Salem Health Pricing


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Salem Hospital Pricing

PROCEDURE NAME
REVENUE ID
CPT CODE
COST
17 HYDROXYPROGESTERONE  
0301  
83498  
$93.00  
2D TEE W OR W/O FOL W/CONTRAST  
0483  
C8925  
$1,960.00  
2D TTE W OR W/O FOL W/CONTRAST, FU  
0483  
C8924  
$1,396.00  
2HR GLUCOSE TOLERANCE  
0301  
82951  
$132.00  
2ND THROMB/LYSIS NON PRIM  
0360  
37186  
$5,382.00  
3D MAPPING, INTRACARDIAC EP  
0480  
93613  
$6,889.00  
3D RENDERING NOT REQUIRING WORKSTATIO  
0350  
76376  
$721.00  
3D RENDERING REQUIRING WORKSTATION  
0350  
76377  
$768.00  
3D TREATMENT PLANNING, INC DOSE-VOLUME HISTOGRAMS  
0333  
77295  
$4,810.00  
41FR BRONCHO CATH - LEFT (422040)  
0270  
 
$133.00  
AB BARTONELLA  
0306  
86611  
$72.00  
AB SCREEN  
0300  
86850  
$132.00  
ABCESS/CYST CONTRAST INJECT  
0360  
49424  
$340.00  
ABDOM/PELVIC/LWR EXTRM ART 1ST  
0360  
36245  
$1,406.00  
ABDOM/PELVIC/LWR EXTRM ART 2ND  
0360  
36246  
$1,570.00  
ABDOM/PELVIC/LWR EXTRM ART 3RD  
0360  
36247  
$1,874.00  
ABDOMINAL AORTOGRAM - ANG  
0320  
75625  
$6,294.00  
ABDOMINAL AORTOGRAM W/RUN OFF  
0320  
75630  
$6,294.00  
ABLATE ARRHYTHMIA ADD ON  
0481  
93655  
$7,283.00  
ABLATION AV NODE +/- TEMP PACE  
0480  
93650  
$6,839.00  
ABLATION,RENAL TUMOR,PERC,UNILAT,CRYOTHERAPY  
0360  
50593  
$6,464.00  
ABO TYPING  
0300  
86900  
$109.00  
ACCUCATH 20G 1.25 BASIC (AC0201250)  
0272  
 
$61.00  
ACCUCATH 20G 2.26 BASIC (AC0202250)  
0272  
 
$116.00  
ACID FAST CULTURE  
0306  
87116  
$152.00  
ACID FAST STAIN  
0306  
87206  
$78.00  
ACT NEEDLE 18X11  
0270  
 
$129.00  
ACT NEEDLE 18X15  
0270  
 
$133.00  
ACT NEEDLE 18X20  
0272  
 
$146.00  
ACT NEEDLE 20X11  
0272  
 
$141.00  
ACT NEEDLE 20X15  
0272  
 
$155.00  
ACT NEEDLE 20X20  
0272  
 
$166.00  
ACTH  
0301  
82024  
$134.00  
ACTIVATED PROTEIN C RESISTANCE RATION  
0300  
85307  
$92.00  
ACUTE HEMODIALYSIS  
0800  
G0257  
$1,282.00  
ACUTE HEPATITIS PANEL  
0301  
80074  
$369.00  
ADDL 2ND,3RD ORDER +INVAS FMLY  
0360  
36218  
$309.00  
ADDL ABDOM/PLVC/LWR EXTRM ART  
0360  
36248  
$286.00  
ADMIN VACCINE-IMMUNIZATION-ONE VACCINE  
0771  
G0008  
$97.00  
AEROBIC IDENTIFICATION  
0306  
87077  
$56.00  
AFP TO SERUM TO ESOTERIX GENZYME  
0301  
82105  
$65.00  
AG DETECT NOS EIA MULTI STEP EACH ORGANISM  
0306  
87449  
$139.00  
AIGIS-DEFIBRILLATOR  
0272  
 
Variable  
AIRWAY RESISTANCE BY IMPULSE OSCILLOMETRY  
0460  
94728  
$577.00  
ALBUMIN ASSAY  
0301  
82042  
$25.00  
ALBUMIN, SERUM  
0301  
82040  
$25.00  
ALCOHOL BIOMARKERS 1 OR 2 (ETHYL GLUCURONIDE)  
0301  
80321  
$124.00  
ALDOLASE ASSAY  
0301  
82085  
$70.00  
ALDOSTERONE ASSAY  
0301  
82088  
$136.00  
ALKALINE PHOSPHATASE  
0301  
84075  
$27.00  
ALKALINE PHOSPHATASE ISOENZYME  
0301  
84080  
$104.00  
ALLERGEN SPECIFIC IGE, EACH  
0302  
86003  
$20.00  
ALPHA 1 ANTITRYPSIN PHENOTYPE  
0301  
82104  
$48.00  
ALPHA FETO PROTEIN  
0301  
82105  
$65.00  
ALPHA FETOPROTEIN  
0301  
82105  
$65.00  
ALPHA FETOPROTEIN, TUMOR MARKER  
0301  
82105  
$65.00  
ALPHA-1-ANTITRYPSIN  
0301  
82103  
$73.00  
ALPHA-FETOPROTEIN (AFP) AMNIO FLUID  
0301  
82106  
$109.00  
ALSIUS CATH STARTER KIT (424164)  
0272  
 
$967.00  
ALSIUS FEMORAL CATH 38CM (424163)  
0272  
 
$1,863.00  
ALSIUS SUBCLAVAN CATH 22CM (424178)  
0272  
 
$1,451.00  
AMBULATING OXIMETRY  
0460  
94761  
$303.00  
AMMONIA  
0301  
82140  
$62.00  
AMNIOCENTESIS-DIAGNOSTIC  
0360  
59000  
$684.00  
AMPHETAMINES; 1 OR 2  
0301  
80324  
$88.00  
AMYLASE ASSAY  
0301  
82150  
$84.00  
ANA BY IFA  
0301  
86039  
$154.00  
ANAEROBE CULTURE SURGICAL SP  
0306  
87075  
$74.00  
ANAEROBIC ID  
0306  
87076  
$72.00  
ANCHOR/SCREW FOR OPPOSING BONE TO BON  
0278  
C1713  
Variable  
ANESTHESIA INHALATION OR IV ADDL MINUTE  
0370  
 
$8.05  
ANESTHESIA INHALATION OR IV FIRST 15 MINUTES  
0370  
 
$380.00  
ANGIO CATH/GUIDEWIRE-CARDIAC  
0272  
 
Variable  
ANGIOGRAPHY EXTREMITY UNILATERAL  
0320  
75710  
$6,294.00  
ANGIOTENSIN CONVERT ENZ  
0301  
82164  
$62.00  
ANTI MITOCHONDRIAL AB  
0301  
83516  
$73.00  
ANTI NUCLEAR ANTIBODY SCREEN  
0301  
86038  
$126.00  
ANTIBODY BRUCELLA  
0302  
86622  
$30.00  
ANTIBODY DETECTION NOS, EACH ORGANISM  
0306  
87299  
$44.00  
ANTIBODY ENCEPHALITIS CALIFORNIA LA CROSSE  
0302  
86651  
$44.00  
ANTIBODY ENCEPHALITIS EASTERN EQUINE  
0302  
86652  
$44.00  
ANTIBODY ENCEPHALITIS ST. LOUIS  
0302  
86653  
$44.00  
ANTIBODY ENCEPHALITIS WESTRN EQUINE  
0302  
86654  
$44.00  
ANTIBODY ENTEROVIRUS  
0302  
86658  
$43.00  
ANTIBODY FRANCISELLA TULARENSIS  
0302  
86668  
$38.00  
ANTIBODY I.D. ELUATE  
0302  
86860  
$382.00  
ANTIBODY ID  
0302  
86870  
$638.00  
ANTIBODY LEPTOSPIRA  
0302  
86720  
$65.00  
ANTIBODY PROTOZOA NES  
0302  
86753  
$56.00  
ANTIBODY RICKETTSIA  
0302  
86757  
$65.00  
ANTIBODY SALMONELLA  
0302  
86768  
$44.00  
ANTIBODY TITER  
0300  
86850  
$132.00  
ANTIBODY TRICHINELLA  
0306  
86784  
$42.00  
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIED  
0302  
86790  
$43.00  
ANTIBODY; TREPONEMA PALLIDUM  
0306  
86780  
$65.00  
ANTICARDIOLIPIN ABS, IGA, G OR M  
0301  
86147  
$94.00  
ANTI-DNA DOUBLE STRAND  
0301  
86225  
$90.00  
ANTINEUTROPHIL CYTOPLASMIC AB  
0301  
86021  
$120.00  
ANTI-STRIATED MUSCLE AB, IGG  
0301  
86255  
$72.00  
ANTITHROMBIN III ACTIV  
0302  
85300  
$145.00  
AORTA CATH (FEMORAL/AXILLARY)  
0360  
36200  
$900.00  
AORTIC ROOT-AORTOGRAPHY-ANG  
0480  
93567  
$2,038.00  
AORTOILIAC/IVC-ILIAC/GRAFT DUPLEX  
0921  
93978  
$690.00  
AORTOILIAC/IVC-ILIAC/GRAFT DUPLEX LTD  
0921  
93979  
$621.00  
APHASIA TESTING 1 HR  
0440  
 
$331.00  
APHASIA TESTING 1 HR  
0440  
96105  
$331.00  
APILGRAF, PER SQ CENTIMETER  
0278  
Q4101  
Variable  
APP OF MULTI-LAYER VENOUS WOUND COMP BELOW KNEE-BILATERAL  
0510  
29581  
$356.00  
APP OF MULTI-LAYER VENOUS WOUND COMP BELOW KNEE-LT  
0510  
29581  
$356.00  
APP OF MULTI-LAYER VENOUS WOUND COMP BELOW KNEE-RT  
0510  
29581  
$356.00  
APP SKIN SUB GRAFT FIRST 25 SQ CM OR LESS TRUNK/ARM/LEG  
0510  
15271  
$4,080.00  
APP SKIN SUB GRAFT FIRST 25 SQCM OR LESS FACE/NECK/HF/G  
0510  
15275  
$4,080.00  
APPL MOD 1+ AREAS ELEC STIM MAN EA 15 MIN  
0430  
97032  
$104.00  
APPL MOD 1+ AREAS ULTRASOUND EACH 15 MINUTES  
0420  
97035  
$74.00  
APPL MODALITY 1+ AREAS ELECT STIM MANUAL EA 15 MIN  
0420  
97032  
$104.00  
APPL OF MOD 1+ AREAS ULTRASOUND EACH 15 MINUTES  
0430  
97035  
$74.00  
APPL OF MODALITY TO 1+ AREAS ELEC STIM UNATTENDED  
0430  
97014  
$56.00  
APPL OF MODALITY TO 1+ AREAS ELECTRICAL STIM UNATTENDED  
0420  
97014  
$56.00  
APPL OF MODALITY TO 1+ AREAS PARAFFIN BATH  
0430  
97018  
$51.00  
APPL OF MODALITY TO 1+ AREAS WHIRLPOOL  
0430  
97022  
$131.00  
APPL OF MODALITY TO ONE OR MORE AREAS WHIRLPOOL  
0420  
97022  
$131.00  
APPLICATION OF MODALITY TO 1+ AREAS IONTOPHORESIS EACH 15 MINUTE  
0420  
97033  
$83.00  
APPLICATION OF MODALITY TO 1+ AREAS IONTOPHORESIS EACH 15 MINUTE  
0430  
97033  
$83.00  
APPLICATION OF MODALITY TO 1+ AREAS TRACTION MECHANICAL  
0420  
97012  
$83.00  
APPLICATION OF RIGID TOTAL CONTACT LEG CAST  
0510  
29445  
$760.00  
APPLICATION OF TENS SURFACE TRANSCUTANEOUS NEUROSTIMULATOR  
0420  
64550  
$149.00  
ARROW DUAL LUMEN SLICK (7627)  
0270  
 
$87.00  
ARSENIC ASSAY  
0301  
82175  
$99.00  
ARTERIAL DUPLEX BILATERAL LE  
0921  
93925  
$917.00  
ARTERIAL DUPLEX BILATERAL UE  
0921  
93930  
$743.00  
ARTERIAL DUPLEX UNILATERAL UE  
0921  
93931  
$533.00  
ARTERIAL LINE (451928)  
0270  
 
$69.00  
ARTERIAL LINE (N/A)  
0270  
 
Variable  
ARTERIAL PUNCTURE  
0300  
36600  
$158.00  
ARTHRO ASP/INJ INTERMED JT/BURSA W/O US GUID  
0360  
20605  
$751.00  
ARTHRO ASP/INJ INTERMED JT/BURSA W/US GUID W/PERM RECORD&REPORT  
0360  
20606  
$890.00  
ARTHRO ASP/INJ MAJOR JT/BURSA W/O US GUID  
0360  
20610  
$703.00  
ARTHRO ASP/INJ MAJOR JT/BURSA W/US GUID W/PERM RECORD&REPORT  
0360  
20611  
$979.00  
ARTHRO ASP/INJ SM JT/BURSA W/O US GUID  
0360  
20600  
$586.00  
ARTHRO ASP/INJ SM JT/BURSA W/US GUID W/PERM RECORD&REPORT  
0360  
20604  
$603.00  
ARTHROGRAM KNEE-DW  
0320  
73580  
$488.00  
ASPERGILLUS AB, SERUM  
0302  
86606  
$61.00  
ASPERGILLUS ANTIGEN DETECTION BY EIA  
0300  
87305  
$270.00  
ASPIRATION BLADDER W/INSERT OF SUPERA  
0360  
51102  
$3,101.00  
ASSAY OF ETHANOL  
0301  
80320  
$175.00  
ASSAY OF MYOGLOBIN  
0301  
83874  
$66.00  
ASSAY OF NICOTINE  
0301  
80323  
$104.00  
ASSAY OF OPIATES  
0301  
80361  
$88.00  
ASSAY OF PHENCYCLIDINE  
0301  
83992  
$60.00  
ASSAY OF SEX HORMONE BINDING GLOBULIN  
0301  
84270  
$86.00  
ASSAY TEST FOR BLOOD FECAL  
0300  
82274  
$59.00  
ATTENDANCE AT DELIVERY INITIAL STABILIZATION  
0410  
99464  
$310.00  
ATTENTION CURRENT STATUS  
0430  
G9165  
$0.01  
ATTENTION CURRENT STATUS  
0440  
G9165  
$0.01  
ATTENTION DISCHARGE STATUS  
0440  
G9167  
$0.01  
ATTENTION GOAL STATUS  
0430  
G9166  
$0.01  
ATTENTION GOAL STATUS  
0440  
G9166  
$0.01  
AUDITORY EVOKED RESPONSE AUDIOMETRY TESTING CENTRAL NERVOUS  
0470  
92585  
$347.00  
BAG BELMONT UNIVERSAL (7648)  
0270  
 
$362.00  
BAG COLLECTION DRAINAGE (9069)  
0270  
 
$117.00  
BAG DRAINAGE BECKER EDMS (9123)  
0270  
 
$117.00  
BAG DRAINAGE LIMITORR (7769)  
0270  
 
$112.00  
BALLOON DILAT BILIARY DUCT/AMPULLA PRQ EA DUCT  
0360  
47542  
$678.00  
BALLOON DILAT URETERAL STRICT W/IMG GID RS&I  
0360  
50706  
$3,531.00  
BARBITURATES CONFIRMATION  
0301  
80345  
$88.00  
BASIC METABOLIC PANEL  
0301  
80048  
$88.00  
BASIC POWERGLIDE 18G X 10CM (435159)  
0278  
C1751  
$138.00  
BASIC POWERGLIDE 18G X 8CM (435157)  
0278  
C1751  
$138.00  
BASIC POWERGLIDE 20G X 10CM (435155)  
0278  
C1751  
$138.00  
BASIC POWERGLIDE 20G X 8CM (435153)  
0278  
C1751  
$138.00  
BCR ABL 1 GENE MAJOR BP  
0300  
81206  
$547.00  
BCR ABL 1 GENE MINOR BP  
0300  
81207  
$702.00  
BEHAVIORAL AND QUALITATIVE ANALYSIS VOICE/RESONANC  
0440  
 
$403.00  
BEHAVIORAL AND QUALITATIVE ANALYSIS VOICE/RESONANC  
0440  
92524  
$403.00  
BENZODIAZEPINES CONFIRMATION  
0301  
80348  
$88.00  
BENZODIAZEPINES; 1-12  
0301  
80346  
$99.00  
BETA 2 GLYCOPROTEIN AB, EA  
0302  
86146  
$85.00  
BETA HCG  
0301  
84702  
$56.00  
BETA HCG TUMOR MARKER  
0301  
84702  
$56.00  
BETA HYDROXYBUTYRATE SERUM QUANT OTHER KETONE BODIES  
0301  
82010  
$52.00  
BETA LACTAMASE TEST  
0306  
87185  
$33.00  
BETA-2 MICROGLOBULIN, QUANTIT  
0301  
82232  
$74.00  
BILIRUBIN TOTAL  
0301  
82247  
$35.00  
BILIRUBIN,TOTAL,TRANCUTANEOUS  
0300  
88720  
$25.00  
BIOFEEDBACK TRAINING BY ANY MODALITY  
0430  
90901  
$111.00  
BIOFEEDBACK TRAINING PERINEAL MUSCLES ANORECTAL OR URETHRAL SPHI  
0420  
90911  
$222.00  
BIOPSY ABDOMINAL/RETROPERITONEAL,PERCUTANEOUS NEEDLE  
0360  
49180  
$1,131.00  
BIOPSY BONE TROCAR OR NEEDLE DEEP  
0360  
20225  
$1,246.00  
BIOPSY BONE TROCAR OR NEEDLE SUPERFICIAL  
0360  
20220  
$2,207.00  
BIOPSY MUSCLE PERCUTANEOUS NEEDLE  
0360  
20206  
$760.00  
BIOPSY OR EXCISION LYMPH NODE BY NEEDLE-SUPERFICIAL  
0360  
38505  
$760.00  
BIOPSY PLEURA PERCUT NEEDLE  
0360  
32400  
$839.00  
BIOPSY SKIN SUBCUTANEIOUS AND OR MUCOUS MEMBRANE 1 LESION  
0510  
11100  
$591.00  
BLADDER INSTILL OF ANTICARCINOGENIC AGENT (INC RETENTION TIME)  
0761  
51720  
$650.00  
BLEDSOE BRACE AK-100-22/4/6/8  
0270  
 
Variable  
BLOOD DRAW-CENTRAL/PERIPHERAL LINE  
0510  
36592  
$126.00  
BLOOD DRAW-COMPLETE IMPLANTABLE VAD  
0510  
36591  
$104.00  
BLOOD TYPING,ANTIGEN TEST OF DONOR BL  
0309  
86902  
$638.00  
BLOOD TYPING;RBC ANTIGENS,OTHER THAN  
0300  
86905  
$638.00  
BNP  
0301  
83880  
$261.00  
BODY FLUID HEMATOCRIT (SPUN)  
0305  
85013  
$45.00  
BODY FLUID PH  
0301  
83986  
$50.00  
BODY FLUID PROTEIN  
0301  
84155  
$27.00  
BODY POSITION CURRENT STATUS  
0420  
G8981  
$0.01  
BODY POSITION CURRENT STATUS  
0430  
G8981  
$0.01  
BODY POSITION DISCHARGE STATUS  
0420  
G8983  
$0.01  
BODY POSITION DISCHARGE STATUS  
0430  
G8983  
$0.01  
BODY POSITION GOAL STATUS  
0420  
G8982  
$0.01  
BODY POSITION GOAL STATUS  
0430  
G8982  
$0.01  
BONE AGE STUDY  
0320  
77072  
$425.00  
BONE DENSITY STUDY, AXIAL  
0320  
77080  
$508.00  
BONE LENGTH STUDY  
0352  
77073  
$279.00  
BONE MARROW CHROMO/INTERP  
0305  
88237  
$421.00  
BONE MARROW SCAN W/B - NM  
0341  
78104  
$1,295.00  
BONE SCAN MULT VIEW W/FLOW-NM  
0341  
78315  
$1,295.00  
BONE SCAN MULTI VIEW-NM  
0341  
78305  
$1,295.00  
BONE SCAN WHOLE BODY-NM  
0341  
78306  
$1,295.00  
BOOT ROOKE HFS (7770)  
0270  
 
$289.00  
BOOT TRUVUE (7257)  
0270  
 
$150.00  
BORRELIA SMEAR  
0306  
87205  
$53.00  
BRACHY SOURCE HD IR 192  
0278  
C1717  
$1,613.00  
BRACHYTHERAPY CATHETERS  
0272  
C1728  
$291.00  
BRACHYTHERAPY SOURCE, NON STRANDED, YTTRIUM-90, PER SOURCE  
0278  
C2616  
Variable  
BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL  
0333  
77316  
$1,277.00  
BREAST CORE NEEDLE (420582)  
0272  
 
$158.00  
BREAST IMPLANTS  
0278  
C1789  
Variable  
BREAST NEEDLE LOC (404322,404320,404319)  
0272  
 
$71.00  
BRIDLE NASAL TUBE RETAINING SYSTEM 12FR (E4-4112)  
0272  
 
$257.00  
BRONCH BLOCKER 7FRX65CM (ARNDT) (422832)  
0270  
 
$506.00  
BRONCH FORCEP (424905)  
0272  
 
$167.00  
BRONCHO CATH - 28FR LEFT (95890) (30115)  
0270  
 
$140.00  
BRONCHO CATH - 35FR LEFT (125035) (30113)  
0270  
 
$140.00  
BRONCHO CATH - 37FR LEFT (95893) (30636)  
0270  
 
$140.00  
BRONCHO CATH - 39FR LEFT (125039) (30111)  
0270  
 
$140.00  
BRONCHOPROVOCATION  
0460  
94070  
$803.00  
BRONCHOSCOPY  
0360  
 
$2,685.00  
BRONCHOSCOPY WITH BRONCHIAL THERMOSPLASTY  
0360  
 
$13,829.00  
BS/MT CUTTING BALLOON  
0272  
C1725  
$7,634.00  
BUFFY COAT DIFFERENTIAL  
0305  
85009  
$49.00  
BUN  
0301  
84520  
$27.00  
BURR HOLE FOR CATH/RESERVOIR/PRESSUR  
0360  
61210  
$2,593.00  
BX BREAST 1ST LESION MR IMAGING  
0360  
19085  
$2,098.00  
BX BREAST 1ST LESION STRTCTC  
0360  
19081  
$2,098.00  
BX BREAST 1ST LESION US IMAGING  
0360  
19083  
$2,098.00  
BX BREAST ADD LESION STRTCTC  
0360  
19082  
$2,098.00  
BX BREAST ADD LESION US IMAGING  
0360  
19084  
$2,098.00  
BX NEEDLE, CATH, OR SUPPLIES  
0270  
 
Variable  
BX PANCREAS PERCUT NEEDLE  
0360  
48102  
$1,519.00  
C DIFFICILE TOXIN A+B  
0306  
87324  
$140.00  
C REACTIVE PROTEIN (CRP)  
0301  
86140  
$115.00  
C4  
0300  
86160  
$98.00  
CA 19-9  
0301  
86301  
$101.00  
CA125 ASSAY  
0302  
86304  
$156.00  
CALCITONIN ASSAY  
0301  
82308  
$98.00  
CALCIUM ASSAY  
0301  
82310  
$27.00  
CALCIUM ASSAY, URINE  
0301  
82340  
$54.00  
CALCIUM, IONIZED  
0301  
82330  
$60.00  
CALPROTECTIN FECAL  
0301  
83993  
$216.00  
CANALITH REPOSITION EPLEY MANEUVER SEMONT MAN PER DAY  
0420  
 
$129.00  
CANALITH REPOSITION EPLEY MANEUVER SEMONT MAN PER DAY  
0420  
95992  
$129.00  
CANDIDA SPECIES DNA PROBE  
0306  
87480  
$74.00  
CANISTER 1000ML (7465)  
0270  
 
$190.00  
CAPD TREATMENT  
0800  
G0257  
$1,536.00  
CAR SEAT/BED TESTING 60 MINUTES  
0410  
94780  
$217.00  
CAR SEAT/BED TESTING EA ADDL 30 MINUTES  
0410  
94781  
$109.00  
CARBOXYHEMOGLOBIN  
0301  
82375  
$56.00  
CARDIAC DOPPLER/NO INTERP  
0480  
93320  
$336.00  
CARDIAC REHAB W/O ECG MONITORING  
0943  
93797  
$147.00  
CARDIOPULMONARY RESUSCITATION  
0480  
92950  
$632.00  
CARDIOVERSION  
0480  
92960  
$1,054.00  
CARNITINE, FREE AND TOTAL, SERUM  
0301  
82379  
$75.00  
CAROTID STENT  
0278  
C1876  
Variable  
CARRY CURRENT STATUS  
0420  
G8984  
$0.01  
CARRY CURRENT STATUS  
0430  
G8984  
$0.01  
CARRY DISCHARGE STATUS  
0420  
G8986  
$0.01  
CARRY DISCHARGE STATUS  
0430  
G8986  
$0.01  
CARRY GOAL STATUS  
0420  
G8985  
$0.01  
CARRY GOAL STATUS  
0430  
G8985  
$0.01  
CASSETTE VERALINK (8057)  
0272  
 
$162.00  
CATECHOLAMINES, UA FRACT  
0301  
82384  
$111.00  
CATH CVC 9FRX10CM DUAL (ARROW) (7454)  
0270  
 
$359.00  
CATH CVP 16G 30 CM ONE LUMEN (2898)  
0270  
 
$66.00  
CATH CVP 16GX20CM SINGLE (ARROW) (2906)  
0270  
 
$220.00  
CATH CVP 4FR 13CM 2 L(PED) (9118)  
0270  
 
$97.00  
CATH CVP 7FR 20CM 3 L (1637)  
0270  
 
$174.00  
CATH CVP 7FRX20CM TRIPLE (ARROW) (1637)  
0270  
 
$188.00  
CATH CVP 8.5FRX16CM 4 LUMEN (7629)  
0272  
 
$388.00  
CATH CVP 8.5FRX20CM 4 LUMEN (7628)  
0272  
 
$388.00  
CATH DOUBLE LUMEN CV KIT (7454)  
0270  
 
$334.00  
CATH FEMORAL ARTERIAL LINE (7381)  
0270  
 
$94.00  
CATH FOLEY TRAY 16FR TEMP SENS (7626)  
0272  
 
$115.00  
CATH FOLEY TRAY W/  
0270  
 
Variable  
CATH HEMODIALYSIS/PERITONEAL,LONG TER  
0278  
C1750  
Variable  
CATH INTRODUCER PERCU ARR 8.5 (6831)  
0272  
 
$147.00  
CATH PIGTAIL (149594)  
0270  
 
$238.00  
CATH PLACEMENT TO MEASURE TRANSPULM PRESSURES  
0410  
94799  
$422.00  
CATH PLC 2ND OR MORE SLCT BRCH  
0360  
36012  
$5,335.00  
CATH SUPPLY - ANGIO  
0272  
 
Variable  
CATH SUPRAPUBIC 14FR 23CM (6287)  
0270  
 
$138.00  
CATH SWAN CHANGE (NONE)  
0272  
 
$219.00  
CATH SWAN GANZ (6978)  
0272  
 
$132.00  
CATH SWAN-GANZ VIP 7.5FR (COOK) (6978)  
0270  
 
$131.00  
CATH THORACIC KIT 28FR (3215)  
0270  
 
$92.00  
CATH UMBILICAL 3.5 DUAL (7354 OR 434354)  
0270  
 
$112.00  
CATH UMBILICAL 5.0 DUAL (7321)  
0270  
 
$94.00  
CATH VENOUS PORT A (9029)  
0270  
 
$817.00  
CATH VENT THORACIC TRUE (7175)  
0272  
 
$705.00  
CATH, BALLOON  
0272  
C1726  
Variable  
CATH, OCCLUSION  
0272  
C2628  
Variable  
CATH, THROMBECTOMY/EMBOLECTOMY  
0272  
C1757  
Variable  
CATH,HEMODIALYSIS/PERITONEAL SHORT TE  
0278  
C1752  
Variable  
CATH/INTRO SALINE OR CONTRAST  
0360  
58340  
$244.00  
CATHETER ASPIRATION (SEPARATE PROCEDURE); NASOTRACHEAL  
0410  
31720  
$425.00  
CATHETER BRONCHO SIZE 35 RIGHT (30635)  
0270  
 
