RFI – REQUEST FOR INFORMATION - BlueCare … Forms/RFI-Clinical-Lab...RFI – REQUEST FOR INFORMATION . ... 2.3 TennCareSelect (TCS) ... market check for the following lines of business:

RFI – REQUEST FOR INFORMATION

BlueCare Tennessee Clinical Laboratory Services

RFI #04202015

BlueCross BlueShield of Tennessee 1 Cameron Hill Circle

Chattanooga, TN 37402

________________________________________________________________________________________ RFI - Point of Service Laboratory Testing/Traditional Clinical Laboratory Services Page 1 of 9

Table of Contents 1 REQUEST FOR INFORMATION (RFI) ....................................................................... 3

1.1 RFI Purpose, Background and Intent ................................................................. 3

2 CORPORATE OVERVIEW ...................................................................................... 3

2.1 BlueCross BlueShield of Tennessee (BCBST)................................................... 3

2.2 BlueCare Tennessee (BCT) ............................................................................... 3

2.3 TennCareSelect (TCS) ....................................................................................... 3

2.4 BlueCare Plus HMO DSNP ................................................................................ 4

2.5 State of Tennessee TennCare Program ............................................................ 4

2.6 Medicare Advantage .......................................................................................... 4

2.7 Target Population ............................................................................................... 5

2.8 2014 BCT Historical Utilization ........................................................................... 5

3 GENERAL INFORMATION ...................................................................................... 5

3.1 Proprietary or Confidential Information ............................................................... 5

3.2 Amendment/Addenda/Right to Cancel ............................................................... 5

3.3 Submission Instructions ..................................................................................... 5

3.4 Industry Discussions .......................................................................................... 6

3.5 Submittal of Questions ....................................................................................... 6

3.6 Point of Contact for BCBST and Deliverables .................................................... 6

3.7 RFI Planned Schedule ....................................................................................... 6

4 RFI PROVIDER QUESTIONS.................................................................................. 7

Attachment A – Confidentiality and Non-Disclosure Agreement (CNDA) ........................ 9

Attachment B – Pricing Proposal Medicaid BCT and TCS .............................................. 9

Attachment C – Pricing Proposal Medicare Advantage ................................................... 9

Attachment D – Pricing Proposal BlueCare Plus (DSNP) ............................................... 9

Attachment E – BlueCare Tennessee Lab Exclusion List ............................................... 9

Attachment F – 2014 Lab Services Utilization by CPT Code per Line of Business ......... 9


1 REQUEST FOR INFORMATION (RFI)

1.1 RFI Purpose, Background and Intent BlueCare Tennessee is distributing this RFI to seek and gather input, suggestions, and feedback as we conduct a market check for the following lines of business: BlueCare Tennessee, BlueCare Plus, TennCareSelect and Medicare Advantage (collectively herein referred to as “BCT”), for the provision of excellent quality and efficient healthcare to our members through Point of Service Laboratory Testing or Traditional clinical laboratory services. This RFI is intended to provide interested Providers with information to enable them to demonstrate their capabilities to provide clinical laboratory services to improve members’ health outcomes, increase patient satisfaction with care, control expenditures, as well as propose creative, competitive solutions for value-added services, i.e., Member Home Visits, Home Kits, and multiple community outreach opportunities. Responses should include a summary of how the Provider would administer and deliver Point of Service Laboratory Testing or Traditional clinical laboratory services statewide, as well develop and implement value-added services: Member Home Visits, Home Kits, and community outreach events. Provider should submit a response describing their Provider network, authorization, coordination, scheduling management and reimbursement protocols. Provider must be capable of filing claims. Providers are required to submit cost models designed to include a fee-for-service arrangement for each line of business. This RFI is issued solely for information and planning purposes. It does not constitute a Request for Proposal (RFP) or a guarantee to issue an RFP in the future. This RFI does not commit BCT to contract for any supply or service. Responders should be advised that BCT will not pay for any information or administrative costs incurred in response to this RFI; all costs will be solely at the interested party’s expense. Not responding to the RFI does not preclude participation in any possible, future RFP; if an RFP is issued, qualified candidates will be notified. 2 CORPORATE OVERVIEW

2.1 BlueCross BlueShield of Tennessee (BCBST) BlueCross BlueShield of Tennessee, Inc., headquartered in Chattanooga, Tennessee is committed to conducting business with ethics, integrity and in accordance with all federal, state and local laws and regulations. The compliance, risk and quality management program model enables the communication and oversight necessary for this commitment. Additional information concerning the organization, operation, goals and objectives of BCBST is available from our website, at http://www.bcbst.com.

2.2 BlueCare Tennessee (BCT) BCT is an independent licensee of the BlueCross BlueShield Association and a licensed HMO affiliate of its parent company BlueCross BlueShield of Tennessee, Inc. Founded in 1993, the Chattanooga-based company focuses on managing care and providing quality health care products, services, and information for the State of Tennessee’s TennCareSM programs. BCT contracts with the State of Tennessee, through the Bureau of TennCare, to manage and deliver integrated physical health, behavioral health, and long term care services to over 550,000 members statewide. A primary goal for BCT is helping TennCare members become healthier. Explore our Web site and learn more about us at http://bluecare.bcbst.com.

2.3 TennCareSelect (TCS) TennCareSelect is the State’s self-insured TennCare Health Maintenance Organization that is available to select TennCare Enrollees effective July 1, 2001. It is administered by BCT and has the same benefits as all other MCO’s. TennCare Enrollees cannot choose TennCareSelect, only the Bureau of TennCare can enroll members. Some of the State's groups for TennCareSelect include:

• Children receiving Social Security Insurance (SSI) benefits;


http://www.bcbst.com/

http://bluecare.bcbst.com/

• Children who are in the custody of the state; • Children who are in an institutional eligibility category; • Enrollees with intellectual disabilities; • and Enrollees who may be temporarily living out of state.

In some areas of the state, other TennCare MCOs cannot serve all Enrollees. TennCareSelect is the backup program in those areas.

2.4 BlueCare Plus HMO DSNP BlueCare Plus is an Independent Licensee of the BlueCross BlueShield Association. BlueCare Plus is an HMO Special Needs Plan (SNP) with a Medicare contract and a contract with the Tennessee Medicaid Program. BlueCare Plus focuses on managing care and providing quality health care products, services, and information for government programs. We take great pride in serving the people of Tennessee statewide, both in our products and services and in our numerous outreach activities. BlueCare Plus is an HMO SNP plan that works with each member and a team of professionals to offer the most appropriate programs to meet physical, behavioral health and long-term care needs ranging from preventive initiatives to care coordination. The BlueCare Plus program is designed for people who have Medicare (Parts A and B) and Medicaid with unique special needs, the program operates as the individual's point of contact for both Medicare and Medicaid benefits and services. Part D prescription drug coverage is included in the BlueCare Plus program with the addition of vision, hearing, dental and transportation benefits for our BlueCare Plus members.

2.5 State of Tennessee TennCare Program TennCare is the State of Tennessee’s Medicaid program that provides health care services for 1.2 million Tennesseans and operates with an annual budget of approximately 8 billion dollars. The TennCare program operates under a Section 1115 waiver from the Centers for Medicare and Medicaid Services (CMS) in the United States Department of Health and Human Services. It is a demonstration program. The principle being demonstrated by TennCare is that a state can organize its Medicaid program under a managed care model and generate sufficient savings to extend coverage to additional populations who would not otherwise be Medicaid eligible, without compromising quality of care. TennCare is one of the oldest Medicaid managed care programs in the country, having begun on January 1, 1994. It is the only program in the nation to enroll the entire state Medicaid population in managed care. The State of Tennessee contracts with managed care organizations for the administration of the TennCare programs under the Contract Risk Agreement (CRA) and the TennCareSelect Agreement (TSA). Provider(s) will need to base their RFI responses on the CRA, including Amendment 13, and the TSA, including Amendment 33 as well as the State wide Agreement effective January 1, 2015. The documents can be downloaded from the following links: http://www.tn.gov/tenncare/forms/eastwestmcocontract.pdf On January 1, 2015, a new five-year contract took effect extending our 20-year partnership of service to the State of Tennessee and our TennCare members.

2.6 Medicare Advantage Medicare Advantage Program - BCBST contracts with Medicare to provide a Medicare Advantage Plan offering four Medicare Advantage Local Preferred Provider Organization (LPPO) products. BlueAdvantage (PPO) BlueCross BlueShield of Tennessee offers four Medicare Advantage Preferred Provider Organization (PPO) products: BlueAdvantage Diamond, BlueAdvantage Ruby, BlueAdvantage Garnet and BlueAdvantage Sapphire. Currently, the four PPO products are available in all 95 counties.


http://www.tn.gov/tenncare/forms/eastwestmcocontract.pdf

BlueChoice (HMO) BlueCross BlueShield of Tennessee offers two Medicare Advantage Health Maintenance Organization (HMO) products: BlueChoice and BlueChoice Plus. Currently, the two HMO products are available in 65 counties: Anderson, Bedford, Benton, Bledsoe, Blount, Bradley, Campbell, Cannon, Cheatham, Chester, Claiborne, Cocke, Coffee, Cumberland, Davidson, DeKalb, Fayette, Franklin, Gibson, Giles, Grainger, Greene, Grundy, Hamblen, Hamilton, Hancock, Hardeman, Hawkins, Henry, Hickman, Jackson, Jefferson, Knox, Lawrence, Lewis, Lincoln, Loudon, Madison, Marion, Marshall, Maury, Meigs, Monroe, Montgomery, Morgan, Overton, Perry, Polk, Rhea, Roane, Robertson, Rutherford, Sequatchie, Sevier, Shelby, Smith, Sullivan Sumner, Trousdale, Union, Warren, Wayne, White, Williamson and Wilson.

2.7 Target Population

The Provider must be able to provide and manage Point of Service Laboratory Testing or Traditional clinical laboratory services to all BCT members throughout the State of Tennessee and its contiguous counties. BCT reserves the right to carve out certain codes and geographical areas from this RFI. BCT currently serves approximately the following number of members:

Region Name Region Location Total Membership as of 3/31/2015 BCT East East Grand Region 187,724 BCT West West Grand Region 146,709

BCT Middle Middle Grand Region 141,049 TennCareSelect Statewide 49,047

DSNP Statewide 4,257 Medicare Advantage Statewide 91,250

2.8 2014 BCT Historical Utilization

Refer to Attachment F. 3 GENERAL INFORMATION

3.1 Proprietary or Confidential Information Any information contained in the RFI responses is proprietary or confidential must be clearly designated. Be advised that all submissions become the Property of BCT and will not be returned. BCT will maintain the confidentiality of Provider’s Information marked “Confidential” of “Proprietary” in accordance with applicable laws. Interested Providers are required to read, sign, and return the included Non-Discrimination Agreement, Attachment A with their RFI responses on or before May 22, 2015.

3.2 Amendment/Addenda/Right to Cancel BCT reserve the right to alter and/or cancel the RFI timeline or other portions of this RFI at any time.

3.3 Submission Instructions Interested parties who need additional information or have questions about this RFI may submit “RFI QUESTIONS” electronically to [email protected] on or before 5 PM (EST) April 30, 2015.

All final RFI responses must be submitted at a minimum in Microsoft Office 2007 compatible software version. Responses are due by May 22, 2015.


mailto:[email protected]

3.4 Industry Discussions At our discretion, BCT may or may not choose to contact responders. In the event we choose to contact responders, such contact and discussions are only intended to gain additional clarification of the Provider’s potential capability to meet the service requirements.

3.5 Submittal of Questions Questions regarding this Request for Information shall be submitted via e-mail to [email protected], please clearly indicate “RFI Lab Services” in the Subject line of all emails. Verbal questions will not be accepted. Questions shall not contain proprietary information. We do not guarantee a response to questions received within two (2) days of the due date.

3.6 Point of Contact for BCT and Deliverables The point of contact for this RFI and all deliverables should be emailed to:[email protected]. Clearly indicate “RFI Lab Services” in the Subject line of all emails.

3.7 RFI Planned Schedule

Action Date Time (ET) RFI Issued to Providers 4/22/2015 5 PM Receipt of Provider Questions 4/30/2015 5 PM BCT Response to Provider Questions 5/7/2015 5 PM RFI Response Due 5/22/2015 5 PM




4 RFI PROVIDER QUESTIONS

4.1 Contact Information: Organization Name: NPI Number:

President & CEO: Complete Mailing Address:

Phone Number:

Website Address:

Dun & Bradstreet Number:

Contact Person’s Name and Title: Contact’s Email Address:

Contact’s Phone Number:

Organizational Background

4.2 Provide a brief history on your organization including headquarters, divisions and operations. Include how long your organization has been in operation and whether it is owned by a parent company, or whether it owns other companies as a parent organization.

4.3 Submit a description of your major facilities.

4.4 Does your organization have the capability to deliver Point of Service Laboratory Testing or Traditional

Clinical Laboratory Services statewide for both physician office practices and facilities?

4.5 Does your organization hold an unrestricted license in Tennessee?

4.6 Describe Medicare certifications currently held.

4.7 Provide a copy of all certifications obtained by your laboratory.

4.8 Provide a listing of Point of Service testing available and Traditional lab testing with turnaround time from draw to results submission to ordering provider.

4.9 Provide an outline of Provider’s Quality Improvement and Utilization Review program.

4.10 Describe prior authorization services for esoteric and pathology labs.

4.11 Provide a list of available testing by CPT code.

4.12 Does your organization meet the National Committee for Quality Assurance (NCQA) accreditation?

4.13 What differentiates you from your competitors?


Service and Access

4.14 For each of your locations, list services provided. Indicate service availability in Tennessee and its contiguous counties (if partial counties, please note). Where only limited services are offered, please indicate and explain. Where additional services are provided, please details.

4.15 Do you provide services on a 24-hour basis? In what manner? Please describe processes of receiving

request for services (from patient, from physician, from emergency department), dispatching care, and following up with regular provider (if applicable). Please provide your turnaround time for results of lab testing to be available for the ordering provider.

4.16 How many patients do you service a day? Describe your capacity to accept additional patients, without

restricting quality or access to services. Describe experience dealing with large fluctuations in service demand.

4.17 Describe, in detail value-added services/programs your organization has successfully implemented. Describe the focus of the value-added services/programs, the method of implementation, and document program results. Tell us about any lessons learned with these value-added services/programs.

4.18 Which value-added services/programs does your organization recommend for each BCT line if business as part of your RFI response? Why?

Staff Selection and Training

4.19 Describe Provider’s screening process for recruiting employees and monitoring existing employees. Describe sanctioned background check processes.

4.20 Does Provider provide training for its staff? Describe training content and curriculum,

Payment/Administrative

4.21 Describe your organization’s electronic billing capabilities and willingness to use BCT billing format – HL7.

4.22 Describe the payment models you believe have been most successful in the delivery of the Point of Service Laboratory Testing or Traditional Clinical Laboratory Services.

4.23 What cost saving initiatives have you previously implemented?

4.24 Does your organization have the ability to provide laboratory values electronically?

4.25 Please include samples of standard reports.

4.26 Describe a timeline for operational readiness from the time of a potential contract award date to full

implementation.

4.27 After review of the State and Federal CMS Contracts requirements, are there any requirements that you believe that your organization could not comply with or would provide significant challenges?


RFI Attachments

Attachment A – Confidentiality and Non-Disclosure Agreement (CNDA) See separate document for review and signature.

Attachment B – Pricing Proposal Medicaid BCT and TCS See attachment Attachment C – Pricing Proposal Medicare Advantage See attachment Attachment D – Pricing Proposal BlueCare Plus (DSNP) See attachment Attachment E – BlueCare Tennessee Lab Exclusion List See attachment Attachment F – 2014 Lab Services Utilization by CPT Code per Line of Business See attachment


Attachment A

Confidentiality and Non-Disclosure Agreement (CNDA)

This Confidentiality and Non-Disclosure Agreement (“Agreement”) is entered into by and between BlueCross BlueShield of Tennessee, Inc., for itself and on behalf of its Affiliates and Representatives, (Collectively “BCBST”), and , for itself and on behalf of its Affiliates and Representatives, (Collectively “________”), and shall be effective on and after the date of the last signature executed below (its “Effective Date”). Recitals. BCBST and _______ may be collectively referred to as the “Parties” or individually referred to as a “Party”, “Disclosing Party”, “Receiving Party”, or “Recipient” and have requested that each Party furnish the other with certain information which is considered confidential and proprietary. Each Party may also obtain additional information regarding the other during the course of discussions between the Parties that prompted the original request for information (the “Parties’ Discussions”). The purpose of this Agreement is to set forth the terms and conditions under which such information will be disclosed concerning the BCT Clinical Laboratory Services RFI (“Subject Program”). As an inducement to each Party furnishing the other with the information, and as a condition to each Party furnishing such information to the other, each Party agrees that it will, and will cause each of its Representatives (as defined herein) to comply with the provisions hereof. 1. For purposes of this Agreement, the term “Affiliates” is that which is defined in Subpart

2.1 of the FAR.

2. “Confidential Information” shall mean all oral and written information in any form or medium, concerning the subject matter of the Parties’ Discussions, and shall include, but is not limited to, technical, business or financial information, and that is: 1) is marked with the legend “CONFIDENTIAL INFORMATION” or an equivalent conspicuous legend, otherwise identified as, legally entitled to protection as, or is of the type or nature that a reasonable person would understand it to be confidential, proprietary, privileged or trade secret information; or (2) if it disclosed orally or visually, and is identified as Confidential at the time of disclosure and is subsequently reduced to writing specifically identifying the items of a Confidential nature and is furnished to the Recipient within fifteen (15) days of disclosure; or (3) is disclosed by or on behalf of a Party (the “Disclosing Party”) to the other Party (the “Receiving Party”) related to the Parties’ Discussions. Confidential information includes information by the Disclosing Party, as well as all copies. If Confidential Information includes “Protected Health Information” as that term is defined in 45 C.F.R. Section 160.103 of the federal privacy regulations, and would be subject to the protections pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), then each Party shall comply, not only with this Agreement with respect to such Protected Health Information that is part of Confidential Information, but also with the HIPAA regulations at 45 C.F.R. Parts 160 and 164 pertaining to the privacy and security of Protected Health Information to the extent that such HIPAA regulations are applicable to such Party, including the execution of appropriate and mutually agreeable Business Associate Agreements pursuant to such regulations.

Attachment A_BCBST_CNDA-Exclusive Lab RFI Page 1 of 4

The term “Confidential Information” does not include information that: (1) is based on documents in the Receiving Party’s possession prior to disclosure of information and was not acquired directly or indirectly from the Disclosing Party; or (2) was in the public domain at the time of disclosure, or subsequently became part of the public domain through no fault of Receiving Party; or (3) was legally received on a non-confidential basis from a third party, who is not known to be bound by a confidentiality agreement preventing the disclosure of such information; or (4) was independently developed by the Receiving Party without reliance on or knowledge of the Disclosing Party’s Confidential Information.

3. “Representatives” means a Party’s officers, directors, members, employees, or consultants, who receive Confidential Information and/or participate in the Parties’ Discussions pursuant to this Agreement.

4. The Receiving Party agrees that it will, and will cause its Representatives to, maintain in

confidence all Confidential Information. In this regard, the Receiving Party agrees to disclose Confidential Information only to Representatives who need to know such information for the purpose of the Parties’ Discussions and shall take all necessary and reasonable precautions to prevent such Confidential Information from being disclosed or provided to any unauthorized person. The Receiving Party agrees that it will not, and will cause its Representatives not to, use Confidential Information for any purpose other than the purpose of the Parties’ Discussions without first obtaining the Disclosing Party’s express written consent. Receiving Party shall be responsible for any improper disclosure or use of Confidential Information by any of its Representatives. The term “person” as used in this Agreement will be interpreted broadly to include, without limitation, any corporation, company, partnership, limited liability company, natural person or government entity.

5. In the event the Receiving Party or any of its Representatives is requested or becomes legally compelled (by deposition, interrogatory, request for documents, subpoena, civil investigative demand or similar process) to disclose any Confidential Information, then the Party so requested or compelled shall provide the Disclosing Party with prompt written notice of such request or requirement so that the Disclosing Party may seek a protective order or other appropriate remedy and/or waive compliance with the terms of this Agreement. In the event that such protective order or other remedy is not obtained, or that the Disclosing Party waives compliance with the provisions hereof, the Party so requested or compelled agrees to furnish only that portion of the Confidential Information that it is advised by counsel is legally required to be disclosed and to exercise reasonable efforts to obtain assurance that confidential treatment will be accorded the Confidential Information.

6. Upon written notice from the Disclosing Party, the Receiving Party agrees to immediately return or destroy all Confidential Information and any copies in whatever medium utilized containing any such Confidential Information. In addition, the Receiving Party agrees to destroy all copies of any analyses, compilations and studies or other documents including notes and other writings that it prepared containing or reflecting any Confidential Information., Each Party, however, shall be entitled to retain copies of any computer records and files which have been created pursuant to its automatic electronic archiving and back up procedures.

7. Except as may be necessary, in the opinion of counsel, to comply with the requirements of law, governmental regulation or any securities exchange on which any securities of


either Party hereto may be listed, without the prior written consent of the Disclosing Party, the Receiving Party will not, and will direct its Representatives not to, disclose to any person either the fact that the Parties Discussions or that the Disclosing Party or the Receiving Party has requested or received any information, including Confidential Information, from the other Party, or any terms, conditions or other facts with respect to the Parties Discussions, including the status thereof.

8. The parties agree that remedies at law for any actual or threatened breach by Receiving Party of the provisions of this Agreement would not be sufficient remedy. Accordingly, the Receiving Party acknowledges and agrees in advance that in the event of any actual or threatened breach of the provisions of this Agreement by it, and without prejudice to any rights and remedies otherwise available to the Disclosing Party, the Disclosing Party may be entitled (a) to equitable relief, including by way of injunction and/or (b) to compel specific performance without the need of proof of actual damages.

9. Nothing in this Agreement shall be construed as establishing any joint venture or other business relationship or as granting any license or right under any patent rights or as representing any commitment by either Party to enter into any license or other agreement by implication or otherwise.

10. It is the intention of the Parties that the provisions of this Agreement shall be enforced to the fullest extent permissible under the laws and public policies of each state and jurisdiction in which such enforcement is sought, but that the unenforceability (or the modification to conform with such laws or public policies) of any provision hereof shall not render unenforceable or impair the remainder of this Agreement which shall be deemed amended to delete or modify, as necessary, the invalid or unenforceable provisions. The Parties further agree to alter the balance of this Agreement in order to render the same valid and enforceable.

11. This Agreement constitutes the full understanding of the Parties and a complete and exclusive statement of the terms and conditions of their agreement relating to the subject matter hereof and supersedes any and all prior agreements, whether written or oral, that may exist between the Parties with respect thereto. Except as otherwise specifically provided in this Agreement, no conditions, usage of trade, course of dealing or performance, understanding or agreement purporting to modify, vary, explain or supplement the terms or conditions of this Agreement shall be binding unless hereafter made in writing and signed by both Parties to be bound, and no modification shall be effected by the acknowledgment or acceptance of documents or forms containing terms or conditions at variance with or in addition to those set forth in this Agreement.

12. The restrictions expressed in this Agreement are in no way to supersede or eliminate any rights which the Parties otherwise may have pursuant to state or federal law pertaining to trade secrets or proprietary information.

13. It is further understood and agreed that no failure or delay by either Party in exercising any right, power or privilege hereunder shall operate as a waiver thereof, nor shall any single or partial exercise thereof preclude any other or further exercise thereof or the exercise of any right, power or privilege hereunder.

