| Note:
Services Highlights in Yellow represent the 70 specified services by
CMS. |
Shoppable
Service |
Service
Description |
CPT/ HCPCS
Code |
Revenue vode |
Gross Charge |
Discouonted
Cash Price |
De-identified
Minimum negotaited Charge |
De-identified
Maximum negotiated charge |
Aetna (72% of
billed charges) |
BCBS TX (Traditional) |
BCBS TX (HMO) |
BCBS TX (PPO) |
Cigna (77% of
billed charges) |
Humana (80% of
billed charges) |
United
(Outpatient) (70% of billed charges) |
Medicaid (39% of
billed charges) |
Medicare Plans
(67% of billed charges) |
Worker's
Compensation (67% of billed charges) |
| Evaluation
and Management |
|
Psychiatric
diagnostic evaluation |
90791 |
961 |
$ 341.00 |
$ 238.70 |
$ 132.99 |
$ 272.80 |
$
245.52 |
$
- |
$ - |
$ - |
$
262.57 |
$
272.80 |
$ 238.70 |
$
132.99 |
$
228.47 |
$
228.47 |
| |
Psychotherapy, 30
min |
90832 |
914 |
$ 184.00 |
$ 128.80 |
$ 71.76 |
$ 147.20 |
$
132.48 |
$
- |
$ - |
$ - |
$
141.68 |
$
147.20 |
$ 128.80 |
$
71.76 |
$
123.28 |
$
123.28 |
| |
Psychotherapy, 45
min |
90834 |
914 |
$ 331.00 |
$ 231.70 |
$ 129.09 |
$ 264.80 |
$
238.32 |
$
- |
$ - |
$ - |
$
254.87 |
$
264.80 |
$ 231.70 |
$
129.09 |
$
221.77 |
$
221.77 |
| |
Psychotherapy, 60
min |
90837 |
NA |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Family psychotherapy,
not including patient, 50 min |
90846 |
NA |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Family psychotherapy,
including patient, 50 min |
90847 |
NA |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Group
psychotherapy |
90853 |
915 |
$ 184.00 |
$ 128.80 |
$ 71.76 |
$ 147.20 |
$
132.48 |
$
- |
$ - |
$ - |
$
141.68 |
$
147.20 |
$ 128.80 |
$
71.76 |
$
123.28 |
$
123.28 |
| |
Hydration infusion
into a vein 31 minutes to 1 hour |
96360 |
260 |
$ 467.94 |
$ 327.56 |
$ 109.42 |
$ 374.35 |
$
336.92 |
$
109.42 |
$
109.42 |
$
109.42 |
$
360.31 |
$
374.35 |
$ 327.56 |
$
182.50 |
$
313.52 |
$
313.52 |
| |
Hydration infusion
into a vein |
96361 |
260 |
$ 94.71 |
$ 66.30 |
$ 32.34 |
$ 75.77 |
$
68.19 |
$
32.34 |
$
32.34 |
$
32.34 |
$
72.93 |
$ 75.77 |
$ 66.30 |
$
36.94 |
$
63.46 |
$
63.46 |
| |
Infusion into a vein
for therapy, prevention, or diagnosis up to 1 hour |
96365 |
260 |
$ 467.94 |
$ 327.56 |
$ 170.78 |
$ 374.35 |
$
336.92 |
$
170.78 |
$
170.78 |
$
170.78 |
$
360.31 |
$
374.35 |
$ 327.56 |
$
182.50 |
$
313.52 |
$
313.52 |
| |
Infusion into a vein
for therapy, prevention, or diagnosis |
96366 |
260 |
$ 113.50 |
$ 79.45 |
$ 44.27 |
$ 90.80 |
$
81.72 |
$
51.40 |
$
51.40 |
$
51.40 |
$
87.40 |
$ 90.80 |
$ 79.45 |
$
44.27 |
$
76.05 |
$
76.05 |
| |
Injection beneath the
skin or into muscle for therapy, diagnosis, or
prevention |
96372 |
521 |
$ 149.38 |
$ 104.57 |
$ 58.26 |
$ 134.44 |
$
107.55 |
$
134.44 |
$
134.44 |
$
134.44 |
$
115.02 |
$
119.50 |
$ 104.57 |
$
58.26 |
$
100.08 |
$
100.08 |
| |
Injection of drug or
substance into a vein for therapy, diagnosis, or
prevention |
96374 |
940 |
$ 467.94 |
$ 327.56 |
$ 108.59 |
$ 374.35 |
$
336.92 |
$
108.59 |
$
108.59 |
$
108.59 |
$
360.31 |
$
374.35 |
$ 327.56 |
$
182.50 |
$
313.52 |
$
313.52 |
| |
Injection of
different drug or substance into a vein for
therapy, diagnosis, or prevention |
96375 |
940 |
$ 94.71 |
$ 66.30 |
$ 36.94 |
$ 75.77 |
$
68.19 |
$
42.27 |
$
42.27 |
$
42.27 |
$
72.93 |
$ 75.77 |
$ 66.30 |
$
36.94 |
$
63.46 |
$
63.46 |
| |
Injection of drug or
substance into a vein for therapy, diagnosis, or
prevention, in a facility |
96376 |
940 |
$ 52.00 |
$ 36.40 |
$ 20.28 |
$ 53.06 |
$
37.44 |
$
53.06 |
$
53.06 |
$
53.06 |
$
40.04 |
$ 41.60 |
$ 36.40 |
$
20.28 |
$
34.84 |
$
34.84 |
| |
New patient office or
other outpatient visit, typically 10 minutes |
99201 |
761 |
$ 65.00 |
$ 45.50 |
$ 25.35 |
$ 63.02 |
$
46.80 |
$
63.02 |
$
63.02 |
$
63.02 |
$
50.05 |
$ 52.00 |
$ 45.50 |
$
25.35 |
$
43.55 |
$
43.55 |
| |
New patient office or
other outpatient visit, typically 30 minutes |
99203 |
521 |
$ 155.00 |
$ 108.50 |
$ 60.45 |
$ 179.90 |
$
111.60 |
$
179.90 |
$
179.90 |
$
179.90 |
$
119.35 |
$
124.00 |
$ 108.50 |
$
60.45 |
$
103.85 |
$
103.85 |
| |
New patient office or
other outpatient visit, typically 45 minutes |
99204 |
521 |
$ 210.00 |
$ 147.00 |
$ 81.90 |
$ 303.42 |
$
151.20 |
$
303.42 |
$
303.42 |
$
303.42 |
$
161.70 |
$
168.00 |
$ 147.00 |
$
81.90 |
$
140.70 |
$
140.70 |
| |
New patient office or
other outpatient visit, typically 60 minutes |
99205 |
521 |
$ 530.00 |
$ 371.00 |
$ 206.70 |
$ 424.00 |
$
381.60 |
$
396.28 |
$
396.28 |
$
396.28 |
$
408.10 |
$
424.00 |
$ 371.00 |
$
206.70 |
$
355.10 |
$
355.10 |
| |
Established patient
office or other outpatient visit, typically 5
minutes |
99211 |
521 |
$ 412.10 |
$ 288.47 |
$ 21.55 |
$ 329.68 |
$
296.71 |
$
21.55 |
$
21.55 |
$
21.55 |
$
317.32 |
$
329.68 |
$ 288.47 |
$
160.72 |
$
276.11 |
$
276.11 |
| |
Established patient
office or other outpatient visit, typically 10
minutes |
99212 |
521 |
$ 412.10 |
$ 288.47 |
$ 59.69 |
$ 329.68 |
$
296.71 |
$
59.69 |
$
59.69 |
$
59.69 |
$
317.32 |
$
329.68 |
$ 288.47 |
$
160.72 |
$
276.11 |
$
276.11 |
| |
Established patient
office or other outpatient visit, typically 15
minutes |
99213 |
521 |
$ 474.50 |
$ 332.15 |
$ 120.21 |
$ 379.60 |
$
341.64 |
$
120.21 |
$
120.21 |
$
120.21 |
$
365.37 |
$
379.60 |
$ 332.15 |
$
185.06 |
$
317.92 |
$
317.92 |
| |
Established patient
office or other outpatient visit, typically 15
minutes |
99213 |
521 |
$ 474.50 |
$ 332.15 |
$ 120.21 |
$ 379.60 |
$
341.64 |
$
120.21 |
$
120.21 |
$
120.21 |
$
365.37 |
$
379.60 |
$ 332.15 |
$
185.06 |
$
317.92 |
$
317.92 |
| |
Established patient
office or other outpatient, visit typically 25
minutes |
99214 |
521 |
$ 530.00 |
$ 371.00 |
$ 184.04 |
$ 424.00 |
$
381.60 |
$
184.04 |
$
184.04 |
$
184.04 |
$
408.10 |
$
424.00 |
$ 371.00 |
$
206.70 |
$
355.10 |
$
355.10 |
| |
Established patient
office or other outpatient, visit typically 40
minutes |
99215 |
521 |
$ 530.00 |
$ 371.00 |
$ 206.70 |
$ 424.00 |
$
381.60 |
$
260.31 |
$
260.31 |
$
260.31 |
$
408.10 |
$
424.00 |
$ 371.00 |
$
206.70 |
$
355.10 |
$
355.10 |
| |
Patient office
consultation, typically 40 minutes |
99243 |
NA |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Patient office
consultation, typically 60 minutes |
99244 |
NA |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Initial new patient
preventive medicine evaluation age 18-39 years |
99385 |
521 |
$ 141.00 |
$ 98.70 |
$ 54.99 |
$ 229.64 |
$
101.52 |
$
229.64 |
$
229.64 |
$
229.64 |
$
108.57 |
$
112.80 |
$ 98.70 |
$
54.99 |
$
94.47 |
$
94.47 |
| |
Initial new patient
preventive medicine evaluation age 40-64 years |
99386 |
521 |
$ 152.00 |
$ 106.40 |
$ 59.28 |
$ 279.37 |
$
109.44 |
$
279.37 |
$
279.37 |
$
279.37 |
$
117.04 |
$
121.60 |
$ 106.40 |
$
59.28 |
$
101.84 |
$
101.84 |
| |
Observation per
Hour |
G0378 |
762 |
$ 37.70 |
$ 26.39 |
$ 14.70 |
$ 292.65 |
$
27.14 |
$
292.65 |
$
292.65 |
$
292.65 |
$
29.03 |
$ 30.16 |
$ 26.39 |
$
14.70 |
$
25.26 |
$
25.26 |
| Laboratory & Pathology Services |
|
Insertion of needle
into vein for collection of blood sample |
36415 |
300 |
$ 24.70 |
$ 17.29 |
$ 9.63 |
$ 19.76 |
$
17.78 |
$
- |
$ - |
$ - |
$
19.02 |
$ 19.76 |
$ 17.29 |
$
9.63 |
$
16.55 |
$
16.55 |
| |
Blood test, basic
group of blood chemicals |
80048 |
301 |
$ 175.50 |
$ 122.85 |
$ 30.80 |
$ 140.40 |
$
126.36 |
$
36.23 |
$
30.80 |
$
36.23 |
$
135.14 |
$
140.40 |
$ 122.85 |
$
68.45 |
$
117.59 |
$
117.59 |
| |
Blood test panel for
electrolytes (sodium potassium, chloride, carbon
dioxide) |
80051 |
301 |
$ 90.00 |
$ 63.00 |
$ 25.55 |
$ 72.00 |
$
64.80 |
$
30.05 |
$
30.05 |
$
25.55 |
$
69.30 |
$ 72.00 |
$ 63.00 |
$
35.10 |
$
60.30 |
$
60.30 |
| |
Blood test,
comprehensive group of blood chemicals |
80053 |
301 |
$ 234.00 |
$ 163.80 |
$ 38.47 |
$ 187.20 |
$
168.48 |
$
45.25 |
$
38.47 |
$
45.25 |
$
180.18 |
$
187.20 |
$ 163.80 |
$
91.26 |
$
156.78 |
$
156.78 |
| |
Obstetric blood test
panel |
80055 |
301 |
$ 263.00 |
$ 184.10 |
$ 102.57 |
$ 210.40 |
$
189.36 |
$
204.80 |
$
174.11 |
$
204.80 |
$
202.51 |
$
210.40 |
$ 184.10 |
$
102.57 |
$
176.21 |
$
176.21 |
| |
Blood test, lipids
(cholesterol and triglycerides) |
80061 |
301 |
$ 194.00 |
$ 135.80 |
$ 48.76 |
$ 155.20 |
$
139.68 |
$
57.36 |
$
48.76 |
$
57.36 |
$
149.38 |
$
155.20 |
$ 135.80 |
$
75.66 |
$
129.98 |
$
129.98 |
| |
Kidney function blood
test panel |
80069 |
301 |
$ 152.00 |
$ 106.40 |
$ 31.62 |
$ 121.60 |
$
109.44 |
$
37.20 |
$
31.62 |
$
37.20 |
$
117.04 |
$
121.60 |
$ 106.40 |
$
59.28 |
$
101.84 |
$
101.84 |
| |
Liver function blood
test panel |
80076 |
301 |
$ 175.50 |
$ 122.85 |
$ 29.77 |
$ 140.40 |
$
126.36 |
$
35.01 |
$
29.77 |
$
35.01 |
$
135.14 |
$
140.40 |
$ 122.85 |
$
68.45 |
$
117.59 |
$
117.59 |
| |
Vancomycin
(antibiotic) level |
80202 |
301 |
$ 162.00 |
$ 113.40 |
$ 49.32 |
$ 129.60 |
$
116.64 |
$
58.02 |
$
49.32 |
$
58.02 |
$
124.74 |
$
129.60 |
$ 113.40 |
$
63.18 |
$
108.54 |
$
108.54 |
| |
Testing for presence
