Price Transparency Kittson Healthcare Complete
Ambulance
AMBULANCE SCT RES TO HOSP $2,103.50
AMBULANCE SCT HOSP TO HOSP $2,208.68
AMBULANCE SCT SCENE TO HOSP $2,103.50
GROUND AMBULANCE PER MILE $31.00
AMBULANCE ALS EMERGENCY LVL 1 $2,036.85
AMBULANCE BLS EMERGENCY $1,379.03
AMBULANCE ALS LEVEL 2 $2,051.05
AMBULANCE SCT N HOME TO HOSP $2,103.50
Anesthesia
ANESTHESIA 0-60 MN $42.62
ANESTHESIA 61-75 MN $52.53
ANESTHESIA COMPONENT $160.00
ANESTHESIA PRO FEE INITIAL 15 MIN $371.53
ANESTHESIA PRO FEE ADDL 15 MIN $151.89
Cardiac Rehab
CARD REHAB PHASE 2 WMONITOR $218.00
OP CARD REHAB WO CONT ECG MON $171.00
CARDIAC REHAB PHASE 1 $217.45
CARDIAC REHAB INITIAL VISIT $217.45
Central/Sterile Supply
NEBULIZER KIT $29.50
OXYGEN/HOUR $27.08
OXYGEN DAILY $37.15
DERMABOND $172.11
ARM IMMOBILIZER $87.42
TRAY CATHETER DISP $72.39
�1
COLLAR CERIVCAL FOAM $187.94
IOL $1,886.31
IV SETUP $47.80
OXYGEN 1ST HOUR $131.42
BRIEF ADLT WINGS HVY $20.76
BNDG ELAS PREM W CLIP 2X5YD $50.26
BNDG ELAS PREM W CLIP 3X5YD $49.17
BNDG ELAS PREM W CLIP 4X5YD $50.26
BNDG ELAS PREM W CLIP 6X5.5YD $50.26
BNDG COMP PROFORE MULT LAYER $29.50
DRSG HYDRCOLL DUODERM 8.5X8.75 $33.02
BOOT HEEL PREVALON W WEDGE $22.95
CAST SPLT ONE4X30*VAT 6220395* $16.39
CAST SPLT ONE STE*VAT 6220390* $17.48
CRUTCHES ADLT 5FT2IN-5FT10IN $114.30
CRUTCHES ADLT TALL 5FT10IN-6FT $142.24
TRAY EYELID REPAIR SVH N 4985* $-
TRAY LUMBAR ADLT 20GX3.5 $13.11
TRAY PARACERV CTRL SYR 10ML $86.32
TRAY BX BONE JAMSHIDI 11GX4 $77.58
TRAY IRG 50CC BULB SYR W *CIP* $37.15
PK LAPAROTOMY VI*USE 6259403* $24.04
CNTRST MAGNEVIST GAD 20ML*CIP* $385.74
SOAP HAIR BODY WASH NO RINSE $12.02
OTO HD ONLY 3.5V $128.95
CUFF BP BARE 2TB TP REUS ADLT $16.39
PLUG PERFIX MD 3.3X3.9CM 2CA $337.65
PLUG PERFIX LG 4.1X4.8CM 2CA $337.65
BINDER ABD 3PNL 9X30-45IN $16.39
BRC KNEE NEO OPEN PTLA XSM $13.11
ELTD DEFIB MULT *USE 6239546* $27.53
ELTD PAD PLUS PE*DISC 6239547* $28.41
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BRC ANK SWEDE-O WO STBL XL $24.04
BRC ANK SWEDE-O WO STBL MD $24.04
ELTD QK PACE*VAT 6168344* $52.45
SPNG CURITY STER 16PLYPK10 4X4 $-
SPLT CLAV MCLEOD CLSR MD $121.29
DRSG RAPIDRHINO ANT/PSTR 7.5CM $89.60
DRSG MEPILEX TRANSFER 8X8 $18.35
MOUTHPIECE DISP INTOXILYZER 20 $89.60
TRAY THORA-PARA SAFE-T+ 8FR $215.27
DRSG AQUACEL AG XTRA 8X12 $22.95
SUT ETHILON 6-0 PS4 18 $18.58
SUT ETHILON 3-0 PS1 18 $18.35
SUT PROLENE 5-0 RB1/RB1 36 $30.48
SUT PROLENE 5-0 PS3 18 $35.56
SUT VICRYL 5-0 PS4 18 UNDY $26.67
SPLT ORTHOGLS PRECUT 4X30SHT $16.39
TRAY SPINAL EPIDURAL 18GX3.5 $289.57
DRSG MEPILEX BORD AG 4X12 $34.42
DRSG MEPILEX BORD AG 4X4 $18.58
SUPP KNEE ANT CLSR HNG LG $240.03
BOOT ANKLIZERII LOW TOP F*NLU* $33.88
IMMOB KNEE B-COOL PCKT 26IN $152.40
BOOT ANKLIZER II FIXED LG*NLU* $28.41
BOOT ANKLIZERII LOW TOP FIX MD $28.41
SPLT THB SPI LFT LG/XL $133.35
SUT ETHILON 5-0 PS4 18 BLK $24.13
SPLT CAST PRE CUT 3X35IN $17.48
ELTD DEFIB HEARTSTART ADLT $26.22
ELTD DEFIB HEARTSTART INFANT $28.41
SLING ARM W FM ST*VAT 6258664* $32.89
BRC WRIST PRO 8 LFT MD $107.95
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Clinic Surgical Procedures
COLONOSCOPY $1,771.53
CYST EXCISION $1,753.82
CATARACT SURGERY $4,334.74
YAG LASER $1,733.67
HERNIA REPAIR $1,294.89
BLOOD ADMIN >8 HRS $1,016.24
TREATMENT RM LVL 1 W PROCEDURE $994.76
TREATMENT RM LVL 2 W PROCEDURE $947.39
COLONOSCOPY WBX $2,019.36
COLONOSCOPY FLEXIBLE $1,757.00
EGD DIAG $1,721.48
EGD WBIOP SING MULT $1,495.94
NG TUBE PLACEMENT $541.55
COLON WREM TUMOR SNARE $2,265.23
TX RM TREATMENT ROOM $663.18
ED 99211 NURSE ONLY VISITS $87.00
OR TIME 1 MIN $29.83
EGD WADDL PROCEDURE $500.00
COLONOSCOPY WADDL PROCEDURE $500.00
TX RM LVL 1 WO PROCEDURE $631.60
CT Scans
CT HEAD WO CONTRAST $1,349.15
CT HEAD W CONTRAST $1,427.11
CT HEAD WO THEN W CONTRAST $1,739.62
CT ORBIT SELLA FOSSA EAR WO CONTRAST$1,410.71
CT MAXILLOFACIAL WO CONTRAST $1,407.85
CT MAXILOFACIAL WCONT $1,855.88
CT SOFT TISSUE NECK WO CON $1,161.57
CT THORAX W CONTRAST $1,933.84
CT THORAX WO THEN W CONTRAST $2,005.15
�4
CTA CHEST WCONT +WO IF PERF $2,483.78
CT THORACIC SPINE WO CONT $1,638.79
CT LUMBAR SPINE WO CONT $1,689.71
CT PELVIS WO CONTRAST $1,238.06
CT PELVIS W CONTRAST $1,588.83
CT PELVIS WO THEN W CONT $1,940.68
CT EXT UPPER WO CONT $1,399.65
CT EXT LOWER WO CONT $1,410.41
CT ABDOMEN WO CONTRAST $2,041.21
CT ABDOMEN W CONTRAST $2,001.04
CT ABDOMEN WO THEN W CONT $2,350.95
CT CERVICAL SPINE WO CONTRAST $1,701.53
CT SOFT TISSUE NECK W CONTRAST $1,638.00
CT SFT TISUE NECK WWO THEN W $2,047.77
CT 3D RECONSTRUCT WO IPP $140.97
PFR 70450 CT HEAD WO CONTRAST $166.10
OPTIRAY 100VDS 300-349MG MLS $337.65
CT ABD PELVIS WO CONTRAST $2,776.62
CT ABD PELVIS W CONTRAST $3,589.95
CT ABD PELVIS WO THEN W CONT $3,568.69
CTA ABD PELVIS W CONTRAST+WO IF PERFORM$2,983.15
EKG & EEG
ECG TRACING WO INTERP $196.69
HOLTER MONITOR APP $291.75
EVENT MONITOR RECORDING 30 DAY $397.84
EKG TRACING MEDICARE $196.69
EKG 12 LEAD W INTERP & REPORT $207.67
EKG 12 LEAD TRACING ONLY $334.38
EKG RHYTHM WPF $360.27
Emergency Room
�5
ED 99291 CRITICAL CARE E&M 30-74 MIN$1,835.78
ED 99284 VISIT LEVEL 4 $672.02
ED 99281 VISIT LEVEL 1 $166.00
ED 99285 VISIT LEVEL 5 $1,082.00
ED 99282 VISIT LEVEL 2 $266.00
ED 99283 VISIT LEVEL 3 $403.21
ED 96375 THER PROPH DIAG INJ IV PUSH ADDL SEQ$110.00
ER O2 $150.00
ED 96366 IV INFUS THER PROPH DIAG EA ADDL HR$103.00
ED 96365 IV INFUS THER PROPH DIAG INITIAL UP TO 1HR$372.00
ED 96360 IV INFUS THERAPY HYDRATION FLUIDS INITIAL 31 MIN-1HR$500.00
ED 96372 THER PROPH DIAG INJECTION SQ IM$116.93
ED 96374 THER PROPH DIAG INJ IV PUSH INITIAL$173.00
ED 90471 IMMUNE ADMIN 1 VACCINE $58.00
ED 90472 IMMUN ADMIN EA ADDL VACCINE$32.00
ED 96367 IV INFUS THER PROPH DIAG ADDL SEQ NEW DRUG UP TO 1 HR$144.00
ED 96368 IV INFUS FOR THER PROPH DIAG CONCUR$123.00
ED 96376 THER PROPH DIAG INJ IV PUSH SAME DRUG >30MINS$106.00
ED 96523 IRRIGATE IMPLANTED VENOUS ACCESS DEVICE$148.00
ED 94640 NON OR PRES'D INHALATION TX$119.00
ED 10060 I&D SKIN ABSCESS SMPL $536.53
ED 10120 INC&REMV FB SMPL $484.08
ED 11730 REMV OF NAIL PLATE $213.09
ED 12001 RPR SUPERFCL WND 2.5CM OR<$359.51
ED 12002 RPR SUPERFCL WND 2.6-7.5CM $370.44
ED 12004 RPR SUPRFCL WND 7.6-12.5CM $371.32
ED 12005 RPR SUPRFL WND 12.6-20.0CM $634.00