14. This Agreement will be governed by and construed in accordance with the laws of the State of Tennessee


15. This Agreement shall be binding upon and inure to the benefit of the Parties hereto and shall be binding upon and inure to the benefit of the successors, assigns, personal representatives, executors and administrators of the Parties hereto.

This Agreement may be executed by facsimile transmission and in two or more counterparts, each of which shall be deemed an original and which, when taken together, shall constitute one and the same instrument. Any signatures delivered by a Party by facsimile transmission or by e-mail transmission, including in Adobe portable document format, shall be deemed an original signature.

IN WITNESS WHEREOF, the Parties have executed this Agreement intending to be bound on and after its last signature date below, referred to as the “Effective Date”. BlueCross BlueShield of Tennessee, Inc. [Company Name] By: ______________________________ By: _______________________________ Title: _____________________________ Title: ______________________________ Signature: ________________________ Signature: __________________________ Address: _________________________ Address: ___________________________ _________________________________ __________________________________ Date: ____________________________ Date: _____________________________


Attachment B[Offeror's Name]: Proposed Laboratory Pricing by Procedure

RFI - Clinical Laboratory Services

1

Line of Business: Medicaid - BlueCare Tennessee and TennCareSelect

NPI Tax ID CPT Code Modifier

Do you offer this service

(Y/N)

% of Medicare Proposed Comments

Attachment C[Offeror's Name]: Proposed Laboratory Pricing by Procedure


1

Line of Business: Medicare Advantage



(Y/N)


Attachment D[Offeror's Name]: Proposed Laboratory Pricing by Procedure


1

Line of Business: BlueCare Plus - DSNP



(Y/N)


Updated March 19, 2015CPT® is a registered trademark of the American Medical Association

CPT® Code Description36415 Collection of venous blood by venipuncture36416 Collection of capillary blood specimen (eg, finger, heel, ear stick).36591 Collection of blood spec from implantable device (port)36592 Collection of blood specimen from central line, venous

*80048 Basic Metabolic Panel80051 Electrolyte Panel*80061 Lipid Panel*80076 Hepatic Panel80150 Amikacin80170 Gentamycin80200 Tobramycin80202 Vancomycin

*80299 Methotrexate81000 Urinalysis, by dip stick or tablet reagent; non-automated, with microscopy81001 Urinalysis, by dip stick or tablet reagent; automated, with microscopy81002 Urinalysis, by dip stick or tablet reagent; non-automated, without microscopy81003 Urinalysis, by dip stick or tablet reagent; automated, without microscopy81005 Urinalysis; qualitative or semiquantitative, except immunoassays81025 Urine pregnancy test, by visual color comparison methods82044 Albumin; urine, microalbumin, semiquantitative (eg, reagent strip assay)82140 Ammonia82150 Amylase82247 Bilirubin; Total82248 Bilirubin; Direct82270 Blood, occult, by peroxidase activity, multiple specimen82272 Blood, occult, by peroxidase activity, single specimen

*82310 Calcium82438 Chloride; Sweat82550 CK, total82553 Creatine Kinase (CK) (CPK); MB Frac82565 Creatinine; blood82570 Creatinine, other source82731 Fetal fibronectin, cervicovaginal secretions, quantitative82803 Gases; Blood

The Primary Criteria for the Exclusion List is as follows: Test Results needed in an Outpatient Setting to Facilitate Immediate care of the Patient.

NOTE: Codes added during the Q1 2014 review are indicated by green highlights

BlueCare Tennessee Lab Exclusion List

BCT RFI - ATTACHMENT E


82805 Gases, blood with O2 saturation, by direct measurement, except pulse oximetry82810 Gases; Blood O2 saturation only

82820 Hemoglobin-oxygen affinity (pO2 for %50 hemoglobin saturation with oxygen)

82945 Glucose, body fluid, other than blood (CSF)82947 Glucose; quantitative, blood (except reagent strip)82948 Glucose; blood, reagent strip82950 Glucose; Post Glucose Dose82951 Glucose tolerance test, 3 specimens (includes glucose)82962 Glucose, blood by glucose monitoring device(s) 83014 Helicobacter pylori; drug administration83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use83605 Lactate

*83615 LDH*83655 Lead83663 Fetal lung maturity assessment; flourescence polarization83664 Fetal lung maturity assessment; lamellar body density83690 Lipase83735 Magnesium83861 Microfluidic analysis, tear osmolality83880 Natriuretic Peptide84081 Phosphatidylglycerol

*84100 Phosphorus

84112 Placental alpha microglobulin-1 (PAMG-1), cervicovaginal secretion, qualitative84132 Potassium; Serum84155 CSF Protein84157 Protein, total, other source (CSF)84295 Sodium; Serum

*84439 Free T4*84443 TSH*84450 AST*84460 ALT84484 Troponin, quantitative84512 Troponin, qualitative84520 Urea Nitrogen; Quantitative

*84550 Uric Acid84702 Gonadotropin, chorionic (HCG); Quantitative84703 Gonadotropin, chorionic (hCG); qualitative85002 Bleeding time




85013 Blood count; spun microhematocrit85014 Hematocrit

*85018 Hemoglobin

85025Blood count; hemogram and platelet count, automated, and automated complete differential WBC count (CBC)

85049 Blood count; platelet automated85060 Blood smear, peripheral; with written report85378 Fibrin degradation products, D-dimer; qualitative85379 Fibrin Degradation Products, D-Dimer; quantitative85460 Hemoglobin, fetal for fetomaternal hemorrhage85576 Platelet aggregation, each agent85610 Prothrombin time85611 Prothrombin time substitution, plasma fractions, each85652 Sedimentation rate, erythrocyte, automated85660 Sickling of RBC, reduction85730 Thromboplastin time, partial (PTT); plasma or whole blood85732 Thromboplastin time, partial (PTT); substitution, plasma fractions, each86308 Heterophile antibodies; screening86318 Immunoassay for infectious agent antibody, single step86485 Skin test; candida86486 Skin test; unlisted antigen, each86490 Skin test; coccidioidomycosis86510 Skin test; histoplasmosis86580 Skin test; tuberculosis, intradermal86710 Antibody; influenza virus86738 Antibody; Mycoplasma86850 Antibody screen, RBC, each serum technique86860 Antibody elution (RBC), each elution86870 Antibody identification, RBC antibodies, each panel for each serum technique86880 Antihuman globulin test (Coombs test); direct, each antiserum86885 Antihuman globulin test (Coombs); indirect, qualitative, each reagent red cell86900 Blood Typing; ABO86901 Blood Typing; RH (D)

86902 Blood typing; antigen testing of donor blood using reagent serum, each antigen test86904 Antigen screen for compatible unit, patient serum86920 Compatability test each unit; immediate spin technique86921 Compatability test each unit; incubation technique




86922 Compatability test each unit; antiglobulin technique86923 Compatability test each unit; electronic86927 Thawing fresh frozen plasma86931 Thawing frozen blood86965 Pooling of platelets or other blood products86970 Pretreatment of RBCs with chemical agents86971 Pretreatment of RBCs with enzymes86975 Pretreatment of serum with drugs86976 Pretreatment of serum by dilution86977 Pretreatment of serum with inhibitors86978 Pretreatment of serum by differential red cells86985 Splitting of blood products

87205Smear, primary source with interpretation, Gram or Giemsa stain for bacteria, fungi, or cell types

87210Smear, primary source with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps)

87220Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites

87400Infectious agent antigen detection by enzyme immunoassay technique; Influenza, A or B, each

87430Infectious agent antigen detection by enzyme immunoassay technique; Streptococcus, group A (Rapid Strep)

87802Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B

87803Infectious agent antigen detection by immunoassay with direct optical observation; Clostridium difficile toxin A

87804Infectious agent antigen detection by immunoassay with direct optical observation; Influenza (Rapid Flu)

87807Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus

87880Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A (Strep Test)

*88160 Tzanck smear

88172Cytopathology, eval of fine needle aspirate; immediate cytohistologic study to determine adequacy for dx, first episode, each site

88173Cytopathology, eval of fine needle aspirate; immediate cytohistologic study to determine adequacy for dx, first episode, each site, interpretation and report

88177Cytopathology, eval of fine needle aspirate; immediate cytohistologic study to determine adequacy for dx, each separate additional episode, same site




**88300 Level I Surgical Pathology, gross exam only**88302 Level II Surgical Pathology, gross and microscopic exam **88304 Level III Surgical Pathology, gross and microscopic exam **88305 Level IV - Surg Path, Gross and Micro Exam**88307 Level V Surgical Pathology, gross and microscopic exam **88309 Level VI Surgical Pathology, gross and microscopic exam **88311 Decalcification procedure**88312 Spec Stain; Grp I for Micro Interp and Report**88313 Spec Stain; Grp II for Micro Interp and Report

88314 Histochemical stain on frozen tissue block88329 Pathology consultation during surgery88331 First tissue block, with frozen section(s), single specimen88332 Each additional tissue block with frozen section(s)

**88341Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure

**88342 Immunohistochemistry; Ea Antibody**88346 Immunoflourescent Study; Direct Method

88348 Electron microscopy, diagnostic

**88367 Morphmetric analysis; in situ hybridization, quantitative, each probe; automated88720 Bilirubin, total, transcutaneous88738 Hemoglobin (Hgb), quantitative, trancutaneous89050 Cell count, misc. body fluids89051 Cell count, misc body fluids with differential count89230 Sweat collection by iontophoresis89300 Semen Analy; Presence/Motility Incl Huhner Test89310 Semen Analy; Motility and Count89320 Semen Analysis; Complete89321 Semen Analysis Presence And/Or Motility of Sperm89330 Sperm; Cerv Mucos Penetrat W/Wo SpinnbarkeitG0434 Drug Screen by CLIA waived test, per patient encounterQ0111 Wet mounts, including preparation of vaginal, cervical or skin specimens

* Excluded for Members age 11 and younger only** Excluded for Outpatient Surgical setting only



RFI ATTACHMENT F

BCT 2014 LABORATORY UTILIZATION DATA BY LINE OF BUSINESS

Independent Lab

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Outpatient Facility

Services

Practitioner Other

Services

BlueCare Total

Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Plus

Total Services

Independent Lab

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Outpatient Facility

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Practitioner Other

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Medicare

Advantage Total

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Independent Lab

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Medicare

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Total Services

36415 COLLECTION OF VENOUS BLOOD BY VENIP 67,455 158,761 162,965 389,181 619 1,182 1,886 3,687 38,042 56,877 123,718 218,637 88 140 435 663

78267 UREA BREATH TEST, C-14 (ISOTOPIC); 0 0 59 59 0 0 0 0 0 0 4 4 0 0 0 0

78268 UREA BREATH TEST, C-14; ANALYSIS 0 0 16 16 0 0 0 0 0 0 5 5 0 0 0 0

80047 BASIC METABOLIC PANEL (INCL: 82330, 3 3,588 167 3,758 0 48 4 52 1 1,178 240 1,419 0 1 0 1

80048 BASIC METABOLIC PANEL 14,171 53,925 6,037 74,133 250 508 101 859 10,676 25,368 10,651 46,695 24 33 59 116

80050 GENERAL HEALTH PANEL. (A) 80053+850 26,148 1,298 1,690 29,136 230 1 9 240 5,064 131 1,324 6,519 27 0 16 43

80051 ELECTROLYTE PANEL 476 905 1,708 3,089 1 19 9 29 201 783 271 1,255 0 0 0 0

80053 COMPREHENSIVE METABOLIC PANEL 92,636 105,741 7,341 205,718 1,169 954 338 2,461 49,963 39,042 44,334 133,339 143 90 203 436

80055 OB PANEL, MUST INCLUDE 85025 OR (85 10,135 264 235 10,634 1 0 0 1 1 0 2 3 0 0 0 0

80061 LIPID PANEL 62,994 8,198 9,009 80,201 901 212 287 1,400 40,827 15,939 33,518 90,284 144 15 192 351

80069 RENAL FUNCTION PANEL 1,343 900 206 2,449 31 18 28 77 1,893 1,047 1,184 4,124 3 3 6 12

80074 ACUTE HEPATITIS PANEL 7,159 867 190 8,216 31 6 1 38 619 248 69 936 2 1 1 4

80076 HEPATIC FUNCTION PANEL 7,017 6,661 849 14,527 30 71 29 130 2,032 3,178 3,218 8,428 2 1 16 19

80150 AMIKACIN 1 5 0 6 0 0 0 0 28 8 0 36 0 0 0 0

80155 (blank) 3 1 1 5 0 0 0 0 0 0 0 0 0 0 0 0

80156 CARBAMAZEPINE TOTAL 866 369 26 1,261 8 9 0 17 129 93 21 243 0 0 0 0

80157 CARBAMAZEPINE FREE 64 3 2 69 3 0 0 3 1 0 0 1 0 0 0 0

80158 CYCLOSPORINE 32 190 3 225 1 2 0 3 62 125 8 195 0 0 0 0

80159 (blank) 694 0 0 694 3 0 0 3 52 0 0 52 1 0 0 1

80162 DIGOXIN 271 234 31 536 6 9 1 16 490 506 127 1,123 0 0 0 0

80164 DIPROPYLACETIC ACID (VALPROIC ACID) 3,726 1,600 68 5,394 41 11 0 52 282 214 23 519 2 0 0 2

80168 ETHOSUXIMIDE 29 28 1 58 0 0 0 0 1 1 0 2 0 0 0 0

80169 (blank) 6 3 5 14 0 0 0 0 2 2 0 4 0 0 0 0

80170 GENTAMICIN 15 93 9 117 0 0 0 0 11 57 3 71 0 0 0 0

80171 (blank) 18,417 12 912 19,341 133 0 78 211 1,294 5 1,074 2,373 8 0 0 8

80173 HALOPERIDOL 677 0 0 677 3 0 0 3 36 0 0 36 1 0 0 1

80175 (blank) 457 217 17 691 4 1 0 5 67 27 2 96 0 0 0 0

80176 LIDOCAINE 0 1 29 30 0 1 0 1 0 2 10 12 0 0 0 0

80177 (blank) 946 706 12 1,664 9 9 0 18 120 71 6 197 0 0 0 0

80178 LITHIUM 1,291 368 60 1,719 12 3 0 15 202 119 12 333 4 0 0 4

80180 (blank) 4 30 0 34 0 0 0 0 0 7 0 7 0 0 0 0

80183 (blank) 94 175 13 282 1 0 0 1 5 8 2 15 0 0 0 0

80184 PHENOBARBITAL 27,430 260 748 28,438 223 1 68 292 3,102 37 1,728 4,867 10 0 0 10

80185 PHENYTOIN; TOTAL 1,470 1,444 64 2,978 31 9 0 40 269 177 58 504 1 0 0 1

80186 PHENYTOIN; FREE 45 17 0 62 0 0 0 0 7 14 1 22 0 0 0 0

80188 PRIMIDONE 3,593 8 102 3,703 14 0 0 14 134 2 5 141 0 0 0 0

80192 PROCAINAMIDE; WITH METABOLITES 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

80194 QUINIDINE 0 23 0 23 0 0 0 0 0 1 1 2 0 0 0 0

80195 SIROLIMUS 67 171 20 258 0 0 0 0 6 49 12 67 0 0 0 0

80197 TACROLIMUS 562 1,206 65 1,833 0 1 0 1 162 484 27 673 0 0 0 0

80198 THEOPHYLLINE 108 83 6 197 5 2 0 7 86 60 11 157 0 0 0 0

80199 (blank) 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

80200 TOBRAMYCIN 11 43 6 60 0 4 0 4 1 25 1 27 0 0 0 0

80201 TOPIRAMATE 318 193 3 514 3 1 0 4 14 8 1 23 0 0 0 0

80202 VANCOMYCIN 223 604 74 901 4 10 0 14 168 389 5 562 0 1 0 1

80203 (blank) 80 87 1 168 0 0 0 0 5 6 0 11 0 0 0 0

80299 QUANTITATION OF DRUG, NOT ELSEWHERE 27,074 393 2,314 29,781 241 0 148 389 3,317 230 5,942 9,489 1 0 9 10

80400 ACTH STIMULATION PANEL; FOR ADRENAL 7 15 0 22 0 0 0 0 0 6 8 14 0 0 0 0

80414 CHORIONIC GONADOTROPIN STIMULATION 20 0 1 21 0 0 0 0 0 0 0 0 0 0 0 0

80415 CHORIONIC GONADOTROPIN STIMULATION 7 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0

80422 GLUCAGON TOLERANCE PANEL; FOR INSUL 1 0 58 59 0 0 0 0 0 0 0 0 0 0 0 0

80424 GLUCAGON TOLERANCE PANEL; FOR PHEOC 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

80426 GONADOTROPIN RELEASING HORMONE STIM 0 0 1 1 0 0 0 0 0 0 1 1 0 0 0 0

80428 GROWTH HORMONE STIMULATION PANEL 7 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0

80435 INSULIN TOLERANCE PANEL; FOR GROWTH 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

80500 CLINICAL PATHOLOGY CONSULTATION; LI 18 1 865 884 0 0 15 15 0 0 159 159 0 0 13 13

80502 CLINICAL PATHOLOGY CONSULTATION; CO 0 0 33 33 0 0 0 0 0 0 11 11 0 0 0 0

81000 URINALYSIS BY DIP STICK OR TABLET; 63 4,308 14,497 18,868 0 39 58 97 301 741 5,898 6,940 0 0 17 17

81001 URINALYSIS BY DIP STICK OR TABLET; 9,468 82,785 11,855 104,108 80 358 90 528 4,795 11,840 12,951 29,586 17 32 42 91

81002 URINALYSIS BY DIP STICK OR TABLET; 614 4,906 90,577 96,097 28 17 433 478 31 373 15,620 16,024 0 4 41 45

81003 URINALYSIS BY DIP STICK OR TABLET; 27,380 42,096 81,755 151,231 233 136 601 970 5,937 5,468 23,502 34,907 18 18 133 169

81005 URINALYSIS QUALITATIVE OR SEMIQUANI 6,578 98 159 6,835 88 0 0 88 908 39 53 1,000 0 0 0 0

81007 URINALYSIS BACTERIURIA SCREEN EXCEP 0 0 29 29 0 0 0 0 0 0 1 1 0 0 0 0

BlueCare BlueCare Plus Medicare Advantage LPPO Medicare Advantage HMO

Procedure Code Description

Page Number 1

LEGEND:

Period: Claims Date of Service: 1/1/14 - 12/31/14 with 3 months run out

Reported by Units of Service

RFI ATTACHMENT F


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Practitioner Other

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Practitioner Other

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BlueCare Plus

Total Services

Independent Lab

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Services

Practitioner Other

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Medicare

Advantage Total

Services

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81015 URINALYSIS MICROSCOPIC ONLY 524 719 80 1,323 2 0 0 2 187 25 56 268 0 0 3 3

