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	Atrium Medical Center 




	Standard Charges 


	Effective January 01, 2024 Payer Negotiated Charges - per diem 


	Charge Code or DRG Description Gross Charges Cash Prices Average Gross Charges De-Identified Minimum Charges De-Identified Maximum Charges BCBS - PPO BCBS - Blue Essential BCBS - Traditional


	166 OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC per day per day 16,735.18 10,927.34 24,706.21  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	177 RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC per day per day 14,421.77 14,421.77 14,421.77  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	189 PULMONARY EDEMA AND RESPIRATORY FAILURE per day per day 12,485.99 8,080.74 17,119.39  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	193 SIMPLE PNEUMONIA AND PLEURISY WITH MCC per day per day 15,947.75 15,947.75 15,947.75  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	198 INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC per day per day 23,150.67 23,150.67 23,150.67  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	204 RESPIRATORY SIGNS AND SYMPTOMS per day per day 20,837.94 20,837.94 20,837.94  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	207 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS per day per day 25,311.77 25,311.77 25,311.77  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	208 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS per day per day 32,274.14 32,274.14 32,274.14  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	312 SYNCOPE AND COLLAPSE per day per day 13,398.39 13,398.39 13,398.39  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	438 DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC per day per day 16,373.47 16,373.47 16,373.47  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	637 DIABETES WITH MCC per day per day 10,523.43 10,523.43 10,523.43  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	682 RENAL FAILURE WITH MCC per day per day 15,170.58 15,170.58 15,170.58  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	867 OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC per day per day 11,146.11 11,146.11 11,146.11  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	870 SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS per day per day 18,021.79 18,021.79 18,021.79  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	974 HIV WITH MAJOR RELATED CONDITION WITH MCC per day per day 15,544.32 15,544.32 15,544.32  ranging from $1,200 to $1,950  ranging from $950 to $1,800  ranging from $1,200 to $1,950 


	 


	 Room & Board 


	1000001 ICU 5,918.22 5,918.22 5,918.22 5,918.22 5,918.22 


	1000003 Intermediate - Tele 4,931.08 4,931.08 4,931.08 4,931.08 4,931.08 


	1400001 Private Room & Board 4,490.64 4,490.64 4,490.64 4,490.64 4,490.64 


	 


	 X-Rays 


	3100001 Abdomen 1 View 1,001.71 1,001.71 1,001.71 1,001.71 1,001.71 


	3100002 Chest 1 View 1,022.67 1,022.67 1,022.67 1,022.67 1,022.67 


	3100003 Chest 2 Views 1,047.82 1,047.82 1,047.82 1,047.82 1,047.82 


	3100004 Shoulder 2+ Views 1,320.25 1,320.25 1,320.25 1,320.25 1,320.25 


	3100005 Calcaneous 2+ Views 838.25 838.25 838.25 838.25 838.25 


	3100006 Foot 2 Views 645.45 645.45 645.45 645.45 645.45 


	3100007 Foot 3 Views 1,108.59 1,108.59 1,108.59 1,108.59 1,108.59 


	3100008 Ankle 2 Views 597.25 597.25 597.25 597.25 597.25 


	3100009 Humerus 2+ Views 917.89 917.89 917.89 917.89 917.89 


	3100010 Knee 1-2 Views 930.46 930.46 930.46 930.46 930.46 


	3100011 Spine 1 View 712.51 712.51 712.51 712.51 712.51 


	3100012 Cervical Spine 2-3 Views 1,186.13 1,186.13 1,186.13 1,186.13 1,186.13 


	3100013 Lumbar Spine 2-3 Views 1,395.69 1,395.69 1,395.69 1,395.69 1,395.69 


	3100014 Pelvis 1-2 Views 767 767 767 767 767 


	3100015 Unilat Hips 2+ Views 1,387.31 1,387.31 1,387.31 1,387.31 1,387.31 


	3100016 Portable KUB IV 792.98 792.98 792.98 792.98 792.98 


	3100017 hands/ wrist 2 view 645.45 645.45 645.45 645.45 645.45 


	3100018 Skull 1,047.82 1,047.82 1,047.82 1,047.82 1,047.82 


	3100019 Elbow 930.46 930.46 930.46 930.46 930.46 


	 


	 CT Scans 


	3800001 CT Head/Brain w/o & w/Dye 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800002 CT Head/Brain w/o Dye 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800003 CT Pelvis w/o & w/Dye 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800004 CT Pelvis w/o Dye 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800005 CT Abdomen w/o & w/Dye 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800006 CT Abdomen w/o Dye 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800007 CT of Chest w/o Contrast 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800008 CT of Chest w/Contrast 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800009 CT Soft Tissue Neck w/o Dye 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800010 CT Maxillofacial w/o contrast 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800011 CT Maxillofacial w/ contrast 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800013 C.T. Abdomen s 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800014 C.T. Abdomen c 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800015 C.T. Abdomen c/s 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800016 C.T. Chest s 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800017 C.T. Chest c/s 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800018 C.T. Extre. (upper) s 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800019 C.T. Extre. (upper) c 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800020 C.T. Extre. (lower) s 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800021 C.T. Extre. (lower) c 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800022 C.T. Facial Bones c 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800023 C.T. Head s 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800024 C.T. Head c 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800025 C.T. Head c/s 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800026 C.T. I.A.C 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800027 C.T. Orbits 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800028 Bone Density 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800029 Urogram Antegrade 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800030 CT Angiography, Abd and bil. Run off 4,645.20 4,645.20 4,645.20 4,645.20 4,645.20 


	3800012 Ionic Contrast 940.8 940.8 940.8 940.8 940.8 


	 


	 Ultrasound 


	3500001 US Abdominal limited 1,793.86 1,793.86 1,793.86 1,793.86 1,793.86 


	3500002 US Exam, Extemity 1,584.30 1,584.30 1,584.30 1,584.30 1,584.30 


	3500003 US Renal 1,745.66 1,745.66 1,745.66 1,745.66 1,745.66 


	3500004 Unilat/Limited 1,835.77 1,835.77 1,835.77 1,835.77 1,835.77 


	3500005 US Lower Extremity Lim 1,274.14 1,274.14 1,274.14 1,274.14 1,274.14 


	3500006 Limited 1,257.38 1,257.38 1,257.38 1,257.38 1,257.38 


	3500007 US Scrotum 1,544.48 1,544.48 1,544.48 1,544.48 1,544.48 


	3500008 Venous dobler 1 view 1,274.15 1,274.15 1,274.15 1,274.15 1,274.15 


	3500009 Echocardiogram 2,587.20 2,587.20 2,587.20 2,587.20 2,587.20 


	 


