United Agriculture Benefit Trust
Group Health Plan
ANCILLARY CHARGES
CPT
H0015
2020
ALCOHOL AND/OR DRUG SERVICES
ein
462906975
22
Institutional
250.00
95
1500.00
1114411360
CHIROPRACTIC
CPT
98940
2020
CHIROPRACTIC MANIPULATIVE TX SPINAL 1-2 REGIONS
ein
200884343
11
Professional
27.95
80.00
1700076528
CHIROPRACTIC
CPT
98941
2020
CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS
ein
851608883
11
Professional
25.00
55.00
1720606452
25.00
AT
55.00
1720606452
DIALYSIS
CPT
90945
2020
DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL
ein
953372911
65
Institutional
416.55
3477.00
1851851117
DIALYSIS
CPT
90999
2020
UNLISTED DIALYSIS PROCEDURE INPATIENT/OUTPATIENT
ein
464312318
65
Institutional
352.48
8113.00
1942654595
455.79
8113.00
1942654595
ein
474563109
65
Institutional
302.65
7026.98
1700230430
ein
833074738
65
Institutional
433.38
3202.75
1861033953
433.38
G5
3202.75
1861033953
DIALYSIS
CPT
A4657
2020
SYRINGE W/WO NEEDLE
ein
833074738
65
Institutional
0.00
18.50
1861033953
55.50
1861033953
92.50
1861033953
DIALYSIS
CPT
J1644
2020
INJ HEPARIN SODIUM PER 1000U
ein
833074738
65
Institutional
0.00
177.52
1861033953
DIALYSIS - FACILITY
CPT
90945
2020
DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL
ein
953372911
65
Institutional
416.55
3477.00
1851851117
DIALYSIS - FACILITY
CPT
90999
2020
UNLISTED DIALYSIS PROCEDURE INPATIENT/OUTPATIENT
ein
474563109
65
Institutional
302.65
7026.98
1700230430
HOSPICE
CPT
Q5001
2020
HOSPICE OR HOME HLTH IN HOME
ein
850302297
34
Institutional
189.97
226.78
1285659003
HOSPITAL OUTPATIENT
CPT
H0015
2020
ALCOHOL AND/OR DRUG SERVICES
ein
462906975
22
Institutional
250.00
95
1500.00
1114411360
HOSPITAL OUTPATIENT
CPT
S0201
2020
PARTIAL HOSPITALIZATION SERV
ein
472510145
22
Institutional
1666.77
2595.00
1497153563
MEDICAL SERVICES
CPT
C9803
2020
HOPD COVID-19 SPEC COLLECT
ein
851729048
15
Professional
75.00
80.00
1750970109
MEDICAL SERVICES
CPT
G2023
2020
SPECIMEN COLLECT COVID-19
ein
852421177
81
Professional
0.00
48.00
1366048019
60.00
1366048019
48.00
48.00
1366048019
60.00
60.00
1366048019
ein
990370089
81
Professional
0.00
46.92
1265897078
MEDICAL SERVICES
CPT
U0003
2020
COV-19 AMP PRB HGH THRUPUT
ein
743204993
81
Professional
55.00
55.00
1689281784
ein
852421177
81
Professional
86.00
200.00
1366048019
250.00
1366048019
200.00
200.00
1366048019
250.00
1366048019
250.00
250.00
1366048019
ein
943147701
81
Professional
110.00
110.00
1396837605
ein
990370089
81
Professional
200.00
CS
0.00
1265897078
200.00
1265897078
MEDICAL SERVICES
CPT
U0005
2020
INFEC AGEN DETEC AMPLI PROBE
ein
852421177
81
Professional
50.00
50.00
1366048019
63.00
63.00
1366048019
ein
943147701
81
Professional
25.00
25.00
1396837605
OFFICE VISIT
CPT
90834
2020
PSYCHOTHERAPY W/PATIENT 45 MINUTES
ein
611714675
11
Professional
126.07
150.00
1922239144
126.07
95
150.00
1922239144
OFFICE VISIT
CPT
90837
2020
PSYCHOTHERAPY W/PATIENT 60 MINUTES
ein
831506859
11
Professional
150.00
150.00
1518435171
SUBST SVCS
CPT
H0015
2020
ALCOHOL AND/OR DRUG SERVICES
ein
462906975
22
Institutional
250.00
1500.00
1114411360
250.00
95
1500.00
1114411360
TELEMEDICINE
CPT
90837
2020
PSYCHOTHERAPY W/PATIENT 60 MINUTES
ein
261804108
2
Professional
165.00
95
165.00
1588746259
ein
831506859
2
Professional
150.00
150.00
1518435171
2024-03-01