02,91.02,99.80
3153,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0521,revCode,Freestanding Clinic Clinic Visit By Member Torhc/Fqhc,aetna,EPO,O,195.00,111.87,111.87,244.91,117.00
3154,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11401,cpt,"Removal Of Growth (0.6 To 1.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,Medicaid,O,4292.00,309.74,309.74,2167.15,2575.20
3155,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna,PPO,O,14.15,0.48,0.89,8.71,8.49
3156,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0463,cpt,Hospital Outpatient Clinic Visit For Assessment And Management Of A Patient,aetna,Medicare Part B,O,176.96,59.81,102.70,107.50,106.18
3157,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C8908,cpt,"Magnetic Resonance Imaging Without Contrast Followed By With Contrast, Breast; Bilateral",aetna,EPO,O,3010.79,326.02,1716.15,1716.15,1806.47
3158,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77063,cpt,Screening Digital Tomography Of Both Breasts,aetna,EPO,O,184.03,20.92,100.70,167.23,110.42
3159,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna,HMO,O,93.19,18.38,53.12,74.09,55.91
3160,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43244,cpt,Tying Of Dilated Veins Of Stomach And/Or Esophagus Using A Flexible Endoscope,aetna,POS,O,4323.48,1441.59,1441.59,1469.46,2594.09
3161,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,236,ms-drg,Coronary Bypass Without Cardiac Catheterization Without MCC,aetna,HMO,I,156904.89,23866.31,23891.99,44284.10,94142.93
3162,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna,Medicare Part B,O,50.72,6.48,17.70,38.04,7.78
3163,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,POS,O,2882.19,207.14,1577.05,2666.05,1729.31
3164,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86696,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 2",aetna,Medicare Part A,O,126.23,19.24,69.07,94.67,23.22
3165,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73218,cpt,MRI Scan Of Arm Without Contrast,aetna,POS,O,2882.19,206.00,1642.85,2719.05,1729.31
3166,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2505,cpt,"Injection, Pegfilgrastim, 6 Mg",aetna,POS,O,17508.60,2251.51,6955.90,6955.90,10505.16
3167,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96361,cpt,"Infusion Into A Vein For Hydration, Each Additional Hour",aetna,Medicaid,O,58.98,10.31,33.62,44.24,35.39
3168,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0521,revCode,Freestanding Clinic Clinic Visit By Member Torhc/Fqhc,aetna,Medicare Part A,O,195.00,111.87,111.87,244.91,117.00
3169,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70487,cpt,CT Scan Of Face With Contrast,aetna,HMO,O,1358.47,810.86,810.86,810.86,815.08
3170,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97163,cpt,"Evaluation For Physical Therapy, Typically 45 Minutes",aetna,HMO,O,281.58,53.70,154.08,154.08,168.95
3171,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0881,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (Non-Esrd Use)",aetna,POS,O,15.58,2.38,7.43,7.43,9.35
3172,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,PPO,O,2882.19,207.14,1577.05,2666.05,1729.31
3173,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87045,cpt,Stool Culture,aetna,HMO,O,80.09,9.05,46.05,46.05,11.33
3174,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76805,cpt,"Ultrasound Scan Of Pregnant Uterus (14 Weeks Or More), Single Or First Fetus",aetna,Medicare Part A,O,442.41,49.86,252.17,292.16,117.01
3175,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71101,cpt,"X-Ray Of Ribs On One Side Of Body Including The Chest, Minimum Of 3 Views",aetna,POS,O,356.28,61.44,203.08,203.08,115.81
3176,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84703,cpt,Gonadotropin (Reproductive Hormone) Analysis,aetna,HMO,O,69.48,7.52,37.26,48.18,9.02
3177,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76805,cpt,"Ultrasound Scan Of Pregnant Uterus (14 Weeks Or More), Single Or First Fetus",aetna,PPO,O,442.41,49.86,252.17,292.16,117.01
3178,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,271,ms-drg,Other Major Cardiovascular Procedures With CC,aetna,Medicaid,I,68161.35,20934.94,27743.68,28893.46,40896.81
3179,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna,EPO,O,2882.19,207.14,1577.05,2666.05,1729.31
3180,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84703,cpt,Gonadotropin (Reproductive Hormone) Analysis,aetna,EPO,O,69.48,7.52,37.26,48.18,9.02
3181,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83883,cpt,"Nephelometry, Test Method Using Light",aetna,Medicare Part A,O,93.19,11.70,13.60,69.89,16.32
3182,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna,EPO,O,329.15,22.74,190.91,261.67,197.49
3183,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,HMO,I,268.98,56.00,329.15,795.98,161.39
3184,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93970,cpt,Ultrasound Scan Of Veins Of Both Arms Or Legs Including Assessment Of Compression And Functional Maneuvers,aetna,PPO,O,1047.64,203.81,415.78,773.81,628.58
3185,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28080,cpt,Removal Of Fibrous Nerve Growth From Between Toes,aetna,Medicare Part B,O,17456.96,1200.71,9928.29,9928.29,10474.18
3186,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87186,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or Agar Dilution",aetna,EPO,O,47.53,6.92,8.65,35.65,10.38
3187,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,064,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With MCC,aetna,Medicaid,I,42514.90,11561.36,11613.14,15935.29,25508.94
3188,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna,POS,O,331.51,82.43,181.40,301.25,102.14
3189,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9263,cpt,"Injection, Oxaliplatin, 0.5 Mg",aetna,POS,O,7.79,0.10,0.10,1.89,4.67
3190,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76999,cpt,Other Ultrasound Procedure,aetna,PPO,O,238.30,71.65,130.40,216.32,142.98
3191,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3010,cpt,"Injection, Fentanyl Citrate, 0.1 Mg",aetna,EPO,O,82.61,17.19,37.17,85.93,49.57
3192,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9190,cpt,"Injection, Fluorouracil, 500 Mg",aetna,HMO,O,8.25,1.86,1.89,8.07,4.95
3193,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,PPO,O,33.76,8.03,18.27,694.79,20.26
3194,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73620,cpt,"X-Ray Of Foot, 2 Views",aetna,POS,O,252.47,61.44,143.91,143.91,151.48
3195,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43244,cpt,Tying Of Dilated Veins Of Stomach And/Or Esophagus Using A Flexible Endoscope,aetna,Medicaid,O,4323.48,1441.59,1441.59,1469.46,2594.09
3196,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9190,cpt,"Injection, Fluorouracil, 500 Mg",aetna,PPO,O,8.25,1.86,1.89,8.07,4.95
3197,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9035,cpt,"Injection, Bevacizumab, 10 Mg",aetna,POS,O,282.70,75.76,77.46,77.46,169.62
3198,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76881,cpt,Complete Ultrasound Scan Of Joint,aetna,Medicare Part A,O,379.88,96.50,216.53,216.53,227.93
3199,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86300,cpt,"Immunologic Analysis For Detection Of Tumor Antigen, Quantitative; Ca 15-3",aetna,HMO,O,85.70,20.40,51.78,90.84,24.97
3200,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0921,revCode,"Other Diagnostic Services, Peripheral Vascular Laboratory",aetna,EPO,I,726.73,207.37,642.32,642.32,436.04
3201,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0280,revCode,Oncology General,aetna,Medicaid,O,192.29,49.29,109.61,144.22,115.37
3202,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0482,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,EPO,O,315.99,78.44,78.44,208.68,189.59
3203,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84403,cpt,"Testosterone (Hormone) Level, Total",aetna,Medicare Part A,O,135.66,25.30,77.33,101.75,30.97
3204,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70553,cpt,MRI Scan Of Brain Before And After Contrast,aetna,Medicare Part B,O,3824.84,25.27,2092.84,3040.75,391.22
3205,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,Medicare Part B,I,2452.75,716.49,1897.41,2313.92,1471.65
3206,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81050,cpt,Urine Volume Measurement,aetna,HMO,O,30.08,3.64,17.15,22.56,4.37
3207,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93452,cpt,Insertion Of Tube In Left Heart Chambers For Diagnosis With Review By Radiologist,aetna,HMO,I,54103.79,7333.25,7333.25,7333.25,32462.27
3208,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0482,revCode,"Cardiology, Stress Test",aetna,Medicare Part A,O,474.26,84.78,270.33,377.03,284.56
3209,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,065,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With CC Or Tpa In 24 Hours,aetna,Medicare Part B,I,23737.47,6483.31,6483.31,11599.87,14242.48
3210,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87070,cpt,"Bacterial Culture, Any Other Source Except Urine, Blood Or Stool, Aerobic",aetna,Medicare Part B,O,65.11,8.45,8.58,48.83,10.34
3211,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2175,cpt,"Injection, Meperidine Hydrochloride, Per 100 Mg",aetna,Medicare Part A,O,85.94,17.32,39.53,86.60,51.56
3212,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93798,cpt,"Outpatient Heart Rehabilitation With Electrocardiogram (Ecg) Monitoring, Quality Health Care Professional Services",aetna,EPO,O,173.89,102.78,102.79,130.42,123.35
3213,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0946,revCode,Medical Rehabilitation Day Program Complex Medical Equipment - Routine,aetna,Medicare Part B,I,144.44,64.00,258.21,258.21,86.66
3214,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85018,cpt,"Blood Count, Hemoglobin",aetna,EPO,O,33.02,2.35,18.82,24.77,2.84
3215,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99283,cpt,Emergency Department Visit For Problem Of Moderate Severity,aetna,PPO,E,871.53,205.11,459.97,892.25,522.92
3216,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93017,cpt,Exercise Or Drug-Induced Heart And Blood Vessel Stress Test With Ekg Tracing And Monitoring,aetna,Medicare Part A,O,474.26,84.78,270.33,377.03,284.56
3217,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37230,cpt,"Insertion Of Stents Into Artery In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna,EPO,I,262831.76,27743.68,27743.68,27743.68,157699.06
3218,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5106,cpt,"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (For Non-Esrd Use), 1000 Units",aetna,Medicaid,O,32.27,8.13,8.62,13.29,19.36
3219,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28008,cpt,Incision Of Tissues Of Muscle Compartment Of Foot And/Or Toe,aetna,Medicare Part B,O,15422.69,8682.40,8682.40,15484.76,9253.61
3220,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82397,cpt,Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,aetna,PPO,O,51.39,6.88,29.29,29.29,30.83
3221,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0114,revCode,Room And Board Private (One Bed) Psychiatric,aetna,Medicare Part A,I,2200.28,629.26,1203.93,7562.58,1320.17
3222,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99213,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes",aetna,Medicare Part A,O,270.16,52.43,153.99,211.73,162.10
3223,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna,EPO,O,373.98,199.25,204.64,352.82,359.94
3224,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76801,cpt,Abdominal Ultrasound Of Pregnant Uterus (Less Than 14 Weeks 0 Days) Single Or First Fetus,aetna,EPO,O,357.27,96.50,217.76,229.19,115.81
3225,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88177,cpt,"Pap Test, Evaluation Of Fine Needle Aspirate, Immediate, Each Additional Evaluation Episode",aetna,Medicare Part A,O,49.54,26.22,93.48,93.48,29.72
3226,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76700,cpt,"Ultrasound Of Abdomen, Complete",aetna,POS,O,970.94,96.51,542.36,771.89,116.30
3227,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77385,cpt,"Intensity Modulated Radiation Therapy Delivery, Simple",aetna,POS,O,1786.18,480.50,485.97,729.06,576.60
3228,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77385,cpt,"Intensity Modulated Radiation Therapy Delivery, Simple",aetna,PPO,O,1786.18,480.50,485.97,729.06,576.60
3229,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,POS,I,145.10,44.06,100.82,507.29,87.06
3230,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,Medicare Part B,I,3199.87,740.21,1855.92,2543.89,1919.92
3231,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28080,cpt,Removal Of Fibrous Nerve Growth From Between Toes,aetna,POS,O,17456.96,1200.71,9928.29,9928.29,10474.18
3232,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,Medicare Part B,O,1884.10,207.52,1030.93,11598.92,1130.46
3233,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83735,cpt,Magnesium Level,aetna,EPO,O,65.11,6.70,35.63,46.07,8.04
3234,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93798,cpt,"Outpatient Heart Rehabilitation With Electrocardiogram (Ecg) Monitoring, Quality Health Care Professional Services",aetna,HMO,O,173.89,102.78,102.79,130.42,123.35
3235,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0510,revCode,Clinic General,aetna,HMO,O,167.48,51.31,51.31,289.51,100.49
3236,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna,Medicare Part A,I,5647.36,1115.96,3413.14,3995.78,3388.42
3237,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2250,cpt,"Injection, Midazolam Hydrochloride, Per 1 Mg",aetna,Medicare Part B,O,41.06,10.28,18.48,41.06,24.64
3238,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0771,revCode,"Preventive Care Services, Vaccine Administration",aetna,Medicaid,O,820.44,35.43,512.23,512.23,492.26
3239,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,483,ms-drg,Major Joint Or Limb Reattachment Procedures Of Upper Extremities,aetna,HMO,I,77640.79,14258.73,14814.57,23206.53,46584.47
3240,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87635,cpt,Amplifed DNA Or Rna Probe Detection Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antigen,aetna,Medicaid,O,168.00,50.29,97.44,126.00,61.57
3241,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,Medicare Part B,I,268.98,56.00,329.15,795.98,161.39
3242,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,M0243,cpt,"Intravenous Infusion, Casirivimab And Imdevimab Includes Infusion And Post Administration Monitoring",aetna,POS,O,820.47,138.86,502.86,502.86,492.28
3243,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17003,cpt,"Destruction Of Precancer Skin Growth, 2-14 Growths",aetna,Medicare Part A,O,982.00,159.01,162.47,1222.94,589.20
3244,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82951,cpt,"Blood Glucose (Sugar) Tolerance Test, 3 Specimens",aetna,Medicare Part A,O,117.61,12.87,39.96,84.59,15.44
3245,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2599,cpt,Contact Lens/Es Other Type,aetna,HMO,O,3822.87,1002.34,4045.37,4045.37,2293.72
3246,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73610,cpt,"X-Ray Of Ankle, Minimum Of 3 Views",aetna,HMO,O,329.15,46.08,180.10,261.67,197.49
3247,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92526,cpt,Treatment Of Swallowing And/Or Oral Feeding Function,aetna,Medicare Part B,O,407.71,81.63,232.39,232.39,244.63
3248,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9299,cpt,"Injection, Nivolumab, 1 Mg",aetna,EPO,O,107.35,13.51,28.82,29.25,64.41
3249,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna,Medicaid,I,25207.44,6812.39,8243.81,14290.40,15124.46
3250,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85379,cpt,"Coagulation Function Measurement, D-Dimer; Quantitative",aetna,Medicaid,O,122.56,9.98,71.08,71.08,12.22
3251,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7030,cpt,"Infusion, Normal Saline Solution , 1000 Cc",aetna,HMO,O,8.25,3.71,3.71,162.78,4.95
3252,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87389,cpt,Detection Test By Immunoassay Technique For Hiv-1 Antigen And Hiv-1 And Hiv-2 Antibodies,aetna,Medicaid,O,101.33,8.97,55.45,76.00,28.90
3253,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9000,cpt,"Injection, Doxorubicin Hydrochloride, 10 Mg",aetna,Medicare Part A,O,10.61,1.82,2.81,2.81,6.37
3254,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73560,cpt,"X-Ray Of Knee, 1 Or 2 Views",aetna,EPO,O,231.22,26.24,126.52,126.52,138.73
3255,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna,PPO,O,331.51,82.43,181.40,301.25,102.14
3256,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna,POS,O,145.10,26.57,41.28,89.17,49.54
3257,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76705,cpt,Limited Ultrasound Scan Of Abdomen,aetna,Medicare Part A,O,710.22,96.50,404.83,564.62,115.81
3258,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0214,revCode,Coronary Care Unit Intermediate Ccu,aetna,POS,I,3917.76,854.59,2252.72,11926.72,2350.66
3259,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,Medicare Part B,I,710.22,207.44,407.05,747.97,426.13
3260,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0278,revCode,Medical/Surgical Supplies And Devices Other Implants,aetna,Medicare Part B,I,12498.86,118.53,1501.07,6933.25,7499.32
3261,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87147,cpt,"Identification Of Organisms By Immunologic Analysis, Other Than Immunofluorescence Method",aetna,POS,O,25.94,5.18,5.18,19.46,6.22
3262,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77295,cpt,"Management Of Radiation Therapy, 3d",aetna,EPO,O,1926.57,1003.61,1098.14,1531.62,1341.41
3263,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97166,cpt,"Evaluation For Occupational Therapy, Typically 45 Minutes",aetna,Medicare Part B,O,265.44,85.51,151.30,163.25,159.26
3264,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70490,cpt,CT Scan Of Soft Tissue Of Neck Without Contrast,aetna,EPO,O,1267.08,96.50,693.31,693.31,760.25
3265,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0335,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration -Iv,aetna,Medicaid,O,487.49,86.82,282.74,11490.04,292.49
3266,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82952,cpt,"Blood Glucose (Sugar) Tolerance Test, Each Additional Beyond 3 Specimens",aetna,EPO,O,48.36,3.92,27.57,36.27,4.70
3267,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86592,cpt,Syphilis Detection Test,aetna,Medicare Part A,O,40.11,4.27,22.41,30.08,5.12
3268,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0690,cpt,"Injection, Cefazolin Sodium, 500 Mg",aetna,HMO,O,35.58,12.05,29.43,64.88,21.35
3269,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73200,cpt,CT Scan Of Arm Without Contrast,aetna,Medicare Part B,O,1267.08,96.51,482.16,482.16,760.25
3270,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83001,cpt,"Gonadotropin, Follicle Stimulating (Reproductive Hormone) Level",aetna,Medicaid,O,103.81,18.58,56.81,77.86,22.30
3271,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,EPO,O,83.80,8.07,29.33,89.04,50.28
3272,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,PPO,O,332.78,61.44,194.95,261.67,199.67
3273,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85049,cpt,"Platelet Count, Automated Test",aetna,POS,O,36.32,4.39,4.39,9.15,5.38
3274,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0121,cpt,Colorectal Cancer Screening; Colonoscopy On Individual Not Meeting Criteria For High Risk,aetna,EPO,O,3036.82,702.86,1604.70,2259.70,1822.09
3275,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0946,revCode,Medical Rehabilitation Day Program Complex Medical Equipment - Routine,aetna,Medicare Part A,I,144.44,64.00,258.21,258.21,86.66
3276,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86787,cpt,Analysis For Antibody To Varicella-Zoster Virus (Chicken Pox),aetna,Medicare Part B,O,53.08,6.47,29.05,39.81,15.46
3277,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,EPO,O,1673.95,97.51,795.53,1330.78,1004.37
3278,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85384,cpt,Fibrinogen (Factor 1) Activity Measurement,aetna,Medicare Part B,O,89.70,9.63,54.20,54.20,11.66
3279,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,872,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours Without MCC,aetna,EPO,I,20748.35,5256.97,6524.49,9809.76,12449.01
3280,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0481,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,EPO,O,315.99,155.10,155.10,156.59,189.59
3281,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43450,cpt,Dilation Of Esophagus Unguided,aetna,Medicare Part A,O,3778.61,1075.52,1753.96,3815.86,2267.17
3282,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0510,revCode,Clinic General,aetna,Medicare Part B,O,167.48,51.31,51.31,289.51,100.49
3283,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73030,cpt,"X-Ray Of Shoulder, Minimum Of 2 Views",aetna,POS,O,252.47,45.52,143.91,176.73,151.48
3284,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76830,cpt,Ultrasound Pelvis Through Vagina,aetna,EPO,O,795.16,96.50,435.09,632.15,115.81
3285,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5107,cpt,"Injection, Bevacizumab-Awwb, Biosimilar, (Mvasi), 10 Mg",aetna,EPO,O,219.45,31.72,60.94,74.56,131.67
3286,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,247,ms-drg,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without MCC,aetna,Medicare Part A,I,79628.76,11995.52,12110.64,46153.54,47777.26
3287,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90686,cpt,"Vaccine For Influenza For Administration Into Muscle, 0.5 Ml Dosage, Quadrivalent, Preservation Free",aetna,PPO,O,132.44,13.48,20.93,79.94,79.46
3288,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72110,cpt,"X-Ray Of Lower And Sacral Spine, Minimum Of 4 Views",aetna,EPO,O,613.48,46.08,335.68,365.14,115.81
3289,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9045,cpt,"Injection, Carboplatin, 50 Mg",aetna,Medicaid,O,16.51,2.82,2.82,4.53,9.91
3290,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77334,cpt,"Radiation Treatment Devices, Design And Construction, Complex",aetna,EPO,O,599.32,299.94,327.93,327.93,359.94
3291,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78815,cpt,Nuclear Medicine Study From Skull Base To Mid-Thigh With CT Scan,aetna,POS,O,7116.42,1311.00,3893.89,5657.55,4269.85
3292,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70450,cpt,CT Of Head Without Contrast,aetna,Medicare Part A,O,2452.75,96.51,1398.07,1839.56,115.81
3293,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74246,cpt,X-Ray Of Upper Digestive Tract With Double Contrast,aetna,Medicaid,O,484.07,158.13,264.87,284.00,189.76
3294,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3480,cpt,"Injection, Potassium Chloride, Per 2 Meq",aetna,EPO,O,2.35,0.80,1.02,1.02,1.41
3295,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1885,cpt,"Injection, Ketorolac Tromethamine, Per 15 Mg",aetna,PPO,O,39.72,7.88,18.17,40.53,23.83
3296,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna,Medicaid,O,226.51,61.44,126.53,160.27,135.91
3297,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82952,cpt,"Blood Glucose (Sugar) Tolerance Test, Each Additional Beyond 3 Specimens",aetna,PPO,O,48.36,3.92,27.57,36.27,4.70
3298,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna,POS,O,271.34,80.51,148.47,215.72,96.61
3299,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna,Medicare Part B,O,226.51,61.44,126.53,160.27,135.91
3300,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7121,cpt,"5% Dextrose In Lactated Ringers Infusion, Up To 1000 Cc",aetna,HMO,O,164.65,75.76,75.76,75.76,98.79
3301,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81003,cpt,Automated Urinalysis Test,aetna,Medicaid,O,13.80,2.25,7.55,9.77,2.70
3302,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52260,cpt,Dilation Of The Bladder Using An Endoscope Under General Or Spinal Anesthesia,aetna,PPO,O,14589.65,1578.66,8790.54,8790.54,8753.79
3303,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna,HMO,O,982.00,159.01,162.47,1222.94,589.20
3304,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64636,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Each Additional Facet Joint",aetna,POS,O,7088.87,1523.14,4237.46,4237.46,4253.32
3305,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93017,cpt,Exercise Or Drug-Induced Heart And Blood Vessel Stress Test With Ekg Tracing And Monitoring,aetna,Medicare Part B,O,474.26,84.78,270.33,377.03,284.56
3306,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna,HMO,O,116.31,19.19,63.64,84.77,23.26
3307,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,620,ms-drg,O.R. Procedures For Obesity With CC,aetna,POS,I,57057.61,10746.01,10746.01,20648.25,34234.57
3308,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87660,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Direct Probe Technique",aetna,PPO,O,114.43,12.03,62.62,85.82,24.06
3309,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86200,cpt,Measurement Of Antibody For Rheumatoid Arthritis Assessment,aetna,POS,O,251.28,12.89,140.36,140.36,15.54
3310,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0481,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,PPO,O,315.99,155.10,155.10,156.59,189.59
3311,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0946,revCode,Medical Rehabilitation Day Program Complex Medical Equipment - Routine,aetna,Medicaid,I,144.44,64.00,258.21,258.21,86.66
3312,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96523,cpt,Irrigation Of Implanted Venous Access Drug Delivery Device,aetna,Medicare Part A,O,192.29,49.29,109.61,144.22,115.37
3313,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna,HMO,O,373.98,199.25,204.64,352.82,359.94
3314,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna,Medicare Part B,O,1884.10,427.65,1030.93,1413.08,1130.46
3315,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2469,cpt,"Injection, Palonosetron Hcl, 25 Mcg",aetna,Medicare Part A,O,90.84,19.36,39.42,85.70,54.50
3316,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84480,cpt,"Thyroid Hormone, T3 Measurement, Total",aetna,Medicare Part A,O,60.03,11.72,34.82,34.82,17.02
3317,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78472,cpt,Nuclear Medicine Study Of Heart Pumping Function By Labeling Red Blood Cells With Measurement Of Internal Blood Volume Ejected With Every Beat Over Multiple Cycles,aetna,PPO,O,2168.12,333.98,333.99,645.81,1300.87
3318,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93798,cpt,"Outpatient Heart Rehabilitation With Electrocardiogram (Ecg) Monitoring, Quality Health Care Professional Services",aetna,POS,O,173.89,102.78,102.79,130.42,123.35
3319,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85045,cpt,"Red Blood Count, Automated Test",aetna,Medicaid,O,38.92,2.44,3.98,14.01,4.79
3320,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87641,cpt,"Detection Test By Nucleic Acid For Staphylococcus Aureus, Methicillin Resistant (Mrsa Bacteria), Amplified Probe Technique",aetna,HMO,O,90.84,13.32,51.78,64.28,42.11
3321,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19081,cpt,"Biopsy Of Breast And Placement Of Locating Device Using X-Ray With Needle, First Growth",aetna,POS,O,8708.58,1254.46,4315.79,4315.79,5225.15
3322,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5107,cpt,"Injection, Bevacizumab-Awwb, Biosimilar, (Mvasi), 10 Mg",aetna,Medicare Part A,O,219.45,31.72,60.94,74.56,131.67
3323,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33430,cpt,Replacement Of Valve Between Left Upper And Lower Chambers On Heart-Lung Machine,aetna,Medicare Part A,I,207801.54,46497.02,46497.02,46497.02,124680.92
3324,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,689,ms-drg,Kidney And Urinary Tract Infections With MCC,aetna,Medicare Part B,I,22796.06,6348.25,8547.01,9085.55,13677.64
3325,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna,HMO,E,5923.22,592.08,2036.44,2288.99,3553.93
3326,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88162,cpt,"Screening Examination Of Specimen Cells, Extended Study",aetna,HMO,O,303.20,44.07,44.07,97.64,181.92
3327,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28008,cpt,Incision Of Tissues Of Muscle Compartment Of Foot And/Or Toe,aetna,POS,O,15422.69,8682.40,8682.40,15484.76,9253.61
3328,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83001,cpt,"Gonadotropin, Follicle Stimulating (Reproductive Hormone) Level",aetna,Medicare Part A,O,103.81,18.58,56.81,77.86,22.30
3329,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82397,cpt,Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,aetna,POS,O,51.39,6.88,29.29,29.29,30.83
3330,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0214,revCode,Coronary Care Unit Intermediate Ccu,aetna,HMO,I,3917.76,854.59,2252.72,11926.72,2350.66
3331,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,POS,I,490.78,103.68,279.74,347.25,294.47
3332,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76819,cpt,Ultrasound Scan Of Fetus,aetna,EPO,O,611.12,96.51,348.34,485.84,366.67
3333,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9503,cpt,"Technetium Tc-99m Medronate, Diagnostic, Per Study Dose, Up To 30 Millicuries",aetna,EPO,O,212.36,61.08,121.05,130.93,127.42
3334,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna,Medicaid,O,4055.15,194.15,2179.00,3854.73,1125.84
3335,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0946,revCode,Medical Rehabilitation Day Program Complex Medical Equipment - Routine,aetna,POS,I,144.44,64.00,258.21,258.21,86.66
3336,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64718,cpt,Release And/Or Relocation Of Ulnar Nerve At Elbow,aetna,PPO,O,16595.69,1553.71,9876.73,9876.73,9957.41
3337,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87177,cpt,Smear For Parasites,aetna,Medicare Part B,O,123.87,8.72,70.61,70.61,10.68
3338,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73721,cpt,MRI Scan Of Leg Joint,aetna,PPO,O,2882.19,141.17,1577.05,2039.29,245.82
3339,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76870,cpt,Ultrasound Scan Of Scrotum,aetna,Medicare Part A,O,528.53,96.50,295.23,396.40,317.12
3340,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna,Medicare Part A,O,1956.07,299.94,1070.30,1213.17,359.94
3341,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84112,cpt,Cervicovaginal Secretion Of Placenta Protein,aetna,HMO,O,243.07,29.33,29.33,243.07,49.58
3342,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93458,cpt,Insertion Of Catheter In Left Heart For Imaging Of Blood Vessels And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna,Medicare Part A,O,25037.36,2421.03,5730.96,15138.17,15022.42
3343,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna,Medicare Part B,O,95.71,16.18,16.18,21.31,19.42
3344,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,Medicare Part A,I,58214.47,42815.71,42815.71,42815.71,34928.68
3345,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,M0243,cpt,"Intravenous Infusion, Casirivimab And Imdevimab Includes Infusion And Post Administration Monitoring",aetna,Medicaid,O,820.47,138.86,502.86,502.86,492.28
3346,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9601,cpt,"Percutaneous Transcatheter Placement Of Drug-Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery (List Separately In Addition To",aetna,PPO,O,71354.64,14191.44,14191.44,14191.44,42812.78
3347,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84144,cpt,Progesterone (Reproductive Hormone) Level,aetna,HMO,O,101.45,17.03,55.51,71.78,25.03
3348,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64483,cpt,"Injection Of Anesthetic And/Or Steroid Drug Into Sacral Spine Nerve Root Using Imaging Guidance, Single Level",aetna,POS,O,2134.28,1064.77,4498.33,4498.33,1311.13
3349,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,POS,I,45.29,12.02,38.30,59.57,27.17
3350,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74420,cpt,Imaging Of Urinary Tract Following Injection Of A Contrast Agent,aetna,Medicare Part A,O,1007.53,278.97,574.29,574.29,253.90
3351,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19120,cpt,"Removal Of 1 Or More Breast Growth, Open Procedure",aetna,POS,O,19283.58,2826.79,11249.61,11249.61,3355.94
3352,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0946,revCode,Medical Rehabilitation Day Program Complex Medical Equipment - Routine,aetna,EPO,I,144.44,64.00,258.21,258.21,86.66
3353,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9552,cpt,"Fluorodeoxyglucose F-18 Fdg, Diagnostic, Per Study Dose, Up To 45 Millicuries",aetna,Medicare Part A,O,1552.58,289.56,849.53,1645.73,931.55
3354,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86235,cpt,"Measurement Of Antibody For Assessment Of Autoimmune Disorder, Any Method",aetna,PPO,O,43.81,6.19,24.97,30.69,21.52
3355,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna,Medicare Part A,I,1307.77,398.79,745.43,8974.67,784.66
3356,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1030,cpt,"Injection, Methylprednisolone Acetate, 40 Mg",aetna,Medicare Part A,O,93.27,42.90,42.90,65.77,55.96
3357,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81003,cpt,Automated Urinalysis Test,aetna,PPO,O,13.80,2.25,7.55,9.77,2.70
3358,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73130,cpt,"X-Ray Of Hand, Minimum Of 3 Views",aetna,Medicaid,O,329.15,46.08,180.10,261.67,197.49
3359,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,673,ms-drg,Other Kidney And Urinary Tract Procedures With MCC,aetna,PPO,I,61701.73,20358.57,20462.06,20647.19,37021.04
3360,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45378,cpt,Diagnostic Colonoscopy Of Large Bowel Using A Flexible Endoscope,aetna,EPO,O,3131.25,717.01,1860.41,2251.40,861.59
3361,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9552,cpt,"Fluorodeoxyglucose F-18 Fdg, Diagnostic, Per Study Dose, Up To 45 Millicuries",aetna,PPO,O,1552.58,289.56,849.53,1645.73,931.55
3362,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84480,cpt,"Thyroid Hormone, T3 Measurement, Total",aetna,Medicare Part B,O,60.03,11.72,34.82,34.82,17.02
3363,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A4565,cpt,Slings; Medical And Surgical Supplies - Various Medical Supplies Including Tapes And Surgical Dressings,aetna,EPO,O,21.33,6.00,7.91,29.48,12.80
3364,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36415,cpt,Insertion Of Needle Into Vein For Collection Of Blood Sample,aetna,POS,O,29.48,2.94,3.00,22.11,17.69
3365,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna,POS,O,4055.15,194.15,2179.00,3854.73,1125.84
3366,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0439,cpt,"Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (Pps), Subsequent Visit",aetna,EPO,O,154.00,125.26,125.26,125.26,92.40
3367,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77385,cpt,"Intensity Modulated Radiation Therapy Delivery, Simple",aetna,Medicare Part A,O,1786.18,480.50,485.97,729.06,576.60