	 Respiratory 


	4200001 Respiratory Evaluation 504 504 504 504 504 


	4200002 Resp Patient/Family Education 224 224 224 224 224 


	4200003 Vent Initial Setup 5,824.00 5,824.00 5,824.00 5,824.00 5,824.00 


	4200004 Vent Per Day 6,160.00 6,160.00 6,160.00 6,160.00 6,160.00 


	4200005 Vent Per Hour 256.67 256.67 256.67 256.67 256.67 


	4200022 CPAP/BiPAP Per day 2,800.00 2,800.00 2,800.00 2,800.00 2,800.00 


	4200023 CPAP/BiPAP 1/2 day 1,400.00 1,400.00 1,400.00 1,400.00 1,400.00 


	4200024 CPAP/BiPAP setup 5,600.00 5,600.00 5,600.00 5,600.00 5,600.00 


	4200006 CPAP/BiPAP Per Hr 116.67 116.67 116.67 116.67 116.67 


	4200007 Oxygen/Aerosol Per Hr 224 224 224 224 224 


	4200008 Trach Care every 12 hrs 392 392 392 392 392 


	4200009 Change Trach Tube 504 504 504 504 504 


	4200010 Suctioning 168 168 168 168 168 


	4200011 Pulse Oximetry Per Use 134.4 134.4 134.4 134.4 134.4 


	4200012 Pulse Oximetry Daily/Cont 308 308 308 308 308 


	4200013 Incentive Spirometry Tx 280 280 280 280 280 


	4200014 Aerosol Treatment 504 504 504 504 504 


	4200015 CPT Treatment 448 448 448 448 448 


	4200016 MDI Treatment 336 336 336 336 336 


	4200017 Neb Treatment 336 336 336 336 336 


	4200018 EKG 1,120.00 1,120.00 1,120.00 1,120.00 1,120.00 


	4200019 ABG 616 616 616 616 616 


	4200020 Sputum Collection 224 224 224 224 224 


	4200021 Code Blue 1 hour 9,184.00 9,184.00 9,184.00 9,184.00 9,184.00 


	 


	 Physical Therapy 


	4800001 PT Evaluation 628.69 628.69 628.69 628.69 628.69 


	4800002 PT Reassessment 419.13 419.13 419.13 419.13 419.13 


	4800003 PT Discharge Summary 314.34 314.34 314.34 314.34 314.34 


	4800004 Gait Training 209.56 209.56 209.56 209.56 209.56 


	4800005 Manual Therapy Technique 209.56 209.56 209.56 209.56 209.56 


	4800006 Electrical Stimulation 209.56 209.56 209.56 209.56 209.56 


	4800007 PT Theraputic Activities 209.56 209.56 209.56 209.56 209.56 


	4800008 PT Theraputic Exercise 209.56 209.56 209.56 209.56 209.56 


	4800009 Wheelchair Management 209.56 209.56 209.56 209.56 209.56 


	4800010 PT Neuromuscular Re-Ed 209.56 209.56 209.56 209.56 209.56 


	4800011 App of Short Leg Slint 209.56 209.56 209.56 209.56 209.56 


	 


	 Occupational Therapy 


	5000001 OT Evaluation 628.69 628.69 628.69 628.69 628.69 


	5000002 OT Reassessment 419.13 419.13 419.13 419.13 419.13 


	5000003 OT Discharge Summary 314.34 314.34 314.34 314.34 314.34 


	5000004 OT Theraputic Exercise 209.56 209.56 209.56 209.56 209.56 


	5000005 OT Theraputic Activities 209.56 209.56 209.56 209.56 209.56 


	5000006 OT Self Care Training 209.56 209.56 209.56 209.56 209.56 


	5000007 OT Neuromuscular Re-Ed 209.56 209.56 209.56 209.56 209.56 


	5000008 OT ADL 209.56 209.56 209.56 209.56 209.56 


	5000009 Manual Therapy Technique 209.56 209.56 209.56 209.56 209.56 


	5000010 Cognitive Training 209.56 209.56 209.56 209.56 209.56 


	5000011 App of Arm/Hand Slint 209.56 209.56 209.56 209.56 209.56 


	 


	 Speech Therapy 


	4900001 ST SP/Language Evaluation 628.69 628.69 628.69 628.69 628.69 


	4900002 Tx of Speech/Language 314.34 314.34 314.34 314.34 314.34 


	4900003 Speech Language Cognitive Eval 628.69 628.69 628.69 628.69 628.69 


	4900004 Cognitive Skills Dev't ea 15 min 209.56 209.56 209.56 209.56 209.56 


	4900005 Eval Swallow Radio-Opaque Mat 1,089.73 1,089.73 1,089.73 1,089.73 1,089.73 


	4900006 Clinical Eval of Swallow Function 628.69 628.69 628.69 628.69 628.69 


	4900007 TX of Swallow Dysfunction 314.34 314.34 314.34 314.34 314.34 


	4900008 Eval for Symbol-Based Comm 628.69 628.69 628.69 628.69 628.69 


	4900009 Tx for Symbol-Based Comm 314.34 314.34 314.34 314.34 314.34 


	4900010 Eval/PMV 628.69 628.69 628.69 628.69 628.69 


	4900011 Treatment for PMV 314.34 314.34 314.34 314.34 314.34 


	4900012 Eval/Elect Comp-Based SGD 628.69 628.69 628.69 628.69 628.69 


	4900013 Tx for Elect/Comp-Based SGD 314.34 314.34 314.34 314.34 314.34 


	4900014 Neuromuscular Re-Educate per 15 min 209.56 209.56 209.56 209.56 209.56 


	 


	 Blood & Blood Admin 


	2700001 Blood 2,744.28 2,744.28 2,744.28 2,744.28 2,744.28 


	2700002 Blood Administration 1,372.14 1,372.14 1,372.14 1,372.14 1,372.14 


	 


	 Telemetry 


	1500001 Telemetry Monitoring 429.6 429.6 429.6 429.6 429.6 


	 


	 Dialysis 


	4400001 Inpatient Hemodialysis 8,820.00 8,820.00 8,820.00 8,820.00 8,820.00 


	 


