Procedure Price 17, HYDROXYPROGESTERONE, RIA $67.10 5 HIAA (SERATONIN METABOLITE) $62.50 5% dextrose in lac ringers $60.00 5% dextrose/normal saline $60.00 5% dextrose/water $60.00 A GALACTO AG $151.60 Abatacept injection $84.87 Abciximab injection $2,563.50 ACETAMINOPHEN $311.10 Acetaminophen injection $3.72 Acetazolamid sodium injectio $170.50 ACETYL MODULATING AB $61.40 ACETYLCHOL BLOCK AB $55.10 ACETYLCHOLINESTERASE, AMNIOTIC $324.10 Acetylcysteine injection $8.64 ACID FAST STAIN $122.90 ACID PHOSPHATASE PROSTATIC $21.00 ACTH STIMULATION TEST $565.20 ACTH(ADRENOCORTICOTROPIC HOR $272.10 Acyclovir injection $1.73 ADAMTS 13 $168.90 Adenosine inj 1mg $31.15 Adrenalin epinephrine inject $87.60 Affinity1 square cm $1,236.00 Albumin (human) 25% 50ml $186.10 Albumin (human) 5% 50ml $52.45 ALBUMIN, BLOOD $64.40 ALCOHOL , ETHYL ALCOHOL $247.90 ALDOLASE $78.80 ALDOSTERONE (SERUM) $361.20 ALKALINE PHOSPHATASE $64.40 ALLERGEN , MILK $19.40 ALLERGEN LATEX $142.30 ALLERGEN, ALTERNIA MOLD $19.40 ALLERGEN, ASPERGILLUS FUMIGATUS $19.40 ALLERGEN, BERMUDA GRASS $19.40 ALLERGEN, CAT DANDER $19.40 1 of 155 Procedure Price ALLERGEN, CLADOSPORIUM HERBARIUM $19.40 ALLERGEN, CLAM $19.40 ALLERGEN, COCKROACH $19.40 ALLERGEN, COMMON RAGWEED $19.40 ALLERGEN, CORN, MAIZE $19.40 ALLERGEN, DERM, PTERONYSSINUS $19.40 ALLERGEN, DERMATO, FARINAE $19.40 ALLERGEN, DOG DANDER $19.40 ALLERGEN, EGG WHITE $19.40 ALLERGEN, ELM $19.40 ALLERGEN, FISH, COD $19.40 ALLERGEN, GLUTEN $19.40 ALLERGEN, HAZELNUT $19.40 ALLERGEN, MAPLE LEAF SYCAMORE $19.40 ALLERGEN, MAPLE, BOXELDER $19.40 ALLERGEN, MOUNTAIN CEDAR $19.40 ALLERGEN, MULBERRY $19.40 ALLERGEN, OAK $19.40 ALLERGEN, PEANUT $19.40 ALLERGEN, PECAN/HICKORY TREE $19.40 ALLERGEN, PENICILLIUM NOTATUM $19.40 ALLERGEN, ROUGH MARCHELDER $19.40 ALLERGEN, RUSSIAN THISTLE $19.40 ALLERGEN, SCALLOP $19.40 ALLERGEN, SESAME $19.40 ALLERGEN, SHRIMP $19.40 ALLERGEN, SOYBEAN $19.40 ALLERGEN, WALNUT $19.40 ALLERGEN, WALNUT TREE $19.40 ALLERGEN, WHEAT $19.40 Alloderm $117.00 Alloskin $334.00 ALPHA FETOPROTEIN, TUMOR MARKER $186.00 ALPHA FETOPROTEIN/AMINO FLD $115.80 ALPHA, 1 ANTITRYPSIN $234.60 ALPHA, 1, ANTITRYPSIN,PHENOTYPE $53.20 Alteplase recombinant $393.65 2 of 155 Procedure Price AMIKACIN, RANDOM LEVEL $62.50 AMINO ACID, PLASMA $518.60 Aminophyllin 250 mg inj $101.15 AMIODARONE AND METABOLITES $29.00 Amiodarone hcl $88.00 AMITRIPTYLINE $206.00 AMMONIA $159.20 Amnioband guardian 1 sq cm $412.00 AMNIOTIC RUPTURE OF MEMBRANES $151.90 AMOEBIC ANTIBODY TITER $220.00 Ampicillin 500 mg inj $92.90 Ampicillin sodium per 1.5 gm $102.70 AMYLASE , FLUID $159.20 AMYLASE , SERUM $159.20 ANA (QUANTITATIVE) $159.20 ANA(ANTINUCLEAR ANTIBODY) SCREEN $116.70 ANAEROBIC IDENTIFICATION $51.00 ANCA TITER $67.80 ANDROSTENEDIONE $51.10 ANGIOTENSIN CONVERTIN ENZY $85.70 ANGIOTENSIN CONVERTING ENZ, CSF $85.70 ANTI, CARDIOLIPIN,IGA $36.30 ANTI, DNA, DOUBLE STRANDED $56.70 ANTI, DNASE B $16.40 ANTIBODY ELUTION $533.60 ANTIBODY IDENTIFICATION $487.40 ANTIBODY PANEL CHARGE $487.40 ANTIBODY TITER $273.50 ANTI-CARDIOLIPIN, IGM $36.30 ANTI-CARDIOLIPIN,IGG $36.30 ANTIDIURETIC HORM ADH $43.70 ANTIGEN TYPE $71.70 ANTIMITOCHONDRIAL M2 AB IGG $29.80 ANTISTREPTOLYSIN O QUANT $151.90 ANTITHROMBIN III $141.20 Antithrombin iii injection $7.91 Apligraf $157.00 3 of 155 Procedure Price APTT(ACT. PART. THROMBIN TIME) $113.00 ARSENIC , BLOOD $141.20 ARSENIC, URINE $59.90 ARSENIC, URINE, FRACTIONATED $141.20 ARTERIAL BLOOD GAS PROFILE $282.00 Atropine sulfate injection $4.73 AUTOLOGOUS DEGLY RED CELLS $741.40 AUTOLOGOUS PACK CELLS DIST CHG $741.40 AUTOLOGOUS PROCESSING CHARGE $289.30 Azacitidine injection $10.10 Azathioprine oral 50mg $1.70 Azithromycin $102.40 Azithromycin dihydrate oral $39.30 B2 MICROGLOBULIN , SERUM $131.40 BARTONELLA ANTIBODY $67.60 BASIC METABOLIC PANEL $149.50 Belatacept injection $7.74 Belimumab injection $98.63 BETA, HYDROXY BUTYRATE $90.00 BETA-2, GLYCOPROTEIN IGA $92.60 BETA-2, GLYCOPROTEIN IGG $92.60 BETA-2, GLYCOPROTEIN IGM $92.60 Betamethasone acetsod phosp $53.65 BILE ACIDS, TOTAL $62.50 BILIRUBIN (TOTAL) , NEONATAL $64.40 BILIRUBIN , DIRECT $64.40 BILIRUBIN , TOTAL , ADULT $64.40 BILIRUBIN, FLUID $64.40 Bivalirudin $4.75 BK VIRUS, DNA, URINE, QUANT $198.50 BKV, QNT PCR $495.50 BLD TYPING; RH PHENOTYPING COMPLETE $86.30 BLOOD CULTURE, ROUTINE $175.00 BODY FLUID , HEMATOCRIT $52.30 BODY FLUID, ALBUMIN $64.40 BODY FLUID, CHOLESTEROL $64.40 BORDETELLA PERTUSSIS BY PCR $143.50 4 of 155 Procedure Price BORDETELLA PERTUSSIS, IGA, IGG, IGM $42.80 Brachytx non-stryttrium-90 $43,788.00 BREATH HYDROGEN TEST $376.30 Brentuximab vedotin inj $284.63 BRONCH LAVAGE COUNT $163.20 BRUCELLA ANTIBODY $18.40 Budesonide non-comp unit $20.00 BUN (BLOOD UREA NITROGEN) $64.40 Bupren/nal 3.1 to 6mg bupren $10.80 Bupren/nal 6.1 to 10mg bupre $10.80 Bupren/nal up to 3mg bupreno $6.50 Buprenorphine oral 1mg $1.79 Butorphanol tartrate 1 mg $95.50 C PEPTIDE $148.30 C REACTIVE PROTEIN $113.00 C. DIFFICILE TOXIN $234.60 C1 ESTERASE INHIBITOR FUNCTIONAL $218.80 C3 COMPLEMENT $212.60 C4 COMPLEMENT $212.60 CA 125 $232.20 CA 19, 9 $122.90 Cabergoline oral 0.25mg $10.25 Calcium gluconate injection $105.80 CALCIUM, SERUM $64.40 CALCIUM, URINE, 24 HOUR $100.90 CALCIUM, URINE, RANDOM $64.40 CALPROTECTIN, FECAL $216.20 CALRETICULIN EXON 9 MUTATION ANAYSIS $393.80 CAMPYLOBACTER ANTIGEN BY EIA $94.80 CANCER ANTIGEN 27 , 29 $173.70 CANDIDA ANTIBODY $15.60 CAPILLARY BLOOD GAS $282.00 Capsaicin 8% patch $6.60 CARBON MONOXIDE (CARBOXYHGB) $363.40 Carboplatin injection $103.41 Carmustine injection $6,858.74 CARNITINE PANEL $275.50 5 of 155 Procedure Price CAROTENE $56.70 CATECHOLAMINES PANEL, PLASMA $231.50 CATECHOLAMINES, FRACTIONATED FREE URINE $231.50 CBC (HEMOGRAM) $91.10 CBC WITH DIFFERENTIAL $116.70 CCP AB, IGG $102.60 CEA (CARCINOEMBRYONIC ANTIGEN) $220.10 Cefazolin sodium injection $103.10 Cefepime hcl for injection $50.88 Cefotaxime sodium injection $91.90 Cefoxitin sodium injection $100.30 Ceftriaxone sodium injection $89.90 CELL COUNT W/DIFF, BODY FLUID $164.00 CENTROMERE B $48.50 Certolizumab pegol inj 1mg $19.20 CERULOPLASMIN $22.10 CHLAMYDIA TRACHOMATIS BY LCR $176.30 CHLAMYDIA/GONORRHOEA PROBES $352.60 CHLORIDE , SERUM $64.40 CHLORIDE , URINE $64.40 Chloroprocaine hcl injection $132.30 Chlorothiazide sodium inj $639.15 Chlorpromazine hcl injection $144.95 CHOLESTEROL $64.40 CHROMATIN $48.50 CHROMIUM, BLOOD $105.30 CHROMIUM, URINE $105.30 CHROMOGRANIN A $373.90 Cisplatin 10 mg injection $65.99 CITRATE, URINE $151.60 CK TOTAL $64.40 CK, MB $60.80 CLONAZEPAM (CLONOPIN) $46.80 CLOZAPINE AND METABOLITES $298.60 CMV (CYTOMEGALOVIRUS) AB, IGM $61.70 CMV BY PCR $186.40 CO2 CONTENT $64.40 6 of 155 Procedure Price COBALT, BLOOD $46.30 COLD AGGLUTININS TITER $45.10 COLLECTION OF CAPILLARY BLOOD SPECIMEN $32.90 COMP REVIEW OF CASE W SLIDES & HI $131.40 COMPLEMENT COMP 4A $149.30 COMPREHENSIVE METABOLIC PANEL $264.90 CONSULT & REPORT REQUIRING PREP OF SLIDES $176.40 COPPER , SERUM $75.30 CORD BLOOD GAS, VENOUS OR ARTERIAL $268.70 CORTISOL $188.40 CORTISOL FREE $137.80 CORTISOL FREE, URINE $90.30 Cosyntropin cortrosyn inj $300.70 COTININE SERUM $75.60 CREATININE CLEARANCE, URINE $159.20 CREATININE URINE, 24HR $100.90 CREATININE URINE, RANDOM $64.40 CREATININE, FLUID $64.40 CREATININE, SERUM $64.40 CROSSMATCH $279.60 CROSSMATCH FRZ DEGLY CELLS $279.60 CROSSMATCH PACKED CELLS LEUK $279.60 CROSSMATCH PLATELET ARC $279.60 CROSSMATCH, COOMBS $351.20 CRYOGLOBULINS, QUALITATIVE $70.70 CRYOPRECIPITATE DIST CHG $154.30 CRYPTOCOCCAL ANTIGEN, CSF $178.70 CRYPTOCOCCUS AG, CSF $34.40 CRYPTOSPORIDUIM ANTIGEN $128.80 CRYSTALS , FLUID $77.80 CSF , CHLORIDE $94.80 CSF , PROTEIN $94.80 CSF ARRAY BY PCR (BIOFIRE) $1,157.60 CSF CELL COUNT $159.20 CSF, GLUCOSE $94.80 CULTURE , ANAEROBIC $175.00 CULTURE , LEGIONELLA $175.00 7 of 155 Procedure Price CULTURE , MYCOPLASMA $175.00 CULTURE , STOOL $175.00 CULTURE , TB AND ACID FAST STAIN $175.00 CULTURE AFB $151.90 CULTURE BLOOD, FUNGUS $175.00 CULTURE SINUS W/GS $175.00 CULTURE, AEROBIC $175.00 CULTURE, AEROBIC W/GRAM STAIN $175.00 CULTURE, BRONCH, AEROBIC W/GS $175.00 CULTURE, CATHETER TIP, AEROBIC $175.00 CULTURE, EAR $175.00 CULTURE, EYE $175.00 CULTURE, FUNGI $175.00 CULTURE, MRSA $137.30 CULTURE, NOSE $175.00 CULTURE, PATHOGENIC ORGANISM, SCREEN $175.00 CULTURE, STREP A, NON-THROAT $175.00 CULTURE, THROAT $175.00 CULTURE, TISSUE, AEROBIC & ANAEROBIC W/GS $175.00 CULTURE, URINE $175.00 CULTURE, URINE, CYSTO $175.00 CULTURE, VIBRIO (STOOL) $175.00 CULTURE, VRE (VANCOMYCIN RESISTANT ENTEN) SCREEN $175.00 CULTURE, YEAST SCREEN $175.00 CULTURE, YERSINIA, STOOL $175.00 Cyclophosphamide 100 mg inj $218.33 Cyclophosphamide oral 25 mg $9.56 CYCLOSPORINE A $174.80 Cyclosporine oral 100 mg $16.95 Cyclosporine oral 25 mg $4.78 Cystic Fibrosis (CFTR) 165 Pathogenic Variants $338.60 Cytarabine hcl 100 mg inj $356.35 CYTO CELL BLOCK $335.50 CYTO TOUCH SMEAR, PREP AND EVAL $151.90 CYTOLOGY , CELL BLOCK $335.50 CYTOMEGALOVIRUS, DNA QUANT BY PCR $243.10 CYTOMEGALOVIRUS, IGG $62.90 8 of 155 Procedure Price CYTOPATH , NON GYN WITH INTERP $170.10 CYTOPATH CONCENTRATION TECH, SMEAR $180.60 CYTOPATH, CONC TECH SMEARS $151.90 CYTOPATH, EVAL OF FNA $237.10 CYTOPATH, NG, SCREEN & INTERP $110.60 CYTOPATH,CERV/VAG LIQ MED,SCR/RES $119.10 CYTOPATH,FNA INTERP AND REPORT $194.50 CYTOPATHOLOGY, OTHER THAN GYN $85.20 D DIMER,QUANTITATIVE $168.90 D5w infusion $60.00 Dacarbazine 100 mg inj $67.96 Daptomycin injection $2.20 Daunorubicin injection $143.35 DECALCIFICATION PROCEDURES $102.10 DECALCIFY , TISSUE $118.10 Degarelix injection $13.52 DEGLYCEROLIZED RBC $780.40 Denosumab injection $40.91 DET HIST/CYTO TO ID ENZYME CONST. $353.60 Dexamethasone sodium phos $88.60 DHEA $54.40 DHEA, SULFATE $175.00 Diazepam injection $71.10 Dicyclomine injection $247.80 Digoxin immune fab (ovine) $7,108.75 Digoxin injection $98.50 DIHYDROTESTOSTERONE $111.10 DILANTIN (PHENYTOIN) $186.00 Diphenhydramine hcl injectio $93.00 DIRECT COOMBS $70.50 DIRECT IMMUNOFLOURESNCES , AP $319.50 DIRECTED PACKED CELLS DIST CHG $621.20 Dopamine injection $11.35 Dornase alfa non-comp unit $52.74 DOXEPIN/DESMETHYL DOXEPIN $238.50 Doxorubicin hcl injection $1,095.55 Doxorubicin inj 10mg $1,067.76 9 of 155 Procedure Price DPT AB, IGG $54.40 DRUG ABUSE , URINE (DAU8, MED) $204.20 EBV BY PCR $132.30 EBV QUANTITATIVE BY PCR $167.90 ECHO VIRUS $444.60 ELECTROLYTES (NA,K,CL, CO2)SERUM $102.10 ELECTROLYTES, FECAL $97.20 ELECTRON MICROSCOPY $4,321.20 ELECTRONIC CROSSMATCH $139.80 ELECTROPHORESIS-HGB $141.00 ENDOMYSIAL AB, TITER ONLY $59.00 ENTEROVIRUS BY PCR $441.10 Epifix or epicord $625.00 Epoetin alfa non-esrd $78.22 Epoprostenol injection $113.65 EPSTEIN BARR EARLY AG IGG $137.90 EPSTEIN BARR HETEROPHILE AG IGM $107.00 EPSTEIN BARR NUCLEAR AG IGG $97.00 EPSTEIN BARR VIRAL CAPSID AG IGG $97.00 EPSTEIN BARR VIRAL CAPSID AG IGM $97.00 Eptifibatide injection $96.88 Ertapenem injection $172.43 Erythro lactobionate /500 mg $224.05 ERYTHROPOIETIN LEVEL $204.20 ESTRADIOL, 17B(SERUM) $232.20 ESTRIOL $78.80 ESTROGENS, SERUM, FRACTIONATED $285.90 ESTRONE, SERUM $582.30 ETH GLYCO $612.70 Etonogestrel implant system $1,783.30 Etoposide injection $45.53 EVEROLIMUS BY HPLC-MS/MS $121.30 FACTOR V LEIDEN PANEL $110.30 Factor viia $3.53 FACTOR VIII REFLEX TO BETH ASSAY $51.90 FATTY ACIDS PROF $621.60 FDP SPLIT PRO $70.70 10 of 155 Procedure Price FECAL FAT (QUANT) $151.60 FECAL FAT, RANDOM $74.10 FECAL LACTOFERRIN $60.80 FECAL OCCULT BLOOD, IMMUNOASSAY $56.10 FELBAMATE (FELBATROL) $298.60 Fentanyl citrate injection $97.10 FENTANYL METABOLITES, URINE, QUANT $102.40 FERRITIN $194.50 Ferumoxytol non-esrd $3.33 FETAL FIBRONECTIN $524.00 FETAL HGB STAIN (KLEIHAUER) $357.30 FETAL SCREEN TEST $80.20 FIBRINOGEN LEVEL $184.80 FIBROSPECT II $42.80 Finasteride 5 mg $2.55 FINE NEEDLE ASP.BX , INTERPRET $215.40 FINE NEEDLE ASP.BX, IMMED EVALU $282.40 Flebogamma injection $100.09 FLECAINIDE ACETATE (TAMBOCAR) $298.60 FLM, FETAL LUNG MATURITY ASSAY $347.70 FLOW CYTOMETRY $153.10 FLOW, EA ADDT'L MARKER $116.70 Fluconazole $124.90 Fluphenazine decanoate 25 mg $149.50 FOLIC ACID (FOLATE), SERUM $159.20 Fomepizole 15 mg $5.02 Fondaparinux sodium $35.00 Formoterol fumarate inh $20.45 Fosaprepitant injection $5.05 Fosphenytoin inj pe $76.93 FREE LIGHT CHAINS, SERUM $172.60 FREE TESTOSTERONE, FEMALE/CHILD $81.10 FRUCTOSAMINE $16.90 FRUCTOSE (SEMEN) $257.00 FSH (FOLLICLE STIM HORMONE) $195.70 FUNGUS SMEAR $86.30 Furosemide injection $99.90 11 of 155 Procedure Price GABAPENTIN (NEUROTONIN) $156.20 GAD AB $82.20 Gadoxetate disodium inj $39.63 Gammagard liquid injection $132.09 Ganciclovir sodium injection $311.15 GANGLIOSIDE AB $252.80 Garamycin gentamicin inj $95.40 GASTRIN, SERUM $107.60 GASTROCCULT BLOOD $83.10 Gemcitabine hcl injection $368.85 GENERAL HEALTH PANEL $346.40 GENTAMICIN (POST, DOSE) $205.40 GENTAMICIN (PRE, DOSE) $205.40 GENTAMICIN RANDOM $205.40 GGT(GAMMA GLUTAMYL TRANSPEPT) $64.40 GLIADIN ANTIBODIES, IGA&IGG $171.40 GLIADIN, IGA $44.10 GLIADIN, IGG $44.10 GLOMERULAR BASEMENT MEMBRANE, IGG $44.10 GLUCAGON $117.00 Glucagon hydrochloride/1 mg $551.67 GLUCOSE , FLUID $64.40 GLUCOSE 6 PHOSPHODEHYDROQENASE $70.70 GLUCOSE GESTATIONAL SCREEN 1 HR 50G LOAD $64.40 GLUCOSE GESTATIONAL SCREENING $55.90 GLUCOSE GESTATIONAL TOLERANCE $186.00 GLUCOSE TOLERANCE TEST , 2HR $279.60 GLUCOSE, BLOOD $64.40 GM1 ANTIBODY $342.80 Golimumab for iv use 1mg $69.93 GRAM STAIN $80.20 Granisetron hcl injection $3.44 H PYLORI AG, STOOL $109.20 H PYLORI BREATH COLLECTION $59.50 H PYLORI SCREEN TISSUE (CLO TEST) $102.10 H PYLORI UREA BREATH TEST $303.90 HALOPERIDOL (HALDOL) $132.00 12 of 155 Procedure Price Haloperidol decanoate inj $139.30 Haloperidol injection $99.50 HAPTOGLOBIN (QUANT) $175.00 HBS AG (HEPATITIS B SUR ANTI) $175.00 HC 12 LEAD EKG; TRACING ONLY $398.00 HC 1-3 LEAD EKG TRACING ONLY $108.00 HC 2-D ECHO LIMITED OR FOLLOWUP $1,073.00 HC 2D TEE W OR W/O FOL W/CON IN $2,249.00 HC 2D TTE W OR W/O FOL W/CON CO $2,249.00 HC 3D RENDER W POSTPROCESS $1,083.00 HC 3D RENDER WO POSTPROCESS $1,024.00 HC A/D TX PROG PER DIEM INTENSIVE $2,077.00 HC A/D TX PROG PER DIEM INTENSIVE ADOL/YA $2,211.00 HC A/D TX PROG PER DIEM MODERATE $2,071.00 HC A/D TX PROG PER DIEM MODERATE ADOL/YA $2,208.00 HC ABD AORTOGRAM W BILATERAL RUNOFF $6,846.00 HC ABD PARACENTESIS $1,576.00 HC ABD PARACENTESIS W/IMAGING $2,575.00 HC ABDOMINAL AORTOGRAM $6,423.00 HC ABLATE ARRHYTHMIA ADD ON $39,649.00 HC ABLATE BONE TUMOR(S) PERQ CRYO $13,190.00 HC ABLATE LIVER RADIOFREQ PERC $10,921.00 HC ABLATE LIVER TUMOR(S) PERQ CRYO $10,724.00 HC ABLATE RENAL TUMOR CRYO PERC $14,151.00 HC ABLATE RENAL TUMOR RF PERC $10,921.00 HC ABLATE, BONE TUMOR(S) PERQ $13,667.00 HC ABSCESS FISTULA SINUS TRACT STUDY $1,842.00 HC ACJ BILATERAL W WO WEIGHTS $470.00 HC ACTIGRAPHY TESTING 72 HRS-14 DAYS $777.00 HC ADD JNT TO UE PROSTH EA JOINT LVL 1 $1,431.00 HC ADD JNT TO UE PROSTH EA JOINT LVL 2 $2,861.00 HC ADD JNT TO UE PROSTH EA JOINT LVL 3 $3,935.00 HC ADD JNT TO UE PROSTH EA JOINT LVL 4 $5,247.00 HC ADD JNT TO UE PROSTH EA JOINT LVL 5 $6,558.00 HC ADHESION BARRIER LVL 1 $477.00 HC ADHESION BARRIER LVL 2 $835.00 HC ADHESION BARRIER LVL 3 $1,670.00 13 of 155 Procedure Price HC ADHESION BARRIER LVL 4 $2,147.00 HC ADHESION BARRIER LVL 5 $2,861.00 HC ADHESION BARRIER LVL 6 $3,577.00 HC ADJ FLEXION EXT HIP JNT CNTRL EA LVL1 $835.00 HC ADJ FLEXION EXT HIP JNT CNTRL EA LVL2 $1,431.00 HC ADJ FLEXION EXT HIP JNT CNTRL EA LVL3 $2,147.00 HC ADJ FLEXION EXT HIP JNT CNTRL EA LVL4 $2,861.00 HC ADJ FLEXION EXT HIP JNT CNTRL EA LVL5 $3,577.00 HC ADJ GASTRIC BAND DIAM VIA INJ/ASP SALINE $1,014.00 HC ADL/SELF CARE TRN EA 15M $149.00 HC ADMIN HEPATITIS B VACCINE $76.00 HC ADMIN INFLUENZA VIRUS VACCINE $65.00 HC ADMIN PNEUMONIA VACCINE $65.00 HC ADRENAL ANGIOGRAM BILAT $3,383.00 HC ADRENAL ANGIOGRAM UNIL $3,008.00 HC ADRENAL VENOGRAM SELECTIVE BILAT $9,036.00 HC ADRENAL VENOGRAM UNIL SELCTV $3,188.00 HC AEROSOL PENTAMIDEN FOR P CARINII $483.00 HC AFFINITY PER SQ CM LVL 1 $412.00 HC AFFINITY PER SQ CM LVL 2 $824.00 HC AFFINITY PER SQ CM LVL 3 $1,236.00 HC AFFINITY PER SQ CM LVL 4 $1,648.00 HC AFFINITY PER SQ CM LVL 5 $2,060.00 HC AFFINITY PER SQ CM LVL 6 $4,120.00 HC AFO STATIC W SOFT INTERFACE ADJ PF LVL1 $1,431.00 HC AFO STATIC W SOFT INTERFACE ADJ PF LVL2 $2,861.00 HC AFO STATIC W SOFT INTERFACE ADJ PF LVL3 $3,935.00 HC AFO STATIC W SOFT INTERFACE ADJ PF LVL4 $5,247.00 HC AFO STATIC W SOFT INTERFACE ADJ PF LVL5 $6,558.00 HC AICD, DUAL CHAMBER LVL 1 $3,577.00 HC AICD, DUAL CHAMBER LVL 2 $6,558.00 HC AICD, DUAL CHAMBER LVL 5 $44,713.00 HC AICD, DUAL CHAMBER LVL 6 $59,617.00 HC AICD, DUAL CHAMBER LVL 7 $74,522.00 HC AICD, OTHER THAN SING/DUAL LVL 1 $3,577.00 HC AICD, OTHER THAN SING/DUAL LVL 2 $6,558.00 HC AICD, OTHER THAN SING/DUAL LVL 5 $44,713.00 14 of 155 Procedure Price HC AICD, OTHER THAN SING/DUAL LVL 6 $59,617.00 HC AICD, OTHER THAN SING/DUAL LVL 7 $74,522.00 HC AICD, OTHER THAN SING/DUAL LVL 8 $89,427.00 HC AICD, OTHER THAN SING/DUAL LVL 9 $104,331.00 HC AICD, SINGLE CHAMBER LVL 1 $3,577.00 HC AICD, SINGLE CHAMBER LVL 2 $6,558.00 HC AICD, SINGLE CHAMBER LVL 4 $29,809.00 HC AICD, SINGLE CHAMBER LVL 5 $44,713.00 HC AICD, SINGLE CHAMBER LVL 6 $59,617.00 HC AICD, SINGLE CHAMBER LVL 7 $74,522.00 HC AIRWAY INHALATION TREATMENT INITIAL $417.00 HC AIRWAY INHALATION TREATMENT SUBQ $417.00 HC ALC/SUBST ABUSE SCREEN (AUDIT/DAST) >30 MIN $188.00 HC ALC/SUBST ABUSE SCREEN (AUDIT/DAST) 15-30 MIN $119.00 HC ALCOHOL BREATH TEST $40.00 HC ALGINATE DRESSING > 48 SQ IN LVL 1 $347.00 HC ALGINATE DRESSING > 48 SQ IN LVL 2 $520.00 HC ALGINATE DRESSING > 48 SQ IN LVL 3 $693.00 HC ALGINATE DRESSING > 48 SQ IN LVL 4 $868.00 HC ALGINATE/FG DRESS 16 SQIN/ $48.00 HC ALLODERM PER SQ CM LVL 1 $117.00 HC ALLODERM PER SQ CM LVL 2 $117.00 HC ALLODERM PER SQ CM LVL 3 $117.00 HC ALLODERM PER SQ CM LVL 4 $117.00 HC ALLODERM PER SQ CM LVL 5 $117.00 HC ALLOSKIN PER SQ CM LVL 1 $334.00 HC ALLOSKIN PER SQ CM LVL 2 $501.00 HC ALLOSKIN PER SQ CM LVL 3 $667.00 HC ALLOSKIN PER SQ CM LVL 4 $835.00 HC AMBULATORY CARE CLASS I $576.00 HC AMBULATORY CARE CLASS II $721.00 HC AMBULATORY CARE CLASS III $968.00 HC AMBULATORY CARE CLASS IV $993.00 HC AMBULATORY CARE CLASS V $1,326.00 HC AMNIOBAND, GUARDIAN PER SQ CM LVL 1 $412.00 HC AMNIOBAND, GUARDIAN PER SQ CM LVL 2 $824.00 HC AMNIOBAND, GUARDIAN PER SQ CM LVL 3 $1,236.00 15 of 155 Procedure Price HC AMNIOBAND, GUARDIAN PER SQ CM LVL 4 $1,648.00 HC AMNIOBAND, GUARDIAN PER SQ CM LVL 5 $2,060.00 HC AMNIOBAND, GUARDIAN PER SQ CM LVL 6 $4,120.00 HC AMNIOCENTESIS, DIAGNOSTIC $410.00 HC AMNIOEXCEL OR BIODEXCEL PER SQ CM LVL 1 $412.00 HC AMNIOEXCEL OR BIODEXCEL PER SQ CM LVL 2 $824.00 HC AMNIOEXCEL OR BIODEXCEL PER SQ CM LVL 3 $1,236.00 HC AMNIOEXCEL OR BIODEXCEL PER SQ CM LVL 4 $1,648.00 HC AMNIOEXCEL OR BIODEXCEL PER SQ CM LVL 5 $2,060.00 HC AMNIOEXCEL OR BIODEXCEL PER SQ CM LVL 6 $4,120.00 HC AMNIOTIC MEMBRANE LVL 1 $835.00 HC AMNIOTIC MEMBRANE LVL 2 $1,670.00 HC AMNIOTIC MEMBRANE LVL 3 $2,147.00 HC AMNIOTIC MEMBRANE LVL 4 $2,861.00 HC AMNIOTIC MEMBRANE LVL 5 $3,577.00 HC AMPUTATE FING/TH SGL W DIR CLOSE $3,310.00 HC AMPUTATE TOE; IP JOINT $4,175.00 HC AMPUTATE TOE; MTP JOINT $4,837.00 HC ANAL SP INF PUMP W MD REPROG & FILL $1,369.00 HC ANAL SP INF PUMP W REPROG & FILL $1,369.00 HC ANALYZE NEUROSTIM COMPLX W PROG $433.00 HC ANALYZE NEUROSTIM SIMPLE $491.00 HC ANALYZE NEUROSTIM WO REPROG $184.00 HC ANALYZE SPINE INFUS PUMP WO PROGR $1,369.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 1 $239.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 10 $8,347.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 11 $9,539.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 12 $8,048.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 13 $8,942.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 14 $9,838.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 15 $10,732.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 16 $11,627.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 17 $12,520.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 18 $13,415.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 19 $14,309.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 2 $477.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 20 $15,203.00 16 of 155 Procedure Price HC ANCHOR/SCREW BN/BN,TIS/BN LVL 23 $17,886.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 24 $18,780.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 26 $20,569.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 29 $23,251.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 3 $1,043.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 30 $24,145.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 4 $2,088.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 5 $3,577.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 6 $4,472.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 7 $5,963.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 8 $6,706.00 HC ANCHOR/SCREW BN/BN,TIS/BN LVL 9 $8,048.00 HC ANESTHESIA BASE $3,393.00 HC ANESTHESIA BASE INCIDENT TO RADIOLOGY $2,667.00 HC ANESTHESIA LOCAL BASE $908.00 HC ANESTHESIA LOCAL MIN $5.00 HC ANESTHESIA MAC BASE $2,196.00 HC ANESTHESIA MAC MIN $13.00 HC ANESTHESIA MIN $21.00 HC ANESTHESIA MINUTE INCIDENT TO RADIOLOGY $21.00 HC ANESTHESIA SUPPLIES GENERAL LVL 1 $835.00 HC ANESTHESIA SUPPLIES GENERAL LVL 2 $3,577.00 HC ANGIOGR EA ADDTL VESSEL $2,758.00 HC ANGIOGRAM EXISTING CATHETER FOLLOW-UP $3,686.00 HC ANKLE 2 VIEWS $478.00 HC ANKLE ARTHROGRAM S&I $871.00 HC ANKLE ARTHROGRAPHY INJ $552.00 HC ANKLE MIN 3 VIEWS $720.00 HC ANO RECTAL MANOMETRY $1,063.00 HC ANOSCOPY DX $160.00 HC ANOSCOPY ENDO $437.00 HC ANOSCOPY; W REM FB $2,153.00 HC ANTEGRADE PYEL NEPHR LOOPOGRAM $1,619.00 HC APHASIA ASSESSMENT PER HR $316.00 HC APHERESIS PLASMA $1,685.00 HC APHERESIS RBC $2,226.00 HC APHERESIS SELECTIVE $11,488.00 17 of 155 Procedure Price HC APHERESIS WBC $3,988.00 HC APLIGRAF PER SQ CM LVL 1 $157.00 HC APLIGRAF PER SQ CM LVL 2 $157.00 HC APLIGRAF PER SQ CM LVL 3 $157.00 HC APLIGRAF PER SQ CM LVL 4 $157.00 HC APLIGRAF PER SQ CM LVL 5 $157.00 HC APPLY FINGER SPLINT DYNAMIC $172.00 HC APPLY FINGER SPLINT STATIC $255.00 HC APPLY LONG ARM CAST $391.00 HC APPLY LONG ARM SPLINT $307.00 HC APPLY LONG LEG CAST $465.00 HC APPLY LONG LEG SPLINT $498.00 HC APPLY MULTLAY COMPRS ARM/HAND $300.00 HC APPLY MULTLAY COMPRS ARM/HAND BILAT $504.00 HC APPLY MULTLAY COMPRS LWR LEG $300.00 HC APPLY MULTLAY COMPRS LWR LEG BILAT $529.00 HC APPLY RIGID TOTAL CONTACT LEG CAST $680.00 HC APPLY SH LEG CAST $391.00 HC APPLY SHORT ARM CAST $550.00 HC APPLY SHORT ARM SPLINT DYNAMIC $232.00 HC APPLY SHORT ARM SPLINT STATIC $326.00 HC APPLY SHORT LEG SPLINT $413.00 HC APPLY TENS UNIT $230.00 HC APPLY WLKR SH LEG CAST $917.00 HC AQUATIC THERAPY W EX EA 15 MIN $118.00 HC ARRHYTHMIA INDUCTION $6,146.00 HC ART OCCLUSIVE DEVICE PLCMT $1,575.00 HC ARTERIAL CATH SAMPLE/MONITOR/TRANSF $575.00 HC ARTERIAL PUNCTURE BLOOD FOR DX $247.00 HC ARTHROFLEX PER 1 SQ CM LVL 1 $334.00 HC ARTHROFLEX PER 1 SQ CM LVL 2 $501.00 HC ARTHROFLEX PER 1 SQ CM LVL 3 $667.00 HC ARTHROFLEX PER 1 SQ CM LVL 4 $835.00 HC ARTISS FIBRIN SEALANT 2 ML LVL 1 $334.00 HC ARTISS FIBRIN SEALANT 2 ML LVL 2 $501.00 HC ARTISS FIBRIN SEALANT 2 ML LVL 3 $667.00 HC ARTISS FIBRIN SEALANT 2 ML LVL 4 $835.00 18 of 155 Procedure Price HC ASP INJ RENAL CYST/PELVIS PERC $1,852.00 HC ASP INJ SHUNT/RESERVOIR $1,066.00 HC ASP INJ THYROID CYST $1,156.00 HC ASP INTERDISCAL DX PERC $1,431.00 HC ASPIRATE PLEURA W/ IMAGING $1,961.00 HC ASPIRATE PLEURA W/O IMAGING $1,961.00 HC ASPIRATE/INJ GANGLION CYST $256.00 HC ASSESS HLTH/BEHAVE INIT 15 MIN $86.00 HC ASSESS HLTH/BEHAVE SUBQ 15 MIN $86.00 HC ASTIGMATISM-CORRECT FUNCTION LVL 3 $568.00 HC ASTIGMATISM-CORRECT FUNCTION LVL 6 $1,249.00 HC ATHERECTOMY ABD AORTA TRLUML PERHP $26,966.00 HC ATHERECTOMY ILIAC TRLUML PERIP EA VES $31,471.00 HC ATT F/C/M/N/A/G/H/F 10 SQ CM $3,801.00 HC ATTEN CURRENT STATUS $0.01 HC ATTEN D/C STATUS $0.01 HC ATTEN GOAL STATUS $0.01 HC AUD OSSEO DEV, INT/EXT COMP LVL 1 $2,088.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 15 $13,415.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 2 $3,577.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 25 $22,655.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 3 $4,472.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 4 $5,963.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 5 $6,706.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 7 $8,347.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 8 $9,539.00 HC AUD OSSEO DEV, INT/EXT COMP LVL 9 $8,048.00 HC AUDITORY EP COMPREHENSIVE $342.00 HC AUDITORY EP LIMITED $185.00 HC BALLOON DILATE URTRL STRIX $4,200.00 HC BASIC DOSIMETRY CALC $687.00 HC BEHAVIORAL QUAL ANALYSIS VOICE $379.00 HC BF PERINEAL MUSCLES OR SPINCTER $141.00 HC BILIARY ERCP $1,127.00 HC BILIARY PANCREATIC ERCP $1,165.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 1 $750.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 11 $15,000.00 19 of 155 Procedure Price HC BILIARY STENT, COAT/COV W/DEL SYS LVL 2 $1,500.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 3 $3,000.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 4 $4,500.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 5 $6,000.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 6 $7,500.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 7 $9,000.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 8 $10,500.00 HC BILIARY STENT, COAT/COV W/DEL SYS LVL 9 $12,000.00 HC BILIARY STENT, NO-COAT/NO-COV W/DL LVL 1 $2,088.00 HC BILIARY STENT, NO-COAT/NO-COV W/DL LVL 2 $3,577.00 HC BILIARY STENT, NO-COAT/NO-COV W/DL LVL 3 $4,472.00 HC BILIARY STENT, NO-COAT/NO-COV W/DL LVL 4 $5,963.00 HC BILIARY STENT, NO-COAT/NO-COV W/DL LVL 5 $6,706.00 HC BILIARY STENT, NO-COAT/NO-COV W/DL LVL 6 $8,048.00 HC BILIARY STENT, NO-COAT/NO-COV W/DL LVL 7 $8,347.00 HC BILIRUBIN TOTAL TRANSCUT $43.00 HC BIOFEEDBACK ANY MODALITY $71.00 HC BIOPSY $722.00 HC BK WAIST BELT WEBBING LVL 3 $370.00 HC BLEPHAROTOMY DRAIN ABSC EYELID $7,526.00 HC BLOOD CELL SAVER LVL 1 $835.00 HC BLOOD CELL SAVER LVL 10 $5,247.00 HC BLOOD CELL SAVER LVL 11 $5,903.00 HC BLOOD CELL SAVER LVL 12 $6,558.00 HC BLOOD CELL SAVER LVL 2 $1,073.00 HC BLOOD CELL SAVER LVL 3 $1,431.00 HC BLOOD CELL SAVER LVL 4 $1,789.00 HC BLOOD CELL SAVER LVL 5 $2,147.00 HC BLOOD CELL SAVER LVL 6 $2,861.00 HC BLOOD CELL SAVER LVL 7 $3,577.00 HC BLOOD CELL SAVER LVL 8 $3,935.00 HC BLOOD CELL SAVER LVL 9 $4,591.00 HC BLUE CROSS OBSERVATION $1.00 HC BM IMAGING; LIMITED $822.00 HC BODY POS CURRENT STATUS $0.01 HC BODY POS D/C STATUS $0.01 HC BODY POS GOAL STATUS $0.01 20 of 155 Procedure Price HC BONE AGE STUDIES $542.00 HC BONE LENGTH STUDIES $817.00 HC BONE MARROW ASPIRATION $900.00 HC BONE MARROW BIOPSY $726.00 HC BONE SURVEY COMPLETE $1,019.00 HC BONE SURVEY INFANT $946.00 HC BONE SURVEY LIMITED $694.00 HC BONE VOID FILLER-STRIP PER 0.5 CC LVL 1 $334.00 HC BONE VOID FILLER-STRIP PER 0.5 CC LVL 2 $501.00 HC BONE VOID FILLER-STRIP PER 0.5 CC LVL 3 $667.00 HC BONE VOID FILLER-STRIP PER 0.5 CC LVL 4 $835.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 1 $477.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 10 $3,577.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 11 $4,472.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 12 $5,963.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 13 $6,706.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 14 $8,048.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 15 $8,347.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 16 $9,539.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 17 $8,048.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 18 $8,942.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 19 $9,838.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 2 $835.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 20 $10,732.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 21 $11,627.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 22 $12,520.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 3 $1,252.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 4 $1,670.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 5 $2,088.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 6 $2,147.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 7 $2,504.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 8 $2,861.00 HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 9 $3,220.00 HC BRACHYTH SEED ADMIN CATH LVL 1 $309.00 HC BRACHYTH SEED ADMIN CATH LVL 2 $1,545.00 HC BRACHYTH SEED ADMIN CATH LVL 3 $3,090.00 HC BRACHYTH SEED ADMIN CATH LVL 4 $4,635.00 21 of 155 Procedure Price HC BRACHYTH SEED ADMIN CATH LVL 5 $6,180.00 HC BRACHYTH SEED ADMIN CATH LVL 7 $9,270.00 HC BRACHYTH SEED ADMIN CATH LVL 9 $12,360.00 HC BRACHYTHERAPY NEEDLE LVL 1 $1,431.00 HC BRACHYTHERAPY NEEDLE LVL 2 $2,861.00 HC BRACHYTHERAPY NEEDLE LVL 3 $3,935.00 HC BRACHYTHERAPY NEEDLE LVL 4 $5,247.00 HC BRACHYTHERAPY NEEDLE LVL 5 $6,558.00 HC BRACHYTX ISODOSE PLAN COMPLEX $1,869.00 HC BRACHYTX ISODOSE PLAN INTERMED $1,703.00 HC BRACHYTX ISODOSE PLAN SIMPLE $697.00 HC BRACHYTX NON-STRAND YTTRIUM-90 $43,788.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 1 $835.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 10 $5,963.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 2 $1,670.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 3 $2,147.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 4 $2,861.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 5 $3,577.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 6 $3,577.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 7 $4,174.