81020 URINALYSIS 2 OR 3 GLASS TEST 0 2 2 4 0 0 0 0 0 0 0 0 0 0 0 0

81025 URINE PREGNANCY TEST BY VISUAL COLO 962 45,038 69,071 115,071 2 76 101 179 5 209 217 431 0 0 1 1

81050 VOLUME MEASUREMENT FOR TIMED COLLEC 343 117 24 484 14 2 0 16 217 102 6 325 0 0 0 0

81099 UNLISTED URINALYSIS PROCEDURE (BR) 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0

81200 ASPA GENE ANALYSIS, COMMON VARIANTS 6 2 1 9 0 0 0 0 0 0 0 0 0 0 0 0

81201 (blank) 14 6 0 20 0 0 0 0 19 2 1 22 0 0 0 0

81202 (blank) 21 0 2 23 0 0 0 0 7 0 0 7 0 0 0 0

81203 (blank) 4 0 0 4 0 0 0 0 3 0 0 3 0 0 0 0

81205 BCKDHB GENE ANALYSIS, COMMON VARIAN 22 5 0 27 0 0 0 0 0 0 0 0 0 0 0 0

81206 BCR/ABL1 TRANSLOCATION ANALYSIS; MA 75 38 8 121 1 0 0 1 67 30 28 125 0 0 0 0

81207 BCR/ABL1 TRANSLOCATION ANALYSIS; MI 28 1 2 31 1 0 0 1 22 1 2 25 0 0 0 0

81208 BCR/ABL1 TRANSLOCATION ANALYSIS; OT 0 3 0 3 0 0 0 0 0 2 0 2 0 0 0 0

81209 BLM GENE ANALYSIS, 2281DEL6INS7 VAR 6 0 1 7 0 0 0 0 0 0 0 0 0 0 0 0

81210 BRAF, GENE ANALYSIS, V600E VARIANT 42 6 12 60 0 0 0 0 34 7 27 68 0 0 0 0

81211 VRCA1, BRCA2, GENE ANALYSIS; FULL S 290 1 1 292 0 0 0 0 69 0 4 73 0 0 0 0

81212 VRCA1, BRCA2, GENE ANALYSIS; 185DEL 1 0 1 2 0 0 0 0 1 0 0 1 0 0 0 0

81213 VRCA1, BRCA2, GENE ANALYSIS; UNCOMM 156 1 0 157 0 0 0 0 54 0 3 57 0 0 0 0

81215 BRCA1 GENE ANALYSIS; KNOWN FAMILIAL 6 0 0 6 0 0 0 0 1 0 0 1 0 0 0 0

81217 BRCA2 GENE ANALYSIS; KNOWN FAMILIAL 3 0 0 3 0 0 0 0 2 0 0 2 0 0 0 0

81220 CFTR GENE ANALYSIS; COMMON VARIANTS 2,147 291 544 2,982 0 1 0 1 1 0 0 1 0 0 0 0

81221 CFTR GENE ANALYSIS; KNOWN FAMILIAL 15 1 0 16 0 0 0 0 0 0 0 0 0 0 0 0

81222 CFTR GENE ANALYSIS; DUPLICATION/DEL 4 17 0 21 0 0 0 0 0 0 0 0 0 0 0 0

81223 CFTR GENE ANALYSIS; FULL GENE SEQUE 3 22 0 25 0 0 0 0 2 0 0 2 0 0 0 0

81224 CFTR GENE ANALYSIS; INTRON 8 POLY-T 0 17 0 17 0 0 0 0 0 0 0 0 0 0 0 0

81225 CYP2C19, GENE ANALYSIS, COMMON VARI 2,071 0 355 2,426 23 0 4 27 1,008 2 129 1,139 6 0 0 6

81226 CYP2D6, GENE ANALYSIS COMMON VARIAN 1,726 16 297 2,039 20 0 4 24 886 0 120 1,006 7 0 0 7

81227 CYP2C9, GENE ANALYSIS, COMMON VARIA 1,308 0 193 1,501 21 0 3 24 759 0 107 866 7 0 0 7

81228 CYTOGENOMIC CONSTITUTIONAL MICROARR 10 2 0 12 0 0 0 0 2 0 0 2 0 0 0 0

81229 CYTOGENOMIC CONSTITUTIONAL MICROARR 209 300 53 562 0 0 0 0 0 0 0 0 0 0 0 0

81235 (blank) 44 6 17 67 1 0 0 1 62 8 30 100 0 0 0 0

81240 F2 GENE ANALYSIS, 20210G>A VARIANT 1,152 153 124 1,429 15 3 3 21 927 29 69 1,025 5 0 0 5

81241 F5 GENE ANALYSIS, LEIDEN VARIANT 1,211 140 136 1,487 15 3 3 21 928 47 71 1,046 5 0 0 5

81242 FANCC GENE ANALYSIS, COMMON VARIANT 13 0 1 14 0 0 0 0 12 0 1 13 0 0 0 0

81243 FMR1 GENE ANALYSIS; EVALUATION TO D 254 152 8 414 0 0 0 0 0 0 0 0 0 0 0 0

81244 FMR1 GENE ANALYSIS; CHARACTERIZATIO 21 0 3 24 0 0 0 0 0 0 0 0 0 0 0 0

81245 FLT3, GENE ANALYSIS, INTERNAL TANDE 35 8 5 48 0 0 0 0 22 6 15 43 0 0 0 0

81250 G6PC GENE ANALYSIS, COMMON VARIANTS 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0

81251 GBA GENE ANALYSIS, COMMON VARIANTS 1 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0

81252 (blank) 14 1 2 17 0 0 0 0 0 0 0 0 0 0 0 0

81254 (blank) 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

81255 HESA GENE ANALYSIS, COMMON VARIANTS 0 0 2 2 0 0 0 0 0 0 0 0 0 0 0 0

81256 HFE GENE ANALYSIS, COMMON VARIANTS 70 9 14 93 2 0 0 2 35 11 8 54 0 0 0 0

81257 HBA1/HBA2, GENE ANALYSIS, FOR COMMO 3 5 1 9 0 0 0 0 0 2 0 2 0 0 0 0

81260 IKBKAP GENE ANALYSIS, COMMON VARIAN 1 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0

81261 IGH@ GENE REARRANGEMENT ANALYSIS TO 1 0 2 3 0 0 0 0 2 5 7 14 0 0 0 0

81263 IGH@, VARIABLE REGION SOMATIC MUTAT 0 0 0 0 0 0 0 0 5 1 3 9 0 0 0 0

81264 IGK@ GENE REARRANGEMENT ANALYSIS, E 1 0 0 1 0 0 0 0 0 0 3 3 0 0 0 0

81265 COMPARATIVE ANALYSIS USING SHORT TA 5 19 0 24 0 0 0 0 0 2 0 2 0 0 0 0

81266 COMPARATIVE ANALYSIS USING SHORT TA 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

81267 CHIMERISM ANALYSIS, POST TRANSPLANT 0 221 0 221 0 0 0 0 0 22 0 22 0 0 0 0

81268 CHIMERISM ANALYSIS, POST TRANSPLANT 0 60 0 60 0 0 0 0 0 20 0 20 0 0 0 0

81270 JAK2 GENE ANALYSIS, P.VAL617PHE VAR 102 16 10 128 0 0 0 0 60 25 32 117 0 0 0 0

81275 KRAS GENE ANALYSIS, VARIANTS IN COD 50 7 12 69 1 0 0 1 41 5 30 76 0 0 0 0

81280 LONG QT SYNDROME GENE ANALYSES; FUL 2 1 0 3 0 0 0 0 0 0 0 0 0 0 0 0

81281 LONG QT SYNDROME GENE ANALYSES; KNO 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0

81287 (blank) 0 0 0 0 0 0 0 0 2 0 0 2 0 0 0 0

81290 MCOLN1 GENE ANALYSIS, COMMON VARIAN 0 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0

81291 MTHFR GENE ANALYSIS, COMMON VARIANT 1,540 59 137 1,736 17 2 3 22 747 14 80 841 5 0 0 5

81292 MLH1 GENE ANALYSIS; FULL SEQUENCE A 21 6 0 27 0 0 0 0 24 2 1 27 0 0 0 0

81293 MLH1 GENE ANALYSIS; KNOWN FAMILIAL 0 0 0 0 0 0 0 0 2 0 0 2 0 0 0 0

81294 MLH1 GENE ANALYSIS; DUPLICATION/DEL 9 1 0 10 0 0 0 0 9 0 0 9 0 0 0 0

81295 MSH2 GENE ANALYSIS; FULL SEQUENCE A 20 1 0 21 0 0 0 0 19 0 1 20 0 0 0 0

Page Number 2

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RFI ATTACHMENT F


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Services

Practitioner Other

Services

BlueCare Total

Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Plus

Total Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

Medicare

Advantage Total

Services

Independent Lab

Services

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Services

Practitioner Other

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Medicare

Advantage HMO

Total Services



81297 MSH2 GENE ANALYSIS; DUPLICATION/DEL 8 1 0 9 0 0 0 0 6 0 0 6 0 0 0 0

81298 MSH6 GENE ANALYSIS; FULL SEQUENCE A 20 1 0 21 0 0 0 0 16 0 1 17 0 0 0 0

81300 MSH6 GENE ANALYSIS; DUPLICATION/DEL 8 1 0 9 0 0 0 0 4 0 0 4 0 0 0 0

81301 MICROSATELLITE INSTABILITY ANALYSIS 6 2 1 9 0 0 0 0 3 0 1 4 0 0 0 0

81302 MECP2 GENE ANALYSIS; FULL SEQUENCE 2 8 0 10 0 0 0 0 0 0 0 0 0 0 0 0

81304 MECP2 GENE ANALYSIS; DUPLICATION/DE 0 12 0 12 0 0 0 0 0 2 0 2 0 0 0 0

81310 NPM1 GENE ANALYSIS, EXON 12 VARIANT 18 3 7 28 0 0 0 0 17 5 21 43 0 0 0 0

81315 PML/RARALPHA, TRANSLOCATION ANALYSI 16 9 0 25 0 0 0 0 14 5 1 20 0 0 0 0

81317 PMS2 GENE ANALYSIS; FULL SEQUENCE A 8 1 0 9 0 0 0 0 6 0 0 6 0 0 0 0

81318 PMS2 GENE ANALYSIS; KNOWN FAMILIAL 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0

81319 PMS2 GENE ANALYSIS; DUPLICATION/DEL 8 1 0 9 0 0 0 0 4 0 0 4 0 0 0 0

81321 (blank) 19 7 2 28 0 0 0 0 18 2 6 26 0 0 0 0

81323 (blank) 6 1 0 7 0 0 0 0 3 0 0 3 0 0 0 0

81330 SMPD1 GENE ANALYSIS, COMMON VARIANT 0 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0

81331 SNRPN/UBE3A, METHYLATION ANALYSIS 16 6 0 22 0 0 0 0 0 0 0 0 0 0 0 0

81332 SERPINA-1, GENE ANALYSIS, COMMON VA 22 0 3 25 1 0 0 1 7 0 0 7 0 0 0 0

81340 TRB@, GENE REARRANGEMENT ANALYSIS T 0 0 3 3 0 0 0 0 0 0 7 7 0 0 0 0

81342 TRG@, GENE REARRANGEMENT ANALYSIS, 5 3 3 11 0 0 0 0 2 3 9 14 0 0 0 0

81350 UGT1A1, GENE ANALYSIS, COMMON VARIA 1,245 2 3 1,250 5 0 0 5 82 0 8 90 0 0 0 0

81355 VKORC1, GENE ANALYSIS, COMMON VARIA 1,617 0 191 1,808 17 0 3 20 589 0 95 684 1 0 0 1

81370 HLA CLASS I & II TYPING, LOW RESOLU 1 11 0 12 0 0 0 0 0 6 0 6 0 0 0 0

81371 HLA CLASS I & II TYPING, LOW RESOLU 0 20 0 20 0 0 0 0 0 3 0 3 0 0 0 0

81372 HLA CLASS I TYPING, LOW RESOLUTION; 12 18 0 30 0 0 0 0 0 6 0 6 0 0 0 0



81375 HLA CLASS II TYPING, LOW RESOLUTION 10 0 0 10 0 0 0 0 4 0 0 4 0 0 0 0



81378 HLA CLASS I & II TYPING, HIGH RESOL 0 5 0 5 0 0 0 0 0 2 0 2 0 0 0 0

81379 HLA CLASS I TYPING, HIGH RESOLUTION 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0



81382 HLA CLASS II TYPING, HIGH RESOLUTIO 222 101 1 324 0 0 0 0 0 10 0 10 0 0 0 0


81400 MOLECULAR PATHOLOGY PROCEDURE, LEVE 4,809 41 36 4,886 18 0 1 19 494 4 31 529 0 0 0 0

81401 MOLECULAR PATHOLOGY PROCEDURE, LEVE 12,272 32 499 12,803 45 0 6 51 2,192 9 305 2,506 19 0 0 19

81402 MOLECULAR PATHOLOGY PROCEDURE, LEVE 84 2 14 100 0 0 0 0 36 4 22 62 0 0 0 0




81406 MOLECULAR PATHOLOGY PROCEDURE LEVEL 14 30 13 57 0 0 0 0 4 0 19 23 0 0 0 0



81479 (blank) 12,045 288 168 12,501 95 0 1 96 1,735 59 272 2,066 1 0 0 1

81503 (blank) 3 0 1 4 0 0 0 0 5 3 1 9 0 0 0 0

81504 (blank) 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0

81507 (blank) 360 0 4 364 0 0 0 0 0 0 0 0 0 0 0 0

81511 (blank) 1 17 8 26 0 0 0 0 0 0 0 0 0 0 0 0

81599 (blank) 283 0 4 287 0 0 0 0 0 0 0 0 0 0 0 0

82009 ACETONE OR OTHER KETON BODIES, SERU 5 831 20 856 0 4 1 5 0 76 0 76 0 0 0 0

82010 ACETONE OR OTHER KETON BODIES, SERU 9 401 13 423 0 4 0 4 1 31 0 32 0 1 0 1

82013 ACETYLCHOLINESTERASE 17 1 2 20 0 0 0 0 0 0 0 0 0 0 0 0

82017 ACYLCARNITINES; QUANTITATIVE EACH S 13 84 1 98 0 0 0 0 0 0 0 0 0 0 0 0

82024 ADRENOCORTICOTROPIC HORMONE (ACTH) 340 121 7 468 6 0 0 6 97 43 16 156 0 0 0 0

82030 ADENOSINE 5-MONOPHOSPHATE CYCLIC 9 0 0 9 0 0 0 0 2 0 0 2 0 0 0 0

82040 ALBUMIN; SERUM, PLASMA OR WHOLE BLO 1,452 746 614 2,812 16 0 8 24 1,005 488 229 1,722 3 0 0 3

82042 ALBUMIN URINE OR OTHER SOURCE QUANT 71 252 26 349 0 0 1 1 2 323 95 420 0 0 0 0

82043 ALBUMIN URINE MICROALBUMIN QUANTITA 6,721 757 528 8,006 146 30 21 197 6,912 2,022 3,303 12,237 29 0 5 34

82044 ALBUMIN URINE MICROALBUMIN SEMIQUAN 59 82 2,402 2,543 0 3 77 80 56 138 3,114 3,308 0 0 16 16

82075 ALCOHOL (ETHANOL) BREATH 0 44 0 44 0 1 0 1 0 4 1 5 0 0 0 0

82085 ALDOLASE 264 52 0 316 4 2 0 6 203 54 17 274 5 0 0 5

82088 ALDOSTERONE 156 116 4 276 2 0 0 2 80 35 9 124 0 0 0 0

82103 ALPHA-1-ANTITRYPSIN; TOTAL 476 139 10 625 5 4 0 9 116 66 7 189 1 0 1 2

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RFI ATTACHMENT F


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Independent Lab

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82104 ALPHA-1-ANTITRYPSIN; PHENOTYPE 193 54 1 248 2 3 0 5 42 24 1 67 1 0 0 1

82105 ALPHA-FETOPROTEIN; SERUM 7,988 577 144 8,709 19 3 0 22 369 237 20 626 1 0 0 1

82106 ALPHA-FETOPROTEIN; AMNIOTIC FLUID 31 14 0 45 0 0 0 0 0 0 0 0 0 0 0 0

82107 ALPHA-FETOPROTEIN; AFP-L3 FRACTION 63 0 3 66 0 0 0 0 7 1 0 8 0 0 0 0

82108 ALUMINUM 93 34 33 160 0 0 0 0 41 117 2 160 0 0 0 0

82120 AMINES VAGINAL FLUID QUALITATIVE 0 3 39 42 0 0 0 0 0 0 10 10 0 0 0 0

82127 AMINO ACIDS; SINGLE QUALITATIVE, EA 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

82128 AMINO ACIDS; MULTIPLE QUALITATIVE, 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

82131 AMINO ACIDS; SINGLE QUANTITATIVE, E 12 60 1 73 0 0 0 0 28 0 1 29 0 0 0 0

82135 AMINOLEVULINIC ACID DELTA (ALA) 1 1 0 2 0 0 0 0 0 1 0 1 0 0 0 0

82136 AMINO ACIDS 2 TO 5 AMINO ACIDS, QUA 5 0 0 5 0 0 0 0 10 0 4 14 0 0 0 0

82139 AMINO ACIDS, 6 OR MORE AMINO ACIDS, 57 262 0 319 0 0 0 0 4 3 2 9 0 0 0 0

82140 AMMONIA 706 1,578 44 2,328 7 10 0 17 389 521 20 930 0 0 0 0

82143 AMNIOTIC FLUID SCAN (SPECTROPHOTOME 20 0 1 21 0 0 0 0 0 0 0 0 0 0 0 0

82150 AMYLASE 3,375 18,865 953 23,193 29 76 11 116 1,030 2,109 457 3,596 4 13 3 20

82157 ANDROSTENEDIONE 136 99 1 236 0 0 0 0 4 0 6 10 0 0 0 0

82160 ANDROSTERONE 0 0 0 0 0 0 0 0 2 0 2 4 0 0 0 0

82163 ANGIOTENSIN II 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

82164 ANGIOTENSIN I CONVERTING ENZYME (AC 418 67 3 488 1 0 0 1 103 64 2 169 2 0 0 2

82172 APOLIPOPROTEIN DENY INV/N10 2,012 5 0 2,017 31 0 0 31 1,640 7 70 1,717 1 0 0 1

82175 ARSENIC 77 8 2 87 0 1 0 1 36 37 1 74 0 0 0 0

82180 ASCORBIC ACID (VITAMIN C) BLOOD 87 3 1 91 3 0 0 3 63 2 8 73 0 0 0 0

82190 ATOMIC ABSORPTION SPECTROSCOPY, EAC 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

82232 BETA-2 MICROGLOBULIN 85 40 3 128 0 0 0 0 380 88 68 536 1 0 0 1

82239 BILE ACIDS; TOTAL 162 28 1 191 0 0 0 0 3 0 1 4 0 0 0 0

82247 BILIRUBIN; TOTAL 2,528 3,606 3,015 9,149 11 3 9 23 557 323 250 1,130 2 0 0 2

82248 BILIRUBIN; DIRECT 5,965 4,826 936 11,727 58 7 1 66 2,429 378 680 3,487 1 0 1 2

82261 BIOTINIDASE EACH SPECIMEN 1 40 72 113 0 0 0 0 0 0 0 0 0 0 0 0

82270 BLOOD OCCULT PEROXIDASE ACTIVITY, Q 12 530 2,268 2,810 1 7 53 61 21 259 2,611 2,891 0 0 12 12

82271 BLOOD OCCULT PEROXIDASE ACTIVITY, Q 0 56 7 63 0 0 0 0 0 9 7 16 0 0 0 0

82272 BLOOD OCCULT PEROXIDASE ACTIVITY, Q 182 1,560 1,927 3,669 1 8 12 21 77 361 647 1,085 0 0 1 1

82274 BLOOD, OCCULT, FECAL HGB BY IMMUNOA 247 39 526 812 3 2 48 53 504 186 4,658 5,348 0 0 31 31

82300 CADMIUM 14 0 0 14 0 0 0 0 10 3 3 16 0 0 0 0

82306 CALCIFEDIOL (25-OH VITAMIN D-3) 22,020 4,352 875 27,247 280 72 31 383 14,613 5,398 4,923 24,934 59 3 37 99

82308 CALCITONIN 51 59 0 110 1 0 0 1 21 27 5 53 0 0 0 0

82310 CALCIUM; TOTAL 2,465 917 635 4,017 14 2 8 24 973 912 400 2,285 2 0 0 2

82330 CALCIUM; IONIZED 284 1,158 134 1,576 3 2 0 5 602 316 41 959 1 0 4 5

82340 CALCUIM; URINE QUANTITATIVE TIMED S 575 412 6 993 1 1 0 2 143 49 13 205 0 0 0 0

82355 CALCULUS; QUALITATIVE ANALYSIS 1 8 0 9 0 0 0 0 0 16 0 16 0 0 0 0

82360 CALCULUS; QUANTITATIVE ANALYSIS, CH 25 47 17 89 0 0 0 0 16 34 1 51 0 0 0 0

82365 CALCULUS; INFRARED SPECTROSCOPY 33 73 4 110 0 1 1 2 52 79 12 143 0 0 0 0

82370 CALCULUS; X-RAY DIFFRACTION 38 0 0 38 0 0 0 0 1 4 0 5 0 0 0 0

82373 CARBOHYDRATE DEFICIENT TRANSFERRIN 18 19 0 37 0 0 0 0 8 1 0 9 0 0 0 0

82374 CARBON DIOXIDE (BICARBONATE) 174 279 592 1,045 0 0 7 7 35 128 102 265 0 0 0 0

82375 CARBON MONOXIDE (CARBOXYHEMOGLOBIN) 23 139 11 173 1 0 0 1 6 70 20 96 0 0 5 5

82378 CARCINOEMBRYONIC ANTIGEN (CEA) - DE 1,115 240 61 1,416 11 3 5 19 452 495 538 1,485 8 0 1 9

82379 CARNITINE (TOTAL & FREE) QUANTITATI 33 109 1 143 0 0 0 0 8 9 3 20 0 0 0 0

82380 CAROTENE 4 1 0 5 0 0 0 0 1 0 0 1 0 0 0 0

82382 CATECHOLAMINES TOTAL URINE 0 4 1 5 0 0 0 0 0 3 0 3 0 0 0 0

82383 CATECHOLAMINES BLOOD 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0

82384 CATECHOLAMINES FRACTIONATED 99 25 0 124 3 0 0 3 40 37 1 78 0 0 0 0

82390 CERULOPLASMIN 414 132 3 549 5 2 0 7 84 42 4 130 1 0 0 1

82397 CHEMILUMINESCENT ASSAY 629 222 9 860 3 0 0 3 12 49 6 67 0 0 0 0

82435 CHLORIDE; BLOOD 497 241 489 1,227 5 1 7 13 188 130 107 425 2 0 0 2

82436 CHLORIDES; URINE 94 32 6 132 0 0 0 0 92 6 4 102 0 0 0 0

82438 CHLORIDES; OTHER SOURCE 0 270 0 270 0 0 0 0 0 2 0 2 0 0 0 0

82465 CHOLESTEROL, SERUM OR WHOLE BLOOD, 8,960 594 2,514 12,068 10 4 6 20 200 258 271 729 4 0 7 11

82480 CHOLESTERINASE; SERUM 3 0 0 3 0 0 0 0 0 1 0 1 0 0 0 0

82482 CHOLINESTERASE; RBC 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0

82486 CHROMATOGRAPHY QUALITATIVE; COLUMN 2 4 426 432 0 0 2 2 2 1 114 117 0 0 0 0

82487 CHROMATOGRAPHY QUALITATIVE; PAPER 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

82489 CHROMATOGRAPHY QUALITATIVE; THIN LA 0 2 0 2 0 0 0 0 0 2 0 2 0 0 0 0

82491 CHROMATOGRAPHY QUANTITATIVE COLUMN; 2,068 554 28 2,650 2 1 3 6 96 24 24 144 0 0 0 0

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82492 CHROMATOGRAPHY QUANTITATIVE COLUMN; 176 11 702 889 1 0 38 39 35 5 2,143 2,183 0 0 0 0

82495 CHROMIUM 58 10 87 155 0 0 0 0 35 32 4 71 0 0 0 0

82507 CITRATE 111 8 1 120 0 0 0 0 102 4 3 109 0 0 0 0

82523 COLLAGEN CROSS LINKS ANY METHOD DEN 29 102 1 132 0 0 0 0 27 50 14 91 6 0 0 6

82525 COPPER 202 86 0 288 4 4 1 9 83 61 6 150 0 0 0 0

82528 CORTICOSTERONE 5 0 0 5 0 0 0 0 1 0 0 1 0 0 0 0

82530 CORTISOL; FREE 102 6 3 111 1 0 0 1 34 15 49 98 0 0 0 0

82533 CORTISOL; TOTAL 1,576 593 330 2,499 13 3 7 23 305 289 176 770 2 0 0 2

82540 CREATINE 24 1 105 130 0 0 2 2 7 0 421 428 0 0 0 0

82541 COLUMN CHROMATOGRAPHY MASS SPECTROM 4,857 31 1 4,889 46 0 0 46 1,488 17 21 1,526 0 0 0 0

82542 COLUMN CHROMATOGRAPHY MASS SPECTROM 169,827 699 13,299 183,825 1,634 4 719 2,357 32,799 73 13,549 46,421 94 0 8 102