	 Lab 


	2200001 ACTH 157.56 157.56 157.56 157.56 157.56 


	2200002 ACETAMINOPHEN 171.07 171.07 171.07 171.07 171.07 


	2200003 ACETONE 171.07 171.07 171.07 171.07 171.07 


	2200004 AFB 470.43 470.43 470.43 470.43 470.43 


	2200005 ALANINE AMINOTRANSFERASE 45.02 45.02 45.02 45.02 45.02 


	2200006 ALBUMIN, SERUM 126.05 126.05 126.05 126.05 126.05 


	2200007 ALBUMIN, URINE 126.05 126.05 126.05 126.05 126.05 


	2200008 ALDOLASE, SERUM 146.31 146.31 146.31 146.31 146.31 


	2200009 ALDOSTERONE 153.06 153.06 153.06 153.06 153.06 


	2200010 ALKALINE PHOSPATASE 366.89 366.89 366.89 366.89 366.89 


	2200011 ALPHA FETOPROTEIN 544.71 544.71 544.71 544.71 544.71 


	2200012 ALPHA FETOPROTEIN SERUM (AFP) 972.37 972.37 972.37 972.37 972.37 


	2200013 AMIKACIN 252.1 252.1 252.1 252.1 252.1 


	2200014 AMITRIPTYLINE SERUM 299.36 299.36 299.36 299.36 299.36 


	2200015 AMMONIA 371.39 371.39 371.39 371.39 371.39 


	2200016 AMYLASE SERUM 452.42 452.42 452.42 452.42 452.42 


	2200017 ANA 402.9 402.9 402.9 402.9 402.9 


	2200018 ANGIOTENSIN CONVERTING ENZYME 225.09 225.09 225.09 225.09 225.09 


	2200019 ANTICARDIOLIPIN ANTIBODIES 306.12 306.12 306.12 306.12 306.12 


	2200020 ANTI-DNA, SINGLE STRANDED ANT. 414.16 414.16 414.16 414.16 414.16 


	2200021 ANTIMYOCARDIAL ANTIBODIES -QU 306.12 306.12 306.12 306.12 306.12 


	2200022 ANTIPARIETAL CELL, ANTIBODIES 243.09 243.09 243.09 243.09 243.09 


	2200023 ANTIPLATELET ANTIBODIES 351.13 351.13 351.13 351.13 351.13 


	2200024 ANTISTREPTOLYSIN, ASO 135.05 135.05 135.05 135.05 135.05 


	2200025 APTT- PROLONGED ACTIVATED 990.38 990.38 990.38 990.38 990.38 


	2200026 ASPARTATE AMINOTRANSFERASE 135.05 135.05 135.05 135.05 135.05 


	2200027 BACTERIAL ANTIGENS, SERUM 535.71 535.71 535.71 535.71 535.71 


	2200028 BASIC METABOLIC PANEL (BMP) 355.64 355.64 355.64 355.64 355.64 


	2200029 BETA-GLOBULINE, URINE 817.06 817.06 817.06 817.06 817.06 


	2200030 BILIRUBEN, TOTAL 108.04 108.04 108.04 108.04 108.04 


	2200031 BILIRUBIN, DIRECT -SERUM 108.04 108.04 108.04 108.04 108.04 


	2200032 BLEEDING TIME 198.08 198.08 198.08 198.08 198.08 


	2200033 BLOOD CULTURE ANAEROBIC I 450.17 450.17 450.17 450.17 450.17 


	2200034 BLOOD CULTURE, AEROBIC I 450.17 450.17 450.17 450.17 450.17 


	2200035 BNP 216.08 216.08 216.08 216.08 216.08 


	2200036 BODY FLUID CHOLESTEROL 234.09 234.09 234.09 234.09 234.09 


	2200037 BODY FLUID, AMYLASE 108.04 108.04 108.04 108.04 108.04 


	2200038 BODY FLUID, CELL COUNT AND DIFF. 202.58 202.58 202.58 202.58 202.58 


	2200039 BODY FLUID, GLUCOSE 234.09 234.09 234.09 234.09 234.09 


	2200040 BODY FLUID, LDH 76.53 76.53 76.53 76.53 76.53 


	2200041 BODY FLUID, LIPASE 162.06 162.06 162.06 162.06 162.06 


	2200042 BODY FLUID, PH 162.06 162.06 162.06 162.06 162.06 


	2200043 BRUCELLA ABORTUS 243.09 243.09 243.09 243.09 243.09 


	2200044 C- PEPTIDE, SERUM 249.85 249.85 249.85 249.85 249.85 


	2200045 CA-125 270.1 270.1 270.1 270.1 270.1 


	2200046 C3, COMPLEMENT 301.62 301.62 301.62 301.62 301.62 


	2200047 C4, COMPLEMENT 301.62 301.62 301.62 301.62 301.62 


	2200048 CALCIUM, SERUM 222.84 222.84 222.84 222.84 222.84 


	2200049 CALCIUM, URINE 24 HOUR 222.84 222.84 222.84 222.84 222.84 


	2200050 CALCIUM-IONIZED 274.61 274.61 274.61 274.61 274.61 


	2200051 CANCER ANTIGEN 15 - 222.84 222.84 222.84 222.84 222.84 


	2200052 CANCER ANTIGEN 27- 28 222.84 222.84 222.84 222.84 222.84 


	2200053 CARBAMAZEPINE, (TEGRATOL) 180.07 180.07 180.07 180.07 180.07 


	2200054 CARBOHYDRATE ANTIGEN CA-19-9 198.08 198.08 198.08 198.08 198.08 


	2200055 CARBON DIOXIDE 76.53 76.53 76.53 76.53 76.53 


	2200056 CARCINOEMBRYONIC ANTIGEN 497.44 497.44 497.44 497.44 497.44 


	2200057 CARNITINE, TOTAL AND FREE 303.87 303.87 303.87 303.87 303.87 


	2200058 CATECHOLAMINES, FRACTIONATED 501.94 501.94 501.94 501.94 501.94 


	2200059 CBC W / O DIFF 871.08 871.08 871.08 871.08 871.08 


	2200060 CBC W/ DIFF 871.08 871.08 871.08 871.08 871.08 


	2200061 CERULOPASMIN, SERUM 252.1 252.1 252.1 252.1 252.1 


	2200283 CHEM 12 3,038.67 3,038.67 3,038.67 3,038.67 3,038.67 


	2200284 CHEM 20 3,038.67 3,038.67 3,038.67 3,038.67 3,038.67 


	2200062 CHLAMYDIA ANTIBODIES, SERUM 704.52 704.52 704.52 704.52 704.52 


	2200063 CHLORIDE, SERUM 261.1 261.1 261.1 261.1 261.1 


	2200064 CHLORIDE, URINE RANDOM 261.1 261.1 261.1 261.1 261.1 


	2200065 CHLOSTEROL 159.81 159.81 159.81 159.81 159.81 


	2200066 CITRIC ACID 24 HOUR URINE 553.71 553.71 553.71 553.71 553.71 


	2200067 CK ISOENZYMES 585.22 585.22 585.22 585.22 585.22 


	2200068 CLOSTRIDIUM DIFFICLE TOXINS 162.06 162.06 162.06 162.06 162.06 


	2200069 CMP Comp Metabolic Panel 774.3 774.3 774.3 774.3 774.3 


	2200070 CIOLISTIN SENSITIVITY 414.16 414.16 414.16 414.16 414.16 


	2200071 COLD AGGUTININ SCREEN, TITER 153.06 153.06 153.06 153.06 153.06 


