| 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 | BCBS TX Trad | BCBS TX PPO | BCBS TX HMO | Cigna | Humana | United (Outpatient Services) | Medicaid and Medicaid Advantage Plans (STAR, STAR + PLUS, STAR Kids, First Care and Superior Medicaid) | Medicare and Medicare Advanatge Plans (Humana Medicare, Aetna Medicare, United Healthcare Medicare Solutions, BCBS Medicare, Superior Medicare) | Worker's Compensation Plans |
| Evaluation and Management | Psychiatric diagnostic evaluation | 90791 | 961 | $ 358.05 | $ 250.64 | $ 139.64 | $ 286.44 | $ 257.80 | $ - | $ - | $ - | $ 275.70 | $ 286.44 | $ 250.64 | $ 139.64 | $ 239.89 | $ 239.89 | |
| Psychotherapy, 30 min | 90832 | 914 | $ 193.20 | $ 135.24 | $ 75.35 | $ 154.56 | $ 139.10 | $ - | $ - | $ - | $ 148.76 | $ 154.56 | $ 135.24 | $ 75.35 | $ 129.44 | $ 129.44 | ||
| Psychotherapy, 45 min | 90834 | 914 | $ 347.55 | $ 243.29 | $ 135.54 | $ 278.04 | $ 250.24 | $ - | $ - | $ - | $ 267.61 | $ 278.04 | $ 243.29 | $ 135.54 | $ 232.86 | $ 232.86 | ||
| Psychotherapy, 60 min | 90837 | NA | 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 | ||
| Family psychotherapy, not including patient, 50 min | 90846 | NA | 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 | ||
| Family psychotherapy, including patient, 50 min | 90847 | NA | 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 | ||
| Group psychotherapy | 90853 | 915 | $ 193.20 | $ 135.24 | $ 75.35 | $ 154.56 | $ 139.10 | $ - | $ - | $ - | $ 148.76 | $ 154.56 | $ 135.24 | $ 75.35 | $ 129.44 | $ 129.44 | ||
| Hydration infusion into a vein 31 minutes to 1 hour | 96360 | 260 | $ 491.34 | $ 343.94 | $ 109.42 | $ 393.07 | $ 353.76 | $ 109.42 | $ 109.42 | $ 109.42 | $ 378.33 | $ 393.07 | $ 343.94 | $ 191.62 | $ 329.20 | $ 329.20 | ||
| Hydration infusion into a vein | 96361 | 260 | $ 99.45 | $ 69.61 | $ 32.34 | $ 79.56 | $ 71.60 | $ 32.34 | $ 32.34 | $ 32.34 | $ 76.57 | $ 79.56 | $ 69.61 | $ 38.78 | $ 66.63 | $ 66.63 | ||
| Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour | 96365 | 260 | $ 491.34 | $ 343.94 | $ 170.78 | $ 393.07 | $ 353.76 | $ 170.78 | $ 170.78 | $ 170.78 | $ 378.33 | $ 393.07 | $ 343.94 | $ 191.62 | $ 329.20 | $ 329.20 | ||
| Infusion into a vein for therapy, prevention, or diagnosis | 96366 | 260 | $ 119.18 | $ 83.42 | $ 46.48 | $ 95.34 | $ 85.81 | $ 51.40 | $ 51.40 | $ 51.40 | $ 91.76 | $ 95.34 | $ 83.42 | $ 46.48 | $ 79.85 | $ 79.85 | ||
| Injection beneath the skin or into muscle for therapy, diagnosis, or prevention | 96372 | 521 | $ 156.85 | $ 109.79 | $ 61.17 | $ 134.44 | $ 112.93 | $ 134.44 | $ 134.44 | $ 134.44 | $ 120.77 | $ 125.48 | $ 109.79 | $ 61.17 | $ 105.09 | $ 105.09 | ||
| Injection of drug or substance into a vein for therapy, diagnosis, or prevention | 96374 | 940 | $ 491.34 | $ 343.94 | $ 108.59 | $ 393.07 | $ 353.76 | $ 108.59 | $ 108.59 | $ 108.59 | $ 378.33 | $ 393.07 | $ 343.94 | $ 191.62 | $ 329.20 | $ 329.20 | ||
| Injection of different drug or substance into a vein for therapy, diagnosis, or prevention | 96375 | 940 | $ 99.45 | $ 69.61 | $ 38.78 | $ 79.56 | $ 71.60 | $ 42.27 | $ 42.27 | $ 42.27 | $ 76.57 | $ 79.56 | $ 69.61 | $ 38.78 | $ 66.63 | $ 66.63 | ||
| Injection of drug or substance into a vein for therapy, diagnosis, or prevention, in a facility | 96376 | 940 | $ 54.60 | $ 38.22 | $ 21.29 | $ 53.06 | $ 39.31 | $ 53.06 | $ 53.06 | $ 53.06 | $ 42.04 | $ 43.68 | $ 38.22 | $ 21.29 | $ 36.58 | $ 36.58 | ||
| New patient office or other outpatient visit, typically 10 minutes | 99201 | 761 | $ 68.25 | $ 47.78 | $ 26.62 | $ 63.02 | $ 49.14 | $ 63.02 | $ 63.02 | $ 63.02 | $ 52.55 | $ 54.60 | $ 47.78 | $ 26.62 | $ 45.73 | $ 45.73 | ||
| New patient office or other outpatient visit, typically 30 minutes | 99203 | 521 | $ 162.75 | $ 113.93 | $ 63.47 | $ 179.90 | $ 117.18 | $ 179.90 | $ 179.90 | $ 179.90 | $ 125.32 | $ 130.20 | $ 113.93 | $ 63.47 | $ 109.04 | $ 109.04 | ||
| New patient office or other outpatient visit, typically 45 minutes | 99204 | 521 | $ 220.50 | $ 154.35 | $ 86.00 | $ 303.42 | $ 158.76 | $ 303.42 | $ 303.42 | $ 303.42 | $ 169.79 | $ 176.40 | $ 154.35 | $ 86.00 | $ 147.74 | $ 147.74 | ||
| New patient office or other outpatient visit, typically 60 minutes | 99205 | 521 | $ 556.50 | $ 389.55 | $ 217.04 | $ 445.20 | $ 400.68 | $ 396.28 | $ 396.28 | $ 396.28 | $ 428.51 | $ 445.20 | $ 389.55 | $ 217.04 | $ 372.86 | $ 372.86 | ||
| Established patient office or other outpatient visit, typically 5 minutes | 99211 | 521 | $ 432.71 | $ 302.89 | $ 21.55 | $ 346.16 | $ 311.55 | $ 21.55 | $ 21.55 | $ 21.55 | $ 333.18 | $ 346.16 | $ 302.89 | $ 168.75 | $ 289.91 | $ 289.91 | ||
| Established patient office or other outpatient visit, typically 10 minutes | 99212 | 521 | $ 432.71 | $ 302.89 | $ 59.69 | $ 346.16 | $ 311.55 | $ 59.69 | $ 59.69 | $ 59.69 | $ 333.18 | $ 346.16 | $ 302.89 | $ 168.75 | $ 289.91 | $ 289.91 | ||
| Established patient office or other outpatient visit, typically 15 minutes | 99213 | 521 | $ 498.23 | $ 348.76 | $ 120.21 | $ 398.58 | $ 358.72 | $ 120.21 | $ 120.21 | $ 120.21 | $ 383.63 | $ 398.58 | $ 348.76 | $ 194.31 | $ 333.81 | $ 333.81 | ||
| Established patient office or other outpatient visit, typically 15 minutes | 99213 | 521 | $ 498.23 | $ 348.76 | $ 120.21 | $ 398.58 | $ 358.72 | $ 120.21 | $ 120.21 | $ 120.21 | $ 383.63 | $ 398.58 | $ 348.76 | $ 194.31 | $ 333.81 | $ 333.81 | ||
| Established patient office or other outpatient, visit typically 25 minutes | 99214 | 521 | $ 556.50 | $ 389.55 | $ 184.04 | $ 445.20 | $ 400.68 | $ 184.04 | $ 184.04 | $ 184.04 | $ 428.51 | $ 445.20 | $ 389.55 | $ 217.04 | $ 372.86 | $ 372.86 | ||
| Established patient office or other outpatient, visit typically 40 minutes | 99215 | 521 | $ 556.50 | $ 389.55 | $ 217.04 | $ 445.20 | $ 400.68 | $ 260.31 | $ 260.31 | $ 260.31 | $ 428.51 | $ 445.20 | $ 389.55 | $ 217.04 | $ 372.86 | $ 372.86 | ||
| Patient office consultation, typically 40 minutes | 99243 | NA | 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 | ||
| Patient office consultation, typically 60 minutes | 99244 | NA | 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 | ||
| Initial new patient preventive medicine evaluation age 18-39 years | 99385 | 521 | $ 148.05 | $ 103.64 | $ 57.74 | $ 229.64 | $ 106.60 | $ 229.64 | $ 229.64 | $ 229.64 | $ 114.00 | $ 118.44 | $ 103.64 | $ 57.74 | $ 99.19 | $ 99.19 | ||
| Initial new patient preventive medicine evaluation age 40-64 years | 99386 | 521 | $ 159.60 | $ 111.72 | $ 62.24 | $ 279.37 | $ 114.91 | $ 279.37 | $ 279.37 | $ 279.37 | $ 122.89 | $ 127.68 | $ 111.72 | $ 62.24 | $ 106.93 | $ 106.93 | ||
| Observation per Hour | G0378 | 762 | $ 39.59 | $ 27.71 | $ 15.44 | $ 292.65 | $ 28.50 | $ 292.65 | $ 292.65 | $ 292.65 | $ 30.48 | $ 31.67 | $ 27.71 | $ 15.44 | $ 26.52 | $ 26.52 | ||
| Laboratory & Pathology Services | Insertion of needle into vein for collection of blood sample | 36415 | 300 | $ 25.94 | $ 18.15 | $ 10.11 | $ 20.75 | $ 18.67 | $ - | $ - | $ - | $ 19.97 | $ 20.75 | $ 18.15 | $ 10.11 | $ 17.38 | $ 17.38 | |
| Blood test, basic group of blood chemicals | 80048 | 301 | $ 184.28 | $ 128.99 | $ 30.80 | $ 147.42 | $ 132.68 | $ 36.23 | $ 30.80 | $ 36.23 | $ 141.89 | $ 147.42 | $ 128.99 | $ 71.87 | $ 123.46 | $ 123.46 | ||
| Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide) | 80051 | 301 | $ 94.50 | $ 66.15 | $ 25.55 | $ 75.60 | $ 68.04 | $ 30.05 | $ 30.05 | $ 25.55 | $ 72.77 | $ 75.60 | $ 66.15 | $ 36.86 | $ 63.32 | $ 63.32 | ||
| Blood test, comprehensive group of blood chemicals | 80053 | 301 | $ 245.70 | $ 171.99 | $ 38.47 | $ 196.56 | $ 176.90 | $ 45.25 | $ 38.47 | $ 45.25 | $ 189.19 | $ 196.56 | $ 171.99 | $ 95.82 | $ 164.62 | $ 164.62 | ||
| Obstetric blood test panel | 80055 | 301 | $ 276.15 | $ 193.31 | $ 107.70 | $ 220.92 | $ 198.83 | $ 204.80 | $ 174.11 | $ 204.80 | $ 212.64 | $ 220.92 | $ 193.31 | $ 107.70 | $ 185.02 | $ 185.02 | ||
| Blood test, lipids (cholesterol and triglycerides) | 80061 | 301 | $ 203.70 | $ 142.59 | $ 48.76 | $ 162.96 | $ 146.66 | $ 57.36 | $ 48.76 | $ 57.36 | $ 156.85 | $ 162.96 | $ 142.59 | $ 79.44 | $ 136.48 | $ 136.48 | ||
| Kidney function blood test panel | 80069 | 301 | $ 159.60 | $ 111.72 | $ 31.62 | $ 127.68 | $ 114.91 | $ 37.20 | $ 31.62 | $ 37.20 | $ 122.89 | $ 127.68 | $ 111.72 | $ 62.24 | $ 106.93 | $ 106.93 | ||