of drug |
80305 |
301 |
$ 111.80 |
$ 78.26 |
$ 39.71 |
$ 89.44 |
$
80.50 |
$
46.71 |
$
39.71 |
$
46.71 |
$
86.09 |
$ 89.44 |
$ 78.26 |
$
43.60 |
$
74.91 |
$
74.91 |
| |
Manual urinalysis
test with examination using microscope |
81000 |
NA |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Manual urinalysis
test with examination using microscope |
81001 |
300 |
$ 63.70 |
$ 44.59 |
$ 11.56 |
$ 50.96 |
$
45.86 |
$
13.60 |
$
11.56 |
$
13.60 |
$
49.05 |
$ 50.96 |
$ 44.59 |
$
24.84 |
$
42.68 |
$
42.68 |
| |
Urinalysis, manual
test |
81002 |
306 |
$ 27.00 |
$ 18.90 |
$ 10.27 |
$ 21.60 |
$
19.44 |
$
12.08 |
$
10.27 |
$
12.08 |
$
20.79 |
$ 21.60 |
$ 18.90 |
$
10.53 |
$
18.09 |
$
18.09 |
| |
Automated urinalysis
test |
81003 |
301 |
$ 29.00 |
$ 20.30 |
$ 8.17 |
$ 23.20 |
$
20.88 |
$
9.61 |
$
8.17 |
$
9.61 |
$
22.33 |
$ 23.20 |
$ 20.30 |
$
11.31 |
$
19.43 |
$
19.43 |
| |
Urine pregnancy test |
81025 |
301 |
$ 66.30 |
$ 46.41 |
$ 25.40 |
$ 53.04 |
$
47.74 |
$
29.88 |
$
25.40 |
$
29.88 |
$
51.05 |
$ 53.04 |
$ 46.41 |
$
25.86 |
$
44.42 |
$
44.42 |
| |
Albumin (protein)
level |
82040 |
300 |
$ 35.10 |
$ 24.57 |
$ 13.69 |
$ 28.08 |
$
25.27 |
$
21.20 |
$
21.20 |
$
18.02 |
$
27.03 |
$ 28.08 |
$ 24.57 |
$
13.69 |
$
23.52 |
$
23.52 |
| |
Urine microalbumin
(protein) analysis |
82044 |
301 |
$ 19.00 |
$ 13.30 |
$ 7.41 |
$ 21.62 |
$
13.68 |
$
21.62 |
$
21.62 |
$
18.38 |
$
14.63 |
$ 15.20 |
$ 13.30 |
$
7.41 |
$
12.73 |
$
12.73 |
| |
Ammonia level |
82140 |
301 |
$ 143.00 |
$ 100.10 |
$ 53.07 |
$ 114.40 |
$
102.96 |
$
62.43 |
$
62.43 |
$
53.07 |
$
110.11 |
$
114.40 |
$ 100.10 |
$
55.77 |
$
95.81 |
$
95.81 |
| |
Amylase (enzyme)
level |
82150 |
301 |
$ 56.00 |
$ 39.20 |
$ 21.84 |
$ 44.80 |
$
40.32 |
$
27.76 |
$
27.76 |
$
23.60 |
$
43.12 |
$ 44.80 |
$ 39.20 |
$
21.84 |
$
37.52 |
$
37.52 |
| |
Bilirubin level |
82247 |
301 |
$ 58.50 |
$ 40.95 |
$ 18.26 |
$ 46.80 |
$
42.12 |
$
21.48 |
$
21.48 |
$
18.26 |
$
45.05 |
$ 46.80 |
$ 40.95 |
$
22.82 |
$
39.20 |
$
39.20 |
| |
Stool analysis for
blood to screen for colon tumors |
82270 |
301 |
$ 31.20 |
$ 21.84 |
$ 12.17 |
$ 24.96 |
$
22.46 |
$
15.20 |
$
15.20 |
$
12.92 |
$
24.02 |
$ 24.96 |
$ 21.84 |
$
12.17 |
$
20.90 |
$
20.90 |
| |
Vitamin D-3 level |
82306 |
301 |
$ 265.00 |
$ 185.50 |
$ 103.35 |
$ 212.00 |
$
190.80 |
$
126.83 |
$
126.83 |
$
107.82 |
$
204.05 |
$
212.00 |
$ 185.50 |
$
103.35 |
$
177.55 |
$
177.55 |
| |
Calcium level |
82310 |
301 |
$ 47.00 |
$ 32.90 |
$ 18.33 |
$ 37.60 |
$
33.84 |
$
22.10 |
$
22.10 |
$
18.79 |
$
36.19 |
$ 37.60 |
$ 32.90 |
$
18.33 |
$
31.49 |
$
31.49 |
| |
Carcinoembryonic
antigen (CEA) protein level |
82378 |
301 |
$ 205.40 |
$ 143.78 |
$ 69.06 |
$ 164.32 |
$
147.89 |
$
81.23 |
$
81.23 |
$
69.06 |
$
158.16 |
$
164.32 |
$ 143.78 |
$
80.11 |
$
137.62 |
$
137.62 |
| |
Cholesterol level |
82465 |
301 |
$ 33.00 |
$ 23.10 |
$ 12.87 |
$ 26.40 |
$
23.76 |
$
18.63 |
$
18.63 |
$
15.84 |
$
25.41 |
$ 26.40 |
$ 23.10 |
$
12.87 |
$
22.11 |
$
22.11 |
| |
Creatine kinase
(cardiac enzyme) level |
82550 |
301 |
$ 113.10 |
$ 79.17 |
$ 23.72 |
$ 90.48 |
$
81.43 |
$
27.90 |
$
27.90 |
$
23.72 |
$
87.09 |
$ 90.48 |
$ 79.17 |
$
44.11 |
$
75.78 |
$
75.78 |
| |
Creatine kinase
(cardiac enzyme) level |
82553 |
301 |
$ 193.70 |
$ 135.59 |
$ 42.07 |
$ 154.96 |
$
139.46 |
$
49.48 |
$
49.48 |
$
42.07 |
$
149.15 |
$
154.96 |
$ 135.59 |
$
75.54 |
$
129.78 |
$
129.78 |
| |
Blood creatinine
level |
82565 |
301 |
$ 35.00 |
$ 24.50 |
$ 13.65 |
$ 28.00 |
$
25.20 |
$
21.97 |
$
21.97 |
$
18.67 |
$
26.95 |
$ 28.00 |
$ 24.50 |
$
13.65 |
$
23.45 |
$
23.45 |
| |
Cyanocobalamin
(vitamin B-12) level |
82607 |
301 |
$ 121.00 |
$ 84.70 |
$ 47.19 |
$ 96.80 |
$
87.12 |
$
64.58 |
$
64.58 |
$
54.90 |
$
93.17 |
$ 96.80 |
$ 84.70 |
$
47.19 |
$
81.07 |
$
81.07 |
| |
Ferritin (blood
protein) level |
82728 |
301 |
$ 124.00 |
$ 86.80 |
$ 48.36 |
$ 99.20 |
$
89.28 |
$
58.40 |
$
58.40 |
$
49.65 |
$
95.48 |
$ 99.20 |
$ 86.80 |
$
48.36 |
$
83.08 |
$
83.08 |
| |
Folic acid level |
82746 |
301 |
$ 153.40 |
$ 107.38 |
$ 53.54 |
$ 122.72 |
$
110.45 |
$
62.98 |
$
62.98 |
$
53.54 |
$
118.12 |
$
122.72 |
$ 107.38 |
$
59.83 |
$
102.78 |
$
102.78 |
| |
Gammaglobulin (immune
system protein) measurement |
82784 |
301 |
$ 105.30 |
$ 73.71 |
$ 33.87 |
$ 84.24 |
$
75.82 |
$
39.84 |
$
39.84 |
$
33.87 |
$
81.08 |
$ 84.24 |
$ 73.71 |
$
41.07 |
$
70.55 |
$
70.55 |
| |
Blood glucose (sugar)
level |
82947 |
301 |
$ 51.00 |
$ 35.70 |
$ 14.31 |
$ 40.80 |
$
36.72 |
$
16.83 |
$
16.83 |
$
14.31 |
$
39.27 |
$ 40.80 |
$ 35.70 |
$
19.89 |
$
34.17 |
$
34.17 |
| |
Blood glucose (sugar)
tolerance test |
82951 |
301 |
$ 143.00 |
$ 100.10 |
$ 46.88 |
$ 114.40 |
$
102.96 |
$
55.14 |
$
55.14 |
$
46.88 |
$
110.11 |
$
114.40 |
$ 100.10 |
$
55.77 |
$
95.81 |
$
95.81 |
| |
Blood glucose (sugar)
test performed by hand-held instrument |
82962 |
301 |
$ 42.90 |
$ 30.03 |
$ 9.68 |
$ 34.32 |
$
30.89 |
$
11.38 |
$
11.38 |
$
9.68 |
$
33.03 |
$ 34.32 |
$ 30.03 |
$
16.73 |
$
28.74 |
$
28.74 |
| |
Hemoglobin A1C level |
83036 |
301 |
$ 118.30 |
$ 82.81 |
$ 35.37 |
$ 94.64 |
$
85.18 |
$
41.61 |
$
41.61 |
$
35.37 |
$
91.09 |
$ 94.64 |
$ 82.81 |
$
46.14 |
$
79.26 |
$
79.26 |
| |
Iron binding capacity |
83550 |
301 |
$ 80.00 |
$ 56.00 |
$ 31.20 |
$ 64.00 |
$
57.60 |
$
37.44 |
$
37.44 |
$
31.83 |
$
61.60 |
$ 64.00 |
$ 56.00 |
$
31.20 |
$
53.60 |
$
53.60 |
| |
Lactic acid level |
83605 |
301 |
$ 125.00 |
$ 87.50 |
$ 38.91 |
$ 100.00 |
$
90.00 |
$
45.77 |
$
45.77 |
$
38.91 |
$
96.25 |
$
100.00 |
$ 87.50 |
$
48.75 |
$
83.75 |
$
83.75 |
| |
Lactate dehydrogenase
(enzyme) level |
83615 |
301 |
$ 81.90 |
$ 57.33 |
$ 21.98 |
$ 65.52 |
$
58.97 |
$
25.85 |
$
25.85 |
$
21.98 |
$
63.06 |
$ 65.52 |
$ 57.33 |
$
31.94 |
$
54.87 |
$
54.87 |
| |
Lipase (fat enzyme)
level |
83690 |
301 |
$ 96.20 |
$ 67.34 |
$ 25.10 |
$ 76.96 |
$
69.26 |
$
29.53 |
$
29.53 |
$
25.10 |
$
74.07 |
$ 76.96 |
$ 67.34 |
$
37.52 |
$
64.45 |
$
64.45 |
| |
Magnesium level |
83735 |
301 |
$ 102.70 |
$ 71.89 |
$ 24.40 |
$ 82.16 |
$
73.94 |
$
28.70 |
$
28.70 |
$
24.40 |
$
79.08 |
$ 82.16 |
$ 71.89 |
$
40.05 |
$
68.81 |
$
68.81 |
| |
Natriuretic peptide
(heart and blood vessel protein) level |
83880 |
301 |
$ 319.50 |
$ 223.65 |
$ 123.61 |
$ 255.60 |
$
230.04 |
$
145.39 |
$
145.39 |
$
123.61 |
$
246.02 |
$
255.60 |
$ 223.65 |
$
124.61 |
$
214.07 |
$
214.07 |
| |
Parathormone
(parathyroid hormone) level |
83970 |
301 |
$ 308.10 |
$ 215.67 |
$ 120.16 |
$ 246.48 |
$
221.83 |
$
176.83 |
$
176.83 |
$
150.33 |
$
237.24 |
$
246.48 |
$ 215.67 |
$
120.16 |
$
206.43 |
$
206.43 |
| |
Blood potassium level |
84132 |
301 |
$ 41.00 |
$ 28.70 |
$ 15.99 |
$ 32.80 |
$
29.52 |
$
19.71 |
$
19.71 |
$
16.76 |
$
31.57 |
$ 32.80 |
$ 28.70 |
$
15.99 |
$
27.47 |
$
27.47 |
| |
Progesterone
(reproductive hormone) level |
84144 |
301 |
$ 142.00 |
$ 99.40 |
$ 55.38 |
$ 113.60 |
$
102.24 |
$
89.39 |
$
89.39 |
$
75.99 |
$
109.34 |
$
113.60 |
$ 99.40 |
$
55.38 |
$
95.14 |
$
95.14 |
| |
PSA (prostate
specific antigen) measurement |
84153 |
301 |
$ 172.90 |
$ 121.03 |
$ 66.99 |
$ 138.32 |
$
124.49 |
$
78.80 |
$
78.80 |
$
66.99 |
$
133.13 |
$
138.32 |
$ 121.03 |
$
67.43 |
$
115.84 |
$
115.84 |
| |
PSA (prostate
specific antigen) measurement |
84154 |
301 |
$ 119.00 |
$ 83.30 |
$ 46.41 |
$ 95.20 |
$
85.68 |
$
78.80 |
$
78.80 |
$
66.99 |
$
91.63 |
$ 95.20 |
$ 83.30 |
$
46.41 |
$
79.73 |
$
79.73 |
| |
Testosterone
(hormone) level |
84402 |
301 |
$ 150.00 |
$ 105.00 |
$ 58.50 |
$ 120.00 |
$
108.00 |
$
109.13 |
$
109.13 |
$
92.78 |
$
115.50 |
$
120.00 |
$ 105.00 |
$
58.50 |
$
100.50 |
$
100.50 |
| |
Thyroxine (thyroid
chemical) measurement |
84439 |
301 |
$ 136.50 |
$ 95.55 |
$ 32.83 |
$ 109.20 |
$
98.28 |
$
38.62 |
$
38.62 |
$
32.83 |
$
105.11 |
$
109.20 |
$ 95.55 |
$
53.24 |
$
91.46 |
$
91.46 |
| |
Blood test, thyroid
stimulating hormone (TSH) |
84443 |
301 |
$ 178.10 |
$ 124.67 |
$ 61.21 |
$ 142.48 |
$
128.23 |
$
72.00 |
$
72.00 |
$
61.21 |
$
137.14 |
$
142.48 |
$ 124.67 |
$
69.46 |
$
119.33 |
$
119.33 |
| |
Thyroid hormone, T3
measurement |
84480 |
301 |
$ 148.20 |
$ 103.74 |
$ 51.65 |
$ 118.56 |
$
106.70 |
$
60.76 |
$
60.76 |
$
51.65 |
$
114.11 |
$
118.56 |
$ 103.74 |
$
57.80 |
$
99.29 |
$
99.29 |
| |
Troponin (protein)
analysis |
84484 |
301 |
$ 210.60 |
$ 147.42 |
$ 36.79 |
$ 168.48 |
$
151.63 |
$
43.27 |
$
43.27 |
$
36.79 |
$
162.16 |
$
168.48 |
$ 147.42 |
$
82.13 |
$
141.10 |
$
141.10 |
| |
Urea nitrogen level
to assess kidney function |
84520 |
301 |
$ 46.50 |
$ 32.55 |
$ 14.40 |
$ 37.20 |
$
33.48 |
$
16.93 |
$
16.93 |
$
14.40 |
$
35.81 |
$ 37.20 |
$ 32.55 |
$
18.14 |
$
31.16 |
$
31.16 |
| |
Uric acid level,
blood |
84550 |
300 |
$ 33.00 |
$ 23.10 |
$ 12.87 |
$ 26.40 |
$
23.76 |
$
19.36 |
$
19.36 |
$
16.46 |
$
25.41 |
$ 26.40 |
$ 23.10 |
$
12.87 |
$
22.11 |
$
22.11 |
| |
Microscopic
examination for white blood cells with manual cell
count |
85007 |
305 |
$ 40.30 |
$ 28.21 |
$ 12.51 |
$ 32.24 |
$
29.02 |
$
14.71 |
$