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 8 $4,770.00 HC BRACHYTX, NON-STR,HDR IR-192 LVL 9 $5,365.00 HC BRACHYTX, NON-STRANDED, I-125 $173.00 HC BRACHYTX, NON-STRANDED, P-103 $173.00 HC BRACHYTX, STRANDED, I-125 $307.00 HC BRACHYTX, STRANDED, P-103 $293.00 HC BREAST TOMOSYNTHESIS DIG DX BILAT $161.00 HC BREAST TOMOSYNTHESIS DIG DX UNIL $81.00 HC BREAST TOMOSYNTHESIS DIG SCREEN BILAT $81.00 HC BREATH HYDROGEN TEST $382.00 HC BRONCHOSCOPY LEVEL I $4,561.00 HC BRONCHOSCOPY LEVEL II $6,128.00 HC BRONCHOSCOPY LEVEL III $6,644.00 HC BRONCHOSCOPY LEVEL IV $9,784.00 HC BRONCHOSCOPY W/EBUS LEVEL I $8,476.00 HC BRONCHOSCOPY W/EBUS LEVEL II $10,395.00 HC BRONCHOSCOPY W/EBUS LEVEL III $11,492.00 22 of 155 Procedure Price HC BRONCHOSPASM PRE & POST BD $833.00 HC BRONCHOSPASM PROVOCATION EVAL $2,253.00 HC BUNDLE OF HIS RECORDING $5,121.00 HC BURS, BLADES, BITS, LVL 1 $835.00 HC BURS, BLADES, BITS, LVL 10 $6,558.00 HC BURS, BLADES, BITS, LVL 11 $7,215.00 HC BURS, BLADES, BITS, LVL 2 $1,431.00 HC BURS, BLADES, BITS, LVL 3 $2,147.00 HC BURS, BLADES, BITS, LVL 4 $2,861.00 HC BURS, BLADES, BITS, LVL 5 $3,577.00 HC BURS, BLADES, BITS, LVL 6 $3,935.00 HC BURS, BLADES, BITS, LVL 7 $4,591.00 HC BURS, BLADES, BITS, LVL 8 $5,247.00 HC BURS, BLADES, BITS, LVL 9 $5,903.00 HC BX ABD RETROPERITO MASS PERC NDL $2,283.00 HC BX BONE TROCAR NDL DEEP $2,020.00 HC BX BONE TROCAR NDL SUPERFICIAL $2,186.00 HC BX BREAST 1ST LESION MR IMAG $5,295.00 HC BX BREAST 1ST LESION STEREOTACTIC $4,710.00 HC BX BREAST 1ST LESION US IMAG $4,042.00 HC BX BREAST ADD LESION MR IMAG $2,995.00 HC BX BREAST ADD LESION STEREOTACTIC $2,995.00 HC BX BREAST ADD LESION US IMAG $2,995.00 HC BX BREAST OPEN INCIS $9,157.00 HC BX LUNG/MEDIASTINUM PERC NDL $1,945.00 HC BX LYMPH NODES PERC SUPERFICIAL $2,013.00 HC BX MUSCLE PERC NDL $1,604.00 HC BX NEEDLE LIVER PERC $3,098.00 HC BX PANCREAS PERC $2,293.00 HC BX PLEURA PERC NDL $1,459.00 HC BX PROSTATE NDLE PUNCH $2,719.00 HC BX RENAL PERC $2,283.00 HC BX SALIVARY GLAND $1,453.00 HC BX SKIN SQ/MM EA ADDTL $252.00 HC BX SKIN SQ/MM SGL $1,374.00 HC BX SOFT TISSUE HIP/PELVIS SUPERFICIAL $6,138.00 HC BX SOFT TISSUE NECK/THORAX $3,221.00 23 of 155 Procedure Price HC BX THYROID PERC CORE NDL $882.00 HC BX TRANSCATHETER $1,664.00 HC BX TRANSCATHETER RAD $4,041.00 HC C MOTOR EVOKED LWR LIMBS $428.00 HC C MOTOR EVOKED UPPR LIMBS $428.00 HC C REP S/A/L 1.1-2.5 CM $409.00 HC C REP TRUNK EA ADDTL 5 CM/< $465.00 HC C0/MEMBRANE DIFFUSE CAPACITY $632.00 HC CABLES/CRIMP/CLAMP/FORCEPS LVL 1 $358.00 HC CABLES/CRIMP/CLAMP/FORCEPS LVL 2 $716.00 HC CABLES/CRIMP/CLAMP/FORCEPS LVL 3 $1,193.00 HC CABLES/CRIMP/CLAMP/FORCEPS LVL 4 $1,670.00 HC CABLES/CRIMP/CLAMP/FORCEPS LVL 5 $2,147.00 HC CABLES/CRIMP/CLAMP/FORCEPS LVL 6 $2,623.00 HC CALCANEUS MIN 2 VIEWS $530.00 HC CANALITH REPOSITIONING PROCEDURE $103.00 HC CAPILLARY BLOOD DRAW $30.00 HC CAR SEAT/BED TEST 60 MIN $103.00 HC CAR SEAT/BED TEST ADDTL 30 MIN $86.00 HC CARDIAC ASSIST OR IMPL DEVICE NO HCPCS LVL 1 $2,088.00 HC CARDIAC ASSIST OR IMPL DEVICE NO HCPCS LVL 2 $3,577.00 HC CARDIAC ASSIST OR IMPL DEVICE NO HCPCS LVL 5 $26,827.00 HC CARDIAC ASSIST OR IMPL DEVICE NO HCPCS LVL 6 $35,771.00 HC CARDIAC ASSIST OR IMPL DEVICE NO HCPCS LVL 7 $44,713.00 HC CARDIAC ASSIST OR IMPL DEVICE NO HCPCS LVL 8 $53,657.00 HC CARDIAC REHAB W CONT ECG PHASE I $208.00 HC CARDIAC REHAB W CONT ECG PHASE II $236.00 HC CARDIAC REHAB WO CONT ECG $217.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 1 $1,500.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 12 $18,000.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 13 $19,500.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 2 $3,000.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 28 $42,000.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 3 $4,500.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 4 $6,000.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 5 $7,500.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 6 $9,000.00 24 of 155 Procedure Price HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 7 $10,500.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 8 $12,000.00 HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 9 $13,500.00 HC CARDIAC STENT, COAT/COV W/O DL SY LVL 10 $15,000.00 HC CARDIAC STENT, COAT/COV W/O DL SYS LVL 1 $1,500.00 HC CARDIAC STENT, COAT/COV W/O DL SYS LVL 2 $3,000.00 HC CARDIAC STENT, COAT/COV W/O DL SYS LVL 3 $4,500.00 HC CARDIAC STENT, COAT/COV W/O DL SYS LVL 4 $6,000.00 HC CARDIAC STENT, COAT/COV W/O DL SYS LVL 5 $7,500.00 HC CARDIAC STENT, COATCOV W/DEL SYS LVL 10 $15,000.00 HC CARDIAC STENT, NO-COA/NO-COV W/DL LVL 1 $2,088.00 HC CARDIAC STENT, NO-COA/NO-COV W/DL LVL 2 $3,577.00 HC CARDIAC STENT, NO-COA/NO-COV W/DL LVL 3 $4,472.00 HC CARDIAC STENT, NO-COA/NO-COV W/DL LVL 4 $5,963.00 HC CARDIAC STENT, NO-COA/NO-COV W/DL LVL 5 $6,706.00 HC CARDIAC STENT, NO-COA/NO-COV W/DL LVL 6 $8,048.00 HC CARDIAC STENT, NO-COA/NO-COV W/DL LVL 7 $8,347.00 HC CARDIAC STENT, NO-COAT/COV W/O DL LVL 1 $2,088.00 HC CARDIAC STENT, NO-COAT/COV W/O DL LVL 2 $3,577.00 HC CARDIAC STENT, NO-COAT/COV W/O DL LVL 3 $4,472.00 HC CARDIAC STENT, NO-COAT/COV W/O DL LVL 4 $5,963.00 HC CARDIAC STENT, NO-COAT/COV W/O DL LVL 5 $6,706.00 HC CARDIAC STENT, NO-COAT/COV W/O DL LVL 6 $8,048.00 HC CARDIAC STENT, NO-COAT/COV W/O DL LVL 7 $8,347.00 HC CARDIOVASC/HEART SUPPLIES GENERAL LVL 1 $835.00 HC CARDIOVASC/HEART SUPPLIES GENERAL LVL 2 $3,577.00 HC CARDIOVASC/HEART SUPPLIES GENERAL LVL 3 $6,558.00 HC CARDIOVASC/HEART SUPPLIES GENERAL LVL 4 $11,923.00 HC CARDIOVASC/HEART SUPPLIES GENERAL LVL 5 $16,693.00 HC CARDIOVASC/HEART SUPPLIES GENERAL LVL 6 $16,396.00 HC CARDIOVASCULAR CATHS, NO HCPCS LVL 1 $1,431.00 HC CARDIOVASCULAR CATHS, NO HCPCS LVL 10 $10,732.00 HC CARDIOVASCULAR CATHS, NO HCPCS LVL 2 $2,861.00 HC CARDIOVASCULAR CATHS, NO HCPCS LVL 3 $3,935.00 HC CARDIOVASCULAR CATHS, NO HCPCS LVL 4 $5,247.00 HC CARDIOVASCULAR CATHS, NO HCPCS LVL 5 $6,558.00 HC CARDIOVASCULAR CATHS, NO HCPCS LVL 6 $6,440.00 25 of 155 Procedure Price HC CARDIOVASCULAR CATHS, NO HCPCS LVL 7 $7,512.00 HC CARDIOVASCULAR CATHS, NO HCPCS LVL 9 $9,658.00 HC CARDIOVERSION $2,288.00 HC CARDIOVERSION ELECTIVE INT $1,431.00 HC CAROTID DUPLEX SCAN; BILAT $1,584.00 HC CAROTID DUPLEX SCAN; UNIL/LIMIT $1,052.00 HC CARPAL TUNNEL TX INJ $1,004.00 HC CARRY CURRENT STATUS $0.01 HC CARRY D/C STATUS $0.01 HC CARRY GOAL STATUS $0.01 HC CAST ORTHO SOFT GOODS LVL 1 $334.00 HC CAST ORTHO SOFT GOODS LVL 10 $1,574.00 HC CAST ORTHO SOFT GOODS LVL 11 $1,717.00 HC CAST ORTHO SOFT GOODS LVL 12 $1,860.00 HC CAST ORTHO SOFT GOODS LVL 13 $2,003.00 HC CAST ORTHO SOFT GOODS LVL 14 $2,147.00 HC CAST ORTHO SOFT GOODS LVL 15 $2,504.00 HC CAST ORTHO SOFT GOODS LVL 16 $2,861.00 HC CAST ORTHO SOFT GOODS LVL 17 $3,220.00 HC CAST ORTHO SOFT GOODS LVL 18 $3,577.00 HC CAST ORTHO SOFT GOODS LVL 19 $3,935.00 HC CAST ORTHO SOFT GOODS LVL 2 $501.00 HC CAST ORTHO SOFT GOODS LVL 20 $4,591.00 HC CAST ORTHO SOFT GOODS LVL 21 $5,247.00 HC CAST ORTHO SOFT GOODS LVL 22 $5,903.00 HC CAST ORTHO SOFT GOODS LVL 23 $6,558.00 HC CAST ORTHO SOFT GOODS LVL 25 $7,512.00 HC CAST ORTHO SOFT GOODS LVL 3 $667.00 HC CAST ORTHO SOFT GOODS LVL 4 $835.00 HC CAST ORTHO SOFT GOODS LVL 5 $859.00 HC CAST ORTHO SOFT GOODS LVL 6 $1,001.00 HC CAST ORTHO SOFT GOODS LVL 7 $1,144.00 HC CAST ORTHO SOFT GOODS LVL 8 $1,289.00 HC CAST ORTHO SOFT GOODS LVL 9 $1,431.00 HC CATH CAROTID VERTEBRAL $1,334.00 HC CATH CHANGE UNDER FLUORO $3,598.00 HC CATH LAB RECOVERY PER HOUR $286.00 26 of 155 Procedure Price HC CATH OF UMBILICAL VEIN FOR DX $203.00 HC CATH PLC SEGMENTAL ARTERY $1,725.00 HC CATH PLC SVC/IVC NONSELECTIVE $1,568.00 HC CATH PLC VEIN 1ST ORDER SELECTIVE $1,465.00 HC CATH PLC VEIN 2ND ORDER SELECTIVE $1,535.00 HC CATH PORTAL VEIN PERC $2,024.00 HC CATH SUPRAPUBIC/CYSTOSCOPIC LVL 1 $417.00 HC CATH SUPRAPUBIC/CYSTOSCOPIC LVL 2 $835.00 HC CATH SUPRAPUBIC/CYSTOSCOPIC LVL 3 $1,073.00 HC CATH VENOUS ORGAN BLOOD SAMPLE SELECTIVE $574.00 HC CATH, EP, 19 OR FEW ELECT LVL 1 $835.00 HC CATH, EP, 19 OR FEW ELECT LVL 10 $14,309.00 HC CATH, EP, 19 OR FEW ELECT LVL 11 $14,606.00 HC CATH, EP, 19 OR FEW ELECT LVL 2 $1,431.00 HC CATH, EP, 19 OR FEW ELECT LVL 3 $2,147.00 HC CATH, EP, 19 OR FEW ELECT LVL 4 $2,861.00 HC CATH, EP, 19 OR FEW ELECT LVL 5 $3,577.00 HC CATH, EP, 19 OR FEW ELECT LVL 6 $6,558.00 HC CATH, EP, 19 OR FEW ELECT LVL 7 $8,048.00 HC CATH, EP, 19 OR FEW ELECT LVL 8 $10,732.00 HC CATH, EP, 19 OR FEW ELECT LVL 9 $11,923.00 HC CATH, EP, 20 OR MORE ELEC LVL 1 $3,577.00 HC CATH, EP, 20 OR MORE ELEC LVL 10 $14,904.00 HC CATH, EP, 20 OR MORE ELEC LVL 2 $6,558.00 HC CATH, EP, 20 OR MORE ELEC LVL 3 $8,048.00 HC CATH, EP, 20 OR MORE ELEC LVL 4 $10,732.00 HC CATH, EP, 20 OR MORE ELEC LVL 5 $11,923.00 HC CATH, EP, 20 OR MORE ELEC LVL 6 $14,309.00 HC CATH, EP, 20 OR MORE ELEC LVL 7 $14,606.00 HC CATH, EP, 20 OR MORE ELEC LVL 8 $16,693.00 HC CATH, EP, 20 OR MORE ELEC LVL 9 $13,415.00 HC CATH, EP, COOL-TIP LVL 1 $3,577.00 HC CATH, EP, COOL-TIP LVL 10 $14,904.00 HC CATH, EP, COOL-TIP LVL 2 $6,558.00 HC CATH, EP, COOL-TIP LVL 3 $8,048.00 HC CATH, EP, COOL-TIP LVL 4 $10,732.00 HC CATH, EP, COOL-TIP LVL 5 $11,923.00 27 of 155 Procedure Price HC CATH, EP, COOL-TIP LVL 6 $14,309.00 HC CATH, EP, COOL-TIP LVL 7 $14,606.00 HC CATH, EP, COOL-TIP LVL 8 $16,693.00 HC CATH, EP, DIAG/ABL, 3D/VECT LVL 1 $3,577.00 HC CATH, EP, DIAG/ABL, 3D/VECT LVL 2 $6,558.00 HC CATH, EP, DIAG/ABL, 3D/VECT LVL 4 $10,732.00 HC CATH, EP, DIAG/ABL, 3D/VECT LVL 5 $11,923.00 HC CATH, EP, DIAG/ABL, 3D/VECT LVL 6 $14,309.00 HC CATH, EP, DIAG/ABL, 3D/VECT LVL 7 $14,606.00 HC CATH, EP, DIAG/ABL, 3D/VECT LVL 8 $16,693.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 1 $3,577.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 10 $14,904.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 2 $6,558.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 3 $8,048.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 4 $10,732.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 5 $11,923.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 6 $14,309.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 8 $16,693.00 HC CATH, EP, OTHR THAN COOL-TIP LVL 9 $13,415.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 1 $477.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 10 $8,048.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 11 $8,347.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 2 $835.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 3 $1,252.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 4 $1,670.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 5 $2,088.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 6 $3,577.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 7 $4,472.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 8 $5,963.00 HC CATH, HEMODIALYSIS,LONG-TERM LVL 9 $6,706.00 HC CATH, INTRA ECHOCARDIOGRAPHY LVL 1 $835.00 HC CATH, INTRA ECHOCARDIOGRAPHY LVL 10 $14,309.00 HC CATH, INTRA ECHOCARDIOGRAPHY LVL 2 $1,431.00 HC CATH, INTRA ECHOCARDIOGRAPHY LVL 3 $2,147.00 HC CATH, INTRA ECHOCARDIOGRAPHY LVL 4 $2,861.00 HC CATH, INTRA ECHOCARDIOGRAPHY LVL 5 $3,577.00 HC CATH, INTRA ECHOCARDIOGRAPHY LVL 6 $6,558.00 28 of 155 Procedure Price HC CATH, INTRA ECHOCARDIOGRAPHY LVL 8 $10,732.00 HC CATH, INTRA ECHOCARDIOGRAPHY LVL 9 $11,923.00 HC CATH, INTRAVAS ULTRASOUND LVL 1 $835.00 HC CATH, INTRAVAS ULTRASOUND LVL 10 $14,309.00 HC CATH, INTRAVAS ULTRASOUND LVL 11 $14,606.00 HC CATH, INTRAVAS ULTRASOUND LVL 2 $1,431.00 HC CATH, INTRAVAS ULTRASOUND LVL 3 $2,147.00 HC CATH, INTRAVAS ULTRASOUND LVL 4 $2,861.00 HC CATH, INTRAVAS ULTRASOUND LVL 5 $3,577.00 HC CATH, INTRAVAS ULTRASOUND LVL 6 $6,558.00 HC CATH, INTRAVAS ULTRASOUND LVL 8 $10,732.00 HC CATH,HEMODIALYSIS,SHORT-TERM LVL 1 $835.00 HC CATH,HEMODIALYSIS,SHORT-TERM LVL 2 $1,670.00 HC CATH,HEMODIALYSIS,SHORT-TERM LVL 3 $2,147.00 HC CATH,HEMODIALYSIS,SHORT-TERM LVL 4 $2,861.00 HC CATH,HEMODIALYSIS,SHORT-TERM LVL 5 $3,577.00 HC CATHETER ASPIRATION NASOTRACHEAL $476.00 HC CATHETER OCCLUSION LVL 1 $477.00 HC CATHETER OCCLUSION LVL 2 $835.00 HC CATHETER OCCLUSION LVL 3 $1,670.00 HC CATHETER OCCLUSION LVL 4 $2,147.00 HC CATHETER OCCLUSION LVL 5 $2,861.00 HC CATHETER OCCLUSION LVL 6 $3,577.00 HC CATHETER, ABLATION LVL 1 $3,577.00 HC CATHETER, ABLATION LVL 10 $14,904.00 HC CATHETER, ABLATION LVL 2 $6,558.00 HC CATHETER, ABLATION LVL 3 $8,048.00 HC CATHETER, ABLATION LVL 4 $10,732.00 HC CATHETER, ABLATION LVL 5 $11,923.00 HC CATHETER, ABLATION LVL 8 $16,693.00 HC CATHETER, ABLATION LVL 9 $13,415.00 HC CATHETER, GUIDING LVL 1 $538.00 HC CATHETER, GUIDING LVL 10 $3,697.00 HC CATHETER, GUIDING LVL 11 $4,114.00 HC CATHETER, GUIDING LVL 12 $4,710.00 HC CATHETER, GUIDING LVL 13 $5,307.00 HC CATHETER, GUIDING LVL 14 $5,903.00 29 of 155 Procedure Price HC CATHETER, GUIDING LVL 15 $6,201.00 HC CATHETER, GUIDING LVL 2 $864.00 HC CATHETER, GUIDING LVL 3 $1,193.00 HC CATHETER, GUIDING LVL 4 $1,520.00 HC CATHETER, GUIDING LVL 5 $1,848.00 HC CATHETER, GUIDING LVL 6 $2,176.00 HC CATHETER, GUIDING LVL 7 $2,534.00 HC CATHETER, GUIDING LVL 8 $2,891.00 HC CATHETER, GUIDING LVL 9 $3,280.00 HC CATHETER, INTRASPINAL LVL 1 $3,577.00 HC CATHETER, INTRASPINAL LVL 2 $6,558.00 HC CATHETER, INTRASPINAL LVL 7 $14,606.00 HC CATHETER, URETERAL LVL 1 $835.00 HC CATHETER, URETERAL LVL 2 $1,431.00 HC CATHETER, URETERAL LVL 3 $2,861.00 HC CATHETER, URETERAL LVL 4 $3,935.00 HC CATHETER, URETERAL LVL 5 $5,247.00 HC CATHETER, URETERAL LVL 6 $6,558.00 HC CATHETER, URETERAL LVL 7 $6,440.00 HC CATHETER, URETERAL LVL 8 $7,512.00 HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 1 $1,431.00 HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 2 $2,861.00 HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 3 $3,935.00 HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 4 $5,247.00 HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 5 $6,558.00 HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 6 $6,440.00 HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 7 $7,512.00 HC CEREBR SEIZURE 16/> CH; EA 24 HRS $4,324.00 HC CEREBR SEIZURE 8-CH; EA 24 HRS $3,709.00 HC CERV HALO W JKT VEST LVL 1 $3,577.00 HC CERV HALO W JKT VEST LVL 2 $6,558.00 HC CERVICAL FOAM COLLAR LVL 1 $334.00 HC CERVICAL FOAM COLLAR LVL 2 $501.00 HC CERVICAL FOAM COLLAR LVL 3 $667.00 HC CERVICAL FOAM COLLAR LVL 4 $835.00 HC CERVICAL SPINE 2 OR 3 VIEWS $528.00 HC CERVICAL SPINE MIN 4 VIEWS $753.00 30 of 155 Procedure Price HC CHANGE GASTROSTOMY TUBE $2,379.00 HC CHANGE G-TUBE TO G-J PERC $4,493.00 HC CHANGE OF CYSTOSTOMY TUBE COMPLICATED $1,330.00 HC CHANGE OF CYSTOSTOMY TUBE SIMPLE $626.00 HC CHANGE OF URETER TUBE/STENT $2,802.00 HC CHANGE URETER STENT PERCUT $5,653.00 HC CHEM CAUT GRANULATION TISS $423.00 HC CHEM DEPENDENCY GROUP IOP $1,258.00 HC CHEMO ANTI-NEOPL SQ/IM $184.00 HC CHEMO CNS INTRATHECAL W LP $1,068.00 HC CHEMO HORMON ANTINEOPL SQ/IM $220.00 HC CHEMO IA PUSH TECHNIQUE $366.00 HC CHEMO IV INFUS EACH ADDL SEQ $143.00 HC CHEMO PROLONG INFUSE W/PUMP $973.00 HC CHEMO, IV INFUSION, 1 HR $504.00 HC CHEMO, IV INFUSION, ADDL HR $186.00 HC CHEMO, IV PUSH, ADDL DRUG $352.00 HC CHEMO, IV PUSH, SNGL DRUG $396.00 HC CHEMODENERV 1 EXTREM 1-4 MUSC $1,506.00 HC CHEMODENERV 1 EXTREM 1-4 MUSC ADDTL $457.00 HC CHEMODENERV 1 EXTREM 5/> MUSC $1,506.00 HC CHEMODENERV 1 EXTREM 5/> MUSC ADDTL $457.00 HC CHEMODENERV MUSC MIGRAINE $559.00 HC CHEMODENERV MUSC NECK DYSTON $860.00 HC CHEMODENERV TRUNK MUSC 1-5 $1,759.00 HC CHEMODENERV TRUNK MUSC 6/> $1,759.00 HC CHEMODENERVATION; FACE NERVE MUSCLES $1,004.00 HC CHEST PT INIT OR EVAL $112.00 HC CHEST PT SUBSEQUENT $148.00 HC CHEST/NG TUBE; SUCTION/DRAIN SUPPLY LVL1 $835.00 HC CHEST/NG TUBE; SUCTION/DRAIN SUPPLY LVL2 $1,431.00 HC CHEST/NG TUBE; SUCTION/DRAIN SUPPLY LVL3 $2,147.00 HC CHOLANGIOGRAM INTRAOP $972.00 HC CHOLANGIOGRAM INTRAOP ADDTL $570.00 HC CHOLECYSTOSTOMY PERC $6,850.00 HC CIRCUMCISION $608.00 HC CL LACERATION MOUTH VESTIB >2.5 CM $1,595.00 31 of 155 Procedure Price HC CL LACERATION MOUTH VESTIB 2.5 CM/< $614.00 HC CL TX ACLAV DISLOC W MANIP $481.00 HC CL TX ANKLE DISLOC W ANESTH $3,656.00 HC CL TX ANKLE DISLOCATION WO ANESTH $345.00 HC CL TX ART FX MCP/IP JNT W MANIP $3,196.00 HC CL TX BIMALLEOLAR ANKLE FX W MANIP $1,240.00 HC CL TX BIMALLEOLAR ANKLE FX WO MANIP $505.00 HC CL TX C HUMERUS FX W MANIP $340.00 HC CL TX CALCANEAL FX WO MANIP $506.00 HC CL TX CARP B FX (NOT NAV) WO MANIP $505.00 HC CL TX CARPAL SCAPHOID FX WO MANIP $410.00 HC CL TX CLAVICULAR FX WO MANIP $500.00 HC CL TX CMC DISL W MANIP EA $352.00 HC CL TX CMC DISLOC THUMB W MANIP $375.00 HC CL TX CMC FX DISLOC THUMB W MANIP $481.00 HC CL TX COCCYGEAL FRACTURE $506.00 HC CL TX D PHAL FX FGR/THMB W MANIP $481.00 HC CL TX D PHAL FX FGR/THMB WO MANIP $375.00 HC CL TX DISTL FIB FX W MANIP $568.00 HC CL TX DSTL FIB FX WO MANIP $507.00 HC CL TX DSTL RADIOULNAR DISLOC W MANIP $345.00 HC CL TX EC HUMERUS FX W MANIP $843.00 HC CL TX EC HUMERUS FX WO MANIP $506.00 HC CL TX FX GT PHALANX W MANIP $352.00 HC CL TX FX GT PHALANX WO MANIP $220.00 HC CL TX FX PHALANX/PHALANG W MANIP $526.00 HC CL TX FX PHALNX/PHALNG WO MANIP $507.00 HC CL TX GR TUBEROSITY FX WO MANIP $506.00 HC CL TX GTR TROCHNTRC FX WO MANIP $506.00 HC CL TX HUMERUS FX W MANIP $375.00 HC CL TX HUMERUS FX WO MANIP $506.00 HC CL TX IC SPINE/TUBEROSITY FX KNEE $506.00 HC CL TX IP JNT D W MANIP WO ANESTH $386.00 HC CL TX IP JOINT DISL WO ANESTH $298.00 HC CL TX IP JT DISLOC W MANIP W ANESTH $1,512.00 HC CL TX KNEE DISL WO ANESTH $345.00 HC CL TX LUNATE DISLOC W MANIP $345.00 32 of 155 Procedure Price HC CL TX MANDIBULAR FX WO MANIP $1,082.00 HC CL TX MC FX SGL W MANIP $352.00 HC CL TX MC FX SGL WO MANIP EA BONE $445.00 HC CL TX MCP DISLOC SGL W MANIP $350.00 HC CL TX MCP DISLOC W MANIP W ANESTH $481.00 HC CL TX MED ANKLE FX W/ MANIP $4,565.00 HC CL TX METATARSAL FX W MANIP $481.00 HC CL TX METATARSAL FX WO MANIP $635.00 HC CL TX MONTEGGIA ELB FX W MANIP $3,176.00 HC CL TX MTP JNT DISLOC WO ANESTH $481.00 HC CL TX NASAL BONE FX W STABILIZ $2,021.00 HC CL TX NURSEMAID ELBOW W MANIP $481.00 HC CL TX OF RADIAL SHAFT FX WO MANIP $506.00 HC CL TX ORBIT FX NOT BLOW OUT WO MANIP $1,100.00 HC CL TX PATELLAR DISLOCATION W ANESTH $3,829.00 HC CL TX PATELLAR DISLOCATION WO ANESTH $298.00 HC CL TX PELVIC RING FX WO MANIP $506.00 HC CL TX PHAL SHAFT FX WO MANIP $505.00 HC CL TX PHALANG SHFT FX W MANIP $481.00 HC CL TX POST HIP DISLOC WO ANESTH $481.00 HC CL TX POSTOP HIP DISLOC W ANESTH $2,582.00 HC CL TX PROX FEM FX WO MANIP $506.00 HC CL TX PROX FIB/SHAFT FX WO MANIP $506.00 HC CL TX PROX HUMERAL FX W MANIP $3,456.00 HC CL TX PROX HUMERAL FX WO MANIP $437.00 HC CL TX PROX TIBIAL FX WO MANIP $506.00 HC CL TX RADIAL & ULNA FX W MANIP $481.00 HC CL TX RADIAL & ULNAR FX WO MANIP $416.00 HC CL TX RADIAL HD/NECK FX W MANIP $481.00 HC CL TX RADIAL HD/NECK FX WO MANIP $481.00 HC CL TX RADIAL SHFT FX W MANIP $1,240.00 HC CL TX SC/TC FEMUR FX WO MANIP $506.00 HC CL TX SC/TC HUMERUS FX WO MANIP $506.00 HC CL TX SC/TX HUMERUS SHFT FX W MANIP $481.00 HC CL TX SESAMOID FRACTURE $506.00 HC CL TX SHDR DISLOC W NK FX W MANIP $445.00 HC CL TX SHLDR DISL W MANI WO ANESTH $638.00 33 of 155 Procedure Price HC CL TX SHLDR DISL W MANIP W ANESTH $3,813.00 HC CL TX SHLDR DISLOC & FX GT W MANIP $1,240.00 HC CL TX TALUS FX W MANIP $2,977.00 HC CL TX TALUS FX WO MANIP $507.00 HC CL TX TARSAL BONE DISLOC WO ANESTH $426.00 HC CL TX TIB SHFT FX W MANIP $3,196.00 HC CL TX TIB SHFT FX WO MANIP $506.00 HC CL TX TMJ DISLOCATION INITIAL $204.00 HC CL TX TRAUMA HIP DISLOC W ANESTH $1,240.00 HC CL TX TRAUMA HIP DISLOC WO ANESTH $631.00 HC CL TX TRIMALL ANKLE FX W MANIP $3,198.00 HC CL TX ULNAR FX PROXIMAL END W MANIP $352.00 HC CL TX ULNAR SHAFT FX WO MANIP $506.00 HC CL TX ULNAR SHFT FX W MANIP $481.00 HC CL TX VERTEBRAL BODY FX WO MANIP $506.00 HC CL TX WB DSTL TIB FX W MANIP $3,196.00 HC CL TX WB DSTL TIB WO MANIP $506.00 HC CL TXT OF NASAL BONE FX WO MANIP $500.00 HC CLAVICLE COMPLETE $491.00 HC CLOSED TX OF ULNAR STYLOID FX $505.00 HC CLOSED TX PATELLAR FX WO MANIP $510.00 HC CLTX MEDIAL ANKLE FX WO MANIP $506.00 HC CLTX POST ANKLE FX WO MANIP $506.00 HC CLTX RAD/INTERCARPL DISL 1+ BONE W MANIP $960.00 HC CNTRL POST EPISTAX INIT $704.00 HC CO2 EXPIRED GAS BY IR $313.00 HC COCHLEAR IMPLANT SYSTEM LVL 1 $2,088.00 HC COCHLEAR IMPLANT SYSTEM LVL 11 $44,713.00 HC COCHLEAR IMPLANT SYSTEM LVL 12 $53,657.00 HC COCHLEAR IMPLANT SYSTEM LVL 13 $62,598.00 HC COCHLEAR IMPLANT SYSTEM LVL 14 $71,542.00 HC COCHLEAR IMPLANT SYSTEM LVL 15 $80,484.00 HC COCHLEAR IMPLANT SYSTEM LVL 16 $89,427.00 HC COCHLEAR IMPLANT SYSTEM LVL 2 $3,577.00 HC COCHLEAR IMPLANT SYSTEM LVL 3 $5,963.00 HC COCHLEAR IMPLANT SYSTEM LVL 4 $8,048.00 HC COCHLEAR IMPLANT SYSTEM LVL 5 $9,539.00 34 of 155 Procedure Price HC COGNITIVE SKILLS DEVELOPMENT EA 15M $153.00 HC COGNITIVE TEST BY HC PRO $461.00 HC COLLAG DRESS 16 SQIN/ $112.00 HC COLLAGEN IMPLANT URINARY TRACT 2.5 ML LVL 1 $835.00 HC COLLAGEN IMPLANT URINARY TRACT 2.5 ML LVL 2 $1,670.00 HC COLLAGEN IMPLANT URINARY TRACT 2.5 ML LVL 3 $2,147.00 HC COLLAGEN IMPLANT URINARY TRACT 2.5 ML LVL 4 $2,861.00 HC COLLAGEN IMPLANT URINARY TRACT 2.5 ML LVL 5 $3,577.00 HC COLLECT BLOOD FROM PICC $141.00 HC COLON W AIR AND BARIUM $1,527.00 HC COLON W CONTRAST $1,068.00 HC COLONOSCOPY LEVEL I $8,057.00 HC COLONOSCOPY LEVEL II $9,005.00 HC COLONOSCOPY LEVEL III $10,125.00 HC COLONOSCOPY LEVEL IV $12,208.00 HC COLONOSCOPY W/DECOMPRESSION $2,349.00 HC COMMUNITY/WORK TRAINING EA 15M $175.00 HC COMP EP EVAL W INDUCTION $13,953.00 HC COMP EP EVAL W LA RECORDING $9,174.00 HC COMP EP EVAL W LV RECORDING $13,536.00 HC COMP EP EVAL WO A INDUCTION $13,953.00 HC COMPL ACUTE ABDOMEN W PA CHEST $758.00 HC COMPLETE CERVICAL SPINE $945.00 HC COMPLEX CYSTOMETROGRAM $1,121.00 HC COMPLEX UROFLOWMETRY $618.00 HC COMPRESSION STOCKING BK18-30 LVL 1 TAKE HOME $347.00 HC COMPRESSION STOCKING BK18-30 LVL 2 TAKE HOME $520.00 HC COMPRESSION STOCKING BK18-30 LVL 3 TAKE HOME $693.00 HC COMPRESSION STOCKING BK18-30 LVL 4 TAKE HOME $868.00 HC COMPRESSION STOCKING BK30-40 LVL 1 TAKE HOME $347.00 HC COMPRESSION STOCKING BK30-40 LVL 2 TAKE HOME $520.00 HC COMPRESSION STOCKING BK30-40 LVL 3 TAKE HOME $693.00 HC COMPRESSION STOCKING BK30-40 LVL 4 TAKE HOME $868.00 HC COMPRESSION STOCKING BK40-50 LVL 1 TAKE HOME $347.00 HC COMPRESSION STOCKING BK40-50 LVL 2 TAKE HOME $520.00 HC COMPRESSION STOCKING BK40-50 LVL 3 TAKE HOME $693.00 HC COMPRESSION STOCKING BK40-50 LVL 4 TAKE HOME $868.00 35 of 155 Procedure Price HC CONN TISS, HUMAN (INC FASCIA) LVL 1 $2,088.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 10 $8,942.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 12 $10,732.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 13 $11,627.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 2 $3,577.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 20 $17,886.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 3 $4,472.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 4 $5,963.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 5 $6,706.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 6 $8,048.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 7 $8,347.00 HC CONN TISS, HUMAN (INC FASCIA) LVL 9 $8,048.00 HC CONN TISS, NON-HUMAN LVL 1 $2,088.00 HC CONN TISS, NON-HUMAN LVL 10 $8,942.00 HC CONN TISS, NON-HUMAN LVL 14 $12,520.00 HC CONN TISS, NON-HUMAN LVL 2 $3,577.00 HC CONN TISS, NON-HUMAN LVL 20 $17,886.00 HC CONN TISS, NON-HUMAN LVL 3 $4,472.00 HC CONN TISS, NON-HUMAN LVL 4 $5,963.00 HC CONN TISS, NON-HUMAN LVL 5 $6,706.00 HC CONN TISS, NON-HUMAN LVL 6 $8,048.00 HC CONN TISS, NON-HUMAN LVL 7 $8,347.00 HC CONN TISS, NON-HUMAN LVL 8 $9,539.00 HC CONT BRONCHODILATOR TX 1ST HOUR $225.00 HC CONT BRONCHODILATOR TX EA ADDL HOUR $225.00 HC CONT VENO VENOUS HEMOFILTRATION (CVVH) $4,802.00 HC CONTINUED CARE PER DIEM $376.00 HC CONTINUED CARE PER DIEM ADOL/YA $483.00 HC CONTINUING RADIATION PHYSICS CONSULT $627.00 HC CONTINUOUS GLUCOSE MONITOR $486.00 HC CONTINUOUS PULSE OX $708.00 HC CONTRAST GADOLINIUM NOS PER ML $23.00 HC CONTROL NASAL HEMORRH ANT COMPL $351.00 HC CONTROL NASAL HEMORRH ANT SMPL $205.00 HC CONTROL OROPHARYNGEAL HEMORRH REQ SURG $5,231.00 HC CONTROL OROPHARYNGEAL HEMORRH SMPL $310.00 HC CONVERSION EXT BIL DRG CATH $6,756.00 36 of 155 Procedure Price HC CONVERT NEPHROSTOMY CATH EXIST TRACT $1,627.00 HC CORNEAL TISSUE PROCESSING AND PERSERVING $17,609.00 HC CORONARY ART/GRFT ANGIO S&I $9,425.00 HC CORONARY ARTERY ANGIO S&I $13,187.00 HC CORPORA CAVERNOSOGRAM $1,279.00 HC CPR $1,155.00 HC CREATININE; BLOOD $71.00 HC CREP E/N/E/L 1.1-2.5 CM $465.00 HC CREP E/N/E/L 2.6-7.5 CM $1,088.00 HC CREP E/N/E/L EA ADDTL 5 CM/< $310.00 HC CREP F/G/H/F 1.1-2.5 CM $1,086.00 HC CREP F/G/H/F 2.6-7.5 CM $1,509.00 HC CREP F/G/H/F EA ADD 5 CM/< $465.00 HC CREP S/A/L 2.6-7.5 CM $465.00 HC CREP S/A/L EA ADD 5 CM/< $314.00 HC CREP TRUNK 1.1-2.5 CM $1,071.00 HC CREP TRUNK 2.6-7.5 CM $751.00 HC CRITICAL CARE 30-74 MIN $3,249.00 HC CRITICAL CARE EACH ADDTL 30 MIN $1,297.00 HC CRRT DAILY MONITORING FEE $3,418.00 HC CRYOABLATION PROBE LVL 1 $835.00 HC CRYOABLATION PROBE LVL 10 $6,558.00 HC CRYOABLATION PROBE LVL 11 $6,440.00 HC CRYOABLATION PROBE LVL 12 $7,512.00 HC CRYOABLATION PROBE LVL 14 $9,658.00 HC CRYOABLATION PROBE LVL 16 $10,493.00 HC CRYOABLATION PROBE LVL 17 $11,446.00 HC CRYOABLATION PROBE LVL 18 $12,400.00 HC CRYOABLATION PROBE LVL 2 $1,431.00 HC CRYOABLATION PROBE LVL 22 $16,693.00 HC CRYOABLATION PROBE LVL 23 $13,415.00 HC CRYOABLATION PROBE LVL 25 $16,396.00 HC CRYOABLATION PROBE LVL 26 $17,886.00 HC CRYOABLATION PROBE LVL 27 $19,376.00 HC CRYOABLATION PROBE LVL 3 $2,147.00 HC CRYOABLATION PROBE LVL 4 $2,861.00 HC CRYOABLATION PROBE LVL 5 $3,577.00 37 of 155 Procedure Price HC CRYOABLATION PROBE LVL 6 $3,935.00 HC CRYOABLATION PROBE LVL 7 $4,591.00 HC CRYOABLATION PROBE LVL 8 $5,247.00 HC CRYOABLATION PROBE LVL 9 $5,903.00 HC CRYOPRESERVE STEM CELLS $2,092.00 HC CT ABD & PELVIS W WO CONTR 1+ REG/SEC $6,081.00 HC CT ABD & PELVIS WO CONTRAST $5,126.00 HC CT ABDOMEN & PELVIS W CONTRAST $6,081.00 HC CT ABDOMEN W CONTRAST $3,815.00 HC CT ABDOMEN W WO CONTRAST $4,533.00 HC CT ABDOMEN WO CONTRAST $2,525.00 HC CT ANGIO ABD AND PELV WO W CONTRAST $6,081.00 HC CT ANGIOGRAPHY ABDOMEN W WO CONTRAST $5,857.00 HC CT ANGIOGRAPHY AORTA ILIOFEMORAL RUNOFF $7,586.00 HC CT ANGIOGRAPHY CHEST W WO CONTRAST $4,481.00 HC CT ANGIOGRAPHY HEAD W WO CONTRAST $5,781.00 HC CT ANGIOGRAPHY HEART $3,199.00 HC CT ANGIOGRAPHY LOWER EXTR W WO CONTRAST $3,924.00 HC CT ANGIOGRAPHY NECK W WO CONTRAST $4,705.00 HC CT ANGIOGRAPHY PELVIS W WO CONTRAST $5,308.00 HC CT ANGIOGRAPHY UPPER EXTR W WO CONTRAST $4,671.00 HC CT CERVICAL SPINE W CONTRAST $3,869.00 HC CT CERVICAL SPINE W WO CONTRAST $4,522.00 HC CT CERVICAL SPINE WO CONTRAST $3,825.00 HC CT CHEST W CONTRAST $3,850.00 HC CT CHEST W WO CONTRAST $4,628.00 HC CT CHEST WO CONTRAST $3,816.00 HC CT COLONOGRAPHY SCREEN $852.00 HC CT COLONOGRAPHY WO CONTRAST DX $3,305.00 HC CT GUIDANCE FOR RADIATION THERAPY $1,310.00 HC CT GUIDANCE NEEDLE PLACEMENT $4,768.00 HC CT GUIDANCE TISSUE ABLATION $3,722.00 HC CT HEAD OR BRAIN W CONTRAST $3,625.00 HC CT HEAD OR BRAIN W WO CONTRAST $4,054.00 HC CT HEAD OR BRAIN WO CONTRAST $3,337.00 HC CT HEART WO CONTRAST W CALCIUM SCORE $358.00 HC CT LIMITED OR FOLLOWUP STUDY $1,575.00 38 of 155 Procedure Price HC CT LOWER EXTR W CONTRAST $3,754.00 HC CT LOWER EXTR W WO CONTRAST $3,825.00 HC CT LOWER EXTR WO CONTRAST $3,662.00 HC CT LUMBAR SPINE W CONTRAST $4,191.00 HC CT LUMBAR SPINE W WO CONTRAST $4,460.00 HC CT LUMBAR SPINE WO CONTRAST $3,916.00 HC CT LUNG CANCER SCREEN $119.00 HC CT MAXILLOFACIAL W CONTRAST $3,434.00 HC CT MAXILLOFACIAL W WO CONTRAST $4,062.00 HC CT MAXILLOFACIAL WO CONTRAST $3,180.00 HC CT ORBIT SELLA MID INNER EAR W CONTR $3,733.00 HC CT ORBIT SELLA MID INNER EAR W WO CONTR $3,881.00 HC CT ORBIT SELLA MID INNER EAR WO CONTR $3,643.00 HC CT PELVIS W CONTRAST $4,074.00 HC CT PELVIS W WO CONTRAST $4,716.00 HC CT PELVIS WO CONTRAST $3,893.00 HC CT PERFUSION W/CONTRAST CBF $667.00 HC CT SCAN FOR STEREOTACTIC LOCALIZATION $2,265.00 HC CT SOFT TISSUE NECK W CONTRAST $3,836.00 HC CT SOFT TISSUE NECK W WO CONTRAST $4,287.00 HC CT SOFT TISSUE NECK WO CONTRAST $3,629.00 HC CT THORACIC SPINE W CONTRAST $3,959.00 HC CT THORACIC SPINE W WO CONTRAST $4,224.00 HC CT THORACIC SPINE WO CONTRAST $3,505.00 HC CT UPPER EXTR W CONTRAST $3,959.00 HC CT UPPER EXTR W WO CONTRAST $4,257.00 HC CT UPPER EXTR WO CONTRAST $3,549.00 HC CTRL POST EPISTAX SQ $471.00 HC CUSTOM PLASTIC AFO SOLID ANKLE LVL 1 $1,431.00 HC CUSTOM PLASTIC AFO SOLID ANKLE LVL 2 $2,861.00 HC CUSTOM PLASTIC AFO SOLID ANKLE LVL 3 $3,935.00 HC CUSTOM PLASTIC AFO SOLID ANKLE LVL 4 $5,247.00 HC CUSTOM PLASTIC AFO SOLID ANKLE LVL 5 $6,558.00 HC CUSTOM PLASTIC AFO W ANKLE JNT LVL 1 $1,431.00 HC CUSTOM PLASTIC AFO W ANKLE JNT LVL 2 $2,861.00 HC CUSTOM PLASTIC AFO W ANKLE JNT LVL 3 $3,935.00 HC CUSTOM PLASTIC AFO W ANKLE JNT LVL 4 $5,247.00 39 of 155 Procedure Price HC CUSTOM PLASTIC AFO W ANKLE JNT LVL 5 $6,558.00 HC CUSTOM PLASTIC AFO W ANKLE JNT LVL 6 $6,440.00 HC CUSTOM PLASTIC AFO W ANKLE JNT LVL 7 $7,512.00 HC CUSTOM STANDARD PACKS, KITS LVL 1 $835.00 HC CUSTOM STANDARD PACKS, KITS LVL 2 $1,431.00 HC CUSTOM STANDARD PACKS, KITS LVL 3 $2,147.00 HC CUSTOM STANDARD PACKS, KITS LVL 4 $2,861.00 HC CUSTOM STANDARD PACKS, KITS LVL 5 $3,577.00 HC CUSTOM STANDARD PACKS, KITS LVL 6 $3,935.00 HC CUSTOM STANDARD PACKS, KITS LVL 7 $2,861.00 HC CUSTOM TLSO 2PC PL SHELL W LINER LVL 6 $12,356.00 HC CUSTOM TLSO 2PC PL SHELL WO LINER LVL1 $835.00 HC CUSTOM TLSO 2PC PL SHELL WO LINER LVL10 $13,415.00 HC CUSTOM TLSO 2PC PL SHELL WO LINER LVL11 $14,904.00 HC CUSTOM TLSO 2PC PL SHELL WO LINER LVL2 $3,577.00 HC CUSTOM TLSO 2PC PL SHELL WO LINER LVL3 $6,558.00 HC CVSLR STRESS TEST; TRACING $1,448.00 HC CYMETRA INJECTABLE 1 CC LVL 1 $334.00 HC CYMETRA INJECTABLE 1 CC LVL 2 $501.00 HC CYMETRA INJECTABLE 1 CC LVL 3 $667.00 HC CYMETRA INJECTABLE 1 CC LVL 4 $835.00 HC CYMETRA INJECTABLE 1 CC LVL 5 $859.00 HC CYMETRA INJECTABLE 1 CC LVL 6 $1,001.00 HC CYMETRA INJECTABLE 1 CC LVL 7 $1,144.00 HC CYMETRA INJECTABLE 1 CC LVL 8 $1,289.00 HC CYMETRA INJECTABLE 1 CC LVL 9 $1,431.00 HC CYSTO W DIL OF URETHRAL STRICTURE $4,413.00 HC CYSTO W EJACULATORY DUCT CATH $636.00 HC CYSTO W URET CATH & BRUSH BX $2,543.00 HC CYSTOGRAM MIN 3 VIEWS $812.00 HC CYSTOMETROGRAM W/VP $686.00 HC CYSTOURETHROSCOPY $1,824.00 HC CYSTOURETHROSCOPY W URETERAL CATH $4,606.00 HC DAILY CARE ICU ONCOLOGY $4,121.00 HC DAILY CARE INTENSIVE $4,833.00 HC DAILY CARE INTENSIVE STEP DOWN $3,241.00 HC DAILY CARE INTENSIVE TELE $3,087.00 40 of 155 Procedure Price HC DAILY CARE INTERMEDIATE ICU $4,121.00 HC DAILY CARE INTERMEDIATE ICU TELE $3,087.00 HC DAILY CARE NURSERY LEVEL I $1,071.00 HC DAILY CARE NURSERY LEVEL II $1,824.00 HC DAILY CARE NURSERY LEVEL III $2,663.00 HC DAILY CARE NURSERY LEVEL IV NICU $3,589.00 HC DAILY CARE PACU $1.00 HC DAILY CARE PRIVATE OB $1,563.00 HC DAILY CARE PRIVATE REHAB $1,563.00 HC DAILY CARE PRIVATE ROUTINE $1,563.00 HC DAILY CARE SEMIPRIVATE DETOX $2,287.00 HC DAILY CARE SEMIPRIVATE MED/SURG (3 OR 4 BEDS) $1,563.00 HC DAILY CARE SEMIPRIVATE OB (3 OR 4 BEDS) $1,563.00 HC DAILY CARE SEMIPRIVATE OBSTETRICS $1,563.00 HC DAILY CARE SEMIPRIVATE OBSTETRICS INTERMEDIATE $3,087.00 HC DAILY CARE SEMIPRIVATE ONCOLOGY $1,563.00 HC DAILY CARE SEMIPRIVATE PSYCH $2,287.00 HC DAILY CARE SEMIPRIVATE PSYCH (3 OR 4 BEDS) $2,287.00 HC DAILY CARE SEMIPRIVATE REHAB $1,563.00 HC DAILY CARE SEMIPRIVATE ROUTINE $1,563.00 HC DAILY CARE SEMIPRIVATE TELE $3,087.00 HC DAILY CARE SUBACUTE (SKILLED) $891.00 HC DEB BONE ADD-ON $2,079.00 HC DEB MUSC/FASCIA ADD-ON $1,718.00 HC DEB SUBQ TISSUE ADD-ON $1,768.00 HC DEBR O FX SKIN TO BONE $1,802.00 HC DEBR W OPEN FX SKIN & SQ $1,433.00 HC DEBRIDE NAILS 1-5 $170.00 HC DEBRIDE NAILS 6/> $222.00 HC DEBRIDE SKIN & BONE $7,138.00 HC DEBRIDE SKIN & MUSCLE $6,921.00 HC DEBRIDE SKIN MUSC AT FX SITE $1,035.00 HC DEBRIDE SKIN TO SQ TISSUE $1,269.00 HC DECLOT VASCULAR DEVICE $1,164.00 HC DEEP I&D - UA/ELBOW $3,082.