82543 COLUMN CHROMATOGRAPHY MASS SPECTROM 14,658 1 1,866 16,525 60 0 28 88 2,701 0 600 3,301 0 0 0 0

82544 COLUMN CHROMATOGRAPHY MASS SPECTROM 3,791 19 1,499 5,309 64 0 12 76 2,856 0 283 3,139 1 0 0 1

82550 CREATINE KINASE (CK) (CPK); TOTAL 3,089 6,665 733 10,487 55 81 24 160 4,959 4,965 2,424 12,348 23 13 22 58

82552 CREATINE KINASE (CK), (CPK); ISOENZ 69 25 8 102 1 0 0 1 23 13 19 55 0 0 0 0

82553 CREATINE KINASE (CK) (CPK); MB FRAC 93 5,249 251 5,593 4 77 5 86 98 4,307 210 4,615 0 19 0 19

82565 CREATININE; BLOOD 1,933 4,642 3,227 9,802 17 65 24 106 1,521 5,071 2,329 8,921 5 11 6 22

82570 CREATININE; OTHER SOURCE 69,263 2,700 23,266 95,229 525 31 573 1,129 13,601 1,933 17,194 32,728 46 0 53 99

82575 CREATININE; CLEARANCE 471 310 56 837 3 10 1 14 138 126 35 299 6 0 0 6

82585 CRYOFIBRINOGEN 0 1 0 1 0 0 0 0 1 0 0 1 0 0 0 0

82595 CRYOGLOBULIN QUALITATIVE OR SEMI-QU 56 3 2 61 0 0 0 0 13 10 1 24 0 0 0 0

82607 CYANOCOBALAMIN (VITAMIN B-12) 14,664 1,562 847 17,073 192 60 55 307 8,711 3,943 4,301 16,955 15 1 10 26

82608 CYANOCOBALAMIN (VITAMIN B-12) UNSAT 15 5 2 22 0 0 0 0 3 2 2 7 0 0 0 0

82610 CYSTATIN C 960 347 0 1,307 12 0 0 12 496 3 24 523 0 0 0 0

82615 CYSTINE & HOMOCYSTINE URINE QUALITA 52 1 0 53 0 0 0 0 54 0 0 54 0 0 0 0

82626 DEHYDROEPIANDROSTERONE (DHEA) 248 53 283 584 3 0 7 10 101 18 76 195 0 0 0 0

82627 DEHYDROEPIANDROSTERONE SULFATE (DHE 1,080 155 23 1,258 8 0 1 9 685 65 83 833 0 0 0 0

82633 DESOXYCORTICOSTERONE 11 2 10 0 12 0 0 0 0 0 0 0 0 0 0 0 0

82634 DEOXYCORTISOL 11 4 12 0 16 0 0 0 0 2 1 2 5 0 0 0 0

82638 DIBUCAINE NUMBER 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0

82652 DIHYDROXYVITAMIN D 1, 25- 1,922 241 10 2,173 17 0 0 17 523 115 28 666 1 0 0 1

82656 ELASTASE, PANCREATIC (EL-1) FECAL,Q 170 188 4 362 1 0 0 1 10 4 1 15 0 0 0 0

82657 ENZYME ACTIVITY BLOOD CELLS, CULTUR 32 1,067 48 1,147 0 0 0 0 8 3 2 13 0 0 0 0

82658 ENZYME ACTIVITY IN BLOOD CELLS CULT 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0

82664 ELECTROPHORETIC TECHNIQUE, NOT ELSE 383 12 0 395 3 1 0 4 161 0 3 164 0 0 0 0

82668 ERYTHROPOIETIN 175 73 2 250 5 3 0 8 367 102 14 483 0 0 0 0

82670 ESTRADIOL 2,991 437 53 3,481 16 0 4 20 977 217 268 1,462 1 0 0 1

82671 ESTROGENS; FRACTIONATED 86 3 0 89 3 0 0 3 21 15 12 48 0 0 0 0

82672 ESTROGENS; TOTAL 341 14 5 360 2 1 0 3 137 8 8 153 0 0 0 0

82677 ESTRIOL 6,145 136 87 6,368 1 0 0 1 14 5 4 23 0 0 0 0

82679 ESTRONE 87 30 0 117 0 0 0 0 54 5 28 87 0 0 0 0

82693 ETHYLENE GLYCOL 1 5 44 50 0 0 1 1 3 1 15 19 0 0 0 0

82696 ETIOCHOLANOLONE 0 0 0 0 0 0 0 0 2 0 2 4 0 0 0 0

82705 FAT OR LIPIDS, FECES; QUALITATIVE 288 161 1 450 4 2 0 6 30 43 8 81 0 0 0 0

82710 FAT OR LIPIDS, FECES; QUANTITATIVE 8 2 2 12 0 0 0 0 6 6 0 12 0 0 0 0

82715 FAT DIFFERENTIAL, FECES, QUANTITATI 1 0 0 1 0 0 0 0 6 0 0 6 0 0 0 0

82725 FATTY ACIDS, NONESTERIFIED 760 24 0 784 8 0 0 8 314 0 7 321 0 0 0 0

82726 VERY LONG CHAIN FATTY ACIDS 46 23 0 69 0 0 0 0 35 0 3 38 0 0 0 0

82728 FERRITIN 10,178 3,036 613 13,827 119 43 46 208 4,647 2,876 3,307 10,830 16 0 5 21

82731 FETAL FIBRONECTIN, CERVICOVAGINAL S 260 1,033 28 1,321 0 0 0 0 2 4 0 6 0 0 0 0

82735 FLUORIDE 0 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0

82746 FOLIC ACID; SERUM 8,077 978 248 9,303 120 29 27 176 4,286 1,484 1,733 7,503 4 0 7 11

82747 FOLIC ACID; RBC 419 67 9 495 5 5 2 12 177 213 17 407 0 0 0 0

82759 GALACTOKINASE RBC 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

82760 GALACTOSE 0 40 75 115 0 0 0 0 0 0 0 0 0 0 0 0

82775 GALACTOSE 1-PHOSPHATE URIDYL TRANSF 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0

82776 GALACTOSE 1-PHOSPHATE URIDYL TRANSF 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0

82777 (blank) 797 0 0 797 9 0 0 9 318 0 4 322 0 0 0 0

82784 GAMMAGLOBULIN IGA, IGD, IGG, IGM, E 7,116 2,433 119 9,668 40 31 1 72 2,340 1,530 963 4,833 0 0 0 0

82785 GAMMAGLOBULIN IGE 2,782 386 39 3,207 4 6 0 10 206 90 20 316 1 0 0 1

82787 GAMMAGLOBULIN IMMUNOGLOBULIN SUBCLA 492 170 8 670 1 0 0 1 112 23 4 139 0 0 0 0

82800 GASES, BLOOD, PH ONLY 0 220 8 228 0 0 0 0 0 26 1 27 0 2 0 2

82803 GASES BLOOD ANY COMBINATION PH, PCO 0 3,660 140 3,800 0 40 3 43 0 1,208 77 1,285 0 0 4 4

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82805 GASES BLOOD; W O2 SATURATION BY DIR 0 525 44 569 0 6 0 6 0 158 10 168 0 0 2 2

82810 BLOOD GASES O2 SATURATION ONLY BY D 0 497 5 502 0 11 0 11 0 196 7 203 0 0 0 0

82820 HEMOGLOBIN OXYGEN AFFINITY 0 1 0 1 0 0 0 0 0 2 0 2 0 0 0 0

82930 GASTRIC ACID ANALYSIS, INCLUDES PH 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

82941 GASTRIN 29 11 1 41 1 0 0 1 27 18 1 46 0 0 0 0

82943 GLUCAGON 2 0 0 2 0 0 0 0 1 0 0 1 0 0 0 0

82945 GLUCOSE BODY FLUID, OTHER THAN BLOO 43 602 57 702 0 4 0 4 13 194 7 214 0 0 0 0

82946 GLUCAGON TOLERANCE TEST 0 0 134 134 0 0 0 0 0 0 12 12 0 0 0 0

82947 GLUCOSE; QUANTITATIVE, BLOOD 5,671 3,171 10,223 19,065 22 23 195 240 1,192 1,401 2,832 5,425 6 2 46 54

82948 GLUCOSE; BLOOD REAGENT STRIP 0 5,949 6,101 12,050 0 65 46 111 0 1,696 1,344 3,040 0 13 14 27

82950 GLUCOSE; POST GLUCOSE DOSE 7,388 1,224 1,682 10,294 3 0 1 4 33 5 34 72 0 0 0 0

82951 GLUCOSE; TOLERANCE TEST (GTT), 3 SP 2,144 903 664 3,711 2 1 2 5 22 31 40 93 0 0 0 0

82952 GLUCOSE; TOLERANCE TEST, EACH ADDIT 1,950 354 189 2,493 3 1 1 5 16 26 31 73 0 0 0 0

82955 GLUCOSE 6-PHOSPHATE DEHYDROGENASE ( 30 24 0 54 1 0 0 1 32 7 5 44 0 0 0 0

82960 GLUCOSE 6-PHOSPHATE DEHYDROGENASE ( 0 3 0 3 0 0 0 0 0 8 1 9 0 0 0 0

82962 GLUCOSE, BLOOD BY GLUCOSE MONITORIN 402 17,735 20,283 38,420 9 166 273 448 21 6,848 5,681 12,550 0 56 126 182

82977 GLUTAMYLTRANSFERASE GAMMA (GGT) 2,041 1,457 244 3,742 24 2 0 26 642 180 532 1,354 1 0 6 7

82978 GLUTATHIONE 13 2 0 15 0 0 0 0 14 0 3 17 0 0 0 0

82985 GLYCATED PROTEIN 568 9 0 577 12 0 0 12 272 36 13 321 0 0 0 0

83001 GONADOTROPIN; FOLLICLE STIMULATING 4,201 592 72 4,865 19 1 1 21 524 141 150 815 1 0 0 1

83002 GONADOTROPIN; LUTEINIZING HORMONE ( 3,536 541 59 4,136 13 0 0 13 386 79 122 587 1 0 0 1

83003 GROWTH HORMONE, HUMAN (HGH) (SOMATO 175 219 7 401 0 0 0 0 15 4 2 21 0 0 0 0

83009 HELICOBACTER PYLORI : BLOOD TEST AN 0 0 13 13 0 0 0 0 0 0 4 4 0 0 0 0

83010 HAPTOGLOBIN; QUANTITATIVE 300 107 8 415 2 0 0 2 285 82 6 373 0 0 0 0

83013 HELICOBACTER PYLORI; BREATH TEST AN 270 4 63 337 7 0 2 9 104 14 106 224 1 0 0 1

83014 HELICOBACTER PYLORI; DRUG ADMINISTR 10 1 160 171 0 0 5 5 14 1 121 136 0 0 0 0

83015 HEAVY METAL SCREEN (ARSENIC, BARIUM 0 4 0 4 0 0 0 0 3 6 0 9 0 0 0 0

83018 HEAVY METAL; QUANTITATIVE, EACH 14 0 0 14 0 0 0 0 25 14 0 39 0 0 0 0

83020 HEMOGLOBIN FRACTIONATION & QUANTITA 700 765 314 1,779 1 2 3 6 9 3 9 21 1 0 0 1

83021 HEMOGLOBIN FRACTIONATION & QUANTITA 2,454 1,986 21 4,461 2 1 0 3 24 13 1 38 3 0 0 3

83026 HEMOGLOBIN; BY COPPER SULFATE METHO 0 0 4 4 0 0 0 0 0 0 7 7 0 0 0 0

83030 HEMOGLOBIN F (FETAL) CHEMICAL 0 5 0 5 0 0 0 0 0 0 0 0 0 0 0 0

83033 HEMOGLOBIN F (FETAL) QUALITATIVE 1 2 1 4 0 0 0 0 0 0 0 0 0 0 0 0

83036 HEMOGLOBIN GLYCOSYLATED (A1C) 39,613 6,276 5,875 51,764 589 139 243 971 23,800 9,827 21,886 55,513 68 6 121 195

83037 HEMOGLOBIN; GLYCOSYLATED (A1C) BY D 0 0 3,189 3,189 0 0 22 22 0 0 519 519 0 0 28 28

83050 HEMOGLOBIN METHEMOGLOBIN QUANTITATI 0 76 8 84 0 0 0 0 0 36 1 37 0 0 0 0

83051 HEMOGLOBIN PLASMA 0 68 0 68 0 0 0 0 1 34 0 35 0 0 0 0

83060 HEMOGLOBIN SULFHEMOGLOBIN QUANTITAT 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

83068 HEMOGLOBIN UNSTABLE SCREEN 0 7 0 7 0 0 0 0 0 0 0 0 0 0 0 0

83070 HEMOSIDERIN QUALITATIVE 1 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0

83080 B-HEXOSAMINIDASE, EACH ASSAY 1 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0

83088 HISTAMINE 1 8 0 9 0 0 0 0 2 0 1 3 0 0 0 0

83090 HOMOCYSTINE 1,760 221 8 1,989 26 3 0 29 1,093 116 71 1,280 5 2 0 7

83150 HOMOVANILLIC ACID (HVA) 21 73 0 94 0 0 0 0 5 1 1 7 0 0 0 0

83491 HYDROXYCORTICOSTEROIDS 17- (17-OHCS 0 1 0 1 0 0 0 0 6 1 8 15 0 0 0 0

83497 HYDROXYINDOLACETIC ACID 5-(HIAA) 25 2 4 31 0 0 0 0 31 21 2 54 0 0 0 0

83498 HYDROXYPROGESTERONE 17-D 650 202 86 938 1 0 0 1 7 0 1 8 1 0 0 1

83500 HYDROXYPROLINE; FREE 0 0 1 1 0 0 0 0 1 0 0 1 0 0 0 0

83505 HYDROXYPROLINE; TOTAL 4 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0

83516 IMMUNOASSAY FOR ANALYTE OTHER THAN 7,821 2,966 590 11,377 23 21 16 60 1,138 538 464 2,140 6 0 0 6

83518 IMMUNOASSAY FOR ANALYTE OTHER THAN 0 2 255 257 0 0 2 2 0 0 142 142 0 0 0 0

83519 IMMUNOASSAY ANALYTE QUANTITATIVE BY 516 388 4 908 34 0 0 34 2,803 392 22 3,217 5 0 0 5

83520 IMMUNOASSAY ANALYTE QUANTITATIVE, N 5,152 2,545 98 7,795 66 9 0 75 1,384 336 103 1,823 9 0 0 9

83525 INSULIN; TOTAL 5,891 954 345 7,190 34 0 7 41 1,209 71 171 1,451 2 0 0 2

83527 INSULIN; FREE 36 4 0 40 0 0 0 0 9 0 0 9 0 0 0 0

83540 IRON 10,181 2,262 552 12,995 145 42 22 209 7,433 3,355 2,418 13,206 10 0 7 17

83550 IRON BINDING CAPACITY 8,489 1,266 495 10,250 107 24 26 157 4,498 1,932 2,108 8,538 9 0 6 15

83570 ISOCITRIC DEHYDROGENASE (IDH) 1 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0

83586 KETOSTEROIDS 17-(17-KS); TOTAL 0 1 0 1 0 0 0 0 0 1 2 3 0 0 0 0

83593 KETOSTEROIDS 17-(17-KS); FRACTIONAT 0 0 0 0 0 0 0 0 8 0 8 16 0 0 0 0

83605 LACTATE (LACTIC ACID) 46 4,916 155 5,117 1 53 3 57 22 1,368 46 1,436 0 2 2 4

83615 LACTATE DEHYDROGENASE (LD) (LDH) 3,483 6,525 708 10,716 34 26 19 79 1,000 1,672 2,198 4,870 3 0 0 3

83625 LACTATE DEHYDROGENASE (LD) (LDH); I 53 2 0 55 0 0 0 0 6 0 1 7 0 0 0 0

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Practitioner Other

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Practitioner Other

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83630 LACTOFERRIN, FECAL, QUALITATIVE 404 220 9 633 1 5 0 6 63 77 6 146 0 0 0 0

83631 LACTOFERRIN, FECAL, QUANTITATIVE (R 11 5 2 18 0 0 0 0 2 1 0 3 0 0 0 0

83655 LEAD 14,378 2,030 14,654 31,062 0 1 0 1 48 44 2 94 0 0 0 0

83661 FETAL LUNG MATURITY ASSESSMENT; LEC 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

83663 FETAL LUNG MATURITY ASSESSMENT; FLU 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

83664 FETAL LUNG MATURITY ASSESSMENT; LAM 1 7 0 8 0 0 0 0 0 1 0 1 0 0 0 0

83670 LEUCINE AMINOPEPTIDASE (LAP) 3 0 0 3 0 0 0 0 1 0 0 1 0 0 0 0

83690 LIPASE 3,646 33,612 849 38,107 28 170 15 213 1,093 4,334 401 5,828 4 16 3 23

83695 LIPOPROTEIN DENY INV/N10 883 6 0 889 15 0 0 15 1,013 2 13 1,028 2 0 0 2

83698 LIPOPROTEIN-ASSOCIATED PHOSPHOLIIPA 1,114 0 0 1,114 21 0 0 21 1,037 1 16 1,054 2 0 0 2

83700 LIPOPROTEIN, BLOOD; ELECTROPHORETIC 801 1 7 809 8 0 0 8 373 0 9 382 0 0 0 0

83701 LIPOPROTEIN, BLD; HIGH RESOL'N FRAC 399 2 0 401 23 0 0 23 1,000 29 12 1,041 1 0 0 1

83704 LIPOPROTEIN BLOOD QUANTIT-LIPOPR PR 1,170 0 1 1,171 21 0 0 21 954 2 47 1,003 1 0 0 1

83718 LIPOPROTEIN DIRECT MEASUREMENT; HIG 130 73 46 249 2 0 4 6 69 68 124 261 0 0 0 0

83719 LIPOPROTEIN DIRECT MEASUREMENT VLDL 2 0 0 2 0 0 0 0 26 0 10 36 0 0 0 0

83721 LIPOPROTEIN DIRECT MEASUREMENT LDL 841 112 78 1,031 20 4 87 111 885 534 4,346 5,765 0 0 45 45

83727 LUTEINIZING RELEASING FACTOR (LRH) 2 0 0 2 0 0 0 0 2 0 0 2 0 0 0 0

83735 MAGNESIUM 6,598 21,870 2,249 30,717 105 230 17 352 4,138 8,097 3,525 15,760 17 32 18 67

83785 MANGANESE 8 13 1 22 0 0 0 0 12 10 2 24 0 0 0 0

83788 MASS SPECTROMETRY & TANDEM MASS SPE 2,697 58 179 2,934 31 0 13 44 300 1 71 372 0 0 0 0

83789 MASS SPECTROMETRY & TANDEM MASS SPE 70,297 47 13,953 84,297 514 0 552 1,066 7,483 5 11,112 18,600 13 0 16 29

83825 MERCURY QUANTITATIVE 79 9 2 90 0 1 0 1 38 41 1 80 0 0 0 0

83835 METANEPHRINES 116 64 3 183 4 0 0 4 62 49 5 116 0 0 0 0

83861 MICROFLUIDIC ANALYSIS UTILIZING AN 0 0 395 395 0 0 10 10 0 0 877 877 0 0 0 0

83864 MUCOPOLYSACCHARIDES ACID QUANTITATI 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0

83872 MUCIN SYNOVIAL FLUID (ROPES TEST) 4 0 1 5 0 0 0 0 0 3 1 4 0 0 0 0

83873 MYELIN BASIC PROTEIN CSF 36 24 0 60 0 0 0 0 2 14 0 16 0 0 0 0

83874 MYOGLOBIN 117 2,451 116 2,684 4 13 0 17 59 1,091 118 1,268 0 1 0 1

83876 MYELOPEROXIDASE (MPO) 800 16 0 816 14 1 0 15 580 14 9 603 1 0 0 1

83880 NATRIURETIC PEPTIDE 2,151 7,912 570 10,633 47 154 12 213 2,716 5,571 883 9,170 3 11 1 15

83883 NEPHELOMETRY EA ANALYTE NOT ELSEWHE 590 159 4 753 13 6 0 19 1,149 618 69 1,836 0 0 0 0

83885 NICKEL 1 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0

83915 NUCLEOTIDASE 5- 17 11 0 28 0 0 0 0 6 4 0 10 0 0 0 0

83916 OLIGOCLONAL IMMUNE 37 38 0 75 0 0 0 0 2 15 0 17 0 0 0 0

83918 ORGANIC ACIDS; TOTAL QUANTITATIVE E 8 84 0 92 0 0 0 0 2 1 1 4 0 0 0 0

83919 ORGANIC ACIDS; QUALITATIVE EA SPECI 22 19 1 42 0 0 0 0 0 0 0 0 0 0 0 0

83921 ORGANIC ACID SINGLE QUANTITATIVE 324 50 0 374 33 2 0 35 2,554 122 96 2,772 5 0 0 5

83930 OSMOLALITY; BLOOD 101 361 24 486 1 1 0 2 59 62 9 130 0 0 1 1

83935 OSMOLALITY; URINE 116 123 14 253 1 2 0 3 56 74 5 135 0 0 0 0

83937 OSTEOCALCIN 11 10 0 21 0 0 0 0 1 9 0 10 0 0 0 0

83945 OXALATE 110 8 0 118 0 0 0 0 100 4 2 106 0 0 0 0

83970 PARATHORMONE 2,686 1,061 288 4,035 37 25 11 73 2,656 1,911 961 5,528 6 1 1 8

83986 PH, BODY FLUID, EXCEPT BLOOD 58,557 234 7,459 66,250 382 0 274 656 6,971 25 6,292 13,288 24 0 10 34

83992 PHENCYCLIDINE (PCP) 36,179 6 7,215 43,400 270 0 267 537 4,765 0 5,664 10,429 6 0 8 14

83993 CALPROTECTIN, FECAL - DENY INV/N10 511 507 0 1,018 1 0 0 1 9 11 1 21 0 0 0 0

84030 PHENYLALANINE (PKU) BLOOD 3 83 112 198 0 0 0 0 0 0 0 0 0 0 0 0

84035 PHENYLKETONES QUALITATIVE 0 0 1,671 1,671 0 0 0 0 0 0 4 4 0 0 0 0

84060 PHOSPHATASE ACID; TOTAL 0 1 0 1 0 0 0 0 1 0 0 1 0 0 0 0

84066 PHOSPHATASE ACID; PROSTATIC 0 0 0 0 0 0 0 0 3 0 1 4 0 0 0 0

84075 PHOSPHATASE ALKALINE 1,380 1,048 574 3,002 18 7 9 34 1,163 507 383 2,053 3 0 5 8

84078 PHOSPHATASE ALKALINE; HEAT STABLE 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0

84080 PHOSPHATASE ALKALINE; ISOENZYMES 152 30 4 186 2 1 0 3 67 144 6 217 0 0 0 0

84081 PHOSPHATIDYLGLYCEROL 28 13 1 42 0 0 0 0 0 0 0 0 0 0 0 0

84087 PHOSPHOHEXOSE ISOMERASE 0 4 57 61 0 0 0 0 1 0 0 1 0 0 0 0

84100 PHOSPHORUS INORGANIC (PHOSPHATE) 2,968 11,351 8,393 22,712 39 57 7 103 1,925 2,578 1,105 5,608 14 8 2 24

84105 PHOSPHORUS INORGANIC (PHOSPHATE); U 105 24 0 129 0 0 0 0 93 5 1 99 0 0 0 0

84110 PORPHOBILINOGEN, URINE; QUANTITATIV 5 9 0 14 0 0 0 0 2 1 1 4 0 0 0 0

84112 PLACENTAL ALPHA MICROGLOBULIN-1 (PA 15 286 5 306 0 0 0 0 0 0 0 0 0 0 0 0

84119 PORPHYRINS, URINE; QUALITATIVE 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

84120 PORPHYRINS URINE; QUANTITATION & FR 9 13 0 22 0 0 0 0 11 2 0 13 0 0 0 0

84126 PORPHYRINS FECES; QUANTITATIVE 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0

84132 POTASSIUM; SERUM, PLASMA OR WHOLE B 871 2,481 918 4,270 13 18 3 34 615 1,163 575 2,353 10 0 4 14

84133 POTASSIUM; URINE 120 45 8 173 0 0 0 0 101 12 5 118 0 0 0 0

Page Number 7

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RFI ATTACHMENT F


Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Total

Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Plus

Total Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

Medicare

Advantage Total

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Independent Lab

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Practitioner Other

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Medicare

Advantage HMO

Total Services



84134 PREALBUMIN 492 414 35 941 6 9 1 16 322 404 9 735 1 0 1 2

84135 PREGNANEDIOL 0 0 0 0 0 0 0 0 1 0 3 4 0 0 0 0

84138 PREGNANETRIOL 0 0 0 0 0 0 0 0 1 0 2 3 0 0 0 0

84140 PREGNENOLONE 99 1 0 100 3 0 0 3 49 2 8 59 0 0 0 0

84143 17-HYDROXYPREGNENOLONE 11 14 0 25 0 0 0 0 0 0 0 0 0 0 0 0

84144 PROGESTERONE 2,825 964 370 4,159 14 0 8 22 442 105 155 702 0 0 0 0

84145 PROCALCITONIN (PCT) 4 181 31 216 0 5 0 5 3 101 3 107 0 0 0 0

84146 PROLACTIN 3,786 666 88 4,540 9 0 0 9 242 105 94 441 1 0 0 1

84150 PROSTAGLANDIN, EACH 0 0 1,692 1,692 0 0 300 300 0 0 32 32 0 0 0 0

84152 PROSTATE SPECIFIC ANTIGEN (PSA); CO 3 1 2,432 2,436 0 0 0 0 5 15 797 817 0 0 0 0

84153 PROSTATE SPECIFIC ANTIGEN (PSA); TO 3,648 179 2,484 6,311 70 8 70 148 6,143 2,456 6,364 14,963 41 2 15 58

84154 PROSTATE SPECIFIC ANTIGEN (PSA); FR 164 17 3,695 3,876 9 0 0 9 413 290 1,466 2,169 9 0 4 13

84155 PROTEIN, TOTAL, EXCEPT BY REFRACTOM 1,605 853 1,656 4,114 23 3 8 34 1,392 466 225 2,083 9 0 0 9

84156 PROTEIN, TOTAL, EXCEPT BY REFRACTOM 3,057 1,654 111 4,822 42 23 22 87 1,594 905 1,026 3,525 13 0 3 16

84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOM 69 770 734 1,573 0 3 0 3 5 187 51 243 0 0 0 0