14.71 |
$
12.51 |
$
31.03 |
$ 32.24 |
$ 28.21 |
$
15.72 |
$
27.00 |
$
27.00 |
| |
Hemoglobin
measurement |
85018 |
305 |
$ 27.30 |
$ 19.11 |
$ 8.64 |
$ 21.84 |
$
19.66 |
$
10.17 |
$
10.17 |
$
8.64 |
$
21.02 |
$ 21.84 |
$ 19.11 |
$
10.65 |
$
18.29 |
$
18.29 |
| |
Complete blood cell
count (red cells, white blood cell, platelets),
automated test |
85025 |
305 |
$ 119.60 |
$ 83.72 |
$ 28.29 |
$ 95.68 |
$
86.11 |
$
33.28 |
$
33.28 |
$
28.29 |
$
92.09 |
$ 95.68 |
$ 83.72 |
$
46.64 |
$
80.13 |
$
80.13 |
| |
Complete blood cell
count (red cells, white blood cell, platelets),
automated test |
85027 |
305 |
$ 76.00 |
$ 53.20 |
$ 23.54 |
$ 60.80 |
$
54.72 |
$
27.69 |
$
27.69 |
$
23.54 |
$
58.52 |
$ 60.80 |
$ 53.20 |
$
29.64 |
$
50.92 |
$
50.92 |
| |
Clotting factor V
(AcG or proaccelerin) measurement |
85220 |
305 |
$ 237.00 |
$ 165.90 |
$ 64.28 |
$ 189.60 |
$
170.64 |
$
75.61 |
$
75.61 |
$
64.28 |
$
182.49 |
$
189.60 |
$ 165.90 |
$
92.43 |
$
158.79 |
$
158.79 |
| |
Coagulation function
measurement |
85378 |
305 |
$ 137.00 |
$ 95.90 |
$ 28.67 |
$ 109.60 |
$
98.64 |
$
33.73 |
$
33.73 |
$
28.67 |
$
105.49 |
$
109.60 |
$ 95.90 |
$
53.43 |
$
91.79 |
$
91.79 |
| |
Fibrinogen (factor 1)
activity measurement |
85384 |
305 |
$ 218.00 |
$ 152.60 |
$ 30.95 |
$ 174.40 |
$
156.96 |
$
36.40 |
$
36.40 |
$
30.95 |
$
167.86 |
$
174.40 |
$ 152.60 |
$
85.02 |
$
146.06 |
$
146.06 |
| |
Blood test, clotting
time |
85610 |
305 |
$ 68.90 |
$ 48.23 |
$ 14.31 |
$ 55.12 |
$
49.61 |
$
16.83 |
$
16.83 |
$
14.31 |
$
53.05 |
$ 55.12 |
$ 48.23 |
$
26.87 |
$
46.16 |
$
46.16 |
| |
Red blood cell
sedimentation rate, to detect inflammation |
85652 |
305 |
$ 33.80 |
$ 23.66 |
$ 9.82 |
$ 27.04 |
$
24.34 |
$
11.56 |
$
11.56 |
$
9.82 |
$
26.03 |
$ 27.04 |
$ 23.66 |
$
13.18 |
$
22.65 |
$
22.65 |
| |
Coagulation
assessment blood test |
85730 |
305 |
$ 113.10 |
$ 79.17 |
$ 21.89 |
$ 90.48 |
$
81.43 |
$
25.75 |
$
25.75 |
$
21.89 |
$
87.09 |
$ 90.48 |
$ 79.17 |
$
44.11 |
$
75.78 |
$
75.78 |
| |
Measurement of
antibody (IgE) to allergic substance |
86003 |
302 |
$ 39.00 |
$ 27.30 |
$ 15.21 |
$ 31.20 |
$
28.08 |
$
22.35 |
$
22.35 |
$
19.00 |
$
30.03 |
$ 31.20 |
$ 27.30 |
$
15.21 |
$
26.13 |
$
26.13 |
| |
Measurement
C-reactive protein for detection of infection or
inflammation |
86140 |
302 |
$ 98.80 |
$ 69.16 |
$ 18.85 |
$ 79.04 |
$
71.14 |
$
22.17 |
$
22.17 |
$
18.85 |
$
76.08 |
$ 79.04 |
$ 69.16 |
$
38.53 |
$
66.20 |
$
66.20 |
| |
Analysis for
detection of tumor marker |
86316 |
300 |
$ 96.00 |
$ 67.20 |
$ 37.44 |
$ 89.18 |
$
69.12 |
$
89.18 |
$
89.18 |
$
75.82 |
$
73.92 |
$ 76.80 |
$ 67.20 |
$
37.44 |
$
64.32 |
$
64.32 |
| |
Rheumatoid factor
level |
86431 |
302 |
$ 70.00 |
$ 49.00 |
$ 20.65 |
$ 56.00 |
$
50.40 |
$
24.29 |
$
24.29 |
$
20.65 |
$
53.90 |
$ 56.00 |
$ 49.00 |
$
27.30 |
$
46.90 |
$
46.90 |
| |
Analysis for antibody
to Herpes simplex virus |
86694 |
302 |
$ 90.00 |
$ 63.00 |
$ 35.10 |
$ 72.00 |
$
64.80 |
$
61.66 |
$
61.66 |
$
52.42 |
$
69.30 |
$ 72.00 |
$ 63.00 |
$
35.10 |
$
60.30 |
$
60.30 |
| |
Bacterial blood
culture |
87040 |
306 |
$ 211.90 |
$ 148.33 |
$ 37.58 |
$ 169.52 |
$
152.57 |
$
44.21 |
$
44.21 |
$
37.58 |
$
163.16 |
$
169.52 |
$ 148.33 |
$
82.64 |
$
141.97 |
$
141.97 |
| |
Bacterial culture for
aerobic isolates |
87077 |
300 |
$ 97.50 |
$ 68.25 |
$ 29.41 |
$ 78.00 |
$
70.20 |
$
34.60 |
$
34.60 |
$
29.41 |
$
75.08 |
$ 78.00 |
$ 68.25 |
$
38.03 |
$
65.33 |
$
65.33 |
| |
Bacterial colony
count, urine |
87086 |
300 |
$ 131.30 |
$ 91.91 |
$ 29.38 |
$ 105.04 |
$
94.54 |
$
34.56 |
$
34.56 |
$
29.38 |
$
101.10 |
$
105.04 |
$ 91.91 |
$
51.21 |
$
87.97 |
$
87.97 |
| |
Evaluation of
antimicrobial drug (antibiotic, antifungal,
antiviral) |
87186 |
300 |
$ 114.40 |
$ 80.08 |
$ 31.48 |
$ 91.52 |
$
82.37 |
$
37.02 |
$
37.02 |
$
31.48 |
$
88.09 |
$ 91.52 |
$ 80.08 |
$
44.62 |
$
76.65 |
$
76.65 |
| |
Immunologic analysis
for detection of organism |
87449 |
300 |
$ 131.30 |
$ 91.91 |
$ 43.66 |
$ 105.04 |
$
94.54 |
$
51.36 |
$
51.36 |
$
43.66 |
$
101.10 |
$
105.04 |
$ 91.91 |
$
51.21 |
$
87.97 |
$
87.97 |
| |
Detection test for
chlamydia |
87490 |
306 |
$ 119.00 |
$ 83.30 |
$ 46.41 |
$ 95.20 |
$
85.68 |
$
85.92 |
$
85.92 |
$
73.04 |
$
91.63 |
$ 95.20 |
$ 83.30 |
$
46.41 |
$
79.73 |
$
79.73 |
| |
Detection test for
multiple types influenza virus |
87502 |
300 |
$ 282.10 |
$ 197.47 |
$ 110.02 |
$ 364.56 |
$
203.11 |
$
364.56 |
$
364.56 |
$
309.93 |
$
217.22 |
$
225.68 |
$ 197.47 |
$
110.02 |
$
189.01 |
$
189.01 |
| |
Detection test for
Neisseria gonorrhoeae (gonorrhoeae bacteria) |
87590 |
306 |
$ 180.00 |
$ 126.00 |
$ 70.20 |
$ 144.00 |
$
129.60 |
$
93.27 |
$
93.27 |
$
79.30 |
$
138.60 |
$
144.00 |
$ 126.00 |
$
70.20 |
$
120.60 |
$
120.60 |
| |
Infectious agent
detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2)
(Coronavirus disease [COVID-19]), amplified probe technique |
87635 |
309 |
$ 150.00 |
$ 105.00 |
$ 58.50 |
$ 178.12 |
$
108.00 |
$
178.12 |
$
178.12 |
$
151.42 |
$
115.50 |
$
120.00 |
$ 105.00 |
$
58.50 |
$
100.50 |
$
100.50 |
| |
Detection test for
Strep (Streptococcus, group A) |
87651 |
306 |
$ 125.00 |
$ 87.50 |
$ 48.75 |
$ 150.36 |
$
90.00 |
$
150.36 |
$
150.36 |
$
127.82 |
$
96.25 |
$
100.00 |
$ 87.50 |
$
48.75 |
$
83.75 |
$
83.75 |
| |
Detection test for
influenza virus |
87804 |
306 |
$ 123.50 |
$ 86.45 |
$ 48.17 |
$ 98.80 |
$
88.92 |
$
57.43 |
$
57.43 |
$
48.82 |
$
95.10 |
$ 98.80 |
$ 86.45 |
$
48.17 |
$
82.75 |
$
82.75 |
| |
Detection test for
respiratory syncytial virus (RSV) |
87807 |
301 |
$ 55.00 |
$ 38.50 |
$ 21.45 |
$ 51.36 |
$
39.60 |
$
51.36 |
$
51.36 |
$
43.66 |
$
42.35 |
$ 44.00 |
$ 38.50 |
$
21.45 |
$
36.85 |
$
36.85 |
| |
Pathology examination
of tissue using a microscope, intermediate
complexity |
88305 |
971 |
$ 445.00 |
$ 311.50 |
$ 131.87 |
$ 356.00 |
$
320.40 |
$
155.11 |
$
155.11 |
$
131.87 |
$
342.65 |
$
356.00 |
$ 311.50 |
$
173.55 |
$
298.15 |
$
298.15 |
| |
Handling and/or
conveyance of specimen for transfer to a
laboratory |
99001 |
300 |
$ 54.00 |
$ 37.80 |
$ 18.00 |
$ 43.20 |
$
38.88 |
$
21.17 |
$
21.17 |
$
18.00 |
$
41.58 |
$ 43.20 |
$ 37.80 |
$
21.06 |
$
36.18 |
$
36.18 |
| Radiology Services |
|
CT scan head or brain |
70450 |
351 |
$ 1,207.00 |
$ 844.90 |
$ 402.90 |
$ 965.60 |
$
869.04 |
$
453.26 |
$
453.26 |
$
402.90 |
$
929.39 |
$
965.60 |
$ 844.90 |
$
470.73 |
$
808.69 |
$
808.69 |
| |
MRI scan of brain
before and after contrast |
70553 |
611 |
$ 2,742.00 |
$ 1,919.40 |
$ 1,069.38 |
$ 2,193.60 |
$
1,974.24 |
$
1,807.23 |
$
1,807.23 |
$
1,606.42 |
$
2,111.34 |
$
2,193.60 |
$ 1,919.40 |
$
1,069.38 |
$
1,837.14 |
$
1,837.14 |
| |
X-ray of chest, 1
view |
71045 |
324 |
$ 300.00 |
$ 210.00 |
$ 77.03 |
$ 240.00 |
$
216.00 |
$
90.70 |
$
90.70 |
$
77.03 |
$
231.00 |
$
240.00 |
$ 210.00 |
$
117.00 |
$
201.00 |
$
201.00 |
| |
X-ray of chest, 2
views |
71046 |
324 |
$ 329.00 |
$ 230.30 |
$ 77.03 |
$ 263.20 |
$
236.88 |
$
90.70 |
$
90.70 |
$
77.03 |
$
253.33 |
$
263.20 |
$ 230.30 |
$
128.31 |
$
220.43 |
$
220.43 |
| |
MRI scan of chest
before and after contrast |
71552 |
610 |
$ 1,140.85 |
$ 798.60 |
$ 444.93 |
$ 1,807.23 |
$
821.41 |
$
1,807.23 |
$
1,807.23 |
$
1,606.42 |
$
878.45 |
$
912.68 |
$ 798.60 |
$
444.93 |
$
764.37 |
$
764.37 |
| |
X-ray of spine of
neck, 2 or 3 views |
72040 |
320 |
$ 390.00 |
$ 273.00 |
$ 77.03 |
$ 312.00 |
$
280.80 |
$
90.70 |
$
90.70 |
$
77.03 |
$
300.30 |
$
312.00 |
$ 273.00 |
$
152.10 |
$
261.30 |
$
261.30 |
| |
X-ray of upper spine,
4 or 5 views |
72050 |
320 |
$ 682.50 |
$ 477.75 |
$ 141.93 |
$ 546.00 |
$
491.40 |
$
167.11 |
$
167.11 |
$
141.93 |
$
525.53 |
$
546.00 |
$ 477.75 |
$
266.18 |
$
457.28 |
$
457.28 |
| |
X-ray of middle and
lower spine, 2 views |
72080 |
320 |
$ 300.00 |
$ 210.00 |
$ 77.03 |
$ 240.00 |
$
216.00 |
$
90.70 |
$
90.70 |
$
77.03 |
$
231.00 |
$
240.00 |
$ 210.00 |
$
117.00 |
$
201.00 |
$
201.00 |
| |
X-ray of lower and
sacral spine, 2 or 3 views |
72100 |
320 |
$ 390.00 |
$ 273.00 |
$ 141.93 |
$ 312.00 |
$
280.80 |
$
167.11 |
$
167.11 |
$
141.93 |
$
300.30 |
$
312.00 |
$ 273.00 |
$
152.10 |
$
261.30 |
$
261.30 |
| |
X-ray of lower and
sacral spine, minimum of 4 views |
72110 |
320 |
$ 682.50 |
$ 477.75 |
$ 141.93 |
$ 546.00 |
$
491.40 |
$
167.11 |
$
167.11 |
$
141.93 |
$
525.53 |
$
546.00 |
$ 477.75 |
$
266.18 |
$
457.28 |
$
457.28 |
| |
MRI scan of lower
spinal canal |
72148 |
612 |
$ 3,035.00 |
$ 2,124.50 |
$ 817.73 |
$ 2,428.00 |
$
2,185.20 |
$
919.95 |
$
919.95 |
$
817.73 |
$
2,336.95 |
$
2,428.00 |
$ 2,124.50 |
$
1,183.65 |
$
2,033.45 |
$
2,033.45 |
| |
CT scan pelvis with
contrast |
72193 |
350 |
$ 1,994.00 |
$ 1,395.80 |
$ 777.66 |
$ 1,595.20 |
$
1,435.68 |
$
1,000.85 |
$
1,000.85 |
$
889.64 |
$
1,535.38 |
$
1,595.20 |
$ 1,395.80 |
$
777.66 |
$
1,335.98 |
$
1,335.98 |
| |
MRI scan of pelvis
before and after contrast |
72197 |
610 |
$ 5,412.00 |
$ 3,788.40 |
$ 1,606.42 |
$ 4,329.60 |
$
3,896.64 |
$
1,807.23 |
$
1,807.23 |
$
1,606.42 |
