Bristol Bay Area Health Corporation Chargemaster As of: 12/20/2018

Section 2718(e) of the Public Health Service Act, which was enacted as part of the Affordable Care Act, requires that each hospital operating within the United States, for each year, to make public a list of the hospital’s standard charges for items and services provided by the hospital. The following list fulfill this requirement.

Physician Hospital Village Description # Charge Charge Charge 1 1 cc sterile syringe&needle - 4.00 4.00 2 1 pc ost pou w built-in conv 34.00 34.00 3 1 pc ost pouch w filter 19.00 19.00 4 100 insulin syringes - 102.00 102.00 5 12-24hr sealed lead acid 102.00 102.00 6 1pc ost pch drain hgh output 25.00 25.00 7 1ST PSYC COLLAB CARE MGMT 216.00 - 8 1ST/SBSQ PSYC COLLAB CARE 98.00 - 9 2 pc drainable ost pouch 25.00 25.00 10 20+ cc syringe only 9.00 9.00 11 22nf nonsealed leadacid 367.00 367.00 12 22nf sealed leadacid battery 390.00 390.00 13 2VHPV VACCINE 3 DOSE IM 130.00 14 3 cc sterile syringe&needle - 4.00 4.00 15 3-D RADIOTHERAPY PLAN 2,806.00 - 16 3D RENDER W/INTRP POSTPROCES 158.00 - 17 3D RENDER W/INTRP POSTPROCES 180.00 - 18 4VHPV VACCINE 3 DOSE IM - 163.00 163.00 19 5% dextrose and 0.45% saline 2.00 2.00 20 5% dextrose/normal saline - 5.00 5.00 21 5% dextrose/water - 5.00 5.00 22 5+ cc sterile syringe&needle 5.00 5.00 23 9VHPV VACCINE 2/3 DOSE IM - 130.00 130.00 24 A/d tx program, per hour 72.00 72.00 25 Abatacept injection 67.00 67.00 26 ABD PARACENTESIS 733.00 2,550.00 733.00 27 Abdominal pad 316.00 316.00 28 Abduct control hip semi-flex 493.00 493.00 29 Abduct rotation bar w/o shoe 204.00 204.00 30 Abduction bar jointed adjust 977.00 977.00 31 Abduction bar-straight 518.00 518.00 32 Abduction rotation bar shoe 223.00 223.00 33 ABLATE INF TURBINATE SUPERF 655.00 3,780.00 655.00 34 Abobotulinumtoxina 24.00 24.00 35 Above knee surgical stocking - 27.00 27.00 36 ABRASION LESION SINGLE 833.00 624.00 833.00 37 ABSCESS DRAINAGE UNDER X-RAY 248.00 - 38 ABSCESS IMAGING LTD AREA 1,432.00 - 39 ABSCESS IMAGING WHOLE BODY 1,432.00 - 40 Absorpt drg <=16 sq in w/bdr - 3.00 3.00 41 Absorpt drg <=16 sq in w/o b 9.00 9.00 42 Absorpt drg > 48 sq in w/o b 9.00 9.00 43 Absorpt drg >16 <=48 w/o bdr - 15.00 15.00 44 Absorpt drg >16<=48 in w/bdr 14.00 14.00 45 Acetaminophen injection 2.00 2.00 46 Acetazolamid sodium injectio 85.00 85.00 47 ACETONE ASSAY 86.00 86.00 48 ACETYLCHOLINESTERASE ASSAY 44.00 - 49 Acetylcysteine injection 11.00 11.00 50 Acetylcysteine non-comp unit 5.00 5.00 51 ACNE SURGERY 231.00 624.00 - 52 ACOUSTIC IMMITANCE TESTING 104.00 236.00 - 53 ACOUSTIC REFL THRESHOLD TST 77.00 88.00 77.00 54 ACTH STIMULATION PANEL 128.00 - 55 ACTH STIMULATION PANEL 307.00 - 56 ACTH STIMULATION PANEL 341.00 - 57 ACUPUNCT W/O STIMUL 15 MIN 106.00 - Physician Hospital Village Description # Charge Charge Charge 58 ACUPUNCT W/O STIMUL ADDL 15M 88.00 - 59 ACUPUNCT W/STIMUL 15 MIN 105.00 105.00 60 ACUPUNCT W/STIMUL ADDL 15M 53.00 53.00 61 ACUTE GI BLOOD LOSS IMAGING 732.00 - 62 ACUTE HEPATITIS PANEL - 184.00 184.00 63 ACUTE VENOUS THROMBUS IMAGE 943.00 - 64 Acyclovir injection 2.00 2.00 65 ACYLCARNITINES QUAL 54.00 - 66 ACYLCARNITINES QUANT 66.00 - 67 Adalimumab injection - 969.00 969.00 68 Add le poly knee custom kafo 443.00 443.00 69 Add pwr joystick 636.00 636.00 70 Add ue prost a/e ultlite mat 689.00 689.00 71 Add ue prost b/e acrylic 740.00 740.00 72 Add ue prost be/wd, ultlite 616.00 616.00 73 Add ue prost s/d ultlite mat 744.00 744.00 74 Additional switch, ext power 827.00 827.00 75 Adenosine inj 1mg - 25.00 - 76 ADENOVIRUS AG IA 47.00 - 77 ADENOVIRUS AG IF 47.00 - 78 ADENOVIRUS ANTIBODY 83.00 83.00 79 ADENOVIRUS ASSAY W/OPTIC 47.00 - 80 Adhesive remover per ounce 6.00 6.00 81 Adhesive remover, wipes - 2.00 2.00 82 Adhesive, liquid or equal 25.00 25.00 83 Adj motion knee jnt lerman t 411.00 411.00 84 Adj shoulder ext/flex device 972.00 972.00 85 Adj skin pro w/c cus wd<22in 742.00 742.00 86 Adj skin pro wc cus wd>=22in 945.00 945.00 87 Adj skin pro/pos cus<22in 749.00 749.00 88 Adj skin pro/pos wc cus>=22 948.00 948.00 89 Adjst forearm pro/sup device 849.00 849.00 90 Adjust ankle ext/flex device 423.00 423.00 91 Adjust elbow ext/flex device 423.00 423.00 92 Adjust finger ext/flex devc 423.00 423.00 93 Adjust knee ext/flex device 423.00 423.00 94 Adjust toe ext/flex device 423.00 423.00 95 Adjust wrist ext/flex device 423.00 423.00 96 Adjustable angle footplate 209.00 209.00 97 Adjustment gastric band 165.00 165.00 98 Admin hepatitis b vaccine - 39.00 39.00 99 Admin influenza virus vac - 39.00 39.00 100 Admin pneumococcal vaccine - 39.00 39.00 101 ADRENAL CORTEX & MEDULLA IMG 2,723.00 - 102 Adrenalin epinephrine inject - 5.00 5.00 103 Adult size brief/diaper lg 4.00 4.00 104 Adult size brief/diaper med 4.00 4.00 105 Adult size brief/diaper sm - 4.00 4.00 106 Aerosol compressor adjust pr 146.00 146.00 107 Aerosol mask used w nebulize - 5.00 5.00 108 Afluria vacc, 3 yrs & >, im 35.00 35.00 109 Afo ankle gauntlet pre ots 232.00 232.00 110 Afo doub solid stirrup calf 1,410.00 1,410.00 111 Afo multilig ank sup pre ots - 387.00 387.00 112 Afo plastic - 349.00 349.00 113 Afo rig ant tib prefab tcf/= - 1,342.00 1,342.00 114 Afo sing bar clasp attach sh 897.00 897.00 115 Afo sprng wir drsflx calf bd 605.00 605.00 116 Afo w/ankle joint, prefab 940.00 940.00 117 Afo, walk boot type, cus fab 2,761.00 2,761.00 118 AG DETECT NOS IA MULT 47.00 - 119 AG DETECT NOS IA SINGLE 38.00 - 120 AG DETECT POLYVAL IA MULT 38.00 - Physician Hospital Village Description # Charge Charge Charge 121 AG DETECTION POLYVAL IF 47.00 - 122 Agalsidase beta injection 352.00 352.00 123 AGENT NOS ASSAY W/OPTIC 47.00 - 124 AGGLUTININS FEBRILE ANTIGEN 133.00 133.00 125 Air pressure mattress 157.00 157.00 126 Air pressure pad for mattres 783.00 783.00 127 AIRWAY INHALATION TREATMENT - 162.00 113.00 128 Ak pelvic control belt light 446.00 446.00 129 Ak pelvic control belt pad/l 571.00 571.00 130 Ak sleeve susp neoprene/equa 422.00 422.00 131 Ak/knee disartic pelvic band 301.00 301.00 132 Ak/knee disartic pelvic join 554.00 554.00 133 Ak/knee disartic silesian ba 378.00 378.00 134 ALANINE AMINO (ALT) (SGPT) - 51.00 51.00 135 Albumin (human), 25%, 20 ml 59.00 59.00 136 Albumin (human), 25%, 50ml 148.00 148.00 137 Albumin (human), 5%, 250 ml 143.00 143.00 138 Albumin (human),5%, 50ml 33.00 33.00 139 ALBUMIN ISCHEMIA MODIFIED 133.00 - 140 Albuterol comp con 4.00 4.00 141 Albuterol ipratrop non-comp - 5.00 5.00 142 Albuterol non-comp con 2.00 2.00 143 Albuterol non-comp unit - 8.00 8.00 144 Alcohol and/or drug assess - 158.00 158.00 145 Alcohol and/or drug interven 19.00 19.00 146 Alcohol and/or drug services 11.00 11.00 147 Alcohol and/or drug services 18.00 18.00 148 Alcohol and/or drug services 20.00 20.00 149 Alcohol and/or drug services 79.00 79.00 150 Alcohol or peroxide per pint 8.00 8.00 151 Alcohol wipes per box - 11.00 11.00 152 Alcohol/drug abuse svc nos - 250.00 250.00 153 Alcohol/subs interv >30 min 343.00 135.00 - 154 Alcohol/subs interv 15-30mn 175.00 135.00 - 155 Alcohol/substance abuse skil 20.00 20.00 156 ALCOHOLS BIOMARKERS 1OR 2 60.00 - 157 ALCOHOLS BIOMARKERS 3/MORE 60.00 - 158 ALDOSTERONE SUPPRESSION EVAL 492.00 - 159 Alefacept 125.00 125.00 160 Alginate dressing <=16 sq in 25.00 25.00 161 Alginate drsg >16 <=48 sq in 64.00 64.00 162 Alginate drsg wound filler 24.00 24.00 163 Alglucerase injection 126.00 126.00 164 Alglucosidase alfa injection 412.00 412.00 165 Alkalin batt for glucose mon 4.00 4.00 166 ALKALOIDS NOS - 131.00 - 167 ALLERGEN SPECIFIC IGG 20.00 - 168 ALLG SPEC IGE CRUDE XTRC EA - 51.00 51.00 169 ALLG SPEC IGE MULTIALLG SCR 31.00 - 170 Alloderm 97.00 97.00 171 Alloskin 28.00 28.00 172 Alloskin 42.00 42.00 173 Alpha 1 proteinase inhibitor 14.00 14.00 174 ALPHA-1-ANTITRYPSIN PHENO 57.00 - 175 ALPHA-1-ANTITRYPSIN TOTAL 83.00 83.00 176 ALPHA-FETOPROTEIN AMNIOTIC 66.00 - 177 ALPHA-FETOPROTEIN L3 252.00 - 178 ALPHA-FETOPROTEIN SERUM - 83.00 83.00 179 Als 1 412.00 - 180 Als 2 943.00 - 181 Als1-emergency 652.00 - 182 Alteplase recombinant - 156.00 156.00 183 Alternating pressure pad 206.00 206.00 Physician Hospital Village Description # Charge Charge Charge 184 Amb infusion pump mechanical 73.00 73.00 185 Ambulance response/treatment 500.00 - 186 Ambulatory surgical boot eac - 35.00 35.00 187 Amifostine 612.00 612.00 188 Amikacin sulfate injection 3.00 3.00 189 AMINES VAGINAL FLUID QUAL 15.00 - 190 AMINO ACID SINGLE QUAL 51.00 51.00 191 AMINO ACIDS MULT QUAL 51.00 51.00 192 AMINO ACIDS QUAN 6 OR MORE 651.00 651.00 193 AMINO ACIDS QUANT 2-5 66.00 - 194 AMINO ACIDS SINGLE QUANT 422.00 422.00 195 Aminolevulinic acid hcl top 402.00 402.00 196 Aminophyllin 250 mg inj 5.00 5.00 197 Amiodarone hcl - 5.00 5.00 198 AMNIOTIC FLUID SCAN 27.00 - 199 Amobarbital 125 mg inj 381.00 381.00 200 AMPHETAMINES 3OR 4 86.00 - 201 AMPHETAMINES 5 OR MORE 86.00 - 202 Ampho b cholesteryl sulfate 42.00 42.00 203 Amphotericin b 53.00 53.00 204 Amphotericin b lipid complex 36.00 36.00 205 Amphotericin b liposome inj 43.00 43.00 206 Ampicillin 500 mg inj - 10.00 10.00 207 Ampicillin sodium per 1.5 gm - 20.00 20.00 208 AMPUTATION OF FINGER/THUMB 2,387.00 4,800.00 - 209 Amputee adapter 203.00 203.00 210 ANABOLIC STEROID 1 OR 2 142.00 - 211 ANABOLIC STEROID 3 OR MORE 142.00 - 212 ANALGESICS NON-OPIOID 1 OR 2 - 112.00 - 213 ANALGESICS NON-OPIOID 3-5 112.00 - 214 ANALGESICS NON-OPIOID 6/MORE 112.00 - 215 ANALYSIS NERVE 109.00 - 216 ANALYSIS SKELETAL MUSCLE 109.00 - 217 ANALYSIS TUMOR 109.00 - 218 ANALYZE NEUROSTIM NO PROG 276.00 200.00 276.00 219 ANALYZE PACEMAKER SYSTEM 840.00 100.00 - 220 ANDROSTANEDIOL GLUCURONIDE 113.00 - 221 ANGIOTENSIN I ENZYME TEST - 133.00 133.00 222 Anidulafungin injection 4.00 4.00 223 Ankle control ortho pre ots - 158.00 159.00 224 Annual alcohol screen 15 min 32.00 135.00 - 225 Annual gynecological examina 255.00 255.00 226 ANNUAL NURSING FAC ASSESSMNT 330.00 - 227 ANOGENITAL EXAM CHILD W IMAG 307.00 - 228 ANOSCOPY AND BIOPSY 260.00 3,000.00 260.00 229 ANOSCOPY CONTROL BLEEDING 918.00 3,000.00 918.00 230 ANTEPARTUM CARE ONLY 1,306.00 - 1,306.00 231 ANTEPARTUM CARE ONLY 2,614.00 - 2,614.00 232 Anterior asis pad 212.00 212.00 233 Anterior swing band 704.00 704.00 234 Anterior thoracic derotation 234.00 234.00 235 Anterior thoracic extension 974.00 974.00 236 ANTIBODY DETECTION NOS IF 47.00 - 237 ANTIDEPRESSANT TRICYCLIC 1/2 - 99.00 - 238 ANTIDEPRESSANT TRICYCLIC 3-5 99.00 - 239 ANTIDEPRESSANTS CLASS 1 OR 2 99.00 - 240 ANTIDEPRESSANTS CLASS 3-5 99.00 - 241 ANTIDEPRESSANTS CLASS 6/MORE 99.00 - 242 ANTIEPILEPTICS NOS 1-3 82.00 - 243 ANTIEPILEPTICS NOS 4-6 82.00 - 244 ANTIEPILEPTICS NOS 7/MORE 82.00 - 245 Antihemophilic viii/vwf comp 3.00 3.00 246 Anti-inhibitor 6.00 6.00 Physician Hospital Village Description # Charge Charge Charge 247 ANTINOMYCES ANTIBODY 40.00 - 248 ANTINUCLEAR ANTIBODIES - 83.00 83.00 249 ANTINUCLEAR ANTIBODIES (ANA) 44.00 - 250 ANTI-PHOSPHOLIPID ANTIBODY - 63.00 - 251 ANTIPSYCHOTICS NOS 1-3 86.00 - 252 ANTIPSYCHOTICS NOS 4-6 86.00 - 253 ANTIPSYCHOTICS NOS 7/MORE 86.00 - 254 Antisperm antibodies test 42.00 42.00 255 ANTISTREPTOLYSIN O SCREEN 23.00 - 256 ANTISTREPTOLYSIN O TITER - 83.00 83.00 257 ANTITHROMBIN III ACTIVITY 83.00 83.00 258 ANTITHROMBIN III ANTIGEN - 189.00 189.00 259 Antithrombin iii injection 11.00 11.00 260 Antithrombin recombinant 258.00 258.00 261 Apligraf 118.00 118.00 262 Apnea monitor 751.00 751.00 263 Apomorphine hydrochloride 99.00 99.00 264 APPENDECTOMY ADD-ON 688.00 - - 265 APPL SURFACE