84160 PROTEIN; REFRACTOMETRIC 1 1 13,691 13,693 0 0 0 0 0 20 0 20 0 0 0 0

84163 PREGNANCY-ASSOCIATED PLASMA PROTEIN 1,422 0 12 1,434 0 0 0 0 0 0 0 0 0 0 0 0

84165 PROTEIN; ELECTROPHORETIC FRACTIONAT 812 165 220 1,197 17 6 4 27 1,332 741 560 2,633 7 3 1 11

84166 ELECTROPHORETIC FRACTIONATION & QUA 146 45 40 231 3 3 1 7 333 174 162 669 2 0 0 2

84181 PROTEIN; WESTERN BLOT W INTERPRETAT 11 1 247 259 0 0 0 0 8 6 2 16 0 0 0 0

84182 PROTEIN; WESTERN BLOT, W I&R, BLOOD 4 15 0 19 0 0 0 0 1 20 0 21 0 0 0 0

84202 PROTOPORPHYRIN, RBC; QUANTITATIVE 99 37 2 138 0 0 0 0 2 2 0 4 0 0 0 0

84206 PROINSULIN 438 2 0 440 6 0 0 6 49 1 2 52 0 0 0 0

84207 PYRIDOXAL PHOSPHATE (VITAMIN B-6) 185 23 0 208 0 2 0 2 180 144 8 332 0 0 0 0

84210 PYRUVATE 8 21 0 29 0 0 0 0 5 1 1 7 0 0 0 0

84220 PYRUVATE KINASE 0 5 1 6 0 0 0 0 0 0 0 0 0 0 0 0

84234 RECEPTOR ASSAY; PROGESTERONE 0 0 2 2 0 0 0 0 0 0 0 0 0 0 0 0

84235 RECEPTOR ASSAY; ENDOCRINE, OTHER TH 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

84238 RECEPTOR ASSAY; NON-ENDOCRINE (SPEC 81 46 0 127 0 0 0 0 28 9 0 37 0 0 0 0

84244 RENIN 149 155 3 307 2 0 0 2 67 36 4 107 0 0 0 0

84252 RIBOFLAVIN (VITAMIN B-2) 11 12 0 23 0 0 0 0 45 44 3 92 0 0 0 0

84255 SELENIUM 21 36 1 58 0 0 0 0 19 8 4 31 0 0 0 0

84260 SEROTONIN 34 3 1 38 0 2 0 2 46 5 4 55 0 0 0 0

84270 SEX HORMONE BINDING GLOBULIN (SHBG) 1,071 58 8 1,137 19 0 1 20 689 96 104 889 4 0 0 4

84275 SIALIC ACID 1 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0

84295 SODIUM; SERUM, PLASMA OR WHOLE BLOO 571 1,145 895 2,611 8 3 7 18 264 252 190 706 7 0 0 7

84300 SODIUM; URINE 208 234 20 462 0 3 1 4 177 118 15 310 0 0 0 0

84302 SODIUM; OTHER SOURCE 21 1 0 22 0 0 0 0 0 1 0 1 0 0 0 0

84305 SOMATOMEDIN 483 710 7 1,200 1 0 0 1 65 22 11 98 0 0 0 0

84307 SOMATOSTATIN 4 0 0 4 0 0 0 0 0 1 0 1 0 0 0 0

84311 SPECTROPHOTOMETRY, ANALYTE NOT ELSE 59,097 25 5,297 64,419 381 0 165 546 8,982 7 4,765 13,754 23 0 8 31

84315 SPECIFIC GRAVITY (EXCEPT URINE) 85 2 136 223 0 0 3 3 16 1 115 132 0 0 0 0

84375 SUGARS, CHROMATOGRAPHIC TLC OR PAPE 0 12 0 12 0 0 0 0 0 0 0 0 0 0 0 0

84376 SUGARS; SINGLE QUALITATIVE EACH SPE 80 166 4 250 0 0 0 0 1 0 0 1 0 0 0 0

84377 SUGARS; MULTIPLE QUALITATIVE EACH S 10 25 0 35 0 0 0 0 1 1 0 2 0 0 0 0

84378 SUGARS; SINGLE QUANTITATIVE EACH SP 672 15 0 687 17 0 0 17 376 6 15 397 0 0 0 0

84392 SULFATE, URINE 93 5 0 98 0 0 0 0 93 2 1 96 0 0 0 0

84402 TESTOSTERONE; FREE 1,829 142 37 2,008 13 0 0 13 702 315 172 1,189 3 0 0 3

84403 TESTOSTERONE; TOTAL 4,844 424 444 5,712 50 0 12 62 3,326 934 1,407 5,667 19 0 7 26

84425 THIAMINE (VITAMIN B-1) 217 47 2 266 3 1 0 4 207 162 14 383 0 0 0 0

84431 THROMBOXANE METABOLITE(S), INCLUDIN 0 0 0 0 0 0 0 0 17 0 1 18 0 0 0 0

84432 THYROGLOBULIN 248 49 7 304 2 1 0 3 133 92 49 274 0 0 1 1

84436 THYROXINE; TOTAL 9,101 546 460 10,107 68 9 7 84 3,349 671 1,160 5,180 7 1 11 19

84437 THYROXINE; REQUIRING ELUTION 0 27 0 27 0 0 0 0 0 0 0 0 0 0 0 0

84439 THYROXINE; FREE 21,138 7,214 1,414 29,766 219 55 54 328 10,567 4,100 7,342 22,009 12 4 13 29

84442 THYROXINE; BINDING GLOBULIN (TBG) 16 6 0 22 0 0 0 0 11 3 15 29 0 0 0 0

84443 THYROID STIMULATING HORMONE (TSH) 49,523 13,233 2,579 65,335 533 214 154 901 26,350 14,483 19,666 60,499 80 10 91 181

84445 THYROID STIMULATING IMMUNE GLOBULIN 238 76 6 320 1 0 0 1 77 13 6 96 1 0 0 1

84446 TOCOPHEROL ALPHA (VITAMIN E) 107 165 1 273 2 0 0 2 61 36 3 100 0 0 0 0

84449 TRANSCORTIN 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

84450 TRANSFERASE; ASPARTATE AMINO (AST) 3,182 2,277 777 6,236 26 12 12 50 2,142 1,151 981 4,274 3 0 7 10

84460 TRANSFERASE; ALANINE AMINO (ALT) (S 2,903 2,333 713 5,949 19 12 13 44 1,704 1,058 1,685 4,447 2 0 7 9

84466 TRANSFERRIN 474 705 42 1,221 6 9 0 15 261 804 179 1,244 3 0 0 3

Page Number 8

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RFI ATTACHMENT F


Independent Lab

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Outpatient Facility

Services

Practitioner Other

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BlueCare Total

Services

Independent Lab

Services

Outpatient Facility

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Practitioner Other

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BlueCare Plus

Total Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

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Medicare

Advantage Total

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Independent Lab

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Practitioner Other

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Advantage HMO

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84478 TRIGLYCERIDES 3,686 725 115 4,526 13 0 5 18 317 105 145 567 0 0 0 0

84479 THYROID HORMONE (T3 OR T4) UPTAKE O 5,343 204 215 5,762 39 4 1 44 1,747 228 482 2,457 1 0 9 10

84480 TRIIODOTHYRONINE T3; TOTAL (TT-3) 3,786 363 101 4,250 15 5 1 21 1,158 271 402 1,831 5 1 8 14

84481 TRIIDOTHYRONINE (T-3) FREE 5,442 678 159 6,279 45 4 16 65 2,005 646 1,378 4,029 3 0 1 4

84482 TRIIDOTHYRONINE (T-3) REVERSE 162 24 274 460 1 0 8 9 129 13 85 227 1 0 0 1

84484 TROPONIN, QUANTITATIVE 651 36,134 832 37,617 10 527 22 559 210 17,223 568 18,001 0 82 2 84

84490 TRYPSIN; FECES QUANTITATIVE 24-HOUR 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

84510 TYROSINE 1 0 9 10 0 0 0 0 0 0 0 0 0 0 0 0

84520 UREA NITROGEN; QUANTITATIVE 1,578 3,396 2,545 7,519 14 20 17 51 1,120 2,643 560 4,323 3 0 0 3

84525 UREA NITROGEN; SEMIQUANTITATIVE 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

84540 UREA NITROGEN, URINE 89 20 27 136 0 0 0 0 99 80 3 182 0 0 0 0

84545 UREA NITROGEN, CLEARANCE 13 2 0 15 0 0 0 0 5 0 0 5 0 0 0 0

84550 URIC ACID; BLOOD 7,405 5,246 393 13,044 97 37 20 154 4,537 1,820 2,461 8,818 24 0 20 44

84560 URIC ACID; OTHER SOURCE 120 12 1 133 0 0 0 0 113 13 4 130 0 0 0 0

84585 VANILLYMANDELIC ACID (VMA), URINE 55 78 2 135 0 0 0 0 19 11 1 31 0 0 0 0

84586 VASOACTIVE INTESTINAL PEPTIDE (VIP) 3 0 0 3 0 0 0 0 3 5 0 8 0 0 0 0

84588 VASOPRESSIN (ANTIDIURETIC HORMONE A 16 11 0 27 1 0 0 1 5 0 0 5 0 0 0 0

84590 VITAMIN A 175 198 1 374 2 2 0 4 72 95 3 170 0 0 0 0

84591 VITAMIN, NOT OTHERWISE SPECIFIED 33 6 0 39 0 0 0 0 20 2 1 23 0 0 0 0

84597 VITAMIN K 32 19 5 56 0 0 0 0 18 13 4 35 0 0 0 0

84600 VOLATILES 96 334 0 430 0 2 0 2 5 151 0 156 0 0 0 0

84630 ZINC 195 140 0 335 2 4 0 6 78 74 6 158 0 0 0 0

84681 C-PEPTIDE 2,034 262 21 2,317 30 0 0 30 858 100 106 1,064 3 0 1 4

84702 GONADOTROPIN CHORIONIC (HCG); QUANT 13,095 11,550 751 25,396 11 11 1 23 23 44 5 72 0 0 0 0

84703 GONADOTROPIN CHORIONIC (HCG); QUALI 1,047 19,709 2,272 23,028 0 38 1 39 8 141 3 152 0 0 0 0

84704 GONADOTROPIN, CHORIONIC (HCG); FREE 1,470 0 8 1,478 0 0 0 0 0 0 0 0 0 0 0 0

84999 UNLISTED CHEMISTRY PROCEDURE (BR) 162 19 3 184 1,508 0 0 1,508 107 30 8 145 0 0 0 0

85002 BLEEDING TIME 0 5 2 7 0 2 0 2 2 6 3 11 0 0 0 0

85004 BLOOD COUNT; AUTOMATED DIFFERENTIAL 89 59 344 492 1 0 3 4 42 66 24 132 2 0 0 2

85007 BLOOD SMEAR; MICROSCOPIC EXAM W MAN 274 3,912 174 4,360 3 25 0 28 94 700 75 869 0 0 0 0

85008 BLOOD SMEAR; MICROSCOPIC EXAM WO MA 23 70 56 149 0 1 0 1 10 28 4 42 0 0 0 0

85009 BLOOD COUNT; MANUAL DIFFERENTIAL WB 0 10 26 36 0 0 0 0 0 1 5 6 0 0 0 0

85013 BLOOD COUNT; SPUN MICROHEMATOCRIT 0 0 5,963 5,963 0 0 0 0 0 1 48 49 0 0 0 0

85014 BLOOD COUNT; HEMATOCRIT (HCT) 2,781 4,444 8,378 15,603 13 20 8 41 725 2,312 541 3,578 11 1 0 12

85018 BLOOD COUNT, HEMOGLOBIN (HGB) 3,941 6,549 27,709 38,199 13 12 27 52 655 2,211 1,140 4,006 6 1 1 8

85025 BLOOD COUNT COMPLETE, AUTOMATED & A 63,295 159,005 114,823 337,123 824 1,211 691 2,726 35,472 38,421 52,952 126,845 73 101 193 367

85027 BLOOD COUNT; COMPLETE, AUTOMATED 13,553 33,106 2,588 49,247 127 284 55 466 4,194 18,890 6,682 29,766 11 17 58 86

85041 BLOOD COUNT; RED BLOOD CELL (RBC), 389 67 3 459 2 0 0 2 194 119 6 319 5 0 0 5

85044 BLOOD COUNT; RETICULOCYTE, MANUAL 4 177 13 194 0 3 0 3 7 33 36 76 0 0 0 0

85045 BLOOD COUNT; RETICULOCYTE AUTOMATED 2,087 6,037 210 8,334 20 3 1 24 829 539 100 1,468 3 0 0 3

85046 BLOOD COUNT; RETICULOCYTES AUTOMATE 120 25 28 173 8 0 3 11 157 17 105 279 0 0 0 0

85048 BLOOD COUNT; LEUKOCYTE (WBC), AUTOM 185 97 66 348 1 0 0 1 191 197 17 405 2 0 0 2

85049 BLOOD COUNT; PLATELET, AUTOMATED 87 513 29 629 0 1 0 1 25 555 10 590 0 0 0 0

85055 RETICULATED PLATELET ASSAY 0 0 7 7 0 0 0 0 0 3 0 3 0 0 0 0

85060 BLOOD SMEAR PERIPHERAL INTERPRETATI 355 45 1,296 1,696 7 0 10 17 98 1 469 568 0 0 1 1

85097 BONE MARROW, SMEAR INTERPRETATION 34 106 318 458 0 1 3 4 9 47 302 358 0 0 0 0

85130 CHROMOGENIC SUBSTRATE ASSAY 94 0 0 94 0 0 0 0 8 1 0 9 0 0 0 0

85175 CLOT LYSIS TIME, WHOLE BLOOD DILUTI 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0

85210 CLOTTING; FACTOR II PROTHROMBIN, SP 19 0 1 20 0 0 0 0 1 2 0 3 0 0 0 0

85220 CLOTTING; FACTOR V, LABILE FACTOR 41 15 0 56 2 0 0 2 9 6 0 15 0 0 0 0

85230 CLOTTING; FACTOR VII, PROCONVERTIN 11 21 0 32 0 0 0 0 1 2 1 4 0 0 0 0

85240 CLOTTING; FACTOR VIII (AHG), 1 STAG 136 217 0 353 1 5 0 6 43 17 3 63 0 0 0 0

85244 CLOTTING; FACTOR VIII RELATED ANTIG 3 8 0 11 0 2 0 2 0 1 0 1 0 0 0 0

85245 CLOTTING; FACTOR VIII, VW FACTOR RI 100 128 0 228 0 5 0 5 18 3 1 22 0 0 0 0

85246 CLOTTING; FACTOR VIII, VW FACTOR AN 133 117 0 250 2 0 0 2 19 4 1 24 0 0 0 0

85247 CLOTTING; FACTOR VIII, VON WILLEBRA 46 40 0 86 0 0 0 0 15 1 1 17 0 0 0 0

85250 CLOTTING; FACTOR IX (PTC OR CHRISTM 19 35 0 54 0 0 0 0 2 2 0 4 0 0 0 0

85260 CLOTTING; FACTOR X (STUART-PROWER) 8 2 0 10 0 0 0 0 3 2 0 5 0 0 0 0

85270 CLOTTING; FACTOR XI (PTA) 6 14 1 21 0 0 0 0 0 0 0 0 0 0 0 0

85280 CLOTTING; FACTOR XII (HAGEMAN) 26 6 0 32 1 0 0 1 0 1 0 1 0 0 0 0

85290 CLOTTING; FACTOR XIII (FIBRIN STABI 5 7 0 12 0 2 0 2 1 0 0 1 0 0 0 0

85291 CLOTTING; FACTOR XIII (FIBRIN STABI 2 8 0 10 0 0 0 0 0 0 0 0 0 0 0 0

85300 CLOTTING INHIBITORS OR ANTICOAGULAN 180 225 3 408 0 3 0 3 47 40 6 93 0 0 0 0

Page Number 9

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RFI ATTACHMENT F


Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Total

Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Plus

Total Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

Medicare

Advantage Total

Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

Medicare

Advantage HMO

Total Services








85307 ACTIVATED PROTEIN C (APC) RESISTANC 37 60 5 102 0 0 0 0 27 11 1 39 0 0 0 0

85335 FACTOR INHIBITOR TEST 4 33 0 37 0 0 0 0 0 4 0 4 0 0 0 0

85347 COAGULATION TIME; ACTIVATED 0 584 151 735 0 8 0 8 0 785 7 792 0 0 0 0

85360 EUGLOBULIN LYSIS 1 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0

85362 FIBRIN DEGRADATION PRODUCTS; AGGLUT 11 17 0 28 0 0 0 0 10 0 0 10 0 0 0 0

85370 FIBRIN DEGRADATION PRODUCTS; QUANTI 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

85378 FIBRIN DEGRADATION PRODUCTS, D-DIME 0 386 16 402 0 6 1 7 4 324 3 331 0 0 0 0

85379 FIBRIN DEGRADATION PRODUCTS, D-DIME 415 6,772 183 7,370 5 58 7 70 241 1,535 171 1,947 1 15 0 16

85380 FIBRIN DEGRADATION PRODUCTS, D-DIME 0 8 0 8 0 1 0 1 0 21 0 21 0 0 0 0

85384 FIBRINOGEN; ACTIVITY 566 646 44 1,256 3 2 0 5 206 72 18 296 0 0 0 0

85385 FIBRINOGEN; ANTIGEN 764 19 0 783 8 0 0 8 334 0 2 336 0 0 0 0

85390 FIBRINOLYSINS OR COAGULOPATHY SCREE 0 4 170 174 0 0 3 3 0 2 50 52 0 0 0 0

85396 COAGULATION/FIBRINOLYSIS ASSAY, WHO 0 107 0 107 0 0 0 0 0 0 0 0 0 0 0 0

85397 COAGULATION AND FIBRINOLYSIS, FUNCT 4 5 0 9 0 0 0 0 0 0 0 0 0 0 0 0

85410 FIBRINOLYTIC FACTORS & INHIBITORS; 3 3 0 6 0 0 0 0 0 0 0 0 0 0 0 0




85441 HEINZ BODIES; DIRECT 2 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0

85460 HEMOGLOBIN OR RBCS FETAL FOR FETOMA 8 84 1 93 0 0 0 0 0 0 0 0 0 0 0 0

85461 HEMOGLOBIN OR RBCS FETAL FOR FETOMA 0 44 6 50 0 0 0 0 0 1 0 1 0 0 0 0

85520 HEPARIN ASSAY 73 137 28 238 0 0 0 0 0 42 27 69 2 0 0 2

85525 HEPARIN NEUTRALIZATION 0 3 0 3 0 0 0 0 1 0 0 1 0 0 0 0

85540 LEUKOCYTE ALKALINE PHOSPHATASE WITH 11 2 0 13 0 0 0 0 7 4 1 12 0 0 0 0

85549 MURAMIDASE 6 5 2 13 0 0 0 0 2 3 1 6 0 0 0 0

85555 OSMOTIC FRAGILITY RBC; UNINCUBATED 1 2 0 3 0 0 0 0 0 0 0 0 0 0 0 0

85557 OSMOTIC FRAGILITY RBC; INCUBATED 1 3 0 4 0 0 0 0 0 0 0 0 0 0 0 0

85576 PLATELET, AGGREGATION (IN VITRO), E 45 541 71 657 0 11 0 11 99 287 41 427 0 0 0 0

85597 PHOSPHOLIPID NEUTRALIZATION; PLATEL 64 112 3 179 0 2 0 2 15 16 0 31 0 0 0 0

85598 PHOSPHOLIPID NEUTRALIZATION; HEXAGO 105 9 0 114 0 0 0 0 26 1 0 27 0 0 0 0

85610 PROTHROMBIN TIME 7,093 25,718 9,979 42,790 99 360 356 815 8,724 23,582 32,914 65,220 15 35 75 125

85611 PROTHROMBIN TIME; SUBSTITUTION PLAS 5 28 0 33 0 0 0 0 8 1 2 11 0 0 0 0

85612 RUSSELL VIPER VENOM TIME; UNDILUTED 0 3 2 5 0 0 0 0 0 0 0 0 0 0 0 0

85613 RUSSELL VIPER VENOM TIME; DILUTED 678 261 38 977 1 3 0 4 123 41 12 176 0 0 0 0

85635 REPTILASE TEST 3 5 1 9 0 0 0 0 0 0 0 0 0 0 0 0

85651 SEDIMENTATION RATE ERYTHROCYTE; NON 72 1,832 580 2,484 0 6 15 21 68 1,534 2,069 3,671 0 0 4 4

85652 SEDIMENTATION RATE ERYTHROCYTE; AUT 8,769 5,660 2,223 16,652 88 48 30 166 4,258 1,810 1,598 7,666 27 0 0 27

85660 SICKLING OF RBC REDUCTION 2,610 546 18 3,174 4 2 0 6 9 9 1 19 0 0 0 0

85670 THROMBIN TIME; PLASMA 127 98 1 226 0 0 0 0 33 27 0 60 0 0 0 0

85705 THROMBOPLASTIN INHIBITION; TISSUE 68 23 4 95 0 0 0 0 12 8 0 20 0 0 0 0

85730 THROMBOPLASTIN TIME PARTIAL (PTT); 2,276 16,766 946 19,988 26 165 23 214 571 7,687 404 8,662 1 15 0 16

85732 THROMBOPLASTIN TIME PARTIAL; SUBSTI 145 250 20 415 0 2 0 2 56 18 7 81 0 0 0 0

85810 VISCOSITY 7 23 2 32 0 1 2 3 41 9 1 51 0 0 0 0

85999 UNLISTED HEMATOLOGY & COAGULATION P 9 0 0 9 0 0 0 0 8 2 1 11 0 0 0 0

86000 AGGLUTININS, FEBRILE EACH ANTIGEN 0 7 0 7 0 0 0 0 14 0 0 14 0 0 0 0

86001 ALLERGEN SPECIFIC IGG QUANTITATIVE 287 16 0 303 0 0 0 0 406 16 1,248 1,670 0 0 0 0

86003 ALLERGEN SPEC IGE QUANTI/SEMI-QUANT 47,681 13,304 583 61,568 83 26 0 109 4,223 640 1,509 6,372 26 0 0 26

86005 ALLERG SPEC IGE QUALITATIVE, MULTIA 93 4 3 100 0 0 0 0 12 0 1 13 0 0 0 0

86021 ANTIBODY IDENTIFICATION; LEUKOCYTE 923 93 1 1,017 2 0 0 2 60 27 8 95 0 0 0 0

86022 ANTIBODY IDENTIFICATION; PLATELET A 68 22 3 93 7 0 0 7 62 23 1 86 0 0 0 0

86023 ANTIBODY IDENTIFICATION; PLATELET A 1 1 0 2 0 0 0 0 8 2 0 10 0 0 0 0

86038 ANTINUCLEAR ANTIBODIES (ANA) 7,416 1,051 97 8,564 57 18 10 85 1,933 809 158 2,900 25 0 0 25

86039 ANTINUCLEAR ANTIBODIES (ANA); TITER 1,828 80 10 1,918 11 1 1 13 258 123 13 394 1 0 0 1

86060 ANTISTREPTOLYSIN O; TITER 631 160 10 801 2 0 0 2 94 11 13 118 0 0 0 0

86063 ANTISTREPTOLYSIN O; SCREEN 50 20 3 73 0 0 0 0 1 2 1 4 0 0 0 0

86077 BLOOD BANK PHYSICIAN SERVICE; DIFFI 0 0 101 101 0 0 0 0 0 1 34 35 0 0 0 0

86078 BLOOD BANK PHYSICIAN SERVICES INVES 0 0 51 51 0 0 0 0 0 3 12 15 0 0 0 0

86079 BLOOD BANK DR. SERVICES AUTHORIZE D 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0

Page Number 10

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RFI ATTACHMENT F


Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Total

Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Plus

Total Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

Medicare

Advantage Total

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Independent Lab

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Practitioner Other

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Medicare

Advantage HMO

Total Services



86140 C-REACTIVE PROTEIN 7,262 6,866 303 14,431 64 25 27 116 2,888 2,044 1,536 6,468 18 0 0 18

86141 C-REACTIVE PROTEIN; HIGH SENSITIVIT 2,140 912 39 3,091 29 2 0 31 1,364 206 45 1,615 3 0 1 4

86146 BETA 2 GLYCOPROTEIN I ANTIBODY, EAC 1,176 385 11 1,572 2 6 0 8 170 70 7 247 0 0 0 0

86147 CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY 2,136 532 26 2,694 7 4 0 11 344 169 12 525 0 0 0 0

86148 ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIP 264 27 6 297 0 0 0 0 75 9 2 86 0 0 0 0

