United Agriculture Benefit Trust Group Health Plan CHIROPRACTIC CPT 97012 2020 MECHANICAL TRACTION THERAPY ein 912038984 11 Professional 14.37 59 185.00 1093042244 14.37 59, GP 185.00 1093042244 CHIROPRACTIC CPT 97140 2020 MANUAL THERAPY 1/> REGIONS ein 770356967 11 Professional 33.12 59, GP 40.00 1740335249 CHIROPRACTIC CPT 98940 2020 CHIROPRACT MANJ 1-2 REGIONS ein 770356967 11 Professional 23.76 65.00 1740335249 ein 912038984 11 Professional 27.95 65.00 1093042244 27.95 AT 65.00 1093042244 CHIROPRACTIC CPT 98941 2020 CHIROPRACT MANJ 3-4 REGIONS ein 390829072 11 Professional 33.28 75.00 1932413937 ein 61644980 11 Professional 38.89 88.00 1114952694 CHIROPRACTIC CPT 98943 2020 CHIROPRACT MANJ XTRSPINL 1/> ein 390829072 11 Professional 19.02 45.00 1932413937 CHIROPRACTIC CPT G0283 2020 ELEC STIM OTHER THAN WOUND ein 912038984 11 Professional 5.64 GP 65.00 1093042244 DIALYSIS CPT 90945 2020 DIALYSIS ONE EVALUATION ein 462642183 65 Institutional 465.75 2217.97 1467847202 DIALYSIS CPT 90999 2020 UNLISTED DIALYSIS PROCEDURE ein 831840496 65 Institutional 475.14 G4 8212.08 1356826713 8622.68 1356826713 475.14 G5 8622.68 1356826713 475.14 G6 8212.08 1356826713 8622.68 1356826713 ein 932674567 65 Institutional 0.00 G4, V7 12071.50 1972380723 0.00 G5, V7 11388.21 1972380723 12071.50 1972380723 DIALYSIS CPT A4657 2020 SYRINGE W/WO NEEDLE ein 932674567 65 Institutional 0.00 119.42 1972380723 126.59 1972380723 253.18 1972380723 DIALYSIS CPT Q4081 2020 EPOETIN ALFA, 100 UNITS ESRD ein 932674567 65 Institutional 0.00 JA 1465.44 1972380723 1728.15 1972380723 1831.80 1972380723 HOME HEALTH CPT S9328 2020 HIT PAIN IMP PUMP DIEM ein 510269822 12 Professional 47.69 275.00 1770528994 HOSPITAL OUTPATIENT CPT A4649 2020 SURGICAL SUPPLIES ein 770506185 24 Institutional 0.00 5.00 1396748547 8.30 1396748547 24.64 1396748547 30.00 1396748547 42.20 1396748547 73.62 1396748547 110.00 1396748547 181.50 1396748547 467.50 1396748547 1210.00 1396748547 HOSPITAL OUTPATIENT CPT H0018 2020 ALCOHOL AND/OR DRUG SERVICES ein 471904183 22 Institutional 700.00 4500.00 1861879116 HOSPITAL OUTPATIENT CPT H0019 2020 ALCOHOL AND/OR DRUG SERVICES ein 472232057 22 Institutional 1850.99 1942.86 1902285919 OFFICE VISIT CPT 90834 2020 PSYTX W PT 45 MINUTES ein 825026508 11 Professional 167.25 300.00 1164865390 OFFICE VISIT CPT 90837 2020 PSYTX W PT 60 MINUTES ein 464019998 1 Professional 190.00 190.00 1720319874 ein 464019998 11 Professional 190.00 190.00 1720319874 ein 464543675 11 Professional 248.55 300.00 1912113564 ein 473463341 11 Professional 185.00 185.00 1790070647 ein 474664484 11 Professional 94.50 120.00 1669934261 94.50 HL 220.00 1669934261 ein 562290462 11 Professional 94.50 200.00 1689709339 ein 833296681 11 Professional 120.00 120.00 1720512957 180.00 1720512957 PED DENTAL EXAM CPT D0120 2020 PERIODIC ORAL EVALUATION ein 461309150 11 76.94 103.00 1053650739 107.00 1053650739 PED DENTAL PREVENTATIVE CPT D0230 2020 INTRAORAL