$
4,167.24 |
$
4,329.60 |
$ 3,788.40 |
$
2,110.68 |
$
3,626.04 |
$
3,626.04 |
| |
X-ray of shoulder,
minimum of 2 views |
73030 |
320 |
$ 401.70 |
$ 281.19 |
$ 77.03 |
$ 321.36 |
$
289.22 |
$
90.70 |
$
90.70 |
$
77.03 |
$
309.31 |
$
321.36 |
$ 281.19 |
$
156.66 |
$
269.14 |
$
269.14 |
| |
X-ray of elbow,
minimum of 3 views |
73080 |
521 |
$ 469.30 |
$ 328.51 |
$ 77.03 |
$ 375.44 |
$
337.90 |
$
90.70 |
$
90.70 |
$
77.03 |
$
361.36 |
$
375.44 |
$ 328.51 |
$
183.03 |
$
314.43 |
$
314.43 |
| |
X-ray of forearm, 2
views |
73090 |
320 |
$ 452.40 |
$ 316.68 |
$ 77.03 |
$ 361.92 |
$
325.73 |
$
90.70 |
$
90.70 |
$
77.03 |
$
348.35 |
$
361.92 |
$ 316.68 |
$
176.44 |
$
303.11 |
$
303.11 |
| |
X-ray of wrist,
minimum of 3 views |
73110 |
320 |
$ 391.30 |
$ 273.91 |
$ 77.03 |
$ 313.04 |
$
281.74 |
$
90.70 |
$
90.70 |
$
77.03 |
$
301.30 |
$
313.04 |
$ 273.91 |
$
152.61 |
$
262.17 |
$
262.17 |
| |
X-ray of hand,
minimum of 3 views |
73130 |
320 |
$ 452.40 |
$ 316.68 |
$ 77.03 |
$ 361.92 |
$
325.73 |
$
90.70 |
$
90.70 |
$
77.03 |
$
348.35 |
$
361.92 |
$ 316.68 |
$
176.44 |
$
303.11 |
$
303.11 |
| |
CT scan of arm |
73200 |
352 |
$ 2,599.50 |
$ 1,819.65 |
$ 402.90 |
$ 2,079.60 |
$
1,871.64 |
$
453.26 |
$
453.26 |
$
402.90 |
$
2,001.62 |
$
2,079.60 |
$ 1,819.65 |
$
1,013.81 |
$
1,741.67 |
$
1,741.67 |
| |
CT scan of arm with
contrast |
73201 |
352 |
$ 2,007.00 |
$ 1,404.90 |
$ 782.73 |
$ 1,605.60 |
$
1,445.04 |
$
1,000.85 |
$
1,000.85 |
$
889.64 |
$
1,545.39 |
$
1,605.60 |
$ 1,404.90 |
$
782.73 |
$
1,344.69 |
$
1,344.69 |
| |
CT scan of arm before
and after contrast |
73202 |
352 |
$ 2,035.00 |
$ 1,424.50 |
$ 793.65 |
$ 1,628.00 |
$
1,465.20 |
$
1,000.85 |
$
1,000.85 |
$
889.64 |
$
1,566.95 |
$
1,628.00 |
$ 1,424.50 |
$
793.65 |
$
1,363.45 |
$
1,363.45 |
| |
X-ray of hip with
pelvis, 2-3 views |
73502 |
320 |
$ 496.60 |
$ 347.62 |
$ 77.03 |
$ 397.28 |
$
357.55 |
$
90.70 |
$
90.70 |
$
77.03 |
$
382.38 |
$
397.28 |
$ 347.62 |
$
193.67 |
$
332.72 |
$
332.72 |
| |
X-ray of knee, 1 or 2
views |
73560 |
320 |
$ 325.00 |
$ 227.50 |
$ 77.03 |
$ 260.00 |
$
234.00 |
$
90.70 |
$
90.70 |
$
77.03 |
$
250.25 |
$
260.00 |
$ 227.50 |
$
126.75 |
$
217.75 |
$
217.75 |
| |
X-ray of knee, 3
views |
73562 |
320 |
$ 516.10 |
$ 361.27 |
$ 77.03 |
$ 412.88 |
$
371.59 |
$
90.70 |
$
90.70 |
$
77.03 |
$
397.40 |
$
412.88 |
$ 361.27 |
$
201.28 |
$
345.79 |
$
345.79 |
| |
X-ray of ankle, 2
views |
73600 |
521 |
$ 343.20 |
$ 240.24 |
$ 77.03 |
$ 274.56 |
$
247.10 |
$
90.70 |
$
90.70 |
$
77.03 |
$
264.26 |
$
274.56 |
$ 240.24 |
$
133.85 |
$
229.94 |
$
229.94 |
| |
X-ray of ankle,
minimum of 3 views |
73610 |
320 |
$ 401.70 |
$ 281.19 |
$ 77.03 |
$ 321.36 |
$
289.22 |
$
90.70 |
$
90.70 |
$
77.03 |
$
309.31 |
$
321.36 |
$ 281.19 |
$
156.66 |
$
269.14 |
$
269.14 |
| |
X-ray of foot,
minimum of 3 views |
73630 |
521 |
$ 390.00 |
$ 273.00 |
$ 77.03 |
$ 312.00 |
$
280.80 |
$
90.70 |
$
90.70 |
$
77.03 |
$
300.30 |
$
312.00 |
$ 273.00 |
$
152.10 |
$
261.30 |
$
261.30 |
| |
CT scan leg |
73700 |
352 |
$ 1,869.00 |
$ 1,308.30 |
$ 402.90 |
$ 1,495.20 |
$
1,345.68 |
$
453.26 |
$
453.26 |
$
402.90 |
$
1,439.13 |
$
1,495.20 |
$ 1,308.30 |
$
728.91 |
$
1,252.23 |
$
1,252.23 |
| |
CT scan leg with
contrast injection |
73701 |
350 |
$ 1,869.00 |
$ 1,308.30 |
$ 728.91 |
$ 1,495.20 |
$
1,345.68 |
$
1,000.85 |
$
1,000.85 |
$
889.64 |
$
1,439.13 |
$
1,495.20 |
$ 1,308.30 |
$
728.91 |
$
1,252.23 |
$
1,252.23 |
| |
CT scan of leg before
and after contrast injection |
73702 |
352 |
$ 2,016.00 |
$ 1,411.20 |
$ 786.24 |
$ 1,612.80 |
$
1,451.52 |
$
1,000.85 |
$
1,000.85 |
$
889.64 |
$
1,552.32 |
$
1,612.80 |
$ 1,411.20 |
$
786.24 |
$
1,350.72 |
$
1,350.72 |
| |
MRI scan of leg joint |
73721 |
610 |
$ 2,830.00 |
$ 1,981.00 |
$ 817.73 |
$ 2,264.00 |
$
2,037.60 |
$
919.95 |
$
919.95 |
$
817.73 |
$
2,179.10 |
$
2,264.00 |
$ 1,981.00 |
$
1,103.70 |
$
1,896.10 |
$
1,896.10 |
| |
MRI scan of leg joint
with contrast |
73722 |
610 |
$ 2,958.00 |
$ 2,070.60 |
$ 1,153.62 |
$ 2,700.24 |
$
2,129.76 |
$
2,700.24 |
$
2,700.24 |
$
2,400.22 |
$
2,277.66 |
$
2,366.40 |
$ 2,070.60 |
$
1,153.62 |
$
1,981.86 |
$
1,981.86 |
| |
MRI scan of leg joint
before and after contrast |
73723 |
610 |
$ 3,686.00 |
$ 2,580.20 |
$ 1,437.54 |
$ 2,948.80 |
$
2,653.92 |
$
1,807.23 |
$
1,807.23 |
$
1,606.42 |
$
2,838.22 |
$
2,948.80 |
$ 2,580.20 |
$
1,437.54 |
$
2,469.62 |
$
2,469.62 |
| |
X-ray of abdomen, 1
view |
74018 |
320 |
$ 300.00 |
$ 210.00 |
$ 77.03 |
$ 240.00 |
$
216.00 |
$
90.70 |
$
90.70 |
$
77.03 |
$
231.00 |
$
240.00 |
$ 210.00 |
$
117.00 |
$
201.00 |
$
201.00 |
| |
X-ray of abdomen, 2
views |
74019 |
320 |
$ 317.00 |
$ 221.90 |
$ 123.63 |
$ 253.60 |
$
228.24 |
$
167.11 |
$
167.11 |
$
141.93 |
$
244.09 |
$
253.60 |
$ 221.90 |
$
123.63 |
$
212.39 |
$
212.39 |
| |
X-ray of abdomen,
minimum of 3 views |
74021 |
320 |
$ 468.00 |
$ 327.60 |
$ 141.93 |
$ 374.40 |
$
336.96 |
$
167.11 |
$
167.11 |
$
141.93 |
$
360.36 |
$
374.40 |
$ 327.60 |
$
182.52 |
$
313.56 |
$
313.56 |
| |
Complete X-ray study
of abdomen with single X-ray of chest |
74022 |
320 |
$ 687.70 |
$ 481.39 |
$ 141.93 |
$ 550.16 |
$
495.14 |
$
167.11 |
$
167.11 |
$
141.93 |
$
529.53 |
$
550.16 |
$ 481.39 |
$
268.20 |
$
460.76 |
$
460.76 |
| |
CT scan of abdomen
and pelvis |
74176 |
352 |
$ 1,951.50 |
$ 1,366.05 |
$ 761.09 |
$ 1,561.20 |
$
1,405.08 |
$
919.95 |
$
919.95 |
$
817.73 |
$
1,502.66 |
$
1,561.20 |
$ 1,366.05 |
$
761.09 |
$
1,307.51 |
$
1,307.51 |
| |
CT scan of abdomen
and pelvis with contrast |
74177 |
352 |
$ 2,248.00 |
$ 1,573.60 |
$ 876.72 |
$ 1,798.40 |
$
1,618.56 |
$
1,000.85 |
$
1,000.85 |
$
889.64 |
$
1,730.96 |
$
1,798.40 |
$ 1,573.60 |
$
876.72 |
$
1,506.16 |
$
1,506.16 |
| |
CT scan of abdomen
and pelvis before and after contrast |
74178 |
352 |
$ 2,883.00 |
$ 2,018.10 |
$ 889.64 |
$ 2,306.40 |
$
2,075.76 |
$
1,000.85 |
$
1,000.85 |
$
889.64 |
$
2,219.91 |
$
2,306.40 |
$ 2,018.10 |
$
1,124.37 |
$
1,931.61 |
$
1,931.61 |
| |
MRI scan of abdomen
before and after contrast |
74183 |
610 |
$ 4,979.00 |
$ 3,485.30 |
$ 1,606.42 |
$ 3,983.20 |
$
3,584.88 |
$
1,807.23 |
$
1,807.23 |
$
1,606.42 |
$
3,833.83 |
$
3,983.20 |
$ 3,485.30 |
$
1,941.81 |
$
3,335.93 |
$
3,335.93 |
| |
Imaging for
evaluation of swallowing function |
74230 |
320 |
$ 800.80 |
$ 560.56 |
$ 141.93 |
$ 640.64 |
$
576.58 |
$
167.11 |
$
167.11 |
$
141.93 |
$
616.62 |
$
640.64 |
$ 560.56 |
$
312.31 |
$
536.54 |
$
536.54 |
| |
X-ray of large bowel
with single contrast |
74270 |
320 |
$ 1,218.10 |
$ 852.67 |
$ 313.40 |
$ 974.48 |
$
877.03 |
$
369.00 |
$
369.00 |
$
313.40 |
$
937.94 |
$
974.48 |
$ 852.67 |
$
475.06 |
$
816.13 |
$
816.13 |
| |
Imaging of urinary
tract |
74420 |
320 |
$ 1,078.00 |
$ 754.60 |
$ 420.42 |
$ 862.40 |
$
776.16 |
$
664.40 |
$
664.40 |
$
564.29 |
$
830.06 |
$
862.40 |
$ 754.60 |
$
420.42 |
$
722.26 |
$
722.26 |
| |
CT scan of abdominal
aorta and both leg arteries with contrast |
75635 |
352 |
$ 3,339.00 |
$ 2,337.30 |
$ 889.64 |
$ 2,671.20 |
$
2,404.08 |
$
1,000.85 |
$
1,000.85 |
$
889.64 |
$
2,571.03 |
$
2,671.20 |
$ 2,337.30 |
$
1,302.21 |
$
2,237.13 |
$
2,237.13 |
| |
Ultrasound of abdomen |
76700 |
402 |
$ 949.00 |
$ 664.30 |
$ 141.93 |
$ 759.20 |
$
683.28 |
$
167.11 |
$
167.11 |
$
141.93 |
$
730.73 |
$
759.20 |
$ 664.30 |
$
370.11 |
$
635.83 |
$
635.83 |
| |
Ultrasound behind
abdominal cavity |
76770 |
402 |
$ 889.20 |
$ 622.44 |
$ 141.93 |
$ 711.36 |
$
640.22 |
$
167.11 |
$
167.11 |
$
141.93 |
$
684.68 |
$
711.36 |
$ 622.44 |
$
346.79 |
$
595.76 |
$
595.76 |
| |
Ultrasound of spinal
canal |
76800 |
402 |
$ 315.00 |
$ 220.50 |
$ 122.85 |
$ 252.00 |
$
226.80 |
$
167.11 |
$
167.11 |
$
141.93 |
$
242.55 |
$
252.00 |
$ 220.50 |
$
122.85 |
$
211.05 |
$
211.05 |
| |
Abdominal ultrasound
of pregnant uterus (greater or equal to 14 weeks 0
days) single or first fetus |
76805 |
402 |
$ 406.00 |
$ 284.20 |
$ 116.60 |
$ 324.80 |
$
292.32 |
$
137.28 |
$
137.28 |
$
116.60 |
$
312.62 |
$
324.80 |
$ 284.20 |
$
158.34 |
$
272.02 |
$
272.02 |
| |
Vaginal ultrasound of
pregnant uterus |
76817 |
402 |
$ 406.00 |
$ 284.20 |
$ 141.93 |
$ 324.80 |
$
292.32 |
$
167.11 |
$
167.11 |
$
141.93 |
$
312.62 |
$
324.80 |
$ 284.20 |
$
158.34 |
$
272.02 |
$
272.02 |
| |
Ultrasound pelvis
through vagina |
76830 |
402 |
$ 889.20 |
$ 622.44 |
$ 110.81 |
$ 711.36 |
$
640.22 |
$
130.47 |
$
130.47 |
$
110.81 |
$
684.68 |
$
711.36 |
$ 622.44 |
$
346.79 |
$
595.76 |
$
595.76 |
| |
Ultrasound of pelvis |
76857 |
402 |
$ 256.00 |
$ 179.20 |
$ 99.84 |
$ 204.80 |
$
184.32 |
$
167.11 |
$
167.11 |
$
141.93 |
$
197.12 |
$
204.80 |
$ 179.20 |
$
99.84 |
$
171.52 |
$
171.52 |
| |
Complete ultrasound
of joint of arm or leg |
76881 |
402 |
$ 684.00 |
$ 478.80 |
$ 88.56 |
$ 547.20 |
$
492.48 |
$
104.27 |
$
104.27 |
$
88.56 |
$
526.68 |
$
547.20 |
$ 478.80 |
$
266.76 |
$
458.28 |
$
458.28 |
| |
Partial ultrasound of
joint or other non-blood vessel structure of arm
or leg |
76882 |