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 1 $477.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 10 $3,577.00 41 of 155 Procedure Price HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 2 $835.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 3 $1,252.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 4 $1,670.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 5 $2,088.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 6 $2,147.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 7 $2,504.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 8 $2,861.00 HC DENTAL/MAXILLOFACIAL IMPLANTS LVL 9 $3,220.00 HC DERMACELL PER 1 SQ CM LVL 1 $334.00 HC DERMACELL PER 1 SQ CM LVL 2 $501.00 HC DERMACELL PER 1 SQ CM LVL 3 $667.00 HC DERMACELL PER 1 SQ CM LVL 4 $835.00 HC DERMAGRAFT PER SQ CM LVL 1 $194.00 HC DERMAGRAFT PER SQ CM LVL 2 $194.00 HC DERMAGRAFT PER SQ CM LVL 3 $194.00 HC DERMAGRAFT PER SQ CM LVL 4 $194.00 HC DERMAGRAFT PER SQ CM LVL 5 $194.00 HC DESIGN MLC DEVICE FOR IMRT $1,893.00 HC DESTR W NEUROLYTIC CELIAC PLEXUS $5,634.00 HC DESTR W NEUROLYTIC OTHER PERIPH NRV $2,850.00 HC DESTR W NEUROLYTIC SUP HYPOGASTRIC PLEX $2,850.00 HC DESTR W NEUROLYTIC TRIGEM NRV INF ALV BR $5,634.00 HC DESTR W NEUROLYTIC; INTERCOSTAL NRV $5,742.00 HC DESTROY C/TH FACET JNT ADDL BILAT $4,507.00 HC DESTROY C/TH FACET JNT ADDL UNIL $4,507.00 HC DESTROY CERV/THOR FACET JNT BILAT $5,634.00 HC DESTROY CERV/THOR FACET JNT UNIL $5,634.00 HC DESTROY L/S FACET JNT ADDL BILAT $4,507.00 HC DESTROY L/S FACET JNT ADDL UNIL $4,507.00 HC DESTROY LUMB/SAC FACET JNT BILAT $5,634.00 HC DESTROY LUMB/SAC FACET JNT UNIL $5,634.00 HC DESTRUCT B9 LESION 1-14 $270.00 HC DEVELOPMENTAL SCREEN $327.00 HC DEVELOPMENTAL TEST EXTEND $334.00 HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 1 $477.00 HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 2 $2,088.00 HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 3 $3,577.00 42 of 155 Procedure Price HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 4 $4,472.00 HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 5 $5,963.00 HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 6 $6,706.00 HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 7 $8,048.00 HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 8 $8,347.00 HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 9 $9,539.00 HC DIABETES OP SELF-MGMT, GROUP 30 MIN $89.00 HC DIABETES OP SELF-MGMT, INDIV 30 MIN $160.00 HC DIALYSIS DAILY TREATMENT CAPD $600.00 HC DIALYSIS DAILY TREATMENT CCPD $600.00 HC DIALYSIS TRAINING HEMODIALYSIS $1,450.00 HC DIALYSIS TRAINING INCOMPLETE CAPD $1,400.00 HC DIALYSIS TRAINING INCOMPLETE CCPD $1,400.00 HC DIALYSIS, NOT HD, 1 EVAL $993.00 HC DIALYSIS, NOT HD; REPEAT EVAL $1,674.00 HC DIETARY CONSULT $85.00 HC DIL URETH STRICT SOUND MALE INITIAL $986.00 HC DILATE BILIARY DUCT/AMPULLA $3,600.00 HC DILATE BILIARY STRICTURE W/O STENT PERC $3,442.00 HC DILATE BILIARY STRICTURE W/STENT PERC $2,783.00 HC DILATE FOR STRICTURE OR OBSTR $1,398.00 HC DILATE NEPHROSTOMY TRACT PERC $4,633.00 HC DILATE URETERS/URETHRA/NEPHROSTOMY $4,902.00 HC DIRECT REFER HOSPITAL OBSERV $122.00 HC DISPOSABLE INSTRUMENTS LVL 1 $417.00 HC DISPOSABLE INSTRUMENTS LVL 10 $5,903.00 HC DISPOSABLE INSTRUMENTS LVL 11 $6,558.00 HC DISPOSABLE INSTRUMENTS LVL 2 $835.00 HC DISPOSABLE INSTRUMENTS LVL 3 $1,431.00 HC DISPOSABLE INSTRUMENTS LVL 4 $2,147.00 HC DISPOSABLE INSTRUMENTS LVL 5 $2,861.00 HC DISPOSABLE INSTRUMENTS LVL 6 $3,577.00 HC DISPOSABLE INSTRUMENTS LVL 7 $3,935.00 HC DISPOSABLE INSTRUMENTS LVL 8 $4,591.00 HC DISPOSABLE INSTRUMENTS LVL 9 $5,247.00 HC DISPOSABLE RADIOLOGY SUPPLIES LVL 1 $125.00 HC DISPOSABLE RADIOLOGY SUPPLIES LVL 2 $250.00 43 of 155 Procedure Price HC DISPOSABLE RADIOLOGY SUPPLIES LVL 3 $500.00 HC DISPOSABLE RADIOLOGY SUPPLIES LVL 4 $750.00 HC DISPOSABLE RADIOLOGY SUPPLIES LVL 5 $1,000.00 HC DISPOSABLE RADIOLOGY SUPPLIES LVL 6 $1,250.00 HC DLYD PLMT XTN PROSTH 1ST VSL $9,000.00 HC DLYD PLMT XTN PROSTH EA ADDL $3,000.00 HC DONATED BREAST MILK $77.00 HC DOPPLER COLOR FLOW $737.00 HC DOPPLER ECHO; COMPLETE $1,041.00 HC DOPPLER ECHO; LIMITED/ F-UP $455.00 HC DR ABSC CYST HEMAT MOUTH SIMPLE $617.00 HC DR ABSC CYST HEMATOM DENTOALVEOLAR $421.00 HC DR ABSC/HEMATOMA NASAL INT $500.00 HC DR EXT EAR ABSCESS/HEMATOMA COMPL $2,376.00 HC DR EXT EAR ABSCESS/HEMATOMA SIMPLE $441.00 HC DR LN ABSCESS/INFECTION SIMPLE $542.00 HC DRAIN ABSC APPENDIX OPEN $563.00 HC DRAIN ABSCESS RETROPERITONEAL OPEN $457.00 HC DRAIN BL W/CATH INSERTION SUPRAPUBIC $4,812.00 HC DRAIN EXTERNAL AUDITORY CANAL ABSCESS $441.00 HC DRAIN FINGER ABSC COMPLICATED $2,448.00 HC DRAIN FINGER ABSC SIMPLE $449.00 HC DRAIN PERIRENAL/RENAL ABSCESS OPEN $2,543.00 HC DRAIN PERITONEAL ABSCESS OR CYST; OPEN $457.00 HC DRAIN PRE/PERIVESIC SPACE ABSC $1,882.00 HC DRAIN/INJ INTERM JNT/BURSA $982.00 HC DRAIN/INJ INTERM JOINT/BURSA W US $1,279.00 HC DRAIN/INJ MAJOR JNT/BURSA $982.00 HC DRAIN/INJ MAJOR JNT/BURSA BILAT $1,737.00 HC DRAIN/INJ MAJOR JOINT/BURSA W US $576.00 HC DRAIN/INJECT SM JNT/BURSA $1,000.00 HC DRAINAGE CATH LVL 1 $835.00 HC DRAINAGE CATH LVL 12 $16,693.00 HC DRAINAGE CATH LVL 14 $14,904.00 HC DRAINAGE CATH LVL 2 $1,431.00 HC DRAINAGE CATH LVL 3 $2,147.00 HC DRAINAGE CATH LVL 4 $2,861.00 44 of 155 Procedure Price HC DRAINAGE CATH LVL 5 $3,577.00 HC DRAINAGE CATH LVL 6 $6,558.00 HC DRAINAGE CATH LVL 7 $8,048.00 HC DRAINAGE CATH LVL 8 $10,732.00 HC DRAINAGE CATH PLACEMENT W IMG GUIDANCE $4,414.00 HC DRAINAGE CATHS LVL 1 $3,577.00 HC DRAINAGE CATHS LVL 2 $6,558.00 HC DRAINAGE OF ABSCESS OF PALATE UVULA $614.00 HC DRAINAGE OF SCROTAL WALL ABCESS $2,332.00 HC DRAW BLOOD OFF VENOUS DEVICE $76.00 HC DRESS/DEBRID P-THICK BURN L >10% $658.00 HC DRESS/DEBRID P-THICK BURN M 5-10% $571.00 HC DRESS/DEBRID P-THICK BURN S <5% $504.00 HC DRESSING/SKIN SEALANTS LVL 1 $835.00 HC DRESSING/SKIN SEALANTS LVL 10 $6,558.00 HC DRESSING/SKIN SEALANTS LVL 11 $5,903.00 HC DRESSING/SKIN SEALANTS LVL 12 $6,440.00 HC DRESSING/SKIN SEALANTS LVL 13 $6,976.00 HC DRESSING/SKIN SEALANTS LVL 14 $7,512.00 HC DRESSING/SKIN SEALANTS LVL 15 $8,048.00 HC DRESSING/SKIN SEALANTS LVL 2 $1,431.00 HC DRESSING/SKIN SEALANTS LVL 3 $2,147.00 HC DRESSING/SKIN SEALANTS LVL 4 $2,861.00 HC DRESSING/SKIN SEALANTS LVL 5 $3,577.00 HC DRESSING/SKIN SEALANTS LVL 6 $3,935.00 HC DRESSING/SKIN SEALANTS LVL 7 $4,591.00 HC DRESSING/SKIN SEALANTS LVL 8 $5,247.00 HC DRESSING/SKIN SEALANTS LVL 9 $5,903.00 HC DRILL SKULL FOR IMPLANTATION $2,339.00 HC DRUG ADMIN & HEMODYNMIC MEAS $5,463.00 HC DSTR W NEUROLYTIC OTHER PERIPH NRV BILAT $2,850.00 HC DUPLEX A IVC IL/BPG; COMPL $1,435.00 HC DUPLEX A IVC IL/BPG; UNIL/LIMIT $767.00 HC DUPLEX ARTERIAL FLOW LIMITED $1,094.00 HC DUPLEX EXT VEINS UNIL/LIMIT $1,264.00 HC DUPLEX EXT VEINS; BILAT $1,877.00 HC DUPLEX FLOW PENILE V; COMPL $1,087.00 45 of 155 Procedure Price HC DUPLEX HEMODIALYSIS ACCESS $989.00 HC DUPLEX LE ART/BPG; BILAT $1,559.00 HC DUPLEX LE ART/BPG; UNIL/LIMIT $973.00 HC DUPLEX UE ART/BPG; BILAT $1,804.00 HC DUPLEX UE ART/BPG; UNIL/LIMIT $1,000.00 HC DX BONE MARROW BX & ASPIR $3,172.00 HC DX BRONCHOSCOPE/LAVAGE $2,139.00 HC DX BRONCHOSCOPE/WASH $3,211.00 HC DX GASTR INTUB W/ASP SGL SPEC $1,502.00 HC DX INJ SI JOINT ARTHROGRAPHY $1,818.00 HC DX LARYNGOSCOPY EXCL NB $3,121.00 HC DX MAMMO INCL CAD BILAT $632.00 HC DX MAMMO INCL CAD UNIL $404.00 HC DXA BONE DENSITY AXIAL $614.00 HC EARS, NOSE, THROAT SUP NON-AIRWAY LVL 12 $6,440.00 HC EARS, NOSE, THROAT SUP NON-AIRWAY LVL 20 $10,732.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 1 $835.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 2 $1,431.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 3 $2,147.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 4 $2,861.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 5 $3,577.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 6 $3,935.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 7 $4,591.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 8 $5,247.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 9 $5,903.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL10 $6,558.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL11 $5,903.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL13 $6,976.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL14 $7,512.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL15 $8,048.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL17 $9,123.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL19 $10,195.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL21 $10,016.00 HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL23 $4,576.00 HC ECG 0-24 HRS SCANNING ANALYSIS REPORT $768.00 HC ECG 0-48 HRS SCANNING ANALYSIS REPORT $1,132.00 HC ECG MONITOR 0-24 HRS RECORDING $370.00 46 of 155 Procedure Price HC ECG MONITOR 0-48 HRS RECORDING $370.00 HC ECHO TRANSESOPHAGEAL COMPLETE $2,084.00 HC ED LEVEL 1 INIT ASSESS $70.00 HC ED LEVEL 1 VISIT $180.00 HC ED LEVEL 2 INIT ASSESS $70.00 HC ED LEVEL 2 VISIT $362.00 HC ED LEVEL 3 INIT ASSESS $70.00 HC ED LEVEL 3 VISIT $610.00 HC ED LEVEL 4 INIT ASSESS $70.00 HC ED LEVEL 4 VISIT $1,024.00 HC ED LEVEL 5 INIT ASSESS $70.00 HC ED LEVEL 5 VISIT $1,560.00 HC EEG 41-60 MINUTES $1,658.00 HC EEG AWAKE & ASLEEP $1,507.00 HC EEG AWAKE & DROWSY $1,507.00 HC EEG CEREBRAL SILENCE $1,240.00 HC EEG COMA OR SLEEP ONLY $1,507.00 HC EEG DURING NONCRANIAL SURG $2,916.00 HC EEG OVER 1 HOUR $1,824.00 HC EGD DILATE STRICTURE $1,971.00 HC EGD GUIDE WIRE INSERTION $6,218.00 HC EKG SIGNAL-AVERAGED $614.00 HC ELBOW 2 VIEWS $480.00 HC ELBOW ARTHROGRAM $871.00 HC ELBOW MIN 3 VIEWS $570.00 HC ELECTROCONVULSIVE THERAPY $1,479.00 HC ELECTROPHYS MAP 3D ADD ON $13,691.00 HC EMBOLIZ PROTECT SYS LVL 1 $477.00 HC EMBOLIZ PROTECT SYS LVL 10 $8,048.00 HC EMBOLIZ PROTECT SYS LVL 11 $8,347.00 HC EMBOLIZ PROTECT SYS LVL 2 $835.00 HC EMBOLIZ PROTECT SYS LVL 3 $1,252.00 HC EMBOLIZ PROTECT SYS LVL 4 $1,670.00 HC EMBOLIZ PROTECT SYS LVL 5 $2,088.00 HC EMBOLIZ PROTECT SYS LVL 6 $3,577.00 HC EMBOLIZ PROTECT SYS LVL 7 $4,472.00 HC EMBOLIZ PROTECT SYS LVL 8 $5,963.00 47 of 155 Procedure Price HC EMBOLIZ PROTECT SYS LVL 9 $6,706.00 HC EMERG DIALYSIS ESRD PT $1,621.00 HC EMG ANAL/URETHR SPHINCT NOT NEEDLE $940.00 HC EMPLOYEE DRUG SCREEN $28.00 HC ENDO PROBE, BALLOON, SNARE, OTHER LVL 1 $835.00 HC ENDO PROBE, BALLOON, SNARE, OTHER LVL 2 $1,431.00 HC ENDO PROBE, BALLOON, SNARE, OTHER LVL 3 $2,147.00 HC ENDO PROBE, BALLOON, SNARE, OTHER LVL 4 $2,861.00 HC ENDO PROBE, BALLOON, SNARE, OTHER LVL 5 $3,577.00 HC ENDO PROBE, BALLOON, SNARE, OTHER LVL 6 $3,935.00 HC ENDO PROBES, BALLOONS, SNARES LVL 10 $6,558.00 HC ENDO PROBES, BALLOONS, SNARES LVL 11 $6,440.00 HC ENDO PROBES, BALLOONS, SNARES LVL 12 $7,512.00 HC ENDO PROBES, BALLOONS, SNARES LVL 16 $10,493.00 HC ENDO PROBES, BALLOONS, SNARES LVL 17 $10,599.00 HC ENDO PROBES, BALLOONS, SNARES LVL 7 $4,591.00 HC ENDO PROBES, BALLOONS, SNARES LVL 8 $5,247.00 HC ENDO PROBES, BALLOONS, SNARES LVL 9 $5,903.00 HC ENDOLUMINAL BX URETER/RENAL PLVS $870.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 1 $835.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 2 $1,431.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 3 $2,147.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 4 $2,861.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 5 $3,577.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 6 $3,935.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 7 $4,591.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 8 $5,247.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 9 $5,903.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL10 $6,558.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL11 $5,903.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL12 $6,440.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL13 $6,976.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL14 $7,512.00 HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL15 $8,048.00 HC ENDOMYOCARDIAL BIOPSY $4,402.00 HC ENDOSCOPY RECOVERY PER HOUR $180.00 HC ENDOVAS FEM ART EXP FOR PROSTH UNIL $6,857.00 48 of 155 Procedure Price HC ENDOVASC TAA REPR INCL SUBCL $21,952.00 HC ENDOVENOUS MCHNCHEM 1ST VEIN $5,865.00 HC ENDOVENOUS MCHNCHEM ADD-ON $1,500.00 HC ENDOVENOUS RF 1ST VEIN $11,827.00 HC ENDOVENOUS RF VEIN ADD-ON $9,886.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 1 $239.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 10 $2,088.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 11 $2,147.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 12 $2,504.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 13 $2,861.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 14 $3,220.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 15 $3,577.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 16 $3,747.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 17 $4,429.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 18 $4,770.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 19 $4,997.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 2 $477.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 20 $5,224.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 3 $626.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 4 $835.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 5 $1,043.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 6 $1,252.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 7 $1,461.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 8 $1,670.00 HC ENT, EYE IMPLANTS NO HCPCS LVL 9 $1,879.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 1 $334.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 2 $501.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 3 $667.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 4 $835.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 5 $859.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 6 $1,001.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 7 $1,144.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 8 $1,289.00 HC EO - PREFAB ELASTIC W METAL JNTS LVL 9 $1,431.00 HC EO - PREFAB RIGID WO JNTS LVL 1 $334.00 HC EO - PREFAB RIGID WO JNTS LVL 2 $501.00 HC EO - PREFAB RIGID WO JNTS LVL 3 $667.00 49 of 155 Procedure Price HC EO - PREFAB RIGID WO JNTS LVL 4 $835.00 HC EO - PREFAB RIGID WO JNTS LVL 5 $859.00 HC EO - PREFAB RIGID WO JNTS LVL 6 $1,001.00 HC EO - PREFAB RIGID WO JNTS LVL 7 $1,144.00 HC EO - PREFAB RIGID WO JNTS LVL 8 $1,289.00 HC EO - PREFAB RIGID WO JNTS LVL 9 $1,431.00 HC EO CUSTOM DBL UPRIGHT W FLEX ASSIST LVL1 $1,431.00 HC EO CUSTOM DBL UPRIGHT W FLEX ASSIST LVL2 $2,861.00 HC EO CUSTOM DBL UPRIGHT W FLEX ASSIST LVL3 $3,935.00 HC EO CUSTOM DBL UPRIGHT W FLEX ASSIST LVL4 $5,247.00 HC EO CUSTOM DBL UPRIGHT W FLEX ASSIST LVL5 $6,558.00 HC EO PREFAB W ADJ POSIT LOCKING JNTS LVL 1 $1,431.00 HC EO PREFAB W ADJ POSIT LOCKING JNTS LVL 2 $2,861.00 HC EO PREFAB W ADJ POSIT LOCKING JNTS LVL 3 $3,935.00 HC EO PREFAB W ADJ POSIT LOCKING JNTS LVL 4 $5,247.00 HC EO PREFAB W ADJ POSIT LOCKING JNTS LVL 5 $6,558.00 HC EO W/O JOINTS CF LVL 1 $334.00 HC EO W/O JOINTS CF LVL 2 $501.00 HC EO W/O JOINTS CF LVL 3 $667.00 HC EO W/O JOINTS CF LVL 4 $835.00 HC EO W/O JOINTS CF LVL 5 $859.00 HC EO W/O JOINTS CF LVL 6 $1,001.00 HC EO W/O JOINTS CF LVL 7 $1,144.00 HC EO W/O JOINTS CF LVL 8 $1,289.00 HC EO W/O JOINTS CF LVL 9 $1,431.00 HC EP & ABLATE SUPRAVENT ARRHYT $39,649.00 HC EP & ABLATE VENTRIC TACHY $39,649.00 HC EP EVAL CD LEADS INIT/REPLACEMENT $2,706.00 HC EP EVAL CD W GENERATOR TEST $2,621.00 HC EP EVAL CD W PACING $2,963.00 HC EP F/UP STUDY W PACING $2,702.00 HC EP INTR FX-CV GUID INTR/SHTH NO PL LVL 1 $1,431.00 HC EP INTR FX-CV GUID INTR/SHTH NO PL LVL 2 $2,861.00 HC EP INTR FX-CV GUID INTR/SHTH NO PL LVL 3 $3,935.00 HC EP INTR FX-CV GUID INTR/SHTH NO PL LVL 4 $5,247.00 HC EP INTR FX-CV GUID INTR/SHTH NO PL LVL 5 $6,558.00 HC EP INTR FX-CV GUID INTR/SHTH NO PL LVL 6 $6,440.00 50 of 155 Procedure Price HC EP INTR FX-CV GUID INTR/SHTH NO PL LVL 7 $7,512.00 HC EP INTRAC FX-CV GUID INTRO/SHTH PL LVL 1 $835.00 HC EP INTRAC FX-CV GUID INTRO/SHTH PL LVL 2 $1,789.00 HC EP INTRAC FX-CV GUID INTRO/SHTH PL LVL 3 $3,577.00 HC EP INTRAC FX-CV GUID INTRO/SHTH PL LVL 4 $6,558.00 HC EP INTRAC FX-CV GUID INTRO/SHTH PL LVL11 $13,415.00 HC EP INTRAC FX-CV GUID INTRO/SHTH PL LVL12 $14,904.00 HC EP STEERABLE GUIDING INTRO/SHEATH LVL 1 $835.00 HC EP STEERABLE GUIDING INTRO/SHEATH LVL 2 $1,431.00 HC EP STEERABLE GUIDING INTRO/SHEATH LVL 3 $2,147.00 HC EP STEERABLE GUIDING INTRO/SHEATH LVL 6 $6,558.00 HC EP STEERABLE GUIDING INTRO/SHEATH LVL 7 $8,048.00 HC EP STEERABLE GUIDING INTROSHEATH LVL 4 $2,861.00 HC EP STEERABLE GUIDING INTROSHEATH LVL 5 $3,577.00 HC EP/ABLATION CATHS, NO HCPCS LVL 1 $3,577.00 HC EP/ABLATION CATHS, NO HCPCS LVL 2 $6,558.00 HC EP/ABLATION CATHS, NO HCPCS LVL 3 $8,048.00 HC EP/ABLATION CATHS, NO HCPCS LVL 7 $14,606.00 HC EP/ABLATION CATHS, NO HCPCS LVL 8 $16,693.00 HC EP/ABLATION CATHS, NO HCPCS LVL 9 $13,415.00 HC EPIFIX PER 1 SQ CM LVL 1 $312.00 HC EPIFIX PER 1 SQ CM LVL 2 $625.00 HC EPIFIX PER 1 SQ CM LVL 3 $966.00 HC EPIFIX PER 1 SQ CM LVL 4 $1,249.00 HC EPIFIX PER 1 SQ CM LVL 5 $1,590.00 HC ERCP CLASS I $8,272.00 HC ERCP CLASS II $12,756.00 HC ERCP CLASS III $14,531.00 HC ERCP CLASS IV $16,629.00 HC ERCP CLASS V $18,218.00 HC ESCHAROTOMY INIT INC $391.00 HC ESOPH ATRIAL ELECTROGRAM $5,121.00 HC ESOPH ATRIAL ELECTROGRAM W PACING $6,146.00 HC ESOPH IMPED FUNCT TEST > 1H $2,893.00 HC ESOPH IMPED FUNCTION TEST $2,654.00 HC ESOPHAGEAL DIL W/O EGD W WIRE $4,668.00 HC ESOPHAGEAL MAL/HURST DIL $4,668.00 51 of 155 Procedure Price HC ESOPHAGOSCOPY FLEX REMOVE FB $4,571.00 HC ESOPHAGRAM $662.00 HC ESOPHAGUS MOTILITY STUDY $6,883.00 HC EVAC SU HEMATOMA $102.00 HC EVAL FOR NON-SPEECH DEVICE RX $150.00 HC EVAL FOR SPEECH DEVICE RX 1HR $399.00 HC EVAL IMPL PUMP W PROGR $1,369.00 HC EVAL NON-SPEECH DEVICE RX ADDTL 30 MIN $156.00 HC EVAL SPEECH SOUND LANG COMPREHEN $450.00 HC EVAL TO USE/FIT VOICE PROSTH $270.00 HC EVALUATE PT USE OF INHALER $146.00 HC EVALUATE SPEECH FLUENCY $389.00 HC EVALUATE SPEECH PRODUCTION $379.00 HC EVALUATE SWALLOWING FUNCTION $382.00 HC EVASC RPR A-AO NDGFT $18,000.00 HC EVASC RPR A-AO NDGFT RUPTR $20,000.00 HC EVASC RPR A-BIILIAC NDGFT $18,000.00 HC EVASC RPR A-BIILIAC RUPTR $20,000.00 HC EVASC RPR A-UNILAC NDGFT $18,000.00 HC EVASC RPR ILIAC ART BIFUR $16,050.00 HC EVASC RPR ILIO-ILIAC NDGFT $18,000.00 HC EVASC RPR ILIO-ILIAC RUPTR $20,000.00 HC EVENT RECORDER, CARDIAC LVL 1 $2,088.00 HC EVENT RECORDER, CARDIAC LVL 10 $8,942.00 HC EVENT RECORDER, CARDIAC LVL 11 $9,838.00 HC EVENT RECORDER, CARDIAC LVL 2 $3,577.00 HC EVENT RECORDER, CARDIAC LVL 3 $4,472.00 HC EVENT RECORDER, CARDIAC LVL 4 $5,963.00 HC EVENT RECORDER, CARDIAC LVL 5 $6,706.00 HC EVENT RECORDER, CARDIAC LVL 7 $8,347.00 HC EVENT RECORDER, CARDIAC LVL 9 $8,048.00 HC EVOKED AUDITORY TEST QUAL $284.00 HC EWHO RIGID W/O JNTS CF LVL 1 $1,431.00 HC EWHO RIGID W/O JNTS CF LVL 2 $2,861.00 HC EWHO RIGID W/O JNTS CF LVL 3 $3,935.00 HC EWHO RIGID W/O JNTS CF LVL 4 $5,247.00 HC EWHO RIGID W/O JNTS CF LVL 5 $6,558.00 52 of 155 Procedure Price HC EWHO W/JOINT(S) CF LVL 1 $1,431.00 HC EWHO W/JOINT(S) CF LVL 2 $2,861.00 HC EWHO W/JOINT(S) CF LVL 3 $3,935.00 HC EWHO W/JOINT(S) CF LVL 4 $5,247.00 HC EWHO W/JOINT(S) CF LVL 5 $6,558.00 HC EX FOR SPEECH DEVICE RX ADDL 30M $156.00 HC EXC BEN LES S/N/HF/G; 0.5 CM/< $1,889.00 HC EXC BEN LES T/A/L > 4.0 CM $3,306.00 HC EXC BEN LES T/A/L 1.1-2.0 CM $1,331.00 HC EXC BENIGN LES S/N/EX/G 0.6-1.0 CM $1,343.00 HC EXC EXT THROMBOSED HEMORRHOIDS $2,292.00 HC EXC FACE-MM B9+MARG 0.5 < CM $993.00 HC EXC SHOULDER TUM DEEP < 5.0 CM $4,202.00 HC EXC TR-EXT B9+MARG 0.5 CM/< $789.00 HC EXCHANGE BILIARY DRG CATH $6,756.00 HC EXCHANGE NEPHROSTOMY CATH $1,627.00 HC EXCHANGE PREVIOUS DRAINAGE CATH $3,155.00 HC EXCISE ANAL EXT TAG/PAPILLA $2,203.00 HC EXERCISE TST BRNCSPSM $313.00 HC EXHALED NITRIC OXIDE MEAS $103.00 HC EXPL FOR CONG ATRESIA BILE DUCTS WO REP $29,481.00 HC EXPL P WND ABD/FLANK $2,196.00 HC EXPL P WND CHEST $2,237.00 HC EXPL P WND EXTREM $769.00 HC EXPL P WND NECK $989.00 HC EXPL POSTOP HEMOR/THROMB/INFECT NECK $3,724.00 HC EXT CEPHALIC VERSION $2,065.00 HC EXT ECG 48 HRS TO 21 DAYS SCAN W/REPORT $285.00 HC EXT ECG RECORDING 48 HRS TO 21 DAYS $370.00 HC EXTENDED RECOVERY EA ADDTL HR $156.00 HC EXTENDED RECOVERY INITIAL HR $646.00 HC EXTENSOR TENDON REPAIR FINGER EACH $3,541.00 HC EXTERNAL FIXATOR LEVEL 1 $239.00 HC EXTERNAL FIXATOR LEVEL 10 $9,539.00 HC EXTERNAL FIXATOR LEVEL 13 $9,838.00 HC EXTERNAL FIXATOR LEVEL 14 $10,732.00 HC EXTERNAL FIXATOR LEVEL 16 $12,520.00 53 of 155 Procedure Price HC EXTERNAL FIXATOR LEVEL 18 $14,309.00 HC EXTERNAL FIXATOR LEVEL 2 $477.00 HC EXTERNAL FIXATOR LEVEL 3 $2,088.00 HC EXTERNAL FIXATOR LEVEL 4 $3,577.00 HC EXTERNAL FIXATOR LEVEL 5 $4,472.00 HC EXTERNAL FIXATOR LEVEL 6 $5,963.00 HC EXTERNAL FIXATOR LEVEL 7 $6,706.00 HC EXTERNAL FIXATOR LEVEL 8 $8,048.00 HC EXTREM VENOGRAM INJ $1,555.00 HC EXTREMITY ANGIO BILAT $6,179.00 HC EXTREMITY ANGIO UNIL $5,155.00 HC EXTREMITY VENOGRAM BILAT $4,356.00 HC EXTREMITY VENOGRAM UNIL $3,756.00 HC EYE DISPOSABLE SUPPLIES LVL 1 $835.00 HC EYE DISPOSABLE SUPPLIES LVL 10 $6,558.00 HC EYE DISPOSABLE SUPPLIES LVL 11 $6,440.00 HC EYE DISPOSABLE SUPPLIES LVL 12 $7,512.00 HC EYE DISPOSABLE SUPPLIES LVL 14 $9,658.00 HC EYE DISPOSABLE SUPPLIES LVL 16 $10,493.00 HC EYE DISPOSABLE SUPPLIES LVL 2 $1,431.00 HC EYE DISPOSABLE SUPPLIES LVL 3 $2,147.00 HC EYE DISPOSABLE SUPPLIES LVL 4 $2,861.00 HC EYE DISPOSABLE SUPPLIES LVL 5 $3,577.00 HC EYE DISPOSABLE SUPPLIES LVL 6 $3,935.00 HC EYE DISPOSABLE SUPPLIES LVL 7 $4,591.00 HC EYE DISPOSABLE SUPPLIES LVL 8 $5,247.00 HC EYE DISPOSABLE SUPPLIES LVL 9 $5,903.00 HC EYE MEDICATIONS LEVEL 1 $209.00 HC EYE MEDICATIONS LEVEL 10 $4,591.00 HC EYE MEDICATIONS LEVEL 2 $417.00 HC EYE MEDICATIONS LEVEL 3 $835.00 HC EYE MEDICATIONS LEVEL 4 $1,073.00 HC EYE MEDICATIONS LEVEL 5 $1,431.00 HC EYE MEDICATIONS LEVEL 6 $2,147.00 HC EYE MEDICATIONS LEVEL 7 $2,861.00 HC EYE MEDICATIONS LEVEL 8 $3,577.00 HC EYE MEDICATIONS LEVEL 9 $3,935.00 54 of 155 Procedure Price HC EYE SUPPLIES MISC LVL 1 $626.00 HC EYE SUPPLIES MISC LVL 2 $1,073.00 HC F18 FDG TO 45 MCI $2,428.00 HC FACIAL BONES LESS THAN 3 VIEWS $470.00 HC FACIAL BONES MIN 3 VIEWS $777.00 HC FAMILY THERAPY W PT 50 MIN $218.00 HC FAMILY THERAPY WO PT 50 MIN $242.00 HC FEES W CINE OR VIDEO $320.00 HC FEM/POPL REVAS W/ATHER $39,545.00 HC FEM/POPL REVAS W/TLA $18,628.00 HC FEM/POPL REVASC STNT & ATHER $68,489.00 HC FEM/POPL REVASC W/STENT $39,545.00 HC FEMALE STERILIZATION IMPLANT LVL 1 $477.00 HC FEMALE STERILIZATION IMPLANT LVL 10 $5,365.00 HC FEMALE STERILIZATION IMPLANT LVL 11 $5,963.00 HC FEMALE STERILIZATION IMPLANT LVL 2 $835.00 HC FEMALE STERILIZATION IMPLANT LVL 3 $1,670.00 HC FEMALE STERILIZATION IMPLANT LVL 4 $2,147.00 HC FEMALE STERILIZATION IMPLANT LVL 5 $2,861.00 HC FEMALE STERILIZATION IMPLANT LVL 6 $3,577.00 HC FEMALE STERILIZATION IMPLANT LVL 7 $3,577.00 HC FEMALE STERILIZATION IMPLANT LVL 8 $4,174.00 HC FEMALE STERILIZATION IMPLANT LVL 9 $4,770.00 HC FEMORAL N BLOCK SGL $1,293.00 HC FETAL CONTRACTION STRESS TEST $357.00 HC FETAL NON-STRESS TEST $356.00 HC FETAL NON-STRESS TEST MULTIPLE $356.00 HC FINANCIAL COUNSELING INTENSIVE $221.00 HC FINANCIAL COUNSELING MODERATE $221.00 HC FINGER OR FINGERS MIN 2 VIEWS $367.00 HC FIT OR INSERT PESSARY $334.00 HC FIT TESTING $169.00 HC FLEX TENDON REP ZONE 2 EACH $2,718.00 HC FLEXHD/ALLOPATCHHD/MATRIXHD PER 1 SQ CM LVL 1 $50.00 HC FLEXHD/ALLOPATCHHD/MATRIXHD PER 1 SQ CM LVL 2 $125.00 HC FLEXHD/ALLOPATCHHD/MATRIXHD PER 1 SQ CM LVL 3 $175.00 HC FLEXHD/ALLOPATCHHD/MATRIXHD PER 1 SQ CM LVL 4 $225.00 55 of 155 Procedure Price HC FLEXHD/ALLOPATCHHD/MATRIXHD PER 1 SQ CM LVL 5 $250.00 HC FLOW VOLUME LOOP $379.00 HC FLUCICLOVINE F-18 PER 1 MCI $1,545.00 HC FLUORO EXAM MORE THAN 1HR NON RAD $2,326.00 HC FLUOROGUIDANCE FOR NEEDLE PLC $1,989.00 HC FLUOROGUIDANCE FOR SPINE INJECT $1,281.00 HC FLUOROGUIDE FOR VENOUS DEVICE $1,325.00 HC FLUOROSCOPE EXAMINATION $740.00 HC FLUTTER VALVE/ACAPELLA CHEST PT INIT $211.00 HC FLUTTER VALVE/ACAPELLA CHEST PT SUBQ $140.00 HC FNA W GUIDANCE $1,442.00 HC FNA WO IMAGING $3,165.00 HC FO NONTORSION JOINT CF LVL 1 $334.00 HC FO NONTORSION JOINT CF LVL 2 $501.00 HC FO NONTORSION JOINT CF LVL 3 $667.00 HC FO NONTORSION JOINT CF LVL 4 $835.00 HC FO NONTORSION JOINT CF LVL 5 $859.00 HC FO NONTORSION JOINT CF LVL 6 $1,001.00 HC FO NONTORSION JOINT CF LVL 7 $1,144.00 HC FO NONTORSION JOINT CF LVL 8 $1,289.00 HC FO NONTORSION JOINT CF LVL 9 $1,431.00 HC FO PIP/DIP W/O JOINT/SPRING LVL 1 $334.00 HC FO PIP/DIP W/O JOINT/SPRING LVL 2 $501.00 HC FO PIP/DIP W/O JOINT/SPRING LVL 3 $667.00 HC FO PIP/DIP W/O JOINT/SPRING LVL 4 $835.00 HC FO PIP/DIP WITH JOINT/SPRING LVL 1 $334.00 HC FO PIP/DIP WITH JOINT/SPRING LVL 2 $501.00 HC FO PIP/DIP WITH JOINT/SPRING LVL 3 $667.00 HC FO PIP/DIP WITH JOINT/SPRING LVL 4 $835.00 HC FO W/O JOINTS CF LVL 1 $334.00 HC FO W/O JOINTS CF LVL 2 $501.00 HC FO W/O JOINTS CF LVL 3 $667.00 HC FO W/O JOINTS CF LVL 4 $835.00 HC FO W/O JOINTS CF LVL 5 $859.00 HC FO W/O JOINTS CF LVL 6 $1,001.00 HC FO W/O JOINTS CF LVL 7 $1,144.00 HC FO W/O JOINTS CF LVL 8 $1,289.00 56 of 155 Procedure Price HC FO W/O JOINTS CF LVL 9 $1,431.00 HC FOAM DRESSING PAD >16&<=48SQIN TAKE HOME $61.00 HC FOOT 2 VIEWS $538.00 HC FOOT INSERT FORM TO PATIENT LVL 1 $334.00 HC FOOT INSERT FORM TO PATIENT LVL 2 $501.00 HC FOOT INSERT FORM TO PATIENT LVL 3 $667.00 HC FOOT INSERT FORM TO PATIENT LVL 4 $835.00 HC FOOT INSERT FORM TO PATIENT LVL 5 $859.00 HC FOOT INSERT FORM TO PATIENT LVL 6 $1,001.00 HC FOOT INSERT FORM TO PATIENT LVL 7 $1,144.00 HC FOOT INSERT FORM TO PATIENT LVL 8 $1,289.00 HC FOOT INSERT FORM TO PATIENT LVL 9 $1,431.00 HC FOOT MIN 3 VIEWS $640.00 HC FOREARM 2 VIEWS $497.00 HC FOREIGN BODY IN EYE $163.00 HC FORESKIN MANIPULATION $921.00 HC FORK STRAP BELOW KNEE LVL 1 $1,431.00 HC FORK STRAP BELOW KNEE LVL 2 $2,861.00 HC FORK STRAP BELOW KNEE LVL 3 $3,935.00 HC FORK STRAP BELOW KNEE LVL 4 $5,247.00 HC FORK STRAP BELOW KNEE LVL 5 $6,558.00 HC FORK STRAP BELOW KNEE LVL 6 $6,440.00 HC FORK STRAP BELOW KNEE LVL 7 $7,512.00 HC FORK STRAP BELOW KNEE LVL 8 $8,585.00 HC FORK STRAP BELOW KNEE LVL 9 $9,658.00 HC FRONT LSO CORSET LVL 1 $334.00 HC FRONT LSO CORSET LVL 2 $501.00 HC FRONT LSO CORSET LVL 3 $667.00 HC FRONT LSO CORSET LVL 4 $835.00 HC FRONT LSO CORSET LVL 5 $859.00 HC FRONT LSO CORSET LVL 6 $1,001.00 HC FRONT LSO CORSET LVL 7 $1,144.00 HC FRONT LSO CORSET LVL 8 $1,289.00 HC FRONT LSO CORSET LVL 9 $1,431.00 HC G COMPRESSION STOCKING/SLEEVE LVL 1 $334.00 HC G COMPRESSION STOCKING/SLEEVE LVL 2 $501.00 HC G COMPRESSION STOCKING/SLEEVE LVL 3 $667.00 57 of 155 Procedure Price HC G COMPRESSION STOCKING/SLEEVE LVL 4 $835.00 HC G COMPRESSION STOCKING/SLEEVE LVL 5 $859.00 HC G COMPRESSION STOCKING/SLEEVE LVL 6 $1,001.00 HC GA67 GALLIUM PER MCI $188.00 HC GADOBUTROL INJECTION 0.1 ML $2.00 HC GADOFOSVESET TRISODIUM INJ 1 ML $93.00 HC GADOXETATE DISODIUM INJ 1 ML $399.00 HC GAIT TRAINING THERAPY EA 15 MIN $150.00 HC GAMMAGRAFT PER SQ CM LVL 1 $334.00 HC GAMMAGRAFT PER SQ CM LVL 2 $501.00 HC GAMMAGRAFT PER SQ CM LVL 3 $667.00 HC GAMMAGRAFT PER SQ CM LVL 4 $835.00 HC GASTRIC BAND LEVEL 1 $2,088.00 HC GASTRIC BAND LEVEL 10 $8,942.00 HC GASTRIC BAND LEVEL 2 $3,577.00 HC GASTRIC BAND LEVEL 3 $4,472.00 HC GASTRIC BAND LEVEL 4 $5,963.00 HC GASTRIC BAND LEVEL 5 $6,706.00 HC GASTRIC BAND LEVEL 6 $8,048.00 HC GASTRIC BAND LEVEL 7 $8,347.00 HC GASTROSCOPY LEVEL I $6,663.00 HC GASTROSCOPY LEVEL II $7,845.00 HC GASTROSCOPY LEVEL III $10,288.00 HC GASTROSCOPY LEVEL IV $13,367.00 HC GASTROSCOPY W/EUS LEVEL I $9,679.00 HC GASTROSCOPY W/EUS LEVEL II $9,864.00 HC GASTROSCOPY W/EUS LEVEL III $9,707.00 HC GASTROSCOPY W/EUS LEVEL IV $11,800.00 HC GAUZE NON-IMPREG 16 IN/< WO BORDER TAKE HOME $181.00 HC GC STOCKING FULL LNGTH 30-40 LVL 1 TAKE HOME $347.00 HC GC STOCKING FULL LNGTH 30-40 LVL 2 TAKE HOME $520.00 HC GC STOCKING FULL LNGTH 30-40 LVL 3 TAKE HOME $693.00 HC GC STOCKING FULL LNGTH 30-40 LVL 4 TAKE HOME $868.00 HC GC STOCKING FULL LNGTH 40-50 LVL 1 TAKE HOME $347.00 HC GC STOCKING FULL LNGTH 40-50 LVL 2 TAKE HOME $520.00 HC GC STOCKING FULL LNGTH 40-50 LVL 3 TAKE HOME $693.00 HC GC STOCKING FULL LNGTH 40-50 LVL 4 TAKE HOME $868.00 58 of 155 Procedure Price HC GC