$165.00  
CATHETER SET ON-Q OVER THE NEEDLE NOSTIM (439426)  
0270  
 
$78.00  
CATHETER SET ON-Q OVER THE NEEDLE STIM (439428)  
0270  
 
$89.00  
CATHETER SET ON-Q OVER THE NEEDLE STIM (439780)  
0270  
 
$94.00  
CATHETER TRIALYSIS 15CM (7785)  
0278  
C1752  
$593.00  
CATHETER TRIALYSIS 20CM (7786)  
0278  
C1752  
$593.00  
CATHETER, DRAINAGE, PLEURA (9120)  
0272  
C1729  
$1,547.00  
CATHETER, EXTRAVASCULAR TISSUE ABLATION, ANY MODALITY  
0272  
C1886  
Variable  
CATHETER, GUIDING  
0272  
C1887  
Variable  
CATHETER, SKATER PIGTAIL (435731)  
0272  
 
$284.00  
CATHETER, SUPRAPUBIC/CYSTOSCOPY  
0272  
C2627  
Variable  
CATHETER, TRANSLUMINAL ANGIOPLASTY, LASER  
0272  
C1885  
Variable  
CATHETER, URETERAL  
0272  
C1758  
Variable  
CATHETER,TRANSLUMINAL ANGIO,DRUG COATED,NON LASER  
0272  
C2623  
Variable  
CATHETER,TRANSLUMINAL ANGIO,NON LASER  
0272  
C1725  
Variable  
CBC (AUTOMATED)  
0305  
85027  
$58.00  
CBC WITH AUTOMATED DIFF  
0305  
85025  
$81.00  
CD4  
0301  
86361  
$164.00  
CEA ASSAY  
0301  
82378  
$94.00  
CELL CNT AND DIFFERENTIATION  
0305  
89051  
$98.00  
CELL COUNT AND DIFF BODY FLUID  
0305  
89051  
$98.00  
CELL COUNT CSF WITHOUT DIFF  
0301  
89050  
$98.00  
CERULOPLASMIN  
0301  
82390  
$57.00  
CERVICAL RIPENING BALLOON W/STYLET (434894)  
0272  
 
$129.00  
CHANGE URETEROSTOMY TUBE OR EXTERNALL  
0360  
50688  
$3,912.00  
CHECKOUT ORTHO PROSTH USE EST PT EACH 15 MINUTES  
0420  
 
$105.00  
CHECKOUT ORTHO PROSTH USE EST PT EACH 15 MINUTES  
0420  
97762  
$105.00  
CHEMICAL CAUT. OF GRAN. TISSUE  
0510  
17250  
$308.00  
CHEMO ADMIN,SQ OR IM, HORMONAL ANTI-NEOPLASTIC  
0280  
96402  
$207.00  
CHEMO ADMIN,SQ OR IM, NON-HORMONAL ANTI-NEOPLASTIC  
0280  
96401  
$207.00  
CHEMO IV INF 1ST HR SINGLE OR 1ST DRU  
0280  
96413  
$633.00  
CHEMO IV INF ADDT'L DRUG SEQ  
0280  
96417  
$323.00  
CHEMO IV INF ADDT'L HRS  
0280  
96415  
$143.00  
CHEMO IV PUSH EACH ADDT'L DRUG  
0280  
96411  
$290.00  
CHEMO IV PUSH SINGLE OR 1ST DRUG  
0331  
96409  
$420.00  
CHEMOTHERAPY ADMIN INTRA ARTERIAL PUSH TECHNIQUE  
0331  
96420  
$341.00  
CHEMOTHERAPY ADMINISTRATION CNS/INTRATHECAL  
0331  
96450  
$997.00  
CHEST PT AND PD  
0410  
94668  
$184.00  
CHLAMYDIA PNEUMONIAE CULTURE  
0306  
87110  
$108.00  
CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TECHNIQUE  
0306  
87491  
$191.00  
CHLORIDE URINE  
0301  
82436  
$48.00  
CHLORIDE, SERUM  
0301  
82435  
$27.00  
CHNG PRCUT DRAIN CATH W/CNTST  
0320  
75984  
$355.00  
CHOLANGIOGRAPHY SURGICAL  
0320  
74300  
$298.00  
CHOLANGIOGRAPHY SURGICAL ADDITIONAL VIEWS  
0320  
74301  
$229.00  
CHOLESTEROL  
0301  
82465  
$27.00  
CHROMIUM ASSAY  
0301  
82495  
$168.00  
CHROMOGRANIN-A  
0301  
86316  
$138.00  
CHROMOSOME ADDL KARYOTYPES  
0301  
88280  
$93.00  
CHROMOSOME ANAL TISSUE CULT  
0301  
88230  
$388.00  
CHROMOSOME ANALY AF OR CV 15 CELLS 1K WITH BANDING  
0300  
88267  
$666.00  
CHROMOSOME ANALYSIS ANALYZE 20-25 CELLS  
0310  
88264  
$415.00  
CHROMOSOME ANL; 15-20 CELLS, 2 KARYOTYPE, BANDING  
0301  
88262  
$763.00  
CISTERNOGRAPHY-NM  
0341  
78630  
$1,677.00  
CITRIC ACID, 24 HOUR URINE  
0301  
82507  
$97.00  
CKMB  
0301  
82553  
$75.00  
CLOG ZAPPER FEED TUBE (7081)  
0270  
 
$72.00  
CLOSURE DEVICE VASCULAR  
0272  
C1760  
$1,867.00  
CLOTTING FUNCT ACTIVITY, NOS EA ANALYTE  
0305  
85397  
$185.00  
CO2  
0301  
82374  
$48.00  
COCAINE CONFIRMATION  
0301  
80353  
$88.00  
COCCIDIOIDES AB IGG OR IGM  
0302  
86635  
$64.00  
COGNITIVE SKILLS DEVELOPMENT  
0430  
 
$106.00  
COGNITIVE SKILLS DEVELOPMENT  
0430  
G0515  
$106.00  
COGNITIVE SKILLS DEVELOPMENT  
0440  
G0515  
$106.00  
COLLAR VISTA UNIVERSAL (7853)  
0270  
 
$213.00  
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE  
0300  
36415  
$28.00  
COLONOSCOPY - SIMPLE  
0360  
 
$2,465.00  
COLONOSCOPY FLX W/ EUS LIMITED STRUCTURES  
0360  
 
$3,130.00  
COLONOSCOPY FLX W/ REMOVAL FOREIGN BODY(S)  
0360  
 
$3,130.00  
COLONOSCOPY FLX W/COLL SPEC WHEN PFRMD  
0360  
 
$2,465.00  
COLONOSCOPY FLX W/DECOMPRESSION  
0360  
 
$3,130.00  
COLONOSCOPY FLX W/ENDOSCOPIC STENT PLACEMENT  
0360  
 
$3,130.00  
COLONOSCOPY FLX W/SUBMUCOSAL INJECTION(S) ANY SUB  
0360  
 
$3,130.00  
COLONOSCOPY FLX W/TRANSENDOSCOPIC BALLOON DILATION  
0360  
 
$3,130.00  
COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION  
0360  
 
$3,130.00  
COLOR FLOW DOPPLER  
0480  
93325  
$538.00  
COLUMN CHROMATOGRAPHY NON DRUG NOS EA SPEC  
0301  
82542  
$256.00  
COMMUNITY WORK REINTEGRATION TRAIN 15 MIN DIRECT 1/1  
0420  
97537  
$87.00  
COMMUNITY WORK REINTEGRATION TRAIN 15 MIN DIRECT 1/1  
0430  
97537  
$87.00  
COMP EPS W INDUCT  
0480  
93620  
$8,226.00  
COMPATABILITY TEST ANTIGLOBULIN  
0309  
86922  
$382.00  
COMPATABILITY TEST IMMEDIATE SPIN  
0309  
86920  
$382.00  
COMPATABILITY TEST INCUBATION PHASE  
0309  
86921  
$382.00  
COMPLEMENT, TOTAL (CH-50)  
0301  
86162  
$102.00  
COMPLEX STAIN FOR O AND P  
0306  
87209  
$60.00  
COMPREHENSIVE MET PANEL  
0301  
80053  
$126.00  
CONC FOR INFECTIOUS AGENT  
0306  
87015  
$85.00  
CONNECTIVE TISSUE, HUMAN (INCLUDES FA  
0278  
C1762  
Variable  
CONNECTIVE TISSUE,NON HUMAN  
0278  
C1763  
Variable  
CONTINUING MEDICAL PHYSICS  
0333  
77336  
$481.00  
CONTINUOUS NEBULIZER  
0410  
94645  
$142.00  
CONTINUOUS NEBULIZER 1ST HOUR  
0410  
94644  
$142.00  
CONTRAST C02  
0636  
A9698  
$1.00  
CONVERT PERQ NEPHROSTOMY CATH TO NEPHROURTRL CATH RS&I  
0360  
50434  
$2,622.00  
COPPER  
0301  
82525  
$59.00  
COR ARTERY(S) ONLY,INCL INJ/S&I  
0480  
93454  
$8,931.00  
COR ARTERY(S) ONLY,INCL INJ/S&I  
0480  
93456  
$10,497.00  
COR ARTERY(S) ONLY,W/GRAFTS,INCL INJ  
0480  
93457  
$11,639.00  
COR ARTERY(S),ONLY,W/GRAFTS,INCL INJ  
0480  
93455  
$8,112.00  
COR DOPPLER/PRESSURE EA ADDL  
0480  
93572  
$428.00  
COR DOPPLER/PRESSURE INI VESS  
0480  
93571  
$1,001.00  
COR PAK TUBE (166280)  
0272  
 
$106.00  
CORONARY THROMBECTOMY  
0480  
92973  
$7,159.00  
CORTISOL, SERUM  
0301  
82533  
$96.00  
CORTISOL,FREE,24 HR URINE  
0301  
82530  
$62.00  
COUNT 15-20 CELLS  
0305  
88262  
$763.00  
COXIELLA BURNETII ANTIBODY (Q FEVER)  
0302  
86638  
$58.00  
CPAP ACUTE  
0410  
94660  
$789.00  
CPAP CHRONIC  
0410  
94660  
$302.00  
C-PEPTIDE  
0301  
84681  
$70.00  
CPK  
0301  
82550  
$64.00  
CREATININE CLEARANCE  
0301  
82575  
$76.00  
CREATININE SERUM  
0301  
82565  
$27.00  
CREATININE, URINE RANDOM  
0301  
82570  
$45.00  
CRITICAL CARE 30-74 MINUTES  
0450  
99291  
$2,641.00  
CRITICAL CARE EACH ADDTNL 30 MIN  
0450  
99292  
$773.00  
CRYO AHF PART OF POOL  
0390  
P9012  
$143.00  
CRYOGLOBULINS QUAL OR SEMI QUANT  
0301  
82595  
$39.00  
CRYPTOCOCCUS ANTIGEN  
0306  
86403  
$96.00  
CRYPTOCOCCUS NEOFORM AG EIA  
0306  
87327  
$48.00  
CRYPTOSPORIDIUM AG DETECTION BY EIA  
0306  
87328  
$59.00  
CRYSTAL I.D  
0307  
89060  
$86.00  
CSF SHUNT PATENCY-NM  
0341  
78645  
$1,677.00  
CSF VDRL  
0300  
86592  
$48.00  
CT ABD AND PELVIS W/CONTRAST  
0350  
74177  
$1,667.00  
CT ABD AND PELVIS W/O AND W/CONTRAST  
0350  
74178  
$1,834.00  
CT ABD AND PELVIS W/O CONTRAST (OR OR  
0350  
74176  
$1,421.00  
CT ABDO/RETROPERITONEAL BIOPSY  
0360  
49180  
$1,131.00  
CT ABDOMEN W/CONTRAST  
0350  
74160  
$1,667.00  
CT ABDOMEN W/O AND W/CONTRAST  
0350  
74170  
$1,834.00  
CT ABDOMEN W/O CONTRAST  
0350  
74150  
$709.00  
CT ANGIO ABD AND PELVIS W/CON,INCLUDING NON CONTRT  
0352  
74174  
$1,667.00  
CT ANGIO ABDOMEN W/CONTRAST  
0352  
74175  
$1,667.00  
CT ANGIO ABDOMEN W/RUNOFFS  
0350  
75635  
$2,068.00  
CT ANGIO CHEST W/CONTRAST  
0352  
71275  
$1,667.00  
CT ANGIO HEAD W/CONTRAST  
0350  
70496  
$1,667.00  
CT ANGIO HEART AND COR BYPASS (WHEN P  
0350  
75574  
$1,667.00  
CT ANGIO LOWER EXTREMITY W/CONTRAST  
0350  
73706  
$1,667.00  
CT ANGIO NECK W/CONTRAST  
0350  
70498  
$1,667.00  
CT ANGIO PELVIS W/CONTRAST  
0352  
72191  
$1,667.00  
CT ANGIO UPPER EXTREMITY W/O AND W/CO  
0350  
73206  
$1,667.00  
CT CERVICAL SPINE W/CONTRAST  
0350  
72126  
$2,685.00  
CT CERVICAL SPINE W/O AND W/CONTRAST  
0350  
72127  
$2,952.00  
CT CERVICAL SPINE W/O CONTRAST  
0350  
72125  
$709.00  
CT CHEST W/CONTRAST  
0350  
71260  
$1,667.00  
CT CHEST W/O AND W/CONTRAST  
0350  
71270  
$1,834.00  
CT CHEST W/O CONTRAST  
0350  
71250  
$758.00  
CT COLONOGRAPHY-DIAGNOSTIC  
0350  
74261  
$709.00  
CT COLONOGRAPHY-SCREENING  
0350  
74263  
$2,173.00  
CT GUIDANCE AND MONITORING FOR ABLATION,PARENCHYMAL TISSUE  
0350  
77013  
$1,673.00  
CT GUIDANCE FOR NEEDLE PLACEMENT  
0350  
77012  
$1,314.00  
CT HEAD OR BRAIN W/CONTRAST  
0351  
70460  
$1,667.00  
CT HEAD OR BRAIN W/O AND W/CONTRAST  
0351  
70470  
$1,834.00  
CT HEAD OR BRAIN W/O CONTRAST  
0351  
70450  
$709.00  
CT HEART STRUCTURE W/CONTRAST  
0350  
75572  
$1,667.00  
CT INJ,N BLOCK,CELIAC PLEXUS W/O OR W/RX MONITORING  
0360  
64530  
$1,913.00  
CT LIMITED F/U  
0350  
76380  
$377.00  
CT LOWER EXTREMITY W/CONTRAST  
0350  
73701  
$1,667.00  
CT LOWER EXTREMITY W/O AND W/CONTRST  
0350  
73702  
$1,834.00  
CT LOWER EXTREMITY W/O CONTRAST  
0350  
73700  
$709.00  
CT LUMBAR SPINE W/CONTRAST  
0350  
72132  
$2,685.00  
CT LUMBAR SPINE W/O CONTRAST  
0350  
72131  
$709.00  
CT LUMBAR SPINE W-W/O CONTRAST  
0350  
72133  
$2,952.00  
CT MAXILLOFACIAL W/CONTRAST  
0350  
70487  
$1,667.00  
CT MAXILLOFACIAL W/O AND W/CONTRAST  
0350  
70488  
$1,834.00  
CT MAXILLOFACIAL W/O CONTRAST  
0350  
70486  
$709.00  
CT NECK W/CONTRAST  
0350  
70491  
$1,667.00  
CT NECK W/O AND W/CONTRAST  
0350  
70492  
$1,834.00  
CT NECK W/O CONTRAST  
0350  
70490  
$709.00  
CT ORBIT OR SELLA W/CONTRAST  
0350  
70481  
$1,667.00  
CT ORBIT OR SELLA W/O AND W/CONTRAST  
0350  
70482  
$1,834.00  
CT ORBIT OR SELLA W/O CONTRAST  
0350  
70480  
$709.00  
CT PELVIS W/CONTRAST  
0350  
72193  
$1,667.00  
CT PELVIS W/O AND W/CONTRAST  
0350  
72194  
$1,834.00  
CT PELVIS W/O CONTRAST  
0350  
72192  
$709.00  
CT RENAL BIOPSY PERCUT  
0360  
50200  
$888.00  
CT SIMULATION  
0350  
77014  
$793.00  
CT THORACENTESIS FOR ASPIRATION W/IMAGING  
0360  
32555  
$1,265.00  
CT THORACIC SPINE W/CONTRAST  
0350  
72129  
$1,667.00  
CT THORACIC SPINE W/O CONTRAST  
0350  
72128  
$709.00  
CT UPPER EXTREMITY W/CONTRAST  
0350  
73201  
$1,667.00  
CT UPPER EXTREMITY W/O AND W/CONTRAST  
0350  
73202  
$2,470.00  
CT UPPER EXTREMITY W/O CONTRAST  
0350  
73200  
$709.00  
CULTURE AEROBIC  
0306  
87070  
$118.00  
CULTURE BLOOD  
0306  
87040  
$171.00  
CULTURE FUNGAL  
0306  
87102  
$156.00  
CULTURE GRP B STREP ONLY  
0306  
87081  
$92.00  
CULTURE STOOL  
0306  
87045  
$127.00  
CULTURE STREP SCREEN ONLY  
0306  
87081  
$92.00  
CULTURE TYPING BY RNA/DNA PROBE EA CULT/ISOLATE  
0306  
87150  
$130.00  
CULTURE URINE  
0306  
87086  
$78.00  
CULTURE, STOOL ADDT'L PATHOGENS  
0306  
87046  
$32.00  
CULTURE, TYPING IMMUNOLOGIC METHOD, OTHER, PER ANTISERUM  
0306  
87147  
$33.00  
CULTURE,PRESUMPTIVE,PATHOGENIC ORGANI  
0306  
87081  
$92.00  
CUSTOM DELIVERY PACK (159654)  
0272  
 
Variable  
CVVH CRRT TREATMENT  
0800  
G0257  
$3,031.00  
CYCLIC CITRUL PEPTIDE  
0301  
86200  
$78.00  
CYCLOSPORINE ASSAY(SANDIMMUNE)  
0301  
80158  
$100.00  
CYSTIC FIBROSIS GENE ANALYSIS  
0300  
81220  
$1,503.00  
CYSTOGRAM  
0320  
74430  
$486.00  
CYSTOGRAM-VOIDING-DW  
0320  
74455  
$861.00  
CYSTOURETHROSCOPY  
0360  
52000  
$830.00  
CYTOGENETIC AND MOLECULAR CYTOGENETICS INTERP & RPT  
0311  
88291  
$53.00  
CYTOMEG, DNA OR RNA AMP PROBE  
0306  
87496  
$117.00  
CYTOMEGALOVIRUS (CMV) QUANT (DNA OR RNA)  
0306  
87497  
$364.00  
CYTOMEGALOVIRUS AB, IGM  
0302  
86645  
$72.00  
CYTOMEGALOVIRUS, IGG  
0302  
86644  
$65.00  
CYTOPATHOLOGY EVAL FOR ADEQUACY OF FINE NEEDLE ASP FIRST EVAL  
0311  
88172  
$382.00  
CYTOPATHOLOGY FLUIDS WASHINGS OR BRUSHINGS SMEARS WITH INTERPRET  
0311  
88104  
$224.00  
CYTOPATHOLOGY FNA INTERP/REPORT EVALUATION OF FINE NEEDLE ASP  
0311  
88173  
$202.00  
CYTOPATHOLOGY SMEAR CONE CONCENTRATION TECHNIQUE SMEARS/INTERP  
0311  
88108  
$138.00  
CYTOPATHOLOGY SMEARS SLIDES MADE PREP SCREENING AND INTERP  
0311  
88161  
$238.00  
CYTOPATHOLOGY SMEARS SLIDES RECEIVED SCREENING/INTERPRETATION  
0311  
88160  
$164.00  
CYTOPATHOLOGY THIN LAYER PAP CERVICAL/VAGINAL PREP AND MANUAL  
0311  
88142  
$82.00  
D-DIMER, QUANT  
0305  
85379  
$98.00  
DEBRIDEMENT BONE MUSCLE &/FASCIA 20 SQ CM/<  
0510  
11044  
$2,815.00  
DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/<  
0510  
11043  
$1,122.00  
DEBRIDEMENT MUSCLE &/FASCIA EA ADDL 20 SQ CM  
0510  
11046  
$964.00  
DEBRIDEMENT OPEN WOUND 20 SQ CM/<  
0510  
97597  
$497.00  
DEBRIDEMENT OPEN WOUND EACH ADDL 20 SQ CM  
0510  
97598  
$497.00  
DEBRIDEMENT SQ, EA ADDTNL 20 SQ CM  
0510  
11045  
$964.00  
DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<  
0510  
11042  
$591.00  
DECALCIFICATION PROCEDURES LIST SEPARATE IN ADDITION TO CODE  
0312  
88311  
$54.00  
DECLOT OF ACCESS DEVICE/CATH  
0761  
36593  
$523.00  
DECLOTTING BY THROMB AGENT-IMPL VAD  
0510  
36593  
$523.00  
DEFIB PAD (4230)  
0270  
 
Variable  
DELIVERY BIRTHING ROOM RESUCITATION  
0410  
99465  
$562.00  
DHEA (UNCONJUGATED)  
0301  
82626  
$84.00  
DHEA SULFATE-SEND OUT TEST  
0301  
82627  
$90.00  
DIABETES O/P SELF MGMT TRAIN GRP 2+ PER 30 MIN  
0942  
G0109  
$44.00  
DIABETES O/P SELF MGMT TRAINING SERVICES INDIV PER 30 MIN  
0942  
G0108  
$101.00  
DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS  
0360  
38222  
$3,639.00  
DIAGNOSTIC BONE MARROW; ASPIRATION(S)  
0360  
38220  
$1,770.00  
DIAGNOSTIC BONE MARROW; BIOPSY(IES)  
0360  
38221  
$1,563.00  
DIALYSIS CATH IMPLANTABLE  
0278  
C1750  
Variable  
DIALYSIS CIRCUIT VASC EMBOLI OCCLS EVASC IMG S&I  
0360  
36909  
$19,899.00  
DIALYSIS GRAFT DUPLEX  
0921  
93990  
$526.00  
DIAMONDBACK-ROTATIONAL  
0272  
C1724  
Variable  
DIFFERENTIAL, MANUAL  
0305  
85007  
$35.00  
DIFFUSION STUDY  
0460  
94729  
$175.00  
DIGOXIN ASSAY  
0301  
80162  
$136.00  
DILANTIN, TOTAL  
0301  
80185  
$58.00  
DILATE NEPH/URETER/URETHERA  
0320  
74485  
$3,593.00  
DILATE-NEPHROSTOMY TRACT-ANG  
0360  
50395  
$4,562.00  
DIRECT BILIRUBIN  
0301  
82248  
$39.00  
DIRECT COOMBS  
0302  
86880  
$94.00  
DONJOY ULTRASLING 11  
0270  
 
Variable  
DONJOY ULTRASLING AB  
0270  
 
Variable  
DOPPLER LIMITED OR F/U  
0483  
93321  
$131.00  
DOSIMETRY CALC-BASIC-GAP-NSO  
0333  
77300  
$417.00  
DRAIN ATRIUM HEART (6879)  
0270  
 
$119.00  
DRAIN CHEST ATRIUM #3600 (6878)  
0270  
 
$95.00  
DRAIN CHEST ATRIUM MINI 500 EX (7750)  
0270  
 
$191.00  
DRAIN PLEUX BOTTLE (9121)  
0270  
 
$184.00  
DRAIN VENTRICULAR (9122)  
0270  
 
$531.00  
DRAIN, 8FR FLEXI-FIRM PIGTAIL  
0272  
 
$237.00  
DRAINAGE CATHETER  
0272  
C1729  
Variable  
DRESS FERRIS POLYMEM (7392)  
0270  
 
$73.00  
DRESSING AND OR DEBRIDEMENT PRTL-THKNS BURNS MEDIUM  
0510  
16025  
$591.00  
DRESSING PROMOGRAN PRISMA MATRIX  
0272  
 
$69.00  
DRESSING VERAFLO (8056)  
0272  
 
$339.00  
DRESSING VERAFLO CLEANSE WHITE MEDIUM (8119)  
0272  
 
$375.00  
DRIVING OCCUPATIONAL THERAPY EVALUATION  
0430  
 
$232.00  
DRUG TEST(S) LC/MS OR GC/MS 1-7 DRUG CLASSES  
0301  
G0480  
$564.00  
DRUG TESTS DEFINITIVE MULTI METHOD 15-21 CLASSES  
0301  
G0482  
$537.00  
DRUG TESTS PRESUMPTIVE ANY NUMBER CLASSES, PER DATE OF SERVICE  
0300  
80307  
$302.00  
DRUG TESTS PRESUMPTIVE ANY NUMBER CLASSES, PER DOS  
0300  
80307  
$302.00  
DRUG(S) DEFINITIVE QUAL OR QUANT NOS 1-3  
0301  
80375  
$88.00  
D-STAT DRY PATCH  
0271  
 
$165.00  
DUPLEX SCAN ABDOMINAL,PELVIC,SCROTAL,RETROPERIONEAL-LIMITED STUD  
0921  
93976  
$1,016.00  
DUPLEX SCAN EXTRACRANIAL ARTERIES-COMPLETE BILATERAL STUDY  
0921  
93880  
$735.00  
DUPLEX SCAN EXTRACRANIAL ARTERIES-UNILATERAL OR LIMITED STUDY  
0921  
93882  
$503.00  
DUPLEX SCAN LOWER EXTREMITY,ARTERIAL/GRAFT-UNILATERAL OR LIMITED  
0920  
93926  
$634.00  
EACH ADDITIONAL CYST  
0360  
19001  
$154.00  
EACH ADDITIONAL TISSUE BLOCK WITH FROZEN SECTIONS PATH CONSULT  
0312  
88332  
$145.00  
EBUS  
0360  
 
$2,139.00  
ECG 12 LEAD  
0730  
93005  
$155.00  
ECT BONE SCAN  
0341  
78320  
$1,677.00  
ECT BRAIN SCAN  
0341  
78607  
$4,452.00  
ED FACILITY FEE CLASS 1  
0450  
99281  
$278.00  
ED FACILITY FEE CLASS 2  
0450  
99282  
$590.00  
ED FACILITY FEE CLASS 3  
0450  
99283  
$862.00  
ED FACILITY FEE CLASS 4  
0450  
99284  
$1,394.00  
ED FACILITY FEE CLASS 5  
0450  
99285  
$1,955.00  
ED LAB CHLORIDE  
0301  
82435  
$27.00  
ED PROCEDURE LEVEL 1  
0450  
 
$245.00  
ED PROCEDURE LEVEL 2  
0450  
 
$375.00  
ED PROCEDURE LEVEL 3  
0450  
 
$767.00  
ED PROCEDURE LEVEL 4  
0450  
 
$905.00  
ED PROCEDURE LEVEL 5  
0450  
 
$1,440.00  
EEG AWAKE AND ASLEEP 20-40 MIN  
0740  
95819  
$968.00  
EEG AWAKE AND DROWSY 20-40 MIN  
0740  
95816  
$635.00  
EEG EXTENDED, 41-60 MIN  
0740  
95812  
$1,181.00  
EEG EXTENDED, GREATER THAN 60 MIN  
0740  
95813  
$1,393.00  
EEG, AMBULATORY OR LONG TERM, 24 HRS  
0740  
95953  
$1,703.00  
EEG, VIDEO FOR SEIZURES, 24 HRS  
0740  
95951  
$2,346.00  
ELBOW ORTHOSIS W/O JOINTS CUSTOM FABRICATED  
0274  
L3702  
$403.00  
ELBOW ORTHOSIS WITH ADJ LOCK JNT PREFABRICATED W/ EXPERTISE  
0274  
L3760  
$697.00  
ELECTROLYTES, SERUM  
0301  
80051  
$44.00  
ELECTRONS, TELETHERAPY PLAN  
0333  
77321  
$1,152.00  
EMBOLIZATION COILS/PARTICLES  
0278  
 
Variable  
EMBOLIZATION PROTECTIVE DEVICE  
0272  
C1884  
Variable  
ENDOLUMINAL BX BILIARY TREE PERQ ANY METH SINGLE/MULTI  
0360  
47543  
$5,520.00  
ENDOLUMINAL CORONARY IVUS OCT I&R EA ADDL VESSEL  
0480  
92979  
$513.00  
ENDOLUMINAL CORONARY IVUS OCT I&R INITIAL VESSEL  
0480  
92978  
$1,001.00  
ENDOTRACH INTUBATION  
0360  
31500  
$1,097.00  
ENT NASOPHARYNGOSCOPE  
0510  
92511  
$257.00  
ENZYME ACTIV BLD, CELLS OR TISSUE; NONRADIOACTIVE SUBSTRATE, EA  
0301  
82657  
$181.00  
EP & ABLATE SUPRAVENT ARRHYT  
0481  
93653  
$24,388.00  
EP & ABLATE VENTRIC TACHY  
0481  
93654  
$26,062.00  
EP ABLATION 3D/VECTOR (CT)  
0272  
C1732  
Variable  
EP ABLATION 3D/VECTOR (NON CT)  
0272  
C1733  
Variable  
EP ABLATION NON 3D/VECTOR (CT)  
0272  
C2630  
Variable  
EP CATH NON 3D-20 OR MORE ELECTRODES  
0272  
C1731  
Variable  
EP CATH NON-3D 19 OR LESS ELECT  
0272  
C1730  
Variable  
EP EVAL + TEST ICD; INI OR REP  
0480  
93641  
$5,748.00  
EP MAPPING OF TACHYCARDIA  
0480  
93609  
$571.00  
EP SHEATH FIXED NON PEEL-AWAY  
0272  
C1893  
Variable  
EP SHEATH FIXED PEEL-AWAY  
0272  
C1892  
Variable  
EP SHEATH STEERABLE NON-PEEL  
0272  
C1766  
Variable  
EPIDURAL BLOCK ADDL MINUTE  
0370  
 