	2200072 COMPLEMENT, TOTAL CH 50 472.68 472.68 472.68 472.68 472.68 


	2200073 COOMBS DIRECT 67.53 67.53 67.53 67.53 67.53 


	2200074 COOMBS INDIRECT 67.53 67.53 67.53 67.53 67.53 


	2200075 COPPER, SERUM 252.1 252.1 252.1 252.1 252.1 


	2200076 CORTISOL, TOTAL 285.86 285.86 285.86 285.86 285.86 


	2200077 CORTISOL, URINARY FREE,  BY ICM 285.86 285.86 285.86 285.86 285.86 


	2200078 CREATIN CLEARANCE 283.61 283.61 283.61 283.61 283.61 


	2200079 CREATIN KINASE, (CK, MB) 283.61 283.61 283.61 283.61 283.61 


	2200080 CREATIN KINASE, SERUM 283.61 283.61 283.61 283.61 283.61 


	2200081 CREATININE, SERUM 283.61 283.61 283.61 283.61 283.61 


	2200082 CREATININE, URINE 24 HOUR 252.1 252.1 252.1 252.1 252.1 


	2200083 CRP C-REACTIVE PROTIEN( high sens) 126.05 126.05 126.05 126.05 126.05 


	2200084 CRYPTOCOCAL ANTIGEN INFLUENZA 279.11 279.11 279.11 279.11 279.11 


	2200085 CSF CULTURE GRAM STAIN- OTHER 135.05 135.05 135.05 135.05 135.05 


	2200086 CULTURE, FUNGI, SKIN HAIR, . 135.05 135.05 135.05 135.05 135.05 


	2200087 CULTURE, VARIOUS SOURCE 135.05 135.05 135.05 135.05 135.05 


	2200088 CULTURE BRONCHIAL ASPIRATE 135.05 135.05 135.05 135.05 135.05 


	2200089 CYANIDE, BLOOD 252.1 252.1 252.1 252.1 252.1 


	2200090 CYTOMEGALOVIRUS (CMV) Igm ANT 315.12 315.12 315.12 315.12 315.12 


	2200091 CYTOLOGY  PROC FEE 168.81 168.81 168.81 168.81 168.81 


	2200092 D-DIMER 1,760.18 1,760.18 1,760.18 1,760.18 1,760.18 


	2200093 DIGOXIN 380.4 380.4 380.4 380.4 380.4 


	2200094 DRUG CONFIRAMTION, EACH PROCED 126.05 126.05 126.05 126.05 126.05 


	2200095 EHTHANOL, SERUM 360.14 360.14 360.14 360.14 360.14 


	2200096 ELECTROLYTE PANEL, SERUM, URINE 33.76 33.76 33.76 33.76 33.76 


	2200097 ELECTROPHORESIS, (SPE) SERUM 225.09 225.09 225.09 225.09 225.09 


	2200098 ERYTHROCYTE SED TARE (  ESR ) 72.03 72.03 72.03 72.03 72.03 


	2200099 ERYTHROPROTEIN  ( EPO ) SERUM 222.84 222.84 222.84 222.84 222.84 


	2200100 ESTRADIOL 384.9 384.9 384.9 384.9 384.9 


	2200101 EUGLOBULIN LYSIS TIME 1,035.40 1,035.40 1,035.40 1,035.40 1,035.40 


	2200102 FECAL FAT, QUALITATIVE 288.11 288.11 288.11 288.11 288.11 


	2200103 FECAL FAT, QUANTITAVE 288.11 288.11 288.11 288.11 288.11 


	2200104 FERRITIN 420.91 420.91 420.91 420.91 420.91 


	2200105 FIBRIN DEGREDATION PRODUCT 495.19 495.19 495.19 495.19 495.19 


	2200106 FIBRINOGEN 92.29 92.29 92.29 92.29 92.29 


	2200107 FOSFOMYCIN Sesitivity 414.16 414.16 414.16 414.16 414.16 


	2200108 FOLATE, SERUM (FOLIC ACID) 382.65 382.65 382.65 382.65 382.65 


	2200109 FUNGUS CULTURE AND SMEAR 569.47 569.47 569.47 569.47 569.47 


	2200110 GAMMA GLUTAMYL TRANSFERASE 159.81 159.81 159.81 159.81 159.81 


	2200111 GENTAMICIN LEVEL 542.46 542.46 542.46 542.46 542.46 


	2200112 GLUCOSE TOLERANCE 2 HOUR POST P 193.57 193.57 193.57 193.57 193.57 


	2200113 GLUCOSE TOLERANCE TEST  5 SPEC 193.57 193.57 193.57 193.57 193.57 


	2200114 GLUCOSE,  CSF 193.57 193.57 193.57 193.57 193.57 


	2200115 GLUCOSE, SERUM 193.57 193.57 193.57 193.57 193.57 


	2200116 GRAM STAIN, EOSINOPHILS, URINE 112.54 112.54 112.54 112.54 112.54 


	2200117 HAPTOGLOBIN 225.09 225.09 225.09 225.09 225.09 


	2200118 HCG QUALITIVE,  SERUM 128.3 128.3 128.3 128.3 128.3 


	2200119 HCG QUALITIVE, URINE 128.3 128.3 128.3 128.3 128.3 


	2200120 HDL CHOLESTEROL 216.08 216.08 216.08 216.08 216.08 


	2200121 HEAPTITIS A ANTOBODY - TOTAL 315.12 315.12 315.12 315.12 315.12 


	2200122 HELICOBACTER PYLORI, IGM, IGG.. 252.1 252.1 252.1 252.1 252.1 


	2200123 HEMATOCRIT 135.05 135.05 135.05 135.05 135.05 


	2200124 HEMO ELECTROPHERISIS 186.82 186.82 186.82 186.82 186.82 


	2200125 HEMOGLOBIN 177.82 177.82 177.82 177.82 177.82 


	2200126 HEMOGLOBIN A1C 177.82 177.82 177.82 177.82 177.82 


	2200127 HEPARIN INDUCED PLATELET ANTIBODY 303.87 303.87 303.87 303.87 303.87 


	2200128 HEPARIN PLATELET AGGREGATION 303.87 303.87 303.87 303.87 303.87 


	2200129 HEPATIC PANEL (LIVER) 598.73 598.73 598.73 598.73 598.73 


	2200130 HEPATITIS A ANTIBODY -IGM 173.32 173.32 173.32 173.32 173.32 


	2200131 HEPATITIS A ANTIBODY -TOTAL 173.32 173.32 173.32 173.32 173.32 


	2200132 HEPATITIS B CORE ANTIBODY IGM 204.83 204.83 204.83 204.83 204.83 


	2200133 HEPATITIS B CORE ANTIBODY -TOTAL 204.83 204.83 204.83 204.83 204.83 


	2200134 HEPATITIS B SURFACE ANTIGEN 162.06 162.06 162.06 162.06 162.06 


	2200135 HEPATITIS BE ANTIBODY 1,204.21 1,204.21 1,204.21 1,204.21 1,204.21 


	2200136 HEPATITIS BE ANTIGEN 162.06 162.06 162.06 162.06 162.06 


	2200137 HEPATITIS C ANTIBODIES 474.93 474.93 474.93 474.93 474.93 


	2200138 HEPATITIS C VIRUS RNA BY PCR 243.09 243.09 243.09 243.09 243.09 


	2200139 HEPATITIS PROFILE, ACUTE 288.11 288.11 288.11 288.11 288.11 


	2200140 HEPATITIS SURFACE ANTIBODY 193.57 193.57 193.57 193.57 193.57 