402 |
$ 525.00 |
$ 367.50 |
$ 141.93 |
$ 420.00 |
$
378.00 |
$
167.11 |
$
167.11 |
$
141.93 |
$
404.25 |
$
420.00 |
$ 367.50 |
$
204.75 |
$
351.75 |
$
351.75 |
| |
Mammography of one
breast |
77065 |
401 |
$ 276.00 |
$ 193.20 |
$ 107.64 |
$ 220.80 |
$
198.72 |
$
139.90 |
$
139.90 |
$
118.82 |
$
212.52 |
$
220.80 |
$ 193.20 |
$
107.64 |
$
184.92 |
$
184.92 |
| |
Mammography of both
breasts |
77066 |
401 |
$ 551.00 |
$ 385.70 |
$ 151.75 |
$ 440.80 |
$
396.72 |
$
178.67 |
$
178.67 |
$
151.75 |
$
424.27 |
$
440.80 |
$ 385.70 |
$
214.89 |
$
369.17 |
$
369.17 |
| |
Mammography of both
breasts |
77067 |
403 |
$ 216.00 |
$ 151.20 |
$ 84.24 |
$ 172.80 |
$
155.52 |
$
147.77 |
$
147.77 |
$
125.50 |
$
166.32 |
$
172.80 |
$ 151.20 |
$
84.24 |
$
144.72 |
$
144.72 |
| |
Bone density
measurement using dedicated X-ray machine |
77080 |
320 |
$ 385.00 |
$ 269.50 |
$ 40.05 |
$ 308.00 |
$
277.20 |
$
47.16 |
$
47.16 |
$
40.05 |
$
296.45 |
$
308.00 |
$ 269.50 |
$
150.15 |
$
257.95 |
$
257.95 |
| |
Nuclear medicine
imaging for thyroid uptake measurements |
78012 |
341 |
$ 800.00 |
$ 560.00 |
$ 93.46 |
$ 640.00 |
$
576.00 |
$
110.04 |
$
110.04 |
$
93.46 |
$
616.00 |
$
640.00 |
$ 560.00 |
$
312.00 |
$
536.00 |
$
536.00 |
| |
Bone and/or joint
imaging |
78300 |
341 |
$ 1,168.00 |
$ 817.60 |
$ 261.68 |
$ 934.40 |
$
840.96 |
$
308.10 |
$
308.10 |
$
261.68 |
$
899.36 |
$
934.40 |
$ 817.60 |
$
455.52 |
$
782.56 |
$
782.56 |
| |
Routine
electrocardiogram (EKG) with tracing using at
least 12 leads |
93005 |
730 |
$ 326.30 |
$ 228.41 |
$ 127.26 |
$ 261.04 |
$
234.94 |
$
129.27 |
$
129.27 |
$
129.27 |
$
251.25 |
$
261.04 |
$ 228.41 |
$
127.26 |
$
218.62 |
$
218.62 |
| |
Ultrasound scanning
of blood flow (outside the brain) on both sides of
head and neck |
93880 |
921 |
$ 1,447.00 |
$ 1,012.90 |
$ 272.74 |
$ 1,157.60 |
$
1,041.84 |
$
272.74 |
$
272.74 |
$
272.74 |
$
1,114.19 |
$
1,157.60 |
$ 1,012.90 |
$
564.33 |
$
969.49 |
$
969.49 |
| |
Ultrasound scan of
veins of both arms or legs including assessment of
compression and functional maneuvers |
93970 |
921 |
$ 1,479.40 |
$ 1,035.58 |
$ 383.83 |
$ 1,183.52 |
$
1,065.17 |
$
383.83 |
$
383.83 |
$
383.83 |
$
1,139.14 |
$
1,183.52 |
$ 1,035.58 |
$
576.97 |
$
991.20 |
$
991.20 |
| |
Initial nursing
facility visit, typically 45 minutes per day |
99306 |
|
$ 253.00 |
$ 177.10 |
$ 98.67 |
$ 202.40 |
$
182.16 |
$
- |
$ - |
$ - |
$
194.81 |
$
202.40 |
$ 177.10 |
$
98.67 |
$
169.51 |
$
169.51 |
| |
MRI Contrast -
Multihance 20 ml |
A9577 |
636 |
$ 7.97 |
$ 5.58 |
$ 3.11 |
$ 6.38 |
$ 5.74 |
N/A |
N/A |
N/A |
$ 6.14 |
$ 6.38 |
$ 5.58 |
$
3.11 |
$
5.34 |
$ 5.34 |
| |
CT Lung Cancer
screening |
G0297 |
|
$ 2,796.00 |
$ 1,957.20 |
$ 234.52 |
$ 2,236.80 |
$
2,013.12 |
$
276.13 |
$
276.13 |
$
234.52 |
$
2,152.92 |
$
2,236.80 |
$ 1,957.20 |
$
1,090.44 |
$
1,873.32 |
$
1,873.32 |
| |
CT scan contrast
100ML or 75ML low osmolar contrast |
Q9967 |
636 |
$ 2.46 |
$ 1.72 |
$ 0.96 |
$ 1.97 |
$ 1.77 |
N/A |
N/A |
N/A |
$ 1.89 |
$ 1.97 |
$ 1.72 |
$
0.96 |
$
1.65 |
$ 1.65 |
| Medicine and Surgery Services |
|
Drainage of tailbone
cyst |
10080 |
981 |
$ 266.88 |
$ 186.82 |
$ 104.08 |
$ 213.50 |
$
192.15 |
$
140.62 |
$
140.62 |
$
133.92 |
$
205.50 |
$
213.50 |
$ 186.82 |
$
104.08 |
$
178.81 |
$
178.81 |
| |
Drainage of tailbone
cyst |
10081 |
981 |
$ 443.53 |
$ 310.47 |
$ 172.98 |
$ 354.82 |
$
319.34 |
$
182.95 |
$
182.95 |
$
174.24 |
$
341.52 |
$
354.82 |
$ 310.47 |
$
172.98 |
$
297.17 |
$
297.17 |
| |
Removal of skin and
tissue first 20 sq cm or less |
11042 |
761 |
$ 2,094.33 |
$ 1,466.03 |
$ 310.80 |
$ 1,675.46 |
$
1,507.92 |
$
326.34 |
$
326.34 |
$
310.80 |
$
1,612.63 |
$
1,675.46 |
$ 1,466.03 |
$
816.79 |
$
1,403.20 |
$
1,403.20 |
| |
Removal of skin and
tissue |
11045 |
761 |
$ 1,168.70 |
$ 818.09 |
$ 455.79 |
$ 934.96 |
$
841.46 |
$
- |
$ - |
$ - |
$
899.90 |
$
934.96 |
$ 818.09 |
$
455.79 |
$
783.03 |
$
783.03 |
| |
Removal of growth
(0.5 centimeters or less) of the trunk, arms or
legs |
11400 |
983 |
$ 212.20 |
$ 148.54 |
$ 82.76 |
$ 169.76 |
$
152.78 |
$
96.39 |
$
96.39 |
$
91.80 |
$
163.39 |
$
169.76 |
$ 148.54 |
$
82.76 |
$
142.17 |
$
142.17 |
| |
Removal of growth
(0.6 to 1.0 centimeters) of the trunk, arms, or
legs |
11401 |
983 |
$ 785.20 |
$ 549.64 |
$ 100.80 |
$ 628.16 |
$
565.34 |
$
105.84 |
$
105.84 |
$
100.80 |
$
604.60 |
$
628.16 |
$ 549.64 |
$
306.23 |
$
526.08 |
$
526.08 |
| |
Removal of growth
(1.1 to 2.0 centimeters) of the trunk, arms, or
legs |
11402 |
960 |
$ 299.45 |
$ 209.62 |
$ 110.88 |
$ 239.56 |
$
215.60 |
$
116.42 |
$
116.42 |
$
110.88 |
$
230.58 |
$
239.56 |
$ 209.62 |
$
116.79 |
$
200.63 |
$
200.63 |
| |
Removal of growth
(2.1 to 3.0 centimeters) of the trunk, arms, or
legs |
11403 |
521 |
$ 189.00 |
$ 132.30 |
$ 73.71 |
$ 151.20 |
$
136.08 |
$
126.63 |
$
126.63 |
$
120.60 |
$
145.53 |
$
151.20 |
$ 132.30 |
$
73.71 |
$
126.63 |
$
126.63 |
| |
Removal of growth
(3.1 to 4.0 centimeters) of the trunk, arms, or
legs |
11404 |
983 |
$ 242.00 |
$ 169.40 |
$ 94.38 |
$ 1,415.43 |
$
174.24 |
$
1,415.43 |
$
1,415.43 |
$
1,348.03 |
$
186.34 |
$
193.60 |
$ 169.40 |
$
94.38 |
$
162.14 |
$
162.14 |
| |
Removal of growth
(0.5 centimeters or less) of the scalp, neck,
hands, feet, or genitals |
11420 |
977 |
$ 226.00 |
$ 158.20 |
$ 84.60 |
$ 180.80 |
$
162.72 |
$
88.83 |
$
88.83 |
$
84.60 |
$
174.02 |
$
180.80 |
$ 158.20 |
$
88.14 |
$
151.42 |
$
151.42 |
| |
Removal of growth
(0.6 to 1.0 centimeters) of the scalp, neck,
hands, feet, or genitals |
11421 |
983 |
$ 159.00 |
$ 111.30 |
$ 62.01 |
$ 127.20 |
$
114.48 |
$
106.22 |
$
106.22 |
$
101.16 |
$
122.43 |
$
127.20 |
$ 111.30 |
$
62.01 |
$
106.53 |
$
106.53 |
| |
Removal of growth
(1.1 to 2.0 centimeters) of the scalp, neck,
hands, feet, or genitals |
11422 |
977 |
$ 206.00 |
$ 144.20 |
$ 80.34 |
$ 164.80 |
$
148.32 |
$
117.18 |
$
117.18 |
$
111.60 |
$
158.62 |
$
164.80 |
$ 144.20 |
$
80.34 |
$
138.02 |
$
138.02 |
| |
Removal of growth
(2.1 to 3.0 centimeters) of the scalp, neck,
hands, feet, or genitals |
11423 |
983 |
$ 200.00 |
$ 140.00 |
$ 78.00 |
$ 160.00 |
$
144.00 |
$
127.01 |
$
127.01 |
$
120.96 |
$
154.00 |
$
160.00 |
$ 140.00 |
$
78.00 |
$
134.00 |
$
134.00 |
| |
Removal of growth
(3.1 to 4.0 centimeters) of the scalp, neck,
hands, feet, or genitals |
11424 |
521 |
$ 216.00 |
$ 151.20 |
$ 84.24 |
$ 1,415.43 |
$
155.52 |
$
1,415.43 |
$
1,415.43 |
$
1,348.03 |
$
166.32 |
$
172.80 |
$ 151.20 |
$
84.24 |
$
144.72 |
$
144.72 |
| |
Removal of malignant
growth (0.5 centimeters or less) of the trunk,
arms, or legs |
11600 |
521 |
$ 168.00 |
$ 117.60 |
$ 65.52 |
$ 137.97 |
$
120.96 |
$
137.97 |
$
137.97 |
$
131.40 |
$
129.36 |
$
134.40 |
$ 117.60 |
$
65.52 |
$
112.56 |
$
112.56 |
| |
Removal of malignant
growth (0.6 to 1.0 centimeters) of the trunk,
arms, or legs |
11601 |
977 |
$ 267.00 |
$ 186.90 |
$ 104.13 |
$ 213.60 |
$
192.24 |
$
157.25 |
$
157.25 |
$
149.76 |
$
205.59 |
$
213.60 |
$ 186.90 |
$
104.13 |
$
178.89 |
$
178.89 |
| |
Removal of malignant
growth (1.1 to 2.0 centimeters) of the trunk,
arms, or legs |
11602 |
977 |
$ 453.00 |
$ 317.10 |
$ 161.28 |
$ 362.40 |
$
326.16 |
$
169.34 |
$
169.34 |
$
161.28 |
$
348.81 |
$
362.40 |
$ 317.10 |
$
176.67 |
$
303.51 |
$
303.51 |
| |
Removal of malignant
growth (2.1 to 3.0 centimeters) of the trunk,
arms, or legs |
11603 |
983 |
$ 237.00 |
$ 165.90 |
$ 92.43 |
$ 189.60 |
$
170.64 |
$
183.33 |
$
183.33 |
$
174.60 |
$
182.49 |
$
189.60 |
$ 165.90 |
$
92.43 |
$
158.79 |
$
158.79 |
| |
Removal of malignant
growth (3.1 to 4 centimeters) of the trunk, arms,
or legs |
11604 |
521 |
$ 216.00 |
$ 151.20 |
$ 84.24 |
$ 601.49 |
$
155.52 |
$
601.49 |
$
601.49 |
$
572.85 |
$
166.32 |
$
172.80 |
$ 151.20 |
$
84.24 |
$
144.72 |
$
144.72 |
| |
Removal of malignant
growth (0.5 centimeters or less) of the scalp,
neck, hands, feet, or genitals |
11620 |
521 |
$ 152.00 |
$ 106.40 |
$ 59.28 |
$ 138.73 |
$
109.44 |
$
138.73 |
$
138.73 |
$
132.12 |
$
117.04 |
$
121.60 |
$ 106.40 |
$
59.28 |
$
101.84 |
$
101.84 |
| |
Removal of malignant
growth (0.6 to 1.0 centimeters) of the scalp,
neck, hands, feet, or genitals |
11621 |
521 |
$ 184.00 |
$ 128.80 |
$ 71.76 |
$ 157.63 |
$
132.48 |
$
157.63 |
$
157.63 |
$
150.12 |
$
141.68 |
$
147.20 |
$ 128.80 |
$
71.76 |
$
123.28 |
$
123.28 |
| |
Removal of malignant
growth (1.1 to 2.0 centimeters) of the scalp,
neck, hands, feet, or genitals |
11622 |
983 |
$ 225.00 |
$ 157.50 |
$ 87.75 |
$ 180.00 |
$
162.00 |
$
171.99 |
$
171.99 |
$
163.80 |
$
173.25 |
$
180.00 |
$ 157.50 |
$
87.75 |
$
150.75 |
$
150.75 |
| |
Removal of malignant
growth (2.1 to 3.0 centimeters) of the scalp,
neck, hands, feet, or genitals |
11623 |
521 |
$ 243.00 |
$ 170.10 |
$ 94.77 |
$ 194.40 |
$
174.96 |
$
188.62 |
$
188.62 |
$
179.64 |
$
187.11 |
$
194.40 |
$ 170.10 |
$
94.77 |
$
162.81 |
$
162.81 |
| |
Removal of malignant
growth (3.1 to 4 centimeters) of the scalp, neck,
hands, feet, or genitals |
