United Agriculture Benefit Trust Group Health Plan CHIROPRACTIC CPT 97110 2020 THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES ein 204086272 11 Professional 24.78 45.00 1811053697 24.78 59, GP 45.00 1811053697 CHIROPRACTIC CPT 97140 2020 MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES ein 204086272 11 Professional 0.00 45.00 1811053697 ein 770356967 11 Professional 28.15 59, GP 40.00 1740335249 33.12 59, GP 40.00 1740335249 CHIROPRACTIC CPT 98940 2020 CHIROPRACTIC MANIPULATIVE TX SPINAL 1-2 REGIONS ein 770356967 11 Professional 23.76 65.00 1740335249 ein 992930906 11 Professional 27.95 60.00 1265281414 ein 992930906 49 Professional 27.95 60.00 1265281414 CHIROPRACTIC CPT 98941 2020 CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS ein 200205735 11 Professional 33.28 93.54 1598703753 ein 204086272 11 Professional 33.28 AT 60.00 1811053697 ein 390829072 11 Professional 33.28 75.00 1932413937 ein 770356967 11 Professional 38.89 80.00 1740335249 CHIROPRACTIC CPT 98943 2020 CHIROPRACTIC MANIPLTV TX EXTRASPINAL 1/> REGION ein 204086272 11 Professional 8.95 40.00 1811053697 DIALYSIS CPT 90945 2020 DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL ein 462642183 65 Institutional 98.18 2217.97 1467847202 DIALYSIS CPT 90999 2020 UNLISTED DIALYSIS PROCEDURE INPATIENT/OUTPATIENT ein 831840496 65 Institutional 475.14 G4 8212.08 1356826713 475.14 G6 8212.08 1356826713 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 861723552 22 Institutional 1054.00 6023.70 1104568377 HOSPITAL ROOM & BOARD CPT H0018 2020 ALCOHOL AND/OR DRUG SERVICES ein 861723552 22 Institutional 1054.00 6023.70 1104568377 OFFICE VISIT CPT 90837 2020 PSYCHOTHERAPY W/PATIENT 60 MINUTES ein 474664484 11 Professional 94.50 120.00 1669934261 94.50 HL 220.00 1669934261 94.50 HO 220.00 1669934261 ein 830999317 11 Professional 145.00 145.00 1326484775 PED DENTAL EXAM CPT D0120 2020 PERIODIC ORAL EVALUATION - EST PATIENT ein 461309150 11 76.94 103.00 1053465591 1053650739 PED DENTAL PREVENTATIVE CPT D0230 2020 INTRAORAL-PERIAPICAL-EACH ADDITIONAL IMAGE ein 651202122 11 36.04 22.00 1053651539 1225226566 PED DENTAL PREVENTATIVE CPT D1351 2020 SEALANT - PER TOOTH ein 770204484 11 91.52 60.00 1033242144 1205922705 1831285329 PED FLOURIDE TX CPT D1206 2020 TOPICAL APPLICATION OF FLUORIDE VARNISH ein 461309150 11 57.33 68.00 1053465591 1053650739 PED PROPHYLAXIS CPT D1120 2020 PROPHYLAXIS - CHILD ein 461309150 11 98.79 106.00 1053465591 1053650739 RAD/ DIAG TESTING-OFFICE CPT 70220 2020 RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS ein 274197732 11 Professional 40.98 59 58.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 71047 2020 RADIOLOGIC EXAM CHEST 3 VIEWS ein 274197732 11 Professional 47.19 59 63.00 1821387051 RAD/ DIAG TESTING-OFFICE CPT 71110 2020 RADEX RIBS BILATERAL 3 VIEWS ein 274197732 11 Professional 47.31 59 112.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 72052 2020 RADEX SPINE CERVICAL 6 OR MORE VIEWS ein 274197732 11 Professional 67.80 91.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 72072 2020 RADEX SPINE THORACIC 3 VIEWS ein 274197732 11 Professional 42.81 59 58.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 72110 2020 RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS ein 274197732 11 Professional 56.80 59 79.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73030 2020 RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS ein 274197732 11 Professional 37.77 59 54.00 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73521 2020 RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS ein 274197732 11 Professional 46.43 59 64.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73564 2020 RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS ein 274197732 11 Professional 51.76 59 70.50 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73610 2020 RADEX ANKLE COMPLETE MINIMUM 3 VIEWS ein 274197732 11 Professional 39.73 59 60.00 1821387051 RAD/ DIAG TESTING-OFFICE CPT 73630 2020 RADEX FOOT COMPLETE MINIMUM 3 VIEWS ein 274197732 11 Professional 37.15 59 54.00 1821387051 TELEMEDICINE CPT 90837 2020 PSYCHOTHERAPY W/PATIENT 60 MINUTES ein 331964295 2 Professional 175.00 175.00 1316660608 2026-05-01