	2200141 HEPATITIS PANEL 1,269.49 1,269.49 1,269.49 1,269.49 1,269.49 


	2200142 HERPES SIMPLES VIRUS IGG 247.6 247.6 247.6 247.6 247.6 


	2200143 HERPES SIMPLEX VIRUS (HSV) CU 823.82 823.82 823.82 823.82 823.82 


	2200144 HETEROPHILE ( MONO) 315.12 315.12 315.12 315.12 315.12 


	2200145 HISTOPLASMA ANTOBODIES, QUANT 700.02 700.02 700.02 700.02 700.02 


	2200146 HIV AG/AB Combo Assay 434.42 434.42 434.42 434.42 434.42 


	2200147 HIV ANTIBODIES 434.42 434.42 434.42 434.42 434.42 


	2200148 HOMOCYSINE 236.34 236.34 236.34 236.34 236.34 


	2200149 INFLAMATORY BOWEL DISEASE PROF 627.99 627.99 627.99 627.99 627.99 


	2200150 IMMUMOGLOBULIN A 522.2 522.2 522.2 522.2 522.2 


	2200151 IMMUMOGLOBULIN G 522.2 522.2 522.2 522.2 522.2 


	2200152 IMMUMOGLOBULIN M 522.2 522.2 522.2 522.2 522.2 


	2200153 IMMUNOFIXATION (IFE) PROTEIN 335.38 335.38 335.38 335.38 335.38 


	2200154 IMMUNOGLOBULIN D 522.2 522.2 522.2 522.2 522.2 


	2200155 INDIAN INK PREPARATION 306.12 306.12 306.12 306.12 306.12 


	2200156 INFLUENZA A AND B QUANT 486.19 486.19 486.19 486.19 486.19 


	2200157 INSULIN AND C-PEPTIDE, SERUM 760.79 760.79 760.79 760.79 760.79 


	2200158 IRON,  SERUM 36.01 36.01 36.01 36.01 36.01 


	2200159 IRON SATURATION 679.76 679.76 679.76 679.76 679.76 


	2200160 KLONOPIN, SERUM 252.1 252.1 252.1 252.1 252.1 


	2200161 LACTATE DEHYDROGENASE Serum 249.85 249.85 249.85 249.85 249.85 


	2200162 LACTIC ACID Plasma 328.63 328.63 328.63 328.63 328.63 


	2200163 LEAD, ADULT ,  BLOOD, SERUM 220.58 220.58 220.58 220.58 220.58 


	2200164 LEGIONALLA PNEUMOPHILA 157.56 157.56 157.56 157.56 157.56 


	2200165 LEUKOCYTE ALKALINE PHOSPHATE 207.08 207.08 207.08 207.08 207.08 


	2200166 LEVETRIRACETAM 1,643.13 1,643.13 1,643.13 1,643.13 1,643.13 


	2200167 LIDOCAINE, SERUM 324.12 324.12 324.12 324.12 324.12 


	2200168 LIPASE 452.42 452.42 452.42 452.42 452.42 


	2200169 LIPID PANEL 510.95 510.95 510.95 510.95 510.95 


	2200170 LITHIUM 270.1 270.1 270.1 270.1 270.1 


	2200171 LUPUS ANTICOAGULANT COMPHR. PRO 990.38 990.38 990.38 990.38 990.38 


	2200172 LUTEINIZING HOROME, SERUM 245.34 245.34 245.34 245.34 245.34 


	2200173 MAGNESIUM, SERUM 371.39 371.39 371.39 371.39 371.39 


	2200174 MANUAL DIFF 146.31 146.31 146.31 146.31 146.31 


	2200175 METANEPHRINES, FRACTIONATED 607.73 607.73 607.73 607.73 607.73 


	2200176 METHYMALONIC ACID 738.28 738.28 738.28 738.28 738.28 


	2200177 MICROALBUMIN, 24 HOUR URINE 312.87 312.87 312.87 312.87 312.87 


	2200178 MRSA, CULTURE, SUSCEPIBILITY Screen 315.12 315.12 315.12 315.12 315.12 


	2200179 MUMPS ANTIBODIES 585.22 585.22 585.22 585.22 585.22 


	2200180 MYCOPLASMA ANTIBODIES 605.48 605.48 605.48 605.48 605.48 


	2200181 MYELIN BASIC PROTEIN CEREBRO 459.18 459.18 459.18 459.18 459.18 


	2200182 NORTRIPTYLINE, SERUM 384.9 384.9 384.9 384.9 384.9 


	2200183 OCCULT BLOOD, x 1 155.31 155.31 155.31 155.31 155.31 


	2200184 ORGANISM IDENTIFICATION, YEAST 141.8 141.8 141.8 141.8 141.8 


	2200185 OSMOMALITY, SERUM 114.79 114.79 114.79 114.79 114.79 


	2200186 OSOMALITY, URINE 114.79 114.79 114.79 114.79 114.79 


	2200187 OVA AND PARASITE EXAM 301.62 301.62 301.62 301.62 301.62 


	2200188 PARATHYROID HORMONE- RELATED 1,114.18 1,114.18 1,114.18 1,114.18 1,114.18 


	2200189 PARATHYROID HORMONE, INTACT 1,114.18 1,114.18 1,114.18 1,114.18 1,114.18 


	2200190 PARVOVIRUS B-19 1,201.96 1,201.96 1,201.96 1,201.96 1,201.96 


	2200191 PHENOBARBITAL 400.65 400.65 400.65 400.65 400.65 


	2200192 PHENYTION, ( DILANTIN) 400.65 400.65 400.65 400.65 400.65 


	2200193 PHENYTION, TOTAL -FREE 400.65 400.65 400.65 400.65 400.65 


	2200194 PHOSPHORUS, INORGANIC, SERUM 252.1 252.1 252.1 252.1 252.1 


	2200195 PIN WORM EXAM 432.17 432.17 432.17 432.17 432.17 


	2200196 PLASMINOGEN, ACTIVITY 333.13 333.13 333.13 333.13 333.13 


	2200197 PLATELET 108.04 108.04 108.04 108.04 108.04 


	2200198 PLATELET ASSOCIATED IMMUNOGLO 468.18 468.18 468.18 468.18 468.18 


	2200199 PLATELET COUNT 315.12 315.12 315.12 315.12 315.12 


	2200200 POTASSIUM, SERUM 182.32 182.32 182.32 182.32 182.32 


	2200201 POTASSIUM, URINE 182.32 182.32 182.32 182.32 182.32 


	2200202 PREALBUMIN 407.41 407.41 407.41 407.41 407.41 


	2200203 PRIMIDONE 279.11 279.11 279.11 279.11 279.11 


	2200204 PROCAINAMIDE, (PRONESTYL) SERUM 240.84 240.84 240.84 240.84 240.84 


	2200205 PROLACTIN, SERUM 454.67 454.67 454.67 454.67 454.67 


	2200206 PROTEIN C  FUNCTIONAL 1,037.65 1,037.65 1,037.65 1,037.65 1,037.65 


	2200207 PROTEIN C , ANTIGEN 1,332.51 1,332.51 1,332.51 1,332.51 1,332.51 


	2200208 PROTEIN S FUNCTIONAL 162.06 162.06 162.06 162.06 162.06 


	2200209 PROTEIN, TOTAL 162.06 162.06 162.06 162.06 162.06 


	2200210 PROTEIN, TOTAL BODY FLUID 162.06 162.06 162.06 162.06 162.06 


	2200211 PROTHROMBIN TIME PT 189.07 189.07 189.07 189.07 189.07 