ED 12011 RPR SUPERFCL WND 2.5CM OR<$371.53
ED 12013 RPR SUPERFCL WND 2.6-5.0CM $470.97
ED 12014 RPR SUPERFCL WND 5.1-7.5CM $525.15
ED 12015 RPR SUPERFL WND 7.6-12.5CM $646.89
ED 12031 LYR CLSR OF WND 2.5CM OR < $480.00
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ED 12032 LYR CLSR OF WND 2.6-7.5CM $655.64
ED 12034 LYR CLSR OF WND 7.6-12.5CM $476.43
ED 12041 LYR CLSR WND 2.5CM OR <NHF$523.42
ED 12042 LYR CLSR WND 2.6-7.5CM NHF $514.67
ED 12051 LYR CLSR OF WND 2.5CM OR < $420.70
ED 12052 LYR CLSR OF WND 2.6-5.0CM $469.45
ED 12054 LYR CLSR OF WND 7.6-12.5CM$1,350.61
ED 13101 RPR CMPLX TRUNK 2.6-7.5CM $567.13
ED 13120 RPR CMPLX WND 1.1-2.5CM $387.00
ED 13131RPR CPX WD OR LSN 1.1-2.5CM $338.75
ED 13132RPR CPX WD OR LSN 2.6-7.5CM $882.00
ED 23650 CLSD TX SHOULDER DISLOC $535.75
ED 25500 CLSD TX RAD SHAFT FX $549.64
ED 25530 CLSD TX ULNAR SHAFT FX $523.42
ED 25605 CLSD TX DISTAL RADIAL WMANIP$790.37
ED 26600 CLSD TX METACARPAL FX $569.31
ED 28450 TX TARSAL BONE WO MANIP $427.25
ED 29065 APPL CAST LONG ARM $225.11
ED 29075 APPL CAST FOREARM ARM $308.00
ED 29405 APPL CAST SHORT LEG $151.89
ED 30901 CONTROL NOSEBLEED ANT SMPL$325.63
ED 31500 INTUBATE ENDOTRACEAL $916.80
ED 36680 INSERT NEEDLE BONE CAVITY $581.00
ED 43752 NG TUBE PLACEMENT $516.00
ED 51701 INSERT BLADDER CATH $194.00
ED 51702 INSERT BLADDER CATH TEMP SMPL$301.59
ED 56420 I&D VULVA ABSCESS $372.38
ED 65205 REMV FB EYE CONJ SUPERFCL $201.57
ED 92960 CARDIOVERSION $959.00
ED 99211 EST PAT CASE LEVEL I $84.14
ED 99281 EMER CASE LEVEL I $149.70
ED 99282 EMER CASE LEVEL II $241.49
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ED 99283 EMER CASE LEVEL III $403.21
ED 99284 EMER CASE LEVEL IV $672.02
ED 99285 EMER CASE LEVEL V $1,009.68
ED 99211 NURSE ONLY VISITS $87.00
ED 99291 EMER LEVEL 6 $1,835.78
ED 13100 EXC LSN MAL FACE EAR 2.1-3 $567.13
ED NEBULIZER TREATMENT $150.00
ED 36430 BLOOD ADMIN 4-6 HR $1,016.24
ED 36430 BLOOD ADMIN 0-2 HR $1,016.24
ED 36430 BLOOD ADMIN 2-4 HR $1,016.24
ED 36430 BLOOD ADMIN >8 HR $1,016.24
ED 36430 BLOOD ADMIN 6-8 HR $1,016.24
ED 94644 MED NEB TX CONT FIRST HR $131.30
ED 94645 MED NEB TX CONT EA ADDL HR$131.30
IV Department
ED 96361 IV INFUS THERAPY HYDRATION FLUIDS ADDL HR$161.72
TX RM TREATMENT RM LEVEL I $631.60
TX RM TREATMENT RM LEVEL II $947.39
TX RM TREATMENT ROOM LEVEL I (1HR) $631.60
Laboratory
HCG QUANT 84702 $137.68
AFP TUMOR MRKR 82105 $172.65
CULTUR TB ACID FST BACILL87116 $163.91
CONCENTRATION (AFB) 87015 $163.91
SMEAR FLUORES ACD FST STN87206 $113.64
CBC AUTOMATED WDIFF 85025 $152.99
HEMATOCRIT 85014 $54.64
HEMOGLOBIN 85018 $48.08
DIFFERENTAIL MANUAL 85007 $37.15
PROTIME 85610 $77.58
�8
PTT 85730 $95.00
ESR AUTOMATED 85652 $40.43
WBC 85048 $61.19
ABO 86900 $88.51
ANTIBODY SCREEN 86850 $142.00
RH 86901 $63.00
DIRECT COOMBS 86880 $83.05
ALBUMIN 82040 $218.55
ALKALINE PHOSPHATE 84075 $76.49
ALT 84460 $73.21
AMYLASE 82150 $93.00
AST 84450 $72.12
TOTAL BILI 82247 $78.00
DIRECT BILI 82248 $81.96
BUN 84520 $66.65
CALCIUM 82310 $71.03
CARBON DIOXIDE 82374 $77.58
CHLORIDE 82435 $74.30
CHOLESTEROL 82465 $74.30
CPK 82550 $90.00
CREATININE 82565 $63.38
GLUCOSE 82947 $63.00
IRON 83540 $99.40
LDH 83615 $81.96
PHOSPHORUS 84100 $71.03
POTASSIUM 84132 $66.65
SODIUM 84295 $63.38
TRIGLYCERIDES 84478 $101.00
URIC ACID 84550 $71.03
DIGOXIN 80162 $147.52
MAGNESIUM 83735 $92.89
CKMB 82553 $144.00
�9
PSA 84153 $160.63
T4 84436 $61.00
TROPONIN QUANT 84484 $146.00
TSH 84443 $151.89
D DIMER QUAL OR SCREEN 85378 $166.10
MONOSCREEN 86308 $92.89
PREGNANCY TEST (URINE) 81025 $127.85
HCG QUAL 84703 $86.00
RPD GROUP A STREP SCREEN 87880 $108.18
BASIC METABOLIC PANEL 80048 $177.03
COMPREHENS METABOLC PANL 80053 $240.40
PANEL HEPATIC FUNCTION 80076 $178.12
LIPID PROFILE 80061 $156.26
RENAL FUNCTION PANEL 80069 $170.47
ELECTROLYTE PANEL 80051 $120.20
CAPILLARY COLLECTION 36416 $40.13
GRAM STAIN 87205 $88.51
OCCULT BLD SCR 82270 $78.67
URINALYSIS-DIPSTICK ONLY 81003 $52.00
URINALYSIS W MICROSCOPIC 81001 $74.00
MICROALBUMIN 82043 $99.00
VENIPUNCTURE 36415 $27.00
WET MOUNT INFECT AGENT 87210 $64.47
CULTURE ANAEROBIC 87075 $118.00
CULTURE URINE 87086 $125.66
OVA AND PARASITES 87177 $116.93
CLOSTRIDIUM DIFFICILE 87324 $168.28
SENSITIVITY STUDY MIC 87186 $107.09
VITAMIN B12 82607 $128.00
CA 125 86304 $150.00
CREATININE CLEARANCE 82575 $142.06
CA 27-29 86300 $176.00
�10
CEA 82378 $155.00
CYCLOSPORINE 80158 $27.48
PHENYTOIN 80185 $140.97
FERRITIN 82728 $131.00
FOLATE 82746 $120.00
FREE T4 84439 $106.00
H PYLORI IGG 86677 $155.00
LIPASE 83690 $96.00
TACROLIMUS 80197 $230.57
CARBAMAZEPINE (TEGRETOL) 80156 $125.66
CBC AUTOMATED NO DIFF 85027 $130.04
CROSSMATCH ANTIGLOBULIN 86922 $162.81
GLUC TOL 3 SPEC & DOSE 82951 $167.19
HDL 83718 $80.87
GLUCOSE BODY FLD 82945 $78.67
PROTEIN TOT SER 84155 $69.94
B-TYPE NATRI PEPT 83880 $346.40
GLYCOSYLATED (A1C) HGB 83036 $87.00
SPERM PRESENCE MOTILITY 89321 $117.49
CULTURE SPUTUM 87070 $138.77
CULTURE BLOOD 87040 $160.63
CULTURE VIRAL 87252 $170.47
AEROBIC DEFINITIVE ID 87077 $147.52
RBC LR PROC UNIT P9016 $608.00
IRON BINDING 83550 $99.44
PHENOBARBITOL 80184 $140.97
THEOPHYLLINE 80198 $145.33
AMMONIA 82140 $147.00
CALCIUM IONIZED 82330 $120.20
GGTP (GAMMA GT) 82977 $80.87
SODIUM URINE 84300 $59.01
C PEPTIDE 84681 $144.00
�11
ANTITHROMBIN III ACTIVITY85300 $39.34
PROTEIN C ACTIVITY 85303 $39.34
PROTEIN S ACTIVITY 85306 $39.34
FIBRINOGEN QUANT ASSAY 85384 $122.81
ANTINUCLEAR ANTIBODY SCRE86038 $127.00
C REACTIVE PROTEIN QUANT 86140 $102.71
CARDIOLIPIN ANTIBODY IGA 86147 $76.49
ANTI MITOCHONDRIAL ANTIBO86255 $137.14
RPR 86592 $95.07
MYCOPLASMA ANTIBODY TITER86738 $11.91
LEGIONELLA ANTIGEN URINE 87450 $185.66
CELL COUNT BDY FLD WDIFF89051 $93.98
HOMOCYSTEINE PLASMA 83090 $167.19
PSA SCREENING G0103 $167.19
COLD AGGLUTININ 86157 $77.45
STONE ANAL 82365 $114.73
CORTISOL TOTAL SER 82533 $151.00
FSH 83001 $139.00
LUTENIZING HORMONE 83002 $138.77
INSULIN LEVEL 83525 $140.97
LITHIUM 80178 $86.32
ACTH HIGH SENS 82024 $186.85
MUMPS IGG SCREEN 86735 $161.26
HEPATITIS B SURFACE ANTIB86706 $103.00
ELECTROPHORESIS SER 84165 $107.09
RUBELLA ANTIBODY SCRN IGG86762 $110.36
CALCIUM 24 HR UR 82340 $59.01
PLATELET COUNT 85049 $52.00
HEPATITIS PANEL ACUTE 80074 $313.61