11624 |
521 |
$ 251.00 |
$ 175.70 |
$ 97.89 |
$ 1,415.43 |
$
180.72 |
$
1,415.43 |
$
1,415.43 |
$
1,348.03 |
$
193.27 |
$
200.80 |
$ 175.70 |
$
97.89 |
$
168.17 |
$
168.17 |
| |
Removal of malignant
growth (0.5 centimeters or less) of the face,
ears, eyelids, nose, or lips |
11640 |
977 |
$ 201.00 |
$ 140.70 |
$ 78.39 |
$ 160.80 |
$
144.72 |
$
144.02 |
$
144.02 |
$
137.16 |
$
154.77 |
$
160.80 |
$ 140.70 |
$
78.39 |
$
134.67 |
$
134.67 |
| |
Removal of malignant
growth (0.6 to 1.0 centimeters) of the face, ears,
eyelids, nose, or lips |
11641 |
521 |
$ 206.00 |
$ 144.20 |
$ 80.34 |
$ 164.80 |
$
148.32 |
$
162.16 |
$
162.16 |
$
154.44 |
$
158.62 |
$
164.80 |
$ 144.20 |
$
80.34 |
$
138.02 |
$
138.02 |
| |
Removal of malignant
growth (1.1 to 2.0 centimeters) of the face, ears,
eyelids, nose, or lips |
11642 |
983 |
$ 282.00 |
$ 197.40 |
$ 109.98 |
$ 225.60 |
$
203.04 |
$
178.42 |
$
178.42 |
$
169.92 |
$
217.14 |
$
225.60 |
$ 197.40 |
$
109.98 |
$
188.94 |
$
188.94 |
| |
Removal of malignant
growth (2.1 to 3.0 centimeters) of the face, ears,
eyelids, nose, or lips |
11643 |
521 |
$ 281.00 |
$ 196.70 |
$ 109.59 |
$ 224.80 |
$
202.32 |
$
195.43 |
$
195.43 |
$
186.12 |
$
216.37 |
$
224.80 |
$ 196.70 |
$
109.59 |
$
188.27 |
$
188.27 |
| |
Removal of malignant
growth (3.1 to 4.0 centimeters) of the face, ears,
eyelids, nose, or lips |
11644 |
521 |
$ 331.00 |
$ 231.70 |
$ 129.09 |
$ 1,415.43 |
$
238.32 |
$
1,415.43 |
$
1,415.43 |
$
1,348.03 |
$
254.87 |
$
264.80 |
$ 231.70 |
$
129.09 |
$
221.77 |
$
221.77 |
| |
Repair of finger or
toe nail bed |
11760 |
981 |
$ 298.10 |
$ 208.67 |
$ 116.26 |
$ 512.61 |
$
214.63 |
$
512.61 |
$
512.61 |
$
488.20 |
$
229.54 |
$
238.48 |
$ 208.67 |
$
116.26 |
$
199.73 |
$
199.73 |
| |
Removal of skin of
finger or toe nail |
11765 |
983 |
$ 356.00 |
$ 249.20 |
$ 138.84 |
$ 326.34 |
$
256.32 |
$
326.34 |
$
326.34 |
$
310.80 |
$
274.12 |
$
284.80 |
$ 249.20 |
$
138.84 |
$
238.52 |
$
238.52 |
| |
Biopsy of breast
accessed through the skin with ultrasound guidance |
19083 |
361 |
$ 5,033.50 |
$ 3,523.45 |
$ 1,348.03 |
$ 4,026.80 |
$
3,624.12 |
$
1,415.43 |
$
1,415.43 |
$
1,348.03 |
$
3,875.80 |
$
4,026.80 |
$ 3,523.45 |
$
1,963.07 |
$
3,372.45 |
$
3,372.45 |
| |
Needle biopsy of
breast |
19100 |
983 |
$ 196.00 |
$ 137.20 |
$ 76.44 |
$ 1,415.43 |
$
141.12 |
$
1,415.43 |
$
1,415.43 |
$
1,348.03 |
$
150.92 |
$
156.80 |
$ 137.20 |
$
76.44 |
$
131.32 |
$
131.32 |
| |
Removal of 1 or more
breast growth, open procedure |
19120 |
521 |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Injections of tendon
sheath, ligament, or muscle membrane |
20550 |
521 |
$ 96.00 |
$ 67.20 |
$ 24.12 |
$ 76.80 |
$
69.12 |
$
25.33 |
$
25.33 |
$
24.12 |
$
73.92 |
$ 76.80 |
$ 67.20 |
$
37.44 |
$
64.32 |
$
64.32 |
| |
Biopsy of tissue of
back or flank |
21920 |
521 |
$ 235.00 |
$ 164.50 |
$ 91.65 |
$ 188.00 |
$
169.20 |
$
185.98 |
$
185.98 |
$
177.12 |
$
180.95 |
$
188.00 |
$ 164.50 |
$
91.65 |
$
157.45 |
$
157.45 |
| |
Drainage of
fluid-filled sac (bursa) of upper arm or elbow |
23931 |
981 |
$ 407.63 |
$ 285.34 |
$ 158.98 |
$ 1,415.43 |
$
293.49 |
$
1,415.43 |
$
1,415.43 |
$
1,348.03 |
$
313.88 |
$
326.10 |
$ 285.34 |
$
158.98 |
$
273.11 |
$
273.11 |
| |
Closed treatment of
knee dislocation |
27550 |
521 |
$ 632.00 |
$ 442.40 |
$ 214.90 |
$ 505.60 |
$
455.04 |
$
225.65 |
$
225.65 |
$
214.90 |
$
486.64 |
$
505.60 |
$ 442.40 |
$
246.48 |
$
423.44 |
$
423.44 |
| |
Shaving of shoulder
bone using an endoscope |
29826 |
521 |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Removal of one knee
cartilage using an endoscope |
29881 |
521 |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Removal of fluid from
chest cavity |
32554 |
981 |
$ 235.25 |
$ 164.68 |
$ 91.75 |
$ 643.20 |
$
169.38 |
$
643.20 |
$
643.20 |
$
612.57 |
$
181.14 |
$
188.20 |
$ 164.68 |
$
91.75 |
$
157.62 |
$
157.62 |
| |
Removal of fluid from
chest cavity with imaging guidance |
32555 |
361 |
$ 1,765.40 |
$ 1,235.78 |
$ 612.57 |
$ 1,412.32 |
$
1,271.09 |
$
643.20 |
$
643.20 |
$
612.57 |
$
1,359.36 |
$
1,412.32 |
$ 1,235.78 |
$
688.51 |
$
1,182.82 |
$
1,182.82 |
| |
Transfusion of blood
or blood products |
36430 |
391 |
$ 827.00 |
$ 578.90 |
$ 35.28 |
$ 661.60 |
$
595.44 |
$
37.04 |
$
37.04 |
$
35.28 |
$
636.79 |
$
661.60 |
$ 578.90 |
$
322.53 |
$
554.09 |
$
554.09 |
| |
Diagnostic bone
marrow aspiration |
38220 |
310 |
$ 1,926.00 |
$ 1,348.20 |
$ 124.56 |
$ 1,540.80 |
$
1,386.72 |
$
130.79 |
$
130.79 |
$
124.56 |
$
1,483.02 |
$
1,540.80 |
$ 1,348.20 |
$
751.14 |
$
1,290.42 |
$
1,290.42 |
| |
Bone marrow biopsy |
38221 |
521 |
$ 963.30 |
$ 674.31 |
$ 107.64 |
$ 770.64 |
$
693.58 |
$
113.02 |
$
113.02 |
$
107.64 |
$
741.74 |
$
770.64 |
$ 674.31 |
$
375.69 |
$
645.41 |
$
645.41 |
| |
Removal of tonsils
and adenoid glands patient younger than age 12 |
42820 |
521 |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Diagnostic
examination of esophagus, stomach, and/or upper
small bowel using an endoscope |
43235 |
521 |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Biopsy of the
esophagus, stomach, and/or upper small bowel using
an endoscope |
43239 |
521 |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| Diagnostic examination of large bowel using an
endoscope |
Diagnostic
examination of large bowel using an endoscope |
45378 |
521 |
$ 1,034.80 |
$ 724.36 |
$ 403.57 |
$ 827.84 |
$
745.06 |
$
745.48 |
$
745.48 |
$
709.98 |
$
796.80 |
$
827.84 |
$ 724.36 |
$
403.57 |
$
693.32 |
$
693.32 |
| Professional Fee (Anesthesia) |
45378 |
521 |
$ 2,694.00 |
$ 1,885.80 |
$ 1,050.66 |
$ 2,155.20 |
$
1,939.68 |
|
|
|
$
2,074.38 |
$
2,155.20 |
$ 1,885.80 |
$
1,050.66 |
$
1,804.98 |
$
1,804.98 |
| Additional Professional Fee |
45378 |
|
$ 516.38 |
$ 361.46 |
$ 201.39 |
$ 413.10 |
$
371.79 |
|
|
|
$
397.61 |
$
413.10 |
$ 361.46 |
$
201.39 |
$
345.97 |
$
345.97 |
| Biopsy of large bowel using
an endoscope |
Biopsy of large bowel
using an endoscope |
45380 |
521 |
$ 3,407.25 |
$ 2,385.08 |
$ 936.39 |
$ 2,725.80 |
$
2,453.22 |
$
983.21 |
$
983.21 |
$
936.39 |
$
2,623.58 |
$
2,725.80 |
$ 2,385.08 |
$
1,328.83 |
$
2,282.86 |
$
2,282.86 |
| Professional Fee (Anesthesia) |
45380 |
521 |
$ 3,006.00 |
$ 2,104.20 |
$ 1,172.34 |
$ 2,404.80 |
$
2,164.32 |
|
|
|
$
2,314.62 |
$
2,404.80 |
$ 2,104.20 |
$
1,172.34 |
$
2,014.02 |
$
2,014.02 |
| Additional Professional Fee |
45380 |
|
$ 459.00 |
$ 321.30 |
$ 179.01 |
$ 367.20 |
$
330.48 |
|
|
|
$
353.43 |
$
367.20 |
$ 321.30 |
$
179.01 |
$
307.53 |
$
307.53 |
| Biopsy of large bowel using
an endoscope |
Removal of polyps or
growths of large bowel using an endoscope |
45385 |
521 |
$ 4,747.44 |
$ 3,323.21 |
$ 936.39 |
$ 3,797.95 |
$
3,418.16 |
$
983.21 |
$
983.21 |
$
936.39 |
$
3,655.53 |
$
3,797.95 |
$ 3,323.21 |
$
1,851.50 |
$
3,180.78 |
$
3,180.78 |
| Professional Fee (Anesthesia) |
45385 |
521 |
$ 3,095.00 |
$ 2,166.50 |
$ 1,207.05 |
$ 2,476.00 |
$
2,228.40 |
|
|
|
$
2,383.15 |
$
2,476.00 |
$ 2,166.50 |
$
1,207.05 |
$
2,073.65 |
$
2,073.65 |
| Additional Professional Fee |
45385 |
|
$ 593.61 |
$ 415.53 |
$ 231.51 |
$ 474.89 |
$
427.40 |
|
|
|
$
457.08 |
$
474.89 |
$ 415.53 |
$
231.51 |
$
397.72 |
$
397.72 |
| |
Ultrasound
examination of lower large bowel using an
endoscope |
45391 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Removal of engorged
hemorrhoid |
46320 |
521 |
$ 292.73 |
$ 204.91 |
$ 114.16 |
$ 234.18 |
$
210.77 |
$
127.76 |
$
127.76 |
$
121.68 |
$
225.40 |
$
234.18 |
$ 204.91 |
$
114.16 |
$
196.13 |
$
196.13 |
| |
Removal of
gallbladder using an endoscope |
47562 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Repair of groin
hernia patient age 5 years or older |
49505 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Removal of foreskin
of using clamp or device |
54150 |
521 |
$ 297.00 |
$ 207.90 |
$ 115.83 |
$ 1,780.46 |
$
213.84 |
$
1,780.46 |
$
1,780.46 |
$
1,695.68 |
$
228.69 |
$
237.60 |
$ 207.90 |
$
115.83 |
$
198.99 |
$
198.99 |
| |
Removal of foreskin,
neonate (28 days of age or less) |
54160 |
521 |
$ 321.00 |
$ 224.70 |
$ 157.29 |
$ 110.10 |
$
231.12 |
$
1,780.46 |
$
1,780.46 |
$
1,695.68 |
$
247.17 |
$
256.80 |
$ 224.70 |
$
125.19 |
$
215.07 |
$
215.07 |
| |
Biopsy of prostate
gland |
55700 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Surgical removal of
prostate and surrounding lymph nodes using an
endoscope |
55866 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Obstetrical pre- and
postpartum care and vaginal delivery |
59400 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Cesarean delivery
with pre- and post-delivery care |
59510 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Vaginal delivery
after prior cesarean delivery |
59610 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Injection of
substance into spinal canal of lower back or
sacrum |
62322 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Injection of