3368,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97605,cpt,"Negative Pressure Wound Therapy, Surface Area Less Than Or Equal To 50 Square Centimeters, Per Session",aetna,PPO,O,1788.02,425.00,754.73,826.48,1072.81
3369,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9130,cpt,Dacarbazine 100 Mg Inj,aetna,EPO,O,15.58,5.03,5.03,16.51,9.35
3370,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81003,cpt,Automated Urinalysis Test,aetna,Medicare Part A,O,13.80,2.25,7.55,9.77,2.70
3371,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,23472,cpt,"Prosthetic Repair Of Shoulder Joint, Total Shoulder",aetna,POS,I,123346.27,14814.57,14814.57,14814.57,74007.76
3372,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86778,cpt,Analysis For Antibody (Igm) To Toxoplasma (Parasite),aetna,EPO,O,152.18,14.27,86.74,86.74,91.31
3373,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9579,cpt,"Injection, Gadolinium-Based Magnetic Resonance Contrast Agent, Not Otherwise Specified (Nos), Per Ml",aetna,Medicare Part A,O,15.32,0.10,6.89,16.23,9.19
3374,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0341,revCode,"Nuclear Medicine, Diagnostic",aetna,Medicaid,O,5568.56,800.20,3046.95,5465.13,3341.14
3375,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0214,revCode,Coronary Care Unit Intermediate Ccu,aetna,Medicaid,I,3917.76,854.59,2252.72,11926.72,2350.66
3376,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9228,cpt,"Injection, Ipilimumab, 1 Mg",aetna,Medicare Part A,O,588.70,104.49,157.23,157.23,353.22
3377,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81001,cpt,"Manual Urinalysis Test With Examination Using Microscope, Automated",aetna,Medicare Part B,O,13.80,2.37,7.87,10.35,8.28
3378,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74420,cpt,Imaging Of Urinary Tract Following Injection Of A Contrast Agent,aetna,PPO,O,1007.53,278.97,574.29,574.29,253.90
3379,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96374,cpt,"Injection Of Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,PPO,O,218.25,39.35,154.75,181.39,130.95
3380,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76642,cpt,Limited Ultrasound Scan Of 1 Breast,aetna,HMO,O,305.55,71.65,167.19,242.91,183.33
3381,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86360,cpt,"T Cell Count And Ratio, Including Ratio",aetna,HMO,O,220.61,31.37,125.75,125.75,132.37
3382,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,186,ms-drg,Pleural Effusion With MCC,aetna,Medicare Part A,I,29279.58,9460.85,9734.76,9734.76,17567.75
3383,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0690,cpt,"Injection, Cefazolin Sodium, 500 Mg",aetna,POS,O,35.58,12.05,29.43,64.88,21.35
3384,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,853,ms-drg,Infectious And Parasitic Diseases With O.R. Procedures With MCC,aetna,EPO,I,131887.09,28277.35,28277.35,59129.81,79132.25
3385,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,HMO,I,58214.47,42815.71,42815.71,42815.71,34928.68
3386,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87046,cpt,"Stool Culture, Additional Pathogens",aetna,EPO,O,52.60,5.92,30.25,30.25,11.33
3387,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93225,cpt,Electrocardiogram (Ecg) 2-Day Continuous,aetna,HMO,O,251.28,64.70,119.50,199.77,150.77
3388,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,HMO,O,110.40,7.04,8.00,129.02,66.24
3389,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87205,cpt,Special Gram Or Giemsa Stain For Microorganism,aetna,Medicare Part B,O,87.53,4.18,4.25,65.65,5.12
3390,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80162,cpt,"Digoxin Level, Total",aetna,HMO,O,101.33,13.28,13.28,18.31,15.94
3391,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0762,revCode,Specialty Services Observation Hours,aetna,Medicaid,I,15.11,4.72,10.23,10.23,9.07
3392,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna,POS,O,251.28,64.70,137.49,266.35,150.77
3393,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0771,revCode,"Preventive Care Services, Vaccine Administration",aetna,Medicare Part A,O,820.44,35.43,512.23,512.23,492.26
3394,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0510,revCode,Clinic General,aetna,POS,O,167.48,51.31,51.31,289.51,100.49
3395,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86695,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 1",aetna,Medicaid,O,89.65,13.19,49.06,67.24,15.83
3396,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73721,cpt,MRI Scan Of Leg Joint,aetna,Medicare Part A,O,2882.19,141.17,1577.05,2039.29,245.82
3397,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82731,cpt,Fetal Fibronectin (Protein) Analysis,aetna,Medicaid,O,565.34,60.62,64.37,424.01,115.33
3398,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,EPO,O,654.73,185.98,323.41,694.53,392.84
3399,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,853,ms-drg,Infectious And Parasitic Diseases With O.R. Procedures With MCC,aetna,PPO,I,131887.09,28277.35,28277.35,59129.81,79132.25
3400,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7050,cpt,"Infusion, Normal Saline Solution, 250 Cc",aetna,POS,O,157.33,71.59,71.59,118.00,94.40
3401,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,Medicare Part A,I,2882.19,650.30,2882.19,2882.19,1729.31
3402,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86709,cpt,Measurement Of Hepatitis A Antibody (Igm),aetna,PPO,O,106.28,11.21,60.58,60.58,63.77
3403,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96415,cpt,"Administration Of Chemotherapy Into Vein, Each Additional Hour",aetna,Medicaid,O,110.89,25.40,60.68,83.17,66.53
3404,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9130,cpt,Dacarbazine 100 Mg Inj,aetna,PPO,O,15.58,5.03,5.03,16.51,9.35
3405,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72072,cpt,"X-Ray Of Middle Spine, 3 Views",aetna,HMO,O,356.28,33.86,199.02,249.40,116.30
3406,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna,HMO,O,2882.19,203.81,1577.05,2291.34,244.57
3407,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2785,cpt,"Injection, Regadenoson, 0.1 Mg",aetna,EPO,O,154.74,25.67,69.52,154.76,92.84
3408,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92611,cpt,Fluoroscopic And Video Recorded Motion Evaluation Of Swallowing Function,aetna,PPO,O,328.90,87.83,190.76,190.76,197.34
3409,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,Medicare Part B,I,2882.19,650.30,2882.19,2882.19,1729.31
3410,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77338,cpt,Design And Construction Of Radiation Treatment Device For High Precision Radiation Therapy,aetna,Medicare Part A,O,2028.03,299.94,1109.68,1109.68,359.94
3411,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36561,cpt,"Insertion Of Central Venous Catheter And Implanted Device For Infusion Beneath The Skin, Patient 5 Years Or Older",aetna,EPO,O,18382.66,2534.31,2589.99,17974.64,11029.60
3412,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97162,cpt,"Evaluation For Physical Therapy, Typically 30 Minutes",aetna,POS,O,224.82,58.86,123.02,136.58,134.89
3413,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77373,cpt,Stereotactic Body Radiation Therapy 1 Or More Lesions Using Imaging Guidance,aetna,PPO,O,4368.52,843.53,2639.46,2639.46,1842.56
3414,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87081,cpt,Screening Test For Pathogenic Organisms,aetna,Medicare Part B,O,45.06,3.98,25.68,32.84,9.19
3415,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna,PPO,O,2535.33,203.81,1416.20,1958.54,244.57
3416,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78816,cpt,Nuclear Medicine Study With CT Imaging Whole Body,aetna,POS,O,7556.48,1311.05,1311.05,2704.61,4533.89
3417,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92526,cpt,Treatment Of Swallowing And/Or Oral Feeding Function,aetna,POS,O,407.71,81.63,232.39,232.39,244.63
3418,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82525,cpt,Copper Level,aetna,Medicaid,O,71.96,9.63,39.38,39.38,14.89
3419,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96374,cpt,"Injection Of Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,EPO,O,218.25,39.35,154.75,181.39,130.95
3420,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88175,cpt,"Pap Test, Automated Thin Layer Preparation; Automated System And Manual Rescreening",aetna,HMO,O,83.33,0.35,47.50,60.74,31.93
3421,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82525,cpt,Copper Level,aetna,EPO,O,71.96,9.63,39.38,39.38,14.89
3422,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2599,cpt,Contact Lens/Es Other Type,aetna,PPO,O,3822.87,1002.34,4045.37,4045.37,2293.72
3423,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99212,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 10 Minutes",aetna,Medicare Part A,O,180.14,52.17,102.68,135.10,108.08
3424,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9354,cpt,"Injection, Ado-Trastuzumab Emtansine, 1 Mg",aetna,EPO,O,123.87,25.63,36.89,41.57,74.32
3425,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99211,cpt,Office Or Other Outpatient Visit For The Evaluation And Management Of Established Patient That May Not Require Presence Of Healthcare Professional,aetna,POS,O,91.30,29.79,52.04,190.38,54.78
3426,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,811,ms-drg,Red Blood Cell Disorders With MCC,aetna,Medicare Part A,I,34462.34,8519.29,8897.14,15450.42,20677.40
3427,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96413,cpt,"Administration Of Chemotherapy Into Vein, 1 Hour Or Less",aetna,HMO,O,516.73,113.98,282.74,387.55,310.04
3428,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72148,cpt,MRI Scan Of Lower Spinal Canal,aetna,Medicare Part B,O,2882.19,203.81,1642.85,2039.29,244.57
3429,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9500,cpt,"Technetium Tc-99m Sestamibi, Diagnostic, Per Study Dose",aetna,EPO,O,692.52,114.53,394.74,734.07,415.51
3430,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,784,ms-drg,Cesarean Section With Sterilization With CC,aetna,PPO,I,14658.24,5823.07,5823.07,10802.78,8794.94
3431,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88309,cpt,"Pathology Examination Of Tissue Using A Microscope, High Complexity",aetna,Medicaid,O,696.07,273.94,396.76,396.76,417.64
3432,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9145,cpt,"Injection, Daratumumab, 10 Mg",aetna,EPO,O,87.92,56.29,56.29,56.29,52.75
3433,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88313,cpt,Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,aetna,PPO,O,119.15,45.38,67.92,67.92,71.49
3434,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,57522,cpt,Removal Or Destruction Of Cervix With Electrical Cautery,aetna,Medicaid,O,18168.39,2323.14,10911.60,10911.60,10901.03
3435,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85732,cpt,"Coagulation Assessment Blood Test, Substitution, Plasma Fractions",aetna,HMO,O,35.39,3.71,20.17,26.54,7.76
3436,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87510,cpt,"Detection Test For Gardnerella Vaginalis (Bacteria), Direct Probe Technique",aetna,HMO,O,107.59,12.03,58.87,104.55,24.06
3437,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna,Medicare Part B,O,135.07,18.96,76.99,121.94,81.04
3438,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74175,cpt,CT Scan Of Blood Vessels Of Abdomen With Contrast,aetna,Medicare Part B,O,1737.39,158.13,158.13,1841.63,1042.43
3439,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19084,cpt,"Biopsy Of Breast And Placement Of Locating Device Using Ultrasound, Each Additional Growth",aetna,HMO,O,12042.88,1246.10,6742.37,6742.37,7225.73
3440,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna,POS,O,332.78,61.44,194.95,261.67,199.67
3441,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0431,revCode,Occupational Therapy Visit Charge,aetna,Medicare Part A,O,173.42,21.75,80.69,875.96,104.05
3442,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2405,cpt,"Injection, Ondansetron Hydrochloride, Per 1 Mg",aetna,PPO,O,19.54,1.76,8.78,19.52,11.72
3443,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0121,cpt,Colorectal Cancer Screening; Colonoscopy On Individual Not Meeting Criteria For High Risk,aetna,HMO,O,3036.82,702.86,1604.70,2259.70,1822.09
3444,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5107,cpt,"Injection, Bevacizumab-Awwb, Biosimilar, (Mvasi), 10 Mg",aetna,PPO,O,219.45,31.72,60.94,74.56,131.67
3445,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9601,cpt,"Percutaneous Transcatheter Placement Of Drug-Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery (List Separately In Addition To",aetna,Medicare Part B,O,71354.64,14191.44,14191.44,14191.44,42812.78
3446,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1437,cpt,"Injection, Ferric Derisomaltose, 10 Mg",aetna,Medicare Part B,O,80.56,14.43,25.38,25.82,48.34
3447,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93660,cpt,Evaluation Of Heart Function Using Tilt Table,aetna,HMO,O,1139.65,276.48,649.60,649.60,683.79
3448,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96402,cpt,Hormonal Anti-Neoplastic Chemotherapy Administration Beneath The Skin Or Into Muscle,aetna,PPO,O,125.04,21.31,71.27,71.27,75.02
3449,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,Medicare Part A,I,140.26,41.63,88.86,224.92,84.16
3450,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1100,cpt,"Injection, Dexamethasone Sodium Phosphate, 1 Mg",aetna,Medicare Part B,O,7.91,1.12,1.12,7.91,4.75
3451,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93289,cpt,"Evaluation Of Defibrillator Including Connection, Recording And Disconnection",aetna,Medicare Part A,O,206.45,32.90,115.33,115.33,123.87
3452,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70490,cpt,CT Scan Of Soft Tissue Of Neck Without Contrast,aetna,HMO,O,1267.08,96.50,693.31,693.31,760.25
3453,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86140,cpt,Measurement C-Reactive Protein For Detection Of Infection Or Inflammation,aetna,Medicaid,O,67.58,5.08,38.52,50.69,6.22
3454,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87493,cpt,"Detection Test By Nucleic Acid For Clostridium Difficile, Amplified Probe Technique",aetna,PPO,O,100.03,11.59,58.02,58.02,44.72
3455,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna,HMO,O,3391.86,327.84,1855.92,2543.90,462.44
3456,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97605,cpt,"Negative Pressure Wound Therapy, Surface Area Less Than Or Equal To 50 Square Centimeters, Per Session",aetna,Medicare Part A,O,1788.02,425.00,754.73,826.48,1072.81
3457,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,20680,cpt,Removal Of Deep Implant From Bone,aetna,Medicare Part A,O,21223.25,2098.90,12436.52,12436.52,12733.95
3458,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,HMO,I,1884.10,527.05,1030.93,1360.64,1130.46
3459,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,Medicare Part B,I,179.32,42.72,98.12,174.25,107.59
3460,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93458,cpt,Insertion Of Catheter In Left Heart For Imaging Of Blood Vessels And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna,Medicaid,O,25037.36,2421.03,5730.96,15138.17,15022.42
3461,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64636,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Each Additional Facet Joint",aetna,EPO,O,7088.87,1523.14,4237.46,4237.46,4253.32
3462,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1442,cpt,"Injection, Filgrastim (G-Csf), Excludes Biosimilars, 1 Microgram",aetna,HMO,O,4.45,0.72,0.93,1.48,2.67
3463,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86360,cpt,"T Cell Count And Ratio, Including Ratio",aetna,EPO,O,220.61,31.37,125.75,125.75,132.37
3464,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78227,cpt,Nuclear Medicine Study Of Liver And Bile Duct System With Use Of Drugs,aetna,HMO,O,1528.98,161.81,836.62,1038.75,520.12
3465,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11042,cpt,Removal Of Skin And Tissue First 20 Sq Cm Or Less,aetna,Medicare Part B,O,1315.41,306.28,624.03,3179.32,789.25
3466,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83615,cpt,Lactate Dehydrogenase (Enzyme) Level,aetna,Medicare Part B,O,50.72,6.04,28.91,70.62,7.25
3467,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93660,cpt,Evaluation Of Heart Function Using Tilt Table,aetna,POS,O,1139.65,276.48,649.60,649.60,683.79
3468,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82607,cpt,Cyanocobalamin (Vitamin B-12) Level,aetna,Medicare Part A,O,73.83,10.37,42.08,42.08,18.10
3469,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93971,cpt,Ultrasound Scan Of Veins Of One Arm Or Leg Or Limited Including Assessment Of Compression And Functional Maneuvers,aetna,Medicare Part A,O,726.73,96.51,397.65,397.65,436.04
3470,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77338,cpt,Design And Construction Of Radiation Treatment Device For High Precision Radiation Therapy,aetna,EPO,O,2028.03,299.94,1109.68,1109.68,359.94
3471,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90686,cpt,"Vaccine For Influenza For Administration Into Muscle, 0.5 Ml Dosage, Quadrivalent, Preservation Free",aetna,Medicare Part B,O,132.44,13.48,20.93,79.94,79.46
3472,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5106,cpt,"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (For Non-Esrd Use), 1000 Units",aetna,Medicare Part A,O,32.27,8.13,8.62,13.29,19.36
3473,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,871,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours With MCC,aetna,Medicare Part A,I,36297.45,7941.64,11794.58,17432.39,21778.47
3474,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88307,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately High Complexity",aetna,Medicare Part A,O,298.47,86.80,170.13,298.47,179.08
3475,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78452,cpt,Nuclear Medicine Study Of Vessels Of Heart Using Drugs Or Exercise Multiple Studies,aetna,PPO,O,5568.56,920.95,3046.95,4176.42,1387.91
3476,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86360,cpt,"T Cell Count And Ratio, Including Ratio",aetna,Medicaid,O,220.61,31.37,125.75,125.75,132.37
3477,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2599,cpt,Contact Lens/Es Other Type,aetna,EPO,O,3822.87,1002.34,4045.37,4045.37,2293.72
3478,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83001,cpt,"Gonadotropin, Follicle Stimulating (Reproductive Hormone) Level",aetna,Medicare Part B,O,103.81,18.58,56.81,77.86,22.30
3479,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,20680,cpt,Removal Of Deep Implant From Bone,aetna,POS,O,21223.25,2098.90,12436.52,12436.52,12733.95
3480,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93971,cpt,Ultrasound Scan Of Veins Of One Arm Or Leg Or Limited Including Assessment Of Compression And Functional Maneuvers,aetna,PPO,O,726.73,96.51,397.65,397.65,436.04
3481,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna,Medicare Part B,O,251.28,64.70,137.49,266.36,150.77
3482,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82952,cpt,"Blood Glucose (Sugar) Tolerance Test, Each Additional Beyond 3 Specimens",aetna,HMO,O,48.36,3.92,27.57,36.27,4.70
3483,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88177,cpt,"Pap Test, Evaluation Of Fine Needle Aspirate, Immediate, Each Additional Evaluation Episode",aetna,EPO,O,49.54,26.22,93.48,93.48,29.72
3484,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86200,cpt,Measurement Of Antibody For Rheumatoid Arthritis Assessment,aetna,Medicare Part A,O,251.28,12.89,140.36,140.36,15.54
3485,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73523,cpt,"X-Ray Of Both Hips With Pelvis, Minimum Of 5 Views",aetna,HMO,O,636.63,58.51,384.65,536.48,115.81
3486,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28008,cpt,Incision Of Tissues Of Muscle Compartment Of Foot And/Or Toe,aetna,HMO,O,15422.69,8682.40,8682.40,15484.76,9253.61
3487,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73700,cpt,CT Scan Of Leg Without Contrast,aetna,Medicare Part B,O,1395.67,96.50,779.60,809.76,837.40
3488,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,PPO,I,179.32,42.72,98.12,174.25,107.59
3489,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna,EPO,I,1307.77,398.79,745.43,8974.67,784.66
3490,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93971,cpt,Ultrasound Scan Of Veins Of One Arm Or Leg Or Limited Including Assessment Of Compression And Functional Maneuvers,aetna,EPO,O,726.73,96.51,397.65,397.65,436.04
3491,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83002,cpt,"Gonadotropin, Luteinizing (Reproductive Hormone) Level",aetna,Medicare Part A,O,250.10,18.52,142.56,187.58,22.22
3492,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna,EPO,I,5647.36,1115.96,3413.14,3995.78,3388.42
3493,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0439,cpt,"Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (Pps), Subsequent Visit",aetna,HMO,O,154.00,125.26,125.26,125.26,92.40
3494,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna,EPO,O,142.89,8.03,64.15,113.59,16.07
3495,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0124,revCode,Room And Board Semiprivate (Two Beds) Psychiatric,aetna,POS,I,2075.74,728.48,728.48,1347.17,1245.44
3496,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,HMO,I,179.32,42.72,98.12,174.25,107.59
3497,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84145,cpt,Procalcitonin (Hormone) Level,aetna,POS,O,97.91,20.28,53.57,53.57,32.66
3498,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64636,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Each Additional Facet Joint",aetna,Medicare Part B,O,7088.87,1523.14,4237.46,4237.46,4253.32
3499,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86140,cpt,Measurement C-Reactive Protein For Detection Of Infection Or Inflammation,aetna,Medicare Part A,O,67.58,5.08,38.52,50.69,6.22
3500,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9144,cpt,"Injection, Daratumumab, 10 Mg And Hyaluronidase-Fihj",aetna,EPO,O,139.92,43.18,45.07,45.65,83.95
3501,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19307,cpt,Removal Of Breast And Underarm Lymph Nodes,aetna,PPO,O,22716.20,13126.41,13126.41,13126.41,13629.72
3502,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,620,ms-drg,O.R. Procedures For Obesity With CC,aetna,EPO,I,57057.61,10746.01,10746.01,20648.25,34234.57
3503,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1100,cpt,"Injection, Dexamethasone Sodium Phosphate, 1 Mg",aetna,Medicare Part A,O,7.91,1.12,1.12,7.91,4.75
3504,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76705,cpt,Limited Ultrasound Scan Of Abdomen,aetna,EPO,O,710.22,96.50,404.83,564.62,115.81
3505,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85732,cpt,"Coagulation Assessment Blood Test, Substitution, Plasma Fractions",aetna,PPO,O,35.39,3.71,20.17,26.54,7.76
3506,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96375,cpt,"Injection Of Different Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,Medicaid,O,88.47,19.71,48.41,66.35,53.08
3507,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0920,revCode,"Other Diagnostic Services, General",aetna,HMO,O,1599.77,95.44,145.06,814.63,959.86
3508,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,EPO,I,225.33,71.10,128.44,225.33,135.20
3509,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93005,cpt,Routine Electrocardiogram (Ekg) With Tracing Using At Least 12 Leads,aetna,POS,O,218.25,35.36,121.91,154.43,130.95
3510,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9537,cpt,"Technetium Tc-99m Mebrofenin, Diagnostic, Per Study Dose, Up To 15 Millicuries",aetna,EPO,O,218.14,24.47,126.52,157.09,130.88
3511,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88313,cpt,Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,aetna,EPO,O,119.15,45.38,67.92,67.92,71.49
3512,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87536,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Quantification",aetna,PPO,O,519.10,67.96,295.89,295.89,311.46
3513,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9217,cpt,"Leuprolide Acetate (For Depot Suspension), 7.5 Mg",aetna,Medicaid,O,950.89,129.50,183.03,183.03,570.53
3514,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0331,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration - Injection,aetna,Medicare Part B,O,270.45,26.27,71.27,513.21,162.27
3515,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83550,cpt,Iron Binding Capacity,aetna,HMO,O,106.28,8.57,60.58,106.28,10.49
3516,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,46255,cpt,Removal Of Single External And Internal Hemorrhoid Group,aetna,PPO,O,17900.37,2210.31,9939.29,9939.29,10740.22
3517,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97035,cpt,"Application Of Ultrasound To 1 Or More Areas, Each 15 Minutes",aetna,Medicare Part A,O,106.18,10.67,46.92,46.92,63.71
3518,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82731,cpt,Fetal Fibronectin (Protein) Analysis,aetna,Medicare Part A,O,565.34,60.62,64.37,424.01,115.33
3519,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19307,cpt,Removal Of Breast And Underarm Lymph Nodes,aetna,Medicaid,O,22716.20,13126.41,13126.41,13126.41,13629.72
3520,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73721,cpt,MRI Scan Of Leg Joint,aetna,EPO,O,2882.19,141.17,1577.05,2039.29,245.82
3521,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97018,cpt,Application Of Hot Wax Bath To 1 Or More Areas,aetna,Medicare Part A,O,79.04,3.64,32.08,34.45,47.42
3522,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84145,cpt,Procalcitonin (Hormone) Level,aetna,HMO,O,97.91,20.28,53.57,53.57,32.66
3523,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19083,cpt,"Biopsy Of Breast Accessed Through The Skin With Ultrasound Guidance, First Lesion",aetna,Medicare Part A,O,8391.01,1246.10,6742.37,6742.37,5034.61
3524,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0450,revCode,"Emergency Room, General",aetna,POS,I,891.51,282.04,810.79,6159.07,534.91
3525,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97597,cpt,"Removal Of Tissue From Wounds Per Session, First 20 Sq Cms Or Less",aetna,POS,O,596.96,89.68,159.02,159.02,358.18
3526,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36591,cpt,Collection Of Blood Specimen From A Completely Implantable Venous Access Device,aetna,EPO,O,172.23,13.59,102.02,102.02,103.34
3527,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9000,cpt,"Injection, Doxorubicin Hydrochloride, 10 Mg",aetna,EPO,O,10.61,1.82,2.81,2.81,6.37
3528,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85613,cpt,"Clotting Factor X Assessment Test, Diluted",aetna,POS,O,44.82,4.71,25.55,33.62,11.50
3529,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82670,cpt,Measurement Of Total Estradiol (Hormone),aetna,Medicaid,O,166.34,27.94,91.02,145.43,99.80
3530,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83001,cpt,"Gonadotropin, Follicle Stimulating (Reproductive Hormone) Level",aetna,HMO,O,103.81,18.58,56.81,77.86,22.30
3531,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna,PPO,O,251.28,64.70,137.49,266.36,150.77
3532,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna,Medicare Part B,O,4055.15,194.15,2179.00,3854.73,1125.84
3533,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93798,cpt,"Outpatient Heart Rehabilitation With Electrocardiogram (Ecg) Monitoring, Quality Health Care Professional Services",aetna,Medicare Part B,O,173.89,102.78,102.79,130.42,123.35
3534,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,191,ms-drg,Chronic Obstructive Pulmonary Disease With CC,aetna,Medicare Part B,I,15955.32,4343.49,5733.83,7724.36,9573.19
3535,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86140,cpt,Measurement C-Reactive Protein For Detection Of Infection Or Inflammation,aetna,PPO,O,67.58,5.08,38.52,50.69,6.22
3536,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19307,cpt,Removal Of Breast And Underarm Lymph Nodes,aetna,Medicare Part B,O,22716.20,13126.41,13126.41,13126.41,13629.72
3537,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87081,cpt,Screening Test For Pathogenic Organisms,aetna,EPO,O,45.06,3.98,25.68,32.84,9.19
3538,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87536,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Quantification",aetna,Medicare Part B,O,519.10,67.96,295.89,295.89,311.46
3539,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96413,cpt,"Administration Of Chemotherapy Into Vein, 1 Hour Or Less",aetna,Medicare Part A,O,516.73,113.98,282.74,387.55,310.04
3540,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96415,cpt,"Administration Of Chemotherapy Into Vein, Each Additional Hour",aetna,PPO,O,110.89,25.40,60.68,83.17,66.53
3541,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86762,cpt,Analysis For Antibody To Rubella (German Measles Virus),aetna,Medicare Part A,O,50.01,4.42,27.36,37.51,17.10
3542,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,853,ms-drg,Infectious And Parasitic Diseases With O.R. Procedures With MCC,aetna,HMO,I,131887.09,28277.35,28277.35,59129.81,79132.25
3543,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,Medicaid,I,710.22,207.44,407.05,747.97,426.13
3544,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0897,cpt,"Injection, Denosumab, 1 Mg",aetna,Medicare Part A,O,62.32,12.82,18.35,21.26,37.39
3545,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85732,cpt,"Coagulation Assessment Blood Test, Substitution, Plasma Fractions",aetna,Medicare Part B,O,35.39,3.71,20.17,26.54,7.76
3546,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0372,revCode,Anesthesia Incident To Other Diagnostic Services,aetna,POS,O,47.19,22.12,27.37,27.37,28.31
3547,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78452,cpt,Nuclear Medicine Study Of Vessels Of Heart Using Drugs Or Exercise Multiple Studies,aetna,HMO,O,5568.56,920.95,3046.95,4176.42,1387.91
3548,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81003,cpt,Automated Urinalysis Test,aetna,EPO,O,13.80,2.25,7.55,9.77,2.70
3549,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9040,cpt,"Injection, Bleomycin Sulfate, 15 Units",aetna,POS,O,435.33,29.13,29.13,51.36,261.20
3550,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78452,cpt,Nuclear Medicine Study Of Vessels Of Heart Using Drugs Or Exercise Multiple Studies,aetna,Medicare Part B,O,5568.56,920.95,3046.95,4176.42,1387.91
3551,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36591,cpt,Collection Of Blood Specimen From A Completely Implantable Venous Access Device,aetna,Medicaid,O,172.23,13.59,102.02,102.02,103.34
3552,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93005,cpt,Routine Electrocardiogram (Ekg) With Tracing Using At Least 12 Leads,aetna,Medicare Part B,O,218.25,35.36,121.91,154.43,130.95
3553,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0762,revCode,Specialty Services Observation Hours,aetna,EPO,I,15.11,4.72,10.23,10.23,9.07
3554,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97113,cpt,"Water Pool Therapy With Therapeutic Exercises To 1 Or More Areas, Each 15 Minutes",aetna,Medicaid,O,132.12,28.83,54.93,62.54,79.27
3555,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52260,cpt,Dilation Of The Bladder Using An Endoscope Under General Or Spinal Anesthesia,aetna,POS,O,14589.65,1578.66,8790.54,8790.54,8753.79
3556,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0410,revCode,"Respiratory Services, General",aetna,PPO,I,205.27,71.94,125.75,182.34,123.16
3557,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1100,cpt,"Injection, Dexamethasone Sodium Phosphate, 1 Mg",aetna,HMO,O,7.91,1.12,1.12,7.91,4.75
3558,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,191,ms-drg,Chronic Obstructive Pulmonary Disease With CC,aetna,POS,I,15955.32,4343.49,5733.83,7724.36,9573.19
3559,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0280,revCode,Oncology General,aetna,PPO,O,192.29,49.29,109.61,144.22,115.37
3560,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna,PPO,I,1307.77,398.79,745.43,8974.67,784.66
3561,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86235,cpt,"Measurement Of Antibody For Assessment Of Autoimmune Disorder, Any Method",aetna,Medicaid,O,43.81,6.19,24.97,30.69,21.52
3562,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2469,cpt,"Injection, Palonosetron Hcl, 25 Mcg",aetna,HMO,O,90.84,19.36,39.42,85.70,54.50
3563,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93971,cpt,Ultrasound Scan Of Veins Of One Arm Or Leg Or Limited Including Assessment Of Compression And Functional Maneuvers,aetna,Medicare Part B,O,726.73,96.51,397.65,397.65,436.04
3564,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92611,cpt,Fluoroscopic And Video Recorded Motion Evaluation Of Swallowing Function,aetna,HMO,O,328.90,87.83,190.76,190.76,197.34
3565,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52260,cpt,Dilation Of The Bladder Using An Endoscope Under General Or Spinal Anesthesia,aetna,Medicaid,O,14589.65,1578.66,8790.54,8790.54,8753.79
3566,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36415,cpt,Insertion Of Needle Into Vein For Collection Of Blood Sample,aetna,Medicaid,O,29.48,2.94,3.00,22.11,17.69
3567,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1030,cpt,"Injection, Methylprednisolone Acetate, 40 Mg",aetna,HMO,O,93.27,42.90,42.90,65.77,55.96
3568,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,Medicaid,I,225.33,71.10,128.44,225.33,135.20
3569,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86803,cpt,Hepatitis C Antibody Measurement,aetna,HMO,O,113.25,14.27,64.55,140.68,17.12
3570,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19307,cpt,Removal Of Breast And Underarm Lymph Nodes,aetna,POS,O,22716.20,13126.41,13126.41,13126.41,13629.72
3571,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,HMO,I,710.22,207.44,407.05,747.97,426.13
3572,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,Medicare Part A,I,179.32,42.72,98.12,174.25,107.59
3573,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88177,cpt,"Pap Test, Evaluation Of Fine Needle Aspirate, Immediate, Each Additional Evaluation Episode",aetna,HMO,O,49.54,26.22,93.48,93.48,29.72
3574,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,POS,I,58214.47,42815.71,42815.71,42815.71,34928.68
3575,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9045,cpt,"Injection, Carboplatin, 50 Mg",aetna,POS,O,16.51,2.82,2.82,4.53,9.91
3576,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0771,revCode,"Preventive Care Services, Vaccine Administration",aetna,HMO,O,820.44,35.43,512.23,512.23,492.26
3577,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,EPO,O,1884.10,207.52,1030.93,11598.92,1130.46
3578,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84466,cpt,Transferrin (Iron Binding Protein) Level,aetna,Medicare Part B,O,67.24,10.47,36.80,36.80,40.34
3579,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77417,cpt,Therapeutic Radiology Port Films,aetna,Medicare Part B,O,37.84,21.95,21.95,28.66,9.54
3580,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna,Medicaid,O,251.28,64.70,137.49,266.36,150.77