	2200212 PSA (PROSTATE SPECIFIC ANTIGEN) 315.12 315.12 315.12 315.12 315.12 


	2200213 PSA FREE 315.12 315.12 315.12 315.12 315.12 


	2200214 PTT 198.08 198.08 198.08 198.08 198.08 


	2200215 RED BLOOD CELL COUNT 29.26 29.26 29.26 29.26 29.26 


	2200216 RENAL FUNCTIONAL PANEL 366.89 366.89 366.89 366.89 366.89 


	2200217 RENIN, ACTIVE 375.89 375.89 375.89 375.89 375.89 


	2200218 RETICULOCYTE COUNT 162.06 162.06 162.06 162.06 162.06 


	2200219 RHESUS FACTOR 126.05 126.05 126.05 126.05 126.05 


	2200220 RHEUMATOID FACTOR 146.31 146.31 146.31 146.31 146.31 


	2200221 ROTAVIRUS, DIRECT DETECTION 292.61 292.61 292.61 292.61 292.61 


	2200222 RUBELLA ANTIBODIES 216.08 216.08 216.08 216.08 216.08 


	2200223 RUBEOLA ANTIBODIES 216.08 216.08 216.08 216.08 216.08 


	2200224 SALICYLATE, SERUM 540.21 540.21 540.21 540.21 540.21 


	2200225 SODIUM, SERUM 58.52 58.52 58.52 58.52 58.52 


	2200226 SODIUM, URINE 139.55 139.55 139.55 139.55 139.55 


	2200227 SPECIFIC GRAVITY FLUID 54.02 54.02 54.02 54.02 54.02 


	2200228 SPUTUM CULTURE & GRAM STAIN 315.12 315.12 315.12 315.12 315.12 


	2200229 SUSCEPTIBILITY studies 153.06 153.06 153.06 153.06 153.06 


	2200230 TACROLIMUS 1,012.89 1,012.89 1,012.89 1,012.89 1,012.89 


	2200231 TB DETECTION BY NECULIC ACID 1,733.17 1,733.17 1,733.17 1,733.17 1,733.17 


	2200232 TEICHOIC ACID, ANTIBODIES 650.5 650.5 650.5 650.5 650.5 


	2200233 TESTOSTERONE,  FREE 357.89 357.89 357.89 357.89 357.89 


	2200234 TESTOSTERONE, TOTAL SERUM 362.39 362.39 362.39 362.39 362.39 


	2200235 THEOPHYLLINE 425.41 425.41 425.41 425.41 425.41 


	2200236 THYROID ANTITHYROGLOBULIN ANT 378.15 378.15 378.15 378.15 378.15 


	2200237 THYROID UPTAKE 346.63 346.63 346.63 346.63 346.63 


	2200238 THYROXINE 1,215.47 1,215.47 1,215.47 1,215.47 1,215.47 


	2200239 THYROXINE, FREE 1,215.47 1,215.47 1,215.47 1,215.47 1,215.47 


	2200240 TISSUE CULTURE 555.96 555.96 555.96 555.96 555.96 


	2200241 TISSUE CULTURE, MYCOBACTERIA 555.96 555.96 555.96 555.96 555.96 


	2200242 TOBRAMYCIN trough level 420.91 420.91 420.91 420.91 420.91 


	2200243 TOPIRMATE (TOPAMAX) SERUM 940.86 940.86 940.86 940.86 940.86 


	2200244 TOTAL IRON BINDING CAPACITY (FE-PL) 105.79 105.79 105.79 105.79 105.79 


	2200245 TOXOPLASA GONDII ANTIBODIES 553.71 553.71 553.71 553.71 553.71 


	2200246 TRANSFERRIN 288.11 288.11 288.11 288.11 288.11 


	2200247 TREPONEMA PALLIDUM ANTIBODIES 263.35 263.35 263.35 263.35 263.35 


	2200248 TRI-IODOTHYRONINE (T3) 310.62 310.62 310.62 310.62 310.62 


	2200249 TRI-IODOTHYRONINE (T3) FREE 310.62 310.62 310.62 310.62 310.62 


	2200250 TROPONIN - I 1,301.00 1,301.00 1,301.00 1,301.00 1,301.00 


	2200251 TRYGLYCERIDES 270.1 270.1 270.1 270.1 270.1 


	2200252 TSH, (THYROID STIMULATING HORMONE) 216.08 216.08 216.08 216.08 216.08 


	2200253 UREA NITROGEN , BUN 36.01 36.01 36.01 36.01 36.01 


	2200254 UREA NITROGEN CLEARANCE, URINE 180.07 180.07 180.07 180.07 180.07 


	2200255 UREA REDUCTION RATIO 360.14 360.14 360.14 360.14 360.14 


	2200256 URIC ACID 270.1 270.1 270.1 270.1 270.1 


	2200257 URINALYSIS (ML) 128.3 128.3 128.3 128.3 128.3 


	2200258 URINE CULTURE 65.28 65.28 65.28 65.28 65.28 


	2200259 URINE DRUG SCREEN 252.1 252.1 252.1 252.1 252.1 


	2200260 URINE MICRISCOPIC 128.3 128.3 128.3 128.3 128.3 


	2200261 URINE, PH 351.13 351.13 351.13 351.13 351.13 


	2200262 VALPORIC ACID 470.43 470.43 470.43 470.43 470.43 


	2200263 VANCOMYCIN 600.98 600.98 600.98 600.98 600.98 


	2200264 VANILLYMANDELIC ACID, 24 HOUR 261.1 261.1 261.1 261.1 261.1 


	2200265 VARICELLA ZOSTER VIRUS 684.26 684.26 684.26 684.26 684.26 


	2200266 VDRL/RPR 207.08 207.08 207.08 207.08 207.08 


	2200267 VIRAL CULTURE, GENERAL 315.12 315.12 315.12 315.12 315.12 


	2200268 VIRAL CULTURE, RAPID INFLUENZA 855.33 855.33 855.33 855.33 855.33 


	2200269 VISCOSITY, SERUM 189.07 189.07 189.07 189.07 189.07 


	2200270 VITAMIN A, SERUM 162.06 162.06 162.06 162.06 162.06 


	2200271 VITAMIN B1, PLASMA 693.27 693.27 693.27 693.27 693.27 


	2200272 VITAMIN B12 135.05 135.05 135.05 135.05 135.05 


	2200273 VITAMIN B6, PLASMA 252.1 252.1 252.1 252.1 252.1 


	2200274 VITAMIN C ASCORBIC ACID, SERUM 189.07 189.07 189.07 189.07 189.07 


	2200275 VITAMIN D 1,769.18 1,769.18 1,769.18 1,769.18 1,769.18 


	2200276 VITAMIN D, 25 HYDROXY 1,474.32 1,474.32 1,474.32 1,474.32 1,474.32 


	2200277 VON WILLEBRAND FACTOR ACTIVITY 1,395.54 1,395.54 1,395.54 1,395.54 1,395.54 


	2200278 VON WILLEBRAND FACTOR ANTIGEN 1,809.69 1,809.69 1,809.69 1,809.69 1,809.69 


	2200279 WET PREP FUNGUS STAIN CULTURE 65.28 65.28 65.28 65.28 65.28 


	2200280 WHITE BLOOD CELL 249.85 249.85 249.85 249.85 249.85 


	2200281 ZINC, SERUM 213.83 213.83 213.83 213.83 213.83 


	2200282 FINGER STICK, BLOOD GLUCOSE 58.8 58.8 58.8 58.8 58.8 


	 


	 