$4.55  
EPIDURAL BLOCK FIRST 15 MINUTES  
0370  
 
$284.00  
EPIDURAL TRAY (4222)  
0270  
 
Variable  
EPIFIX, PER SQ CENTIMETER  
0278  
Q4131  
Variable  
EPSTEIN BARR AB TO EARLY AG  
0302  
86663  
$84.00  
EPSTEIN BARR AB TO NUCLEAR AG  
0302  
86664  
$101.00  
EPSTEIN BARR AB VCA  
0302  
86665  
$70.00  
EPSTEIN BARR AB VCA  
0306  
86665  
$70.00  
ERCP  
0360  
 
$4,512.00  
ERCP-DW  
0320  
74330  
$739.00  
ERYTHROPOIETIN ASSAY  
0301  
82668  
$77.00  
ESOPHAGEAL MOTILITY  
0750  
91010  
$2,145.00  
ESOPHAGOGASTRODUODENOSCOPY W/INJ SCLEROSIS ESOPH/GASTRIC VARICES  
0360  
43243  
$632.00  
ESOPHAGOSCOPY  
0360  
 
$1,449.00  
ESOPHAGUS-DW  
0320  
74220  
$526.00  
ESTRADIOL  
0301  
82670  
$146.00  
ESTROGEN FRACTIONATION  
0301  
82671  
$182.00  
ETHOSUXIMIDE ASSAY (ZARONTIN)  
0301  
80168  
$56.00  
ETHYLENE GLYCOL  
0301  
82693  
$202.00  
EVAL FOR SPEECH DEVICE RX EACH ADDL 30 MIN  
0444  
92608  
$235.00  
EVAL NON SPEECH GEN AUGMENT ALTERNATIVE COMM DEVICE 1ST HR  
0440  
92605  
$235.00  
EVAL NON SPEECH GEN AUGMENT ALTERNATIVE COMM DEVICE 1ST HR  
0440  
 
$235.00  
EVAL OF PT NEBULIZER  
0410  
94664  
$161.00  
EVAL OF SPEECH FLUENCY  
0440  
92521  
$235.00  
EVAL OF SPEECH PRODUCTION  
0440  
 
$235.00  
EVAL OF SPEECH PRODUCTION  
0440  
92522  
$235.00  
EVAL OF SPEECH PRODUCTION W/LANG COMP & EXPRESSION  
0440  
 
$235.00  
EVAL OF SPEECH PRODUCTION W/LANG COMP & EXPRESSION  
0440  
92523  
$235.00  
EVAL PACG CVDFB PROGRM/REPROGRM PARAMETERS  
0480  
93642  
$1,601.00  
EVAL PRESCRIPT SPEECH GENERAT AUG DEVICE FACE TO FACE 1ST HR  
0440  
92607  
$235.00  
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION  
0440  
 
$235.00  
EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION  
0440  
92610  
$235.00  
EVASC PLMT ILIAC ART OCCLS DEVICE  
0360  
34808  
$230.00  
EVASC PLMT PROX XTN PRSTH DESC THORAC AORTA RS&I  
0320  
75958  
$3,568.00  
EVASC RPR DESCND THORCIC AORTA CELIAC ORIG RS&I  
0320  
75957  
$3,568.00  
EVASC RPR DESCND THORCIC AORTA SUBCLAV ORIG RS&I  
0320  
75956  
$3,568.00  
EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT  
0360  
34705  
$35,004.00  
EVASC RPR DPLMNT AORTO-UN-ILIAC NDGFT  
0360  
34703  
$35,004.00  
EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH  
0360  
33880  
$20,524.00  
EVASC RPR DTA EXP COVERAGE W/O ART ORIGIN  
0360  
33881  
$20,524.00  
EVENT MONITOR HOOK UP  
0731  
93270  
$302.00  
EVENT RECORDER CARDIAC  
0278  
C1764  
Variable  
EWHO RIGID W/O JOINTS CUSTOM FABRICATED  
0274  
L3763  
$1,092.00  
EXCHANGE BILIARY DRAIN CATH W/IMG GID RS&I  
0360  
47536  
$4,259.00  
EXCHANGE DRAINAGE CATH  
0360  
49423  
$3,344.00  
EXPLORATORY LAP W/WO BIOPSY  
0360  
49000  
$2,622.00  
EXPORT ASPIRATION CATHETER  
0272  
C1757  
$5,769.00  
EXT VENOUS DUPLEX BILATERAL UE/LE  
0921  
93970  
$754.00  
EXT VENOUS DUPLEX UNILATERAL UE/LE  
0921  
93971  
$533.00  
EXTERNAL CEPHALIC VERSION WITH OR WITHOUT TUCOLYSIS  
0761  
59412  
$2,042.00  
EXTRACTABLE NUCLEAR ANTIGEN  
0300  
86235  
$74.00  
EXTREMITY BILATERAL-ANG  
0320  
75716  
$6,294.00  
EXTREMITY VENOGRAPHY-BILATERAL  
0320  
75822  
$2,030.00  
EXTREMITY VENOGRAPHY-UNILATERAL  
0320  
75820  
$2,030.00  
EZ-IO INTRAOSSEOUS NEEDLE  
0272  
 
$359.00  
F2 GENE ANALYSIS PT COAG FACTOR II  
0300  
81240  
$352.00  
F5 GENE ANALYSIS LEIDEN VARIANT  
0300  
81241  
$322.00  
FACTOR 8 RISTOCETIN COFACTOR  
0302  
85245  
$158.00  
FACTOR IX ACTIVITY  
0302  
85250  
$147.00  
FACTOR VIII ACTIVITY  
0302  
85240  
$105.00  
FACTOR VIII RELATED ANTIGEN  
0302  
85246  
$182.00  
FATS OR LIPIDS, FECES; QUALITATIVE  
0301  
82705  
$18.00  
FECAL FAT 72 HR  
0301  
82710  
$105.00  
FECAL LACTOFERRIN QUAL  
0301  
83630  
$77.00  
FEMSTOP COMPRESSION ARCH (9057)  
0270  
 
$247.00  
FERRITIN  
0301  
82728  
$123.00  
FETAL CGEN ABNOR FOUR ANALYTES  
0300  
81511  
$384.00  
FETAL CGEN ABNOR TWO PROTEINS  
0300  
81508  
$243.00  
FETAL FIBRONECTIN  
0301  
82731  
$458.00  
FETAL NON STRESS TEST  
0920  
59025  
$441.00  
FIBRINOGEN LEVEL  
0302  
85384  
$74.00  
FILTER VAPOR CLEAN (433939)  
0270  
 
$219.00  
FINE NEEDLE ASP W/O GUIDANCE  
0360  
10021  
$591.00  
FINE NEEDLE ASPIRATION W/IMAGING GUIDANCE  
0360  
10022  
$1,101.00  
FINGER OTHOSIS W/O JOINTS CUSTOM FABRICATED  
0274  
L3933  
$298.00  
FIRST TISSUE BLOCK WITH FROZEN SECTIONS SINGLE SPECIMEN CONSULT  
0312  
88331  
$382.00  
FLEXIBLE ENDO EVAL SWALLOW C/V RECORDING  
0440  
92612  
$235.00  
FLEXIBLE ENDO EVAL SWALLOW C/V RECORDING  
0440  
 
$235.00  
FLEXIBLOCK ECHO CATH 17GA X 9CM (442077)  
0270  
 
$97.00  
FLOW CYTO EA ADD MARKER  
0301  
88185  
$136.00  
FLOW CYTO FIRST CELL MARKER  
0301  
88184  
$638.00  
FLOW CYTOMETRY EACH ADDL  
0305  
88185  
$88.00  
FLOW CYTOMETRY FIRST MARKER  
0301  
88184  
$638.00  
FLUIDOTHERAPY  
0420  
97039  
$66.00  
FLUIDOTHERAPY  
0430  
97039  
$66.00  
FLUORESCENT NONINFECTIOUS AGENT ANTIB  
0301  
86256  
$77.00  
FLUORESCENT NONINFECTIOUS AGENT, EACH ANTIBODY  
0301  
86255  
$72.00  
FLUORO CVC PLACE REPLAC REM  
0320  
77001  
$278.00  
FLUORO GUIDE NEEDLE PLCMNT  
0320  
77002  
$423.00  
FLUORO NEEDLE GUIDE, SPINAL  
0320  
77003  
$348.00  
FLUOROSCOPY UP TO 1 HOUR  
0320  
76000  
$416.00  
FO PIP/DIP W/O JNT/SPR EXT/FLEX PREFABRICATED  
0274  
L3927  
$48.00  
FO PIP/DIP WITH NONTORS JNT/SPRING PREFABRICATED  
0274  
L3925  
$91.00  
FOLATE ASSAY  
0301  
82746  
$92.00  
FSH  
0301  
83001  
$113.00  
FUHRMAN DRAINAGE TUBE  
0272  
C1729  
$308.00  
FULL POWERGLIDE 18G X 10CM (435160)  
0278  
C1751  
$246.00  
FULL POWERGLIDE 18G X 8CM (435158)  
0278  
C1751  
$246.00  
FULL POWERGLIDE 20G X 10CM (435156)  
0278  
C1751  
$226.00  
FULL POWERGLIDE 20G X 8CM (435154)  
0278  
C1751  
$226.00  
FUNGUS ANTIBODIES  
0302  
86671  
$68.00  
G TUBE 24FR (420098)  
0272  
 
$88.00  
G/J TUBE CHANGE W/FLUORO  
0360  
49452  
$2,535.00  
GABAPENTIN QUANTITATIVE  
0301  
80171  
$95.00  
GALL BLADDER TUBE PLCMENT  
0360  
47490  
$4,605.00  
GARDNERELLA DNA PROBE  
0306  
87510  
$74.00  
GASES, BLOOD ARTERIAL OR VENOUS  
0301  
82803  
$182.00  
GASTRIC EMPTYING-NM  
0341  
78264  
$1,295.00  
GASTRIC LAP BAND ADJUSTMENT  
0510  
43999  
$95.00  
GASTRIN, SERUM RIA  
0301  
82941  
$73.00  
GASTRO TUBE CHANGE/REPOSITION  
0360  
9018479  
$886.00  
GASTROCCULT  
0307  
82271  
$26.00  
GASTROESOPH RFLX TST (PH)  
0750  
91034  
$926.00  
GASTRO-JEJUNOSTOMY TUBE REPLACEMENT W/FLOUROSCOPY  
0320  
49452  
$2,535.00  
GASTROSCOPY - SIMPLE  
0360  
 
$1,875.00  
GASTROSTOMY TUBE CHANGE W/FLUORO  
0360  
49450  
$1,963.00  
GATED CARDIAC SCAN-NM  
0341  
78472  
$1,295.00  
GENERAL HEALTH PANEL  
0300  
80050  
$267.00  
GENERATOR, NEUROSTIM (IMPLANT), HIGH FREQ, W/RECHA  
0278  
C1822  
Variable  
GENERATOR,NEUROSTIM (IMPLANT),W/RECHA  
0278  
C1820  
Variable  
GENERATOR,NEUROSTIMULATOR (IMPLANTABL  
0278  
C1767  
Variable  
GENTAMICIN - RANDOM  
0301  
80170  
$126.00  
GGT  
0301  
82977  
$32.00  
GI BLOOD LOSS SCAN-NM  
0341  
78278  
$1,295.00  
GIARDIA ANTIGEN BY EIA  
0306  
87329  
$75.00  
GLUCOSE 6 PD QUANTITATIVE  
0301  
82955  
$95.00  
GLUCOSE ASSAY  
0301  
82947  
$27.00  
GLUCOSE ASSAY, POST DOSE  
0301  
82950  
$73.00  
GLUCOSE BODY FLUID  
0301  
82945  
$39.00  
GLUCOSE TOL TEST, EACH ADDN  
0301  
82952  
$35.00  
GLYCOSYLATED HEMOGLOBIN  
0301  
83036  
$73.00  
GRAFTJACKET  
0278  
Q4107  
Variable  
GRAM STAIN  
0306  
87205  
$53.00  
GROSHONG CATHETER  
0278  
C1751  
Variable  
GROUP 1 GMS STAINS FOR MICROORGANISM  
0312  
88312  
$301.00  
GROUP 1 PNEUMOCYSTIS FUNGAL STAINS FOR MICROORGANISM  
0312  
88312  
$301.00  
GROUP 2 SPECIAL STAINS ALL OTHER  
0312  
88313  
$145.00  
GROWTH HORMONE ASSAY  
0301  
83003  
$87.00  
GTUBE REMOVE/CHECK  
0761  
99211  
$174.00  
GUIDANCE FOR LOC OF TARGET VOL RADIAJ TX DLVR  
0333  
77387  
$320.00  
GUIDANCE PERCUTANEOUS DRAIN W/CATH  
0320  
75989  
$568.00  
GUIDANCE PERCUTANEOUS DRAINAGE W/PLACEMENT OF CATHETER  
0350  
75989  
$568.00  
GUIDE CATHETER  
0272  
C1887  
Variable  
GUIDE WIRE  
0272  
C1769  
Variable  
GUIDEWIRE  
0272  
C1769  
Variable  
H PYLORI (C-13) BREATH ANALYSIS UREASE ACT NON-RADACT ISTOPE  
0300  
83013  
$225.00  
H PYLORI ANTIGEN STOOL  
0306  
87338  
$124.00  
HAND FINGER ORTHOSIS W/O JNTS PREFABRICATED OTS  
0274  
L3924  
$110.00  
HAND FINGER ORTHOSIS W/O JNTS PREFABRICATED W/ EXPERTISE  
0274  
L3923  
$138.00  
HAND FINGER ORTHOSIS W/O JOINTS CUSTOM FABRICATED  
0274  
L3913  
$378.00  
HAPTOGLOBIN  
0301  
83010  
$73.00  
HAWKINS-AKINS 18G NEEDLE  
0272  
 
$105.00  
HCG SCREEN  
0301  
84703  
$67.00  
HCG, URINE  
0307  
81025  
$48.00  
HCHRG AMNIOCENTESIS-DIAGNOSTIC  
0360  
59000  
$684.00  
HCHRG FINE NEEDLE ASPIRATION W/IMAGING GUIDANCE  
0360  
10022  
$1,101.00  
HCV GENOTYPE  
0301  
87902  
$858.00  
HCV RNA QUANT BY PCR ULTRASEN  
0301  
87522  
$437.00  
HDR ELECTRONIC BRACHYTHERAPY SKIN  
0333  
0394T  
$1,049.00  
HEART VALVE  
0278  
 
Variable  
HEEL WEDGE  
0274  
L3350  
$35.00  
HELICOBACTER PYLORI IGG  
0306  
86677  
$86.00  
HELIUM/OXYGEN DAILY  
0271  
 
$361.00  
HEMATOCRIT (AUTOMATED)  
0305  
85014  
$26.00  
HEMOCHROMATOSIS GENE ANALYSIS  
0300  
81256  
$365.00  
HEMOGLOBIN (AUTOMATED)  
0305  
85018  
$26.00  
HEMOGLOBIN CHROMOTOGRAPHY  
0305  
83021  
$64.00  
HEMOGLOBIN FRACTJ/QUANTJ ELECTROPHORESIS  
0301  
83020  
$54.00  
HEMOSIDERIN, URINE  
0305  
83070  
$108.00  
HEPARIN ASSAY  
0305  
85520  
$146.00  
HEPARIN NEUTRALIZATION  
0300  
85525  
$47.00  
HEPARIN-PF4 ANTIBODY (HIT)  
0302  
86022  
$318.00  
HEPATIC FUNCTION PANEL  
0301  
80076  
$101.00  
HEPATITIS A ANTIBODY (IGM)  
0301  
86709  
$64.00  
HEPATITIS A VIRUS AB, TOTAL  
0301  
86708  
$80.00  
HEPATITIS B CORE AB (IGM)  
0301  
86705  
$94.00  
HEPATITIS B CORE ANTIBODY, TOT  
0301  
86704  
$163.00  
HEPATITIS B SURF AG  
0301  
87340  
$74.00  
HEPATITIS B SURG AG NEUTRALIZATION  
0302  
87341  
$92.00  
HEPATITIS B VIRAL DNA, PCR QUANT  
0306  
87517  
$300.00  
HEPATITIS BE ANTIBODY  
0300  
86707  
$62.00  
HEPATITIS BE ANTIGEN EIA  
0300  
87350  
$52.00  
HEPATITIS C ANTIBODY  
0301  
86803  
$125.00  
HERNIA MESH  
0278  
C1781  
Variable  
HEXAGONAL PHOS NEUT 85598  
0301  
85598  
$81.00  
HFO WITH 1 OR MORE NONTORSION JNTS CUSTOM FABRICATED  
0274  
L3921  
$448.00  
HIAA-5 24HR URINE  
0301  
83497  
$76.00  
HIGH FLOW THERAPY (432406)  
0270  
 
$304.00  
HIGH SENSITIVITY CRP  
0301  
86141  
$115.00  
HIP ABDUCTION PILLOW 1916S/M/L  
0270  
 
Variable  
HISTOPLASMA YEAST  
0306  
86698  
$47.00  
HIV 1 AND HIV 2 ANTIBODIES WITH HIV 1 ANTIGEN  
0302  
87389  
$148.00  
HIV 1 ANTIBODY  
0302  
86701  
$190.00  
HIV 2 ANTIBODY  
0302  
86702  
$77.00  
HIV1 QUANT BY RNA OR DNA  
0306  
87536  
$421.00  
HLA B27  
0300  
86812  
$126.00  
HLA CLASS I&II ANTIBODY QUAL  
0300  
86828  
$173.00  
HLA I TYPING 1 LOCUS LR  
0300  
81373  
$523.00  
HLA II, HIGH RESOLUTION, 1 ALLELE OR ALLELE GROUP, EACH  
0310  
81383  
$452.00  
HLA II, LOW RESOLUTION, 1 LOCUS, EACH  
0310  
81376  
$507.00  
HLTH & BEHAVIOR ASSMT EA 15 MIN W/PT, INITIAL  
0900  
96150  
$129.00  
HLTH & BEHAVIOR INTERVENTION EA 15 MIN W/PT  
0900  
96152  
$129.00  
HOLTER MONITOR UP TO 48 HR-HOOKUP  
0731  
93225  
$366.00  
HOLTER MONITOR UP TO 48 HR-W/REPORT  
0731  
93226  
$612.00  
HOMOCYSTEINE  
0301  
83090  
$101.00  
HOMOGENIZE TISSUE  
0306  
87176  
$46.00  
HOT ICE PAD (7345)  
0270  
 
$150.00  
HOVER MAT DISP (7652)  
0270  
 
$213.00  
HPYORI DRUG ADMINISTRATION  
0300  
83014  
$32.00  
HSV TYPE 1 AND 2, IGM AB  
0306  
86694  
$65.00  
HSV TYPE 1, IGG AB  
0302  
86695  
$56.00  
HSV TYPE 2, IGG AB  
0302  
86696  
$67.00  
HYSTEROSALPINGOGRAM-DW  
0320  
74740  
$861.00  
I & D ABSCESS COMPLICATED/MULTIPLE  
0510  
10061  
$598.00  
I & D ABSCESS SIMPLE/SINGLE  
0510  
10060  
$308.00  
IADNA DNA/RNA ZIKA VIRUS AMPLIFIED PROBE TQ  
0306  
87662  
$171.00  
IADNA ENTEROVIRUS AMPLIF PROBE & REVRSE TRNSCRIP  
0306  
87498  
$117.00  
IADNA STREPTOCOCCU GROUP B AMPLIFIED PROBE TQ  
0306  
87653  
$130.00  
IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH  
0306  
87661  
$117.00  
IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 6-11  
0306  
87506  
$711.00  
ICD GENERATOR BI-V  
0275  
C1882  
Variable  
ICD GENERATOR DUAL CH  
0275  
C1721  
Variable  
ICD GENERATOR SINGLE CH  
0275  
C1722  
Variable  
IDENTIFICATION SENTINEL NODE  
0360  
38792  
$1,295.00  
ILEOSCOPY/JEJUNOSCOPY  
0360  
 
$3,377.00  
IMAGE GUIDE FLUID COLLECT CATH,PE/RETROPE/PERQ  
0360  
49406  
$3,274.00  
IMAGE GUIDE FLUID COLLECT CATH,SOFT TISSUE,PERQ  
0360  
10030  
$2,832.00  
IMAGE GUIDE FLUID COLLECT CATH,VISCERAL,PERQ  
0360  
49405  
$2,866.00  
IMMATURE PLATELET FRACTION  
0305  
85055  
$136.00  
IMMUNIZATION ADMIN-ONE VACCINE  
0771  
90471  
$97.00  
IMMUNIZATION: EA ADDL VACC  
0771  
90472  
$57.00  
IMMUNOASSAY FOR ANALYTE QUAL OR SEMIQUANT MULTI STEP  
0301  
83516  
$73.00  
IMMUNOASSAY FOR ANALYTE QUANT BY RIA  
0301  
83519  
$125.00  
IMMUNOASSAY FOR ANALYTE QUANTITATIVE  
0301  
83520  
$74.00  
IMMUNOASSAY FOR INF AGENT QT,HEP B SU  
0301  
86317  
$82.00  
IMMUNOASSAY TUMOR ANTIGEN QUANT 15-3 (27.29)  
0302  
86300  
$89.00  
IMMUNOASSAY, EACH  
0301  
83520  
$74.00  
IMMUNOFIXATION PROCEDURE  
0301  
86334  
$266.00  
IMMUNOFIXATION URINE  
0301  
86335  
$266.00  
IMMUNOGLOBULIN  
0301  
82784  
$104.00  
IMMUNOGLOBULIN IGE  
0301  
82785  
$64.00  
IMMUNOGLOBULIN SUBCLASSES 1 2 3 OR 4 EACH  
0301  
82787  
$42.00  
IMMUNOHISTOCHEM PER SPEC EA ADDL SINGLE AB STAIN  
0312  
88341  
$290.00  
IMMUNOHISTOCHEM PER SPEC EA MULTIPLEX AB STAIN  
0312  
88344  
$638.00  
IMMUNOHISTOCHEM PER SPEC INITIAL AB STAIN  
0312  
88342  
$638.00  
IMMUNOSAY INFECTIOUS AGENT AB OR AG QUAL OR SEMI QUAL  
0301  
83516  
$73.00  
IMPELLA 2.5  
0275  
 
Variable  
IMPLANT, INFUSION PORT  
0278  
C1788  
Variable  
IMPLANTED VENOUS ACCESS DEVICE IRRIGA  
0510  
96523  
$78.00  
IMPLATABLE WIRELESS PULM ARTERY PRESSURE SENSOR W/ CATH  
0278  
C2624  
Variable  
IMPLT PT-ACT CARD EVENT REC  
0360  
33282  
$10,880.00  
IN SITU HYBRIDIZATION EACH PROBE  
0310  
88365  
$382.00  
INCISION AND DRAINAGE HEMATOMA SEROMA OR FLUID COLLECTION  
0360  
10140  
$2,467.00  
INCISION AND DRAINAGE PELVIS OR HIP-DEEP  
0360  
26990  
$2,385.00  
INCISION AND DRAINAGE-SIMPLE OR SINGLE  
0360  
10060  
$308.00  
INEXSUFFLATOR TREATMENT  
0410  
 
Variable  
INF AG DET BY DNA OR RNA NOS QUANT EA ORGANISM  
0306  
87799  
$396.00  
INF AGENT BY DNA/RNA HSV AMP PROBE  
0306  
87529  
$150.00  
INF AGENT DET NUCL ACID CLOSTRIDIUM AMP PROBE  
0306  
87493  
$223.00  
INF AGENT DNA/RNA NOS AMP PROBE EA ORGANISM  
0306  
87798  
$232.00  
INF AGENT GENOTYPE DNA/RNA HEP B VIRUS  
0300  
87912  
$858.00  
INFECT AG BY NA CHLAMYDIA PNEUMONIAE AMP PROBE  
0306  
87486  
$159.00  
INFECT AGENT DET BY NA RESP VIRUS 12 TO 25 TARGETS  
0306  
87633  
$1,389.00  
INFECTION - LIMITED SCAN  
0341  
78805  
$4,452.00  
INFECTION - WHOLE BODY SCAN  
0341  
78806  
$4,452.00  
INFECTIOUS AGENT AG IMMUNOASSAY;HISTOPLASMA  
0306  
87385  
$163.00  
INFECTIOUS AGENT BY DNA/RNA STAPH AUREUS AMP PROBE  
0306  
87640  
$148.00  
INFECTIOUS AGENT DETECT NUCLEIC ACID  
0306  
87798  
$232.00  
INFLATION DEVICE (ELECT)  
0272  
 
$460.00  
INFLUENZA ANTIGEN A OR B, EACH  
0306  
87400  
$129.00  
INFUSION CATHETER  
0272  
C1751  
Variable  
INHALATION TREATMENT  
0410  
94640  
$161.00  
INHIBIN A  
0301  
86336  
$110.00  
INITIAL ORTHO MGMT TRAIN UP LOW EXTR OR TRUNK EA 15 MIN  
0430  
 
$113.00  
INITIAL ORTHO MGMT TRAIN UPPER LOWER EXTREMITY OR TRUNK EA 15 MIN  
0430  
97760  
$113.00  
INITIAL ORTHO MGMT TRAINING UPPER/LOWER EXTREM AND OR TRUNK EA 15 MIN  
0420  
 
$113.00  
INITIAL ORTHO MGMT TRAINING UPPER/LOWER EXTREM AND OR TRUNK EA 15 MIN  
0420  
97760  
$113.00  
INITIAL PROSTHETIC TRAINING 15 MIN  
0420  
97761  
$81.00  
INITIAL PROSTHETIC TRAINING 15 MIN  
0430  
97761  
$81.00  
INJ ANESTHETIC AGENT OTHER PERIPHERAL NERVE BLOCK  
0360  
64450  
$735.00  
INJ ANTEGRDE NFROSGRM AND/OR URTRGRM IMG GUIDE RS&I; NEW ACCESS  
0360  
50430  
$1,298.00  
INJ ANTEGRDE NFROSGRM AND/OR URTRGRM IMGGUIDE RS&I; EXISTING  
0360  
50431  
$1,298.00  
INJ CHOLANGIO W/IMG INCLUDE IMG GUIDANCE RS&I; EXSISTING ACCESS  
0360  
47531  
$871.00  
INJ CHOLANGIO W/IMG INCLUDE IMG GUIDANCE RS&I; NEW ACCESS  
0360  
 