3581,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9217,cpt,"Leuprolide Acetate (For Depot Suspension), 7.5 Mg",aetna,HMO,O,950.89,129.50,183.03,183.03,570.53
3582,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna,HMO,O,226.51,61.44,126.53,160.27,135.91
3583,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1030,cpt,"Injection, Methylprednisolone Acetate, 40 Mg",aetna,POS,O,93.27,42.90,42.90,65.77,55.96
3584,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,PPO,O,576.53,96.50,334.39,562.62,345.92
3585,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87510,cpt,"Detection Test For Gardnerella Vaginalis (Bacteria), Direct Probe Technique",aetna,PPO,O,107.59,12.03,58.87,104.55,24.06
3586,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,219,ms-drg,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With MCC,aetna,Medicaid,I,256090.54,46435.26,46497.02,47950.73,153654.32
3587,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73560,cpt,"X-Ray Of Knee, 1 Or 2 Views",aetna,HMO,O,231.22,26.24,126.52,126.52,138.73
3588,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0450,revCode,"Emergency Room, General",aetna,EPO,I,891.51,282.04,810.79,6159.07,534.91
3589,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0280,revCode,Oncology General,aetna,Medicare Part A,O,192.29,49.29,109.61,144.22,115.37
3590,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93350,cpt,"Ultrasound Examination Of The Heart Performed During Rest, Exercise, And/Or Drug-Induced Stress With Interpretation And Report",aetna,EPO,O,1353.20,427.67,740.43,1075.79,811.92
3591,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84100,cpt,Phosphate Level,aetna,EPO,O,40.11,4.74,13.80,13.80,5.69
3592,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77412,cpt,Delivery Of Complex Radiation Treatment,aetna,PPO,O,933.20,214.04,510.62,666.46,256.85
3593,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70490,cpt,CT Scan Of Soft Tissue Of Neck Without Contrast,aetna,Medicaid,O,1267.08,96.50,693.31,693.31,760.25
3594,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,784,ms-drg,Cesarean Section With Sterilization With CC,aetna,Medicaid,I,14658.24,5823.07,5823.07,10802.78,8794.94
3595,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,483,ms-drg,Major Joint Or Limb Reattachment Procedures Of Upper Extremities,aetna,PPO,I,77640.79,14258.73,14814.57,23206.53,46584.47
3596,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,193,ms-drg,Simple Pneumonia And Pleurisy With MCC,aetna,Medicare Part B,I,28945.31,6804.78,18583.72,18583.72,17367.19
3597,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86235,cpt,"Measurement Of Antibody For Assessment Of Autoimmune Disorder, Any Method",aetna,EPO,O,43.81,6.19,24.97,30.69,21.52
3598,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna,Medicaid,O,116.31,19.19,63.64,84.77,23.26
3599,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2785,cpt,"Injection, Regadenoson, 0.1 Mg",aetna,PPO,O,154.74,25.67,69.52,154.76,92.84
3600,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0214,revCode,Coronary Care Unit Intermediate Ccu,aetna,Medicare Part A,I,3917.76,854.59,2252.72,11926.72,2350.66
3601,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74175,cpt,CT Scan Of Blood Vessels Of Abdomen With Contrast,aetna,PPO,O,1737.39,158.13,158.13,1841.63,1042.43
3602,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82607,cpt,Cyanocobalamin (Vitamin B-12) Level,aetna,POS,O,73.83,10.37,42.08,42.08,18.10
3603,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87086,cpt,"Bacterial Colony Count, Urine",aetna,HMO,O,71.96,7.91,39.38,53.97,9.68
3604,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,HMO,O,576.53,96.50,334.39,562.62,345.92
3605,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,872,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours Without MCC,aetna,Medicare Part A,I,20748.35,5256.97,6524.49,9809.76,12449.01
3606,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82951,cpt,"Blood Glucose (Sugar) Tolerance Test, 3 Specimens",aetna,HMO,O,117.61,12.87,39.96,84.59,15.44
3607,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83002,cpt,"Gonadotropin, Luteinizing (Reproductive Hormone) Level",aetna,PPO,O,250.10,18.52,142.56,187.58,22.22
3608,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0410,revCode,"Respiratory Services, General",aetna,HMO,I,205.27,71.94,125.75,182.34,123.16
3609,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna,Medicare Part A,O,373.98,199.25,204.64,352.82,359.94
3610,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,32408,cpt,"Core Needle Biopsy Of Lung Or Center Cavity Of Chest (Mediastinum), Accessed Through Skin",aetna,Medicaid,O,3883.82,638.16,1248.81,1248.81,2330.29
3611,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna,Medicare Part A,O,145.10,26.57,41.28,89.17,49.54
3612,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9040,cpt,"Injection, Bleomycin Sulfate, 15 Units",aetna,Medicare Part B,O,435.33,29.13,29.13,51.36,261.20
3613,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0372,revCode,Anesthesia Incident To Other Diagnostic Services,aetna,Medicare Part A,O,47.19,22.12,27.37,27.37,28.31
3614,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93017,cpt,Exercise Or Drug-Induced Heart And Blood Vessel Stress Test With Ekg Tracing And Monitoring,aetna,EPO,O,474.26,84.78,270.33,377.03,284.56
3615,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9537,cpt,"Technetium Tc-99m Mebrofenin, Diagnostic, Per Study Dose, Up To 15 Millicuries",aetna,Medicare Part B,O,218.14,24.47,126.52,157.09,130.88
3616,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82390,cpt,Ceruloplasmin (Protein) Level,aetna,EPO,O,71.96,6.02,39.38,39.38,43.18
3617,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93971,cpt,Ultrasound Scan Of Veins Of One Arm Or Leg Or Limited Including Assessment Of Compression And Functional Maneuvers,aetna,HMO,O,726.73,96.51,397.65,397.65,436.04
3618,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82670,cpt,Measurement Of Total Estradiol (Hormone),aetna,PPO,O,166.34,27.94,91.02,145.43,99.80
3619,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,HMO,I,216.65,43.99,86.21,184.92,129.99
3620,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96523,cpt,Irrigation Of Implanted Venous Access Drug Delivery Device,aetna,POS,O,192.29,49.29,109.61,144.22,115.37
3621,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5111,cpt,"Injection, Pegfilgrastim-Cbqv, Biosimilar, (Udenyca), 0.5 Mg",aetna,Medicare Part A,O,1901.34,181.58,880.52,880.52,1140.80
3622,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84144,cpt,Progesterone (Reproductive Hormone) Level,aetna,Medicaid,O,101.45,17.03,55.51,71.78,25.03
3623,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9217,cpt,"Leuprolide Acetate (For Depot Suspension), 7.5 Mg",aetna,Medicare Part A,O,950.89,129.50,183.03,183.03,570.53
3624,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85652,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Automated",aetna,Medicare Part A,O,38.92,2.65,21.30,29.59,3.24
3625,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36591,cpt,Collection Of Blood Specimen From A Completely Implantable Venous Access Device,aetna,Medicare Part B,O,172.23,13.59,102.02,102.02,103.34
3626,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97113,cpt,"Water Pool Therapy With Therapeutic Exercises To 1 Or More Areas, Each 15 Minutes",aetna,Medicare Part A,O,132.12,28.83,54.93,62.54,79.27
3627,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92526,cpt,Treatment Of Swallowing And/Or Oral Feeding Function,aetna,PPO,O,407.71,81.63,232.39,232.39,244.63
3628,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87493,cpt,"Detection Test By Nucleic Acid For Clostridium Difficile, Amplified Probe Technique",aetna,Medicare Part A,O,100.03,11.59,58.02,58.02,44.72
3629,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82670,cpt,Measurement Of Total Estradiol (Hormone),aetna,POS,O,166.34,27.94,91.02,145.43,99.80
3630,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1439,cpt,"Injection, Ferric Carboxymaltose, 1 Mg",aetna,EPO,O,4.45,0.79,2.09,2.09,2.67
3631,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82627,cpt,Dehydroepiandrosterone (Dhea-S) Hormone Level,aetna,Medicare Part B,O,119.15,19.46,67.92,67.92,71.49
3632,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93005,cpt,Routine Electrocardiogram (Ekg) With Tracing Using At Least 12 Leads,aetna,HMO,O,218.25,35.36,121.91,154.43,130.95
3633,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96377,cpt,Application Of On-Body Injector For Under Skin Injection,aetna,HMO,O,44.52,9.67,25.82,25.82,26.71
3634,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87086,cpt,"Bacterial Colony Count, Urine",aetna,PPO,O,71.96,7.91,39.38,53.97,9.68
3635,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73221,cpt,MRI Scan Of Arm Joint Without Contrast,aetna,Medicare Part A,O,2882.19,203.81,1577.05,1715.45,245.82
3636,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19081,cpt,"Biopsy Of Breast And Placement Of Locating Device Using X-Ray With Needle, First Growth",aetna,Medicare Part A,O,8708.58,1254.46,4315.79,4315.79,5225.15
3637,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,219,ms-drg,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With MCC,aetna,EPO,I,256090.54,46435.26,46497.02,47950.73,153654.32
3638,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,23472,cpt,"Prosthetic Repair Of Shoulder Joint, Total Shoulder",aetna,Medicare Part B,I,123346.27,14814.57,14814.57,14814.57,74007.76
3639,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84145,cpt,Procalcitonin (Hormone) Level,aetna,EPO,O,97.91,20.28,53.57,53.57,32.66
3640,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2469,cpt,"Injection, Palonosetron Hcl, 25 Mcg",aetna,PPO,O,90.84,19.36,39.42,85.70,54.50
3641,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93971,cpt,Ultrasound Scan Of Veins Of One Arm Or Leg Or Limited Including Assessment Of Compression And Functional Maneuvers,aetna,Medicaid,O,726.73,96.51,397.65,397.65,436.04
3642,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19307,cpt,Removal Of Breast And Underarm Lymph Nodes,aetna,EPO,O,22716.20,13126.41,13126.41,13126.41,13629.72
3643,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,292,ms-drg,Heart Failure And Shock With CC,aetna,Medicare Part B,I,18032.02,5781.24,12207.78,12207.78,10819.21
3644,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85613,cpt,"Clotting Factor X Assessment Test, Diluted",aetna,Medicare Part B,O,44.82,4.71,25.55,33.62,11.50
3645,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77334,cpt,"Radiation Treatment Devices, Design And Construction, Complex",aetna,Medicaid,O,599.32,299.94,327.93,327.93,359.94
3646,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna,Medicaid,O,373.98,199.25,204.64,352.82,359.94
3647,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84153,cpt,"PSA (Prostate Specific Antigen) Measurement, Total",aetna,Medicare Part A,O,91.30,18.03,51.00,60.30,22.07
3648,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9040,cpt,"Injection, Bleomycin Sulfate, 15 Units",aetna,HMO,O,435.33,29.13,29.13,51.36,261.20
3649,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78472,cpt,Nuclear Medicine Study Of Heart Pumping Function By Labeling Red Blood Cells With Measurement Of Internal Blood Volume Ejected With Every Beat Over Multiple Cycles,aetna,Medicaid,O,2168.12,333.98,333.99,645.81,1300.87
3650,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77412,cpt,Delivery Of Complex Radiation Treatment,aetna,HMO,O,933.20,214.04,510.62,666.46,256.85
3651,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83735,cpt,Magnesium Level,aetna,Medicare Part B,O,65.11,6.70,35.63,46.07,8.04
3652,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84466,cpt,Transferrin (Iron Binding Protein) Level,aetna,EPO,O,67.24,10.47,36.80,36.80,40.34
3653,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85384,cpt,Fibrinogen (Factor 1) Activity Measurement,aetna,POS,O,89.70,9.63,54.20,54.20,11.66
3654,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82670,cpt,Measurement Of Total Estradiol (Hormone),aetna,EPO,O,166.34,27.94,91.02,145.43,99.80
3655,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77080,cpt,"Bone Density Measurement Of The Core Or Central Skeleton (E.G., Hips, Pelvis, Spine)",aetna,Medicare Part A,O,352.74,96.51,201.06,249.59,115.81
3656,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83036,cpt,Hemoglobin A1c Level,aetna,Medicare Part B,O,76.68,5.83,41.96,57.51,11.65
3657,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97605,cpt,"Negative Pressure Wound Therapy, Surface Area Less Than Or Equal To 50 Square Centimeters, Per Session",aetna,HMO,O,1788.02,425.00,754.73,826.48,1072.81
3658,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64718,cpt,Release And/Or Relocation Of Ulnar Nerve At Elbow,aetna,Medicare Part B,O,16595.69,1553.71,9876.73,9876.73,9957.41
3659,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36591,cpt,Collection Of Blood Specimen From A Completely Implantable Venous Access Device,aetna,PPO,O,172.23,13.59,102.02,102.02,103.34
3660,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0920,revCode,"Other Diagnostic Services, General",aetna,POS,O,1599.77,95.44,145.06,814.63,959.86
3661,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85613,cpt,"Clotting Factor X Assessment Test, Diluted",aetna,Medicare Part A,O,44.82,4.71,25.55,33.62,11.50
3662,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86200,cpt,Measurement Of Antibody For Rheumatoid Arthritis Assessment,aetna,Medicaid,O,251.28,12.89,140.36,140.36,15.54
3663,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86803,cpt,Hepatitis C Antibody Measurement,aetna,POS,O,113.25,14.27,64.55,140.68,17.12
3664,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna,HMO,I,25207.44,6812.39,8243.81,14290.40,15124.46
3665,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86850,cpt,Screening Test For Red Blood Cell Antibodies,aetna,PPO,O,93.19,8.25,53.12,67.92,53.95
3666,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88304,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately Low Complexity",aetna,Medicaid,O,212.36,44.07,116.20,200.34,127.42
3667,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99153,cpt,"Use Of A Drug To Induce Depression Of Consciousness By Physician Performing A Procedure, Each Additional 15 Minutes",aetna,Medicaid,O,47.19,6.59,27.37,47.19,28.31
3668,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86762,cpt,Analysis For Antibody To Rubella (German Measles Virus),aetna,Medicare Part B,O,50.01,4.42,27.36,37.51,17.10
3669,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,483,ms-drg,Major Joint Or Limb Reattachment Procedures Of Upper Extremities,aetna,POS,I,77640.79,14258.73,14814.57,23206.53,46584.47
3670,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,HMO,I,225.33,71.10,128.44,225.33,135.20
3671,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0439,cpt,"Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (Pps), Subsequent Visit",aetna,Medicaid,O,154.00,125.26,125.26,125.26,92.40
3672,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87086,cpt,"Bacterial Colony Count, Urine",aetna,Medicare Part B,O,71.96,7.91,39.38,53.97,9.68
3673,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9537,cpt,"Technetium Tc-99m Mebrofenin, Diagnostic, Per Study Dose, Up To 15 Millicuries",aetna,POS,O,218.14,24.47,126.52,157.09,130.88
3674,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94729,cpt,Test To Examine How Well The Lungs Exchange Gases,aetna,POS,O,218.25,52.60,119.42,119.42,130.95
3675,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna,Medicare Part A,I,25207.44,6812.39,8243.81,14290.40,15124.46
3676,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84153,cpt,"PSA (Prostate Specific Antigen) Measurement, Total",aetna,POS,O,91.30,18.03,51.00,60.30,22.07
3677,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73700,cpt,CT Scan Of Leg Without Contrast,aetna,PPO,O,1395.67,96.50,779.60,809.76,837.40
3678,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82397,cpt,Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,aetna,EPO,O,51.39,6.88,29.29,29.29,30.83
3679,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A4565,cpt,Slings; Medical And Surgical Supplies - Various Medical Supplies Including Tapes And Surgical Dressings,aetna,Medicare Part A,O,21.33,6.00,7.91,29.48,12.80
3680,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80307,cpt,"Testing For Presence Of Drug, By Chemistry Analyzers",aetna,Medicaid,O,197.60,49.05,49.06,62.39,118.56
3681,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84550,cpt,"Uric Acid Level, Blood",aetna,Medicare Part B,O,50.01,4.52,29.01,79.60,5.42
3682,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86200,cpt,Measurement Of Antibody For Rheumatoid Arthritis Assessment,aetna,EPO,O,251.28,12.89,140.36,140.36,15.54
3683,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,POS,I,225.33,71.10,128.44,225.33,135.20
3684,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73721,cpt,MRI Scan Of Leg Joint,aetna,Medicare Part B,O,2882.19,141.17,1577.05,2039.29,245.82
3685,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17003,cpt,"Destruction Of Precancer Skin Growth, 2-14 Growths",aetna,Medicare Part B,O,982.00,159.01,162.47,1222.94,589.20
3686,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9217,cpt,"Leuprolide Acetate (For Depot Suspension), 7.5 Mg",aetna,EPO,O,950.89,129.50,183.03,183.03,570.53
3687,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,EPO,I,3199.87,740.21,1855.92,2543.89,1919.92
3688,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71260,cpt,CT Scan Of Chest With Contrast,aetna,HMO,O,1774.38,129.65,1011.40,1330.79,189.76
3689,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97597,cpt,"Removal Of Tissue From Wounds Per Session, First 20 Sq Cms Or Less",aetna,Medicare Part B,O,596.96,89.68,159.02,159.02,358.18
3690,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84702,cpt,"Gonadotropin, Chorionic (Reproductive Hormone) Level",aetna,POS,O,67.24,15.05,36.80,47.58,18.06
3691,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,620,ms-drg,O.R. Procedures For Obesity With CC,aetna,HMO,I,57057.61,10746.01,10746.01,20648.25,34234.57
3692,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9217,cpt,"Leuprolide Acetate (For Depot Suspension), 7.5 Mg",aetna,Medicare Part B,O,950.89,129.50,183.03,183.03,570.53
3693,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97535,cpt,"Training For Self-Care Or Home Management, Each 15 Minutes",aetna,Medicaid,O,200.56,25.86,84.86,87.79,120.34
3694,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78452,cpt,Nuclear Medicine Study Of Vessels Of Heart Using Drugs Or Exercise Multiple Studies,aetna,Medicaid,O,5568.56,920.95,3046.95,4176.42,1387.91
3695,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19307,cpt,Removal Of Breast And Underarm Lymph Nodes,aetna,Medicare Part A,O,22716.20,13126.41,13126.41,13126.41,13629.72
3696,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76819,cpt,Ultrasound Scan Of Fetus,aetna,Medicaid,O,611.12,96.51,348.34,485.84,366.67
3697,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3480,cpt,"Injection, Potassium Chloride, Per 2 Meq",aetna,HMO,O,2.35,0.80,1.02,1.02,1.41
3698,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97140,cpt,"Manual (Physical) Therapy Techniques To 1 Or More Regions, Each 15 Minutes",aetna,EPO,O,232.41,20.93,103.49,164.45,139.45
3699,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna,EPO,O,356.28,61.44,194.95,194.95,213.77
3700,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85613,cpt,"Clotting Factor X Assessment Test, Diluted",aetna,EPO,O,44.82,4.71,25.55,33.62,11.50
3701,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73700,cpt,CT Scan Of Leg Without Contrast,aetna,Medicare Part A,O,1395.67,96.50,779.60,809.76,837.40
3702,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93005,cpt,Routine Electrocardiogram (Ekg) With Tracing Using At Least 12 Leads,aetna,EPO,O,218.25,35.36,121.91,154.43,130.95
3703,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9040,cpt,"Injection, Bleomycin Sulfate, 15 Units",aetna,PPO,O,435.33,29.13,29.13,51.36,261.20
3704,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0444,revCode,Occupational Therapy Evaluation Or Reevaluation,aetna,EPO,I,509.00,129.95,286.62,370.63,305.40
3705,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0401,revCode,Other Imaging Services Diagnostic Mammography,aetna,Medicare Part A,O,266.00,50.09,79.04,224.15,159.60
3706,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,59025,cpt,Fetal Non-Stress Test,aetna,PPO,O,250.10,17.49,145.06,176.96,150.06
3707,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87389,cpt,Detection Test By Immunoassay Technique For Hiv-1 Antigen And Hiv-1 And Hiv-2 Antibodies,aetna,POS,O,101.33,8.97,55.45,76.00,28.90
3708,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86695,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 1",aetna,Medicare Part B,O,89.65,13.19,49.06,67.24,15.83
3709,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73560,cpt,"X-Ray Of Knee, 1 Or 2 Views",aetna,Medicare Part A,O,231.22,26.24,126.52,126.52,138.73
3710,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86376,cpt,Microsomal Antibodies (Autoantibody) Measurement,aetna,EPO,O,90.15,12.00,21.95,21.95,17.46
3711,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36593,cpt,Declotting Infusion Of Implanted Central Venous Access Device Or Catheter,aetna,HMO,O,18177.79,1282.65,9002.79,20624.05,10906.67
3712,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0410,revCode,"Respiratory Services, General",aetna,POS,I,205.27,71.94,125.75,182.34,123.16
3713,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A4565,cpt,Slings; Medical And Surgical Supplies - Various Medical Supplies Including Tapes And Surgical Dressings,aetna,Medicaid,O,21.33,6.00,7.91,29.48,12.80
3714,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70543,cpt,"MRI Scan Of Bone Of Eye Socket, Face, And/Or Neck Before And After Contrast",aetna,HMO,O,2110.61,326.01,1213.60,1213.60,1266.37
3715,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97035,cpt,"Application Of Ultrasound To 1 Or More Areas, Each 15 Minutes",aetna,Medicaid,O,106.18,10.67,46.92,46.92,63.71
3716,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna,Medicaid,O,142.89,8.03,64.15,113.59,16.07
3717,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9217,cpt,"Leuprolide Acetate (For Depot Suspension), 7.5 Mg",aetna,PPO,O,950.89,129.50,183.03,183.03,570.53
3718,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,HMO,O,1884.10,207.52,1030.93,11598.92,1130.46
3719,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86376,cpt,Microsomal Antibodies (Autoantibody) Measurement,aetna,HMO,O,90.15,12.00,21.95,21.95,17.46
3720,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,193,ms-drg,Simple Pneumonia And Pleurisy With MCC,aetna,Medicare Part A,I,28945.31,6804.78,18583.72,18583.72,17367.19
3721,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78472,cpt,Nuclear Medicine Study Of Heart Pumping Function By Labeling Red Blood Cells With Measurement Of Internal Blood Volume Ejected With Every Beat Over Multiple Cycles,aetna,POS,O,2168.12,333.98,333.99,645.81,1300.87
3722,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,Medicaid,O,1673.95,97.51,795.53,1330.78,1004.37
3723,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5114,cpt,"Injection, Trastuzumab-Dkst, Biosimilar, (Ogivri), 10 Mg",aetna,Medicare Part B,O,232.14,60.17,60.17,66.12,139.28
3724,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,Medicare Part A,O,1884.10,207.52,1030.93,11598.92,1130.46
3725,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86480,cpt,"Tuberculosis Test, Gamma Interferon",aetna,POS,O,350.39,35.31,199.72,262.79,74.38
3726,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0372,revCode,Anesthesia Incident To Other Diagnostic Services,aetna,Medicaid,O,47.19,22.12,27.37,27.37,28.31
3727,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19083,cpt,"Biopsy Of Breast Accessed Through The Skin With Ultrasound Guidance, First Lesion",aetna,Medicaid,O,8391.01,1246.10,6742.37,6742.37,5034.61
3728,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0372,revCode,Anesthesia Incident To Other Diagnostic Services,aetna,EPO,O,47.19,22.12,27.37,27.37,28.31
3729,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76830,cpt,Ultrasound Pelvis Through Vagina,aetna,PPO,O,795.16,96.50,435.09,632.15,115.81
3730,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99214,cpt,"Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes",aetna,Medicaid,O,423.60,59.52,255.94,255.94,254.16
3731,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9040,cpt,"Injection, Bleomycin Sulfate, 15 Units",aetna,EPO,O,435.33,29.13,29.13,51.36,261.20
3732,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83615,cpt,Lactate Dehydrogenase (Enzyme) Level,aetna,EPO,O,50.72,6.04,28.91,70.62,7.25
3733,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0421,revCode,Physical Therapy Visit Charge,aetna,PPO,O,173.42,23.17,76.68,1195.53,104.05
3734,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97535,cpt,"Training For Self-Care Or Home Management, Each 15 Minutes",aetna,POS,O,200.56,25.86,84.86,87.79,120.34
3735,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,872,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours Without MCC,aetna,POS,I,20748.35,5256.97,6524.49,9809.76,12449.01
3736,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna,Medicare Part A,O,142.89,8.03,64.15,113.59,16.07
3737,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna,Medicare Part A,O,4055.15,194.15,2179.00,3854.73,1125.84
3738,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76770,cpt,Complete Ultrasound Scan Behind Abdominal Cavity,aetna,POS,O,747.97,96.51,409.27,409.27,115.81
3739,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,POS,I,179.32,42.72,98.12,174.25,107.59
3740,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0274,revCode,"Medical/Surgical Supplies And Devices, Prosthetic/Orthotic Devices",aetna,Medicaid,O,89.04,8.13,2026.64,2026.64,53.42
3741,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74246,cpt,X-Ray Of Upper Digestive Tract With Double Contrast,aetna,Medicare Part B,O,484.07,158.13,264.87,284.00,189.76
3742,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,784,ms-drg,Cesarean Section With Sterilization With CC,aetna,Medicare Part B,I,14658.24,5823.07,5823.07,10802.78,8794.94
3743,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,55250,cpt,Removal Of Sperm Duct,aetna,Medicaid,O,17158.79,1587.89,8468.46,8468.46,10295.27
3744,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86769,cpt,Measure Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antibody,aetna,HMO,O,89.25,16.93,51.77,66.94,50.56
3745,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83615,cpt,Lactate Dehydrogenase (Enzyme) Level,aetna,Medicare Part A,O,50.72,6.04,28.91,70.62,7.25
3746,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82397,cpt,Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,aetna,Medicare Part B,O,51.39,6.88,29.29,29.29,30.83
3747,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93225,cpt,Electrocardiogram (Ecg) 2-Day Continuous,aetna,Medicaid,O,251.28,64.70,119.50,199.77,150.77
3748,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1200,cpt,"Injection, Diphenhydramine Hcl, Up To 50 Mg",aetna,Medicare Part B,O,3.52,0.76,18.38,80.35,2.11
3749,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99153,cpt,"Use Of A Drug To Induce Depression Of Consciousness By Physician Performing A Procedure, Each Additional 15 Minutes",aetna,Medicare Part A,O,47.19,6.59,27.37,47.19,28.31
3750,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85045,cpt,"Red Blood Count, Automated Test",aetna,EPO,O,38.92,2.44,3.98,14.01,4.79
3751,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76870,cpt,Ultrasound Scan Of Scrotum,aetna,PPO,O,528.53,96.50,295.23,396.40,317.12
3752,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5111,cpt,"Injection, Pegfilgrastim-Cbqv, Biosimilar, (Udenyca), 0.5 Mg",aetna,PPO,O,1901.34,181.58,880.52,880.52,1140.80
3753,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9537,cpt,"Technetium Tc-99m Mebrofenin, Diagnostic, Per Study Dose, Up To 15 Millicuries",aetna,HMO,O,218.14,24.47,126.52,157.09,130.88
3754,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82140,cpt,Ammonia Level,aetna,PPO,O,108.53,13.90,59.39,59.39,17.48
3755,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0269,cpt,"Placement Of Occlusive Device Into Either A Venous Or Arterial Access Site, Post Surgical Or Interventional Procedure (E.G., Angioseal Plug, Vascular Plug)",aetna,Medicare Part B,O,67707.99,403.09,4389.98,14226.92,40624.79
3756,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna,PPO,O,50.01,3.11,27.36,66.28,6.22
3757,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73221,cpt,MRI Scan Of Arm Joint Without Contrast,aetna,POS,O,2882.19,203.81,1577.05,1715.45,245.82
3758,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9537,cpt,"Technetium Tc-99m Mebrofenin, Diagnostic, Per Study Dose, Up To 15 Millicuries",aetna,Medicaid,O,218.14,24.47,126.52,157.09,130.88
3759,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87493,cpt,"Detection Test By Nucleic Acid For Clostridium Difficile, Amplified Probe Technique",aetna,HMO,O,100.03,11.59,58.02,58.02,44.72
3760,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36415,cpt,Insertion Of Needle Into Vein For Collection Of Blood Sample,aetna,PPO,O,29.48,2.94,3.00,22.11,17.69
3761,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,59025,cpt,Fetal Non-Stress Test,aetna,Medicare Part A,O,250.10,17.49,145.06,176.96,150.06
3762,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77338,cpt,Design And Construction Of Radiation Treatment Device For High Precision Radiation Therapy,aetna,POS,O,2028.03,299.94,1109.68,1109.68,359.94
3763,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64636,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Each Additional Facet Joint",aetna,Medicare Part A,O,7088.87,1523.14,4237.46,4237.46,4253.32
3764,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82670,cpt,Measurement Of Total Estradiol (Hormone),aetna,Medicare Part B,O,166.34,27.94,91.02,145.43,99.80
3765,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73200,cpt,CT Scan Of Arm Without Contrast,aetna,POS,O,1267.08,96.51,482.16,482.16,760.25
3766,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,603,ms-drg,Cellulitis Without MCC,aetna,PPO,I,19499.58,3283.09,5672.80,12955.93,11699.75
3767,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85613,cpt,"Clotting Factor X Assessment Test, Diluted",aetna,HMO,O,44.82,4.71,25.55,33.62,11.50
3768,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82952,cpt,"Blood Glucose (Sugar) Tolerance Test, Each Additional Beyond 3 Specimens",aetna,POS,O,48.36,3.92,27.57,36.27,4.70
3769,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71275,cpt,CT Scan Of Blood Vessels Of Chest With Contrast,aetna,EPO,O,1841.63,158.13,970.89,1464.09,189.76
3770,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9040,cpt,"Injection, Bleomycin Sulfate, 15 Units",aetna,Medicare Part A,O,435.33,29.13,29.13,51.36,261.20
3771,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82951,cpt,"Blood Glucose (Sugar) Tolerance Test, 3 Specimens",aetna,EPO,O,117.61,12.87,39.96,84.59,15.44
3772,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,55250,cpt,Removal Of Sperm Duct,aetna,EPO,O,17158.79,1587.89,8468.46,8468.46,10295.27
3773,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7030,cpt,"Infusion, Normal Saline Solution , 1000 Cc",aetna,Medicare Part B,O,8.25,3.71,3.71,162.78,4.95
3774,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71275,cpt,CT Scan Of Blood Vessels Of Chest With Contrast,aetna,Medicare Part A,O,1841.63,158.13,970.89,1464.09,189.76
3775,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87591,cpt,"Detection Test By Nucleic Acid For Neisseria Gonorrhoeae (Gonorrhoeae Bacteria), Amplified Probe Technique",aetna,Medicare Part A,O,147.58,21.05,82.44,110.69,42.11
3776,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0431,revCode,Occupational Therapy Visit Charge,aetna,EPO,O,173.42,21.75,80.69,875.96,104.05
3777,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0372,revCode,Anesthesia Incident To Other Diagnostic Services,aetna,HMO,O,47.19,22.12,27.37,27.37,28.31
3778,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna,Medicaid,O,1654.04,96.51,942.80,984.47,115.81
3779,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94729,cpt,Test To Examine How Well The Lungs Exchange Gases,aetna,EPO,O,218.25,52.60,119.42,119.42,130.95
3780,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0280,revCode,Oncology General,aetna,POS,O,192.29,49.29,109.61,144.22,115.37
3781,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,Medicare Part B,O,212.10,40.75,115.12,253.05,127.26
3782,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17261,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Trunk, Arms, Or Legs",aetna,Medicare Part A,O,1857.00,159.01,159.02,543.72,1114.20
3783,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87205,cpt,Special Gram Or Giemsa Stain For Microorganism,aetna,PPO,O,87.53,4.18,4.25,65.65,5.12
3784,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,064,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With MCC,aetna,EPO,I,42514.90,11561.36,11613.14,15935.29,25508.94
3785,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88307,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately High Complexity",aetna,Medicare Part B,O,298.47,86.80,170.13,298.47,179.08
3786,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0762,revCode,Specialty Services Observation Hours,aetna,HMO,I,15.11,4.72,10.23,10.23,9.07
3787,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna,Medicaid,I,5647.36,1115.96,3413.14,3995.78,3388.42
3788,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73221,cpt,MRI Scan Of Arm Joint Without Contrast,aetna,PPO,O,2882.19,203.81,1577.05,1715.45,245.82
3789,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93279,cpt,"Evaluation, Testing, And Programming Adjustment Of Permanent Single Lead Pacemaker System In One Chamber Of Heart With Qualified Health Care Professional Analysis, Review, And Report",aetna,HMO,O,180.49,32.90,32.90,76.59,108.29
3790,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0351,revCode,"Computerized Axial Tomography (Cat)Scan, Head Scan",aetna,EPO,O,1952.12,97.51,1370.07,1839.56,1171.27
3791,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36593,cpt,Declotting Infusion Of Implanted Central Venous Access Device Or Catheter,aetna,EPO,O,18177.79,1282.65,9002.79,20624.05,10906.67
3792,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88307,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately High Complexity",aetna,POS,O,298.47,86.80,170.13,298.47,179.08