| Liver function blood test panel | 80076 | 301 | $ 184.28 | $ 128.99 | $ 29.77 | $ 147.42 | $ 132.68 | $ 35.01 | $ 29.77 | $ 35.01 | $ 141.89 | $ 147.42 | $ 128.99 | $ 71.87 | $ 123.46 | $ 123.46 | ||
| Vancomycin (antibiotic) level | 80202 | 301 | $ 170.10 | $ 119.07 | $ 49.32 | $ 136.08 | $ 122.47 | $ 58.02 | $ 49.32 | $ 58.02 | $ 130.98 | $ 136.08 | $ 119.07 | $ 66.34 | $ 113.97 | $ 113.97 | ||
| Testing for presence of drug | 80305 | 301 | $ 117.39 | $ 82.17 | $ 39.71 | $ 93.91 | $ 84.52 | $ 46.71 | $ 39.71 | $ 46.71 | $ 90.39 | $ 93.91 | $ 82.17 | $ 45.78 | $ 78.65 | $ 78.65 | ||
| 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 | $ 66.89 | $ 46.82 | $ 11.56 | $ 53.51 | $ 48.16 | $ 13.60 | $ 11.56 | $ 13.60 | $ 51.50 | $ 53.51 | $ 46.82 | $ 26.09 | $ 44.81 | $ 44.81 | ||
| Urinalysis, manual test | 81002 | 306 | $ 28.35 | $ 19.85 | $ 10.27 | $ 22.68 | $ 20.41 | $ 12.08 | $ 10.27 | $ 12.08 | $ 21.83 | $ 22.68 | $ 19.85 | $ 11.06 | $ 18.99 | $ 18.99 | ||
| Automated urinalysis test | 81003 | 301 | $ 30.45 | $ 21.32 | $ 8.17 | $ 24.36 | $ 21.92 | $ 9.61 | $ 8.17 | $ 9.61 | $ 23.45 | $ 24.36 | $ 21.32 | $ 11.88 | $ 20.40 | $ 20.40 | ||
| Urine pregnancy test | 81025 | 301 | $ 69.62 | $ 48.73 | $ 25.40 | $ 55.69 | $ 50.12 | $ 29.88 | $ 25.40 | $ 29.88 | $ 53.60 | $ 55.69 | $ 48.73 | $ 27.15 | $ 46.64 | $ 46.64 | ||
| Albumin (protein) level | 82040 | 300 | $ 36.86 | $ 25.80 | $ 14.37 | $ 29.48 | $ 26.54 | $ 21.20 | $ 21.20 | $ 18.02 | $ 28.38 | $ 29.48 | $ 25.80 | $ 14.37 | $ 24.69 | $ 24.69 | ||
| Urine microalbumin (protein) analysis | 82044 | 301 | $ 19.95 | $ 13.97 | $ 7.78 | $ 21.62 | $ 14.36 | $ 21.62 | $ 21.62 | $ 18.38 | $ 15.36 | $ 15.96 | $ 13.97 | $ 7.78 | $ 13.37 | $ 13.37 | ||
| Ammonia level | 82140 | 301 | $ 150.15 | $ 105.11 | $ 53.07 | $ 120.12 | $ 108.11 | $ 62.43 | $ 62.43 | $ 53.07 | $ 115.62 | $ 120.12 | $ 105.11 | $ 58.56 | $ 100.60 | $ 100.60 | ||
| Amylase (enzyme) level | 82150 | 301 | $ 58.80 | $ 41.16 | $ 22.93 | $ 47.04 | $ 42.34 | $ 27.76 | $ 27.76 | $ 23.60 | $ 45.28 | $ 47.04 | $ 41.16 | $ 22.93 | $ 39.40 | $ 39.40 | ||
| Bilirubin level | 82247 | 301 | $ 61.43 | $ 43.00 | $ 18.26 | $ 49.14 | $ 44.23 | $ 21.48 | $ 21.48 | $ 18.26 | $ 47.30 | $ 49.14 | $ 43.00 | $ 23.96 | $ 41.15 | $ 41.15 | ||
| Stool analysis for blood to screen for colon tumors | 82270 | 301 | $ 32.76 | $ 22.93 | $ 12.78 | $ 26.21 | $ 23.59 | $ 15.20 | $ 15.20 | $ 12.92 | $ 25.23 | $ 26.21 | $ 22.93 | $ 12.78 | $ 21.95 | $ 21.95 | ||
| Vitamin D-3 level | 82306 | 301 | $ 278.25 | $ 194.78 | $ 107.82 | $ 222.60 | $ 200.34 | $ 126.83 | $ 126.83 | $ 107.82 | $ 214.25 | $ 222.60 | $ 194.78 | $ 108.52 | $ 186.43 | $ 186.43 | ||
| Calcium level | 82310 | 301 | $ 49.35 | $ 34.55 | $ 18.79 | $ 39.48 | $ 35.53 | $ 22.10 | $ 22.10 | $ 18.79 | $ 38.00 | $ 39.48 | $ 34.55 | $ 19.25 | $ 33.06 | $ 33.06 | ||
| Carcinoembryonic antigen (CEA) protein level | 82378 | 301 | $ 215.67 | $ 150.97 | $ 69.06 | $ 172.54 | $ 155.28 | $ 81.23 | $ 81.23 | $ 69.06 | $ 166.07 | $ 172.54 | $ 150.97 | $ 84.11 | $ 144.50 | $ 144.50 | ||
| Cholesterol level | 82465 | 301 | $ 34.65 | $ 24.26 | $ 13.51 | $ 27.72 | $ 24.95 | $ 18.63 | $ 18.63 | $ 15.84 | $ 26.68 | $ 27.72 | $ 24.26 | $ 13.51 | $ 23.22 | $ 23.22 | ||
| Creatine kinase (cardiac enzyme) level | 82550 | 301 | $ 118.76 | $ 83.13 | $ 23.72 | $ 95.00 | $ 85.50 | $ 27.90 | $ 27.90 | $ 23.72 | $ 91.44 | $ 95.00 | $ 83.13 | $ 46.31 | $ 79.57 | $ 79.57 | ||
| Creatine kinase (cardiac enzyme) level | 82553 | 301 | $ 203.39 | $ 142.37 | $ 42.07 | $ 162.71 | $ 146.44 | $ 49.48 | $ 49.48 | $ 42.07 | $ 156.61 | $ 162.71 | $ 142.37 | $ 79.32 | $ 136.27 | $ 136.27 | ||
| Blood creatinine level | 82565 | 301 | $ 36.75 | $ 25.73 | $ 14.33 | $ 29.40 | $ 26.46 | $ 21.97 | $ 21.97 | $ 18.67 | $ 28.30 | $ 29.40 | $ 25.73 | $ 14.33 | $ 24.62 | $ 24.62 | ||
| Cyanocobalamin (vitamin B-12) level | 82607 | 301 | $ 127.05 | $ 88.94 | $ 49.55 | $ 101.64 | $ 91.48 | $ 64.58 | $ 64.58 | $ 54.90 | $ 97.83 | $ 101.64 | $ 88.94 | $ 49.55 | $ 85.12 | $ 85.12 | ||
| Ferritin (blood protein) level | 82728 | 301 | $ 130.20 | $ 91.14 | $ 49.65 | $ 104.16 | $ 93.74 | $ 58.40 | $ 58.40 | $ 49.65 | $ 100.25 | $ 104.16 | $ 91.14 | $ 50.78 | $ 87.23 | $ 87.23 | ||
| Folic acid level | 82746 | 301 | $ 161.07 | $ 112.75 | $ 53.54 | $ 128.86 | $ 115.97 | $ 62.98 | $ 62.98 | $ 53.54 | $ 124.02 | $ 128.86 | $ 112.75 | $ 62.82 | $ 107.92 | $ 107.92 | ||
| Gammaglobulin (immune system protein) measurement | 82784 | 301 | $ 110.57 | $ 77.40 | $ 33.87 | $ 88.45 | $ 79.61 | $ 39.84 | $ 39.84 | $ 33.87 | $ 85.14 | $ 88.45 | $ 77.40 | $ 43.12 | $ 74.08 | $ 74.08 | ||
| Blood glucose (sugar) level | 82947 | 301 | $ 53.55 | $ 37.49 | $ 14.31 | $ 42.84 | $ 38.56 | $ 16.83 | $ 16.83 | $ 14.31 | $ 41.23 | $ 42.84 | $ 37.49 | $ 20.88 | $ 35.88 | $ 35.88 | ||
| Blood glucose (sugar) tolerance test | 82951 | 301 | $ 150.15 | $ 105.11 | $ 46.88 | $ 120.12 | $ 108.11 | $ 55.14 | $ 55.14 | $ 46.88 | $ 115.62 | $ 120.12 | $ 105.11 | $ 58.56 | $ 100.60 | $ 100.60 | ||
| Blood glucose (sugar) test performed by hand-held instrument | 82962 | 301 | $ 45.05 | $ 31.53 | $ 9.68 | $ 36.04 | $ 32.43 | $ 11.38 | $ 11.38 | $ 9.68 | $ 34.68 | $ 36.04 | $ 31.53 | $ 17.57 | $ 30.18 | $ 30.18 | ||
| Hemoglobin A1C level | 83036 | 301 | $ 124.22 | $ 86.95 | $ 35.37 | $ 99.37 | $ 89.43 | $ 41.61 | $ 41.61 | $ 35.37 | $ 95.65 | $ 99.37 | $ 86.95 | $ 48.44 | $ 83.22 | $ 83.22 | ||
| Iron binding capacity | 83550 | 301 | $ 84.00 | $ 58.80 | $ 31.83 | $ 67.20 | $ 60.48 | $ 37.44 | $ 37.44 | $ 31.83 | $ 64.68 | $ 67.20 | $ 58.80 | $ 32.76 | $ 56.28 | $ 56.28 | ||
| Lactic acid level | 83605 | 301 | $ 131.25 | $ 91.88 | $ 38.91 | $ 105.00 | $ 94.50 | $ 45.77 | $ 45.77 | $ 38.91 | $ 101.06 | $ 105.00 | $ 91.88 | $ 51.19 | $ 87.94 | $ 87.94 | ||
| Lactate dehydrogenase (enzyme) level | 83615 | 301 | $ 86.00 | $ 60.20 | $ 21.98 | $ 68.80 | $ 61.92 | $ 25.85 | $ 25.85 | $ 21.98 | $ 66.22 | $ 68.80 | $ 60.20 | $ 33.54 | $ 57.62 | $ 57.62 | ||
| Lipase (fat enzyme) level | 83690 | 301 | $ 101.01 | $ 70.71 | $ 25.10 | $ 80.81 | $ 72.73 | $ 29.53 | $ 29.53 | $ 25.10 | $ 77.78 | $ 80.81 | $ 70.71 | $ 39.39 | $ 67.68 | $ 67.68 | ||
| Magnesium level | 83735 | 301 | $ 107.84 | $ 75.48 | $ 24.40 | $ 86.27 | $ 77.64 | $ 28.70 | $ 28.70 | $ 24.40 | $ 83.03 | $ 86.27 | $ 75.48 | $ 42.06 | $ 72.25 | $ 72.25 | ||
| Natriuretic peptide (heart and blood vessel protein) level | 83880 | 301 | $ 335.48 | $ 234.83 | $ 123.61 | $ 268.38 | $ 241.54 | $ 145.39 | $ 145.39 | $ 123.61 | $ 258.32 | $ 268.38 | $ 234.83 | $ 130.84 | $ 224.77 | $ 224.77 | ||
| Parathormone (parathyroid hormone) level | 83970 | 301 | $ 323.51 | $ 226.45 | $ 126.17 | $ 258.80 | $ 232.92 | $ 176.83 | $ 176.83 | $ 150.33 | $ 249.10 | $ 258.80 | $ 226.45 | $ 126.17 | $ 216.75 | $ 216.75 | ||
| Blood potassium level | 84132 | 301 | $ 43.05 | $ 30.14 | $ 16.76 | $ 34.44 | $ 31.00 | $ 19.71 | $ 19.71 | $ 16.76 | $ 33.15 | $ 34.44 | $ 30.14 | $ 16.79 | $ 28.84 | $ 28.84 | ||
| Progesterone (reproductive hormone) level | 84144 | 301 | $ 149.10 | $ 104.37 | $ 58.15 | $ 119.28 | $ 107.35 | $ 89.39 | $ 89.39 | $ 75.99 | $ 114.81 | $ 119.28 | $ 104.37 | $ 58.15 | $ 99.90 | $ 99.90 | ||
| PSA (prostate specific antigen) measurement | 84153 | 301 | $ 181.55 | $ 127.08 | $ 66.99 | $ 145.24 | $ 130.71 | $ 78.80 | $ 78.80 | $ 66.99 | $ 139.79 | $ 145.24 | $ 127.08 | $ 70.80 | $ 121.64 | $ 121.64 | ||
| PSA (prostate specific antigen) measurement | 84154 | 301 | $ 124.95 | $ 87.47 | $ 48.73 | $ 99.96 | $ 89.96 | $ 78.80 | $ 78.80 | $ 66.99 | $ 96.21 | $ 99.96 | $ 87.47 | $ 48.73 | $ 83.72 | $ 83.72 | ||
| Testosterone (hormone) level | 84402 | 301 | $ 157.50 | $ 110.25 | $ 61.43 | $ 126.00 | $ 113.40 | $ 109.13 | $ 109.13 | $ 92.78 | $ 121.28 | $ 126.00 | $ 110.25 | $ 61.43 | $ 105.53 | $ 105.53 | ||
| Thyroxine (thyroid chemical) measurement | 84439 | 301 | $ 143.33 | $ 100.33 | $ 32.83 | $ 114.66 | $ 103.19 | $ 38.62 | $ 38.62 | $ 32.83 | $ 110.36 | $ 114.66 | $ 100.33 | $ 55.90 | $ 96.03 | $ 96.03 | ||
| Blood test, thyroid stimulating hormone (TSH) | 84443 | 301 | $ 187.01 | $ 130.90 | $ 61.21 | $ 149.60 | $ 134.64 | $ 72.00 | $ 72.00 | $ 61.21 | $ 143.99 | $ 149.60 | $ 130.90 | $ 72.93 | $ 125.29 | $ 125.29 | ||