STOCKING THIGHLNGTH 18-30 LVL 1 TAKE HOME $347.00 HC GC STOCKING THIGHLNGTH 18-30 LVL 2 TAKE HOME $520.00 HC GC STOCKING THIGHLNGTH 18-30 LVL 3 TAKE HOME $693.00 HC GC STOCKING THIGHLNGTH 18-30 LVL 4 TAKE HOME $868.00 HC GC STOCKING THIGHLNGTH 30-40 LVL 1 TAKE HOME $347.00 HC GC STOCKING THIGHLNGTH 30-40 LVL 2 TAKE HOME $520.00 HC GC STOCKING THIGHLNGTH 30-40 LVL 3 TAKE HOME $693.00 HC GC STOCKING THIGHLNGTH 30-40 LVL 4 TAKE HOME $868.00 HC GC STOCKING THIGHLNGTH 40-50 LVL 1 TAKE HOME $347.00 HC GC STOCKING THIGHLNGTH 40-50 LVL 2 TAKE HOME $520.00 HC GC STOCKING THIGHLNGTH 40-50 LVL 3 TAKE HOME $693.00 HC GC STOCKING THIGHLNGTH 40-50 LVL 4 TAKE HOME $868.00 HC GC STOCKING WAISTLNGTH 18-30 LVL 1 TAKE HOME $347.00 HC GC STOCKING WAISTLNGTH 18-30 LVL 2 TAKE HOME $520.00 HC GC STOCKING WAISTLNGTH 18-30 LVL 3 TAKE HOME $693.00 HC GC STOCKING WAISTLNGTH 18-30 LVL 4 TAKE HOME $868.00 HC GC STOCKING WAISTLNGTH 30-40 LVL 1 TAKE HOME $347.00 HC GC STOCKING WAISTLNGTH 30-40 LVL 2 TAKE HOME $520.00 HC GC STOCKING WAISTLNGTH 30-40 LVL 3 TAKE HOME $693.00 HC GC STOCKING WAISTLNGTH 30-40 LVL 4 TAKE HOME $868.00 HC GC STOCKING WAISTLNGTH 40-50 LVL 1 TAKE HOME $347.00 HC GC STOCKING WAISTLNGTH 40-50 LVL 2 TAKE HOME $520.00 HC GC STOCKING WAISTLNGTH 40-50 LVL 3 TAKE HOME $693.00 HC GC STOCKING WAISTLNGTH 40-50 LVL 4 TAKE HOME $868.00 HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 1 $2,088.00 HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 2 $3,577.00 HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 3 $8,942.00 HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 5 $26,827.00 HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 6 $35,771.00 HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 7 $44,713.00 HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 8 $53,657.00 HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 9 $62,598.00 HC GENERATOR, NEURO NON-RECHARGE LVL 1 $2,088.00 HC GENERATOR, NEURO NON-RECHARGE LVL 2 $3,577.00 HC GENERATOR, NEURO NON-RECHARGE LVL 4 $17,886.00 HC GENERATOR, NEURO NON-RECHARGE LVL 5 $26,827.00 HC GENERATOR, NEURO NON-RECHARGE LVL 6 $35,771.00 59 of 155 Procedure Price HC GENERATOR, NEURO NON-RECHARGE LVL 7 $44,713.00 HC GENERATOR, NEURO NON-RECHARGE LVL 8 $53,657.00 HC GENERATOR, NEURO NON-RECHARGE LVL 9 $62,598.00 HC GENET VIRUS ISOLATE HSV $24.35 HC G-ESOPH REFLUX W MUCOSAL PH $2,893.00 HC G-ESOPH REFLUX W NASAL PH $2,043.00 HC GI TRACT CAPSULE ENDOSCOPY $5,519.00 HC GLUCOSE BLD BY MONITOR DEVICE $49.00 HC GRAFIX CORE PER 1 SQ CM LVL 1 $416.00 HC GRAFIX CORE PER 1 SQ CM LVL 2 $716.00 HC GRAFIX CORE PER 1 SQ CM LVL 3 $1,073.00 HC GRAFIX CORE PER 1 SQ CM LVL 4 $1,431.00 HC GRAFIX CORE PER 1 SQ CM LVL 5 $1,789.00 HC GRAFIX PRIME PER 1 SQ CM LVL 1 $416.00 HC GRAFIX PRIME PER 1 SQ CM LVL 2 $716.00 HC GRAFIX PRIME PER 1 SQ CM LVL 3 $1,073.00 HC GRAFIX PRIME PER 1 SQ CM LVL 4 $1,431.00 HC GRAFIX PRIME PER 1 SQ CM LVL 5 $1,789.00 HC GRAFT, VASCULAR LVL 1 $1,043.00 HC GRAFT, VASCULAR LVL 10 $17,886.00 HC GRAFT, VASCULAR LVL 11 $26,827.00 HC GRAFT, VASCULAR LVL 12 $35,771.00 HC GRAFT, VASCULAR LVL 13 $44,713.00 HC GRAFT, VASCULAR LVL 2 $2,088.00 HC GRAFT, VASCULAR LVL 3 $2,683.00 HC GRAFT, VASCULAR LVL 4 $3,577.00 HC GRAFT, VASCULAR LVL 5 $5,963.00 HC GRAFT, VASCULAR LVL 6 $8,048.00 HC GRAFT, VASCULAR LVL 7 $9,539.00 HC GRAFT, VASCULAR LVL 8 $8,942.00 HC GRAFT, VASCULAR LVL 9 $13,415.00 HC GRAFTJACKET EXPRESS 1 CC LVL 10 $2,147.00 HC GRAFTJACKET EXPRESS 1 CC LVL 11 $2,861.00 HC GRAFTJACKET EXPRESS 1 CC LVL 12 $3,577.00 HC GRAFTJACKET EXPRESS 1 CC LVL 13 $3,935.00 HC GRAFTJACKET EXPRESS 1 CC LVL 14 $4,591.00 HC GRAFTJACKET EXPRESS 1 CC LVL 15 $5,247.00 60 of 155 Procedure Price HC GRAFTJACKET EXPRESS 1 CC LVL 16 $5,903.00 HC GRAFTJACKET EXPRESS 1 CC LVL 17 $6,558.00 HC GRAFTJACKET EXPRESS 1 CC LVL 18 $5,903.00 HC GRAFTJACKET EXPRESS 1 CC LVL 19 $6,440.00 HC GRAFTJACKET EXPRESS 1 CC LVL 2 $501.00 HC GRAFTJACKET EXPRESS 1 CC LVL 3 $667.00 HC GRAFTJACKET EXPRESS 1 CC LVL 4 $835.00 HC GRAFTJACKET EXPRESS 1 CC LVL 5 $859.00 HC GRAFTJACKET EXPRESS 1 CC LVL 6 $1,001.00 HC GRAFTJACKET EXPRESS 1 CC LVL 7 $1,144.00 HC GRAFTJACKET EXPRESS 1 CC LVL 8 $1,289.00 HC GRAFTJACKET EXPRESS 1 CC LVL 9 $1,431.00 HC GRAFTJACKET SKIN SUB PER SQ CM LVL 1 $334.00 HC GRAFTJACKET SKIN SUB PER SQ CM LVL 2 $501.00 HC GRAFTJACKET SKIN SUB PER SQ CM LVL 3 $667.00 HC GRAFTJACKET SKIN SUB PER SQ CM LVL 4 $835.00 HC GRAFTS, NON VASCULAR LVL 1 $1,043.00 HC GRAFTS, NON VASCULAR LVL 2 $2,088.00 HC GRAFTS, NON VASCULAR LVL 3 $3,577.00 HC GRAFTS, NON VASCULAR LVL 4 $4,472.00 HC GRAFTS, NON VASCULAR LVL 5 $5,963.00 HC GRAFTS, NON VASCULAR LVL 6 $6,706.00 HC GRAFTS, NON VASCULAR LVL 7 $8,048.00 HC GRAFTS, NON VASCULAR LVL 8 $8,347.00 HC GRAFTS, NON VASCULAR LVL 9 $9,539.00 HC GROUP THERAPY INTENSIVE $812.00 HC GROUP THERAPY MODERATE $510.00 HC GROUP THERAPY NOT MULTI-FAMILY $184.00 HC GRP NUTRITION THERAPY; EA 30M $39.00 HC GUIDANCE FOR RADIATION TX DLVR $546.00 HC GUIDE CATH FLUID DRAINAGE $1,348.00 HC GUIDE NERV DESTR, ELEC STIM $48.00 HC GUIDE NERV DESTR, NEEDLE EMG $59.00 HC GUIDE WIRE LVL 1 $417.00 HC GUIDE WIRE LVL 10 $6,558.00 HC GUIDE WIRE LVL 11 $6,440.00 HC GUIDE WIRE LVL 12 $7,512.00 61 of 155 Procedure Price HC GUIDE WIRE LVL 13 $8,585.00 HC GUIDE WIRE LVL 15 $10,732.00 HC GUIDE WIRE LVL 2 $835.00 HC GUIDE WIRE LVL 3 $1,431.00 HC GUIDE WIRE LVL 4 $2,147.00 HC GUIDE WIRE LVL 5 $2,861.00 HC GUIDE WIRE LVL 6 $3,577.00 HC GUIDE WIRE LVL 7 $3,935.00 HC GUIDE WIRE LVL 8 $4,591.00 HC GUIDE WIRE LVL 9 $5,247.00 HC GYNE SUPPLIES GENERAL LVL 1 $835.00 HC GYNE SUPPLIES GENERAL LVL 2 $3,577.00 HC GYNE SUPPLIES GENERAL LVL 3 $6,558.00 HC GYNE SUPPLIES GENERAL LVL 4 $8,048.00 HC GYNE SUPPLIES GENERAL LVL 5 $10,732.00 HC HAND 2 VIEWS $451.00 HC HAND MIN 3 VIEWS $562.00 HC HARVEST AUTO STEM CELLS $5,076.00 HC HBOT FULL BODY CHAMBER 30M $634.00 HC HCG QUAL $49.00 HC HDR RDNCL NTRSTL/ICAV BRCHTX >12 CHAN $2,827.00 HC HDR RDNCL NTRSTL/ICAV BRCHTX 1 CHAN $2,827.00 HC HDR RDNCL NTRSTL/ICAV BRCHTX 2-12 CHAN $2,827.00 HC HEART CHECK $23.00 HC HEART FIRST PASS SINGLE $1,075.00 HC HEAVY DUTY PELVIC HIP CNTL EA LVL 1 $835.00 HC HEAVY DUTY PELVIC HIP CNTL EA LVL 2 $1,431.00 HC HEAVY DUTY PELVIC HIP CNTL EA LVL 3 $2,147.00 HC HEAVY DUTY PELVIC HIP CNTL EA LVL 4 $2,861.00 HC HEAVY DUTY PELVIC HIP CNTL EA LVL 5 $3,577.00 HC HEMODIALYSIS 1 EVAL $3,281.00 HC HEMODIALYSIS DAILY TREATMENT $600.00 HC HEMODIALYSIS REPEAT EVAL $1,325.00 HC HEMORRHOID BANDING $1,700.00 HC HEMORRHOIDECTOMY $1,170.00 HC HEMOSTASIS SUPPLIES GENERAL LVL 1 $358.00 HC HEMOSTASIS SUPPLIES GENERAL LVL 2 $1,670.00 62 of 155 Procedure Price HC HEMOSTASIS SUPPLIES GENERAL LVL 3 $3,577.00 HC HEMOSTASIS SUPPLIES GENERAL LVL 4 $5,963.00 HC HFO NONTORSION JOINT, PREFAB LVL 1 $334.00 HC HFO NONTORSION JOINT, PREFAB LVL 2 $501.00 HC HFO NONTORSION JOINT, PREFAB LVL 3 $667.00 HC HFO NONTORSION JOINT, PREFAB LVL 4 $835.00 HC HFO NONTORSION JOINT, PREFAB LVL 5 $859.00 HC HFO NONTORSION JOINT, PREFAB LVL 6 $1,001.00 HC HFO NONTORSION JOINT, PREFAB LVL 7 $1,144.00 HC HFO NONTORSION JOINT, PREFAB LVL 8 $1,289.00 HC HFO NONTORSION JOINT, PREFAB LVL 9 $1,431.00 HC HFO W/JOINT(S) CF LVL 1 $334.00 HC HFO W/JOINT(S) CF LVL 2 $501.00 HC HFO W/JOINT(S) CF LVL 3 $667.00 HC HFO W/JOINT(S) CF LVL 4 $835.00 HC HFO W/JOINT(S) CF LVL 5 $859.00 HC HFO W/JOINT(S) CF LVL 6 $1,001.00 HC HFO W/JOINT(S) CF LVL 7 $1,144.00 HC HFO W/JOINT(S) CF LVL 8 $1,289.00 HC HFO W/JOINT(S) CF LVL 9 $1,431.00 HC HFO W/O JOINTS CF LVL 1 $334.00 HC HFO W/O JOINTS CF LVL 2 $501.00 HC HFO W/O JOINTS CF LVL 3 $667.00 HC HFO W/O JOINTS CF LVL 4 $835.00 HC HFO W/O JOINTS CF LVL 5 $859.00 HC HFO W/O JOINTS CF LVL 6 $1,001.00 HC HFO W/O JOINTS CF LVL 7 $1,144.00 HC HFO W/O JOINTS CF LVL 8 $1,289.00 HC HFO W/O JOINTS CF LVL 9 $1,431.00 HC HFO W/O JOINTS PF LVL 1 $334.00 HC HFO W/O JOINTS PF LVL 2 $501.00 HC HFO W/O JOINTS PF LVL 3 $667.00 HC HFO W/O JOINTS PF LVL 4 $835.00 HC HFO W/O JOINTS PF LVL 5 $859.00 HC HFO W/O JOINTS PF LVL 6 $1,001.00 HC HFO W/O JOINTS PF LVL 7 $1,144.00 HC HFO W/O JOINTS PF LVL 8 $1,289.00 63 of 155 Procedure Price HC HFO W/O JOINTS PF LVL 9 $1,431.00 HC HIGH COMPRES BAND >=3" $83.00 HC HIP ARTHROGRAM $967.00 HC HO W/O JOINTS CF LVL 1 $334.00 HC HO W/O JOINTS CF LVL 2 $501.00 HC HO W/O JOINTS CF LVL 3 $667.00 HC HO W/O JOINTS CF LVL 4 $835.00 HC HO W/O JOINTS CF LVL 5 $859.00 HC HO W/O JOINTS CF LVL 6 $1,001.00 HC HO W/O JOINTS CF LVL 7 $1,144.00 HC HO W/O JOINTS CF LVL 8 $1,289.00 HC HO W/O JOINTS CF LVL 9 $1,431.00 HC HOCM >=400 MG/ML IODINE 1ML $35.00 HC HOCM 150-199 MG/ML IODINE 1ML $177.00 HC HOCM 250-299 MG/ML IODINE 1ML $1.00 HC HOCM 350-399 MG/ML IODINE PER ML $2.00 HC HOCM UP TO 149 MG/ML IODINE PER ML $2.00 HC HOME SLEEP TEST/TYPE 3 PORTA $704.00 HC HOSPITAL BASED TUTORING INTENSIVE $56.00 HC HOSPITAL BASED TUTORING MODERATE $92.00 HC HOSPITALITY LEVEL 0 $31.00 HC HOSPITALITY LEVEL I $340.00 HC HUMERUS MIN 2 VIEWS $522.00 HC HYDRATE IV INFUSION EA ADDTL HR $253.00 HC HYDRATION IV INFUSION INIT 31-60 MIN $496.00 HC HYDROCOLLD DRG <=16 W/O BDR LVL 1 TAKE HOME $347.00 HC HYDROCOLLD DRG <=16 W/O BDR LVL 2 TAKE HOME $520.00 HC HYDROCOLLD DRG <=16 W/O BDR LVL 3 TAKE HOME $693.00 HC HYDROCOLLD DRG <=16 W/O BDR LVL 4 TAKE HOME $868.00 HC HYSTEROSALPINGOGRAM $1,026.00 HC I & D EPIDIDYMIS TESTIS/SCROTAL SP $5,720.00 HC I & D OF BARTHOLINS GLAND ABSCESS $236.00 HC I & D OF VULVA OR PERINEAL ABSCESS $422.00 HC I&D ABSC COMPL OR MULTI $811.00 HC I&D ABSC SMPL OR SGL $792.00 HC I&D ABSC THIGH/KNEE DEEP $1,882.00 HC I&D ABSC/CYST TONGUE/MOUTH LINGUAL $3,460.00 64 of 155 Procedure Price HC I&D ABSCESS PERITONSILLAR $614.00 HC I&D BURSA UA/ELBOW $4,703.00 HC I&D CPLX POSTOP WND INF $893.00 HC I&D HEMATOMA $4,034.00 HC I&D PERIANAL ABSCESS $1,121.00 HC I&D PERIRECTAL OR ISCHIAL ABSCESS $7,299.00 HC I&D PILONID CYS SMPL $259.00 HC I&D PILONID CYST CPLX $4,931.00 HC I&D SOFT TISS ABSC SUBFASCIAL $2,185.00 HC I131 IODIDE CAP DX PER MCI $311.00 HC I131 IODIDE CAP RX MCI $62.00 HC I131 PER 1 UCI TO 100 UCI $179.00 HC IC THROMBOLYSIS $2,496.00 HC ICC ABLATION AV NODE CREATE CHB $14,348.00 HC ICD DEVICE INTERROGATE $153.00 HC ICD DEVICE PROG EVAL 1 SGL $153.00 HC ICD DEVICE PROG EVAL DUAL $153.00 HC ICD DEVICE PROGR EVAL MULT $153.00 HC ILEOSCOPY THRU STOMA ENDO $5,594.00 HC ILIAC ANGIO W CARD CATH $7,410.00 HC ILIAC REVASC $18,628.00 HC ILIAC REVASC ADD-ON $18,628.00 HC ILIAC REVASC W/STENT $18,628.00 HC ILIAC REVASC W/STENT ADD-ON $18,628.00 HC ILR DEVICE EVAL PROGR $93.00 HC ILR DEVICE INTERROGATE $97.00 HC IMAGE CATH FLUID COLL PERI/RETRO $7,660.00 HC IMAGE CATH FLUID COLL TRANSVAG/RECTAL $3,285.00 HC IMAGE CATH FLUID COLL VISCERAL $7,001.00 HC IMMUNIZATION ADM 1 VACCINE $80.00 HC IMMUNIZATION ADM EA ADDTL VACCINE $65.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 1 $835.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 10 $5,963.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 2 $1,670.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 3 $2,147.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 4 $2,861.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 5 $3,577.00 65 of 155 Procedure Price HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 6 $3,577.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 7 $4,174.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 8 $4,770.00 HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 9 $5,365.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 1 $2,125.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 10 $21,250.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 11 $23,375.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 12 $25,500.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 14 $29,750.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 16 $34,000.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 18 $38,250.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 2 $4,250.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 21 $44,625.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 3 $6,375.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 5 $10,625.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 6 $12,750.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 7 $14,875.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 8 $17,000.00 HC IMPL DUAL CHAMB RR PACEMAKER LVL 9 $19,125.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 1 $835.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 10 $5,963.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 11 $5,903.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 12 $6,440.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 2 $1,670.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 3 $2,147.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 4 $2,861.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 5 $3,577.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 6 $3,577.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 7 $4,174.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 8 $4,770.00 HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 9 $5,365.00 HC IMPL INDWELLING PORT LVL 1 $1,043.00 HC IMPL INDWELLING PORT LVL 2 $2,088.00 HC IMPL INDWELLING PORT LVL 3 $3,577.00 HC IMPL INDWELLING PORT LVL 4 $4,472.00 HC IMPL INDWELLING PORT LVL 5 $5,963.00 HC IMPL INDWELLING PORT LVL 6 $6,706.00 66 of 155 Procedure Price HC IMPL INDWELLING PORT LVL 7 $8,048.00 HC IMPL INDWELLING PORT LVL 8 $8,347.00 HC IMPL INDWELLING PORT LVL 9 $9,539.00 HC IMPL NEUROSTIM LEAD TEST KIT LVL 1 $477.00 HC IMPL NEUROSTIM LEAD TEST KIT LVL 19 $16,097.00 HC IMPL NEUROSTIM LEAD TEST KIT LVL 2 $2,088.00 HC IMPL NEUROSTIM LEAD TEST KIT LVL 3 $3,577.00 HC IMPL NEUROSTIM LEAD TEST KIT LVL 4 $4,472.00 HC IMPL NEUROSTIM LEAD TEST KIT LVL 5 $5,963.00 HC IMPL NEUROSTIM LEAD TEST KIT LVL 6 $6,706.00 HC IMPL NEUROSTIM LEAD TEST KIT LVL 8 $8,347.00 HC IMPL NEUROSTIM RECEIV/TRANSMIT LVL 1 $2,088.00 HC IMPL NEUROSTIM RECEIV/TRANSMIT LVL 2 $3,577.00 HC IMPL NEUROSTIM RECEIV/TRANSMIT LVL 3 $5,963.00 HC IMPL NEUROSTIM RECEIV/TRANSMIT LVL 4 $8,048.00 HC IMPL NEUROSTIM RECEIV/TRANSMIT LVL 5 $9,539.00 HC IMPL OR REVISE EPID CATH FOR PAIN $4,486.00 HC IMPL PACEMAKER NOT SGL/DUAL CHAMB LVL 1 $14,904.00 HC IMPL PACEMAKER NOT SGL/DUAL CHAMB LVL 2 $29,809.00 HC IMPL PACEMAKER NOT SGL/DUAL CHAMB LVL 3 $44,713.00 HC IMPL PACEMAKER NOT SGL/DUAL CHAMB LVL 4 $59,617.00 HC IMPL PT ACTIVATED CARD EVENT RECORDER $20,963.00 HC IMPL PULMON LIQUID SEALANT LVL 1 $477.00 HC IMPL PULMON LIQUID SEALANT LVL 2 $835.00 HC IMPL PULMON LIQUID SEALANT LVL 3 $1,670.00 HC IMPL PULMON LIQUID SEALANT LVL 4 $2,147.00 HC IMPL PULMON LIQUID SEALANT LVL 5 $2,861.00 HC IMPL PULMON LIQUID SEALANT LVL 6 $3,577.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 1 $2,125.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 10 $21,250.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 12 $25,500.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 13 $27,625.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 18 $38,250.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 2 $4,250.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 3 $6,375.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 4 $8,500.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 5 $10,625.00 67 of 155 Procedure Price HC IMPL SGL CHAMBR RR PACEMAKER LVL 6 $12,750.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 7 $14,875.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 8 $17,000.00 HC IMPL SGL CHAMBR RR PACEMAKER LVL 9 $19,125.00 HC IMPL SYNTH VOCAL CORD LVL 1 $477.00 HC IMPL SYNTH VOCAL CORD LVL 2 $2,088.00 HC IMPL SYNTH VOCAL CORD LVL 3 $3,577.00 HC IMPL SYNTH VOCAL CORD LVL 4 $4,472.00 HC IMPL SYNTH VOCAL CORD LVL 5 $5,963.00 HC IMPL SYNTH VOCAL CORD LVL 6 $6,706.00 HC IMPL SYNTH VOCAL CORD LVL 7 $8,048.00 HC IMPL SYNTH VOCAL CORD LVL 8 $8,347.00 HC IMPL SYNTH VOCAL CORD LVL 9 $9,539.00 HC IMPL URINARY SPHINCTER PROSTH LVL 1 $477.00 HC IMPL URINARY SPHINCTER PROSTH LVL 10 $8,048.00 HC IMPL URINARY SPHINCTER PROSTH LVL 13 $10,732.00 HC IMPL URINARY SPHINCTER PROSTH LVL 14 $11,627.00 HC IMPL URINARY SPHINCTER PROSTH LVL 2 $2,088.00 HC IMPL URINARY SPHINCTER PROSTH LVL 3 $3,577.00 HC IMPL URINARY SPHINCTER PROSTH LVL 30 $25,934.00 HC IMPL URINARY SPHINCTER PROSTH LVL 4 $4,472.00 HC IMPL URINARY SPHINCTER PROSTH LVL 5 $5,963.00 HC IMPL URINARY SPHINCTER PROSTH LVL 6 $6,706.00 HC IMPL URINARY SPHINCTER PROSTH LVL 7 $8,048.00 HC IMPL URINARY SPHINCTER PROSTH LVL 8 $8,347.00 HC IMPLANT/INSERT DEVICE NOC LVL 1 $150.00 HC IMPLANT/INSERT DEVICE NOC LVL 2 $300.00 HC IMPLANT/INSERT DEVICE NOC LVL 3 $450.00 HC IMPLANT/INSERT DEVICE NOC LVL 4 $600.00 HC IMPLANT/INSERT DEVICE NOC LVL 5 $750.00 HC IMPLANT/INSERT DEVICE NOC LVL 6 $900.00 HC IMPLANT/INSERT DEVICE NOC LVL 8 $4,500.00 HC IMPLANT/INSERT DEVICE NOC LVL 9 $6,000.00 HC IMPLANTABLE TISS MARKER LVL 1 $835.00 HC IMPLANTABLE TISS MARKER LVL 2 $1,670.00 HC IMPLANTABLE TISS MARKER LVL 3 $2,147.00 HC IMPLANTABLE TISS MARKER LVL 4 $2,861.00 68 of 155 Procedure Price HC IMPLANTABLE TISS MARKER LVL 5 $3,577.00 HC IMPLANTABLE TISS MARKER LVL 6 $5,300.00 HC IMPREG GAUZE NO H20/SAL/YARD LVL 1 TAKE HOME $347.00 HC IMPREG GAUZE NO H20/SAL/YARD LVL 2 TAKE HOME $520.00 HC IMPREG GAUZE NO H20/SAL/YARD LVL 3 TAKE HOME $693.00 HC IMPREG GAUZE NO H20/SAL/YARD LVL 4 TAKE HOME $868.00 HC IMRT/CONFORMAL RTH PLAN $6,299.00 HC IN111 INOXINE WBC PER 0.5 MCI $7,107.00 HC IN111 PENTETATE PER 0.5 MCI $6,956.00 HC IN111 PROSTASCINT TO 10 MCI $11,666.00 HC IN111 SATUMOMAB TO 6 MCI $6,360.00 HC INC & REM FB SQ COMPL $6,835.00 HC INC & REM FB SQ SMPL $812.00 HC INCISE THROMBOSED HEMORRHOID EXT $594.00 HC INCISION OF LINGUAL FRENUM (FRENOTOMY) $2,677.00 HC INDIUM IN111 AUTO WBC DX $6,284.00 HC INDIUM IN111 PENTETREO TO 6MCI $16,001.00 HC INFLATABLE PENILE PROSTHESIS LVL 1 $477.00 HC INFLATABLE PENILE PROSTHESIS LVL 10 $8,048.00 HC INFLATABLE PENILE PROSTHESIS LVL 11 $8,942.00 HC INFLATABLE PENILE PROSTHESIS LVL 13 $10,732.00 HC INFLATABLE PENILE PROSTHESIS LVL 15 $12,520.00 HC INFLATABLE PENILE PROSTHESIS LVL 16 $13,415.00 HC INFLATABLE PENILE PROSTHESIS LVL 17 $14,309.00 HC INFLATABLE PENILE PROSTHESIS LVL 18 $15,203.00 HC INFLATABLE PENILE PROSTHESIS LVL 19 $16,097.00 HC INFLATABLE PENILE PROSTHESIS LVL 2 $2,088.00 HC INFLATABLE PENILE PROSTHESIS LVL 20 $16,992.00 HC INFLATABLE PENILE PROSTHESIS LVL 23 $19,674.00 HC INFLATABLE PENILE PROSTHESIS LVL 24 $20,569.00 HC INFLATABLE PENILE PROSTHESIS LVL 25 $21,462.00 HC INFLATABLE PENILE PROSTHESIS LVL 3 $3,577.00 HC INFLATABLE PENILE PROSTHESIS LVL 4 $4,472.00 HC INFLATABLE PENILE PROSTHESIS LVL 5 $5,963.00 HC INFLATABLE PENILE PROSTHESIS LVL 6 $6,706.00 HC INFLATABLE PENILE PROSTHESIS LVL 7 $8,048.00 HC INFUSE RADIOACTIVE MATERIALS $1,948.00 69 of 155 Procedure Price HC INFUSION PUMP, PROGRAMMABLE LVL 1 $2,088.00 HC INFUSION PUMP, PROGRAMMABLE LVL 2 $3,577.00 HC INFUSION PUMP, PROGRAMMABLE LVL 3 $8,942.00 HC INFUSION PUMP, PROGRAMMABLE LVL 5 $26,827.00 HC INFUSION PUMP, PROGRAMMABLE LVL 8 $53,657.00 HC INFUSION PUMP,NON-PROG, PERM LVL 1 $477.00 HC INFUSION PUMP,NON-PROG, PERM LVL 10 $5,365.00 HC INFUSION PUMP,NON-PROG, PERM LVL 11 $5,963.00 HC INFUSION PUMP,NON-PROG, PERM LVL 12 $5,903.00 HC INFUSION PUMP,NON-PROG, PERM LVL 13 $6,440.00 HC INFUSION PUMP,NON-PROG, PERM LVL 2 $835.00 HC INFUSION PUMP,NON-PROG, PERM LVL 3 $1,670.00 HC INFUSION PUMP,NON-PROG, PERM LVL 4 $2,147.00 HC INFUSION PUMP,NON-PROG, PERM LVL 5 $2,861.00 HC INFUSION PUMP,NON-PROG, PERM LVL 6 $3,577.00 HC INFUSION PUMP,NON-PROG, PERM LVL 7 $3,577.00 HC INFUSION PUMP,NON-PROG, PERM LVL 8 $4,174.00 HC INFUSION PUMP,NON-PROG, PERM LVL 9 $4,770.00 HC INIT NUTRITION THERAPY; EACH 15M $72.00 HC INIT TX 1ST DEGR BURN $238.00 HC INJ & ASP FOR TX BONE CYST $1,591.00 HC INJ ABSCESS CYST CONTRAST $1,221.00 HC INJ AIR/CONTRAST INTO PERITONEAL CAVITY $892.00 HC INJ ANESTH CELIAC PLEXUS $2,904.00 HC INJ ANESTH FACIAL NERVE $359.00 HC INJ ANESTH GREATER OCCIP NRV PAIN BILAT $1,506.00 HC INJ ANESTH GREATER OCCIPITAL NERVE $1,506.00 HC INJ ANESTH INTERCOST NRV MULTI/REGION $2,444.00 HC INJ ANESTH INTERCOSTAL NERVE SGL $1,506.00 HC INJ ANESTH LUMB/THOR SYMPATHETIC $2,850.00 HC INJ ANESTH OTHR PERIPHERAL NRV/BRANCH $1,534.00 HC INJ ANESTH PUDENDAL NERVE $1,883.00 HC INJ ANESTH SPHENOPALATINE GANGLION $982.00 HC INJ ANESTH STELLATE GANGLION $2,850.00 HC INJ ANESTH SUPRASCAPULAR NERVE $1,156.00 HC INJ ANESTH TRIGEMINAL NERVE $618.00 HC INJ ANESTH; CERVICAL PLEXUS $1,506.00 70 of 155 Procedure Price HC INJ ARTHROGRAM ELBOW $615.00 HC INJ ARTHROGRAM HIP W/O ANESTH $1,477.00 HC INJ ARTHROGRAM SHOULDER $1,236.00 HC INJ ARTHROGRAM WRIST $673.00 HC INJ BULKING AGENT ANAL CANAL 1 ML LVL 1 $835.00 HC INJ BULKING AGENT ANAL CANAL 1 ML LVL 2 $1,670.00 HC INJ BULKING AGENT ANAL CANAL 1 ML LVL 3 $2,147.00 HC INJ BULKING AGENT ANAL CANAL 1 ML LVL 4 $2,861.00 HC INJ BULKING AGENT ANAL CANAL 1 ML LVL 5 $3,577.00 HC INJ CONGENITAL CARD CATH $1,303.00 HC INJ CONGENITAL CARD CATH BYPASS GRFT $1,303.00 HC INJ CONTRAST KNEE ARTHROGRAPHY $749.00 HC INJ EPIDURAL BLOOD OR CLOT PATCH $2,850.00 HC INJ EXT ANEURYSM PERC $1,012.00 HC INJ FOR CHOLANGIOGRAM EXIST ACCESS $1,091.00 HC INJ FOR CHOLANGIOGRAM NEW ACCESS $6,756.00 HC INJ FOR CYSTOGRAM VCU $641.00 HC INJ FOR EVAL PERITONEAL-VENOUS SHUNT $428.00 HC INJ FOR MYELOGRAM LUMBAR $1,338.00 HC INJ FOR NEPHR/URETEROGRAM EXIST ACCESS $1,627.00 HC INJ FOR NEPHR/URETEROGRAM NEW ACCESS $1,627.00 HC INJ FOR SIALOGRAPHY $463.00 HC INJ FOR URETEROGRAM THRU INDWELLING CATH $1,389.00 HC INJ GADOTERATE MEGLUMI 0.1ML $1.00 HC INJ INTERLAM C/T W CATH PLC W IMG $1,874.00 HC INJ INTERLAM C/T W CATH PLC WO IMG $1,874.00 HC INJ INTERLAM C/T W IMG $1,488.00 HC INJ INTERLAM C/T WO IMG $1,488.00 HC INJ INTERLAM L/S W CATH PLC W IMG $1,582.00 HC INJ INTERLAM L/S W IMG $1,488.00 HC INJ INTERLAM L/S WO IMG $1,488.00 HC INJ LYMPHANGIOGRAPHY $733.00 HC INJ MAMMARY DUCT $453.00 HC INJ MYELOGRAM C1- C2 $1,389.00 HC INJ NEUROLYTIC EPIDURAL CERV/THOR $3,329.00 HC INJ NEUROLYTIC EPIDURAL LUMB/CAUDAL $3,178.00 HC INJ PARAVERT F JNT C/T 1 LEV $2,850.00 71 of 155 Procedure Price HC INJ PARAVERT F JNT C/T 1 LEV BILAT $2,904.00 HC INJ PARAVERT F JNT C/T 2 LEV $2,904.00 HC INJ PARAVERT F JNT C/T 2 LEV BILAT $2,850.00 HC INJ PARAVERT F JNT C/T 3 LEV $2,324.00 HC INJ PARAVERT F JNT C/T 3 LEV BILAT $2,324.00 HC INJ PARAVERT F JNT L/S 1 LEV $2,904.00 HC INJ PARAVERT F JNT L/S 1 LEV BILAT $2,904.00 HC INJ PARAVERT F JNT L/S 2 LEV $2,904.00 HC INJ PARAVERT F JNT L/S 2 LEV BILAT $2,904.00 HC INJ PARAVERT F JNT L/S 3 LEV $2,324.00 HC INJ PARAVERT F JNT L/S 3 LEV BILAT $2,281.00 HC INJ RA TRACER ID SENTINEL NODE $1,766.00 HC INJ SACRAL AUGMT BILAT PERC $9,137.00 HC INJ SACRAL AUGMT UNIL PERC $6,569.00 HC INJ SALINE HYSTEROGRAM $704.00 HC INJ SCLEROSING SOLN - SGL VEIN $250.00 HC INJ SCLEROSING SOLUTION; MULTI, SAME LEG $320.00 HC INJ SGL TENDON SHTH OR LIGAMENT $566.00 HC INJ SINUS TRACT DIAGNOSTIC $255.00 HC INJ SINUS TRACT THERAPEUTIC $538.00 HC INJ TO SEE ILEAL CONDUIT /URETEROPYELOGR $1,081.00 HC INJ TRIGGER POINT 1/2 MUSCL $982.00 HC INJ URETHRA RETRO $641.00 HC INJ W/FLUOR, EVAL CV DEVICE $583.00 HC INJ(S) FORAMEN EPID C/T ADDTL LEV $1,034.00 HC INJ(S) FORAMEN EPID C/T ADDTL LEV BILAT $1,034.00 HC INJ(S) FORAMEN EPID C/T SGL LEV BILAT $5,536.00 HC INJ(S) FORAMEN EPID L/S ADDTL LEV $2,324.00 HC INJ(S) FORAMEN EPID L/S ADDTL LEV BILAT $2,281.00 HC INJ(S) FORAMEN EPID L/S SGL LEV BILAT $2,850.00 HC INJ(S) FORAMEN EPIDURAL C/T SGL LEV $3,329.00 HC INJ(S) FORAMEN EPIDURAL L/S SGL LEV $2,904.00 HC INJECT FOR SPINE DISK X-RAY CERV/THOR $539.00 HC INJECT FOR SPINE DISK X-RAY LUMBAR $1,221.00 HC INJECT L VENTR/ATRIAL ANGIO $1,303.00 HC INJECT PULM ART HRT CATH $1,303.00 HC INJECT R VENTR/ATRIAL ANGIO $1,303.00 72 of 155 Procedure Price HC INJECT SUPRVLV AORTOGRAPHY $1,303.00 HC INJECT TRIGGER POINTS=/>3 $982.00 HC INS 1 TV ELECTRODE PM-DEFIB $12,135.00 HC INS 2 TV ELECTRODE PM-DEFIB $10,081.00 HC INS BLADDER CATH COMPLEX $447.00 HC INS CATH REN ART 1ST BILAT $8,587.00 HC INS CATH REN ART 1ST UNILAT $7,949.00 HC INS CATH REN ART 2ND+ BILAT $9,274.00 HC INS CATH REN ART 2ND+ UNILAT $9,274.00 HC INS ENDOVAS VENA CAVA FILTR $11,827.00 HC INS IA PERC BALLOON $7,955.00 HC INS MARK ABD/PEL FOR RT PERQ $3,372.00 HC INS NON-TUNNEL CV CATH 5 YRS/> $3,686.00 HC INS PICC AGE 5 YRS/> $2,560.00 HC INS PICC DEVICE W PORT 5 YRS/> $6,554.00 HC INS SWAN GANZ BEDSIDE $4,712.00 HC INS TUNNELED CV CATH WO SQ PORT $3,546.00 HC INS/REPL SUBQ DEFIBRILLATOR $85,369.00 HC INS/REPL TEMP TRANSV SC CARD ELECTR/CATH $13,398.00 HC INSERT BLADDER CATHETER $259.00 HC INSERT CARD ELECTRODES DUAL $13,653.00 HC INSERT CATH PLEURA W/ IMAGE $2,451.00 HC INSERT CATH PLEURA W/O IMAGE $1,961.00 HC INSERT CERVICAL DILATOR $642.00 HC INSERT CV ACCESS DEVICE TUNNELED > 5 YRS $8,076.00 HC INSERT CV CATH TUNNELED >5 YRS $4,854.00 HC INSERT DRUG IMPLANT $247.00 HC INSERT HEART PM ATRIAL $23,514.00 HC INSERT HEART PM ATRIAL & VENT $36,237.00 HC INSERT HEART PM VENTRICULAR $29,277.00 HC INSERT HEPATIC SHUNT (TIPS) $30,149.00 HC INSERT IP CATH FOR DR/DIALYSIS PERM $7,121.00 HC INSERT MARK THOR FOR RT PERQ $4,327.00 HC INSERT PACE-DEFIB W/LEAD DUAL $72,748.00 HC INSERT PACE-DEFIB W/LEAD SGL $49,818.00 HC INSERT PACING LEAD & CONNECT $36,237.00 HC INSERT PERM CATH W SQ RESERV $12,174.00 73 of 155 Procedure Price HC INSERT PICC < 5 YRS $3,443.00 HC INSERT PLEURAL CATH $7,658.00 HC INSERT PULSE GEN DUAL LEADS $25,810.00 HC INSERT PULSE GEN MULT LEADS $27,118.00 HC INSERT PULSE GEN SGL LEAD $17,371.00 HC INSERT PULSE GEN W/ SGL LEAD $53,189.00 HC INSERT PULSE GEN W/DUAL LEADS $89,637.00 HC INSERT PULSE GEN W/MULT LEADS $89,637.00 HC INSERT TEMP BLADDER CATH $213.00 HC INSERT TUN IP CATH PERC $9,554.00 HC INSERT TUNNELED CV 2X CATH W SQ PORT $8,395.00 HC INSERT UTERI TANDEMS/OVOIDS $4,723.00 HC INSERT VAD ARTERY ACCESS $14,445.00 HC INSERT VAG BRACHYTX DEVICE $1,206.00 HC INSERTION OF CHEST TUBE $1,580.00 HC INT REP F/E/N/L/MM >30.0 CM $529.00 HC INT REP F/E/N/L/MM 12.6-20.0 CM $529.00 HC INT REP F/E/N/L/MM 2.5 CM/< $310.00 HC INT REP F/E/N/L/MM 2.6-5.0 CM $529.00 HC INT REP F/E/N/L/MM 5.1-7.5 CM $529.00 HC INT REP F/E/N/L/MM 7.6-12.5 CM $529.00 HC INT REP N/H/F/G >30.0 CM $529.00 HC INT REP N/H/F/G 12.6-20.0 CM $1,021.00 HC INT REP N/H/F/G 2.5 CM/< $671.00 HC INT REP N/H/F/G 2.6-7.5 CM $773.00 HC INT REP N/H/F/G 20.1-30.0 CM $529.00 HC INT REP N/H/F/G 7.6-12.5 CM $889.00 HC INT REP S/A/T/EX >30.0 CM $529.00 HC INT REP S/A/T/EX 12.6-20.0 CM $529.00 HC INT REP S/A/T/EX 2.5 CM/< $671.00 HC INT REP S/A/T/EX 2.6-7.5 CM $773.00 HC INT REP S/A/T/EX 20.1-30.0 CM $529.00 HC INT REP S/A/T/EX 7.6-12.5 CM $889.00 HC INTEGRA BMWD PER SQ CM LVL 1 $334.00 HC INTEGRA BMWD PER SQ CM LVL 2 $501.00 HC INTEGRA BMWD PER SQ CM LVL 3 $667.00 HC INTEGRA BMWD PER SQ CM LVL 4 $835.00 74 of 155 Procedure Price HC INTEGRA DRT PER SQ CM LVL 1 $334.00 HC INTEGRA DRT PER SQ CM LVL 2 $501.00 HC INTEGRA DRT PER SQ CM LVL 3 $667.00 HC INTEGRA DRT PER SQ CM LVL 4 $835.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 1 $835.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 10 $6,558.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 2 $1,431.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 3 $2,147.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 4 $2,861.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 5 $3,577.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 6 $3,935.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 7 $4,591.