3793,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85027,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test",aetna,PPO,O,56.26,6.34,30.79,39.81,7.76
3794,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92526,cpt,Treatment Of Swallowing And/Or Oral Feeding Function,aetna,HMO,O,407.71,81.63,232.39,232.39,244.63
3795,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna,PPO,O,356.28,61.44,194.95,194.95,213.77
3796,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73221,cpt,MRI Scan Of Arm Joint Without Contrast,aetna,Medicaid,O,2882.19,203.81,1577.05,1715.45,245.82
3797,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,Medicare Part A,I,281.58,60.08,199.37,281.58,168.95
3798,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,Medicare Part B,I,490.78,103.68,279.74,347.25,294.47
3799,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71046,cpt,"X-Ray Of Chest, 2 Views",aetna,Medicare Part B,O,344.48,61.44,188.49,273.86,85.98
3800,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,90694,cpt,"Influenza Virus Vaccine, Quadrivalent (Aiiv4), Inactivated, Adjuvanted, Preservative Free, For Injection Into Muscle, 0.5 Ml Dosage",aetna,POS,O,193.98,23.39,23.39,61.00,116.39
3801,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0421,revCode,Physical Therapy Visit Charge,aetna,HMO,O,173.42,23.17,76.68,1195.53,104.05
3802,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85379,cpt,"Coagulation Function Measurement, D-Dimer; Quantitative",aetna,PPO,O,122.56,9.98,71.08,71.08,12.22
3803,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2175,cpt,"Injection, Meperidine Hydrochloride, Per 100 Mg",aetna,Medicare Part B,O,85.94,17.32,39.53,86.60,51.56
3804,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17270,cpt,"Destruction Of Malignant Growth (0.5 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,Medicaid,O,1881.00,159.01,159.94,475.20,1128.60
3805,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93971,cpt,Ultrasound Scan Of Veins Of One Arm Or Leg Or Limited Including Assessment Of Compression And Functional Maneuvers,aetna,POS,O,726.73,96.51,397.65,397.65,436.04
3806,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna,Medicare Part A,O,251.28,64.70,137.49,266.36,150.77
3807,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93308,cpt,Follow-Up Or Limited Ultrasound Examination Of Heart,aetna,HMO,O,415.27,203.81,204.22,403.52,249.16
3808,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80162,cpt,"Digoxin Level, Total",aetna,EPO,O,101.33,13.28,13.28,18.31,15.94
3809,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0372,revCode,Anesthesia Incident To Other Diagnostic Services,aetna,PPO,O,47.19,22.12,27.37,27.37,28.31
3810,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96411,cpt,Administration Of Additional New Drug Or Substance Into Vein Using Push Technique,aetna,PPO,O,238.30,49.47,130.40,178.73,142.98
3811,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,57522,cpt,Removal Or Destruction Of Cervix With Electrical Cautery,aetna,PPO,O,18168.39,2323.14,10911.60,10911.60,10901.03
3812,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84153,cpt,"PSA (Prostate Specific Antigen) Measurement, Total",aetna,HMO,O,91.30,18.03,51.00,60.30,22.07
3813,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0431,revCode,Occupational Therapy Visit Charge,aetna,HMO,O,173.42,21.75,80.69,875.96,104.05
3814,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71260,cpt,CT Scan Of Chest With Contrast,aetna,PPO,O,1774.38,129.65,1011.40,1330.79,189.76
3815,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74420,cpt,Imaging Of Urinary Tract Following Injection Of A Contrast Agent,aetna,Medicare Part B,O,1007.53,278.97,574.29,574.29,253.90
3816,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85049,cpt,"Platelet Count, Automated Test",aetna,HMO,O,36.32,4.39,4.39,9.15,5.38
3817,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,191,ms-drg,Chronic Obstructive Pulmonary Disease With CC,aetna,PPO,I,15955.32,4343.49,5733.83,7724.36,9573.19
3818,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73030,cpt,"X-Ray Of Shoulder, Minimum Of 2 Views",aetna,Medicare Part A,O,252.47,45.52,143.91,176.73,151.48
3819,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36593,cpt,Declotting Infusion Of Implanted Central Venous Access Device Or Catheter,aetna,Medicaid,O,18177.79,1282.65,9002.79,20624.05,10906.67
3820,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84100,cpt,Phosphate Level,aetna,Medicare Part B,O,40.11,4.74,13.80,13.80,5.69
3821,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11606,cpt,"Removal Of Malignant Growth (Over 4.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,EPO,O,17489.70,4901.08,9591.25,9591.25,10493.82
3822,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80307,cpt,"Testing For Presence Of Drug, By Chemistry Analyzers",aetna,Medicare Part A,O,197.60,49.05,49.06,62.39,118.56
3823,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76705,cpt,Limited Ultrasound Scan Of Abdomen,aetna,PPO,O,710.22,96.50,404.83,564.62,115.81
3824,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88309,cpt,"Pathology Examination Of Tissue Using A Microscope, High Complexity",aetna,Medicare Part B,O,696.07,273.94,396.76,396.76,417.64
3825,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,885,ms-drg,Psychoses,aetna,Medicare Part A,I,17080.81,5566.92,6861.23,9301.98,10248.49
3826,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88309,cpt,"Pathology Examination Of Tissue Using A Microscope, High Complexity",aetna,HMO,O,696.07,273.94,396.76,396.76,417.64
3827,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82952,cpt,"Blood Glucose (Sugar) Tolerance Test, Each Additional Beyond 3 Specimens",aetna,Medicaid,O,48.36,3.92,27.57,36.27,4.70
3828,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0920,revCode,"Other Diagnostic Services, General",aetna,EPO,O,1599.77,95.44,145.06,814.63,959.86
3829,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83615,cpt,Lactate Dehydrogenase (Enzyme) Level,aetna,Medicaid,O,50.72,6.04,28.91,70.62,7.25
3830,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna,HMO,O,1884.10,427.65,1030.93,1413.08,1130.46
3831,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3370,cpt,"Injection, Vancomycin Hcl, 500 Mg",aetna,POS,O,75.38,22.33,34.67,34.67,45.23
3832,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72202,cpt,"X-Ray Of Joint Between Lower Spine And Hip Bone, 3 Or More Views",aetna,EPO,O,252.47,26.87,145.17,166.73,151.48
3833,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0421,revCode,Physical Therapy Visit Charge,aetna,Medicare Part A,O,173.42,23.17,76.68,1195.53,104.05
3834,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,Medicare Part A,I,145.10,44.06,100.82,507.29,87.06
3835,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72197,cpt,MRI Scan Of Pelvis Before And After Contrast,aetna,HMO,O,2882.19,326.01,329.84,2161.64,391.22
3836,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71275,cpt,CT Scan Of Blood Vessels Of Chest With Contrast,aetna,HMO,O,1841.63,158.13,970.89,1464.09,189.76
3837,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76817,cpt,Vaginal Ultrasound Of Pregnant Uterus,aetna,HMO,O,611.12,96.51,341.37,432.40,115.81
3838,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,186,ms-drg,Pleural Effusion With MCC,aetna,EPO,I,29279.58,9460.85,9734.76,9734.76,17567.75
3839,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,Medicare Part A,I,225.33,71.10,128.44,225.33,135.20
3840,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna,POS,O,373.98,199.25,204.64,352.82,359.94
3841,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76642,cpt,Limited Ultrasound Scan Of 1 Breast,aetna,EPO,O,305.55,71.65,167.19,242.91,183.33
3842,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19307,cpt,Removal Of Breast And Underarm Lymph Nodes,aetna,HMO,O,22716.20,13126.41,13126.41,13126.41,13629.72
3843,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9040,cpt,"Injection, Bleomycin Sulfate, 15 Units",aetna,Medicaid,O,435.33,29.13,29.13,51.36,261.20
3844,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0720,revCode,Labor Room/Delivery General,aetna,PPO,I,141.69,33.03,82.08,5123.48,85.01
3845,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73030,cpt,"X-Ray Of Shoulder, Minimum Of 2 Views",aetna,PPO,O,252.47,45.52,143.91,176.73,151.48
3846,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9217,cpt,"Leuprolide Acetate (For Depot Suspension), 7.5 Mg",aetna,POS,O,950.89,129.50,183.03,183.03,570.53
3847,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86803,cpt,Hepatitis C Antibody Measurement,aetna,Medicaid,O,113.25,14.27,64.55,140.68,17.12
3848,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72197,cpt,MRI Scan Of Pelvis Before And After Contrast,aetna,Medicare Part B,O,2882.19,326.01,329.84,2161.64,391.22
3849,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9503,cpt,"Technetium Tc-99m Medronate, Diagnostic, Per Study Dose, Up To 30 Millicuries",aetna,Medicare Part B,O,212.36,61.08,121.05,130.93,127.42
3850,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0372,revCode,Anesthesia Incident To Other Diagnostic Services,aetna,Medicare Part B,O,47.19,22.12,27.37,27.37,28.31
3851,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,EPO,I,179.32,42.72,98.12,174.25,107.59
3852,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74175,cpt,CT Scan Of Blood Vessels Of Abdomen With Contrast,aetna,Medicare Part A,O,1737.39,158.13,158.13,1841.63,1042.43
3853,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86140,cpt,Measurement C-Reactive Protein For Detection Of Infection Or Inflammation,aetna,POS,O,67.58,5.08,38.52,50.69,6.22
3854,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97166,cpt,"Evaluation For Occupational Therapy, Typically 45 Minutes",aetna,PPO,O,265.44,85.51,151.30,163.25,159.26
3855,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96413,cpt,"Administration Of Chemotherapy Into Vein, 1 Hour Or Less",aetna,PPO,O,516.73,113.98,282.74,387.55,310.04
3856,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17003,cpt,"Destruction Of Precancer Skin Growth, 2-14 Growths",aetna,HMO,O,982.00,159.01,162.47,1222.94,589.20
3857,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,219,ms-drg,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With MCC,aetna,POS,I,256090.54,46435.26,46497.02,47950.73,153654.32
3858,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,57522,cpt,Removal Or Destruction Of Cervix With Electrical Cautery,aetna,Medicare Part B,O,18168.39,2323.14,10911.60,10911.60,10901.03
3859,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S2900,cpt,Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure),aetna,Medicaid,O,26479.60,4481.58,24397.19,24397.19,15887.76
3860,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85045,cpt,"Red Blood Count, Automated Test",aetna,PPO,O,38.92,2.44,3.98,14.01,4.79
3861,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85384,cpt,Fibrinogen (Factor 1) Activity Measurement,aetna,Medicaid,O,89.70,9.63,54.20,54.20,11.66
3862,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,596,ms-drg,Major Skin Disorders Without MCC,aetna,Medicaid,I,17771.27,4749.34,4749.34,8242.06,10662.76
3863,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9000,cpt,"Injection, Doxorubicin Hydrochloride, 10 Mg",aetna,PPO,O,10.61,1.82,2.81,2.81,6.37
3864,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78452,cpt,Nuclear Medicine Study Of Vessels Of Heart Using Drugs Or Exercise Multiple Studies,aetna,Medicare Part A,O,5568.56,920.95,3046.95,4176.42,1387.91
3865,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97018,cpt,Application Of Hot Wax Bath To 1 Or More Areas,aetna,POS,O,79.04,3.64,32.08,34.45,47.42
3866,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76705,cpt,Limited Ultrasound Scan Of Abdomen,aetna,POS,O,710.22,96.50,404.83,564.62,115.81
3867,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86777,cpt,Analysis For Antibody To Toxoplasma (Parasite),aetna,Medicare Part B,O,152.18,14.25,86.74,86.74,91.31
3868,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0171,cpt,"Injection, Adrenalin, Epinephrine, 0.1 Mg",aetna,Medicaid,O,5.83,0.23,2.68,2.68,3.50
3869,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97162,cpt,"Evaluation For Physical Therapy, Typically 30 Minutes",aetna,EPO,O,224.82,58.86,123.02,136.58,134.89
3870,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85613,cpt,"Clotting Factor X Assessment Test, Diluted",aetna,PPO,O,44.82,4.71,25.55,33.62,11.50
3871,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,483,ms-drg,Major Joint Or Limb Reattachment Procedures Of Upper Extremities,aetna,EPO,I,77640.79,14258.73,14814.57,23206.53,46584.47
3872,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,784,ms-drg,Cesarean Section With Sterilization With CC,aetna,HMO,I,14658.24,5823.07,5823.07,10802.78,8794.94
3873,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85732,cpt,"Coagulation Assessment Blood Test, Substitution, Plasma Fractions",aetna,POS,O,35.39,3.71,20.17,26.54,7.76
3874,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9144,cpt,"Injection, Daratumumab, 10 Mg And Hyaluronidase-Fihj",aetna,Medicare Part B,O,139.92,43.18,45.07,45.65,83.95
3875,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73523,cpt,"X-Ray Of Both Hips With Pelvis, Minimum Of 5 Views",aetna,Medicare Part B,O,636.63,58.51,384.65,536.48,115.81
3876,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82731,cpt,Fetal Fibronectin (Protein) Analysis,aetna,Medicare Part B,O,565.34,60.62,64.37,424.01,115.33
3877,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72146,cpt,MRI Scan Of Middle Spinal Canal Without Contrast,aetna,Medicare Part B,O,2882.19,207.32,821.42,821.42,248.82
3878,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0401,revCode,Other Imaging Services Diagnostic Mammography,aetna,Medicaid,O,266.00,50.09,79.04,224.15,159.60
3879,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9537,cpt,"Technetium Tc-99m Mebrofenin, Diagnostic, Per Study Dose, Up To 15 Millicuries",aetna,PPO,O,218.14,24.47,126.52,157.09,130.88
3880,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85049,cpt,"Platelet Count, Automated Test",aetna,Medicare Part B,O,36.32,4.39,4.39,9.15,5.38
3881,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76642,cpt,Limited Ultrasound Scan Of 1 Breast,aetna,Medicare Part B,O,305.55,71.65,167.19,242.91,183.33
3882,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,673,ms-drg,Other Kidney And Urinary Tract Procedures With MCC,aetna,POS,I,61701.73,20358.57,20462.06,20647.19,37021.04
3883,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna,PPO,E,5923.22,592.08,2036.44,2288.99,3553.93
3884,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83036,cpt,Hemoglobin A1c Level,aetna,HMO,O,76.68,5.83,41.96,57.51,11.65
3885,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17261,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Trunk, Arms, Or Legs",aetna,PPO,O,1857.00,159.01,159.02,543.72,1114.20
3886,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9045,cpt,"Injection, Carboplatin, 50 Mg",aetna,PPO,O,16.51,2.82,2.82,4.53,9.91
3887,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2765,cpt,"Injection, Metoclopramide Hcl, Up To 10 Mg",aetna,Medicare Part B,O,79.57,18.17,36.60,79.57,47.74
3888,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0920,revCode,"Other Diagnostic Services, General",aetna,Medicare Part B,O,1599.77,95.44,145.06,814.63,959.86
3889,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97535,cpt,"Training For Self-Care Or Home Management, Each 15 Minutes",aetna,PPO,O,200.56,25.86,84.86,87.79,120.34
3890,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0310,revCode,"Laboratory, Pathology General Classification",aetna,POS,I,216.65,43.99,86.21,184.92,129.99
3891,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83002,cpt,"Gonadotropin, Luteinizing (Reproductive Hormone) Level",aetna,POS,O,250.10,18.52,142.56,187.58,22.22
3892,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36010,cpt,Introduction Of Catheter Into The Upper Or Lower Major Vein (Vena Cava),aetna,EPO,I,37979.62,17796.08,17796.08,17796.08,22787.77
3893,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88309,cpt,"Pathology Examination Of Tissue Using A Microscope, High Complexity",aetna,PPO,O,696.07,273.94,396.76,396.76,417.64
3894,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94726,cpt,Determination Of Lung Volumes Using Plethysmography,aetna,EPO,O,501.40,116.04,274.35,274.35,300.84
3895,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77334,cpt,"Radiation Treatment Devices, Design And Construction, Complex",aetna,Medicare Part B,O,599.32,299.94,327.93,327.93,359.94
3896,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,46255,cpt,Removal Of Single External And Internal Hemorrhoid Group,aetna,HMO,O,17900.37,2210.31,9939.29,9939.29,10740.22
3897,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99213,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes",aetna,Medicare Part B,O,270.16,52.43,153.99,211.73,162.10
3898,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74220,cpt,X-Ray Of Esophagus With Single Contrast,aetna,Medicaid,O,552.13,55.19,320.24,320.24,193.72
3899,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76819,cpt,Ultrasound Scan Of Fetus,aetna,Medicare Part A,O,611.12,96.51,348.34,485.84,366.67
3900,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80162,cpt,"Digoxin Level, Total",aetna,Medicaid,O,101.33,13.28,13.28,18.31,15.94
3901,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1170,cpt,"Injection, Hydromorphone, Up To 4 Mg",aetna,POS,O,82.88,16.96,38.12,82.88,49.73
3902,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0450,revCode,"Emergency Room, General",aetna,Medicare Part A,I,891.51,282.04,810.79,6159.07,534.91
3903,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85732,cpt,"Coagulation Assessment Blood Test, Substitution, Plasma Fractions",aetna,EPO,O,35.39,3.71,20.17,26.54,7.76
3904,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76819,cpt,Ultrasound Scan Of Fetus,aetna,PPO,O,611.12,96.51,348.34,485.84,366.67
3905,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0720,revCode,Labor Room/Delivery General,aetna,POS,I,141.69,33.03,82.08,5123.48,85.01
3906,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0450,revCode,"Emergency Room, General",aetna,HMO,I,891.51,282.04,810.79,6159.07,534.91
3907,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97140,cpt,"Manual (Physical) Therapy Techniques To 1 Or More Regions, Each 15 Minutes",aetna,Medicare Part B,O,232.41,20.93,103.49,164.45,139.45
3908,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85520,cpt,Heparin Assay,aetna,POS,O,67.89,39.38,39.38,39.38,40.73
3909,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97597,cpt,"Removal Of Tissue From Wounds Per Session, First 20 Sq Cms Or Less",aetna,HMO,O,596.96,89.68,159.02,159.02,358.18
3910,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17280,cpt,"Destruction Of Malignant Growth (0.5 Centimeters Or Less) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna,POS,O,1569.00,159.01,162.47,542.48,941.40
3911,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99214,cpt,"Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes",aetna,EPO,O,423.60,59.52,255.94,255.94,254.16
3912,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64718,cpt,Release And/Or Relocation Of Ulnar Nerve At Elbow,aetna,Medicaid,O,16595.69,1553.71,9876.73,9876.73,9957.41
3913,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64635,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Single Facet Joint",aetna,PPO,O,7086.24,1523.14,4237.46,4237.46,4251.74
3914,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97163,cpt,"Evaluation For Physical Therapy, Typically 45 Minutes",aetna,Medicaid,O,281.58,53.70,154.08,154.08,168.95
3915,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36561,cpt,"Insertion Of Central Venous Catheter And Implanted Device For Infusion Beneath The Skin, Patient 5 Years Or Older",aetna,Medicare Part A,O,18382.66,2534.31,2589.99,17974.64,11029.60
3916,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83735,cpt,Magnesium Level,aetna,HMO,O,65.11,6.70,35.63,46.07,8.04
3917,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84144,cpt,Progesterone (Reproductive Hormone) Level,aetna,EPO,O,101.45,17.03,55.51,71.78,25.03
3918,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84100,cpt,Phosphate Level,aetna,Medicare Part A,O,40.11,4.74,13.80,13.80,5.69
3919,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82670,cpt,Measurement Of Total Estradiol (Hormone),aetna,Medicare Part A,O,166.34,27.94,91.02,145.43,99.80
3920,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99213,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes",aetna,PPO,O,270.16,52.43,153.99,211.73,162.10
3921,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82731,cpt,Fetal Fibronectin (Protein) Analysis,aetna,EPO,O,565.34,60.62,64.37,424.01,115.33
3922,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85613,cpt,"Clotting Factor X Assessment Test, Diluted",aetna,Medicaid,O,44.82,4.71,25.55,33.62,11.50
3923,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88313,cpt,Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,aetna,Medicare Part A,O,119.15,45.38,67.92,67.92,71.49
3924,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,HMO,I,1747.84,436.13,970.89,1375.11,1048.70
3925,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76801,cpt,Abdominal Ultrasound Of Pregnant Uterus (Less Than 14 Weeks 0 Days) Single Or First Fetus,aetna,PPO,O,357.27,96.50,217.76,229.19,115.81
3926,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86900,cpt,Blood Group Typing (ABO),aetna,Medicare Part A,O,126.23,11.17,71.95,99.15,118.98
3927,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0450,revCode,"Emergency Room, General",aetna,Medicare Part B,I,891.51,282.04,810.79,6159.07,534.91
3928,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87536,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Quantification",aetna,Medicare Part A,O,519.10,67.96,295.89,295.89,311.46
3929,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0312,revCode,Laboratory Pathology Histology,aetna,EPO,O,419.99,131.76,239.39,419.99,251.99
3930,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11103,cpt,"Biopsy Of Related Skin Growth, Each Additional Growth",aetna,PPO,O,1126.00,160.53,161.01,647.00,675.60
3931,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,P9040,cpt,"Red Blood Cells, Leukocytes Reduced, Irradiated, Each Unit",aetna,PPO,O,756.23,260.55,262.76,509.61,453.74
3932,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88162,cpt,"Screening Examination Of Specimen Cells, Extended Study",aetna,POS,O,303.20,44.07,44.07,97.64,181.92
3933,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,371,ms-drg,Major Gastrointestinal Disorders And Peritoneal Infections With MCC,aetna,Medicaid,I,34185.44,8873.88,8873.88,11142.92,20511.26
3934,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85652,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Automated",aetna,Medicaid,O,38.92,2.65,21.30,29.59,3.24
3935,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84156,cpt,"Total Protein Level, Urine",aetna,PPO,O,80.24,3.60,46.54,53.04,4.40
3936,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71260,cpt,CT Scan Of Chest With Contrast,aetna,Medicaid,O,1774.38,129.65,1011.40,1330.79,189.76
3937,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76770,cpt,Complete Ultrasound Scan Behind Abdominal Cavity,aetna,PPO,O,747.97,96.51,409.27,409.27,115.81
3938,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80307,cpt,"Testing For Presence Of Drug, By Chemistry Analyzers",aetna,HMO,O,197.60,49.05,49.06,62.39,118.56
3939,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9144,cpt,"Injection, Daratumumab, 10 Mg And Hyaluronidase-Fihj",aetna,Medicare Part A,O,139.92,43.18,45.07,45.65,83.95
3940,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna,PPO,O,2882.19,203.81,1577.05,2291.34,244.57
3941,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0920,revCode,"Other Diagnostic Services, General",aetna,PPO,O,1599.77,95.44,145.06,814.63,959.86
3942,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70543,cpt,"MRI Scan Of Bone Of Eye Socket, Face, And/Or Neck Before And After Contrast",aetna,EPO,O,2110.61,326.01,1213.60,1213.60,1266.37
3943,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97113,cpt,"Water Pool Therapy With Therapeutic Exercises To 1 Or More Areas, Each 15 Minutes",aetna,POS,O,132.12,28.83,54.93,62.54,79.27
3944,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84702,cpt,"Gonadotropin, Chorionic (Reproductive Hormone) Level",aetna,PPO,O,67.24,15.05,36.80,47.58,18.06
3945,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0444,revCode,Occupational Therapy Evaluation Or Reevaluation,aetna,POS,I,509.00,129.95,286.62,370.63,305.40
3946,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82670,cpt,Measurement Of Total Estradiol (Hormone),aetna,HMO,O,166.34,27.94,91.02,145.43,99.80
3947,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0439,cpt,"Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (Pps), Subsequent Visit",aetna,Medicare Part A,O,154.00,125.26,125.26,125.26,92.40
3948,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77080,cpt,"Bone Density Measurement Of The Core Or Central Skeleton (E.G., Hips, Pelvis, Spine)",aetna,POS,O,352.74,96.51,201.06,249.59,115.81
3949,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0481,cpt,"Drug Test(S), Definitive, Utilizing (1) Drug Identification Methods Able To Identify Individual Drugs And Distinguish Between Structural Isomers (But Not Necessarily Stereoisomers), Including, But Not",aetna,POS,O,315.99,155.10,155.10,156.59,189.59
3950,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78452,cpt,Nuclear Medicine Study Of Vessels Of Heart Using Drugs Or Exercise Multiple Studies,aetna,EPO,O,5568.56,920.95,3046.95,4176.42,1387.91
3951,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0920,revCode,"Other Diagnostic Services, General",aetna,Medicare Part A,O,1599.77,95.44,145.06,814.63,959.86
3952,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2785,cpt,"Injection, Regadenoson, 0.1 Mg",aetna,HMO,O,154.74,25.67,69.52,154.76,92.84
3953,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74178,cpt,CT Scan Of Abdomen And Pelvis Before And After Contrast,aetna,Medicare Part B,O,4577.54,2.93,2609.20,3536.15,391.22
3954,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5106,cpt,"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (For Non-Esrd Use), 1000 Units",aetna,PPO,O,32.27,8.13,8.62,13.29,19.36
3955,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0008,cpt,Administration Of Influenza Virus Vaccine,aetna,Medicare Part B,O,99.09,11.08,35.43,35.43,42.52
3956,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9537,cpt,"Technetium Tc-99m Mebrofenin, Diagnostic, Per Study Dose, Up To 15 Millicuries",aetna,Medicare Part A,O,218.14,24.47,126.52,157.09,130.88
3957,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,EPO,O,212.10,40.75,115.12,253.05,127.26
3958,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76770,cpt,Complete Ultrasound Scan Behind Abdominal Cavity,aetna,Medicare Part B,O,747.97,96.51,409.27,409.27,115.81
3959,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87086,cpt,"Bacterial Colony Count, Urine",aetna,Medicaid,O,71.96,7.91,39.38,53.97,9.68
3960,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85384,cpt,Fibrinogen (Factor 1) Activity Measurement,aetna,EPO,O,89.70,9.63,54.20,54.20,11.66
3961,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70543,cpt,"MRI Scan Of Bone Of Eye Socket, Face, And/Or Neck Before And After Contrast",aetna,POS,O,2110.61,326.01,1213.60,1213.60,1266.37
3962,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0439,cpt,"Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (Pps), Subsequent Visit",aetna,Medicare Part B,O,154.00,125.26,125.26,125.26,92.40
3963,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66991,cpt,Extracapsular Removal Of Cataract With Insertion Of Artificial Lens And Insertion Of Drainage Device In Front Chamber Of Eye,aetna,EPO,O,8752.90,3729.66,3729.66,3765.43,5251.74
3964,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80162,cpt,"Digoxin Level, Total",aetna,POS,O,101.33,13.28,13.28,18.31,15.94
3965,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,HMO,I,3199.87,740.21,1855.92,2543.89,1919.92
3966,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna,Medicaid,O,982.00,159.01,162.47,1222.94,589.20
3967,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96523,cpt,Irrigation Of Implanted Venous Access Drug Delivery Device,aetna,EPO,O,192.29,49.29,109.61,144.22,115.37
3968,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73721,cpt,MRI Scan Of Leg Joint,aetna,POS,O,2882.19,141.17,1577.05,2039.29,245.82
3969,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77300,cpt,Calculation Of Radiation Therapy Dose,aetna,POS,O,273.70,47.14,131.71,131.71,134.83
3970,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84484,cpt,"Troponin (Protein) Analysis, Quantitative",aetna,PPO,O,80.09,12.47,29.46,56.67,14.96
3971,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77080,cpt,"Bone Density Measurement Of The Core Or Central Skeleton (E.G., Hips, Pelvis, Spine)",aetna,Medicaid,O,352.74,96.51,201.06,249.59,115.81
3972,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85520,cpt,Heparin Assay,aetna,Medicare Part B,O,67.89,39.38,39.38,39.38,40.73
3973,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78452,cpt,Nuclear Medicine Study Of Vessels Of Heart Using Drugs Or Exercise Multiple Studies,aetna,POS,O,5568.56,920.95,3046.95,4176.42,1387.91
3974,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna,POS,O,226.51,61.44,126.53,160.27,135.91
3975,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87496,cpt,"Detection Test By Nucleic Acid For Cytomegalovirus (Cmv), Amplified Probe Technique",aetna,Medicaid,O,191.11,108.93,108.93,108.93,114.67
3976,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,191,ms-drg,Chronic Obstructive Pulmonary Disease With CC,aetna,EPO,I,15955.32,4343.49,5733.83,7724.36,9573.19
3977,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83036,cpt,Hemoglobin A1c Level,aetna,EPO,O,76.68,5.83,41.96,57.51,11.65
3978,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86777,cpt,Analysis For Antibody To Toxoplasma (Parasite),aetna,PPO,O,152.18,14.25,86.74,86.74,91.31
3979,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0897,cpt,"Injection, Denosumab, 1 Mg",aetna,PPO,O,62.32,12.82,18.35,21.26,37.39
3980,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86695,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 1",aetna,HMO,O,89.65,13.19,49.06,67.24,15.83
3981,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19081,cpt,"Biopsy Of Breast And Placement Of Locating Device Using X-Ray With Needle, First Growth",aetna,HMO,O,8708.58,1254.46,4315.79,4315.79,5225.15
3982,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77417,cpt,Therapeutic Radiology Port Films,aetna,POS,O,37.84,21.95,21.95,28.66,9.54
3983,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88309,cpt,"Pathology Examination Of Tissue Using A Microscope, High Complexity",aetna,POS,O,696.07,273.94,396.76,396.76,417.64
3984,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna,Medicaid,I,179.32,42.72,98.12,174.25,107.59
3985,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,EPO,I,1884.10,527.05,1030.93,1360.64,1130.46
3986,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,57522,cpt,Removal Or Destruction Of Cervix With Electrical Cautery,aetna,EPO,O,18168.39,2323.14,10911.60,10911.60,10901.03
3987,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,EPO,I,58214.47,42815.71,42815.71,42815.71,34928.68
3988,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5114,cpt,"Injection, Trastuzumab-Dkst, Biosimilar, (Ogivri), 10 Mg",aetna,POS,O,232.14,60.17,60.17,66.12,139.28
3989,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0920,revCode,"Other Diagnostic Services, General",aetna,Medicaid,O,1599.77,95.44,145.06,814.63,959.86
3990,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19081,cpt,"Biopsy Of Breast And Placement Of Locating Device Using X-Ray With Needle, First Growth",aetna,Medicare Part B,O,8708.58,1254.46,4315.79,4315.79,5225.15
3991,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1439,cpt,"Injection, Ferric Carboxymaltose, 1 Mg",aetna,Medicare Part A,O,4.45,0.79,2.09,2.09,2.67
3992,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna,HMO,E,3350.06,336.55,1455.60,2095.51,2010.04
3993,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna,EPO,O,251.28,64.70,137.49,266.36,150.77
3994,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88173,cpt,Evaluation Of Fine Needle Aspirate With Interpretation And Report,aetna,Medicare Part B,O,109.71,60.12,81.77,81.77,65.83
3995,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77334,cpt,"Radiation Treatment Devices, Design And Construction, Complex",aetna,HMO,O,599.32,299.94,327.93,327.93,359.94
3996,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78227,cpt,Nuclear Medicine Study Of Liver And Bile Duct System With Use Of Drugs,aetna,EPO,O,1528.98,161.81,836.62,1038.75,520.12
3997,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88304,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately Low Complexity",aetna,POS,O,212.36,44.07,116.20,200.34,127.42
3998,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna,Medicaid,O,356.28,61.44,194.95,194.95,213.77
3999,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73110,cpt,"X-Ray Of Wrist, Minimum Of 3 Views",aetna,POS,O,329.15,51.73,183.86,246.86,197.49
4000,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9228,cpt,"Injection, Ipilimumab, 1 Mg",aetna,PPO,O,588.70,104.49,157.23,157.23,353.22
4001,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0124,revCode,Room And Board Semiprivate (Two Beds) Psychiatric,aetna,PPO,I,2075.74,728.48,728.48,1347.17,1245.44
4002,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84156,cpt,"Total Protein Level, Urine",aetna,EPO,O,80.24,3.60,46.54,53.04,4.40
4003,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7121,cpt,"5% Dextrose In Lactated Ringers Infusion, Up To 1000 Cc",aetna,POS,O,164.65,75.76,75.76,75.76,98.79
4004,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87535,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Amplified Probe Technique",aetna,PPO,O,376.19,56.83,218.19,299.07,225.71
4005,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,189,ms-drg,Pulmonary Edema And Respiratory Failure,aetna,HMO,I,29155.17,7655.58,9502.30,14063.21,17493.10
4006,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87510,cpt,"Detection Test For Gardnerella Vaginalis (Bacteria), Direct Probe Technique",aetna,Medicaid,O,107.59,12.03,58.87,104.55,24.06