| Thyroid hormone, T3 measurement | 84480 | 301 | $ 155.61 | $ 108.93 | $ 51.65 | $ 124.49 | $ 112.04 | $ 60.76 | $ 60.76 | $ 51.65 | $ 119.82 | $ 124.49 | $ 108.93 | $ 60.69 | $ 104.26 | $ 104.26 | ||
| Troponin (protein) analysis | 84484 | 301 | $ 221.13 | $ 154.79 | $ 36.79 | $ 176.90 | $ 159.21 | $ 43.27 | $ 43.27 | $ 36.79 | $ 170.27 | $ 176.90 | $ 154.79 | $ 86.24 | $ 148.16 | $ 148.16 | ||
| Urea nitrogen level to assess kidney function | 84520 | 301 | $ 48.83 | $ 34.18 | $ 14.40 | $ 39.06 | $ 35.15 | $ 16.93 | $ 16.93 | $ 14.40 | $ 37.60 | $ 39.06 | $ 34.18 | $ 19.04 | $ 32.71 | $ 32.71 | ||
| Uric acid level, blood | 84550 | 300 | $ 34.65 | $ 24.26 | $ 13.51 | $ 27.72 | $ 24.95 | $ 19.36 | $ 19.36 | $ 16.46 | $ 26.68 | $ 27.72 | $ 24.26 | $ 13.51 | $ 23.22 | $ 23.22 | ||
| Microscopic examination for white blood cells with manual cell count | 85007 | 305 | $ 42.32 | $ 29.62 | $ 12.51 | $ 33.85 | $ 30.47 | $ 14.71 | $ 14.71 | $ 12.51 | $ 32.58 | $ 33.85 | $ 29.62 | $ 16.50 | $ 28.35 | $ 28.35 | ||
| Hemoglobin measurement | 85018 | 305 | $ 28.67 | $ 20.07 | $ 8.64 | $ 22.93 | $ 20.64 | $ 10.17 | $ 10.17 | $ 8.64 | $ 22.07 | $ 22.93 | $ 20.07 | $ 11.18 | $ 19.21 | $ 19.21 | ||
| Complete blood cell count (red cells, white blood cell, platelets), automated test | 85025 | 305 | $ 125.58 | $ 87.91 | $ 28.29 | $ 100.46 | $ 90.42 | $ 33.28 | $ 33.28 | $ 28.29 | $ 96.70 | $ 100.46 | $ 87.91 | $ 48.98 | $ 84.14 | $ 84.14 | ||
| Complete blood cell count (red cells, white blood cell, platelets), automated test | 85027 | 305 | $ 79.80 | $ 55.86 | $ 23.54 | $ 63.84 | $ 57.46 | $ 27.69 | $ 27.69 | $ 23.54 | $ 61.45 | $ 63.84 | $ 55.86 | $ 31.12 | $ 53.47 | $ 53.47 | ||
| Clotting factor V (AcG or proaccelerin) measurement | 85220 | 305 | $ 248.85 | $ 174.20 | $ 64.28 | $ 199.08 | $ 179.17 | $ 75.61 | $ 75.61 | $ 64.28 | $ 191.61 | $ 199.08 | $ 174.20 | $ 97.05 | $ 166.73 | $ 166.73 | ||
| Coagulation function measurement | 85378 | 305 | $ 143.85 | $ 100.70 | $ 28.67 | $ 115.08 | $ 103.57 | $ 33.73 | $ 33.73 | $ 28.67 | $ 110.76 | $ 115.08 | $ 100.70 | $ 56.10 | $ 96.38 | $ 96.38 | ||
| Fibrinogen (factor 1) activity measurement | 85384 | 305 | $ 228.90 | $ 160.23 | $ 30.95 | $ 183.12 | $ 164.81 | $ 36.40 | $ 36.40 | $ 30.95 | $ 176.25 | $ 183.12 | $ 160.23 | $ 89.27 | $ 153.36 | $ 153.36 | ||
| Blood test, clotting time | 85610 | 305 | $ 72.35 | $ 50.64 | $ 14.31 | $ 57.88 | $ 52.09 | $ 16.83 | $ 16.83 | $ 14.31 | $ 55.71 | $ 57.88 | $ 50.64 | $ 28.21 | $ 48.47 | $ 48.47 | ||
| Red blood cell sedimentation rate, to detect inflammation | 85652 | 305 | $ 35.49 | $ 24.84 | $ 9.82 | $ 28.39 | $ 25.55 | $ 11.56 | $ 11.56 | $ 9.82 | $ 27.33 | $ 28.39 | $ 24.84 | $ 13.84 | $ 23.78 | $ 23.78 | ||
| Coagulation assessment blood test | 85730 | 305 | $ 118.76 | $ 83.13 | $ 21.89 | $ 95.00 | $ 85.50 | $ 25.75 | $ 25.75 | $ 21.89 | $ 91.44 | $ 95.00 | $ 83.13 | $ 46.31 | $ 79.57 | $ 79.57 | ||
| Measurement of antibody (IgE) to allergic substance | 86003 | 302 | $ 40.95 | $ 28.67 | $ 15.97 | $ 32.76 | $ 29.48 | $ 22.35 | $ 22.35 | $ 19.00 | $ 31.53 | $ 32.76 | $ 28.67 | $ 15.97 | $ 27.44 | $ 27.44 | ||
| Measurement C-reactive protein for detection of infection or inflammation | 86140 | 302 | $ 103.74 | $ 72.62 | $ 18.85 | $ 82.99 | $ 74.69 | $ 22.17 | $ 22.17 | $ 18.85 | $ 79.88 | $ 82.99 | $ 72.62 | $ 40.46 | $ 69.51 | $ 69.51 | ||
| Analysis for detection of tumor marker | 86316 | 300 | $ 100.80 | $ 70.56 | $ 39.31 | $ 89.18 | $ 72.58 | $ 89.18 | $ 89.18 | $ 75.82 | $ 77.62 | $ 80.64 | $ 70.56 | $ 39.31 | $ 67.54 | $ 67.54 | ||
| Rheumatoid factor level | 86431 | 302 | $ 73.50 | $ 51.45 | $ 20.65 | $ 58.80 | $ 52.92 | $ 24.29 | $ 24.29 | $ 20.65 | $ 56.60 | $ 58.80 | $ 51.45 | $ 28.67 | $ 49.25 | $ 49.25 | ||
| Analysis for antibody to Herpes simplex virus | 86694 | 302 | $ 94.50 | $ 66.15 | $ 36.86 | $ 75.60 | $ 68.04 | $ 61.66 | $ 61.66 | $ 52.42 | $ 72.77 | $ 75.60 | $ 66.15 | $ 36.86 | $ 63.32 | $ 63.32 | ||
| Bacterial blood culture | 87040 | 306 | $ 222.50 | $ 155.75 | $ 37.58 | $ 178.00 | $ 160.20 | $ 44.21 | $ 44.21 | $ 37.58 | $ 171.32 | $ 178.00 | $ 155.75 | $ 86.77 | $ 149.07 | $ 149.07 | ||
| Bacterial culture for aerobic isolates | 87077 | 300 | $ 102.38 | $ 71.66 | $ 29.41 | $ 81.90 | $ 73.71 | $ 34.60 | $ 34.60 | $ 29.41 | $ 78.83 | $ 81.90 | $ 71.66 | $ 39.93 | $ 68.59 | $ 68.59 | ||
| Bacterial colony count, urine | 87086 | 300 | $ 137.87 | $ 96.51 | $ 29.38 | $ 110.29 | $ 99.26 | $ 34.56 | $ 34.56 | $ 29.38 | $ 106.16 | $ 110.29 | $ 96.51 | $ 53.77 | $ 92.37 | $ 92.37 | ||
| Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral) | 87186 | 300 | $ 120.12 | $ 84.08 | $ 31.48 | $ 96.10 | $ 86.49 | $ 37.02 | $ 37.02 | $ 31.48 | $ 92.49 | $ 96.10 | $ 84.08 | $ 46.85 | $ 80.48 | $ 80.48 | ||
| Immunologic analysis for detection of organism | 87449 | 300 | $ 137.87 | $ 96.51 | $ 43.66 | $ 110.29 | $ 99.26 | $ 51.36 | $ 51.36 | $ 43.66 | $ 106.16 | $ 110.29 | $ 96.51 | $ 53.77 | $ 92.37 | $ 92.37 | ||
| Detection test for chlamydia | 87490 | 306 | $ 124.95 | $ 87.47 | $ 48.73 | $ 99.96 | $ 89.96 | $ 85.92 | $ 85.92 | $ 73.04 | $ 96.21 | $ 99.96 | $ 87.47 | $ 48.73 | $ 83.72 | $ 83.72 | ||
| Detection test for multiple types influenza virus | 87502 | 300 | $ 296.21 | $ 207.34 | $ 115.52 | $ 364.56 | $ 213.27 | $ 364.56 | $ 364.56 | $ 309.93 | $ 228.08 | $ 236.96 | $ 207.34 | $ 115.52 | $ 198.46 | $ 198.46 | ||
| Detection test for Neisseria gonorrhoeae (gonorrhoeae bacteria) | 87590 | 306 | $ 189.00 | $ 132.30 | $ 73.71 | $ 151.20 | $ 136.08 | $ 93.27 | $ 93.27 | $ 79.30 | $ 145.53 | $ 151.20 | $ 132.30 | $ 73.71 | $ 126.63 | $ 126.63 | ||
| 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 | $ 157.50 | $ 110.25 | $ 61.43 | $ 178.12 | $ 113.40 | $ 178.12 | $ 178.12 | $ 151.42 | $ 121.28 | $ 126.00 | $ 110.25 | $ 61.43 | $ 105.53 | $ 105.53 | ||
| Detection test for Strep (Streptococcus, group A) | 87651 | 306 | $ 131.25 | $ 91.88 | $ 51.19 | $ 150.36 | $ 94.50 | $ 150.36 | $ 150.36 | $ 127.82 | $ 101.06 | $ 105.00 | $ 91.88 | $ 51.19 | $ 87.94 | $ 87.94 | ||
| Detection test for influenza virus | 87804 | 306 | $ 129.68 | $ 90.77 | $ 48.82 | $ 103.74 | $ 93.37 | $ 57.43 | $ 57.43 | $ 48.82 | $ 99.85 | $ 103.74 | $ 90.77 | $ 50.57 | $ 86.88 | $ 86.88 | ||
| Detection test for respiratory syncytial virus (RSV) | 87807 | 301 | $ 57.75 | $ 40.43 | $ 22.52 | $ 51.36 | $ 41.58 | $ 51.36 | $ 51.36 | $ 43.66 | $ 44.47 | $ 46.20 | $ 40.43 | $ 22.52 | $ 38.69 | $ 38.69 | ||
| Pathology examination of tissue using a microscope, intermediate complexity | 88305 | 971 | $ 467.25 | $ 327.08 | $ 131.87 | $ 373.80 | $ 336.42 | $ 155.11 | $ 155.11 | $ 131.87 | $ 359.78 | $ 373.80 | $ 327.08 | $ 182.23 | $ 313.06 | $ 313.06 | ||
| Handling and/or conveyance of specimen for transfer to a laboratory | 99001 | 300 | $ 56.70 | $ 39.69 | $ 18.00 | $ 45.36 | $ 40.82 | $ 21.17 | $ 21.17 | $ 18.00 | $ 43.66 | $ 45.36 | $ 39.69 | $ 22.11 | $ 37.99 | $ 37.99 | ||
| Radiology Services | CT scan head or brain | 70450 | 351 | $ 1,267.35 | $ 887.15 | $ 402.90 | $ 1,013.88 | $ 912.49 | $ 453.26 | $ 453.26 | $ 402.90 | $ 975.86 | $ 1,013.88 | $ 887.15 | $ 494.27 | $ 849.12 | $ 849.12 | |
| MRI scan of brain before and after contrast | 70553 | 611 | $ 2,879.10 | $ 2,015.37 | $ 1,122.85 | $ 2,303.28 | $ 2,072.95 | $ 1,807.23 | $ 1,807.23 | $ 1,606.42 | $ 2,216.91 | $ 2,303.28 | $ 2,015.37 | $ 1,122.85 | $ 1,929.00 | $ 1,929.00 | ||
| X-ray of chest, 1 view | 71045 | 324 | $ 315.00 | $ 220.50 | $ 77.03 | $ 252.00 | $ 226.80 | $ 90.70 | $ 90.70 | $ 77.03 | $ 242.55 | $ 252.00 | $ 220.50 | $ 122.85 | $ 211.05 | $ 211.05 | ||
| X-ray of chest, 2 views | 71046 | 324 | $ 345.45 | $ 241.82 | $ 77.03 | $ 276.36 | $ 248.72 | $ 90.70 | $ 90.70 | $ 77.03 | $ 266.00 | $ 276.36 | $ 241.82 | $ 134.73 | $ 231.45 | $ 231.45 | ||
| MRI scan of chest before and after contrast | 71552 | 610 | $ 1,197.89 | $ 838.52 | $ 467.18 | $ 1,807.23 | $ 862.48 | $ 1,807.23 | $ 1,807.23 | $ 1,606.42 | $ 922.38 | $ 958.31 | $ 838.52 | $ 467.18 | $ 802.59 | $ 802.59 | ||
| X-ray of spine of neck, 2 or 3 views | 72040 | 320 | $ 409.50 | $ 286.65 | $ 77.03 | $ 327.60 | $ 294.84 | $ 90.70 | $ 90.70 | $ 77.03 | $ 315.32 | $ 327.60 | $ 286.65 | $ 159.71 | $ 274.37 | $ 274.37 | ||