IMMUNOFIX ELECT24HR URINE86335 $172.00
CA 19-9PANCREATIC CANCER86301 $163.00
VIT D 1 25-DIHYDROXY SER 82652 $338.38
�12
VITAMIN B6 84207 $220.73
VIT D 25-HYDR 82306 $222.79
HEP B SURF ANTIGEN HBSAG87340 $101.62
COMPLEMENT ANTIGEN EA 86160 $123.00
HEPARIN ANTI-XA ASSAY 85520 $159.00
HEPATITIS C ANTIBODY 86803 $158.44
VALPROIC ACID (DEPAKANE) 80164 $139.00
PHENYTOIN TOTAL 80185 $118.02
DILANTIN FREE (UNBOUND) $137.68
PRIMIDONE (MYSOLINE) 80188 $99.82
TOPIRAMATE (TOPAMAX) 80201 $167.00
CLOMIPRAMINE (ANAFRANIL) 83789 $40.43
LAMOTRIGINE (LAMICTAL) 80299 $213.09
GABAPENTIN (NEURONTIN) 80299 $213.09
URINALYSIS MICRO 81015 $36.00
ALBUMIN URIN OTHER SOURCE82042 $87.97
ALDOLASE 82085 $81.96
ALDOSTERONE 82088 $177.03
ALPHA-1-ANTITRYP 82103 $211.98
ALPHA-1-ANTITRPSIN FECA $196.47
ALPHA-1-ANTITRYP PHE 82104 $120.20
ANDROSTENEDIONE 82157 $314.71
ANGIOTENSION ENZ ACE 82164 $149.70
ARSENIC 82175 $90.69
BETA 2 MICROGLOBULIN 82232 $161.72
BILE ACIDS TOTAL 82239 $123.48
BILIRUBIN AMNIOTIC FL 82247 $74.30
OCCULT BLOOD 82272 $38.24
CALCITONIN 82308 $163.45
CARNITINE SERUM 82379 $213.09
CAROTENE 82380 $91.38
CATECHOLAMINE FRACT BLOOD82384 $163.91
�13
CERULOPLASMIN 82390 $100.53
CHROMIUM 82495 $239.76
CITRATE URINE 82507 $295.59
COPPER 82525 $97.00
CORTISOL SALIVA $298.75
CREATININE FLUID 82570 $74.30
CRYOGLOBULIN QUAL 82595 $80.87
DHEA 82626 $126.75
DHEA SULFATE 82627 $140.97
ERYTHROPOIETIN 82668 $276.46
ESTRADIOL 82670 $171.56
ESTRONE 82679 $98.34
FECAL FAT QUAL 82705 $17.21
FECAL FAT QUANT 82710 $185.76
FOLIC ACID RBC 82747 $183.58
CELIAC DISEASE TOTAL IGA 82784 $66.65
IMMUNOGLOBULIN G $79.77
IGG SUBCLASS IGG 1 2 3 4 82787 $71.25
GASTRIN 82941 $107.27
GLUCOSE POCT 82962 $60.10
HAPTOGLOBIN 83010 $113.64
HEMOGLOBIN ELP 83020 $85.93
HEMOGLOBIN ELP HPLC 83021 $100.79
METHEMOGLOBIN QUANT 83050 $18.38
VMA W HVA - HVA 83150 $66.65
HIAA-5 24 HR URINE 83497 $123.48
HYDROXYPROGESTERONE-17 $208.63
ANTI SMOOTH MUS AB IGG 83516 $138.77
HISTONE ANTIBODIES 83516 $171.00
TISSUE TRANSGLUT $232.00
THYROTROPIN RECEPTOR AB 83519 $165.01
ANTI GLOMERULAR BASEMT 83520 $196.47
�14
ANTIGLIADIN AB IGA IGG 83516 $281.14
LACTATE (LACTIC ACID) 83605 $140.00
LDH ISOENZYME 83625 $72.46
HEAVY METAL SCR LEAD 83655 $100.53
LIPOPROTEIN A 83695 $123.48
LDL DIRECT 83721 $70.00
METANEPHRINE 83835 $242.59
METANEPHRINES PLASMA 83835 $242.59
MYOGLOBIN 83874 $121.29
METHYLMALONIC ACID SER 83921 $231.00
OSMOLALITY FLUID 83930 $65.56
OSMOLALITY URINE 83935 $86.32
PTH INTACT 83970 $289.00
ALK PHOS ISO TOTAL 84075 $29.33
ALKALINE PHOS ISOENZYME 84080 $83.85
PHOSPHORUS UR 84105 $53.00
K: URINE 84133 $46.68
PREALBUMIN 84134 $103.81
PROGESTERONE 84144 $154.08
PROLACTIN 84146 $154.08
PROTEIN TOT UR 84156 $76.49
PROTEIN TOT OTH 84157 $77.04
PROTEIN ELECTRO URI 84166 $141.10
RENIN 84244 $144.24
SELENIUM BLOOD 84255 $74.30
SEX HORMONE BIND GLOB 84270 $125.00
IGF-1 (END SC) 84305 $133.31
SOMATOMEDIN-C (IGF-1) 84305 $143.15
REDUCING SUB FECAL 84376 $46.99
TESTOSTERONE FREE 84402 $160.00
TESTOST TOTAL COMBO 84403 $207.00
TESTOSTERONE TOTAL 84403 $207.00
�15
VITAMIN B1 84425 $174.00
THYROGLOBULIN 84432 $169.37
T4 FREE BY EQU DIR DIAL $106.00
TBG-THYROXIN BDG GLOB 84442 $152.77
THYROID STIM IMMUNOGLOB 84445 $470.13
TOCOPHERAL ALPHA (VIT E) 84446 $125.66
TRANSFERRIN 84466 $125.66
T3 UPTAKE 84479 $54.64
T3 TOTAL (TRIIODOTHYRON) 84480 $128.95
T3 FREE 84481 $215.27
T3 REVERSE 84482 $73.21
UREA NITROGEN URINE 84540 $7.45
URIC ACID OTHER 84560 $74.30
VMA 24HR UR 84585 $202.68
VMA W HVA - VMA 84585 $66.65
VITAMIN A 84590 $180.30
VITAMIN K 84597 $126.25
ZINC 84630 $115.83
FACTOR V 85220 $158.44
FACTOR VIII IH 85240 $116.93
RISTOCETIN COFACTOR 85245 $116.93
VON WILLIBRAND ANTIGEN 85246 $143.00
ANTITHROMBIN III ANTIGN 85301 $158.44
PROTEIN C ANTIGEN 85302 $77.58
PROTEIN S ANTIGEN 85305 $185.76
PROTEIN S AG FREE 85306 $259.92
ACTIVATED PROTEIN C RES 85307 $251.43
D-DIMER QUANT 85379 $166.10
ALKALINE PHOS LEUKOCYTE 85540 $134.40
DILUTE RUSS VIP CONFIRM $32.78
DILUTE RUSSELLS VIPER 85613 $80.87
SICKLE CELL TEST 85660 $78.22
�16
THROMBIN TIME 85670 $83.43
ALERGEN SPEC IGE QNT SO 86003 $73.21
ANCA-MPO MYELOPEROXIDAS 86021 $256.00
ANCA 86255 $262.00
ANCA-PR3 PROTEINASE 3 86021 $138.97
PLATELET ANTIBODY 86022 $248.04
ANTISTREPTOLYSIN O TITR 86060 $62.28
C-REACTIVE PROTEIN HISEN 86141 $104.91
CYCLIC CITR PEP AB(CCP) 86200 $174.83
ANTI DNA DBL STRAND AB 86225 $124.57
ANTI SCL70 86235 $98.53
ENA ANY AB 86235 $98.53
ANTI NEURONAL NUC AB 86255 $231.66
CA 15-3 ANTIGEN 86300 $123.48
CHROMOGRANIN A 86316 $121.98
HIV 1 & 2 RAPID 86703 $104.91
HYPERSENS PN IMMUNODI AB 86331 $19.49
IMMUNOFIXATION 86334 $142.00
CD4 CD8 86360 $180.30
T-HELPER LYMPH MARKER 86361 $97.25
ANTITHYROID AB ANTI TPO 86376 $115.83
CRYPTOCOCCUS ANTIGEN 86403 $64.47
RHEUMATOID FACTOR FLUID 86430 $59.01
RHEUMATOID FACTOR QUANT 86431 $85.23
FUNGAL SEROLOGY ASPER 86606 $63.38
BLASTOMYCES AB SERUM 86612 $67.75
FUNGAL SEROLOGY BLASTO 86612 $63.38
B PERTUSS AB IGG BY MAID 86615 $82.00
LYMES WESTERN BLOT 86617 $150.79
LYMES TOTAL 86618 $175.92
BRUCELLA ANTIBY IGG IGM 86622 $133.31
COCCIDIOIDES ANTIBODY 86635 $88.51
�17
FUNGAL SEROLOGY COCCID 86635 $89.60
CMV IGG AB 86644 $110.36
CMV IGM AB 86645 $113.64
ECHOVIRUS 86658 $232.75
EPSTEIN BARR EARLY AG 86663 $53.54
EB VIRUS-EBNA 86664 $88.51
EPSTEIN B VIRUS-VCA 86665 $88.00
HEMOPHILUS INFLUENZA AB 86684 $175.00
HERPES SIMPLX VIR1 IGG 86695 $150.79
HERPES SMPLX VIR 2 IGG 86696 $150.79
FUNGAL SEROLOGY HISTO 86698 $32.78
HEP B CORE AB TOTAL 86704 $101.62
HEP B CORE AB-IGM ONLY 86705 $113.64
HEP A TOTAL 86708 $21.92
HEP A ACUTE AB-HAV-IGM 86709 $143.15
MUMPS TITER G&M 86735 $10.79
PARVOVIRUS IGM IGG 86747 $82.75
E HISTOLYTICA AB $136.86
RUBEOLA IGG ANTIBODY 86765 $149.59
FLUORES TREPONEMAL AB 86780 $70.00
VARICELLA ZOSTER IGG&IGM 86787 $109.27
VARICELLA ZOSTER SCREEN 86787 $87.96
HANTAVIRUS ANTIBODY 86790 $192.32
W NILE VIR G SER OR CF 86789 $90.69
ANTI THYROGLOBULIN AB 86800 $116.70
THYROGLOBULIN AB 86800 $131.00
HLA-B27 ANTIGEN 86812 $215.27
CROSSMATCH IMMEDIATESPIN 86920 $103.81
CROSSMATCH INCUBAT MDH 86921 $162.81
CULTURE STOOL ADD PATHGN87046 $46.99
CULTURE: STOOL SAL SHIG 87045 $92.89
CULTURE: BACT OTHER 87070 $138.77
�18
CULTURE: BACT RESPITOR 87070 $138.77
ANAEROBIC IDENTIFICATION 87076 $60.10