4007,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1439,cpt,"Injection, Ferric Carboxymaltose, 1 Mg",aetna,Medicaid,O,4.45,0.79,2.09,2.09,2.67
4008,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73110,cpt,"X-Ray Of Wrist, Minimum Of 3 Views",aetna,EPO,O,329.15,51.73,183.86,246.86,197.49
4009,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66991,cpt,Extracapsular Removal Of Cataract With Insertion Of Artificial Lens And Insertion Of Drainage Device In Front Chamber Of Eye,aetna,POS,O,8752.90,3729.66,3729.66,3765.43,5251.74
4010,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9000,cpt,"Injection, Doxorubicin Hydrochloride, 10 Mg",aetna,Medicaid,O,10.61,1.82,2.81,2.81,6.37
4011,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2997,cpt,"Injection, Alteplase Recombinant, 1 Mg",aetna,EPO,O,318.54,54.09,87.67,232.15,191.12
4012,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84484,cpt,"Troponin (Protein) Analysis, Quantitative",aetna,HMO,O,80.09,12.47,29.46,56.67,14.96
4013,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna,Medicare Part A,O,120.33,10.08,65.84,90.25,20.16
4014,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73030,cpt,"X-Ray Of Shoulder, Minimum Of 2 Views",aetna,Medicaid,O,252.47,45.52,143.91,176.73,151.48
4015,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84153,cpt,"PSA (Prostate Specific Antigen) Measurement, Total",aetna,Medicaid,O,91.30,18.03,51.00,60.30,22.07
4016,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33235,cpt,Removal Of Dual Electrodes From Right Heart,aetna,Medicaid,O,21468.71,3610.13,3610.13,3610.13,12881.23
4017,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85384,cpt,Fibrinogen (Factor 1) Activity Measurement,aetna,HMO,O,89.70,9.63,54.20,54.20,11.66
4018,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0008,cpt,Administration Of Influenza Virus Vaccine,aetna,POS,O,99.09,11.08,35.43,35.43,42.52
4019,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna,Medicare Part A,O,226.51,61.44,126.53,160.27,135.91
4020,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7050,cpt,"Infusion, Normal Saline Solution, 250 Cc",aetna,EPO,O,157.33,71.59,71.59,118.00,94.40
4021,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,23472,cpt,"Prosthetic Repair Of Shoulder Joint, Total Shoulder",aetna,Medicare Part A,I,123346.27,14814.57,14814.57,14814.57,74007.76
4022,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0274,revCode,"Medical/Surgical Supplies And Devices, Prosthetic/Orthotic Devices",aetna,POS,O,89.04,8.13,2026.64,2026.64,53.42
4023,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9354,cpt,"Injection, Ado-Trastuzumab Emtansine, 1 Mg",aetna,HMO,O,123.87,25.63,36.89,41.57,74.32
4024,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87535,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Amplified Probe Technique",aetna,Medicare Part A,O,376.19,56.83,218.19,299.07,225.71
4025,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93289,cpt,"Evaluation Of Defibrillator Including Connection, Recording And Disconnection",aetna,POS,O,206.45,32.90,115.33,115.33,123.87
4026,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,POS,I,3199.87,740.21,1855.92,2543.89,1919.92
4027,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,HMO,O,212.10,40.75,115.12,253.05,127.26
4028,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna,Medicare Part A,O,1654.04,96.51,942.80,984.47,115.81
4029,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,Medicaid,O,8.83,1.76,5.12,26.77,5.30
4030,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0214,revCode,Coronary Care Unit Intermediate Ccu,aetna,EPO,I,3917.76,854.59,2252.72,11926.72,2350.66
4031,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7121,cpt,"5% Dextrose In Lactated Ringers Infusion, Up To 1000 Cc",aetna,Medicaid,O,164.65,75.76,75.76,75.76,98.79
4032,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74220,cpt,X-Ray Of Esophagus With Single Contrast,aetna,Medicare Part A,O,552.13,55.19,320.24,320.24,193.72
4033,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,26055,cpt,Incision Of Tendon Covering Of Finger,aetna,Medicaid,O,16309.48,1233.08,10334.48,10334.48,9785.69
4034,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,EPO,O,1881.00,160.85,162.47,936.63,1128.60
4035,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86800,cpt,Thyroglobulin (Thyroid Protein) Antibody Measurement,aetna,Medicare Part A,O,71.96,14.53,40.56,40.56,19.09
4036,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88173,cpt,Evaluation Of Fine Needle Aspirate With Interpretation And Report,aetna,PPO,O,109.71,60.12,81.77,81.77,65.83
4037,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,PPO,O,212.10,40.75,115.12,253.05,127.26
4038,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94640,cpt,Respiratory Inhaled Pressure Or Nonpressure Treatment To Relieve Airway Obstruction Or For Sputum Specimen,aetna,EPO,O,198.78,56.02,185.11,185.11,119.27
4039,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71260,cpt,CT Scan Of Chest With Contrast,aetna,Medicare Part A,O,1774.38,129.65,1011.40,1330.79,189.76
4040,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12032,cpt,"Repair Of Wound (2.6 To 7.5 Centimeters) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna,POS,O,3063.00,309.74,309.74,3849.84,1837.80
4041,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87660,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Direct Probe Technique",aetna,Medicare Part B,O,114.43,12.03,62.62,85.82,24.06
4042,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97162,cpt,"Evaluation For Physical Therapy, Typically 30 Minutes",aetna,HMO,O,224.82,58.86,123.02,136.58,134.89
4043,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12032,cpt,"Repair Of Wound (2.6 To 7.5 Centimeters) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna,Medicare Part B,O,3063.00,309.74,309.74,3849.84,1837.80
4044,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96377,cpt,Application Of On-Body Injector For Under Skin Injection,aetna,Medicare Part A,O,44.52,9.67,25.82,25.82,26.71
4045,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72110,cpt,"X-Ray Of Lower And Sacral Spine, Minimum Of 4 Views",aetna,Medicare Part B,O,613.48,46.08,335.68,365.14,115.81
4046,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64636,cpt,"Destruction Of Lower Or Sacral Spinal Facet Joint Nerves Using Imaging Guidance, Each Additional Facet Joint",aetna,Medicaid,O,7088.87,1523.14,4237.46,4237.46,4253.32
4047,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0280,revCode,Oncology General,aetna,EPO,O,192.29,49.29,109.61,144.22,115.37
4048,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,M0243,cpt,"Intravenous Infusion, Casirivimab And Imdevimab Includes Infusion And Post Administration Monitoring",aetna,Medicare Part A,O,820.47,138.86,502.86,502.86,492.28
4049,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86592,cpt,Syphilis Detection Test,aetna,HMO,O,40.11,4.27,22.41,30.08,5.12
4050,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97113,cpt,"Water Pool Therapy With Therapeutic Exercises To 1 Or More Areas, Each 15 Minutes",aetna,HMO,O,132.12,28.83,54.93,62.54,79.27
4051,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96368,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Concurrent With Another Infusion",aetna,POS,O,75.68,16.92,43.89,60.16,45.41
4052,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0121,cpt,Colorectal Cancer Screening; Colonoscopy On Individual Not Meeting Criteria For High Risk,aetna,POS,O,3036.82,702.86,1604.70,2259.70,1822.09
4053,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84155,cpt,"Total Protein Level, Blood",aetna,Medicaid,O,69.00,3.67,3.67,51.75,4.40
4054,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33235,cpt,Removal Of Dual Electrodes From Right Heart,aetna,POS,O,21468.71,3610.13,3610.13,3610.13,12881.23
4055,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76705,cpt,Limited Ultrasound Scan Of Abdomen,aetna,Medicare Part B,O,710.22,96.50,404.83,564.62,115.81
4056,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87086,cpt,"Bacterial Colony Count, Urine",aetna,EPO,O,71.96,7.91,39.38,53.97,9.68
4057,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0171,cpt,"Injection, Adrenalin, Epinephrine, 0.1 Mg",aetna,PPO,O,5.83,0.23,2.68,2.68,3.50
4058,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17261,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Trunk, Arms, Or Legs",aetna,POS,O,1857.00,159.01,159.02,543.72,1114.20
4059,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2765,cpt,"Injection, Metoclopramide Hcl, Up To 10 Mg",aetna,HMO,O,79.57,18.17,36.60,79.57,47.74
4060,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70490,cpt,CT Scan Of Soft Tissue Of Neck Without Contrast,aetna,Medicare Part A,O,1267.08,96.50,693.31,693.31,760.25
4061,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87181,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Agar Dilution Method",aetna,Medicare Part A,O,16.51,4.75,9.41,9.41,3.37
4062,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7050,cpt,"Infusion, Normal Saline Solution, 250 Cc",aetna,Medicaid,O,157.33,71.59,71.59,118.00,94.40
4063,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84155,cpt,"Total Protein Level, Blood",aetna,Medicare Part A,O,69.00,3.67,3.67,51.75,4.40
4064,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0312,revCode,Laboratory Pathology Histology,aetna,POS,O,419.99,131.76,239.39,419.99,251.99
4065,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82951,cpt,"Blood Glucose (Sugar) Tolerance Test, 3 Specimens",aetna,POS,O,117.61,12.87,39.96,84.59,15.44
4066,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1439,cpt,"Injection, Ferric Carboxymaltose, 1 Mg",aetna,POS,O,4.45,0.79,2.09,2.09,2.67
4067,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86900,cpt,Blood Group Typing (ABO),aetna,Medicare Part B,O,126.23,11.17,71.95,99.15,118.98
4068,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86709,cpt,Measurement Of Hepatitis A Antibody (Igm),aetna,Medicare Part B,O,106.28,11.21,60.58,60.58,63.77
4069,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna,POS,O,251.28,64.70,137.49,266.36,150.77
4070,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99214,cpt,"Established Patient Office Or Other Outpatient, Visit Typically 25 Minutes",aetna,Medicare Part A,O,423.60,59.52,255.94,255.94,254.16
4071,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87389,cpt,Detection Test By Immunoassay Technique For Hiv-1 Antigen And Hiv-1 And Hiv-2 Antibodies,aetna,PPO,O,101.33,8.97,55.45,76.00,28.90
4072,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0279,cpt,"Diagnostic Digital Breast Tomosynthesis, Unilateral Or Bilateral (List Separately In Addition To 77065 Or 77066)",aetna,POS,O,120.33,22.38,69.79,95.66,72.20
4073,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66991,cpt,Extracapsular Removal Of Cataract With Insertion Of Artificial Lens And Insertion Of Drainage Device In Front Chamber Of Eye,aetna,HMO,O,8752.90,3729.66,3729.66,3765.43,5251.74
4074,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72202,cpt,"X-Ray Of Joint Between Lower Spine And Hip Bone, 3 Or More Views",aetna,Medicaid,O,252.47,26.87,145.17,166.73,151.48
4075,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna,Medicare Part B,O,3391.86,327.84,1855.92,2543.90,462.44
4076,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88304,cpt,"Pathology Examination Of Tissue Using A Microscope, Moderately Low Complexity",aetna,HMO,O,212.36,44.07,116.20,200.34,127.42
4077,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19081,cpt,"Biopsy Of Breast And Placement Of Locating Device Using X-Ray With Needle, First Growth",aetna,PPO,O,8708.58,1254.46,4315.79,4315.79,5225.15
4078,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86803,cpt,Hepatitis C Antibody Measurement,aetna,PPO,O,113.25,14.27,64.55,140.68,17.12
4079,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2175,cpt,"Injection, Meperidine Hydrochloride, Per 100 Mg",aetna,PPO,O,85.94,17.32,39.53,86.60,51.56
4080,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,55250,cpt,Removal Of Sperm Duct,aetna,POS,O,17158.79,1587.89,8468.46,8468.46,10295.27
4081,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74420,cpt,Imaging Of Urinary Tract Following Injection Of A Contrast Agent,aetna,Medicaid,O,1007.53,278.97,574.29,574.29,253.90
4082,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,PPO,I,225.33,71.10,128.44,225.33,135.20
4083,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78816,cpt,Nuclear Medicine Study With CT Imaging Whole Body,aetna,PPO,O,7556.48,1311.05,1311.05,2704.61,4533.89
4084,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1100,cpt,"Injection, Dexamethasone Sodium Phosphate, 1 Mg",aetna,POS,O,7.91,1.12,1.12,7.91,4.75
4085,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87535,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Amplified Probe Technique",aetna,POS,O,376.19,56.83,218.19,299.07,225.71
4086,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74220,cpt,X-Ray Of Esophagus With Single Contrast,aetna,EPO,O,552.13,55.19,320.24,320.24,193.72
4087,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82626,cpt,Dehydroepiandrosterone (Dhea) Hormone Level,aetna,Medicaid,O,148.02,23.79,85.85,85.85,88.81
4088,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2405,cpt,"Injection, Ondansetron Hydrochloride, Per 1 Mg",aetna,Medicare Part A,O,19.54,1.76,8.78,19.52,11.72
4089,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82627,cpt,Dehydroepiandrosterone (Dhea-S) Hormone Level,aetna,HMO,O,119.15,19.46,67.92,67.92,71.49
4090,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9145,cpt,"Injection, Daratumumab, 10 Mg",aetna,Medicare Part A,O,87.92,56.29,56.29,56.29,52.75
4091,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82626,cpt,Dehydroepiandrosterone (Dhea) Hormone Level,aetna,POS,O,148.02,23.79,85.85,85.85,88.81
4092,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87535,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Amplified Probe Technique",aetna,Medicaid,O,376.19,56.83,218.19,299.07,225.71
4093,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,Medicare Part A,O,110.40,7.04,8.00,129.02,66.24
4094,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9601,cpt,"Percutaneous Transcatheter Placement Of Drug-Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery (List Separately In Addition To",aetna,HMO,O,71354.64,14191.44,14191.44,14191.44,42812.78
4095,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,EPO,I,145.10,44.06,100.82,507.29,87.06
4096,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28008,cpt,Incision Of Tissues Of Muscle Compartment Of Foot And/Or Toe,aetna,Medicaid,O,15422.69,8682.40,8682.40,15484.76,9253.61
4097,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87535,cpt,"Detection Test By Nucleic Acid For Hiv-1 Virus, Amplified Probe Technique",aetna,Medicare Part B,O,376.19,56.83,218.19,299.07,225.71
4098,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83002,cpt,"Gonadotropin, Luteinizing (Reproductive Hormone) Level",aetna,EPO,O,250.10,18.52,142.56,187.58,22.22
4099,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80162,cpt,"Digoxin Level, Total",aetna,Medicare Part A,O,101.33,13.28,13.28,18.31,15.94
4100,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0274,revCode,"Medical/Surgical Supplies And Devices, Prosthetic/Orthotic Devices",aetna,HMO,O,89.04,8.13,2026.64,2026.64,53.42
4101,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0720,revCode,Labor Room/Delivery General,aetna,HMO,I,141.69,33.03,82.08,5123.48,85.01
4102,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17003,cpt,"Destruction Of Precancer Skin Growth, 2-14 Growths",aetna,POS,O,982.00,159.01,162.47,1222.94,589.20
4103,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84702,cpt,"Gonadotropin, Chorionic (Reproductive Hormone) Level",aetna,EPO,O,67.24,15.05,36.80,47.58,18.06
4104,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86592,cpt,Syphilis Detection Test,aetna,Medicare Part B,O,40.11,4.27,22.41,30.08,5.12
4105,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna,POS,I,1307.77,398.79,745.43,8974.67,784.66
4106,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0444,revCode,Occupational Therapy Evaluation Or Reevaluation,aetna,HMO,I,509.00,129.95,286.62,370.63,305.40
4107,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36010,cpt,Introduction Of Catheter Into The Upper Or Lower Major Vein (Vena Cava),aetna,Medicare Part B,I,37979.62,17796.08,17796.08,17796.08,22787.77
4108,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71275,cpt,CT Scan Of Blood Vessels Of Chest With Contrast,aetna,POS,O,1841.63,158.13,970.89,1464.09,189.76
4109,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96377,cpt,Application Of On-Body Injector For Under Skin Injection,aetna,PPO,O,44.52,9.67,25.82,25.82,26.71
4110,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92526,cpt,Treatment Of Swallowing And/Or Oral Feeding Function,aetna,EPO,O,407.71,81.63,232.39,232.39,244.63
4111,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,193,ms-drg,Simple Pneumonia And Pleurisy With MCC,aetna,HMO,I,28945.31,6804.78,18583.72,18583.72,17367.19
4112,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5114,cpt,"Injection, Trastuzumab-Dkst, Biosimilar, (Ogivri), 10 Mg",aetna,PPO,O,232.14,60.17,60.17,66.12,139.28
4113,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,32408,cpt,"Core Needle Biopsy Of Lung Or Center Cavity Of Chest (Mediastinum), Accessed Through Skin",aetna,EPO,O,3883.82,638.16,1248.81,1248.81,2330.29
4114,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80306,cpt,"Testing For Presence Of Drug, Read By Instrument Assisted Observation",aetna,HMO,O,513.19,16.97,292.52,384.89,20.57
4115,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,43239,cpt,"Biopsy Of Esophagus, Stomach, And/Or Upper Small Bowel Using A Flexible Endoscope",aetna,Medicare Part B,O,4254.12,439.90,1990.82,4844.32,1282.14
4116,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76817,cpt,Vaginal Ultrasound Of Pregnant Uterus,aetna,Medicare Part A,O,611.12,96.51,341.37,432.40,115.81
4117,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78815,cpt,Nuclear Medicine Study From Skull Base To Mid-Thigh With CT Scan,aetna,PPO,O,7116.42,1311.00,3893.89,5657.55,4269.85
4118,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92611,cpt,Fluoroscopic And Video Recorded Motion Evaluation Of Swallowing Function,aetna,Medicaid,O,328.90,87.83,190.76,190.76,197.34
4119,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5114,cpt,"Injection, Trastuzumab-Dkst, Biosimilar, (Ogivri), 10 Mg",aetna,Medicare Part A,O,232.14,60.17,60.17,66.12,139.28
4120,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,PPO,I,218.25,67.65,124.40,224.80,130.95
4121,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74420,cpt,Imaging Of Urinary Tract Following Injection Of A Contrast Agent,aetna,EPO,O,1007.53,278.97,574.29,574.29,253.90
4122,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0897,cpt,"Injection, Denosumab, 1 Mg",aetna,POS,O,62.32,12.82,18.35,21.26,37.39
4123,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2250,cpt,"Injection, Midazolam Hydrochloride, Per 1 Mg",aetna,HMO,O,41.06,10.28,18.48,41.06,24.64
4124,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9579,cpt,"Injection, Gadolinium-Based Magnetic Resonance Contrast Agent, Not Otherwise Specified (Nos), Per Ml",aetna,HMO,O,15.32,0.10,6.89,16.23,9.19
4125,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9144,cpt,"Injection, Daratumumab, 10 Mg And Hyaluronidase-Fihj",aetna,PPO,O,139.92,43.18,45.07,45.65,83.95
4126,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9299,cpt,"Injection, Nivolumab, 1 Mg",aetna,Medicare Part B,O,107.35,13.51,28.82,29.25,64.41
4127,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73560,cpt,"X-Ray Of Knee, 1 Or 2 Views",aetna,Medicaid,O,231.22,26.24,126.52,126.52,138.73
4128,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna,Medicare Part A,I,710.22,207.44,407.05,747.97,426.13
4129,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,Medicaid,I,58214.47,42815.71,42815.71,42815.71,34928.68
4130,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86800,cpt,Thyroglobulin (Thyroid Protein) Antibody Measurement,aetna,PPO,O,71.96,14.53,40.56,40.56,19.09
4131,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86360,cpt,"T Cell Count And Ratio, Including Ratio",aetna,Medicare Part A,O,220.61,31.37,125.75,125.75,132.37
4132,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88300,cpt,"Pathology Examination Of Tissue Using A Microscope, Limited Examination",aetna,EPO,O,93.19,27.95,50.99,50.99,55.91
4133,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96368,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Concurrent With Another Infusion",aetna,PPO,O,75.68,16.92,43.89,60.16,45.41
4134,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97166,cpt,"Evaluation For Occupational Therapy, Typically 45 Minutes",aetna,HMO,O,265.44,85.51,151.30,163.25,159.26
4135,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna,POS,O,84.93,5.32,30.50,63.70,15.10
4136,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna,PPO,O,271.34,80.51,148.47,215.72,96.61
4137,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna,Medicare Part B,O,116.31,19.19,63.64,84.77,23.26
4138,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73720,cpt,MRI Scan Of Leg Before And After Contrast,aetna,EPO,O,2882.19,326.01,1671.67,1671.67,1729.31
4139,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72197,cpt,MRI Scan Of Pelvis Before And After Contrast,aetna,EPO,O,2882.19,326.01,329.84,2161.64,391.22
4140,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74175,cpt,CT Scan Of Blood Vessels Of Abdomen With Contrast,aetna,POS,O,1737.39,158.13,158.13,1841.63,1042.43
4141,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0439,cpt,"Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (Pps), Subsequent Visit",aetna,POS,O,154.00,125.26,125.26,125.26,92.40
4142,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1437,cpt,"Injection, Ferric Derisomaltose, 10 Mg",aetna,POS,O,80.56,14.43,25.38,25.82,48.34
4143,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36561,cpt,"Insertion Of Central Venous Catheter And Implanted Device For Infusion Beneath The Skin, Patient 5 Years Or Older",aetna,HMO,O,18382.66,2534.31,2589.99,17974.64,11029.60
4144,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna,Medicare Part B,O,84.93,5.32,30.50,63.70,15.10
4145,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72148,cpt,MRI Scan Of Lower Spinal Canal,aetna,HMO,O,2882.19,203.81,1642.85,2039.29,244.57
4146,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,HMO,I,45.29,12.02,38.30,59.57,27.17
4147,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85049,cpt,"Platelet Count, Automated Test",aetna,Medicare Part A,O,36.32,4.39,4.39,9.15,5.38
4148,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0444,revCode,Occupational Therapy Evaluation Or Reevaluation,aetna,PPO,I,509.00,129.95,286.62,370.63,305.40
4149,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84484,cpt,"Troponin (Protein) Analysis, Quantitative",aetna,POS,O,80.09,12.47,29.46,56.67,14.96
4150,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,57522,cpt,Removal Or Destruction Of Cervix With Electrical Cautery,aetna,Medicare Part A,O,18168.39,2323.14,10911.60,10911.60,10901.03
4151,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87177,cpt,Smear For Parasites,aetna,HMO,O,123.87,8.72,70.61,70.61,10.68
4152,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9060,cpt,"Injection, Cisplatin, Powder Or Solution, 10 Mg",aetna,EPO,O,7.79,1.85,1.85,2.82,4.67
4153,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5111,cpt,"Injection, Pegfilgrastim-Cbqv, Biosimilar, (Udenyca), 0.5 Mg",aetna,EPO,O,1901.34,181.58,880.52,880.52,1140.80
4154,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0897,cpt,"Injection, Denosumab, 1 Mg",aetna,Medicare Part B,O,62.32,12.82,18.35,21.26,37.39
4155,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86360,cpt,"T Cell Count And Ratio, Including Ratio",aetna,POS,O,220.61,31.37,125.75,125.75,132.37
4156,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80162,cpt,"Digoxin Level, Total",aetna,Medicare Part B,O,101.33,13.28,13.28,18.31,15.94
4157,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna,Medicare Part B,O,188.09,38.65,107.21,141.02,112.85
4158,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,247,ms-drg,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without MCC,aetna,Medicaid,I,79628.76,11995.52,12110.64,46153.54,47777.26
4159,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0352,revCode,"Computerized Axial Tomography (Cat)Scan, Body Scan",aetna,Medicare Part A,O,1673.95,97.51,795.53,1330.78,1004.37
4160,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97018,cpt,Application Of Hot Wax Bath To 1 Or More Areas,aetna,Medicare Part B,O,79.04,3.64,32.08,34.45,47.42
4161,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna,PPO,O,116.31,19.19,63.64,84.77,23.26
4162,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0430,revCode,"Occupational Therapy, General",aetna,Medicare Part B,I,176.32,32.63,91.02,165.50,105.79
4163,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85049,cpt,"Platelet Count, Automated Test",aetna,EPO,O,36.32,4.39,4.39,9.15,5.38
4164,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80306,cpt,"Testing For Presence Of Drug, Read By Instrument Assisted Observation",aetna,PPO,O,513.19,16.97,292.52,384.89,20.57
4165,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0401,revCode,Other Imaging Services Diagnostic Mammography,aetna,Medicare Part B,O,266.00,50.09,79.04,224.15,159.60
4166,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33430,cpt,Replacement Of Valve Between Left Upper And Lower Chambers On Heart-Lung Machine,aetna,EPO,I,207801.54,46497.02,46497.02,46497.02,124680.92
4167,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83001,cpt,"Gonadotropin, Follicle Stimulating (Reproductive Hormone) Level",aetna,EPO,O,103.81,18.58,56.81,77.86,22.30
4168,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36010,cpt,Introduction Of Catheter Into The Upper Or Lower Major Vein (Vena Cava),aetna,Medicare Part A,I,37979.62,17796.08,17796.08,17796.08,22787.77
4169,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96374,cpt,"Injection Of Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna,Medicare Part A,O,218.25,39.35,154.75,181.39,130.95
4170,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87070,cpt,"Bacterial Culture, Any Other Source Except Urine, Blood Or Stool, Aerobic",aetna,PPO,O,65.11,8.45,8.58,48.83,10.34
4171,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64483,cpt,"Injection Of Anesthetic And/Or Steroid Drug Into Sacral Spine Nerve Root Using Imaging Guidance, Single Level",aetna,EPO,O,2134.28,1064.77,4498.33,4498.33,1311.13
4172,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna,Medicaid,I,1884.10,527.05,1030.93,1360.64,1130.46
4173,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96413,cpt,"Administration Of Chemotherapy Into Vein, 1 Hour Or Less",aetna,POS,O,516.73,113.98,282.74,387.55,310.04
4174,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78815,cpt,Nuclear Medicine Study From Skull Base To Mid-Thigh With CT Scan,aetna,Medicaid,O,7116.42,1311.00,3893.89,5657.55,4269.85
4175,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,23472,cpt,"Prosthetic Repair Of Shoulder Joint, Total Shoulder",aetna,HMO,I,123346.27,14814.57,14814.57,14814.57,74007.76
4176,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5117,cpt,"Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg",aetna,EPO,O,285.60,38.03,46.31,88.21,171.36
4177,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74178,cpt,CT Scan Of Abdomen And Pelvis Before And After Contrast,aetna,HMO,O,4577.54,2.93,2609.20,3536.15,391.22
4178,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,20680,cpt,Removal Of Deep Implant From Bone,aetna,Medicare Part B,O,21223.25,2098.90,12436.52,12436.52,12733.95
4179,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83516,cpt,"Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",aetna,Medicare Part B,O,51.31,8.70,30.43,41.58,13.84
4180,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna,POS,O,116.31,19.19,63.64,84.77,23.26
4181,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86787,cpt,Analysis For Antibody To Varicella-Zoster Virus (Chicken Pox),aetna,HMO,O,53.08,6.47,29.05,39.81,15.46
4182,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,Medicare Part B,O,8.83,1.76,5.12,26.77,5.30
4183,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna,Medicare Part A,O,135.07,18.96,76.99,121.94,81.04
4184,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1442,cpt,"Injection, Filgrastim (G-Csf), Excludes Biosimilars, 1 Microgram",aetna,Medicaid,O,4.45,0.72,0.93,1.48,2.67
4185,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0403,revCode,Other Imaging Services Screening Mammography,aetna,Medicare Part B,O,312.75,51.78,104.90,273.24,187.65
4186,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9601,cpt,"Percutaneous Transcatheter Placement Of Drug-Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Each Additional Branch Of A Major Coronary Artery (List Separately In Addition To",aetna,POS,O,71354.64,14191.44,14191.44,14191.44,42812.78
4187,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19084,cpt,"Biopsy Of Breast And Placement Of Locating Device Using Ultrasound, Each Additional Growth",aetna,Medicare Part B,O,12042.88,1246.10,6742.37,6742.37,7225.73
4188,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96523,cpt,Irrigation Of Implanted Venous Access Drug Delivery Device,aetna,PPO,O,192.29,49.29,109.61,144.22,115.37
4189,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,HMO,I,2882.19,650.30,2882.19,2882.19,1729.31
4190,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0008,cpt,Administration Of Influenza Virus Vaccine,aetna,EPO,O,99.09,11.08,35.43,35.43,42.52
4191,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77417,cpt,Therapeutic Radiology Port Films,aetna,Medicaid,O,37.84,21.95,21.95,28.66,9.54
4192,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,EPO,I,2882.19,650.30,2882.19,2882.19,1729.31
4193,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9060,cpt,"Injection, Cisplatin, Powder Or Solution, 10 Mg",aetna,POS,O,7.79,1.85,1.85,2.82,4.67
4194,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83615,cpt,Lactate Dehydrogenase (Enzyme) Level,aetna,POS,O,50.72,6.04,28.91,70.62,7.25
4195,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7030,cpt,"Infusion, Normal Saline Solution , 1000 Cc",aetna,Medicaid,O,8.25,3.71,3.71,162.78,4.95
4196,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,HMO,O,344.48,61.44,188.49,273.86,206.69
4197,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,Medicaid,I,145.10,44.06,100.82,507.29,87.06
4198,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66991,cpt,Extracapsular Removal Of Cataract With Insertion Of Artificial Lens And Insertion Of Drainage Device In Front Chamber Of Eye,aetna,Medicare Part B,O,8752.90,3729.66,3729.66,3765.43,5251.74
4199,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,189,ms-drg,Pulmonary Edema And Respiratory Failure,aetna,Medicaid,I,29155.17,7655.58,9502.30,14063.21,17493.10
4200,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73700,cpt,CT Scan Of Leg Without Contrast,aetna,POS,O,1395.67,96.50,779.60,809.76,837.40
4201,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,PPO,I,3199.87,740.21,1855.92,2543.89,1919.92
4202,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78472,cpt,Nuclear Medicine Study Of Heart Pumping Function By Labeling Red Blood Cells With Measurement Of Internal Blood Volume Ejected With Every Beat Over Multiple Cycles,aetna,Medicare Part B,O,2168.12,333.98,333.99,645.81,1300.87
4203,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9145,cpt,"Injection, Daratumumab, 10 Mg",aetna,Medicare Part B,O,87.92,56.29,56.29,56.29,52.75
4204,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9145,cpt,"Injection, Daratumumab, 10 Mg",aetna,PPO,O,87.92,56.29,56.29,56.29,52.75
4205,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88162,cpt,"Screening Examination Of Specimen Cells, Extended Study",aetna,PPO,O,303.20,44.07,44.07,97.64,181.92
4206,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93289,cpt,"Evaluation Of Defibrillator Including Connection, Recording And Disconnection",aetna,HMO,O,206.45,32.90,115.33,115.33,123.87
4207,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99213,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes",aetna,POS,O,270.16,52.43,153.99,211.73,162.10
4208,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna,HMO,O,251.28,64.70,137.49,266.35,150.77
4209,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17270,cpt,"Destruction Of Malignant Growth (0.5 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna,Medicare Part B,O,1881.00,159.01,159.94,475.20,1128.60
4210,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87591,cpt,"Detection Test By Nucleic Acid For Neisseria Gonorrhoeae (Gonorrhoeae Bacteria), Amplified Probe Technique",aetna,HMO,O,147.58,21.05,82.44,110.69,42.11
4211,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1442,cpt,"Injection, Filgrastim (G-Csf), Excludes Biosimilars, 1 Microgram",aetna,Medicare Part B,O,4.45,0.72,0.93,1.48,2.67
4212,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7120,cpt,"Ringers Lactate Infusion, Up To 1000 Cc",aetna,Medicare Part B,O,162.48,32.42,74.74,162.48,97.49
4213,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87641,cpt,"Detection Test By Nucleic Acid For Staphylococcus Aureus, Methicillin Resistant (Mrsa Bacteria), Amplified Probe Technique",aetna,Medicaid,O,90.84,13.32,51.78,64.28,42.11
4214,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93660,cpt,Evaluation Of Heart Function Using Tilt Table,aetna,Medicare Part A,O,1139.65,276.48,649.60,649.60,683.79
4215,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73720,cpt,MRI Scan Of Leg Before And After Contrast,aetna,Medicare Part B,O,2882.19,326.01,1671.67,1671.67,1729.31
4216,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78815,cpt,Nuclear Medicine Study From Skull Base To Mid-Thigh With CT Scan,aetna,HMO,O,7116.42,1311.00,3893.89,5657.55,4269.85
4217,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99212,cpt,"Established Patient Office Or Other Outpatient Visit, Typically 10 Minutes",aetna,EPO,O,180.14,52.17,102.68,135.10,108.08
4218,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,219,ms-drg,Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With MCC,aetna,Medicare Part B,I,256090.54,46435.26,46497.02,47950.73,153654.32
4219,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9503,cpt,"Technetium Tc-99m Medronate, Diagnostic, Per Study Dose, Up To 30 Millicuries",aetna,HMO,O,212.36,61.08,121.05,130.93,127.42