| X-ray of upper spine, 4 or 5 views | 72050 | 320 | $ 716.63 | $ 501.64 | $ 141.93 | $ 573.30 | $ 515.97 | $ 167.11 | $ 167.11 | $ 141.93 | $ 551.80 | $ 573.30 | $ 501.64 | $ 279.48 | $ 480.14 | $ 480.14 | ||
| X-ray of middle and lower spine, 2 views | 72080 | 320 | $ 315.00 | $ 220.50 | $ 77.03 | $ 252.00 | $ 226.80 | $ 90.70 | $ 90.70 | $ 77.03 | $ 242.55 | $ 252.00 | $ 220.50 | $ 122.85 | $ 211.05 | $ 211.05 | ||
| X-ray of lower and sacral spine, 2 or 3 views | 72100 | 320 | $ 409.50 | $ 286.65 | $ 141.93 | $ 327.60 | $ 294.84 | $ 167.11 | $ 167.11 | $ 141.93 | $ 315.32 | $ 327.60 | $ 286.65 | $ 159.71 | $ 274.37 | $ 274.37 | ||
| X-ray of lower and sacral spine, minimum of 4 views | 72110 | 320 | $ 716.63 | $ 501.64 | $ 141.93 | $ 573.30 | $ 515.97 | $ 167.11 | $ 167.11 | $ 141.93 | $ 551.80 | $ 573.30 | $ 501.64 | $ 279.48 | $ 480.14 | $ 480.14 | ||
| MRI scan of lower spinal canal | 72148 | 612 | $ 3,186.75 | $ 2,230.73 | $ 817.73 | $ 2,549.40 | $ 2,294.46 | $ 919.95 | $ 919.95 | $ 817.73 | $ 2,453.80 | $ 2,549.40 | $ 2,230.73 | $ 1,242.83 | $ 2,135.12 | $ 2,135.12 | ||
| CT scan pelvis with contrast | 72193 | 350 | $ 2,093.70 | $ 1,465.59 | $ 816.54 | $ 1,674.96 | $ 1,507.46 | $ 1,000.85 | $ 1,000.85 | $ 889.64 | $ 1,612.15 | $ 1,674.96 | $ 1,465.59 | $ 816.54 | $ 1,402.78 | $ 1,402.78 | ||
| MRI scan of pelvis before and after contrast | 72197 | 610 | $ 5,682.60 | $ 3,977.82 | $ 1,606.42 | $ 4,546.08 | $ 4,091.47 | $ 1,807.23 | $ 1,807.23 | $ 1,606.42 | $ 4,375.60 | $ 4,546.08 | $ 3,977.82 | $ 2,216.21 | $ 3,807.34 | $ 3,807.34 | ||
| X-ray of shoulder, minimum of 2 views | 73030 | 320 | $ 421.79 | $ 295.25 | $ 77.03 | $ 337.43 | $ 303.69 | $ 90.70 | $ 90.70 | $ 77.03 | $ 324.77 | $ 337.43 | $ 295.25 | $ 164.50 | $ 282.60 | $ 282.60 | ||
| X-ray of elbow, minimum of 3 views | 73080 | 521 | $ 492.77 | $ 344.94 | $ 77.03 | $ 394.21 | $ 354.79 | $ 90.70 | $ 90.70 | $ 77.03 | $ 379.43 | $ 394.21 | $ 344.94 | $ 192.18 | $ 330.15 | $ 330.15 | ||
| X-ray of forearm, 2 views | 73090 | 320 | $ 475.02 | $ 332.51 | $ 77.03 | $ 380.02 | $ 342.01 | $ 90.70 | $ 90.70 | $ 77.03 | $ 365.77 | $ 380.02 | $ 332.51 | $ 185.26 | $ 318.26 | $ 318.26 | ||
| X-ray of wrist, minimum of 3 views | 73110 | 320 | $ 410.87 | $ 287.61 | $ 77.03 | $ 328.69 | $ 295.82 | $ 90.70 | $ 90.70 | $ 77.03 | $ 316.37 | $ 328.69 | $ 287.61 | $ 160.24 | $ 275.28 | $ 275.28 | ||
| X-ray of hand, minimum of 3 views | 73130 | 320 | $ 475.02 | $ 332.51 | $ 77.03 | $ 380.02 | $ 342.01 | $ 90.70 | $ 90.70 | $ 77.03 | $ 365.77 | $ 380.02 | $ 332.51 | $ 185.26 | $ 318.26 | $ 318.26 | ||
| CT scan of arm | 73200 | 352 | $ 2,729.48 | $ 1,910.63 | $ 402.90 | $ 2,183.58 | $ 1,965.22 | $ 453.26 | $ 453.26 | $ 402.90 | $ 2,101.70 | $ 2,183.58 | $ 1,910.63 | $ 1,064.50 | $ 1,828.75 | $ 1,828.75 | ||
| CT scan of arm with contrast | 73201 | 352 | $ 2,107.35 | $ 1,475.15 | $ 821.87 | $ 1,685.88 | $ 1,517.29 | $ 1,000.85 | $ 1,000.85 | $ 889.64 | $ 1,622.66 | $ 1,685.88 | $ 1,475.15 | $ 821.87 | $ 1,411.92 | $ 1,411.92 | ||
| CT scan of arm before and after contrast | 73202 | 352 | $ 2,136.75 | $ 1,495.73 | $ 833.33 | $ 1,709.40 | $ 1,538.46 | $ 1,000.85 | $ 1,000.85 | $ 889.64 | $ 1,645.30 | $ 1,709.40 | $ 1,495.73 | $ 833.33 | $ 1,431.62 | $ 1,431.62 | ||
| X-ray of hip with pelvis, 2-3 views | 73502 | 320 | $ 521.43 | $ 365.00 | $ 77.03 | $ 417.14 | $ 375.43 | $ 90.70 | $ 90.70 | $ 77.03 | $ 401.50 | $ 417.14 | $ 365.00 | $ 203.36 | $ 349.36 | $ 349.36 | ||
| X-ray of knee, 1 or 2 views | 73560 | 320 | $ 341.25 | $ 238.88 | $ 77.03 | $ 273.00 | $ 245.70 | $ 90.70 | $ 90.70 | $ 77.03 | $ 262.76 | $ 273.00 | $ 238.88 | $ 133.09 | $ 228.64 | $ 228.64 | ||
| X-ray of knee, 3 views | 73562 | 320 | $ 541.91 | $ 379.33 | $ 77.03 | $ 433.52 | $ 390.17 | $ 90.70 | $ 90.70 | $ 77.03 | $ 417.27 | $ 433.52 | $ 379.33 | $ 211.34 | $ 363.08 | $ 363.08 | ||
| X-ray of ankle, 2 views | 73600 | 521 | $ 360.36 | $ 252.25 | $ 77.03 | $ 288.29 | $ 259.46 | $ 90.70 | $ 90.70 | $ 77.03 | $ 277.48 | $ 288.29 | $ 252.25 | $ 140.54 | $ 241.44 | $ 241.44 | ||
| X-ray of ankle, minimum of 3 views | 73610 | 320 | $ 421.79 | $ 295.25 | $ 77.03 | $ 337.43 | $ 303.69 | $ 90.70 | $ 90.70 | $ 77.03 | $ 324.77 | $ 337.43 | $ 295.25 | $ 164.50 | $ 282.60 | $ 282.60 | ||
| X-ray of foot, minimum of 3 views | 73630 | 521 | $ 409.50 | $ 286.65 | $ 77.03 | $ 327.60 | $ 294.84 | $ 90.70 | $ 90.70 | $ 77.03 | $ 315.32 | $ 327.60 | $ 286.65 | $ 159.71 | $ 274.37 | $ 274.37 | ||
| CT scan leg | 73700 | 352 | $ 1,962.45 | $ 1,373.72 | $ 402.90 | $ 1,569.96 | $ 1,412.96 | $ 453.26 | $ 453.26 | $ 402.90 | $ 1,511.09 | $ 1,569.96 | $ 1,373.72 | $ 765.36 | $ 1,314.84 | $ 1,314.84 | ||
| CT scan leg with contrast injection | 73701 | 350 | $ 1,962.45 | $ 1,373.72 | $ 765.36 | $ 1,569.96 | $ 1,412.96 | $ 1,000.85 | $ 1,000.85 | $ 889.64 | $ 1,511.09 | $ 1,569.96 | $ 1,373.72 | $ 765.36 | $ 1,314.84 | $ 1,314.84 | ||
| CT scan of leg before and after contrast injection | 73702 | 352 | $ 2,116.80 | $ 1,481.76 | $ 825.55 | $ 1,693.44 | $ 1,524.10 | $ 1,000.85 | $ 1,000.85 | $ 889.64 | $ 1,629.94 | $ 1,693.44 | $ 1,481.76 | $ 825.55 | $ 1,418.26 | $ 1,418.26 | ||
| MRI scan of leg joint | 73721 | 610 | $ 2,971.50 | $ 2,080.05 | $ 817.73 | $ 2,377.20 | $ 2,139.48 | $ 919.95 | $ 919.95 | $ 817.73 | $ 2,288.06 | $ 2,377.20 | $ 2,080.05 | $ 1,158.89 | $ 1,990.91 | $ 1,990.91 | ||
| MRI scan of leg joint with contrast | 73722 | 610 | $ 3,105.90 | $ 2,174.13 | $ 1,211.30 | $ 2,700.24 | $ 2,236.25 | $ 2,700.24 | $ 2,700.24 | $ 2,400.22 | $ 2,391.54 | $ 2,484.72 | $ 2,174.13 | $ 1,211.30 | $ 2,080.95 | $ 2,080.95 | ||
| MRI scan of leg joint before and after contrast | 73723 | 610 | $ 3,870.30 | $ 2,709.21 | $ 1,509.42 | $ 3,096.24 | $ 2,786.62 | $ 1,807.23 | $ 1,807.23 | $ 1,606.42 | $ 2,980.13 | $ 3,096.24 | $ 2,709.21 | $ 1,509.42 | $ 2,593.10 | $ 2,593.10 | ||
| X-ray of abdomen, 1 view | 74018 | 320 | $ 315.00 | $ 220.50 | $ 77.03 | $ 252.00 | $ 226.80 | $ 90.70 | $ 90.70 | $ 77.03 | $ 242.55 | $ 252.00 | $ 220.50 | $ 122.85 | $ 211.05 | $ 211.05 | ||
| X-ray of abdomen, 2 views | 74019 | 320 | $ 332.85 | $ 233.00 | $ 129.81 | $ 266.28 | $ 239.65 | $ 167.11 | $ 167.11 | $ 141.93 | $ 256.29 | $ 266.28 | $ 233.00 | $ 129.81 | $ 223.01 | $ 223.01 | ||
| X-ray of abdomen, minimum of 3 views | 74021 | 320 | $ 491.40 | $ 343.98 | $ 141.93 | $ 393.12 | $ 353.81 | $ 167.11 | $ 167.11 | $ 141.93 | $ 378.38 | $ 393.12 | $ 343.98 | $ 191.65 | $ 329.24 | $ 329.24 | ||
| Complete X-ray study of abdomen with single X-ray of chest | 74022 | 320 | $ 722.09 | $ 505.46 | $ 141.93 | $ 577.67 | $ 519.90 | $ 167.11 | $ 167.11 | $ 141.93 | $ 556.01 | $ 577.67 | $ 505.46 | $ 281.61 | $ 483.80 | $ 483.80 | ||
| CT scan of abdomen and pelvis | 74176 | 352 | $ 2,049.08 | $ 1,434.35 | $ 799.14 | $ 1,639.26 | $ 1,475.33 | $ 919.95 | $ 919.95 | $ 817.73 | $ 1,577.79 | $ 1,639.26 | $ 1,434.35 | $ 799.14 | $ 1,372.88 | $ 1,372.88 | ||
| CT scan of abdomen and pelvis with contrast | 74177 | 352 | $ 2,360.40 | $ 1,652.28 | $ 889.64 | $ 1,888.32 | $ 1,699.49 | $ 1,000.85 | $ 1,000.85 | $ 889.64 | $ 1,817.51 | $ 1,888.32 | $ 1,652.28 | $ 920.56 | $ 1,581.47 | $ 1,581.47 | ||
| CT scan of abdomen and pelvis before and after contrast | 74178 | 352 | $ 3,027.15 | $ 2,119.01 | $ 889.64 | $ 2,421.72 | $ 2,179.55 | $ 1,000.85 | $ 1,000.85 | $ 889.64 | $ 2,330.91 | $ 2,421.72 | $ 2,119.01 | $ 1,180.59 | $ 2,028.19 | $ 2,028.19 | ||
| MRI scan of abdomen before and after contrast | 74183 | 610 | $ 5,227.95 | $ 3,659.57 | $ 1,606.42 | $ 4,182.36 | $ 3,764.12 | $ 1,807.23 | $ 1,807.23 | $ 1,606.42 | $ 4,025.52 | $ 4,182.36 | $ 3,659.57 | $ 2,038.90 | $ 3,502.73 | $ 3,502.73 | ||
| Imaging for evaluation of swallowing function | 74230 | 320 | $ 840.84 | $ 588.59 | $ 141.93 | $ 672.67 | $ 605.40 | $ 167.11 | $ 167.11 | $ 141.93 | $ 647.45 | $ 672.67 | $ 588.59 | $ 327.93 | $ 563.36 | $ 563.36 | ||
| X-ray of large bowel with single contrast | 74270 | 320 | $ 1,279.01 | $ 895.30 | $ 313.40 | $ 1,023.20 | $ 920.88 | $ 369.00 | $ 369.00 | $ 313.40 | $ 984.83 | $ 1,023.20 | $ 895.30 | $ 498.81 | $ 856.93 | $ 856.93 | ||
| Imaging of urinary tract | 74420 | 320 | $ 1,131.90 | $ 792.33 | $ 441.44 | $ 905.52 | $ 814.97 | $ 664.40 | $ 664.40 | $ 564.29 | $ 871.56 | $ 905.52 | $ 792.33 | $ 441.44 | $ 758.37 | $ 758.37 | ||