PATHOGENIC ORGANISM SCR 87081 $57.92
ISOLAT&PRESUMPT ID URINE 87088 $107.09
CULTURE:FC SKN-HAIR-NAIL 87101 $124.00
CULTURE: FUNGUS $136.59
CULTURE: FUNGUS YEAST ID $78.67
CULTURE: FUNGUS MOLD ID $92.89
CULTURE TB BLOOD 87116 $160.63
CULTURE: AFB ID 87118 $160.63
CULTURE: TYPING ANTISERU 87147 $49.17
PARASITE ID-WORM 87169 $38.99
MALARIA SMEAR 87207 $89.60
TRICHROME STAIN 87209 $131.13
KOH SKIN HAIR NAILS 87220 $62.28
HERPES TYPING 87253 $156.33
GIARDIA LAMBLIA 87329 $138.00
H PYLORI AG STOOL 87338 $155.00
ROTAVIRUS FECAL 87425 $68.85
SHIGA-LIKE TOXIN 87427 $81.41
CHLAMYDIA BY AMPLIFICAT 87491 $212.00
CMV PCR 87496 $327.82
HEP B VIRAL DNA 87517 $281.92
HEP C GENOTYPE PCR 87902 $1,834.83
HEP C RNA PCR QNT 87522 $385.00
HIV 1 RNA PCR QNT 87536 $406.30
GC BY DNA AMPLIFICATION 87591 $236.00
PERTUSSIS PCR 87798 $154.08
BK VIRUS DNA QUANT 87799 $452.00
INFLUENZA A B DIRECT 87804 $95.00
RSV DIRECT ELISA 87807 $51.63
FISH DNA PROBE 88271 $92.30
�19
INTERPHASE 100-300 88275 $198.92
SURGICAL PATH LEVEL II 88302 $122.38
SURGICAL PATH LEVEL III 88304 $217.45
SURGICAL PATH LEVEL IV 88305 $208.00
STAIN SPECIAL I 88312 $185.66
STAIN SPECIAL II 88313 $198.79
IMMUNOPEROXIDASE STAIN 88342 $214.00
LEUKOCYTE FECAL 89055 $24.04
SYN FLUID CRYSTAL 89060 $93.98
EOSINOPHIL SMEAR 89190 $112.01
CYTOPATH CONC 88108 $333.28
FNA INTERP REPORT 88173 $245.00
ESR NON AUTOMATED 85651 $61.19
AB BACTERIUM NES 86609 $19.49
MISC CHEMISTRY $-
RSV DFA 87280 $157.35
VALPROIC ACD TOT S.O.80164.003 $93.36
HERPES SIMPLEX VIR PCR 87529 $216.00
ITRACONAZOLE 80299 $199.75
LEAD 83655 $100.53
GLUCOSE & DOSE 82950 $76.49
VALPROIC ACID FREE S.O. 80165 $205.81
CATECHOLAMINES FRAC URINE 24HR 82384$232.00
ALBUMIN BIOAVAILABLE 82040 $218.55
ALKALINE HOS BONE SPEC $162.81
PANCREATIC ELASTASE 1FE $72.20
STREP PNEUMO URINARY AG 87450 $185.66
BORDETELLA PERT IGA & M $72.12
ENDOMYSIAL IGA AB QUAL 86255 $262.00
H PYLORI IGM $138.98
CMV DNA QUANTITATIVE 87497 $399.00
SENSITIVITY ANAEROB MIC SO $63.00
�20
INFECT AGT NUC ACD AMP EA ORG $334.00
VEN BLD COLLECTION IVAD 36591 $91.00
LACTOFERRIN FECAL QUAL 83630 $105.00
THERAPEUTIC PHLEBOTOMY COMPLEX $910.24
W NILE VIR M SER OR CF 86788 $140.97
NOROVIRUS FECAL 87798 $158.44
GLUC TOL ADD SPECS 82952 $37.15
CORTISOL FREE 82530 $232.00
MANGANESE 83785 $74.30
RETICULOCYTE WITH CELLULAR PARAMETER 85046$74.00
INTRINSIC FACTOR ANTIBODY86340 $110.00
FREE LIGHT CHAIN 83883 $100.53
ESTRADIOL (TANNERS) $203.35
ESTRIOL 82677 $194.67
CATECHOL FRA UR 82384 $115.83
WEST NILE VIRUS PCR $158.44
COCCIDIODES AB 86635 $89.60
OXALATE 83945 $104.36
RAD EXAM SPINE LUMB BENDING VWS ONLY 2 OR 3 VWS$402.12
COLLAGEN XLINK LEVEL 2 82523 $168.30
GENTAMICIN PEK TRGH RANDM80170 $187.94
VANCOMYCIN PEK TRGH RNDM 80202 $165.01
UA NON-AUTOMATED W MICROS81000 $67.75
CATECHOLAMINES BLOOD 82383 $210.89
ESTROGENS FRACTIONATED 82671 $174.83
IMMUNOGLOB A G OR M EACH82784 $86.00
HEAVY METAL 83015 $72.12
PORPHY URINE QUANT&FRACT 84120 $184.67
TROPONIN QUAL 84512 $140.97
COLD AGGLUTININ SCREEN 86156 $106.00
ASPERGILLUS ANTIBODY 86606 $79.76
FRESH FROZEN PLASMA THAW 86927 $107.00
�21
BORDETELLA PERTUSSIS DFA 87265 $128.95
BORDETELLA PERTUSSIS PCR 87801 $185.76
INF AG DET BY IMMUNAS NOS87899 $28.59
PLATE PHER LEUK RED IRADP9037 $1,834.00
RBC LR IRR PROC UNIT P9040 $810.00
GLIADIN ANTI 82397 $232.00
EBV DNA QUANT 87799 $452.00
PLATELET PHERES LEUKOREDUCED $688.81
VEN BLD COLLECTION PICC 36592 $74.30
CRYPTOSPORIDIUM AG STOOL 87328 $104.91
ANCA PANEL $169.37
KEPPRA (LEVETIRACETAM) 80299 $255.70
TB TEST CELL MEDIATED IMMUNITY $260.00
SHBG BIIOAVAILABLE 84270 $218.55
TESTOSTERONE TOTAL BIOV 84403 $218.55
TISSUE TRANSGLUT IGA 82397 $232.00
PAE RFLX BILL GAD65 86341 $242.00
PREGABALIN TIAGABINE 80366 G0480 $105.00
CENTROMERE AB 83520 $94.00
PROCALCITONIN 84145 $38.78
CDMR RSV PCR 87798.59 $136.00
MONOSCREEN WHOLE BLD-QW 86308 $92.89
PT INR FINGERSTICK-QW 85610 $61.00
PARVOVIRUS B19 QUAL PCR 87798 $269.47
RECEPTOR SOLUBL TRNSFRN 84238 $211.15
CDMR INFLUENZA PCR FIRST 2 87502.001$331.00
BETA-2 GLYCOPROTEIN G M 86146 $99.44
C DIFFICILE TOXIN GENE AMP PROBE 87493$244.00
CARDIOLIPIN ANTIBODY G M 86147 $168.28
HEAVY METAL SCR COPPER 82525 $86.32
MRSA PCR NASAL COLONIZATN87641 $200.00
VIT D 25-HYDR(TOT D2 D3)82306 $211.00
�22
FUNGUS MOLD ID 87107 $69.00
BABESIA AB G M 86753 $69.94
BABESIA PCR 87798 $334.00
EHRLICHIA ANAPLASMA PCR 87798 $334.00
BORRELIA BODY FLUID PCR 87476 $289.57
CRYOGLOBULIN S.O. 82595 $56.65
CRYOFIBRINOGEN 82585 $76.97
TISSUE TRANSGLUT IGG REFLEXED 83516$161.72
CYSTINURIA 82136 $303.90
VITAMIN B2 84252 $290.67
LYME BORRELLIA PCR 87476 $335.47
IBD CRP 86140 $106.00
GROUP A STREP PCR 87651 $168.28
CEA PANCREATIC CYST 82378 $134.40
COBALT 83018 $272.65
LACTOFERRIN QUANT 83631 $108.21
ENDOMYSTIAL IGG 86255 $28.18
IA2-AB 86341 $242.00
HNDOT(HANDLING OTHER KITS) 99000 $59.01
PTH RELATED PROTEIN 83519 $272.64
STREPTOCOCCUS GRPB AMP PROBE 87653$53.41
VON WILEBRND WRKUP INTRP 85390 $74.70
MYELOPEROXIDASE AB 83876 $150.76
PROTEINASE 3 AB 83516 $150.76
HEXOGONAL PHOSPHOLIPID NEUT 85598 $37.15
ACEYLCHOLIN RECEP BIND AB83519 $123.75
HFE COMMON VARI 81256 $480.80
MTHFR GENE 81291 $1,405.69
PRADER-WILLI (ANGELMAN) GENE 81331 $356.00
FETAL CONGEN ABN QUAD 81511 $262.15
E TEST CHG CODE $31.69
17-HYDROXYPROGESTERONE $215.27
�23
HEMOGLOBIN A1C $84.14
ALPHA-1-ANTITRYPSIN $248.04
ALLERGEN IGE $75.40
ANTIBODY SCREEN $130.04
ACTH $192.32
AEROBIC CULTURE $138.77
AEROBIC ID CHG $151.89
ALPHA FETOPROTEIN $178.12
HEPATITIS ACUTE PANEL $313.61
ALDOLASE $81.96
ALDOSTERONE 82088 $362.79
ALK PHOS $76.49
AEROBIC MIC $148.61
ANA SCREEN WITH REFLEX $116.93
ANTINUCLEAR ANTIBODY (MULTIPLE) S $157.35
ANAEROBIC CULTURE $112.55
ANAEROBIC ID CHG $62.28
ANGIO CONVERTING ENZYME 82164 $154.08
ACTIVATED PROTEIN C RESISTANCE V $269.90
ASO $64.47
ANTITHROMBIN III ACTIVITY $40.43
VITAMIN B12 $103.81
BABESIA SMEAR 87207 $14.63
BONE ALK PHOSPHATASE S 84080 $162.81
BETA-2-MICROGLOBULIN $156.26
BODY FLUID COUNT $97.25
BLOOD CULTURE $160.63
CA27.29 $126.75
CALCIUM $71.03
CANCER ANTIGEN 125 $148.61
CANCER ANTIGEN 15-3 $126.75
CARNITINE $213.09
�24
CATECHOLAMINE FRACT FREE P $169.37
CALCIUM URINE $65.56
CBC WITH PLATELETS $128.95
CYC CITRULLIN PEPTIDE AB $174.83
