Optim Medical Center-Screven CMS

ID
Description
Standard Charge
64415AN2
N BLOCK, INTERSCALINE
$500.00
64415ANS
N BLOCK, INFRACLAVICULAR
$500.00
64417ANS
N BLOCK, AXILLARY
$500.00
64418ANS
N BLOCK, SUPRASCAPULAR
$500.00
87015LAB
CONCENTRATE (FOR INFECTIOUS AGENTS)
$36.72
87040LAB
CULTURE, BLOOD
$56.76
87045LAB
CULTURE, STOOL
$51.88
87070L02
CULTURE, CATH
$47.36
87070L03
CULTURE, CSF
$47.36
87070L04
CULTURE, EAR
$47.36
87070L05
CULTURE, EYE
$47.36
87070L06
CULTURE, MISC
$47.36
87070L07
CULTURE, NASAL
$47.36
87070L08
CULTURE, SPUTUM
$47.36
87070L09
CULTURE, THROAT
$47.36
87070L10
CULTURE, VAGINAL (CERVIX)
$47.36
87070L11
CULTURE, WOUND
$47.36
87070LAB
CULTURE, BODY FLUID
$47.36
87073LAB
CULTURE, ANAEROBIC
$51.88
87077L2
ORGANISM ID
$44.44
87077LAB
ORGANISM ID
$44.44
87081L03
MRSA - SELECT (NASAL)
$36.48
87086L2
URINE COLONY COUNT
$44.40
87086LAB
URINE COLONY COUNT
$44.40
87088LAB
CULTURE, URINE
$44.52
87102LAB
CULTURE, FUNGUS
$46.20
87116LAB
CULTURE, AFB
$44.50
87177LAB
OVA & PARASITES IDENTIFICATION (STOOL)
$48.92
87185L4
BETA LACTOMASE
$26.12
87186L2
SENSITIVITY STUDIES
$47.52
87186LAB
SENSITIVITY STUDIES
$47.52
87205L02
GRAM STAIN
$12.88
87205LAB
FECAL WBC
$12.88
87206LAB
AFB STAIN
$29.56
87209LAB
COMPLEX SPECIAL STAIN; TRICHROME
$98.84
87210L02
WET MOUNT
$23.48
87252LAB
CULTURE TISSUE
$121.60
87255LAB
HERPES SIMPLEX VIRUS CULTURE
$83.18
87272LAB
INFECTIOUS AGENT ANTIGEN DETECT; CRYPTOS
$65.96
87280LAB
RESPIRATORY SYNCYTIAL VIRUS RSU Ag
$65.96
87324LAB
C DIFFICILE TOXIN
$65.96
87329LAB
GIARDIA ANTIGEN
$65.96
87338LAB
H. PYLORI ANTIBODIES (STOOL)
$79.08
87389LAB
HIV 1/2 AG & AB 4TH GEN W REFLEX
$98.58
87449LAB
C DIFF ANTIGEN
$65.96
87493LAB
CLOSTRIDIUM DIFFICILE TOXIN B QUAL PCR
$107.08
87497LAB
CYTOMEGALOVINO QUANT
$144.00
87517LAB
HEPATITIS B DNA QUANT (PCR)
$117.81
87522LAB
HEPATITIS C qUANT
$117.76
87529LAB
HSV 1 & 2 DNA REAL TIME PCR
$144.00
87536LAB
HIV-1 RNA, QN REAL TIME PCR
$130.00
87590LAB
GONORRHEA DNA PROBE
$108.44
87660LAB
TRRCHOMONAS VAGINALIS
$88.44
87661LAB
TRICHOMONAS, MALES
$107.08
87799LAB
BK VIRUS DNA QUANT
$117.76
87804LAB
INFLUENZA A AND B
$65.96
87880LAB
RAPID STREP (QW)
$65.96
87902LAB
HEP C VIRAL RNA GENOTYPE
$239.76
36430L2
BLOOD ADMINISTRATION LEVEL 2
$592.70
36430L3
BLOOD ADMINISTRATION LEVEL 3
$792.70
36430L4
BLOOD ADMINISTRATION LEVEL 4
$992.70
36430LAB
BLOOD, ADMINISTRATION LEVEL 1
$392.70
86880LAB
COOMBS DIRECT
$29.56
86885LAB
COOMBS INDIRECT
$31.48
P9016LAB
RED BLOOD CELLS, LEUKOCYTES
$364.00
P9034LAB
PLATELET, PHERESIS
$392.70
80048LAB
BMP
$47.92
80051LAB
ELECTROLYTE PANEL
$38.56
80053LAB
CMP
$58.12
80061LAB
LIPID PROFILE
$73.68
80069LAB
RENAL FUNCTION PANEL
$49.20
80074LAB
HEPATITIS PANEL
$269.88
80076LAB
LIVER PROFILE (LFT)
$46.28
80156LAB
TEGRETOL (CARBAMAZEPINE)
$82.48
80158LAB
CYCLOSPORIN
$33.72
80162LAB
DIGOXIN (LANOXIN)
$73.00
80164LAB
DEPAKENE (DEPAKOTE) (VALPORIC)
$74.52
80168LAB
ETHOSUXIMIDE
$89.88
80170LAB
GENTAMYCIN
$90.12
80175LAB
LAMICTAIL
$72.36
80178LAB
LITHIUM
$36.36
80184LAB
PHENOBARBITAL
$62.96
80185LAB
DILATIN (PHENYTION)
$72.88
80197LAB
TACROLIMUS (PROGRAF)
$75.48
80198LAB
THEOPHYLLINE
$77.80
80201LAB
TOPAMAX TOPIRAMATE
$65.56
80202LAB
VANCOMYCIN
$74.52
80301L4
DRUG SCREEN URINE
$394.60
80320LAB
ETHANOL
$59.40
80323LAB
ALKALOIDS, NOT OTHERWISE SPECIFIED
$96.93
80329L2
ACETAMINOPHEN
$111.28
80329LAB
SALICYLATE
$39.00
82009L02
URINE ACETONE
$24.84
82024LAB
ACTH
$218.84
82040LAB
ALBUMIN
$27.20
82043LAB
URINE MICRO ALBUMIN
$31.80
82085LAB
ALDOLASE
$53.36
82088LAB
ALDOSTERONE
$112.04
82103LAB
ALPHA-1-ANTITRYPSIN TOTAL
$147.76
82104LAB
ALPHA-1=ANTITRYPSIN PHENOTYPE
$78.92
82105LAB
ALPHA FETAL PROTEIN
$92.24
82140LAB
AMMONIA
$80.12
82150LAB
AMYLASE
$35.64
82164LAB
ANGIOTENSIN 1, (ACE)
$80.28
82175LAB
ARSENIC
$64.24
82247LAB
BILIRUBIN TOTAL
$27.60
82248LAB
BILIRUBIN DIRECT/INDIRECT
$27.60
82272LAB
OCCULT BLOOD (STOOL)
$17.92
82306LAB
VITAMIN D-25 HYDROXY
$162.80
82310LAB
CALCIUM
$28.36
82330LAB
CALCIUM, IONIZED
$75.16
82435LAB
CHLORIDE
$25.28
82436LAB
URINE CHLORIDE
$27.64
82465LAB
CHOLESTEROL
$23.92
82495LAB
CHROMIUM
$111.52
82507LAB
CITRIC ACID 24 URINE
$114.66
82523LAB
N-TELOPEPTICLE URINE
$102.76
82525LAB
COPPER
$68.24
82530L2
CORTISOL, FREE
$68.24
82533LAB
CORTISOL LEVEL
$89.64
82540LAB
24 URINE CREATINE
$50.96
82550LAB
CPK
$35.80
82553LAB
CKMB
$63.48
82565LAB
CREATININE
$28.16
82570LAB
URINE CREATININE
$28.44
82575LAB
24 HOUR CREATININE CLEARANCE
$51.96
82607LAB
VITAMIN B-12
$82.88
82608LAB
VITAMIN B12 BINDING CAPACITY
$78.16
82627LAB
DHEA SULFATE
$90.99
82652LAB
VITAMIN D, 1, 25 DIHYDROXY
$211.68
82656LAB
PANCREATIC ELASTASE
$58.32
82668LAB
ERYTHROPOIETIN
$103.36
82670LAB
ESTRADIOL
$153.64
82672LAB
ESTROGEN
$119.28
82705LAB
FECAL FAT QUAL
$27.98
82728LAB
FERRITIN
$74.92
82746LAB
FOLATE
$80.84
82747LAB
FELATE BBC
$95.24
82784L02
IGG
$51.12
82784L03
IGM
$51.12
82784LAB
IGA
$51.12
82785LAB
IGE
$90.56
82787L2
IgG SUBCLASS 2
$33.09
82787L3
IgG SUBCLASS 3
$33.09
82787L4
IgG SUBCLASS 4
$33.09
82787LAB
IgG SUBCLASS 1
$33.09
82945L02
SYNOVIAL FLUID GLUCOSE
$21.56
82945LAB
GLUCOSE CSF
$21.56
82947LAB
GLUCOSE
$21.56
82948LAB
REAGENT STRIP/BLOOD GLUCOSE
$17.40
82950LAB
GLUCOSE POSTPRANDIAL 1 HOUR
$26.12
82951LAB
GLUCOSE TOLERANCE TEST- 2HR
$70.76
82952LAB
GLUCOSE TOLERANCE TEST- 3HR
$21.56
82955LAB