| CT scan of abdominal aorta and both leg arteries with contrast | 75635 | 352 | $ 3,505.95 | $ 2,454.17 | $ 889.64 | $ 2,804.76 | $ 2,524.28 | $ 1,000.85 | $ 1,000.85 | $ 889.64 | $ 2,699.58 | $ 2,804.76 | $ 2,454.17 | $ 1,367.32 | $ 2,348.99 | $ 2,348.99 | ||
| Ultrasound of abdomen | 76700 | 402 | $ 996.45 | $ 697.52 | $ 141.93 | $ 797.16 | $ 717.44 | $ 167.11 | $ 167.11 | $ 141.93 | $ 767.27 | $ 797.16 | $ 697.52 | $ 388.62 | $ 667.62 | $ 667.62 | ||
| Ultrasound behind abdominal cavity | 76770 | 402 | $ 933.66 | $ 653.56 | $ 141.93 | $ 746.93 | $ 672.24 | $ 167.11 | $ 167.11 | $ 141.93 | $ 718.92 | $ 746.93 | $ 653.56 | $ 364.13 | $ 625.55 | $ 625.55 | ||
| Ultrasound of spinal canal | 76800 | 402 | $ 330.75 | $ 231.53 | $ 128.99 | $ 264.60 | $ 238.14 | $ 167.11 | $ 167.11 | $ 141.93 | $ 254.68 | $ 264.60 | $ 231.53 | $ 128.99 | $ 221.60 | $ 221.60 | ||
| Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus | 76805 | 402 | $ 426.30 | $ 298.41 | $ 116.60 | $ 341.04 | $ 306.94 | $ 137.28 | $ 137.28 | $ 116.60 | $ 328.25 | $ 341.04 | $ 298.41 | $ 166.26 | $ 285.62 | $ 285.62 | ||
| Vaginal ultrasound of pregnant uterus | 76817 | 402 | $ 426.30 | $ 298.41 | $ 141.93 | $ 341.04 | $ 306.94 | $ 167.11 | $ 167.11 | $ 141.93 | $ 328.25 | $ 341.04 | $ 298.41 | $ 166.26 | $ 285.62 | $ 285.62 | ||
| Ultrasound pelvis through vagina | 76830 | 402 | $ 933.66 | $ 653.56 | $ 110.81 | $ 746.93 | $ 672.24 | $ 130.47 | $ 130.47 | $ 110.81 | $ 718.92 | $ 746.93 | $ 653.56 | $ 364.13 | $ 625.55 | $ 625.55 | ||
| Ultrasound of pelvis | 76857 | 402 | $ 268.80 | $ 188.16 | $ 104.83 | $ 215.04 | $ 193.54 | $ 167.11 | $ 167.11 | $ 141.93 | $ 206.98 | $ 215.04 | $ 188.16 | $ 104.83 | $ 180.10 | $ 180.10 | ||
| Complete ultrasound of joint of arm or leg | 76881 | 402 | $ 718.20 | $ 502.74 | $ 88.56 | $ 574.56 | $ 517.10 | $ 104.27 | $ 104.27 | $ 88.56 | $ 553.01 | $ 574.56 | $ 502.74 | $ 280.10 | $ 481.19 | $ 481.19 | ||
| Partial ultrasound of joint or other non-blood vessel structure of arm or leg | 76882 | 402 | $ 551.25 | $ 385.88 | $ 141.93 | $ 441.00 | $ 396.90 | $ 167.11 | $ 167.11 | $ 141.93 | $ 424.46 | $ 441.00 | $ 385.88 | $ 214.99 | $ 369.34 | $ 369.34 | ||
| Mammography of one breast | 77065 | 401 | $ 289.80 | $ 202.86 | $ 113.02 | $ 231.84 | $ 208.66 | $ 139.90 | $ 139.90 | $ 118.82 | $ 223.15 | $ 231.84 | $ 202.86 | $ 113.02 | $ 194.17 | $ 194.17 | ||
| Mammography of both breasts | 77066 | 401 | $ 578.55 | $ 404.99 | $ 151.75 | $ 462.84 | $ 416.56 | $ 178.67 | $ 178.67 | $ 151.75 | $ 445.48 | $ 462.84 | $ 404.99 | $ 225.63 | $ 387.63 | $ 387.63 | ||
| Mammography of both breasts | 77067 | 403 | $ 226.80 | $ 158.76 | $ 88.45 | $ 181.44 | $ 163.30 | $ 147.77 | $ 147.77 | $ 125.50 | $ 174.64 | $ 181.44 | $ 158.76 | $ 88.45 | $ 151.96 | $ 151.96 | ||
| Bone density measurement using dedicated X-ray machine | 77080 | 320 | $ 404.25 | $ 282.98 | $ 40.05 | $ 323.40 | $ 291.06 | $ 47.16 | $ 47.16 | $ 40.05 | $ 311.27 | $ 323.40 | $ 282.98 | $ 157.66 | $ 270.85 | $ 270.85 | ||
| Nuclear medicine imaging for thyroid uptake measurements | 78012 | 341 | $ 840.00 | $ 588.00 | $ 93.46 | $ 672.00 | $ 604.80 | $ 110.04 | $ 110.04 | $ 93.46 | $ 646.80 | $ 672.00 | $ 588.00 | $ 327.60 | $ 562.80 | $ 562.80 | ||
| Bone and/or joint imaging | 78300 | 341 | $ 1,226.40 | $ 858.48 | $ 261.68 | $ 981.12 | $ 883.01 | $ 308.10 | $ 308.10 | $ 261.68 | $ 944.33 | $ 981.12 | $ 858.48 | $ 478.30 | $ 821.69 | $ 821.69 | ||
| Routine electrocardiogram (EKG) with tracing using at least 12 leads | 93005 | 730 | $ 342.62 | $ 239.83 | $ 129.27 | $ 274.09 | $ 246.68 | $ 129.27 | $ 129.27 | $ 129.27 | $ 263.81 | $ 274.09 | $ 239.83 | $ 133.62 | $ 229.55 | $ 229.55 | ||
| Ultrasound scanning of blood flow (outside the brain) on both sides of head and neck | 93880 | 921 | $ 1,519.35 | $ 1,063.55 | $ 272.74 | $ 1,215.48 | $ 1,093.93 | $ 272.74 | $ 272.74 | $ 272.74 | $ 1,169.90 | $ 1,215.48 | $ 1,063.55 | $ 592.55 | $ 1,017.96 | $ 1,017.96 | ||
| Ultrasound scan of veins of both arms or legs including assessment of compression and functional maneuvers | 93970 | 921 | $ 1,553.37 | $ 1,087.36 | $ 383.83 | $ 1,242.70 | $ 1,118.43 | $ 383.83 | $ 383.83 | $ 383.83 | $ 1,196.09 | $ 1,242.70 | $ 1,087.36 | $ 605.81 | $ 1,040.76 | $ 1,040.76 | ||
| Initial nursing facility visit, typically 45 minutes per day | 99306 | $ 265.65 | $ 185.96 | $ 103.60 | $ 212.52 | $ 191.27 | $ - | $ - | $ - | $ 204.55 | $ 212.52 | $ 185.96 | $ 103.60 | $ 177.99 | $ 177.99 | |||
| MRI Contrast - Multihance 20 ml | A9577 | 636 | $ 8.37 | $ 5.86 | $ 3.26 | $ 6.69 | $ 6.03 | N/A | N/A | N/A | $ 6.44 | $ 6.69 | $ 5.86 | $ 3.26 | $ 5.61 | $ 5.61 | ||
| CT Lung Cancer screening | G0297 | $ 2,935.80 | $ 2,055.06 | $ 234.52 | $ 2,348.64 | $ 2,113.78 | $ 276.13 | $ 276.13 | $ 234.52 | $ 2,260.57 | $ 2,348.64 | $ 2,055.06 | $ 1,144.96 | $ 1,966.99 | $ 1,966.99 | |||
| CT scan contrast 100ML or 75ML low osmolar contrast | Q9967 | 636 | $ 2.58 | $ 1.81 | $ 1.01 | $ 2.07 | $ 1.86 | N/A | N/A | N/A | $ 1.99 | $ 2.07 | $ 1.81 | $ 1.01 | $ 1.73 | $ 1.73 | ||
| Medicine and Surgery Services | Drainage of tailbone cyst | 10080 | 981 | $ 280.22 | $ 196.16 | $ 109.29 | $ 224.18 | $ 201.76 | $ 140.62 | $ 140.62 | $ 133.92 | $ 215.77 | $ 224.18 | $ 196.16 | $ 109.29 | $ 187.75 | $ 187.75 | |
| Drainage of tailbone cyst | 10081 | 981 | $ 465.71 | $ 325.99 | $ 174.24 | $ 372.57 | $ 335.31 | $ 182.95 | $ 182.95 | $ 174.24 | $ 358.59 | $ 372.57 | $ 325.99 | $ 181.63 | $ 312.02 | $ 312.02 | ||
| Removal of skin and tissue first 20 sq cm or less | 11042 | 761 | $ 2,199.05 | $ 1,539.33 | $ 310.80 | $ 1,759.24 | $ 1,583.31 | $ 326.34 | $ 326.34 | $ 310.80 | $ 1,693.27 | $ 1,759.24 | $ 1,539.33 | $ 857.63 | $ 1,473.36 | $ 1,473.36 | ||
| Removal of skin and tissue | 11045 | 761 | $ 1,227.14 | $ 858.99 | $ 478.58 | $ 981.71 | $ 883.54 | $ - | $ - | $ - | $ 944.89 | $ 981.71 | $ 858.99 | $ 478.58 | $ 822.18 | $ 822.18 | ||
| Removal of growth (0.5 centimeters or less) of the trunk, arms or legs | 11400 | 983 | $ 222.81 | $ 155.97 | $ 86.90 | $ 178.25 | $ 160.42 | $ 96.39 | $ 96.39 | $ 91.80 | $ 171.56 | $ 178.25 | $ 155.97 | $ 86.90 | $ 149.28 | $ 149.28 | ||
| Removal of growth (0.6 to 1.0 centimeters) of the trunk, arms, or legs | 11401 | 983 | $ 824.46 | $ 577.12 | $ 100.80 | $ 659.57 | $ 593.61 | $ 105.84 | $ 105.84 | $ 100.80 | $ 634.83 | $ 659.57 | $ 577.12 | $ 321.54 | $ 552.39 | $ 552.39 | ||
| Removal of growth (1.1 to 2.0 centimeters) of the trunk, arms, or legs | 11402 | 960 | $ 314.42 | $ 220.10 | $ 110.88 | $ 251.54 | $ 226.38 | $ 116.42 | $ 116.42 | $ 110.88 | $ 242.11 | $ 251.54 | $ 220.10 | $ 122.62 | $ 210.66 | $ 210.66 | ||
| Removal of growth (2.1 to 3.0 centimeters) of the trunk, arms, or legs | 11403 | 521 | $ 198.45 | $ 138.92 | $ 77.40 | $ 158.76 | $ 142.88 | $ 126.63 | $ 126.63 | $ 120.60 | $ 152.81 | $ 158.76 | $ 138.92 | $ 77.40 | $ 132.96 | $ 132.96 | ||
| Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs | 11404 | 983 | $ 254.10 | $ 177.87 | $ 99.10 | $ 1,415.43 | $ 182.95 | $ 1,415.43 | $ 1,415.43 | $ 1,348.03 | $ 195.66 | $ 203.28 | $ 177.87 | $ 99.10 | $ 170.25 | $ 170.25 | ||
| Removal of growth (0.5 centimeters or less) of the scalp, neck, hands, feet, or genitals | 11420 | 977 | $ 237.30 | $ 166.11 | $ 84.60 | $ 189.84 | $ 170.86 | $ 88.83 | $ 88.83 | $ 84.60 | $ 182.72 | $ 189.84 | $ 166.11 | $ 92.55 | $ 158.99 | $ 158.99 | ||
| Removal of growth (0.6 to 1.0 centimeters) of the scalp, neck, hands, feet, or genitals | 11421 | 983 | $ 166.95 | $ 116.87 | $ 65.11 | $ 133.56 | $ 120.20 | $ 106.22 | $ 106.22 | $ 101.16 | $ 128.55 | $ 133.56 | $ 116.87 | $ 65.11 | $ 111.86 | $ 111.86 | ||
| Removal of growth (1.1 to 2.0 centimeters) of the scalp, neck, hands, feet, or genitals | 11422 | 977 | $ 216.30 | $ 151.41 | $ 84.36 | $ 173.04 | $ 155.74 | $ 117.18 | $ 117.18 | $ 111.60 | $ 166.55 | $ 173.04 | $ 151.41 | $ 84.36 | $ 144.92 | $ 144.92 | ||
| Removal of growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals | 11423 | 983 | $ 210.00 | $ 147.00 | $ 81.90 | $ 168.00 | $ 151.20 | $ 127.01 | $ 127.01 | $ 120.96 | $ 161.70 | $ 168.00 | $ 147.00 | $ 81.90 | $ 140.70 | $ 140.70 | ||
| Removal of growth (3.1 to 4.0 centimeters) of the scalp, neck, hands, feet, or genitals | 11424 | 521 | $ 226.80 | $ 158.76 | $ 88.45 | $ 1,415.43 | $ 163.30 | $ 1,415.43 | $ 1,415.43 | $ 1,348.03 | $ 174.64 | $ 181.44 | $ 158.76 | $ 88.45 | $ 151.96 | $ 151.96 | ||