C. DIFFICILE DNA BY PCR $183.58
CARCINOEMBRYONIC AG $138.77
CERULOPLASMIN $159.54
VENIPUNCTURE $26.22
CK $87.42
C.DIFFICILE TOXIN ASSAY $134.40
CMV PCR MAYO 87496 $337.65
CYTOMEGALOVIRUS IGG AB $110.36
COMP PANEL 14 MCSU $240.40
CONCENTRATE O+P $116.93
CORTISOL 60 MINUTE $142.06
CORTISOL AM $149.70
CORTISOL PM $149.70
CORTISOL POST STIMULATION $149.70
CORTISOL RANDOM $123.48
CREATININE $63.38
CREATININE CLEARANCE $142.06
CREATININE RANDOM URINE (FGO & EF) $74.30
CREATININE URINE $74.30
C-REACTIVE PROTEIN $106.00
CRP HS (CARDIAC) $104.91
CRYSTALS SYNOVIAL FLUID $97.25
CSF $97.25
CULT PROCESS CHG TISSUE $68.96
DHEA-S $140.97
DIGOXIN $147.52
EHRLICHIA ANAPLASMA PCR B $371.53
ELECTROPHORESIS 24HR URINE $97.25
�25
ELECTROPHORESIS PROTEIN $107.09
ELECTROPHORESIS RANDOM URINE $97.25
ENDOMYSIAL ABS S (IGA) $196.69
ERYTHROPOIETIN $285.20
ESTRADIOL WITH ESTRONE 82670 $171.56
ETEST BUNDLING 87181 $63.00
FACTOR V $162.81
FAT STOOL $17.21
IRON $99.44
FERRITIN $126.75
FFP MANUAL CHARGE $217.45
FUNGUS CULT ID CHG MOLD $92.89
FK506 (TACROLIMUS) $237.13
FOLATE $111.46
FREE T3 $215.27
FSH $138.77
FREE THYROXINE $106.00
FREE THYROXINE $106.00
FUNGUS CULTURE $136.59
FUNGUS CULT FOR DERMATOPHYTES $86.32
FUNGUS CULT FOR DERMATOPHYTES $86.32
GENT PEAK (POST) $191.23
GENT TROUGH(PRE) $187.94
GLUCOSE CSF $78.67
GRAM STAIN $66.65
HEPATITIS A VIRUS IGM $143.15
HEPATITIS BS AB $68.85
HEPATITIS B CORE IGM $113.64
HEPATITIS B CORE IGG IGM $87.42
HEPATITIS B SURFACE AG $101.62
HBV DNA DETECT QUANT $281.92
TOTAL BETA HCG $137.68
�26
HEPATITIS C AB $158.44
HCV RNA DETECT QUANT(PCR) $649.08
HELICOBACTER PYLORI IGG $69.94
HEPATIC FUNCTION PANEL $178.12
ZZHEXAGONAL PHOSPHOLIPID NEUT 85598$236.02
HEMOGLOBIN $48.08
HISTONE AUTOANTIBODIES $169.37
HIV-1 HIV-2 $104.91
HANDLING POST-TRANSPLANTS $59.01
HOMOCYSTEINE TOTAL $257.88
HEPARIN XA UNFRACTIONATED $164.44
AEROBIC IDENTIFICATION $230.57
ANAEROBIC IDENTIFICATION $225.11
IMMUNOFIX SERUM $187.94
IMMUNOFIX URINE $210.89
IGA $27.32
IGE IMMUNOGLOBULIN 82785 $195.21
IGG $27.32
IGM $27.32
IMMUNOLOGICAL ID - SINGLE CHARGE $49.17
IMMUNOLOGICAL IDENTIFICATION $49.17
KEPPRA (LEVETIRACETAM) $213.09
POTASSIUM URINE $66.65
LAMOTRIGINE S $213.09
LEUKOCYTE ALKALINE PHOSPHATASE $138.77
LDH $81.96
LEAD BLOOD $103.81
LEGIONELLA AG URINE $171.56
LH 83002 $133.31
LITHIUM $86.32
LIPASE $95.07
LIPOPROTEIN (A) SERUM $126.75
�27
LYME ANTIBODY SCREEN $181.39
MALARIA SMEAR $91.79
MICROALBUMIN $91.79
MIC CHARGE CODE $107.09
UA WITHOUT MICRO $33.88
MITOCHONDRIAL AB M2 S $137.14
METHYLMALONIC ACID $285.20
MYCOPHENOLIC ACID S $194.51
MRSA SCREEN $178.12
MRSA DNA: NASAL SCN $157.35
MTB COMPLEX RAPID PCR $397.58
SODIUM RANDOM URINE $61.19
SED RATE $61.19
OSMOLALITY $65.56
OSMOLALITY URINE $86.32
BORDETELLA PERTUSSIS DNA 87798 $371.53
PHENOBARB $140.97
PHOSPHORUS $71.03
PLASMINOGEN ACTIVITY 85420 $62.12
PROTEIN C ACTIVITY (FUNC) $40.43
PREGNANCY $80.87
PREGABALIN (LYRICA) $135.50
PRENATAL OBSTETRIC PROFILE $25.13
PREGNANCY URINE (FERTILITY) $127.85
PROLACTIN $154.08
PROGESTERONE $154.08
PROLACTIN POOL $154.08
PROTEIN S AG TOTAL $211.98
PROTEIN URINE RANDOM $76.49
PROTEIN S ACTIVITY $40.43
PROSTATIC SPECIFIC AG $160.63
PSA SCREEN $167.19
�28
PTH INTACT $279.74
PTH-RELATED PEPTIDE 82397 $280.83
PHENYTOIN 80185 $121.29
FOLATE (FOLIC ACID) RBC $189.05
RENIN ACTIVITY $204.34
RESPIRATORY CULTURE $138.77
RHEUMATOID FACTOR $59.01
RISTOCETIN COFACTOR $120.20
ROTAVIRUS $112.55
RPR $98.34
RSV $39.34
RUBELLA IGG AB $131.13
RUBEOLA (MEASLES) AB IGG $114.73
SEROTONIN SERUM $205.43
SYNOVIAL FLUID COUNT $101.62
STREP PNEUMONIAE AG U $178.12
STOOL CULTURE $92.89
STOOL CULTURE ADDITIONAL PATHOGEN $46.99
KIDNEY STONE ANALYSIS $118.02
T4(THYROXINE) TOTAL ONLY $73.21
TEGRETOL $125.66
TESTOSTERONE $205.43
THC CONFIRMATION URINE 80299 $154.08
THEOPHYLLINE $145.33
TOPIRAMATE $156.26
TOTAL PROTEIN 84155 $69.94
PROTEIN CSF $79.77
TRANSFERRIN $104.91
TRICHROME O+P $135.50
TRIGLYCERIDE $76.49
TSH $162.81
THYROID-STIMULATING IMM $484.08
�29
URIC ACID RANDOM URINE $74.30
URINE CULTURE SUSCEPTIBILITY $125.66
URIC ACID $71.03
URINE CULT ID CHG $107.09
URINE VOLUME MEASURE 81050 $40.43
VITAMIN D 1 25-DIHYDROXY $348.58
VALPROIC ACID $132.22
VANCO PEAK $170.47
VANCO TROUGH $170.47
VARICELLA IMMUNE IGG TITER $97.25
VITAMIN E $128.95
VRE SCREEN $73.21
VON WILLEBRAND FACTOR AG $120.20
WBC SMEAR $25.13
WET PREP $64.47
WEST NILE VIRUS IGM $192.32
CHG CODE FOR AFBID $275.37
FUNGUS CULT ID CHG YEAST $78.67
17-HYDROXY PROGESTERONE $167.19
VITAMIN D 25-HYDROXY D3 $162.81
JO 1 AB IGG 86235 $128.95
ALBUMIN BODY FLUID 82042 $90.69
ANTINUCLEAR AB (IFA) $116.93
ANDROSTENEDIONE $324.54
APTT $92.89
RNP AB IGG 86235 $128.95
SCL 70 AB IGG 86235 $128.95
SM AB IGG 86235 $128.95
SS-A RO AB IGG $128.95
SS-B LA AB IGG $128.95
BARTONELLA BUNDLE BHG & MB BQG & M 86611$38.00
BARTONELLA IGG/IGM 86611.005 $28.55
�30
BK VIRUS DNA QN BY PCR $437.09
GROUP A STREP SCN:THT $108.18
CARDIOLIPIN IGG AB $143.15
CARDIOLIPIN IGM AB $143.15
CATECHOLAMINE FRACTIONS $185.76
CALCIUM URINE $61.19
CD4% 86361 $100.53
CENTROMERE AB IGG $287.39
CHARGE VMAU $208.71
CHARGE HCVG IF HEPCA POSITIVE $666.56
CITRATE URINE $304.87
CYTOMEGALOVIRUS AB IGM $99.44
CYTOPLASMIC NEUT AB 86255 $231.66
C-PEPTIDE $169.37
CREATININE RANDOM URINE $74.30
CREATININE URINE $74.30
CREATININE URINE $74.30
CRYPTOSPORIDIUM AG, FECES 87328 $104.91
C TRACHOMATIS NUC. ACID 87491 $212.00
CYSTINE $312.52
DEAMID. GLIADIN AB IGA $147.52
DEAMID. GLIADIN AB IGG $147.52
DSDNA AB IGG $124.57
DRVVT CONFIRM 85612 $87.42
DRVVT SCREEN $33.88
TIBC $99.44
EBNA $203.25
EBV AB PROFILE S $237.13
EBV VCA IGG $237.13
FACTOR VIII $120.20
FENTANYL URINE $191.23
PSA FREE 84154 $80.87
�31
TESTOSTERONE FREE S $158.44
GIARDIA LAMBLIA AG FECES 87329 $138.00
GLUCOSE BODY FLUID $78.67
HEPATITIS A TOTAL AB S $123.48
HCV AMPLIFICATION RT-PCR $774.75
5 HIAA $174.83
HISTOPLASMA AG SERUM $136.25
HSV TYPE 1 AB IGG $42.62
HSV1 DNA BY PCR $98.34
HSV TYPE 2 AB IGG $64.47
HSV2 DNA BY PCR $98.34
IGG 1 SUBCLASS $110.36
IGG 2 SUBCLASS $110.36
IGG 3 SUBCLASS $110.36
IGG 4 SUBCLASS $110.36
IGG TOTAL $113.64
LYME IGG WESTERN BLOT $155.17
INSULIN $160.63
KAPPA FREE LIGHT CHAIN 83883 $171.56
LDH BODY FLUID $78.67
LYME IGM WESTERN BLOT $155.17