4220,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1442,cpt,"Injection, Filgrastim (G-Csf), Excludes Biosimilars, 1 Microgram",aetna,Medicare Part A,O,4.45,0.72,0.93,1.48,2.67
4221,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3370,cpt,"Injection, Vancomycin Hcl, 500 Mg",aetna,HMO,O,75.38,22.33,34.67,34.67,45.23
4222,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna,PPO,O,1956.07,299.94,1070.30,1213.17,359.94
4223,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82525,cpt,Copper Level,aetna,Medicare Part A,O,71.96,9.63,39.38,39.38,14.89
4224,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84156,cpt,"Total Protein Level, Urine",aetna,POS,O,80.24,3.60,46.54,53.04,4.40
4225,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1200,cpt,"Injection, Diphenhydramine Hcl, Up To 50 Mg",aetna,PPO,O,3.52,0.76,18.38,80.35,2.11
4226,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86695,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 1",aetna,Medicare Part A,O,89.65,13.19,49.06,67.24,15.83
4227,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87045,cpt,Stool Culture,aetna,Medicare Part B,O,80.09,9.05,46.05,46.05,11.33
4228,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2175,cpt,"Injection, Meperidine Hydrochloride, Per 100 Mg",aetna,POS,O,85.94,17.32,39.53,86.60,51.56
4229,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88342,cpt,"Special Stained Specimen Slides To Examine Tissue, Initial Procedure",aetna,POS,O,419.99,33.03,239.39,314.99,251.99
4230,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17110,cpt,"Destruction Of Skin Growth, 1-14 Growths",aetna,Medicaid,O,958.00,159.01,159.02,479.00,574.80
4231,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna,Medicare Part B,O,281.96,102.95,163.54,224.15,123.54
4232,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96401,cpt,Administration Of Non-Hormonal Anti-Neoplastic Chemotherapy Under Skin Or Into Muscle,aetna,POS,O,286.67,27.44,27.44,63.97,172.00
4233,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11606,cpt,"Removal Of Malignant Growth (Over 4.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,Medicare Part A,O,17489.70,4901.08,9591.25,9591.25,10493.82
4234,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74178,cpt,CT Scan Of Abdomen And Pelvis Before And After Contrast,aetna,Medicare Part A,O,4577.54,2.93,2609.20,3536.15,391.22
4235,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74183,cpt,MRI Scan Of Abdomen Before And After Contrast,aetna,POS,O,3824.84,326.02,2180.16,2180.16,2294.90
4236,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna,POS,O,50.72,6.48,17.70,38.04,7.78
4237,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,065,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With CC Or Tpa In 24 Hours,aetna,HMO,I,23737.47,6483.31,6483.31,11599.87,14242.48
4238,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73080,cpt,"X-Ray Of Elbow, Minimum Of 3 Views",aetna,HMO,O,294.94,49.66,168.12,168.12,176.96
4239,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86901,cpt,Blood Typing For Rh (D) Antigen,aetna,PPO,O,83.76,7.41,47.74,83.76,17.09
4240,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,580,ms-drg,"Other Skin, Subcutaneous Tissue And Breast Procedures With CC",aetna,Medicaid,I,43871.64,9796.13,9809.77,15064.04,26322.98
4241,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80074,cpt,Acute Hepatitis Panel,aetna,EPO,O,213.87,26.66,117.03,117.03,57.16
4242,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,Medicare Part A,O,33.76,8.03,18.27,694.79,20.26
4243,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19084,cpt,"Biopsy Of Breast And Placement Of Locating Device Using Ultrasound, Each Additional Growth",aetna,PPO,O,12042.88,1246.10,6742.37,6742.37,7225.73
4244,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49320,cpt,Diagnostic Examination Of The Abdomen Using An Endoscope,aetna,POS,O,23329.13,4381.91,24397.19,24397.19,13997.48
4245,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,64721,cpt,Release And/Or Relocation Of Median Nerve Of Hand,aetna,HMO,O,15304.77,1553.71,8031.11,8031.11,9182.86
4246,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96367,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Additional Sequential Infusion, 1 Hour Or Less",aetna,HMO,O,117.97,25.86,64.55,88.48,70.78
4247,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0276,revCode,Medical/Surgical Supplies And Devices Intracular Lens,aetna,PPO,O,797.52,202.98,270.86,797.52,478.51
4248,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73200,cpt,CT Scan Of Arm Without Contrast,aetna,Medicare Part A,O,1267.08,96.51,482.16,482.16,760.25
4249,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73200,cpt,CT Scan Of Arm Without Contrast,aetna,Medicaid,O,1267.08,96.51,482.16,482.16,760.25
4250,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0612,revCode,Magnetic Resonance Technology (Mrt) Spinal Cord/Spine,aetna,HMO,O,2882.19,203.81,1642.85,2100.47,1729.31
4251,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna,PPO,O,58.98,6.19,15.24,1399.28,35.39
4252,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76700,cpt,"Ultrasound Of Abdomen, Complete",aetna,EPO,O,970.94,96.51,542.36,771.89,116.30
4253,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70553,cpt,MRI Scan Of Brain Before And After Contrast,aetna,Medicare Part A,O,3824.84,25.27,2092.84,3040.75,391.22
4254,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna,Medicaid,O,67.58,3.47,5.78,47.82,6.94
4255,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1170,cpt,"Injection, Hydromorphone, Up To 4 Mg",aetna,HMO,O,82.88,16.96,38.12,82.88,49.73
4256,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93970,cpt,Ultrasound Scan Of Veins Of Both Arms Or Legs Including Assessment Of Compression And Functional Maneuvers,aetna,Medicare Part A,O,1047.64,203.81,415.78,773.81,628.58
4257,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77373,cpt,Stereotactic Body Radiation Therapy 1 Or More Lesions Using Imaging Guidance,aetna,HMO,O,4368.52,843.53,2639.46,2639.46,1842.56
4258,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99282,cpt,Emergency Department Visit For Problem Of Mild To Moderate Severity,aetna,EPO,E,276.06,99.19,160.11,290.62,165.64
4259,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45378,cpt,Diagnostic Colonoscopy Of Large Bowel Using A Flexible Endoscope,aetna,HMO,O,3131.25,717.01,1860.41,2251.40,861.59
4260,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28008,cpt,Incision Of Tissues Of Muscle Compartment Of Foot And/Or Toe,aetna,PPO,O,15422.69,8682.40,8682.40,15484.76,9253.61
4261,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna,PPO,O,3391.86,327.84,1855.92,2543.90,462.44
4262,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0360,revCode,"Operating Room Services, General",aetna,HMO,O,9825.06,1878.83,4989.15,12996.76,5895.04
4263,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,58558,cpt,Biopsy Of Lining Of Uterus And/Or Removal Of Polyp Using An Endoscope,aetna,Medicare Part B,O,22844.35,2323.22,10420.95,10420.95,13706.61
4264,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,26055,cpt,Incision Of Tendon Covering Of Finger,aetna,Medicare Part B,O,16309.48,1233.08,10334.48,10334.48,9785.69
4265,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna,Medicare Part A,O,490.78,263.76,343.76,353.36,294.47
4266,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna,EPO,O,67.58,3.47,5.78,47.82,6.94
4267,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96368,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Concurrent With Another Infusion",aetna,HMO,O,75.68,16.92,43.89,60.16,45.41
4268,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0371,revCode,Anesthesia Incident To Radiology,aetna,POS,I,47.19,8.72,26.90,26.90,28.31
4269,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna,Medicaid,O,479.00,41.29,159.02,1803.87,287.40
4270,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82950,cpt,Blood Glucose (Sugar) Level After Receiving Dose Of Glucose,aetna,HMO,O,38.92,4.70,21.30,75.94,5.70
4271,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80074,cpt,Acute Hepatitis Panel,aetna,Medicare Part A,O,213.87,26.66,117.03,117.03,57.16
4272,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna,Medicare Part B,O,50.72,5.89,27.75,35.89,7.21
4273,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0333,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Radiation Therapy,aetna,PPO,O,933.20,214.04,481.06,1795.20,559.92
4274,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3010,cpt,"Injection, Fentanyl Citrate, 0.1 Mg",aetna,POS,O,82.61,17.19,37.17,85.93,49.57
4275,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna,Medicare Part A,O,50.72,5.89,27.75,35.89,7.21
4276,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7120,cpt,"Ringers Lactate Infusion, Up To 1000 Cc",aetna,EPO,O,162.48,32.42,74.74,162.48,97.49
4277,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82728,cpt,Ferritin (Blood Protein) Level,aetna,Medicare Part B,O,84.93,11.67,46.48,84.93,16.36
4278,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88175,cpt,"Pap Test, Automated Thin Layer Preparation; Automated System And Manual Rescreening",aetna,Medicare Part B,O,83.33,0.35,47.50,60.74,31.93
4279,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,PPO,I,72.54,19.89,124.91,124.91,43.52
4280,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73070,cpt,"X-Ray Of Elbow, 2 Views",aetna,PPO,O,238.30,35.12,143.98,143.98,142.98
4281,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87661,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Amplified Probe Technique",aetna,Medicare Part B,O,151.64,21.05,84.70,113.73,42.11
4282,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97165,cpt,"Evaluation For Occupational Therapy, Typically 30 Minutes",aetna,EPO,O,211.24,71.93,120.41,120.41,126.74
4283,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80069,cpt,Kidney Function Blood Test Panel,aetna,Medicare Part B,O,67.58,8.51,38.52,38.52,10.42
4284,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88300,cpt,"Pathology Examination Of Tissue Using A Microscope, Limited Examination",aetna,Medicaid,O,93.19,27.95,50.99,50.99,55.91
4285,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5117,cpt,"Injection, Trastuzumab-Anns, Biosimilar, (Kanjinti), 10 Mg",aetna,Medicare Part B,O,285.60,38.03,46.31,88.21,171.36
4286,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna,Medicare Part B,I,281.58,60.08,199.37,281.58,168.95
4287,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9306,cpt,"Injection, Pertuzumab, 1 Mg",aetna,PPO,O,44.82,10.05,14.64,424.56,26.89
4288,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna,Medicaid,O,95.71,16.18,16.18,21.31,19.42
4289,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5107,cpt,"Injection, Bevacizumab-Awwb, Biosimilar, (Mvasi), 10 Mg",aetna,POS,O,219.45,31.72,60.94,74.56,131.67
4290,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,189,ms-drg,Pulmonary Edema And Respiratory Failure,aetna,Medicare Part B,I,29155.17,7655.58,9502.30,14063.21,17493.10
4291,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2704,cpt,"Injection, Propofol, 10 Mg",aetna,Medicaid,O,4.12,0.82,1.89,4.12,2.47
4292,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74018,cpt,"X-Ray Of Abdomen, 1 View",aetna,HMO,O,268.98,61.44,147.18,285.11,85.98
4293,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93289,cpt,"Evaluation Of Defibrillator Including Connection, Recording And Disconnection",aetna,Medicaid,O,206.45,32.90,115.33,115.33,123.87
4294,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33430,cpt,Replacement Of Valve Between Left Upper And Lower Chambers On Heart-Lung Machine,aetna,POS,I,207801.54,46497.02,46497.02,46497.02,124680.92
4295,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9271,cpt,"Injection, Pembrolizumab, 1 Mg",aetna,Medicare Part B,O,192.29,32.26,52.73,144.22,115.37
4296,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82248,cpt,"Bilirubin Level, Direct",aetna,HMO,O,41.28,4.92,14.47,14.47,6.02
4297,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84425,cpt,Vitamin B-1 (Thiamine) Level,aetna,PPO,O,138.03,18.33,75.53,75.53,82.82
4298,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,189,ms-drg,Pulmonary Edema And Respiratory Failure,aetna,POS,I,29155.17,7655.58,9502.30,14063.21,17493.10
4299,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37230,cpt,"Insertion Of Stents Into Artery In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna,Medicaid,I,262831.76,27743.68,27743.68,27743.68,157699.06
4300,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,HMO,I,140.26,41.63,88.86,224.92,84.16
4301,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86141,cpt,"Measurement C-Reactive Protein For Detection Of Infection Or Inflammation, High Sensitivity",aetna,PPO,O,138.33,7.77,7.77,13.00,15.54
4302,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82803,cpt,Blood Gases Measurement,aetna,Medicare Part A,O,158.08,26.07,86.50,86.50,30.97
4303,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74174,cpt,CT Scan Of Blood Vessels Of Abdomen And Pelvis With Contrast,aetna,POS,O,1736.62,326.01,329.84,497.16,391.22
4304,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0283,cpt,"Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound Care, As Part Of A Therapy Plan Of Care",aetna,Medicare Part B,O,93.19,9.47,40.58,93.19,55.91
4305,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82306,cpt,Vitamin D-3 Level,aetna,Medicare Part A,O,101.33,21.15,57.76,63.19,35.52
4306,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0335,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration -Iv,aetna,Medicare Part A,O,487.49,86.82,282.74,11490.04,292.49
4307,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87046,cpt,"Stool Culture, Additional Pathogens",aetna,POS,O,52.60,5.92,30.25,30.25,11.33
4308,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,PPO,O,110.40,7.04,8.00,129.02,66.24
4309,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna,Medicare Part B,O,289.04,102.81,158.15,158.15,134.83
4310,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna,POS,O,281.96,102.95,163.54,224.15,123.54
4311,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86147,cpt,Cardiolipin Antibody (Tissue Antibody) Measurement,aetna,HMO,O,330.33,25.55,188.29,247.75,30.54
4312,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87661,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Amplified Probe Technique",aetna,Medicare Part A,O,151.64,21.05,84.70,113.73,42.11
4313,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11606,cpt,"Removal Of Malignant Growth (Over 4.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,PPO,O,17489.70,4901.08,9591.25,9591.25,10493.82
4314,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76805,cpt,"Ultrasound Scan Of Pregnant Uterus (14 Weeks Or More), Single Or First Fetus",aetna,EPO,O,442.41,49.86,252.17,292.16,117.01
4315,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33216,cpt,Insertion Of Electrode For Permanent Pacemaker Or Pacing Defibrillator Device,aetna,POS,O,31268.54,3610.13,3610.13,3610.13,18761.12
4316,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74174,cpt,CT Scan Of Blood Vessels Of Abdomen And Pelvis With Contrast,aetna,HMO,O,1736.62,326.01,329.84,497.16,391.22
4317,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99283,cpt,Emergency Department Visit For Problem Of Moderate Severity,aetna,POS,E,871.53,205.11,459.97,892.25,522.92
4318,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87660,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Direct Probe Technique",aetna,Medicare Part A,O,114.43,12.03,62.62,85.82,24.06
4319,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87480,cpt,"Detection Test For Candida Species (Yeast), Direct Probe Technique",aetna,HMO,O,107.59,12.03,58.87,80.69,24.06
4320,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77386,cpt,"Intensity Modulated Radiation Therapy Delivery, Complex",aetna,EPO,O,2383.15,480.50,1303.99,1303.99,576.60
4321,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88173,cpt,Evaluation Of Fine Needle Aspirate With Interpretation And Report,aetna,HMO,O,109.71,60.12,81.77,81.77,65.83
4322,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97165,cpt,"Evaluation For Occupational Therapy, Typically 30 Minutes",aetna,Medicaid,O,211.24,71.93,120.41,120.41,126.74
4323,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11401,cpt,"Removal Of Growth (0.6 To 1.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,Medicare Part A,O,4292.00,309.74,309.74,2167.15,2575.20
4324,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,V2632,cpt,"Post Chmbr Intraocular Lens; Prosthetics, Orthotics, And Supplies",aetna,PPO,O,797.52,202.98,270.86,797.52,478.51
4325,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33216,cpt,Insertion Of Electrode For Permanent Pacemaker Or Pacing Defibrillator Device,aetna,HMO,O,31268.54,3610.13,3610.13,3610.13,18761.12
4326,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna,Medicare Part A,O,67.58,3.47,5.78,47.82,6.94
4327,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,A9500,cpt,"Technetium Tc-99m Sestamibi, Diagnostic, Per Study Dose",aetna,HMO,O,692.52,114.53,394.74,734.07,415.51
4328,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99204,cpt,"New Patient Office Or Other Outpatient Visit, 45-59 Minutes",aetna,Medicare Part B,O,634.41,49.54,367.96,475.81,223.37
4329,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,HMO,O,3199.87,326.01,1445.14,2637.87,1919.92
4330,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85018,cpt,"Blood Count, Hemoglobin",aetna,Medicare Part B,O,33.02,2.35,18.82,24.77,2.84
4331,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna,HMO,O,218.25,35.37,121.91,263.09,130.95
4332,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76536,cpt,Ultrasound Scan Of Head And Neck Soft Tissue,aetna,EPO,O,491.96,96.50,269.19,391.10,295.18
4333,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71271,cpt,Low Dose CT Scan Of Chest For Lung Cancer Screening,aetna,Medicare Part A,O,331.51,71.65,98.50,234.56,198.91
4334,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84439,cpt,"Thyroxine (Thyroid Chemical), Free",aetna,Medicare Part B,O,52.60,8.84,28.79,39.45,10.82
4335,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84402,cpt,"Testosterone (Hormone) Level, Free",aetna,PPO,O,70.78,13.11,38.73,53.09,30.56
4336,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77386,cpt,"Intensity Modulated Radiation Therapy Delivery, Complex",aetna,Medicare Part B,O,2383.15,480.50,1303.99,1303.99,576.60
4337,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17110,cpt,"Destruction Of Skin Growth, 1-14 Growths",aetna,PPO,O,958.00,159.01,159.02,479.00,574.80
4338,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97530,cpt,"Therapeutic Activities To Improve Function, With One-On-One Contact Between Patient And Provider, Each 15 Minutes",aetna,Medicare Part B,O,166.34,34.57,91.02,91.02,99.80
4339,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80306,cpt,"Testing For Presence Of Drug, Read By Instrument Assisted Observation",aetna,Medicare Part B,O,513.19,16.97,292.52,384.89,20.57
4340,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0341,revCode,"Nuclear Medicine, Diagnostic",aetna,Medicare Part B,O,5568.56,800.20,3046.95,5465.13,3341.14
4341,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9600,cpt,"Percutaneous Transcatheter Placement Of Drug Eluting Intracoronary Stent(S), With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna,Medicare Part B,O,63819.96,8894.43,14191.44,29488.15,38291.98
4342,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88300,cpt,"Pathology Examination Of Tissue Using A Microscope, Limited Examination",aetna,POS,O,93.19,27.95,50.99,50.99,55.91
4343,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86706,cpt,Hepatitis B Surface Antibody Measurement,aetna,EPO,O,94.38,6.44,52.72,70.79,12.89
4344,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0521,revCode,Freestanding Clinic Clinic Visit By Member Torhc/Fqhc,aetna,POS,O,195.00,111.87,111.87,244.91,117.00
4345,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9228,cpt,"Injection, Ipilimumab, 1 Mg",aetna,POS,O,588.70,104.49,157.23,157.23,353.22
4346,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86592,cpt,Syphilis Detection Test,aetna,POS,O,40.11,4.27,22.41,30.08,5.12
4347,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87186,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or Agar Dilution",aetna,PPO,O,47.53,6.92,8.65,35.65,10.38
4348,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94060,cpt,"Measurement And Graphic Recording Of The Amount And Speed Of Breathed Air, Before And Following Medication Administration",aetna,Medicaid,O,422.68,78.29,218.19,239.44,253.61
4349,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,776,ms-drg,Postpartum And Post Abortion Diagnoses Without O.R. Procedures,aetna,PPO,I,14400.00,2525.16,5439.38,9082.13,8640.00
4350,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna,EPO,I,140.26,41.63,88.86,224.92,84.16
4351,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86696,cpt,"Analysis For Antibody To Herpes Simplex Virus, Type 2",aetna,Medicare Part B,O,126.23,19.24,69.07,94.67,23.22
4352,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74174,cpt,CT Scan Of Blood Vessels Of Abdomen And Pelvis With Contrast,aetna,Medicare Part A,O,1736.62,326.01,329.84,497.16,391.22
4353,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73600,cpt,"X-Ray Of Ankle, 2 Views",aetna,Medicaid,O,252.47,30.86,143.91,143.91,151.48
4354,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0350,revCode,"Computerized Axial Tomography (Cat)Scan, General",aetna,POS,O,3199.87,326.01,1445.14,2637.87,1919.92
4355,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11104,cpt,Punch Biopsy Of Single Skin Lesion,aetna,HMO,O,2056.68,306.29,1669.70,3042.91,1234.01
4356,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82626,cpt,Dehydroepiandrosterone (Dhea) Hormone Level,aetna,PPO,O,148.02,23.79,85.85,85.85,88.81
4357,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86765,cpt,Analysis For Antibody To Rubeola (Measles Virus),aetna,Medicare Part A,O,50.01,7.69,55.32,55.32,30.01
4358,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,330,ms-drg,Major Small And Large Bowel Procedures With CC,aetna,Medicare Part A,I,58731.07,15126.82,15186.72,23610.09,35238.64
4359,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74183,cpt,MRI Scan Of Abdomen Before And After Contrast,aetna,EPO,O,3824.84,326.02,2180.16,2180.16,2294.90
4360,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,Medicaid,O,110.40,7.04,8.00,129.02,66.24
4361,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86778,cpt,Analysis For Antibody (Igm) To Toxoplasma (Parasite),aetna,Medicare Part B,O,152.18,14.27,86.74,86.74,91.31
4362,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82746,cpt,"Folic Acid Level, Serum",aetna,POS,O,65.11,9.14,37.11,37.11,17.64
4363,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73140,cpt,"X-Ray Of Fingers, Minimum Of 2 Views",aetna,PPO,O,226.51,61.44,131.38,131.38,85.98
4364,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96411,cpt,Administration Of Additional New Drug Or Substance Into Vein Using Push Technique,aetna,HMO,O,238.30,49.47,130.40,178.73,142.98
4365,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77295,cpt,"Management Of Radiation Therapy, 3d",aetna,Medicare Part A,O,1926.57,1003.61,1098.14,1531.62,1341.41
4366,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5107,cpt,"Injection, Bevacizumab-Awwb, Biosimilar, (Mvasi), 10 Mg",aetna,Medicaid,O,219.45,31.72,60.94,74.56,131.67
4367,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45385,cpt,Removal Of Polyps Or Growths Of Large Bowel Using An Endoscope With Mechanical Snare,aetna,POS,O,5305.34,938.17,2617.73,5400.89,1653.07
4368,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0258,revCode,Pharmacy Ivsolutions,aetna,EPO,I,137.36,28.95,90.50,129.04,82.42
4369,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,10005,cpt,"Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth",aetna,HMO,O,2422.63,555.63,1193.41,1567.18,1453.58
4370,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna,POS,O,344.48,61.44,188.49,273.86,206.69
4371,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,S2900,cpt,Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure),aetna,HMO,O,26479.60,4481.58,24397.19,24397.19,15887.76
4372,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93225,cpt,Electrocardiogram (Ecg) 2-Day Continuous,aetna,Medicare Part A,O,251.28,64.70,119.50,199.77,150.77
4373,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84703,cpt,Gonadotropin (Reproductive Hormone) Analysis,aetna,Medicare Part A,O,69.48,7.52,37.26,48.18,9.02
4374,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1885,cpt,"Injection, Ketorolac Tromethamine, Per 15 Mg",aetna,Medicare Part B,O,39.72,7.88,18.17,40.53,23.83
4375,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1170,cpt,"Injection, Hydromorphone, Up To 4 Mg",aetna,Medicaid,O,82.88,16.96,38.12,82.88,49.73
4376,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86141,cpt,"Measurement C-Reactive Protein For Detection Of Infection Or Inflammation, High Sensitivity",aetna,Medicaid,O,138.33,7.77,7.77,13.00,15.54
4377,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82626,cpt,Dehydroepiandrosterone (Dhea) Hormone Level,aetna,Medicare Part A,O,148.02,23.79,85.85,85.85,88.81
4378,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77373,cpt,Stereotactic Body Radiation Therapy 1 Or More Lesions Using Imaging Guidance,aetna,EPO,O,4368.52,843.53,2639.46,2639.46,1842.56
4379,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74246,cpt,X-Ray Of Upper Digestive Tract With Double Contrast,aetna,EPO,O,484.07,158.13,264.87,284.00,189.76
4380,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,371,ms-drg,Major Gastrointestinal Disorders And Peritoneal Infections With MCC,aetna,EPO,I,34185.44,8873.88,8873.88,11142.92,20511.26
4381,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83690,cpt,Lipase (Fat Enzyme) Level,aetna,Medicare Part A,O,52.60,6.89,18.70,39.45,8.27
4382,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73080,cpt,"X-Ray Of Elbow, Minimum Of 3 Views",aetna,Medicare Part B,O,294.94,49.66,168.12,168.12,176.96
4383,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1885,cpt,"Injection, Ketorolac Tromethamine, Per 15 Mg",aetna,EPO,O,39.72,7.88,18.17,40.53,23.83
4384,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85651,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Non-Automated",aetna,PPO,O,13.00,1.77,4.25,4.68,7.80
4385,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82803,cpt,Blood Gases Measurement,aetna,HMO,O,158.08,26.07,86.50,86.50,30.97
4386,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,330,ms-drg,Major Small And Large Bowel Procedures With CC,aetna,HMO,I,58731.07,15126.82,15186.72,23610.09,35238.64
4387,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88342,cpt,"Special Stained Specimen Slides To Examine Tissue, Initial Procedure",aetna,PPO,O,419.99,33.03,239.39,314.99,251.99
4388,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,26055,cpt,Incision Of Tendon Covering Of Finger,aetna,Medicare Part A,O,16309.48,1233.08,10334.48,10334.48,9785.69
4389,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77063,cpt,Screening Digital Tomography Of Both Breasts,aetna,PPO,O,184.03,20.92,100.70,167.23,110.42
4390,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0640,cpt,"Injection, Leucovorin Calcium, Per 50 Mg",aetna,PPO,O,17.80,3.56,3.56,14.15,10.68
4391,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9035,cpt,"Injection, Bevacizumab, 10 Mg",aetna,Medicare Part A,O,282.70,75.76,77.46,77.46,169.62
4392,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86706,cpt,Hepatitis B Surface Antibody Measurement,aetna,Medicare Part B,O,94.38,6.44,52.72,70.79,12.89
4393,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86778,cpt,Analysis For Antibody (Igm) To Toxoplasma (Parasite),aetna,PPO,O,152.18,14.27,86.74,86.74,91.31
4394,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J0881,cpt,"Injection, Darbepoetin Alfa, 1 Microgram (Non-Esrd Use)",aetna,Medicare Part A,O,15.58,2.38,7.43,7.43,9.35
4395,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,94726,cpt,Determination Of Lung Volumes Using Plethysmography,aetna,Medicaid,O,501.40,116.04,274.35,274.35,300.84
4396,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84112,cpt,Cervicovaginal Secretion Of Placenta Protein,aetna,EPO,O,243.07,29.33,29.33,243.07,49.58
4397,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87496,cpt,"Detection Test By Nucleic Acid For Cytomegalovirus (Cmv), Amplified Probe Technique",aetna,PPO,O,191.11,108.93,108.93,108.93,114.67
4398,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0430,revCode,"Occupational Therapy, General",aetna,PPO,I,176.32,32.63,91.02,165.50,105.79
4399,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2505,cpt,"Injection, Pegfilgrastim, 6 Mg",aetna,HMO,O,17508.60,2251.51,6955.90,6955.90,10505.16
4400,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,40490,cpt,Biopsy Of Lip,aetna,Medicare Part B,O,1535.00,623.16,642.96,1044.00,921.00
4401,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72050,cpt,"X-Ray Of Upper Spine, 4 Or 5 Views",aetna,Medicaid,O,613.48,42.39,349.68,373.40,115.81
4402,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9171,cpt,"Injection, Docetaxel, 1 Mg",aetna,Medicare Part B,O,15.58,0.67,0.67,4.17,9.35
4403,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99283,cpt,Emergency Department Visit For Problem Of Moderate Severity,aetna,EPO,E,871.53,205.11,459.97,892.25,522.92
4404,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5115,cpt,"Injection, Rituximab-Abbs, Biosimilar, (Truxima), 10 Mg",aetna,Medicare Part B,O,218.36,61.56,68.50,163.77,131.02
4405,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99211,cpt,Office Or Other Outpatient Visit For The Evaluation And Management Of Established Patient That May Not Require Presence Of Healthcare Professional,aetna,EPO,O,91.30,29.79,52.04,190.38,54.78
4406,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0250,revCode,Pharmacy General,aetna,Medicare Part B,I,7.39,2.22,3.59,34.05,4.43
4407,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86920,cpt,"Blood Unit Compatibility Test, Immediate Spin Technique",aetna,Medicare Part A,O,373.98,33.03,132.10,152.61,79.26
4408,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0500,cpt,"Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care Professional Performing A Gastrointestinal Endoscopic Service That Sedation Supports, Requiring The Presence Of",aetna,EPO,O,47.19,27.14,27.14,47.19,28.31
4409,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q0243,cpt,"Injection, Casirivimab And Imdevimab, 2400 Mg",aetna,PPO,O,0.03,0.01,0.01,11.63,0.02
4410,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,064,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With MCC,aetna,Medicare Part A,I,42514.90,11561.36,11613.14,15935.29,25508.94
4411,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna,PPO,O,4073.77,814.60,2322.05,3238.64,977.56
4412,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J7120,cpt,"Ringers Lactate Infusion, Up To 1000 Cc",aetna,HMO,O,162.48,32.42,74.74,162.48,97.49
4413,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna,Medicaid,O,176.96,19.79,96.59,99.98,106.18
4414,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9000,cpt,"Injection, Doxorubicin Hydrochloride, 10 Mg",aetna,POS,O,10.61,1.82,2.81,2.81,6.37
4415,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna,PPO,O,176.96,19.79,96.59,99.98,106.18
4416,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J2710,cpt,"Injection, Neostigmine Methylsulfate, Up To 0.5 Mg",aetna,HMO,O,4.65,0.15,0.15,4.27,2.79
4417,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74183,cpt,MRI Scan Of Abdomen Before And After Contrast,aetna,PPO,O,3824.84,326.02,2180.16,2180.16,2294.90
4418,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96367,cpt,"Infusion Into A Vein For Therapy, Prevention, Or Diagnosis, Additional Sequential Infusion, 1 Hour Or Less",aetna,Medicare Part B,O,117.97,25.86,64.55,88.48,70.78
4419,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97110,cpt,"Therapeutic Exercise To Develop Strength, Endurance, Range Of Motion, And Flexibility, Each 15 Minutes",aetna,HMO,O,173.42,23.35,77.46,114.70,29.09
4420,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84166,cpt,"Protein Measurement, Body Fluid",aetna,Medicare Part A,O,57.87,6.77,17.83,17.90,21.40
4421,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3380,cpt,"Injection, Vedolizumab, 1 Mg",aetna,Medicaid,O,60.64,21.72,28.92,28.92,36.38
4422,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3380,cpt,"Injection, Vedolizumab, 1 Mg",aetna,Medicare Part A,O,60.64,21.72,28.92,28.92,36.38
4423,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87177,cpt,Smear For Parasites,aetna,Medicare Part A,O,123.87,8.72,70.61,70.61,10.68
4424,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80053,cpt,"Blood Test, Comprehensive Group Of Blood Chemicals",aetna,Medicare Part A,O,91.30,10.35,49.96,68.47,12.67
4425,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87340,cpt,Detection Test By Immunoassay Technique For Hepatitis B Surface Antigen,aetna,PPO,O,80.09,7.09,45.65,60.07,12.40
4426,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,065,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With CC Or Tpa In 24 Hours,aetna,Medicaid,I,23737.47,6483.31,6483.31,11599.87,14242.48
4427,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0278,revCode,Medical/Surgical Supplies And Devices Other Implants,aetna,EPO,I,12498.86,118.53,1501.07,6933.25,7499.32
4428,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5103,cpt,"Injection, Infliximab-Dyyb, Biosimilar, (Inflectra), 10 Mg",aetna,POS,O,114.15,40.05,51.37,114.15,68.49
4429,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74220,cpt,X-Ray Of Esophagus With Single Contrast,aetna,HMO,O,552.13,55.19,320.24,320.24,193.72
4430,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna,POS,O,14.15,0.48,0.89,8.71,8.49
4431,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37230,cpt,"Insertion Of Stents Into Artery In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna,PPO,I,262831.76,27743.68,27743.68,27743.68,157699.06
4432,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87301,cpt,Detection Test By Immunoassay Technique For Adenovirus Enteric Types 40/41,aetna,HMO,O,60.03,6.75,34.52,34.52,14.38
4433,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0279,cpt,"Diagnostic Digital Breast Tomosynthesis, Unilateral Or Bilateral (List Separately In Addition To 77065 Or 77066)",aetna,HMO,O,120.33,22.38,69.79,95.66,72.20