| Removal of malignant growth (0.5 centimeters or less) of the trunk, arms, or legs | 11600 | 521 | $ 176.40 | $ 123.48 | $ 68.80 | $ 141.12 | $ 127.01 | $ 137.97 | $ 137.97 | $ 131.40 | $ 135.83 | $ 141.12 | $ 123.48 | $ 68.80 | $ 118.19 | $ 118.19 | ||
| Removal of malignant growth (0.6 to 1.0 centimeters) of the trunk, arms, or legs | 11601 | 977 | $ 280.35 | $ 196.25 | $ 109.34 | $ 224.28 | $ 201.85 | $ 157.25 | $ 157.25 | $ 149.76 | $ 215.87 | $ 224.28 | $ 196.25 | $ 109.34 | $ 187.83 | $ 187.83 | ||
| Removal of malignant growth (1.1 to 2.0 centimeters) of the trunk, arms, or legs | 11602 | 977 | $ 475.65 | $ 332.96 | $ 161.28 | $ 380.52 | $ 342.47 | $ 169.34 | $ 169.34 | $ 161.28 | $ 366.25 | $ 380.52 | $ 332.96 | $ 185.50 | $ 318.69 | $ 318.69 | ||
| Removal of malignant growth (2.1 to 3.0 centimeters) of the trunk, arms, or legs | 11603 | 983 | $ 248.85 | $ 174.20 | $ 97.05 | $ 199.08 | $ 179.17 | $ 183.33 | $ 183.33 | $ 174.60 | $ 191.61 | $ 199.08 | $ 174.20 | $ 97.05 | $ 166.73 | $ 166.73 | ||
| Removal of malignant growth (3.1 to 4 centimeters) of the trunk, arms, or legs | 11604 | 521 | $ 226.80 | $ 158.76 | $ 88.45 | $ 601.49 | $ 163.30 | $ 601.49 | $ 601.49 | $ 572.85 | $ 174.64 | $ 181.44 | $ 158.76 | $ 88.45 | $ 151.96 | $ 151.96 | ||
| Removal of malignant growth (0.5 centimeters or less) of the scalp, neck, hands, feet, or genitals | 11620 | 521 | $ 159.60 | $ 111.72 | $ 62.24 | $ 138.73 | $ 114.91 | $ 138.73 | $ 138.73 | $ 132.12 | $ 122.89 | $ 127.68 | $ 111.72 | $ 62.24 | $ 106.93 | $ 106.93 | ||
| Removal of malignant growth (0.6 to 1.0 centimeters) of the scalp, neck, hands, feet, or genitals | 11621 | 521 | $ 193.20 | $ 135.24 | $ 75.35 | $ 157.63 | $ 139.10 | $ 157.63 | $ 157.63 | $ 150.12 | $ 148.76 | $ 154.56 | $ 135.24 | $ 75.35 | $ 129.44 | $ 129.44 | ||
| Removal of malignant growth (1.1 to 2.0 centimeters) of the scalp, neck, hands, feet, or genitals | 11622 | 983 | $ 236.25 | $ 165.38 | $ 92.14 | $ 189.00 | $ 170.10 | $ 171.99 | $ 171.99 | $ 163.80 | $ 181.91 | $ 189.00 | $ 165.38 | $ 92.14 | $ 158.29 | $ 158.29 | ||
| Removal of malignant growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals | 11623 | 521 | $ 255.15 | $ 178.61 | $ 99.51 | $ 204.12 | $ 183.71 | $ 188.62 | $ 188.62 | $ 179.64 | $ 196.47 | $ 204.12 | $ 178.61 | $ 99.51 | $ 170.95 | $ 170.95 | ||
| Removal of malignant growth (3.1 to 4 centimeters) of the scalp, neck, hands, feet, or genitals | 11624 | 521 | $ 263.55 | $ 184.49 | $ 102.78 | $ 1,415.43 | $ 189.76 | $ 1,415.43 | $ 1,415.43 | $ 1,348.03 | $ 202.93 | $ 210.84 | $ 184.49 | $ 102.78 | $ 176.58 | $ 176.58 | ||
| Removal of malignant growth (0.5 centimeters or less) of the face, ears, eyelids, nose, or lips | 11640 | 977 | $ 211.05 | $ 147.74 | $ 82.31 | $ 168.84 | $ 151.96 | $ 144.02 | $ 144.02 | $ 137.16 | $ 162.51 | $ 168.84 | $ 147.74 | $ 82.31 | $ 141.40 | $ 141.40 | ||
| Removal of malignant growth (0.6 to 1.0 centimeters) of the face, ears, eyelids, nose, or lips | 11641 | 521 | $ 216.30 | $ 151.41 | $ 84.36 | $ 173.04 | $ 155.74 | $ 162.16 | $ 162.16 | $ 154.44 | $ 166.55 | $ 173.04 | $ 151.41 | $ 84.36 | $ 144.92 | $ 144.92 | ||
| Removal of malignant growth (1.1 to 2.0 centimeters) of the face, ears, eyelids, nose, or lips | 11642 | 983 | $ 296.10 | $ 207.27 | $ 115.48 | $ 236.88 | $ 213.19 | $ 178.42 | $ 178.42 | $ 169.92 | $ 228.00 | $ 236.88 | $ 207.27 | $ 115.48 | $ 198.39 | $ 198.39 | ||
| Removal of malignant growth (2.1 to 3.0 centimeters) of the face, ears, eyelids, nose, or lips | 11643 | 521 | $ 295.05 | $ 206.54 | $ 115.07 | $ 236.04 | $ 212.44 | $ 195.43 | $ 195.43 | $ 186.12 | $ 227.19 | $ 236.04 | $ 206.54 | $ 115.07 | $ 197.68 | $ 197.68 | ||
| Removal of malignant growth (3.1 to 4.0 centimeters) of the face, ears, eyelids, nose, or lips | 11644 | 521 | $ 347.55 | $ 243.29 | $ 135.54 | $ 1,415.43 | $ 250.24 | $ 1,415.43 | $ 1,415.43 | $ 1,348.03 | $ 267.61 | $ 278.04 | $ 243.29 | $ 135.54 | $ 232.86 | $ 232.86 | ||
| Repair of finger or toe nail bed | 11760 | 981 | $ 313.01 | $ 219.10 | $ 122.07 | $ 512.61 | $ 225.36 | $ 512.61 | $ 512.61 | $ 488.20 | $ 241.01 | $ 250.40 | $ 219.10 | $ 122.07 | $ 209.71 | $ 209.71 | ||
| Removal of skin of finger or toe nail | 11765 | 983 | $ 373.80 | $ 261.66 | $ 145.78 | $ 326.34 | $ 269.14 | $ 326.34 | $ 326.34 | $ 310.80 | $ 287.83 | $ 299.04 | $ 261.66 | $ 145.78 | $ 250.45 | $ 250.45 | ||
| Biopsy of breast accessed through the skin with ultrasound guidance | 19083 | 361 | $ 5,285.18 | $ 3,699.62 | $ 1,348.03 | $ 4,228.14 | $ 3,805.33 | $ 1,415.43 | $ 1,415.43 | $ 1,348.03 | $ 4,069.58 | $ 4,228.14 | $ 3,699.62 | $ 2,061.22 | $ 3,541.07 | $ 3,541.07 | ||
| Needle biopsy of breast | 19100 | 983 | $ 205.80 | $ 144.06 | $ 80.26 | $ 1,415.43 | $ 148.18 | $ 1,415.43 | $ 1,415.43 | $ 1,348.03 | $ 158.47 | $ 164.64 | $ 144.06 | $ 80.26 | $ 137.89 | $ 137.89 | ||
| 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 | $ 100.80 | $ 70.56 | $ 24.12 | $ 80.64 | $ 72.58 | $ 25.33 | $ 25.33 | $ 24.12 | $ 77.62 | $ 80.64 | $ 70.56 | $ 39.31 | $ 67.54 | $ 67.54 | ||
| Biopsy of tissue of back or flank | 21920 | 521 | $ 246.75 | $ 172.73 | $ 96.23 | $ 197.40 | $ 177.66 | $ 185.98 | $ 185.98 | $ 177.12 | $ 190.00 | $ 197.40 | $ 172.73 | $ 96.23 | $ 165.32 | $ 165.32 | ||
| Drainage of fluid-filled sac (bursa) of upper arm or elbow | 23931 | 981 | $ 428.01 | $ 299.61 | $ 166.92 | $ 1,415.43 | $ 308.17 | $ 1,415.43 | $ 1,415.43 | $ 1,348.03 | $ 329.57 | $ 342.41 | $ 299.61 | $ 166.92 | $ 286.77 | $ 286.77 | ||
| Closed treatment of knee dislocation | 27550 | 521 | $ 663.60 | $ 464.52 | $ 214.90 | $ 530.88 | $ 477.79 | $ 225.65 | $ 225.65 | $ 214.90 | $ 510.97 | $ 530.88 | $ 464.52 | $ 258.80 | $ 444.61 | $ 444.61 | ||
| 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 | $ 247.01 | $ 172.91 | $ 96.33 | $ 643.20 | $ 177.85 | $ 643.20 | $ 643.20 | $ 612.57 | $ 190.20 | $ 197.61 | $ 172.91 | $ 96.33 | $ 165.50 | $ 165.50 | ||
| Removal of fluid from chest cavity with imaging guidance | 32555 | 361 | $ 1,853.67 | $ 1,297.57 | $ 612.57 | $ 1,482.94 | $ 1,334.64 | $ 643.20 | $ 643.20 | $ 612.57 | $ 1,427.33 | $ 1,482.94 | $ 1,297.57 | $ 722.93 | $ 1,241.96 | $ 1,241.96 | ||
| Transfusion of blood or blood products | 36430 | 391 | $ 868.35 | $ 607.85 | $ 35.28 | $ 694.68 | $ 625.21 | $ 37.04 | $ 37.04 | $ 35.28 | $ 668.63 | $ 694.68 | $ 607.85 | $ 338.66 | $ 581.79 | $ 581.79 | ||
| Diagnostic bone marrow aspiration | 38220 | 310 | $ 2,022.30 | $ 1,415.61 | $ 124.56 | $ 1,617.84 | $ 1,456.06 | $ 130.79 | $ 130.79 | $ 124.56 | $ 1,557.17 | $ 1,617.84 | $ 1,415.61 | $ 788.70 | $ 1,354.94 | $ 1,354.94 | ||
| Bone marrow biopsy | 38221 | 521 | $ 1,011.47 | $ 708.03 | $ 107.64 | $ 809.17 | $ 728.25 | $ 113.02 | $ 113.02 | $ 107.64 | $ 778.83 | $ 809.17 | $ 708.03 | $ 394.47 | $ 677.68 | $ 677.68 | ||
| 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 | $ 1,086.54 | $ 760.58 | $ 423.75 | $ 869.23 | $ 782.31 | $ 745.48 | $ 745.48 | $ 709.98 | $ 836.64 | $ 869.23 | $ 760.58 | $ 423.75 | $ 727.98 | $ 727.98 | |
| Professional Fee (Anesthesia) | 45378 | 521 | $ 2,828.70 | $ 1,980.09 | $ 1,103.19 | $ 2,262.96 | $ 2,036.66 | $ 2,178.10 | $ 2,262.96 | $ 1,980.09 | $ 1,103.19 | $ 1,895.23 | $ 1,895.23 | |||||
| Additional Professional Fee | 45378 | $ 542.19 | $ 379.54 | $ 211.46 | $ 433.76 | $ 390.38 | $ 417.49 | $ 433.76 | $ 379.54 | $ 211.46 | $ 363.27 | $ 363.27 | ||||||
| Biopsy of large bowel using an endoscope | Biopsy of large bowel using an endoscope | 45380 | 521 | $ 3,577.61 | $ 2,504.33 | $ 936.39 | $ 2,862.09 | $ 2,575.88 | $ 983.21 | $ 983.21 | $ 936.39 | $ 2,754.76 | $ 2,862.09 | $ 2,504.33 | $ 1,395.27 | $ 2,397.00 | $ 2,397.00 | |
| Professional Fee (Anesthesia) | 45380 | 521 | $ 3,156.30 | $ 2,209.41 | $ 1,230.96 | $ 2,525.04 | $ 2,272.54 | $ 2,430.35 | $ 2,525.04 | $ 2,209.41 | $ 1,230.96 | $ 2,114.72 | $ 2,114.72 | |||||
| Additional Professional Fee | 45380 | $ 481.95 | $ 337.37 | $ 187.96 | $ 385.56 | $ 347.00 | $ 371.10 | $ 385.56 | $ 337.37 | $ 187.96 | $ 322.91 | $ 322.91 | ||||||