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 8 $5,247.00 HC INTEGRA FLOWABLE WOUND MAT 1 CC LVL 9 $5,903.00 HC INTEGRA MATRIX PER SQ CM LVL 1 $334.00 HC INTEGRA MATRIX PER SQ CM LVL 2 $501.00 HC INTEGRA MATRIX PER SQ CM LVL 3 $667.00 HC INTEGRA MATRIX PER SQ CM LVL 4 $835.00 HC INTEGRA MESH BIL WND MAT PER SQ CM LVL 1 $334.00 HC INTEGRA MESH BIL WND MAT PER SQ CM LVL 2 $501.00 HC INTEGRA MESH BIL WND MAT PER SQ CM LVL 3 $667.00 HC INTEGRA MESH BIL WND MAT PER SQ CM LVL 4 $835.00 HC INTENSITY MODUL RAD TX DLVR (IMRT) CPLX $3,351.00 HC INTENSITY MODUL RAD TX DLVR (IMRT) SMPL $3,351.00 HC INTENSIVE ASSESSMENT $7,912.00 HC INTENSIVE OP PSYCH PER DAY $1,258.00 HC INTERCAVITARY APPL COMPLEX $1,976.00 HC INTERCAVITARY APPL INTERMEDIATE $1,976.00 HC INTERSPINOUS IMPLANT LVL 1 $2,088.00 HC INTERSPINOUS IMPLANT LVL 10 $8,942.00 HC INTERSPINOUS IMPLANT LVL 11 $9,838.00 HC INTERSPINOUS IMPLANT LVL 13 $11,627.00 HC INTERSPINOUS IMPLANT LVL 14 $12,520.00 HC INTERSPINOUS IMPLANT LVL 16 $14,309.00 HC INTERSPINOUS IMPLANT LVL 17 $15,203.00 HC INTERSPINOUS IMPLANT LVL 2 $3,577.00 HC INTERSPINOUS IMPLANT LVL 21 $18,780.00 75 of 155 Procedure Price HC INTERSPINOUS IMPLANT LVL 3 $4,472.00 HC INTERSPINOUS IMPLANT LVL 4 $5,963.00 HC INTERSPINOUS IMPLANT LVL 5 $6,706.00 HC INTERSPINOUS IMPLANT LVL 6 $8,048.00 HC INTERSPINOUS IMPLANT LVL 7 $8,347.00 HC INTERSPINOUS IMPLANT LVL 8 $9,539.00 HC INTERSPINOUS IMPLANT LVL 9 $8,048.00 HC INTERST RS APPL; COMPLEX $5,460.00 HC INTERV HLTH/BEHAV FAM W/PT 15 MIN $86.00 HC INTERVENE HLTH/BEHAVE GROUP 15 MIN $86.00 HC INTERVENE HLTH/BEHAVE INDIV 15 MIN $86.00 HC INTMD WND REPAIR FACE/MM 20.1-30.0 CM $529.00 HC INTRA ATRIAL PACING $5,121.00 HC INTRA ATRIAL RECORDING $5,121.00 HC INTRA VENTRICULAR PACING $6,146.00 HC INTRAABDOMINAL PRESSURE TEST $1,566.00 HC INTRA-ARTERIAL RPHARM RX $863.00 HC INTRACARDIAC ECHO AT OP $3,674.00 HC INTRACAV RS APPL; SIMPLE $1,478.00 HC INTRACRANIAL ANGIOPLASTY $4,382.00 HC INTRACRANIAL ANGIOPLASTY W STENT $5,420.00 HC INTRACRANIAL ARTERY DOPPLER LIMITED $731.00 HC INTRACRANIAL ARTERY DOPPLER; COMPL $1,399.00 HC INTRA-OP NEURO MONITOR IN OR EA 15 MIN $145.00 HC INTRA-OP NEURO MONITOR IN OR LVL 1 $744.00 HC INTRA-OP NEURO MONITOR IN OR LVL 2 $1,486.00 HC INTRO CATH DIALYSIS CIRCUIT $2,147.00 HC INTRO CATH DIALYSIS CIRCUIT W STENT $29,153.00 HC INTRO CATH DIALYSIS CIRCUIT W TBA $14,425.00 HC INTRO/SHEATH, LASER LVL 1 $835.00 HC INTRO/SHEATH, LASER LVL 10 $13,415.00 HC INTRO/SHEATH, LASER LVL 2 $3,577.00 HC INTRO/SHEATH, LASER LVL 3 $6,558.00 HC INTRO/SHEATH, LASER LVL 5 $10,732.00 HC INTRO/SHEATH, LASER LVL 7 $14,309.00 HC INTRO/SHEATH, NON-LASER LVL 1 $835.00 HC INTRO/SHEATH, NON-LASER LVL 11 $10,732.00 76 of 155 Procedure Price HC INTRO/SHEATH, NON-LASER LVL 2 $1,431.00 HC INTRO/SHEATH, NON-LASER LVL 3 $2,861.00 HC INTRO/SHEATH, NON-LASER LVL 4 $3,935.00 HC INTRO/SHEATH, NON-LASER LVL 5 $5,247.00 HC INTRO/SHEATH, NON-LASER LVL 6 $6,558.00 HC INTRO/SHEATH, NON-LASER LVL 7 $6,440.00 HC INTRO/SHEATH, NON-LASER LVL 8 $7,512.00 HC INTRODUCE LONG GI TUBE $1,048.00 HC INTRODUCERS/SHEATHS LVL 1 $1,431.00 HC INTRODUCERS/SHEATHS LVL 2 $2,861.00 HC INTRODUCERS/SHEATHS LVL 3 $3,935.00 HC INTRODUCERS/SHEATHS LVL 4 $5,247.00 HC INTRODUCERS/SHEATHS LVL 5 $6,558.00 HC INTRODUCERS/SHEATHS LVL 6 $6,440.00 HC INTRODUCERS/SHEATHS LVL 7 $7,512.00 HC INTRVASC US NONCORONARY 1ST $5,856.00 HC INTRVASC US NONCORONARY ADDTL $944.00 HC INTUBATION ET EMERGENT $899.00 HC IODINE I-123 IOBENGUANE TO 15 MCI $6,767.00 HC IODINE I-123 IOFLUPANE =< 5 MCI $7,627.00 HC IODINE I-123 SOD IODIDE MIL PER 1 MCI $937.00 HC IODINE I-123 SOD IODIDE PER 100 UCI TO 999 UCI $303.00 HC IOP PSYCH ADOL/YA $900.00 HC IP ACUTE DIALYSIS $2,955.00 HC IP STAY RADIOLABELED ITEM $1.00 HC IP UTILIZATION MGMT $51.00 HC IPECAC ADMINISTRATION $28.00 HC IRRIG DRUG DELIVERY DEVICE $246.00 HC IRRIGATE CORPORA CAVERNOSA PRIAPISM $471.00 HC IRRIGATION SUPPLIES GENERAL LVL 1 $299.00 HC IRRIGATION SUPPLIES GENERAL LVL 2 $477.00 HC IV DOPPLER EA ADDTL VESSEL $5,057.00 HC IV DOPPLER INITIAL VESSEL $4,552.00 HC IV US CORONARY V EA ADDTL $792.00 HC IV US CORONARY V INITIAL $7,734.00 HC IVP INFUSION $389.00 HC IVP INFUSION W TOMOGRAPHY $756.00 77 of 155 Procedure Price HC IVP W WO TOMOGRAPHY OR KUB $948.00 HC JOINT DEVICE (IMPLANTABLE) LVL 1 $239.00 HC JOINT DEVICE (IMPLANTABLE) LVL 10 $6,706.00 HC JOINT DEVICE (IMPLANTABLE) LVL 11 $8,048.00 HC JOINT DEVICE (IMPLANTABLE) LVL 12 $8,347.00 HC JOINT DEVICE (IMPLANTABLE) LVL 13 $9,539.00 HC JOINT DEVICE (IMPLANTABLE) LVL 14 $8,048.00 HC JOINT DEVICE (IMPLANTABLE) LVL 15 $8,942.00 HC JOINT DEVICE (IMPLANTABLE) LVL 16 $9,838.00 HC JOINT DEVICE (IMPLANTABLE) LVL 17 $10,732.00 HC JOINT DEVICE (IMPLANTABLE) LVL 18 $11,627.00 HC JOINT DEVICE (IMPLANTABLE) LVL 19 $12,520.00 HC JOINT DEVICE (IMPLANTABLE) LVL 2 $477.00 HC JOINT DEVICE (IMPLANTABLE) LVL 20 $13,415.00 HC JOINT DEVICE (IMPLANTABLE) LVL 21 $14,309.00 HC JOINT DEVICE (IMPLANTABLE) LVL 22 $15,203.00 HC JOINT DEVICE (IMPLANTABLE) LVL 23 $16,097.00 HC JOINT DEVICE (IMPLANTABLE) LVL 24 $16,992.00 HC JOINT DEVICE (IMPLANTABLE) LVL 25 $17,886.00 HC JOINT DEVICE (IMPLANTABLE) LVL 26 $18,780.00 HC JOINT DEVICE (IMPLANTABLE) LVL 27 $19,674.00 HC JOINT DEVICE (IMPLANTABLE) LVL 28 $20,569.00 HC JOINT DEVICE (IMPLANTABLE) LVL 29 $21,462.00 HC JOINT DEVICE (IMPLANTABLE) LVL 3 $835.00 HC JOINT DEVICE (IMPLANTABLE) LVL 30 $22,357.00 HC JOINT DEVICE (IMPLANTABLE) LVL 32 $24,145.00 HC JOINT DEVICE (IMPLANTABLE) LVL 33 $25,040.00 HC JOINT DEVICE (IMPLANTABLE) LVL 34 $25,934.00 HC JOINT DEVICE (IMPLANTABLE) LVL 35 $26,827.00 HC JOINT DEVICE (IMPLANTABLE) LVL 4 $1,252.00 HC JOINT DEVICE (IMPLANTABLE) LVL 5 $1,670.00 HC JOINT DEVICE (IMPLANTABLE) LVL 6 $2,088.00 HC JOINT DEVICE (IMPLANTABLE) LVL 7 $3,577.00 HC JOINT DEVICE (IMPLANTABLE) LVL 8 $4,472.00 HC JOINT DEVICE (IMPLANTABLE) LVL 9 $5,963.00 HC JOINT SURVEY 1 VIEW $478.00 HC KERATOMILEUSIS (LASIK/ASA LASER) LVL 1 $835.00 78 of 155 Procedure Price HC KERATOMILEUSIS (LASIK/ASA LASER) LVL 2 $1,431.00 HC KERATOMILEUSIS (LASIK/ASA LASER) LVL 3 $2,147.00 HC KNEE 1 OR 2 VIEWS $525.00 HC KNEE 3 VIEWS $544.00 HC KNEE ARTHROGRAM $1,051.00 HC KNEE CNTRL/CAP W CUSTOM ORTHOSIS LVL 1 $1,431.00 HC KNEE CNTRL/CAP W CUSTOM ORTHOSIS LVL 2 $2,861.00 HC KNEE CNTRL/CAP W CUSTOM ORTHOSIS LVL 3 $3,935.00 HC KNEE CNTRL/CAP W CUSTOM ORTHOSIS LVL 4 $5,247.00 HC KNEE CNTRL/CAP W CUSTOM ORTHOSIS LVL 5 $6,558.00 HC KNEE MIN 4 VIEWS $729.00 HC KNEE STRAPPING $251.00 HC KNEES STANDING AP $598.00 HC KO ADJ JNT POS RIGID SUPPORT LVL 1 $1,431.00 HC KO ADJ JNT POS RIGID SUPPORT LVL 2 $2,861.00 HC KO ADJ JNT POS RIGID SUPPORT LVL 3 $3,935.00 HC KO ADJ JNT POS RIGID SUPPORT LVL 4 $5,247.00 HC KO ADJ JNT POS RIGID SUPPORT LVL 5 $6,558.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 1 $334.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 2 $501.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 3 $667.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 4 $835.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 5 $859.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 6 $1,001.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 7 $1,144.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 8 $1,289.00 HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 9 $1,431.00 HC L HRT ART/GRFT ANGIO $13,187.00 HC L HRT ARTERY/VENTRICLE ANGIO $13,187.00 HC L HRT CATH TRNSPTL PUNCTURE $10,202.00 HC L201 THALLIUM PER MCI $325.00 HC LACTATION SVC LEVEL I $174.00 HC LACTATION SVC LEVEL II $232.00 HC LANG COMP CURRENT STATUS $0.01 HC LANG COMP D/C STATUS $0.01 HC LANG COMP GOAL STATUS $0.01 HC LANG EXPRESS CURRENT STATUS $0.01 79 of 155 Procedure Price HC LANG EXPRESS D/C STATUS $0.01 HC LANG EXPRESS GOAL STATUS $0.01 HC LAPOROSCOPY SUPPLIES GENERAL LVL 1 $417.00 HC LAPOROSCOPY SUPPLIES GENERAL LVL 2 $835.00 HC LAPOROSCOPY SUPPLIES GENERAL LVL 3 $3,577.00 HC LAPOROSCOPY SUPPLIES GENERAL LVL 4 $4,650.00 HC LARYNGOSCOPY DIRECT W FB REM $5,372.00 HC LARYNGOSCOPY FLEX DIAGNOSTIC $542.00 HC LARYNGOSCOPY FLEXIBLE $575.00 HC LARYNGOSCOPY INDIRECT W FB REM $420.00 HC LASER ABLTN EXT VEIN 1ST VEIN $7,041.00 HC LASER ABLTN EXT VEIN ADD-ON $7,041.00 HC LASER/ROBOTIC SUPPLIES GENERAL LVL 1 $3,577.00 HC LASER/ROBOTIC SUPPLIES GENERAL LVL 2 $6,558.00 HC LCL SURG WND/DEH EXTENSIVE $4,388.00 HC LEAD CORONARY VENOUS LVL 1 $477.00 HC LEAD CORONARY VENOUS LVL 15 $12,520.00 HC LEAD CORONARY VENOUS LVL 16 $13,415.00 HC LEAD CORONARY VENOUS LVL 19 $16,097.00 HC LEAD CORONARY VENOUS LVL 2 $2,088.00 HC LEAD CORONARY VENOUS LVL 20 $16,992.00 HC LEAD CORONARY VENOUS LVL 3 $3,577.00 HC LEAD CORONARY VENOUS LVL 4 $4,472.00 HC LEAD CORONARY VENOUS LVL 5 $5,963.00 HC LEAD CORONARY VENOUS LVL 6 $6,706.00 HC LEAD CORONARY VENOUS LVL 7 $8,048.00 HC LEAD CORONARY VENOUS LVL 8 $8,347.00 HC LEAD CORONARY VENOUS LVL 9 $9,539.00 HC LEAD, AICD, ENDO DUAL COIL LVL 1 $3,577.00 HC LEAD, AICD, ENDO DUAL COIL LVL 10 $14,904.00 HC LEAD, AICD, ENDO DUAL COIL LVL 2 $6,558.00 HC LEAD, AICD, ENDO DUAL COIL LVL 6 $14,309.00 HC LEAD, AICD, ENDO DUAL COIL LVL 7 $14,606.00 HC LEAD, AICD, ENDO DUAL COIL LVL 8 $16,693.00 HC LEAD, AICD, ENDO SINGLE COIL LVL 1 $3,577.00 HC LEAD, AICD, ENDO SINGLE COIL LVL 2 $835.00 HC LEAD, AICD, ENDO SINGLE COIL LVL 3 $14,904.00 80 of 155 Procedure Price HC LEAD, AICD, NON SING/DUAL LVL 1 $3,577.00 HC LEAD, AICD, NON SING/DUAL LVL 2 $6,558.00 HC LEAD, AICD, NON SING/DUAL LVL 9 $13,415.00 HC LEAD, NEUROSTIMULATOR LVL 1 $2,088.00 HC LEAD, NEUROSTIMULATOR LVL 2 $3,577.00 HC LEAD, NEUROSTIMULATOR LVL 3 $8,942.00 HC LEAD, NEUROSTIMULATOR LVL 4 $17,886.00 HC LEAD, NEUROSTIMULATOR LVL 6 $35,771.00 HC LEAD, PMKR, TRANSVENOUS VDD LVL 1 $835.00 HC LEAD, PMKR, TRANSVENOUS VDD LVL 2 $3,577.00 HC LEAD, PMKR, TRANSVENOUS VDD LVL 3 $6,558.00 HC LEAD, PMKR, TRANSVENOUS VDD LVL 4 $8,048.00 HC LEAD, PMKR, TRANSVENOUS VDD LVL 5 $10,732.00 HC LEADLESS C PM INS/RPL VENTR $36,061.00 HC LEFT HRT CATH W/VENTRCLGRPHY $9,425.00 HC LENS, INTRAOCULAR (NEW TECH) LVL 1 $1,431.00 HC LENS, INTRAOCULAR (NEW TECH) LVL 2 $2,861.00 HC LENS, INTRAOCULAR (NEW TECH) LVL 3 $3,935.00 HC LENS, INTRAOCULAR (NEW TECH) LVL 4 $5,247.00 HC LENS, INTRAOCULAR (NEW TECH) LVL 5 $6,558.00 HC LENS, INTRAOCULAR (NEW TECH) LVL 6 $6,440.00 HC LENS, INTRAOCULAR (NEW TECH) LVL 7 $7,512.00 HC LENS, INTRAOCULAR ANTERIOR LVL 1 $1,431.00 HC LENS, INTRAOCULAR ANTERIOR LVL 2 $2,861.00 HC LENS, INTRAOCULAR ANTERIOR LVL 3 $3,935.00 HC LENS, INTRAOCULAR ANTERIOR LVL 4 $5,247.00 HC LENS, INTRAOCULAR ANTERIOR LVL 5 $6,558.00 HC LENS, INTRAOCULAR ANTERIOR LVL 6 $6,440.00 HC LENS, INTRAOCULAR ANTERIOR LVL 7 $7,512.00 HC LENS, INTRAOCULAR POSTERIOR LVL 1 $1,431.00 HC LENS, INTRAOCULAR POSTERIOR LVL 2 $2,861.00 HC LENS, INTRAOCULAR POSTERIOR LVL 3 $3,935.00 HC LENS, INTRAOCULAR POSTERIOR LVL 4 $5,247.00 HC LENS, INTRAOCULAR POSTERIOR LVL 5 $6,558.00 HC LENS, INTRAOCULAR POSTERIOR LVL 6 $6,440.00 HC LENS, INTRAOCULAR POSTERIOR LVL 7 $7,512.00 HC LENS, INTRAOCULAR POSTERIOR LVL 8 $8,585.00 81 of 155 Procedure Price HC LEV 1 HOSP TYPE B ED VISIT $197.00 HC LEV 2 HOSP TYPE B ED VISIT $278.00 HC LEV 3 HOSP TYPE B ED VISIT $461.00 HC LEV 4 HOSP TYPE B ED VISIT $732.00 HC LEV 5 HOSP TYPE B ED VISIT $1,318.00 HC LEXTREM ORTHOSIS NOS LVL 1 $1,431.00 HC LEXTREM ORTHOSIS NOS LVL 2 $2,861.00 HC LEXTREM ORTHOSIS NOS LVL 3 $3,935.00 HC LEXTREM ORTHOSIS NOS LVL 4 $5,247.00 HC LEXTREM ORTHOSIS NOS LVL 5 $6,558.00 HC LIMIT ANKLE MOTION ADDTN EA JNT LVL 1 $334.00 HC LIMIT ANKLE MOTION ADDTN EA JNT LVL 2 $501.00 HC LIMIT ANKLE MOTION ADDTN EA JNT LVL 3 $667.00 HC LIMIT ANKLE MOTION ADDTN EA JNT LVL 4 $835.00 HC LITHOTRIPSY ESWL BILATERAL $20,601.00 HC LITHOTRIPSY ESWL UNILATERAL $16,378.00 HC LO FLEX W/O RIGID STAYS PRE LVL 1 $334.00 HC LO FLEX W/O RIGID STAYS PRE LVL 2 $501.00 HC LO FLEX W/O RIGID STAYS PRE LVL 3 $667.00 HC LO FLEX W/O RIGID STAYS PRE LVL 4 $835.00 HC LO FLEXIBL L1-BELOW L5 PRE LVL 1 $334.00 HC LO FLEXIBL L1-BELOW L5 PRE LVL 2 $501.00 HC LO FLEXIBL L1-BELOW L5 PRE LVL 3 $667.00 HC LO FLEXIBL L1-BELOW L5 PRE LVL 4 $835.00 HC LO SAG RIG PNL STAYS PRE CST LVL 1 $1,431.00 HC LO SAG RIG PNL STAYS PRE CST LVL 2 $2,861.00 HC LO SAG RIG PNL STAYS PRE CST LVL 3 $3,935.00 HC LO SAG RIG PNL STAYS PRE CST LVL 4 $5,247.00 HC LO SAG RIG PNL STAYS PRE CST LVL 5 $6,558.00 HC LOCM 100-199 MG/ML IODINE 1ML $1.00 HC LOCM 200-299 MG/ML IODINE 1ML $12.00 HC LOCM 300-399 MG/ML IODINE 1ML $1.00 HC LOCM>=400 MG/ML IODINE 1ML $24.00 HC LOW COST SKIN SUB APP F/NK/HF/G +25 SQCM $405.00 HC LOW COST SKIN SUB APP F/NK/HF/G 25 SQCM $1,618.00 HC LOW COST SKIN SUB APP F/NK/HF/G CH +100 SQCM $405.00 HC LOW COST SKIN SUB APP F/NK/HF/G CH 100 SQCM $1,618.00 82 of 155 Procedure Price HC LOW COST SKIN SUB APP T/A/L +25 SQCM $405.00 HC LOW COST SKIN SUB APP T/A/L 25 SQCM $1,618.00 HC LOW COST SKIN SUB APP T/A/L CH +100 SQCM $1,357.00 HC LOW COST SKIN SUB APP T/A/L CH 100 SQCM $5,420.00 HC LOW DOSE CT LUNG SCREENING $180.00 HC LOWR EXTR INFANT MIN 2 VIEWS $384.00 HC LSO SAG R AN/POS PNL PRE CST LVL 1 $1,431.00 HC LSO SAG R AN/POS PNL PRE CST LVL 10 $10,732.00 HC LSO SAG R AN/POS PNL PRE CST LVL 2 $2,861.00 HC LSO SAG R AN/POS PNL PRE CST LVL 3 $3,935.00 HC LSO SAG R AN/POS PNL PRE CST LVL 4 $5,247.00 HC LSO SAG R AN/POS PNL PRE CST LVL 5 $6,558.00 HC LSO SAG R AN/POS PNL PRE CST LVL 6 $6,440.00 HC LSO SAG R AN/POS PNL PRE CST LVL 7 $7,512.00 HC LSO SAG R AN/POS PNL PRE CST LVL 8 $8,585.00 HC LSO SAG R AN/POS PNL PRE CST LVL 9 $9,658.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 1 $1,431.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 10 $10,732.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 2 $2,861.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 3 $3,935.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 4 $5,247.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 5 $6,558.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 6 $6,440.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 7 $7,512.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 8 $8,585.00 HC LSO SAG-CORONAL PANEL CUSTOM LVL 9 $9,658.00 HC LUMBAR SPINE DISK $2,288.00 HC LUMBOSACR SPINE 2 OR 3 VIEWS $564.00 HC LUMBOSACR SPINE BEND 2 OR 3 VIEWS $181.00 HC LUMBOSACR SPINE COMPL W BENDING MIN 6 VW $996.00 HC LUMBOSACR SPINE MIN 4 VIEWS $784.00 HC LUNG BX PLUG W/DEL SYS LVL 3 $743.00 HC LV PACING LEAD ADD ON $23,038.00 HC LWR XTR VASC STUDY BILAT $1,173.00 HC LYSE CHEST FIBRIN INIT DAY $1,745.00 HC LYSE CHEST FIBRIN SUBQ DAY $1,745.00 HC LYSIS OF ADH MULTI 1 DAY $2,850.00 83 of 155 Procedure Price HC MAMMARY INTERNAL ANGIOGRAM $2,319.00 HC MANDIBLE LESS THAN 4 VIEWS $519.00 HC MANDIBLE MIN 4 VIEWS $689.00 HC MANOMETRY THRU INDWELLING CATH (WHITAKER) $601.00 HC MANUAL THERAPY EA 15M $157.00 HC MAP TACHYCARDIA ADD ON $13,691.00 HC MASSAGE THERAPY EA 15M $209.00 HC MASTOIDS LESS THAN 3 VIEWS EACH $456.00 HC MASTOIDS MIN 3 VIEWS EACH SIDE $528.00 HC MASTOTOMY W EXPL DEEP $4,413.00 HC MATRISTEM MICROMATRIX 1 MG LVL 1 $191.00 HC MATRISTEM MICROMATRIX 1 MG LVL 2 $286.00 HC MATRISTEM MICROMATRIX 1 MG LVL 3 $382.00 HC MATRISTEM MICROMATRIX 1 MG LVL 4 $477.00 HC MD HBO THERAPY PER SESSION LEVEL 1 $3,046.00 HC MDI AIRWAY INHALATION TX INITIAL $417.00 HC MDI AIRWAY INHALATION TX SUBQ $417.00 HC MECH REM OBSTRUCTION CVAD $1,634.00 HC MEDIASTINOSCPY W/LYMPH NODE BX $9,783.00 HC MEDIASTINOSCPY W/MEDSTNL BX $9,783.00 HC MEDICAL DEPOSITION PER HOUR $278.00 HC MEMORY CURRENT STATUS $0.01 HC MEMORY D/C STATUS $0.01 HC MEMORY GOAL STATUS $0.01 HC MESH (IMPLANTABLE) LVL 1 $477.00 HC MESH (IMPLANTABLE) LVL 10 $8,048.00 HC MESH (IMPLANTABLE) LVL 11 $8,347.00 HC MESH (IMPLANTABLE) LVL 12 $9,539.00 HC MESH (IMPLANTABLE) LVL 13 $8,048.00 HC MESH (IMPLANTABLE) LVL 14 $8,942.00 HC MESH (IMPLANTABLE) LVL 15 $9,838.00 HC MESH (IMPLANTABLE) LVL 18 $12,520.00 HC MESH (IMPLANTABLE) LVL 2 $835.00 HC MESH (IMPLANTABLE) LVL 20 $14,309.00 HC MESH (IMPLANTABLE) LVL 21 $15,203.00 HC MESH (IMPLANTABLE) LVL 22 $16,097.00 HC MESH (IMPLANTABLE) LVL 24 $17,886.00 84 of 155 Procedure Price HC MESH (IMPLANTABLE) LVL 26 $25,956.00 HC MESH (IMPLANTABLE) LVL 27 $28,119.00 HC MESH (IMPLANTABLE) LVL 28 $30,282.00 HC MESH (IMPLANTABLE) LVL 3 $1,252.00 HC MESH (IMPLANTABLE) LVL 31 $36,771.00 HC MESH (IMPLANTABLE) LVL 33 $41,097.00 HC MESH (IMPLANTABLE) LVL 4 $1,670.00 HC MESH (IMPLANTABLE) LVL 5 $2,088.00 HC MESH (IMPLANTABLE) LVL 6 $3,577.00 HC MESH (IMPLANTABLE) LVL 7 $4,472.00 HC MESH (IMPLANTABLE) LVL 8 $5,963.00 HC MESH (IMPLANTABLE) LVL 9 $6,706.00 HC METHACHOLINE CHLORIDE IH THRU NEBULIZER 1 MG $15.00 HC MIDLINE INFUSION CATH LVL 1 $477.00 HC MIDLINE INFUSION CATH LVL 10 $8,048.00 HC MIDLINE INFUSION CATH LVL 11 $8,347.00 HC MIDLINE INFUSION CATH LVL 12 $9,539.00 HC MIDLINE INFUSION CATH LVL 2 $835.00 HC MIDLINE INFUSION CATH LVL 3 $1,252.00 HC MIDLINE INFUSION CATH LVL 4 $1,670.00 HC MIDLINE INFUSION CATH LVL 5 $2,088.00 HC MIDLINE INFUSION CATH LVL 6 $3,577.00 HC MIDLINE INFUSION CATH LVL 7 $4,472.00 HC MIDLINE INFUSION CATH LVL 8 $5,963.00 HC MIDLINE INFUSION CATH LVL 9 $6,706.00 HC MINOR PROCEDURE $236.00 HC MINOR PROCEDURE LEVEL 1 $241.00 HC MINOR PROCEDURE LEVEL 2 $417.00 HC MINOR PROCEDURE LEVEL 3 $853.00 HC MINOR PROCEDURE LEVEL 4 $1,094.00 HC MINOR PROCEDURE LEVEL 5 $1,428.00 HC MISC IMPLANT CHARGE LVL1 $2,861.00 HC MISC IMPLANT CHARGE LVL10 $7,870.00 HC MISC IMPLANT CHARGE LVL11 $8,585.00 HC MISC IMPLANT CHARGE LVL12 $9,301.00 HC MISC IMPLANT CHARGE LVL2 $3,577.00 HC MISC IMPLANT CHARGE LVL3 $4,770.00 85 of 155 Procedure Price HC MISC IMPLANT CHARGE LVL4 $5,963.00 HC MISC IMPLANT CHARGE LVL5 $6,440.00 HC MISC IMPLANT CHARGE LVL6 $7,512.00 HC MISC IMPLANT CHARGE LVL7 $7,631.00 HC MISC IMPLANT CHARGE LVL8 $8,585.00 HC MISC IMPLANT CHARGE LVL9 $9,539.00 HC MISC PATIENT CONVENIENCE ITEM LVL 1 $42.00 HC MISC PATIENT CONVENIENCE ITEM LVL 10 $752.00 HC MISC PATIENT CONVENIENCE ITEM LVL 11 $835.00 HC MISC PATIENT CONVENIENCE ITEM LVL 2 $84.00 HC MISC PATIENT CONVENIENCE ITEM LVL 3 $167.00 HC MISC PATIENT CONVENIENCE ITEM LVL 4 $251.00 HC MISC PATIENT CONVENIENCE ITEM LVL 5 $334.00 HC MISC PATIENT CONVENIENCE ITEM LVL 6 $417.00 HC MISC PATIENT CONVENIENCE ITEM LVL 7 $501.00 HC MISC PATIENT CONVENIENCE ITEM LVL 8 $585.00 HC MISC PATIENT CONVENIENCE ITEM LVL 9 $667.00 HC MISC SUPPLY CHARGE LVL 1 $379.00 HC MISC SUPPLY CHARGE LVL 10 $10,599.00 HC MISC SUPPLY CHARGE LVL 12 $13,519.00 HC MISC SUPPLY CHARGE LVL 14 $15,141.00 HC MISC SUPPLY CHARGE LVL 2 $757.00 HC MISC SUPPLY CHARGE LVL 3 $1,136.00 HC MISC SUPPLY CHARGE LVL 4 $1,514.00 HC MISC SUPPLY CHARGE LVL 5 $3,028.00 HC MISC SUPPLY CHARGE LVL 6 $4,542.00 HC MISC SUPPLY CHARGE LVL 7 $6,056.00 HC MISC SUPPLY CHARGE LVL 8 $7,571.00 HC MISC SUPPLY CHARGE LVL 9 $9,085.00 HC MM DXA BONE DENSITY/PERIPHERAL 1+ SITES $212.00 HC MM X-RAY OF MAMMARY DUCT $542.00 HC MM X-RAY OF MAMMARY DUCTS $943.00 HC MNT EA 15 M AFTER 2ND REFRL $74.00 HC MNT GROUP/30M AFTER 2ND REFERRAL $30.00 HC MOBILITY CURRENT STATUS $0.01 HC MOBILITY D/C STATUS $0.01 HC MOBILITY GOAL STATUS $0.01 86 of 155 Procedure Price HC MOD SED ENDO 5/> YRS INIT 15 MIN $476.00 HC MOD SED OTHER PHYS/QHP 5/>YRS 15M $348.00 HC MOD SED OTHER PHYS/QHP EA 15 MIN $214.00 HC MOD SED SAME PHYS/QHP $294.00 HC MOD SED SAME PHYS/QHP 5/>YRS 15M $348.00 HC MOD SED SAME PHYS/QHP EA ADD 15M $214.00 HC MODALITY CONTRAST BATHS EA 15M $199.00 HC MODALITY HUBBARD TANK EA 15M $305.00 HC MODALITY INFRARED $105.00 HC MODALITY IONTOPHORESIS EA 15M $235.00 HC MODALITY M ELECTR STIM EA 15M $217.00 HC MODALITY MECHANICAL TRACTION $71.00 HC MODALITY PARAFFIN BATH $199.00 HC MODALITY ULTRASOUND EA 15M $173.00 HC MODALITY VASOPNEUMATIC DEVICES $239.00 HC MODALITY WHIRLPOOL $300.00 HC MONITOR INTERST FLD PRESSURE $371.00 HC MORCELLATOR LVL 1 $1,431.00 HC MORCELLATOR LVL 2 $2,861.00 HC MORCELLATOR LVL 3 $3,935.00 HC MORCELLATOR LVL 4 $5,247.00 HC MORCELLATOR LVL 5 $6,558.00 HC MORCELLATOR LVL 6 $6,440.00 HC MORCELLATOR LVL 7 $7,512.00 HC MOTION FLUORO SWALLOW FCN $621.00 HC MOTOR SPEECH CURRENT STATUS $0.01 HC MOTOR SPEECH D/C STATUS $0.01 HC MOTOR SPEECH GOAL STATUS $0.01 HC MR CHOLANGIOPANCREATOGRAPHY (MRCP) $5,660.00 HC MR GUIDANCE FOR NEEDLE PLACE $2,326.00 HC MR SPECTROSCOPY $1,315.00 HC MRA ABDOMEN W CONTRAST $5,798.00 HC MRA ABDOMEN W WO CONTRAST $6,459.00 HC MRA ABDOMEN WO CONTRAST $4,151.00 HC MRA CHEST W CONTRAST $6,459.00 HC MRA CHEST W WO CONTRAST $6,970.00 HC MRA CHEST WO CONTRAST $4,151.00 87 of 155 Procedure Price HC MRA HEAD W CONTRAST $5,852.00 HC MRA HEAD W WO CONTRAST $6,595.00 HC MRA HEAD WO CONTRAST $5,164.00 HC MRA LOW EXTR W CONTRAST $4,636.00 HC MRA LOW EXTR W WO CONTRAST $4,722.00 HC MRA LOW EXTR WO CONTRAST $4,151.00 HC MRA NECK W CONTRAST $5,294.00 HC MRA NECK W WO CONTRAST $7,160.00 HC MRA NECK WO CONTRAST $5,294.00 HC MRA PELVIS W CONTRAST $4,844.00 HC MRA PELVIS W WO CONTRAST $4,844.00 HC MRA PELVIS WO CONTRAST $4,844.00 HC MRA W/DYE SPINAL CANAL $2,414.00 HC MRA W/DYE UPPER EXTREMITY $2,414.00 HC MRA W/O DYE SPINAL CANAL $1,993.00 HC MRA W/O DYE UPPER EXTR $1,993.00 HC MRA W/O&W/DYE SPINAL CANAL $3,048.00 HC MRA W/O&W/DYE UPPER EXTR $3,048.00 HC MRI ABDOMEN W CONTRAST $5,523.00 HC MRI ABDOMEN W WO CONTRAST $6,327.00 HC MRI ABDOMEN WO CONTRAST $5,660.00 HC MRI BRAIN W CONTRAST $5,743.00 HC MRI BRAIN W WO CONTRAST $6,251.00 HC MRI BRAIN WO CONTRAST $5,243.00 HC MRI BREAST BILAT W CONTRAST $5,219.00 HC MRI BREAST BILAT W WO CONTRAST $5,840.00 HC MRI BREAST BILAT WO CONTRAST $4,539.00 HC MRI BREAST UNIL W CONTRAST $2,270.00 HC MRI BREAST UNIL W WO CONTRAST $3,202.00 HC MRI BREAST UNIL WO CONTRAST $2,167.00 HC MRI CAD BREAST $152.00 HC MRI CARDIAC FOR MORPH W WO CONTR $6,273.00 HC MRI CARDIAC FOR MORPH WO CONTRAST $4,593.00 HC MRI CARDIAC VELOC FLOW MAP ADD-ON $5,211.00 HC MRI CHEST W CONTRAST $6,282.00 HC MRI CHEST W WO CONTRAST $7,198.00 HC MRI CHEST WO CONTRAST $5,479.00 88 of 155 Procedure Price HC MRI LOW EXTR ANY JOINT W CONTRAST $6,253.00 HC MRI LOW EXTR ANY JOINT W WO CONTR $6,293.00 HC MRI LOW EXTR ANY JOINT WO CONTRAST $5,243.00 HC MRI LOW EXTR NOT JOINT W CONTRAST $6,105.00 HC MRI LOW EXTR NOT JOINT W WO CONTR $6,245.00 HC MRI LOW EXTR NOT JOINT WO CONTRAST $5,366.00 HC MRI OF TMJ $5,490.00 HC MRI ORBIT FACE NECK W CONTRAST $5,814.00 HC MRI ORBIT FACE NECK W WO CONTRAST $6,255.00 HC MRI ORBIT FACE NECK WO CONTRAST $5,479.00 HC MRI PELVIS W CONTRAST $6,168.00 HC MRI PELVIS W WO CONTRAST $6,473.00 HC MRI PELVIS WO CONTRAST $5,231.00 HC MRI SPINE CERVICAL W CONTRAST $6,239.00 HC MRI SPINE CERVICAL W WO CONTRAST $6,693.00 HC MRI SPINE CERVICAL WO CONTRAST $5,243.00 HC MRI SPINE LUMBAR W CONTRAST $5,559.00 HC MRI SPINE LUMBAR W WO CONTRAST $6,250.00 HC MRI SPINE LUMBAR WO CONTRAST $5,243.00 HC MRI SPINE THORACIC W CONTRAST $5,791.00 HC MRI SPINE THORACIC W WO CONTRAST $6,233.00 HC MRI SPINE THORACIC WO CONTRAST $5,261.00 HC MRI UP EXTR ANY JOINT W CONTRAST $5,804.00 HC MRI UP EXTR ANY JOINT W WO CONTR $6,026.00 HC MRI UP EXTR ANY JOINT WO CONTRAST $5,243.00 HC MRI UP EXTR NOT JOINT W CONTRAST $5,948.00 HC MRI UP EXTR NOT JOINT W WO CONTR $6,210.00 HC MRI UP EXTR NOT JOINT WO CONTRAST $5,243.00 HC MSLT/MWT; GLOBAL $3,842.00 HC MUGA SGL W RV EF BY 1ST PASS $1,655.00 HC MULTI-FAMILY GROUP THERAPY $299.00 HC MULTIHANCE INJ PER ML $7.00 HC MUSCLE TEST 1 LIMB $167.00 HC MUSCLE TEST 2 LIMBS $422.00 HC MUSCLE TEST 3 LIMBS $486.00 HC MUSCLE TEST 4 LIMBS $559.00 HC MUSCLE TEST HAND MANUAL W REPORT $135.00 89 of 155 Procedure Price HC MUSCLE TEST MANUAL EXTREM OR TRUNK $76.00 HC MYELOGRAM CERVICAL $1,733.00 HC MYELOGRAM LUMBOSACRAL $1,659.00 HC MYELOGRAM SPINE 2 OR MORE REGIONS $2,456.00 HC MYELOGRAM THORACIC $1,638.00 HC MYELOGRAPHY LUMBAR INJ 2+ REGIONS $1,737.00 HC MYELOGRAPHY LUMBAR INJ CERV $1,737.00 HC MYELOGRAPHY LUMBAR INJ LS $1,737.00 HC MYELOGRAPHY LUMBAR INJ THOR $1,737.00 HC N BLOCK INJ PLANTAR DIGIT $559.00 HC N BLOCK SGL SCIATIC NRV $2,444.00 HC N EMG; THORACIC MUSCLES NOT T1/T12 $320.00 HC NASAL BONES MIN 3 VIEWS $592.00 HC NASAL ENDO W BLD CNTRL $4,065.00 HC NASOPHARYNGOSCOPY W ENDOSCOPE $195.00 HC NB INJ HYPOGAS PLXS $2,850.00 HC NB RESUSCITATION OB $605.00 HC NEG PRESS WND TX <=50 SQ CM (NON-DME) $676.00 HC NEG PRESS WND TX >50 CM (NON-DME) $676.00 HC NEG PRESS WOUND TX <=50 CM (DME) $305.00 HC NEG PRESS WOUND TX >50 CM (DME) $368.00 HC NERVE BLOCK ILIOING/ILIOHYPOGASTRIC $1,293.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 1 $477.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 2 $2,088.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 3 $3,577.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 4 $4,472.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 5 $5,963.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 6 $6,706.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 7 $8,048.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 8 $8,347.00 HC NEURAGEN NERVE GUIDE, PER CM LVL 9 $9,539.00 HC NEUROBEHAVIORAL STATUS EXAM $533.00 HC NEUROENDOSCOPY ADD-ON $480.00 HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 1 $334.00 HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 2 $501.00 HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 3 $667.00 HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 4 $835.00 90 of 155 Procedure Price HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 5 $859.00 HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 6 $1,001.00 HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 7 $1,144.00 HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 8 $1,289.00 HC NEUROMEND NERVE WRAP PER 0.5 CM LVL 9 $1,431.00 HC NEUROMUSCLE RE-EDUC EA 15M $151.00 HC NG TUBE PLC W FLUORO $837.00 HC NITRIC OXIDE HOURLY $752.00 HC NM ADRENAL CORTEX AND OR MEDULLA $1,522.00 HC NM BONE IMAGING 3 PHASE $2,480.00 HC NM BONE IMAGING LTD $1,427.00 HC NM BONE IMAGING MULT AREAS $1,159.00 HC NM BONE IMAGING WHOLE BODY $2,314.00 HC NM BONE MARROW IMAGING MULT AREAS $960.00 HC NM BONE SPECT $3,180.00 HC NM BRAIN IMAGE W FLOW MIN 4 VIEWS $1,441.00 HC NM BRAIN SPECT $3,586.00 HC NM CARDIAC BLOOD POOL MULT $2,427.00 HC NM CARDIAC BLOOD POOL SGL $2,209.00 HC NM CSF FLOW CISTERNOGRAPHY $1,929.00 HC NM CSF SHUNT EVAL PATENCY $432.00 HC NM GASTRIC EMPTYING STUDY $2,326.00 HC NM GASTRIC REFLUX STUDY $1,594.00 HC NM GI BLEED STUDY $2,150.00 HC NM HEART MUSC IMAGING PLANAR MULT $3,479.00 HC NM HEART MUSCLE SPECT MULT $4,379.00 HC NM HEART MUSCLE SPECT SGL $3,479.00 HC NM HEPATOBIL SYST IMAGE W/DRUG $2,495.00 HC NM HEPATOBILIARY SYSTEM IMAGING $2,121.00 HC NM INFLAMM LOCALIZ LTD AREA $3,649.00 HC NM INFLAMM LOCALIZ SPECT $2,438.00 HC NM INFLAMM LOCALIZ WHOLE BODY $3,609.00 HC NM IV INJ RA DRUG DX STUDY $547.00 HC NM KIDNEY FLOW FUNCT MULT $1,677.00 HC NM KIDNEY FLOW FUNCT W DRUG $2,262.00 HC NM KIDNEY FLOW FUNCT WO DRUG $2,270.00 HC NM KIDNEY IMAGING MORPHOLOGY $572.00 91 of 155 Procedure Price HC NM KIDNEY IMAGING SPECT $2,079.00 HC NM KIDNEY IMAGING WITH FLOW $1,960.00 HC NM LIVER IMAGE STATIC ONLY $725.00 HC NM LIVER IMAGE W VASC FLOW $1,071.00 HC NM LIVER SPECT $1,937.00 HC NM LIVER SPECT W VASC FLOW $2,437.00 HC NM LIVER SPLEEN STATIC $1,154.00 HC NM LIVER SPLEEN W VASC FLOW $890.00 HC NM LUNG PERF&VENTILAT DIFERENTL $2,705.00 HC NM LUNG PERFUSION DIFFERENTIAL $870.00 HC NM LUNG PERFUSION IMAGING $1,844.00 HC NM LUNG VENTILAT&PERFUS IMAGING $2,724.00 HC NM LUNG VENTILATION IMAGING $1,221.00 HC NM LYMPH OR LYMPH NODE IMAGING $2,181.00 HC NM MECKELS DIVERT EXAM $1,386.00 HC NM MI PLANAR SPECT $1,949.00 HC NM PARATHYROID IMAGING $1,644.00 HC NM PERITONEAL VENOUS SHUNT PATENCY $1,342.00 HC NM PET BRAIN METABOLIC EVAL $6,254.00 HC NM PET CARDIAC METABOL EVAL $4,536.00 HC NM PET IMAGE W CT LTD $5,436.00 HC NM PET IMAGE W CT SKULL THIGH $9,113.00 HC NM PET IMAGE W CT WHOLE BODY $9,113.00 HC NM RADIOPHARM THERAPY IV ADMIN $1,130.00 HC NM RADIOPHARM THERAPY ORAL $2,143.00 HC NM SPLEEN IMAGING ONLY $885.00 HC NM TESTICULAR IMAGING W/FLOW $1,692.00 HC NM THYROID METASTASES WHOLE BODY $2,288.00 HC NM TUMOR LOCALIZ LTD RA DISTRIB $1,673.00 HC NM TUMOR LOCALIZ SPECT $2,470.00 HC NM TUMOR LOCALIZ WHOLE BODY 1 DAY $2,127.00 HC NM TUMOR LOCALIZ WHOLE BODY 2 DAY $8,070.00 HC NM UNLISTED ENDOCRINE DX $959.00 HC NM UNLISTED GI PROCEDURE DX $2,059.00 HC NM UNLISTED HEMATOP RETICUL LMYPH DX $1,312.00 HC NM UREA BREATH TEST C14 ACQ $129.00 HC NM UREA BREATH TEST C14 ANALYSIS $326.00 92 of 155 Procedure Price HC NM URETER REFLUX STUDY $1,215.00 HC NO SHOW/CANCELLATION $67.00 HC NON WND ELECT STIM $239.00 HC NON-CARDIAC ENDOVASC CATH LVL 1 $477.00 HC NON-CARDIAC ENDOVASC CATH LVL 10 $5,365.00 HC NON-CARDIAC ENDOVASC CATH LVL 11 $5,963.00 HC NON-CARDIAC ENDOVASC CATH LVL 12 $5,903.00 HC NON-CARDIAC ENDOVASC CATH LVL 13 $6,440.00 HC NON-CARDIAC ENDOVASC CATH LVL 2 $835.00 HC NON-CARDIAC ENDOVASC CATH LVL 3 $1,670.00 HC NON-CARDIAC ENDOVASC CATH LVL 4 $2,147.00 HC NON-CARDIAC ENDOVASC CATH LVL 5 $2,861.00 HC NON-CARDIAC ENDOVASC CATH LVL 6 $3,577.00 HC NON-CARDIAC ENDOVASC CATH LVL 7 $3,577.00 HC NON-CARDIAC ENDOVASC CATH LVL 8 $4,174.00 HC NON-CARDIAC ENDOVASC CATH LVL 9 $4,770.00 HC NON-CARDIAC VASC FLOW IMG $509.00 HC NONCOVERED OBSERVATION PER HOUR $65.00 HC NON-HEU TC-99M ADD-ON/DOSE $10.00 HC NON-MOLDED THIGH LACER ADDTN LVL 1 $835.00 HC NON-MOLDED THIGH LACER ADDTN LVL 2 $1,431.00 HC NON-MOLDED THIGH LACER ADDTN LVL 3 $2,147.00 HC NON-MOLDED THIGH LACER ADDTN LVL 4 $2,861.00 HC NON-MOLDED THIGH LACER ADDTN LVL 5 $3,577.00 HC NON-OPHTHALMIC FVA $865.00 HC NONSELECT CATH RT HEART/MAIN PULMON ART $1,111.00 HC NONSELECT CATH TRANSLUMBAR AORTA $1,389.00 HC NONSELECTIVE CATH AORTA $1,416.00 HC NONSELECTIVE CATH PLACEMENT IN VEIN $105.00 HC NONVASC BALLN TISS DISECTR CATH LVL 1 $835.00 HC NONVASC BALLN TISS DISECTR CATH LVL 2 $1,431.00 HC NONVASC BALLN TISS DISECTR CATH LVL 3 $2,147.00 HC NONVASC BALLN TISS DISECTR CATH LVL 4 $2,861.00 HC NONVASC BALLN TISS DISECTR CATH LVL 5 $3,577.00 HC NONVASC BALLN TISS DISECTR CATH LVL 6 $6,558.00 HC NONVASC BALLN TISS DISECTR CATH LVL 8 $10,732.00 HC NON-VASC BALLOON DILATN CATH LVL 1 $835.00 93 of 155 Procedure Price HC NON-VASC BALLOON DILATN CATH LVL 10 $14,309.00 HC NON-VASC BALLOON DILATN CATH LVL 12 $16,693.00 HC NON-VASC BALLOON DILATN CATH LVL 2 $1,431.00 HC NON-VASC BALLOON DILATN CATH LVL 3 $2,147.00 HC NON-VASC BALLOON DILATN CATH LVL 4 $2,861.00 HC NON-VASC BALLOON DILATN CATH LVL 5 $3,577.00 HC NON-VASC BALLOON DILATN CATH LVL 6 $6,558.00 HC NON-VASC BALLOON DILATN CATH LVL 7 $8,048.00 HC NON-VASC BALLOON DILATN CATH LVL 8 $10,732.00 HC NON-VASC BALLOON DILATN CATH LVL 9 $11,923.00 HC NOT INFLATE PENILE PROSTH LVL 1 $477.00 HC NOT INFLATE PENILE PROSTH LVL 18 $16,097.00 HC NOT INFLATE PENILE PROSTH LVL 2 $2,088.00 HC NOT INFLATE PENILE PROSTH LVL 3 $3,577.00 HC NOT INFLATE PENILE PROSTH LVL 4 $4,472.00 HC NOT INFLATE PENILE PROSTH LVL 5 $5,963.00 HC NOT INFLATE PENILE PROSTH LVL 6 $6,706.00 HC NOT INFLATE PENILE PROSTH LVL 7 $8,048.00 HC NOT INFLATE PENILE PROSTH LVL 8 $8,347.00 HC NS CATH EXTREMITY ARTERY $1,662.00 HC NSW DEBRIDEM WO A/SESSION $250.00 HC NUSHIELD PER SQ CM LVL 1 $412.00 HC NUSHIELD PER SQ CM LVL 2 $824.00 HC NUSHIELD PER SQ CM LVL 3 $1,236.00 HC NUSHIELD PER SQ CM LVL 4 $1,648.00 HC NUSHIELD PER SQ CM LVL 5 $2,060.00 HC NUSHIELD PER SQ CM LVL 6 $4,120.00 HC NUTRITION COUNSELING DIETITIAN $65.00 HC O/P VISIT EST LEVEL 1 $198.00 HC O/P VISIT EST LEVEL 2 $311.00 HC O/P VISIT EST LEVEL 3 $423.00 HC O/P VISIT EST LEVEL 4 $538.00 HC O/P VISIT EST LEVEL 5 $596.00 HC O/P VISIT NEW LEVEL 1 $271.00 HC O/P VISIT NEW LEVEL 2 $414.00 HC O/P VISIT NEW LEVEL 3 $509.00 HC O/P VISIT NEW LEVEL 4 $578.00 94 of 155 Procedure Price HC O/P VISIT NEW LEVEL 5 $725.00 HC OASIS BURN MATRIX PER SQ CM LVL 1 $334.00 HC OASIS BURN MATRIX PER SQ CM LVL 2 $501.00 HC OASIS BURN MATRIX PER SQ CM LVL 3 $667.00 HC OASIS BURN MATRIX PER SQ CM LVL 4 $835.00 HC OASIS TRI-LAYER WND MATRX PER SQ CM LVL1 $334.00 HC OASIS TRI-LAYER WND MATRX PER SQ CM LVL2 $501.00 HC OASIS TRI-LAYER WND MATRX PER SQ CM LVL3 $667.00 HC OASIS TRI-LAYER WND MATRX PER SQ CM LVL4 $835.00 HC OASIS WOUND MATRIX PER SQ CM LVL 1 $24.00 HC OASIS WOUND MATRIX PER SQ CM LVL 2 $24.00 HC OASIS WOUND MATRIX PER SQ CM LVL 3 $24.00 HC OASIS WOUND MATRIX PER SQ CM LVL 4 $24.00 HC OASIS WOUND MATRIX PER SQ CM LVL 5 $24.00 HC OB ADD-ON $3,429.00 HC OB BASE LEVEL 1 $1,298.00 HC OB BASE LEVEL 2 $1,476.00 HC OB BASE LEVEL 3 $1,770.00 HC OB BASE LEVEL 4 $2,359.00 HC OB BASE LEVEL 5 $4,129.00 HC OB BASE LEVEL 6 $5,790.00 HC OB LEVEL O $3,077.00 HC OB PER MIN LEVEL 1 $20.00 HC OB PER MIN LEVEL 2 $32.00 HC OB PER MIN LEVEL 3 $43.00 HC OB PER MIN LEVEL 4 $66.00 HC OB PER MIN LEVEL 5 $94.00 HC OB PER MIN LEVEL 6 $128.00 HC OBSERVATION PER HOUR $65.00 HC OCCULT BLD FECES, 1-3 TESTS $25.00 HC OCTAFLUOROPROPANE MIC INJ 1ML $350.00 HC OCTREOTIDE NOT DEPOT 25 MCG INJ $1,030.00 HC OCULAR IMP AQUEOUS DRAIN LVL 1 $835.00 HC OCULAR IMP AQUEOUS DRAIN LVL 10 $5,963.00 HC OCULAR IMP AQUEOUS DRAIN LVL 11 $6,500.00 HC OCULAR IMP AQUEOUS DRAIN LVL 2 $1,670.00 HC OCULAR IMP AQUEOUS DRAIN LVL 3 $2,147.00 95 of 155 Procedure Price HC OCULAR IMP AQUEOUS DRAIN LVL 4 $2,861.00 HC OCULAR IMP AQUEOUS DRAIN LVL 5 $3,577.00 HC OCULAR IMP AQUEOUS DRAIN LVL 6 $3,577.00 HC OCULAR IMP AQUEOUS DRAIN LVL 7 $4,174.00 HC OCULAR IMP AQUEOUS DRAIN LVL 8 $4,770.00 HC OCULAR IMP AQUEOUS DRAIN LVL 9 $5,365.00 HC OP ACUTE DIALYSIS $1,400.00 HC OPEN BX/EXC LN; AXILLARY NODE(S) $5,822.00 HC OPEN SUPERF BONE BX $6,017.00 HC OPEN TX PHAL SHAFT FX PROX/MID EA $5,552.00 HC OPEN/PERQ PLACE STENT 1ST ART $29,887.00 HC OPEN/PERQ PLACE STENT EA ADD ART $29,887.00 HC OPEN/PERQ PLACE STENT EA ADD VEIN $14,323.00 HC OPEN/PERQ PLACE STENT SAME VEIN $14,323.00 HC OPPS/PHP ACTIVITY THERAPY 45+ MIN $222.00 HC OPPS/PHP TRAIN & EDUC SERV $160.