$445.00  
INJ EVAL OF PREVIOUSLY PLACED PERITONEAL-VENOUS SH  
0360  
49427  
$583.00  
INJ KNEE ARTHROGRAPHY  
0360  
27370  
$305.00  
INJ LUMB/SAC DX/TX SUBST INCL NEEDL OR CATH W/GUID  
0350  
62323  
$1,328.00  
INJ PROC CONTRAST VENOGRAM  
0360  
36005  
$2,314.00  
INJ SELECTIVE LT VENTRICAL OR ART ANGIOGRAPHY  
0480  
93565  
$1,383.00  
INJ, INTERCOSTAL NERVES-MULTIPLE  
0360  
64421  
$1,746.00  
INJ, INTERCOSTAL NERVES-SINGLE  
0360  
64420  
$1,995.00  
INJ,ANES AGENT,FEMORAL,SINGLE  
0360  
64447  
$1,328.00  
INJ,ANES AGENT,INTERSCALENE,SINGLE  
0360  
64415  
$1,274.00  
INJECT,EVAL EXIST GASTRO OR G/J TUBE  
0360  
49465  
$513.00  
INJECTION EPIDURAL LUMBAR/SACRAL SINGLE LEVEL W/GUIDANCE  
0360  
64483  
$1,888.00  
INJECTION EPIDURAL OF BLOOD OR CLOT PATCH  
0360  
62273  
$786.00  
INJECTION FOR EVAL OF EXISTING CENTRAL VENOUS ACCESS DEVICE  
0360  
36598  
$490.00  
INJECTION PROCEDURE LOOP O GRAM  
0320  
50690  
$111.00  
INJECTION PROCEDURE SACROILIAC JOINT ARTHROGRAPHY AND/OR ANESTHE  
0360  
27096  
$826.00  
INJECTION PROCEDURE-CYSTOGRAM  
0320  
51600  
$140.00  
INJECTION PROCEDURE-ELBOW ARTHROGRAM  
0360  
24220  
$251.00  
INJECTION PROCEDURE-HIP ARTHROGRAM  
0360  
27093  
$536.00  
INJECTION PROCEDURE-SHOULDER ARTHROGRAM  
0360  
23350  
$1,022.00  
INJECTION PROCEDURE-URETHROCYSTOGRAPHY  
0360  
51610  
$263.00  
INJECTION PROCEDURE-WRIST ARTHROGRAM  
0360  
25246  
$376.00  
INJECTION SINUS TRACT DIAGNOSTIC  
0360  
20501  
$225.00  
INJECTION SQ OR IM TX,DX,PROPH  
0761  
96372  
$123.00  
INS/REP PERM CVDFB TRNSVEN LEADS 1/2 CHAMBER  
0480  
33249  
$36,245.00  
INS/REPL PERM PCMKR ART/VENT  
0360  
33208  
$16,523.00  
INS/REPL PERM PCMKR ATRIAL  
0360  
33206  
$19,083.00  
INS/REPL PERM PCMKR VENT  
0360  
33207  
$13,512.00  
INS/REPL PULSE GEN 1 CH A/V  
0360  
33212  
$13,112.00  
INS/REPLACE PERM SUBQ IMPLNT EFB W/SUBQ ELTRODE  
0481  
33270  
$30,449.00  
INSERT 1 TRANSVNS ELECTRODE PERM PM OR CVDFB  
0360  
33216  
$11,787.00  
INSERT 2 TRANSVNS ELECTRODE PERM PM OR CVDFB  
0360  
33217  
$8,696.00  
INSERT ELECTRODE CAR VEN SYS ATTCH PM/CVDFB PLS GEN  
0360  
33224  
$18,295.00  
INSERT ELECTRODE CAR VEN SYS TM INS PM/CVDFB PLS GEN  
0360  
33225  
$19,406.00  
INSERT HEPATIC SHUNT (TIPS)  
0360  
37182  
$4,989.00  
INSERT IAB ASSIST DEV PRQ  
0480  
33967  
$1,459.00  
INSERT INTRAVASCULAR VENA CAVA FILTER  
0480  
37191  
$10,282.00  
INSERT NON-TUN CV CATH,5YR OR OLDER  
0360  
36556  
$2,711.00  
INSERT TEMPORARY INDWELLING BLADDER CATHETER, SIMPLE (EG, FOLEY)  
0450  
51702  
$302.00  
INSERT TEMPORARY PACER  
0480  
92953  
$1,232.00  
INSERT TUNNEL CVC W/O PORT/PUMP >5YRS  
0360  
36558  
$5,424.00  
INSERT UTERINE TANDEMS OVOIDS  
0333  
57155  
$4,437.00  
INSERT VAD ARTERY ACCESS  
0481  
33990  
$2,749.00  
INSERTION FLOW DIRECTED CATH FOR MONITORING EG,SWAN-GANZ  
0480  
93503  
$4,202.00  
INSERTION OF DRUG DELIVERY IMPLANT  
0761  
11981  
$275.00  
INSERTION OF NON-INDWELLING BLADDER CATHETER  
0761  
51701  
Variable  
INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER SIMPLE  
0360  
51702  
Variable  
INSTILLATION, AGENT FOR FIBRINOLYSIS; INITIAL DAY  
0761  
32561  
$1,761.00  
INSTILLATION, AGENT FOR FIBRINOLYSIS; SUBSEQUENT DAY  
0761  
32562  
$1,761.00  
INSTILLATION, AGENT FOR PLEURODESIS  
0761  
32560  
$1,761.00  
INSULIN, SERUM  
0301  
83525  
$68.00  
INTENSITY MODULATED RADIATION TX DLVR COMPLEX  
0333  
77386  
$1,865.00  
INTENSITY MODULATED RADIATION TX DLVR SIMPLE  
0333  
77385  
$1,865.00  
INTERCEED 4350  
0272  
 
Variable  
INTERJECT GI SCLERO NEEDLE (421514)  
0272  
 
$164.00  
INTERPRETATION/REPORT  
0310  
88291  
$93.00  
INTERVENTN ABLATION (ARGON)  
0360  
 
$1,800.00  
INTERVENTN BAND LIGATION  
0360  
 
$1,965.00  
INTERVENTN BRUSHING/WASHING  
0360  
 
$133.00  
INTERVENTN BX  
0360  
 
$548.00  
INTERVENTN CONTROL OF BLEEDING  
0360  
 
$1,710.00  
INTERVENTN CRYOTHERAPY  
0360  
 
$1,576.00  
INTERVENTN DECOMPRESSION  
0360  
 
$1,277.00  
INTERVENTN DIL BALLOON/GUIDE  
0360  
 
$262.00  
INTERVENTN DIL NON BALLOON  
0360  
 
$377.00  
INTERVENTN ENDOSCOPIC US  
0360  
 
$1,710.00  
INTERVENTN FINE NEEDLE ASP  
0360  
 
$980.00  
INTERVENTN INSERT / REVISE TUBE  
0360  
 
$947.00  
INTERVENTN POLYP REMOVAL  
0360  
 
$1,452.00  
INTERVENTN REMOVE FB/STENT  
0360  
 
$870.00  
INTERVENTN REMOVE STONE  
0360  
 
$2,165.00  
INTERVENTN RFLX TST W BRAVO  
0750  
91035  
$5,570.00  
INTERVENTN SCLEROSIS INJ  
0360  
 
$1,123.00  
INTERVENTN SPHINCTER OF ODDI  
0360  
 
$1,200.00  
INTRA UTERINE PRESSURE CATHETER  
0272  
 
$112.00  
INTRACARDIAC ECHO/NO INTERP  
0480  
93662  
$4,135.00  
INTRAOSSEOUS NEEDLE PLACEMENT  
0360  
36680  
$233.00  
INTRAVASCULAR US NONCORONARY RS&I 1ST VESSEL  
0481  
37252  
$1,039.00  
INTRAVASCULAR US NONCORONARY RS&I ADDL VESSEL  
0481  
37253  
$515.00  
INTRO CATH DIALYSYS CIRCUIT DX ANGRAPH FLUOR S&I  
0360  
36901  
$1,378.00  
INTRO CATH DIALYSYS CIRCUIT W/TCAT PLMT IV STENT  
0360  
36903  
$19,651.00  
INTRO CATH DIALYSYS CIRCUIT W/TRLUML BALO ANGRIOP  
0360  
36902  
$9,723.00  
INTRO INTRACATH EXTRMTY ARTERY  
0360  
36140  
$591.00  
INTRO OF LONG GI TUBE  
0321  
74340  
$386.00  
INTRO OF LONG GI TUBE (NG,NJ)  
0360  
44500  
$2,072.00  
INTRODUCER NEEDLE (7324)  
0272  
 
$82.00  
INTRODUCER PERCU SHEATH KIT 9FR (6831)  
0270  
 
$161.00  
INTRODUCER SET (218005)  
0270  
 
$62.00  
INTRODUCER/SHEATH  
0272  
C1894  
Variable  
INTRODUCER/SHEATH,GUIDING,INTRACARDIA  
0272  
C1892  
Variable  
IONIZED CALCIUM  
0301  
82330  
$60.00  
IRON  
0301  
83540  
$29.00  
IRON STAIN  
0305  
85536  
$91.00  
ISLET CELL ANTIBODY  
0302  
86341  
$155.00  
IUD INSERTION  
0761  
58300  
$504.00  
IV INF HYDRATION ADDL HRS  
0761  
96361  
$126.00  
IV INF HYDRATION INITIAL 31 MIN TO 1 HR  
0761  
96360  
$420.00  
IV INF TX,DX,PROPH 1ST HR,1ST DRUG  
0761  
96365  
$454.00  
IV INF TX,DX,PROPH ADDL DRUG CCUR  
0761  
96368  
$211.00  
IV INF TX,DX,PROPH ADDL DRUG SEQ  
0761  
96367  
$285.00  
IV INF TX,DX,PROPH ADDL HRS  
0761  
96366  
$132.00  
IV PUSH TX,DX,PROPH EA ADDL NEW DRUG  
0761  
96375  
$173.00  
IV PUSH TX,DX,PROPH REPEAT SEQ DRUG  
0761  
96376  
$125.00  
IV PUSH TX,DX,PROPH SINGLE OR INITIAL  
0761  
96374  
$243.00  
IVUS CATHETER RADIOLOGY  
0272  
C1753  
Variable  
JAK2 GENE ANALYSIS  
0300  
81270  
$475.00  
JEJUNOSTOMY OR DUODENOSTOMY TUBE CHAN  
0360  
49451  
$1,444.00  
JO 1 ANTIBODY IGG  
0301  
86235  
$74.00  
JOINT DEVICE (IMPLANTABLE)  
0278  
C1776  
Variable  
JOINT SURVEY 1 VIEW 2+ JOINTS  
0320  
77077  
$425.00  
KIT FECAL MGMT SYSTEM FLEXISE (7606)  
0270  
 
$706.00  
KIT PERICARDIOCENTESIS (9067)  
0270  
 
$398.00  
KIWI OMNI EXTRACTOR (429990)  
0270  
 
$88.00  
KIWI PRO EXTRACTOR (429989)  
0270  
 
$88.00  
KLEIHAUER-BETKE (FETAL CELL)  
0305  
85460  
$115.00  
KNEE IMMOBILIZER CUSTOM 19  
0270  
 
Variable  
KNEE IMMOBILIZER CUSTOM 24  
0270  
 
Variable  
KOH PREP  
0306  
87210  
$51.00  
KOOL KIT 900  
0272  
 
$968.00  
L AND D EPID BLOCK ADDL MIN  
0370  
 
$4.80  
L AND D EPID BLOCK FIRST 15 MIN  
0370  
 
$284.00  
L AND D REGI BLOCK ADDL MIN  
0370  
 
$4.30  
L AND D REGI BLOCK FIRST 15 MIN  
0370  
 
$245.00  
L AND D SUR LVL 2 ADDL MIN  
0360  
 
$91.00  
L AND D SUR LVL 2 FIRST 15 MIN  
0360  
 
$2,405.00  
L AND D SUR LVL 3 ADDL MIN  
0360  
 
$118.00  
L AND D SUR LVL 3 FIRST 15 MIN  
0360  
 
$3,126.00  
L AND D SURG ANESTHESIA ADDL MIN  
0370  
 
$8.60  
L AND D SURG ANESTHESIA FIRST 15 MIN  
0370  
 
$380.00  
LAB HANDLING CHRG EXPANDED  
0301  
99001  
$56.00  
LACTATION EST 30 MIN  
0761  
99212  
$284.00  
LACTATION EST 45 MIN  
0761  
99213  
$326.00  
LACTATION EST 60 MIN  
0761  
99214  
$459.00  
LACTATION EST 75 MIN  
0761  
99215  
$534.00  
LACTATION NEW 15 MIN  
0761  
99201  
$175.00  
LACTATION NEW 30 MIN  
0761  
99202  
$302.00  
LACTATION NEW 45 MIN  
0761  
99203  
$428.00  
LACTATION NEW 60 MIN  
0761  
99204  
$546.00  
LACTATION NEW 75 MIN  
0761  
99205  
$687.00  
LACTIC ACID ASSAY  
0301  
83605  
$81.00  
LAMOTRIGINE QUANTITATIVE  
0301  
80175  
$76.00  
LANG COMP CURRENT STATUS  
0440  
G9159  
$0.01  
LANG COMP DISCHARGE STATUS  
0440  
G9161  
$0.01  
LANG COMP GOAL STATUS  
0440  
G9160  
$0.01  
LANG EXPRESS CURRENT STATUS  
0440  
G9162  
$0.01  
LANG EXPRESS DISCHARGE STATUS  
0440  
G9164  
$0.01  
LANG EXPRESS GOAL STATUS  
0440  
G9163  
$0.01  
LASER SHEATH II  
0272  
C2629  
$3,157.00  
LDH  
0301  
83615  
$27.00  
LDL-CHOLESTEROL, DIRECT  
0301  
83721  
$67.00  
LEAD LV REPOSITIONING  
0360  
33226  
$3,769.00  
LEAD ASSAY  
0301  
83655  
$94.00  
LEAD ENDOCARDIAL PACEMAKER  
0275  
C1898  
Variable  
LEAD ENDOCARDIAL PACEMKR C1898  
0275  
C1898  
Variable  
LEAD ICD,ENDO SINGLE COIL  
0278  
C1777  
Variable  
LEAD LEFT VENT COR VEN SYSTEM  
0275  
C1900  
Variable  
LEAD, ICD, ENDOCARD DUAL COIL  
0275  
C1895  
Variable  
LEAD, PACER/ICD  
0275  
C1899  
Variable  
LEAD,CARD-DEFIB,OTHER THAN ENDOCARD,SINGLE/DUAL  
0278  
C1896  
Variable  
LEAD,NEUROSTIMULATOR (IMPLANTABLE)  
0278  
C1778  
Variable  
LEGIONELLA DIRECT FLOURES AB  
0306  
87278  
$123.00  
LENS INTRAOCULAR  
0276  
C1780  
Variable  
LEVEL 1 EST PT EVAL AND MGMT  
0510  
99211  
$174.00  
LEVEL 1 EST PT EVAL AND MGMT  
0761  
99211  
$174.00  
LEVEL 1 NEW PT EVAL AND MGMT  
0761  
99201  
$175.00  
LEVEL 1 NEW PT OP VISIT  
0510  
99201  
$175.00  
LEVEL 1 SURGICAL PATHOLOGY GROSS EXAMINATION ONLY  
0312  
88300  
$85.00  
LEVEL 2 EST PT EVAL AND MGMT  
0510  
99212  
$284.00  
LEVEL 2 EST PT EVAL AND MGMT  
0761  
99212  
$284.00  
LEVEL 2 NEW PT EVAL AND MGMT  
0510  
99202  
$302.00  
LEVEL 2 NEW PT EVAL AND MGMT  
0761  
99202  
$302.00  
LEVEL 2 SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINATION  
0312  
88302  
$102.00  
LEVEL 3 EST PT EVAL AND MGMT  
0510  
99213  
$326.00  
LEVEL 3 EST PT EVAL AND MGMT  
0761  
99213  
$336.00  
LEVEL 3 EST PT EVAL AND MGMT  
0761  
99213  
$326.00  
LEVEL 3 NEW OP VISIT  
0510  
99203  
$428.00  
LEVEL 3 NEW PT EVAL AND MGMT  
0510  
99203  
$428.00  
LEVEL 3 NEW PT EVAL AND MGMT  
0761  
99203  
$428.00  
LEVEL 3 SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINATION  
0312  
88304  
$162.00  
LEVEL 4 EST PT EVAL AND MGMT  
0510  
99214  
$459.00  
LEVEL 4 EST PT EVAL AND MGMT  
0761  
99214  
$459.00  
LEVEL 4 NEW OP VISIT  
0510  
99204  
$546.00  
LEVEL 4 NEW PT EVAL AND MGMT  
0761  
99204  
$546.00  
LEVEL 4 SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINATION  
0312  
88305  
$221.00  
LEVEL 5 EST PT EVAL AND MGMT  
0510  
99215  
$534.00  
LEVEL 5 EST PT EVAL AND MGMT  
0761  
99215  
$534.00  
LEVEL 5 NEW OP VISIT  
0510  
99205  
$687.00  
LEVEL 5 NEW PT EVAL AND MGMT  
0761  
99205  
$687.00  
LEVEL 5 SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINATION  
0312  
88307  
$638.00  
LEVEL 6 SURGICAL PATHOLOGY GROSS AND MICROSCOPIC EXAMINATION  
0312  
88309  
$1,602.00  
LEVETIRACETAM (KEPPRA) QUANTITATIVE  
0301  
80177  
$162.00  
LH  
0301  
83002  
$116.00  
LHC BY TRANSSEPTAL PUNCTURE  
0480  
93462  
$5,714.00  
LHC/LV/COR ARTERY(S) W/GRAFTS,INCL IN  
0480  
93459  
$10,468.00  
LHC/LV/COR ARTERY(S),INCL INJ/S&I  
0480  
93458  
$10,218.00  
LIDOCAINE (XYLOCAINE)  
0301  
80176  
$111.00  
LIPASE  
0301  
83690  
$64.00  
LIPID SCREEN  
0301  
80061  
$179.00  
LIPOPROT BLD QT OF LIPOPROT PARTICLE NOS & PARITCS  
0301  
83704  
$105.00  
LIPOPROTEIN A  
0301  
83695  
$63.00  
LIPOPROTEIN A  
0301  
82172  
$57.00  
LIQUID PULMONARY SEALANT  
0278  
C2615  
Variable  
LITHIUM ASSAY  
0301  
80178  
$63.00  
LIVER BIOPSY PERCUT - US  
0360  
47000  
$2,164.00  
LIVER BIOPSY PERCUTANEOUS - CT  
0360  
47000  
$2,164.00  
LOOP O GRAM-DW  
0320  
74425  
$666.00  
LOW DOSE CT SCAN FOR LUNG CANCER SCREENING  
0350  
G0297  
$481.00  
LOWER BALLOON ENTEROSCOPY  
0360  
 
$3,378.00  
LOWER GI COLON-DW  
0320  
74270  
$526.00  
LOWER GI/COLON W/AIR CONT-DW  
0320  
74280  
$526.00  
LUMBAR PUNCTURE THERAPEUTIC DRAINAGE  
0360  
62272  
$1,293.00  
LUNG BIOPSY-ANG  
0360  
32405  
$839.00  
LUNG SCAN (PERFUSION) - NM  
0341  
78580  
$1,295.00  
LUNG VOLUMES  
0460  
94727  
$145.00  
LYME DISEASE AB  
0306  
86618  
$88.00  
LYME DISEASE AB WESTERN BLOT CONFIRMATORY TEST  
0302  
86617  
$52.00  
LYMPHOSCINTIGRAPHY  
0341  
78195  
$1,677.00  
M/PHMTRC ALYS ISH QUANT/SEMIQ MNL EACH  
0310  
88377  
$382.00  
M/PHMTRC ALYS ISHQUANT/SEMIQ CPTR EACH  
0310  
88374  
$382.00  
MAGNESIUM ASSAY  
0301  
83735  
$33.00  
MALARIA SMEAR  
0305  
87207  
$101.00  
MAMM-BREAST WIRE  
0272  
 
$68.00  
MAMMOGRAPHY DIAGNOSTIC CAD BILATERAL  
0401  
77066  
$437.00  
MAMMOGRAPHY DIAGNOSTIC CAD UNILATERAL  
0401  
77065  
$342.00  
MAMMOGRAPHY SCREENING 2 VIEW CAD BILATERAL  
0403  
77067  
$362.00  
MAMMOGRAPHY-DIAGNOSTIC DIGITAL IMAGE BILATERAL  
0401  
G0204  
$540.00  
MAMMOGRAPHY-DIAGNOSTIC DIGITAL IMAGE UNILATERAL  
0401  
G0206  
$421.00  
MAMM-VACUUM CANISTER  
0270  
 
$71.00  
MANIPULATION KNEE JOINT UNDER GENERAL ANESTHESIA  
0360  
27570  
$3,276.00  
MANUAL THERAPY TECHNIQUES 1+ REGIONS EA 15 MINUTES  
0420  
 
$118.00  
MANUAL THERAPY TECHNIQUES 1+ REGIONS EA 15 MINUTES  
0420  
97140  
$118.00  
MANUAL THERAPY TECHNIQUES 1+ REGIONS EA 15 MINUTES  
0430  
 
$118.00  
MANUAL THERAPY TECHNIQUES 1+ REGIONS EA 15 MINUTES  
0430  
97140  
$118.00  
MASS SPEC AND TANDEM MASS SPEC ANALYTE NOS QT EA  
0301  
83789  
$269.00  
MDI INSTRUCT  
0410  
94664  
$161.00  
MEAS POST VOID RESIDUAL URINE AND/OR BLADDER CAP NON IMAGING  
0761  
51798  
$389.00  
MECH REMV INTRA OBSTR MAT CV  
0321  
75902  
$211.00  
MECH REMV INTRA OBSTR MAT CV  
0360  
36596  
$1,784.00  
MED NUTRITION THERAPY INITIAL ASSESS INDIV 1/1 EA 15 MIN  
0942  
97802  
$56.00  
MED NUTRITION THERAPY REASSESS INDIV 1/1 EA 15 MIN  
0942  
97803  
$56.00  
MEDICAL NUTRITION THERAPY GROUP TWO+ INDIVIDUALS EACH 30 MIN  
0942  
97804  
$47.00  
MEDICAL NUTRITION THERAPY INITIAL ASSESS 1/1 EA 15 MIN  
0942  
97802  
$56.00  
MEDICAL NUTRITION THERAPY REASSESS INTERVEN IND 1/1 EA 15 MIN  
0942  
97803  
$56.00  
MEDICAL TEAM CONFERENCE WITH PT AND/OR FAMILY 3O MIN  
0420  
 
$153.00  
MEDICAL TEAM CONFERENCE WITH PT AND/OR FAMILY 3O MIN  
0420  
99366  
$153.00  
MEDICAL TEAM CONFERENCE WITH PT AND/OR FAMILY 3O+ MIN  
0430  
 
$153.00  
MEDICAL TEAM CONFERENCE WITH PT AND/OR FAMILY 3O+ MIN  
0430  
99366  
$153.00  
MEDTRONIC ANALYSIS W/ REPROGRAMMING  
0510  
62368  
$819.00  
MEDTRONIC ANALYSIS W/ REPROGRAMMING AND REFILL  
0510  
62369  
$991.00  
MEDTRONIC REFILL SPINAL(INTRATHECAL,EPIDURAL)OR BRAIN(INTRAVENTR  
0510  
95990  
$419.00  
MEMORY CURRENT STATUS  
0420  
G9168  
$0.01  
MEMORY CURRENT STATUS  
0430  
G9168  
$0.01  
MEMORY DISCHARGE STATUS  
0430  
G9170  
$0.01  
MEMORY DISCHARGE STATUS  
0440  
G9170  
$0.01  
MEMORY GOAL STATUS  
0420  
G9169  
$0.01  
MEMORY GOAL STATUS  
0430  
G9169  
$0.01  
MEMORY GOAL STATUS  
0440  
G9169  
$0.01  
MEMORY STATUS CURRENT  
0440  
G9168  
$0.01  
MERCURY BLOOD  
0301  
83825  
$89.00  
MESH (IMPLANTABLE)  
0278  
C1781  
Variable  
METANEPHRINES  
0301  
83835  
$119.00  
METANEPHRINES PLASMA FREE  
0301  
83835  
$119.00  
METHADONE AND METABOLITE, SERUM OR PLASMA, QUANT  
0301  
80358  
$88.00  
METHEMOGLOBIN  
0301  
83050  
$52.00  
METHOTREXATE ASSAY  
0301  
80299  
$84.00  
METHYLENEDIOXYAMPHETAMINES  
0301  
80359  
$149.00  
METHYLMALONIC ACID  
0301  
83921  
$75.00  
MIC GASTROSTOMY TUBE (KC) 20FR (6270)  
0272  
 
$92.00  
MICRO INTRODCUER GUIDEWIRE (430471)  
0270  
 
$114.00  
MICROALBUMIN  
0301  
82043  
$32.00  
MICROSOMAL ANTIBODY, EA  
0302  
86376  
$67.00  
MINI TRAY AND SET UP  
0270  
 
Variable  
MINI TRAY AND SET UP-CT  
0270  
 
Variable  
MISC PROCEDURE  
 
9000005  
Variable  
MITYVAC VACUUM EXTRACTOR (420422)  
0270  
 
$91.00  
MLC DEVICE FOR IMRT, PLAN  
0333  
77338  
$844.00  
MOBILITY CURRENT STATUS  
0420  
G8978  
$0.01  
MOBILITY CURRENT STATUS  
0430  
G8978  
$0.01  
MOBILITY DISCHARGE STATUS  
0420  
G8980  
$0.01  
MOBILITY GOAL STATUS  
0420  
G8979  
$0.01  
MODERATE SEDATION 5+ 1ST 15MIN  
0370  
99152  
$154.00  
MODERATE SEDATION AGE 0-4 INITIAL 15MIN  
0370  
99151  
$230.00  
MODERATE SEDATION AGE 5+ 1ST 15MIN  
0370  
99152  
$154.00  
MODERATE SEDATION EACH ADDL 15MIN  
0370  
99153  
$135.00  
MOLD ID  
0306  
87107  
$99.00  
MOLECULAR CYTOGENETICS DNA PROBE EA (FISH)  
0300  
88271  
$71.00  
MOLECULAR CYTOGENETICS INTERPHASE 100-300 CELLS  
0300  
88275  
$167.00  
MOLECULAR PATH PROC LEVEL 2  
0300  
81401  
$532.00  
MONITOR ANESTHESIA ADDL MINUTE  
0370  
 
$4.05  
MONITOR ANESTHESIA FIRST 15 MINUTES  
0370  
 
$253.00  
MONO TEST  
0306  
86308  
$68.00  
MONONUCLEAR CELL ANTIGEN QUANT NOS EA  
0300  
86356  
$89.00  
MORGAN LENS  
0270  
 
$72.00  
MORPHOMETRIC ANALYSIS TUMOR IMMUNOHISTOCHEMISTRY QUANT OR SEMI  
0310  
88360  
$638.00  
MOTION FLUOROSCOPIC EVAL OF SWALLOWING FUNCT BY CINE OR VIDEO  
0440  
 
$235.00  
MOTION FLUOROSCOPIC EVAL OF SWALLOWING FUNCT BY CINE OR VIDEO  
0440  
92611  
$235.00  
MOTOR SPEECH CURRENT STATUS  
0440  
G8999  
$0.01  
MOTOR SPEECH DISCHARGE STATUS  
0440  
G9158  
$0.01  
MOTOR SPEECH GOAL STATUS  
0440  
G9186  
$0.01  
MRA ABDOMEN W/CONTRAST  
0618  
C8900  
$1,667.00  
MRA BRAIN W/3D RENDERING  
0615  
70544  
$1,642.00  
MRA BRAIN W/CONTRAST  
0610  
70545  
$2,370.00  
MRA BRAIN W/O AND W/CONTRAST  
0615  
70546  
$2,954.00  
MRA BRAIN W/O CONTRAST  
0615  
70544  
$1,642.00  
MRA CHEST W/CONTRAST  
0618  
C8909  
$1,667.00  
MRA LOWER EXTREMITY W/O CONTRAST  
0610  
C8913  
$1,421.00  
MRA NECK W/O AND W/CONTRAST  
0615  
70549  
$2,954.00  
MRA NECK W/O CONTRAST  
0615  
70547  
$1,421.00  
MRA-ABDOMEN W/3D REND  
0610  
C8900  
$1,667.00  
MRI ABDOMEN W/CONTRAST  
0610  
74182  
$2,685.00  
MRI ABDOMEN W/O AND W/CONTRAST  
0610  
74183  
$2,954.00  
MRI ABDOMEN W/O CONTRAST  
0610  
74181  
$1,790.00  
MRI BRAIN W/CONTRAST  
0611  
70552  
$2,684.00  
MRI BRAIN W/O AND W/CONTRAST  
0611  
70553  
$2,954.00  
MRI BRAIN W/O CONTRAST  
0611  
70551  
$2,263.00  
MRI BREAST BILAT W/O AND W/CONTRAST  
0610  
C8908  
$2,954.00  
MRI BREAST BILATERAL W/O CONTRAST  
0610  
C8907  
$2,829.00  
MRI BREAST UNILAT W/O AND W/CONTRAST  
0610  
C8905  
$2,954.00  
MRI CERVICAL SPINE W/CONTRAST  
0612  
72142  
$2,685.00  
MRI CERVICAL SPINE W/O AND W/CONTRAST  
0612  
72156  
$3,603.00  
MRI CERVICAL SPINE W/O CONTRAST  
0612  
72141  
$1,767.00  
MRI CHEST/HILUM/MED W/O AND W/CONTRAS  
0610  
71552  
$3,436.00  
MRI CHEST/HILUM/MED W/O CONTRAST  
0610  
71550  
$1,421.00  
MRI JOINT LOWER EXTREMITY W/CONTRAST  
0610  
73722  
$4,133.00  
MRI JOINT LOWER EXTREMITY W/O AND W/C  
0610  
73723  
$4,546.00  
MRI JOINT LOWER EXTREMITY W/O CONTRAS  
0610  
73721  
$2,176.00  
MRI JOINT UPPER EXTREMITY W/CONTRAST  
0610  
73222  
$4,133.00  
MRI JOINT UPPER EXTREMITY W/O AND W/C  
0610  
73223  
$4,546.00  
MRI JOINT UPPER EXTREMITY W/O CONTRAS  
0610  
73221  
$1,981.00  
MRI LOWER EXTREMITY W/O AND W/CONTRAS  
0610  
73720  
$2,293.00  
MRI LOWER EXTREMITY W/O CONTRAST  
0610  
73718  
$2,110.00  
MRI LUMBAR SPINE W/CONTRAST  
0612  
72149  
$2,685.00  
MRI LUMBAR SPINE W/O AND W/CONTRAST  
0612  
72158  
$3,215.00  
MRI LUMBAR SPINE W/O CONTRAST  
0612  
72148  
$1,803.00  
MRI ORBIT/FACE/NECK W/CONTRAST  
0610  
70542  
$2,685.00  
MRI ORBIT/FACE/NECK W/O AND W/CONTRAS  
0610  
70543  
$2,954.00  
MRI ORBIT/FACE/NECK W/O CONTRAST  
0610  
70540  
$1,421.00  
MRI PELVIS W/O AND W/CONTRAST  
0610  
72197  
$2,954.00  
MRI PELVIS W/O CONTRAST  
0610  
72195  
$1,815.00  
MRI TEMPOROMANDIBULAR JOINTS  
0610  
70336  
$1,421.00  
MRI THORACIC SPINE W/CONTRAST  
0612  
72147  
$2,685.00  
MRI THORACIC SPINE W/O AND W/CONTRAST  
0612  
72157  
$2,954.00  
MRI THORACIC SPINE W/O CONTRAST  
0612  
72146  
$1,882.00  
MRI UPPER EXTREMITY W AND W/O CONTRAS  
0610  
73220  
$2,954.00  
MRI UPPER EXTREMITY W/O CONTRAST  
0610  
73218  
$2,508.00  
MRSA RAPID ASSAY  
0306  
87641  
$291.00  
MTHFR GENE ANALYSIS COMMON VARIANTS  
0300  
81291  
$176.00  
MULTIPLE SLEEP LATENCY/MAINT OF WAKEF  
0740  
95805  
$2,365.00  
MUMPS AB,IGM  
0306  
86735  
$58.00  
MYCOBACTERIA TUBERCULOSIS AMPLIFIED PROBE  
0306  
87556  
$162.00  
MYCOPLASMA PNEUMONIAE AB, IGG  
0306  
86738  
$58.00  
MYELIN BASIC PROTEIN, CSF  
0301  
83873  
$67.00  
MYELOGRAM/ARTHROGRAM TRAY-DW  
0270  
 