| Biopsy of large bowel using an endoscope | Removal of polyps or growths of large bowel using an endoscope | 45385 | 521 | $ 4,984.81 | $ 3,489.37 | $ 936.39 | $ 3,987.85 | $ 3,589.06 | $ 983.21 | $ 983.21 | $ 936.39 | $ 3,838.31 | $ 3,987.85 | $ 3,489.37 | $ 1,944.08 | $ 3,339.82 | $ 3,339.82 | |
| Professional Fee (Anesthesia) | 45385 | 521 | $ 3,249.75 | $ 2,274.83 | $ 1,267.40 | $ 2,599.80 | $ 2,339.82 | $ 2,502.31 | $ 2,599.80 | $ 2,274.83 | $ 1,267.40 | $ 2,177.33 | $ 2,177.33 | |||||
| Additional Professional Fee | 45385 | $ 623.29 | $ 436.30 | $ 243.08 | $ 498.63 | $ 448.77 | $ 479.93 | $ 498.63 | $ 436.30 | $ 243.08 | $ 417.60 | $ 417.60 | ||||||
| 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 | $ 307.37 | $ 215.16 | $ 119.87 | $ 245.89 | $ 221.30 | $ 127.76 | $ 127.76 | $ 121.68 | $ 236.67 | $ 245.89 | $ 215.16 | $ 119.87 | $ 205.94 | $ 205.94 | ||
| 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 | $ 311.85 | $ 218.30 | $ 121.62 | $ 1,780.46 | $ 224.53 | $ 1,780.46 | $ 1,780.46 | $ 1,695.68 | $ 240.12 | $ 249.48 | $ 218.30 | $ 121.62 | $ 208.94 | $ 208.94 | ||
| Removal of foreskin, neonate (28 days of age or less) | 54160 | 521 | $ 337.05 | $ 235.94 | $ 165.15 | $ 115.61 | $ 242.68 | $ 1,780.46 | $ 1,780.46 | $ 1,695.68 | $ 259.53 | $ 269.64 | $ 235.94 | $ 131.45 | $ 225.82 | $ 225.82 | ||
| 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 | $ 38.22 | $ 26.75 | $ 14.91 | $ 58.76 | $ 27.52 | $ 58.76 | $ 58.76 | $ 55.96 | $ 29.43 | $ 30.58 | $ 26.75 | $ 14.91 | $ 25.61 | $ 25.61 | ||
| Removal of impact ear wax, one ear | 69210 | 521 | $ 89.96 | $ 62.97 | $ 35.09 | $ 71.97 | $ 64.77 | $ 58.76 | $ 58.76 | $ 55.96 | $ 69.27 | $ 71.97 | $ 62.97 | $ 35.09 | $ 60.28 | $ 60.28 | ||
| Administration of 1 vaccine | 90471 | 521 | $ 69.62 | $ 48.73 | $ 27.15 | $ 134.44 | $ 50.12 | $ 134.44 | $ 134.44 | $ 134.44 | $ 53.60 | $ 55.69 | $ 48.73 | $ 27.15 | $ 46.64 | $ 46.64 | ||
| Vaccine for human papilloma virus (3 dose schedule) injection into muscle | 90649 | 521 | $ 221.55 | $ 155.09 | $ 86.40 | $ 177.24 | $ 159.52 | $ - | $ - | $ - | $ 170.59 | $ 177.24 | $ 155.09 | $ 86.40 | $ 148.44 | $ 148.44 | ||
| Vaccine for measles, mumps, and rubella (German measles) injection beneath skin | 90707 | 521 | $ 67.20 | $ 47.04 | $ 26.21 | $ 53.76 | $ 48.38 | $ - | $ - | $ - | $ 51.74 | $ 53.76 | $ 47.04 | $ 26.21 | $ 45.02 | $ 45.02 | ||
| Vaccine for tetanus, diphtheria toxoids and acellular pertussis (whooping cough) for injection into muscle, patient 7 years or older | 90715 | 521 | $ 51.45 | $ 36.02 | $ 20.07 | $ 41.16 | $ 37.04 | $ - | $ - | $ - | $ 39.62 | $ 41.16 | $ 36.02 | $ 20.07 | $ 34.47 | $ 34.47 | ||
| Behavioral and qualitative analysis of voice and resonance | 92524 | 440 | $ 189.00 | $ 132.30 | $ 73.71 | $ 206.42 | $ 136.08 | $ 206.42 | $ 206.42 | $ 206.42 | $ 145.53 | $ 151.20 | $ 132.30 | $ 73.71 | $ 126.63 | $ 126.63 | ||
| 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 | $ 342.62 | $ 239.83 | $ 129.27 | $ 274.09 | $ 246.68 | $ 129.27 | $ 129.27 | $ 129.27 | $ 263.81 | $ 274.09 | $ 239.83 | $ 133.62 | $ 229.55 | $ 229.55 | ||
| 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 | $ 849.45 | $ 594.62 | $ 314.90 | $ 679.56 | $ 611.60 | $ 314.90 | $ 314.90 | $ 314.90 | $ 654.08 | $ 679.56 | $ 594.62 | $ 331.29 | $ 569.13 | $ 569.13 | ||
| Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen | 94640 | 521 | $ 281.40 | $ 196.98 | $ 109.75 | $ 430.54 | $ 202.61 | $ 430.54 | $ 430.54 | $ 430.54 | $ 216.68 | $ 225.12 | $ 196.98 | $ 109.75 | $ 188.54 | $ 188.54 | ||
| Measurement of oxygen saturation in blood using ear or finger device | 94760 | 521 | $ 91.46 | $ 64.02 | $ 6.63 | $ 73.16 | $ 65.85 | $ 6.63 | $ 6.63 | $ 6.63 | $ 70.42 | $ 73.16 | $ 64.02 | $ 35.67 | $ 61.27 | $ 61.27 | ||
| Sleep monitoring of patient (6 years or older) in sleep lab | 95810 | 920 | $ 2,123.10 | $ 1,486.17 | $ 828.01 | $ 1,698.48 | $ 1,528.63 | $ 1,184.68 | $ 1,184.68 | $ 1,184.68 | $ 1,634.79 | $ 1,698.48 | $ 1,486.17 | $ 828.01 | $ 1,422.48 | $ 1,422.48 | ||
| Hydration infusion into a vein 31 minutes to 1 hour | 96360 | 260 | $ 491.34 | $ 343.94 | $ 109.42 | $ 393.07 | $ 353.76 | $ 109.42 | $ 109.42 | $ 109.42 | $ 378.33 | $ 393.07 | $ 343.94 | $ 191.62 | $ 329.20 | $ 329.20 | ||
| Infusion into a vein for therapy, prevention, or diagnosis up to 1 hour | 96365 | 260 | $ 214.31 | $ 150.01 | $ 83.58 | $ 171.44 | $ 154.30 | $ 170.78 | $ 170.78 | $ 170.78 | $ 165.01 | $ 171.44 | $ 150.01 | $ 83.58 | $ 143.58 | $ 143.58 | ||
| Infusion into a vein for therapy, prevention, or diagnosis | 96366 | 260 | $ 182.91 | $ 128.04 | $ 51.40 | $ 146.33 | $ 131.70 | $ 51.40 | $ 51.40 | $ 51.40 | $ 140.84 | $ 146.33 | $ 128.04 | $ 71.33 | $ 122.55 | $ 122.55 | ||
| Injection of drug or substance into a vein for therapy, diagnosis, or prevention | 96374 | 940 | $ 491.34 | $ 343.94 | $ 108.59 | $ 393.07 | $ 353.76 | $ 108.59 | $ 108.59 | $ 108.59 | $ 378.33 | $ 393.07 | $ 343.94 | $ 191.62 | $ 329.20 | $ 329.20 | ||
| Injection of different drug or substance into a vein for therapy, diagnosis, or prevention | 96375 | 940 | $ 167.90 | $ 117.53 | $ 42.27 | $ 134.32 | $ 120.88 | $ 42.27 | $ 42.27 | $ 42.27 | $ 129.28 | $ 134.32 | $ 117.53 | $ 65.48 | $ 112.49 | $ 112.49 | ||
| Application of ultrasound to 1 or more areas, each 15 minutes | 97035 | 420 | $ 71.40 | $ 49.98 | $ 27.85 | $ 57.12 | $ 51.41 | $ 31.51 | $ 31.51 | $ 31.51 | $ 54.98 | $ 57.12 | $ 49.98 | $ 27.85 | $ 47.84 | $ 47.84 | ||
| Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes | 97110 | 420 | $ 77.81 | $ 54.46 | $ 30.34 | $ 72.12 | $ 56.02 | $ 72.12 | $ 72.12 | $ 72.12 | $ 59.91 | $ 62.24 | $ 54.46 | $ 30.34 | $ 52.13 | $ 52.13 | ||
| Walking training to 1 or more areas, each 15 minutes | 97116 | 420 | $ 61.43 | $ 43.00 | $ 23.96 | $ 71.29 | $ 44.23 | $ 71.29 | $ 71.29 | $ 71.29 | $ 47.30 | $ 49.14 | $ 43.00 | $ 23.96 | $ 41.15 | $ 41.15 | ||
| Evaluation of physical therapy, typically 30 minutes | 97162 | 424 | $ 191.10 | $ 133.77 | $ 74.53 | $ 197.32 | $ 137.59 | $ 197.32 | $ 197.32 | $ 197.32 | $ 147.15 | $ 152.88 | $ 133.77 | $ 74.53 | $ 128.04 | $ 128.04 | ||
| Evaluation of occupational therapy, typically 45 minutes | 97166 | 434 | $ 191.10 | $ 133.77 | $ 74.53 | $ 213.05 | $ 137.59 | $ 213.05 | $ 213.05 | $ 213.05 | $ 147.15 | $ 152.88 | $ 133.77 | $ 74.53 | $ 128.04 | $ 128.04 | ||
| Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes | 97530 | 420 | $ 72.35 | $ 50.64 | $ 28.21 | $ 95.33 | $ 52.09 | $ 95.33 | $ 95.33 | $ 95.33 | $ 55.71 | $ 57.88 | $ 50.64 | $ 28.21 | $ 48.47 | $ 48.47 | ||
| Removal of tissue from wounds per session | 97602 | 521 | $ 371.18 | $ 259.82 | $ 144.76 | $ 390.27 | $ 267.25 | $ 390.27 | $ 390.27 | $ 390.27 | $ 285.80 | $ 296.94 | $ 259.82 | $ 144.76 | $ 248.69 | $ 248.69 | ||
| Negative pressure wound therapy, surface area less than or equal to 50 square centimeters, per session | 97605 | 761 | $ 532.35 | $ 372.65 | $ 207.62 | $ 425.88 | $ 383.29 | $ 390.27 | $ 390.27 | $ 390.27 | $ 409.91 | $ 425.88 | $ 372.65 | $ 207.62 | $ 356.67 | $ 356.67 | ||
| Removal of skin and tissue first 20 sq cm or less | 11042 | 270 | $ 2,199.05 | $ 1,539.33 | $ 310.80 | $ 1,759.24 | $ 1,583.31 | $ 326.34 | $ 326.34 | $ 310.80 | $ 1,693.27 | $ 1,759.24 | $ 1,539.33 | $ 857.63 | $ 1,473.36 | $ 1,473.36 | ||
| Hernia Plug/Patch | C1781 | 278 | $ 963.90 | $ 674.73 | $ 375.92 | $ 771.12 | $ 694.01 | $ - | $ - | $ - | $ 742.20 | $ 771.12 | $ 674.73 | $ 375.92 | $ 645.81 | $ 645.81 | ||
| Exparel 266Mg Vial | C9290 | 636 | $ 1.58 | $ 1.10 | $ 0.61 | $ 1.26 | $ 1.13 | N/A | N/A | N/A | $ 1.21 | $ 1.26 | $ 1.10 | $ 0.61 | $ 1.06 | $ 1.06 | ||
| Diabetes self-management, individual | G0108 | 942 | $ 96.60 | $ 67.62 | $ 37.67 | $ 125.18 | $ 69.55 | $ 125.18 | $ 125.18 | $ 125.18 | $ 74.38 | $ 77.28 | $ 67.62 | $ 37.67 | $ 64.72 | $ 64.72 | ||
| Diabetes self-management, group | G0109 | 942 | $ 52.50 | $ 36.75 | $ 20.48 | $ 42.00 | $ 37.80 | $ 33.98 | $ 33.98 | $ 33.98 | $ 40.43 | $ 42.00 | $ 36.75 | $ 20.48 | $ 35.18 | $ 35.18 | ||
| Observation | G0378 | 762 | $ 39.59 | $ 27.71 | $ 15.44 | $ 292.65 | $ 28.50 | $ 292.65 | $ 292.65 | $ 292.65 | $ 30.48 | $ 31.67 | $ 27.71 | $ 15.44 | $ 26.52 | $ 26.52 | ||
| Cefazolin 1Gm Via | J0690 | 636 | $ 0.63 | $ 0.44 | $ 0.25 | $ 0.50 | $ 0.45 | $ 0.40 | $ 0.40 | $ 0.40 | $ 0.49 | $ 0.50 | $ 0.44 | $ 0.25 | $ 0.42 | $ 0.42 | ||