NEUROSTIMULATOR - 154.00 - 266 Appliance cleaner 164.00 164.00 267 APPLICATION LONG LEG SPLINT 314.00 624.00 314.00 268 APPLICATION LOWER LEG SPLINT 262.00 624.00 262.00 269 APPLICATION OF FIGURE EIGHT 373.00 1,026.00 373.00 270 APPLICATION OF FINGER SPLINT 144.00 405.00 144.00 271 APPLICATION OF FINGER SPLINT 154.00 405.00 154.00 272 APPLICATION OF FOREARM CAST 380.00 1,026.00 380.00 273 APPLICATION OF LONG ARM CAST 450.00 1,026.00 450.00 274 APPLICATION OF LONG LEG CAST 615.00 1,026.00 615.00 275 APPLICATION OF LONG LEG CAST 666.00 1,026.00 666.00 276 APPLICATION OF PASTE BOOT 221.00 624.00 221.00 277 APPLY FINGER CAST 262.00 624.00 262.00 278 APPLY FOREARM SPLINT 188.00 405.00 188.00 279 APPLY FOREARM SPLINT 231.00 405.00 231.00 280 APPLY HAND/WRIST CAST 378.00 624.00 378.00 281 APPLY INTERSTIT RADIAT COMPL 2,495.00 - 282 APPLY INTRCAV RADIAT COMPL 1,171.00 - 283 APPLY INTRCAV RADIAT INTERM 1,171.00 - 284 APPLY INTRCAV RADIAT SIMPLE 1,171.00 - 285 APPLY LONG ARM SPLINT 319.00 624.00 319.00 286 APPLY LONG LEG CAST BRACE 572.00 1,026.00 572.00 287 APPLY RIGID LEG CAST 861.00 1,026.00 861.00 288 APPLY SHORT LEG CAST 359.00 1,026.00 - 289 APPLY SHORT LEG CAST 454.00 1,026.00 454.00 290 APPLY SHORT LEG CAST 529.00 1,026.00 529.00 291 APPLY SURF LDR RADIONUCLIDE 272.00 - 292 Aprotonin, 10,000 kiu 9.00 9.00 293 AQUATIC THERAPY/EXERCISES 224.00 - 294 Arbutamine hcl injection 216.00 216.00 295 Arch supp att to shoe long/m 122.00 122.00 296 Arch supp att to shoe metata - 96.00 96.00 297 Arch suprt att to sho longit 96.00 96.00 298 Arformoterol non-comp unit 19.00 19.00 299 Aripiprazole injection 2.00 2.00 300 Arm pad repl, each 72.00 72.00 301 Arm trough each 300.00 300.00 302 Arsenic trioxide injection 135.00 135.00 303 ART PRESSURE WAVEFORM ANALYS 30.00 87.00 - 304 ARTERY X-RAY EACH VESSEL 302.00 - 305 ARTERY X-RAYS ABDOMEN 6,326.00 - 306 ARTERY X-RAYS ADRENAL GLAND 6,326.00 - 307 ARTERY X-RAYS ADRENALS 6,326.00 - 308 ARTERY X-RAYS ARM/LEG 6,326.00 - 309 ARTERY X-RAYS ARMS/LEGS 6,326.00 - Physician Hospital Village Description # Charge Charge Charge 310 ARTERY X-RAYS CHEST 2,041.00 - 311 ARTERY X-RAYS LUNG 2,041.00 - 312 ARTERY X-RAYS LUNG 6,326.00 - 313 ARTERY X-RAYS LUNGS 6,326.00 - 314 ARTERY X-RAYS PELVIS 6,326.00 - 315 ARTERY X-RAYS SPINE 6,326.00 - 316 Arthroflex 285.00 285.00 317 ARTHROSCOP ROTATOR CUFF REPR 6,725.00 4,800.00 - 318 ARTIFICIAL INSEMINATION 414.00 1,026.00 414.00 319 Artificial larynx 818.00 818.00 320 Asparaginase, nos 190.00 190.00 321 ASPERGILLUS AG IA 47.00 - 322 ASPERGILLUS ANTIBODY 59.00 - 323 ASPIRATE PLEURA W/ IMAGING 488.00 2,050.00 - 324 ASPIRATE PLEURA W/O IMAGING 1,246.00 2,050.00 - 325 ASPIRATE/INJ GANGLION CYST 263.00 1,026.00 263.00 326 ASSAY 17- KETOSTEROIDS 83.00 83.00 327 ASSAY ACID PHOSPHATASE 29.00 - 328 ASSAY ACTIVATED PROTEIN C 60.00 - 329 ASSAY ALKALINE PHOSPHATASE 29.00 - 330 ASSAY ALKALINE PHOSPHATASE 30.00 30.00 331 ASSAY ALKALINE PHOSPHATASES 102.00 102.00 332 ASSAY AMINOLEVULINIC ACID 133.00 133.00 333 ASSAY BLD/SERUM CHOLESTEROL - 51.00 51.00 334 ASSAY BLOOD CARBON DIOXIDE 51.00 51.00 335 ASSAY BLOOD CATECHOLAMINES 98.00 - 336 ASSAY CARBAMAZEPINE FREE 83.00 83.00 337 ASSAY CARBAMAZEPINE TOTAL 83.00 83.00 338 ASSAY CARBOXYHB QUAL 51.00 51.00 339 ASSAY CARBOXYHB QUANT - 83.00 83.00 340 ASSAY C-D TRANSFER MEASURE 71.00 - 341 ASSAY CHONDROITIN SULFATE 81.00 - 342 ASSAY DIPROPYLACETIC ACD TOT - 83.00 83.00 343 ASSAY DUODENAL FLUID TRYPSIN 29.00 - 344 ASSAY FOR CALPROTECTIN FECAL - 77.00 - 345 ASSAY FOR PHENCYCLIDINE 58.00 - 346 ASSAY FREE HYDROXYPROLINE 89.00 - 347 ASSAY GALACTOSE TRANSFERASE 83.00 - 348 ASSAY GLUCOSE BLOOD QUANT - 28.00 28.00 349 ASSAY GROWTH HORMONE (HGH) 83.00 83.00 350 ASSAY IGA/IGD/IGG/IGM EACH - 51.00 51.00 351 ASSAY LIPOPROTEIN PLA2 133.00 - 352 ASSAY MALATE DEHYDROGENASE 29.00 - 353 ASSAY MYELOPEROXIDASE 83.00 83.00 354 ASSAY NEPHELOMETRY NOT SPEC - 53.00 - 355 ASSAY NONENDOCRINE RECEPTOR 83.00 83.00 356 ASSAY OF 17-HYDROXYPREGNENO 89.00 - 357 ASSAY OF 5-HIAA 128.00 128.00 358 ASSAY OF ACTH - 269.00 269.00 359 ASSAY OF ADP & AMP 83.00 83.00 360 ASSAY OF ALDOLASE 51.00 51.00 361 ASSAY OF ALDOSTERONE 83.00 83.00 362 ASSAY OF ALUMINUM 100.00 - 363 ASSAY OF AMIKACIN 83.00 83.00 364 ASSAY OF AMMONIA - 111.00 111.00 365 ASSAY OF AMYLASE - 51.00 51.00 366 ASSAY OF ANDROSTENEDIONE - 83.00 83.00 367 ASSAY OF ANDROSTERONE 98.00 - 368 ASSAY OF ANGIOTENSIN II 80.00 - 369 ASSAY OF APOLIPOPROTEIN - 61.00 - 370 ASSAY OF ARSENIC 83.00 83.00 371 ASSAY OF ASCORBIC ACID 39.00 - 372 ASSAY OF B HEXOSAMINIDASE 66.00 - Physician Hospital Village Description # Charge Charge Charge 373 ASSAY OF BETA-2 PROTEIN 83.00 83.00 374 ASSAY OF BIOTINIDASE 66.00 - 375 ASSAY OF BLOOD CHLORIDE 51.00 51.00 376 ASSAY OF BLOOD FATTY ACIDS 52.00 - 377 ASSAY OF BLOOD LIPOPROTEIN 46.00 - 378 ASSAY OF BLOOD LIPOPROTEIN 42.00 42.00 379 ASSAY OF BLOOD OSMOLALITY - 51.00 51.00 380 ASSAY OF BLOOD PKU - 83.00 83.00 381 ASSAY OF BLOOD/URIC ACID - 51.00 51.00 382 ASSAY OF BRADYKININ 27.00 - 383 ASSAY OF BREATH ETHANOL 47.00 - 384 ASSAY OF CADMIUM 91.00 - 385 ASSAY OF CALCITONIN 51.00 51.00 386 ASSAY OF CALCIUM - 51.00 51.00 387 ASSAY OF CALCIUM 51.00 51.00 388 ASSAY OF CALCIUM IN URINE 24.00 - 389 ASSAY OF CARNITINE 66.00 - 390 ASSAY OF CAROTENE 51.00 51.00 391 ASSAY OF CATHEPSIN-D 82.00 - 392 ASSAY OF CERULOPLASMIN 51.00 51.00 393 ASSAY OF CHLORAMPHENICOL 50.00 - 394 ASSAY OF CHROMIUM 79.00 - 395 ASSAY OF CITRATE 159.00 159.00 396 ASSAY OF CK (CPK) - 38.00 38.00 397 ASSAY OF COPPER 83.00 83.00 398 ASSAY OF CORTICOSTEROIDS 17 69.00 - 399 ASSAY OF CORTICOSTERONE 88.00 - 400 ASSAY OF C-PEPTIDE - 83.00 83.00 401 ASSAY OF CPK IN BLOOD 61.00 61.00 402 ASSAY OF CREATINE 18.00 - 403 ASSAY OF CREATININE - 30.00 30.00 404 ASSAY OF CRYOFIBRINOGEN 34.00 - 405 ASSAY OF CRYOGLOBULIN 121.00 121.00 406 ASSAY OF CSF PROTEIN 83.00 83.00 407 ASSAY OF CYANIDE 83.00 83.00 408 ASSAY OF DIBUCAINE NUMBER 48.00 - 409 ASSAY OF DIGOXIN TOTAL - 83.00 83.00 410 ASSAY OF ENDOCRINE HORMONE 205.00 - 411 ASSAY OF ERYTHROPOIETIN 83.00 83.00 412 ASSAY OF ESTRADIOL - 83.00 83.00 413 ASSAY OF ESTRIOL - 83.00 83.00 414 ASSAY OF ESTROGEN 83.00 83.00 415 ASSAY OF ESTROGEN 252.00 - 416 ASSAY OF ESTROGENS 83.00 83.00 417 ASSAY OF ESTRONE 175.00 175.00 418 ASSAY OF ETHOSUXIMIDE - 51.00 51.00 419 ASSAY OF ETHYLENE GLYCOL 58.00 - 420 ASSAY OF ETIOCHOLANOLONE 92.00 - 421 ASSAY OF FECAL FAT 67.00 - 422 ASSAY OF FECES FOR TRYPSIN 30.00 - 423 ASSAY OF FECES PORPHYRINS 100.00 - 424 ASSAY OF FECES/UROBILINOGEN 49.00 - 425 ASSAY OF FERRITIN - 92.00 92.00 426 ASSAY OF FETAL FIBRONECTIN - 681.00 681.00 427 ASSAY OF FLUORIDE 73.00 - 428 ASSAY OF FOLIC ACID RBC - 131.00 131.00 429 ASSAY OF FOLIC ACID SERUM - 114.00 114.00 430 ASSAY OF FREE TESTOSTERONE - 111.00 111.00 431 ASSAY OF FREE THYROXINE - 133.00 133.00 432 ASSAY OF G6PD ENZYME - 83.00 83.00 433 ASSAY OF GALACTOSE 83.00 83.00 434 ASSAY OF GASTRIN 51.00 51.00 435 ASSAY OF GDH ENZYME 30.00 - Physician Hospital Village Description # Charge Charge Charge 436 ASSAY OF GENTAMICIN - 83.00 83.00 437 ASSAY OF GGT - 51.00 51.00 438 ASSAY OF GLUCAGON 56.00 - 439 ASSAY OF GLUCOSIDASE 84.00 - 440 ASSAY OF GLUTATHIONE 56.00 - 441 ASSAY OF GLYCATED PROTEIN 83.00 83.00 442 ASSAY OF GONADOTROPIN (FSH) - 133.00 133.00 443 ASSAY OF GONADOTROPIN (LH) - 135.00 135.00 444 ASSAY OF HALOPERIDOL 57.00 - 445 ASSAY OF HAPTOGLOBIN QUANT - 83.00 83.00 446 ASSAY OF HAPTOGLOBINS 67.00 - 447 ASSAY OF HEMOGLOBIN HEAT 27.00 - 448 ASSAY OF HEMOSIDERIN QUAL 51.00 51.00 449 ASSAY OF HISTAMINE 83.00 83.00 450 ASSAY OF HOMOCYSTINE - 166.00 166.00 451 ASSAY OF HOMOVANILLIC ACID 76.00 - 452 ASSAY OF IDH ENZYME 35.00 - 453 ASSAY OF IGE - 51.00 51.00 454 ASSAY OF INSULIN - 51.00 - 455 ASSAY OF INSULIN - 83.00 83.00 456 ASSAY OF INTRINSIC FACTOR 62.00 - 457 ASSAY OF IRON - 83.00 83.00 458 ASSAY OF KETOGENIC STEROIDS 83.00 83.00 459 ASSAY OF LACTIC ACID - 51.00 51.00 460 ASSAY OF LAP ENZYME 36.00 - 461 ASSAY OF LDH ENZYMES 154.00 154.00 462 ASSAY OF LEAD - 83.00 83.00 463 ASSAY OF LIDOCAINE 51.00 51.00 464 ASSAY OF LIPASE - 51.00 51.00 465 ASSAY OF LIPOPROTEIN 83.00 83.00 466 ASSAY OF LIPOPROTEIN(A) 51.00 - 467 ASSAY OF LITHIUM - 51.00 51.00 468 ASSAY OF LRH HORMONE 67.00 - 469 ASSAY OF MAGNESIUM - 51.00 51.00 470 ASSAY OF MANGANESE 96.00 - 471 ASSAY OF MERCURY 83.00 83.00 472 ASSAY OF METANEPHRINES 192.00 192.00 473 ASSAY OF METHEMALBUMIN 42.00 - 474 ASSAY OF MYOGLOBIN 83.00 83.00 475 ASSAY OF NATRIURETIC PEPTIDE - 166.00 166.00 476 ASSAY OF NEONATAL THYROXINE 25.00 - 477 ASSAY OF NICKEL 96.00 - 478 ASSAY OF NOS VITAMIN 45.00 - 479 ASSAY OF NUCLEOTIDASE 44.00 - 480 ASSAY OF OSTEOCALCIN 117.00 - 481 ASSAY OF OXALATE 51.00 51.00 482 ASSAY OF PARATHORMONE - 262.00 262.00 483 ASSAY OF PHENOBARBITAL - 83.00 83.00 484 ASSAY OF PHENYLKETONES 14.00 - 485 ASSAY OF PHENYTOIN FREE 107.00 107.00 486 ASSAY OF PHENYTOIN TOTAL - 102.00 102.00 487 ASSAY OF PHOSPHORUS - 51.00 51.00 488 ASSAY OF PLASMA HEMOGLOBIN 51.00 51.00 489 ASSAY OF PORPHOBILINOGEN 111.00 111.00 490 ASSAY OF PREALBUMIN - 83.00 83.00 491 ASSAY OF PREGNANEDIOL 75.00 - 492 ASSAY OF PREGNANETRIOL 74.00 - 493 ASSAY OF PREGNENOLONE 81.00 - 494 ASSAY OF PRIMIDONE 91.00 91.00 495 ASSAY OF PROCAINAMIDE 66.00 - 496 ASSAY OF PROCAINAMIDE 153.00 153.00 497 ASSAY OF PROGESTERONE - 83.00 83.00 498 ASSAY OF PROGESTERONE 254.00 - Physician Hospital Village Description # Charge Charge Charge 499 ASSAY OF PROGESTERONE 17-D - 133.00 133.00 500 ASSAY OF PROINSULIN 70.00 - 501 ASSAY OF PROLACTIN - 83.00 83.00 502 ASSAY OF PROSTAGLANDIN 98.00 - 503 ASSAY OF PROTEIN ANY SOURCE 20.00 - 504 ASSAY OF PROTEIN OTHER 29.00 29.00 505 ASSAY OF PROTEIN SERUM - 51.00 51.00 506 ASSAY OF PROTEIN URINE - 29.00 29.00 507 ASSAY OF PSA COMPLEXED 72.00 - 508 ASSAY OF PSA FREE - 133.00 133.00 509 ASSAY OF PSA TOTAL - 194.00 194.00 510 ASSAY OF PYRUVATE 83.00 83.00 511 ASSAY OF PYRUVATE KINASE 37.00 - 512 ASSAY OF QUINIDINE 51.00 51.00 513 ASSAY OF QUININE 46.00 - 514 ASSAY OF RBC GALACTOKINASE 84.00 - 515 ASSAY OF RBC PG6D ENZYME 26.00 - 516 ASSAY OF RENIN - 83.00 83.00 517 ASSAY OF SELENIUM 654.00 654.00 518 ASSAY OF SEMEN FRUCTOSE 68.00 - 519 ASSAY OF SEROTONIN 415.00 415.00 520 ASSAY OF SERUM ALBUMIN - 51.00 51.00 521 ASSAY OF SERUM POTASSIUM - 51.00 51.00 522 ASSAY OF SERUM SODIUM 51.00 51.00 523 ASSAY OF SEX HORMONE GLOBUL 85.00 - 524 ASSAY OF SIALIC ACID 53.00 - 525 ASSAY OF SILICA 92.00 - 526 ASSAY OF SIROLIMUS 54.00 - 527 ASSAY OF SOMATOMEDIN - 83.00 83.00 528 ASSAY OF SOMATOSTATIN 72.00 - 529 ASSAY OF SWEAT SODIUM 19.00 - 530 ASSAY OF TACROLIMUS - 54.00 - 531 ASSAY OF THEOPHYLLINE 83.00 83.00 532 ASSAY OF THIOCYANATE 46.00 - 533 ASSAY OF THYROGLOBULIN 83.00 83.00 534 ASSAY OF THYROID (T3 OR T4) 51.00 51.00 535 ASSAY OF THYROID ACTIVITY 83.00 83.00 536 ASSAY OF TOBRAMYCIN 51.00 51.00 537 ASSAY OF TOPIRAMATE 134.00 134.00 538 ASSAY OF TOTAL TESTOSTERONE - 111.00 111.00 539 ASSAY OF TOTAL THYROXINE - 51.00 51.00 540 ASSAY OF TRANSCORTIN 51.00 51.00 541 ASSAY OF TRANSFERRIN - 83.00 83.00 542 ASSAY OF TRIGLYCERIDES - 51.00 51.00 543 ASSAY OF TROPONIN QUAL 51.00 51.00 544 ASSAY OF TROPONIN QUANT - 83.00 83.00 545 ASSAY OF TSI GLOBULIN - 384.00 384.00 546 ASSAY OF TYROSINE 166.00 166.00 547 ASSAY OF UREA NITROGEN - 29.00 29.00 548 ASSAY OF URINE CHLORIDE 51.00 51.00 549 ASSAY OF URINE CREATININE - 37.00 37.00 550 ASSAY OF URINE HEMOGLOBIN 15.00 - 551 ASSAY OF URINE OSMOLALITY 122.00 122.00 552 ASSAY OF URINE PHOSPHORUS 32.00 32.00 553 ASSAY OF URINE PORPHYRINS 133.00 133.00 554 ASSAY OF