4434,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93571,cpt,"Ultrasound Evaluation Of Heart Blood Vessel During Diagnosis Or Treatment, Initial Vessel",aetna,POS,O,31969.64,4389.98,14191.44,14191.44,19181.78
4435,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna,EPO,O,2882.19,203.81,1577.05,2039.29,1729.31
4436,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77295,cpt,"Management Of Radiation Therapy, 3d",aetna,POS,O,1926.57,1003.61,1098.14,1531.62,1341.41
4437,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,PPO,O,654.73,185.98,323.41,694.53,392.84
4438,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9202,cpt,"Goserelin Acetate Implant, Per 3.6 Mg",aetna,EPO,O,1210.44,149.56,581.30,581.30,726.26
4439,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73552,cpt,"X-Ray Of Thigh Bone, Minimum 2 Views",aetna,POS,O,309.09,42.89,176.18,176.18,185.45
4440,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83498,cpt,"Hydroxyprogesterone, 17-D (Synthetic Hormone) Level",aetna,Medicaid,O,126.23,20.54,69.07,69.07,75.74
4441,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,812,ms-drg,Red Blood Cell Disorders Without MCC,aetna,PPO,I,18593.40,4553.02,5996.54,8936.86,11156.04
4442,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87427,cpt,Detection Test By Immunoassay Technique For Shiga-Like Toxin (Bacterial Toxin),aetna,Medicare Part B,O,60.03,6.75,34.22,34.22,14.38
4443,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72141,cpt,MRI Scan Of Upper Spinal Canal Without Contrast,aetna,PPO,O,2882.19,205.13,1642.85,2291.34,244.57
4444,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80202,cpt,Vancomycin (Antibiotic) Level,aetna,EPO,O,87.53,13.54,49.89,49.89,16.25
4445,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,PPO,I,973.23,169.01,169.01,1031.60,583.94
4446,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11606,cpt,"Removal Of Malignant Growth (Over 4.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna,Medicaid,O,17489.70,4901.08,9591.25,9591.25,10493.82
4447,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna,PPO,O,50.72,5.89,27.75,35.89,7.21
4448,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,Medicare Part A,O,654.73,185.98,323.41,694.53,392.84
4449,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83021,cpt,"Hemoglobin Analysis And Measurement, Chromatography",aetna,PPO,O,130.95,16.12,71.65,71.65,21.67
4450,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80053,cpt,"Blood Test, Comprehensive Group Of Blood Chemicals",aetna,Medicare Part B,O,91.30,10.35,49.96,68.47,12.67
4451,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73218,cpt,MRI Scan Of Arm Without Contrast,aetna,Medicaid,O,2882.19,206.00,1642.85,2719.05,1729.31
4452,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9171,cpt,"Injection, Docetaxel, 1 Mg",aetna,POS,O,15.58,0.67,0.67,4.17,9.35
4453,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86777,cpt,Analysis For Antibody To Toxoplasma (Parasite),aetna,EPO,O,152.18,14.25,86.74,86.74,91.31
4454,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87660,cpt,"Detection Test By Nucleic Acid For Trichomonas Vaginalis (Genital Parasite), Direct Probe Technique",aetna,POS,O,114.43,12.03,62.62,85.82,24.06
4455,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71271,cpt,Low Dose CT Scan Of Chest For Lung Cancer Screening,aetna,POS,O,331.51,71.65,98.50,234.56,198.91
4456,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0370,revCode,Anesthesia General,aetna,Medicare Part B,O,654.73,185.98,323.41,694.53,392.84
4457,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9263,cpt,"Injection, Oxaliplatin, 0.5 Mg",aetna,Medicare Part A,O,7.79,0.10,0.10,1.89,4.67
4458,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88342,cpt,"Special Stained Specimen Slides To Examine Tissue, Initial Procedure",aetna,Medicare Part A,O,419.99,33.03,239.39,314.99,251.99
4459,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73552,cpt,"X-Ray Of Thigh Bone, Minimum 2 Views",aetna,Medicare Part A,O,309.09,42.89,176.18,176.18,185.45
4460,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88173,cpt,Evaluation Of Fine Needle Aspirate With Interpretation And Report,aetna,Medicaid,O,109.71,60.12,81.77,81.77,65.83
4461,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,603,ms-drg,Cellulitis Without MCC,aetna,POS,I,19499.58,3283.09,5672.80,12955.93,11699.75
4462,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0335,revCode,Radiology Therapeutic And/Of Chemotherapy Administration Chemotherapy Administration -Iv,aetna,POS,O,487.49,86.82,282.74,11490.04,292.49
4463,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna,Medicaid,O,281.96,102.95,163.54,224.15,123.54
4464,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,Q5101,cpt,"Injection, Filgrastim-Sndz, Biosimilar, (Zarxio), 1 Microgram",aetna,PPO,O,1.85,0.17,0.35,0.35,1.11
4465,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73070,cpt,"X-Ray Of Elbow, 2 Views",aetna,HMO,O,238.30,35.12,143.98,143.98,142.98
4466,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna,Medicare Part B,O,52.60,6.47,8.08,42.46,9.70
4467,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86765,cpt,Analysis For Antibody To Rubeola (Measles Virus),aetna,Medicare Part B,O,50.01,7.69,55.32,55.32,30.01
4468,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96411,cpt,Administration Of Additional New Drug Or Substance Into Vein Using Push Technique,aetna,EPO,O,238.30,49.47,130.40,178.73,142.98
4469,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna,Medicare Part A,O,3391.86,327.84,1855.92,2543.90,462.44
4470,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88341,cpt,"Special Stained Specimen Slides To Examine Tissue, Each Additional Procedure",aetna,PPO,O,125.04,25.34,71.27,125.04,75.02
4471,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna,EPO,O,33.76,8.03,18.27,694.79,20.26
4472,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78816,cpt,Nuclear Medicine Study With CT Imaging Whole Body,aetna,Medicaid,O,7556.48,1311.05,1311.05,2704.61,4533.89
4473,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84425,cpt,Vitamin B-1 (Thiamine) Level,aetna,Medicare Part A,O,138.03,18.33,75.53,75.53,82.82
4474,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80048,cpt,"Blood Test, Basic Group Of Blood Chemicals (Calcium, Total)",aetna,PPO,O,70.06,8.30,38.34,49.58,10.15
4475,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna,Medicare Part B,O,91.30,14.35,49.96,64.61,54.78
4476,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J3475,cpt,"Injection, Magnesium Sulfate, Per 500 Mg",aetna,Medicare Part A,O,4.45,1.00,2.05,2.05,2.67
4477,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,287,ms-drg,"Circulatory Disorders Except Ami, With Cardiac Catheterization Without MCC",aetna,EPO,I,39655.14,7316.35,7333.25,13218.75,23793.08
4478,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80048,cpt,"Blood Test, Basic Group Of Blood Chemicals (Calcium, Total)",aetna,Medicare Part A,O,70.06,8.30,38.34,49.58,10.15
4479,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74174,cpt,CT Scan Of Blood Vessels Of Abdomen And Pelvis With Contrast,aetna,EPO,O,1736.62,326.01,329.84,497.16,391.22
4480,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83615,cpt,Lactate Dehydrogenase (Enzyme) Level,aetna - medicare advantage,POS,O,50.72,6.04,6.04,70.62,7.25
4481,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna - medicare advantage,POS,O,91.30,14.35,19.31,64.61,54.78
4482,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,394,ms-drg,Other Digestive System Diagnoses With CC,aetna - medicare advantage,HMO,I,28226.22,6182.72,6237.15,10874.89,16935.73
4483,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84165,cpt,"Protein Measurement, Serum",aetna - medicare advantage,EPO,O,116.79,10.63,10.63,82.64,12.89
4484,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna - medicare advantage,Medicare Part B,O,148.64,18.79,18.79,22.56,22.55
4485,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37224,cpt,"Balloon Dilation Of Arteries In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna - medicare advantage,HMO,O,40407.87,4389.28,8996.91,8996.91,24244.72
4486,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna - medicare advantage,PPO,O,92.22,24.06,24.06,24.60,55.33
4487,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna - medicare advantage,PPO,O,93.19,18.38,54.88,74.09,55.91
4488,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna - medicare advantage,Medicare Part A,O,2882.19,207.14,207.14,2666.05,1729.31
4489,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna - medicare advantage,Medicare Part B,O,52.60,6.47,8.08,42.46,9.70
4490,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83880,cpt,Natriuretic Peptide (Heart And Blood Vessel Protein) Level,aetna - medicare advantage,Medicare Part B,O,130.11,25.90,39.26,92.07,47.11
4491,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45385,cpt,Removal Of Polyps Or Growths Of Large Bowel Using An Endoscope With Mechanical Snare,aetna - medicare advantage,EPO,O,5305.34,938.17,1098.80,5400.89,1653.07
4492,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82977,cpt,Glutamyltransferase (Liver Enzyme) Level,aetna - medicare advantage,Medicare Part A,O,40.17,4.32,7.13,30.08,8.64
4493,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84460,cpt,"Liver Enzyme (Sgpt), Level",aetna - medicare advantage,Medicare Part B,O,29.48,3.88,5.25,5.32,6.36
4494,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84403,cpt,"Testosterone (Hormone) Level, Total",aetna - medicare advantage,PPO,O,135.66,25.30,25.81,101.75,30.97
4495,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72131,cpt,CT Scan Of Lower Spine Without Contrast,aetna - medicare advantage,POS,O,1654.04,96.51,96.53,400.81,116.30
4496,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93308,cpt,Follow-Up Or Limited Ultrasound Examination Of Heart,aetna - medicare advantage,POS,O,415.27,203.81,206.00,403.52,249.16
4497,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna - medicare advantage,Medicaid,O,95.71,16.18,16.18,21.31,19.42
4498,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12031,cpt,"Repair Of Wound (2.5 Centimeters Or Less) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna - medicare advantage,Medicare Part A,O,2584.00,464.39,464.39,2584.00,1550.40
4499,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna - medicare advantage,POS,E,5923.22,592.08,2022.06,2288.99,3553.93
4500,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna - medicare advantage,PPO,O,70.06,8.01,8.09,52.55,9.80
4501,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna - medicare advantage,PPO,O,95.71,16.18,16.18,21.31,19.42
4502,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna - medicare advantage,POS,O,2882.19,203.81,206.20,2291.34,244.57
4503,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84520,cpt,"Urea Nitrogen Level To Assess Kidney Function, Quantitative",aetna - medicare advantage,HMO,O,40.11,3.95,3.95,30.08,4.74
4504,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87389,cpt,Detection Test By Immunoassay Technique For Hiv-1 Antigen And Hiv-1 And Hiv-2 Antibodies,aetna - medicare advantage,HMO,O,101.33,8.97,23.96,76.00,28.90
4505,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,49507,cpt,Repair Of Trapped Groin Hernia Patient Age 5 Years Or Older,aetna - medicare advantage,EPO,O,19531.46,2849.74,2849.74,4554.02,11718.88
4506,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86335,cpt,"Immunologic Analysis Technique On Body Fluid, Other Fluids With Concentration",aetna - medicare advantage,POS,O,200.34,23.46,29.20,29.47,35.22
4507,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80162,cpt,"Digoxin Level, Total",aetna - medicare advantage,Medicaid,O,101.33,13.28,17.40,18.31,15.94
4508,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna - medicare advantage,PPO,O,88.82,7.62,7.77,66.62,9.32
4509,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,175,ms-drg,Pulmonary Embolism With MCC Or Acute Cor Pulmonale,aetna - medicare advantage,HMO,I,31206.52,6004.41,6004.41,9735.40,18723.91
4510,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96415,cpt,"Administration Of Chemotherapy Into Vein, Each Additional Hour",aetna - medicare advantage,Medicaid,O,110.89,25.40,54.88,83.17,66.53
4511,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,035,ms-drg,Carotid Artery Stent Procedures With CC,aetna - medicare advantage,EPO,I,49702.56,14481.69,14537.66,15373.03,29821.54
4512,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna - medicare advantage,HMO,O,14.15,0.48,0.67,8.71,8.49
4513,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93225,cpt,Electrocardiogram (Ecg) 2-Day Continuous,aetna - medicare advantage,HMO,O,251.28,64.70,102.02,199.77,150.77
4514,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna - medicare advantage,HMO,O,479.00,41.29,269.25,1803.87,287.40
4515,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33225,cpt,Insertion Of Left Lower Heart Electrode For Pacemaker Or Defibrillator,aetna - medicare advantage,HMO,O,69739.85,16482.88,16482.88,16666.51,41843.91
4516,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77075,cpt,X-Ray Survey Of Forearm Or Wrist Bone Density,aetna - medicare advantage,POS,O,693.70,61.44,97.56,98.50,416.22
4517,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna - medicare advantage,Medicare Part B,O,188.09,38.65,95.42,141.02,112.85
4518,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37224,cpt,"Balloon Dilation Of Arteries In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna - medicare advantage,Medicare Part A,O,40407.87,4389.28,8996.91,8996.91,24244.72
4519,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36223,cpt,Insertion Of Catheter Into Intracranial Artery On One Side Of Neck For Diagnosis Or Treatment Including Radiological Supervision And Interpretation,aetna - medicare advantage,EPO,O,22181.57,4013.59,4013.59,5561.74,13308.94
4520,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna - medicare advantage,EPO,O,188.09,38.65,95.42,141.02,112.85
4521,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52235,cpt,Destruction And/Or Removal Of (2.0 To 5.0 Centimeters) Medium Growths Of The Bladder And Bladder Canal (Urethra) Using An Endoscope,aetna - medicare advantage,PPO,O,19227.60,2724.53,2724.53,9954.52,11536.56
4522,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna - medicare advantage,Medicare Part B,O,218.25,35.37,49.86,263.09,130.95
4523,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna - medicare advantage,HMO,O,4055.15,194.15,918.37,3854.73,1125.84
4524,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,101,ms-drg,Seizures Without MCC,aetna - medicare advantage,EPO,I,22954.57,4657.50,5756.12,9554.59,13772.74
4525,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76705,cpt,Limited Ultrasound Scan Of Abdomen,aetna - medicare advantage,HMO,O,710.22,96.50,96.51,564.62,115.81
4526,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna - medicare advantage,EPO,O,1881.00,160.85,238.53,936.63,1128.60
4527,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna - medicare advantage,Medicare Part B,O,982.00,159.01,161.42,1222.94,589.20
4528,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87147,cpt,"Identification Of Organisms By Immunologic Analysis, Other Than Immunofluorescence Method",aetna - medicare advantage,PPO,O,25.94,5.18,5.18,19.46,6.22
4529,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,640,ms-drg,"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With MCC",aetna - medicare advantage,POS,I,24093.31,7612.86,8213.94,13518.94,14455.99
4530,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0105,cpt,Colorectal Cancer Screening; Colonoscopy On Individual At High Risk,aetna - medicare advantage,HMO,O,3011.53,702.89,911.58,1382.17,1806.92
4531,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33208,cpt,Insertion Of New Or Replacement Of Permanent Pacemaker Including Upper And Lower Chamber Electrodes,aetna - medicare advantage,Medicaid,O,42274.37,9210.48,16482.88,16482.88,25364.62
4532,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52240,cpt,Destruction And/Or Removal Of Large Growths Of The Bladder Using An Endoscope,aetna - medicare advantage,Medicaid,O,26428.89,3951.76,3991.68,6418.51,15857.33
4533,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna - medicare advantage,Medicaid,O,135.07,18.96,18.96,121.94,81.04
4534,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96416,cpt,Prolonged Chemotherapy Infusion Into A Vein By Portable Or Implanted Pump More Than 8 Hours,aetna - medicare advantage,POS,O,535.61,119.50,285.60,401.71,321.37
4535,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,C9602,cpt,"Percutaneous Transluminal Coronary Atherectomy, With Drug Eluting Intracoronary Stent, With Coronary Angioplasty When Performed; Single Major Coronary Artery Or Branch",aetna - medicare advantage,HMO,O,103179.53,14120.90,14120.90,14378.22,61907.72
4536,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87635,cpt,Amplifed DNA Or Rna Probe Detection Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antigen,aetna - medicare advantage,POS,O,168.00,50.29,51.31,126.00,61.57
4537,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna - medicare advantage,Medicare Part B,O,108.88,10.16,16.94,77.04,20.33
4538,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19085,cpt,"Biopsy Of Breast Accessed Through The Skin With MRI Guidance, First Lesion",aetna - medicare advantage,Medicare Part A,O,10715.72,1260.91,1260.91,4095.17,6429.43
4539,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27792,cpt,Open Treatment Of The Outside Prominence Of Bone Of The Leg (Fibula) In The Region Of The Ankle,aetna - medicare advantage,POS,O,31310.33,5299.29,5299.29,5666.83,18786.20
4540,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82668,cpt,Erythropoietin (Protein) Level,aetna - medicare advantage,HMO,O,148.64,18.79,18.79,22.56,22.55
4541,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,70551,cpt,MRI Scan Of Brain Without Contrast,aetna - medicare advantage,Medicare Part A,O,2882.19,203.81,206.20,2291.34,244.57
4542,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0943,revCode,Medical Rehabilitation Day Program Cardiac Rehabilitation,aetna - medicare advantage,Medicare Part B,O,173.89,102.78,103.91,369.10,104.33
4543,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97530,cpt,"Therapeutic Activities To Improve Function, With One-On-One Contact Between Patient And Provider, Each 15 Minutes",aetna - medicare advantage,Medicare Part A,O,166.34,34.57,36.50,91.02,99.80
4544,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86812,cpt,"Immunologic Analysis For Autoimmune Disease, A, B, Or C, Single Antigen",aetna - medicare advantage,Medicare Part A,O,98.58,20.26,25.55,43.47,59.15
4545,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0277,cpt,"Hyperbaric Oxygen Under Pressure, Full Body Chamber, Per 30 Minute Interval",aetna - medicare advantage,HMO,O,730.12,105.64,107.90,579.74,438.07
4546,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99285,cpt,"Emergency Department Visit, Problem With Significant Threat To Life Or Function",aetna - medicare advantage,Medicare Part A,E,5923.22,592.08,2022.06,2288.99,3553.93
4547,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0403,revCode,Other Imaging Services Screening Mammography,aetna - medicare advantage,Medicare Part A,O,312.75,51.78,52.44,273.24,187.65
4548,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna - medicare advantage,PPO,O,108.88,10.16,16.94,77.04,20.33
4549,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna - medicare advantage,POS,O,142.89,8.03,13.39,113.59,16.07
4550,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna - medicare advantage,POS,O,2882.19,207.14,207.14,2666.05,1729.31
4551,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73502,cpt,"X-Ray Of Hip With Pelvis, 2-3 Views",aetna - medicare advantage,Medicare Part B,O,213.53,40.67,71.65,169.76,85.98
4552,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76536,cpt,Ultrasound Scan Of Head And Neck Soft Tissue,aetna - medicare advantage,Medicare Part B,O,491.96,96.50,98.50,391.10,295.18
4553,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna - medicare advantage,PPO,O,251.28,64.70,99.15,266.36,150.77
4554,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87255,cpt,Virus Isolation,aetna - medicare advantage,HMO,O,123.87,33.86,33.86,81.80,40.63
4555,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0402,revCode,Other Imaging Services Ultrasound,aetna - medicare advantage,HMO,O,576.53,96.50,96.51,562.62,345.92
4556,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna - medicare advantage,POS,O,4055.15,194.15,918.37,3854.73,1125.84
4557,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82977,cpt,Glutamyltransferase (Liver Enzyme) Level,aetna - medicare advantage,Medicaid,O,40.17,4.32,7.13,30.08,8.64
4558,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17281,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, Or Mouth",aetna - medicare advantage,POS,O,2354.50,306.29,639.57,1345.09,1412.70
4559,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna - medicare advantage,Medicaid,O,2144.07,645.60,721.07,2047.58,1286.44
4560,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11042,cpt,Removal Of Skin And Tissue First 20 Sq Cm Or Less,aetna - medicare advantage,PPO,O,1315.41,306.28,312.72,3179.32,789.25
4561,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna - medicare advantage,Medicare Part A,O,4055.15,194.15,918.37,3854.73,1125.84
4562,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71046,cpt,"X-Ray Of Chest, 2 Views",aetna - medicare advantage,HMO,O,344.48,61.44,71.65,273.86,85.98
4563,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0301,revCode,"Laboratory, Chemistry",aetna - medicare advantage,EPO,O,30.08,3.64,96.59,96.59,18.05
4564,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna - medicare advantage,PPO,O,1956.07,299.94,299.95,1213.17,359.94
4565,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna - medicare advantage,Medicare Part A,O,3391.86,327.84,385.37,2543.90,462.44
4566,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna - medicare advantage,EPO,O,226.51,61.44,71.65,160.27,135.91
4567,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12052,cpt,"Repair Of Wound (2.6 To 5.0 Centimeters) Of Face, Ears, Eyelids, Nose, Lips, And/Or Mouth",aetna - medicare advantage,Medicare Part B,O,2786.31,703.96,1215.96,4611.26,1671.79
4568,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna - medicare advantage,Medicare Part A,E,3350.06,336.55,879.70,2095.51,2010.04
4569,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,640,ms-drg,"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With MCC",aetna - medicare advantage,EPO,I,24093.31,7612.86,8213.94,13518.94,14455.99
4570,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72110,cpt,"X-Ray Of Lower And Sacral Spine, Minimum Of 4 Views",aetna - medicare advantage,POS,O,613.48,46.08,98.50,365.14,115.81
4571,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82306,cpt,Vitamin D-3 Level,aetna - medicare advantage,EPO,O,101.33,21.15,29.60,63.19,35.52
4572,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36410,cpt,"Insertion Of Needle Into Vein, Patient 3 Years Or Older",aetna - medicare advantage,HMO,O,5269.39,333.17,721.40,1156.59,3161.63
4573,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,99284,cpt,Emergency Department Visit For Problem Of High Severity,aetna - medicare advantage,Medicare Part B,E,3350.06,336.55,879.70,2095.51,2010.04
4574,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97161,cpt,"Evaluation For Physical Therapy, Typically 20 Minutes",aetna - medicare advantage,PPO,O,188.09,38.65,95.42,141.02,112.85
4575,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,392,ms-drg,"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without MCC",aetna - medicare advantage,EPO,I,18218.40,4302.43,5287.39,24583.80,10931.04
4576,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna - medicare advantage,PPO,O,1881.00,160.85,238.53,936.63,1128.60
4577,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,92978,cpt,"Ultrasound Evaluation Of Heart Blood Vessel Or Graft With Review By Radiologist, Initial Vessel",aetna - medicare advantage,Medicare Part A,O,79754.02,6967.48,14120.90,14226.92,47852.41
4578,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73562,cpt,"X-Ray Of Knee, 3 Views",aetna - medicare advantage,Medicare Part B,O,226.51,61.44,71.65,160.27,135.91
4579,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87075,cpt,"Bacterial Culture, Any Source, Except Blood, Anaerobic",aetna - medicare advantage,Medicaid,O,85.05,9.28,9.47,68.13,11.36
4580,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77295,cpt,"Management Of Radiation Therapy, 3d",aetna - medicare advantage,EPO,O,1926.57,1003.61,1117.84,1531.62,1341.41
4581,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna - medicare advantage,EPO,O,92.22,24.06,24.06,24.60,55.33
4582,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83540,cpt,Iron Level,aetna - medicare advantage,HMO,O,41.28,6.35,6.47,41.28,7.76
4583,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna - medicare advantage,Medicaid,O,36.32,4.21,4.29,27.24,5.15
4584,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72148,cpt,MRI Scan Of Lower Spinal Canal,aetna - medicare advantage,Medicaid,O,2882.19,203.81,204.96,2039.29,244.57
4585,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37224,cpt,"Balloon Dilation Of Arteries In One Leg, Endovascular, Accessed Through The Skin Or Open Procedure",aetna - medicare advantage,PPO,O,40407.87,4389.28,8996.91,8996.91,24244.72
4586,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81003,cpt,Automated Urinalysis Test,aetna - medicare advantage,Medicare Part A,O,13.80,2.25,2.25,9.77,2.70
4587,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna - medicare advantage,POS,O,252.47,18.27,44.07,336.23,151.48
4588,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0361,revCode,"Operating Room Services, Minor Surgery",aetna - medicare advantage,POS,O,1775.23,260.44,479.68,1902.32,1065.14
4589,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38525,cpt,"Biopsy Or Removal Of Lymph Nodes Of Under The Arm, Open Procedure",aetna - medicare advantage,Medicare Part A,O,31014.89,4901.08,4906.52,13132.63,18608.93
4590,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86430,cpt,Rheumatoid Factor Analysis,aetna - medicare advantage,Medicare Part B,O,42.58,6.10,6.10,31.94,7.37
4591,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93288,cpt,"Evaluation Of Parameters Of Leadless, Single, Dual, Or Multiple Lead Pacemaker System With Qualified Health Care Professional Analysis, Review, And Report",aetna - medicare advantage,Medicare Part B,O,319.71,32.90,33.35,76.59,191.83
4592,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0277,cpt,"Hyperbaric Oxygen Under Pressure, Full Body Chamber, Per 30 Minute Interval",aetna - medicare advantage,POS,O,730.12,105.64,107.90,579.74,438.07
4593,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38525,cpt,"Biopsy Or Removal Of Lymph Nodes Of Under The Arm, Open Procedure",aetna - medicare advantage,Medicaid,O,31014.89,4901.08,4906.52,13132.63,18608.93
4594,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72220,cpt,"X-Ray Of Sacrum And Tailbone, Minimum Of 2 Views",aetna - medicare advantage,Medicaid,O,226.51,43.15,71.72,73.18,85.98
4595,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna - medicare advantage,Medicare Part B,O,490.78,263.76,351.65,352.65,294.47
4596,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83550,cpt,Iron Binding Capacity,aetna - medicare advantage,EPO,O,106.28,8.57,8.74,106.28,10.49
4597,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna - medicare advantage,PPO,O,1654.04,96.51,97.07,984.47,115.81
4598,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0750,revCode,Gastrointestinal (Gi) Services General,aetna - medicare advantage,EPO,O,2144.07,645.60,721.07,2047.58,1286.44
4599,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84460,cpt,"Liver Enzyme (Sgpt), Level",aetna - medicare advantage,HMO,O,29.48,3.88,5.25,5.32,6.36
4600,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11102,cpt,"Biopsy Of Related Skin Growth, First Growth",aetna - medicare advantage,Medicare Part B,O,1042.00,159.01,238.53,708.35,625.20
4601,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna - medicare advantage,Medicare Part A,O,91.30,14.35,19.31,64.61,54.78
4602,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17000,cpt,"Destruction Of Precancer Skin Growth, 1 Growth",aetna - medicare advantage,Medicare Part A,O,982.00,159.01,161.42,1222.94,589.20
4603,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna - medicare advantage,HMO,O,1884.10,427.65,427.67,1413.08,1130.46
4604,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0463,cpt,Hospital Outpatient Clinic Visit For Assessment And Management Of A Patient,aetna - medicare advantage,Medicare Part B,O,176.96,59.81,105.16,107.50,106.18
4605,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna - medicare advantage,Medicaid,O,116.31,19.19,19.19,84.77,23.26
4606,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0413,revCode,"Respiratory Services, Hyperbaric Oxygen Therapy",aetna - medicare advantage,POS,O,730.12,105.64,107.90,579.74,438.07
4607,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72202,cpt,"X-Ray Of Joint Between Lower Spine And Hip Bone, 3 Or More Views",aetna - medicare advantage,Medicare Part B,O,252.47,26.87,96.73,166.73,151.48
4608,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna - medicare advantage,Medicare Part B,O,212.10,40.75,95.70,253.05,127.26
4609,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71275,cpt,CT Scan Of Blood Vessels Of Chest With Contrast,aetna - medicare advantage,HMO,O,1841.63,158.13,158.13,1464.09,189.76
4610,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72220,cpt,"X-Ray Of Sacrum And Tailbone, Minimum Of 2 Views",aetna - medicare advantage,Medicare Part B,O,226.51,43.15,71.72,73.18,85.98
4611,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96372,cpt,"Injection Beneath The Skin Or Into Muscle For Therapy, Diagnosis, Or Prevention",aetna - medicare advantage,EPO,O,93.19,18.38,54.88,74.09,55.91
4612,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87045,cpt,Stool Culture,aetna - medicare advantage,HMO,O,80.09,9.05,9.40,46.05,11.33
4613,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0103,cpt,Prostate Cancer Screening; Prostate Specific Antigen Test (Psa),aetna - medicare advantage,Medicare Part B,O,91.30,14.35,19.31,64.61,54.78
4614,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73221,cpt,MRI Scan Of Arm Joint Without Contrast,aetna - medicare advantage,HMO,O,2882.19,203.81,481.19,1715.45,245.82
4615,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95811,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab With Continued Pressured Respiratory Assistance By Mask Or Breathing Tube,aetna - medicare advantage,HMO,O,3186.58,814.60,814.63,1816.35,1911.95
4616,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0424,revCode,"Physical Therapy, Evaluation Or Reevaluation",aetna - medicare advantage,Medicaid,O,212.10,40.75,95.70,253.05,127.26
4617,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9271,cpt,"Injection, Pembrolizumab, 1 Mg",aetna - medicare advantage,Medicaid,O,192.29,32.26,52.30,144.22,115.37
4618,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72081,cpt,"X-Ray Of Spine, Entire Middle And Lower Spine, 1 View",aetna - medicare advantage,POS,O,213.53,31.46,71.65,73.18,86.20
4619,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73700,cpt,CT Scan Of Leg Without Contrast,aetna - medicare advantage,Medicare Part A,O,1395.67,96.50,96.51,809.76,837.40
4620,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36410,cpt,"Insertion Of Needle Into Vein, Patient 3 Years Or Older",aetna - medicare advantage,EPO,O,5269.39,333.17,721.40,1156.59,3161.63
4621,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87070,cpt,"Bacterial Culture, Any Other Source Except Urine, Blood Or Stool, Aerobic",aetna - medicare advantage,PPO,O,65.11,8.45,8.62,48.83,10.34
4622,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,37252,cpt,"Ultrasound Evaluation Of Blood Vessel During Diagnosis Or Treatment, Initial Vessel",aetna - medicare advantage,EPO,O,66737.99,8996.91,8996.91,8997.81,40042.79
4623,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85610,cpt,"Blood Test, Clotting Time",aetna - medicare advantage,POS,O,36.32,4.21,4.29,27.24,5.15
4624,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87186,cpt,"Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or Agar Dilution",aetna - medicare advantage,EPO,O,47.53,6.92,8.65,35.65,10.38
4625,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,871,ms-drg,Septicemia Or Severe Sepsis Without Mv >96 Hours With MCC,aetna - medicare advantage,Medicaid,I,36297.45,7941.64,8704.57,17432.39,21778.47
4626,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11602,cpt,"Removal Of Malignant Growth (1.1 To 2.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna - medicare advantage,POS,O,1846.00,459.44,464.39,2217.32,1107.60
4627,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,72131,cpt,CT Scan Of Lower Spine Without Contrast,aetna - medicare advantage,Medicare Part A,O,1654.04,96.51,96.53,400.81,116.30
4628,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna - medicare advantage,EPO,O,3391.86,327.84,385.37,2543.90,462.44
4629,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82378,cpt,Carcinoembryonic Antigen (Cea) Protein Level,aetna - medicare advantage,Medicare Part B,O,135.07,18.96,18.96,121.94,81.04
4630,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36410,cpt,"Insertion Of Needle Into Vein, Patient 3 Years Or Older",aetna - medicare advantage,Medicare Part A,O,5269.39,333.17,721.40,1156.59,3161.63
4631,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0277,cpt,"Hyperbaric Oxygen Under Pressure, Full Body Chamber, Per 30 Minute Interval",aetna - medicare advantage,Medicaid,O,730.12,105.64,107.90,579.74,438.07
4632,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77290,cpt,"Obtaining Data Needed To Develop The Optimal Radiation Treatment, 3 Or More Treatment Areas Or Any Number Of Treatment Areas Where Special Treatment Is Involved",aetna - medicare advantage,Medicare Part A,O,1956.07,299.94,299.95,1213.17,359.94
4633,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52204,cpt,Biopsy Of The Bladder Using An Endoscope,aetna - medicare advantage,Medicare Part A,O,15862.52,1587.94,2724.53,12709.61,9517.51
4634,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93306,cpt,"Ultrasound Examination Of Heart Including Color-Depicted Blood Flow Rate, Direction, And Valve Function",aetna - medicare advantage,Medicare Part B,O,1884.10,427.65,427.67,1413.08,1130.46
4635,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11602,cpt,"Removal Of Malignant Growth (1.1 To 2.0 Centimeters) Of The Trunk, Arms, Or Legs",aetna - medicare advantage,Medicare Part A,O,1846.00,459.44,464.39,2217.32,1107.60