	 Special Procedures 


	2100001 Abscess Drainage 6,209.28 6,209.28 6,209.28 6,209.28 6,209.28 


	2100002 Angioplasty/Atherectomy noncoronary vessel 1,653.22 1,653.22 1,653.22 1,653.22 1,653.22 


	2100003 Toe Amputation (Interphalangeal joint) 4,812.19 4,812.19 4,812.19 4,812.19 4,812.19 


	2100004 Bone Marrow Biopsy Needle 814.97 814.97 814.97 814.97 814.97 


	2100005 Broncoscopy - Diagnostic 5,433.12 5,433.12 5,433.12 5,433.12 5,433.12 


	2100006 Broncoscopy w/Biopsy 7,696.92 7,696.92 7,696.92 7,696.92 7,696.92 


	2100007 Catheter Removal 19,956.63 19,956.63 19,956.63 19,956.63 19,956.63 


	2100008 Central Line Placement (Central Venous Cath) 6,519.74 6,519.74 6,519.74 6,519.74 6,519.74 


	2100009 Chest Tube Placement/Removal 4,656.96 4,656.96 4,656.96 4,656.96 4,656.96 


	2100010 Closure (Dependent on size) 1,862.78 1,862.78 1,862.78 1,862.78 1,862.78 


	2100011 Closure ( arm 6 in.) 1,862.78 1,862.78 1,862.78 1,862.78 1,862.78 


	2100012 Colonoscopy aka small bowel series 4,967.42 4,967.42 4,967.42 4,967.42 4,967.42 


	2100013 CPR 1,397.09 1,397.09 1,397.09 1,397.09 1,397.09 


	2100014 Dobhoff Tube Placament (NG Tube) 853.78 853.78 853.78 853.78 853.78 


	2100015 Debridement Sub Q 3,234.00 3,234.00 3,234.00 3,234.00 3,234.00 


	2100016 Debridement Sub Q & Muscle 4,527.60 4,527.60 4,527.60 4,527.60 4,527.60 


	2100017 Endoscopy Small Intestine 4,967.42 4,967.42 4,967.42 4,967.42 4,967.42 


	2100018 Esophagogastroduodenoscopy (EGD) 4,967.42 4,967.42 4,967.42 4,967.42 4,967.42 


	2100019 Exc Debride Skin/Tissue/Muscle 4,967.42 4,967.42 4,967.42 4,967.42 4,967.42 


	2100020 Exc Debridement Muscle & Bone 4,656.96 4,656.96 4,656.96 4,656.96 4,656.96 


	2100021 Fasciotomy (arm 6 in.) 9,934.85 9,934.85 9,934.85 9,934.85 9,934.85 


	2100022 Flap 7,761.60 7,761.60 7,761.60 7,761.60 7,761.60 


	2100023 Gastric Placement 776.16 776.16 776.16 776.16 776.16 


	2100024 Graft 6,209.28 6,209.28 6,209.28 6,209.28 6,209.28 


	2100025 Incision of vulva & perineum-abcess drainage 3,104.64 3,104.64 3,104.64 3,104.64 3,104.64 


	2100026 Incision w/drainage of skin & sunq tissue w/hematology 6,830.21 6,830.21 6,830.21 6,830.21 6,830.21 


	2100027 Placement of IVC Filter (Inter Vena Cava) 9,313.92 9,313.92 9,313.92 9,313.92 9,313.92 


	2100028 Deposition of IVC Filter (Inter Vena Cava) 9,313.92 9,313.92 9,313.92 9,313.92 9,313.92 


	2100029 Retrieval of IVC Filter (Inter Vena Cava) 16,799.21 16,799.21 16,799.21 16,799.21 16,799.21 


	2100030 Moderate Sedation 1st 30 min 3,880.80 3,880.80 3,880.80 3,880.80 3,880.80 


	2100031 Moderate Sedation additional 15 min 776.16 776.16 776.16 776.16 776.16 


	2100032 Myectomy 1,521.27 1,521.27 1,521.27 1,521.27 1,521.27 


	2100033 Nail Debridement (1-5 nails) 620.93 620.93 620.93 620.93 620.93 


	2100034 Paracentesis 4,967.42 4,967.42 4,967.42 4,967.42 4,967.42 


	2100035 PEG 6,209.28 6,209.28 6,209.28 6,209.28 6,209.28 


	2100036 Plastic repair of external ear 4,656.96 4,656.96 4,656.96 4,656.96 4,656.96 


	2100037 Radical excision of external ear lesion 3,880.80 3,880.80 3,880.80 3,880.80 3,880.80 


	2100038 Replacement Gastronomy Tube 5,433.12 5,433.12 5,433.12 5,433.12 5,433.12 


	2100039 Replacement Trach Tube 1,862.78 1,862.78 1,862.78 1,862.78 1,862.78 


	2100040 Thoracentesis 3,880.80 3,880.80 3,880.80 3,880.80 3,880.80 


	2100041 Tracheotomy 11,642.40 11,642.40 11,642.40 11,642.40 11,642.40 


	2100042 Tracheotomy Percutaneous 6,209.28 6,209.28 6,209.28 6,209.28 6,209.28 


	2100043 Tunnel Dialysis Cath Placement 6,985.44 6,985.44 6,985.44 6,985.44 6,985.44 


	2100044 Venous Catherization 3,880.80 3,880.80 3,880.80 3,880.80 3,880.80 


	2100045 Bursectomy 2,794.18 2,794.18 2,794.18 2,794.18 2,794.18 


	2100046 Repair Hammer Toe 5,433.12 5,433.12 5,433.12 5,433.12 5,433.12 


	2100047 Permanent HD Catheter Placement 3,880.80 3,880.80 3,880.80 3,880.80 3,880.80 


	2100048 Temporary HD Catheter Placement 3,880.80 3,880.80 3,880.80 3,880.80 3,880.80 


	2100049 Breast Lumpectomy 2,794.18 2,794.18 2,794.18 2,794.18 2,794.18 


	2100050 Excision of L/R hip muscle 5,821.20 5,821.20 5,821.20 5,821.20 5,821.20 


	2100051 Excision of back subcutaneous tissue & fascia 5,174.40 5,174.40 5,174.40 5,174.40 5,174.40 


	 


	 


	 Wound Care and HBO 


	5700001 Drainage of Skin Abscess 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700002 Drainage of Pilonidal Cyst 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700003 Remove Foreign Body 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700004 Drainage of Hematoma/Fluid 6,209.28 6,209.28 6,209.28 6,209.28 6,209.28 


	5700005 Debride Infected Skin 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700006 Debride Infected Skin Add-on 739.2 739.2 739.2 739.2 739.2 


	5700007 Debride Skin, FX 2,956.80 2,956.80 2,956.80 2,956.80 2,956.80 


	5700008 Debride Skin/Muscle, FX 5,174.40 5,174.40 5,174.40 5,174.40 5,174.40 


	5700009 Debride Skin/Muscle/Bone, FX 5,913.60 5,913.60 5,913.60 5,913.60 5,913.60 


	5700010 Debride Skin, Partial 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700011 Debride Skin, Full 5,913.60 5,913.60 5,913.60 5,913.60 5,913.60 


	5700012 Debride Skin/Tissue 2,956.80 2,956.80 2,956.80 2,956.80 2,956.80 


	5700013 Debride Tissue/Muscle 5,913.60 5,913.60 5,913.60 5,913.60 5,913.60 


	5700014 Debride Tissue/Muscle/Bone 6,209.28 6,209.28 6,209.28 6,209.28 6,209.28 


	5700015 Debridement;subcutaneous tissue; each additional 20 sq. cm or part thereof 3,104.64 3,104.64 3,104.64 3,104.64 3,104.64 


	5700016 Debridement;muscle and fascia; each additional 20 sq. cm or part thereof 3,104.64 3,104.64 3,104.64 3,104.64 3,104.64 


	5700017 Debridement; bone; each additional 20 sq. cm or part thereof 7,392.00 7,392.00 7,392.00 7,392.00 7,392.00 


	5700018 Trim Skin Lesion 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700019 Trim Skin Lesions, 2 to 4 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700020 Trim Skin Lesions, over 4 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700021 Biopsy, Skin Lesion 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700022 Biopsy, Skin Add-on 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700023 Removal of Skin tags 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700024 Remove skin tags add-on 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700025 Shave skin lesion 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700026 Exc TR-EXT B9-MARG 0.5 < cm 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700027 Exc TR-EXT B9-MARG 0.6-1 cm 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700028 Exc TR-EXT B9-MARG 1.1-2 cm 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700029 Exc TR-EXT B9-MARG 2.1-3 cm 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700030 Exc TR-EXT B9-MARG 3.1-4 cm 7,687.68 7,687.68 7,687.68 7,687.68 7,687.68 


	5700031 Exc TR-EXT B9-MARG > 4.0 cm 7,687.68 7,687.68 7,687.68 7,687.68 7,687.68 


	5700032 Exc H-F-NK-SP B9+MARG 0.5 < 4,730.88 4,730.88 4,730.88 4,730.88 4,730.88 


	5700033 Exc H-F-NK-SP B9+MARG 0.6-1 4,730.88 4,730.88 4,730.88 4,730.88 4,730.88 


	5700034 Exc H-F-NK-SP B9+MARG 1.1-2 4,730.88 4,730.88 4,730.88 4,730.88 4,730.88 


	5700035 Exc H-F-NK-SP B9+MARG 2.1-3 7,687.68 7,687.68 7,687.68 7,687.68 7,687.68 


	5700036 Exc H-F-NK-SP B9+MARG 3.1-4 7,687.68 7,687.68 7,687.68 7,687.68 7,687.68 


	5700037 Exc H-F-NK-SP B9+MARG > 4 cm 10,644.48 10,644.48 10,644.48 10,644.48 10,644.48 


	5700038 Exc Face-MM B9+MARG 0.6-1 cm 4,139.52 4,139.52 4,139.52 4,139.52 4,139.52 


	5700039 Exc TR-EXT MLG+MARG 0.6-1 cm 4,139.52 4,139.52 4,139.52 4,139.52 4,139.52 


	5700040 Exc TR-EXT MLG+MARG 1.1-2 cm 4,139.52 4,139.52 4,139.52 4,139.52 4,139.52 


	5700041 Exc TR-EXT MLG+MARG 2.1-3 cm 4,139.52 4,139.52 4,139.52 4,139.52 4,139.52 


	5700042 Exc TR-EXT MLG+MARG 3.1-4 cm 4,139.52 4,139.52 4,139.52 4,139.52 4,139.52 


	5700043 Exc TR-EXT MLG+MARG > 4 cm 10,644.48 10,644.48 10,644.48 10,644.48 10,644.48 


	5700044 Removal, Sweat gland lesion 10,644.48 10,644.48 10,644.48 10,644.48 10,644.48 


	5700045 Exc TR-EXT MLG+MARG 0.6-1 cm 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700046 Exc TR-EXT MLG+MARG 201-3 cm 4,435.20 4,435.20 4,435.20 4,435.20 4,435.20 