URINE POTASSIUM 83.00 83.00 555 ASSAY OF URINE SODIUM 51.00 51.00 556 ASSAY OF URINE SULFATE 19.00 - 557 ASSAY OF URINE UROBILINOGEN 20.00 - 558 ASSAY OF URINE UROBILINOGEN 28.00 - 559 ASSAY OF URINE VMA 83.00 83.00 560 ASSAY OF URINE/UREA-N 19.00 - 561 ASSAY OF URINE/URIC ACID 51.00 51.00 Physician Hospital Village Description # Charge Charge Charge 562 ASSAY OF VANCOMYCIN - 83.00 83.00 563 ASSAY OF VASOPRESSIN 133.00 - 564 ASSAY OF VIP 138.00 - 565 ASSAY OF VITAMIN A 83.00 83.00 566 ASSAY OF VITAMIN B-1 - 83.00 - 567 ASSAY OF VITAMIN B-2 79.00 - 568 ASSAY OF VITAMIN B-6 110.00 - 569 ASSAY OF VITAMIN E 83.00 83.00 570 ASSAY OF VITAMIN K 54.00 - 571 ASSAY OF VOLATILES 51.00 51.00 572 ASSAY OF ZINC 83.00 83.00 573 ASSAY OTHER FLUID CHLORIDES 19.00 - 574 ASSAY PH BODY FLUID NOS 27.00 27.00 575 ASSAY PHOSPHATIDYLGLYCEROL 65.00 - 576 ASSAY PHOSPHOHEXOSE ENZYMES 40.00 - 577 ASSAY PROSTATE PHOSPHATASE 92.00 92.00 578 ASSAY RBC CHOLINESTERASE 83.00 83.00 579 ASSAY RBC GLUTATHIONE 27.00 - 580 ASSAY RBC PROTOPORPHYRIN 133.00 133.00 581 ASSAY SERUM CHOLINESTERASE 133.00 133.00 582 ASSAY SYNOVIAL FLUID MUCIN 51.00 51.00 583 ASSAY TEST FOR BLOOD FECAL - 62.00 - 584 ASSAY THREE CATECHOLAMINES 83.00 83.00 585 ASSAY THYROID STIM HORMONE - 83.00 83.00 586 ASSAY TOTAL HYDROXYPROLINE 95.00 - 587 ASSAY TOXIN OR ANTITOXIN - 77.00 - 588 ASSAY TRIIODOTHYRONINE (T3) - 128.00 128.00 589 ASSAY URINE CATECHOLAMINES 67.00 - 590 ASSESS HLTH/BEHAVE INIT 175.00 175.00 591 ASSESS HLTH/BEHAVE SUBSEQ 67.00 - 592 ASSESSMENT OF APHASIA 483.00 - 593 ASSIST OOCYTE FERTILIZATION 109.00 - 594 ASSIST OOCYTE FERTILIZATION 172.00 - 595 ASSISTIVE TECHNOLOGY ASSESS 184.00 - 596 ASSMT & CARE PLN PT COG IMP 216.00 - 597 ATOMIC ABSORPTION 58.00 - 598 Atropine sulfate injection - 5.00 5.00 599 ATTENDANCE AT DELIVERY 263.00 - 600 AUD BRAINSTEM IMPLT PROGRAMG 368.00 368.00 - 601 AUD REHAB POSTLING HEAR LOSS 88.00 - 602 AUD REHAB PRE-LING HEAR LOSS 88.00 - 603 AUDIOMETRY AIR & BONE - 354.00 129.00 604 AUDIT/DAST 15-30 MIN 114.00 113.00 114.00 605 AUDIT/DAST OVER 30 MIN 158.00 226.00 158.00 606 AUDITOR EVOKE POTENT COMPRE 747.00 - 607 AUDITOR EVOKE POTENT LIMIT 477.00 236.00 608 AUDITORY FUNCTION + 15 MIN 66.00 66.00 - 609 AUDITORY FUNCTION 60 MIN 289.00 289.00 - 610 AUTOLOGOUS BLOOD OP SALVAGE 51.00 - 611 AUTOLOGOUS BLOOD PROCESS 98.00 - 612 AUTOMATED DIFF WBC COUNT 25.00 - 613 AUTOMATED LEUKOCYTE COUNT 20.00 20.00 614 AUTOMATED PLATELET COUNT 18.00 - 615 AUTOMATED RBC COUNT 17.00 17.00 616 AUTOMATED RETICULOCYTE COUNT - 83.00 83.00 617 Automatic ext defibrillator 790.00 790.00 618 Azacitidine injection 19.00 19.00 619 Azathioprine oral 50mg 3.00 3.00 620 Azathioprine parenteral 403.00 403.00 621 Azithromycin - 8.00 8.00 622 Azithromycin dihydrate, oral 43.00 43.00 623 B CELLS TOTAL COUNT 148.00 - 624 B-12 BINDING CAPACITY 56.00 - Physician Hospital Village Description # Charge Charge Charge 625 Back upholstery, replacement 203.00 203.00 626 Baclofen 10 mg injection 440.00 440.00 627 Baclofen intrathecal trial 191.00 191.00 628 BACTERICIDAL LEVEL SERUM 59.00 - 629 BACTERIUM ANTIBODY 177.00 177.00 630 BARTONELLA ANTIBODY 40.00 - 631 BARTONELLA DNA AMP PROBE - 137.00 - 632 BARTONELLA DNA QUANT 168.00 - 633 BASIC LIFE DISABILITY EXAM 50.00 50.00 634 Basic support routine suppls 46.00 - 635 BASIC VESTIBULAR EVALUATION 270.00 - 636 Bat clps elec/comb vad, rep 940.00 940.00 637 Bath/shower chair 11.00 11.00 638 Battery cables 255.00 255.00 639 Battery charger 390.00 390.00 640 Battery charger, dual mode 939.00 939.00 641 Battery charger, single mode 754.00 754.00 642 Battery for hearing device - 1.00 1.00 643 Bcg live intravesical vac 302.00 302.00 644 BCG VACCINE INTRAVESICAL 242.00 645 BCG VACCINE PERCUT 242.00 646 BCR/ABL1 GENE MAJOR BP 670.00 - 647 BCR/ABL1 GENE MINOR BP 592.00 - 648 Bed cradle 177.00 177.00 649 Bed pan fracture - 21.00 21.00 650 Bed pan standard 60.00 60.00 651 Bed safety enclosure 450.00 450.00 652 Bedside drain btl w/wo tube 80.00 80.00 653 Bedside drainage bag 20.00 20.00 654 BEHAV CHNG SMOKING > 10 MIN 88.00 64.00 88.00 655 BEHAV CHNG SMOKING 3-10 MIN 42.00 56.00 42.00 656 Behavior counsel obesity 15m 82.00 135.00 - 657 BEHAVRAL QUALIT ANALYS VOICE 324.00 - 658 Belatacept injection 13.00 13.00 659 Belimumab injection 115.00 115.00 660 Below knee acrylic socket 868.00 868.00 661 Below knee cuff suspension 252.00 252.00 662 Below knee surgical stocking - 30.00 - 663 Below knee sus/seal sleeve 322.00 322.00 664 Belt strap sleev grmnt cover - 20.00 - 665 Belt/harness extremity 155.00 155.00 666 Belt/vest elec/combo vad rep 419.00 419.00 667 BENZODIAZEPINES 13 OR MORE 109.00 - 668 BENZODIAZEPINES1-12 - 102.00 - 669 BETA-2 GLYCOPROTEIN ANTIBODY - 48.00 48.00 670 Betadine/iodine swabs/wipes 5.00 5.00 671 Betamethasone acet&sod phosp - 20.00 20.00 672 Bevacizumab injection 6.00 6.00 673 Bevacizumab injection 191.00 191.00 674 BILE ACIDS CHOLYLGLYCINE 104.00 - 675 BILE ACIDS TOTAL - 51.00 51.00 676 BILIRUBIN DIRECT - 51.00 51.00 677 BILIRUBIN TOTAL - 51.00 51.00 678 BILIRUBIN TOTAL TRANSCUT - 20.00 - 679 BIOFEEDBACK PERI/URO/RECTAL 155.00 226.00 - 680 BIOFEEDBACK TRAIN ANY METH 71.00 103.00 - 681 BIOPSY FOREARM SOFT TISSUES 1,762.00 4,800.00 - 682 BIOPSY OF CERVIX 473.00 2,050.00 473.00 683 BIOPSY OF CERVIX W/SCOPE 676.00 1,026.00 676.00 684 BIOPSY OF EXTERNAL EAR 290.00 2,050.00 290.00 685 BIOPSY OF LIP 373.00 624.00 373.00 686 BIOPSY OF THYROID 191.00 2,050.00 191.00 687 BIOPSY OF UTERUS LINING 530.00 624.00 530.00 Physician Hospital Village Description # Charge Charge Charge 688 BIOPSY OF VULVA/PERINEUM 285.00 2,050.00 285.00 689 BIOPSY OOCYTE POLAR BODY 172.00 - 690 BIOPSY OOCYTE POLAR BODY 172.00 - 691 BIOPSY ROOF OF MOUTH 548.00 3,780.00 548.00 692 BIOPSY SKIN ADD-ON 162.00 - 162.00 693 BIOPSY SKIN LESION 277.00 1,026.00 277.00 694 Bivalirudin 10.00 10.00 695 Bk back check 190.00 190.00 696 Bk fork strap 266.00 266.00 697 Bk joint covers pair 204.00 204.00 698 Bk molded distal cushion 354.00 354.00 699 Bk molded supracondylar susp 755.00 755.00 700 Bk removable medial brim sus 740.00 740.00 701 Bk thigh lacer non-molded 725.00 725.00 702 Bk waist belt padded and lin 332.00 332.00 703 Bk waist belt webbing 272.00 272.00 704 BL SMEAR W/DIFF WBC COUNT - 51.00 51.00 705 BL SMEAR W/O DIFF WBC COUNT 13.00 - 706 Bladder irrigation tubing 77.00 77.00 707 BLASTOMYCES ANTIBODY 51.00 - 708 Bld glucose monitor w lance 490.00 490.00 709 BLD TYPING SEROLOGIC RH PHNT 51.00 - 710 BLEEDING TIME TEST 83.00 83.00 711 Bleomycin sulfate injection 64.00 64.00 712 BLOOC CLOT FACTOR V TEST 202.00 202.00 713 BLOOD CLOT LYSIS TIME 18.00 - 714 BLOOD CLOT RETRACTION 14.00 - 715 BLOOD CULTURE FOR BACTERIA - 83.00 83.00 716 BLOOD FUNGUS CULTURE 35.00 - 717 BLOOD GASES ANY COMBINATION - 100.00 100.00 718 BLOOD GASES O2 SAT ONLY 34.00 - 719 BLOOD GASES W/O2 SATURATION 143.00 143.00 720 Blood glucose monitor home 98.00 721 Blood glucose/reagent strips 79.00 79.00 722 BLOOD METHEMOGLOBIN ASSAY 51.00 51.00 723 BLOOD METHEMOGLOBIN TEST 19.00 - 724 Blood mucoprotein 20.00 20.00 725 BLOOD PH - 164.00 164.00 726 BLOOD PLATELET AGGREGATION 84.00 - 727 BLOOD PRODUCT/IRRADIATION 51.00 - 728 BLOOD SMEAR INTERPRETATION 83.00 - 729 Blood split unit 341.00 341.00 730 BLOOD SULFHEMOGLOBIN ASSAY 32.00 - 731 BLOOD TRANSFUSION SERVICE - 781.00 - 732 BLOOD TYPE ANTIGEN DONOR EA 51.00 - 733 BLOOD TYPING PATIENT SERUM 51.00 - 734 BLOOD TYPING RBC ANTIGENS 51.00 - 735 BLOOD TYPING SEROLOGIC ABO - 51.00 - 736 BLOOD TYPING SEROLOGIC RH(D) - 51.00 - 737 BLOOD VISCOSITY EXAMINATION 46.00 - 738 BLOOD VOLUME 1,242.00 - 739 Blood, l/r, cmv-neg 463.00 463.00 740 Blood, l/r, froz/degly/wash 306.00 306.00 741 Blood, l/r, irradiated 440.00 440.00 742 BLOOD/LYMPH NUCLEAR EXAM 798.00 - 743 Bls 343.00 - 744 Bls-emergency 549.00 - 745 BODY FLUID CELL COUNT 51.00 51.00 746 BODY FLUID CELL COUNT - 83.00 83.00 747 BODY FLUID SPECIFIC GRAVITY 10.00 - 748 BODY MUSCLE TESTING MANUAL 107.00 - 749 BODY MUSCLE TESTING MANUAL 156.00 - 750 BONE IMAGING (3D) 746.00 - Physician Hospital Village Description # Charge Charge Charge 751 BONE IMAGING 3 PHASE 746.00 - 752 BONE IMAGING LIMITED AREA 746.00 - 753 BONE IMAGING MULTIPLE AREAS 746.00 - 754 BONE IMAGING WHOLE BODY - 746.00 - 755 BONE MARROW IMAGING BODY 798.00 - 756 BONE MARROW IMAGING LTD 798.00 - 757 BONE MARROW IMAGING MULT 798.00 - 758 BONE MARROW INTERPRETATION 109.00 - 759 BONE MINERAL SINGLE PHOTON 80.00 - 760 BORDETELLA ANTIBODY - 52.00 - 761 BORRELIA ANTIBODY 52.00 - 762 Bortezomib injection 133.00 133.00 763 BRAIN FLOW IMAGING ONLY 753.00 - 764 BRAIN IMAGE < 4 VIEWS 753.00 - 765 BRAIN IMAGE 4+ VIEWS 753.00 - 766 BRAIN IMAGE W/FLOW < 4 VIEWS 1,306.00 - 767 BRAIN IMAGE W/FLOW 4 + VIEWS 1,306.00 - 768 BRAIN IMAGING (3D) 1,306.00 - 769 BRAIN IMAGING (PET) 3,010.00 - 770 Brake for wheeled walker 55.00 55.00 771 Breast prosthes w/o adhesive 782.00 782.00 772 Breast prosthesis bra & form 315.00 315.00 773 Breast prosthesis w adhesive 782.00 782.00 774 BREAST TOMOSYNTHESIS BI 102.00 - 775 BREAST TOMOSYNTHESIS BI 120.00 - 776 BREAST TOMOSYNTHESIS UNI 103.00 - 777 BREATH TEST ANALYSIS C-14 264.00 - 778 BREATH TST ATTAIN/ANAL C-14 31.00 - 779 Breath tube kit 777.00 777.00 780 BREATHING CAPACITY TEST - 170.00 - 781 Breathing circuits 71.00 71.00 782 Brentuximab vedotin inj 247.00 247.00 783 Brief alcohol misuse counsel 82.00 135.00 - 784 Brst prsth bra & bilat form 414.00 414.00 785 Brst prsths adhsv attchmnt 22.00 22.00 786 BRUCELLA ANTIBODY 133.00 133.00 787 Budesonide non-comp unit - 19.00 19.00 788 Buprenorphine hydrochloride 2.00 2.00 789 Busulfan injection 66.00 66.00 790 Butorphanol tartrate 1 mg 4.00 4.00 791 BX/CURETT OF CERVIX W/SCOPE 827.00 1,026.00 827.00 792 C DIFF AMPLIFIED PROBE 137.00 - 793 C-1 esterase, berinert 93.00 93.00 794 C-1 esterase, cinryze 142.00 142.00 795 Ca screen;flexi sigmoidscope 230.00 1,038.00 - 796 Ca screen;pelvic/breast exam 105.00 162.00 - 797 Cabazitaxel injection 345.00 345.00 798 Caffeine citrate injection 2.00 2.00 799 Calcitonin salmon injection 188.00 188.00 800 CALCITONIN STIMUL PANEL 315.00 - 801 Calcium gluconate injection - 2.00 2.00 802 CALCIUM INFUSION TEST 20.00 - 803 CALCULUS ANALYSIS QUAL 166.00 166.00 804 CALCULUS ASSAY QUANT 50.00 - 805 CALCULUS SPECTROSCOPY 51.00 - 806 Calibrator solution/chips 19.00 19.00 807 CALORIC VSTBLR TEST W/REC 54.00 628.00 - 808 CALORIC VSTBLR TEST W/REC 108.00 628.00 - 809 Cam rel asm ft/legrst rep ea 177.00 177.00 810 CAMPYLOBACTER ANTIBODY 51.00 - 811 Canakinumab injection 224.00 224.00 812 CANALITH REPOSITIONING PROC 166.00 166.00 166.00 813 CANDIDA ANTIBODY 47.00 - Physician Hospital Village Description # Charge Charge Charge 814 CANDIDA DNA AMP PROBE 137.00 - 815 CANDIDA DNA DIR PROBE 79.00 - 816 CANDIDA DNA QUANT 164.00 - 817 Cane adjust/fixed quad/3 pro - 132.00 100.00 818 Cane adjust/fixed with tip - 100.00 37.00 819 CANNABINOID SYNTHETIC 7/MORE 102.00 - 820 CANNABINOIDS NATURAL 102.00 - 821 CANNABINOIDS SYNTHETIC 1-3 102.00 - 822 CANNABINOIDS SYNTHETIC 4-6 102.00 - 823 Cannula nasal - 13.00 13.00 824 Capecitabine, oral, 150 mg 31.00 31.00 825 Capecitabine, oral, 500 mg 89.00 89.00 826 CAPILLARY BLOOD DRAW - 29.00 - 827 Carbon graphite lamination 328.00 328.00 828 Carboplatin injection 565.00 565.00 829 CARCINOEMBRYONIC ANTIGEN - 83.00 83.00 830 CARD MRI VELOC FLOW MAPPING 185.00 - 831 CARD MRI W/STRESS IMG & DYE 1,566.00 - 832 CARDIAC MRI FOR MORPH 965.00 - 833 CARDIAC MRI FOR MORPH W/DYE 1,566.00 - 834 CARDIAC MRI W/STRESS IMG 965.00 - 835 CARDIAC