GLUCOSE-6 PHOSPATE DEHYDROGENASE , QUANT
$85.76
82977LAB
GGT
$39.60
83001LAB
FOLLICE STIMULATING HORMONE (FSH)
$102.16
83002LAB
LUTEINIZING HORMONE
$101.84
83009LAB
H PYLORI; UREASE
$74.36
83010LAB
HAPTOGLOBIN
$20.48
83013LAB
H PYLORI BREATH TEST
$370.36
83018LAB
COBALT
$120.76
83021ALAB
HEMOGLOBINOPATHY
$33.00
83036LAB
GLYCOHEMOGLOBIN (A1C)
$53.36
83090LAB
HOMOCYSTEINE LEVEL
$92.76
83498LAB
17 HYDROXYPROGESTRONE
$112.05
83516L2
TRONSGLUTAMINASE ANTIBODIES AB(IGA)
$58.72
83516L3
TRANSGLUTAMINOSE AB (IGA)
$58.72
83516L4
ANTIPHOSPHOLIPID Ab IgG
$58.32
83516LAB
CENTROMERE
$58.76
83519L5
PTH RELATED PROTEIN
$73.56
83519L6
PTH RELATED PROTEIN
$73.56
83519L7
TRYPSIN
$73.72
83519LAB
ACETYLCHOLINE RECEPTOR BINDING ANTIBODY
$74.28
83520L5
TRYPTASE
$70.64
83520LAB
GLOMERULAR BASEMENT MEMBRANCE
$60.00
83525LAB
INSULIN
$62.84
83540LAB
IRON
$35.60
83550LAB
IRON BINDING CAPACITY (TIBC)
$48.08
83605L2
LACTIC ACID
$40.08
83605LAB
LACTIC ACID
$117.44
83615LAB
LDH
$33.20
83655LAB
LEAD (BLOOD)
$66.56
83690LAB
LIPASE
$37.88
83695LAB
LIPOPROTEIN A
$71.20
83704LAB
DMR LIPOPROFILE
$86.72
83721LAB
LDL CHOLESTEROL
$52.44
83735LAB
MAGNESIUM (MG)
$36.84
83789LAB
TRILEPTAL (10-HYDROXYCARBAZEPINE)
$99.28
83825LAB
MERCURY
$54.40
83835LAB
24 HOUR METANEPHRINES
$93.16
83873LAB
MYELIN BOSIC PROKIN, CSF
$94.60
83874LAB
MYOGLOBIN URINE
$71.00
83880LAB
BNP B-TYPE NATRIURETIC PEPTIDE
$186.64
83883L2
FREE LAMBDA
$75.56
83883LAB
FREE KAPPA
$75.56
83915L1
5 NUCLEOTIDASE
$60.84
83916LAB
OLIGOCLONAL BANDS CSF
$109.72
83921LAB
METHYLMALONIC ACID
$89.80
83935LAB
OSMOLALITY URINE
$37.48
83945LAB
OXALIC ACID 24 URINE
$70.76
83970LAB
PARATHYROID HORMONE
$113.48
84100LAB
PHOSPHORUS (PO4)
$26.08
84105LAB
PHOSPHATE 24 URINE
$28.44
84120LAB
PORPHYNNS URINE
$108.28
84132LAB
POTASSIUM (K+)
$25.28
84133LAB
URINE POTASSIUM (K+)
$23.64
84134LAB
PRE-ALBUMIN
$80.20
84140LAB
PREGNENOLONE
$85.26
84144LAB
PROGESTERONE
$112.00
84146LAB
PROLACTIN
$106.56
84154LAB
PSA, FREE
$101.16
84156LAB
URINE TOTAL PROTEIN
$20.16
84157L02
SYNOVIAL FLUID PROTEIN
$20.16
84157LAB
CSF TOTAL PROTEIN
$20.16
84207LAB
VITAMIN B6 (pyridoxine)
$115.86
84244LAB
RENIN ACTIVITY PLASMA
$120.96
84270LAB
SEX HORMONE BLOCKING GLOBULIN
$89.61
84295LAB
SODIUM (NA+)
$26.48
84300L02
URINE SODIUM
$19.00
84305ALAB
INSULIN GROWTH IGF
$87.66
84378LAB
GLYCOMARK
$63.36
84402LAB
TESTOSTERONE, FREE & TOTAL
$140.00
84403LAB
TESTOSTERONE
$141.96
84425LAB
THYAMIN, VITAMIN B1
$116.76
84432LAB
THYROGLOBULIN ANTIBODY
$88.32
84436LAB
T-4, TOTAL
$37.76
84439LAB
T-4, FREE
$49.60
84443LAB
TSH
$92.40
84446LAB
VITAMIN E (TOCOPHEROL)
$77.36
84450LAB
AST (SGOT)
$28.44
84460LAB
ALT (SGPT)
$29.08
84478LAB
TRIGLYCERIDES
$31.60
84479LAB
T-3, UPTAKE
$35.56
84480LAB
T-3, TOTAL
$70.12
84481LAB
T-3, FREE
$93.16
84482LAB
T 3 REVERSE
$86.68
84512LAB
TROPONIN I
$40.60
84520LAB
BUN
$21.72
84550LAB
URIC ACID
$24.84
84560L2
URIC ACID SYNOVIAL FLWD
$26.12
84588LAB
ARGININE VASOPRESSIN
$186.64
84630LAB
ZINC
$62.60
84681LAB
C-PEPTIDE
$87.40
84702LAB
HCG BETA QUANTATIVE
$35.28
84703LAB
SERUM PREGNANCY
$35.28
85303LAB
PROTEIN C ACTIVITY
$76.04
85306LAB
PROTEIN S ACTIVITY
$84.24
86300L02
CA 27-29
$114.44
86304LAB
CA 125
$114.44
86334LAB
IMMUNOFIXATION (SERUM)
$122.84
86480LAB
QUANTIFERON TB GOLD
$170.40
86705LAB
HEP B CORE IGM ANTIBODY
$64.72
86812LAB
B 27 (HLA)
$141.92
G0103LAB
PSA (TOTAL) SCREENING
$101.16
S80361C
OPIATES 1-MORE
$56.46
S80365C
OXYCODONE
$56.46
71202RAD
XR CHEST 2 VIEW (HEALTH FAIR)
$12.00
71250RAD
CT THORAX W/O CONTRAST MATERIAL
$974.30
71250RADSC
CT THORAX W/O CONTRAST
$974.30
71260RAD
CT THORAX W/CONTRAST MATERIAL
$1,218.05
71270RAD
CT THORAX W/O &W/CONTRAST MATERIAL
$1,474.10
71275RAD
CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTR
$1,873.20
72125RAD
CT CERVICAL SPINE W/O CONTRAST MATERIAL
$996.55
72126RAD
CT CERVICAL SPINE W/CONTRAST MATERIAL
$1,216.20
72127RAD
CT CERVICAL SPINE W/O &W/CONTRAST MATERI
$1,452.30
72128RAD
CT THORACIC SPINE W/O CONTRAST MATERIAL
$975.50
72129RAD
CT THORACIC SPINE W/CONTRAST MATERIAL
$1,220.75
72130RAD
CT THORACIC SPINE W/O & W/CONTRAST MATER
$1,459.95
72131RAD
CT LUMBAR SPINE W/O CONTRAST MATERIAL
$972.45
72132RAD
CT LUMBAR SPINE W/CONTRAST MATERIAL
$1,217.70
72133RAD
CT LUMBAR SPINE W/O & W/CONTRAST MATERIA
$1,452.30
72192RAD
CT PELVIS W/O CONTRAST MATERIAL
$810.55
72193RAD
CT PELVIS W/CONTRAST MATERIAL
$1,268.60
72194RAD
CT PELVIS W/O & W/CONTRAST MATERIAL
$1,420.90
73200RAD
CT UPPER EXTREMITY W/O CONTRAST MATERIAL
$969.50
73201RAD
CT UPPER EXTREMITY WITH CONTRAST
$1,189.20
73202RAD
CT UPPER EXTREMITY W/O & W/CONTRAST MATE
$1,509.50
73700RAD
CT LOWER EXTREMITY W/O CONTRAST MATERIAL
$1,061.60
73701RAD
CT LOWER EXTREMITY W/CONTRAST MATERIAL
$1,311.95
74150RAD
CT ABDOMEN W/O CONTRAST MATERIAL
$1,064.90
74160RAD
CT ABDOMEN W/CONTRAST MATERIAL
$1,443.75
74170RAD
CT ABDOMEN W/O &W/CONTRAST MATERIAL
$1,832.75
74174RAD
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTR
$2,086.32
74175RAD
CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCON
$1,883.60
74176RAD
CT ABDOMEN & PELVIS W/O CONTRAST MATERIA
$1,074.15
74177RAD
CT ABDOEN & PELVIS W/CONTRAST MATERIAL
$1,638.40
74178RAD
CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY
$2,075.80
75635RAD
CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POS