substance into spinal canal of lower back or
sacrum using imaging guidance |
62323 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Injections of
anesthetic and/or steroid drug into lower or
sacral spine nerve root using imaging guidance |
64483 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Removal of recurring
cataract in lens capsule using laser |
66821 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Removal of cataract
with insertion of lens |
66984 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Removal of impacted
ear wax by washing |
69209 |
981 |
$ 36.40 |
$ 25.48 |
$ 14.20 |
$ 58.76 |
$
26.21 |
$
58.76 |
$
58.76 |
$
55.96 |
$
28.03 |
$ 29.12 |
$ 25.48 |
$
14.20 |
$
24.39 |
$
24.39 |
| |
Removal of impact ear
wax, one ear |
69210 |
521 |
$ 85.68 |
$ 59.98 |
$ 33.42 |
$ 68.54 |
$
61.69 |
$
58.76 |
$
58.76 |
$
55.96 |
$
65.97 |
$ 68.54 |
$ 59.98 |
$
33.42 |
$
57.41 |
$
57.41 |
| |
Administration of 1
vaccine |
90471 |
521 |
$ 66.30 |
$ 46.41 |
$ 25.86 |
$ 134.44 |
$
47.74 |
$
134.44 |
$
134.44 |
$
134.44 |
$
51.05 |
$ 53.04 |
$ 46.41 |
$
25.86 |
$
44.42 |
$
44.42 |
| |
Vaccine for human
papilloma virus (3 dose schedule) injection into
muscle |
90649 |
521 |
$ 211.00 |
$ 147.70 |
$ 82.29 |
$ 168.80 |
$
151.92 |
$
- |
$ - |
$ - |
$
162.47 |
$
168.80 |
$ 147.70 |
$
82.29 |
$
141.37 |
$
141.37 |
| |
Vaccine for measles,
mumps, and rubella (German measles) injection
beneath skin |
90707 |
521 |
$ 64.00 |
$ 44.80 |
$ 24.96 |
$ 51.20 |
$
46.08 |
$
- |
$ - |
$ - |
$
49.28 |
$ 51.20 |
$ 44.80 |
$
24.96 |
$
42.88 |
$
42.88 |
| |
Vaccine for tetanus,
diphtheria toxoids and acellular pertussis
(whooping cough) for injection into muscle, patient 7 years or older |
90715 |
521 |
$ 49.00 |
$ 34.30 |
$ 19.11 |
$ 39.20 |
$
35.28 |
$
- |
$ - |
$ - |
$
37.73 |
$ 39.20 |
$ 34.30 |
$
19.11 |
$
32.83 |
$
32.83 |
| |
Behavioral and
qualitative analysis of voice and resonance |
92524 |
440 |
$ 180.00 |
$ 126.00 |
$ 70.20 |
$ 206.42 |
$
129.60 |
$
206.42 |
$
206.42 |
$
206.42 |
$
138.60 |
$
144.00 |
$ 126.00 |
$
70.20 |
$
120.60 |
$
120.60 |
| |
Routine EKG using at
least 12 leads including interpretation and report |
93000 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Routine
electrocardiogram (EKG) with tracing using at
least 12 leads |
93005 |
730 |
$ 326.30 |
$ 228.41 |
$ 127.26 |
$ 261.04 |
$
234.94 |
$
129.27 |
$
129.27 |
$
129.27 |
$
251.25 |
$
261.04 |
$ 228.41 |
$
127.26 |
$
218.62 |
$
218.62 |
| |
Insertion of catheter
into left heart for diagnosis |
93452 |
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Measurement and
graphic recording of total and timed exhaled air
capacity |
94010 |
460 |
$ 809.00 |
$ 566.30 |
$ 314.90 |
$ 647.20 |
$
582.48 |
$
314.90 |
$
314.90 |
$
314.90 |
$
622.93 |
$
647.20 |
$ 566.30 |
$
315.51 |
$
542.03 |
$
542.03 |
| |
Respiratory inhaled
pressure or nonpressure treatment to relieve
airway obstruction or for sputum specimen |
94640 |
521 |
$ 268.00 |
$ 187.60 |
$ 104.52 |
$ 430.54 |
$
192.96 |
$
430.54 |
$
430.54 |
$
430.54 |
$
206.36 |
$
214.40 |
$ 187.60 |
$
104.52 |
$
179.56 |
$
179.56 |
| |
Measurement of oxygen
saturation in blood using ear or finger device |
94760 |
521 |
$ 87.10 |
$ 60.97 |
$ 6.63 |
$ 69.68 |
$
62.71 |
$
6.63 |
$
6.63 |
$
6.63 |
$
67.07 |
$ 69.68 |
$ 60.97 |
$
33.97 |
$
58.36 |
$
58.36 |
| |
Sleep monitoring of
patient (6 years or older) in sleep lab |
95810 |
920 |
$ 2,022.00 |
$ 1,415.40 |
$ 788.58 |
$ 1,617.60 |
$
1,455.84 |
$
1,184.68 |
$
1,184.68 |
$
1,184.68 |
$
1,556.94 |
$
1,617.60 |
$ 1,415.40 |
$
788.58 |
$
1,354.74 |
$
1,354.74 |
| |
Hydration infusion
into a vein 31 minutes to 1 hour |
96360 |
260 |
$ 467.94 |
$ 327.56 |
$ 109.42 |
$ 374.35 |
$
336.92 |
$
109.42 |
$
109.42 |
$
109.42 |
$
360.31 |
$
374.35 |
$ 327.56 |
$
182.50 |
$
313.52 |
$
313.52 |
| |
Infusion into a vein
for therapy, prevention, or diagnosis up to 1 hour |
96365 |
260 |
$ 204.10 |
$ 142.87 |
$ 79.60 |
$ 170.78 |
$
146.95 |
$
170.78 |
$
170.78 |
$
170.78 |
$
157.16 |
$
163.28 |
$ 142.87 |
$
79.60 |
$
136.75 |
$
136.75 |
| |
Infusion into a vein
for therapy, prevention, or diagnosis |
96366 |
260 |
$ 174.20 |
$ 121.94 |
$ 51.40 |
$ 139.36 |
$
125.42 |
$
51.40 |
$
51.40 |
$
51.40 |
$
134.13 |
$
139.36 |
$ 121.94 |
$
67.94 |
$
116.71 |
$
116.71 |
| |
Injection of drug or
substance into a vein for therapy, diagnosis, or
prevention |
96374 |
940 |
$ 467.94 |
$ 327.56 |
$ 108.59 |
$ 374.35 |
$
336.92 |
$
108.59 |
$
108.59 |
$
108.59 |
$
360.31 |
$
374.35 |
$ 327.56 |
$
182.50 |
$
313.52 |
$
313.52 |
| |
Injection of
different drug or substance into a vein for
therapy, diagnosis, or prevention |
96375 |
940 |
$ 159.90 |
$ 111.93 |
$ 42.27 |
$ 127.92 |
$
115.13 |
$
42.27 |
$
42.27 |
$
42.27 |
$
123.12 |
$
127.92 |
$ 111.93 |
$
62.36 |
$
107.13 |
$
107.13 |
| |
Application of
ultrasound to 1 or more areas, each 15 minutes |
97035 |
420 |
$ 68.00 |
$ 47.60 |
$ 26.52 |
$ 54.40 |
$
48.96 |
$
31.51 |
$
31.51 |
$
31.51 |
$
52.36 |
$ 54.40 |
$ 47.60 |
$
26.52 |
$
45.56 |
$
45.56 |
| |
Therapeutic exercise
to develop strength, endurance, range of motion,
and flexibility, each 15 minutes |
97110 |
420 |
$ 74.10 |
$ 51.87 |
$ 28.90 |
$ 72.12 |
$
53.35 |
$
72.12 |
$
72.12 |
$
72.12 |
$
57.06 |
$ 59.28 |
$ 51.87 |
$
28.90 |
$
49.65 |
$
49.65 |
| |
Walking training to 1
or more areas, each 15 minutes |
97116 |
420 |
$ 58.50 |
$ 40.95 |
$ 22.82 |
$ 71.29 |
$
42.12 |
$
71.29 |
$
71.29 |
$
71.29 |
$
45.05 |
$ 46.80 |
$ 40.95 |
$
22.82 |
$
39.20 |
$
39.20 |
| |
Evaluation of
physical therapy, typically 30 minutes |
97162 |
424 |
$ 182.00 |
$ 127.40 |
$ 70.98 |
$ 197.32 |
$
131.04 |
$
197.32 |
$
197.32 |
$
197.32 |
$
140.14 |
$
145.60 |
$ 127.40 |
$
70.98 |
$
121.94 |
$
121.94 |
| |
Evaluation of
occupational therapy, typically 45 minutes |
97166 |
434 |
$ 182.00 |
$ 127.40 |
$ 70.98 |
$ 213.05 |
$
131.04 |
$
213.05 |
$
213.05 |
$
213.05 |
$
140.14 |
$
145.60 |
$ 127.40 |
$
70.98 |
$
121.94 |
$
121.94 |
| |
Therapeutic
activities to improve function, with one-on-one
contact between patient and provider, each 15 minutes |
97530 |
420 |
$ 68.90 |
$ 48.23 |
$ 26.87 |
$ 95.33 |
$
49.61 |
$
95.33 |
$
95.33 |
$
95.33 |
$
53.05 |
$ 55.12 |
$ 48.23 |
$
26.87 |
$
46.16 |
$
46.16 |
| |
Removal of tissue
from wounds per session |
97602 |
521 |
$ 353.50 |
$ 247.45 |
$ 137.87 |
$ 390.27 |
$
254.52 |
$
390.27 |
$
390.27 |
$
390.27 |
$
272.20 |
$
282.80 |
$ 247.45 |
$
137.87 |
$
236.85 |
$
236.85 |
| |
Negative pressure
wound therapy, surface area less than or equal to
50 square centimeters, per session |
97605 |
761 |
$ 507.00 |
$ 354.90 |
$ 197.73 |
$ 405.60 |
$
365.04 |
$
390.27 |
$
390.27 |
$
390.27 |
$
390.39 |
$
405.60 |
$ 354.90 |
$
197.73 |
$
339.69 |
$
339.69 |
| |
Removal of skin and
tissue first 20 sq cm or less |
11042 |
270 |
$ 2,094.33 |
$ 1,466.03 |
$ 310.80 |
$ 1,675.46 |
$
1,507.92 |
$
326.34 |
$
326.34 |
$
310.80 |
$
1,612.63 |
$
1,675.46 |
$ 1,466.03 |
$
816.79 |
$
1,403.20 |
$
1,403.20 |
| |
Hernia Plug/Patch |
C1781 |
278 |
$ 918.00 |
$ 642.60 |
$ 358.02 |
$ 734.40 |
$
660.96 |
$
- |
$ - |
$ - |
$
706.86 |
$
734.40 |
$ 642.60 |
$
358.02 |
$
615.06 |
$
615.06 |
| |
Exparel 266Mg Vial |
C9290 |
636 |
$ 1.50 |
$ 1.05 |
$ 0.59 |
$ 1.20 |
$ 1.08 |
N/A |
N/A |
N/A |
$ 1.16 |
$ 1.20 |
$ 1.05 |
$
0.59 |
$
1.01 |
$ 1.01 |
| |
Diabetes
self-management, individual |
G0108 |
942 |
$ 92.00 |
$ 64.40 |
$ 35.88 |
$ 125.18 |
$
66.24 |
$
125.18 |
$
125.18 |
$
125.18 |
$
70.84 |
$ 73.60 |
$ 64.40 |
$
35.88 |
$
61.64 |
$
61.64 |
| |
Diabetes
self-management, group |
G0109 |
942 |
$ 50.00 |
$ 35.00 |
$ 19.50 |
$ 40.00 |
$
36.00 |
$
33.98 |
$
33.98 |
$
33.98 |
$
38.50 |
$ 40.00 |
$ 35.00 |
$
19.50 |
$
33.50 |
$
33.50 |
| |
Observation |
G0378 |
762 |
$ 37.70 |
$ 26.39 |
$ 14.70 |
$ 292.65 |
$
27.14 |
$
292.65 |
$
292.65 |
$
292.65 |
$
29.03 |
$ 30.16 |
$ 26.39 |
$
14.70 |
$
25.26 |
$
25.26 |
| |
Cefazolin 1Gm Via |
J0690 |
636 |
$ 0.60 |
$ 0.42 |
$ 0.23 |
$ 0.48 |
$ 0.43 |
$
0.40 |
$
0.40 |
$
0.40 |
$ 0.46 |
$ 0.48 |
$ 0.42 |
$
0.23 |
$
0.40 |
$ 0.40 |
| |
Ceftriaxone 1Gm Vial |
J0696 |
636 |
$ 40.00 |
$ 28.00 |
$ 6.33 |
$ 32.00 |
$
28.80 |
$
6.33 |
$
6.33 |
$
6.33 |
$
30.80 |
$ 32.00 |
$ 28.00 |
$
15.60 |
$
26.80 |
$
26.80 |
| |
Primaxin 500Mg Vial |
J0743 |
636 |
$ 12.00 |
$ 8.40 |
$ 4.68 |
$ 11.23 |
$ 8.64 |
$
11.23 |
$
11.23 |
$
11.23 |
$ 9.24 |
$ 9.60 |
$ 8.40 |
$
4.68 |
$
8.04 |
$ 8.04 |
| |
Dexamethasone 10Mg/Ml
1 Ml |
J1094 |
636 |
$ 0.15 |
$ 0.11 |
$ 0.06 |
$ 0.12 |
$ 0.11 |
|
|
|
$ 0.12 |
$ 0.12 |
$ 0.11 |
$
0.06 |
$
0.10 |
$ 0.10 |
| |
Dexamethasone 4Mg/1Ml
Vial |
J1100 |
636 |
$ 0.47 |
$ 0.33 |
$ 0.08 |
$ 0.38 |
$ 0.34 |
$
0.08 |
$
0.08 |
$
0.08 |
$ 0.36 |
$ 0.38 |
$ 0.33 |
$
0.18 |
$
0.31 |
$ 0.31 |
| |
Heparin Lock Flush
300Units/3Ml |
J1642 |
636 |
$ 0.02 |
$ 0.01 |
$ 0.01 |
$ 0.05 |
$ 0.01 |
$
0.05 |
$
0.05 |
$
0.05 |
$ 0.02 |
$ 0.02 |
$ 0.01 |
$
0.01 |
$
0.01 |
$ 0.01 |
| |