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 1 $835.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 10 $6,558.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 11 $5,903.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 12 $6,440.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 13 $6,976.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 14 $7,512.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 15 $8,048.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 16 $10,732.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 17 $11,923.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 18 $14,309.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 19 $14,606.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 2 $1,670.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 20 $16,693.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 21 $13,415.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 22 $14,904.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 3 $2,147.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 4 $2,861.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 5 $3,577.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 6 $3,935.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 7 $4,591.00 HC OR NEURO SUPPLIES, NO HCPCS LVL 8 $5,247.00 96 of 155 Procedure Price HC OR NEURO SUPPLIES, NO HCPCS LVL 9 $5,903.00 HC ORAL MR CONTRAST PER 100 ML $36.00 HC ORBITS COMPL MIN 4 VIEWS $710.00 HC ORTH DEV REPAIR/REPL MINOR P LVL 1 $110.00 HC ORTH/PROSTH MGMT SUBQ ENC 15M $157.00 HC ORTHO SUPPLIES GENERAL LVL 1 $835.00 HC ORTHO SUPPLIES GENERAL LVL 2 $3,577.00 HC ORTHO SUPPLIES GENERAL LVL 3 $6,558.00 HC ORTHO SUPPLIES GENERAL LVL 4 $11,923.00 HC ORTHO SUPPLIES GENERAL LVL 5 $16,693.00 HC ORTHO SUPPLIES GENERAL LVL 7 $20,867.00 HC ORTHOPANTOGRAM PANORAMIC X-RAY JAWS $254.00 HC ORTHOTIC MGMT AND TRAINING EA 15M $157.00 HC OSSICULAR IMPLANT LVL 1 $835.00 HC OSSICULAR IMPLANT LVL 2 $1,670.00 HC OSSICULAR IMPLANT LVL 3 $2,147.00 HC OSSICULAR IMPLANT LVL 4 $2,861.00 HC OSSICULAR IMPLANT LVL 5 $3,577.00 HC OSTOMY SUPPLY LVL 1 $334.00 HC OSTOMY SUPPLY LVL 2 $501.00 HC OSTOMY SUPPLY LVL 3 $667.00 HC OSTOMY SUPPLY LVL 4 $835.00 HC OSTOMY SUPPLY LVL 5 $1,001.00 HC OT EVAL HIGH COMPLEX $425.00 HC OT EVAL LOW COMPLEX $300.00 HC OT EVAL MOD COMPLEX $350.00 HC OT RE-EVAL EST PLAN CARE $250.00 HC OTHER PACEMAKER LEAD LVL 1 $835.00 HC OTHER PACEMAKER LEAD LVL 2 $3,577.00 HC OTHER PACEMAKER LEAD LVL 3 $6,558.00 HC OTHER PACEMAKER LEAD LVL 4 $8,048.00 HC OTHER PACEMAKER LEAD LVL 5 $10,732.00 HC OTHER PT/OT CURRENT STATUS $0.01 HC OTHER PT/OT D/C STATUS $0.01 HC OTHER PT/OT GOAL STATUS $0.01 HC OTHER SPEECH LANG CURRENT STATUS $0.01 HC OTHER SPEECH LANG D/C STATUS $0.01 97 of 155 Procedure Price HC OTHER SPEECH LANG GOAL STATUS $0.01 HC OUTREACH PROGRAM LEVEL 1 $77.00 HC OUTREACH PROGRAM LEVEL 2 $103.00 HC OUTREACH PROGRAM LEVEL 3 $206.00 HC OUTREACH PROGRAM LEVEL 4 $103.00 HC OUTSIDE AMBULANCE SERVICE $6,145.00 HC OUTSIDE PT TRANSPORT $52.00 HC OXYGEN INITIAL DAY $1,100.00 HC OXYGEN SUBQ DAY $877.00 HC OXYGEN UPTAKE REST INDIRECT $332.00 HC P32 NA PHOSPHATE PER MCI $933.00 HC PACER POCKET REVISION $6,320.00 HC PACU CLASS 1 PER MIN $49.00 HC PACU CLASS 2 PER MIN $58.00 HC PACU CLASS 3 PER MIN $79.00 HC PAD REHAB PER SESSION $184.00 HC PANCREATIC ERCP $994.00 HC PARATHYRD PLANAR W/SPECT & CT $1,879.00 HC PARATHYRD PLANAR W/WO SUBTR $1,502.00 HC PARE BENIGN LES SGL $213.00 HC PART EXC BONE; DISTAL PHALANX $2,126.00 HC PATIENT POSITIONING DEVICE LVL 1 $417.00 HC PATIENT POSITIONING DEVICE LVL 2 $835.00 HC PATIENT POSITIONING DEVICE LVL 3 $1,431.00 HC PATIENT POSITIONING DEVICE LVL 4 $2,147.00 HC PATIENT POSITIONING DEVICE LVL 5 $2,861.00 HC PATIENT POSITIONING DEVICE LVL 6 $3,577.00 HC PATIENT POSITIONING DEVICE LVL 7 $4,300.00 HC PB VALVULOPLASTY AORTOC VALVE $15,667.00 HC PB VALVULOPLASTY MITRAL VALVE $17,315.00 HC PEDICLE FLAP FC/CK/MTH $4,153.00 HC PEG TUBE PLACEMENT ENDO $3,357.00 HC PELVIC ANGIOGRAM $7,008.00 HC PELVIMETRY W WO PLACENTAL LOCALIZ $296.00 HC PELVIS 1 OR 2 VIEWS $485.00 HC PELVIS MIN 3 VIEWS $612.00 HC PENILE PLETHYSMOGRAPHY $482.00 98 of 155 Procedure Price HC PERC CORON THROMBECTOMY $11,028.00 HC PERC DILATION BILE DUCT STRICTURE $3,751.00 HC PERC DRUG-EL COR REVASC CABG EA ADDL BR $27,616.00 HC PERC DRUG-EL COR REVASC CABG SGL $27,616.00 HC PERC DRUG-EL COR REVASC CHRON OCCL ADDL $27,616.00 HC PERC DRUG-EL COR REVASC CHRON OCCL SGL $27,616.00 HC PERC DRUG-EL COR REVASC W AMI SGL $27,616.00 HC PERC DRUG-EL COR STENT ATHER EA ADDL BR $27,616.00 HC PERC DRUG-EL COR STENT ATHER SGL ART/BR $27,616.00 HC PERC DRUG-EL COR STENT EA ADDL BRANCH $27,616.00 HC PERC DRUG-EL COR STENT SGL ART/BRANCH $27,616.00 HC PERC IMPL NS ELECTRODE ARRAY EPIDURAL $18,732.00 HC PERC NEPHROSTOLITHOTOMY TO 2 CM $8,833.00 HC PERC PLACEMENT ENTEROCLYSIS TUBE $994.00 HC PERFLUTREN LIPID MICROS INJ PER ML $214.00 HC PERFUSION BASE $2,188.00 HC PERFUSION PER MINUTE $9.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 1 $835.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 2 $1,431.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 3 $2,147.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 4 $2,861.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 5 $3,577.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 6 $3,935.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 7 $4,591.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 8 $5,247.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 9 $5,903.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL10 $6,558.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL11 $8,048.00 HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL12 $10,732.00 HC PERICARDIOCENTESIS INITIAL $1,411.00 HC PERICARDIOCENTESIS SUBSEQUENT $1,411.00 HC PERITONEAL LAVAGE $1,316.00 HC PERITONEOGRAM AFTER INJECTION $821.00 HC PERQ ACCESS & CLSR FEM ART $3,000.00 HC PERQ CERVICOTHORACIC INJECT $9,572.00 HC PERQ DEV BREAST 1ST LES MAMMO $2,856.00 HC PERQ DEV BREAST 1ST LES MR GUIDE $4,122.00 99 of 155 Procedure Price HC PERQ DEV BREAST 1ST LES STEREOTACT $3,536.00 HC PERQ DEV BREAST 1ST LES US IMAG $2,871.00 HC PERQ DEV BREAST ADD LES MAMMO $1,692.00 HC PERQ DEV BREAST ADD LES MR GUIDE $1,692.00 HC PERQ DEV BREAST ADD LES STEREOTACT $1,692.00 HC PERQ DEV BREAST ADD LES US IMAG $1,692.00 HC PERQ DEV SOFT TISS 1ST IMAG $1,586.00 HC PERQ DEV SOFT TISS ADD IMAG $1,058.00 HC PERQ G/COLON TUBE IMG EXAM W CONTRAST $746.00 HC PERQ LUMBOSACRAL INJECT $9,572.00 HC PERQ RF ABLATE TX PULM TUMOR(S) $10,921.00 HC PERQ STENT/CHEST VERT ART $4,886.00 HC PERQ STENT/CHEST VERT ART EA ADDTL VESS $4,886.00 HC PERQ TRANSCATH SEPTAL REDUCTION $14,921.00 HC PERQ VERTEBRAL AUGMENTATION EA ADDTL $19,345.00 HC PERQ VERTEBRAL AUGMENTATION LUMBAR $24,180.00 HC PERQ VERTEBRAL AUGMENTATION THORACIC $24,180.00 HC PHARMACOLOGIC MGMT W/PSYTX $163.00 HC PHARYNX/LARYNX EXAM W FLUORO $337.00 HC PHLEB VEINS - EXTREM - TO 20 $7,857.00 HC PHLEB VEINS - EXTREM 20+ $8,641.00 HC PHLEBOTOMY, THERAPEUTIC $303.00 HC PHOTOTHERAPY NEWBORN $394.00 HC PHYSICAL PERFORM EA 15M $179.00 HC PIERCE SKULL IMPLANT DEVICE $938.00 HC PINCH GRFT SM DEFECT TO 2 CM $1,071.00 HC PLACE CATH CAROTID ART $21,934.00 HC PLACE CATH EXTERNAL CAROTID $8,046.00 HC PLACE CATH INTRACRANIAL ART $8,045.00 HC PLACE CATH SUBCLAVIAN ART $10,604.00 HC PLACE CATH THORACIC AORTA $8,046.00 HC PLACE CATH VERTEBRAL ART $17,548.00 HC PLACE GASTROSTOMY TUBE PERC $3,534.00 HC PLACE NEEDLE INTRAOSSEOUS INFUSION $1,015.00 HC PLACE NEEDLES PELVIC FOR RT $7,149.00 HC PLACE PO BREAST CATH FOR RAD $21,722.00 HC PLACEMENT LONG GI TUBE $812.00 100 of 155 Procedure Price HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 1 $1,431.00 HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 2 $2,861.00 HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 3 $3,935.00 HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 4 $5,247.00 HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 5 $6,558.00 HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 6 $6,440.00 HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 7 $7,512.00 HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 8 $8,585.00 HC PLANTAR FLEX RESIST ADDTN EA JNT LVL 9 $9,658.00 HC PLC CATH CAROTD/INOM ART W ANG IPSIL EXT $13,210.00 HC PLC CATH CAROTD/INOM ART W ANG IPSIL INT $10,733.00 HC PLC DUOD/JEJ TUBE PERC $3,733.00 HC PLC STENT CCA W/EMBOL PROTECT $13,721.00 HC PLC STENT CHOLEDOCHAL $2,623.00 HC PLMT BILIARY DRAINAGE CATH EXT $6,756.00 HC PLMT BILIARY DRAINAGE CATH INT-EXT $6,756.00 HC PLMT NEPHROSTOMY CATH $4,675.00 HC PLMT NEPHROURETERAL CATH NEW ACCESS $4,675.00 HC PLMT PRQ BIL DUCT STNT EXIST ACCESS $10,562.00 HC PLMT URETERAL STNT PRQ NEW ACCESS W CATH $6,961.00 HC PLMT URETERAL STNT PRQ NEW ACCESS WO CATH $6,961.00 HC PLMT URETERAL STNT PRQ PRE-EXIST TRACT $6,961.00 HC PLMT XTN PROSTH EVASC RPR $7,500.00 HC PM DEVICE EVAL IN PERSON $118.00 HC PM DEVICE PROGR EVAL DUAL $93.00 HC PM DEVICE PROGR EVAL MULTI $93.00 HC PM DEVICE PROGR EVAL SGL $93.00 HC PM PHONE R-STRIP DEVICE EVAL = $153.00 HC PM/ICD REMOTE TECH SERV = $204.00 HC POLYSOM $6,423.00 HC PORCINE IMPLANT PERMACOL PER SQ CM LVL 1 $191.00 HC PORCINE IMPLANT PERMACOL PER SQ CM LVL 2 $286.00 HC PORCINE IMPLANT PERMACOL PER SQ CM LVL 3 $382.00 HC PORCINE IMPLANT PERMACOL PER SQ CM LVL 4 $477.00 HC PORT IMG $478.00 HC POS AIRWAY PRESSURE CPAP/BIPAP INITIAL $835.00 HC POS AIRWAY PRESSURE CPAP/BIPAP SUBQ $777.00 101 of 155 Procedure Price HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 1 $1,431.00 HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 2 $2,861.00 HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 3 $3,935.00 HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 4 $5,247.00 HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 5 $6,558.00 HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 6 $6,440.00 HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 7 $7,512.00 HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 8 $8,585.00 HC POSTOP APP NON-WGT BEAR DSG BELOW KNEE LVL 9 $9,658.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 1 $1,431.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 2 $2,861.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 3 $3,935.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 4 $5,247.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 5 $6,558.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 6 $6,440.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 7 $7,512.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 8 $8,585.00 HC POSTOP DRESS & 1 CAST CHG BK LVL 9 $9,658.00 HC PRE OP PM DEVICE EVAL $49.00 HC PREFAB AFO ANKLE GAUNTLET LVL 1 $334.00 HC PREFAB AFO ANKLE GAUNTLET LVL 2 $501.00 HC PREFAB AFO ANKLE GAUNTLET LVL 3 $667.00 HC PREFAB AFO ANKLE GAUNTLET LVL 4 $835.00 HC PREFAB AFO ANKLE GAUNTLET LVL 5 $859.00 HC PREFAB AFO ANKLE GAUNTLET LVL 6 $1,001.00 HC PREFAB AFO ANKLE GAUNTLET LVL 7 $1,144.00 HC PREFAB AFO ANKLE GAUNTLET LVL 8 $1,289.00 HC PREFAB AFO ANKLE GAUNTLET LVL 9 $1,431.00 HC PREFAB ANKLE-FOOT ORTHOTIC (ACO) LVL 1 $1,431.00 HC PREFAB ANKLE-FOOT ORTHOTIC (ACO) LVL 2 $2,861.00 HC PREFAB ANKLE-FOOT ORTHOTIC (ACO) LVL 3 $3,935.00 HC PREFAB ANKLE-FOOT ORTHOTIC (ACO) LVL 4 $5,247.00 HC PREFAB ANKLE-FOOT ORTHOTIC (ACO) LVL 5 $6,558.00 HC PREFAB ELASTIC KO W JNTS LVL 1 $128.00 HC PREFAB ELASTIC KO W JNTS LVL 2 $191.00 HC PREFAB ELASTIC KO W JNTS LVL 3 $253.00 HC PREFAB ELASTIC KO W JNTS LVL 4 $317.00 102 of 155 Procedure Price HC PREFAB ELASTIC KO W JNTS LVL 5 $445.00 HC PREFAB ELASTIC KO W JNTS LVL 6 $507.00 HC PREFAB ELASTIC KO W JNTS LVL 7 $571.00 HC PREFAB ELASTIC KO W JNTS LVL 8 $634.00 HC PREFAB ELASTIC KO W JNTS LVL 9 $691.00 HC PREFAB METACARPL FX ORTHOSIS LVL 1 $334.00 HC PREFAB METACARPL FX ORTHOSIS LVL 2 $501.00 HC PREFAB METACARPL FX ORTHOSIS LVL 3 $667.00 HC PREFAB METACARPL FX ORTHOSIS LVL 4 $835.00 HC PREFAB METACARPL FX ORTHOSIS LVL 5 $859.00 HC PREFAB METACARPL FX ORTHOSIS LVL 6 $1,001.00 HC PREFAB METACARPL FX ORTHOSIS LVL 7 $1,144.00 HC PREFAB METACARPL FX ORTHOSIS LVL 8 $1,289.00 HC PREFAB METACARPL FX ORTHOSIS LVL 9 $1,431.00 HC PREFAB POSTOP HO LVL 1 $1,431.00 HC PREFAB POSTOP HO LVL 2 $2,861.00 HC PREFAB POSTOP HO LVL 3 $3,935.00 HC PREFAB POSTOP HO LVL 4 $5,247.00 HC PREFAB POSTOP HO LVL 5 $6,558.00 HC PREFAB POSTOP HO LVL 6 $6,440.00 HC PREFAB POSTOP HO LVL 7 $7,512.00 HC PREFAB TLSO TO SCAPULAR SPINE LVL 1 $1,431.00 HC PREFAB TLSO TO SCAPULAR SPINE LVL 2 $2,861.00 HC PREFAB TLSO TO SCAPULAR SPINE LVL 3 $3,935.00 HC PREFAB TLSO TO SCAPULAR SPINE LVL 4 $5,247.00 HC PREFAB TLSO TO SCAPULAR SPINE LVL 5 $6,558.00 HC PREFAB TLSO TO SCAPULAR SPINE LVL 6 $7,300.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 1 $1,431.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 10 $10,732.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 2 $2,861.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 3 $3,935.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 4 $5,247.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 5 $6,558.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 6 $6,440.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 7 $7,512.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 8 $8,585.00 HC PREFAB TLSO W 4 PLASTIC SHELLS LVL 9 $9,658.00 103 of 155 Procedure Price HC PREFAB WHFO WO JNTS LVL 1 $1,431.00 HC PREFAB WHFO WO JNTS LVL 2 $2,861.00 HC PREFAB WHFO WO JNTS LVL 3 $3,935.00 HC PREFAB WHFO WO JNTS LVL 4 $5,247.00 HC PREFAB WHFO WO JNTS LVL 5 $6,558.00 HC PRE-OP ICD DEVICE EVAL $57.00 HC PRESBYOPIA-CORRECT FUNCTION LVL 4 $966.00 HC PRESBYOPIA-CORRECT FUNCTION LVL 5 $1,079.00 HC PRIMATRIX SKIN SUB PER SQ CM LVL 1 $301.00 HC PROCESS EDU GROUP INTENSIVE $376.00 HC PROCESS EDU GROUP MODERATE $376.00 HC PROCESS EDUCATION GROUP $376.00 HC PROSTH SOCK WOOL BELOW KNEE LVL 1 $334.00 HC PROSTH SOCK WOOL BELOW KNEE LVL 2 $501.00 HC PROSTH SOCK WOOL BELOW KNEE LVL 3 $667.00 HC PROSTH SOCK WOOL BELOW KNEE LVL 4 $835.00 HC PROSTHESIS, BREAST, IMP LVL 1 $477.00 HC PROSTHESIS, BREAST, IMP LVL 2 $2,088.00 HC PROSTHESIS, BREAST, IMP LVL 3 $3,577.00 HC PROSTHESIS, BREAST, IMP LVL 4 $4,472.00 HC PROSTHESIS, BREAST, IMP LVL 5 $5,963.00 HC PROSTHESIS, BREAST, IMP LVL 6 $6,706.00 HC PROSTHESIS, BREAST, IMP LVL 7 $8,048.00 HC PROSTHESIS, BREAST, IMP LVL 8 $8,347.00 HC PROSTHESIS, BREAST, IMP LVL 9 $9,539.00 HC PROSTHETIC IMPLANT NOS LVL 1 $835.00 HC PROSTHETIC IMPLANT NOS LVL 10 $5,963.00 HC PROSTHETIC IMPLANT NOS LVL 11 $6,706.00 HC PROSTHETIC IMPLANT NOS LVL 12 $8,048.00 HC PROSTHETIC IMPLANT NOS LVL 13 $8,347.00 HC PROSTHETIC IMPLANT NOS LVL 14 $9,539.00 HC PROSTHETIC IMPLANT NOS LVL 16 $8,942.00 HC PROSTHETIC IMPLANT NOS LVL 17 $9,838.00 HC PROSTHETIC IMPLANT NOS LVL 2 $1,670.00 HC PROSTHETIC IMPLANT NOS LVL 3 $2,147.00 HC PROSTHETIC IMPLANT NOS LVL 4 $2,861.00 HC PROSTHETIC IMPLANT NOS LVL 5 $3,577.00 104 of 155 Procedure Price HC PROSTHETIC IMPLANT NOS LVL 6 $3,577.00 HC PROSTHETIC IMPLANT NOS LVL 7 $4,174.00 HC PROSTHETIC IMPLANT NOS LVL 8 $4,770.00 HC PROSTHETIC IMPLANT NOS LVL 9 $5,365.00 HC PROSTHETIC TRAINING EA 15M $157.00 HC PROTHROMBIN TIME $84.00 HC PRQ CARD ANGIO/ATHRECT 1 ART $27,290.00 HC PRQ CARD ANGIO/ATHRECT ADDL $27,290.00 HC PRQ CARD REVASC CHRONIC 1VSL $21,737.00 HC PRQ CARD REVASC CHRONIC ADDL $21,737.00 HC PRQ CARD REVASC MI 1 VSL $21,737.00 HC PRQ CARD STENT ATHREC/ANGIO 1 ART $21,737.00 HC PRQ CARD STENT ATHREC/ANGIO ADDL $21,737.00 HC PRQ CARD STENT W/ANGIO 1 VSL $21,737.00 HC PRQ CARD STENT W/ANGIO ADDL $21,737.00 HC PRQ CARDIAC ANGIOPLAST 1 ART $14,312.00 HC PRQ CARDIAC ANGIOPLAST ADDL ART $14,312.00 HC PRQ REVASC BYP GRAFT 1 VSL $21,737.00 HC PRQ REVASC BYP GRAFT ADDL $21,737.00 HC PSS W 4/> PARAM W CPAP/BIPAP 6+ YRS $6,764.00 HC PSS W 4/> PARAM W TECH 6+ YRS $6,423.00 HC PSYCH DIAG EVAL W/MED SRVC $401.00 HC PSYCH DIAGNOSTIC EVALUATION $501.00 HC PSYCHO TESTING BY PSYCH/PHYS $586.00 HC PSYTX COMPLEX INTERACTIVE $15.00 HC PSYTX CRISIS INITIAL 60 MIN $394.00 HC PSYTX W PT 30 MIN (16-37 MIN) $238.00 HC PSYTX W PT 45 MIN (38-52 MIN) $327.00 HC PSYTX W PT 60 MIN (>53 MIN) $446.00 HC PSYTX W PT W E&M 30 MIN (16-37 MIN) $193.00 HC PSYTX W PT W E&M 45 MIN (38-52 MIN) $282.00 HC PT EVAL HIGH COMPLEX $425.00 HC PT EVAL LOW COMPLEX $300.00 HC PT EVAL MOD COMPLEX $350.00 HC PT PROGR NEUROSTIM LVL 1 $477.00 HC PT PROGR NEUROSTIM LVL 10 $8,048.00 HC PT PROGR NEUROSTIM LVL 11 $8,347.00 105 of 155 Procedure Price HC PT PROGR NEUROSTIM LVL 12 $9,539.00 HC PT PROGR NEUROSTIM LVL 2 $835.00 HC PT PROGR NEUROSTIM LVL 3 $1,252.00 HC PT PROGR NEUROSTIM LVL 4 $1,670.00 HC PT PROGR NEUROSTIM LVL 5 $2,088.00 HC PT PROGR NEUROSTIM LVL 6 $3,577.00 HC PT PROGR NEUROSTIM LVL 7 $4,472.00 HC PT PROGR NEUROSTIM LVL 8 $5,963.00 HC PT PROGR NEUROSTIM LVL 9 $6,706.00 HC PT RE-EVAL EST PLAN CARE $250.00 HC PULM FCN STRENGTH 2/> INDIV $198.00 HC PULM FCN THERAPY 15 MIN $122.00 HC PULM FUNCT TST PLETHYSMOGRAP $324.00 HC PULM FUNCTION TEST BY GAS $426.00 HC PULM MS THERAPY 15 MIN $122.00 HC PULMONARY ANGIOGRAM SELECT BILAT $5,741.00 HC PULMONARY ANGIOGRAM SELECT UNIL $3,338.00 HC PULMONARY REHAB W EXER $198.00 HC PULMONARY STRESS COMPLEX $1,250.00 HC PULMONARY STRESS TESTING $313.00 HC PULSE OX MULTIPLE $176.00 HC PULSE OX SGL $100.00 HC PUNCT ASP ABSC HEMAT CYST $668.00 HC PUNCT ASP BREAST CYST EA ADDTL $515.00 HC PUNCT ASP BREAST CYST INITIAL $784.00 HC PUNCTURE SPINAL THERAPEUTIC $1,143.00 HC PURAPLY/PURAPLY AM PER SQ CM LVL 1 $100.00 HC PURAPLY/PURAPLY AM PER SQ CM LVL 2 $150.00 HC PURAPLY/PURAPLY AM PER SQ CM LVL 3 $200.00 HC PURAPLY/PURAPLY AM PER SQ CM LVL 4 $250.00 HC PURAPLY/PURAPLY AM PER SQ CM LVL 5 $371.00 HC PURAPLY/PURAPLY AM PER SQ CM LVL 6 $412.00 HC PURAPLY/PURAPLY AM PER SQ CM LVL 7 $458.00 HC PURAPLY/PURAPLY AM PER SQ CM LVL 9 $749.00 HC R HRT ART/GRFT ANGIO $13,187.00 HC R HRT CORONARY ARTERY ANGIO $9,425.00 HC R&L HRT ART/VENTRICLE ANGIO $22,342.00 106 of 155 Procedure Price HC R&L HRT ART/VENTRICLE ANGIO W BYPASS $9,425.00 HC R&L HRT CATH W/VENTRICLGRPHY $9,425.00 HC RAD ENDOVASC THOR AO REPR $5,923.00 HC RAD TX DELIVER SUPERFICIAL/ORTHO VOLTAGE $570.00 HC RAD TX DLVR COMPLEX >= 1 MEV $1,051.00 HC RAD TX DLVR INTERMED >= 1 MEV $633.00 HC RAD TX DLVR SIMPLE >= 1 MEV $587.00 HC RADIOLOGY RECOVERY PER HOUR $137.00 HC RADIOPHARM DX AGENT NOC $761.00 HC RE-ASSESS NUTRITION THER; EA 15M $67.00 HC RECHANNEL ARTERY COMMON FEMORAL $26,718.00 HC RECONSTR CTA AORTA SURG PLAN $3,095.00 HC REDO ENDOVAS VENA CAVA FILTER $9,474.00 HC REDUCTION OF PROCIDENTIA UNDER ANESTH $1,250.00 HC REFILL/MAINT PUMP/RESVR SYST $947.00 HC RELAPSE PREVENTION GROUP $299.00 HC REM DEEP FB OF FOOT $3,225.00 HC REM EMBEDDED FB MOUTH VESTIB SIMPLE $164.00 HC REM ENDOVAS VENA CAVA FILTER $9,474.00 HC REM FB CONJUNCTIVA EMBEDDED $316.00 HC REM FB CONJUNCTIVA SUPERFICIAL $213.00 HC REM FB CORNEAL W SLIT LAMP $323.00 HC REM FB EXT AUDITORY CANAL WO ANESTH $213.00 HC REM FB EXT EYE CORNEAL WO SLIT LAMP $625.00 HC REM FB FOOT SQ $2,581.00 HC REM FB INTRANASAL $276.00 HC REM FB MUSCLE SMPL $1,591.00 HC REM FB MUSCLE/TEND DEEP $5,224.00 HC REM FB SHOULDER; SQ $1,344.00 HC REM FB UP ARM OR ELBOW SQ $845.00 HC REM IAB ASSIST DEVICE PERCUTANEOUS $3,360.00 HC REM IMPL CONTRACEP CAPS $1,033.00 HC REM SC/DC ICD LEAD TV EXTRACT $6,278.00 HC REM SKIN TAGS TO 15 $208.00 HC REM TUNNELED CVAD W PORT/PUMP $3,006.00 HC REMOTE PT 30 DAY ECG REV/REPORT $500.00 HC REMOVAL BIL DUCT/GALLBLDR CALCULI $3,456.00 107 of 155 Procedure Price HC REMOVAL BILIARY DRG CATH $1,748.00 HC REMOVAL IMPACTED CERUMEN (EARWAX) $219.00 HC REMOVAL OF NAIL BED $1,330.00 HC REMOVAL OF PM GENERATOR $6,278.00 HC REMOVE & REPLACE CVD GEN DUAL LEADS $89,637.00 HC REMOVE & REPLACE CVD GEN MULT LEADS $89,637.00 HC REMOVE & REPLACE CVD GEN SGL LEAD $89,637.00 HC REMOVE & REPLACE PM GEN DUAL LEADS $27,118.00 HC REMOVE & REPLACE PM GEN MULT LEADS $27,118.00 HC REMOVE & REPLACE PM GEN SGL LEAD $24,726.00 HC REMOVE 1 PACER LEAD ONLY $5,349.00 HC REMOVE 2 PACER LEAD ONLY $7,856.00 HC REMOVE EMBEDDED FB EYELID $503.00 HC REMOVE FECAL IMPACTION OR FB $4,296.00 HC REMOVE FOREIGN BODY PHARYNX $160.00 HC REMOVE FULL ARM OR LEG CAST $658.00 HC REMOVE IMPACTED EAR WAX UNI $141.00 HC REMOVE IMPLANTABLE LOOP RECORDER $2,076.00 HC REMOVE INTRVAS FOREIGN BODY $8,076.00 HC REMOVE IUD $524.00 HC REMOVE LUNG CATHETER $1,258.00 HC REMOVE PULSE GENERATOR $5,524.00 HC REMOVE RENAL W/NEPHROSTOMY W/FLUORO $1,177.00 HC REMOVE TNL CV CATH $1,818.00 HC REMOVE TUNNELED IP CATH $6,763.00 HC REMOVE URETER STENT PERC $6,115.00 HC REMOVE VAD DIFFERENT SESSION $6,634.00 HC REMOVE/REPLC EXT/INT NEPHROURETER CATH $2,394.00 HC RENAL CYST STUDY $2,209.00 HC RENAL VENOGRAM SELECTIVE BILAT $7,746.00 HC RENAL VENOGRAM SELECTIVE UNIL $4,347.00 HC REP DEV, URINARY, W/SLING LVL 1 $477.00 HC REP DEV, URINARY, W/SLING LVL 10 $8,048.00 HC REP DEV, URINARY, W/SLING LVL 11 $8,347.00 HC REP DEV, URINARY, W/SLING LVL 12 $9,539.00 HC REP DEV, URINARY, W/SLING LVL 14 $8,942.00 HC REP DEV, URINARY, W/SLING LVL 15 $16,396.00 108 of 155 Procedure Price HC REP DEV, URINARY, W/SLING LVL 2 $835.00 HC REP DEV, URINARY, W/SLING LVL 3 $1,252.00 HC REP DEV, URINARY, W/SLING LVL 4 $1,670.00 HC REP DEV, URINARY, W/SLING LVL 5 $2,088.00 HC REP DEV, URINARY, W/SLING LVL 6 $3,577.00 HC REP DEV, URINARY, W/SLING LVL 7 $4,472.00 HC REP DEV, URINARY, W/SLING LVL 8 $5,963.00 HC REP DEV, URINARY, W/SLING LVL 9 $6,706.00 HC REP ET HAND WO FG EA TENDON $3,541.00 HC REP LAC 2.5CM/< FLR MOUTH/ANT 2/3 $204.00 HC REP LAC TONGUE FLR MOUTH > 2.6 CPLX $1,987.00 HC REP LACERAT 2.5CM/<; POST 1/3 TONGUE $721.00 HC REP ORTHO DEV LABOR/15 MIN LVL 1 $1,431.00 HC REP ORTHO DEV LABOR/15 MIN LVL 2 $2,861.00 HC REP ORTHO DEV LABOR/15 MIN LVL 3 $3,935.00 HC REP ORTHO DEV LABOR/15 MIN LVL 4 $5,247.00 HC REP ORTHO DEV LABOR/15 MIN LVL 5 $6,558.00 HC REP TENDN/MSCL FARM/WRIST $6,682.00 HC REPAIR CV ACCESS CATH W/OPORT TUN/NONTUN $817.00 HC REPAIR CVA DEVICE W PORT/PUMP $3,458.00 HC REPAIR LEAD PACE-DEFIB DUAL $5,524.00 HC REPAIR LEAD PACE-DEFIB SGL $4,603.00 HC REPAIR LIP FT VERMILION ONLY $1,595.00 HC REPAIR LIP FT; > 1/2 V HGT OR COMPLEX $1,595.00 HC REPAIR NAIL BED $1,212.00 HC REPL DIGIT TIP TO ST $6,710.00 HC REPLACE CATH ONLY OF VAD $6,313.00 HC REPLACE CV ACCESS DEVICE TUNNELED W/PORT $7,685.00 HC REPLACE CV CATH NONTUNNEL $3,443.00 HC REPLACE CV CATH TUNNEL W/O PORT $4,498.00 HC REPLACE DUOD/JEJ TUBE PERC $1,603.00 HC REPLACE G/C TUBE PERC $1,714.00 HC REPLACE GASTROSTOMY TUBE $1,318.00 HC REPLACE G-J TUBE PERC $1,533.00 HC REPLACE PICC CATH $4,103.00 HC REPLACE STRAP ANY ORTHOSIS LVL 1 $1,431.00 HC REPLACE STRAP ANY ORTHOSIS LVL 2 $2,861.00 109 of 155 Procedure Price HC REPLACE STRAP ANY ORTHOSIS LVL 3 $3,935.00 HC REPLACE STRAP ANY ORTHOSIS LVL 4 $5,247.00 HC REPLACE STRAP ANY ORTHOSIS LVL 5 $6,558.00 HC REPLACEMENT DEVICE NO CHARGE $1.00 HC REPOSITION GASTROSTOMY TUBE $847.00 HC REPOSITION L VENTRIC LEAD $8,289.00 HC REPOSITION PACING DEFIB LEAD $6,278.00 HC REPOSITION PICC/CVC W/FLOURO $2,101.00 HC REPOSITION VAD DIFF SESSION $6,634.00 HC REPOSITIONING OF GASTRO TUBE $1,290.00 HC RESIDENTIAL CARE CHEMICAL DEPENDENCY $2,103.00 HC RESPIRATOR MOTION MGMT SIMUL $1,094.00 HC RESPIRATORY- NON AIRWAY LVL 1 $334.00 HC RESPIRATORY- NON AIRWAY LVL 10 $2,861.00 HC RESPIRATORY- NON AIRWAY LVL 2 $501.00 HC RESPIRATORY- NON AIRWAY LVL 3 $667.00 HC RESPIRATORY- NON AIRWAY LVL 4 $835.00 HC RESPIRATORY- NON AIRWAY LVL 5 $1,073.00 HC RESPIRATORY- NON AIRWAY LVL 6 $1,431.00 HC RESPIRATORY- NON AIRWAY LVL 7 $1,789.00 HC RESPIRATORY- NON AIRWAY LVL 8 $2,147.00 HC RESPIRATORY- NON AIRWAY LVL 9 $2,504.00 HC RESULTS EXPLAINED TO FAMILY $155.00 HC RET DEV, INSERTABLE LVL 1 $835.00 HC RET DEV, INSERTABLE LVL 10 $6,558.00 HC RET DEV, INSERTABLE LVL 11 $6,440.00 HC RET DEV, INSERTABLE LVL 12 $7,512.00 HC RET DEV, INSERTABLE LVL 14 $9,658.00 HC RET DEV, INSERTABLE LVL 15 $10,732.00 HC RET DEV, INSERTABLE LVL 17 $11,446.00 HC RET DEV, INSERTABLE LVL 2 $1,431.00 HC RET DEV, INSERTABLE LVL 3 $2,147.00 HC RET DEV, INSERTABLE LVL 4 $2,861.00 HC RET DEV, INSERTABLE LVL 5 $3,577.00 HC RET DEV, INSERTABLE LVL 6 $3,935.00 HC RET DEV, INSERTABLE LVL 7 $4,591.00 HC RET DEV, INSERTABLE LVL 8 $5,247.00 110 of 155 Procedure Price HC RET DEV, INSERTABLE LVL 9 $5,903.00 HC RETROGRADE PYELOGRAM W WO KUB $961.00 HC RETROGRADE URETHROGRAM $1,029.00 HC REVISE HEPATIC SHUNT (TIPS) $14,619.00 HC REVISE POCKET SC/DC ICD $5,253.00 HC REVISION/REMOVAL OF RF RECEIVER OR IPG $8,533.00 HC REVSC OPN/PRQ TIB/PERO STENT $18,628.00 HC RIBS BILAT 3 VIEWS $676.00 HC RIBS CHEST BILAT MIN 4 VIEWS $773.00 HC RIBS CHEST UNIL MIN 3 VIEWS $582.00 HC RIBS UNILATERAL 2 VIEWS $521.00 HC RIGHT HEART CATH $13,187.00 HC RIGHT VENTRICULAR RECORDING $6,146.00 HC ROUTINE VENIPUNCTURE $32.00 HC RPHARM MONOCLONAL AB THERAPY $3,407.00 HC SACRUM COCCYX MIN 2 VIEWS $524.00 HC SBRT DELIVERY PER FRACTION $11,023.00 HC SCAPULA COMPL $548.00 HC SCLEROTX FLUID COLLECTION $2,106.00 HC SCR MAMMO INCL CAD BILAT $419.00 HC SCR MAMMO INCL CAD UNIL $331.00 HC SELECT CATH ART BRACH CEPH 1ST ORDER $1,593.00 HC SELECT CATH ART BRACH CEPH 2ND ORDER $2,137.00 HC SELECT CATH ART BRACH CEPH 3RD ORDER $2,547.00 HC SELECT CATH ART BRACH CEPH EA ADDTL $1,357.00 HC SELECT CATH ART L EXTR ABD/P 1ST ORDER $1,599.00 HC SELECT CATH ART L EXTR ABD/P 2ND ORDER $1,745.00 HC SELECT CATH ART L EXTR ABD/P 3RD ORDER $2,176.00 HC SELECT CATH ART L EXTR ABD/P EA ADDTL $1,441.00 HC SELECTIVE CATH LT/RT PULMONARY ARTERY $1,608.00 HC SELF CARE CURRENT STATUS $0.01 HC SELF CARE D/C STATUS $0.01 HC SELF CARE GOAL STATUS $0.01 HC SELLA TURCICA $184.00 HC SEMIRIG 2PC THERMOPL CERV COLLAR W EXT LVL 1 $1,431.00 HC SEMIRIG 2PC THERMOPL CERV COLLAR W EXT LVL 2 $2,861.00 HC SEMIRIG 2PC THERMOPL CERV COLLAR W EXT LVL 3 $3,935.00 111 of 155 Procedure Price HC SEMIRIG 2PC THERMOPL CERV COLLAR W EXT LVL 4 $5,247.00 HC SEMIRIG 2PC THERMOPL CERV COLLAR W EXT LVL 5 $6,558.00 HC SENSORY INTEGRATION EA 15M $251.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 1 $477.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 10 $8,048.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 11 $8,347.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 12 $9,539.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 15 $9,838.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 17 $11,627.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 18 $12,520.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 2 $835.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 26 $19,674.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 3 $1,252.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 32 $25,040.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 4 $1,670.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 5 $2,088.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 6 $3,577.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 7 $4,472.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 8 $5,963.00 HC SEPTAL DEFECT IMPL SYSTEM LVL 9 $6,706.00 HC SEWHO, AIRPLANE DESIGNE LVL 1 $1,431.00 HC SEWHO, AIRPLANE DESIGNE LVL 2 $2,861.00 HC SEWHO, AIRPLANE DESIGNE LVL 3 $3,935.00 HC SEWHO, AIRPLANE DESIGNE LVL 4 $5,247.00 HC SEWHO, AIRPLANE DESIGNE LVL 5 $6,558.00 HC SGL NBI BRACHIAL PLEXUS $1,077.00 HC SHAVE LES S/N/H/F/G 0.5 CM/< $225.00 HC SHAVE LES T/A/L 0.5 CM/< $170.00 HC SHOULDER 1 VIEW $403.00 HC SHOULDER ARTHROGRAM $1,149.00 HC SHOULDER MIN 2 VIEWS $540.00 HC SHRINKER ABOVE KNEE LVL 1 $835.00 HC SHRINKER ABOVE KNEE LVL 2 $1,431.00 HC SHRINKER ABOVE KNEE LVL 3 $2,147.00 HC SHRINKER ABOVE KNEE LVL 4 $2,861.00 HC SHRINKER ABOVE KNEE LVL 5 $3,577.00 HC SHRINKER BELOW KNEE LVL 1 $334.00 112 of 155 Procedure Price HC SHRINKER BELOW KNEE LVL 2 $501.00 HC SHRINKER BELOW KNEE LVL 3 $667.00 HC SHRINKER BELOW KNEE LVL 4 $835.00 HC SHUNTOGRAM FOR NV SHUNT $1,041.00 HC SI JOINTS LESS THAN 3 VIEWS $492.00 HC SI JOINTS MIN 3 VIEWS $536.00 HC SIALOGRAM $736.00 HC SIGMOIDOSCOPY LEVEL I $6,312.00 HC SIGMOIDOSCOPY LEVEL II $6,153.00 HC SIGMOIDOSCOPY LEVEL III $7,348.00 HC SIGMOIDOSCOPY LEVEL IV $11,070.00 HC SIGMOIDOSCOPY W/EUS LEVEL I $9,591.00 HC SIGMOIDOSCOPY W/EUS LEVEL II $9,016.00 HC SIGMOIDOSCOPY W/EUS LEVEL III $9,606.00 HC SIGMOIDOSCOPY W/EUS LEVEL IV $10,759.00 HC SIJ ANESTH/STERIOD INJ PAIN $2,850.00 HC SIJ ANESTH/STERIOD INJ PAIN BILAT $2,850.00 HC SIMPLE PROCEDURE $613.00 HC SIMULATION; COMPLEX $1,893.00 HC SIMULATION; INTERMEDIATE $1,893.00 HC SIMULATION; SIMPLE $627.00 HC SINUS OR JUGL CATH VENOGRAM $1,811.00 HC SINUSES LESS THAN 3 VIEWS $522.00 HC SINUSES MIN 3 VIEWS $756.00 HC SIO PANEL PREFAB LVL 1 $334.00 HC SIO PANEL PREFAB LVL 2 $501.00 HC SIO PANEL PREFAB LVL 3 $667.00 HC SIO PANEL PREFAB LVL 4 $835.00 HC SKIN SPLT A-GRFT FAC/NCK/HF/G 100 SQ CM/1% BA $3,760.00 HC SKIN SPLT A-GRFT FAC/NCK/HF/G ADDTL 100 SQ CM/1% BA $630.00 HC SKIN SPLT A-GRFT TRNK/ARM/LEG 100 SQ CM/1% BA $3,679.00 HC SKIN SPLT A-GRFT TRNK/ARM/LEG ADDTL 100 SQ CM/1% BA $527.00 HC SKIN SUB GRAFT T/A/L 25 SQ CM $5,420.00 HC SKIN SUB GRAFT T/A/L ADD 25 SQ CM $380.00 HC SKIN SUB GRFT F/NK/HF/G 25 SQ CM $5,922.00 HC SKIN SUB GRFT F/NK/HF/G ADD 25 SQ CM $3,784.00 HC SKIN SUB GRFT T/A/L CH ADD 100 SQ CM $837.00 113 of 155 Procedure Price HC SKIN SUB GRFT T/A/L CHILD 100 SQ CM $9,763.