SHUNT IMAGING 881.00 - 836 CARDIOASSIST EXTERNAL 322.00 - 837 CARDIOASSIST INTERNAL 617.00 - 838 CARDIOLIPIN ANTIBODY EA IG - 51.00 51.00 839 CARDIOVASCULAR NUCLEAR EXAM 881.00 - 840 CARDIOVASCULAR STRESS TEST 177.00 - 841 CARDIOVASCULAR STRESS TEST 195.00 - 842 CARDIOVASCULAR STRESS TEST 417.00 - 843 CARDIOVERSION ELECTRIC EXT 962.00 962.00 962.00 844 CARDIOVERSION ELECTRIC INT 842.00 - 845 CARE AFTER DELIVERY 393.00 - 393.00 846 CARE MGMT SVC BHVL HLTH COND 91.00 - 847 Carmustine injection 439.00 439.00 848 CAROTID INTIMA ATHEROMA EVAL 157.00 - 849 Case management 16.00 20.00 20.00 850 Caspofungin acetate 38.00 38.00 851 Cast sup gauntlet fiberglass 53.00 53.00 852 Cast sup lng arm splint fbrg 53.00 53.00 853 Cast sup lng arm splint plst 53.00 53.00 854 Cast sup lng arm splnt ped f 53.00 53.00 855 Cast sup lng arm splnt ped p 27.00 27.00 856 Cast sup lng leg ped fbrgls 53.00 53.00 857 Cast sup lng leg splnt fbrgl 53.00 53.00 858 Cast sup lng leg splnt plstr 53.00 53.00 859 Cast sup long arm adult fbrg 53.00 53.00 860 Cast sup long arm adult plst 42.00 42.00 861 Cast sup long arm ped fbrgls 105.00 105.00 862 Cast sup long arm ped plster 53.00 53.00 863 Cast sup long leg fiberglass 53.00 53.00 864 Cast sup long leg plaster 53.00 53.00 865 Cast sup shrt leg fiberglass 105.00 105.00 866 Cast sup shrt leg ped fbrgls 53.00 53.00 867 Cast sup shrt leg ped plster 53.00 53.00 868 Cast sup shrt leg plaster 53.00 53.00 869 Cast sup sht arm adult fbrgl 105.00 105.00 870 Cast sup sht arm adult plstr 83.00 83.00 871 Cast sup sht arm ped fbrglas 105.00 105.00 872 Cast sup sht arm splint fbrg 53.00 53.00 873 Cast sup sht arm splint plst 53.00 53.00 874 Cast sup sht arm splnt ped f 53.00 53.00 875 Cast sup sht leg splnt fbrgl 53.00 53.00 876 Cast sup sht leg splnt ped f 53.00 53.00 Physician Hospital Village Description # Charge Charge Charge 877 Cast sup sht leg splnt plstr 53.00 53.00 878 Cast supplies (plaster) - 105.00 105.00 879 Cast supplies unlisted 27.00 27.00 880 Caster fork 395.00 395.00 881 Caster fork replacement only 148.00 148.00 882 Caster pin lock each 131.00 131.00 883 Caster wheel excludes tire 68.00 68.00 884 Caster wheel excludes tire 183.00 183.00 885 CASTING/STRAPPING PROCEDURE 153.00 624.00 - 886 CAT SCAN FOLLOW-UP STUDY 282.00 - 887 CATARACT SURG W/IOL 1 STAGE 1,167.00 4,800.00 - 888 Cath impl vasc access portal - 11.00 11.00 889 Cath indw foley 2 way silicn 30.00 890 Cath indw foley 3 way 67.00 67.00 891 Cath insertion tray w/bag 62.00 62.00 892 Cath w/drainage 2-way latex - 53.00 53.00 893 Cath w/drainage 2-way silcne - 37.00 37.00 894 Cath w/drainage 3-way 110.00 110.00 895 Cath w/o bag 2-way silicone 83.00 83.00 896 Cath, drainage 164.00 164.00 897 Catheter w/bag 3-way 92.00 92.00 898 Catheter w/o bag 2-way latex 64.00 64.00 899 Catheterize for urine spec - 53.00 53.00 900 Cbc without platelet 25.00 25.00 901 Cbc/diffwbc w/o platelet 30.00 30.00 902 CBT 1ST HOUR 228.00 903 CBT EACH ADDL HOUR 86.00 904 CCP ANTIBODY - 83.00 83.00 905 Cefazolin sodium injection - 5.00 5.00 906 Cefepime hcl for injection - 8.00 8.00 907 Cefotaxime sodium injection 13.00 13.00 908 Cefoxitin sodium injection - 27.00 27.00 909 Ceftaroline fosamil inj 3.00 3.00 910 Ceftizoxime sodium / 500 mg 53.00 53.00 911 Ceftriaxone sodium injection - 5.00 5.00 912 CELL CRYOPRESERVE/STORAGE 40.00 - 913 CELL ENUMERATION & ID 36.00 - 914 CELL ENUMERATION PHYS INTERP 36.00 - 915 CELL FUNCTION ASSAY W/STIM 532.00 - 916 CELL MARKER STUDY 109.00 - 917 Cer post col occ/man sup adj 893.00 893.00 918 CEREBROSPINAL FLUID SCAN 1,306.00 - 919 CEREBROSPINAL FLUID SCAN 1,306.00 - 920 Cerv col sr foam 2pc pre ots 379.00 379.00 921 Cerv flex n/adj foam pre ots - 137.00 137.00 922 Cerv semi-rig adj molded chn 328.00 328.00 923 Cerv sr 2pc thor ext pre ots 816.00 816.00 924 Cerv sr wire occ/man pre ots 456.00 456.00 925 Cervic collar w air bladders 400.00 400.00 926 Cervical head harness/halter 89.00 89.00 927 Cervical semi-rigid adjustab 271.00 271.00 928 Cetuximab injection 155.00 155.00 929 CHCT FOR MAL HYPERTHERMIA 36.00 - 930 CHEM CAUT OF GRANLTJ TISSUE 175.00 624.00 175.00 931 CHEMILUMINESCENT ASSAY 55.00 - 932 CHEMO ANTI-NEOPL SQ/IM - 220.00 111.00 933 CHEMO IA INFUSE EACH ADDL HR 635.00 934 CHEMO IA INFUSION UP TO 1 HR 1,560.00 935 CHEMO IA PUSH TECNIQUE 966.00 936 CHEMO INTRALESIONAL OVER 7 160.00 - 937 CHEMO INTRALESIONAL UP TO 7 106.00 - 938 CHEMO IV INFUS EACH ADDL SEQ 166.00 939 CHEMO IV INFUSION 1 HR 357.00 Physician Hospital Village Description # Charge Charge Charge 940 CHEMO IV INFUSION ADDL HR 66.00 941 CHEMO IV PUSH SNGL DRUG 405.00 942 CHEMO PROLONG INFUSE W/PUMP 378.00 943 CHEMOTAXIS ASSAY 63.00 - 944 CHEMOTHERAPY INJECTION 718.00 718.00 945 CHEMOTHERAPY INTO CNS 277.00 - 946 CHEMOTHERAPY INTRACAVITARY 491.00 - 947 CHEMOTX ADMN PRTL CAVITY 74.00 - 948 CHEST SURGERY PROCEDURE 16.00 2,050.00 - 949 Chest wrap 254.00 254.00 950 Chin cup interface 147.00 147.00 951 CHIROPRACT MANJ 1-2 REGIONS 73.00 - 952 CHIROPRACT MANJ 3-4 REGIONS 107.00 - 953 CHIROPRACT MANJ XTRSPINL 1/> 71.00 - 954 CHIROPRACTIC MANJ 5 REGIONS 143.00 - 955 CHLAMYDIA ANTIBODY 83.00 83.00 956 CHLAMYDIA CULTURE 83.00 83.00 957 CHLAMYDIA IGM ANTIBODY 50.00 - 958 CHLAMYDIA TRACHOMATIS AG IF 47.00 - 959 Chloramphenicol sodium injec 70.00 70.00 960 Chloroprocaine hcl injection 67.00 67.00 961 Chlorothiazide sodium inj 454.00 454.00 962 CHORIONIC GONADOTROPIN ASSAY - 51.00 51.00 963 CHORIONIC GONADOTROPIN TEST - 83.00 83.00 964 Chorionic gonadotropin/1000u 38.00 38.00 965 CHROMATOGRAM ASSAY SUGARS 77.00 - 966 CHROMOGENIC SUBSTRATE ASSAY 47.00 - 967 CHROMOSOME ANALYS AMNIOTIC 652.00 - 968 CHROMOSOME ANALYS PLACENTA 704.00 - 969 CHROMOSOME ANALYSIS 100 678.00 - 970 CHROMOSOME ANALYSIS 15-20 441.00 441.00 971 CHROMOSOME ANALYSIS 20-25 488.00 - 972 CHROMOSOME ANALYSIS 20-25 583.00 - 973 CHROMOSOME ANALYSIS 45 589.00 - 974 CHROMOSOME ANALYSIS 5 692.00 - 975 CHROMOSOME ANALYSIS 50-100 678.00 - 976 CHROMOSOME BANDING STUDY 269.00 - 977 CHROMOSOME COUNT ADDITIONAL 74.00 - 978 CHROMOSOME KARYOTYPE STUDY 98.00 - 979 CHROMOSOME STUDY ADDITIONAL 135.00 - 980 CHYLMD PNEUM DNA AMP PROBE 137.00 - 981 CHYLMD PNEUM DNA DIR PROBE 83.00 83.00 982 CHYLMD PNEUM DNA QUANT 168.00 - 983 CHYLMD TRACH AG IA 47.00 47.00 984 CHYLMD TRACH ASSAY W/OPTIC 47.00 - 985 CHYLMD TRACH DNA AMP PROBE - 83.00 83.00 986 CHYLMD TRACH DNA DIR PROBE 79.00 - 987 CHYLMD TRACH DNA QUANT 137.00 - 988 Cid transmit coil and cable 450.00 450.00 989 Cilastatin sodium injection 27.00 27.00 990 CINE/VID X-RAY THROAT/ESOPH 494.00 - 991 CINE/VIDEO X-RAYS 326.00 - 992 Ciprofloxacin iv 3.00 3.00 993 CIRCUMCISION NEONATE 814.00 4,800.00 814.00 994 CIRCUMCISION W/REGIONL BLOCK 612.00 4,800.00 612.00 995 Cisplatin 10 mg injection 7.00 7.00 996 CLEAN OUT MASTOID CAVITY 324.00 624.00 324.00 997 CLEAR OUTER EAR CANAL 318.00 405.00 318.00 998 Clofarabine injection 316.00 316.00 999 Clonidine hydrochloride 72.00 72.00 1,000 CLOSE TEAR DUCT OPENING 618.00 1,026.00 618.00 1,001 CLOSED TX NOSE FX W/O MANJ 548.00 1,026.00 548.00 1,002 CLOSED TX NOSE FX W/O STABLJ 958.00 3,780.00 958.00 Physician Hospital Village Description # Charge Charge Charge 1,003 CLOSED TX ORBIT W/O MANIPULJ 675.00 2,050.00 - 1,004 CLOSED TX VERT FX W/O MANJ 1,227.00 1,026.00 - 1,005 CLOSTRIDIUM AG IA 133.00 133.00 1,006 CLOSTRIDIUM TOXIN A W/OPTIC 47.00 - 1,007 CLOSURE OF SPLIT WOUND 613.00 1,026.00 613.00 1,008 CLOSURE OF SPLIT WOUND 696.00 2,050.00 696.00 1,009 CLOT FACTOR FLETCHER FACT 74.00 - 1,010 CLOT FACTOR II PROTHROM SPEC - 51.00 - 1,011 CLOT FACTOR IX PTC/CHRSTMAS 180.00 180.00 1,012 CLOT FACTOR VII PROCONVERTIN 70.00 - 1,013 CLOT FACTOR VIII AHG 1 STAGE 70.00 - 1,014 CLOT FACTOR VIII MULTIMETRIC 90.00 - 1,015 CLOT FACTOR VIII RELTD ANTGN 80.00 - 1,016 CLOT FACTOR VIII VW ANTIGEN 90.00 - 1,017 CLOT FACTOR VIII VW RISTOCTN 90.00 - 1,018 CLOT FACTOR WGHT KININOGEN 74.00 - 1,019 CLOT FACTOR X STUART-POWER 83.00 83.00 1,020 CLOT FACTOR XI PTA 187.00 187.00 1,021 CLOT FACTOR XII HAGEMAN 86.00 86.00 1,022 CLOT FACTOR XIII FIBRIN SCRN 35.00 - 1,023 CLOT FACTOR XIII FIBRIN STAB 64.00 - 1,024 CLOT INHIBIT PROT C ACTIVITY - 249.00 249.00 1,025 CLOT INHIBIT PROT C ANTIGEN 233.00 233.00 1,026 CLOT INHIBIT PROT S FREE - 223.00 223.00 1,027 CLOT INHIBIT PROT S TOTAL 175.00 175.00 1,028 CLOTTING ASSAY WHOLE BLOOD 71.00 - 1,029 CLOTTING FUNCT ACTIVITY 90.00 - 1,030 Clsd ostomy pouch faceplate 8.00 8.00 1,031 Clsd ostomy pouch w/flange 8.00 8.00 1,032 Clsd ostomy pouch w/o barr 7.00 7.00 1,033 CLTX MED ANKLE FX W/MNPJ 2,910.00 4,800.00 - 1,034 CLTX MEDIAL ANKLE FX 1,380.00 1,026.00 1,380.00 1,035 CMPLX RPR E/N/E/L 1.1-2.5 CM 1,561.00 2,050.00 1,561.00 1,036 CMPLX RPR E/N/E/L 2.6-7.5 CM 2,498.00 2,050.00 2,498.00 1,037 CMPLX RPR F/C/C/M/N/AX/G/H/F 1,424.00 1,026.00 1,424.00 1,038 CMPLX RPR F/C/C/M/N/AX/G/H/F 1,956.00 2,050.00 1,956.00 1,039 CMPLX RPR S/A/L 2.6-7.5 CM 1,424.00 2,050.00 1,424.00 1,040 CMPLX RPR S/A/L ADDL 5 CM/> 586.00 - 586.00 1,041 CMPLX RPR TRUNK 2.6-7.5 CM 1,295.00 2,050.00 1,295.00 1,042 Cmprsburngarment glove-wrist - 36.00 - 1,043 CMPTR OPHTH DX IMG ANT SEGMT 70.00 121.00 - 1,044 CMPTR OPHTH IMG OPTIC NERVE 160.00 121.00 - 1,045 CMV ANTIBODY 83.00 83.00 1,046 CMV ANTIBODY IGM 137.00 137.00 1,047 COAGULATION TIME ACTIVATED 17.00 - 1,048 COAGULATION TIME LEE & WHITE 17.00 - 1,049 COAGULATION TIME OTR METHOD 15.00 - 1,050 COCCIDIOIDES ANTIBODY 45.00 - 1,051 COCCIDIOIDOMYCOSIS SKIN TEST 19.00 - 1,052 Coch implant headset replace 855.00 855.00 1,053 Coch implant microphone repl 249.00 249.00 1,054 Coch implant tran cable repl 75.00 75.00 1,055 Coch implant trans coil repl 217.00 217.00 1,056 COCHLEAR IMPLT F/UP EXAM <7 401.00 - 1,057 COCHLEAR IMPLT F/UP EXAM 7/> 425.00 - 1,058 COGNITIVE TEST BY HC PRO 555.00 - 1,059 COL CHROMOTOGRAPHY QUAL/QUAN - 214.00 214.00 1,060 COLD AGGLUTININ SCREEN 51.00 51.00 1,061 COLD AGGLUTININ TITER 32.00 - 1,062 Colistimethate sodium inj 39.00 39.00 1,063 Collagen based wound filler 121.00 121.00 1,064 COLLAGEN CROSSLINKS 73.00 - 1,065 Collagen dressing <=16 sq in 82.00 82.00 Physician Hospital Village Description # Charge Charge Charge 1,066 Collagen dressing >48 sq in 495.00 495.00 1,067 Collagen drsg>16<=48 sq in 27.00 27.00 1,068 Collagen dsg wound filler 28.00 28.00 1,069 Collagen gel/paste wound fil 10.00 10.00 1,070 Collagen imp urinary 2.5 ml 819.00 819.00 1,071 Collagenase, clost hist inj 113.00 113.00 1,072 COLLECT BLOOD FROM PICC - 125.00 - 1,073 COLLECT SWEAT FOR TEST 109.00 - 1,074 Colon ca screen;barium enema 636.00 - 1,075 Colon ca scrn not hi rsk ind 778.00 1,968.00 - 1,076 Colon ca scrn; barium enema 636.00 - 1,077 Colon ca scrn; barium enema 866.00 - 1,078 COLON MOTILITY 6 HR STUDY 566.00 - 1,079 COLONOSCOPY & POLYPECTOMY 1,253.00 3,000.00 1,253.00 1,080 COLONOSCOPY AND BIOPSY 928.00 3,000.00 - 1,081 COLONOSCOPY SUBMUCOUS NJX 881.00 3,000.00 - 1,082 COLONOSCOPY THRU STOMA SPX 1,777.00 2,550.00 1,777.00 1,083 COLONOSCOPY W/ABLATION - 2,370.00 - 1,084 COLONOSCOPY W/CONTROL BLEED 1,180.00 3,000.00 - 1,085 COLONOSCOPY W/FB REMOVAL 973.00 3,000.00 - 1,086 COLONOSCOPY W/LESION REMOVAL 968.00 3,000.00 - 1,087 COLONOSCOPY W/LESION REMOVAL 1,100.00 3,000.00 - 1,088 COLOR VISION EXAMINATION 121.00 - 1,089 Colorectal scrn; hi risk ind 778.00 1,529.00 - 1,090 COLPOPEXY INTRAPERITONEAL 3,174.00 4,800.00 - 1,091 Combination oral/nasal mask 414.00 414.00 1,092 Commode chair electric 418.00 418.00 1,093 Commode chair foot rest 189.00 189.00 1,094 Commode chair non-electric 113.00 113.00 1,095 Commode