$2,087.90
76376RAD
3D RENDERING W/INTERP CT/MRI/US/OTHER TO
$273.95
70450RAD
CT HEAD/BRAIN W/O CONTRAST MATERIAL
$766.60
70460RAD
CT HEAD/BRAIN W/CONTRAST MATERIAL
$1,005.25
70470RAD
CT HEAD/BRAIN W/O&W/CONTRAST MATERIAL
$1,018.45
70486RAD
CT MAXILLOFACIAL W/O CONTRAST MATERIAL
$1,058.90
70487RAD
CT MAXILLOFACIAL W/CONTRAST MATERIAL
$1,274.10
70490RAD
CT SOFT TISSUE NECK W/O CONTRAST MATERIA
$1,035.45
70491RAD
CT SOFT TISSUE NECK W/CONTRAST MATERIAL
$1,244.95
70492RAD
CT SOFT TISSUE NECK W/O &W/CONTRAST MATE
$1,483.00
70496RAD
CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRA
$2,313.20
70498RAD
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRA
$2,391.10
76010RAD
RADEX FROM NOSE RECTUM FOREIGN BODY 1 VI
$126.95
70100RAD
MANDIBLE, LESS THAN 4 VIEWS
$163.65
70110RAD
MANDIBLE, COMPLETE, MIN 4 VIEWS
$187.75
70140RAD
RADEX FACIAL BONES < 3 VIEWS
$142.40
70150RAD
RADEX FACIAL BONES COMPLETE MINIMUM 3 VI
$201.70
70160RAD
RADEX NASAL BONES COMPLETE MINIMUM 3 VIE
$158.85
70200RAD
RADEX ORBITS COMPLETE MINIMUM 4 VIEWS
$206.60
70210RAD
RADEX SINUSES PARANASAL < 3 VIEWS
$105.45
70220RAD
RADEX SINUSES PARANASAL COMPL MINIMUM 3
$184.70
70250RAD
RADIOLOGIC EXAMINATION SKULL < 4 VIEWS
$173.90
70260RAD
RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4
$222.95
70360RAD
RADIOLOGIC EXAMINATION NECK SOFT TISSUE
$131.35
71010RAD
RADIOLOGIC EXAMINATION CHEST SINGLE VIEW
$110.15
71020RAD
RADIOLOGIC EXAM CHEST 2 VIEWS FRONTAL&LA
$142.95
71021RAD
RADEX CH 2 VIEWS FRNT&LAT APICAL LORDOTI
$177.40
71045RAD
RADIOLOGIC EXAM CHEST SINGLE VIEW
$132.18
71046RAD
RADIOLOGIC EXAM CHEST 2 VIEWS FRONT & LA
$171.54
71047RAD
RADEX CHEST 3 VIEWS FRONT LA APIC LORDOT
$212.88
71100RAD
RADEX RIBS UNILATERAL 2 VIEWS
$153.65
71101RAD
RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3
$186.80
71110RAD
RADEX RIBS BILATERAL 3 VIEWS
$192.70
71111RAD
RADEX RIBS BI W/POSTEROANT CH MINIMUM 4
$277.05
71120RAD
RADEX STERNUM MINIMUM 2 VIEWS
$148.70
72040RAD
RADEX SPINE CERVICAL 2/3 VIEWS
$169.00
72050RAD
RADEX SPINE CERVICAL MINIMUM 4 VIEWS
$228.60
72052RAD
RADEX SPINE CRV COMPL W/OBLQ&FLEX&/XTN S
$293.65
72070RAD
RADEX SPINE THORACIC 2 VIEWS
$159.75
72072RAD
RADEX SPINE THORACIC 3 VIEWS
$175.00
72074RAD
RADEX SPINE THORACIC MINIMUM 4 VIEWS
$208.60
72080RAD
RADEX SPINE THORACOLUMBAR 2 VIEWS
$142.40
72081RAD
RADEX SPINE THORACOLMBR STANDING SCOLIOS
$180.15
72082RAD
RADEX SPINE SCOLIOS STUDY W/SUPINE&EREC
$287.30
72100RAD
RADEX SPINE LUMBOSACRAL 2/3 VIEWS
$170.55
72110RAD
RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS
$231.65
72114RAD
RADEX SPINE LUMBSCRL COMPL W/BENDING VIE
$302.15
72170RAD
RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS
$137.60
72190RAD
RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 V
$205.50
72200RAD
RADIOLOGIC EXAMINATION SACROILIAC JNTS <
$140.55
72202RAD
RADIOLOGIC EXAM SACROILIAC JOINTS 3/MORE
$163.80
72220RAD
RADEX SACRUM & COCCYX MINIMUM 2 VIEWS
$137.50
72240RAD
MYELOGRAPY CERVICAL RS&I
$605.75
72255RAD
MYELOGRAPY THORACIC RS&I
$578.20
72265RAD
MYELOGRAPY LUMBOSACRAL RS&I
$593.65
72270RAD
MYELOGRAPY 2/MORE REGIONS RS&I
$924.80
73000RAD
RADEX CLAVICLE COMPLETE
$137.30
73010RAD
RADEX SCAPULA COMPLETE
$152.85
73020RAD
RADEX SHOULDER 1 VIEW
$112.70
73030RAD
RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS
$146.90
73040RAD
RADEX SHOULDER ARTHROGRAPHY RS&I
$500.00
73050RAD
RADEX A-C JOINTS BI W/WO WEIGHTED DISTRC
$191.55
73060RAD
RADEX HUMERUS MINIMUM 2 VIEWS
$137.50
73070RAD
RADEX ELBOW 2 VIEWS
$135.60
73080RAD
RADEX ELBOW COMPLETE MINIMUM 3 VIEWS
$158.85
73085RAD
RADEX ELBOW ARTHROGRAPHY RS&I
$481.60
73090RAD
RADEX FOREARM 2 VIEWS
$132.75
73092RAD
RADEX UPPER EXTREMITY INFANT MINIMUM 2 V
$154.10
73100RAD
RADEX WRIST 2 VIEWS
$152.70
73110RAD
RADEX WRIST COMPLETE MINIMUM 3 VIEWS
$178.75
73115RAD
RADEX WRIST ARTHROGRAPHY RS&I
$525.95
73120RAD
RADEX HAND 2 VIEWS
$131.20
73130RAD
RADEX HAND MINIMUM 3 VIEWS
$154.30
73140RAD
RADEX FINGR MINIMUM 2 VIEWS
$159.70
73501RAD
RADEX HIP UNILATERAL 1 VIEW
$136.85
73502RAD
RADEX HIP UNILATERAL COMPLETE MIN 2-3 VI
$187.15
73521RAD
RADEX HIPS BILATERAL 2 VIEWS ANTEROPOST
$255.71
73522RAD
RADEX HIPS BILATERAL 3-4V WITH PELVIS
$225.75
73525RAD
RADEX HIP ARTHROGRAPHY RS&I
$498.45
73551RAD
RADIOLOGIC EXAMINATION FEMUR 1 VIEW
$128.45
73552RAD
RADIOLOGIC EXAMINATION FEMUR 2 VIEWS
$136.05
73560RAD
RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS
$148.30
73562RAD
RADIOLOGIC EXAMINATION KNEE 3 VIEWS
$179.00
73564RAD
RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIE
$208.70
73565RAD
RADIOLOGIC EXAM BOTH KNEES STANDING ANTE
$171.20
73590RAD
RADIOLOGIC EXAMINATION TIBIA & FIBULA 2
$131.35
73592RAD
RADEX LOWER EXTREMITY INFANT MINIMUM 2 V
$132.75
73600RAD
RADIOLOGIC EXAMINATION ANKLE 2 VIEWS
$137.30
73610RAD
RADEX ANKLE COMPLETE MINIMUM 3 VIEWS
$158.85
73620RAD
RADIOLOGIC EXAMINATION FOOT 2 VIEWS
$131.20
73630RAD
RADEX FOOT COMPLETE MINIMUM 3 VIEWS
$149.70
73650RAD
RADEX CALCANEUS MINIMUM 2 VIEWS
$135.80
73660RAD
RADEX TOE MINIMUM 2 VIEWS
$144.45
74000RAD
RADEX ABDOMEN 1 ANTEROPOSTERIOR VIEW
$116.30
74018RAD
RADEX ABDOMEN 1 VIEW
$137.70
74019RAD
RADEX ABDOMEN 2 VIEWS
$229.38
74020RAD
RADEX ABDOMEN COMPL W/DCBTS&/ERC VIEWS
$191.15
74022RAD
RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1