86152 (blank) 88 0 2 90 0 0 0 0 5 0 36 41 0 0 0 0

86153 (blank) 88 0 0 88 0 0 0 0 5 0 0 5 0 0 0 0

86156 COLD AGGLUTININ; SCREEN 0 1 264 265 0 0 0 0 0 2 8 10 0 0 0 0

86157 COLD AGGLUTININ; TITER 5 3 0 8 0 0 0 0 11 1 0 12 0 0 0 0

86160 COMPLEMENT; ANTIGEN EACH COMPONENT 2,345 599 32 2,976 13 9 8 30 655 312 197 1,164 2 0 0 2

86161 COMPLEMENT; FUNCTIONAL ACTIVITY, EA 32 11 0 43 0 0 0 0 5 6 1 12 0 0 0 0

86162 COMPLEMENT; TOTAL HEMOLYTIC (CH50) 134 48 0 182 3 0 0 3 48 17 1 66 0 0 0 0

86171 COMPLEMENT FIXATION TESTS, EACH ANT 6 193 0 199 0 0 0 0 0 0 0 0 0 0 0 0

86200 CYCLIC CITRULLINATED PEPTIDE, ANTIB 1,300 57 9 1,366 8 3 7 18 438 181 42 661 5 0 0 5

86215 DEOXYRIBONUCLEASE, ANTIBODY 87 18 1 106 1 0 0 1 2 2 0 4 0 0 0 0

86225 DEOXYRIBONUCLEIC ACID (DNA) ANTIBOD 1,363 239 16 1,618 13 2 2 17 511 115 44 670 4 0 0 4

86226 DEOXYRIBONUCLEIC ACID (DNA) ANTIBOD 11 8 0 19 1 0 2 3 5 8 0 13 0 0 0 0

86235 EXTRACTABLE NUCLEAR ANTIGEN ANTIBOD 6,846 588 79 7,513 48 2 22 72 2,442 630 175 3,247 26 0 0 26

86255 FLUORESCENT NONINFECTIOUS AGENT ANT 2,619 504 61 3,184 11 7 1 19 351 262 17 630 4 0 0 4

86256 FLUORESCENT NONINFECTIOUS AGENT ANT 283 1,332 10 1,625 3 3 0 6 218 316 41 575 1 0 0 1

86277 HUMAN GROWTH HORMONE (HGH), ANTIBOD 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

86280 HEMAGGLUTINATION INHIBITION TEST (H 0 3 0 3 0 0 0 0 0 0 0 0 0 0 0 0

86294 IMMUNOASSAY FOR TUMOR ANTIGEN QUANT 1 0 3 4 0 0 0 0 0 0 3 3 0 0 1 1

86300 IMMUNOASSAY FOR TUMOR ANTIGEN - DEN 1,224 233 55 1,512 2 1 2 5 332 212 387 931 8 0 2 10



86305 HUMAN EPIDIDYMIS PROTEIN 4 (HE4) DE 13 14 0 27 0 0 0 0 1 10 2 13 0 0 0 0

86308 HETEROPHILE ANTIBODIES; SCREENING 684 2,520 3,648 6,852 1 0 3 4 25 50 85 160 0 0 0 0

86309 HETEROPHILE ANTIBODIES; TITER 4 0 0 4 0 0 0 0 0 3 1 4 0 0 0 0

86316 IMMUNOASSAY FOR TUMOR ANTIGEN; OTHE 42 25 1 68 0 0 0 0 56 43 3 102 0 0 0 0

86317 IMMUNOASSAY FOR INFECTIOUS AGENT AN 3,455 1,351 86 4,892 4 2 0 6 381 293 14 688 0 0 0 0

86318 IMMUNOASSAY INFECTIOUS AGENT ANTIBO 0 96 728 824 0 0 2 2 0 19 86 105 0 0 0 0

86320 IMMUNOELECTROPHORESIS; SERUM 0 15 9 24 0 0 0 0 1 12 35 48 0 0 0 0

86325 IMMUNOELECTROPHORESIS; OTHER FLUIDS 0 14 2 16 0 0 0 0 1 11 3 15 0 0 0 0

86329 IMMUNODIFFUSION; NOT ELSEWHERE SPEC 7 0 0 7 0 0 0 0 2 0 0 2 0 0 0 0

86331 IMMUNODIFFUSION GEL DIFFUSION QUALI 10 51 0 61 0 1 0 1 16 7 0 23 0 0 0 0

86332 IMMUNE COMPLEX ASSAY 804 1 26 831 8 0 0 8 410 1 6 417 0 0 0 0

86334 IMMUNOFIXATION ELECTROPHORESIS; SER 586 81 57 724 13 6 1 20 948 370 171 1,489 2 0 0 2

86335 IMMUNOFIXATION ELECTROPHORESIS; OTH 152 29 18 199 3 5 1 9 308 99 52 459 1 0 0 1

86336 INHIBIN A 6,049 44 70 6,163 1 0 0 1 0 3 0 3 0 0 0 0

86337 INSULIN ANTIBODIES 96 95 0 191 1 0 0 1 5 4 4 13 0 0 0 0

86340 INTRINSIC FACTOR ANTIBODIES 20 3 0 23 1 0 0 1 28 12 1 41 0 0 0 0

86341 ISLET CELL ANTIBODY 738 234 2 974 7 0 0 7 88 12 14 114 2 0 0 2

86343 LEUKOCYTE HISTAMINE RELEASE TEST (L 41 6 0 47 0 0 0 0 6 8 0 14 0 0 0 0

86352 CELLULAR FUNCTION ASSAY INVOLVING S 12 18 0 30 0 0 0 0 0 3 0 3 0 0 0 0

86353 LYMPHOCYTE TRANSFORM MITOGEN OR ANT 33 49 0 82 0 0 0 0 8 7 3 18 0 0 0 0

86355 B CELLS, TOTAL COUNT 208 144 8 360 4 0 0 4 30 26 1 57 1 0 0 1

86356 MONONUCLEAR CELL ANTIGEN, QUANTITAT 10 84 5 99 0 0 0 0 9 0 4 13 0 0 0 0

86357 NATURAL KILLER (NK) CELLS, TOTAL CO 106 128 0 234 2 0 0 2 21 11 3 35 1 0 0 1

86359 T CELLS; TOTAL COUNT 4,068 197 1 4,266 15 0 0 15 62 55 2 119 1 0 0 1

86360 T CELLS; ABSOLUTE CD4 & CD8 COUNT, 1,787 223 7 2,017 16 0 0 16 87 59 4 150 1 0 0 1

86361 T CELLS; ABSOLUTE CD4 COUNT 327 344 3 674 8 1 0 9 48 9 4 61 0 0 0 0

86367 STEM CELLS (IE CD34), TOTAL COUNT 2 21 0 23 0 0 0 0 6 3 1 10 0 0 0 0

86376 MICROSOMAL ANTIBODIES, EACH 2,685 601 41 3,327 31 4 1 36 664 157 146 967 2 0 1 3

86382 NEUTRALIZATION TEST, VIRAL 8 1 0 9 0 0 0 0 0 0 0 0 0 0 0 0

86386 NUCLEAR MATRIX PROTEIN 22, QUALITAT 0 0 0 0 0 0 0 0 0 0 3 3 0 0 0 0

86403 PARTICLE AGGLUTINATION; SCREEN EACH 122 909 705 1,736 0 1 0 1 12 36 31 79 0 0 0 0

86406 PARTICLE AGGLUTINATION; TITER EACH 4 8 0 12 0 0 0 0 0 0 0 0 0 0 0 0

86430 RHEUMATOID FACTOR QUALITATIVE 61 207 31 299 0 1 1 2 24 159 92 275 0 0 0 0

86431 RHEUMATIOD FACTOR; QUANTITATIVE 6,259 344 85 6,688 50 3 11 64 1,370 330 334 2,034 27 0 0 27

86480 TUBERCULOSIS TEST, CELL MEDIATED IM 167 168 11 346 4 0 0 4 100 60 13 173 0 0 0 0

86481 TUBERCULOSIS TEST, CELL MEDIATED IM 0 14 5 19 0 0 0 0 0 15 7 22 0 0 0 0

86485 SKIN TEST; CANDIDA 0 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0

Page Number 11

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RFI ATTACHMENT F


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BlueCare Total

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86486 SKIN TEST; UNLISTED ANTIGEN, EACH 0 0 353 353 0 0 0 0 0 0 0 0 0 0 0 0

86510 SKIN TEST; HISTOPLASMOSIS 0 1 2 3 0 0 0 0 0 1 6 7 0 0 0 0

86580 SKIN TEST; TUBERCULOSIS INTRADERMAL 0 258 4,439 4,697 0 3 10 13 0 90 291 381 0 0 5 5

86590 STREPTOKINASE ANTIBODY 0 0 5 5 0 0 0 0 0 0 0 0 0 0 0 0

86592 SYPHILIS TEST; QUALITATIVE 17,753 2,615 368 20,736 43 5 2 50 306 263 51 620 5 1 0 6

86593 SYPHILIS TEST; QUANTITATIVE 457 43 7 507 0 2 0 2 10 6 3 19 0 0 0 0

86602 ANTIBODY; ACTINOMYCES 6 0 0 6 0 0 0 0 14 6 0 20 0 0 0 0

86603 ANTIBODY; ADENOVIRUS 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

86606 ANTIBODY ASPIRGILLUS 63 58 4 125 3 1 0 4 49 47 4 100 0 0 0 0

86609 ANTIBODY; BACTERIUM NOT ELSEWHERE S 90 89 0 179 14 14 0 28 26 43 1 70 0 0 0 0

86611 ANTIBODY BARTONELLA 260 148 0 408 0 0 0 0 40 10 4 54 0 0 0 0

86612 ANTIBODY BLASTOMYCES 19 36 2 57 1 0 0 1 13 23 0 36 0 0 1 1

86615 ANTIBODY BORDETELLA 193 49 3 245 0 0 0 0 104 19 0 123 0 0 0 0

86617 ANTIBODY; BORRELIA BURGDORFERI (LYM 418 56 2 476 0 0 0 0 147 22 12 181 0 0 0 0

86618 ANTIBODY; BORELLIA BURGDORFERI (LYM 948 131 10 1,089 3 2 0 5 354 133 30 517 3 0 0 3

86622 ANTIBODY; BRUCELLA 2 0 0 2 0 0 0 0 6 1 0 7 0 0 0 0

86625 ANTIBODY; CAMPYLOBACTER 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

86628 ANTIBODY; CANDIDA 54 10 0 64 0 0 0 0 31 9 0 40 0 0 0 0

86631 ANTIBODY; CHLAMYDIA 85 61 0 146 0 0 0 0 20 5 2 27 0 0 0 0

86632 ANTIBODY; CHLAMYDIA IGM 59 2 0 61 0 0 0 0 15 4 1 20 0 0 0 0

86635 ANTIBODY; COCCIDIOIDES 20 25 2 47 1 0 0 1 10 18 0 28 0 0 3 3

86638 ANTIBODY; COXIELLA BRUNETII (Q FEVE 18 4 0 22 0 0 0 0 11 7 0 18 0 0 0 0

86641 ANTIBODY; CRYPTOCOCCUS 3 12 0 15 0 1 0 1 0 4 0 4 0 0 0 0

86644 ANTIBODY; CYTOMEGALOVIRUS (CMV) 360 252 11 623 0 0 0 0 22 66 4 92 0 0 0 0

86645 ANTIBODY; CYTOMEGALOVIRUS (CMV), IG 361 195 5 561 0 0 0 0 19 33 3 55 0 0 0 0

86648 ANTIBODY; DIPTHERIA 92 88 0 180 0 0 0 0 7 2 0 9 0 0 0 0

86651 ANTIBODY; ENCEPHALITIS, CALIFORNIA 2 6 0 8 0 0 0 0 0 0 1 1 0 0 0 0

86652 ANTIBODY; ENCEPHALITIS EASTERN EQUI 2 6 0 8 0 0 0 0 2 0 0 2 0 0 0 0

86653 ANTIBODY; ENCEPHALITIS, ST. LOUIS 2 6 0 8 0 0 0 0 0 0 0 0 0 0 0 0

86654 ANTIBODY; ENCEPHALITIS, WESTERN EQU 2 6 0 8 0 0 0 0 0 0 0 0 0 0 0 0

86658 ANTIBODY; ENTEROVIRUS (EG, COXSAKIE 87 112 0 199 0 0 0 0 6 6 0 12 0 0 0 0

86663 ANTIBODY; EPSTEIN-BARR VIRUS, EARLY 519 240 31 790 1 1 0 2 46 17 2 65 0 0 0 0

86664 ANTIBODY EPSTEIN-BARR VIRUS, NUCLEA 998 302 15 1,315 1 1 0 2 49 41 1 91 0 0 0 0

86665 ANTIBODY EPSTEIN-BARR VIRUS, VIRAL 2,302 545 27 2,874 4 2 0 6 127 72 9 208 0 0 0 0

86666 ANTIBODY EHRLICHIA 185 92 0 277 0 0 0 0 166 74 12 252 0 0 0 0

86668 ANTIBODY FRANCISELLA TULARENSIS 0 0 0 0 0 0 0 0 2 0 0 2 0 0 0 0

86671 ANTIBODY; FUNGUS, NOT ELSEWHERE SPE 268 28 2 298 0 0 0 0 28 6 0 34 0 0 0 0

86674 ANTIBODY GIARDIA LAMBLIA 6 0 0 6 0 0 0 0 3 0 0 3 0 0 0 0

86677 ANTIBODY HELICOBACTER PYLORI 3,372 423 226 4,021 29 5 2 36 588 227 108 923 1 0 0 1

86682 ANTIBODY; HELMINTH, NOT ELSEWHERE S 8 15 1 24 0 0 0 0 13 7 2 22 0 0 0 0

86684 ANTIBODY; HEMOPHILUS INFLUENZA 15 17 0 32 0 0 0 0 0 1 1 2 0 0 0 0

86687 ANTIBODY HTLV-I 0 17 0 17 0 0 0 0 0 9 2 11 0 0 0 0

86689 ANTIBODY; HTLV OR HIV ANTIBODY, CON 122 26 13 161 0 0 0 0 5 4 0 9 0 0 0 0

86692 ANTIBODY; HEPATITIS, DELTA AGENT 7 8 0 15 0 0 0 0 2 0 0 2 0 0 0 0

86694 ANTIBODY; HERPES SIMPLEX, NON-SPECI 660 138 23 821 2 0 0 2 17 27 4 48 0 0 0 0

86695 ANTIBODY; HERPES SIMPLEX, TYPE 1 4,691 189 115 4,995 7 0 0 7 61 26 10 97 0 0 0 0

86696 ANTIBODY; HERPES SIMPLEX, TYPE 2 6,589 380 129 7,098 7 1 0 8 68 30 13 111 0 0 0 0

86698 ANTIBODY; HISTOPLASMA 38 104 2 144 1 0 0 1 14 26 0 40 0 0 1 1

86701 ANTIBODY HIV-1 8 525 62 595 3 0 0 3 7 14 4 25 0 0 0 0

86702 ANTIBODY HIV-2 29 37 0 66 3 0 0 3 7 0 1 8 0 0 0 0

86703 ANTIBODY; HIV-1 & HIV-2, SINGLE RES 33,344 700 553 34,597 59 2 1 62 380 98 32 510 6 0 0 6

86704 HEPATITIS B CORE ANTIBODY (HBCAB), 1,321 400 89 1,810 10 1 0 11 212 236 28 476 3 0 0 3

86705 HEPATITIS B CORE ANTIBODY; IGM ANTI 536 173 9 718 1 0 0 1 60 29 7 96 2 0 1 3

86706 HEPATITIS B SURFACE ANTIBODY (HBSAB 2,068 705 136 2,909 17 1 0 18 341 399 36 776 6 0 2 8

86707 HEPATITIS BE ANTIBODY (HBEAB) 278 38 8 324 2 0 0 2 57 28 6 91 3 0 0 3

86708 HEPATITIS A ANTIBODY (HAAB), TOTAL 1,282 195 48 1,525 14 0 0 14 159 56 15 230 1 0 0 1

86709 HEPATITIS A ANTIBODY (HAAB), IGM AN 450 183 1 634 4 0 0 4 34 32 1 67 0 0 0 0

86710 ANTIBODY; INFLUENZA VIRUS 16 918 133 1,067 0 2 0 2 6 136 3 145 0 0 0 0

86711 (blank) 7 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0

86713 ANTIBODY LEGIONELLA 1 0 0 1 0 0 0 0 2 0 0 2 0 0 0 0

86723 ANTIBODY; LISTERIA MONOCYTOGENES 0 0 5 5 0 0 0 0 0 0 0 0 0 0 0 0

86735 ANTIBODY; MUMPS 300 54 9 363 0 0 0 0 9 4 1 14 0 0 0 0

86738 ANTIBODY MYCOPLASMA 351 842 1,206 2,399 1 0 0 1 72 33 216 321 0 0 0 0

Page Number 12

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RFI ATTACHMENT F


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Practitioner Other

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BlueCare Total

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Independent Lab

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Practitioner Other

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BlueCare Plus

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Medicare

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86741 ANTIBODY; NEISSERIA MENINGITIDIS 0 16 0 16 0 0 0 0 0 2 2 4 0 0 0 0