chair pail or pan 45.00 45.00 1,096 Commode chair with detacharm 76.00 76.00 1,097 Commode chair with fixed arm 393.00 393.00 1,098 COMMUNITY/WORK REINTEGRATION 154.00 - 1,099 Comp comm supp svc, 15 min 18.00 18.00 18.00 1,100 Comp multidisipln evaluation 27.00 27.00 1,101 COMPATIBILITY TEST ANTIGLOB - 105.00 - 1,102 COMPATIBILITY TEST ELECTRIC 51.00 - 1,103 COMPATIBILITY TEST INCUBATE 51.00 - 1,104 COMPATIBILITY TEST SPIN 51.00 - 1,105 COMPLEMENT ANTIGEN - 83.00 83.00 1,106 COMPLEMENT FIXATION EACH 39.00 - 1,107 COMPLEMENT TOTAL (CH50) - 133.00 133.00 1,108 COMPLEMENT/FUNCTION ACTIVITY 47.00 - 1,109 COMPLETE CBC AUTOMATED - 51.00 51.00 1,110 COMPLETE CBC W/AUTO DIFF WBC - 83.00 83.00 1,111 COMPLEX BODY SECTION X-RAY 728.00 - 1,112 COMPLEX BODY SECTION X-RAYS 728.00 - 1,113 COMPLEX DRAINAGE WOUND 833.00 4,800.00 833.00 1,114 Composite drsg <= 16 sq in 15.00 15.00 1,115 Composite drsg >16<=48 sq in 28.00 28.00 1,116 COMPREHEN METABOLIC PANEL - 133.00 133.00 1,117 COMPREHENSIVE HEARING TEST 228.00 397.00 228.00 1,118 Comprehensive med svc 15 min 75.00 - 1,119 COMPREHENSIVE REVIEW OF DATA 172.00 - 1,120 Compression bandage - 15.00 15.00 1,121 Compression stocking bk30-40 169.00 169.00 1,122 Compression stocking bk40-50 - 198.00 198.00 1,123 Compressor air power source 205.00 205.00 1,124 Compressor nondispos filter 20.00 20.00 1,125 CONDITIONING PLAY AUDIOMETRY - 354.00 149.00 1,126 Conductive gel or paste 27.00 27.00 1,127 Conform band n/s w<3"/yd 2.00 2.00 1,128 Conform band n/s w>=3"<5"/yd 2.00 2.00 Physician Hospital Village Description # Charge Charge Charge 1,129 Conform band n/s w>=5"/yd 3.00 3.00 1,130 Conform band s w <3"/yd - 4.00 4.00 1,131 Conform band s w >=5"/yd 3.00 3.00 1,132 Conform band s w>=3" <5"/yd - 14.00 14.00 1,133 CONSULTATION WITH FAMILY 262.00 - 1,134 Cont airway pressure device 274.00 274.00 1,135 CONT GLUC MNTR PHYS/QHP EQP 375.00 - 1,136 Cont pas motion exercise dev 27.00 1,137 Contact layer >16<= 48 sq in 33.00 33.00 1,138 CONTACT LENS FITTING 30.00 50.00 30.00 1,139 CONTACT LENS FITTING 175.00 - 1,140 CONTACT LENS FITTING 222.00 121.00 - 1,141 CONTACT LENS FITTING 200.00 185.00 - 1,142 CONTACT LENS FITTING FOR TX 262.00 50.00 262.00 1,143 Continent stoma catheter 39.00 39.00 1,144 CONTRAST BATH THERAPY 93.00 - 1,145 CONTRAST EXAM ABDOMINL AORTA 6,326.00 - 1,146 CONTRAST EXAM THORACIC AORTA 6,326.00 - 1,147 CONTRAST EXAM THORACIC AORTA 6,326.00 - 1,148 CONTRAST X-RAY BLADDER 372.00 - 1,149 CONTRAST X-RAY ESOPHAGUS 425.00 - 1,150 CONTRAST X-RAY EXAM OF COLON 350.00 - 1,151 CONTRAST X-RAY EXAM OF COLON 599.00 - 1,152 CONTRAST X-RAY EXAM OF COLON 822.00 - 1,153 CONTRAST X-RAY GALLBLADDER 236.00 - 1,154 CONTRAST X-RAY OF ANKLE 851.00 - 1,155 CONTRAST X-RAY OF BRAIN 1,447.00 - 1,156 CONTRAST X-RAY OF BRAIN 1,447.00 - 1,157 CONTRAST X-RAY OF ELBOW 851.00 - 1,158 CONTRAST X-RAY OF HIP 851.00 - 1,159 CONTRAST X-RAY OF KNEE JOINT 851.00 - 1,160 CONTRAST X-RAY OF SHOULDER 851.00 - 1,161 CONTRAST X-RAY OF WRIST 851.00 - 1,162 CONTROL NOSE/THROAT BLEEDING 1,421.00 624.00 - 1,163 CONTROL OF NOSEBLEED 412.00 405.00 412.00 1,164 CONTROL OF NOSEBLEED 615.00 405.00 615.00 1,165 CONTROL OF NOSEBLEED 978.00 405.00 978.00 1,166 CONTRST X-RAY EXAM OF THROAT 353.00 - 1,167 CONTRST X-RAY UPPR GI TRACT 585.00 - 1,168 CONTRST X-RAY UPPR GI TRACT 655.00 - 1,169 CONTRST X-RAY UPPR GI TRACT 922.00 - 1,170 CONTRST X-RAY URINARY TRACT 586.00 - 1,171 CONTRST X-RAY URINARY TRACT 597.00 - 1,172 CONTRST X-RAY URINARY TRACT 597.00 - 1,173 CONTRST X-RAY URINARY TRACT 597.00 - 1,174 CONTRST X-RAY URINARY TRACT 597.00 - 1,175 COOMBS TEST DIRECT - 51.00 - 1,176 COOMBS TEST INDIRECT QUAL 28.00 - 1,177 COOMBS TEST INDIRECT TITER 51.00 - 1,178 CORNEAL HYSTERESIS DETER 30.00 156.00 - 1,179 CORNEAL TOPOGRAPHY 102.00 121.00 - 1,180 Corticorelin ovine triflutal 20.00 20.00 1,181 CORTISOL FREE 83.00 83.00 1,182 Cosyntropin cortrosyn inj 206.00 206.00 1,183 Cosyntropin injection nos 254.00 254.00 1,184 Coude tip urinary catheter 17.00 1,185 Coupling gel or paste 2.00 2.00 1,186 Covers for upright each 218.00 218.00 1,187 Cpap full face mask 423.00 423.00 1,188 CPTR OPHTH DX IMG POST SEGMT 150.00 121.00 - 1,189 Cranial cervical torticollis 572.00 572.00 1,190 C-REACTIVE PROTEIN - 83.00 83.00 1,191 C-REACTIVE PROTEIN HS 67.00 67.00 Physician Hospital Village Description # Charge Charge Charge 1,192 CREATE EARDRUM OPENING 880.00 2,050.00 880.00 1,193 CREATINE ISOFORMS 47.00 - 1,194 CREATINE MB FRACTION - 39.00 39.00 1,195 CREATININE CLEARANCE TEST 71.00 71.00 1,196 CRH STIMULATION PANEL 1,291.00 - 1,197 Crisis interven svc, 15 min 17.00 23.00 23.00 1,198 Crisis intervention per hour 300.00 121.00 121.00 1,199 CRITICAL CARE ADDL 30 MIN 485.00 764.00 485.00 1,200 CRITICAL CARE FIRST HOUR 914.00 1,527.00 914.00 1,201 Cromolyn sodium noncomp unit 2.00 2.00 1,202 Crutch and cane holder 169.00 169.00 1,203 Crutch forearm each 122.00 183.00 1,204 Crutch forearm pair 215.00 269.00 1,205 Crutch underarm each no wood 101.00 101.00 1,206 Crutch underarm each wood 127.00 127.00 1,207 Crutch underarm pair no wood - 162.00 162.00 1,208 Crutch underarm pair wood 121.00 146.00 1,209 Cryoprecipitate each unit 197.00 197.00 1,210 Cryoprecipitatereducedplasma 204.00 204.00 1,211 CRYOPRESERVATION EMBRYO(S) 172.00 - 1,212 CRYOPRESERVATION SPERM 67.00 - 1,213 CRYOPRESERVE TESTICULAR TISS 172.00 - 1,214 CRYOSURGERY ANAL LESION(S) 543.00 624.00 543.00 1,215 CRYOSURGERY PENIS LESION(S) 579.00 624.00 579.00 1,216 CRYOTHERAPY OF SKIN 175.00 - 175.00 1,217 CRYPTOCOCCUS ANTIBODY 56.00 - 1,218 CRYPTOCOCCUS NEOFORM AG IA 47.00 - 1,219 CRYPTOSPORIDIUM AG IA 47.00 - 1,220 CRYPTOSPORIDIUM AG IF 47.00 - 1,221 CSF LEAKAGE IMAGING 1,306.00 - 1,222 CSF SHUNT EVALUATION 753.00 - 1,223 CSF VENTRICULOGRAPHY 1,306.00 - 1,224 CT ABD & PELV 1/> REGNS 431.00 2,310.00 - 1,225 CT ABD & PELV W/CONTRAST 389.00 1,827.00 - 1,226 CT ABD & PELVIS W/O CONTRAST 372.00 1,160.00 - 1,227 CT ABDOMEN W/DYE 272.00 2,443.00 - 1,228 CT ABDOMEN W/O & W/DYE 300.00 2,929.00 - 1,229 CT ABDOMEN W/O DYE 255.00 1,902.00 - 1,230 CT ANGIO ABD&PELV W/O&W/DYE 588.00 1,375.00 - 1,231 CT ANGIO ABDOM W/O & W/DYE 473.00 967.00 - 1,232 CT ANGIO ABDOMINAL ARTERIES 593.00 967.00 - 1,233 CT ANGIO HRT W/3D IMAGE 635.00 762.00 - 1,234 CT ANGIO LWR EXTR W/O&W/DYE 471.00 967.00 - 1,235 CT ANGIO UPR EXTRM W/O&W/DYE 446.00 967.00 - 1,236 CT ANGIOGRAPH PELV W/O&W/DYE 452.00 967.00 - 1,237 CT ANGIOGRAPHY CHEST 478.00 967.00 - 1,238 CT ANGIOGRAPHY HEAD 374.00 2,552.00 - 1,239 CT ANGIOGRAPHY NECK 374.00 967.00 - 1,240 CT BONE DENSITY AXIAL 211.00 - 1,241 CT CHEST SPINE W/DYE 261.00 2,499.00 - 1,242 CT CHEST SPINE W/O & W/DYE 270.00 3,014.00 - 1,243 CT CHEST SPINE W/O DYE 213.00 2,113.00 - 1,244 CT COLONOGRAPHY DX 495.00 - 1,245 CT COLONOGRAPHY DX W/DYE 847.00 - 1,246 CT COLONOGRAPHY SCREENING 2,376.00 - 1,247 CT HEAD/BRAIN W/DYE 240.00 1,825.00 - 1,248 CT HEAD/BRAIN W/O & W/DYE 272.00 2,172.00 - 1,249 CT HEAD/BRAIN W/O DYE 180.00 1,586.00 - 1,250 CT HRT W/3D IMAGE 762.00 - 1,251 CT HRT W/3D IMAGE CONGEN 762.00 - 1,252 CT HRT W/O DYE W/CA TEST 141.00 - 1,253 CT LOWER EXTREMITY W/DYE 249.00 2,174.00 - 1,254 CT LOWER EXTREMITY W/O DYE 216.00 1,919.00 - Physician Hospital Village Description # Charge Charge Charge 1,255 CT LUMBAR SPINE W/DYE 261.00 2,534.00 - 1,256 CT LUMBAR SPINE W/O & W/DYE 270.00 3,631.00 - 1,257 CT LUMBAR SPINE W/O DYE 213.00 2,151.00 - 1,258 CT LWR EXTREMITY W/O&W/DYE 260.00 2,662.00 - 1,259 CT MAXILLOFACIAL W/DYE 278.00 2,103.00 - 1,260 CT MAXILLOFACIAL W/O & W/DYE 303.00 2,656.00 - 1,261 CT MAXILLOFACIAL W/O DYE 243.00 1,834.00 - 1,262 CT NECK SPINE W/DYE 261.00 2,585.00 - 1,263 CT NECK SPINE W/O & W/DYE 270.00 3,526.00 - 1,264 CT NECK SPINE W/O DYE 227.00 2,072.00 - 1,265 CT ORBIT/EAR/FOSSA W/DYE 2,129.00 2,129.00 - 1,266 CT ORBIT/EAR/FOSSA W/O DYE 184.00 1,754.00 - 1,267 CT ORBIT/EAR/FOSSA W/O&W/DYE 2,518.00 - 1,268 CT PELVIS W/DYE 249.00 2,037.00 - 1,269 CT PELVIS W/O & W/DYE 260.00 2,436.00 - 1,270 CT PELVIS W/O DYE 231.00 1,775.00 - 1,271 CT PROCEDURE 282.00 - 1,272 CT SCAN FOR LOCALIZATION 589.00 - 1,273 CT SCAN FOR NEEDLE BIOPSY 263.00 - 1,274 CT SCAN FOR THERAPY GUIDE 292.00 - 1,275 CT SFT TSUE NCK W/O & W/DYE 309.00 2,377.00 - 1,276 CT SOFT TISSUE NECK W/DYE 294.00 2,074.00 - 1,277 CT SOFT TISSUE NECK W/O DYE 273.00 1,730.00 - 1,278 CT THORAX W/DYE 266.00 2,297.00 - 1,279 CT THORAX W/O & W/DYE 293.00 2,813.00 - 1,280 CT THORAX W/O DYE 216.00 2,037.00 - 1,281 CT UPPER EXTREMITY W/DYE 248.00 2,121.00 - 1,282 CT UPPER EXTREMITY W/O DYE 216.00 1,890.00 - 1,283 CT UPPR EXTREMITY W/O&W/DYE 260.00 1,930.00 - 1,284 Ctlso axilla sling 195.00 195.00 1,285 Ctlso infant immobilizer 300.00 300.00 1,286 Cuffs adj lock w/ active con 1,879.00 1,879.00 1,287 CULTR BACTERIA EXCEPT BLOOD 83.00 83.00 1,288 CULTR OOCYTE/EMBRYO <4 DAYS 172.00 - 1,289 CULTR OOCYTE/EMBRYO <4 DAYS 172.00 - 1,290 CULTURE AEROBIC IDENTIFY - 83.00 83.00 1,291 CULTURE AEROBIC QUANT OTHER 51.00 51.00 1,292 CULTURE ANAEROBE IDENT EACH 32.00 - 1,293 CULTURE BACTERIA ANAEROBIC 37.00 - 1,294 CULTURE OF SPECIMEN BY KIT 34.00 - 1,295 CULTURE OTHR SPECIMN AEROBIC - 83.00 83.00 1,296 CULTURE SCREEN ONLY - 83.00 83.00 1,297 CULTURE TYPE IMMUNOFLUORESC 133.00 133.00 1,298 CULTURE TYPE IMMUNOLOGIC 20.00 - 1,299 CULTURE TYPE PULSE FIELD GEL 20.00 - 1,300 CULTURE TYPING ADDED METHOD 20.00 - 1,301 CULTURE TYPING GLC/HPLC 49.00 - 1,302 Cushioned headrest 453.00 453.00 1,303 Custom mold shoe remov prost 36.00 36.00 1,304 Cyclophosphamide 100 mg inj 70.00 70.00 1,305 Cyclophosphamide oral 25 mg 3.00 3.00 1,306 Cyclosporin parenteral 250mg 101.00 101.00 1,307 Cyclosporine oral 100 mg 13.00 13.00 1,308 Cyclosporine oral 25 mg 3.00 3.00 1,309 Cylinder tank carrier 333.00 333.00 1,310 Cymetra injectable 789.00 - 1,311 CYSTATIN C 53.00 - 1,312 CYSTOSCOPY 864.00 2,050.00 864.00 1,313 Cytarabine hcl 100 mg inj 3.00 3.00 1,314 CYTO/MOLECULAR REPORT 441.00 441.00 1,315 CYTOGENETIC STUDY 36.00 - 1,316 CYTOGENETICS 100-300 157.00 - 1,317 CYTOGENETICS 10-30 126.00 - Physician Hospital Village Description # Charge Charge Charge 1,318 CYTOGENETICS 25-99 136.00 - 1,319 CYTOGENETICS 3-5 105.00 - 1,320 CYTOGENETICS DNA PROBE 84.00 - 1,321 CYTOMEG DNA AMP PROBE 137.00 - 1,322 CYTOMEG DNA DIR PROBE 79.00 - 1,323 CYTOMEG DNA QUANT - 215.00 215.00 1,324 CYTOMEGALOVIRUS AG IA 47.00 - 1,325 CYTOMEGALOVIRUS DFA 47.00 - 1,326 CYTOPATH C/V AUTO FLUID REDO - 104.00 - 1,327 CYTOPATH C/V AUTO IN FLUID - 88.00 88.00 1,328 CYTOPATH C/V AUTO REDO 41.00 - 1,329 CYTOPATH C/V AUTO RESCREEN 60.00 - 1,330 CYTOPATH C/V AUTOMATED 45.00 - 1,331 CYTOPATH C/V INDEX ADD-ON 23.00 - 1,332 CYTOPATH C/V INTERPRET 53.00 53.00 1,333 CYTOPATH C/V MANUAL 133.00 133.00 1,334 CYTOPATH C/V REDO 41.00 - 1,335 CYTOPATH C/V THIN LAYER 40.00 40.00 1,336 CYTOPATH C/V THIN LAYER REDO 79.00 - 1,337 CYTOPATH CELL ENHANCE TECH 67.00 - 1,338 CYTOPATH CONCENTRATE TECH 67.00 - 1,339 CYTOPATH EVAL FNA REPORT 109.00 - 1,340 CYTOPATH FL NONGYN FILTER 67.00 - 1,341 CYTOPATH FL NONGYN SMEARS - 133.00 - 1,342 CYTOPATH SMEAR OTHER SOURCE 36.00 - 1,343 CYTOPATH SMEAR OTHER SOURCE 36.00 - 1,344 CYTOPATH SMEAR OTHER SOURCE 67.00 - 1,345 CYTOPATH TBS C/V AUTO REDO 41.00 - 1,346 CYTOPATH TBS C/V MANUAL 19.00 19.00 1,347 CYTOPATH TBS C/V REDO 41.00 - 1,348 CYTOPATH TBS C/V SELECT 41.00 - 1,349 CYTOPATHOLOGY PROCEDURE 36.00 - 1,350 CYTOTOXIC ANTIBODY SCREENING 116.00 - 1,351 CYTOTOXIC ANTIBODY SCREENING 155.00 - 1,352 CYTP DX EVAL FNA 1ST EA SITE 67.00 - 1,353 CYTP FNA EVAL EA ADDL 36.00 - 1,354 CYTP URINE 