$230.20
74220RAD
RADEX ESOPHAGUS
$429.80
74247RAD
RADEX UPPER GI W/WO GLUCAGON/DELAY FLMS
$624.10
74250RAD
RADEX SMALL INTESTINE W/MULTIPLE SERIAL
$478.50
77071RAD
MANUAL APPL STRESS PFRMD PHYS JOINT RADI
$242.75
77072RAD
BONE AGE STUDIES
$110.35
77073RAD
BONE LENGTH STUDIES
$182.15
77075RAD
RADIOLOGIC EXAMINATION OSSEOUS SURVEY CO
$444.95
93306RAD
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&
$873.70
93000RES
ROUTINE ECG W/LEAST 12 LDS W/I&R
$79.00
93005RES
ELECTROCARDIOGRAM
$172.45
10060ER
INCISION & DRAINAGE ABSCESS SIMPLE/SINGL
$322.28
10061ER
INCISION&DRAINAGE ABSCESS COMPLICATED/MU
$603.12
10080ER
INCISION & DRAINAGE PILONIDAL CYST SIMPL
$346.12
10120ER
INCISION&REMOVAL FOREIGN BODY SUBQ TISS
$346.05
10121ER
INCISION&REMOVAL FOREIGN BODY SUBQ TISS
$631.79
10140ER
I&D HEMATOMA SEROMA/FLUID COLLECTION
$322.74
11200ER
REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA
$1,250.00
11730ER
AVULSION NAIL PLATE PARTIAL/COMPLETE SIM
$178.68
11740ER
EVACUATION SUBUNGUAL HEMATOMA
$109.59
11750ER
EXCISION NAIL MATRIX PERMANENT REMOVAL
$588.91
11760ER
REPAIR NAIL BED
$449.51
12001ER
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK
$156.31
12002ER
SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.
$418.68
12004ER
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6
$257.67
12005ER
SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-
$638.52
12007ER
SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK
$524.69
12011ER
SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<
$195.41
12013ER
SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0CM
$218.75
12014ER
SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5CM
$278.53
12015ER
SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5CM
$346.99
12020ER
TX SUPERFICIAL WOUND DEHISCENCE SIMPLE C
$1,073.92
12031ER
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<
$515.17
12032ER
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM
$653.72
12034ER
REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM
$701.40
12035ER
REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM
$824.53
12036ER
REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM
$959.21
12041ER
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5
$527.73
12042ER
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6
$675.26
12045ER
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.
$916.72
12051ER
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 C
$579.15
12052ER
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5
$687.58
12053ER
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7
$740.01
12054ER
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-1
$781.55
13121ER
REPAIR COMPLEX SCALP/ARM/LEG 2.6 CM-7.5
$909.65
13122ER
REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 C
$296.07
16020ER
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SM
$183.93
16025ER
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ ME
$384.44
20103ER
EXPLORATION PENETRATING WOUND SPX EXTREM
$1,194.55
20520ER
REMOVAL FOREIGN BODY MUSCLE/TENDON SHEAT
$495.85
20552ER
INJECTION SINGLE/MLT TRIGGER POINT 1/2 M
$131.36
20600ER
ARTHROCENTESIS ASPIR&/INJECTION SMALL JT
$123.48
20605ER
ARTHROCENTESIS ASPIR&/INJECTION INTERM J
$249.96
20610ER
ARTHROCENTESIS ASPIR&/INJECTION MAJOR JT
$201.85
23650ER
CLSD TX SHOULDER DISLC W/MANIPULATION W/
$1,045.73
23655ER
CLSD TX SHOULDER DISLC W/MANIPULATION RE
$1,338.02
24201ER
REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEE
$932.00
24605ER
TREATMENT CLOSED ELBOW DISLOCATION REQ A
$1,918.24
24640ER
CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELB
$319.52
25660ER
CLTX RDCRPL/INTERCARPL DISLC 1/> BONES W
$855.32
26750ER
CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ E
$612.99
26770ER
CLTX IPHAL JT DISLC W/MANJ W/O ANES
$859.32
27250ER
CLTX HIP DISLOCATION TRAUMATIC W/O ANEST
$642.64
27252ER
CLTX HIP DISLOCATION TRAUMATIC REQ ANEST
$2,586.61
27842ER
CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL
$1,671.32
28190ER
REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS
$458.68
28515ER
CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ
$535.22
28660ER
CLTX INTERPHALANGEAL JOINT DISLOCATION W
$304.05
29105ER
APPLICATION LONG ARM SPLINT SHOULDER HAN
$202.90
29125ER
APPLICATION SHORT ARM SPLINT FOREARM-HAN
$133.88
29126ER
APP OF SHORT ARM CAST; DYNAMIC
$295.84
29130ER
APPLICATION FINGER SPLINT STATIC
$138.36
29345ER
APPLICATION LONG LEG CAST THIGH-TOE
$345.17
29405ER
APPLICATION SHORT LEG CAST BELOW KNEE-TO
$203.11
29505ER
APPLICATION LONG LEG SPLINT THIGH ANKLE/
$65.17
29515ER
APPLICATION SHORT LEG SPLINT CALF FOOT
$170.63
30901ER
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE
$197.96
30905ER
CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY
$353.57
31500ER
INTUBATION ENDOTRACHEAL-ER
$460.96
32405ER
PNEUMOCENTESIS PUNCTURE LUNG ASPIRATION
$444.95
32551ER
TUBE THORACOSTOMY INCLUDES WATER SEAL
$621.43
36556ER
INSJ NON-TUNNELED CENTRAL VENOUS CATH AG
$427.95
36569ER
INSERTION OF PICC LINE
$697.14
36680ER
EZ I O Intraosseus Venous Access Device
$492.80
43760ER
CHANGE GASTROSTOMY TUBE PERCUTANEOUS W/O
$976.00
46050ER
I&D PERIANAL ABSCESS SUPERFICIAL
$331.80
46083ER
INCISION THROMBOSED HEMORRHOID EXTERNAL
$361.52
46320ER