PERIAPICAL EACH ADD IMAGE ein 461173538 11 44.88 6.00 1841638624 20.00 1841638624 1962114785 ein 900217702 11 37.66 26.00 1043886559 1134737315 31.00 1013299411 1235118969 ein 941747220 11 38.47 20.00 1295752384 PED DENTAL PREVENTATIVE CPT D1351 2020 DENTAL SEALANT PER TOOTH ein 770204484 11 91.52 60.00 1205922705 1831285329 PED DENTAL PREVENTATIVE CPT D1354 2020 APPL CARIES ARR MEDICAMENT ein 454444189 11 98.10 44.00 1255627592 ein 882750939 11 98.10 79.00 1912631474 PED FLOURIDE TX CPT D1206 2020 TOPICAL APPLICATN FLUORIDE VARNISH ein 461309150 11 57.33 68.00 1053650739 71.00 1053650739 PED NOT COVERED DENTAL CPT D1354 2020 APPL CARIES ARR MEDICAMENT ein 454444189 11 98.10 44.00 1255627592 PED PROPHYLAXIS CPT D1120 2020 DENTAL PROPHYLAXIS CHILD ein 461309150 11 98.79 106.00 1053650739 110.00 1053650739 PHYSICAL THERAPY CPT 97012 2020 MECHANICAL TRACTION THERAPY ein 912038984 11 Professional 14.37 59, GP 185.00 1093042244 PHYSICAL THERAPY CPT 97140 2020 MANUAL THERAPY 1/> REGIONS ein 770356967 11 Professional 33.12 59, GP 40.00 1740335249 ein 932102337 12 Professional 112.50 GP 112.50 1295086387 150.00 GP 150.00 1295086387 PHYSICAL THERAPY CPT G0283 2020 ELEC STIM OTHER THAN WOUND ein 912038984 11 Professional 5.64 59, GP 65.00 1093042244 RAD/ DIAG TESTING-OFFICE CPT 70220 2020 X-RAY EXAM OF SINUSES ein 274197732 11 Professional 40.98 59 58.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 71047 2020 X-RAY EXAM CHEST 3 VIEWS ein 274197732 11 Professional 47.19 59 63.00 1821387051 RAD/ DIAG TESTING-OFFICE CPT 71110 2020 X-RAY EXAM RIBS BIL 3 VIEWS ein 274197732 11 Professional 47.31 59 112.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 72052 2020 X-RAY EXAM NECK SPINE 6/>VWS ein 274197732 11 Professional 67.80 91.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 72072 2020 X-RAY EXAM THORAC SPINE 3VWS ein 274197732 11 Professional 42.81 59 58.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 72110 2020 X-RAY EXAM L-2 SPINE 4/>VWS ein 274197732 11 Professional 56.80 59 79.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73030 2020 X-RAY EXAM OF SHOULDER ein 274197732 11 Professional 37.77 59 54.00 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73521 2020 X-RAY EXAM HIPS BI 2 VIEWS ein 274197732 11 Professional 46.43 59 64.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73564 2020 X-RAY EXAM KNEE 4 OR MORE ein 274197732 11 Professional 51.76 59 70.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73610 2020 X-RAY EXAM OF ANKLE ein 274197732 11 Professional 39.73 59 60.00 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73630 2020 X-RAY EXAM OF FOOT ein 274197732 11 Professional 37.15 59 54.00 1821387051 TELEMEDICINE CPT 90837 2020 PSYTX W PT 60 MINUTES ein 464543675 10 Professional 248.55 300.00 1912113564 248.55 GT 300.00 1912113564 TELEMEDICINE CPT S0201 2020 PARTIAL HOSPITALIZATION SERV ein 881815444 22 Institutional 436.00 95 6500.00 1346984804 2026-07-01