86747 ANTIBODY; PARVOVIRUS 335 240 5 580 1 0 0 1 58 10 0 68 3 0 0 3

86753 ANTIBODY; PROTOZOA, NOT ELSEWHERE S 64 16 1 81 0 0 0 0 29 10 5 44 0 0 0 0

86756 ANTIBODY; RESPIRATORY SYNCYTIAL VIR 0 236 320 556 0 0 0 0 0 0 0 0 0 0 0 0

86757 ANTIBODY RICKETTSIA 608 171 1 780 2 2 0 4 276 116 15 407 0 0 0 0

86759 ANTIBODY; ROTAVIRUS 0 39 0 39 0 0 0 0 0 3 0 3 0 0 0 0

86762 ANTIBODY; RUBELLA 3,755 853 94 4,702 1 1 0 2 11 4 1 16 0 0 0 0

86765 ANTIBODY; RUBEOLA 383 41 7 431 0 0 0 0 9 3 1 13 0 0 0 0

86768 ANTIBODY SALMONELLA 12 0 0 12 0 0 0 0 10 0 0 10 0 0 0 0

86771 ANTIBODY SHIGELLA 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

86774 ANTIBODY; TETANUS 130 102 1 233 0 0 0 0 11 5 0 16 0 0 0 0

86777 ANTIBODY TOXOPLASMA 233 162 7 402 0 0 0 0 8 17 3 28 0 0 0 0

86778 ANTIBODY TOXOPLASMA IGM 165 131 5 301 0 0 0 0 7 14 1 22 0 0 0 0

86780 TREPONEMA PALLADIUM 2,226 74 15 2,315 3 0 0 3 122 19 4 145 2 0 0 2

86784 ANTIBODY; TRICHINELLA 1 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0

86787 ANTIBODY; VARICELLA-ZOSTER 2,384 410 80 2,874 1 2 0 3 107 59 5 171 0 0 1 1

86788 WEST NILE VIRUS, IGM 16 4 0 20 0 0 0 0 9 6 0 15 0 0 0 0

86789 WEST NILE VIRUS 16 25 0 41 0 0 0 0 9 10 0 19 0 0 0 0

86790 ANTIBODY; VIRUS, NOT ELSEWHERE SPEC 23 65 0 88 0 0 0 0 6 24 3 33 0 0 0 0

86793 ANTIBODY YERSINIA 0 0 0 0 0 0 0 0 0 3 0 3 0 0 0 0

86800 THYROGLOBULIN ANTIBODY 1,306 450 20 1,776 16 1 0 17 451 165 83 699 1 0 1 2

86803 HEPATITIS C ANTIBODY 9,277 1,540 187 11,004 25 3 0 28 511 352 55 918 9 0 0 9

86804 HEPATITIS C ANTIBODY; CONFIRMATORY 9 10 3 22 0 0 0 0 4 0 0 4 0 0 0 0

86807 SERUM SCREENING FOR CYTOTOXIC PERCE 0 23 2 25 0 0 0 0 0 16 2 18 0 0 0 0

86808 SERUM SCREENING FOR CYTOTOXIC PERCE 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0

86812 HLA TYPING A, B, OR C, SINGLE ANTIG 316 42 1 359 2 0 0 2 41 5 0 46 3 0 0 3

86813 HLA TYPING A, B, OR C, MULTIPLE ANT 0 1 0 1 0 0 0 0 0 0 2 2 0 0 0 0

86816 HLA TYPING DR/DQ, SINGLE ANTIGEN 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

86817 HLA TYPING DR/DQ, MULTIPLE ANTIGENS 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

86825 HUMAN LEUKOCYTE ANTIGEN (HLA) CROSS 0 16 0 16 0 0 0 0 0 4 0 4 0 0 0 0

86826 HUMAN LEUKOCYTE ANTIGEN (HLA) CROSS 0 11 0 11 0 0 0 0 0 4 0 4 0 0 0 0

86828 (blank) 1 36 0 37 0 0 0 0 0 25 0 25 0 0 0 0

86829 (blank) 0 1 0 1 0 0 0 0 0 4 0 4 0 0 0 0

86830 (blank) 0 4 0 4 0 0 0 0 1 3 0 4 0 0 0 0

86831 (blank) 0 3 0 3 0 0 0 0 1 0 0 1 0 0 0 0

86832 (blank) 0 43 0 43 0 0 0 0 0 16 1 17 0 0 0 0

86833 (blank) 0 40 0 40 0 0 0 0 0 14 1 15 0 0 0 0

86849 UNLISTED IMMUNOLOGY PROCEDURE 25 4 0 29 0 0 0 0 17 1 1 19 0 0 0 0

86850 ANTIBODY SCREEN, RBC, EA SERUM TECH 3,344 9,453 381 13,178 1 37 0 38 20 2,838 47 2,905 0 2 0 2

86860 ANTIBODY ELUTION (RBC), EA ELUTION 0 11 0 11 0 0 0 0 0 6 0 6 0 0 0 0

86870 ANTIBODY IDENTIFICATION, RBC ANTIBO 385 477 23 885 0 0 0 0 0 87 4 91 0 0 0 0

86880 ANTIHUMAN GLOBULIN TEST; DIRECT EA 59 418 63 540 3 0 0 3 79 57 8 144 0 0 0 0

86885 ANTIHUMAN GLOBULIN TEST; INDIRECT, 0 865 3 868 0 0 0 0 0 14 2 16 0 0 0 0

86886 ANTIHUMAN GLOBULIN TEST; INDIRECT, 174 176 12 362 0 0 0 0 0 15 0 15 0 0 3 3

86891 AUTOLOGOUS BLOOD COLLECTION & PROCE 0 3 1 4 0 0 0 0 0 1 0 1 0 0 0 0

86900 BLOOD TYPING; ABO 2,313 11,318 424 14,055 2 32 0 34 38 2,809 61 2,908 0 2 3 5

86901 BLOOD TYPING; RH (D) 2,345 11,474 395 14,214 3 35 0 38 33 2,825 59 2,917 0 2 3 5

86902 BLOOD TYPING; ANTIGEN TESTING OF DO 0 4,718 120 4,838 0 15 0 15 0 321 1 322 0 0 0 0

86904 BLOOD TYPING; ANTIGEN SCREENING FOR 0 75 0 75 0 0 0 0 0 2 0 2 0 0 0 0

86905 BLOOD TYPING; RBC ANTIGENS, OTHER T 45 2,257 17 2,319 0 2 0 2 0 205 0 205 0 0 0 0

86906 BLOOD TYPING; RH PHENOTYPING, COMPL 4 1 1 6 0 0 0 0 1 1 0 2 0 0 0 0

86910 BLOOD TYPING; FOR PATERNITY TESTING 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

86920 COMPATIBILITY TEST EA UNIT; IMMEDIA 0 3,004 102 3,106 0 17 0 17 0 1,491 14 1,505 0 0 6 6

86921 COMPATIBILITY TEST EA UNIT; INCUBAT 0 100 0 100 0 0 0 0 0 49 0 49 0 0 0 0

86922 COMPATIBILITY TEST EA UNIT; ANTIGLO 0 2,008 55 2,063 0 6 0 6 0 434 6 440 0 0 0 0

86923 BLOOD TYPING; FOR PATERNITY TESTING 0 1,223 134 1,357 0 2 0 2 0 641 28 669 0 0 0 0

86927 FRESH FROZEN PLASMA, THAWING, EA UN 0 186 0 186 0 0 0 0 0 13 11 24 0 0 0 0

86940 HEMOLYSINS & AGGLUTININS; AUTO, SCR 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

86945 IRRADIATION OF BLOOD PRODUCT, EA UN 0 455 12 467 0 0 0 0 0 25 3 28 0 0 0 0

86960 VOLUME REDUCTION OF BLOOD/BLOOD PRO 0 23 0 23 0 0 0 0 0 0 0 0 0 0 0 0

86965 POOLING OF PLATELETS OR OTHER BLOOD 0 82 13 95 0 0 0 0 0 15 0 15 0 0 0 0

86971 PRETREATMENT OF RBCS FOR ANTIBODY D 0 0 0 0 0 0 0 0 0 2 0 2 0 0 0 0

86972 PRETREATMENT OF RBCS FOR ANTIBODY D 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0

Page Number 13

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RFI ATTACHMENT F


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Outpatient Facility

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Practitioner Other

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BlueCare Total

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Independent Lab

Services

Outpatient Facility

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Practitioner Other

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BlueCare Plus

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Independent Lab

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Outpatient Facility

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Practitioner Other

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Medicare

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86976 PRETREATMENT OF SERUM USE IN RBC AN 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

86977 PRETREATMENT SERUM USE IN RBC ANTIB 0 3 0 3 0 0 0 0 0 0 0 0 0 0 0 0

86978 PRETREATMENT OF SERUM USE IN RBC AN 0 6 0 6 0 0 0 0 0 9 0 9 0 0 0 0

86985 SPLITTING OF BLOOD OR BLOOD PRODUCT 0 90 14 104 0 0 0 0 0 0 0 0 0 0 0 0

86999 UNLISTED TRANSFUSION MEDICINE PROCE 0 86 0 86 0 0 0 0 0 0 0 0 0 0 0 0

87015 CONCENTRATION (ANY TYPE) FOR INFECT 145 615 35 795 4 4 0 8 49 344 9 402 0 0 0 0

87040 CULTURE BACTERIAL; BLOOD, AEROBIC W 754 16,917 473 18,144 9 99 3 111 281 4,075 185 4,541 0 10 0 10

87045 CULTURE BACTERIAL; FECES W ISOLATIO 1,495 861 61 2,417 8 11 0 19 369 394 21 784 0 0 0 0

87046 CULTURE, BACTERIAL; STOOL, AEROBIC, 1,983 1,911 74 3,968 11 15 0 26 584 766 22 1,372 0 0 0 0

87070 CULTURE BACTERIAL; ANY SOURCE EXCEP 16,908 11,620 2,757 31,285 42 42 2 86 1,470 2,242 250 3,962 2 3 2 7

87071 CULTURE BACTERIAL; QUANTITATIVE AER 0 398 2 400 0 1 0 1 4 81 0 85 0 0 0 0

87073 CULTURE BACTERIAL; QUANTITATIVE ANA 2 6 0 8 0 0 0 0 0 8 0 8 0 0 0 0

87075 CULTURE BACTERIAL; ANAEROBIC W ISOL 1,425 975 34 2,434 6 15 0 21 302 471 33 806 0 0 0 0

87076 CULTURE BACTERIAL; ANAEROBIC ADD'L 145 146 12 303 0 1 0 1 17 34 13 64 0 0 0 0

87077 CULTURE BACTERIAL; AEROBIC ISOLATE 11,957 7,761 406 20,124 82 43 1 126 3,567 3,497 496 7,560 7 7 3 17

87081 CULTURE PRESUMPTIVE PATHOGENIC ORGA 18,710 12,476 5,245 36,431 8 27 2 37 122 606 52 780 1 1 0 2

87084 CULTURE PRESUMPTIVE PATHOGENIC ORGA 0 0 550 550 0 0 0 0 0 0 2 2 0 0 0 0

87086 CULTURE BACTERIAL QUANTITATIVE COLO 44,393 26,088 1,391 71,872 189 118 11 318 11,098 7,411 1,602 20,111 22 3 4 29

87088 CULTURE BACTERIAL W ISOLATION & PRE 15,948 5,273 450 21,671 74 26 3 103 3,001 910 736 4,647 4 0 0 4

87101 CULTURE FUNGI ISOLATON W IDENTIFICA 573 14 47 634 5 0 0 5 128 26 25 179 0 0 0 0

87102 CULTURE FUNGI ISOLATON W IDENTIFICA 219 667 216 1,102 2 2 0 4 49 400 16 465 0 0 0 0

87103 CULTURE FUNGI ISOLATON W IDENTIFICA 1 289 2 292 0 0 0 0 0 3 0 3 0 0 0 0

87106 CULTURE FUNGI DEFINITIVE IDENTIFICA 143 158 7 308 1 8 0 9 34 115 2 151 0 0 0 0

87107 CULTURE FUNGI DEFINITIVE IDENTIFICA 234 14 0 248 0 0 0 0 44 10 1 55 0 0 0 0

87109 CULTURE MYCOPLASMA ANY SOURCE 34 12 0 46 0 0 0 0 9 31 0 40 0 0 0 0

87110 CULTURE CHLAMYDIA ANY SOURCE 37 268 8 313 0 1 0 1 1 0 0 1 0 0 0 0

87116 CULT TUBERCLE OR OTHER ACID FAST BA 97 594 30 721 4 6 0 10 46 386 13 445 0 0 0 0

87118 CULTURE MYCOBACTERIC DEFINITIVE IDE 1 3 0 4 0 0 0 0 0 4 0 4 0 0 0 0

87140 CULTURE TYPING IMMUNOFLUORESCENT ME 206 276 1 483 0 2 0 2 2 9 0 11 0 0 0 0

87147 CULTURE TYPING IMMUNOLOGIC METHOD O 4,603 3,524 118 8,245 8 10 1 19 246 227 76 549 2 2 0 4

87149 CULTURE IDENTIFICATION BY NUCLEIC A 2,824 100 19 2,943 148 0 0 148 1,601 115 19 1,735 0 0 0 0

87150 CULTURE, TYPING; IDENTIFICATION BY 1,861 0 14 1,875 148 0 0 148 1,598 2 19 1,619 0 0 0 0

87153 CULTURE, TYPING; IDENTIFICATION BY 9 1 0 10 0 0 0 0 3 1 0 4 0 0 0 0

87158 CULTURE TYPING OTHER METHODS 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

87164 DARK FIELD EXAMINATION ANY SOURCE I 0 0 3 3 0 0 0 0 0 0 0 0 0 0 0 0

87168 MACROSCOPIC EXAMINATION ARTHROPOD 4 2 2 8 0 0 0 0 2 2 0 4 0 0 0 0

87169 MACROSCOPIC EXAMINATION PARASITE 8 1 99 108 0 0 0 0 0 2 0 2 0 0 0 0

87172 PINWORN EXAM (CELLOHANE TAPE PREP) 21 3 19 43 0 0 0 0 0 0 0 0 0 0 0 0

87176 TISSUE HOMOGENIZATION FOR CULTURE 6 28 1 35 0 0 0 0 0 29 0 29 0 0 0 0

87177 OVA & PARASITES DIRECT SMEARS CONCE 1,312 536 32 1,880 10 4 1 15 351 231 29 611 0 0 0 0

87181 MICROBE SUSCEPTIBILITY STUDIES ANTI 27 263 2 292 0 6 0 6 4 45 0 49 0 0 0 0

87184 MICROBE SUSCEPTIBILITY STUDIES ANTI 227 484 409 1,120 0 0 0 0 2 59 375 436 0 0 4 4

87185 MICROBE SUSCEPTIBILITY STUDIES ENZY 140 55 2 197 0 1 0 1 15 14 4 33 0 0 0 0

87186 MICROBE SUSCEPTIBLE MICRODILUTION O 14,560 12,250 454 27,264 118 76 2 196 5,019 4,409 517 9,945 9 7 2 18

87187 SUSCEPTIBILITY STUDIES MICRODILUTIO 0 0 2 2 0 0 0 0 0 0 2 2 0 0 0 0

87188 SUSCEPTIBILITY STUDIES MACROBROTH D 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

87205 SMEAR PRIMARY SOURCE W INTERPRETATI 2,806 4,459 748 8,013 22 38 4 64 823 1,667 107 2,597 2 3 1 6

87206 SMEAR PRIMARY SOURCE W INTERPRETATI 349 765 35 1,149 8 6 0 14 82 455 18 555 0 0 0 0

87207 SMEAR W INTERPRETATION; SPECIAL STA 22 10 4 36 0 0 0 0 6 4 3 13 0 0 0 0

87209 SMEAR, PRIMARY SOURCE W INTERPRETAT 1,263 189 25 1,477 10 0 0 10 354 104 18 476 0 0 0 0

87210 SMEAR WET MOUNT FOR INFECTIOUS AGEN 198 5,786 19,709 25,693 0 2 16 18 19 83 581 683 0 0 2 2

87220 TISSUE EXAM BY KOH SLIDE SAMPLES FR 191 226 1,739 2,156 0 0 4 4 10 14 206 230 0 0 2 2

87230 TOXIN OR ANTITOXIN ASSAY TISSUE CUL 27 316 11 354 0 4 0 4 5 60 12 77 0 0 0 0

87252 VIRUS ISOLATION; TISSUE CULTURE INO 84 299 13 396 0 1 0 1 5 83 6 94 0 0 0 0

87253 VIRUS ISOLATION; TISSUE CULTURE, AD 42 2 0 44 0 0 0 0 1 0 1 2 0 0 0 0

87254 VIRUS ISOLATION; CENTIFUGE ENHANCED 403 436 15 854 0 1 0 1 16 74 5 95 0 0 0 0

87255 VIRUS ISOLATION; ID BY NON-IMMUNOLO 575 57 14 646 4 0 0 4 19 3 1 23 0 0 0 0

87260 INFECTIOUS AGENT ANTIGEN DETECTION 321 587 1 909 0 0 0 0 0 0 0 0 0 0 0 0

87265 INFECTIOUS AGENT DETECTION BY IMMUN 20 35 0 55 0 0 0 0 0 1 0 1 0 0 0 0



87271 INFECTIOUS AGENT ANTIGEN DETECTION; 0 4 0 4 0 0 0 0 0 17 0 17 0 0 0 0


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87273 INFECTIOUS AGENT DETECTION, HERPES 17 10 4 31 0 0 0 0 2 0 0 2 0 0 0 0

87274 INFECTIOUS AGENT DETECTION, HERPES 11 27 0 38 0 0 0 0 1 0 0 1 0 0 0 0

87275 INFECTIOUS AGENT DETECTION, INFLUEN 374 1,608 46 2,028 0 1 1 2 6 37 7 50 0 0 0 0

87276 INFECTIOUS AGENT DETECTION, INFLUEN 374 1,615 37 2,026 0 1 1 2 6 37 10 53 0 0 0 0

87278 INFECTIOUS AGENT DETECTION, LEGIONE 0 14 0 14 0 0 0 0 0 24 0 24 0 0 0 0

87279 INFECTIOUS AGENT DETECTION, PARAINF 391 1,771 4 2,166 0 0 0 0 0 6 0 6 0 0 0 0

87280 INFECTIOUS AGENT DETECTION, RESPIRA 357 640 31 1,028 0 0 0 0 0 0 0 0 0 0 0 0

87281 INFECTIOUS AGENT DETECTION, PNEUMOC 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0

87285 INFECTIOUS AGENT DETECTION, TREPONE 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

87290 INFECTIOUS AGENT DETECTION, VARICEL 0 5 0 5 0 0 0 0 0 0 0 0 0 0 0 0

87299 INFECTIOUS AGENT DETECTION, NOT OTH 0 18 0 18 0 0 0 0 0 16 0 16 0 0 0 0

87300 INFECTIOUS AGENT DETECTION, POLYVAL 17 4 0 21 0 0 0 0 0 1 0 1 0 0 0 0

87305 ASPERGILLUS- INFECTIOUS AGENT ANTIG 0 71 0 71 0 0 0 0 2 26 0 28 0 0 0 0

87320 INFECTIOUS AGENT DETECTION BY ENZYM 0 14 13 27 0 0 0 0 0 1 0 1 0 0 0 0

87324 INFECTIOUS AGENT DETECTION BY ENZYM 779 353 48 1,180 9 14 0 23 369 187 37 593 0 0 0 0




87332 ANTIGEN DETECTION BY ENZYME IMMUNOA 0 172 0 172 0 0 0 0 0 0 0 0 0 0 0 0





87340 ANTIGEN DETECTION ENZYME IMMUNOASSA 8,177 1,682 255 10,114 16 2 0 18 471 959 101 1,531 8 0 1 9

87341 ANTIGEN DETECTION ENZYME IMMUNOASSA 14 8 0 22 0 0 0 0 3 0 0 3 0 0 0 0



87389 HIV-1 ANTIGEN(S), W/HIV-1 & HIV-2 A 1,557 2,000 37 3,594 0 5 0 5 7 103 0 110 0 1 1 2


87400 ANTIGEN DETECTION BY ENZYME IMMUNOA 32 12,464 1,281 13,777 0 2 3 5 16 341 188 545 0 4 0 4

87420 ANTIGEN DETECTION BY ENZYME IMMUNOA 9 1,607 877 2,493 0 0 0 0 0 1 0 1 0 0 0 0


87427 ANTIGEN DETECTION BY ENZYME IMMUNOA 1,080 851 67 1,998 6 14 0 20 192 282 21 495 0 0 0 0

87430 ANTIGEN DETECTION BY ENZYME IMMUNOA 266 13,575 5,865 19,706 0 9 1 10 2 121 86 209 0 0 0 0

87449 ANTIGEN DETECTION BY ENZYME IMMUNOA 262 1,573 67 1,902 1 2 0 3 54 147 21 222 0 0 0 0


87451 INFECTIOUS AGENT DETECTION MULTIPLE 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

87470 INFECTIOUS AGENT DETECTION BY NUCLE 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0


87476 BORRELIA BURGDORFERI AMPLIFIED PROB 1 1 0 2 0 0 0 0 1 2 0 3 0 0 0 0

87480 CANDIDA SPECIES DIRECT PROBE TECHNI 1,126 7 811 1,944 0 0 5 5 28 1 68 97 1 0 0 1

87481 CANDIDA SPECIES AMPLIFIED PROBE TEC 22,139 0 678 22,817 36 0 0 36 470 12 33 515 0 0 4 4

87482 CANDIDA SPECIES QUANTIFICATION 1 0 0 1 0 0 0 0 1 0 7 8 0 0 0 0

87486 CHLAMYDIA PNEUMONIAE AMPLIFIED PROB 4,767 330 9 5,106 7 0 1 8 137 12 1 150 1 0 1 2

87490 CHLAMYDIA TRACHOMATIS DETECTION DIR 0 108 66 174 0 0 0 0 0 1 3 4 0 0 0 0

87491 CHLAMYDIA TRACHOMATIS DETECTION AMP 53,780 4,610 6,128 64,518 56 3 7 66 270 53 75 398 4 0 2 6

87492 CHLAMYDIA TRACHOMATIS QUANTIFICATIO 0 14 0 14 0 0 0 0 0 1 0 1 0 0 0 0

87493 INFECTIOUS AGENT DETECTION BY NUCLE 880 483 66 1,429 0 6 1 7 121 524 73 718 0 0 0 0

87496 CYTOMEGALOVIRUS AMPLIFIED PROBE TEC 32 32 3 67 0 2 0 2 2 90 0 92 0 0 0 0

87497 CYTOMEGALOVIRUS QUANTIFICATION 20 385 2 407 0 0 0 0 6 86 15 107 0 0 0 0

87498 CHLAMYDIA TRACHOMATIS, ENTEROVIRUS, 4,923 42 7 4,972 7 0 1 8 127 3 0 130 1 0 0 1



87502 INFECTIOUS AG DETECTION BY NUCLEIC 3 1,379 11 1,393 0 0 2 2 2 2 0 4 0 0 0 0


87510 GARDNERELLA VAGINALIS DIRECT PROBE 1,124 7 807 1,938 0 0 5 5 28 0 66 94 1 0 0 1

87511 GARDNERELLA VAGINALIS AMPLIFIED PRO 3,300 0 139 3,439 6 0 0 6 75 0 7 82 0 0 1 1

87512 GARDNERELLA VAGINALIS QUANTIFICATIO 3,250 0 4 3,254 7 0 0 7 5 3 0 8 0 0 0 0

87516 ANTIGEN DETECTION, HEPATITIS B VIRU 10 4 0 14 0 0 0 0 0 2 1 3 0 0 0 0

87517 ANTIGEN DETECTION, HEPATITIS B VIRU 182 39 13 234 0 0 0 0 18 23 6 47 0 0 0 0

87520 ANTIGEN DETECTION, HEPATITIS C DIRE 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

87521 ANTIGEN DETECTION, HEPATITIS C AMPL 194 61 11 266 3 4 0 7 50 20 2 72 0 0 0 0

87522 ANTIGEN DETECTION, HEPATITIS C QUAN 2,293 371 182 2,846 16 6 3 25 193 143 37 373 0 0 0 0

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87529 ANTIGEN DETECTION, HERPES SIMPLEX V 3,634 130 832 4,596 4 1 6 11 62 18 49 129 0 0 0 0