EXC OF THROMBOSED HEMORRHOID EXTERNAL
$1,743.20
51798ER
BLADDER SCAN
$59.75
56405ER
I&D VULVA/PERINEAL ABSCESS
$372.19
56420ER
I&D OF BARTHOLINS GLAND ABSCESS
$470.72
64402ER
INJECTION ANESTHETIC AGENT FACIAL NERVE
$257.39
65205ER
REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL
$218.04
65222
REMOVE FB CORNEA W SLIT LAMP
$186.38
69200ER
RMVL FB XTRNL AUDITORY CANAL W/O ANES
$198.21
69209ER
REMOVAL IMPACTED CERUMEN UNILATERAL
$28.98
69210ER
RMVL IMPACTED CERUMEN SPX 1/BOTH EARS
$114.94
90471ER
IMMUNIZATION ADMIINISTRATION (FIRST)
$81.06
90714ER
TETANUS/DIPTHERIA TOXOIDS ABSORBED
$167.28
90715ER
TETANUS/DIPTHERIA/PERTUSSIS TOXOIDS ABSO
$296.80
99195ER
PHLEBOTOMY, THERAPEUTIC
$184.64
99281ER
ER LEVEL 1
$150.00
99282ER
ER LEVEL 2
$221.10
99283ER
ER LEVEL 3
$319.55
99284ER
ER LEVEL 4
$475.20
99285ER
ER LEVEL 5
$820.60
99291ER
ER CRITICAL CARE LEVEL 1ST HOUR
$1,041.52
99292ER
ER CRITICAL CARE EACH ADD'L 30 MINUTES
$465.80
G00008ER
Flu Administration Charge
$81.06
97001PT
PHYSICAL THERAPY EVALUATION
$214.29
97002PT
PHYSICAL THERAPY RE-EVALUATION
$116.37
97161PT
PT EVAL LOW COMPLEXITY
$215.13
97162PT
PT EVAL MODERATE COMPLEXITY
$215.13
97163PT
PT EVAL HIGH COMPLEXITY
$215.13
97164PT
PT RE-EVAL CODE 2017
$145.61
RESPITE
RESPITE ROOM CHARGE
$175.00
85002LAB
BLEEDING TIME
$24.76
85007LAB
BLOOD COUNT, DIFFERENTIAL
$18.92
85014LAB
HCT
$13.04
85018LAB
HEMOGLOBIN
$13.04
85025LAB
CBC/AUTO DIFF
$42.76
85027LAB
CBC (NO AUTO DIFF)
$35.56
85041LAB
RBC
$24.00
85044LAB
Retic
$23.64
85048LAB
WBC
$13.96
85049LAB
PLATELET COUNT
$24.60
85060LAB
PATHOLOGY SMEAR REVIEW
$29.15
85220LAB
FACTOR V
$97.04
85301LAB
ANTITHROMBIN III ANTIGEN
$59.44
85302LAB
PROTEIN C ANTIGEN
$66.08
85305LAB
PROTEIN S ANTIGEN
$63.80
85379LAB
D-DIMER
$55.96
85384LAB
FIBINOGEN
$46.72
85610LAB
PROTIME (PT)
$21.60
85613L2
LUPUS ANTICOAGULANT EVALUATION
$52.64
85651LAB
SED RATE (ESR)
$19.52
85730LAB
PTT (APTT)
$33.00
85999LAB
EOSINOPHIL COUNT URINE
$23.48
93225RES
HOLTER RECORDING
$220.55
93226RES
HOLTER SCANNING
$555.25
80177LAB
LEVETIRACETAM
$75.32
80299LAB
LAMOTRIGINE (LAMICTAIL)
$75.32
82009LAB
ACETONE (SERUM)
$18.08
82271LAB
GASTRIC OCCULT
$17.92
82378LAB
CEA
$104.32
82390LAB
CERULOPLASMIN
$59.04
84300LAB
24 HOUR SODIUM (NA+)
$26.76
85660LAB
SICKLE CELL
$30.36
86003L10
LIVE OAK Ige
$10.28
86003L12
DOG Ige
$10.28
86003L13
PECAN TREE IGE
$28.68
86003L22
ASPERGILLUS FUMIGATUS
$10.28
86003L23
BERMUDA GRASS
$10.28
86003L24
BIRCH
$10.28
86003L25
CIADOSPORIUM HERBARUM
$10.28
86003L26
COCROACH
$10.28
86003L27
DERMATOPHOGOIDES FARINAE
$10.28
86003L28
ELM
$10.28
86003L29
MAPLE
$10.28
86003L30
MOUNTAIN CEDAR
$10.28
86003L31
NETTLE
$10.28
86003L32
PENICILLIUM NOTATUM
$10.28
86003L33
SHEEP SORREL
$10.28
86003L34
TIMOTHY GRASS
$10.28
86003L35
ROUGH PIGWEED IgE
$28.48
86003L36
DERMATOPHAGOIDES PTERONYSSINUS IgE
$28.48
86003L7
BAHIA GRASS Ige
$10.28
86003L8
ALTERNARIA Ige
$10.28
86003L9
RAGWEED Ige
$10.28
86003LAB
CAT Ige
$10.28
86021
MYELOPEROXIDASE Ab (Anca-c)
$25.00
86021L2
PROTEINASE -3 Ab (Anca-p)
$25.00
86038LAB
ANA
$66.48
86039LAB
ANA TITER
$61.40
86060LAB
ASO TITER
$38.44
86140LAB
C REACTIVE PROTEIN
$28.44
86141LAB
HS-CRP
$70.00
86147LAB
CARDIOLIPIN Ab (IgG)
$104.91
86160L02
C4
$66.00
86160LAB
C3
$66.00
86162LAB
CH50
$111.72
86200LAB
CYCLIC CITRULLINE PEPTIDE (CCP)
$71.20
86235L02
SMOOTH MUSCLE RNP ANTIBODY
$98.60
86235L03
SJOGREN'S ANTIBODY A; SS-A
$98.60
86235L04
SJOGREN'S ANTIBODY B; SS-B
$98.60
86235LAB
ANTI SMOOTH MUSCLE
$109.32
86255L02
MILOCHONDRIAL Ab
$66.28
86255L3
SMOOTH MUSCLE Ab
$65.76
86255LAB
PARIETAL CELL AB
$66.28
86301
CA19-9
$114.44
86308LAB
MONO TEST
$28.44
86317L27
HEPATITIS B SURFACE AB QUANT
$66.00
86335LAB
IMMUNOFIXATION URINE
$93.68
86337LAB
GAD-65
$117.22
86340LAB
INTRIOSIC FACTOR BLOCKING AB
$82.88
86341L2
INSULIN AUTOANTIBODY
$108.80
86341LAB
IA-2
$108.80
86360LAB
LYMPHOCYTE SUBSET PANEL 4
$129.18
86361LAB
LYMPHOCYTE SUBSET PANEL 5
$107.67
86376LAB
THYROID PEROXIDOSE ANTIBODY
$79.96
86403LAB
CRYPTOCOCCAL Ag CSF
$56.04
86430LAB
RA LATEX
$31.20
86431L02
QUANTITATIVE TITER
$31.20
86431LAB
RA LATEX (TITER)
$31.20
86592L2
VDRL CSF
$23.48
86592LAB
RPR
$23.48
86606LAB
ASPERGILLUS, FUMIGATUS
$20.54
86609L2
PIGEON SERUM
$17.58
86609LAB
MICROPOLYSPORA FAENI
$17.58
86617LAB
LYME DISEASE Ab IgG
$85.20
86618LAB
LYME DISEASE Ab WITH REFLEX TO BLOT, EIA
$93.64
86644LAB
CYTOMEGAIOVIRUS Ab IgG
$64.00
86664LAB
EPSTEIN BARR VIRUS AB
$84.12
86671L02
ASCA (IgA)
$67.40
86671LAB
ASCA (IgG)
$67.40
86677LAB
H. PYLORI ANTIBODIES
$85.20
86689LAB
HIV Ab, WESTERN BLOCK
$106.40
86695LAB
HERPES ANTIBODY 1
$72.52
86696LAB
HERPES ANITBODY 2
$106.40
86703LAB
HIV
$75.40
86704LAB
HEP B CORE TOTAL
$66.28
86706LAB
HEPATITIS B SURF ANTIBODY HBSAB
$59.04
86708LAB
HEP A ANTIBODY
$68.12
86757LAB
RICKETTSIA
$106.41
86762L2
RUBELLA IMMUNE STATUS
$64.00
86762LAB
RUBELLA
$64.00
86774LAB
TETANUS ANTITOXOID
$81.36
86777LAB
TOXOPLASMA Ab IgG
$64.00
86787LAB
VARICEIN ZOSTER Ab(IgG)
$70.84
86800LAB
THYROGLUBLIN Ab
$87.44
86803LAB
HEPATITIS C ANTIBODY
$78.48
86850LAB
ANTIBODY SCREEN
$70.00
86900LAB
ABO
$16.40
86901LAB
RH
$16.40
86905LAB
PATIENT RBC TYPING PER AG
$41.20
86922LAB
CROSSMATCH
$61.50
87210LAB
KOH
$23.48
87340LAB
HEP B SURGACE ANTIGEN
$56.80
87380LAB
HEP B ANTIGEN
$90.24
96360ER
INTRAVENOUS HYDRATION INIT 31MIN-1 HOUR