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 1 $2,088.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 10 $16,097.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 11 $17,886.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 12 $19,674.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 2 $3,577.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 3 $5,963.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 4 $8,048.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 5 $9,539.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 6 $8,942.00 HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 9 $14,309.00 HC SKIN SUBSTITUTE NOS LVL 1 $1,431.00 HC SKIN SUBSTITUTE NOS LVL 2 $2,861.00 HC SKIN SUBSTITUTE NOS LVL 3 $3,935.00 HC SKIN SUBSTITUTE NOS LVL 4 $5,247.00 HC SKIN SUBSTITUTE NOS LVL 5 $6,558.00 HC SKN SUB GRFT F/NK/HF/G CH ADD 100 SQ CM $837.00 HC SKN SUB GRFT F/NK/HF/G CHILD 100 SQ CM $5,922.00 HC SKULL LESS THAN 4 VIEWS $344.00 HC SKULL MIN 4 VIEWS $787.00 HC SLCTV WND DEBRIDEM 20 CM OR < $436.00 HC SLCTV WND DEBRIDEM ADDTL 20 CM/< $436.00 HC SLEEP STUDY UNATT & RESP EFFT $957.00 HC SLS-EPS PERIPH NRV; LWR LIMBS $1,487.00 HC SLS-EPS; PERIPH NRV; UP LIMBS $1,487.00 HC SM 153 LEXIDRONAM UP TO 150 MCI $29,464.00 HC SMALL BOWEL ENDO LEVEL I $4,098.00 HC SMALL BOWEL ENDO LEVEL II $5,756.00 HC SMALL BOWEL ENDO LEVEL III $6,192.00 HC SMALL BOWEL ENDO LEVEL IV $7,774.00 HC SMALL BOWEL VIA ENTEROCLYSIS TUBE $929.00 HC SMALL BOWEL W SERIAL IMG $817.00 HC SMOKE/TOBACCO COUNSELING > 10 MIN $106.00 HC SMOKE/TOBACCO COUNSELING 3-10 MIN $70.00 HC SMPL BLADDER IRRIGATE LAVAGE/INSTILL $574.00 HC SO - ACROMIOCLAVICULAR PREFAB LVL 1 $334.00 HC SO - ACROMIOCLAVICULAR PREFAB LVL 2 $501.00 114 of 155 Procedure Price HC SO - ACROMIOCLAVICULAR PREFAB LVL 3 $667.00 HC SO - ACROMIOCLAVICULAR PREFAB LVL 4 $835.00 HC SO - PREFAB FIG OF 8 RESTRAINER LVL 1 $334.00 HC SO - PREFAB FIG OF 8 RESTRAINER LVL 2 $501.00 HC SO - PREFAB FIG OF 8 RESTRAINER LVL 3 $667.00 HC SO - PREFAB FIG OF 8 RESTRAINER LVL 4 $835.00 HC SO AIRPLANE W/WO JOINT CF LVL 1 $1,431.00 HC SO AIRPLANE W/WO JOINT CF LVL 2 $2,861.00 HC SO AIRPLANE W/WO JOINT CF LVL 3 $3,935.00 HC SO AIRPLANE W/WO JOINT CF LVL 4 $5,247.00 HC SO AIRPLANE W/WO JOINT CF LVL 5 $6,558.00 HC SO CAP DESIGN W/O JNTS CF LVL 1 $1,431.00 HC SO CAP DESIGN W/O JNTS CF LVL 2 $2,861.00 HC SO CAP DESIGN W/O JNTS CF LVL 3 $3,935.00 HC SO CAP DESIGN W/O JNTS CF LVL 4 $5,247.00 HC SO CAP DESIGN W/O JNTS CF LVL 5 $6,558.00 HC SOCKET INSERT W/O LOCK LOWER LVL 1 $1,431.00 HC SOCKET INSERT W/O LOCK LOWER LVL 2 $2,861.00 HC SOCKET INSERT W/O LOCK LOWER LVL 3 $3,935.00 HC SOCKET INSERT W/O LOCK LOWER LVL 4 $5,247.00 HC SOCKET INSERT W/O LOCK LOWER LVL 5 $6,558.00 HC SOCKET INSERT W/O LOCK LOWER LVL 6 $6,440.00 HC SOCKET INSERT W/O LOCK LOWER LVL 7 $7,512.00 HC SOCKET INSERT W/O LOCK LOWER LVL 8 $8,585.00 HC SOCKET INSERT W/O LOCK LOWER LVL 9 $9,658.00 HC SODIUM FLUORIDE F-18 TO 30 MCI $987.00 HC SOFT INERFACE MOLD PLASTIC ABV KNEE LVL 1 $835.00 HC SOFT INERFACE MOLD PLASTIC ABV KNEE LVL 2 $1,431.00 HC SOFT INERFACE MOLD PLASTIC ABV KNEE LVL 3 $2,147.00 HC SOFT INERFACE MOLD PLASTIC ABV KNEE LVL 4 $2,861.00 HC SOFT INERFACE MOLD PLASTIC ABV KNEE LVL 5 $3,577.00 HC SOFT INTERFACE MOLD PLASTIC BELW KNEE LVL 1 $835.00 HC SOFT INTERFACE MOLD PLASTIC BELW KNEE LVL 2 $1,431.00 HC SOFT INTERFACE MOLD PLASTIC BELW KNEE LVL 3 $2,147.00 HC SOFT INTERFACE MOLD PLASTIC BELW KNEE LVL 4 $2,861.00 HC SOFT INTERFACE MOLD PLASTIC BELW KNEE LVL 5 $3,577.00 HC SOFT TISSUE NECK $503.00 115 of 155 Procedure Price HC SOLUTION DIALYSIS LEVEL 1 $209.00 HC SOLUTION DIALYSIS LEVEL 2 $417.00 HC SP HEPATIC VENOGRAM WO HDM $2,754.00 HC SP MECH REMOV INTRALUMINAL OBST MATERIAL $648.00 HC SP MECH REMOV PERICATHETER OBST MATERIAL $2,122.00 HC SP PULMONARY ANGIOGRAM NONSEL S&I $3,008.00 HC SPEC COLL/MAIL $15.00 HC SPECIAL DOSIMETRY $697.00 HC SPECIAL PHYSICS CONSULT $627.00 HC SPECIAL RADIATION TREATMENT $2,377.00 HC SPECIALITY NEEDLE LVL 1 $835.00 HC SPECIALITY NEEDLE LVL 2 $1,431.00 HC SPECIALITY NEEDLE LVL 3 $2,147.00 HC SPECIALITY NEEDLE LVL 4 $2,861.00 HC SPECIALITY NEEDLE LVL 5 $3,577.00 HC SPECIALITY NEEDLE LVL 6 $3,735.00 HC SPEECH/HEARING THERAPY $310.00 HC SPEECH/HEARING THERAPY GROUP $480.00 HC SPEECH/HEARING THERAPY HOME $294.00 HC SPIN/BRAIN PUMP REFIL & MAIN $759.00 HC SPINAL ANGIOGRAM SELECTIVE $10,105.00 HC SPINAL EPIDURAL PACU $1,554.00 HC SPINAL IMPLANT LVL 1 $2,088.00 HC SPINAL IMPLANT LVL 10 $8,942.00 HC SPINAL IMPLANT LVL 11 $9,838.00 HC SPINAL IMPLANT LVL 12 $10,732.00 HC SPINAL IMPLANT LVL 13 $11,627.00 HC SPINAL IMPLANT LVL 14 $12,520.00 HC SPINAL IMPLANT LVL 15 $13,415.00 HC SPINAL IMPLANT LVL 16 $14,309.00 HC SPINAL IMPLANT LVL 17 $15,203.00 HC SPINAL IMPLANT LVL 18 $16,097.00 HC SPINAL IMPLANT LVL 19 $16,992.00 HC SPINAL IMPLANT LVL 2 $3,577.00 HC SPINAL IMPLANT LVL 20 $17,886.00 HC SPINAL IMPLANT LVL 22 $19,674.00 HC SPINAL IMPLANT LVL 23 $20,569.00 116 of 155 Procedure Price HC SPINAL IMPLANT LVL 24 $21,462.00 HC SPINAL IMPLANT LVL 25 $22,357.00 HC SPINAL IMPLANT LVL 28 $25,040.00 HC SPINAL IMPLANT LVL 29 $25,934.00 HC SPINAL IMPLANT LVL 3 $4,472.00 HC SPINAL IMPLANT LVL 30 $26,827.00 HC SPINAL IMPLANT LVL 4 $5,963.00 HC SPINAL IMPLANT LVL 5 $6,706.00 HC SPINAL IMPLANT LVL 6 $8,048.00 HC SPINAL IMPLANT LVL 7 $8,347.00 HC SPINAL IMPLANT LVL 8 $9,539.00 HC SPINAL IMPLANT LVL 9 $8,048.00 HC SPINAL PUNCTURE LUMBAR DIAG $1,843.00 HC SPINE 1 VIEW ANY LOCATION $441.00 HC SPIROMETRY $324.00 HC SPL AVULSE NP EA ADDTL $236.00 HC SPL AVULSE NP SGL $1,707.00 HC SR89 STRONTIUM PER MCI $4,631.00 HC SREP F/E/N/L/MM >30.0 CM $732.00 HC SREP F/E/N/L/MM 12.6-20.0 CM $608.00 HC SREP F/E/N/L/MM 2.5 CM/< $360.00 HC SREP F/E/N/L/MM 2.6-5.0 CM $422.00 HC SREP F/E/N/L/MM 20.1-30.0 CM $669.00 HC SREP F/E/N/L/MM 5.1-7.5 CM $485.00 HC SREP F/E/N/L/MM 7.6-12.5 CM $545.00 HC SREP S/N/A/G/TR/E >30 CM $574.00 HC SREP S/N/A/G/TR/E 12.6-20.0 CM $499.00 HC SREP S/N/A/G/TR/E 2.5 CM/< $387.00 HC SREP S/N/A/G/TR/E 2.6-7.5 CM $425.00 HC SREP S/N/A/G/TR/E 20.1-30.0 CM $537.00 HC SREP S/N/A/G/TR/E 7.6-12.5 CM $463.00 HC SRS LINEAR BASED 1 SESSION $18,522.00 HC ST BX SHOULDER SUPERFICIAL $2,452.00 HC STENT OTHERS, COAT/COV W/DEL SYS LVL 1 $1,043.00 HC STENT OTHERS, COAT/COV W/DEL SYS LVL 2 $2,088.00 HC STENT OTHERS, COAT/COV W/DEL SYS LVL 3 $2,683.00 HC STENT OTHERS, COAT/COV W/DEL SYS LVL 4 $3,577.00 117 of 155 Procedure Price HC STENT OTHERS, COAT/COV W/DEL SYS LVL 5 $4,472.00 HC STENT OTHERS, COAT/COV W/DEL SYS LVL 6 $5,963.00 HC STENT PLMT CTR DIALYSIS SEG $10,165.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL 1 $835.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL 2 $1,670.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL 3 $2,147.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL 4 $2,861.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL 5 $3,577.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL 6 $3,577.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL10 $5,963.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL7 $4,174.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL8 $4,770.00 HC STENT, NON-COR, TEM W/DEL SYSTEM LVL9 $5,365.00 HC STENT, NON-COR, TEM W/O DEL LVL 1 $835.00 HC STENT, NON-COR, TEM W/O DEL LVL 11 $9,539.00 HC STENT, NON-COR, TEM W/O DEL LVL 2 $1,670.00 HC STENT, NON-COR, TEM W/O DEL LVL 3 $2,147.00 HC STENT, NON-COR, TEM W/O DEL LVL 4 $2,861.00 HC STENT, NON-COR, TEM W/O DEL LVL 5 $3,577.00 HC STENT, NON-COR, TEM W/O DEL LVL 6 $4,472.00 HC STENT, NON-COR, TEM W/O DEL LVL 7 $5,963.00 HC STENT, NON-COR, TEM W/O DEL LVL 8 $6,706.00 HC STENT, NON-COR, TEM W/O DEL LVL 9 $8,048.00 HC STENTS, NON VASCULAR LVL 1 $1,043.00 HC STENTS, NON VASCULAR LVL 2 $2,088.00 HC STENTS, NON VASCULAR LVL 3 $3,577.00 HC STENTS, NON VASCULAR LVL 4 $4,472.00 HC STENTS, NON VASCULAR LVL 5 $5,963.00 HC STENTS, NON VASCULAR LVL 6 $6,706.00 HC STENTS, NON VASCULAR LVL 7 $8,048.00 HC STENTS, NON VASCULAR LVL 8 $8,347.00 HC STENTS, NON VASCULAR LVL 9 $9,539.00 HC STERNOCLAVICULAR MIN 3 VIEWS $503.00 HC STERNUM MIN 2 VIEWS $582.00 HC STIM & PACING S/P IV DRUGS $9,174.00 HC STRAP ANKLE OR FOOT $301.00 HC STRAPPING ELBOW OR WRIST $304.00 118 of 155 Procedure Price HC STRAPPING HAND OR FINGER $301.00 HC STRAPPING HIP $295.00 HC STRAPPING OF TOES $301.00 HC STRAPPING SHOULDER $264.00 HC STRAPPING THORAX $337.00 HC STRATTICE TM PER 1 SQ CM LVL 1 $334.00 HC STRATTICE TM PER 1 SQ CM LVL 2 $501.00 HC STRATTICE TM PER 1 SQ CM LVL 3 $667.00 HC STRATTICE TM PER 1 SQ CM LVL 4 $835.00 HC STRESS TTE COMPLETE $3,163.00 HC STRESS TTE ONLY $1,345.00 HC STRESS VIEW ANY JOINT $178.00 HC STUMP SOCK SINGLE BELOW KNEE LVL 1 $40.00 HC SUB PT/OT CURRENT STATUS $0.01 HC SUB PT/OT D/C STATUS $0.01 HC SUB PT/OT GOAL STATUS $0.01 HC SUPERF SOFT TISS BX THIGH/KNEE $3,171.00 HC SUPERV, HNDL, LOAD - RAD SOURCE $881.00 HC SURFACE APPL LDR RADIONUCLIDE $1,051.00 HC SURFACTANT ADMIN THRU TUBE $397.00 HC SURG TX INCOMPL ABORTION $7,299.00 HC SURG TX MISSED ABORT 1ST TRIMESTER $3,795.00 HC SURGERY LEVEL 1 - EA ADDTL 15 MIN $355.00 HC SURGERY LEVEL 1 - INIT 30 MIN $3,495.00 HC SURGERY LEVEL 2 - EA ADDTL 15 MIN $575.00 HC SURGERY LEVEL 2 - INIT 30 MIN $6,420.00 HC SURGERY LEVEL 3 - EA ADDTL 15 MIN $795.00 HC SURGERY LEVEL 3 - INIT 30 MIN $9,345.00 HC SURGERY LEVEL 4 - EA ADDTL 15 MIN $1,015.00 HC SURGERY LEVEL 4 - INIT 30 MIN $12,270.00 HC SURGERY LEVEL 5 - EA ADDTL 15 MIN $1,235.00 HC SURGERY LEVEL 5 - INIT 30 MIN $15,195.00 HC SURGERY LEVEL 6 - EA ADDTL 15 MIN $1,455.00 HC SURGERY LEVEL 6 - INIT 30 MIN $18,120.00 HC SURGICAL SOLUTIONS SVCS $372.00 HC SURGICAL SPECIMEN $1,158.00 HC SURGIMEND FETAL PER 0.5 SQ CM LVL 1 $334.00 119 of 155 Procedure Price HC SURGIMEND FETAL PER 0.5 SQ CM LVL 2 $501.00 HC SURGIMEND FETAL PER 0.5 SQ CM LVL 3 $667.00 HC SURGIMEND FETAL PER 0.5 SQ CM LVL 4 $835.00 HC SURGIMEND NEONATAL PER 0.5 SQ CM LVL 1 $334.00 HC SURGIMEND NEONATAL PER 0.5 SQ CM LVL 2 $501.00 HC SURGIMEND NEONATAL PER 0.5 SQ CM LVL 3 $667.00 HC SURGIMEND NEONATAL PER 0.5 SQ CM LVL 4 $835.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 1 $835.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 10 $11,923.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 2 $1,431.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 3 $2,147.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 4 $2,861.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 5 $3,577.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 6 $4,918.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 7 $6,558.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 8 $8,048.00 HC SUTURE/STAPLES/CLOSURE DEVICES LVL 9 $10,732.00 HC SVC VENOGRAM W/SERIALOGRAPHY $3,053.00 HC SWALLOW CURRENT STATUS $0.01 HC SWALLOW D/C STATUS $0.01 HC SWALLOW GOAL STATUS $0.01 HC SWALLOWING FUNCTION W CINE VIDEO $614.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 1 $835.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 10 $5,963.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 2 $1,670.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 3 $2,147.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 4 $2,861.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 5 $3,577.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 6 $3,577.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 7 $4,174.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 8 $4,770.00 HC SYNTHETIC IMPLNT URINARY 1ML LVL 9 $5,365.00 HC TAP BLOCK UNIL BY INJ $1,303.00 HC TBA CENTRAL DIALYSIS SEG $562.00 HC TC99 TILMANOCEPT DIAG TO 0.5 MCI $2,216.00 HC TC99M APCITIDE TO 20 MCI $2,013.00 HC TC99M BICISATE TO 25 MCI $2,377.00 120 of 155 Procedure Price HC TC99M DISOFENIN TO 15 MCI $382.00 HC TC99M DMSA TO 10 MCI $1,868.00 HC TC99M GLUCEPTATE TO 25 MCI $606.00 HC TC99M HMPAO TO 25 MCI $7,318.00 HC TC99M LABELED RBC TO 30 MCI $730.00 HC TC99M MAA TO 10 MCI $307.00 HC TC99M MAG3 TO 15 MCI $1,635.00 HC TC99M MEBROFENIN TO 15 MCI $366.00 HC TC99M MEDRONATE TO 30 MCI $164.00 HC TC99M OXIDRONATE TO 30 MCI $289.00 HC TC99M PENTETATE TO 25 MCI $176.00 HC TC99M PERTECHNETATE PER MCI $121.00 HC TC99M PYROPHOSPHATE TO 25 MCI $246.00 HC TC99M SESTAMIBI $735.00 HC TC99M SULFUR COLLOID TO 20 MCI $787.00 HC TC99M TETROFOSMIN $894.00 HC TCAT DLVR ENHNCD FIXJ DEV $11,500.00 HC TCM HOURLY $41.00 HC TCM INITIATION $98.00 HC TEAM CONF W/O PAT BY HC PRO 30+ MINS $122.00 HC TEAM CONF W/PAT BY HC PRO 30+ MINS $122.00 HC TECHNETIUM TC99M AEROSOL =< 75 MCI $350.00 HC TECHNETIUM TC99M AUTO WBC DX $6,284.00 HC TEE FOR MONITORING $1,791.00 HC TEE W OR W/O FOL W/CONT MON $2,249.00 HC TELETHERAPY ISODOSE PLAN COMPLEX $697.00 HC TELETHERAPY ISODOSE PLAN SIMPLE $697.00 HC TELETHERAPY PLAN SPECIAL, TOTAL BODY $1,703.00 HC TEMP TRANSCUTAN PACING $582.00 HC TEMPERATURE GRADIENT STUDIES $309.00 HC TENOGLIDE TENDON PROT PER SQ CM LVL 1 $334.00 HC TENOGLIDE TENDON PROT PER SQ CM LVL 2 $501.00 HC TENOGLIDE TENDON PROT PER SQ CM LVL 3 $667.00 HC TENOGLIDE TENDON PROT PER SQ CM LVL 4 $835.00 HC TENOTOMY SQ TOE SINGLE $4,621.00 HC TENSILON TEST $87.00 HC THAW PRESERVED STEM CELLS $1,060.00 121 of 155 Procedure Price HC THER/DX CONCURRENT INF $159.00 HC THER/PRO/DX INJ IA $220.00 HC THER/PRO/DX INJ IV PUSH $371.00 HC THER/PROPH/DIAG INJ SC/IM $133.00 HC THER/PROPH/DX IV INF EA ADDTL HR $159.00 HC THER/PROPH/DX IV INF INIT UP TO 1HR $496.00 HC THERAP BE OR AIR FOR OBSTRUCT $517.00 HC THERAP EXERCISE ROM EA 15M $156.00 HC THERAPEUTIC ACTIVITY DIR EA 15M $153.00 HC THERAPEUTIC RAD SIMUL 3 DIMENSIONAL $5,669.00 HC THERAPEUTIC REHAB GROUP $288.00 HC THERAPEUTIC SP DEVICE SERVICE $324.00 HC THERASKIN PER SQ CM LVL 1 $100.00 HC THERASKIN PER SQ CM LVL 2 $230.00 HC THERASKIN PER SQ CM LVL 3 $300.00 HC THERASKIN PER SQ CM LVL 4 $410.00 HC THERASKIN PER SQ CM LVL 5 $680.00 HC THORACIC AORTOGRAM W SERIALOGRAPHY $6,857.00 HC THORACIC SPINE 2 VIEWS $527.00 HC THORACIC SPINE 3 VIEWS $694.00 HC THORACIC SPINE MIN 4 VIEWS $759.00 HC THORACOLUMBAR SPINE 2 VIEWS MIN $533.00 HC THRMBC/INFS DIALYSIS CIRCUIT $14,425.00 HC THRMBC/INFS DIALYSIS CIRCUIT W STENT $36,824.00 HC THRMBC/INFS DIALYSIS CIRCUIT W TBA $29,153.00 HC THROMBECT VC ILIAC FEMPOP ABD/LEG INC $2,672.00 HC THROMBECT/EMBOLECTOMY CATH LVL 1 $835.00 HC THROMBECT/EMBOLECTOMY CATH LVL 10 $9,500.00 HC THROMBECT/EMBOLECTOMY CATH LVL 11 $10,500.00 HC THROMBECT/EMBOLECTOMY CATH LVL 13 $13,500.00 HC THROMBECT/EMBOLECTOMY CATH LVL 14 $13,750.00 HC THROMBECT/EMBOLECTOMY CATH LVL 2 $1,431.00 HC THROMBECT/EMBOLECTOMY CATH LVL 3 $2,147.00 HC THROMBECT/EMBOLECTOMY CATH LVL 4 $2,861.00 HC THROMBECT/EMBOLECTOMY CATH LVL 5 $3,577.00 HC THROMBECT/EMBOLECTOMY CATH LVL 6 $6,558.00 HC THROMBECT/EMBOLECTOMY CATH LVL 7 $8,048.00 122 of 155 Procedure Price HC THROMBECT/EMBOLECTOMY CATH LVL 8 $8,500.00 HC THROMBECT/EMBOLECTOMY CATH LVL 9 $9,000.00 HC THROMBECTOMY AXILL & SUBCLAV ARM INC $3,986.00 HC THROMBECTOMY OF ARTERIAL/VENOUS GRAFT $10,457.00 HC THROMBECTOMY PERC TRANSLUM MCH VEIN ADDL $12,163.00 HC THROMBECTOMY PERC TRANSLUM MECH ART ADDL $11,238.00 HC THROMBECTOMY PERC TRANSLUM MECH ART INIT $10,711.00 HC THROMBECTOMY PERC TRANSLUM MECH VEIN $12,306.00 HC THROMBECTOMY SUBCLAV VEIN NECK INC $3,981.00 HC THROMBECTOMY TRANSLUM MECH VEIN SEC PERC $5,444.00 HC THROMBOLYSIS CEREBRAL BY IV INFUSION $526.00 HC THROMBOLYSIS CORON IV INFUS $684.00 HC THROMBOLYTIC ART THERAPY $7,027.00 HC THROMBOLYTIC ART/VEN THER CESS&CATH REM $8,479.00 HC THROMBOLYTIC ART/VEN THERAPY $8,479.00 HC THROMBOLYTIC VENOUS THERAPY $3,803.00 HC THYROID IMAG W/BLOOD FLOW $1,186.00 HC THYROID IMAG W/BLOOD FLOW SGL/MULT QUAN $1,569.00 HC THYROID METS UPTAKE $1,227.00 HC THYROID UPTAKE MEASUREMENT $428.00 HC THYROTROPIN ALFA 0.9 MG IN 1.1 MG VIAL $6,605.00 HC TIB/PER REVASC ADD-ON $18,628.00 HC TIB/PER REVASC STENT & ATHER $68,489.00 HC TIB/PER REVASC STNT & ATHER $18,628.00 HC TIB/PER REVASC W/ATHER $39,545.00 HC TIB/PER REVASC W/STENT $39,545.00 HC TIB/PER REVASC W/TLA $18,628.00 HC TIBIA FIBULA 2 VIEWS $554.00 HC TIBPER REVASC W/ATHER ADD-ON $39,545.00 HC TILT TABLE TESTING $1,077.00 HC TLSO TRIPLANE CNTRL W HYPEREXT LVL 1 $1,431.00 HC TLSO TRIPLANE CNTRL W HYPEREXT LVL 2 $2,861.00 HC TLSO TRIPLANE CNTRL W HYPEREXT LVL 3 $3,935.00 HC TLSO TRIPLANE CNTRL W HYPEREXT LVL 4 $5,247.00 HC TLSO TRIPLANE CNTRL W HYPEREXT LVL 5 $6,558.00 HC TMJ BILATERAL $570.00 HC TMJ UNILATERAL $425.00 123 of 155 Procedure Price HC TOE OR TOES MIN 2 VIEWS $379.00 HC TOMOGRAM $894.00 HC TORSION CNTR ANKLE JNT ADDTN LVL 1 $835.00 HC TORSION CNTR ANKLE JNT ADDTN LVL 2 $1,431.00 HC TORSION CNTR ANKLE JNT ADDTN LVL 3 $2,147.00 HC TORSION CNTR ANKLE JNT ADDTN LVL 4 $2,861.00 HC TORSION CNTR ANKLE JNT ADDTN LVL 5 $3,577.00 HC TORSION CNTRL ST KNEE EA JNT LVL 1 $835.00 HC TORSION CNTRL ST KNEE EA JNT LVL 2 $1,431.00 HC TORSION CNTRL ST KNEE EA JNT LVL 3 $2,147.00 HC TORSION CNTRL ST KNEE EA JNT LVL 4 $2,861.00 HC TORSION CNTRL ST KNEE EA JNT LVL 5 $3,577.00 HC TOTAL VITAL CAPACITY $188.00 HC TRACH SUPPLIES LVL 1 $835.00 HC TRACH SUPPLIES LVL 2 $1,431.00 HC TRACH SUPPLIES LVL 3 $2,147.00 HC TRACH SUPPLIES LVL 4 $2,861.00 HC TRACH SUPPLIES LVL 5 $3,577.00 HC TRACH TUBE CHG BEFORE FISTULA TRACT $307.00 HC TRACHEOSTOMY EMERG CRICOTHYROID $1,658.00 HC TRACHEOSTOMY SPEAKING VALVE LVL 1 $835.00 HC TRACHEOSTOMY SPEAKING VALVE LVL 2 $1,431.00 HC TRACHEOSTOMY SPEAKING VALVE LVL 3 $2,147.00 HC TRACHEOSTOMY SPEAKING VALVE LVL 4 $2,861.00 HC TRACHEOSTOMY SPEAKING VALVE LVL 5 $3,577.00 HC TRACH-ESOPH VOICE PROS MD IN LVL 1 $1,431.00 HC TRACH-ESOPH VOICE PROS MD IN LVL 2 $2,861.00 HC TRACH-ESOPH VOICE PROS MD IN LVL 3 $3,935.00 HC TRACH-ESOPH VOICE PROS MD IN LVL 4 $5,247.00 HC TRACH-ESOPH VOICE PROS MD IN LVL 5 $6,558.00 HC TRANSCATH CLOSURE OF ASD $42,597.00 HC TRANSCATH EMBOL HEAD/NECK NOT CNS $9,443.00 HC TRANSCATH EMBOLIZATION TX $5,681.00 HC TRANSFUSION BLOOD > 6 UNITS $1,121.00 HC TRANSFUSION BLOOD 1 UNIT $1,121.00 HC TRANSFUSION BLOOD 2 UNITS $1,121.00 HC TRANSFUSION BLOOD 3 UNITS $1,121.00 124 of 155 Procedure Price HC TRANSFUSION BLOOD 4 UNITS $1,121.00 HC TRANSFUSION BLOOD 5 UNITS $1,121.00 HC TRANSFUSION BLOOD 6 UNITS $1,121.00 HC TRANSHEP PORTOGRAM W/HEMO PERC $2,672.00 HC TRANSHEP PORTOGRAM W/O HEMO PERC $5,491.00 HC TRANSL ANGIO LASER CATH LVL 1 $835.00 HC TRANSL ANGIO LASER CATH LVL 2 $3,577.00 HC TRANSL ANGIO LASER CATH LVL 3 $6,558.00 HC TRANSL ANGIO LASER CATH LVL 6 $11,923.00 HC TRANSL ATHERECT ROTATN CATH LVL 1 $835.00 HC TRANSL ATHERECT ROTATN CATH LVL 10 $14,309.00 HC TRANSL ATHERECT ROTATN CATH LVL 11 $14,606.00 HC TRANSL ATHERECT ROTATN CATH LVL 12 $16,693.00 HC TRANSL ATHERECT ROTATN CATH LVL 2 $1,431.00 HC TRANSL ATHERECT ROTATN CATH LVL 3 $2,147.00 HC TRANSL ATHERECT ROTATN CATH LVL 4 $2,861.00 HC TRANSL ATHERECT ROTATN CATH LVL 5 $3,577.00 HC TRANSL ATHERECT ROTATN CATH LVL 6 $6,558.00 HC TRANSL ATHERECT ROTATN CATH LVL 7 $8,048.00 HC TRANSL ATHERECT ROTATN CATH LVL 8 $10,732.00 HC TRANSL ATHERECT ROTATN CATH LVL 9 $11,923.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 1 $835.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 10 $14,309.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 11 $14,606.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 2 $1,431.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 3 $2,147.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 4 $2,861.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 5 $3,577.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 6 $6,558.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 7 $8,048.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 8 $10,732.00 HC TRANSLUM ANGIOPL NON-LASER CATH LVL 9 $11,923.00 HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 1 $1,511.00 HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 2 $3,021.00 HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 3 $6,041.00 HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 4 $9,062.00 HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 5 $12,083.00 125 of 155 Procedure Price HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 6 $15,103.00 HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 7 $18,124.00 HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 8 $21,145.00 HC TRANSPLT AUTOL HCT/DONOR $3,286.00 HC TRAUMA RESPONS LEV1 FAC LEV 2 $1,952.00 HC TREAT BIG TOE FRACTURE $3,410.00 HC TREAT FINGER DISLOCATION $2,514.00 HC TREAT PLEURODESIS W/AGENT $762.00 HC TREAT SWALLOWING DYSFUNCTION $308.00 HC TREAT ULNAR FRACTURE WO MANIP $506.00 HC TRIM DYSTROPHIC NAIL(S) $168.00 HC TRIM ND NAILS $223.00 HC TRIM SKIN LESIONS 2 TO 4 $326.00 HC TRIM SKIN LESIONS OVER 4 $486.00 HC TRLUML BALLOON ANGIOP EA ADDTL ART $4,882.00 HC TRLUML BALLOON ANGIOP EA ADDTL VEIN $6,769.00 HC TRLUML BALLOON ANGIOP INIT ART $14,425.00 HC TRLUML BALLOON ANGIOP INIT VEIN $14,425.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 1 $835.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 10 $14,309.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 11 $14,606.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 12 $16,693.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 14 $14,904.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 2 $1,431.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 3 $2,147.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 4 $2,861.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 5 $3,577.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 6 $6,558.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 7 $8,048.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 8 $10,732.00 HC TRNSLUM ATHERECT DIRECTNL CATH LVL 9 $11,923.00 HC TTE 2D W OR W/O CONTR FOLLOW W CONTR F-UP $1,461.00 HC TTE CONG ABN; COMPLETE WO CONTRAST $1,429.00 HC TTE W OR W/O CONTR FOLLOW W CONTR DOPPLER $2,249.00 HC TTE W OR W/O CONTR FOLLOW W CONTR ECG $2,249.00 HC TTE W OR W/O CONTR FOLLOW W CONTR STRESS $2,249.00 HC TTE W OR W/O FOL W/CONT COM $2,249.00 126 of 155 Procedure Price HC TTE W OR W/O FOL W/CONT F/U $2,249.00 HC TTE W/ DOPPLER COMPLETE $3,367.00 HC TTE W/O DOPPLER COMPLETE $1,541.00 HC TX ATRIAL FIB PULM VEIN ISOL $39,649.00 HC TX CL ELBOW DISLOC W ANESTH $2,727.00 HC TX CL ELBOW DISLOC WO ANESTH $481.00 HC TX DEVICES; COMPLEX $1,271.00 HC TX DEVICES; INTERMED $1,168.00 HC TX DEVICES; SIMPLE $1,168.00 HC TX FRACTURE D RADIUS/ULNA W MANIP $4,709.00 HC TX FRACTURE D RADIUS/ULNA WO MANIP $352.00 HC TX GASTRO INTUB W/ASP $643.00 HC TX L/R ATRIAL FIB ADDL $39,649.00 HC TX NON-SPEECH DEVICE $175.00 HC TX S WND DEHIS W PACK $465.00 HC TX S WND DEHISC SMPL $610.00 HC TX TARSAL BONE FX WO MANIP $506.00 HC TX/PRO/DX INJ NEW DRG ADD-ON $236.00 HC TX/PRO/DX INJ SAME DRG ADD-ON $211.00 HC TX/PROPH/DX ADDL SEQ IV INF UP TO 1HR $175.00 HC UE FX ORTHOSIS, HUMERAL LVL 1 $477.00 HC UE FX ORTHOSIS, HUMERAL LVL 2 $1,073.00 HC UE FX ORTHOSIS, HUMERAL LVL 3 $1,670.00 HC UE FX ORTHOSIS, HUMERAL LVL 4 $2,266.00 HC UE FX ORTHOSIS, HUMERAL LVL 5 $2,861.00 HC UE FX ORTHOSIS, HUMERAL LVL 6 $3,458.00 HC UGI BALLOON DIL ESOPH < 30 MM DIA $6,040.00 HC UGI W AIR BARIUM W SMALL BOWEL $1,028.00 HC UGI W AIR W KUB $543.00 HC UGI W AIR WO KUB $758.00 HC UGI W BX SGL/MULTIPLE $6,779.00 HC UGI W KUB $608.00 HC UGI W REMOVAL OF FB $5,314.00 HC UGI W SMALL BOWEL $1,304.00 HC UGI WO KUB $907.00 HC UMBIL CATH NB FOR DX OR TX $227.00 HC UNIT RECOVERY PER HOUR $196.00 127 of 155 Procedure Price HC UNLISTED CLINICAL BRACHYTHERAPY $447.00 HC UNLISTED MRI PROCEDURE $1,137.00 HC UNLISTED PROC DENTOALVEOLAR STRUCT $614.00 HC UNLISTED PROC SKIN MM & SQ TISS $3,735.00 HC UNLISTED PROCEDURE ANT SEG EYE $265.00 HC UNLISTED PROCEDURE ANUS $2,298.00 HC UNLISTED PROCEDURE CASTING OR STRAPPING $282.00 HC UNLISTED PROCEDURE ENDOCRINE SYSTEM $8,273.00 HC UNLISTED PROCEDURE FOOT/TOES $304.00 HC UNLISTED PROCEDURE HEMIC OR LYMPHATIC $2,537.00 HC UNLISTED PROCEDURE HUMERUS/ELBOW $304.00 HC UNLISTED PROCEDURE LEG OR ANKLE $352.00 HC UNLISTED PROCEDURE LIPS $490.00 HC UNLISTED PROCEDURE LIVER $10,724.00 HC UNLISTED PROCEDURE MALE GENITAL SYSTEM $343.00 HC UNLISTED PROCEDURE MUSCULOSKELETAL $5,632.00 HC UNLISTED PROCEDURE NERVOUS SYSTEM $751.00 HC UNLISTED PROCEDURE RECTUM $5,160.00 HC UNLISTED PROCEDURE SALIVARY GLAND $236.00 HC UNLISTED PROCEDURE STOMACH $873.00 HC UNLISTED PROCEDURE TONGUE FLR-MOUTH $614.00 HC UNLISTED PROCEDURE URINARY SYSTEM $6,184.00 HC UNLISTED PULMONARY SERVICE $259.00 HC UNLISTED THER/PROP/DIAG INJ/INF PROC $90.00 HC UNLISTED VASC PROCEDURE $4,639.00 HC UNNA BOOT STRAPPING $356.00 HC UNNA BOOT STRAPPING BILATERAL $435.00 HC UPGRADE IMPL PACEMKR SC TO DC $36,237.00 HC UPPR EXTR INFANT MIN 2 VIEWS $384.00 HC UPR/L XTREMITY ART 2 LEVELS $629.00 HC UPR/L XTREMITY ART STDY 3+ LEVELS $835.00 HC URETER ENDO EST OSTOMY W CATH $1,377.00 HC URINARY INCONT REP DEV WO SLG GRFT LVL 1 $477.00 HC URINARY INCONT REP DEV WO SLG GRFT LVL 2 $2,088.00 HC URINARY INCONT REP DEV WO SLG GRFT LVL 3 $3,577.00 HC URINARY INCONT REP DEV WO SLG GRFT LVL 4 $4,472.00 HC URINARY INCONT REP DEV WO SLG GRFT LVL 5 $5,963.00 128 of 155 Procedure Price HC URINARY INCONT REP DEV WO SLG GRFT LVL 6 $6,706.00 HC URINARY INCONT REP DEV WO SLG GRFT LVL 7 $8,048.00 HC URINARY INCONT REP DEV WO SLG GRFT LVL 8 $8,347.00 HC URINARY INCONT REP DEV WO SLG GRFT LVL 9 $9,539.00 HC URINE PREGNANCY, VISUAL COLOR $61.00 HC UROLOGY SUPPLIES GENERAL LVL 1 $835.00 HC UROLOGY SUPPLIES GENERAL LVL 2 $3,577.00 HC US ABDL AORTA SCREEN AAA $324.00 HC US BREAST COMPLETE $473.00 HC US BREAST LIMITED $473.00 HC US CAROTID SCREEN $113.00 HC US DUPLEX ARTERIAL FLOW COMPL $1,641.00 HC US EXAM ABDOMEN COMPLETE $1,671.00 HC US EXAM ABDOMEN LIMITED $947.00 HC US EXAM CHEST $762.00 HC US EXAM KIDNEY TRANSPL W DOPPLER $491.00 HC US EXAM OF HEAD AND NECK $1,041.00 HC US EXAM OF HEAD ECHOENCEPHALOGRAM $1,375.00 HC US EXAM PELVIC COMP TRANSABDOMINAL $1,220.00 HC US EXAM PELVIC LTD TRANSABDOMINAL $700.00 HC US EXAM RETROPERITONEAL COMPL $1,304.00 HC US EXAM RETROPERITONEAL LTD $982.00 HC US FBP W NON-STRESS TEST $593.00 HC US FBP WO NONSTRESS TEST $462.00 HC US FOLLOWUP STUDY $473.00 HC US GUIDANCE COMPRESSION REPAIR $758.00 HC US GUIDANCE INTRAOPERATIVE $1,230.00 HC US GUIDANCE TISSUE ABLATION $700.00 HC US GUIDANCE VASCULAR ACCESS $1,137.00 HC US GUIDED NEEDLE PLACEMENT $1,059.00 HC US GUIDED PERICARDIOCENTESIS $1,244.00 HC US INFANT HIPS W MANIPULATION $296.00 HC US INFANT HIPS WO MANIPULATION $415.00 HC US INTERSTITIAL RE APPLIC $2,463.00 HC US NON OB TRANSVAG $840.00 HC US OB COMPLETE ADDL FETUS $408.00 HC US OB COMPLETE SNGL FETUS $1,185.00 129 of 155 Procedure Price HC US OB DETAILED ADDL FETUS $538.00 HC US OB DETAILED SNGL FETUS $1,575.00 HC US OB FOLLOW UP PER FETUS $945.00 HC US OB LESS THAN 14 WKS ADDL FETUS $383.00 HC US OB LESS THAN 14 WKS SNGL FETUS $918.00 HC US OB LIMITED FETUS(S) $694.00 HC US OB TRANSVAGINAL $945.00 HC US PV RESIDUAL URINE $183.00 HC US SALINE INFUSED SONOHYSTEROGRAM $1,171.00 HC US SCROTUM AND CONTENTS $1,112.00 HC US SPINE $1,158.00 HC US TRANSRECTAL $1,175.00 HC US UNLISTED PROCEDURE $1,337.00 HC US XTR NON-VASC COMPLETE $456.00 HC US XTR NON-VASC LTD $382.00 HC VACUUM DRAIN BOTTLE/TUBE KIT LVL 1 $417.00 HC VACUUM DRAIN BOTTLE/TUBE KIT LVL 2 $835.00 HC VACUUM DRAIN BOTTLE/TUBE KIT LVL 3 $1,431.00 HC VACUUM DRAIN BOTTLE/TUBE KIT LVL 4 $2,147.00 HC VAGINAL DELIVERY LEVEL 1 $7,277.00 HC VAGINAL DELIVERY LEVEL 2 $8,600.00 HC VAGINAL DELIVERY LEVEL 3 $10,253.00 HC VAGINAL DELIVERY LEVEL 4 $12,679.00 HC VAGINAL DELIVERY ONLY $5,293.00 HC VALVES, HEART LVL 1 $2,088.00 HC VALVES, HEART LVL 10 $8,942.00 HC VALVES, HEART LVL 11 $9,838.00 HC VALVES, HEART LVL 12 $10,732.00 HC VALVES, HEART LVL 13 $11,627.00 HC VALVES, HEART LVL 14 $12,520.00 HC VALVES, HEART LVL 15 $13,415.00 HC VALVES, HEART LVL 16 $14,309.00 HC VALVES, HEART LVL 17 $15,203.00 HC VALVES, HEART LVL 18 $16,097.00 HC VALVES, HEART LVL 19 $16,992.00 HC VALVES, HEART LVL 2 $3,577.00 HC VALVES, HEART LVL 3 $4,472.00 130 of 155 Procedure Price HC VALVES, HEART LVL 4 $5,963.00 HC VALVES, HEART LVL 5 $6,706.00 HC VALVES, HEART LVL 6 $8,048.00 HC VALVES, HEART LVL 7 $8,347.00 HC VALVES, HEART LVL 8 $9,539.00 HC VALVES, HEART LVL 9 $8,048.00 HC VARUG/VALGUS PLASTIC CORRECTION LVL 1 $835.00 HC VARUG/VALGUS PLASTIC CORRECTION LVL 2 $1,431.00 HC VARUG/VALGUS PLASTIC CORRECTION LVL 3 $2,147.00 HC VARUG/VALGUS PLASTIC CORRECTION LVL 4 $2,861.00 HC VARUG/VALGUS PLASTIC CORRECTION LVL 5 $3,577.00 HC VASC EMBOLIZE/OCCLUDE ARTERY $26,485.00 HC VASC EMBOLIZE/OCCLUDE BLEED $12,765.00 HC VASC EMBOLIZE/OCCLUDE ORGAN $18,280.00 HC VASC EMBOLIZE/OCCLUDE VENOUS $26,485.00 HC VASCULAR CLOSURE DEVICE LVL 1 $835.00 HC VASCULAR CLOSURE DEVICE LVL 10 $5,963.00 HC VASCULAR CLOSURE DEVICE LVL 2 $1,670.00 HC VASCULAR CLOSURE DEVICE LVL 3 $2,147.00 HC VASCULAR CLOSURE DEVICE LVL 4 $2,861.00 HC VASCULAR CLOSURE DEVICE LVL 5 $3,577.00 HC VASCULAR CLOSURE DEVICE LVL 6 $3,577.00 HC VASCULAR CLOSURE DEVICE LVL 7 $4,174.00 HC VASCULAR CLOSURE DEVICE LVL 8 $4,770.00 HC VASCULAR CLOSURE DEVICE LVL 9 $5,365.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 1 $2,088.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 2 $3,577.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 3 $4,472.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 4 $5,963.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 5 $6,706.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 6 $8,048.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 7 $8,347.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 8 $9,539.00 HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 9 $8,048.00 HC VASCULAR GRAFT, SYNTHTIC, IMPLANT LVL 10 $8,942.00 HC VASCULAR GRAFT, SYNTHTIC, IMPLANT LVL 11 $10,732.00 HC VASCULAR GRAFT, SYNTHTIC, IMPLANT LVL 12 $12,520.00 131 of 155 Procedure Price HC VASCULAR GRAFT, SYNTHTIC, IMPLANT LVL 14 $16,097.00 HC VASCULAR GRAFT, SYNTHTIC, IMPLANT LVL 15 $17,886.