	5700047 Exc TR-EXT MLG+MARG > 4 cm 7,687.68 7,687.68 7,687.68 7,687.68 7,687.68 


	5700048 Exc H-F-NK-SP MLG+MARG 0.6-1 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700049 Exc H-F-NK-SP MLG+MARG 1.1-2 5,617.92 5,617.92 5,617.92 5,617.92 5,617.92 


	5700050 Exc Face-MM MALIG+MARG 0.6-1 cm 5,617.92 5,617.92 5,617.92 5,617.92 5,617.92 


	5700051 Exc Face-MM MALIG+MARG 1.1-2 cm 5,617.92 5,617.92 5,617.92 5,617.92 5,617.92 


	5700052 Exc Face-MM MALIG+MARG 2.1-3 cm 5,617.92 5,617.92 5,617.92 5,617.92 5,617.92 


	5700053 Exc Face-MM MALIG+MARG 3.1-4 cm 7,687.68 7,687.68 7,687.68 7,687.68 7,687.68 


	5700054 Exc Face-MM MALIG+MARG > 4 cm 10,644.48 10,644.48 10,644.48 10,644.48 10,644.48 


	5700055 Trim nails 443.52 443.52 443.52 443.52 443.52 


	5700056 Debride Nail, 1-5 887.04 887.04 887.04 887.04 887.04 


	5700057 Debride Nail, 6 or more 887.04 887.04 887.04 887.04 887.04 


	5700058 Removal of Nail Plate 887.04 887.04 887.04 887.04 887.04 


	5700059 Removal of Nail Plate, add-on 887.04 887.04 887.04 887.04 887.04 


	5700060 Drain Blood from under nail 887.04 887.04 887.04 887.04 887.04 


	5700061 Removal of nail bed 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700062 Biopsy, nail unit 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700063 Repair of nail bed 1,182.72 1,182.72 1,182.72 1,182.72 1,182.72 


	5700064 Reconstruction of nail bed 6,399.62 6,399.62 6,399.62 6,399.62 6,399.62 


	5700065 Excision of nail fold, toe 887.04 887.04 887.04 887.04 887.04 


	5700066 Removal of pilonidal lesion 9,322.79 9,322.79 9,322.79 9,322.79 9,322.79 


	5700067 Apply cult skin substitute 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700068 Apply cult skin sub add-on 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700069 Apply cult derm sub, T/A/L 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700070 Apply cult derm sub, T/A/L add 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700071 Apply cult derm sub, F/N/HF/G 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700072 Apply cult derm F/HF/G Add 1,774.08 1,774.08 1,774.08 1,774.08 1,774.08 


	5700073 Apply Acellular Xenograft 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700074 Apply Acellular Xenograft add 3,696.00 3,696.00 3,696.00 3,696.00 3,696.00 


	5700075 Chemical Cautery, tissue 1,182.72 1,182.72 1,182.72 1,182.72 1,182.72 


	5700076 Removal of foot foreign body 4,139.52 4,139.52 4,139.52 4,139.52 4,139.52 


	5700077 Apply rigid leg cast 1,330.56 1,330.56 1,330.56 1,330.56 1,330.56 


	5700078 Application of paste boot 1,921.92 1,921.92 1,921.92 1,921.92 1,921.92 


	5700079 Apply multlay comprs lwr leg 1,921.92 1,921.92 1,921.92 1,921.92 1,921.92 


	5700080 Injection(s), spider veins 1,921.92 1,921.92 1,921.92 1,921.92 1,921.92 


	5700081 Injection therapy of vein 1,921.92 1,921.92 1,921.92 1,921.92 1,921.92 


	5700082 Injection therapy of veins 1,921.92 1,921.92 1,921.92 1,921.92 1,921.92 


	5700083 Endovenous RF, 1st vein 13,527.36 13,527.36 13,527.36 13,527.36 13,527.36 


	5700084 Phleb veins - Extrem - to 20 10,592.00 10,592.00 10,592.00 10,592.00 10,592.00 


	5700085 Vascular surgery procedure 244.68 244.68 244.68 244.68 244.68 


	5700086 Doppler Art ext sng lvt bil 898.87 898.87 898.87 898.87 898.87 


	5700087 Doppler Art ext multi comp 913.65 913.65 913.65 913.65 913.65 


	5700088 Duplex venous extrem bilat 4,287.36 4,287.36 4,287.36 4,287.36 4,287.36 


	5700089 Duplex venous ext unilat/LMTD 4,287.36 4,287.36 4,287.36 4,287.36 4,287.36 


	5700090 OT manual thrpy 15 min 517.44 517.44 517.44 517.44 517.44 


	5700091 OT adl 15 min 517.44 517.44 517.44 517.44 517.44 


	5700092 OT Comm.work reintegrate 15 m 517.44 517.44 517.44 517.44 517.44 


	5700093 PT Debr sel wo anes <20 scm 887.04 887.04 887.04 887.04 887.04 


	5700094 PT Debr sel wo anes >20 scm 887.04 887.04 887.04 887.04 887.04 


	5700095 Neg pressure wound thrpy < 50 1,108.80 1,108.80 1,108.80 1,108.80 1,108.80 


	5700096 Neg pressure wound thrpy > 50 1,478.40 1,478.40 1,478.40 1,478.40 1,478.40 


	5700097 Hyperbaric oxygen therapy 4,139.52 4,139.52 4,139.52 4,139.52 4,139.52 


	5700098 Clinic level 1 new patient 322.88 322.88 322.88 322.88 322.88 


	5700099 Clinic level 2 new patient 520.84 520.84 520.84 520.84 520.84 


	5700100 Clinic level 3 new patient 741.86 741.86 741.86 741.86 741.86 


	5700101 Clinic level 4 new patient 985.94 985.94 985.94 985.94 985.94 


	5700102 Clinic level 5 new patient 1,206.97 1,206.97 1,206.97 1,206.97 1,206.97 


	5700103 Clinic level 1 est pt 115.32 115.32 115.32 115.32 115.32 


	5700104 Clinic level 2 est pt 161.44 161.44 161.44 161.44 161.44 


	5700105 Clinic level 3 est pt 207.57 207.57 207.57 207.57 207.57 


	5700106 Clinic level 4 est pt 253.69 253.69 253.69 253.69 253.69 


	5700107 Clinic level 5 est pt 297.9 297.9 297.9 297.9 297.9 


	5700108 Apply multlay comprs lwr leg - bilateral 887.04 887.04 887.04 887.04 887.04 


	5700109 Mattresses, specialty per day 224 224 224 224 224 


	5700111 Wound vac 392 392 392 392 392
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