3-5 PROBES CMPTR 448.00 - 1,355 CYTP URNE 3-5 PROBES EA SPEC 448.00 - 1,356 D & C AFTER DELIVERY 1,780.00 4,800.00 1,780.00 1,357 D5w infusion - 7.00 7.00 1,358 Dacarbazine 100 mg inj 12.00 12.00 1,359 Dalteparin sodium 32.00 32.00 1,360 Daptomycin injection 2.00 2.00 1,361 Darbepoetin alfa, esrd use 12.00 12.00 1,362 Darbepoetin alfa, non-esrd 12.00 12.00 1,363 DARK FIELD EXAMINATION 42.00 - 1,364 DARK FIELD EXAMINATION 44.00 - 1,365 Daunorubicin citrate inj 610.00 610.00 1,366 Daunorubicin injection 66.00 66.00 1,367 DEB SKIN BONE AT FX SITE 3,554.00 4,800.00 3,554.00 1,368 DEB SUBQ TISSUE 20 SQ CM/< 493.00 1,026.00 493.00 1,369 DEBRIDE INFECTED SKIN 236.00 2,050.00 236.00 1,370 DEBRIDE INFECTED SKIN ADD-ON 141.00 - 141.00 1,371 DEBRIDE NAIL 1-5 98.00 405.00 98.00 1,372 DEBRIDE NAIL 6 OR MORE 162.00 405.00 162.00 1,373 DEBRIDE SKIN AT FX SITE 1,575.00 2,050.00 1,575.00 1,374 DEBRIDE SKIN MUSC AT FX SITE 2,012.00 2,050.00 2,012.00 1,375 DECALCIFY TISSUE 36.00 - 1,376 Decitabine injection 102.00 102.00 1,377 Degarelix injection 10.00 10.00 1,378 DEHYDROEPIANDROSTERONE 198.00 198.00 1,379 DEHYDROEPIANDROSTERONE 258.00 258.00 1,380 DELIVER PLACENTA 800.00 4,800.00 800.00 Physician Hospital Village Description # Charge Charge Charge 1,381 Denosumab injection 43.00 43.00 1,382 DEOXYCORTISOL 171.00 171.00 1,383 DEOXYRIBONUCLEASE ANTIBODY 83.00 83.00 1,384 Depo-estradiol cypionate inj 26.00 26.00 1,385 Depression screen annual 32.00 135.00 - 1,386 Dermacell 216.00 216.00 1,387 Dermagraft 123.00 123.00 1,388 DESIGN MLC DEVICE FOR IMRT 829.00 - 1,389 DESOXYCORTICOSTERONE 121.00 - 1,390 DESTROY PREMAL LESIONS 15/> 761.00 1,026.00 761.00 1,391 DESTROY VAG LESIONS SIMPLE 603.00 4,800.00 603.00 1,392 DESTROY VULVA LESIONS SIM 276.00 4,800.00 276.00 1,393 DESTRUCT B9 LESION 1-14 216.00 624.00 216.00 1,394 DESTRUCT LESION 15 OR MORE 286.00 624.00 286.00 1,395 DESTRUCT PREMALG LES 2-14 65.00 - 65.00 1,396 DESTRUCT PREMALG LESION 199.00 624.00 199.00 1,397 DESTRUCTION OF SKIN LESIONS 1,028.00 1,026.00 1,028.00 1,398 Detach adjust armrest base 172.00 172.00 1,399 Detach adjust armrst upper 96.00 96.00 1,400 Detach non-adj ht armrst rep 407.00 407.00 1,401 DETECT AGENT NOS DNA AMP 184.00 184.00 1,402 DETECT AGENT NOS DNA DIR 79.00 - 1,403 DETECT AGENT NOS DNA QUANT 168.00 - 1,404 DETECT AGNT MULT DNA AMPLI 275.00 - 1,405 DETECT AGNT MULT DNA DIREC 180.00 180.00 1,406 DETERMINE REFRACTIVE STATE 197.00 46.00 197.00 1,407 DEV INTERROG REMOTE 1/2/MLT 284.00 - 1,408 DEVELOPMENTAL SCREEN W/SCORE 101.00 101.00 1,409 DEVELOPMENTAL TEST EXTEND 422.00 259.00 - 1,410 DEVICE HANDLING PHYS/QHP 11.00 11.00 1,411 Dexamethasone intra implant 490.00 490.00 1,412 DEXAMETHASONE PANEL 282.00 - 1,413 Dexamethasone sodium phos - 2.00 2.00 1,414 Dexrazoxane hcl injection 415.00 415.00 1,415 Dextran 40 infusion 66.00 66.00 1,416 Dextran 75 infusion 44.00 44.00 1,417 Diab shoe for density insert 207.00 207.00 1,418 Diab shoe w/metatarsal bar 101.00 101.00 1,419 Diabetic custom molded shoe 413.00 413.00 1,420 Diabetic management program, 60.00 60.00 1,421 Diabetic shoe w/off set heel 101.00 101.00 1,422 Diabetic shoe w/roller/rockr 101.00 101.00 1,423 Diabetic shoe with wedge 101.00 101.00 1,424 DIAGNOSTIC ANOSCOPY SPX 220.00 405.00 220.00 1,425 DIAGNOSTIC COLONOSCOPY 778.00 2,550.00 - 1,426 DIAGNOSTIC LARYNGOSCOPY 268.00 624.00 268.00 1,427 DIAGNOSTIC LARYNGOSCOPY 697.00 624.00 697.00 1,428 DIAGNOSTIC SIGMOIDOSCOPY 535.00 2,550.00 535.00 1,429 Dialysis blood pressure cuff - 54.00 54.00 1,430 DIALYSIS ONE EVALUATION 299.00 - 1,431 DIALYSIS REPEATED EVAL 430.00 - 1,432 DIATHERMY EG MICROWAVE 33.00 - 1,433 Diazepam injection - 12.00 12.00 1,434 Diazoxide injection 221.00 221.00 1,435 Dicyclomine injection 100.00 100.00 1,436 Digoxin injection - 5.00 5.00 1,437 DILATE TEAR DUCT OPENING 548.00 1,026.00 548.00 1,438 DILATION AND CURETTAGE 1,020.00 4,800.00 1,020.00 1,439 DILATION OF CERVICAL CANAL 108.00 4,800.00 108.00 1,440 Dimecaprol injection 90.00 90.00 1,441 Dimenhydrinate injection 18.00 18.00 1,442 Dimethyl sulfoxide 50% 50 ml 215.00 215.00 1,443 Diphenhydramine hcl 50mg 2.00 2.00 Physician Hospital Village Description # Charge Charge Charge 1,444 Diphenhydramine hcl injectio - 5.00 5.00 1,445 DIPHTHERIA ANTIBODY 60.00 - 1,446 Dipyridamole injection 3.00 3.00 1,447 DIRECT ADVANCED LIFE SUPPORT 419.00 419.00 1,448 DISABILITY EXAMINATION 50.00 50.00 1,449 DISCOGRAPHY CERV/THOR SPINE 4,933.00 - 1,450 Disconnect insert locking wr 201.00 201.00 1,451 Disconnect locking wrist uni 401.00 401.00 1,452 Disk/foam pad +or- adhesive 7.00 7.00 1,453 Disposable canister for pump 31.00 31.00 1,454 Disposable compressor filter 3.00 3.00 1,455 Disposable corrugated tubing - 77.00 77.00 1,456 Disposable ext urethral dev 2.00 2.00 1,457 Disposable male external cat - 7.00 7.00 1,458 Disposable nebulizer prefill 41.00 41.00 1,459 Disposable nebulizer sml vol 7.00 7.00 1,460 Disposable underpads - 7.00 7.00 1,461 Dme supply or accessory, nos - 11.00 11.00 1,462 DNA ANTIBODY NATIVE - 83.00 83.00 1,463 DNA ANTIBODY SINGLE STRAND 47.00 - 1,464 DNA/RNA AMPLIFIED PROBE 137.00 - 1,465 DNA/RNA DIRECT PROBE 79.00 - 1,466 DNA/RNA SEQUENCING 452.00 - 1,467 Docetaxel injection 22.00 22.00 1,468 Dolasetron mesylate 55.00 55.00 1,469 DOMICIL/R-HOME VISIT EST PAT 105.00 1,470 DOMICIL/R-HOME VISIT NEW PAT 234.00 - 1,471 Dopamine injection - 2.00 2.00 1,472 DOPPLER COLOR FLOW ADD-ON 18.00 72.00 - 1,473 DOPPLER ECHO EXAM HEART 37.00 74.00 - 1,474 DOPPLER ECHO EXAM HEART 91.00 119.00 - 1,475 DOPPLER FLOW TESTING 63.00 298.00 - 1,476 Doripenem injection 2.00 2.00 1,477 Dornase alfa non-comp unit 92.00 92.00 1,478 Dorsi & plantar flex ass/res 374.00 374.00 1,479 Dorsiflexion assist each joi 312.00 312.00 1,480 DRAIN BLOOD FROM UNDER NAIL 194.00 405.00 194.00 1,481 DRAIN BREAST LESION ADD-ON 202.00 - 202.00 1,482 DRAIN CEREBRO SPINAL FLUID 1,045.00 2,050.00 1,045.00 1,483 DRAIN EXTERNAL EAR LESION 242.00 2,050.00 242.00 1,484 DRAIN LOWER LEG LESION 2,186.00 4,800.00 2,186.00 1,485 Drain ostomy pouch w/flange 12.00 12.00 1,486 DRAIN THIGH/KNEE LESION 2,280.00 4,800.00 2,280.00 1,487 DRAIN/INJ JOINT/BURSA W/O US 235.00 1,026.00 235.00 1,488 DRAIN/INJ JOINT/BURSA W/O US 262.00 1,026.00 262.00 1,489 DRAIN/INJ JOINT/BURSA W/O US 317.00 1,026.00 317.00 1,490 DRAIN/INJ JOINT/BURSA W/US 562.00 1,026.00 - 1,491 Drainable pch ex wear convex - 87.00 87.00 1,492 Drainable pch w ex wear barr 18.00 18.00 1,493 Drainable pch w st wear barr 26.00 26.00 1,494 Drainable plastic pch w fcpl 61.00 61.00 1,495 Drainable plstic pch w/o fp 18.00 18.00 1,496 Drainable rubber pch w fcplt 170.00 170.00 1,497 Drainable rubber pch w/o fp 110.00 110.00 1,498 DRAINAGE ABDOM ABSCESS OPEN 4,597.00 - - 1,499 Drainage board postural 76.00 76.00 1,500 DRAINAGE OF ARM BURSA 1,293.00 4,800.00 1,293.00 1,501 DRAINAGE OF ARM LESION 828.00 4,800.00 828.00 1,502 DRAINAGE OF BREAST LESION 347.00 2,050.00 347.00 1,503 DRAINAGE OF EYELID ABSCESS 639.00 1,026.00 639.00 1,504 DRAINAGE OF FINGER ABSCESS 837.00 624.00 837.00 1,505 DRAINAGE OF GLAND ABSCESS 194.00 624.00 194.00 1,506 DRAINAGE OF GUM LESION 279.00 405.00 279.00 Physician Hospital Village Description # Charge Charge Charge 1,507 DRAINAGE OF HEMATOMA/FLUID 366.00 4,800.00 366.00 1,508 DRAINAGE OF MOUTH LESION 516.00 2,050.00 516.00 1,509 DRAINAGE OF PILONIDAL CYST 417.00 2,050.00 - 1,510 DRAINAGE OF PILONIDAL CYST 618.00 2,050.00 - 1,511 DRAINAGE OF RECTAL ABSCESS 897.00 3,000.00 897.00 1,512 DRAINAGE OF SCROTUM 1,313.00 4,800.00 - 1,513 DRAINAGE OF SKIN ABSCESS 301.00 624.00 301.00 1,514 DRAINAGE OF SKIN ABSCESS 557.00 1,026.00 557.00 1,515 DRAINAGE OF TONSIL ABSCESS 703.00 624.00 703.00 1,516 DRAW BLOOD OFF VENOUS DEVICE - 123.00 - 1,517 DRESS/DEBRID P-THICK BURN L 579.00 1,026.00 500.00 1,518 DRESS/DEBRID P-THICK BURN M 413.00 624.00 413.00 1,519 DRESS/DEBRID P-THICK BURN S 231.00 624.00 231.00 1,520 Drive belt for pwc, repl 89.00 89.00 1,521 Drive wheel excludes tire 215.00 215.00 1,522 Drnble ostomy pouch w/o barr 9.00 9.00 1,523 Dronabinol 2.5mg oral 12.00 12.00 1,524 Drop lock knee 267.00 267.00 1,525 Drop lock retainer each 166.00 166.00 1,526 Droperidol injection 21.00 21.00 1,527 DRUG ASSAY CYCLOSPORINE - 51.00 51.00 1,528 DRUG SCREEN AMPHETAMINES 1/2 - 86.00 - 1,529 DRUG SCREEN QUANTALCOHOLS - 95.00 - 1,530 DRUG SCREENING BARBITURATES 63.00 - 1,531 DRUG SCREENING BUPRENORPHINE 90.00 - 1,532 DRUG SCREENING COCAINE 84.00 - 1,533 DRUG SCREENING FENTANYL 134.00 - 1,534 DRUG SCREENING METHADONE - 90.00 - 1,535 DRUG SCREENING OXYCODONE - 112.00 - 1,536 DRUG SCREENING PREGABALIN 76.00 - 1,537 DRUG SCREENING PROPOXYPHENE 107.00 - 1,538 DRUG SCREENING TAPENTADOL 76.00 - 1,539 DRUG SCREENING TRAMADOL 76.00 - 1,540 DRUG TEST PRSMV CHEM ANLYZR - 270.00 - 1,541 DRUG TEST PRSMV DIR OPT OBS - 55.00 - 1,542 DRUG TEST PRSMV INSTRMNT 70.00 - 1,543 DRUG/SUBSTANCE NOS 1-3 90.00 - 1,544 DRUG/SUBSTANCE NOS 4-6 90.00 - 1,545 DRUG/SUBSTANCE NOS 7/MORE 90.00 - 1,546 Drugs unclassified injection - 34.00 34.00 1,547 Dry pressure mattress 501.00 501.00 1,548 Dry pressure pad for mattres - 256.00 256.00 1,549 DTAP VACCINE < 7 YRS IM - 70.00 - 1,550 DTAP-HEP B-IPV VACCINE IM - 120.00 - 1,551 DTAP-IPV VACCINE 4-6 YRS IM - 171.00 - 1,552 DTAP-IPV/HIB VACCINE IM - 12.00 - 1,553 DX LARYNGOSCOPY EXCL NB 1,343.00 4,800.00 1,343.00 1,554 DX MAMMO INCL CAD BI 175.00 444.00 - 1,555 DX MAMMO INCL CAD UNI 150.00 348.00 - 1,556 DXA BONE DENSITY AXIAL 35.00 211.00 - 1,557 DXA BONE DENSITY/PERIPHERAL 100.00 - 1,558 E COLI 0157 AG IA 47.00 - 1,559 EAR AND THROAT EXAMINATION 342.00 - 1,560 Ear impression - 21.00 21.00 1,561 EAR MICROSCOPY EXAMINATION 141.00 35.00 141.00 1,562 EAR PROTECTOR EVALUATION 102.00 - 1,563 Ecallantide injection 639.00 639.00 1,564 ECG MONIT/REPRT UP TO 48 HRS 189.00 247.00 1,565 ECG MONIT/REPRT UP TO 48 HRS - 250.00 250.00 1,566 ECG MONIT/REPRT UP TO 48 HRS 458.00 312.00 1,567 ECG MONIT/REPRT UP TO 48 HRS 955.00 1,568 ECG RECORD/REVIEW 1,365.00 1,569 ECG/MONITORING AND ANALYSIS 320.00 - Physician Hospital Village Description # Charge Charge Charge 1,570 ECHO EXAM OF ABDOMEN 101.00 518.00 - 1,571 ECHO EXAM OF EYE 108.00 184.00 - 1,572 ECHO EXAM OF EYE 116.00 184.00 - 1,573 ECHO EXAM OF EYE 112.00 283.00 - 1,574 ECHO EXAM OF EYE THICKNESS 34.00 98.00 - 1,575 ECHO EXAM OF EYE WATER BATH 126.00 283.00 - 1,576 ECHO EXAM OF FETAL HEART 184.00 - 1,577 ECHO EXAM OF FETAL HEART 184.00 - 1,578 ECHO EXAM OF FETAL HEART 606.00 - 1,579 ECHO EXAM OF FETAL HEART 606.00 - 1,580 ECHO EXAM OF HEAD 109.00 184.00 - 1,581 ECHO EXAM UTERUS 684.00 - 1,582 ECHO EXAMINATION PROCEDURE 152.00 65.00 - 1,583 ECHO GUIDANCE RADIOTHERAPY 86.00 - 1,584 ECHO GUIDE CARDIOCENTESIS 192.00 - 1,585 ECHO GUIDE FOR AMNIOCENTESIS 494.00 - 1,586 ECHO GUIDE FOR ARTERY REPAIR 310.00 - 1,587 ECHO GUIDE FOR BIOPSY 115.00 744.00 - 1,588 ECHO GUIDE OVA ASPIRATION 50.00 - 1,589 ECHO TRANSESOPHAGEAL 183.00 - 1,590 ECHOGRAP TRANS R PROS STUDY 268.00 441.00 - 1,591 Eculizumab injection 498.00 498.00 1,592 Edetate calcium disodium inj - 403.00 403.00 1,593 Ef blenderized foods 5.00 - 1,594 Ef calorie dense>/=1.5kcal 2.00 2.00 1,595 Ef complet w/intact nutrient 3.00 3.00 1,596 Ef hydrolyzed/amino acids 3.00 3.00 1,597 Ef incomplete/modular 3.00 3.00 1,598 Ef ped caloric dense>/=0.7kc 2.00 2.00 1,599 Ef ped fluid and electrolyte 3.00 3.00 1,600 Ef ped hydrolyzed/amino acid 2.00 2.00 1,601 Ef spec metabolic noninherit 3.00 3.00 1,602 EGD BIOPSY SINGLE/MULTIPLE 616.00 2,550.00 1,675.00 1,603 EGD CAUTERY TUMOR