$181.44
96361ER
IV INFUS HYDRATION EACH ADDTL HOUR
$48.51
96365ER
IV INFUSION FOR THERAPY; INTL TO 1HR
$274.36
96366ER
IV INFUSION, THERAPY, EACH ADDTL HR
$60.90
96367ER
ADDTL SEQ INFUS OF NEW DRUG TO 1 HR
$97.13
96368ER
CONCURRENT INFUSION
$66.43
96370ER
SUBCUT INFUSION EACH ADDTL HR
$50.79
96372ER
INJECTION; SUBCUT OR INTRAMUSCULAR
$81.06
96374ER
INJECTION INTRAVEN PUSH SNG OR INITIAL
$179.31
96375ER
EH ADDLT PUSH OF NEW DRUG
$71.16
96376ER
IV PUSH EACH ADD'TNAL SEQUENTIAL
$71.16
36415LAB
VENIPUNCTURE
$12.00
82340LAB
24 HR URINE CALCIUM
$33.16
82803RES
ABG
$200.00
83630LAB
FECAL LACTOFERRIN
$106.84
84153LAB
PSA (TOTAL) DIAGNOSTIC
$101.16
84165LAB
PROTEIN ELECTROPHORESIS SERUM
$59.04
84166L2
24 HR URINE PROTEN ELECTROPHORESIS
$98.08
84166LAB
URINE PROTEIN ELECTROPHORESES SERUM
$98.08
84445LAB
THYROID STIM IMMUNE GLOBULINS TSI
$86.70
84466LAB
TRANSFERRIN
$70.20
86003SC
RAST
$20.56
86063LAB
ASO
$31.72
86225LAB
DNA DS ANTIBODY
$75.52
86707LAB
HEP B ANTIBODY
$63.60
86780LAB
FTA-ABS
$72.12
86870LAB
ANTIBODY IDENTIFICATION
$300.00
86904LAB
ANTIGEN SCREEN
$52.28
87185L2
CATALASE ENZYME TEST
$26.12
87491LAB
CHLAMYDIA AMPLIFIED PROBE
$107.88
87502LAB
MOLECULAR FLU
$282.48
87521LAB
HEPATITIS C VIRAL RNA QUALITATIVE
$106.80
87591LAB
GONORRHOEAE AMPLIFIED PROBE
$107.88
87651LAB
MOLECULAR STREP
$106.80
89051L02
SYNOVIAL CELL COUNT WITH DIFF
$9.72
89051LAB
CSF CELL COUNT WITH DIFF
$9.72
CB005
SCH LAB CORP VENIPUNCTURE
$10.00
CB006
DRUG SCREEN URINE
$25.00
S80307
UTOX DRUG SCREEN
$394.60
S80324C
AMPHETAMINES 1-2
$56.46
S80332C
ANTI-DEPRESSANT SEROTONERGIC CLASS
$56.46
S80335C
ANTI-DEPRESSANT TRICYCLIC
$56.46
S80338C
ANTI-DEPRESSANT NOS
$56.46
S80346C
BENZO PANEL (C)
$56.46
S80348C
BUPRENORPHINE
$56.46
S80349C
THC
$56.46
S80353C
COCAINE
$56.46
S80354C
FENTANYL
$56.46
S80355C
GABAPENTIN
$56.46
S80356C
6 MONOACETYLMORPHONE
$56.46
S80358C
METHADONE
$56.46
S80359C
MDE,MDEA, MDMA
$56.46
S80360C
METHYLPHENIDATE RITALINIC ACID
$56.46
S80363C
OPIODS AND OPIATES ANALOG 3 OR 4
$56.46
S80366C
PREGABALIN
$56.46
S80368C
ZOLIPIDEM
$56.46
S80370C
SKELETAL MUSCLE 3 OR MORE
$56.46
S80372C
TAPENTADOL
$56.46
S80373C
TRAMADOL
$56.46
S83992C
PHENCYCLIDINE
$56.46
SG0480
DRUG CLASSES 1-7
$395.22
SG0481
DRUG CLASSES 8-14
$790.44
SG0482
DRUG CLASSES 15-21
$1,185.66
SG0483
DRUG CLASSES 22 OR MORE
$1,298.58
SY87493
CDIFF TOXIN B QUAL PCR
$49.83
89220RES
SPUTUM COLLECTION
$97.90
81001LAB
URINALYSIS W MICROSOPIC
$17.40
81003LAB
URINALYSIS W/O MICROSCOPIC
$12.36
81025LAB
URINE PREGNANCY
$34.80
TELEM-INPT
TELEMETRY INPT
$3,280.88
SWINGBED
SWINGBED
$2,105.00
SWINGBEDSC
SWINGBED
$2,105.00
70551MRI
MRI BRAIN BRAIN STEM W/O CONTRAST MATERI
$1,642.25
70553MRI
MRI BRAIN BRAIN STEM W/O &W/CONTRAST MAT
$2,056.25
70543MRI
MRI ORBIT FACE & NCK W/O &W/CONTRAST MAT
$2,106.65
70544MRI
MRA HEAD W/O CONTRST MATERIAL
$1,834.75
70547MRI
MRA NECK W/O CONTRST MATERIAL
$1,839.45
71550MRI
MRI CHEST W/O CONTRAST MATERIAL
$1,830.15
72141MRI
MRI SPINAL CANAL CERVICAL W/O CONTRAST M
$1,390.20
72146MRI
MRI SPINAL CANAL THORACIC W/O CONTRAST M
$1,558.25
72147MRI
MRI SPINAL CANAL THORACIC W/CONTRAST MAT
$1,558.25
72148MRI
MRI SPINAL CANAL LUMBAR W/O CONTRAST MAT
$1,391.70
72156MRI
MRI SPINAL CANAL CERVICAL W/O & W/CONTR
$1,828.65
72157MRI
MRI SPINAL CANAL THORACIC W/O & W/CONTR
$1,828.65
72158MRI
MRI SPINAL CANAL LUMBAR W/O &W/CONTR MAT
$1,998.20
72195MRI
MRI PELVIS W/O CONTRAST MATERIAL
$1,620.85
72197MRI
MRI PELVIS W/O & W/CONTRAST MATERIAL
$2,143.30
73218MRI
MRI UPPER EXTREMITY OTH THAN JT W/O CONT
$1,614.75
73219MRI
MRI UPPER EXTREMITY OTH THAN JT W/CONTR
$1,764.45
73220MRI
MRI UPPER EXTREM OTHER THAN JT W/O & W/C
$2,144.85
73221MRI
MRI ANY JT UPPER EXTREMITY W/O CONTRAST
$967.05
73222MRI
MRI ANY JT UPPER EXTREMITY W/CONTRAST MA
$1,634.60
73223MRI
MRI ANY JT UPPER EXTREMITY W/O & W/CONTR
$1,995.15
73718MRI
MRI LOWER EXTREM OTH/THN JT W/O CONTR MA
$1,602.55
73720MRI
MRI LOWER EXTREM OTH/THN JT W/O & W/CONT
$2,163.20
73721MRI
MRI ANY JT LOWER EXTREM W/O CONTRAST MAT
$967.05
73722MRI
MRI ANY JT LOWER EXTREM W/CONTRAST MATER
$1,660.60
73723MRI
MRI ANY JT LOWER EXTREM W/O & W/CONTRAST
$1,993.60
74181MRI
MRI ABDOMEN W/O CONTRAST MATERIAL
$1,402.40
74183MRI
MRI ABDOMEN W/O &W/CONTRAST MATERIAL
$2,152.50
95860EMG
NDL EMG 1 XTR W/WO RELATED PARASPINAL AR
$500.00
95885EMG
NEEDLE EMG EA EXTREMITY W/PARASPINL AREA
$500.00
95886EMG
NEEDLE EMG EA EXTREMTY W/PARASPINL AREA
$500.00
95908EMG
NVR CNDJ TST 3-4 STUDIES
$79.53
95909EMG
NVR CNDJ TST 5-6 STUDIES
$167.88
97003OT
OCCUPATIONAL THERAPY EVALUATION
$266.75
97004OT
OCCUPATIONAL THERAPY RE-EVALUATION
$266.75
97014OT
APPL MODALITY 1/> AREAS ELEC STIMJ UNATT
$106.00
97018OT
APPL MODALITY 1/> AREAS PARAFFIN BATH
$107.00
97022OT
APPLICATION MODALITY 1/> AREAS WHIRLPOOL
$129.55
97032OT
APPL MODALITY 1/> AREAS ELEC STIMJ EA 15
$107.00
97033OT
APPL MODALITY 1/> AREAS IONTOPHORESIS EA
$129.55
97035OT
APPL MODALITY 1/> AREAS ULTRASOUND EA 15
$91.85
97110OT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXE
$90.87
97112OT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC
$129.55
97140OT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 M
$149.00
97165OT
OT EVAL LOW COMPLEXITY
$208.95
97166OT
OT EVAL MODERATE COMPLEXITY
$208.95
97168OT
OT RE-EVAL
$137.56