Variable  
MYELOGRAPHY LUMBAR INJ RS&I 2+ REGIONS  
0320  
62305  
$1,786.00  
MYELOGRAPHY LUMBAR INJ RS&I CERVICAL  
0320  
62302  
$1,786.00  
MYELOGRAPHY LUMBAR INJ RS&I LUMBOSACRAL  
0320  
62304  
$1,786.00  
MYELOGRAPHY LUMBAR INJ RS&I THORACIC  
0320  
62303  
$1,786.00  
MYOCARDIAL PERFUSION IMAGING-MULTIPLE STUDIES  
0341  
78452  
$4,452.00  
MYOCARDIAL PERFUSION IMAGING-SINGLE STUDY  
0341  
78451  
$4,452.00  
N BLOCK INJ HYPOGAS PLXS  
0360  
64517  
$3,411.00  
NASAL EOSINOPHIL SMEAR  
0305  
89190  
$54.00  
NASO-ORO GASTRIC TUBE PLACEMENT  
0360  
43752  
$744.00  
NAVIGATIONAL BRONCHOSCOPY  
0360  
 
$5,573.00  
NEEDLE ELECTRODE  
0272  
 
$80.00  
NEEDLE, 21 GAUGE ACCUSTICK  
0272  
 
$190.00  
NEISSERIA GONORRHOEAE AMPLIFIED PROBE TECHNIQUE  
0306  
87591  
$191.00  
NEPHELOMETRY EACH ANALYTE NOT ELSEWHERE SPECIFIED  
0301  
83883  
$110.00  
NEPHROSTOMY,TUBE REM USING FLUORO  
0360  
50389  
$2,019.00  
NEPHROURETERAL STENT  
0278  
C2617  
Variable  
NERVE BLOCK INJECTION, AXILLARY  
0360  
64417  
$1,328.00  
NERVE BLOCK SET (ARROW) (428925)  
0270  
 
$202.00  
NEURO IMPLANT  
0278  
C1713  
Variable  
NEUROPSYCHOLOGICAL TESTING BY COMPUTER  
0900  
96120  
$270.00  
NEUROPSYCHOLOGICAL TESTING PER HR OF PSYCHOLOGISTS OR PHYS TIME  
0900  
96118  
$376.00  
NEWBORN SERVICES-MED/SURG  
0170  
 
$1,400.00  
NFCT AGENT DNA/RNA GASTROINTESTINAL PATHOGEN  
0306  
87505  
$428.00  
NITRICOXIDE HOURLY  
0271  
 
$617.00  
NM BRAIN IMAGE W/FLOW 4 OR MORE VIEWS  
0341  
78606  
$1,677.00  
NM HEPATOBILIARY SYSTEM W/MEDICATION  
0341  
78227  
$1,677.00  
NM HEPATOBILIARY SYSTEM W/O MEDICATION  
0341  
78226  
$1,295.00  
NM INTRA-ARTERL PART TREATMENT  
0342  
79445  
$448.00  
NM IV TREATMENT  
0342  
79101  
$448.00  
NM MECKELS IMAGING  
0341  
78290  
$1,295.00  
NM PARATHYROID PLANAR IMAGING W/SPECT  
0341  
78071  
$1,295.00  
NM PARATHYROID PLANAR IMAGING W/SPECT AND CONCUR T  
0341  
78072  
$1,677.00  
NM PARATHYROID PLANAR ONLY IMAGING  
0341  
78070  
$1,295.00  
NM PULMONARY VENT AEROSOL OR GAS  
0341  
78579  
$516.00  
NM PULMONARY VENT/PERFUSION AEROSOL OR GAS  
0341  
78582  
$1,677.00  
NM QUANTITATIVE PULMONARY VENT/PERFUSION AEROSOL O  
0341  
78598  
$1,677.00  
NM THRYOID IMAGING W/UPTAKE-SINGLE OR MULTIPLE  
0341  
78014  
$1,295.00  
NM THYROID CARCINOMA IMAGING-WHOLE BO  
0341  
78018  
$1,677.00  
NM THYROID CARCINOMA UPTAKE  
0341  
78020  
$256.00  
NON HEPARIN 5FR SWAN-GANZ CATHETER (435164)  
0270  
 
$117.00  
NON INVASIVE OVERNIGHT OXIMETER  
0460  
94762  
$265.00  
NON LATEX 7FR SWAN-GANZ CATHETER (435163)  
0270  
 
$1,418.00  
O2 SATURATION  
0301  
82810  
$47.00  
OBSERVATION DIRECT ADMIT  
0762  
G0379  
$708.00  
OBSTETRIC PANEL WITH HIV  
0301  
80081  
$380.00  
OCCLUSION CATHETER  
0272  
C2628  
Variable  
OCCULT BLOOD DIAGNOSTIC STOOL  
0307  
82270  
$32.00  
OCULAR PHOTOSCREENING INTERPRETATION AND REPORT BILATERAL  
0920  
99174  
$251.00  
OFFICE VISIT NEW LEVEL 5  
0510  
99205  
$687.00  
OLIGOCLONAL IMMUNE (BANDS)  
0301  
83916  
$87.00  
OPEN/PERQ PLACE STENT EA ADD ARTERY  
0481  
37237  
$21,588.00  
OPEN/PERQ PLACE STENT EA ADD VEIN  
0481  
37239  
$13,748.00  
OPEN/PERQ PLACE STENT,INITIAL ARTERY  
0481  
37236  
$15,700.00  
OPEN/PERQ PLACE STENT,INITIAL VEIN  
0481  
37238  
$15,504.00  
ORTHC/PROSTC MGMT SBSQ ENC  
0420  
 
$105.00  
ORTHC/PROSTC MGMT SBSQ ENC  
0420  
97763  
$105.00  
ORTHC/PROSTC MGMT SBSQ ENC  
0430  
97763  
$105.00  
ORTHO SUPPLY-  
0274  
 
Variable  
ORTHOPANTOGRAM  
0320  
70355  
$231.00  
ORTHOPEDIC IMPLANT  
0278  
C1713  
Variable  
OSCILLATORY VENT CIRCUIT  
0272  
 
$435.00  
OSMOLALITY, SERUM  
0301  
83930  
$72.00  
OSMOLALITY, URINE  
0301  
83935  
$60.00  
OSTOMY GEL IODOSORB 40G (7603)  
0272  
 
$98.00  
OT EVAL HIGH COMPLEX  
0434  
 
$210.00  
OT EVAL HIGH COMPLEX  
0434  
97167  
$210.00  
OT EVAL LOW COMPLEX  
0434  
 
$125.00  
OT EVAL LOW COMPLEX  
0434  
97165  
$125.00  
OT EVAL MOD COMPLEX  
0434  
 
$200.00  
OT EVAL MOD COMPLEX  
0434  
97166  
$200.00  
OT RE-EVAL EST PLAN CARE  
0434  
 
$125.00  
OT RE-EVAL EST PLAN CARE  
0434  
97168  
$125.00  
OTHER IMPLANTABLE  
0278  
 
Variable  
OTHER OT CURRENT STATUS  
0430  
G8990  
$0.01  
OTHER OT DISCHARGE STATUS  
0430  
G8992  
$0.01  
OTHER OT GOAL STATUS  
0430  
G8991  
$0.01  
OTHER PT CURRENT STATUS  
0420  
G8990  
$0.01  
OTHER PT DISCHARGE STATUS  
0420  
G8992  
$0.01  
OTHER PT GOAL STATUS  
0420  
G8991  
$0.01  
OVA AND PARASITE EXAM  
0306  
87177  
$140.00  
OXALATE, 24 HOUR URINE  
0301  
83945  
$63.00  
OXCARBAZEPINE (TRILEPTAL) QUANTITATIVE  
0301  
80183  
$116.00  
OXYCODONE  
0301  
80365  
$119.00  
PACE/RECORD LA/COR SINUS  
0480  
93621  
$5,157.00  
PACE/RECORD LV  
0480  
93622  
$2,336.00  
PACEMAKER DUAL RATE  
0275  
C1785  
Variable  
PACEMAKER SINGLE RATE  
0275  
C1786  
Variable  
PACEMAKER BRADY DUAL RAT C1785  
0275  
C1785  
Variable  
PACEMKR, OTHER THAN SNGLE/DUAL  
0275  
C2621  
Variable  
PAD GEO MATT (9025)  
0270  
 
$129.00  
PAD HEMOSTATIC D-STAT (7612)  
0272  
 
$127.00  
PAD HYPOTHERMIA LRG (5745)  
0270  
 
Variable  
PAMG-1,CERVICOVAGINAL SECRETION,QUAL  
0301  
84112  
$265.00  
PANCREAS BIOPSY, PERC - CT  
0360  
48102  
$1,519.00  
PAPP-A FOR SEQUENTIAL SCREEN  
0301  
84163  
$56.00  
PAPP-A SEQUENTIAL SCRN GENZYME  
0301  
84163  
$56.00  
PARACENTESIS  
0360  
49083  
$1,098.00  
PARAVERTEBRAL BLOCK, THORACIC, BY CONT CATH W/IMG GUIDE  
0360  
64463  
$1,562.00  
PARTIAL THROMBOPLASTIN  
0302  
85730  
$58.00  
PARVOVIRUS B19 ABS IGG/IGM  
0306  
86747  
$80.00  
PATIENT PROGRAMMER, NEUROSTIMULATOR  
0278  
C1787  
Variable  
PEG KIT 20-24F (424878)  
0272  
 
$220.00  
PELVIC SELECT/SUPRASELECT  
0320  
75736  
$6,294.00  
PENILE PROSTHESIS  
0278  
C1813  
Variable  
PERC CONV GASTRO TUBE TO GASTO-JEJUNO  
0360  
49446  
$1,357.00  
PERC DRUG EL CORONARY STENT ATHERECTOMY SINGLE  
0481  
C9602  
$19,605.00  
PERC DRUG EL CORONARY STENT BRANCH  
0481  
C9601  
$16,633.00  
PERC DRUG EL CORONARY STENT SINGLE  
0481  
C9600  
$17,710.00  
PERC DRUG EL REVASC CHRO SINGLE  
0481  
C9607  
$14,476.00  
PERC DRUG EL REVASC T CABG BRANCH  
0481  
C9605  
$17,387.00  
PERC DRUG EL REVASC T CABG SINGLE  
0481  
C9604  
$17,732.00  
PERC DRUG EL REVASC W/AMI SINGLE  
0481  
C9606  
$9,763.00  
PERC PLACEMENT OF JEJUNOSTOMY OR DEOD  
0360  
49441  
$5,277.00  
PERCUT GAST TB PLACE  
0360  
49440  
$2,391.00  
PERCUT GAST TB PLACE  
0360  
 
$1,723.00  
PERCUTANEOUS DRAINAGE W/CATHETER AND FLUOROSCOPY  
0320  
75989  
$568.00  
PERI PROCEDURAL DEVICE EVAL-PACEMAKER  
0480  
93286  
$84.00  
PERICARDIOCENTESIS, INITIAL  
0360  
33010  
$1,299.00  
PERI-PX EVAL & PROG CARDIOV/DEFIB  
0480  
93287  
$95.00  
PERQ ACCESS & CLSR FEM ART  
0360  
34713  
$359.00  
PERQ DEVICE BREAST 1ST IMAGE  
0360  
19281  
$2,883.00  
PERQ DEVICE BREAST 1ST MR GUID  
0360  
19287  
$2,883.00  
PERQ DEVICE BREAST 1ST US IMAGING  
0360  
19285  
$2,883.00  
PERQ DEVICE BREAST ADD LESION  
0360  
19282  
$2,883.00  
PERQ DEVICE BREAST ADD LESION US IMAGING  
0360  
19286  
$2,883.00  
PERQ EXCHANGE NEPHROSTOMY CATH INCLUDE IMG GUIDE RS&I  
0360  
50435  
$3,941.00  
PERQ PLMT BILIARY DRAIN CATH W/IMG GID RS&I EXTERNAL  
0360  
47533  
$8,910.00  
PERQ PLMT BILIARY DRAIN CATH W/IMG GID RS&I INTERNAL-EXTERNAL  
0360  
47534  
$5,135.00  
PERQ PLMT NEPHROSTOMY CATH AND OR URTRGRM INCLUDE IMG GUIDE RS&I  
0360  
50432  
$4,897.00  
PERQ PLMT NEPHROURETERAL CATH INCLUDE IMG GUIDE RS&I; NEW ACCESS  
0360  
50433  
$4,358.00  
PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE  
0360  
10035  
$1,820.00  
PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT  
0360  
36906  
$29,785.00  
PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGRP  
0360  
36905  
$19,651.00  
PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH  
0360  
36904  
$9,723.00  
PERQ VERT AUGMNT CAVITY CRTJ UNI/BI CANNULATION  
0360  
22513  
$13,650.00  
PERQ VERT AUGMNT CAVITY CRTJ UNI/BI CANNULATION EA  
0360  
22515  
$10,083.00  
PERQ VERT AUGMNT CAVITY CRTJ UNI/BI CANNULATION LUMBAR  
0360  
22514  
$13,538.00  
PET - BRAIN METABOLISM  
0404  
78608  
$5,424.00  
PET-MYOCARDIAL METABOLIC  
0404  
78459  
$4,452.00  
PET-TUMOR LTD AREA W/CT AC  
0404  
78814  
$5,158.00  
PET-TUMOR SKULL-THIGH W/CT AC  
0404  
78815  
$8,315.00  
PET-TUMOR W/B W/CT AC  
0404  
78816  
$8,315.00  
PFO-ACUNAV ICE CATH  
0272  
C1759  
Variable  
PH URINE  
0307  
81002  
$35.00  
PHARMACY CHG REV 250  
0250  
 
Variable  
PHARMACY CHG REV 258  
0258  
 
Variable  
PHARMACY CHG REV 635  
0635  
 
Variable  
PHARMACY CHG REV 636  
0250  
 
Variable  
PHARMACY CHG REV 637  
0250  
 
Variable  
PHARMACY SUPPLY REV 272  
0272  
 
Variable  
PHARYNX-SPEECH PATHOLOGY-DW  
0320  
74230  
$425.00  
PHENOBARBITOL ASSAY  
0301  
80184  
$87.00  
PHENYTOIN FREE  
0301  
80186  
$72.00  
PHLEBOTOMY, THERAPEUTIC  
0940  
99195  
$98.00  
PHOSPHOLIPID NEUT PLT 85597  
0300  
85597  
$60.00  
PHOSPHORUS  
0301  
84100  
$27.00  
PHOSPHORUS ASSAY, URINE  
0301  
84105  
$53.00  
PHYSICAL PERFORM TEST OR MEASURE W/REPORT EA 15 MIN  
0420  
 
$59.00  
PHYSICAL PERFORM TEST OR MEASURE W/REPORT EA 15 MIN  
0420  
97750  
$59.00  
PHYSICAL PERFORM TEST OR MEASURE W/REPORT EA 15 MIN  
0430  
97750  
$59.00  
PHYSICIAN SERV O/P CARDIAC REHAB CONT ECG MONITORING P/SESSION  
0943  
93798  
$173.00  
PHYSIOLOGIC MULTI LEVEL UE/LE  
0921  
93923  
$404.00  
PHYSIOLOGIC SINGLE LEVEL UE/LE  
0921  
93922  
$260.00  
PICC INSERTION OVER 5 YRS TO ADULT  
0761  
36569  
$2,414.00  
PICC INSERTION UNDER 5 YRS  
0761  
36568  
$2,076.00  
PICC KIT  
0272  
 
$273.00  
PICC LINE REPAIR  
0761  
36575  
$1,190.00  
PICC REPLACEMENT OVER CATH  
0761  
36584  
$4,697.00  
PICC TRAY SI  
0278  
C1751  
$790.00  
PILLOW HIP ABDUCTION LG (7262)  
0270  
 
$111.00  
PILLOW HIP ABDUCTION MD (7261)  
0270  
 
$111.00  
PILLOW HIP ABDUCTION SM (7263)  
0270  
 
$111.00  
PINWORM PREP  
0306  
87172  
$67.00  
PKU COLLECTION  
0270  
 
$169.00  
PLACE CATH COMMON CAROTID/INOM ART EXTRACRANIAL  
0481  
36222  
$6,294.00  
PLACE CATH COMMON CAROTID/INOM ART INTRACRANIAL  
0481  
36223  
$6,294.00  
PLACE CATH SUBCLAVAN/INOM ART UNILATERAL  
0481  
36225  
$6,294.00  
PLACE CATH THORACIC AORTA  
0481  
36221  
$6,294.00  
PLACEMENT XTN PROSTH FOR ENDOVASCULAR RPR  
0360  
34709  
$20,524.00  
PLASMA, FRESH FROZEN  
0390  
P9017  
$199.00  
PLASMA, FROZEN WITHIN 24 HOURS  
0390  
P9059  
$200.00  
PLASMAPHERESIS TREATMENT  
0361  
36514  
$1,908.00  
PLATELET ANTIBODY SCREEN  
0302  
86022  
$318.00  
PLATELET COUNT  
0305  
85049  
$35.00  
PLATELET CROSSMATCH SCREEN  
0300  
86022  
$318.00  
PLATELET FUNCTION ASSAY, ADP  
0305  
85576  
$95.00  
PLATELET RICH PLASMA, EACH UNIT  
0390  
P9020  
$333.00  
PLATELETPHERESIS IRRAD LR  
0390  
P9037  
$1,748.00  
PLATELETPHERESIS LEUKOREDUCED  
0390  
P9035  
$1,350.00  
PLATELETS HLA MATCHED LR  
0390  
P9052  
$2,077.00  
PLETHYSMOGRAPHY FOR DET OF LUNG VOL INC AIRWAY RESIST  
0460  
94726  
$577.00  
PLEURX CATHETER INSERTION  
0360  
32550  
$3,185.00  
PLMT PROX XTN PROSTH EVASC RPR DTA 1ST XTN  
0360  
33883  
$9,925.00  
PLMT PROX XTN PROSTH EVASC RPR DTA EA PROX XTN  
0360  
33884  
$20,524.00  
PLMT URTRL STENT PRQ NEW ACCESS W/SEP NFROS CATH  
0360  
50695  
$7,244.00  
PLMT URTRL STENT PRQ NEW W/O SEP NFROS CATH  
0360  
50694  
$4,878.00  
PLMT URTRL STENT PRQ PRE-EXST NEPH TRACT  
0360  
50693  
$7,413.00  
POC ACT CLOT TIME  
0302  
85347  
$58.00  
POC FECAL OCCULT BLOOD  
0307  
82270  
$32.00  
POC GASES, BLOOD ARTERIAL OR VENOUS  
0301  
82805  
$213.00  
POC POTASSIUM  
0301  
84132  
$19.00  
POC PT INR  
0305  
85610  
$49.00  
PORPHOBILINGEN/PORPHRINS UR QT  
0305  
84120  
$103.00  
PORPHOBILINOGEN, URINE  
0301  
84110  
$64.00  
PORT INDWELLING (IMPLANTABLE)  
0278  
C1788  
Variable  
PORTABLE MATTRESS WARMER  
0272  
 
$85.00  
POTASSIUM  
0301  
84132  
$19.00  
POTASSIUM ASSAY, SERUM  
0301  
84132  
$19.00  
POTASSIUM ASSAY, URINE  
0301  
84133  
$58.00  
POTASSIUM FLUID  
0301  
84999  
$322.00  
POWER PICC TRAY  
0278  
C1751  
$790.00  
PREALBUMIN  
0301  
84134  
$112.00  
PRESUMPTIVE ID, URINE  
0306  
87088  
$74.00  
PRIMIDONE  
0301  
80188  
$59.00  
PRIMIDONE METABOLITE  
0301  
80184  
$87.00  
PRO RIT BASIC POWERGLIDE 18G X 10CM  
0278  
C1751  
$195.00  
PRO RIT BASIC POWERGLIDE 18G X 8CM  
0278  
C1751  
$195.00  
PRO RIT BASIC POWERGLIDE 20G X 10CM  
0278  
C1751  
$195.00  
PRO RIT BASIC POWERGLIDE 20G X 8CM  
0278  
C1751  
$195.00  
PRO RIT FULL POWERGLIDE 18G X 10CM  
0278  
C1751  
$315.00  
PRO RIT FULL POWERGLIDE 18G X 8CM  
0278  
C1751  
$315.00  
PRO RIT FULL POWERGLIDE 20G X 10CM  
0278  
C1751  
$315.00  
PRO RIT FULL POWERGLIDE 20G X 8CM  
0278  
C1751  
$315.00  
PROBE, CRYOABLATION  
0279  
C2618  
Variable  
PROCALCITONIN  
0301  
84145  
$146.00  
PROCEDURE OVERRIDE (OML)  
0301  
4288963  
Variable  
PROCEDURE OVERRIDE (OML)  
0301  
4289963  
Variable  
PROG STIM/PACE AFTER MEDS  
0480  
93623  
$3,897.00  
PROGESTERONE SERUM  
0301  
84144  
$111.00  
PROLACTIN  
0301  
84146  
$137.00  
PROSTHETIC IMPLANT,NOT OTHERWISE SPEC  
0278  
L8699  
Variable  
PROTEIN SERUM TOTAL  
0301  
84155  
$27.00  
PROTEIN C ACTIVITY  
0302  
85303  
$215.00  
PROTEIN ELECTROPHORESIS  
0301  
84165  
$122.00  
PROTEIN ELECTROPHORESIS  
0301  
84166  
$193.00  
PROTEIN S ACTIVITY  
0302  
85306  
$215.00  
PROTEIN TOTAL REFRACTOMETRY ANY SRC  
0301  
84160  
$17.00  
PROTEIN, CSF  
0301  
84157  
$63.00  
PROTEIN, URINE  
0301  
84156  
$73.00  
PROTIME  
0305  
85610  
$49.00  
PRQ CARD ANGIO/ATHRECT 1 ARTERY  
0481  
92924  
$17,830.00  
PRQ CARD REVASC CHRONIC 1 VESSEL  
0481  
92943  
$10,474.00  
PRQ CARD REVASC MI 1 VESSEL  
0481  
92941  
$14,110.00  
PRQ CARD STENT W/ANGIO 1 VESSEL  
0481  
92928  
$13,602.00  
PRQ CARD STENT W/ANGIO VESSEL ADD ON  
0481  
92929  
$14,110.00  
PRQ CARDIAC ANGIOPLASTY 1 ARTERY  
0481  
92920  
$9,787.00  
PRQ CARDIAC ANGIOPLASTY ARTERY ADD ON  
0481  
92921  
$9,983.00  
PRQ REVASC BYP GRAFT 1 VESSEL  
0481  
92937  
$18,166.00  
PSA  
0301  
84153  
$108.00  
PSA SCREENING  
0300  
G0103  
$130.00  
PSA, FREE  
0301  
84154  
$136.00  
PSYCH COMPUTER TEST BATTERY  
0900  
96103  
$284.00  
PSYCH TESTING PER HR OF PSYCHOLOGISTS OR PHYS TIME  
0900  
96101  
$376.00  
PSYCH TREATMENT PROGRAM  
0919  
 
$661.00  
PSYCHIATRIC DIAGNOSTIC EVALUATION  
0900  
90791  
$406.00  
PSYCHOTHERAPY 30 MIN WITH PATIENT  
0900  
90832  
$186.00  
PSYCHOTHERAPY 45 MIN WITH PATIENT  
0900  
90834  
$327.00  
PSYCHOTHERAPY 60 OR MORE MIN WITH PATIENT  
0900  
90837  
$415.00  
PT EVAL HIGH COMPLEX  
0424  
 
$210.00  
PT EVAL HIGH COMPLEX  
0424  
97163  
$210.00  
PT EVAL LOW COMPLEX  
0424  
 
$125.00  
PT EVAL LOW COMPLEX  
0424  
97161  
$125.00  
PT EVAL MOD COMPLEX  
0424  
 
$200.00  
PT EVAL MOD COMPLEX  
0424  
97162  
$200.00  
PT RE-EVAL EST PLAN CARE  
0424  
 
$125.00  
PT RE-EVAL EST PLAN CARE  
0424  
97164  
$125.00  
PTH (INTACT)  
0301  
83970  
$157.00  
PTT  
0300  
85730  
$58.00  
PTT PLASMA FRACTIONS, EACH  
0305  
85732  
$41.00  
PULMONARY BILATERAL SELECTIVE  
0320  
75743  
$6,294.00  
PULMONARY REHAB INC EXERCISE INC MONITOR PER HOUR PER SESSION  
0948  
G0424  
$200.00  
PULMONARY STRESS TESTING  
0460  
94618  
$275.00  
PULMONARY UNILATERAL SELECTIVE  
0320  
75741  
$6,294.00  
PUMP BREAST DOUBLE KIT (6292)  
0270  
 