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 1 $750.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 2 $1,500.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 3 $3,000.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 4 $4,500.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 5 $6,000.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 6 $7,500.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 7 $9,000.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 8 $10,500.00 HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 9 $12,000.00 HC VASCULAR STENT, COAT/COV W/DL SYS LVL 10 $13,500.00 HC VASCULAR STENT, COAT/COV W/DL SYS LVL 13 $18,000.00 HC VASCULAR STENT, COAT/COV W/DL SYS LVL 14 $19,500.00 HC VASCULAR STENT, COAT/COV W/DL SYS LVL 15 $21,000.00 HC VASCULAR STENT, COAT/COV W/DL SYS LVL 19 $27,000.00 HC VASCULAR STENT, COAT/COV W/DL SYS LVL 22 $31,500.00 HC VASCULAR STENT, COAT/COV W/DL SYS LVL 24 $34,500.00 HC VASCULAR STENT, COAT/COV W/O DL SY LVL 1 $1,500.00 HC VASCULAR STENT, COAT/COV W/O DL SY LVL 2 $3,000.00 HC VASCULAR STENT, COAT/COV W/O DL SY LVL 3 $4,500.00 HC VASCULAR STENT, COAT/COV W/O DL SY LVL 5 $7,500.00 HC VASCULAR STENT, COAT/COV W/O DL SY LVL 6 $9,000.00 HC VASCULAR STENT, COAT/COV W/O DL SY LVL 7 $10,500.00 HC VASCULAR STENT, COAT/COV W/O DL SY LVL10 $15,000.00 HC VASCULAR STENT, COATCOV W/O DL SY LVL 4 $6,000.00 HC VASCULAR STENT, NO-COA/NO-COV W/DL LVL 1 $2,088.00 HC VASCULAR STENT, NO-COA/NO-COV W/DL LVL 2 $3,577.00 HC VASCULAR STENT, NO-COA/NO-COV W/DL LVL 3 $4,472.00 HC VASCULAR STENT, NO-COA/NO-COV W/DL LVL 4 $5,963.00 HC VASCULAR STENT, NO-COA/NO-COV W/DL LVL 5 $6,706.00 HC VASCULAR STENT, NO-COA/NO-COV W/DL LVL 6 $8,048.00 HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 1 $2,088.00 HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 2 $3,577.00 HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 3 $4,472.00 HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 4 $5,963.00 HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 5 $6,706.00 132 of 155 Procedure Price HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 6 $8,048.00 HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 7 $8,347.00 HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 8 $9,539.00 HC VASCULAR STENT, NO-COAT/COV W/O DL LVL17 $15,203.00 HC VASCULAR SUPPLIES GENERAL LVL 1 $835.00 HC VASCULAR SUPPLIES GENERAL LVL 2 $3,577.00 HC VASCULAR SUPPLIES GENERAL LVL 3 $6,558.00 HC VASCULAR SUPPLIES GENERAL LVL 4 $8,048.00 HC VASCULAR SUPPLIES GENERAL LVL 5 $10,732.00 HC VENA CAVA FILTER LVL 1 $2,088.00 HC VENA CAVA FILTER LVL 11 $11,030.00 HC VENA CAVA FILTER LVL 2 $3,577.00 HC VENA CAVA FILTER LVL 3 $4,472.00 HC VENA CAVA FILTER LVL 4 $5,963.00 HC VENA CAVA FILTER LVL 5 $6,706.00 HC VENA CAVA FILTER LVL 6 $8,048.00 HC VENA CAVA FILTER LVL 7 $8,347.00 HC VENA CAVA FILTER LVL 8 $9,539.00 HC VENIPUNCTURE AGE 3 YRS/> $30.00 HC VENOGRAM HEPATIC W/HEMO $5,884.00 HC VENOGRAM IVC W SERIALOGRAPHY $7,746.00 HC VENOUS SAMPLING - RENIN VEIN $5,154.00 HC VENT MGMT INPAT INIT DAY $2,267.00 HC VENT MGMT INPAT SUBQ DAY $1,507.00 HC VEP TEST CNS; CHECKERBD/FLASH $1,389.00 HC VERTEBROPLASTY INJECT EA ADDTL $7,658.00 HC VESSEL MAP FOR HEMODIALYSIS ACCESS $462.00 HC VISCERAL ANGIOGRAM SELECTIVE $7,746.00 HC VISUAL ACUITY SCREEN BILAT QUAN $62.00 HC VOICE CURRENT STATUS $0.01 HC VOICE D/C STATUS $0.01 HC VOICE GOAL STATUS $0.01 HC VOIDING URETHROCYSTOGRAM $858.00 HC WAIST BELT PADDED LINED BELOW KNEE LVL 1 $1,431.00 HC WAIST BELT PADDED LINED BELOW KNEE LVL 2 $2,861.00 HC WAIST BELT PADDED LINED BELOW KNEE LVL 3 $3,935.00 HC WAIST BELT PADDED LINED BELOW KNEE LVL 4 $5,247.00 133 of 155 Procedure Price HC WAIST BELT PADDED LINED BELOW KNEE LVL 5 $6,558.00 HC WAIST BELT PADDED LINED BELOW KNEE LVL 6 $6,440.00 HC WAIST BELT PADDED LINED BELOW KNEE LVL 7 $7,512.00 HC WAIST BELT PADDED LINED BELOW KNEE LVL 8 $8,585.00 HC WAIST BELT PADDED LINED BELOW KNEE LVL 9 $9,658.00 HC WEDGE EXC NAIL FOLD $501.00 HC WHEELCHAIR MNGMENT TRAINING EA 15M $207.00 HC WHFO - PREFAB WRIST COCK-UP LVL 1 $334.00 HC WHFO - PREFAB WRIST COCK-UP LVL 2 $501.00 HC WHFO - PREFAB WRIST COCK-UP LVL 3 $667.00 HC WHFO - PREFAB WRIST COCK-UP LVL 4 $835.00 HC WHFO - PREFAB WRIST COCK-UP LVL 5 $859.00 HC WHFO - PREFAB WRIST COCK-UP LVL 6 $1,001.00 HC WHFO - PREFAB WRIST COCK-UP LVL 7 $1,144.00 HC WHFO - PREFAB WRIST COCK-UP LVL 8 $1,289.00 HC WHFO - PREFAB WRIST COCK-UP LVL 9 $1,431.00 HC WHFO NONTORSION JOINT PREFAB LVL 1 $334.00 HC WHFO NONTORSION JOINT PREFAB LVL 2 $501.00 HC WHFO NONTORSION JOINT PREFAB LVL 3 $667.00 HC WHFO NONTORSION JOINT PREFAB LVL 4 $835.00 HC WHFO NONTORSION JOINT PREFAB LVL 5 $859.00 HC WHFO NONTORSION JOINT PREFAB LVL 6 $1,001.00 HC WHFO NONTORSION JOINT PREFAB LVL 7 $1,144.00 HC WHFO NONTORSION JOINT PREFAB LVL 8 $1,289.00 HC WHFO NONTORSION JOINT PREFAB LVL 9 $1,431.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 1 $334.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 2 $501.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 3 $667.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 4 $835.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 5 $859.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 6 $1,001.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 7 $1,144.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 8 $1,289.00 HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 9 $1,431.00 HC WHFO W/JOINT(S) CUSTOM FAB LVL 1 $1,431.00 HC WHFO W/JOINT(S) CUSTOM FAB LVL 2 $2,861.00 HC WHFO W/JOINT(S) CUSTOM FAB LVL 3 $3,935.00 134 of 155 Procedure Price HC WHFO W/JOINT(S) CUSTOM FAB LVL 4 $5,247.00 HC WHFO W/JOINT(S) CUSTOM FAB LVL 5 $6,558.00 HC WHFO, RIGID W/O JOINTS LVL 1 $1,431.00 HC WHFO, RIGID W/O JOINTS LVL 2 $2,861.00 HC WHFO, RIGID W/O JOINTS LVL 3 $3,935.00 HC WHFO, RIGID W/O JOINTS LVL 4 $5,247.00 HC WHFO, RIGID W/O JOINTS LVL 5 $6,558.00 HC WHO W/NONTORSION JNT(S) CF LVL 1 $1,431.00 HC WHO W/NONTORSION JNT(S) CF LVL 2 $2,861.00 HC WHO W/NONTORSION JNT(S) CF LVL 3 $3,935.00 HC WHO W/NONTORSION JNT(S) CF LVL 4 $5,247.00 HC WHO W/NONTORSION JNT(S) CF LVL 5 $6,558.00 HC WHO W/O JOINTS CF LVL 1 $1,431.00 HC WHO W/O JOINTS CF LVL 2 $2,861.00 HC WHO W/O JOINTS CF LVL 3 $3,935.00 HC WHO W/O JOINTS CF LVL 4 $5,247.00 HC WHO W/O JOINTS CF LVL 5 $6,558.00 HC WINDOWING OF CAST $260.00 HC WOC THERAPY/EDU IP 15 MIN $48.00 HC WORK HARDENING EA ADDTL HR $163.00 HC WORK HARDENING INIT 2 HRS $324.00 HC WOUND PREP F/N/HF/G 100 SQ CM/1% BA $813.00 HC WOUND PREP F/N/HF/G ADDTL 100 SQ CM/1% BA $437.00 HC WOUND PREP TRNK/ARM/LEG 100 SQ CM/1% BA $1,357.00 HC WOUND PREP TRNK/ARM/LEG ADDTL 100 SQ CM/1% BA $221.00 HC WOUND VAC SUPPLIES LVL 1 $716.00 HC WOUND VAC SUPPLIES LVL 10 $2,445.00 HC WOUND VAC SUPPLIES LVL 2 $954.00 HC WOUND VAC SUPPLIES LVL 3 $1,193.00 HC WOUND VAC SUPPLIES LVL 4 $1,371.00 HC WOUND VAC SUPPLIES LVL 5 $1,550.00 HC WOUND VAC SUPPLIES LVL 6 $1,729.00 HC WOUND VAC SUPPLIES LVL 7 $1,908.00 HC WOUND VAC SUPPLIES LVL 8 $2,088.00 HC WOUND VAC SUPPLIES LVL 9 $2,266.00 HC WRIST 2 VIEWS $457.00 HC WRIST ARTHROGRAM $993.00 135 of 155 Procedure Price HC WRIST COMPL MIN 3 VIEWS $569.00 HC XE133 XENON PER 10 MCI $927.00 HC XRAY CONSULTATION REFERRED $69.00 HC X-RAY EXAM ABDOMEN 1 VIEW $500.00 HC X-RAY EXAM ABDOMEN 2 VIEWS $586.00 HC X-RAY EXAM ABDOMEN 3+ VIEWS $636.00 HC X-RAY EXAM CHEST 1 VIEW $389.00 HC X-RAY EXAM CHEST 2 VIEWS $396.00 HC X-RAY EXAM CHEST 3 VIEWS $409.00 HC X-RAY EXAM CHEST 4+ VIEWS $450.00 HC X-RAY EXAM ENTIRE SPINE 1 VW $242.00 HC X-RAY EXAM ENTIRE SPINE 2/3 VW $402.00 HC X-RAY EXAM ENTIRE SPINE 4/5 VW $764.00 HC X-RAY EXAM HIP UNI 1 VIEW $242.00 HC X-RAY EXAM HIP UNI 2-3 VIEWS $242.00 HC X-RAY EXAM HIP UNI 4/> VIEWS $402.00 HC X-RAY EXAM HIPS BI 2 VIEWS $402.00 HC X-RAY EXAM HIPS BI 3-4 VIEWS $402.00 HC X-RAY EXAM HIPS BI 5/> VIEWS $764.00 HC X-RAY EXAM OF FEMUR 1 VW $242.00 HC X-RAY EXAM OF FEMUR 2/> VW $639.00 HCG PREGNANCY, URINE $63.80 HCG, PREG, INTACT, QUANT $205.40 HCG, TUMOR, BETA, QUANT $195.60 HELICOBACTER PYLORI A.B. IGG $175.00 HEMA PROGENITOR CELL PROCESS $2,072.50 HEMATOCRIT $52.30 HEMOCHR 3 MUT $393.60 HEMOGLOBIN $52.30 HEMOQUANT (TOTAL) $137.80 Hep b ig im $272.86 HEPARIN ANTI, XA LMWH $208.40 HEPARIN ASSOCIATED ANTIBODY $451.00 HEPARIN NEUTRALIZATION $32.90 HEPATITIS A AB, IGM $297.80 HEPATITIS A ANTIBODY, TOTAL $105.30 HEPATITIS B CORE AB, TOTAL $209.60 136 of 155 Procedure Price HEPATITIS B CORE ANTIBODY, IGM $297.80 HEPATITIS B DELTA ANTIBODY $164.40 HEPATITIS B SURFACE ANTIBODY $175.00 HEPATITIS B VIRUS BY QUANT PCR $360.00 HEPATITIS BE ANTIBODY $68.30 HEPATITIS BE ANTIGEN $55.50 HEPATITIS C ANTIBODY $158.00 HEPATITIS C VIRUS GENOTYPE BY PCR $805.70 HEPATITIS PANEL, ACUTE $582.20 Hepb vacc 3 dose ped/adol im $148.75 HETEROPHILE SCREEN (MONOSPOT) $107.00 HGB A1C (GLYCOHEMOGLOBIN) $172.60 HGB A2 & F BY COL $54.40 HGB F $54.40 HGH (HUMAN GROWTH HORMONE) $26.30 Hib prp-omp vacc 3 dose im $140.00 HIGH SENSITIVITY C, REACTIVE PROTE $131.40 HIST/CYTO CHEMICAL STNS, ENZYME $388.90 HISTAMINE, BLOOD $174.80 HISTO AG, URINE $208.40 HISTOCHEM STAN, OTHER THAN MICR $178.30 HISTOCHEMICAL STAINS, MICRO, ORG $218.80 HISTONE AB,IGG $68.30 Histoplasma Antigen Serum by EIA $152.50 HIV 1 AB, CONFIRM, WESTERN BLOT $82.20 HIV 1-2 AB/AG $262.50 HIV 2 AB $44.10 HIV ULTRASENSITIVE QNT BY PCR $282.40 HIV, RAPID SCREEN $144.70 HIV1 GENOTYPE BY SEQUECING $516.60 HLA FOR TRANSPLANTS $389.00 HLA, B27 $184.10 HLA-A GENOTYPE $185.20 HLA-B 5701 ABACAVIR $220.50 HLA-B GENOTYPE $185.20 Hocm <=149 mg/ml iodine 1ml $0.66 Hocm 250-299mg/ml iodine1ml $2.33 137 of 155 Procedure Price HOMOCYSTEINE, QUANT (PLASMA) $204.20 HPV GENOTYPE BY PCR $430.00 HSV (HERPES SIMPLEX VIRUS) CULTURE $91.10 HSV 1, GLYCO G AB $44.10 HSV 2, GLYCO G AB $44.10 HSV BY PCR $185.20 HSV IGM I/II COMBINED $86.80 HTLV, 1 $130.80 Humate-p inj $2.32 Hyaluronidase recombinant $1.33 Hydralazine hcl injection $172.45 Hydrocortisone sodium succ i $116.90 Hydromorphone injection $113.90 Hydroxyzine hcl injection $108.90 Hydroxyzine pamoate 25mg $1.30 Ibandronate sodium injection $380.77 IBD PROFILE $166.70 IBUPROFEN $156.20 Idarubicin hcl injection $193.95 Ifosfamide injection $105.49 IGD $27.80 IGG SUB (1,2,3,4) $104.30 Iiv no prsv increased ag im $91.00 Iiv4 vacc no prsv 0.5 ml im $123.45 IMMEDIATE CYTOHISTOLOGIC STUDY $231.50 IMMUNE COMPLEX (C1, Q, BIND) $252.30 IMMUNE COMPLEX PROFILE $504.60 IMMUNOFIXATION ELECTROPHORESIS $247.90 IMMUNOFIXATION, URINE $247.90 IMMUNOFLOUR EA ADDL SINGLE AB STAIN PROCEDURE $250.40 IMMUNOGLOBULIN A $155.60 IMMUNOGLOBULIN E (IGE) $170.10 IMMUNOGLOBULIN G $155.60 IMMUNOGLOBULIN M $155.60 IMMUNOHISTOCHEM 1ST SINGLE OR MULTI AB STAIN $109.40 IMMUNOHISTOCHEM EA ADDITIONAL AB $285.70 IMMUNOHISTOCHEM EACH AB $285.70 138 of 155 Procedure Price IMMUNOHISTOCHEM EACH ADD SINGLE OR MULTI AB STAIN $97.20 IMMUNOHISTOCHEMISTRY, EA AB $331.10 IN SITU HYBRIDIZATION, INITIAL PROBE, GLOBAL $285.70 IN SITU HYBRIDIZATION, PER SPEC, INITIAL PROBE $285.70 INDICANS, URINE $67.10 INDIRECT COOMBS $145.80 INFEC AGT-DNA/RNA,PAPILLOMAVIRUS $283.20 INFLIXIMAB HACA $413.30 Infliximab not biosimil 10mg $237.94 INFLUENZA ABS,IGG,IGM $162.00 INHIBIN A $43.10 INHIBIN B $140.20 Inj benztropine mesylate $147.50 Inj calcitriol per 0.1 mcg $19.01 Inj ceftazidime per 500 mg $49.60 Inj ceftolozane tazobactam $14.92 Inj desmopressin acetate $120.55 Inj dihydroergotamine mesylt $2,441.05 Inj dobutamine hcl/250 mg $78.75 Inj enoxaparin sodium $58.63 Inj estrogen conjugate 25 mg $681.10 Inj ferric carboxymaltos 1mg $2.69 Inj filgrastim excl biosimil $2.39 Inj heparin sodium per 10 u $87.65 Inj heparin sodium per 1000u $88.25 Inj iron dextran $8.03 Inj levocarnitine per 1 gm $103.38 Inj magnesium sulfate $89.05 Inj melphalan hydrochl 50 mg $3,687.60 Inj midazolam hydrochloride $88.65 Inj milrinone lactate / 5 mg $36.33 Inj morphine pf epid ithc $90.55 Inj multihance $29.36 Inj nalbuphine hydrochloride $111.50 Inj naloxone hydrochloride $163.45 Inj pembrolizumab $88.79 Inj perflutren lip micros ml $214.00 139 of 155 Procedure Price Inj potassium chloride $87.95 Inj propofol 10 mg $44.35 Inj protamine sulfate/10 mg $90.45 Inj tbo filgrastim 1 microg $1.96 Inj testosterone cypionate $1.08 Injection clindamycin phosp $122.40 Injection famotidine 20 mg $89.30 Injection inflectra $32.76 Injection lacosamide $2.46 Injection metronidazole $92.10 Injection ocrelizumab 1 mg $108.63 Injection onabotulinumtoxina $13.77 Injection pegfilgrastim 6mg $12,549.65 Injection vedolizumab $40.06 Injection voriconazole $17.94 INSULIN ANTIBODIES (RIA) $332.20 INSULIN FASTING $122.90 Insulin injection $6.00 Insulin long acting 5 u $2.50 Insulin most rapid 5 u $311.05 INSULIN RANDOM $122.90 Interferon alfa-2b inj $56.75 INTRINSIC FACTOR ANTIBODY $76.40 IODINE 24 HR URINE $275.50 IODINE, SERUM $108.10 IONIZED CALCIUM $182.40 Ipratropium bromide non-comp $1.55 IRON $102.10 Iron sucrose injection $1.84 IRON, URINE $264.00 IRRAD LEUKORED CMV DIST CHG $847.10 IRRAD LEUKORED CMV PLTPH DIST CHG $1,769.80 ISLET AB $142.40 ITRACONAZOLE, QT $94.90 JAK2 (V617F) MUTATION $376.20 JO-1 AB, IGG $48.50 Kcentra per i.u. $3.88 140 of 155 Procedure Price KETONES , URINE $49.80 Ketorolac tromethamine inj $92.50 KOH PREP, TISSUE/SCABIES $86.30 L/S RATIO, AMNIOTIC FLUID $418.20 LACOSAMIDE, BLOOD $157.50 LACTIC ACID (LACTATE) $144.70 LACTIC ACID, CSF $144.70 LAMELLAR BODY COUNT AMNIOTIC FLUID $116.70 LAMOTRIGINE $156.20 LANOXIN (DIGOXIN) $204.20 LDH (LACTIC DEHYDROGENASE) $64.40 LDH, CSF $64.40 LDH, FLUID $64.40 LDL CHOLESTEROL DIRECT MEAS $97.20 LEAD, CAPILLARY $82.20 LEAD, WHOLE BLOOD $82.20 LEGIONELLA AB SCREEN $79.90 LEGIONELLA AG, URINE $128.80 LEGIONELLA PNEUMOPHILIA AG, DFA $273.50 Leucovorin calcium injection $369.00 LEUKOCYTE ALK PHOS (LAP) $150.70 Leuprolide acetate /3.75 mg $2,676.50 Leuprolide acetate suspnsion $2,889.02 Levalbuterol non-comp unit $3.85 LEVEL I SURG PATH,GROSS EXAM ONLY $98.50 LEVEL II, SP GROSS & MICRO $250.40 LEVEL III, SP GROSS & MICRO $297.80 LEVEL IV, SP GROSS & MICRO $335.50 LEVEL V, SP GROSS & MICRO $472.80 LEVEL VI, SP GROSS & MICRO $781.50 LEVETIRACETAM (KEPPRA) $156.20 Levetiracetam injection $3.92 Levofloxacin injection $101.90 LH (LUTEINIZING HORMONE) $195.70 Lidocaine injection $9.55 LIDOCAINE, PLASMA $189.60 Linezolid injection $82.57 141 of 155 Procedure Price LIPASE, SERUM $180.00 LIPID PANEL $244.30 LIPOPROFILE BY NMR $171.40 LIPOPROTEIN (A) $125.10 LIPOPROTEIN ELECTROPHORESIS $470.00 LIQUID BASED PAP SMEAR $132.50 LITHIUM $172.60 LIVER FUNCTION PANEL $180.00 LK M-1, IGG $27.80 LKM AB, IGG $27.80 Locm 200-299mg/ml iodine 1ml $13.23 Locm 300-399mg/ml iodine 1ml $17.28 Lorazepam injection $91.00 LYME AB TOTAL W/REFLEX $15.80 LYME ANTIBODY, CSF $148.20 LYME DISEASE ANTIBODY WB $75.30 LYMPHOCYTE SUBSET PANEL 4 $145.80 LYSOZYME $23.20 MAG ANTIBODY $257.00 MAGNESIUM $126.40 MAGNESIUM (OBSTET. USE ONLY) $126.40 MAGNESIUM, RBC $85.70 MAGNESIUM, URINE $148.30 MALARIA SMEAR $137.30 MANGANESE $42.80 Mannitol injection $91.90 MATERNAL SCREEN, AFP ONLY $27.80 Mcv4 menacwy vaccine im $320.10 MEASLES (RUBEOLA) AB, IGG $16.20 MEASLES (RUBEOLA) IGG $97.00 MEBARAL (MEPHOBARBITAL) $142.40 MECONIUM TOX PANEL $196.90 Medroxyprogesterone acetate $1.67 Meperidine hydrochl /100 mg $112.10 MERCURY, BLOOD $104.20 MERCURY, URINE $104.20 Meropenem $21.50 142 of 155 Procedure Price Mesna injection $123.00 METANEPHRINES FRACT, URINE $144.70 METANEPHRINES, PLASMA FREE $188.70 Methacholine chloride neb $15.00 METHANOL $527.50 METHEMOGLOBIN $282.00 METHOTREXATE $156.20 Methotrexate oral 2.5 mg $6.38 Methotrexate sodium inj $356.85 METHSUXIMDE (CELONTIN) $132.00 METHYL MALONIC ACID, QUANT $414.40 Methylergonovin maleate inj $136.90 Methylnaltrexone injection $4.74 Methylprednisolone 40 mg inj $110.65 Methylprednisolone 80 mg inj $127.65 Methylprednisolone injection $108.70 Methylprednisolone oral $5.60 Metoclopramide hcl injection $94.20 MEXILETINE (MEXITIL) $156.20 Micafungin sodium injection $4.62 MICROALBUMIN , URINE QUANT $117.80 Mirena 52 mg $1,010.40 Misoprostol oral 200 mcg $2.18 Mitomycin injection $422.05 MMA, URINE QNT $54.40 Mmr vaccine sc $229.35 MNDA RECEPTOR AB W/REFLEX $220.70 Morphine sulfate injection $108.55 MORPHOMETRIC ANALYSIS, TUMOR IMMU $427.90 MRSA BY PCR $182.00 MSS, INTEGR, #1 $97.20 MSS, INTEGR, #2 $326.40 MTHFR MUTATION $749.00 MUCOPOLYSACCARIDES $413.30 MULLERIAN HORMONE AB $111.80 MULTIPLEX AB STAIN PROCEDURE, EACH $857.90 MULTIPLEX AB, STAIN, EA, GLOBAL BILL $907.60 143 of 155 Procedure Price MUMPS VIRUS ANTIBODY, IGG $97.00 MUMPS VIRUS ANTIBODY, IGM $97.20 MURAMIDASE (LYSOZYME) $94.90 MUSCLE-SPECIFIC RECEPTOR (MuSK) AB $1,502.50 Mycophenolate mofetil oral $1.50 Mycophenolic acid $156.20 MYCOPLASMA PNEUMO IGG,IGM $234.00 MYELIN BASIC PROTEIN $138.90 MYLOPEROXIDASE IGG $44.10 MYOGLOBIN , SERUM (QUANT) $149.50 MYOGLOBIN, URINE $157.00 Natalizumab injection $41.49 NEISSERIA GONORRHOEAS BY LCR $176.30 Neostigmine methylslfte inj $97.85 NEURON, SPECIFIC ENOLASE $373.90 NEURONAL NUCLEAR ANTIBODY $218.80 NEUTRO-ASSOC AB $112.50 NEUTROPHIL CYTOPLASMIC AB $46.80 NIACIN $195.60 NICOTINE AND METABOLIES, BLOOD $77.70 NICOTINE AND METABOLITES, URINE $75.50 Nicotine patch nonlegend $3.55 NON, ESTERIFIED FATTY ACID $189.80 NON, GYN CYT, OTHER THAN UA & SP $207.30 Non-covered item or service $5,061.15 Non-heu tc-99m add-on/dose $25.00 Normal saline solution infus $156.00 NORTRIPTYLINE $93.80 NT pro BNP $211.50 N-TELO X, URINE $54.40 Nushield 1 square cm $824.00 O2 SATURATION % $107.00 Oasis wound matrix $24.00 OBSTETRIC PANEL $164.00 Octreotide inj non-depot $48.73 Omalizumab injection $73.77 Ondansetron hcl injection $88.05 144 of 155 Procedure Price OR CONSULTATION , FS $445.70 OR CONSULTATION, WITHOUT FS $194.50 OR CONSULTATION,EA ADD FS $223.40 Oral dexamethasone $0.63 ORGANIC ACIDS, URINE $221.10 Orphenadrine injection $119.25 OSMOLALITY , SERUM $137.30 OSMOLALITY , URINE $137.30 OXALATE, 24 HOUR, URINE $96.10 OXCARBAZEPINE $156.20 Oxytocin injection $90.50 Paclitaxel injection $1.78 PAIN MGMT DRUG PANEL $363.80 Paliperidone palmitate inj $21.94 Palonosetron hcl $99.35 Pamidronate disodium /30 mg $71.38 PANCREATIC ELASTASE, FECAL $224.60 Papaverin hcl injection $156.20 PAPILLOMAVIRUS,HMN,AMP PROB TECH $269.70 PARAINFLUENZA 1, 2, 3 $1,083.60 PARATHYROID HORMONE RELATED PEPTIDE $346.10 PARVOVIRUS B, 19, IGG/IGM $328.80 PATH CONSULT DURING SURG W/SEC AD $183.50 PATH CONSULT DURING SURG W/SECTIO $365.90 PATH CONSULT DURING SURGERY $148.30 Pcv13 vaccine im $308.00 Penicillin g benzathine inj $37.58 Penicillin g potassium inj $90.30 Pentamidine non-comp unit $201.30 Perphenazine 4mg oral $2.30 PH , BLOOD $77.80 PH , BODY FLUIDS $77.80 PH , URINE $49.80 Phenobarbital $199.30 Phenobarbital sodium inj $9.22 Phentolaine mesylate inj $937.50 Phenylephrine hcl injection $111.50 145 of 155 Procedure Price Phenytoin sodium injection $44.90 PHOSPHATIDYGLYCEROL LATEX AGGL $421.80 PHOSPHORUS , SERUM $64.40 PHOSPHORUS , URINE , 24 HOUR $100.90 PHOSPHORUS , URINE , RANDOM $64.40 PINWORM EXAM $48.60 Piperacillin/tazobactam $53.00 PLASMA HEMOGLOBIN $164.00 PLASMIN ACT INHIB $97.20 PLATELET ANTIBODY $429.50 PLATELET ASSOCIATED AB $171.30 PLATELET ASSOCIATED ANTIBODIES $342.60 PLATELET COUNT $85.20 Plerixafor injection $641.13 PML/RAR ALPHA $591.60 PNH PROF, WBC $729.00 POC CA++ $137.30 POC CREATININE $71.70 POC GLUCOSE $49.90 POC LACTATE $137.30 POC POTASSIUM $64.40 POLIO VIRUS 1, 3 $222.30 PORPHOBILINOGEN (QUANT) $112.20 PORPHYRINS , URINE (QUANT) $162.00 PORPHYRINS,PLASMA $30.50 POTASSIUM $64.40 POTASSIUM , URINE $64.40 POTASSIUM URINE, 24HR $64.40 Ppsv23 vacc 2 yrs+ subq/im $276.55 PR APPLY MULTLAY COMPRESS LOWER LEG $220.00 PR APPLY RIGID TOTAL CONTACT LEG CAST $441.00 PR BEHAV CHNG SMOKING > 10 MIN $113.00 PR BX BONE TROCAR NDL SUPERFICIAL $336.00 PR BX SKIN SQ/MM EA ADDTL LESION $159.00 PR BX-SKIN SQ/MM SGL $188.00 PR CHEM CAUT GRANULATION TISS $142.00 PR DEB BONE ADD-ON $259.00 146 of 155 Procedure Price PR DEB MUSC/FASCIA ADD-ON $149.00 PR DEB SUBQ TISSUE 20 SQ CM/< $660.00 PR DEB SUBQ TISSUE ADD-ON $70.00 PR DEBR MUSC/FASCIA 20 SQ CM/< $1,226.00 PR DEBRIDE BONE 20 SQ CM/< $1,405.00 PR DEBRIDE NAILS 1-5 $76.00 PR DEBRIDE NAILS 6/> $106.00 PR DRAIN FINGER ABSC SIMPLE $275.00 PR DRESS/DEBRID P-THICK BURN LARGE >10% $581.00 PR DRESS/DEBRID P-THICK BURN M $481.00 PR DRESS/DEBRID P-THICK BURN S $245.00 PR EXC BEN LES T/A/L > 4.0 CM $666.00 PR EXC BENIGN LESION T/A/L 0.5 CM/< $260.00 PR HOSP DC DAY MANAGEMENT > 30 MIN (MD) $324.00 PR HOSP DC DAY MANAGEMENT 30 MIN/< (MD) $156.00 PR I&D ABSC COMPL OR MULTI $543.00 PR I&D ABSC SMPL OR SGL $357.00 PR I&D HEMATOMA/FLUID $542.00 PR I&D PERIRECTAL OR ISCHIAL ABSCESS $2,127.00 PR INC & REM FB SQ SMPL $420.00 PR INITIAL HOSPITAL CARE LVL 1 $300.00 PR INITIAL HOSPITAL CARE LVL 2 $409.00 PR INITIAL HOSPITAL CARE LVL 3 $600.00 PR INPATIENT CONSULT LVL 1 $199.00 PR INPATIENT CONSULT LVL 2 $211.00 PR INPATIENT CONSULT LVL 3 $320.00 PR INPATIENT CONSULT LVL 4 $459.00 PR INPATIENT CONSULT LVL 5 $565.00 PR MD HBO THERAPY PER SESSION $452.00 PR NEG PRESS WOUND TX >50 CM $168.00 PR NEG PRESSURE WOUND TX $156.00 PR OP VISIT EST PT LEVEL 1 $89.00 PR OP VISIT EST PT LEVEL 2 $130.00 PR OP VISIT EST PT LEVEL 3 $184.00 PR OP VISIT EST PT LEVEL 4 $272.00 PR OP VISIT EST PT LEVEL 5 $341.00 PR OP VISIT NEW PT LEVEL 1 $104.00 147 of 155 Procedure Price PR OP VISIT NEW PT LEVEL 2 $181.00 PR OP VISIT NEW PT LEVEL 3 $273.00 PR OP VISIT NEW PT LEVEL 4 $347.00 PR OP VISIT NEW PT LEVEL 5 $444.00 PR OPEN SUPERF BONE BX $1,007.00 PR PARE BENIGN LESION 2 TO 4 $106.00 PR PARE BENIGN LESION SGL $82.00 PR PUNCT ASP ABSC HEMATOMA CYST $357.00 PR REMOVAL IMPACTED CERUMEN/EARWAX $104.00 PR REMOVL OF NAIL BED $453.00 PR SKIN SUB GRAFT T/A/L 25 SQ CM $285.00 PR SKIN SUB GRAFT T/A/L ADD 25 SQ CM $56.00 PR SKIN SUB GRFT F/NK/HF/G 25 SQ CM $333.00 PR SKIN SUB GRFT F/NK/HF/G ADD 25 SQ CM $80.00 PR SKIN SUB GRFT T/A/L CH ADD 100 SQ CM $143.00 PR SKIN SUB GRFT T/A/L CHILD 100 SQ CM $682.00 PR SKN SUB GRFT F/NK/HF/G CH ADD 100 SQ CM $177.00 PR SKN SUB GRFT F/NK/HF/G CHILD 100 SQ CM $705.00 PR SLCTV WND DEBRIDEM >20 CM $135.00 PR SLCTV WND DEBRIDEM 20 CM OR < $105.00 PR SMOKE/TOBACCO COUNSELING 3-10 MIN $60.00 PR SMPL AVULSE NP SGL $151.00 PR SPL AVULSE NP EA ADDTL $98.00 PR SREP S/N/A/G/TR/E 2.6-7.5 CM $444.00 PR STRAPPING UNNA BOOT $195.00 PR SUBQ HOSPITAL CARE LVL 1 $124.00 PR SUBQ HOSPITAL CARE LVL 2 $221.00 PR SUBQ HOSPITAL CARE LVL 3 $319.00 PR TRIM ND NAILS $69.00 PR TRIM SKIN LESIONS OVER 4 $181.00 PR UPR/L XTREMITY ART 2 LEVELS $152.00 PR UPR/L XTREMITY ART STDY 3+ LEVELS $251.00 PREALBUMIN $204.20 Prednisolone oral per 5 mg $1.20 Prednisone ir or dr oral 1mg $1.05 PREGNENOLONE $70.70 PROCAINAMIDE (PRONESTY) NAPA $147.00 148 of 155 Procedure Price PROCALCITONIN $131.40 Prochlorperazine injection $124.50 PROGESTERONE (RIA) $232.20 PROLACTIN $232.20 Promethazine hcl injection $90.15 Propranolol injection $103.50 PROST SPECIFIC ANTGN DIAGNOSTIC $213.90 PROST SPECIFIC ANTGN SCREENING $172.60 PROT C, FUNCTIONAL $70.70 PROT S FREE, AG $111.10 PROT S, FUNCTIONAL $70.70 PROTEIN , FLUID $64.40 PROTEIN C TOTAL $200.20 PROTEIN S , TOTAL $204.90 PROTEIN, TOTAL $64.40 PROTEIN, URINE, 24 HOUR $100.90 PROTEINASE 3 IGG $44.10 PROTHROMBIN GENE MUTATION $138.40 PROTHROMBIN LEVEL (PT) $83.90 PROTOPORPHYRIN, ZINC $137.80 PROTRIPTYLINE (VIVACTYL) $156.20 PSEUDOCHOLINESTERASE $131.40 PTH INTEROPERATIVE $417.00 Puraply or puraply am $371.00 PYRUVATE KINASE $76.80 PYRUVIC ACID $85.70 QUAD MARKER $326.40 QUANTIFERON TB GOLD $151.60 QUINIDINE $118.10 RABIES AB,IGG $180.60 Rabies ig heat treated $641.11 Rabies ig im/sc $895.90 Rabies vaccine im $766.30 RAJI CELL ASSAY $252.30 RAPID BETA STREP SCREEN GRP A $127.70 RAPID INFLUENZAE A/B AG $193.30 Rasburicase $582.62 149 of 155 Procedure Price RBC CHOLINESTERASE $82.20 RBC FOLATE $262.50 RBC PHENOTYPE $119.10 RED BLOOD COUNT $47.40 REDPATH AMYLASE $18.20 REDPATH CEA $52.30 Regadenoson injection $143.36 RENAL FUNCTION PANEL $215.10 RENIN $97.20 RETICULOCYTE COUNT $42.50 RH TYPE $80.20 RHEUMATOID FACTOR, QUANT $96.10 Rho d immune globulin inj $456.80 Rhophylac injection $27.22 RIBOSOMAL P $48.50 Ringers lactate infusion $60.00 Risperidone long acting $19.89 RISTOCETIN COFACTOR $68.10 RISTOCETIN COFACTOR (VON WILL) $201.40 Rituximab injection $2,000.40 RNP ANTIBODY $48.50 Ropivacaine hcl injection $2.64 ROUTINE VENIPUNCTURE $32.90 RPR REVERSE W/TITER $9.50 RPR TITER $39.00 RSV (RESP SYNCYTIAL VIRUS) AG $175.00 RUBELLA , IGM $24.30 RUBELLA IGG $24.30 S PNEUMO, IGG (14) $97.20 S-100B PROTEIN $275.50 SALICYLATES (BLOOD) $205.40 Sargramostim injection $108.29 SCHISTOSOMA AB $111.10 SCL-70 (SCLERODERMA) ANTIBODY $48.50 SEDIMENTATION RATE (ESR) $104.50 SELENIUM, BLOOD $93.80 SEROTONIN , BLOOD $192.20 150 of 155 Procedure Price SEROTONIN RELEASE ASSAY HEPARIN DEPEN PLATELET AB $578.90 SEX CHROMATIN IDENT, BARR BODIES $175.00 SEX HORMONE BINDING GLOBULIN $35.30 SGOT (AST) $64.40 SGPT (ALT) $64.40 SICKLE CELL SCREEN $82.70 Sincalide injection $289.85 SINGLE AB STAIN PROC, EA ADD, GLOBALBILL $312.60 SINGLE AB STAIN PROCEDURE, EA ADDITIONAL $285.70 SINGLE PROBE STAIN EA, ADD, GLOBAL BILL $319.50 SINGLE PROBE STAIN, EA ADDITIONAL $285.70 SIROLIMUS $171.40 Sirolimus oral $36.30 SMA AB IGG $224.60 SMEARS , CELLS $96.10 SMITH ANTIBODY $48.50 SMITH RNP $48.50 SMOOTH MUSCLE AB TITER $54.60 SODIUM , SERUM $64.40 SOL TRANS RECP $42.80 SOMATOMEDIN, C $137.80 SP LEVEL 1 , GROSS ONLY $104.20 SP LEVEL 2 , NON SKIN $259.40 SP LEVEL 3 , NON SKIN $312.60 SP LEVEL 4 , NON, SKIN $384.30 SP LEVEL 5 $580.00 SP LEVEL 6 $970.10 SPECIAL STAIN, GROUP 1 FOR MICROOR $184.80 SPECIAL STAINS, GROUP II $162.90 SPECIFIC GRAVITY , FLUIDS $41.00 SPERM AB, IGG & IGA $166.70 SS-A $48.50 SSA & SSB ABS, IGG $97.00 SS-B $48.50 STONE ANALYSIS $96.10 STOOL , REDUCING SUBSTANCE $17.90 STOOL FILM ARRAY BY PCR (BIOFIRE) $926.10 151 of 155 Procedure Price STREP B DNA PROBE AMPLIFICATION $196.80 STREP PNEUMONIA AG, URINE $128.80 STREPTOZYME SCREEN W/REFLEX TO TI $93.80 STRIATED MUSCLE AB $22.60 Succinycholine chloride inj $91.35 Sumatriptan succinate / 6 mg $223.80 T PALLIDUM AB BY TP-PA $22.10 T3 (UPTAKE) $45.10 T3 TOTAL $121.60 T3, FREE $222.50 T4 (THYROXINE , TOTAL) $102.10 T4 FREE' $198.10 TACROLIMUS $168.00 Tacrolimus imme rel oral 1mg $8.20 Td vacc no presv 7 yrs+ im $153.30 Tdap vaccine 7 yrs/> im $176.00 TEGRETOL (CARBAMAZEPINE) $186.00 TEICHOIC ACID ANTIBODY $99.50 Temozolomide $4.96 Terbutaline sulfate inj $123.50 TESTOSTERONE, FREE $81.10 TESTOSTERONE, TOTAL $226.20 TETANUS AB,IGG $141.20 Tetanus immune globulin inj $1,083.60 THEOPHYLLINE , SERUM (AMINOPHYL) $220.10 Theraskin $117.00 Thiamine hcl 100 mg $97.45 THIN PREP IMAGING DIRECTED SCREENING $119.10 THIOCYANATE $202.50 THIOPURINE METABOLITE $413.30 THYROGLOBULIN ANTIBODY $92.40 THYROID PEROXIDASE ANTIBODY $92.40 THYROID STIM IG $125.10 Thyrotropin injection $1,622.25 THYROXINE, BINDING GLOBULIN $82.20 TIMED URINE AMYLASE $159.20 TISSUE TRANSGLUTAMINASE, IGA $44.10 152 of 155 Procedure Price TISSUE TRANSGLUTAMINASE, IGG $44.10 TOBRAMYCIN (NEBCIN) POST, DOSE $205.40 TOBRAMYCIN (NEBCIN) PRE, DOSE $205.40 TOBRAMYCIN RANDOM $205.40 Tobramycin sulfate injection $34.82 Tocilizumab injection $113.75 TOPIRAMATE $120.40 TOTAL , ACID PHOSPHATASE $50.90 TOTAL COMPLEMENT $120.40 TOTAL IRON BINDING CAPACITY $102.10 TOUCH SMEAR CYTO PREP & EVAL $184.10 TOUCH SMEAR, PATH CONSULT,EACH AD $64.40 TOUCH SMEAR, PATH CONSULT,FIRST S $83.90 TOX CONFIRMATION BY GC/MS $264.90 TOXICOLOGY SCREEN, CORD BLOOD $263.00 TOXOPLASMA GONDI IGG $38.60 TPMT GENETICS $709.60 TRANSFERRIN $212.60 TRANSFUSION REACTION CULTURE $175.00 TRANSFUSION REACTION WORKUP $141.00 Triamcinolone acet inj nos $30.00 TRICHOMONAS , URINE $111.10 TRICHROME STAIN $116.70 TRICYCLIC ANTIDEPRESSANT ID $171.40 TRIGLYCERIDES $102.10 TRIGLYCERIDES, FLUID $64.40 Trimethobenzamide hcl 250mg $1.30 Trimethobenzamide hcl inj $157.65 TRIODOTHYRONINE T3, REVERSE $115.80 TRIPLE MARKER $288.20 TROPONIN I, QUANTITATIVE $211.50 TRYPTASE $208.40 TSH (THYROID STIM. HORMONE) $199.30 TSH RECEPTOR AB $52.90 TULAREMIA ANTIBODY $40.50 UREA , URINE , 24 HOUR $100.90 UREA , URINE , RANDOM $64.40 153 of 155 Procedure Price UREA NITROGEN, BODY FLUID $59.50 URIC ACID , SERUM $64.40 URIC ACID , URINE , 24 HOUR $100.90 URIC ACID , URINE , RANDOM $64.40 URINALYSIS W/REFLEX MICROSCOPIC $49.80 URINE , GLUCOSE $49.80 URINE , LEAD $98.40 URINE , SODIUM $64.40 URINE PROTEIN , RANDOM $90.00 URINE, DIP AND MICRO $68.90 URINE, PROTEIN $49.80 URINE, SODIUM, 24HR $64.40 UROPORPHYRINOGEN, 1, SYNTHASE $363.50 Ustekinumab sub cu inj 1 mg $425.88 V ZOSTER BY PCR $441.10 V ZOSTER, IGG $33.60 VALPROIC ACID (VALPROATE) $186.00 VANCOMYCIN (POST, DOSE) $289.30 VANCOMYCIN (PRE, DOSE) $289.30 Vancomycin hcl injection $103.60 VANCOMYCIN RANDOM $289.30 VAP CHOLES $85.70 VARICELLA ZOSTER AB, IGG $33.10 VASC ENDOTH GF $171.30 VASOACTIVE INHIB. POLYPEPTIDE $275.50 VENOUS BG $282.00 Vinblastine sulfate inj $40.00 Vincristine sulfate 1 mg inj $375.75 VIRUS CULTURE, NON-RESPIRATORY $73.50 VIRUS CULTURE, RESPIRATORY $121.30 VIRUS TISS CUL ADDL STD/ID EA ISOLATE $33.60 VISCOSITY, SERUM $164.40 Visualization adjunct $37.13 VIT B2, RIBOFLAVIN $275.50 VIT D, 25 HY, 2 & 3 $70.70 VIT K1 $111.10 VITAMIN A $107.60 154 of 155 Procedure Price VITAMIN B, 12 $220.10 VITAMIN B, 12 BINDING CAP $82.20 VITAMIN B, 6 $173.70 VITAMIN B1, THIAMINE $130.80 Vitamin b12 injection $101.50 VITAMIN D,1,25 DIHYDROXY $162.00 VITAMIN D,25, HYDROXY $260.20 VITAMIN E $107.60 Vitamin k phytonadione inj $132.50 VOLATILE SCREEN $527.50 VOLATILES $527.50 VOLT-GATED CHANNEL AB $324.20 VONWILLEBRAND FAC COLL BINDING $272.50 WASHED RBC LR IRRADIATED $753.70 WHITE BLOOD COUNT $71.70 YEAST IDENTIFICATION $175.00 Zika Virus by PCR, Blood $236.30 Zika Virus by PCR, Urine $236.30 ZINC, BLOOD $74.10 Ziprasidone mesylate $137.20 Zoledronic acid 1mg $451.02 ZONISAMIDE $156.20

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