LAMBDA FREE LIGHT CHAIN 83883 $171.56
LUPUS ANTICOAGULANT $50.26
METANEPHRINES URINE $175.92
SODIUM URINE $61.19
N GONORRHOEAE NUC. ACID 87591 $236.00
AMMONIA $106.00
OXALATE CONCENTRATION $107.09
PROTEIN C AG $226.20
PHOSPHORUS URINE $54.64
PREGNANCY SERUM $80.87
PROTEIN URINE $76.49
�32
PROTEIN S AG FREE $191.23
PROTHROMBIN TIME $77.58
APTT 50% NP $69.94
Q FEVER PHASE I IGG $163.91
Q FEVER PHASE I IGM $163.91
RETIC $54.64
IONIZED CALCIUM - RT $114.73
STRIATIONAL(MUSCLE) AB 83520 $51.98
GROUP A STREP DNA:THT $173.74
THYROGLOBULIN AB SCREEN $174.83
THYROGLOBULIN TUMOR MRK $174.83
THYROTROPIN RECEPTOR AB 83520 $122.58
PROTEIN BODY FLUID 84157 $79.77
PROTEIN BODY FLUID $79.77
THYROPEROXIDASE AB $135.50
TOTAL PORPHYRINS WB $214.18
TESTOSTERONE TOTAL S $205.43
TISSUE TRANSGLUTAM. IGA 83516 $138.77
TISSUE TRANSGLUTAM. IGG 83516 $138.77
URIC ACID URINE $74.30
A-TOCOPHEROL VITAMIN E $133.31
VARICELLA-ZOSTER IGG AB $112.55
VARICELLA-ZOSTER IGM AB $112.55
ALPHA-1-ANTITRYPSIN S $123.48
ALPHA-1-ANTITRYPSIN PHENO $101.62
TESTOSTERONE BIOAVAIL S $218.55
COCCI COMPLEMENT F $90.69
COCCI IMMUNODIFFUSION IGG $90.69
COCCI IMMUNODIFFUSION IGM $90.69
TESTOSTERONE FREE S $218.55
HERPES SIMPLEX VIRUS TYPES 1 AND 2 $88.51
HUMAN GRAN EHRLICHIOSIS AB $118.78
�33
EHRL.CHAFFEE. (HME) IGG $118.78
HELICOBACTER PYLORI AG F $253.51
LYME DISEASE PCR B $345.30
PNEUMO AB TYPE 12 (12F) $110.36
PNEUMO AB TYPE 14 $110.36
PNEUMO AB TYPE 19 (19F) $110.36
PNEUMO AB TYPE 23 (23F) $110.36
PNEUMO AB TYPE 26 (6B) $110.36
PNEUMO AB TYPE 51 (7F) $110.36
PNEUMO AB TYPE 56 (18C) $110.36
PNEUMO AB TYPE 1 $110.36
PNEUMO AB TYPE 3 $110.36
PNEUMO AB TYPE 4 $110.36
PNEUMO AB TYPE 8 $110.36
PNEUMO AB TYPE 9 (9N) $110.36
RHEUMATOID FACTOR $59.01
S. PNEUMO IGG 23 SERO 86317 $110.36
SS-A RO AB 86235 $128.95
SS-B LA AB 86235 $128.95
TESTOSTERONE FREE BIOAVAIL 84402 $160.00
OXCARBAZEPINE METABOLITE $213.09
TISSUE TRANSGLUTAM. IGA $138.77
TESTOSTERONE TOTAL S $218.55
URIC ACID $71.03
LISTERIA AB 86609 $107.09
CREAT OTHER SOURCE 82570 $43.75
PHENOBARB WITH PRIMIDONE 80184 $140.97
C DIFF ANTIGEN 87449 $201.07
GABAPENTIN 80171 $224.00
LAMOTRIGINE 80175 $206.53
LEVETIRACETAM 80177 $120.00
MYCOPHENOLATE 80180 $189.05
�34
OXCARBAZEPINE 80183 $206.53
IODINE BLOOD 83789 $184.60
PNEUMOCOCCAL AB EA PNL 23 86317 $9.00
B PERTUSSIS A G M EA ELISA 86615 $160.63
B PERTUSSIS A G M EA IMUNOBLT REFL 86615$74.30
RA FACTOR QUANT 86431 $81.00
EOSINOPHIL SMEAR BODY FLUID 89050 $84.00
CYTOMEGALOVIRUS AB IGG $179.21
CYTOMEGALOVIRUS AB IGM $110.36
CYTOMEGALOVIRUS $50.26
CYTOMEGALOVIRUS IGM $50.26
HLA B27 TYPING 86812 $215.27
HFE GENE ANALYSIS BLOOD $480.80
CDMR RESPIRATORY PCR PANEL 87631.001$499.00
PROTHROMBIN G20210A MUTATION $112.55
FACTOR V LEIDEN GENE 81241 $193.00
EBV IGG $150.65
EBV IGM $150.65
EBV NUCLEAR ANTIGEN IGG $150.65
GABAPENTIN (NERONTIN) $230.57
FLOURESC NONINFECTIOUS AB SCREEN 86255$134.37
TISSUE TRANSGLUTAMINASE AB IGA $143.15
ENDOMYSIAL IGA AB SEMI QUANT $174.83
HV 1 ANTIBODY 86701 $12.98
HIV 2 ANTIBODY 86702 $114.80
HIV1 AG HIV 1 2 AB $102.00
BLOOD CULTURE ORGANISM ID NAD 87149$105.00
PS/PT AB G,M 86148 $170.62
CONNECT TISSUE ANTINUCLEAR AB 86038.007$87.50
CONNECT TISS CYCLIC CITRULLINATED PEPTIDE AB 86200.003$101.06
TISSUE TRANSGLUT IGA REFLEXED 83516.033$88.75
TESTOSTERONE,BIOAVAILALBE DIRECT MEASURE 84410$178.68
�35
HEPATITIS C RNA GENOTYPE 3 NS5A DRUG RESISTANCE 87902$567.25
FIBRINOGEN DEGRADATION PRODUCTS PARACOAGULATION 85366`$125.88
TESTOSTERONE FREE MEASURED 84402 $212.18
ESTRONE WITH ESTRADIOL 82679 $71.55
MALARIA ANTIGEN 87899 $33.68
HPV HIGH-RISK TYPES 87624 $171.87
OPIATES 80361 G0480 $64.75
NICOTINE 80323 G0480 $150.00
OXYCODONE 80365 G0480 $107.10
AMPHETAMINE 80324 G0480 $54.78
METHYLENEDIOXYAMPHETAMINE 80359 G0480$64.98
NEPHELOM KAPPA LAMBDA PROTEIN 83883$38.75
KAPPA LAMBDA PROTEIN URINE 84156 $21.30
IMMUNOFIX KAPPA LAMBDA URINE 86335$100.16
HEP C SCREEN HIGH RISK/OTHER $158.44
CRC SCR OCCULT BLD FIT (1-3 CARDS) 82274$55.12
CRC SCR OCCULT BLD GUAIAC (3 CARDS) 82270$44.00
BASIC ENTERIC PATHOGENIC PANEL NAD 87506$818.00
THYROGLOBLULIN AB FOR REFLEX 86800$174.83
THYROGLOBULIN RUMOR MARKER REFLEXED 84432$176.47
ANGIOTENSIS CONVERTING ENZYME 82164$149.70
SUPERSATURATION, CALCIUM, 82340 $55.00
SUPERSATURATION, CHLORIDE 82436 $52.00
SUPERSATURATION,CITRATE EXCRETN, 82507$209.00
SUPERSATURATION,CREATININE, 82570 $67.00
SUPERSATURATION, MAGNESIUM, 83735 $81.00
SUPERSATURATION, OSMOLALITY, 83935 $80.00
SUPERSATURATION, OXALATE, 83945 $84.00
SUPERSATURATION, PH, 83986 $48.00
SUPERSATURATION, PHOSPHORUS, 84105 $62.00
SUPERSATURATION, POTASSIUM, 84133 $56.00
SUPERSATURATION, SODIUM, 84300 $63.00
�36
SUPERSATURATION, SULFATE, 84392 $100.00
SUPERSATURATION, URIC ACID, 84560 $54.00
SUPERSATURATION, AMMONIUM, 82140 $147.00
SUPERSATURATION, UREA NITROGEN, 84540$87.00
THC CONFIRMATION URINE 80349 G0480 $149.06
MTB RIFAMPIN RESISTANCE 87798.067 $334.00
CARBAPENEM RESIST ENTEROBACTER NAD 87150.004$50.79
MAMMO DX UNILAT INCL CAD $256.79
MAMMO DX BILAT INCL CAD $315.80
MAMMO SCREEN BILAT INCL CAD $293.94
DRUG SCR PRESUMP DIRECT OPTICAL OBS 80305$216.30
DRUG SCR PRESUM INST ASSIST DIRECT OPT 80306$206.00
NICOTINE SCREEN 80305 $65.00
SALICYLATE 80307 $50.13
ACETAMINOPHEN 80307 $46.79
ALCOHOL NOT BREATH 80307 $164.07
ALCOHOL URINE 80307 $262.50
DRUG SCR PRESC OTC 80307 $273.75
TISSUE TRANSGLUTAMINASE IGG AB 83516$55.00
RAD EXAM CHEST SINGLE VW $225.11
RAD EXAM CHEST 2 VWS $336.56
RAD EXAM ABDOMEN 1 VW $309.24
CDMR RSV DNA/RNA AMP PROBE 87634.01$136.00
IGF BINDING PROTEIN 3 83520.053 $61.25
CENTROMERE AB SO 83516.038 $53.75
HIV 1 RNA,QUALIATIVE NAT SO 87535.004 $298.38
Mammorgraphy
US S&I GUID NDLE PLMT $587.88
MAMMO SCREEN UNILAT INCL CAD $293.94
Medical/Surgical
�37
ROUTINE ROOM & BOARD $1,618.33
CHOLECYSTECTOMY $5,469.09
COLONOSCOPY $1,771.53
MULTIPLE SLEEP LATENCY 95805 $2,589.76
PSG 4+ PARAMETERS $3,503.33
SLEEP STUDY SPLT NGHT 95811 $3,731.66
SLEEP STUDY PARTIAL 95810 $3,233.38
ECG TRACING WO INTERP $196.69
CONTINUOUS INHAL TX W AEROSOL ADD HR$131.30
PF A9540 NM TC99M MAAUP 10MCI $211.98
ED 99281 VISIT LEVEL 1 $166.00
MD 99195 PHLEBOTOMYTHERAPEU(SEP PROC$910.24
CARDIAC EVENT MONITOR APPLICAT $1,254.45
IMMUN ADMIN 1 VACCINE $58.00
CATARACT SURGERY $4,334.74