$85.00  
PUNCTURE ASPIRATION OF ABSCESS,HEMATOMA,BULLA,CYST  
0360  
10160  
$598.00  
PUNCTURE ASPIRTN CYST(BREAST)  
0360  
19000  
$446.00  
PUNCTURE SHUNT TUBE/RESERVOIR ASPIRATION/INJ PROCEDURE  
0360  
61070  
$1,265.00  
QUANTIFERON GOLD TB  
0301  
86480  
$230.00  
QUANTITATION OF DRUG NES THERAPEUTIC DRUG ASSAY  
0301  
80299  
$84.00  
QUANTITATIVE SCREEN METALS  
0301  
83018  
$139.00  
RAD TX DEL, =1 MEV; COMPLEX  
0333  
77412  
$599.00  
RAD TX DEL, =1 MEV; INTERMEDIATE  
0333  
77407  
$353.00  
RAD TX DEL, =1 MEV; SIMPLE  
0333  
77402  
$372.00  
RADIATION PHYSICS CONSULT  
0333  
77370  
$860.00  
RADIATION PHYSICS, DOSIMETRY & TREAMENT, SPECIAL SERVICES  
0333  
77399  
$328.00  
RADIO PHARMA I-131 TX  
0344  
A9517  
$28.00  
RADIO:TC-99M EXAMETAZIME LBLD AUTOL WBC  
0343  
A9569  
$2,387.00  
RADIOLOGIC EXAM ABDOMEN 1 VIEW  
0320  
74018  
$210.00  
RADIOLOGIC EXAM ABDOMEN 2 VIEWS  
0320  
74019  
$401.00  
RADIOLOGIC EXAM CHEST 2 VIEWS  
0320  
71046  
$200.00  
RADIOLOGIC EXAM CHEST 3 VIEWS  
0320  
71047  
$200.00  
RADIOLOGIC EXAM CHEST 4+ VIEWS  
0320  
71048  
$401.00  
RADIOLOGIC EXAM CHEST SINGLE VIEW  
0320  
71045  
$210.00  
RADIOLOGICAL EXAM SURGICAL SPECIMEN  
0400  
76098  
$1,802.00  
RADIOPH: EXAMETAZINE/DOSE  
0343  
A9521  
Variable  
RADIOPH: INDIUM IN-111 PENTETREOTIDE  
0343  
A9572  
$4,227.00  
RADIOPH: MEDRONATE/DOSE  
0343  
A9503  
$49.00  
RADIOPH:GA-67/MCI  
0343  
A9556  
$118.00  
RADIOPH:I-123 DX/PER 100 UCI  
0343  
A9516  
$168.00  
RADIOPH:I-131 DX CAP/MCI  
0343  
A9528  
$28.00  
RADIOPH:IN-111 DTPA/0.5MCI  
0343  
A9548  
$2,482.00  
RADIOPH:MAA/UNIT DOSE  
0343  
A9540  
$289.00  
RADIOPH:MAA/VIAL  
0343  
A9540  
$1,151.00  
RADIOPH:MEBROFENIN/DOSE  
0343  
A9537  
$70.00  
RADIOPH:MERTIATIDE/DOSE  
0343  
A9562  
$732.00  
RADIOPH:MIBG/I-123  
0343  
A9582  
$4,079.00  
RADIOPH:RADIUM RA 223 DICHLORIDE,TX,PER MICROCURIE  
0344  
A9606  
Variable  
RADIOPH:RBC TAG/DOSE  
0343  
A9560  
$222.00  
RADIOPH:S COLLOID FILTERED TC99M-LYMPHO  
0343  
A9541  
$473.00  
RADIOPH:S COLLOID TC99M-DOSE  
0343  
A9541  
$165.00  
RADIOPH:S COLLOID TC99M-LYMPHO  
0343  
A9541  
$543.00  
RADIOPH:SESTAMIBI/DOSE  
0343  
A9500  
$75.00  
RADIOPH:XE-133/10 MCI  
0343  
A9558  
$112.00  
RADIOPHARM PROVIDED DURING HOSP INPT STAY  
0342  
C9898  
$1.00  
RADIOPHARM THERAPY ORAL ADMIN  
0342  
79005  
$756.00  
RADIOPHARM: FDG-18  
0343  
A9552  
$611.00  
RADIOPHARM: I-123 DATSCAN (PER DOSE UP TO 5MCI)  
0343  
A9584  
$3,037.00  
RADIOPHARM: TC-99M/MCI  
0343  
A9512  
$2.00  
RAPID HIV 1/2  
0301  
86703  
$206.00  
RBC FOLATE  
0301  
82747  
$60.00  
RBC SED RATE (AUTOMATED)  
0305  
85652  
$43.00  
RCH W/IMPLANT OF WIRELESS PRESSURE SENSOR PULM ARTERY  
0483  
C9741  
$7,450.00  
REC L AND D STAGE 1 LVL 1 ADDL MIN  
0710  
 
$17.00  
REC L AND D STAGE 1 LVL 1 FIRST 15 MIN  
0710  
 
$665.00  
REC L AND D STAGE 1 LVL 2 ADDL MIN  
0710  
 
$26.00  
REC L AND D STAGE 1 LVL 2 FIRST 15 M  
0710  
 
$869.00  
REC L AND D STAGE 1 LVL 3 ADDL MIN  
0710  
 
$32.00  
REC L AND D STAGE 1 LVL 3 FIRST 15 MIN  
0710  
 
$1,130.00  
REC L AND D STAGE 1 LVL 4 ADDL MIN  
0710  
 
$35.00  
REC L AND D STAGE 1 LVL 4 FIRST 15 MIN  
0710  
 
$1,306.00  
RECOVERY MAIN STAGE 1 LVL 1 ADDL MIN  
0710  
 
$17.00  
RECOVERY MAIN STAGE 1 LVL 1 FIRST 15MS  
0710  
 
$666.00  
RECOVERY MAIN STAGE 1 LVL 2 ADDL MIN  
0710  
 
$25.00  
RECOVERY MAIN STAGE 1 LVL 2 FIRST 15MS  
0710  
 
$868.00  
RECOVERY MAIN STAGE 1 LVL 3 ADDL MINS  
0710  
 
$31.00  
RECOVERY MAIN STAGE 1 LVL 3 FIRST 15  
0710  
 
$1,130.00  
RECOVERY MAIN STAGE 1 LVL 4 ADDL MIN  
0710  
 
$41.00  
RECOVERY MAIN STAGE 1 LVL 4 FIRST 15 S  
0710  
 
$1,514.00  
RECOVERY MAIN STAGE 2 ADDL MIN  
0710  
 
$11.35  
RECOVERY MAIN STAGE 2 FIRST 15 MIN  
0710  
 
$245.00  
RECOVERY STAGE 2 ADDL MIN  
0710  
 
$11.35  
RECOVERY STAGE 2 FIRST 15 MIN  
0710  
 
$245.00  
RED BLOOD CELLS, EACH UNIT  
0390  
P9021  
$428.00  
RED CELLS LEUKODEPL IRRADIATED  
0390  
P9040  
$719.00  
RED CELLS, LEUKODEPLETE  
0390  
P9016  
$551.00  
REGIONAL BLOCK ADDL MINUTE  
0370  
 
$4.05  
REGIONAL BLOCK FIRST 15 MINUTES  
0370  
 
$253.00  
RELOCATE SKIN POCKET FOR PACEMAKER  
0360  
33222  
$2,682.00  
REM 1/2 CHMBR PACG CVDFB ELTRD TRANSVNS XTR  
0360  
33244  
$8,290.00  
REM IMP PT-ACT CARD EVENT REC  
0360  
33284  
$2,713.00  
REM OF TUNNELED PLEURAL CATH W/CUFF  
0360  
32552  
$526.00  
REM PAC CVDFB PLS GEN & REPL PLS GEN DUAL LEAD  
0360  
33263  
$44,274.00  
REM PAC CVDFB PLS GEN & REPL PLS GEN MULTI LEAD  
0360  
33264  
$33,496.00  
REM PAC CVDFB PLS GEN & REPL PLS GEN SNGL LEAD  
0360  
33262  
$31,852.00  
REMOTE AFTLD INTERSTITIAL OR INTRACAV BRACHY 1 CHANNEL  
0333  
77770  
$1,858.00  
REMOTE AFTLD INTERSTITIAL OR INTRACAV BRACHY 2-12 CHANNEL  
0333  
77771  
$1,858.00  
REMOVAL DEVITALIZED TISS FR WOUND NON SELECT DEBRIDE ONGOING  
0430  
97602  
$166.00  
REMOVAL FB, FOREARM/WRIST - US  
0360  
25248  
$1,563.00  
REMOVAL TUNNELED CVAD  
0360  
36590  
$1,978.00  
REMOVAL TUNNELED CVC  
0360  
36589  
$1,464.00  
REMOVE IABP  
0480  
33968  
$312.00  
REMOVE PAC CVDFB PLS GEN ONLY  
0360  
33241  
$12,454.00  
REMOVE PCMKR PULSE GEN W/REPL-DUAL LEAD  
0360  
33228  
$16,016.00  
REMOVE PCMKR PULSE GEN W/REPL-MULTIPLE LEAD  
0360  
33229  
$19,070.00  
REMOVE PCMKR PULSE GEN W/REPL-SINGLE LEAD  
0360  
33227  
$16,029.00  
REMOVE PCMKR PULSE GENERATOR  
0360  
33233  
$9,114.00  
REMOVE TRANSCAT PERCUT OF INTRAVASCULAR FB  
0481  
37197  
$6,162.00  
REMOVE TVP ELECT 1 LEAD A OR V  
0360  
33234  
$3,715.00  
REMOVE TVP ELECT 2 LEAD A OR V  
0360  
33235  
$6,953.00  
REMOVE VAD  
0481  
33992  
$2,667.00  
REMOVE/REPLACE EXT ACCESIBLE NEPHROURETERAL CATH/STENT  
0360  
50387  
$3,799.00  
RENAL CYST/PELV ASP OR INJT-CT  
0360  
50390  
$1,680.00  
RENAL FLOW FUNCTION  
0341  
78707  
$1,677.00  
RENAL FUNCTION PANEL  
0301  
80069  
$81.00  
RENAL FUNCTION W/MEDS-NM  
0341  
78708  
$1,677.00  
RENAL SELECTIVE UNILATERAL  
0480  
36251  
$6,294.00  
RENAL SUPERSELECTIVE UNILATERAL  
0480  
36253  
$6,294.00  
RENAL/MESENTERIC/PORTAL(TIPS)DUPLEX  
0921  
93975  
$1,695.00  
RENAL/MESENTERIC/PORTAL(TIPS)LTD  
0921  
93976  
$986.00  
RENIN ASSAY  
0301  
84244  
$81.00  
RE-OPEN LAP  
0360  
49002  
$2,983.00  
REPAIR CVAD W/PORT,PUMP CENTRL,PERIPH  
0360  
36576  
$2,076.00  
REPLACE AORTIC VALVE OPEN FEMORAL ARTERY APPROACH  
0360  
33362  
$23,143.00  
REPLACE TUNNELED CNTRL CVC  
0360  
36581  
$4,654.00  
REPLACE,COMPLETE,TUNNELED CVC W/PORT  
0360  
36582  
$8,265.00  
REPO G-TUBE THRU DUODENUM  
0360  
43761  
$1,646.00  
REPO PREV IMPLNT PM/CVDFB RA/RV ELECTRODE  
0360  
33215  
$3,501.00  
REPOSITION VENOUS CATHETER  
0360  
36597  
$1,252.00  
REPTILASE TEST  
0305  
85635  
$39.00  
RESPIRATOR MOTION MGMT SIMUL  
0333  
77293  
$317.00  
RESPIRATORY VIRUS 3 TO 5 TARGETS  
0306  
87631  
$475.00  
RESPIRATORY VIRUS PANEL BY PCR  
0300  
87633  
$1,389.00  
RETIC COUNT (AUTOMATED)  
0305  
85046  
$48.00  
RETICULOCYTE PROFILE, AUTOMATED  
0305  
85046  
$48.00  
RETRIEVAL DEVICE(S)  
0272  
C1773  
Variable  
RETRIEVAL INTRAVASCULAR VENA CAVA FILTER  
0480  
37193  
$7,772.00  
REVASC FEM-POP,UNILAT W/PTA  
0360  
37224  
$10,239.00  
REVASC FEM-POP,UNILAT,STENT,INCL PTA  
0360  
37226  
$20,498.00  
REVASC FEM-POP,UNILAT,STENT/ATH,INCL  
0360  
37227  
$33,311.00  
REVASC FEMP-POP,UNILAT,ATH,INCL PTA S  
0360  
37225  
$22,492.00  
REVASC ILIAC,UNILAT EA ADD IPSILAT VE  
0360  
37222  
$8,178.00  
REVASC ILIAC,UNILAT EA ADD IPSILAT VE  
0360  
37223  
$10,483.00  
REVASC ILIAC,UNILAT INT VES W/PTA  
0360  
37220  
$11,444.00  
REVASC ILIAC,UNILAT INT VES,STENT,INC  
0360  
37221  
$20,719.00  
REVASC ILIAC,UNILAT,ATH,INCLUDES PTA  
0360  
0238T  
$27,500.00  
REVASC TIBIOPERONEAL UNILAT EA ADD VE  
0360  
37232  
$9,114.00  
REVASC TIBIOPERONEAL UNILAT EA ADD VE  
0360  
37233  
$16,816.00  
REVASC TIBIOPERONEAL UNILAT EA ADD VE  
0360  
37234  
$1,374.00  
REVASC TIBIOPERONEAL UNILAT INTL VES  
0360  
37228  
$11,931.00  
REVASC TIBIOPERONEAL UNILAT,ATH,INCLU  
0360  
37229  
$24,193.00  
REVASC TIBIOPERONEAL UNILAT,STENT,INC  
0360  
37230  
$23,910.00  
REVISION OF AORTIC VALVE  
0481  
92986  
$8,468.00  
REVISION OF HEPATIC SHUNT (TIPS)  
0360  
37183  
$14,683.00  
REVSE SKIN POCKET FOR CARDIOVERT-DEFIB  
0360  
33223  
$4,660.00  
RF ABLATION-LIVER PERCUT  
0360  
47382  
$9,445.00  
RH IG TESTING  
0302  
85461  
$62.00  
RH TYPING  
0300  
86901  
$94.00  
RH TYPING (WEAK DU)  
0300  
86901  
$94.00  
RHEUMATOID FACTOR, QT  
0300  
86431  
$53.00  
RNP ANTIBODY  
0300  
86235  
$74.00  
ROOM AND BOARD HOURLY OBS FIRST 48  
0762  
G0378  
Variable  
ROOM AND BOARD HOURLY OBS OVER 48  
0762  
G0378  
Variable  
ROOM AND BOARD-HOURLY OBS-MED/SURG  
0762  
G0378  
$83.00  
ROOM AND BOARD-INTENSIVE  
0200  
 
$5,683.00  
ROOM AND BOARD-INTERMEDIATE  
0206  
 
$3,745.00  
ROOM AND BOARD-MED/SURG  
0120  
 
$2,230.00  
ROOM AND BOARD-MED/SURG-W/TELEMETRY  
0120  
 
$2,896.00  
ROOM AND BOARD-NURSERY  
0171  
 
$1,829.00  
ROOM AND BOARD-NURSERY-LEVEL I  
0171  
 
$3,676.00  
ROOM AND BOARD-NURSERY-LEVEL II  
0172  
 
$5,020.00  
ROOM AND BOARD-NURSERY-LEVEL III  
0173  
 
$6,224.00  
ROOM AND BOARD-NURSERY-LEVEL IV  
0174  
 
$7,498.00  
ROOM AND BOARD-PSYCHIATRIC UNIT  
0124  
 
$2,370.00  
ROOM AND BOARD-REHABILITATION  
0128  
 
$2,520.00  
ROTAVIRUS (ROTAZYME) AG  
0306  
87425  
$94.00  
RPR  
0300  
86592  
$48.00  
RPR QUANTITATION  
0302  
86593  
$32.00  
RSV  
0301  
87807  
$77.00  
RT AND LEFT HEART CATH  
0480  
93453  
$8,638.00  
RT AND LT HEART CATH W/LV,INCL INJ/S&  
0480  
93460  
$10,981.00  
RT AND LT HEART CATH W/LV,W/GRAFTS,IN  
0480  
93461  
$11,187.00  
RT HEART CATH-ANG  
0480  
93451  
$8,536.00  
RT TECHT BEDSIDE PROCEDURE  
0410  
 
Variable  
RT TECHT CONSCIOUS SEDATION  
0410  
 
Variable  
RT TECHT DELIVERY  
0410  
 
Variable  
RT TECHT ED TRAUMA  
0410  
 
Variable  
RT TECHT INTUBATION  
0410  
 
Variable  
RT TECHT OTHER  
0410  
 
Variable  
RT TECHT RETAPE  
0410  
 
Variable  
RT TECHT ROAD TRIP  
0410  
 
Variable  
RT TECHT RRT RESPONSE  
0410  
 
Variable  
RT TECHT SWALLOW EVAL  
0410  
 
Variable  
RUBELLA AB IGG OR IGM  
0302  
86762  
$68.00  
RUBELLA AB, IGG  
0301  
86762  
$68.00  
RUBELLA AB, IGM  
0306  
86762  
$68.00  
RUBEOLA ANTIBODY  
0301  
86765  
$106.00  
RUSSELL VIPER VENOM TIME  
0301  
85613  
$127.00  
SBRT DELIVERY,PER FRACTION TO 1 OR MORE LESIONS  
0333  
77373  
$5,727.00  
SCL 70 AUTOANTIBODIES  
0301  
86235  
$74.00  
SELCT EA ADD VES AFTR BSIC EXM  
0320  
75774  
$2,385.00  
SELCT PLC RT/LT PULM ARTERY  
0360  
36014  
$1,368.00  
SELECT CATH PLACE PULM ARTERY  
0360  
36015  
$1,721.00  
SELF CARE CURRENT STATUS  
0420  
G8987  
$0.01  
SELF CARE CURRENT STATUS  
0430  
G8987  
$0.01  
SELF CARE DISCHARGE STATUS  
0420  
G8989  
$0.01  
SELF CARE DISCHARGE STATUS  
0430  
G8989  
$0.01  
SELF CARE GOAL STATUS  
0420  
G8988  
$0.01  
SELF CARE GOAL STATUS  
0430  
G8988  
$0.01  
SELFCARE HOME MGMT 1/1 BY PROVIDER EA 15 MINUTES  
0430  
 
$87.00  
SELFCARE HOME MGMT 1/1 BY PROVIDER EA 15 MINUTES  
0430  
97535  
$87.00  
SELFCARE HOME MGMT TRAIN DIRECT 1/1 BY PROVIDER EA 15 MIN  
0420  
97535  
$87.00  
SELFCARE HOME MGMT TRAIN DIRECT 1/1 BY PROVIDER EA 15 MIN  
0420  
 
$87.00  
SEMEN ANALYSIS  
0309  
89322  
$88.00  
SENSITIVITY PER ORGANISM MIC  
0306  
87186  
$114.00  
SENSITIVITY PER PLATE DISC  
0306  
87184  
$98.00  
SENSORY INTEGRATIVE TECHNIQUES SENSORY PROC EA 15 MIN  
0430  
 
$109.00  
SENSORY INTEGRATIVE TECHNIQUES SENSORY PROC EA 15 MIN  
0430  
97533  
$109.00  
SEPRAFILM ADHESION BARRIER  
0278  
 
Variable  
SEROTONIN  
0301  
84260  
$103.00  
SET PNEUMOTHORAX (9079)  
0270  
 
$481.00  
SGMDSC FLX DECOMPRESSION VOLVULUS ANY METHOD  
0360  
 
$3,278.00  
SGOT (AST)  
0301  
84450  
$27.00  
SGPT (ALT)  
0301  
84460  
$30.00  
SHUNTOGRAM OF PREVPLACE INDWELLING NONVASCULAR  
0481  
75809  
$225.00  
SICKLE TESTING  
0305  
85660  
$44.00  
SIGMOIDOSCOPY  
0360  
 
$585.00  
SIGMOIDOSCOPY FLX CONTROL BLEEDING  
0360  
 
$3,278.00  
SIGMOIDOSCOPY FLX SNARE TUMOR POLYP OTH LESION  
0360  
 
$3,278.00  
SIGMOIDOSCOPY FLX W/RMVL FOREIGN BODY  
0360  
 
$3,278.00  
SIGMOIDOSCOPY FLX WITH WITH BAND LIGATION(S)  
0360  
 
$3,278.00  
SIMPLE REPAIR SUPERFICIAL WOUNDS 2.6 CM TO 7.5 CM  
0510  
12002  
$308.00  
SIMPLE REPAIR SUPERFICIAL WOUNDS 7.6 CM TO 12.5 CM  
0510  
12004  
$308.00  
SIMULATION-COMPLEX  
0333  
77290  
$1,106.00  
SIMULATION-SIMPLE  
0333  
77280  
$481.00  
SIO FLEX PELVI-SACRAL PREFAB (SI BELT)  
0274  
L0621  
$187.00  
SIROLIMUS (SACROLINUS)  
0301  
80195  
$123.00  
SKIN SUBST,ALLODERM,PER SQ CM  
0278  
Q4116  
Variable  
SKIN SUBSTITUTE, AMNIOEXCEL, PER SQ CM  
0278  
Q4137  
Variable  
SKIN SUBSTITUTE, NOT OTHERWISE SPECIF  
0278  
Q4100  
Variable  
SKIN SUBSTITUTE, STRATTICE TM, PER SQ CM  
0278  
Q4130  
Variable  
SKIN SUBSTITUTE,SURGIMEND,PER 0.5SQ C  
0278  
C9358  
Variable  
SKIN TEST: TB  
0302  
86580  
$76.00  
SLCT CATH PLC 1ST ORDR, VENOUS  
0360  
36011  
$4,096.00  
SLEEP DISORDER STUDY  
0740  
95810  
$3,125.00  
SLEEP STUDY W/CPAP  
0740  
95811  
$3,629.00  
SLEEP STUDY, AMBULATORY  
0510  
G0399  
$1,063.00  
SMALL BOWEL STUDY-DW  
0320  
74250  
$425.00  
SMOKING CESS OVER 10 MIN  
0942  
99407  
$108.00  
SMOKING CESS UP TO 10 MIN  
0942  
99406  
$58.00  
SNARE SMALL/MEDIUM (424967)  
0272  
 
$65.00  
SODIUM  
0301  
84295  
$27.00  
SODIUM OTHER SOURCE  
0301  
84302  
$32.00  
SODIUM, LEVEL  
0301  
84295  
$27.00  
SODIUM, URINE  
0301  
84300  
$40.00  
SOMATOMEDIN C  
0301  
84305  
$106.00  
SPECIAL TX PROCEDURE  
0333  
77470  
$1,426.00  
SPECIFIC GRAVITY URINE  
0307  
81002  
$35.00  
SPECTROPHOTOMETRY ANALYTE NES  
0301  
84311  
$26.00  
SPEECH LANG CURRENT STATUS  
0440  
G9174  
$0.01  
SPEECH LANG DISCHARGE STATUS  
0440  
G9176  
$0.01  
SPEECH LANG GOAL STATUS  
0440  
G9175  
$0.01  
SPEECH LANGUAGE GROUP 2 OR MORE INDIVIDUALS  
0440  
92508  
$184.00  
SPERM CHECK  
0305  
89310  
$41.00  
SPHINCTER URINARY (C1815)  
0278  
C1815  
Variable  
SPINAL ANESTHESIA TRAY (1320)  
0270  
 
Variable  
SPINAL BLOCK EACH ADDL MIN  
0370  
 
$4.30  
SPINAL BLOCK FIRST 15 MIN  
0370  
 
$253.00  
SPINAL BLOCK FIRST 15 MINUTES  
0370  
 
$253.00  
SPINAL BLOCK FIRST ADDL MINUTE  
0370  
 
$4.05  
SPINAL PUNCTURE LUMBAR DIAGNOSTIC  
0360  
62270  
$1,167.00  
SPIROMETRY  
0460  
94010  
$140.00  
SPIROMETRY PRE AND POST ADMIN  
0460  
94060  
$252.00  
SPLINT FAB. 1ST 30 MIN  
0430  
 
$166.00  
SPLINT FAB. EA. 15 MIN'S.  
0430  
 
$69.00  
SRS LINEAR BASED,COMPLETE COURSE CRANIAL LESION 1  
0333  
77372  
$10,705.00  
SS-A/RO ANTIBODIES  
0300  
86235  
$74.00  
SS-B/LA ANTIBODIES  
0300  
86235  
$74.00  
STANDARD COGNITIVE PERF TEST PER HR  
0430  
 
$270.00  
STANDARD COGNITIVE PERF TEST PER HR  
0430  
96125  
$270.00  
STANDARD COGNITIVE PERF TEST PER HR  
0440  
 
$270.00  
STANDARD COGNITIVE PERF TEST PER HR  
0440  
96125  
$270.00  
STANDARD DELIVERY  
0720  
 
$4,830.00  
STCB PROBE  
0272  
A4649  
$859.00  
STENT BARE CORONARY (DEVICE)  
0278  
C1876  
$8,773.00  
STENT DRUG CORONARY (DEVICE)  
0278  
C1874  
$23,072.00  
STENT ANGIO PERIPHERAL  
0278  
C1876  
Variable  
STENT COATED NON-COR (DEVICE)  
0278  
C1874  
Variable  
STENT GRAFT  
0278  
C1874  
Variable  
STENT INSERT/CHANGE  
0360  
 
$1,088.00  
STENT, COATED/COVERED, WITH DELIVERY  
0278  
C1874  
Variable  
STENT, NON CORONARY, TEMPORARY  
0278  
C2625  
Variable  
STENT, URETERAL  
0278  
C2617  
Variable  
STENT,NON-COATED/NON-COVERED W/DELIVE  
0278  
C1876  
Variable  
STONE ANALYSIS  
0301  
82365  
$81.00  
STREP GRP A ANTIGEN DETECTION  
0306  
87880  
$71.00  
STREPTOLYSIN O ANTIBODY (ASO)  
0302  
86060  
$59.00  
STRESS ECHO  
0483  
93350  
$953.00  
STRESS TEST TRACING  
0482  
93017  
$490.00  
STRESS TTE COMPLETE  
0483  
93351  
$1,693.00  
STRESS TTE W OR W/O CONTRAST CONT ECG  
0483  
C8930  
$1,960.00  
STRYKER QUICK STICK 0295-002  
0270  
 
$190.00  
SUBFASCIAL SLING  
0278  
C1771  
Variable  
SULFATE ASSAY, URINE  
0301  
84392  
$75.00  
SUPERIOR/INFERIOR VENA CAVA  
0360  
36010  
$729.00  
SUPPLIES PROCEDURE  
0272  
 
Variable  
SURGERY LEVEL 1 ADD MINUTES  
0360  
 
$71.00  
SURGERY LEVEL 1 FIRST 15 MIN  
0360  
 
$1,477.00  
SURGERY LEVEL 2 ADD MINUTES  
0360  
 
$90.00  
SURGERY LEVEL 2 FIRST 15 MIN  
0360  
 
$1,923.00  
SURGERY LEVEL 3 ADD MINUTES  
0360  
 
$118.00  
SURGERY LEVEL 3 FIRST 15 MIN  
0360  
 
$2,500.00  
SURGERY LEVEL 4 ADD MINUTES  
0360  
 
$151.00  
SURGERY LEVEL 4 FIRST 15 MIN  
0360  
 
$3,253.00  
SURGERY LEVEL 5 ADD MINUTES  
0360  
 
$190.00  
SURGERY LEVEL 5 FIRST 15 MIN  
0360  
 
$4,229.00  
SURGIFLO HEMOSTATIC MATRIX KIT (2994)  
0278  
 
Variable  
SURVEILLANCE CULTURE  
0306  
87071  
$80.00  
SWALLOW CURRENT STATUS  
0440  
G8996  
$0.01  
SWALLOW DISCHARGE STATUS  
0440  
G8998  
$0.01  
SWALLOW GOAL STATUS  
0440  
G8997  
$0.01  
T CELLS TOTAL COUNT CD3  
0302  
86359  
$126.00  
T3 - TOTAL  
0301  
84480  
$70.00  
T3 FREE  
0301  
84481  
$91.00  
T3 REVERSE  
0301  
84482  
$63.00  
T4 (THYROXINE)  
0301  
84436  
$73.00  
T4, FREE  
0301  
84439  
$41.00  
TACROLIMUS FK507  
0301  
80197  
$121.00  
TAP BLOCK BILATERAL BY INJECTION(S)  
0360  
64488  
$195.00  
TAVR HEART VALVE  
0272  
 
Variable  
TB CELL MEDIATED ANTIGEN RESPONSE; GAMMA INTERFERON  
0302  
86480  
$230.00  
TCAT IV STENT CRV CRTD ART EMBOLIC PROTEC  
0360  
37215  
$4,530.00  
TCAT PLMT IV STENT CTR DIALYSIS SEG W/IMG S&I  
0360  
36908  
$19,651.00  
TEE OR CONTINUOUS  
0483  
93318  
$1,325.00  
TEGRETOL ASSAY (CARBAMAZEPIN)  
0301  
80156  
$87.00  
TELETHX ISODOSE PLN CPLX W/BASIC DOSIMETRY  
0333  
77307  
$1,376.00  
TELETHX ISODOSE PLN SMPL W/DOSIMETRY CALCULATION  
0333  
77306  
$959.00  
TEMP TRANSVENOUS PACEMAKER  
0360  
33210  
$10,238.00  
TESTOSTERONE TOTAL SERUM  
0301  
84403  
$136.00  
TESTOSTERONE, FREE  
0301  
84402  
$88.00  
THC CANNABINOIDS CONFIRMATION  
0301  
80349  
$88.00  
THEAPEUTIC PROCEDURES GROUP TWO OR MORE INDIVIDUALS  
0430  
97150  
$62.00  
THEOPHYLLINE ASSAY  
0301  
80198  
$109.00  
THERA PROC 1+ AREAS EA 15 MIN AQUATIC THERA EXCERCISES  
0430  
97113  
$117.00  
THERA PROC 1+ AREAS EA 15 MIN GAIT TRAIN INC STAIR CLIMBING  
0420  
 
$81.00  
THERA PROC 1+ AREAS EA 15 MIN GAIT TRAIN INC STAIR CLIMBING  
0420  
97116  
$81.00  
THERA PROC 1+ AREAS EA 15 MIN NEUROMUSC REEDUCATION  
0430  
 