POLYP 1,998.00 4,800.00 - 1,604 EGD DIAGNOSTIC BRUSH WASH 522.00 2,550.00 1,374.00 1,605 EGD DILATE STRICTURE 673.00 4,800.00 - 1,606 EGD INJECTION VARICES 954.00 4,800.00 - 1,607 EGD PLACE GASTROSTOMY TUBE 900.00 4,800.00 - 1,608 EGD REMOVE FOREIGN BODY 1,755.00 2,550.00 - 1,609 EGD REMOVE LESION SNARE 1,971.00 4,800.00 - 1,610 EGD TUBE/CATH INSERTION 559.00 4,800.00 - 1,611 EGD US FINE NEEDLE BX/ASPIR 1,038.00 4,800.00 - 1,612 EGD US FINE NEEDLE BX/ASPIR 1,508.00 4,800.00 - 1,613 EGD VARICES LIGATION 1,052.00 4,800.00 - 1,614 EGD W/TRANSMURAL DRAIN CYST 1,415.00 4,800.00 - 1,615 EHRLICHIA ANTIBODY 40.00 - 1,616 Eia hiv-1/hiv-2 screen 54.00 54.00 1,617 Ekg interpret & report preve 86.00 - 1,618 Elec osteogen stim implanted 616.00 616.00 1,619 Elec stim other than wound - 70.00 - 1,620 ELECTRIC CURRENT THERAPY 109.00 109.00 1,621 Electric heat pad moist 295.00 295.00 1,622 Electric heat pad standard 243.00 243.00 1,623 ELECTRIC STIMULATION THERAPY - 74.00 74.00 1,624 ELECTRICAL STIMULATION - 83.00 83.00 1,625 ELECTRO HEARNG AID TEST ONE 80.00 80.00 1,626 ELECTRO HEARNG AID TST BOTH 126.00 126.00 1,627 ELECTROCARDIOGRAM COMPLETE - - 171.00 1,628 ELECTROCARDIOGRAM REPORT 86.00 86.00 1,629 ELECTROCARDIOGRAM TRACING - 107.00 107.00 1,630 ELECTROCONVULSIVE THERAPY 382.00 - 1,631 Electrodes, pair 39.00 39.00 1,632 ELECTROLYTE PANEL 61.00 61.00 Physician Hospital Village Description # Charge Charge Charge 1,633 ELECTRON MICROSCOPY 448.00 - 1,634 ELECTROPHORETIC TEST 135.00 - 1,635 Elev legrst upr hangr rep ea 214.00 214.00 1,636 Elev lgrst lwr exten repl ea 66.00 66.00 1,637 Elevat proximal arm support 886.00 886.00 1,638 Elevate footrest articulate 286.00 286.00 1,639 Elevating whlchair leg rests 71.00 71.00 1,640 Elisa hiv-1/hiv-2 screen 54.00 54.00 1,641 Elliotts b solution per ml 14.00 14.00 1,642 EMBRYO HATCHING 172.00 - 1,643 EMERGENCY DEPT VISIT 146.00 84.00 - 1,644 EMERGENCY DEPT VISIT 230.00 145.00 - 1,645 EMERGENCY DEPT VISIT 385.00 380.00 - 1,646 EMERGENCY DEPT VISIT 592.00 607.00 - 1,647 EMERGENCY DEPT VISIT 853.00 948.00 - 1,648 Emr hd pmp elec/combo, rep 431.00 431.00 1,649 Emr pwr cbl combo vad, rep 509.00 509.00 1,650 Emr pwr cbl elec vad, rep 224.00 224.00 1,651 ENCEPHALITIS CALIFORN ANTBDY 52.00 - 1,652 ENCEPHALTIS EAST EQNE ANBDY 52.00 - 1,653 ENCEPHALTIS ST LOUIS ANTBODY 52.00 - 1,654 ENCEPHALTIS WEST EQNE ANTBDY 52.00 - 1,655 Enclosed walker w rear seat 713.00 713.00 1,656 Endo ak/hip knee extens assi 397.00 397.00 1,657 ENDOCERV CURETTAGE W/SCOPE 502.00 1,026.00 502.00 1,658 ENDOCRINE NUCLEAR PROCEDURE 428.00 - 1,659 ENDOSCOPIC US EXAM ESOPH 835.00 4,800.00 - 1,660 ENDOSCOPY BOWEL POUCH/BIOP 2,578.00 2,550.00 2,578.00 1,661 ENDOSCOPY SWALLOW (FEES) I&R 133.00 - 1,662 ENDOSCOPY SWALLOW (FEES) VID 234.00 234.00 - 1,663 Enfuvirtide injection 2.00 2.00 1,664 ENTAMOEB HIST DISPR AG IA 47.00 - 1,665 ENTAMOEB HIST GROUP AG IA 47.00 - 1,666 Enter feed supkit syr by day 21.00 - 1,667 Enteral feed sup kit grav by 28.00 - 1,668 Enteral feed supp pump per d 13.00 13.00 1,669 Enteral ng tubing w/ stylet 65.00 - 1,670 Enteral ng tubing w/o stylet 48.00 - 1,671 Enteral stomach tube levine 15.00 15.00 1,672 Enteral supp not otherwise c 4.00 4.00 1,673 ENTEROVIRUS ANTIBODY 83.00 83.00 1,674 ENTEROVIRUS ANTIBODY DFA 47.00 - 1,675 ENTEROVIRUS PROBE&REVRS TRNS 137.00 - 1,676 ENZYME CELL ACTIVITY 71.00 - 1,677 ENZYME CELL ACTIVITY RA 71.00 - 1,678 ENZYME HISTOCHEMISTRY 67.00 - 1,679 Eo adj jt prefab custom fit 995.00 995.00 1,680 Eo elas w/metal jnts pre ots 334.00 334.00 1,681 Eo rigid w/o joints pre ots 98.00 98.00 1,682 Eo w/o joints cf 263.00 263.00 1,683 EPIDUROGRAPHY 295.00 - 1,684 Epifix or epicord 383.00 383.00 1,685 Epoetin alfa, 100 units esrd - 4.00 4.00 1,686 Epoetin alfa, non-esrd - 36.00 36.00 1,687 Epoprostenol injection 42.00 42.00 1,688 EPSTEIN-BARR ANTIBODY 83.00 83.00 1,689 EPSTEIN-BARR CAPSID VCA - 124.00 124.00 1,690 EPSTEIN-BARR NUCLEAR ANTIGEN - 95.00 95.00 1,691 Eptifibatide injection 75.00 75.00 1,692 Eribulin mesylate injection 239.00 239.00 1,693 Ertapenem injection 95.00 95.00 1,694 Erwinaze injection 669.00 669.00 1,695 ESOPHAGEAL MOTILITY STUDY 732.00 - Physician Hospital Village Description # Charge Charge Charge 1,696 ESOPHAGOSCOPY FLEX REMOVE FB 1,860.00 4,800.00 - 1,697 ESOPHAGOSCOPY FLEXIBLE BRUSH 1,482.00 2,550.00 1,482.00 1,698 ESRD HOME PT SERV P DAY <2 61.00 - 1,699 ESRD HOME PT SERV P DAY 20+ 28.00 - 1,700 ESRD HOME PT SERV P MO <2YRS 1,894.00 - 1,701 ESRD HOME PT SERV P MO 12-19 1,570.00 - 1,702 ESRD HOME PT SERV P MO 20+ 836.00 - 1,703 ESRD HOME PT SERV P MO 2-11 1,651.00 - 1,704 ESRD HOME PT SRV P DAY 12-19 52.00 - 1,705 ESRD HOME PT SRV P DAY 2-11 53.00 - 1,706 ESRD SERV 1 VISIT P MO 20+ 649.00 - 1,707 ESRD SERV 1 VST P MO 12-19 1,031.00 - 1,708 ESRD SERV 4 VISITS P MO <2YR 3,221.00 - 1,709 ESRD SERV 4 VSTS P MO 2-11 2,802.00 - 1,710 ESRD SRV 1 VISIT P MO 2-11 1,100.00 - 1,711 ESRD SRV 2-3 VSTS P MO 12-19 1,518.00 - 1,712 ESRD SRV 2-3 VSTS P MO 20+ 838.00 - 1,713 ESRD SRV 2-3 VSTS P MO 2-11 1,582.00 - 1,714 ESRD SRV 4 VISITS P MO 20+ 994.00 - 1,715 ESRD SRV 4 VSTS P MO 12-19 2,232.00 - 1,716 ESTRADIOL RESPONSE PANEL 219.00 - 1,717 Estradiol valerate 10 mg inj 33.00 33.00 1,718 Etanercept injection - 483.00 483.00 1,719 Ethanolamine oleate 100 mg 600.00 600.00 1,720 Etonogestrel implant system - 660.00 660.00 1,721 Etoposide injection 2.00 2.00 1,722 Etoposide oral 50 mg 157.00 157.00 1,723 Euflexxa inj per dose 378.00 378.00 1,724 EUGLOBULIN LYSIS 33.00 - 1,725 EVAL AMNIOTIC FLUID PROTEIN 252.00 - 1,726 EVAL AUD REHAB STATUS 266.00 266.00 - 1,727 EVAL AUD STATUS REHAB ADD-ON 61.00 61.00 - 1,728 EVALUATE PT USE OF INHALER 110.00 110.00 1,729 EVALUATE SPEECH PRODUCTION 315.00 - 1,730 EVALUATE SWALLOWING FUNCTION 236.00 236.00 - 1,731 EVALUATION CERVICAL MUCUS 39.00 - 1,732 EVALUATION OF SPEECH FLUENCY 385.00 - 1,733 EVALUATION OF WHEEZING 44.00 711.00 - 1,734 EVOKED AUDITORY TEST LIMITED 429.00 - 1,735 EVOKED AUDITORY TEST QUAL 334.00 - 1,736 EVOKED AUDITORY TST COMPLETE - 429.00 - 1,737 EX FOR NONSPEECH DEV RX ADD 113.00 113.00 - 1,738 EX FOR NONSPEECH DEVICE RX 306.00 306.00 - 1,739 EX FOR SPEECH DEVICE RX 1HR 420.00 - 1,740 EX FOR SPEECH DEVICE RX ADDL 168.00 - 1,741 EXAM FECES FOR MEAT FIBERS 14.00 - 1,742 EXAM OF CERVIX W/SCOPE 569.00 624.00 569.00 1,743 EXAM SYNOVIAL FLUID CRYSTALS 51.00 51.00 1,744 EXC F/E/E/N/L MAL+MRG 0.6-1 811.00 2,050.00 811.00 1,745 EXC FACE-MM B9+MARG >4 CM 929.00 4,800.00 929.00 1,746 EXC FACE-MM B9+MARG 0.5 CM/< 447.00 2,050.00 447.00 1,747 EXC FACE-MM B9+MARG 0.6-1 CM 559.00 2,050.00 559.00 1,748 EXC FACE-MM B9+MARG 1.1-2 CM 698.00 2,050.00 698.00 1,749 EXC FACE-MM B9+MARG 2.1-3 CM 966.00 4,800.00 966.00 1,750 EXC FACE-MM B9+MARG 3.1-4 CM 639.00 4,800.00 639.00 1,751 EXC H-F-NK-SP B9+MARG >4 CM 1,356.00 4,800.00 1,356.00 1,752 EXC H-F-NK-SP B9+MARG 0.5/< 368.00 4,800.00 368.00 1,753 EXC H-F-NK-SP B9+MARG 0.6-1 482.00 2,050.00 482.00 1,754 EXC H-F-NK-SP B9+MARG 1.1-2 598.00 4,800.00 598.00 1,755 EXC H-F-NK-SP B9+MARG 2.1-3 785.00 4,800.00 785.00 1,756 EXC H-F-NK-SP B9+MARG 3.1-4 958.00 4,800.00 958.00 1,757 EXC THIGH/KNEE LES SC < 3 CM 964.00 4,800.00 964.00 1,758 EXC TR-EXT B9+MARG >4.0 CM 1,203.00 4,800.00 1,203.00 Physician Hospital Village Description # Charge Charge Charge 1,759 EXC TR-EXT B9+MARG 0.5 CM< 352.00 2,050.00 352.00 1,760 EXC TR-EXT B9+MARG 0.6-1 CM 431.00 1,026.00 431.00 1,761 EXC TR-EXT B9+MARG 1.1-2 CM 534.00 2,050.00 534.00 1,762 EXC TR-EXT B9+MARG 2.1-3CM 682.00 2,050.00 682.00 1,763 EXC TR-EXT B9+MARG 3.1-4 CM 843.00 4,800.00 843.00 1,764 EXCISE/REPAIR MOUTH LESION 1,818.00 4,800.00 - 1,765 EXCISION OF ANAL LESION(S) 909.00 4,800.00 909.00 1,766 EXCISION OF NAIL FOLD TOE 307.00 1,026.00 307.00 1,767 EXCISION OF TONGUE FOLD 1,541.00 3,780.00 - 1,768 EXCISION OF TONGUE LESION 542.00 4,800.00 - 1,769 Excursion amplifier pulley t 512.00 512.00 1,770 Exercise equipment - 61.00 - 1,771 EXHALED BREATH CONDENSATE 62.00 - 1,772 Expandable controller, initl 997.00 997.00 1,773 EXPLORE WOUND EXTREMITY 2,236.00 2,050.00 2,236.00 1,774 Ext breastprosthesis garment 197.00 197.00 1,775 EXT ECG RECORDING - 200.00 - 1,776 EXT ECG REVIEW AND INTERP 90.00 - 1,777 Ext ureth clmp or compr dvc 181.00 181.00 1,778 Ext wear ost skn barr <=4sq" 34.00 34.00 1,779 Ext wear ost skn barr >4sq" 38.00 38.00 1,780 EXTENDED CULTURE OF OOCYTES 172.00 - 1,781 Extended steel shank 221.00 221.00 1,782 Extension drainage tubing 15.00 15.00 1,783 Extension per extension per 301.00 301.00 1,784 External ambulatory infus pu 735.00 735.00 1,785 EXTERNAL RADIATION DOSIMETRY 313.00 - 1,786 External recharg sys extern 47.00 47.00 1,787 Extra heavy duty wheelchair 460.00 460.00 1,788 EXTRACRANIAL BILAT STUDY 151.00 464.00 - 1,789 EXTRACRANIAL UNI/LTD STUDY 102.00 464.00 - 1,790 EXTREMITY STUDY 114.00 298.00 - 1,791 EXTREMITY STUDY 177.00 464.00 - 1,792 EYE EXAM & TREATMENT 245.00 - 1,793 EYE EXAM ESTABLISH PATIENT 174.00 75.00 174.00 1,794 EYE EXAM NEW PATIENT 194.00 249.00 194.00 1,795 EYE EXAM NEW PATIENT 315.00 249.00 315.00 1,796 EYE EXAM WITH PHOTOS 120.00 185.00 - 1,797 EYE EXAM WITH PHOTOS 193.00 121.00 - 1,798 EYE EXAM&TX ESTAB PT 1/>VST 242.00 100.00 242.00 1,799 EYE PHOTOGRAPHY 167.00 121.00 - 1,800 F5 GENE - 291.00 - 1,801 Face tent 8.00 8.00 1,802 FACIAL NERVE FUNCTION TEST 80.00 196.00 - 1,803 FACTOR INHIBITOR TEST 50.00 - 1,804 Factor ix complex 4.00 4.00 1,805 Factor ix non-recombinant 3.00 3.00 1,806 Factor ix recombinant nos 4.00 4.00 1,807 Factor viia 6.00 6.00 1,808 Factor viii 3.00 3.00 1,809 Factor viii recombinant nos 4.00 4.00 1,810 Factor xiii anti-hem factor 22.00 22.00 1,811 FAMILY PSYTX W/O PT 50 MIN 276.00 53.00 - 1,812 FAMILY PSYTX W/PT 50 MIN 325.00 232.00 - 1,813 Family/couple counseling 20.00 20.00 1,814 FATS/LIPIDS FECES QUAL 70.00 70.00 1,815 FATS/LIPIDS FECES QUANT 81.00 81.00 1,816 FECAL BILIRUBIN TEST 18.00 - 1,817 Fecal blood scrn immunoassay - 62.00 62.00 1,818 FECES CULTURE AEROBIC BACT - 83.00 83.00 1,819 FEES W/LARYNGEAL SENSE I&R 145.00 - 1,820 FEES W/LARYNGEAL SENSE TEST 348.00 348.00 - 1,821 Fem urinary collect dev cup 180.00 180.00 Physician Hospital Village Description # Charge Charge Charge 1,822 Fem urinary collect pouch 38.00 38.00 1,823 Femoral lgth sock fx or equa 216.00 216.00 1,824 Fentanyl citrate injection - 5.00 5.00 1,825 Fern test 28.00 28.00 1,826 Ferumoxytol, esrd use 2.00 2.00 1,827 Ferumoxytol, non-esrd 2.00 2.00 1,828 FETAL BIOPHYS PROFIL W/O NST 133.00 283.00 - 1,829 FETAL BIOPHYS PROFILE W/NST 182.00 781.00 - 1,830 FETAL HEMOGLOBIN ASSAY QUAL 23.00 - 1,831 FETAL HEMOGLOBIN CHEMICAL 32.00 - 1,832 FETAL MONITOR/INTERPRET ONLY 151.00 - - 1,833 FETAL NON-STRESS TEST 154.00 320.00 318.00 1,834 FIBRIN DEGRADATION PRODUCTS 83.00 83.00 1,835 FIBRIN DEGRADATION QUANT - 133.00 133.00 1,836 FIBRIN DEGRADE SEMIQUANT 82.00 82.00 1,837 FIBRIN DEGRADJ D-DIMER 166.00 166.00 1,838 FIBRINOGEN ACTIVITY 83.00 83.00 1,839 FIBRINOGEN ANTIGEN 83.00 83.00 1,840 FIBRINOGEN TEST 34.00 - 1,841 FIBRINOGEN TEST 44.00 - 1,842 FIBRINOLYSINS SCREEN I&R 20.00 - 1,843 FIBRINOLYTIC ANTIPLASMIN 30.00 - 1,844 FIBRINOLYTIC PLASMIN 35.00 - 1,845 FIBRINOLYTIC PLASMINOGEN 26.00 - 1,846 FIBRINOLYTIC PLASMINOGEN 40.00 - 1,847 FIBRINOLYTIC PLASMINOGEN 67.00 - 1,848 Filter, non disposable w pap 43.00 43.00 1,849 Filtered nebulizer admin set 45.00 45.00 1,850 Filters elec/combo vad, rep 92.00 92.00 1,851 Finger splint, static 16.00 16.00 1,852 FIT APHAKIA SPECTCL MONOFOCL 66.00 185.00 - 1,853 FIT APHAKIA SPECTCL