87530 ANTIGEN DETECTION, HERPES SIMPLEX V 4 7 4 15 0 0 0 0 0 6 0 6 0 0 0 0



87535 ANTIGEN DETECTION, HIV-1 AMPLIFIED 33 133 1 167 0 0 0 0 1 13 0 14 0 0 0 0

87536 ANTIGEN DETECTION, HIV-1 QUANTIFICA 1,576 491 33 2,100 21 3 0 24 111 68 11 190 1 0 0 1

87538 ANTIGEN DETECTION, HIV-2 AMPLIFIED 3 0 1 4 0 0 0 0 0 0 0 0 0 0 0 0

87541 ANTIGEN DETECTION, LEGIONELLA PNEUM 2,142 16 6 2,164 7 0 2 9 100 1 0 101 0 0 0 0

87550 ANTIGEN DETECTION, MYCOBACTERIA SPE 1 0 0 1 0 0 0 0 2 0 0 2 0 0 0 0

87551 ANTIGEN DETECTION, MYCOBACTERIA SPE 0 1 2 3 0 0 0 0 0 18 0 18 0 0 0 0

87555 ANTIGEN DETECTION, MYCOBACTERIA TUB 0 0 0 0 0 0 0 0 0 4 0 4 0 0 0 0

87556 ANTIGEN DETECTION, MYCOBACTERIA TUB 0 6 0 6 0 0 0 0 0 26 0 26 0 0 0 0

87560 ANTIGEN DETECTION, MYCOBACTERIA AVI 0 0 0 0 0 0 0 0 0 3 0 3 0 0 0 0

87561 ANTIGEN DETECTION, MYCOBACTERIA AVI 2 0 0 2 0 0 0 0 0 10 0 10 0 0 0 0

87581 ANTIGEN DETECTION, MYCOPLASMA PNEUM 4,811 320 8 5,139 7 0 2 9 137 14 1 152 1 0 1 2

87590 ANTIGEN DETECTION, NEISSERIA GONORR 0 192 62 254 0 0 0 0 0 2 3 5 0 0 0 0

87591 ANTIGEN DETECTION, NEISSERIA GONORR 53,467 4,552 6,064 64,083 56 3 7 66 268 51 74 393 4 0 2 6

87592 ANTIGEN DETECTION, NEISSERIA GONORR 0 14 0 14 0 0 0 0 0 1 0 1 0 0 0 0

87631 (blank) 0 53 1 54 0 0 0 0 0 2 0 2 0 0 0 0

87632 (blank) 51 12 0 63 0 0 0 0 4 4 2 10 0 0 0 0

87633 (blank) 4,911 542 3 5,456 7 0 0 7 135 30 1 166 0 0 1 1

87640 STAPHYLOCOCCUS AUREUS, AMPLIFIED PR 99 25 1 125 0 0 0 0 12 9 17 38 0 0 0 0

87641 STAPHYLOCOCCUS AUREUS, METHICILLIN 3,080 305 9 3,394 15 1 4 20 226 184 23 433 1 0 0 1

87650 ANTIGEN DETECTION, STREPTOCOCCUS GR 977 5 22 1,004 0 0 0 0 36 0 2 38 0 0 0 0

87651 ANTIGEN DETECTION, STREPTOCOCCUS GR 5,481 23 10 5,514 15 0 3 18 206 6 4 216 0 0 0 0

87652 ANTIGEN DETECTION, STREPTOCOCCUS GR 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

87653 STREPTOCOCCUS, GROUP B AMPLIFIED CO 1,333 75 539 1,947 1 0 1 2 12 1 20 33 0 0 0 0

87660 TRICHOMONAS VAGINALIS, DIRECT PROBE 1,124 7 809 1,940 0 0 5 5 28 1 61 90 1 0 0 1

87661 (blank) 13,252 0 161 13,413 24 0 0 24 112 3 3 118 1 0 0 1


87798 INFECTIOUS AGENT DETECTION BY DNA O 39,846 1,538 1,185 42,569 154 1 33 188 2,838 211 235 3,284 16 0 9 25

87799 INFECTIOUS AGENT DETECTION BY DNA O 9,821 413 16 10,250 21 0 0 21 20 68 0 88 0 0 0 0

87800 INFECTIOUS AGENT DETECTED BY NUCLEI 0 37 55 92 0 0 0 0 0 0 3 3 0 0 0 0

87801 INFECTIOUS AGENT DETECTED BY NUCLEI 10 71 20 101 0 0 0 0 3 10 15 28 0 0 0 0


87803 INFECTIOUS AGENT DETECTION W DIRECT 0 15 0 15 0 2 0 2 0 4 0 4 0 0 0 0

87804 INFECTIOUS AGENT ANTIGEN DETECTION 754 29,511 75,279 105,544 0 64 72 136 38 1,379 4,789 6,206 0 1 22 23

87807 RESPIRATORY SYNCYTIAL VIRUS 67 4,539 6,239 10,845 0 0 0 0 2 0 1 3 0 0 0 0



87810 INFECTION DETECTION IMMUNOASSAY W D 0 298 16 314 0 0 0 0 0 0 0 0 0 0 0 0

87880 INFECTION DETECTION IMMUNOASSAY W D 493 16,051 116,822 133,366 0 8 53 61 7 169 2,237 2,413 0 1 7 8

87899 INFECTION DETECTION IMMUNOASSAY W D 342 563 20 925 2 6 0 8 263 234 7 504 0 0 0 0

87900 INFECTIOUS AGENT DRUG SUSCEPTIBILIT 157 3 3 163 0 0 0 0 1 1 1 3 0 0 0 0

87901 INFECTIOUS AGENT GENOTYPE ANALYSIS 174 34 5 213 0 0 0 0 0 2 1 3 0 0 0 0

87902 INFECTIOUS AGENT GENOTYPE ANALYSIS 933 136 60 1,129 8 5 0 13 58 24 11 93 0 0 0 0

87903 INFECTIOUS AGENT PHENOTYPE ANALYSIS 4 1 0 5 0 0 0 0 0 0 0 0 0 0 0 0

87904 INFECTIOUS AGENT PHENOTYPE ANALYSIS 44 10 0 54 0 0 0 0 0 0 0 0 0 0 0 0

87905 INFECTIOUS AGENT ENZYMATIC ACTIVITY 6 4 0 10 0 0 1 1 0 0 6 6 0 0 0 0

87906 INFECTIOUS AGENT GENOTYPE ANALYSIS 26 2 0 28 0 0 0 0 0 0 0 0 0 0 0 0

87910 (blank) 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

87912 (blank) 16 0 1 17 0 0 0 0 1 0 0 1 0 0 0 0

87999 UNLISTED MICROBIOLOGY PROCEDURE (BR 40 0 305 345 0 0 0 0 5 0 9 14 0 0 0 0

88014 NECROPSY (AUTOPSY) GROSS EXAM ONLY; 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

88025 NECROPSY (AUTOPSY) GROSS & MICROSCO 0 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0

88104 CYTOPATHOLOGY FLUIDS WASHINGS OR BR 4 23 134 161 0 0 1 1 1 61 193 255 0 0 0 0

88106 CYTOPATH FLUID WASHING/BRUSHING NOT 1 32 71 104 0 0 0 0 2 4 42 48 0 0 0 0

88108 CYTOPATHOLOGY CONCENTRATION TECHNIQ 68 172 379 619 1 0 0 1 14 53 163 230 0 0 0 0

88112 CYTOPATHOLOGY, SELECTIVE CELLULAR E 695 299 1,997 2,991 6 2 29 37 201 454 2,229 2,884 0 0 9 9

88120 CYTOPATHOLOGY, IN SITU HYBRIDIZATIO 0 0 54 54 1 0 0 1 4 0 67 71 0 0 2 2

88121 CYTOPATHOLOGY, IN SITU HYBRIDIZATIO 2 0 19 21 0 0 0 0 2 0 45 47 0 0 0 0

88140 SEX CHROMATIN ID PERIPHERAL BLOOD S 2 1 3 6 0 0 0 0 0 0 0 0 0 0 0 0

88141 CYTOPATHOLOGY CERVICAL VAGINAL REQU 4,876 0 2,256 7,132 2 0 9 11 101 0 192 293 0 0 2 2

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88142 CYTOPATHOLOGY CERVICAL OR VAG COLLE 9,058 77 1,949 11,084 27 0 6 33 298 155 243 696 4 0 6 10

88143 CYTOPATH CERVICAL OR VAGINAL W MANU 0 0 9 9 0 0 2 2 0 0 16 16 0 0 0 0

88148 CYTOPATHOLOGY SMEARS CERVICAL/VAGIN 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

88150 CYTOPATH SLIDES CERVICAL OR VAGINAL 0 0 145 145 0 0 1 1 0 0 24 24 0 0 1 1

88155 CYTOPATH SLIDES CERVICAL OR VAGINAL 17 0 1 18 0 0 0 0 3 0 1 4 0 0 0 0

88160 CYTOPATH SMEARS ANY OTHER SOURCE SC 7 0 33 40 0 0 0 0 1 8 15 24 0 0 0 0

88161 CYTOPATH SMEARS ANY OTHER SOURCE PR 15 4 3 22 0 0 0 0 2 8 12 22 0 0 0 0

88162 CYTOPATH SMEARS ANY OTHER SOURCE EX 0 0 0 0 0 0 0 0 0 0 3 3 0 0 0 0

88164 CYTOPATHOLOGY SLIDES CERVICAL/VAGIN 509 0 175 684 1 0 0 1 7 0 2 9 0 0 1 1

88165 CYTOPATHOLOGY SLIDES, CERVICAL/VAGI 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

88172 CYTOPATHOLOGY, EVALUATION OF FINE N 28 63 321 412 0 1 7 8 0 240 399 639 0 2 2 4

88173 CYTOPATH EVALUATION OF FINE NEEDLE 169 174 718 1,061 1 1 16 18 64 377 873 1,314 3 2 5 10

88174 CYTOPATHOLOGY CERVICAL OR VAG; AUTO 0 0 2 2 0 0 0 0 0 0 26 26 0 0 0 0

88175 CYTOPATHOLOGY CERVICAL OR VAG; AUTO 22,216 8 5,892 28,116 31 0 13 44 1,131 90 608 1,829 3 0 0 3

88177 CYTOPATHOLOGY, EVALUATION OF FINE N 25 18 109 152 0 0 0 0 0 46 107 153 0 2 2 4

88182 FLOW CYTOMETRY CELL CYCLE OR DNA AN 0 41 5 46 0 0 0 0 0 3 2 5 0 0 0 0

88184 FLOW CYTOMETRY, CELL SURFACE, CYTOP 163 439 130 732 4 8 1 13 122 228 193 543 0 0 0 0

88185 FLOW CYTOMETRY CELL SURFACE CYTOPLA 3,262 2,556 2,507 8,325 69 32 24 125 2,452 3,353 4,192 9,997 0 0 0 0

88187 FLOW CYTOMETRY, INTERPRETATION; 2 T 14 70 127 211 1 0 0 1 14 39 66 119 0 0 0 0

88188 FLOW CYTOMETRY, INTERPRETATION; 9 T 12 32 149 193 0 1 0 1 3 27 101 131 0 0 0 0

88189 FLOW CYTOMETRY, INTERPRETATION; 16 113 12 216 341 3 0 2 5 84 23 353 460 0 0 0 0

88199 UNLISTED CYTOPATHOLOGY PROCEDURE 0 25 0 25 0 0 0 0 0 6 0 6 0 0 0 0

88230 TISSUE CULTURE FOR NON-NEOPLASTIC D 246 209 81 536 1 0 0 1 1 0 0 1 0 0 0 0



88237 TISSUE CULTURE FOR NEOPLASTIC DISOR 98 120 20 238 0 0 1 1 146 64 116 326 0 0 0 0

88239 TISSUE CULTURE FOR NEOPLASTIC DISOR 2 0 1 3 0 0 0 0 7 0 0 7 0 0 0 0

88240 CRYOPRESERVATION FREEZING & STORAGE 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0

88241 THAWING AND EXPANSION OF FROZEN CEL 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

88245 CHROMOSOME ANALYSIS FOR BREAKAGE SY 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

88249 CHROMOSOME ANAYLSIS FOR BREAKAGE SY 0 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0

88261 CHROMOSOME ANALYSIS COUNT 5 CELLS 1 13 3 74 90 0 0 0 0 1 1 1 3 0 0 0 0

88262 CHROMOSOME ANALYSIS COUNT 15-20 CEL 254 85 75 414 1 0 0 1 6 2 7 15 0 0 0 0

88263 CHROMOSOME ANALYSIS COUNT 45 CELLS 4 9 3 16 0 0 0 0 0 0 0 0 0 0 0 0

88264 CHROMOSOME ANAYLSIS ANALYZE 20-25 C 53 125 17 195 0 0 1 1 79 56 99 234 0 0 0 0

88267 CHROMOSOME ANALYSIS AMNIOTIC FLUID 16 1 1 18 0 0 0 0 0 0 0 0 0 0 0 0

88269 CHROMOSOME ANALYSIS IN SITU HYBRIDI 18 15 2 35 0 0 0 0 0 0 0 0 0 0 0 0

88271 MOLECULAR CYTOGENETICS DNA PROBE EA 11,208 197 103 11,508 0 0 0 0 293 33 81 407 0 0 2 2

88272 MOLECULAR CYTOGENETICS CHROMOSOMAL 0 0 14 14 0 0 0 0 0 0 0 0 0 0 0 0

88273 MOLECULAR CYTOGENETICS CHROMOSOMAL 22 11 0 33 0 0 0 0 0 0 0 0 0 0 0 0

88274 MOLECULAR CYTOGENETICS INTERPHASE I 25 24 12 61 0 0 0 0 8 2 2 12 0 0 1 1

88275 MOLECULAR CYTOGENETICS INTERPHASE I 67 43 6 116 0 0 0 0 106 17 61 184 0 0 0 0

88280 CHROMOSOME ANALYSIS ADDITIONAL KARY 77 349 138 564 0 0 3 3 223 139 266 628 0 0 0 0

88283 CHROMOSOME ANALYSIS ADDITIONAL SPEC 0 0 12 12 0 0 0 0 0 0 5 5 0 0 0 0

88285 CHROMOSOME ANALYSIS ADDITIONAL CELL 24 0 0 24 0 0 0 0 0 0 0 0 0 0 0 0

88289 CHROMOSOME ANALYSIS ADDITIONAL HIGH 86 0 0 86 0 0 0 0 0 0 0 0 0 0 0 0

88291 CYTOGENETICS & MOLECULAR CYTOGENETI 66 35 35 136 0 0 0 0 79 0 31 110 0 0 0 0

88300 LEVEL I SURGICAL PATHOLOGY GROSS EX 92 614 1,168 1,874 0 4 2 6 1 125 233 359 0 0 0 0

88302 LEVEL II SURGICAL PATHOLOGY GROSS & 380 240 2,959 3,579 0 1 9 10 0 76 187 263 0 0 0 0

88304 LEVEL III SURGICAL PATHOLOGY GROSS 1,183 1,918 5,617 8,718 4 21 42 67 49 671 2,532 3,252 0 1 2 3

88305 LEVEL IV SURGICAL PATHOLOGY GROSS & 14,325 7,339 32,619 54,283 93 106 461 660 1,683 7,645 43,450 52,778 13 5 154 172

88307 LEVEL V SURGICAL PATHOLOGY GROSS & 896 1,267 6,635 8,798 0 12 48 60 3 931 2,361 3,295 0 4 6 10

88309 LEVEL VI SURGICAL PATHOLOGY GROSS & 35 68 329 432 0 1 4 5 0 73 471 544 0 0 1 1

88311 DECALCIFICATION PROCEDURE **ADD ON 242 367 1,346 1,955 2 3 19 24 10 341 1,535 1,886 0 0 3 3

88312 SPECIAL STAIN INCLUDING INTERPRETAT 2,108 506 3,994 6,608 26 3 57 86 229 649 3,309 4,187 4 2 9 15

88313 SPECIAL STAIN INCLUDING INTERPRETAT 891 837 3,648 5,376 4 16 69 89 150 679 2,614 3,443 1 0 2 3

88314 SPECIAL STAIN INCLUDING INTERPRETAT 15 1 106 122 0 0 5 5 15 15 34 64 0 0 0 0

88319 SPECIAL STAIN INCLUDING INTERPRETAT 2 4 138 144 0 0 6 6 6 32 46 84 0 0 0 0

88321 CONSULTATION & REPORT ON REFERRED S 14 22 254 290 0 0 3 3 5 3 270 278 0 0 0 0

88323 CONSULTATION & REPORT ON REFERRED M 12 6 34 52 0 0 0 0 26 7 38 71 0 0 0 0

88325 CONSULTATION COMPREHENSIVE W REVIEW 0 3 5 8 0 0 0 0 0 1 7 8 0 0 0 0

88329 PATHOLOGY CONSULTATION DURING SURGE 5 42 196 243 0 1 4 5 0 10 109 119 0 0 0 0

88331 PATHOLOGY CONSULTATION DURING SURGE 91 150 674 915 1 0 5 6 0 379 1,170 1,549 0 0 3 3

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88342 IMMUNOHISTOCHEMISTRY (INCLUDING TIS 1,357 1,430 6,452 9,239 5 9 27 41 174 468 1,278 1,920 4 0 9 13

88346 IMMUNOFLUORESCENT STUDY EA ANTIBODY 38 219 876 1,133 0 6 20 26 9 58 417 484 0 0 0 0

88347 IMMUNOFLUORESCENT STUDY EA ANTIBODY 217 119 48 384 2 1 5 8 6 35 16 57 0 0 0 0

88348 ELECTRON MICROSCOPY DIAGNOSTIC 2 22 74 98 0 1 0 1 0 8 18 26 0 0 0 0

88355 MORPHOMETRIC ANALYSIS; SKELETAL MUS 0 0 2 2 0 0 0 0 0 0 1 1 0 0 0 0

88356 MORPHOMETRIC ANALYSIS; NERVE 58 0 9 67 2 0 0 2 96 0 2 98 0 0 0 0

88358 MORPHOMETRIC ANALYSIS; TUMOR 8 0 0 8 0 0 0 0 0 0 0 0 0 0 0 0

88360 MORPHOMETRIC ANALYSIS TUMOR IMMUNOH 510 132 588 1,230 0 5 18 23 174 285 690 1,149 0 0 0 0

88361 MORPHOMETRIC ANALYSIS TUMOR IMMUNOH 66 8 66 140 0 0 0 0 116 50 199 365 0 0 0 0

88362 NERVE TEASING PREPARATIONS 0 0 3 3 0 0 0 0 0 0 2 2 0 0 0 0

88363 EXAMINATION AND SELECTION OF RETRIE 1 0 23 24 0 0 1 1 3 2 24 29 0 0 0 0

88365 MORPHOMETRIC ANALYSIS, TUMOR IMMUNO 24 11 75 110 0 0 0 0 5 22 71 98 0 0 0 0

88367 MORPHOMETRIC ANALYSIS, IN SITU HYBR 438 51 611 1,100 0 0 0 0 549 234 969 1,752 0 0 0 0

88368 MORPHOMETRIC ANALYSIS, IN SITU HYBR 221 94 253 568 4 8 0 12 191 142 568 901 0 0 0 0

88372 PROTEIN ANALYSIS OF TISSUE BY WESTE 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

88380 MICRODISSECTION (EG, MECHANICAL, LA 1 0 0 1 0 0 0 0 2 0 0 2 0 0 0 0

88381 MICRODISSECTION (IE, SAMPLE PREPARA 45 1 18 64 1 0 0 1 77 5 65 147 0 0 0 0

88387 MACROSCOPIC EXAMINATION, DISSECTION 0 0 2 2 0 0 0 0 66 0 0 66 0 0 0 0

88399 UNLISTED SURGICAL PATHOLOGY PROCEDU 3 44 41 88 0 0 0 0 0 0 0 0 0 0 0 0

88720 BILIRUBIN, TOTAL, TRANSCUTANEOUS 0 5 1,743 1,748 0 0 0 0 0 0 0 0 0 0 0 0

88738 HEMOGLOBIN (HGB), QUANTITATIVE, TRA 0 7 1,701 1,708 0 0 0 0 0 25 12 37 0 0 0 0

88740 HEMOGLOBIN, QUANTITATIVE, TRANSCUTA 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0

89050 CELL COUNT MISCELLANEOUS BODY FLUID 20 286 9 315 0 3 0 3 4 87 6 97 0 0 0 0

89051 CELL COUNT MISCELLANEOUS BODY FLUID 108 1,093 21 1,222 0 4 0 4 48 286 7 341 0 0 0 0

89055 LEUKOCYTE COUNT, FECAL 445 557 15 1,017 7 3 0 10 123 132 11 266 0 0 0 0

89060 CRYSTAL ID BY LIGHT MICROSCOPY W OR 31 162 83 276 0 1 4 5 40 56 31 127 0 0 0 0

89125 FAT STAIN FECES URINE OR RESPIRATOR 23 16 2 41 0 0 0 0 30 25 0 55 0 0 0 0

89160 MEAT FIBERS FECES 0 0 1 1 0 0 0 0 3 1 0 4 0 0 0 0

89190 NASAL SMEAR FOR EOSINOPHILS 2 8 83 93 0 0 0 0 1 3 3 7 0 0 0 0

89220 SPUTUM, OBTAINING SPECIMEN, AEROSOL 0 19 1 20 0 0 0 0 0 7 6 13 0 0 0 0

89230 SWEAT COLLECTION BY IONTOPHORESIS-T 1 301 1 303 0 0 0 0 0 0 0 0 0 0 0 0

89240 UNLISTED MISCELLANEOUS PATHOLOGY TE 17 0 0 17 0 0 0 0 114 0 0 114 0 0 0 0

89250 CULTURE OF OOCYTE(S)/EMBRYO(S), LES 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0

89300 SEMEN ANALYSIS PRESENCE/MOTILITY OF 0 0 2 2 0 0 0 0 0 0 0 0 0 0 0 0

89310 SEMEN ANALYSIS; MOTILITY AND COUNT 0 0 4 4 0 0 0 0 1 0 0 1 0 0 0 0

89320 SEMEN ANALYSIS COMPLETE 2 2 0 4 0 0 0 0 0 0 0 0 0 0 0 0

89321 SEMEN ANALYSIS PRESENCE & OR MOTILI 1 4 5 10 0 0 0 0 0 0 0 0 0 0 0 0

89325 SPERM ANTIBODIES 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

G0103 PROSTATE CANCER SCREENING; PROSTATE 78 60 66 204 16 5 14 35 2,790 1,210 2,636 6,636 10 0 14 24

G0123 SCREENING CYTOPATHOLOGY, CERVICAL O 7 0 32 39 0 0 4 4 161 1 157 319 1 0 0 1

G0124 SCREENING CYTOPATHOLOGY, CERVICAL O 1 0 14 15 0 0 4 4 20 0 112 132 0 0 0 0

G0143 SCREENING CYTOPATHOLOGY SMEARS, CER 0 0 0 0 0 0 0 0 0 0 2 2 0 0 0 0

G0144 SCREENING CYTOPATH, CERV/VAG, IN PR 0 0 0 0 0 0 0 0 3 0 8 11 0 0 0 0

G0145 SCREENING CYTOPATHOLOGY, CERV/VAG I 25 13 12 50 3 0 17 20 323 1 1,528 1,852 1 0 1 2

G0148 SCREENING CYTOPATHOLOGY SMEARS CERV 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0

G0306 CBC, AUTOMATED (HGB, HCT, RBC, WBC, 12 2 9 23 0 0 0 0 18 2 0 20 0 0 0 0

G0307 CBC AUTOMATED (HGB, HCT, RBC, WBC; 31 4 0 35 0 0 0 0 20 8 0 28 0 0 0 0

G0328 FECAL BLOOD SCREENING IMMUNOASSAY 2 13 123 138 1 0 10 11 129 38 1,863 2,030 0 0 3 3

G0416 SURG PATH GROSS/MICROS EXAM-PROSTAT 0 0 2 2 0 0 0 0 0 0 93 93 0 0 0 0

G0431 DRUG SCREEN, QUALITATIVE; MULTIPLE 21,287 20,964 21,363 63,614 240 115 562 917 3,284 1,182 11,108 15,574 2 4 9 15

G0432 INFECTIOUS AGENT ANTIBODY DETECTION 0 4 0 4 0 0 0 0 0 5 0 5 0 0 0 0

G0433 INFECTIOUS AGENT ANTIBODY DETECTION 0 51 0 51 0 0 0 0 0 5 0 5 0 0 0 0

G0434 DRUG SCREEN OTHER THAN CHROMATOGRAP 34,901 5,146 61,421 101,468 86 15 551 652 480 338 9,328 10,146 6 0 28 34

G0435 INFECTIOUS AGENT ANTIGEN DETECTION 0 1 1 2 0 0 0 0 0 2 1 3 0 0 0 0

G0452 (blank) 160 13 730 903 6 0 13 19 114 1 339 454 0 0 0 0

G6040 (blank) 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0

P3000 SCREENING PAPANICOLAOU SMEAR, CERVI 0 0 0 0 0 0 0 0 1 0 16 17 0 0 0 0

P3001 SCREENING PAPANICOLAOU SMEAR, CERVI 0 0 8 8 0 0 0 0 1 0 0 1 0 0 0 0

P7001 CULTURE, BACTERIAL, URINE; QUANTITA 0 0 2 2 0 0 0 0 0 0 1 1 0 0 0 0

P9603 TRAVEL ALLOWANCE ONE WAY COLLECTION 23,366 0 1,371 24,737 15 0 195 210 3,478 57 7,888 11,423 36 0 0 36

Page Number 18

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RFI ATTACHMENT F


Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Total

Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

BlueCare Plus

Total Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

Medicare

Advantage Total

Services

Independent Lab

Services

Outpatient Facility

Services

Practitioner Other

Services

Medicare

Advantage HMO

Total Services



P9604 TRAVEL ALLOWANCE ONE WAY COLLECTION 10 0 0 10 0 0 0 0 0 9 28 37 0 0 0 0

P9612 CATHETERIZATION FOR COLLECTION OF S 0 333 7 340 0 0 5 5 0 108 141 249 0 0 0 0

P9615 CATHETERIZATION FOR COLLECTION OF S 0 0 4 4 0 0 0 0 0 0 0 0 0 0 0 0

Q0111 WET MOUNTS, INCLUDING PREPARATIONS 0 5 503 508 0 0 3 3 0 1 87 88 0 0 0 0

Q0112 ALL POTASSIUM HYDROXIDE (KOH) PREPA 0 0 154 154 0 0 2 2 0 0 81 81 0 0 0 0

Q0114 FERN TEST 0 1 23 24 0 0 0 0 0 0 0 0 0 0 0 0

S3645 HIV-1 ANTIBODY TESTING OF ORAL MUCO 0 0 16 16 0 0 0 0 0 0 0 0 0 0 0 0

S3650 SALIVA TEST, HORMONE LEVEL; DURING 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0

S3854 GENE EXP PROFIL PANEL IN MGT OF BRE 28 0 2 30 0 0 0 0 9 0 0 9 0 0 0 0

2,333,473 1,538,344 1,328,638 5,200,455 18,859 10,552 13,250 42,661 625,048 507,122 726,116 1,858,286 1,981 912 2,825 5,718Grand Total

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