YAG LASER $1,733.67
CBC AUTOMATED WDIFF 85025 $152.99
ABO 86900 $88.51
ANTIBODY SCREEN 86850 $142.00
RH 86901 $63.00
POTASSIUM 84132 $66.65
COMPREHENS METABOLC PANL 80053 $240.40
URINALYSIS-DIPSTICK ONLY 81003 $52.00
URINALYSIS W MICROSCOPIC 81001 $74.00
VENIPUNCTURE 36415 $27.00
CBC AUTOMATED NO DIFF 85027 $130.04
THERAPEUTIC PHLEBOTOMY $214.18
RECOVERY ROOM $532.38
IV HYDRAT INITIAL 31-60MINS $500.00
IV HYDRATION EACH ADDL HR $135.50
INFUSION TX PROP DX 1HR 1V $372.00
IV INFUSION EA ADD HR $103.00
�38
IV INFUS ADD SEQUEN NEW DRG1HR $144.00
SC IM INJECTION $116.93
IV PUSH INITIAL $173.00
CHEMO SQ IM NON HORMONAL $154.00
CHEMO IV PUSH $340.00
CHEMO IV PUSH EA ADD DRUG $181.00
CHEMO INFUSION 1ST HR $582.00
CHEMO INFUSION EA ADD HR $134.00
IRRIG IMPL VENOUS ACCESS DEVIC $92.70
INFUSION TX CONCURRENT $123.00
CARDIAC REHAB PHASE 1 $217.45
BLOOD ADMIN 0-2 HRS $1,016.24
BLOOD ADMIN 2-4 HRS $1,016.24
BLOOD ADMIN 4-6 HRS $1,016.24
BLOOD ADMIN 6-8 HRS $1,016.24
BLOOD ADMIN >8 HRS $1,016.24
ISOLATION ROOM $2,267.19
PSG CPAP BIPAP 4+ PARAMETERS $3,731.66
IV PUSH SEQUENTIAL NEW DRUG $111.00
IV PUSH ADDL SAME DRUG >30MINS $106.00
SEMI PRIVATE ROOM $1,699.25
RESPITE ROOM & BOARD - LVL III $382.46
IMMUN ADMIN EA ADDL VACCINE $32.00
NEB INITIAL TX $119.00
NEB SUBSEQ TX $59.50
INTUBATION (OP) $916.80
GENERAL CORONARY CARE $2,030.28
SEMI PRIVATE ROOM&BOARD LVL II $2,267.19
TREATMENT RM LVL 1 W PROCEDURE $994.76
TREATMENT RM LVL 2 W PROCEDURE $947.39
TX RM NURSING BLD COLLECTION IVAD $83.81
OR ROOM 15 MIN $421.80
�39
COLONOSCOPY SUBMUC INJECT $1,148.00
UNATTENDED SLEEP STUDY 95806 $2,489.23
TX RM TREATMENT ROOM $663.18
OR TIME 1 MIN $29.83
TX RM CATH BLADDER NON-INDWELLING$194.00
TX RM INSERT TEMP INDEWELLING CATH/SIMPLE$301.59
ED NEBULIZER TREATMENT $150.00
OBSERVATION WITH ISOLATION $81.45
EXCISION OR TRANSPOSITION OF PTERYGIUM W GRAFT$2,173.50
NURSE ONLY VISIT $116.93
THERAPEUTIC PHLEBOTOMY NURSING $232.00
THERAPEUTIC PHLEBOTOMY COMPLEX NURSING$910.24
STAT PRE-OP FOR OBSERVATION $-
MRI
MRI TMJ WO CONTRAST $2,448.96
CT MAXILLOCFACL WO THEN WCONT $1,620.51
CTA HEAD W CONT WO IF PERF $2,042.23
CT ANGIO NECK W CON+WO IF PERF $2,042.23
MRI FACE NECK ORB WO THEN W CONT$3,039.96
MRA HEAD WO CONTRAST $2,514.49
MRA NECK WO CONTRAST $2,137.71
MRA NECK WO THEN W CONT $3,224.55
MRI BRAIN WO CONTRAST $2,420.25
MRI BRAIN W CONTRAST $2,493.60
MRI BRAIN WO THEN W CONT $3,521.86
CT THORAX WO CONTRAST $1,538.78
MRI CHEST WO CONTRAST $2,009.53
CT CERVICAL SPINE W CONTRAST $1,702.59
MRI C SPINE WO CONTRAST $2,424.76
MRI C SPINE W CONTRAST $2,813.77
MRI T SPINE WO CONTRAST $2,903.37
�40
MRI L SPINE WO CONTRAST $2,799.57
MRI L SPINE W CONTRAST $3,097.88
MRI C SPINE WO THEN W CONT $3,233.38
MRI T SPINE WO THEN W CONT $3,589.43
MRI L SPINE WO THEN W CONT $3,683.40
MRI PELVIS WO CONTRAST $2,242.80
MRI PELVIS WO THEN W CONT $2,233.19
CT EXT UPPER W CONT $1,176.00
MRI UP EXT WO CONT $2,302.38
MRI UPPER EXT JT WO CONTRAST $2,394.53
MRI UPPER EXT JT WO THEN W CONT $3,048.68
CT BONE LENGTH STUDY $628.32
CT EXT LOWER W CONT $1,568.70
MRI LOWER EXT WO CONTRAST $3,124.10
MRI LOWER EXT WO THEN W CONT $3,054.18
MRI LOWER EXT JT WO CONTRAST $2,232.04
MRI LOWER EXT JT W CONTRAST $2,420.39
MRI LOWER EXT JT WO THEN W CONT $3,000.11
CTA ABD WCONT +WO IF PERF $2,233.19
MRI ABDOMEN WO CONTRAST $2,949.45
MRI ABDOMEN WO THEN W CONT $3,690.23
CT LIMITED OR LOCALIZED FOLLOW UP STUDY$689.51
US CHEST $418.43
US GUIDED VASCULAR ACCESS $896.46
MRA ABDOMEN W CONTRAST $2,882.97
DOPPLER LIMITED $263.17
ECHO 2-D LIMITED $1,280.92
DUPLEX ABD PELVIS RETROPERITONEAL LTD$626.99
NM THYROID IMG W VASC FLOW $911.31
CT ORBIT SELLA FOSSA EAR W CONTRAST$1,803.00
NM HEPATOBILIARY IMG INCL GALLBLADDER W PHARM INTV$2,327.29
MRI PELVIS W CONTRAST $2,091.42
�41
TC99M MEBROFENIN PER STUDY DOSE UP TO 15 MCI$136.00
TC99M PERTECHNETATE PER MCI $142.42
MRI FACE NECK ORB W CONTRAST $3,388.17
MRI LOWER EXT W CONTRAST $3,123.29
NM PARATHYROID PLANAR IMG W SPECT$719.20
Nuclear Medicine
NM BONE AND OR JNT IMG 3 PHASE STDY$1,360.44
NM BONE AND OR JNT IMG WHOLE BODY$1,433.66
NM BONE AND OR JNT IMG TOMOGRAPHIC SPECT$1,663.13
TC99M MEDRONATE PER STUDY DOSE UP TO 30 MCI$140.97
NM HEPATOBILIARY IMG INCL GALLBLADDER$1,525.45
Observation
OBSERVATION ROOM HOURLY $57.37
OBSERVATION INITIAL ASSESSMENT $57.37
OBSERVATION TELEMETRY 1HR $81.46
OBSERVATION 1HR $349.67
OBSERVATION 2HR $405.40
OBSERVATION 3HR $460.04
OBSERVATION 4HR $515.76
OBSERVATION 5HR $570.40
OBSERVATION 6HR $626.14
OBSERVATION 7HR $680.77
OBSERVATION 8HR $736.50
OBSERVATION 9HR $791.13
OBSERVATION 10HR $846.87
OBSERVATION 11HR $901.50
OBSERVATION 12HR $957.23
OBSERVATION 13HR $1,011.86
OBSERVATION 14HR $1,066.50
OBSERVATION 15HR $1,122.23
�42
OBSERVATION 16HR $1,176.87
OBSERVATION 17HR $1,232.60
OBSERVATION 18HR $1,287.23
OBSERVATION 19HR $1,342.97
OBSERVATION 20HR $1,397.60
OBSERVATION 21HR $1,453.33
OBSERVATION 22HR $1,507.96
OBSERVATION 23HR $1,563.69
OBSERVATION 24HR $1,618.33
Occupational Therapy
EVAL ORAL & PHARYNGEAL SWALLOW 92610$352.80
DYSPHAGIA THERAPY 92526 $235.46
PARAFFIN BATH 97018 $115.83
THER EXERCISE EA 15 MIN 97110 $108.11
ORTHOTICS MGMT&TRAIN INITIAL 15MIN 97760$95.07
SLFCR HOME MGMT TRN15MIN 97535 $113.64
COMM WORK REINTGR EA15MIN97537 $121.62
HOT COLD PACKS $98.34
VASOPNEUMATIC DVC APPL 97016 $93.36
OT EVAL LOW COMPLEXITY 97165 $249.83
OT EVAL MODERATE COMPLEXITY 97166 $255.23
OT EVAL HIGH COMPLEXITY 97167 $260.64
OT RE-EVAL EST PLAN CARE 97168 $253.38
Operating Room
SURG INS NT CENT CVA >5 $2,068.76
BX LIVER NEEDLE BIOPSY $1,097.09
SURG BIOP LIVER NEEDLE PERCUT $1,097.09
ABD HYSTERECTOMY BSO $449.11
APPENDECTOMY $5,808.93
BREAST BIOPSY $903.68
�43
TONSILLECTOMY $3,078.22
MD 45005 I & D ABCESS RECTUM $1,584.46
SECRETIN STIMULATION $125.66
FLEX SIG DIAG $1,012.95
Physical Therapy
TENS APPLICATION 64550 $95.07
TRACTION MECHANICAL 97012 $100.53
ULTRASOUND 15 MIN 97035 $95.07
THER EXERCISE EA 15 MIN 97110 $108.11
NEUROMUSC RE ED EA 15MIN 97112 $126.53
GAIT TRAINING 15 MIN 97116 $103.81
MASSAGE 15 MIN 97124 $95.07
MANUAL THERAPY 15 MIN 97140 $111.02
THER ACTIVITES EA15 MIN 97530 $112.88
TX RM WND NEG PRESS UTILIZ DME <= 50SQCM 97605$128.75
TENS SETUP 64550 $95.07
WHLCHR MGMT 15 MIN 97542 $130.73