$121.00  
THERA PROC 1+ AREAS EA 15 MIN NEUROMUSC REEDUCATION  
0430  
97112  
$121.00  
THERA PROC 1+ AREAS EA 15 MIN NEUROMUSCULAR REEDUCATION  
0420  
 
$121.00  
THERA PROC 1+ AREAS EA 15 MIN NEUROMUSCULAR REEDUCATION  
0420  
97112  
$121.00  
THERAPEUT DYNAMIC ACT IMPROVE FUNCT PERF 1/1 EA 15 MIN  
0420  
 
$100.00  
THERAPEUT DYNAMIC ACT IMPROVE FUNCT PERF 1/1 EA 15 MIN  
0420  
97530  
$100.00  
THERAPEUT PROC 1+ AREAS EA 15 MIN AQUATIC EXCERCISES  
0420  
97113  
$117.00  
THERAPEUTIC DYN ACTIV IMPROVE FUNCT PERF 1/1 EA 15 MINUTES  
0430  
 
$100.00  
THERAPEUTIC DYN ACTIV IMPROVE FUNCT PERF 1/1 EA 15 MINUTES  
0430  
97530  
$100.00  
THERAPEUTIC IVNTJ W/FOCUS ON COGNITIVE FUNCTION  
0440  
97127  
$106.00  
THERAPEUTIC IVNTJ W/FOCUS ON CONGNITIVE FUNCTION  
0430  
 
$106.00  
THERAPEUTIC IVNTJ W/FOCUS ON CONGNITIVE FUNCTION  
0430  
97127  
$106.00  
THERAPEUTIC IVNTJ W/FOCUS ON CONGNITIVE FUNCTION  
0440  
97127  
$106.00  
THERAPEUTIC PROC 1+ AREAS EACH 15 MIN MASSAGE INCL EFF/PET  
0420  
 
$95.00  
THERAPEUTIC PROC 1+ AREAS EACH 15 MIN MASSAGE INCL EFF/PET  
0430  
97124  
$95.00  
THERAPEUTIC PROCEDURES 1+ AREAS EA 15 MIN THERA EXCERCISES  
0430  
 
$105.00  
THERAPEUTIC PROCEDURES 1+ AREAS EA 15 MIN THERA EXCERCISES  
0430  
97110  
$105.00  
THERAPEUTIC PROCEDURES 1+ AREAS EA 15 MIN THERA EXERCISES  
0420  
 
$105.00  
THERAPEUTIC PROCEDURES 1+ AREAS EA 15 MIN THERA EXERCISES  
0420  
97110  
$105.00  
THERAPEUTIC PROCEDURES GROUP TWO OR MORE INDIVIDUALS  
0420  
97150  
$62.00  
THERAPEUTIC PROCEDURES GROUP TWO OR MORE INDIVIDUALS  
0420  
 
$62.00  
THERAPEUTIC PROCEDURES GROUP TWO OR MORE INDIVIDUALS  
0440  
97150  
$62.00  
THERAPEUTIC PROCEDURES INCR STRENGTH END RESP MUSCLES GROUP 2+  
0460  
G0239  
$52.00  
THERAPEUTIC SERV NON SPEECH GEN DEVICE INCL PROGRAM AND MOD  
0440  
92606  
$176.00  
THORACIC/BRACHIOCEPHALIC 1ST  
0323  
36215  
$1,374.00  
THORACIC/BRACHIOCEPHALIC 2ND  
0360  
36216  
$1,570.00  
THORACIC/BRACHIOCEPHALIC 3RD  
0360  
36217  
$1,874.00  
THROMB/LYSIS ART ADDL VESL  
0360  
37185  
$7,184.00  
THROMB/LYSIS ART PRIM 1ST VESL  
0360  
37184  
$6,511.00  
THROMB/LYSIS VEIN REPEAT TREAT  
0360  
37188  
$7,184.00  
THROMB/LYSIS VEIN(S)  
0360  
37187  
$7,353.00  
THROMBIN INJECT FOR PSEUDOANEURYSM  
0360  
36002  
$606.00  
THROMBIN TIME  
0300  
85670  
$24.00  
THROMBOLYSIS, CEREBRAL, BY INTRAVENOUS INFUSION  
0450  
37195  
$779.00  
THROMBOLYSIS, CORONARY, BY INTRAVENOUS INFUSION  
0450  
92977  
$779.00  
THROMBOLYTIC ART OR VEN TX-SUB W/CESSATION OF TX  
0481  
37214  
$4,065.00  
THROMBOLYTIC ART OR VENOUS THERAPY-SUBSEQUENT DAY  
0481  
37213  
$4,065.00  
THROMBOLYTIC ART THERAPY-INITIAL DAY  
0481  
37211  
$5,437.00  
THROMBOLYTIC VENOUS THERAPY-INITIAL DAY  
0481  
37212  
$1,768.00  
THYROGLOBULIN  
0301  
84432  
$55.00  
THYROGLOBULIN ANTIBODY  
0302  
86800  
$68.00  
THYROID HORMONE UPTAKE  
0301  
84479  
$73.00  
THYROID STIM IMMUNOGLOBULIN  
0301  
84445  
$170.00  
TISSUE CULTURE AMNIOTIC FLUID  
0300  
88235  
$491.00  
TISSUE MARKER/CLIP-IMPLANTABLE  
0278  
A4648  
$265.00  
TISSUE MARKER-IMPLANTABLE  
0278  
A4648  
$265.00  
TISSUE TRANSGLUTAMINASE AB IGA  
0301  
83520  
$74.00  
TOBRAMYCIN - RANDOM  
0301  
80200  
$121.00  
TOPIRAMATE (TOPAMAX)  
0301  
80201  
$109.00  
TOTAL ALLERGEN IGE  
0301  
82785  
$64.00  
TOXOPLASMA ANTIBODY, IGG  
0302  
86777  
$74.00  
TOXOPLASMA ANTIBODY, IGM  
0302  
86778  
$80.00  
TPMT GENE ANALAYSIS COMMON VARIANTS  
0310  
81335  
$472.00  
TRACH 4 CFS SHILEY (9097)  
0270  
 
$121.00  
TRACH 4 DCT SHILEY (9090)  
0270  
 
$110.00  
TRACH 5.0 PORTEX (9007)  
0270  
 
$71.00  
TRACH 6 CFN SHILEY (9088)  
0270  
 
$121.00  
TRACH 6 CFS SHILEY (9096)  
0270  
 
$113.00  
TRACH 6 DCT SHILEY (9091)  
0270  
 
$110.00  
TRACH 6 EXL CUFF (NS)(7642)  
0270  
 
$194.00  
TRACH 6 EXL CUFFLESS (NS) (7641)  
0270  
 
$194.00  
TRACH 7 EXL CUFF SHILEY (7440)  
0270  
 
$194.00  
TRACH 7.0 UNCUF PORTEX (9106)  
0270  
 
$71.00  
TRACH 8 CFN SHILEY (9089)  
0270  
 
$121.00  
TRACH 8 CUST 129 CUFF SHILEY (7428)  
0270  
 
$178.00  
TRACH 8 DCT SHILEY (9092)  
0270  
 
$110.00  
TRACH 8 EXL CUFF SHILEY (7428)  
0270  
 
$194.00  
TRACH 8 EXL CUFLS SHILEY (7427)  
0272  
 
$188.00  
TRACH 8 FEN SHILEY (9087)  
0270  
 
$130.00  
TRACH BUTTON OLYMPIC 10X27 (7514)  
0270  
 
$547.00  
TRACH CHANGE  
0360  
 
$854.00  
TRACH CUFFD 6MM PORTEX (4514)  
0270  
 
$81.00  
TRACH CUFFD 7MM PORTEX (5979)  
0270  
 
$81.00  
TRACH CUFFD 8MM PORTEX (4515)  
0270  
 
$81.00  
TRACH CUFLS 6MM PORTEX (4505)  
0270  
 
$71.00  
TRACH PORT 7 CUFF FEN (7539)  
0272  
 
$85.00  
TRACH SPEAKING VALVE  
0274  
 
$232.00  
TRAIN IN USE OF SPEECH DEVICE  
0440  
92609  
$349.00  
TRANSCATH INSERT OR REPLACE LEADLESS PM VENTR  
0481  
0387T  
$29,269.00  
TRANSCATH/BRUSH/BX-ANG  
0320  
75970  
$2,045.00  
TRANSCATHETER BIOPSY  
0360  
37200  
$5,411.00  
TRANSCRANIAL DOPPLER  
0921  
93886  
$1,168.00  
TRANSCRANIAL DOPPLER INTRACRANIAL ARTERIES-LIMITED STUDY  
0921  
93888  
$760.00  
TRANSESOPHAGEAL ECHOCARDIO  
0480  
93312  
$1,121.00  
TRANSFERRIN  
0301  
84466  
$67.00  
TRANSFUSION BLOOD OR BLOOD COMPONENTS  
0391  
36430  
$877.00  
TRAUMA ACTIVATION FULL  
0682  
G0390  
$3,727.00  
TRAUMA ACTIVATION FULL W/UNDER 30 MIN CC  
0682  
 
$3,727.00  
TRAUMA ACTIVATION MOD W/UNDER 30 MIN CC  
0682  
 
$2,855.00  
TRAUMA ACTIVATION MODIFIED  
0682  
G0390  
$2,855.00  
TRAUMA CRITICAL CARE 30-74 MINUTES  
0450  
99291  
$4,215.00  
TRAUMA CRITICAL CARE LESS THAN 30 MIN  
0450  
99285  
$1,955.00  
TRAUMA-MODIFIED W/O ACTIVATION  
0450  
99285  
$2,345.00  
TRAY THORACENTESIS 17G 6" (1323)  
0270  
 
Variable  
TRAY THORACENTESIS 18G (7560)  
0272  
 
Variable  
TRAY THOROCENTESIS  
0270  
 
Variable  
TREATMENT DEVICES-COMPLEX  
0333  
77334  
$843.00  
TREATMENT DEVICES-INTERMED  
0333  
77333  
$686.00  
TREATMENT DEVICES-SIMPLE  
0333  
77332  
$843.00  
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AUDITORY PROCES  
0440  
 
$317.00  
TREATMENT OF SPEECH LANGUAGE VOICE COMMUNICATION AUDITORY PROCES  
0440  
92507  
$317.00  
TREATMENT PORT IMAGE(S) VERIFI  
0333  
77417  
$244.00  
TREATMENT SWALLOWING DYSFUNCTION AND OR ORAL FUNCTION FOR FEEDING  
0440  
92526  
$247.00  
TRICHOMONAS DNA PROBE  
0306  
87660  
$74.00  
TRICYCLIC, ANTIDEPRESSANTS, QUANTITATIVE, URINE  
0301  
80337  
$93.00  
TRIGLYCERIDE  
0301  
84478  
$26.00  
TRIP FEE, 1 DRAW  
0300  
P9604  
$28.00  
TRIP FEE, 10 DRAWS  
0300  
P9604  
$2.80  
TRIP FEE, 11 DRAWS  
0300  
P9604  
$2.54  
TRIP FEE, 12 DRAWS  
0300  
P9604  
$2.33  
TRIP FEE, 14 DRAW  
0300  
P9604  
$2.00  
TRIP FEE, 15 DRAW  
0300  
P9604  
$1.86  
TRIP FEE, 2 DRAWS  
0300  
P9604  
$14.00  
TRIP FEE, 3 DRAWS  
0300  
P9604  
$9.33  
TRIP FEE, 4 DRAWS  
0300  
P9604  
$7.00  
TRIP FEE, 5 DRAWS  
0300  
P9604  
$5.60  
TRIP FEE, 6 DRAWS  
0300  
P9604  
$4.67  
TRIP FEE, 7 DRAWS  
0300  
P9604  
$4.00  
TRIP FEE, 8 DRAWS  
0300  
P9604  
$3.50  
TRIP FEE, 9 DRAWS  
0300  
P9604  
$3.11  
TRLML BALO ANGIOP OPEN/PERQ IMG S&I 1ST ART  
0481  
37246  
$9,723.00  
TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I 1ST VEIN  
0481  
37248  
$9,723.00  
TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I ADDL VEIN  
0481  
37249  
$4,702.00  
TRLUML BALO ANGIOP CTR DIALYSIS SEG W/IMG S&I  
0360  
36907  
$9,723.00  
TROPONIN T  
0301  
84484  
$132.00  
TSH  
0301  
84443  
$147.00  
TTE LIMITED OR F/U  
0480  
93308  
$823.00  
TTE W OR W/O FOL W/CONTRAST, DOPPLER  
0483  
C8929  
$1,960.00  
TTE WITH DOPPLER AND COLOR FLOW  
0483  
93306  
$1,696.00  
TTE-CHD  
0483  
93303  
$815.00  
TTE-CHD LIMITED OR F/U  
0483  
93304  
$504.00  
TTMT SWLLOWING DYSFUNCTION AND OR ORAL FCTN FOR FEEDING  
0440  
 
$247.00  
TUBE CHEST THALQIK (9114)  
0270  
 
$409.00  
TUBE EXHANGER (433587)  
0270  
 
$177.00  
TUBE MIC GASTROSTOMY 20FR (6270)  
0270  
 
$95.00  
TUBE THORACOSTOMY INCLUDES WATER SEAL  
0360  
32551  
$1,408.00  
TUBE THORACOSTOMY-OPEN  
0360  
32551  
$1,265.00  
TUMOR LOC ECT  
0341  
78803  
$1,677.00  
TUMOR LOC LIMITED AREA  
0341  
78800  
$720.00  
TUMOR LOC WB - 1 DAY  
0341  
78802  
$4,452.00  
TUMOR LOC WB - MULT DAYS  
0341  
78804  
$4,452.00  
TUNNELED CVAD W/PORT AGE +5  
0360  
36561  
$7,023.00  
TX ATRIAL FIB PULM VEIN ISOL  
0481  
93656  
$21,022.00  
TX L/R ATRIAL FIB ADD ON  
0481  
93657  
$13,999.00  
TX PLANNING IMRT  
0333  
77301  
$4,553.00  
ULTRASOUND TRANSRECTAL  
0402  
76872  
$425.00  
UMBILICAL ARTERY CATH, NEWBORN  
0761  
36660  
$1,059.00  
UMBILICAL VENOUS CATH, NEWBORN  
0761  
36510  
$1,059.00  
UNCONJUGATED ESTRIOL  
0301  
82677  
$81.00  
UNNA BOOT APPLICATION - BILATERAL  
0510  
29580  
$240.00  
UNNA BOOT APPLICATION - LEFT  
0510  
29580  
$240.00  
UNNA BOOT APPLICATION - RIGHT  
0510  
29580  
$240.00  
UPPER BALLOON ENTERSCOPY  
0360  
 
$3,378.00  
UPPER GI W/AIR W/KUB-DR  
0320  
74247  
$526.00  
UPPER GI W/AIR W/O KUB-DR  
0320  
74246  
$526.00  
UPPER GI W/KUB - DR  
0320  
74241  
$526.00  
UPPER GI W/O KUB - DR  
0320  
74240  
$526.00  
UPPER GI W/SMALL BOWEL-DW  
0320  
74245  
$861.00  
UPR GI NDSC REMOVAL LESION/POLYP/TUMOR BY HOT BX  
0360  
 
$4,220.00  
UREA NITROGEN, URINE  
0301  
84540  
$44.00  
URETERAL STENT  
0272  
 
Variable  
URETHROCYSTOGRAM-DW  
0320  
74450  
$861.00  
URIC ACID  
0301  
84550  
$27.00  
URIC ACID, URINE  
0301  
84560  
$75.00  
URINALYSIS W/MICRO  
0307  
81001  
$48.00  
URINALYSIS, CULTURE IF INDICAT  
0307  
81001  
$48.00  
URINE CHEMISTRY STRIP  
0307  
81002  
$35.00  
URINE HEMOGLOBIN  
0307  
83069  
$27.00  
URINE MACRO, C AND S IF INDICATED  
0307  
81003  
$21.00  
URINE MACRO, MICROSCOPIC IF IND  
0307  
81003  
$21.00  
URINE MICROSCOPIC  
0307  
81015  
$29.00  
URINE MICROSCOPIC, CULT IF IND  
0307  
81015  
$29.00  
URINE PROTEIN  
0301  
84156  
$73.00  
URO IV W/NEPHROTOMOGRAPH-DW  
0320  
74415  
$936.00  
UROGRAPHY RETROGRADE-DW  
0320  
74420  
$1,691.00  
US ABDOMEN COMPLETE  
0402  
76700  
$589.00  
US ABDOMEN LIMITED  
0402  
76705  
$437.00  
US ABDOMINAL AORTA, RT W/IMAGE DOC, SCREENING FOR AAA  
0402  
76706  
$425.00  
US BREAST UNI REAL TIME W/IMAGE LIMITED  
0402  
76642  
$362.00  
US CHEST (INCLUDES MEDIASTINUM)  
0402  
76604  
$336.00  
US CHEST WALL BIOPSY  
0360  
21550  
$3,819.00  
US COMPLETE JOINT  
0402  
76881  
$498.00  
US FETAL MIDDLE CEREBRAL ARTERY DOPPL  
0402  
76821  
$425.00  
US FETAL UMBILICAL ARTERY DOPPLER  
0402  
76820  
$425.00  
US GUID PARENCHYMAL TISSUE ABLATION  
0402  
76940  
$802.00  
US GUIDANCE FOR AMNIOCENTESIS  
0402  
76946  
$411.00  
US GUIDANCE FOR NEEDLE PLACEMENT  
0402  
76942  
$1,041.00  
US GUIDANCE FOR PERICARDIOCENTESIS  
0402  
76930  
$335.00  
US GUIDANCE FOR VASCULAR ACCESS  
0402  
76937  
$471.00  
US GUIDANCE-INTRAOPERATIVE  
0402  
76998  
$560.00  
US GUIDED PERICARDIOCENTESIS  
0761  
76930  
$335.00  
US HEAD/BRAIN  
0402  
76506  
$366.00  
US INFANT HIPS-DYNAMIC  
0402  
76885  
$329.00  
US LIMITED JOINT OR OTHER NONVASCULAR EXTREMITY  
0402  
76882  
$366.00  
US OBSTETRIC AFTER 14 WKS PREG-EA ADDSTER  
0402  
76810  
$421.00  
US OBSTETRIC AFTER 14 WKS PREG-SINGLE OR FIRST GESTATION  
0402  
76805  
$624.00  
US OBSTETRIC BPP W/O NON STRESS TEST  
0402  
76819  
$425.00  
US OBSTETRIC DETAILED EXAM-EA ADD GES  
0402  
76812  
$453.00  
US OBSTETRIC DETAILED EXAM-SINGLE OR FIRST GESTATION  
0402  
76811  
$968.00  
US OBSTETRIC NUCHAL TRANSLUCENCY-EA A  
0402  
76814  
$392.00  
US OBSTETRIC NUCHAL TRANSLUCENCY-SINGLE OR FIRST GESTATION  
0402  
76813  
$631.00  
US OBSTETRIC TRANSABDOMINAL F/U GROWTH-PER FETUS  
0402  
76816  
$350.00  
US OBSTETRIC TRANSVAGINAL  
0402  
76817  
$455.00  
US OBSTETRIC UP TO 14 WKS PREG-EA ADD  
0402  
76802  
$226.00  
US OBSTETRIC UP TO 14 WKS PREG-SINGLE OR FIRST GESTATION  
0402  
76801  
$400.00  
US PELVIS-COMPLETE  
0402  
76856  
$492.00  
US PELVIS-LIMITED OR F/U  
0402  
76857  
$425.00  
US PREGNANT UTERUS RT W/IMAGE DOCUMENT ONE OR MORE FETUSES  
0402  
76815  
$382.00  
US PREGNANT UTERUS RT W/IMAGE DOCUMENT ONE OR MORE FETUSES  
0402  
76815  
$425.00  
US RENAL BIOPSY PERCUT  
0360  
50200  
$888.00  
US RENAL CYST ASP/INJ  
0360  
50390  
$1,680.00  
US RETROPERITONEAL COMPLETE  
0402  
76770  
$510.00  
US RETROPERITONEAL LIMITED  
0402  
76775  
$425.00  
US SCROTUM AND CONTENTS  
0402  
76870  
$425.00  
US SOFT TISSUES OF HEAD AND NECK  
0402  
76536  
$425.00  
US SPINAL CANAL AND CONTENTS  
0402  
76800  
$366.00  
US THORACENTESIS FOR ASPIRATION W/IMAGING  
0360  
32555  
$1,265.00  
US THORACENTESIS W/TUBE PLACEMENT W/IMAGING  
0360  
32557  
$2,887.00  
US TRANSPLANTED KIDNEY  
0402  
76776  
$461.00  
US TRANSVAGINAL  
0402  
76830  
$455.00  
VAC CANISTER 500ML (7464)  
0270  
 
$117.00  
VAC DRESS SM (7468)  
0272  
 
$110.00  
VAC DRESS X-LARGE (7460)  
0270  
 
$346.00  
VAC DRESSING ABD ABTHERA (7744)  
0272  
 
$1,152.00  
VAC DRESSING LG (7462)  
0272  
 
$168.00  
VAC DRESSING LG WHITE (7461)  
0270  
 
Variable  
VAC DRESSING MED (7466)  
0272  
 
$146.00  
VAC DRESSING MED SILVER (7583)  
0270  
 
$219.00  
VAC DRESSING MED WHITE (7469)  
0270  
 
$177.00  
VAC DRESSING SM WHITE (7470)  
0270  
 
$168.00  
VAGINAL INSERTION FOR CYLINDERS  
0333  
57156  
$598.00  
VALPROIC ACID ASSAY  
0301  
80164  
$87.00  
VANCOMYCIN - RANDOM  
0301  
80202  
$108.00  
VARICELLA ZOSTER AB, IGG  
0301  
86787  
$86.00  
VASC EMBOLIZE/OCCLUDE ARTERY  
0481  
37242  
$16,087.00  
VASC EMBOLIZE/OCCLUDE BLEED  
0481  
37244  
$17,278.00  
VASC EMBOLIZE/OCCLUDE ORGAN  
0481  
37243  
$17,112.00  
VASC EMBOLIZE/OCCLUDE VENOUS  
0481  
37241  
$19,195.00  
VASCULAR GRAFTS  
0278  
C1768  
Variable  
VEN HEPATIC W/HEMODYNAMIC EVAL  
0320  
75889  
$6,294.00  
VEN HEPATIC W/O HEMODYNMC EVAL  
0320  
75891  
$6,294.00  
VENA CAVA FILTER  
0278  
C1880  
Variable  
VENO CAVA/INFERIOR W/SERIAL  
0320  
75825  
$6,294.00  
VENO CAVAL/SUPERIOR W/SERIAL  
0320  
75827  
$2,030.00  
VENO RENAL UNILAT SELECT-ANG  
0320  
75831  
$6,294.00  
VENTILATOR CHRONIC  
0410  
94003  
$2,743.00  
VENTILATOR CIRCUIT  
0272  
 
Variable  
VENTILATOR MANAGEMENT  
0410  
94003  
$2,743.00  
VIRUS INOCULATION  
0306  
87254  
$128.00  
VIRUS TISS CULTURE ADDL/EACH ISOLATE  
0306  
87253  
$75.00  
VIRUS TISS CULTURE INOCULATION  
0306  
87252  
$124.00  
VISCER & INFRARENAL ABDOM AORTA 2 PROSTHESIS  
0360  
34846  
$20,524.00  
VISCERL SUPRA/SELECT W/WO AORT  
0320  
75726  
$6,294.00  
VISCOSITY, SERUM  
0301  
85810  
$53.00  
VITAL CAPACITY  
0460  
94150  
$140.00  
VITAMIN A, SERUM  
0301  
84590  
$62.00  
VITAMIN B1 PYROPHOSPHATE (THIAMINE)  
0301  
84425  
$77.00  
VITAMIN B-12 ASSAY  
0301  
82607  
$92.00  
VITAMIN B-6 ASSAY  
0301  
84207  
$94.00  
VITAMIN D 25-OH ASSAY  
0301  
82306  
$108.00  
VITAMIN E  
0301  
84446  
$63.00  
VMA 24HR URINE  
0301  
84585  
$70.00  
VOICE CURRENT STATUS  
0440  
G9171  
$0.01  
VOICE DISCHARGE STATUS  
0440  
G9173  
$0.01  
VOICE GOAL STATUS  
0440  
G9172  
$0.01  
VOLATILES, METHANOL, OR ISOPROPANOL  
0301  
84600  
$165.00  
WBC (AUTOMATED)  
0305  
85048  
$25.00  
WC PHYS CAP EVAL - LEVEL 1  
0429  
99196  
$300.00  
WC PHYS CAP EVAL - LEVEL II  
0429  
99197  
$616.00  
WC PHYS CAP EVAL ADD'L 15 MIN  
0429  
99193  
$78.00  
WC WORK CAPACITY EVAL  
0429  
99198  
$1,230.00  
WEST NILE VIRUS AB  
0302  
86789  
$77.00  
WHEELCHAIR MANAGEMENT ASSESSMENT FITTING TRAINING EA 15 MIN  
0420  
 
$97.00  
WHEELCHAIR MANAGEMENT ASSESSMENT FITTING TRAINING EA 15 MIN  
0420  
97542  
$97.00  
WHFO CF INCL 1 OR MORE NONTORSION JNTS  
0274  
L3806  
$673.00  
WHFO RIGID W/O JNTS CUSTOM FABRICATED  
0274  
L3808  
$533.00  
WHFO W/O JNTS PREFABRICATED OTS  
0274  
L3809  
$279.00  
WHFO W/O JNTS PREFABRICATED W/ EXPERTISE  
0274  
L3807  
$349.00  
WHO INCL 1 OR MORE NONTORSION JNTS CUSTOM FABRICATED  
0274  
L3905  
$1,381.00  
WHO INCL 1 OR MORE NT JNTS PREFABRICATED W/ EXPERTISE  
0274  
L3915  
$220.00  
WHO W/O JNTS CUSTOM FABRICATED  
0274  
L3906  
$631.00  
WHO WRST EXT CONTROL COCK UP NON MOLDED PREFABRICATED  
0274  
L3908  
$195.00  
WIRE, 80CM EXTRA STIFF AMPLATZ  
0272  
C1769  
$108.00  
WORK HARDENING CONDITIONING INITIAL TWO HOURS  
0429  
97545  
$242.00  
WOUND DEBRIDE, 1ST 20 SQ CM  
0420  
97597  
$512.00  
WOUND DEBRIDE, 1ST 20 SQ CM  
0430  
97597  
$512.00  
WOUND VAC DAY RENTAL KCI (N/A)  
0270  
 
