PRCDR_

CD PRCDR_DSCRPTN

TOTAL_UNI

TS

PRCDR_MODIFIER

_CD BILLED_AMT ALLOWED_AMT Relevant Amount Relevant Savings SRC_PRVDR_ID

C

I

T

Y

_

N

M

72193 Computerized Axial Tomography, Pelvis- With Contrast Material(s) 1.00 26 $204.00 $106.99 $50.00 $56.99 4049762 Newport News

71260 Computerized Axial Tomography, Thorax- With Contrast Material(s) 1.00 26 $218.00 $113.81 $50.00 $63.81 4049762 Newport News

74160 Computerized Axial Tomography, Abdomen- With Contrast Material(s) 1.00 26 $224.00 $116.90 $50.00 $66.90 4049762 Newport News

72146 Magnetic Resonance (eg, Proton) Imaging, Spinal Canal And Contents, Thor 1.00 26 $275.00 $147.19 $60.00 $87.19 7994013 Norfolk

72132 Computerized Axial Tomography, Lumbar Spine- With Contrast Material 2.00 26 $484.00 $225.58 $100.00 $125.58 7387561 Norfolk

73721 Magnetic Resonance (eg, Proton) Imaging, Any Joint Of Lower Extremity-wi 1.00 $1,390.00 $1,105.00 $900.00 $205.00 7328055 Virginia Beach

73718 Magnetic Resonance (eg, Proton) Imaging, Lower Extremity, Other Than Joi 1.00 $1,225.00 $1,097.00 $900.00 $197.00 7328055 Virginia Beach

72193 Computerized Axial Tomography, Pelvis- With Contrast Material(s) 1.00 $1,599.00 $1,311.18 $550.00 $761.18 6560700 Virginia Beach

71260 Computerized Axial Tomography, Thorax- With Contrast Material(s) 1.00 $1,626.00 $1,333.32 $550.00 $783.32 6560700 Virginia Beach

74160 Computerized Axial Tomography, Abdomen- With Contrast Material(s) 1.00 $1,699.00 $1,393.18 $550.00 $843.18 6560700 Virginia Beach

70450 Computed Tomography, Head Or Brain- Without Contrast Material 1.00 $1,617.00 $1,519.98 $450.00 $1,069.98 6560425 Norfolk

70450 Computed Tomography, Head Or Brain- Without Contrast Material 1.00 $1,617.00 $1,519.98 $450.00 $1,069.98 6560435 Norfolk

72146 Magnetic Resonance (eg, Proton) Imaging, Spinal Canal And Contents, Thor 1.00 $2,276.00 $1,934.60 $900.00 $1,034.60 6560685 Virginia Beach

73721 Magnetic Resonance (eg, Proton) Imaging, Any Joint Of Lower Extremity-wi 1.00 26 $213.10 $131.41 $60.00 $71.41 7974947 Seattle

73721 Magnetic Resonance (eg, Proton) Imaging, Any Joint Of Lower Extremity-wi 1.00 RT $213.10 $131.41 $60.00 $71.41 7974947 Seattle

73721 Magnetic Resonance (eg, Proton) Imaging, Any Joint Of Lower Extremity-wi 1.00 RT $1,502.53 $1,166.93 $700.00 $466.93 7723468 Vancouver

73721 Magnetic Resonance (eg, Proton) Imaging, Any Joint Of Lower Extremity-wi 1.00 RT $2,153.00 $1,197.22 $700.00 $497.22 6580495 Seattle

70486 Computed Tomography, Maxillofacial Area- Without Contrast Material 1.00 26 $241.00 $77.41 $50.00 $27.41 7274613 Milwaukee

72193 Computerized Axial Tomography, Pelvis- With Contrast Material(s) 1.00 26 $354.25 $354.25 $50.00 $304.25 7781395 Tomah

74160 Computerized Axial Tomography, Abdomen- With Contrast Material(s) 1.00 26 $391.00 $391.00 $50.00 $341.00 7781395 Tomah

70553 Magnetic Resonance (eg, Proton) Imaging, Brain (including Brain Stem)- W 1.00 26 $620.75 $620.75 $70.00 $550.75 7781395 Tomah

71250 Computed Tomography, Thorax- Without Contrast Material 1.00 $1,704.00 $1,618.80 $715.00 $903.80 7924354 La Crosse

73700 Computed Tomography, Lower Extremity- Without Contrast Material 1.00 LT $1,738.00 $1,651.10 $715.00 $936.10 4131595 Tomah

72193 Computerized Axial Tomography, Pelvis- With Contrast Material(s) 1.00 $1,673.25 $1,673.25 $765.00 $908.25 6590365 La Crosse

74160 Computerized Axial Tomography, Abdomen- With Contrast Material(s) 1.00 $1,673.25 $1,673.25 $765.00 $908.25 6590365 La Crosse

74170 Computerized Axial Tomography, Abdomen- Without Contrast Material, Follo 1.00 $2,628.00 $2,496.60 $865.00 $1,631.60 9021253 Sparta

73221 Magnetic Resonance (eg, Proton) Imaging, Any Joint Of Upper Extremity-wi 1.00 RT $2,884.00 $2,739.80 $1,000.00 $1,739.80 7924354 La Crosse

70553 Magnetic Resonance (eg, Proton) Imaging, Brain (including Brain Stem)- W 1.00 $3,819.25 $3,819.25 $1,200.00 $2,619.25 6590365 La Crosse

70450 Computed Tomography, Head Or Brain- Without Contrast Material 1.00 26 $118.00 $71.40 $50.00 $21.40 7893231 Morgantown

70450 Computed Tomography, Head Or Brain- Without Contrast Material 1.00 $832.00 $732.16 $715.00 $17.16 6600315 Morgantown

$1,593,407.84 $1,001,978.45 $546,465.00 $449,683.55

Self Funded Employer Using Aetna Employer Group through Aetna Employer Group through Relevant

1700 Total Lives on the Plan Total Paid $1,001,978.45 Total Paid $546,465.00

Total PPO

Savings $591,429.39

Additional

Savings BELOW

PPO $449,683.55 44.88%

****Represents page 1 of 29. Total claims reviewed = 1211

Avg Cost Per

CPT $828.08

Avg Cost Per

CPT $451.62Avg Savings Per

CPT $376.46 45.46%