| Ceftriaxone 1Gm Vial | J0696 | 636 | $ 42.00 | $ 29.40 | $ 6.33 | $ 33.60 | $ 30.24 | $ 6.33 | $ 6.33 | $ 6.33 | $ 32.34 | $ 33.60 | $ 29.40 | $ 16.38 | $ 28.14 | $ 28.14 | ||
| Primaxin 500Mg Vial | J0743 | 636 | $ 12.60 | $ 8.82 | $ 4.91 | $ 11.23 | $ 9.07 | $ 11.23 | $ 11.23 | $ 11.23 | $ 9.70 | $ 10.08 | $ 8.82 | $ 4.91 | $ 8.44 | $ 8.44 | ||
| Dexamethasone 10Mg/Ml 1 Ml | J1094 | 636 | $ 0.16 | $ 0.11 | $ 0.06 | $ 0.13 | $ 0.11 | $ 0.12 | $ 0.13 | $ 0.11 | $ 0.06 | $ 0.11 | $ 0.11 | |||||
| Dexamethasone 4Mg/1Ml Vial | J1100 | 636 | $ 0.49 | $ 0.35 | $ 0.08 | $ 0.39 | $ 0.36 | $ 0.08 | $ 0.08 | $ 0.08 | $ 0.38 | $ 0.39 | $ 0.35 | $ 0.19 | $ 0.33 | $ 0.33 | ||
| Heparin Lock Flush 300Units/3Ml | J1642 | 636 | $ 0.02 | $ 0.01 | $ 0.01 | $ 0.05 | $ 0.02 | $ 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 | $ 0.04 | $ 0.04 | ||
| Heparin Flush 10,000 Units/Ml | J1642 | 636 | $ 0.02 | $ 0.01 | $ 0.01 | $ 0.05 | $ 0.02 | $ 0.05 | $ 0.05 | $ 0.05 | $ 0.02 | $ 0.02 | $ 0.01 | $ 0.01 | $ 0.01 | $ 0.01 | ||
| Lovenox 40Mg Syringe | J1650 | 636 | $ 1.21 | $ 0.85 | $ 0.47 | $ 0.97 | $ 0.87 | $ 0.68 | $ 0.68 | $ 0.68 | $ 0.93 | $ 0.97 | $ 0.85 | $ 0.47 | $ 0.81 | $ 0.81 | ||
| Humalog 100 Units/1Ml | J1815 | 637 | $ 0.24 | $ 0.17 | $ 0.09 | $ 0.35 | $ 0.17 | $ 0.35 | $ 0.35 | $ 0.35 | $ 0.19 | $ 0.19 | $ 0.17 | $ 0.09 | $ 0.16 | $ 0.16 | ||
| Humulin R Per 5 Units | J1815 | 637 | $ 0.26 | $ 0.18 | $ 0.10 | $ 0.35 | $ 0.19 | $ 0.35 | $ 0.35 | $ 0.35 | $ 0.20 | $ 0.21 | $ 0.18 | $ 0.10 | $ 0.18 | $ 0.18 | ||
| Ketorolac Tromethamine 60Mg Vial | J1885 | 636 | $ 0.26 | $ 0.18 | $ 0.10 | $ 0.55 | $ 0.19 | $ 0.55 | $ 0.55 | $ 0.55 | $ 0.20 | $ 0.21 | $ 0.18 | $ 0.10 | $ 0.18 | $ 0.18 | ||
| Ketorolac Trometh 30Mg/Ml Vial | J1885 | 636 | $ 0.47 | $ 0.33 | $ 0.18 | $ 0.55 | $ 0.34 | $ 0.55 | $ 0.55 | $ 0.55 | $ 0.36 | $ 0.38 | $ 0.33 | $ 0.18 | $ 0.32 | $ 0.32 | ||
| Furosemide 40Mg Vial | J1940 | 636 | $ 0.63 | $ 0.44 | $ 0.25 | $ 4.13 | $ 0.45 | $ 4.13 | $ 4.13 | $ 4.13 | $ 0.49 | $ 0.50 | $ 0.44 | $ 0.25 | $ 0.42 | $ 0.42 | ||
| Meropen 1Gm Vial | J2185 | 637 | $ 0.74 | $ 0.51 | $ 0.29 | $ 6.90 | $ 0.53 | $ 6.90 | $ 6.90 | $ 6.90 | $ 0.57 | $ 0.59 | $ 0.51 | $ 0.29 | $ 0.49 | $ 0.49 | ||
| Ondamsetron 4Mg/2Ml Vial | J2405 | 636 | $ 0.08 | $ 0.06 | $ 0.03 | $ 1.48 | $ 0.06 | $ 1.48 | $ 1.48 | $ 1.48 | $ 0.06 | $ 0.07 | $ 0.06 | $ 0.03 | $ 0.06 | $ 0.06 | ||
| Zosyn 3.375Gm | J2543 | 636 | $ 1.31 | $ 0.92 | $ 0.51 | $ 6.40 | $ 0.95 | $ 6.40 | $ 6.40 | $ 6.40 | $ 1.01 | $ 1.05 | $ 0.92 | $ 0.51 | $ 0.88 | $ 0.88 | ||
| Propofol 200Mg Per 20Ml | J2704 | 636 | $ 0.11 | $ 0.07 | $ 0.04 | $ 0.18 | $ 0.08 | $ 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 | $ 6.14 | $ 4.30 | $ 2.40 | $ 8.65 | $ 4.42 | $ 8.65 | $ 8.65 | $ 8.65 | $ 4.73 | $ 4.91 | $ 4.30 | $ 2.40 | $ 4.12 | $ 4.12 | ||
| Kenalog 40Mg/Ml | J3301 | 636 | $ 2.17 | $ 1.52 | $ 0.85 | $ 4.28 | $ 1.56 | $ 4.28 | $ 4.28 | $ 4.28 | $ 1.67 | $ 1.74 | $ 1.52 | $ 0.85 | $ 1.46 | $ 1.46 | ||
| Vancomycin Hcl 1000Mg Vial | J3370 | 636 | $ 2.10 | $ 1.47 | $ 0.82 | $ 11.18 | $ 1.51 | $ 11.18 | $ 11.18 | $ 11.18 | $ 1.62 | $ 1.68 | $ 1.47 | $ 0.82 | $ 1.41 | $ 1.41 | ||
| Vancomycin 500Mg Vial | J3370 | 636 | $ 3.05 | $ 2.13 | $ 1.19 | $ 11.18 | $ 2.19 | $ 11.18 | $ 11.18 | $ 11.18 | $ 2.34 | $ 2.44 | $ 2.13 | $ 1.19 | $ 2.04 | $ 2.04 | ||
| Albuterol Sulfate Inhal Solu 2.5Mg/3Ml | J7613 | 636 | $ 0.06 | $ 0.04 | $ 0.02 | $ 0.20 | $ 0.05 | $ 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 | $ 0.53 | $ 0.37 | $ 0.20 | $ 3.70 | $ 0.38 | $ 3.70 | $ 3.70 | $ 3.70 | $ 0.40 | $ 0.42 | $ 0.37 | $ 0.20 | $ 0.35 | $ 0.35 | ||
| Budesonide Inhal Susp 0.5Mg/2Ml | J7626 | 636 | $ 2.73 | $ 1.91 | $ 1.06 | $ 15.95 | $ 1.97 | $ 15.95 | $ 15.95 | $ 15.95 | $ 2.10 | $ 2.18 | $ 1.91 | $ 1.06 | $ 1.83 | $ 1.83 | ||
| Ipratropium Bromide Solu 0.5Mg/2.5Ml | J7644 | 636 | $ 0.16 | $ 0.11 | $ 0.06 | $ 1.28 | $ 0.11 | $ 1.28 | $ 1.28 | $ 1.28 | $ 0.12 | $ 0.13 | $ 0.11 | $ 0.06 | $ 0.11 | $ 0.11 | ||
| 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 | $ 887.25 | $ 621.08 | $ 346.03 | $ 709.80 | $ 638.82 | $ 683.18 | $ 709.80 | $ 621.08 | $ 346.03 | $ 594.46 | $ 594.46 | ||||||
| Semi-private hospital room | 120 | $ 1,182.30 | $ 827.61 | $ 461.10 | $ 945.84 | $ 851.26 | $ 910.37 | $ 945.84 | $ 827.61 | $ 461.10 | $ 792.14 | $ 792.14 | ||||||
| Private hospital room | 110 | $ 1,204.35 | $ 843.05 | $ 469.70 | $ 963.48 | $ 867.13 | $ 927.35 | $ 963.48 | $ 843.05 | $ 469.70 | $ 806.91 | $ 806.91 | ||||||
| Swing bed, private | 110 | $ 1,045.80 | $ 732.06 | $ 407.86 | $ 836.64 | $ 752.98 | $ 805.27 | $ 836.64 | $ 732.06 | $ 407.86 | $ 700.69 | $ 700.69 | ||||||
| Sodium Chloride For Injection | 250 | $ 0.42 | $ 0.29 | $ 0.16 | $ 0.34 | $ 0.30 | $ 0.32 | $ 0.34 | $ 0.29 | $ 0.16 | $ 0.28 | $ 0.28 | ||||||
| Acetaminophen 325Mg Ud Tablets | 637 | $ 0.03 | $ 0.02 | $ 0.01 | $ 0.03 | $ 0.02 | $ 0.02 | $ 0.03 | $ 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 | $ 0.32 | $ 0.22 | $ 0.12 | $ 0.25 | $ 0.23 | $ 0.24 | $ 0.25 | $ 0.22 | $ 0.12 | $ 0.21 | $ 0.21 | ||||||
| Sucralfate 1Gm Tablet | 637 | $ 0.24 | $ 0.17 | $ 0.09 | $ 0.19 | $ 0.17 | $ 0.19 | $ 0.19 | $ 0.17 | $ 0.09 | $ 0.16 | $ 0.16 | ||||||
| Xylocaine 1% Mdv 5Ml | 250 | $ 0.37 | $ 0.26 | $ 0.14 | $ 0.29 | $ 0.26 | $ 0.28 | $ 0.29 | $ 0.26 | $ 0.14 | $ 0.25 | $ 0.25 | ||||||
| Pantoprazole Dr 40Mg Tablet | 637 | $ 0.16 | $ 0.11 | $ 0.06 | $ 0.13 | $ 0.11 | $ 0.12 | $ 0.13 | $ 0.11 | $ 0.06 | $ 0.11 | $ 0.11 | ||||||
| Lisinopril U D 20Mg Tabs | 637 | $ 0.05 | $ 0.04 | $ 0.02 | $ 0.04 | $ 0.04 | $ 0.04 | $ 0.04 | $ 0.04 | $ 0.02 | $ 0.04 | $ 0.04 | ||||||
| Clindamycin Capsule 150 Mg | 637 | $ 0.08 | $ 0.06 | $ 0.03 | $ 0.07 | $ 0.06 | $ 0.06 | $ 0.07 | $ 0.06 | $ 0.03 | $ 0.06 | $ 0.06 | ||||||
| Lidocaine Hcl/Pf Vial 2% 20Mg/Ml 5Ml | 250 | $ 3.47 | $ 2.43 | $ 1.35 | $ 2.77 | $ 2.49 | $ 2.67 | $ 2.77 | $ 2.43 | $ 1.35 | $ 2.32 | $ 2.32 | ||||||
| Major surgery between two hundred eleven minutes and two hundred fourty minutes | 360 | $ 10,056.90 | $ 7,039.83 | $ 3,922.19 | $ 8,045.52 | $ 7,240.97 | $ 7,743.81 | $ 8,045.52 | $ 7,039.83 | $ 3,922.19 | $ 6,738.12 | $ 6,738.12 | ||||||
| Major surgery, more than two hundred fourty-one minutes | 360 | $ 11,030.25 | $ 7,721.18 | $ 4,301.80 | $ 8,824.20 | $ 7,941.78 | $ 8,493.29 | $ 8,824.20 | $ 7,721.18 | $ 4,301.80 | $ 7,390.27 | $ 7,390.27 | ||||||
| Hernia Tacker | 270 | $ 68.25 | $ 47.78 | $ 26.62 | $ 54.60 | $ 49.14 | $ 52.55 | $ 54.60 | $ 47.78 | $ 26.62 | $ 45.73 | $ 45.73 | ||||||
| Gel foam, large | 270 | $ 51.45 | $ 36.02 | $ 20.07 | $ 41.16 | $ 37.04 | $ 39.62 | $ 41.16 | $ 36.02 | $ 20.07 | $ 34.47 | $ 34.47 | ||||||
| Cytostomy catheter | 270 | $ 157.50 | $ 110.25 | $ 61.43 | $ 126.00 | $ 113.40 | $ 121.28 | $ 126.00 | $ 110.25 | $ 61.43 | $ 105.53 | $ 105.53 | ||||||
| Meniscus Cutter Or Burr | 270 | $ 187.95 | $ 131.57 | $ 73.30 | $ 150.36 | $ 135.32 | $ 144.72 | $ 150.36 | $ 131.57 | $ 73.30 | $ 125.93 | $ 125.93 | ||||||
| Op Recovery Room | 710 | $ 292.95 | $ 205.07 | $ 114.25 | $ 234.36 | $ 210.92 | $ 225.57 | $ 234.36 | $ 205.07 | $ 114.25 | $ 196.28 | $ 196.28 | ||||||
| Recovery Room Day Surgery | 710 | $ 418.95 | $ 293.27 | $ 163.39 | $ 335.16 | $ 301.64 | $ 322.59 | $ 335.16 | $ 293.27 | $ 163.39 | $ 280.70 | $ 280.70 | ||||||
| Recovery Room | 710 | $ 368.55 | $ 257.99 | $ 143.73 | $ 294.84 | $ 265.36 | $ 283.78 | $ 294.84 | $ 257.99 | $ 143.73 | $ 246.93 | $ 246.93 | ||||||
| Angio Dynamics Smart Port | 278 | $ 4,254.60 | $ 2,978.22 | $ 1,659.29 | $ 3,403.68 | $ 3,063.31 | $ 3,276.04 | $ 3,403.68 | $ 2,978.22 | $ 1,659.29 | $ 2,850.58 | $ 2,850.58 | ||||||
| Alexis Wound Protector | 270 | $ 225.75 | $ 158.03 | $ 88.04 | $ 180.60 | $ 162.54 | $ 173.83 | $ 180.60 | $ 158.03 | $ 88.04 | $ 151.25 | $ 151.25 | ||||||
| Fogarty | 270 | $ 278.25 | $ 194.78 | $ 108.52 | $ 222.60 | $ 200.34 | $ 214.25 | $ 222.60 | $ 194.78 | $ 108.52 | $ 186.43 | $ 186.43 | ||||||
| Carter Thompson | 270 | $ 438.90 | $ 307.23 | $ 171.17 | $ 351.12 | $ 316.01 | $ 337.95 | $ 351.12 | $ 307.23 | $ 171.17 | $ 294.06 | $ 294.06 | ||||||
| Gelport | 270 | $ 2,390.85 | $ 1,673.60 | $ 932.43 | $ 1,912.68 | $ 1,721.41 | $ 1,840.95 | $ 1,912.68 | $ 1,673.60 | $ 932.43 | $ 1,601.87 | $ 1,601.87 | ||||||