VASOPNEUMATIC DVC APPL 97016 $93.36
TX RM DEBR WUND TIS ADDL 20SQCM97598$195.70
WORK COND INIT 2HR 97545 $120.20
PHYS PERF TST MSRE-15MIN 97750 $349.67
TX RM APPL MULTI-LAYER COMPRESS SYS LWR LEG$211.56
MOBILITY CURRENT STATUS $0.01
MOBILITY GOAL STATUS $0.01
MOBILITY D C STATUS $0.01
BODY POS CURRENT STATUS $0.01
BODY POS GOAL STATUS $0.01
BODY POS D C STATUS $0.01
CARRY CURRENT STATUS $0.01
CARRY GOAL STATUS $0.01
CARRY D C STATUS $0.01
�44
SELF-CARE CURRENT STATUS $0.01
SELF-CARE GOAL STATUS $0.01
SELF-CARE D C STATUS $0.01
OTHER PT OT CURRENT STATUS $0.01
OTHER PT OT GOAL STATUS $0.01
OTHER PT OT D C STATUS $0.01
SUB PT OT CURRENT STATUS $0.01
SUB PT OT GOAL STATUS $0.01
SUB PT OT D. C STATUS $0.01
STRAPPING OF HIP $112.55
STRAPPING OF KNEE $112.55
STRAPPING OF ANKLE FOOT $112.55
PT EVAL LOW COMPLEXITY 97161 $254.15
PT EVAL MODERATE COMPLEXITY 97162 $259.56
PT EVAL HIGH COMPLEXITY 97163 $252.35
PT RE-EVAL EST PLAN CARE 97164 $201.16
Radiology
CT ORBIT SELLA FOSSA EAR WO THEN W CONTRAST$2,200.00
CT LUMBAR SPINE W CONT $1,708.00
RAD EXAM AC JOINTS BILAT W WO WTS $337.65
RAD EXAM ANKLE MIN 3 VWS $297.22
RAD EXAM ANKLE 2 VWS $239.31
RAD EXAM SPINE CERV 6 + VWS $587.88
RAD EXAM SPINE CERV 4 OR 5 VWS $485.17
RAD EXAM SPINE CERV 2 OR 3 VWS $360.60
RAD S&I CHOLANGIO AND OR PANCREATO INTRAOP$731.30
RAD EXAM CLAVICLE COMPL $270.99
RAD EXAM SPINE THOR MIN 4 VWS $475.33
RAD EXAM SPINE THOR 3 VWS $438.18
RAD EXAM ELBOW COMPL MIN 3 VWS $297.22
RAD EXAM ELBOW 2 VWS $250.24
�45
RAD EXAM FACIAL BONES COMPL MIN 3 VWS$359.51
RAD EXAM FINGER(S) MIN 2 VWS $237.13
RAD EXAM FOOT MIN 3 VWS $309.24
RAD EXAM FOOT 2 VWS $235.84
RAD EXAM FOREARM 2 VWS $257.88
RAD EXAM HAND MIN 3 VWS $297.22
RAD EXAM HAND 2 VWS $205.43
RAD EXAM CALCANEUS MIN 2 VWS $237.13
RAD EXAM HUMERUS MIN 2 VWS $297.22
RAD UROGRAPHY IV W WO KUB W WO TOMO$802.06
RAD EXAM KNEE 1 OR 2 VWS $297.22
RAD EXAM KNEE COMPL 4 + VWS $375.90
RAD EXAM KNEE BOTH STANDING ANTEROPOSTERIOR$296.13
PFT SCREEN SPIROMETRY (WITH BD) $381.92
RAD EXAM OSSEOUS SURVEY LTD $540.90
RAD EXAM SPINE LUMB 2 OR 3 VWS $402.12
RAD EXAM SPINE LUMB MIN 4 VWS $466.59
RAD EXAM MANDIBLE COMPL MIN 4 VWS$502.65
RAD EXAM OSSEOUS SURVEY COMPL $545.90
RAD EXAM NASAL BONES COMPL MIN 3 VWS$359.51
RAD EXAM NECK SOFT TISSUE $238.22
RAD EXAM OPTIC FORAMINA COMPL MIN 4 VWS$471.57
RAD ORTHOPANTOGRAM $268.81
RAD EXAM SINUSES PARANASAL COMPL MIN 3 VWS$394.47
RAD EXAM PELVIS 1 OR 2 VWS $297.22
RAD EXAM RIBS UNILAT W CHEST MIN 3 VWS$437.09
RAD EXAM RIBS BILAT W CHEST MIN 4 VWS$507.03
RAD EXAM SACROILIAC JNTS 3 + VWS $402.12
RAD EXAM SACRUM COCCYX MIN 2 VWS $297.22
RAD EXAM SCAPULA COMPL $332.19
RAD EXAM SHOULDER 1 VW $246.95
RAD EXAM SHOULDER COMPL MIN 2 VWS$298.32
�46
RAD EXAM SINUSES PARANASAL < 3 VWS$268.81
RAD EXAM SKULL COMPL MIN 4 VWS $526.69
RAD EXAM SKULL < 4 VWS $336.56
RAD EXAM SMALL INTESTINE INCL MULT SER IMG$249.15
RAD EXAM SPINE SINGLE VW $142.06
RAD EXAM STERNUM MIN 2 VWS $297.22
RAD EXAM TIBIA FIBULA 2 VWS $297.22
RAD EXAM TOES MIN 2 VWS $237.13
RAD EXAM UPPER EXTREM INFANT MIN 2 VWS$257.88
RAD EXAM WRIST 2 VWS $261.17
RAD EXAM WRIST COMPL MIN 3 VWS $284.10
PFT SCREEN SPIROMETRY (NO BD) $167.19
DUP CAROTID BILAT $853.42
DUPLEX VENOUS EXT LTD UNILAT $668.28
RAD EXAM RIBS UNILAT 2 VWS $351.86
RAD EXAM PELVIS COMPL MIN 3 VWS $442.55
RAD EXAM SPINE THOR 2 VWS $401.03
BONE DENSITY DEXA AXIAL SKELET $647.98
RAD EXAM KNEE 3 VWS $296.57
RAD EXAM RIBS BILAT 3 VWS $449.11
CT THORACIC SPINE W CONTRAST $1,831.00
RAD EXAM EYE FOREIGN BODY $297.22
RAD EXAM MANDIBLE PARTIAL < 4 VWS $466.59
RAD EXAM FACIAL BONES < 3 VWS $297.22
RAD EXAM SPINE THORACOLUMBAR JUNC MIN 2 VWS$401.03
RAD EXAM SPINE LUMB BENDING VWS ONLY 2 OR 3 VWS$402.12
RAD EXAM ABDOMEN COMPL ACUTE ABD SINGL CHEST$560.57
RAD EXAM NOSE TO RECTUM FB SNGL VW CHILD$248.99
RAD EXAM SACROILIAC JNTS < 3 VWS $286.30
RAD EXAM SPINE ENTIRE THOR LUMB 1 VW$401.03
RAD EXAM SPINE ENTIRE THOR LUMB 2 OR 3 VWS$426.78
RAD EXAM SPINE ENTIRE THOR LUMB 4 OR 5 VWS$452.53
�47
RAD EXAM SPINE ENTIRE THOR LUMB 6 + VWS$478.28
RAD EXAM HIP UNILAT W PELV WHEN PERF 1 VW$258.01
RAD EXAM HIP UNILAT W PELV WHEN PERF 2 OR 3 VWS$300.30
RAD EXAM HIP UNILAT W PELV WHEN PERF MIN 4 VWS$312.08
RAD EXAM HIPS BILAT W PELV WHEN PERF 2 VWS$382.46
RAD EXAM HIPS BILAT W PELV WHEN PERF 3 OR 4 VWS$408.21
RAD EXAM HIPS BILAT W PELV WHEN PERF MIN 5 VWS$433.96
RAD EXAM FEMUR 1 VW $290.67
RAD EXAM FEMUR MIN 2 VWS $290.67
RAD EXAM ABDOMEN 2 VWS $449.11
Speech Therapy
DYSPHAGIA THERAPY 92526 $235.46
COGNITIVE TEST STNDRD HR 96125 $297.05
SWALLOW DYSFUNCTN TREAT $115.83
SWALLOW CURRENT STATUS $0.01
SWALLOW GOAL STATUS $0.01
SWALLOW D C STATUS $0.01
MOTOR SPEECH CURRENT STATUS $0.01
MOTOR SPEECH GOAL STATUS $0.01
MOTOR SPEECH D C STATUS $0.01
LANG COMP CURRENT STATUS $0.01
LANG COMP GOAL STATUS $0.01
LANG COMP D C STATUS $0.01
LANG EXPRESS CURRENT STATUS $0.01
LANG EXPRESS GOAL STATUS $0.01
LANG EXPRESS D C STATUS $0.01
ATTEN CURRENT STATUS $0.01
ATTEN GOAL STATUS $0.01
ATTEN D C STATUS $0.01
MEMORY CURRENT STATUS $0.01
MEMORY GOAL STATUS $0.01
�48
MEMORY D C STATUS $0.01
VOICE CURRENT STATUS $0.01
VOICE GOAL STATUS $0.01
VOICE D C STATUS $0.01
SPEECH LANG CURRENT STATUS $0.01
SPEECH LANG GOAL SATUS $0.01
SPEECH LANG D C STATUS $0.01
SPEECH EVAL FLUENCY 92521 $507.14
Swingbed
RESPITE ROOM & BOARD $213.09
SKILLED SWING ROOM & BRD SEMI $1,699.25
RESPITE ROOM & BOARD - LVL II $289.57
Ultrasound
US SOFT TISSUE HEAD NECK $477.52
US ABD COMPLETE $608.65
US ABD LIMITED $430.53
US RETROPERITONEUM $561.49
US RETROPERITONEUM LTD $401.70
US PREG UTER 1ST TRI SGL $552.92
US TRANSVAGINAL $492.42
US PELVIC COMPLETE $543.09
US SCROTUM $397.43
US LIMITED JNT REAL TIME W IMAGE DOC$450.88
COLOR FLOW VEL MAP $440.37
DUP CAROTID BILAT $853.42
DUPLEX VENOUS EXT CMPL BILAT $884.02
DUPLEX ABD PELVIS RETROPERITONEAL CMPL$868.61
DUPLEX ART LOWER EXT CMPL BILAT $605.00
DUPLEX ABD PELVIS RETROPERITONEAL LTD$626.99
US PELVIC LIMITED $363.88
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ECHO (2D) COMPLETE W DOPPLER & COLOR$1,972.37
US COMPLETE JNT REAL TIME W IMAGE DOC$503.93
DUPLEX ABD PELVIS RETROPERITONEAL CMPL$868.61
US ABD AORTA SCREEN AAA $375.19
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