97530OT
THER ACTV DIR PT CONTACT BY PROVIDER EAC
$144.65
97535OT
SELF-CARE/HOME MGMT TRAINING EACH 15 MIN
$85.25
97597OT
DEBRIDEMENT OPEN WOUND 20 SQ CM/<
$159.80
97598OT
REMOVAL DEVITALIZED TISSUE >20 CM
$402.00
97750OT
PHYSICAL PERFORMANCE TEST/MEAS W/REPRT E
$165.00
97760OT
ORTHO MGMT&TRAINJ LXTR&/TRNK EA INITIAL
$182.00
97762OT
ORTHODIC CHECKOUT
$25.00
97763OT
ORTHO/PROST MNGMNT- SUBSEQUENT ENC
$182.00
10061OR
INCISION&DRAINAGE ABSCESS COMPLICATED/MU
$4,125.00
11012OR
DBRDMT FX&/DISLC SUBQ T/M/F BONE
$2,500.00
11042OR
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM
$2,500.00
11043OR
DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/<
$2,500.00
11044OR
DEBRIDEMENT BONE MUSCLE &/FASCIA 20 SQ C
$2,990.75
11100OR
BX SKIN SUBCUTANEOUS&/MUCOUS MEMBRANE 1
$2,500.00
11402OR
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2.0
$2,500.00
11403OR
EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3.0
$2,983.48
11404OR
EXC B9 LES MRGN XCP SK TG T/A/L 3.1-4.0
$5,966.95
11406OR
EXC B9 LES MRGN XCP SK TG T/A/L > 4.0 CM
$5,966.95
11426OR
EXC B9 LES MRGN XCP SK TG S/N/H/F/G > 4.
$8,128.00
11440OR
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.
$2,500.00
11442OR
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.
$2,990.75
11443OR
EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.
$2,990.75
11450OR
EXCISION HIDRADENITIS AXILLARY SMPL/INTR
$8,128.00
11606OR
EXCISION MALIGNANT LESION TRUNK/ARM/LEG
$5,966.95
11622OR
EXCISION MALIGNANT LESION S/N/H/F/G 1.1-
$2,990.75
11765OR
WEDGE EXCISION SKIN NAIL FOLD
$1,250.00
11771OR
EXCISION PILONIDAL CYST/SINUS EXTENSIVE
$4,125.00
11772OR
EXCISION PILONIDAL CYST/SINUS COMPLICATE
$7,071.40
12002OR
SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.
$1,250.00
12020OR
TX SUPERFICIAL WOUND DEHISCENCE SIMPLE C
$2,500.00
12032OR
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM
$2,500.00
12042OR
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6
$2,500.00
13102OR
REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 C
$2,500.00
13132OR
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6 CM
$2,500.00
19303OR
MASTECTOMY SIMPLE COMPLETE
$15,653.25
19307OR
MAST MODF RAD W/AX LYMPH NOD W/WO PECT/A
$15,653.25
20103OR
EXPLORATION PENETRATING WOUND SPX EXTREM
$4,678.20
20520OR
REMOVAL FOREIGN BODY MUSCLE/TENDON SHEAT
$2,500.00
20552PM
INJECTION SINGLE/MLT TRIGGER POINT 1/2 M
$4,125.00
20553PM
INJECTION SINGLE/MLT TRIGGER POINT 3/> M
$4,125.00
21012OR
EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ
$2,990.58
21931OR
EXCISION TUMOR SOFT TIS BACK/FLANK SUBQ
$8,128.00
23071OR
EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ
$7,071.40
23073OR
EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIA
$8,128.00
24071OR
EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SU
$2,990.58
24073OR
EXC TUMOR SOFT TISS UPPER ARM/ELBW SUBFA
$8,128.00
24076OR
EXC TUMOR SOFT TISS UPR ARM/ELBOW SUBFAS
$5,966.95
25075OR
EXC TUMOR SOFT TISSUE FOREARM &/WRIST SU
$5,966.95
25076OR
EXC TUMOR SOFT TISS FOREARM&/WRIST SUBFA
$5,966.95
25111OR
EXCISION GANGLION WRIST DORSAL/VOLAR PRI
$7,694.30
27096OR
JOINT INJECTION
$3,033.60
27096PM
INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID
$4,322.84
27328OR
EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC
$5,966.95
36561OR
INSERT TUNNELED CV CATH
$8,715.64
36578OR
PORTA CATH INSERTION
$17,443.20
38500OR
BIOPSY /REMOVAL LYMPH NODE
$8,846.70
43235OR
UPPR GI ENDOSCOPY DIAGNOSIS
$4,198.74
43239OR
UPPER GI ENDOSCOPY BIOPSY
$4,198.74
43245OR
EGD WITH BALLOON DILATION
$5,440.00
43246OR
PEG TUBE PLACEMENT
$8,008.98
43249OR
EGD W/BALLOON DILATION OF ESOPHAGUS
$8,008.98
43760OR
CHANGE GASTROSTOMY TUBE PERCUTANEOUS W/O
$2,500.00
44950OR
Appendectomy
$17,176.44
44970OR
LAPAROSCOPY, SURGICAL, APPENDECTOMY
$20,995.65
45005OR
INCISION AND DRAINAGE OF SUBMUCOSAL ABCE
$4,857.60
45330OR
DIAGNOSTIC SIGMOIDOSCOPY
$2,500.00
45331OR
SIGMOIDOSCOPY AND BIOPSY
$4,006.02
45333OR
SIGMOIDSCOPY W/RMVL OF TUMORS,POLYPS
$4,006.02
45335OR
SIGMOIDSCOPY W/DIRECTED SUBMUC INJ
$4,006.02
45338OR
SIGMOIDOSCOPY W/TUMR REMOVE
$13,954.56
45378OR
DIAGNOSTIC COLONSCOPY
$4,006.02
45380OR
COLONSCOPY AND BIOPSY
$5,265.60
45381OR
COLONOSCOPY, FLEXIBLE, W INJECTION
$5,265.60
45384OR
LESION REMOVAL COLONSCOPY BY HOT BIOPSY
$5,265.60
45385OR
LESION REMOVAL COLONSCOPY BY SNARE
$5,265.60
46250OR
HEMRRHOIDECTOMY
$13,005.06
46270OR
REMOVAL ANAL FIST SUBQ
$8,721.60
46999OR
UNLISTED PROCEDURE , ANUS
$24,268.80
47000OR
BIOPSY OF LIVER, NEEDLE, PERCUTANEOUS
$10,784.24
47562OR
LAPAROSCOPIC CHOLECYSTECTOMY
$20,995.65
47563OR
LAPARO CHOLECYSTECTOMY/GRAPH
$20,995.65
49000OR
Exploratory Laparotomy/Celio w or wo Bio
$17,443.20
49329OR
LAPAROSCOPY UNLISTED
$20,995.65
49505OR
REPAIR INITIAL INGUINNAL HERNIA OVER 5YR
$11,445.40
49560OR
VENTRAL HERNIA REPAID
$17,176.44
49561OR
REPAIR VENTRAL HERNIA
$17,176.44
49565OR
REPAIR RECURRENT INCIS/VEN HERNIA REDUCI
$20,995.65
49566OR
REPAIR HERNIA INGUINAL
$23,257.60
49568OR
REPAIR VENTRAL HERNIAWITH MESH
$20,995.65
49585OR
REPAIR HERNIA UMBILICAL
$17,176.44
49587OR
RPR UMBIL HERNIA BLOCKED > 5 YRS
$17,176.44
49653OR
LAP VENTRAL HERNIA REPAIR
$20,995.68
49655OR
LAP INC HERNIA REPAIR COMP
$34,849.20
62290OR
Lumbar Inject for discography each level
$6,067.20
62321PM