Variable  
WOUND VAC DRESS WHITE SMALL (7470)  
0270  
 
$152.00  
WOUND VAC-NEG PRESS GREATER THAN 50 SQ CM  
0510  
97606  
$501.00  
WOUND VAC-NEG PRESS UP THRU 50 SQ CM  
0510  
97605  
$285.00  
X-MATCH 1 UNIT  
0309  
86923  
$382.00  
XR UGI W/AIR AND SBFT  
0320  
74249  
$511.00  
XRAY ABDOMEN W/CHEST COMPLETE  
0320  
74022  
$425.00  
XRAY ABSCESS FISTULA SINUS TRACT  
0320  
76080  
$499.00  
XRAY ACROMIOCLAVICULAR JOINTS BILATERAL  
0320  
73050  
$231.00  
XRAY ANKLE 2 VIEWS  
0320  
73600  
$231.00  
XRAY ANKLE 3+ VIEWS COMPLETE  
0320  
73610  
$231.00  
XRAY CERVICAL SPINE 4+ VIEWS  
0320  
72050  
$425.00  
XRAY CERVICAL SPINE 2-3 VIEWS  
0320  
72040  
$231.00  
XRAY CERVICAL SPINE COMPLETE  
0320  
72052  
$425.00  
XRAY CLAVICAL COMPLETE  
0320  
73000  
$231.00  
XRAY ELBOW 2 VIEWS  
0320  
73070  
$231.00  
XRAY ELBOW 3+ VIEWS  
0320  
73080  
$231.00  
XRAY EXAM ENTIRE SPINE 4 OR 5 VIEWS  
0320  
72083  
$843.00  
XRAY EXAM ENTIRE SPINE W/SKULL 1 VIEW  
0320  
72081  
$231.00  
XRAY EXAM ENTIRE SPINE W/SKULL 2-3 VIEWS  
0320  
72082  
$425.00  
XRAY EXAM HIP UNILATERAL 1 VIEW  
0320  
73501  
$231.00  
XRAY EXAM HIP UNILATERAL 2 OR 3 VIEWS  
0320  
73502  
$231.00  
XRAY EXAM HIPS BILATERAL 3 OR 4 VIEWS  
0320  
73522  
$425.00  
XRAY EXAM OF FEMUR 1 VIEW  
0320  
73551  
$231.00  
XRAY EXAM OF FEMUR 2 VIEWS MINIMUM  
0320  
73552  
$231.00  
XRAY FACIAL BONES 1-2 VIEWS  
0320  
70140  
$231.00  
XRAY FACIAL BONES 3+ VIEWS  
0320  
70150  
$425.00  
XRAY FOOT 2 VIEWS  
0320  
73620  
$231.00  
XRAY FOOT 3+ VIEWS COMPLETE  
0320  
73630  
$231.00  
XRAY FOR FOREIGN BODY-CHILD  
0320  
76010  
$231.00  
XRAY FOREARM 2 VIEWS  
0320  
73090  
$231.00  
XRAY HAND 2 VIEWS  
0320  
73120  
$425.00  
XRAY HAND 3+ VIEWS  
0320  
73130  
$231.00  
XRAY HEEL 2+ VIEWS  
0320  
73650  
$231.00  
XRAY HUMERUS 2+ VIEWS  
0320  
73060  
$231.00  
XRAY KNEE 1-2 VIEWS  
0320  
73560  
$231.00  
XRAY KNEE 3 VIEWS  
0320  
73562  
$231.00  
XRAY KNEE 4+ VIEWS COMPLETE  
0320  
73564  
$425.00  
XRAY LOWER EXTREMITY INFANT 2+ VIEWS  
0320  
73592  
$231.00  
XRAY LUMBAR SPINE BENDING 4+ VIEWS  
0320  
72120  
$279.00  
XRAY LUMBARSACRAL SPINE 2-3 VIEWS  
0320  
72100  
$425.00  
XRAY LUMBARSACRAL SPINE 4+ VIEWS  
0320  
72110  
$425.00  
XRAY LUMBARSACRAL SPINE COMPLETE  
0320  
72114  
$425.00  
XRAY MANDIBLE 4+ VIEWS  
0320  
70110  
$425.00  
XRAY NASAL BONES 3+ VIEWS  
0320  
70160  
$231.00  
XRAY NECK SOFT TISSUE  
0320  
70360  
$231.00  
XRAY OSSEOUS SURVEY COMPLETE  
0320  
77075  
$425.00  
XRAY OSSEOUS SURVEY-INFANT  
0320  
77076  
$425.00  
XRAY PELVIS 1-2 VIEWS  
0320  
72170  
$425.00  
XRAY RIBS BILATERAL 3 VIEWS  
0320  
71110  
$425.00  
XRAY RIBS BILATERAL 4 VIEWS  
0320  
71111  
$425.00  
XRAY RIBS UNILATERAL 2 VIEWS  
0320  
71100  
$231.00  
XRAY RIBS UNILATERAL 3 VIEWS  
0320  
71101  
$425.00  
XRAY SACROILIAC JOINTS 3+ VIEWS  
0320  
72202  
$425.00  
XRAY SACRUM/COCCYX 2+ VIEWS  
0320  
72220  
$231.00  
XRAY SCAPULA COMPLETE  
0320  
73010  
$279.00  
XRAY SHOULDER 1 VIEW  
0320  
73020  
$231.00  
XRAY SHOULDER 2+ VIEWS COMPLETE  
0320  
73030  
$231.00  
XRAY SINUSES 1-2 VIEWS  
0320  
70210  
$231.00  
XRAY SINUSES 3+ VIEWS  
0320  
70220  
$231.00  
XRAY SKULL 1-3 VIEWS  
0320  
70250  
$425.00  
XRAY SKULL 4+ VIEWS  
0320  
70260  
$425.00  
XRAY SPINE 1 VIEW  
0320  
72020  
$231.00  
XRAY STERNOCLAVICULAR JOINTS 3+ VIEWS  
0320  
71130  
$231.00  
XRAY STERNUM 2+ VIEWS  
0320  
71120  
$231.00  
XRAY SURGICAL SPECIMEN  
0320  
76098  
$1,802.00  
XRAY TEMPOROMANDIBULAR JOINTS BILATERAL  
0320  
70330  
$231.00  
XRAY THORACIC SPINE 2 VIEWS  
0320  
72070  
$425.00  
XRAY THORACIC SPINE 3 VIEWS  
0320  
72072  
$425.00  
XRAY THORACOLUMBAR JUNCTION 2 VIEWS MIN  
0320  
72080  
$231.00  
XRAY TIBIA/FIBULA 2 VIEWS  
0320  
73590  
$231.00  
XRAY UPPER EXTREMITY INFANT 2+ VIEWS  
0320  
73092  
$425.00  
XRAY WRIST 2 VIEWS  
0320  
73100  
$231.00  
XRAY WRIST 3+ VIEWS COMPLETE  
0320  
73110  
$231.00  
YEAST ID  
0306  
87106  
$94.00  
YUEH-CENTISIS CATH NEEDLE  
0272  
 
$61.00  
ZIKA VIRUS IGM ANTIBODY  
0302  
86794  
$56.00  
ZINC LEVEL PLASMA  
0301  
84630  
$63.00  
ZINC PROTOPORPHYRIN  
0301  
84202  
$57.00  
ZIO 48HRS UP TO 21DAYS-HOOK UP  
0731  
0296T  
$366.00  
ZONISAMIDE QUANTITATIVE  
0301  
80203  
$116.00  

West Valley Hospital Pricing


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PROCEDURE NAME
REVENUE ID
CPT CODE
COST
17 HYDROXYPROGESTERONE  
301  
83498  
$93.00  
2HR GLUCOSE TOLERANCE  
301  
82951  
$132.00  
3D RENDERING REQUIRING WORKSTATION  
350  
76377  
$768.00  
AB BARTONELLA  
306  
86611  
$72.00  
AB SCREEN  
300  
86850  
$132.00  
ABO TYPING  
300  
86900  
$109.00  
ACID FAST CULTURE  
306  
87116  
$152.00  
ACID FAST STAIN  
306  
87206  
$78.00  
ACTH  
301  
82024  
$134.00  
ACTIVATED PROTEIN C RESISTANCE RATION  
300  
85307  
$92.00  
ACUTE HEPATITIS PANEL  
301  
80074  
$369.00  
ADMIN OF HEPATITIS B VACCINE  
771  
G0010  
$62.00  
ADMIN OF INFLUENZA VACCINE  
771  
G0008  
$62.00  
ADMIN OF PNEUMOCOCCAL VACCINE  
771  
G0009  
$62.00  
ADMIN VACCINE-IMMUNIZATION-ONE VACCINE  
771  
G0008  
$97.00  
AEROBIC IDENTIFICATION  
306  
87077  
$56.00  
AFP TO SERUM TO ESOTERIX GENZYME  
301  
82105  
$65.00  
AG DETECT NOS EIA MULTI STEP EACH ORGANISM  
306  
87449  
$139.00  
AIRWAY INHALATION TREATMENT  
410  
94640  
$45.00  
ALBUMIN ASSAY  
301  
82042  
$25.00  
ALCOHOL BIOMARKERS 1 OR 2 (ETHYL GLUCURONIDE)  
301  
80321  
$124.00  
ALDOLASE ASSAY  
301  
82085  
$70.00  
ALDOSTERONE ASSAY  
301  
82088  
$136.00  
ALKALINE PHOSPHATASE  
301  
84075  
$27.00  
ALKALINE PHOSPHATASE ISOENZYME  
301  
84080  
$104.00  
ALLERGEN SPECIFIC IGE, EACH  
302  
86003  
$20.00  
ALPHA 1 ANTITRYPSIN PHENOTYPE  
301  
82104  
$48.00  
ALPHA FETOPROTEIN, TUMOR MARKER  
301  
82105  
$65.00  
ALPHA-1-ANTITRYPSIN  
301  
82103  
$73.00  
AMMONIA  
301  
82140  
$62.00  
AMPHETAMINES; 1 OR 2  
301  
80324  
$88.00  
AMYLASE ASSAY  
301  
82150  
$84.00  
ANA BY IFA  
301  
86039  
$154.00  
ANAEROBE CULTURE SURGICAL SP  
306  
87075  
$74.00  
ANAEROBIC ID  
306  
87076  
$72.00  
ANCHOR/SCREW FOR OPPOSING BONE TO BON  
278  
C1713  
Variable  
ANESTHESIA INHALATION OR IV ADDL MINUTE  
370  
 
$8.05  
ANESTHESIA INHALATION OR IV FIRST 15 MINUTES  
370  
 
$380.00  
ANGIOTENSIN CONVERT ENZ  
301  
82164  
$62.00  
ANTI MITOCHONDRIAL AB  
301  
83516  
$73.00  
ANTI NUCLEAR ANTIBODY SCREEN  
301  
86038  
$126.00  
ANTIBODY ENTEROVIRUS  
302  
86658  
$43.00  
ANTIBODY I.D. ELUATE  
302  
86860  
$382.00  
ANTIBODY ID  
302  
86870  
$638.00  
ANTIBODY TITER  
300  
86850  
$132.00  
ANTIBODY VIRUS NOT ELSEWHERE SPECIFIED  
302  
86790  
$43.00  
ANTIBODY; TREPONEMA PALLIDUM  
306  
86780  
$65.00  
ANTICARDIOLIPIN ABS, IGA, G OR M  
301  
86147  
$94.00  
ANTI-DNA DOUBLE STRAND  
301  
86225  
$90.00  
ANTINEUTROPHIL CYTOPLASMIC AB  
301  
86021  
$120.00  
ANTI-STRIATED MUSCLE AB, IGG  
301  
86255  
$72.00  
ANTITHROMBIN III ACTIV  
302  
85300  
$145.00  
APP OF MULTI-LAYER VENOUS WOUND COMP BELOW KNEE-BILATERAL  
510  
29581  
$356.00  
APP OF MULTI-LAYER VENOUS WOUND COMP BELOW KNEE-LT  
510  
29581  
$356.00  
APP OF MULTI-LAYER VENOUS WOUND COMP BELOW KNEE-RT  
510  
29581  
$356.00  
APPL MOD 1+ AREAS ELEC STIM MAN EA 15 MIN  
430  
97032  
$104.00  
APPL MOD 1+ AREAS ULTRASOUND EACH 15 MINUTES  
420  
97035  
$74.00  
APPL OF MOD 1+ AREAS ULTRASOUND EACH 15 MINUTES  
430  
97035  
$74.00  
APPL OF MODALITY TO 1+ AREAS ELECTRICAL STIM UNATTENDED  
420  
97014  
$56.00  
APPL OF MODALITY TO 1+ AREAS PARAFFIN BATH  
430  
97018  
$51.00  
APPLICATION OF MODALITY TO 1+ AREAS IONTOPHORESIS EACH 15 MINUTE  
420  
97033  
$83.00  
APPLICATION OF MODALITY TO 1+ AREAS IONTOPHORESIS EACH 15 MINUTE  
430  
97033  
$83.00  
APPLICATION OF MODALITY TO 1+ AREAS TRACTION MECHANICAL  
420  
97012  
$83.00  
ARSENIC ASSAY  
301  
82175  
$99.00  
ARTERIAL PUNCTURE  
300  
36600  
$158.00  
ASSAY OF ETHANOL  
301  
80320  
$175.00  
ASSAY OF MYOGLOBIN  
301  
83874  
$66.00  
ASSAY OF NICOTINE  
301  
80323  
$104.00  
ASSAY OF PHENCYCLIDINE  
301  
83992  
$60.00  
ASSAY OF SEX HORMONE BINDING GLOBULIN  
301  
84270  
$86.00  
ASSAY TEST FOR BLOOD FECAL  
300  
82274  
$59.00  
ATTENTION CURRENT STATUS  
440  
G9165  
$0.01  
ATTENTION DISCHARGE STATUS  
440  
G9167  
$0.01  
ATTENTION GOAL STATUS  
440  
G9166  
$0.01  
BARBITURATES CONFIRMATION  
301  
80345  
$88.00  
BASIC METABOLIC PANEL  
301  
80048  
$88.00  
BCR ABL 1 GENE MAJOR BP  
300  
81206  
$547.00  
BCR ABL 1 GENE MINOR BP  
300  
81207  
$702.00  
BENZODIAZEPINES; 1-12  
301  
80346  
$99.00  
BETA 2 GLYCOPROTEIN AB, EA  
302  
86146  
$85.00  
BETA HCG  
301  
84702  
$56.00  
BETA HYDROXYBUTYRATE SERUM QUANT OTHER KETONE BODIES  
301  
82010  
$52.00  
BETA LACTAMASE TEST  
306  
87185  
$33.00  
BETA-2 MICROGLOBULIN, QUANTIT  
301  
82232  
$74.00  
BILIRUBIN TOTAL  
301  
82247  
$35.00  
BIOPSY OR EXCISION LYMPH NODE BY NEEDLE-SUPERFICIAL  
360  
38505  
$760.00  
BLOOD DRAW-CENTRAL/PERIPHERAL LINE  
510  
36592  
$126.00  
BLOOD DRAW-COMPLETE IMPLANTABLE VAD  
510  
36591  
$104.00  
BLOOD TYPING;RBC ANTIGENS,OTHER THAN  
300  
86905  
$638.00  
BNP  
301  
83880  
$261.00  
BODY FLUID PH  
301  
83986  
$50.00  
BODY FLUID PROTEIN  
301  
84155  
$27.00  
BODY POSITION CURRENT STATUS  
420  
G8981  
$0.01  
BODY POSITION CURRENT STATUS  
430  
G8981  
$0.01  
BODY POSITION DISCHARGE STATUS  
420  
G8983  
$0.01  
BODY POSITION DISCHARGE STATUS  
430  
G8983  
$0.01  
BODY POSITION GOAL STATUS  
420  
G8982  
$0.01  
BODY POSITION GOAL STATUS  
430  
G8982  
$0.01  
BONE AGE STUDY  
320  
77072  
$425.00  
BONE DENSITY STUDY, AXIAL  
320  
77080  
$508.00  
BREAST CORE NEEDLE (420582)  
272  
 
$158.00  
BREAST NEEDLE LOC (404322,404320,404319)  
272  
 
$71.00  
BRONCHOSCOPY  
360  
 
$2,685.00  
BUN  
301  
84520  
$27.00  
BX BREAST 1ST LESION US IMAGING  
360  
19083  
$2,098.00  
C DIFFICILE TOXIN A+B  
306  
87324  
$140.00  
C REACTIVE PROTEIN (CRP)  
301  
86140  
$115.00  
C4  
300  
86160  
$98.00  
CA 19-9  
301  
86301  
$101.00  
CA125 ASSAY  
302  
86304  
$156.00  
CALCITONIN ASSAY  
301  
82308  
$98.00  
CALCIUM ASSAY  
301  
82310  
$27.00  
CALCIUM ASSAY, URINE  
301  
82340  
$54.00  
CALCIUM, IONIZED  
301  
82330  
$60.00  
CALPROTECTIN FECAL  
301  
83993  
$216.00  
CANALITH REPOSITION EPLEY MANEUVER SEMONT MAN PER DAY  
420  
95992  
$129.00  
CANDIDA SPECIES DNA PROBE  
306  
87480  
$74.00  
CAPILLARY PUNCTURE  
300  
36416  
$301.00  
CARBOXYHEMOGLOBIN  
301  
82375  
$56.00  
CARDIAC DOPPLER/NO INTERP  
480  
93320  
$336.00  
CARDIOPULMONARY RESUSCITATION  
480  
92950  
$632.00  
CARDIOVERSION  
480  
92960  
$1,054.00  
CARNITINE, FREE AND TOTAL, SERUM  
301  
82379  
$75.00  
CARRY CURRENT STATUS  
420  
G8984  
$0.01  
CARRY CURRENT STATUS  
430  
G8984  
$0.01  
CARRY DISCHARGE STATUS  
420  
G8986  
$0.01  
CARRY DISCHARGE STATUS  
430  
G8986  
$0.01  
CARRY GOAL STATUS  
420  
G8985  
$0.01  
CARRY GOAL STATUS  
430  
G8985  
$0.01  
CATARACT REMOVAL W/INSERT INTRAOCULAR LENS 1 STAGE  
360  
66984  
$5,889.00  
CATECHOLAMINES, UA FRACT  
301  
82384  
$111.00  
CATH FOLEY TRAY 16FR TEMP SENS (7626)  
272  
 
Variable  
CATH, BALLOON  
272  
C1726  
Variable  
CATHETER, URETERAL  
272  
C1758  
Variable  
CBC (AUTOMATED)  
305  
85027  
$58.00  
CBC WITH AUTOMATED DIFF  
305  
85025  
$81.00  
CD4  
301  
86361  
$164.00  
CEA ASSAY  
301  
82378  
$94.00  
CELL COUNT AND DIFF BODY FLUID  
305  
89051  
$98.00  
CELL COUNT CSF WITHOUT DIFF  
301  
89050  
$98.00  
CERULOPLASMIN  
301  
82390  
$57.00  
CHEMO IV INF 1ST HR SINGLE OR 1ST DRU  
280  
96413  
$633.00  
CHEMO IV INF ADDT'L HRS  
280  
96415  
$143.00  
CHEST PT AND PD  
410  
94668  
$184.00  
CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TECHNIQUE  
306  
87491  
$191.00  
CHLORIDE URINE  
301  
82436  
$48.00  
CHLORIDE, SERUM  
301  
82435  
$27.00  
CHOLANGIOGRAPHY SURGICAL  
320  
74300  
$298.00  
CHOLESTEROL  
301  
82465  
$27.00  
CHROMIUM ASSAY  
301  
82495  
$168.00  
CHROMOGRANIN-A  
301  
86316  
$138.00  
CITRIC ACID, 24 HOUR URINE  
301  
82507  
$97.00  
CKMB  
301  
82553  
$75.00  
COCCIDIOIDES AB IGG OR IGM  
302  
86635  
$64.00  
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE  
300  
36415  
$20.00  
COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE  
761  
36415  
$28.00  
COLONOSCOPY - SIMPLE  
360  
 
$2,465.00  
COLOR FLOW DOPPLER  
480  
93325  
$538.00  
COLUMN CHROMATOGRAPHY NON DRUG NOS EA SPEC  
301  
82542  
$256.00  
COMBINED VACCINE,MMR+VARICELLA,SQ  
636  
90710  
Variable  
COMPATABILITY TEST ANTIGLOBULIN  
309  
86922  
$382.00  
COMPATABILITY TEST IMMEDIATE SPIN  
309  
86920  
$382.00  
COMPATABILITY TEST INCUBATION PHASE  
309  
86921  
$382.00  
COMPLEMENT, TOTAL (CH-50)  
301  
86162  
$102.00  
COMPLEX STAIN FOR O AND P  
306  
87209  
$60.00  
COMPREHENSIVE MET PANEL  
301  
80053  
$126.00  
CONC FOR INFECTIOUS AGENT  
306  
87015  
$85.00  
CONNECTIVE TISSUE, HUMAN (INCLUDES FA  
278  
C1762  
Variable  
CONTINUOUS NEBULIZER 1ST HOUR  
410  
94644  
$142.00  
COPPER  
301  
82525  
$59.00  
CORTISOL, SERUM  
301  
82533  
$96.00  
CORTISOL,FREE,24 HR URINE  
301  
82530  
$62.00  
CPAP ACUTE  
410  
94660  
$789.00  
CPAP CHRONIC  
410  
94660  
$302.00  
C-PEPTIDE  
301  
84681  
$70.00  
CPK  
301  
82550  
$64.00  
CREATININE CLEARANCE  
301  
82575  
$76.00  
CREATININE SERUM  
301  
82565  
$27.00  
CREATININE, URINE RANDOM  
301  
82570  
$45.00  
CRITICAL CARE 30-74 MINUTES  
450  
99291  
$2,641.00  
CRITICAL CARE EACH ADDTNL 30 MIN  
450  
99292  
$773.00  
CRYOGLOBULINS QUAL OR SEMI QUANT  
301  
82595  
$39.00  
CRYPTOSPORIDIUM AG DETECTION BY EIA  
306  
87328  
$59.00  
CRYSTAL I.D  
307  
89060  
$86.00  
CT ABD AND PELVIS W/CONTRAST  
350  
74177  
$1,667.00  
CT ABD AND PELVIS W/O AND W/CONTRAST  
350  
74178  
$1,834.00  
CT ABD AND PELVIS W/O CONTRAST (OR OR  
350  
74176  
$1,421.00  
CT ABDOMEN W/CONTRAST  
350  
74160  
$1,667.00  
CT ABDOMEN W/O AND W/CONTRAST  
350  
74170  
$1,834.00  
CT ABDOMEN W/O CONTRAST  
350  
74150  
$709.00  
CT ANGIO ABD AND PELVIS W/CON,INCLUDING NON CONTRT  
352  
74174  
$1,667.00  
CT ANGIO ABDOMEN W/CONTRAST  
352  
74175  
$1,667.00  
CT ANGIO ABDOMEN W/RUNOFFS  
350  
75635  
$2,068.00  
CT ANGIO CHEST W/CONTRAST  
352  
71275  
$1,667.00  
CT ANGIO HEAD W/CONTRAST  
350  
70496  
$1,667.00  
CT ANGIO LOWER EXTREMITY W/CONTRAST  
350  
73706  
$1,667.00  
CT ANGIO NECK W/CONTRAST  
350  
70498  
$1,667.00  
CT CERVICAL SPINE W/CONTRAST  
350  
72126  
$1,614.00  
CT CERVICAL SPINE W/O CONTRAST  
350  
72125  
$709.00  
CT CHEST W/CONTRAST  
350  
71260  
$1,667.00  
CT CHEST W/O AND W/CONTRAST  
350  
71270  
$1,834.00  
CT CHEST W/O CONTRAST  
350  
71250  
$758.00  
CT HEAD OR BRAIN W/CONTRAST  
351  
70460  
$1,667.00  
CT HEAD OR BRAIN W/O AND W/CONTRAST  
351  
70470  
$1,834.00  
CT HEAD OR BRAIN W/O CONTRAST  
351  
70450  
$709.00  
CT LOWER EXTREMITY W/CONTRAST  
350  
73701  
$1,667.00  
CT LOWER EXTREMITY W/O CONTRAST  
350  
73700  
$709.00  
CT LUMBAR SPINE W/CONTRAST  
350  
72132  
$2,685.00  
CT LUMBAR SPINE W/O CONTRAST  
350  
72131  
$709.00  
CT MAXILLOFACIAL W/CONTRAST  
350  
70487  
$1,667.00  
CT MAXILLOFACIAL W/O CONTRAST  
350  
70486  
$709.00  
CT NECK W/CONTRAST  
350  
70491  
$1,667.00  
CT NECK W/O CONTRAST  
350  
70490  
$709.00  
CT ORBIT OR SELLA W/CONTRAST  
350  
70481  
$1,667.00  
CT ORBIT OR SELLA W/O CONTRAST  
350  
70480  
$709.00  
CT PELVIS W/CONTRAST  
350  
72193  
$1,667.00  
CT PELVIS W/O AND W/CONTRAST  
350  
72194  
$1,834.00  
CT PELVIS W/O CONTRAST  
350  
72192  
$709.00  
CT THORACIC SPINE W/CONTRAST  
350  
72129  
$1,667.00  
CT THORACIC SPINE W/O CONTRAST  
350  
72128  
$709.00  
CT UPPER EXTREMITY W/CONTRAST  
350  
73201  
$1,667.00  
CT UPPER EXTREMITY W/O CONTRAST  
350  
73200  
$709.00  
CULTURE AEROBIC  
306  
87070  
$118.00  
CULTURE BLOOD  
306  
87040  
$171.00  
CULTURE FUNGAL  
306  
87102  
$156.00  
CULTURE STOOL  
306  
87045  
$127.00  
CULTURE STREP SCREEN ONLY  
306  
87081  
$92.00  
CULTURE TYPING BY RNA/DNA PROBE EA CULT/ISOLATE  
306  
87150  
$130.00  
CULTURE URINE  
306  
87086  
$78.00  
CULTURE, STOOL ADDT'L PATHOGENS  
306  
87046  
$32.00  
CULTURE, TYPING IMMUNOLOGIC METHOD, OTHER, PER ANTISERUM  
306  
87147  
$33.00  
CULTURE,PRESUMPTIVE,PATHOGENIC ORGANI  
306  
87081  
$92.00  
CYCLIC CITRUL PEPTIDE  
301  
86200  
$78.00  
CYCLOSPORINE ASSAY(SANDIMMUNE)  
301  
80158  
$100.00  
CYSTIC FIBROSIS GENE ANALYSIS  
300  
81220  
$1,503.00  
CYSTOGRAM-VOIDING-DW  
320  
74455  
$861.00  
CYTOMEG, DNA OR RNA AMP PROBE  
306  
87496  
$117.00  
CYTOMEGALOVIRUS (CMV) QUANT (DNA OR RNA)  
306  
87497  
$364.00  
CYTOMEGALOVIRUS AB, IGM  
302  
86645  
$72.00  
CYTOMEGALOVIRUS, IGG  
302  
86644  
$65.00  
CYTOPATHOLOGY SMEAR CONE CONCENTRATION TECHNIQUE SMEARS/INTERP  
311  
88108  
$138.00  
CYTOPATHOLOGY THIN LAYER PAP CERVICAL/VAGINAL PREP AND MANUAL  
311  
88142  
$82.00  
D-DIMER, QUANT  
305  
85379  
$98.00  
DECLOTTING BY THROMB AGENT-IMPL VAD  
510  
36593  
$523.00  
DHEA (UNCONJUGATED)  
301  
82626  
$84.00  
DHEA SULFATE-SEND OUT TEST  
301  
82627  
$90.00  
DIFFERENTIAL, MANUAL  
305  
85007  
$35.00  
DIGOXIN ASSAY  
301  
80162  
$136.00  
DILANTIN, TOTAL  
301  
80185  
$58.00  
DIP-TET-PERTUSS VACCINE UNDER 7 YRS  
636  
90700  
$54.00  
DIRECT BILIRUBIN  
301  
82248  
$39.00  
DIRECT COOMBS  
302  
86880  
$94.00  
DOPPLER LIMITED OR F/U  
483  
93321  
$131.00  
DRIVING OCCUPATIONAL THERAPY EVALUATION  
430  
 
$232.00  
DRUG TEST(S) LC/MS OR GC/MS 1-7 DRUG CLASSES  
301  
G0480  
$564.00  
DRUG TESTS PRESUMPTIVE ANY NUMBER CLASSES, PER DATE OF SERVICE  
300  
80307  
$302.00  
DRUG TESTS PRESUMPTIVE ANY NUMBER CLASSES, PER DOS  
300  
80307  
$302.00  
DRUG TST PRESUMP INSTR ASSISTED DIR OPTICAL  
300  
80306  
$222.00  
DRUG(S) DEFINITIVE QUAL OR QUANT NOS 1-3  
301  
80375  
$88.00  
DTAP/HEPB/IPV VACCINE,IM  
636  
90723  
$91.00  
DTAP-HIB-IP VACCINE, IM  
636  
90698  
Variable  
DTAP-IPV 4-6 YRS  
636  
90696  
Variable  
DUPLEX SCAN ABDOMINAL,PELVIC,SCROTAL,RETROPERIONEAL-LIMITED STUD  
921  
93976  
$1,016.00  
DUPLEX SCAN EXTRACRANIAL ARTERIES-COMPLETE BILATERAL STUDY  
921  
93880  
$735.00  
DUPLEX SCAN EXTRACRANIAL ARTERIES-UNILATERAL OR LIMITED STUDY  
921  
93882  
$503.00  
ECG 12 LEAD  
730  
93005  
$155.00  
ED FACILITY FEE CLASS 1  
450  
99281  
$278.00  
ED FACILITY FEE CLASS 2  
450  
99282  
$590.00  
ED FACILITY FEE CLASS 3  
450  
99283  
$862.00  
ED FACILITY FEE CLASS 4  
450  
99284  
$1,394.00  
ED FACILITY FEE CLASS 5  
450  
99285  
$1,916.00  
ED FACILITY FEE CLASS 5  
450  
99285  
$1,955.00  
ED PROCEDURE LEVEL 1  
450  
 
$245.00  
ED PROCEDURE LEVEL 2  
450  
 
$375.00  
ED PROCEDURE LEVEL 3  
450  
 
$767.00  
ED PROCEDURE LEVEL 4  
450  
 
$905.00  
ED PROCEDURE LEVEL 5  
450  
 
$1,440.00  
ELBOW ORTHOSIS WITH ADJ LOCK JNT PREFABRICATED W/ EXPERTISE  
274  
L3760  
$697.00  
ELECTROLYTES, SERUM  
301  
80051  
$44.00  
ENDOTRACH INTUBATION  
360  
31500  
$1,097.00  
ENZYME ACTIV BLD, CELLS OR TISSUE; NONRADIOACTIVE SUBSTRATE, EA  
301  
82657  
$181.00  
EPSTEIN BARR AB TO EARLY AG  
302  
86663  
$84.00  
EPSTEIN BARR AB TO NUCLEAR AG  
302