Heparin Flush Syr 100
Units/Ml |
J1642 |
636 |
$ 0.05 |
$ 0.04 |
$ 0.02 |
$ 0.05 |
$ 0.04 |
$
0.05 |
$
0.05 |
$
0.05 |
$ 0.04 |
$ 0.04 |
$ 0.04 |
$
0.02 |
$
0.03 |
$ 0.03 |
| |
Heparin Flush 10,000
Units/Ml |
J1642 |
636 |
$ 0.02 |
$ 0.01 |
$ 0.01 |
$ 0.05 |
$ 0.01 |
$
0.05 |
$
0.05 |
$
0.05 |
$ 0.02 |
$ 0.02 |
$ 0.01 |
$
0.01 |
$
0.01 |
$ 0.01 |
| |
Lovenox 40Mg Syringe |
J1650 |
636 |
$ 1.15 |
$ 0.81 |
$ 0.45 |
$ 0.92 |
$ 0.83 |
$
0.68 |
$
0.68 |
$
0.68 |
$ 0.89 |
$ 0.92 |
$ 0.81 |
$
0.45 |
$
0.77 |
$ 0.77 |
| |
Humalog 100 Units/1Ml |
J1815 |
637 |
$ 0.23 |
$ 0.16 |
$ 0.09 |
$ 0.35 |
$ 0.17 |
$
0.35 |
$
0.35 |
$
0.35 |
$ 0.18 |
$ 0.18 |
$ 0.16 |
$
0.09 |
$
0.15 |
$ 0.15 |
| |
Humulin R Per 5 Units |
J1815 |
637 |
$ 0.25 |
$ 0.18 |
$ 0.10 |
$ 0.35 |
$ 0.18 |
$
0.35 |
$
0.35 |
$
0.35 |
$ 0.19 |
$ 0.20 |
$ 0.18 |
$
0.10 |
$
0.17 |
$ 0.17 |
| |
Ketorolac
Tromethamine 60Mg Vial |
J1885 |
636 |
$ 0.25 |
$ 0.18 |
$ 0.10 |
$ 0.55 |
$ 0.18 |
$
0.55 |
$
0.55 |
$
0.55 |
$ 0.19 |
$ 0.20 |
$ 0.18 |
$
0.10 |
$
0.17 |
$ 0.17 |
| |
Ketorolac Trometh
30Mg/Ml Vial |
J1885 |
636 |
$ 0.45 |
$ 0.32 |
$ 0.18 |
$ 0.55 |
$ 0.32 |
$
0.55 |
$
0.55 |
$
0.55 |
$ 0.35 |
$ 0.36 |
$ 0.32 |
$
0.18 |
$
0.30 |
$ 0.30 |
| |
Furosemide 40Mg Vial |
J1940 |
636 |
$ 0.60 |
$ 0.42 |
$ 0.23 |
$ 4.13 |
$ 0.43 |
$
4.13 |
$
4.13 |
$
4.13 |
$ 0.46 |
$ 0.48 |
$ 0.42 |
$
0.23 |
$
0.40 |
$ 0.40 |
| |
Meropen 1Gm Vial |
J2185 |
637 |
$ 0.70 |
$ 0.49 |
$ 0.27 |
$ 6.90 |
$ 0.50 |
$
6.90 |
$
6.90 |
$
6.90 |
$ 0.54 |
$ 0.56 |
$ 0.49 |
$
0.27 |
$
0.47 |
$ 0.47 |
| |
Ondamsetron 4Mg/2Ml
Vial |
J2405 |
636 |
$ 0.08 |
$ 0.06 |
$ 0.03 |
$ 1.48 |
$ 0.06 |
$
1.48 |
$
1.48 |
$
1.48 |
$ 0.06 |
$ 0.06 |
$ 0.06 |
$
0.03 |
$
0.05 |
$ 0.05 |
| |
Zosyn 3.375Gm |
J2543 |
636 |
$ 1.25 |
$ 0.88 |
$ 0.49 |
$ 6.40 |
$ 0.90 |
$
6.40 |
$
6.40 |
$
6.40 |
$ 0.96 |
$ 1.00 |
$ 0.88 |
$
0.49 |
$
0.84 |
$ 0.84 |
| |
Propofol 200Mg Per
20Ml |
J2704 |
636 |
$ 0.10 |
$ 0.07 |
$ 0.04 |
$ 0.18 |
$ 0.07 |
$
0.18 |
$
0.18 |
$
0.18 |
$ 0.08 |
$ 0.08 |
$ 0.07 |
$
0.04 |
$
0.07 |
$ 0.07 |
| |
Solu-Medrol 40 Mg/Ml |
J2920 |
636 |
$ 5.85 |
$ 4.10 |
$ 2.28 |
$ 8.65 |
$ 4.21 |
$
8.65 |
$
8.65 |
$
8.65 |
$ 4.50 |
$ 4.68 |
$ 4.10 |
$
2.28 |
$
3.92 |
$ 3.92 |
| |
Kenalog 40Mg/Ml |
J3301 |
636 |
$ 2.07 |
$ 1.45 |
$ 0.81 |
$ 4.28 |
$ 1.49 |
$
4.28 |
$
4.28 |
$
4.28 |
$ 1.59 |
$ 1.66 |
$ 1.45 |
$
0.81 |
$
1.39 |
$ 1.39 |
| |
Vancomycin Hcl 1000Mg
Vial |
J3370 |
636 |
$ 2.00 |
$ 1.40 |
$ 0.78 |
$ 11.18 |
$ 1.44 |
$
11.18 |
$
11.18 |
$
11.18 |
$ 1.54 |
$ 1.60 |
$ 1.40 |
$
0.78 |
$
1.34 |
$ 1.34 |
| |
Vancomycin 500Mg Vial |
J3370 |
636 |
$ 2.90 |
$ 2.03 |
$ 1.13 |
$ 11.18 |
$ 2.09 |
$
11.18 |
$
11.18 |
$
11.18 |
$ 2.23 |
$ 2.32 |
$ 2.03 |
$
1.13 |
$
1.94 |
$ 1.94 |
| |
Albuterol Sulfate
Inhal Solu 2.5Mg/3Ml |
J7613 |
636 |
$ 0.06 |
$ 0.04 |
$ 0.02 |
$ 0.20 |
$ 0.04 |
$
0.20 |
$
0.20 |
$
0.20 |
$ 0.05 |
$ 0.05 |
$ 0.04 |
$
0.02 |
$
0.04 |
$ 0.04 |
| |
Levalbuterol Inhal
Solu 1.25Mg/3Ml |
J7614 |
636 |
$ 0.50 |
$ 0.35 |
$ 0.20 |
$ 3.70 |
$ 0.36 |
$
3.70 |
$
3.70 |
$
3.70 |
$ 0.39 |
$ 0.40 |
$ 0.35 |
$
0.20 |
$
0.34 |
$ 0.34 |
| |
Budesonide Inhal Susp
0.5Mg/2Ml |
J7626 |
636 |
$ 2.60 |
$ 1.82 |
$ 1.01 |
$ 15.95 |
$ 1.87 |
$
15.95 |
$
15.95 |
$
15.95 |
$ 2.00 |
$ 2.08 |
$ 1.82 |
$
1.01 |
$
1.74 |
$ 1.74 |
| |
Ipratropium Bromide
Solu 0.5Mg/2.5Ml |
J7644 |
636 |
$ 0.15 |
$ 0.11 |
$ 0.06 |
$ 1.28 |
$ 0.11 |
$
1.28 |
$
1.28 |
$
1.28 |
$ 0.12 |
$ 0.12 |
$ 0.11 |
$
0.06 |
$
0.10 |
$ 0.10 |
| |
Cardiac valve and
other major cardiothoracic procedures with cardiac
catheterization with major complications or comorbidities |
|
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Spinal fusion except
cervical without major comorbid conditions or
complications (MCC) |
|
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Major joint
replacement or reattachment of lower extremity
without major comorbid conditions or complications (MCC). |
|
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Cervical spinal
fusion without comorbid conditions (CC) or major
comorbid conditions or complications (MCC). |
|
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Uterine and adnexa
procedures for non-malignancy without comorbid
conditions (CC) or major comorbid conditions or complications (MCC) |
|
|
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
| |
Swing bed,
semi-private |
|
120 |
$ 845.00 |
$ 591.50 |
$ 329.55 |
$ 676.00 |
$
608.40 |
|
|
|
$
650.65 |
$
676.00 |
$ 591.50 |
$
329.55 |
$
566.15 |
$
566.15 |
| |
Semi-private hospital
room |
|
120 |
$ 1,126.00 |
$ 788.20 |
$ 439.14 |
$ 900.80 |
$
810.72 |
|
|
|
$
867.02 |
$
900.80 |
$ 788.20 |
$
439.14 |
$
754.42 |
$
754.42 |
| |
Private hospital room |
|
110 |
$ 1,147.00 |
$ 802.90 |
$ 447.33 |
$ 917.60 |
$
825.84 |
|
|
|
$
883.19 |
$
917.60 |
$ 802.90 |
$
447.33 |
$
768.49 |
$
768.49 |
| |
Swing bed, private |
|
110 |
$ 996.00 |
$ 697.20 |
$ 388.44 |
$ 796.80 |
$
717.12 |
|
|
|
$
766.92 |
$
796.80 |
$ 697.20 |
$
388.44 |
$
667.32 |
$
667.32 |
| |
Sodium Chloride For
Injection |
|
250 |
$ 0.40 |
$ 0.28 |
$ 0.16 |
$ 0.32 |
$ 0.29 |
|
|
|
$ 0.31 |
$ 0.32 |
$ 0.28 |
$
0.16 |
$
0.27 |
$ 0.27 |
| |
Acetaminophen 325Mg
Ud Tablets |
|
637 |
$ 0.03 |
$ 0.02 |
$ 0.01 |
$ 0.02 |
$ 0.02 |
|
|
|
$ 0.02 |
$ 0.02 |
$ 0.02 |
$
0.01 |
$
0.02 |
$ 0.02 |
| |
Mapap Es 500Mg Tablet |
|
257 |
$ 0.01 |
$ 0.01 |
$ 0.00 |
$ 0.01 |
$ 0.01 |
|
|
|
$ 0.01 |
$ 0.01 |
$ 0.01 |
$
0.00 |
$
0.01 |
$ 0.01 |
| |
Klor Con 20Meq Tablet |
|
637 |
$ 0.30 |
$ 0.21 |
$ 0.12 |
$ 0.24 |
$ 0.22 |
|
|
|
$ 0.23 |
$ 0.24 |
$ 0.21 |
$
0.12 |
$
0.20 |
$ 0.20 |
| |
Sucralfate 1Gm Tablet |
|
637 |
$ 0.23 |
$ 0.16 |
$ 0.09 |
$ 0.18 |
$ 0.17 |
|
|
|
$ 0.18 |
$ 0.18 |
$ 0.16 |
$
0.09 |
$
0.15 |
$ 0.15 |
| |
Xylocaine 1% Mdv 5Ml |
|
250 |
$ 0.35 |
$ 0.25 |
$ 0.14 |
$ 0.28 |
$ 0.25 |
|
|
|
$ 0.27 |
$ 0.28 |
$ 0.25 |
$
0.14 |
$
0.23 |
$ 0.23 |
| |
Pantoprazole Dr 40Mg
Tablet |
|
637 |
$ 0.15 |
$ 0.11 |
$ 0.06 |
$ 0.12 |
$ 0.11 |
|
|
|
$ 0.12 |
$ 0.12 |
$ 0.11 |
$
0.06 |
$
0.10 |
$ 0.10 |
| |
Lisinopril U D 20Mg
Tabs |
|
637 |
$ 0.05 |
$ 0.04 |
$ 0.02 |
$ 0.04 |
$ 0.04 |
|
|
|
$ 0.04 |
$ 0.04 |
$ 0.04 |
$
0.02 |
$
0.03 |
$ 0.03 |
| |
Clindamycin Capsule
150 Mg |
|
637 |
$ 0.08 |
$ 0.06 |
$ 0.03 |
$ 0.06 |
$ 0.06 |
|
|
|
$ 0.06 |
$ 0.06 |
$ 0.06 |
$
0.03 |
$
0.05 |
$ 0.05 |
| |
Lidocaine Hcl/Pf Vial 2% 20Mg/Ml 5Ml |
|
250 |
$ 3.30 |
$ 2.31 |
$ 1.29 |
$ 2.64 |
$ 2.38 |
|
|
|
$ 2.54 |
$ 2.64 |
$ 2.31 |
$
1.29 |
$
2.21 |
$ 2.21 |
| |
Major surgery between
two hundred eleven minutes and two hundred fourty
minutes |
|
360 |
$ 9,578.00 |
$ 6,704.60 |
$ 3,735.42 |
$ 7,662.40 |
$
6,896.16 |
|
|
|
$
7,375.06 |
$
7,662.40 |
$ 6,704.60 |
$
3,735.42 |
$
6,417.26 |
$
6,417.26 |
| |
Major surgery, more
than two hundred fourty-one minutes |
|
360 |
$ 10,505.00 |
$ 7,353.50 |
$ 4,096.95 |
$ 8,404.00 |
$
7,563.60 |
|
|
|
$
8,088.85 |
$
8,404.00 |
$ 7,353.50 |
$
4,096.95 |
$
7,038.35 |
$
7,038.35 |
| |
Hernia Tacker |
|
270 |
$ 65.00 |
$ 45.50 |
$ 25.35 |
$ 52.00 |
$
46.80 |
|
|
|
$
50.05 |
$ 52.00 |
$ 45.50 |
$
25.35 |
$
43.55 |
$
43.55 |
| |
Gel foam, large |
|
270 |
$ 49.00 |
$ 34.30 |
$ 19.11 |
$ 39.20 |
$
35.28 |
|
|
|
$
37.73 |
$ 39.20 |
$ 34.30 |
$
19.11 |
$
32.83 |
$
32.83 |
| |
Cytostomy catheter |
|
270 |
$ 150.00 |
$ 105.00 |
$ 58.50 |
$ 120.00 |
$
108.00 |
|
|
|
$
115.50 |
$
120.00 |
$ 105.00 |
$
58.50 |
$
100.50 |
$
100.50 |
| |
Meniscus Cutter Or
Burr |
|
270 |
$ 179.00 |
$ 125.30 |
$ 69.81 |
$ 143.20 |
$
128.88 |
|
|
|
$
137.83 |
$
143.20 |
$ 125.30 |
$
69.81 |
$
119.93 |
$
119.93 |
| |
Op Recovery Room |
|
710 |
$ 279.00 |
$ 195.30 |
$ 108.81 |
$ 223.20 |
$
200.88 |
|
|
|
$
214.83 |
$
223.20 |
$ 195.30 |
$
108.81 |
$
186.93 |
$
186.93 |
| |
Recovery Room Day
Surgery |
|
710 |
$ 399.00 |
$ 279.30 |
$ 155.61 |
$ 319.20 |
$
287.28 |
|
|
|
$
307.23 |
$
319.20 |
$ 279.30 |
$
155.61 |
$
267.33 |
$
267.33 |
| |
Recovery Room |
|
710 |
$ 351.00 |
$ 245.70 |
$ 136.89 |
$ 280.80 |
$
252.72 |
|
|
|
$
270.27 |
$
280.80 |
$ 245.70 |
$
136.89 |
$
235.17 |
$
235.17 |
| |
Angio Dynamics Smart
Port |
|
278 |
$ 4,052.00 |
$ 2,836.40 |
$ 1,580.28 |
$ 3,241.60 |
$
2,917.44 |
|
|
|
$
3,120.04 |
$
3,241.60 |
$ 2,836.40 |
$
1,580.28 |
$
2,714.84 |
$
2,714.84 |
| |
Alexis Wound
Protector |
|
270 |
$ 215.00 |
$ 150.50 |
$ 83.85 |
$ 172.00 |
$
154.80 |
|
|
|
$
165.55 |
$
172.00 |
$ 150.50 |
$
83.85 |
$
144.05 |
$
144.05 |
| |
Fogarty |
|
270 |
$ 265.00 |
$ 185.50 |
$ 103.35 |
$ 212.00 |
$
190.80 |
|
|
|
$
204.05 |
$
212.00 |
$ 185.50 |
$
103.35 |
$
177.55 |
$
177.55 |
| |
Carter Thompson |
|
270 |
$ 418.00 |
$ 292.60 |
$ 163.02 |
$ 334.40 |
$
300.96 |
|
|
|
$
321.86 |
$
334.40 |
$ 292.60 |
$
163.02 |
$
280.06 |
$
280.06 |
| |
Gelport |
|
270 |
$ 2,277.00 |
$ 1,593.90 |
$ 888.03 |
$ 1,821.60 |
$
1,639.44 |
|
|
|
$
1,753.29 |
$
1,821.60 |
$ 1,593.90 |
$
888.03 |
$
1,525.59 |
$
1,525.59 |
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