4636,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74177,cpt,CT Scan Of Abdomen And Pelvis With Contrast,aetna - medicare advantage,PPO,O,3391.86,327.84,385.37,2543.90,462.44
4637,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85379,cpt,"Coagulation Function Measurement, D-Dimer; Quantitative",aetna - medicare advantage,PPO,O,122.56,9.98,10.18,71.08,12.22
4638,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84481,cpt,"Thyroid Hormone, T3 Measurement, Free",aetna - medicare advantage,Medicare Part A,O,108.88,10.16,16.94,77.04,20.33
4639,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna - medicare advantage,POS,O,251.28,64.70,99.15,266.36,150.77
4640,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77075,cpt,X-Ray Survey Of Forearm Or Wrist Bone Density,aetna - medicare advantage,Medicare Part B,O,693.70,61.44,97.56,98.50,416.22
4641,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52204,cpt,Biopsy Of The Bladder Using An Endoscope,aetna - medicare advantage,HMO,O,15862.52,1587.94,2724.53,12709.61,9517.51
4642,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97166,cpt,"Evaluation For Occupational Therapy, Typically 45 Minutes",aetna - medicare advantage,POS,O,265.44,85.51,93.22,163.25,159.26
4643,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86021,cpt,Antibody Identification Test For White Blood Cell Antibodies,aetna - medicare advantage,Medicaid,O,152.18,14.73,14.98,54.78,91.31
4644,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87077,cpt,Bacterial Culture For Aerobic Isolates,aetna - medicare advantage,Medicare Part A,O,52.60,6.47,8.08,42.46,9.70
4645,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17271,cpt,"Destruction Of Malignant Growth (0.6 To 1.0 Centimeters) Of Scalp, Neck, Hands, Feet, Or Genitals",aetna - medicare advantage,Medicare Part B,O,1881.00,160.85,238.53,936.63,1128.60
4646,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86812,cpt,"Immunologic Analysis For Autoimmune Disease, A, B, Or C, Single Antigen",aetna - medicare advantage,PPO,O,98.58,20.26,25.55,43.47,59.15
4647,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82728,cpt,Ferritin (Blood Protein) Level,aetna - medicare advantage,EPO,O,84.93,11.67,13.63,84.93,16.36
4648,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97140,cpt,"Manual (Physical) Therapy Techniques To 1 Or More Regions, Each 15 Minutes",aetna - medicare advantage,Medicare Part B,O,232.41,20.93,20.93,164.45,139.45
4649,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0731,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg), Holter Monitor",aetna - medicare advantage,EPO,O,251.28,64.70,99.15,266.36,150.77
4650,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52204,cpt,Biopsy Of The Bladder Using An Endoscope,aetna - medicare advantage,PPO,O,15862.52,1587.94,2724.53,12709.61,9517.51
4651,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80061,cpt,"Blood Test, Lipids (Cholesterol And Triglycerides)",aetna - medicare advantage,Medicaid,O,142.89,8.03,13.39,113.59,16.07
4652,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86140,cpt,Measurement C-Reactive Protein For Detection Of Infection Or Inflammation,aetna - medicare advantage,PPO,O,67.58,5.08,5.18,50.69,6.22
4653,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36410,cpt,"Insertion Of Needle Into Vein, Patient 3 Years Or Older",aetna - medicare advantage,Medicaid,O,5269.39,333.17,721.40,1156.59,3161.63
4654,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,45380,cpt,"Colonoscopy Of Large Bowel Using A Flexible Endoscope, With Biopsy",aetna - medicare advantage,Medicaid,O,4055.15,194.15,918.37,3854.73,1125.84
4655,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71250,cpt,CT Scan Of Chest Without Contrast,aetna - medicare advantage,Medicaid,O,1654.04,96.51,97.07,984.47,115.81
4656,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0611,revCode,Magnetic Resonance Technology (Mrt) Brain/Brain Stem,aetna - medicare advantage,HMO,O,2882.19,207.14,207.14,2666.05,1729.31
4657,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0270,revCode,Medical/Surgical Supplies And Devices General,aetna - medicare advantage,HMO,O,33.76,8.03,694.79,694.79,20.26
4658,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,G0105,cpt,Colorectal Cancer Screening; Colonoscopy On Individual At High Risk,aetna - medicare advantage,Medicare Part A,O,3011.53,702.89,911.58,1382.17,1806.92
4659,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0636,revCode,Pharmacy - Extension Of 025x Drugs Requiring Detailed Coding,aetna - medicare advantage,Medicaid,O,58.98,6.19,9.19,1399.28,35.39
4660,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna - medicare advantage,Medicare Part B,O,70.06,8.01,8.09,52.55,9.80
4661,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19281,cpt,"Placement Of Breast Localization Devices Accessed Through The Skin With Mammographic Guidance, First Lesion",aetna - medicare advantage,Medicaid,O,25245.69,2796.62,4911.95,11689.68,15147.41
4662,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52601,cpt,Removal Of Prostate Gland Using An Electrocautery Knife Through Urethra With Control Of Bleeding Using An Endoscope,aetna - medicare advantage,Medicare Part A,O,23458.82,3909.13,3928.44,10203.85,14075.29
4663,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna - medicare advantage,Medicare Part B,O,356.28,61.44,89.75,194.95,213.77
4664,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80076,cpt,Liver Function Blood Test Panel,aetna - medicare advantage,Medicaid,O,70.06,8.01,8.09,52.55,9.80
4665,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna - medicare advantage,EPO,O,2535.33,203.81,203.81,1958.54,244.57
4666,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93460,cpt,Insertion Of Catheter In Right And Left Heart And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna - medicare advantage,Medicare Part B,O,18038.69,2418.26,2567.49,13615.16,10823.21
4667,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna - medicare advantage,HMO,O,251.28,64.70,99.15,266.35,150.77
4668,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna - medicare advantage,Medicare Part A,O,50.72,5.89,6.01,35.89,7.21
4669,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,522,ms-drg,Hip Replacement With Principal Diagnosis Of Hip Fracture Without MCC,aetna - medicare advantage,Medicare Part B,I,70836.26,13137.65,13659.63,14627.96,42501.76
4670,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82550,cpt,"Creatine Kinase (Cardiac Enzyme) Level, Total",aetna - medicare advantage,POS,O,60.16,6.44,6.44,33.61,7.81
4671,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna - medicare advantage,EPO,O,176.96,19.79,99.15,99.98,106.18
4672,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna - medicare advantage,PPO,O,271.34,80.51,80.51,215.72,96.61
4673,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0391,revCode,"Administration, Processing And Storage For Blood And Blood Components Administration (E.G., Transfusions)",aetna - medicare advantage,Medicare Part A,O,490.78,263.76,351.65,353.36,294.47
4674,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna - medicare advantage,POS,O,4073.77,814.60,814.63,3238.64,977.56
4675,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11301,cpt,"Shaving Of 0.6 Centimeters To 1.0 Centimeters Skin Growth Of The Trunk, Arms, Or Legs",aetna - medicare advantage,Medicare Part A,O,1042.00,160.93,160.93,160.93,625.20
4676,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,064,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With MCC,aetna - medicare advantage,Medicaid,I,42514.90,11561.36,15935.29,15935.29,25508.94
4677,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71271,cpt,Low Dose CT Scan Of Chest For Lung Cancer Screening,aetna - medicare advantage,POS,O,331.51,71.65,71.65,234.56,198.91
4678,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93926,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of One Leg Or Limited,aetna - medicare advantage,Medicare Part B,O,609.94,96.50,96.51,359.62,365.96
4679,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80306,cpt,"Testing For Presence Of Drug, Read By Instrument Assisted Observation",aetna - medicare advantage,PPO,O,513.19,16.97,16.97,384.89,20.57
4680,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna - medicare advantage,HMO,O,83.80,8.07,8.85,89.04,50.28
4681,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11301,cpt,"Shaving Of 0.6 Centimeters To 1.0 Centimeters Skin Growth Of The Trunk, Arms, Or Legs",aetna - medicare advantage,Medicare Part B,O,1042.00,160.93,160.93,160.93,625.20
4682,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna - medicare advantage,Medicare Part A,O,120.33,10.08,16.80,90.25,20.16
4683,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86769,cpt,Measure Of Severe Acute Respiratory Syndrome Coronavirus 2 (Covid-19) Antibody,aetna - medicare advantage,PPO,O,89.25,16.93,42.13,66.94,50.56
4684,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna - medicare advantage,Medicare Part A,I,1307.77,398.79,1092.59,8974.67,784.66
4685,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77063,cpt,Screening Digital Tomography Of Both Breasts,aetna - medicare advantage,HMO,O,184.03,20.92,22.44,167.23,110.42
4686,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna - medicare advantage,Medicare Part A,O,356.28,61.44,89.75,194.95,213.77
4687,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,192,ms-drg,Chronic Obstructive Pulmonary Disease Without CC/MCC,aetna - medicare advantage,EPO,I,13652.22,4644.61,4644.61,6115.68,8191.33
4688,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna - medicare advantage,Medicare Part B,O,67.58,3.47,5.78,47.82,6.94
4689,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52601,cpt,Removal Of Prostate Gland Using An Electrocautery Knife Through Urethra With Control Of Bleeding Using An Endoscope,aetna - medicare advantage,Medicare Part B,O,23458.82,3909.13,3928.44,10203.85,14075.29
4690,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,192,ms-drg,Chronic Obstructive Pulmonary Disease Without CC/MCC,aetna - medicare advantage,Medicare Part A,I,13652.22,4644.61,4644.61,6115.68,8191.33
4691,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,20610,cpt,Aspiration And/Or Injection Of Large Joint Or Joint Capsule,aetna - medicare advantage,POS,O,669.42,231.30,231.30,1031.80,401.65
4692,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna - medicare advantage,POS,O,331.51,82.43,85.12,301.25,102.14
4693,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna - medicare advantage,PPO,O,331.51,82.43,85.12,301.25,102.14
4694,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna - medicare advantage,Medicare Part B,O,373.98,199.25,301.71,352.82,359.94
4695,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna - medicare advantage,PPO,O,84.93,5.32,12.46,63.70,15.10
4696,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93926,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of One Leg Or Limited,aetna - medicare advantage,Medicare Part A,O,609.94,96.50,96.51,359.62,365.96
4697,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93460,cpt,Insertion Of Catheter In Right And Left Heart And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna - medicare advantage,HMO,O,18038.69,2418.26,2567.49,13615.16,10823.21
4698,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96401,cpt,Administration Of Non-Hormonal Anti-Neoplastic Chemotherapy Under Skin Or Into Muscle,aetna - medicare advantage,PPO,O,286.67,27.44,27.44,63.97,172.00
4699,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0761,revCode,Specialty Services Treatment Room,aetna - medicare advantage,Medicaid,O,479.00,41.29,269.25,1803.87,287.40
4700,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73660,cpt,"X-Ray Of Toes, Minimum Of 2 Views",aetna - medicare advantage,HMO,O,231.22,53.64,71.65,173.42,138.73
4701,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73564,cpt,"X-Ray Of Knee, 4 Or More Views",aetna - medicare advantage,EPO,O,356.28,61.44,89.75,194.95,213.77
4702,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87046,cpt,"Stool Culture, Additional Pathogens",aetna - medicare advantage,POS,O,52.60,5.92,9.40,30.25,11.33
4703,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87075,cpt,"Bacterial Culture, Any Source, Except Blood, Anaerobic",aetna - medicare advantage,Medicare Part A,O,85.05,9.28,9.47,68.13,11.36
4704,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,88305,cpt,"Pathology Examination Of Tissue Using A Microscope, Intermediate Complexity",aetna - medicare advantage,EPO,O,252.47,18.27,44.07,336.23,151.48
4705,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0480,revCode,"Cardiology, General",aetna - medicare advantage,Medicare Part B,O,1884.10,207.52,427.67,11598.92,1130.46
4706,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,81001,cpt,"Manual Urinalysis Test With Examination Using Microscope, Automated",aetna - medicare advantage,POS,O,13.80,2.37,3.14,10.35,8.28
4707,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82540,cpt,Creatine Measurement,aetna - medicare advantage,Medicaid,O,14.00,4.64,4.64,4.64,8.40
4708,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84146,cpt,Prolactin (Milk Producing Hormone) Level,aetna - medicare advantage,EPO,O,116.31,19.19,19.19,84.77,23.26
4709,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36430,cpt,Transfusion Of Blood Or Blood Products,aetna - medicare advantage,EPO,O,490.78,263.76,351.65,352.65,294.47
4710,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna - medicare advantage,Medicare Part A,O,344.48,61.44,71.65,273.86,206.69
4711,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95813,cpt,"Measurement Of Brain Wave Activity (Eeg) Extended Monitoring, 61-119 Minutes",aetna - medicare advantage,Medicare Part A,O,680.29,234.65,458.67,458.67,408.17
4712,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,003,ms-drg,"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures",aetna - medicare advantage,PPO,I,487147.16,98898.50,108683.43,148363.04,292288.30
4713,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86160,cpt,"Measurement Of Complement (Immune System Proteins), Antigen,",aetna - medicare advantage,POS,O,50.72,6.89,12.00,38.04,14.40
4714,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74018,cpt,"X-Ray Of Abdomen, 1 View",aetna - medicare advantage,EPO,O,268.98,61.44,73.18,285.11,85.98
4715,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,52601,cpt,Removal Of Prostate Gland Using An Electrocautery Knife Through Urethra With Control Of Bleeding Using An Endoscope,aetna - medicare advantage,HMO,O,23458.82,3909.13,3928.44,10203.85,14075.29
4716,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93460,cpt,Insertion Of Catheter In Right And Left Heart And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna - medicare advantage,EPO,O,18038.69,2418.26,2567.49,13615.16,10823.21
4717,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93926,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of One Leg Or Limited,aetna - medicare advantage,EPO,O,609.94,96.50,96.51,359.62,365.96
4718,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,065,ms-drg,Intracranial Hemorrhage Or Cerebral Infarction With CC Or Tpa In 24 Hours,aetna - medicare advantage,Medicare Part A,I,23737.47,6483.31,6783.88,11599.87,14242.48
4719,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,391,ms-drg,"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With MCC",aetna - medicare advantage,Medicaid,I,24453.90,3581.16,9483.69,10143.06,14672.34
4720,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77021,cpt,Radiological Supervision And Interpretation Of MRI Guidance For Insertion Of Needle,aetna - medicare advantage,Medicare Part A,O,10715.72,1260.91,1260.91,4095.17,6429.43
4721,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna - medicare advantage,POS,O,145.10,26.57,41.28,89.17,49.54
4722,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna - medicare advantage,Medicaid,O,329.15,22.74,72.49,261.67,197.49
4723,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86920,cpt,"Blood Unit Compatibility Test, Immediate Spin Technique",aetna - medicare advantage,HMO,O,373.98,33.03,132.10,152.61,79.26
4724,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna - medicare advantage,Medicaid,O,331.51,82.43,85.12,301.25,102.14
4725,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93017,cpt,Exercise Or Drug-Induced Heart And Blood Vessel Stress Test With Ekg Tracing And Monitoring,aetna - medicare advantage,HMO,O,474.26,84.78,234.21,377.03,284.56
4726,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84550,cpt,"Uric Acid Level, Blood",aetna - medicare advantage,PPO,O,50.01,4.52,4.52,79.60,5.42
4727,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna - medicare advantage,Medicaid,O,50.01,3.11,5.18,66.28,6.22
4728,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,11644,cpt,"Removal Of Malignant Growth (3.1 To 4.0 Centimeters) Of The Face, Ears, Eyelids, Nose, Or Lips",aetna - medicare advantage,Medicare Part A,O,15031.39,1215.96,1215.96,5287.17,9018.83
4729,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85025,cpt,"Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test And Automated Differential White Blood Cell Count",aetna - medicare advantage,Medicare Part B,O,88.82,7.62,7.77,66.62,9.32
4730,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna - medicare advantage,POS,O,2882.19,203.81,203.81,2039.29,1729.31
4731,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,71101,cpt,"X-Ray Of Ribs On One Side Of Body Including The Chest, Minimum Of 3 Views",aetna - medicare advantage,POS,O,356.28,61.44,96.51,203.08,115.81
4732,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0771,revCode,"Preventive Care Services, Vaccine Administration",aetna - medicare advantage,Medicare Part A,O,820.44,35.43,399.09,512.23,492.26
4733,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,73630,cpt,"X-Ray Of Foot, Minimum Of 3 Views",aetna - medicare advantage,PPO,O,329.15,22.74,72.49,261.67,197.49
4734,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna - medicare advantage,Medicaid,O,281.96,102.95,102.95,224.15,123.54
4735,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84402,cpt,"Testosterone (Hormone) Level, Free",aetna - medicare advantage,Medicare Part A,O,70.78,13.11,25.47,53.09,30.56
4736,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,87427,cpt,Detection Test By Immunoassay Technique For Shiga-Like Toxin (Bacterial Toxin),aetna - medicare advantage,HMO,O,60.03,6.75,11.92,34.22,14.38
4737,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86038,cpt,Screening Test For Autoimmune Disorder,aetna - medicare advantage,EPO,O,105.06,0.47,11.98,45.12,14.51
4738,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna - medicare advantage,Medicaid,O,50.72,5.89,6.01,35.89,7.21
4739,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,246,ms-drg,Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With MCC Or 4+ Arteries Or Stents,aetna - medicare advantage,Medicare Part A,I,104383.95,18750.33,19156.60,31296.06,62630.37
4740,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna - medicare advantage,POS,O,2535.33,203.81,203.81,1958.54,244.57
4741,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0730,revCode,"Electrocardiogram (Ekg), Electroencephalogram (Eeg)",aetna - medicare advantage,EPO,O,218.25,35.37,49.86,263.09,130.95
4742,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84156,cpt,"Total Protein Level, Urine",aetna - medicare advantage,EPO,O,80.24,3.60,3.66,53.04,4.40
4743,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,95810,cpt,Sleep Monitoring Of Patient (6 Years Or Older) In Sleep Lab,aetna - medicare advantage,Medicare Part A,O,4073.77,814.60,814.63,3238.64,977.56
4744,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82232,cpt,Beta-2 Microglobulin (Protein) Level,aetna - medicare advantage,EPO,O,95.71,16.18,16.18,21.31,19.42
4745,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83970,cpt,Parathormone (Parathyroid Hormone) Level,aetna - medicare advantage,PPO,O,145.10,26.57,41.28,89.17,49.54
4746,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77080,cpt,"Bone Density Measurement Of The Core Or Central Skeleton (E.G., Hips, Pelvis, Spine)",aetna - medicare advantage,Medicare Part B,O,352.74,96.51,98.50,249.59,115.81
4747,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85652,cpt,"Red Blood Cell Sedimentation Rate, To Detect Inflammation, Automated",aetna - medicare advantage,Medicaid,O,38.92,2.65,2.70,29.59,3.24
4748,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0320,revCode,"Radiology, Diagnostic General Classification",aetna - medicare advantage,PPO,O,332.78,61.44,96.51,261.67,199.67
4749,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0360,revCode,"Operating Room Services, General",aetna - medicare advantage,HMO,O,9825.06,1878.83,2759.45,12996.76,5895.04
4750,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83010,cpt,Haptoglobin (Serum Protein) Level,aetna - medicare advantage,Medicare Part A,O,84.93,5.32,12.46,63.70,15.10
4751,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,28820,cpt,Amputation Of Toe At Joint Between The Forefoot And Toes,aetna - medicare advantage,Medicare Part A,O,17369.19,2534.38,2562.21,2562.21,10421.51
4752,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna - medicare advantage,Medicare Part A,O,331.51,82.43,85.12,301.25,102.14
4753,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77321,cpt,Special Radiation Therapy Planning For Delivery Of External Radiation,aetna - medicare advantage,EPO,O,373.98,199.25,301.71,352.82,359.94
4754,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna - medicare advantage,EPO,O,50.72,6.48,6.48,38.04,7.78
4755,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77334,cpt,"Radiation Treatment Devices, Design And Construction, Complex",aetna - medicare advantage,Medicare Part B,O,599.32,299.94,299.95,327.93,359.94
4756,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J1439,cpt,"Injection, Ferric Carboxymaltose, 1 Mg",aetna - medicare advantage,Medicare Part B,O,4.45,0.79,0.81,2.09,2.67
4757,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna - medicare advantage,HMO,O,344.48,61.44,71.65,273.86,206.69
4758,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82784,cpt,Gammaglobulin (Immune System Protein) Measurement,aetna - medicare advantage,HMO,O,65.66,9.30,9.30,52.19,11.16
4759,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97110,cpt,"Therapeutic Exercise To Develop Strength, Endurance, Range Of Motion, And Flexibility, Each 15 Minutes",aetna - medicare advantage,HMO,O,173.42,23.35,23.94,114.70,29.09
4760,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9358,cpt,"Injection, Fam-Trastuzumab Deruxtecan-Nxki, 1 Mg",aetna - medicare advantage,HMO,O,92.22,24.06,24.06,24.60,55.33
4761,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0324,revCode,"Radiology, Diagnostic Chest X-Ray",aetna - medicare advantage,POS,O,344.48,61.44,71.65,273.86,206.69
4762,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,74176,cpt,CT Scan Of Abdomen And Pelvis Without Contrast,aetna - medicare advantage,Medicare Part A,O,2535.33,203.81,203.81,1958.54,244.57
4763,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,24685,cpt,Open Treatment Of The Forearm Bone On The Small Finger Side Of The Forearm (Ulna Bone) In The Elbow Region,aetna - medicare advantage,Medicaid,O,35027.25,5548.49,5548.49,5667.02,21016.35
4764,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,69100,cpt,Biopsy Of Ear,aetna - medicare advantage,POS,O,1693.00,639.57,639.57,1044.00,1015.80
4765,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna - medicare advantage,POS,O,289.04,102.81,112.36,158.15,134.83
4766,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77066,cpt,Diagnostic Mammography Of Both Breasts,aetna - medicare advantage,Medicare Part A,O,281.96,102.95,102.95,224.15,123.54
4767,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82310,cpt,"Calcium Level, Total",aetna - medicare advantage,EPO,O,36.61,5.16,5.16,36.61,21.97
4768,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna - medicare advantage,Medicare Part B,O,176.96,19.79,99.15,99.98,106.18
4769,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,76770,cpt,Complete Ultrasound Scan Behind Abdominal Cavity,aetna - medicare advantage,Medicare Part A,O,747.97,96.51,96.51,409.27,115.81
4770,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,33215,cpt,Repositioning Of Implanted Pacemaker Or Defibrillator Device,aetna - medicare advantage,EPO,O,18936.52,2534.31,2534.40,2534.40,11361.91
4771,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9025,cpt,"Injection, Azacitidine, 1 Mg",aetna - medicare advantage,EPO,O,14.15,0.48,0.67,8.71,8.49
4772,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna - medicare advantage,POS,O,50.72,6.48,6.48,38.04,7.78
4773,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82570,cpt,Creatinine Level To Test For Kidney Function Or Muscle Injury,aetna - medicare advantage,POS,O,50.01,3.11,5.18,66.28,6.22
4774,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,12031,cpt,"Repair Of Wound (2.5 Centimeters Or Less) Of The Scalp, Underarms, Trunk, Arms, And/Or Legs",aetna - medicare advantage,Medicaid,O,2584.00,464.39,464.39,2584.00,1550.40
4775,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86200,cpt,Measurement Of Antibody For Rheumatoid Arthritis Assessment,aetna - medicare advantage,Medicaid,O,251.28,12.89,12.89,140.36,15.54
4776,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna - medicare advantage,EPO,O,50.72,5.89,6.01,35.89,7.21
4777,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,78306,cpt,Nuclear Medicine Study Of Bone And/Or Joint Whole Body,aetna - medicare advantage,Medicare Part B,O,848.21,330.97,336.23,522.98,400.79
4778,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93460,cpt,Insertion Of Catheter In Right And Left Heart And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna - medicare advantage,PPO,O,18038.69,2418.26,2567.49,13615.16,10823.21
4779,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna - medicare advantage,Medicaid,O,289.04,102.81,112.36,158.15,134.83
4780,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,812,ms-drg,Red Blood Cell Disorders Without MCC,aetna - medicare advantage,POS,I,18593.40,4553.02,5714.43,8936.86,11156.04
4781,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93005,cpt,Routine Electrocardiogram (Ekg) With Tracing Using At Least 12 Leads,aetna - medicare advantage,Medicare Part A,O,218.25,35.36,49.58,154.43,130.95
4782,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,38792,cpt,Injection Of Radioactive Material For X-Ray Identification Of Lymph Node,aetna - medicare advantage,Medicare Part B,O,32276.49,2796.62,4906.52,13180.74,19365.89
4783,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna - medicare advantage,Medicare Part A,I,25207.44,6812.39,8153.24,14290.40,15124.46
4784,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,83735,cpt,Magnesium Level,aetna - medicare advantage,POS,O,65.11,6.70,6.70,46.07,8.04
4785,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82043,cpt,Urine Microalbumin (Protein) Level,aetna - medicare advantage,HMO,O,67.58,3.47,5.78,47.82,6.94
4786,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,27235,cpt,"Insertion Of Hardware To Broken Thigh Bone, Accessed Through The Skin",aetna - medicare advantage,Medicaid,I,118203.50,13111.06,13111.06,13111.06,70922.10
4787,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,66984,cpt,"Removal Of Cataract With Insertion Of Lens, Simple",aetna - medicare advantage,Medicaid,O,14664.91,1841.26,3469.71,4337.53,8798.95
4788,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna - medicare advantage,Medicare Part B,O,331.51,82.43,85.12,301.25,102.14
4789,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,82150,cpt,Amylase (Enzyme) Level,aetna - medicare advantage,Medicaid,O,50.72,6.48,6.48,38.04,7.78
4790,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,97163,cpt,"Evaluation For Physical Therapy, Typically 45 Minutes",aetna - medicare advantage,Medicaid,O,281.58,53.70,89.29,154.08,168.95
4791,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0280,revCode,Oncology General,aetna - medicare advantage,Medicare Part B,O,192.29,49.29,49.29,144.22,115.37
4792,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93880,cpt,Ultrasound Scanning Of Blood Flow (Outside The Brain) On Both Sides Of Head And Neck,aetna - medicare advantage,Medicare Part B,O,711.39,203.81,204.22,397.38,426.83
4793,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,291,ms-drg,Heart Failure And Shock With MCC,aetna - medicare advantage,Medicaid,I,25207.44,6812.39,8153.24,14290.40,15124.46
4794,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84132,cpt,Blood Potassium Level,aetna - medicare advantage,PPO,O,34.27,4.67,4.76,27.24,5.71
4795,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19303,cpt,Simple Complete Removal Of Breast,aetna - medicare advantage,EPO,O,30320.19,4901.08,4901.08,9859.30,18192.11
4796,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna - medicare advantage,HMO,O,331.51,82.43,85.12,301.25,102.14
4797,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93926,cpt,Ultrasound Study Of Arteries And Arterial Grafts Of One Leg Or Limited,aetna - medicare advantage,Medicaid,O,609.94,96.50,96.51,359.62,365.96
4798,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna - medicare advantage,EPO,O,83.80,8.07,8.85,89.04,50.28
4799,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96417,cpt,Infusion Of Different Chemotherapy Drug Or Substance Into A Vein Up To 1 Hour,aetna - medicare advantage,EPO,O,241.84,54.88,55.53,181.38,145.10
4800,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,P9037,cpt,"Platelets, Pheresis, Leukocytes Reduced, Irradiated, Each Unit",aetna - medicare advantage,Medicaid,O,3187.75,617.33,617.33,1430.41,1912.65
4801,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,19303,cpt,Simple Complete Removal Of Breast,aetna - medicare advantage,POS,O,30320.19,4901.08,4901.08,9859.30,18192.11
4802,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0610,revCode,Magnetic Resonance Technology (Mrt) General,aetna - medicare advantage,EPO,O,2882.19,203.81,203.81,2039.29,1729.31
4803,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77065,cpt,Diagnostic Mammography Of 1 Breast,aetna - medicare advantage,Medicaid,O,271.34,80.51,80.51,215.72,96.61
4804,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77336,cpt,Continuing Radiation Therapy Consultation Per Week,aetna - medicare advantage,HMO,O,289.04,102.81,112.36,158.15,134.83
4805,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,17264,cpt,"Destruction Of Malignant Growth (3.1 To 4.0 Centimeters) Of Trunk, Arms, Or Legs",aetna - medicare advantage,POS,O,1456.00,306.29,306.29,306.29,873.60
4806,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77067,cpt,Screening Mammography Of Both Breasts,aetna - medicare advantage,EPO,O,331.51,82.43,85.12,301.25,102.14
4807,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,77386,cpt,"Intensity Modulated Radiation Therapy Delivery, Complex",aetna - medicare advantage,Medicaid,O,2383.15,480.50,490.88,1303.99,576.60
4808,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36600,cpt,Arterial Puncture Withdrawal Of Blood For Diagnosis,aetna - medicare advantage,HMO,O,179.32,34.87,96.59,147.18,107.59
4809,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93226,cpt,"Heart Rhythm Analysis, Interpretation And Report Of 48-Hour Ekg",aetna - medicare advantage,Medicare Part B,O,251.28,64.70,99.15,266.35,150.77
4810,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,391,ms-drg,"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With MCC",aetna - medicare advantage,POS,I,24453.90,3581.16,9483.69,10143.06,14672.34
4811,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93460,cpt,Insertion Of Catheter In Right And Left Heart And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna - medicare advantage,Medicare Part A,O,18038.69,2418.26,2567.49,13615.16,10823.21
4812,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36592,cpt,Collection Of Blood Specimen From Central Or Peripheral Venous Catheter,aetna - medicare advantage,POS,O,176.96,19.79,99.15,99.98,106.18
4813,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,80177,cpt,Levetiracetam Level,aetna - medicare advantage,Medicare Part A,O,71.96,12.99,13.25,28.24,43.18
4814,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna - medicare advantage,EPO,I,5647.36,1115.96,3505.92,3995.78,3388.42
4815,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,93460,cpt,Insertion Of Catheter In Right And Left Heart And Left Lower Heart Including Imaging Interpretation And Supervision And Injection,aetna - medicare advantage,Medicaid,O,18038.69,2418.26,2567.49,13615.16,10823.21
4816,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,85730,cpt,"Coagulation Assessment Blood Test, Plasma Or Whole Blood",aetna - medicare advantage,PPO,O,50.72,5.89,6.01,35.89,7.21
4817,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,86593,cpt,Syphilis Test,champus insurance,EPO,O,50.01,4.36,4.42,6.32,30.01
4818,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0341,revCode,"Nuclear Medicine, Diagnostic",aetna - medicare advantage,HMO,O,5568.56,800.20,800.20,5465.13,3341.14
4819,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0110,revCode,Room And Board Private (One Bed) General,aetna - medicare advantage,HMO,I,1307.77,398.79,1092.59,8974.67,784.66
4820,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36569,cpt,"Insertion Of Peripherally Inserted Central Venous Catheter For Infusion (Picc), Patient 5 Years Or Older",aetna - medicare advantage,HMO,O,2539.67,1245.33,1259.55,4006.95,1523.80
4821,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0200,revCode,Intensive Care Unit General,aetna - medicare advantage,POS,I,5647.36,1115.96,3505.92,3995.78,3388.42
4822,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,84443,cpt,"Blood Test, Thyroid Stimulating Hormone (TSH)",aetna - medicare advantage,EPO,O,120.33,10.08,16.80,90.25,20.16
4823,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,96375,cpt,"Injection Of Different Drug Or Substance Into A Vein For Therapy, Diagnosis, Or Prevention",aetna - medicare advantage,Medicare Part B,O,88.47,19.71,35.43,66.35,53.08
4824,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,J9301,cpt,"Injection, Obinutuzumab, 10 Mg",aetna - medicare advantage,HMO,O,243.02,44.56,46.12,182.27,145.81
4825,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,0300,revCode,"Laboratory, General Classification",aetna - medicare advantage,Medicaid,O,83.80,8.07,8.85,89.04,50.28
4826,2023-03-28,877d74ae-cda2-11ed-a585-536ad537c29c,Comanche County Memorial Hospital,73-6061037,36569,cpt,"Insertion Of Peripherally Inserted Central Venous