NJX DX/EPIDURAL/SUBRACH CERV/T w guid
$4,322.84
62322PM
NJX DX/THER SBST EPIDURAL/SUBARACH LUMBA
$4,322.84
62323PM
NJX DX/EPIDURAL/SUBARACH LUMBA w guidanc
$4,322.84
62325PM
NJX CATH PLCMT CONT DX/THER CER THR IMG
$4,322.84
62350OR
Implant, Revis, Reposit of Tun/Epid Cath
$10,112.00
63650PM
SSPINAL STIMULATOR TRIAL
$13,358.42
63661PM
RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL F
$1,162.88
64490PM
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1
$4,322.84
64491PM
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2
$1,585.98
64492PM
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3
$1,585.98
64493PM
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1
$4,322.84
64494PM
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2
$1,585.98
64495PM
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3
$1,585.98
64510PM
STELLATE GANGLION INJECTION
$4,322.84
66984OR
CATARACT SURGERY
$5,834.00
67840OR
EXCISION OF LESION OF EYELID W/OUT CLOSU
$24,268.80
69421OR
MYRINGOTOMY
$17,443.20
69620OR
MYRINGOPLASTY
$17,443.20
69631OR
Tympanoplasty w/o Mastoidectomy
$23,257.60
G0105OR
COLORECTAL CANCER SCREEN COLONOSCOPY HR
$11,628.80
G0121OR
COLORECTAL CANCER SCREENING
$3,234.40
G0259PM
SI JOINT INJ ARTJROGRAPY
$4,322.84
G0260PM
SI JOINT INJECTION
$4,322.84
81241LAB
FACTOR V LEIDEN
$80.00
82310L2
CALCIUM RANDOM URINE
$28.36
87807LAB
RSV IMMUNOASSAY
$65.96
88104TC
CYTOPATHOLOGY
$34.00
88302TC
LEVEL II
$68.00
88304TC
LEVEL I I I
$183.44
88305TC
LEVEL IV
$250.68
88307TC
LEVEL V
$229.08
88311TC
DECALCIFICATION PROCEDURE
$20.56
88312TC
SPECIAL STAIN
$243.36
89060LAB
SYNOVIAL FLUID CRYSTALS
$39.32
93880RAD
US CAROTID
$1,106.15
93923RAD
NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY
$664.95
93925RAD
DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STU
$1,167.70
93926RAD
DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STU
$672.05
93970RAD
DUP-SCAN XTR VEINS COMPLETE BILATERAL ST
$881.80
93971RAD
DUP-SCAN XTR VEINS UNILATERAL/LIMITED ST
$533.55
97010PT
APPLICATION MODALITY 1/> AREAS HOT/COLD
$36.30
97012PT
APPL MODALITY 1/> AREAS TRACTION MECHANI
$44.82
97014PT
APPL MODALITY 1/> AREAS ELEC STIMJ UNATT
$114.40
97016PT
VASOPNEUMATIC
$73.44
97018PT
APPL MODALITY 1/> AREAS PARAFFIN BATH
$28.17
97022PT
APPLICATION MODALITY 1/= AREA WHIRLPOOL
$61.41
97032PT
APPL MODALITY 1/> AREAS ELEC STIMJ EA 15
$107.00
97033PT
APPL MODALITY 1/> AREAS IONTOPHORESIS EA
$129.55
97035PT
APPL MODALITY 1/> AREAS ULTRASOUND EA 15
$35.22
97110PT
THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXE
$174.48
97112PT
THER PX 1/> AREAS EACH 15 MIN NEUROMUSC
$90.90
97116PT
THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ
$77.55
97140PT
MANUAL THERAPY TQS 1/> REGIONS EACH 15 M
$81.54
97530PT
THER ACTV DIR PT CONTACT BY PROVIDER EAC
$95.40
97750PT
PHYSICAL PERFORMANCE TEST/MEAS W/REPRT E
$91.89
G0283PT
APPL MODALITY 1/> AREAS ELEC STIMJ UNAT
$114.40
94010RES
SPIROMETRY W/WO MVV
$78.65
94060RES
BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILA
$168.00
94640R02
AEROSOL SUBSEQUENT
$69.72
94640R05
MDI TREATMENT
$47.05
94640RES
INITIAL AEROSOL
$133.16
94727RES
GAS DILUT/WASHOUT LUNG VOL W/WO DISTRIB
$218.50
94729RES
CO DIFFUSING CAPACITY
$317.05
94762RES
NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT
$291.50
94620RES
PULMONARY STRESS TESTING SIMPLE(six min)
$288.20
99406RES
TOBACCO USE CESSATION INTERMEDIATE 3-10
$47.72
36569PR
INSERTION PICC LINE
$500.00
96360OP
INTRAVENOUS HYDRATION INIT 31 MIN-1 HOUR
$181.44
96361OP
IV INFUS HYDRATION EACH ADDITL HOUR
$48.51
96365OP
IV INFUSION FOR THERAPY, INTL TO 1 HR
$274.36
96366OP
IV INFUSION THERAPY, EA ADDTL HR
$60.90
96367OP
ADDTL SEQ INFUS OF NEW DRUG TO 1 HOUR
$97.13
96372OP
INJECTION SUBCUT OR INTRAMUSCULAR
$81.06
96374OP
INJECTION INTRAVEN PUSH SNG OR INITIAL
$179.31
96376OP
IV PUSH EACH ADD'TNAL SEQ
$71.16
INF90471
ADMINISTRATION OF VACCINE
$95.28
INF96360
IV HYDRATION INITIAL 31 MIN TO 1 HOUR
$212.68
INF96361
IV HYDRATION EA ADD'L HOUR
$56.28
INF96365
IV INFUSION UP TO ONE HOUR
$274.36
INF96366
IV INFUSION EA ADD'L HOUR
$80.76
INF96372
IM/SUBQ INJECTION
$71.16
INF96374
IV PUSH INITIAL
$209.16
INF96376
IV PUSH ADD'L SEQ SAME DRUG
$61.59
INF96523
PORT, PICC LINE FLUSH
$95.28
99211ER
OFFICE OUTPATIENT VISIT 5 MINUTES
$152.62
99211OP
OUTPATIENT VISIT 5 MINUTES
$75.88
99211OPTR
OUTPATIENT TREATMENT ROOM
$152.82
76536RAD
US SOFT TISSUE HEAD & NECK REAL TIME IMG
$570.55
76604RAD
US CHEST REAL TIME W/IMAGE DOCUMENTATION
$413.05
76700RAD
US ABDOMINAL REAL TIME W/IMAGE DOCUMENTA
$657.45
76705RAD
ULTRASOUND ABDOMINAL REAL TIME W/IMAGE L
$505.40
76770RAD
US RETROPERITONEAL REAL TIME W/IMAGE COM
$619.55
76801RAD
US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST
$596.35
76805RAD
US PREG UTERUS AFTER 1ST TRIMEST 1/1ST G
$694.10
76817RAD
US PREG UTERUS REAL TIME W/IMAGE DCMTN T
$480.65
76830RAD
ULTRASOUND TRANSVAGINAL
$354.35
76856RAD
US PELVIC NONOBSTETRIC REAL-TIME IMAGE C
$582.00
76857RAD
US PELVIC NONOBSTETRIC IMAGE DCMTN LIMIT
$443.70
76870RAD
ULTRASOUND SCROTUM & CONTENTS
$581.15
76881RAD
US EXTREMITY NON-VASC REAL-TIME IMG COMP
$570.30
76882RAD
US EXTREMITY NON-VASC REAL-TIME IMG LMTD
$167.65
76942ANS
ULTRASOUND NEEDLE GUIDANCE
$0.00
76942RAD
US GUIDANCE NEEDLE PLACEMENT RS&I
$948.30