MULTIFOC 88.00 185.00 - 1,854 FIT CONTAC LENS FOR MANAGMNT 344.00 50.00 - 1,855 FIT SPECTACLES BIFOCAL 175.00 175.00 1,856 FIT SPECTACLES COMPOUND LENS 121.00 - 1,857 FIT SPECTACLES MONOFOCAL 155.00 155.00 1,858 FIT SPECTACLES MULTIFOCAL 386.00 386.00 1,859 FIT SPECTACLES SINGLE SYSTEM 121.00 - 1,860 FITTING OF DIAPHRAGM/CAP 152.00 624.00 152.00 1,861 Fixed adjust armrest pair 156.00 156.00 1,862 Fixed wing air mileage - 48.00 - 1,863 Fixed wing air transport - 11,018.00 - 1,864 Flebogamma injection 105.00 105.00 1,865 Flex/ext/rotation wrist unit 4,539.00 4,539.00 1,866 Flexhd/allopatchhd/matrixhd 96.00 - 1,867 Flexible metal hinge pair 540.00 540.00 1,868 Flexion/extension wrist unit 781.00 781.00 1,869 FLOWCYTOMETRY/ TC 1 MARKER 67.00 - 1,870 FLOWCYTOMETRY/READ 16 & > 67.00 - 1,871 FLOWCYTOMETRY/READ 2-8 67.00 - 1,872 FLOWCYTOMETRY/READ 9-15 67.00 - 1,873 FLOWCYTOMETRY/TC ADD-ON 36.00 - 1,874 Floxuridine injection 196.00 196.00 1,875 FLU VACC IIV3 NO PRESERV ID - 12.00 12.00 1,876 Fluconazole 15.00 15.00 1,877 Fludarabine phosphate inj 217.00 217.00 1,878 Flulaval vacc, 3 yrs & >, im 34.00 34.00 1,879 FLUORESCEIN ANGRPH UNI/BI 483.00 724.00 - 1,880 FLUORESCENT ANTIBODY SCREEN - 304.00 304.00 1,881 FLUORESCENT ANTIBODY TITER 133.00 133.00 1,882 FLUORO POLARIZE FETAL LUNG 74.00 - 1,883 FLUOROGUIDE FOR SPINE INJECT 230.00 - 1,884 FLUOROGUIDE FOR VEIN DEVICE 65.00 365.00 - Physician Hospital Village Description # Charge Charge Charge 1,885 FLUOROSCOPIC PROCEDURE 326.00 - 1,886 FLUOROSCOPY <1 HR PHYS/QHP 811.00 - 1,887 Fluphenazine decanoate 25 mg - 54.00 54.00 1,888 Fluvirin vacc, 3 yrs & >, im 42.00 42.00 1,889 Fluzone vacc, 3 yrs & >, im 42.00 42.00 1,890 FMRI BRAIN BY PHYS/PSYCH 965.00 - 1,891 FMRI BRAIN BY TECH 965.00 - 1,892 FNA W/IMAGE 228.00 2,050.00 - 1,893 FNA W/O IMAGE 452.00 1,026.00 - 1,894 Fo nontorsion joint cf 403.00 403.00 1,895 Fo pip dip jnt/sprng pre ots 173.00 173.00 1,896 Fo pip dip no jt spr pre ots 96.00 96.00 1,897 Fo w/o joints cf 487.00 487.00 1,898 Foam caster tire 84.00 84.00 1,899 Foam caster tire any size ea 266.00 266.00 1,900 Foam drg <=16 sq in w/border 38.00 38.00 1,901 Foam drg > 48 sq in w/border 40.00 40.00 1,902 Foam drg > 48 sq in w/o brdr 114.00 114.00 1,903 Foam drg >16<=48 sq in w/o b 78.00 78.00 1,904 Foam drive wheel tire 155.00 155.00 1,905 Foam drsg <=16 sq in w/o bdr 34.00 34.00 1,906 Foam filled caster tire 218.00 218.00 1,907 Foam filled drive wheel tire 421.00 421.00 1,908 FOAM STABILITY FETAL LUNG 74.00 - 1,909 Foam/fabric leg strap 61.00 61.00 1,910 FOLLOW-UP ANGIOGRAPHY 943.00 - 1,911 Followup eval of foot pt lop 100.00 100.00 - 1,912 Fomepizole, 15 mg 22.00 22.00 1,913 Fondaparinux sodium 15.00 15.00 1,914 Food thickener oral - 3.00 3.00 1,915 Foot arch supp longitud/meta - 222.00 222.00 1,916 Foot arch supp premold metat 142.00 142.00 1,917 Foot arch support remov prem 77.00 77.00 1,918 Foot drop splint pre ots 211.00 211.00 1,919 Foot external keel sach foot 530.00 530.00 1,920 Foot insert plastazote or eq 405.00 405.00 1,921 Foot insert remov molded spe 331.00 331.00 1,922 Foot insert silicone gel eac 437.00 437.00 1,923 Foot longitud/metatarsal sup 497.00 497.00 1,924 Foot longitudinal arch suppo 437.00 437.00 1,925 Foot plas heel stabi pre ots - 153.00 153.00 1,926 Foot single axis ankle/foot 805.00 805.00 1,927 Forearm crutch platform atta 242.00 242.00 1,928 Forearm/arm cuffs ext/flex a 1,250.00 1,250.00 1,929 Forearm/arm cuffs free motio 1,159.00 1,159.00 1,930 FORENSIC CYTOPATHOLOGY 67.00 - 1,931 Formoterol fumarate, inh 19.00 19.00 1,932 Fosaprepitant injection 6.00 6.00 1,933 Fosphenytoin inj pe 4.00 4.00 1,934 Fr cstr asmb sol tire rep ea 191.00 191.00 1,935 Fr cstr comp pne tire rep ea 355.00 355.00 1,936 Fr cstr semi-pne tire rep ea 214.00 214.00 1,937 Fr frz plasma donor retested 170.00 170.00 1,938 FRACTIONATION KETOSTEROIDS 103.00 - 1,939 Fracture frame attached to b 207.00 207.00 1,940 Fracture frame dual w cross 214.00 214.00 1,941 Fracture frame free standing 153.00 153.00 1,942 FRANCISELLA TULARENSIS 51.00 51.00 1,943 FREE ASSAY (FT-3) - 119.00 119.00 1,944 FROZEN BLOOD FREEZE/THAW 98.00 - 1,945 FROZEN BLOOD PREP 98.00 - 1,946 FROZEN BLOOD THAW 98.00 - 1,947 FROZEN CELL PREPARATION 40.00 - Physician Hospital Village Description # Charge Charge Charge 1,948 Frozen plasma, pooled, sd 217.00 217.00 1,949 Ft arch suprt premold longit 142.00 142.00 1,950 Ft insert ucb berkeley shell 630.00 630.00 1,951 Ft prosth multiaxial ankl/ft 991.00 991.00 1,952 Ftrst compl assembly repl ea 490.00 490.00 1,953 Ftrst lowr exten tube rep ea 66.00 66.00 1,954 Ftrst upr hanger brac rep ea 56.00 56.00 1,955 FULL MOUTH X-RAY OF TEETH 41.00 102.00 - 1,956 Full sole/heel wedge btween 164.00 164.00 1,957 FUNGI IDENTIFICATION MOLD 40.00 - 1,958 FUNGI IDENTIFICATION YEAST 51.00 51.00 1,959 FUNGUS ISOLATION CULTURE - 51.00 51.00 1,960 FUNGUS NES ANTIBODY - 186.00 186.00 1,961 Furosemide injection - 8.00 8.00 1,962 FUSION OF BIG TOE JOINT 3,179.00 4,800.00 3,179.00 1,963 GABAPENTIN NON-BLOOD 76.00 - 1,964 Gad-base mr contrast nos,1ml 4.00 4.00 1,965 Gadobutrol injection 2.00 2.00 1,966 Gadofosveset trisodium inj 36.00 36.00 1,967 Gadoxetate disodium inj 40.00 40.00 1,968 GAIT TRAINING THERAPY - 93.00 93.00 1,969 GALACTOSE TRANSFERASE TEST 33.00 - 1,970 GALECTIN-3 51.00 - 1,971 Galsulfase injection 711.00 711.00 1,972 Gamma globulin > 10 cc inj 475.00 475.00 1,973 Gamma globulin 1 cc inj 71.00 71.00 1,974 Gammagard liquid injection 113.00 113.00 1,975 Gammagraft 25.00 25.00 1,976 Gammaplex injection 110.00 110.00 1,977 Gamunex-c/gammaked 115.00 115.00 1,978 Ganciclovir sodium injection 217.00 217.00 1,979 Garamycin gentamicin inj - 5.00 5.00 1,980 GARDNER VAG DNA AMP PROBE 137.00 - 1,981 GARDNER VAG DNA DIR PROBE 79.00 - 1,982 GARDNER VAG DNA QUANT 164.00 - 1,983 GASTRIC ANALY W/PH EA SPEC 21.00 - 1,984 GASTRIC EMPTYING IMAG STUDY 732.00 - 1,985 GASTRIC MUCOSA IMAGING 732.00 - 1,986 Gastric suction pump hme mdl 197.00 197.00 1,987 GASTRIN TEST 69.00 - 1,988 Gastro/jejuno tube, low-pro 107.00 - 1,989 Gastro/jejuno tube, std 107.00 - 1,990 GASTROESOPHAGEAL REFLUX EXAM 732.00 - 1,991 GATED HEART MULTIPLE 881.00 - 1,992 GATED HEART PLANAR SINGLE 881.00 - 1,993 Gauze <= 16 sq in w/border 4.00 4.00 1,994 Gauze <=16 in no w/sal w/o b - 4.00 4.00 1,995 Gauze > 48 in no w/sal w/o b 6.00 1,996 Gauze >16 <=48 sq in w/bordr 12.00 12.00 1,997 Gauze >16<=48 no w/sal w/o b 6.00 6.00 1,998 Gauze >16<=48 sq in watr/sal 16.00 16.00 1,999 Gc stocking garter belt 27.00 27.00 2,000 Gc stocking thighlngth 18-30 - 50.00 - 2,001 Gel cap app device for trach 190.00 190.00 2,002 Gel cap for trach voice pros 8.00 8.00 2,003 Gel pressure mattress 157.00 157.00 2,004 Gel pressure mattress pad 392.00 392.00 2,005 Gen use back cush wdth <22in 700.00 700.00 2,006 Gen use back cush wdth>=22in 946.00 946.00 2,007 Gen w/c cushion wdth < 22 in 205.00 205.00 2,008 Gen w/c cushion wdth >=22 in 334.00 334.00 2,009 GENET VIRUS ISOLATE HSV 162.00 162.00 2,010 GENITOURINARY NUCLEAR EXAM 949.00 - Physician Hospital Village Description # Charge Charge Charge 2,011 GENOTYPE CYTOMEGALOVIRUS 1,009.00 - 2,012 GENOTYPE DNA HEPATITIS B 1,009.00 - 2,013 GENOTYPE DNA HIV REVERSE T 1,437.00 1,437.00 2,014 GENOTYPE DNA/RNA HEP C - 1,071.00 1,071.00 2,015 GENOTYPE DNA/RNA HIV 504.00 - 2,016 GI ENDOSCOPIC ULTRASOUND 152.00 441.00 - 2,017 GI NUCLEAR PROCEDURE 732.00 - 2,018 GI PROTEIN LOSS EXAM 732.00 - 2,019 GIARDIA AG IA - 83.00 83.00 2,020 GIARDIA AG IF 47.00 - 2,021 GIARDIA LAMBLIA ANTIBODY 58.00 - 2,022 Glassia injection 14.00 14.00 2,023 Glaucoma scrn hgh risk direc 203.00 145.00 - 2,024 Glaucoma scrn hgh risk direc 284.00 222.00 - 2,025 Glucagon hydrochloride/1 mg - 295.00 295.00 2,026 GLUCAGON TOLERANCE PANEL 180.00 - 2,027 GLUCAGON TOLERANCE PANEL 198.00 - 2,028 GLUCAGON TOLERANCE TEST 59.00 - 2,029 GLUCOSE BLOOD TEST - 28.00 28.00 2,030 Glucose monitor platforms 17.00 17.00 2,031 GLUCOSE OTHER FLUID - 51.00 51.00 2,032 GLUCOSE TEST - 83.00 83.00 2,033 GLUCOSE TOLERANCE TEST (GTT) - 139.00 139.00 2,034 GLYCOSYLATED HB HOME DEVICE - 38.00 - 2,035 GLYCOSYLATED HEMOGLOBIN TEST - 83.00 83.00 2,036 Gold sodium thiomaleate inj 75.00 75.00 2,037 Gonadorelin hydroch/ 100 mcg 21.00 21.00 2,038 GONADOTROPIN HORMONE PANEL 581.00 - 2,039 Goserelin acetate implant 446.00 446.00 2,040 Gr24 nonsealed leadacid 299.00 299.00 2,041 Gr24 sealed leadacid battery 417.00 417.00 2,042 Gr27 sealed leadacid battery 422.00 422.00 2,043 Gr34 sealed leadacid battery 483.00 483.00 2,044 Grafix core, grafixpl core 323.00 323.00 2,045 Grafix prime grafix pl prime 310.00 310.00 2,046 Graftjacket 248.00 248.00 2,047 Graftjacket xpress 789.00 - 2,048 Granisetron hcl 1 mg oral 6.00 6.00 2,049 Granisetron hcl injection 2.00 2.00 2,050 Gravity assisted traction de 215.00 215.00 2,051 Ground mileage 20.00 - 2,052 GROUP PSYCHOTHERAPY 63.00 126.00 63.00 2,053 GROUP THERAPEUTIC PROCEDURES 92.00 92.00 2,054 GROWTH HORMONE ANTIBODY 62.00 - 2,055 GROWTH HORMONE PANEL 261.00 - 2,056 GROWTH HORMONE PANEL 307.00 - 2,057 GTT-ADDED SAMPLES 51.00 51.00 2,058 H PYLORI (C-13) BLOOD 264.00 - 2,059 H PYLORI (C-13) BREATH - 387.00 387.00 2,060 H PYLORI AG IA 47.00 - 2,061 H PYLORI DRUG ADMIN 31.00 31.00 2,062 Haberman feeder - 22.00 - 2,063 Hallus-valgus nt dyn pre ots 130.00 130.00 2,064 Hallux implant 704.00 704.00 2,065 Halo repl liner/interface 432.00 432.00 2,066 Haloperidol decanoate inj - 55.00 55.00 2,067 Haloperidol injection - 7.00 7.00 2,068 HAND MUSCLE TESTING MANUAL 86.00 86.00 86.00 2,069 Handgrip for cane etc 16.00 16.00 2,070 Hand-held pefr meter 78.00 78.00 2,071 Hard protect helmet prefab 498.00 498.00 2,072 Harness chest/shlder saddle 868.00 868.00 2,073 Harness figure of 8 dual con 470.00 470.00 Physician Hospital Village Description # Charge Charge Charge 2,074 Harness figure of 8 sing con 386.00 386.00 2,075 HC PRO PHONE CALL 11-20 MIN 88.00 - 2,076 HC PRO PHONE CALL 21-30 MIN 1,120.00 - 2,077 HC PRO PHONE CALL 5-10 MIN 43.00 - 2,078 HCG FREE BETACHAIN TEST 59.00 - 2,079 Hd hosp bed, 350-600 lbs 605.00 605.00 2,080 Hd trapeze bar attach to bed 167.00 167.00 2,081 Hd trapeze bar free standing 320.00 320.00 2,082 HEARING AID CHECK BOTH EARS - 141.00 141.00 2,083 HEARING AID CHECK ONE EAR - 82.00 82.00 2,084 HEARING AID EXAM BOTH EARS 319.00 319.00 2,085 HEARING AID EXAM ONE EAR 230.00 230.00 2,086 Hearing aid fitting/checking - 93.00 93.00 2,087 Hearing service 93.00 93.00 2,088 HEART FIRST PASS ADD-ON 77.00 - 2,089 HEART FIRST PASS MULTIPLE 881.00 - 2,090 HEART FIRST PASS SINGLE 881.00 - 2,091 HEART IMAGE (PET) MULTIPLE 3,010.00 - 2,092 HEART IMAGE (PET) SINGLE 3,010.00 - 2,093 HEART IMAGE SPECT 881.00 - 2,094 HEART INFARCT IMAGE 881.00 - 2,095 HEART INFARCT IMAGE (3D) 881.00 - 2,096 HEART INFARCT IMAGE (EF) 881.00 - 2,097 HEART MUSCLE IMAGING (PET) 3,010.00 - 2,098 HEART/LUNG RESUSCITATION CPR 1,158.00 500.00 1,158.00 2,099 Heat & moisture exchange sys 6.00 6.00 2,100 Heat lamp with stand 563.00 563.00 2,101 Heat lamp without stand 451.00 451.00 2,102 Heavy duty battery 574.00 574.00 2,103 Heavy duty control cable 397.00 397.00 2,104 Heavy duty wheelchair 479.00 479.00 2,105 Heavy duty wheeled walker - 500.00 500.00 2,106 HEAVY METAL QUAL ANY ANAL 171.00 171.00 2,107 HEAVY METAL QUANT EACH NES 86.00 - 2,108 Heavyduty walker no wheels 356.00 356.00 2,109 Heavyduty/wide commode chair 490.00 490.00 2,110 Heel leather reinforced 191.00 191.00 2,111 HEINZ BODIES DIRECT 16.00 - 2,112 HEINZ BODIES INDUCED 27.00 - 2,113 HELICOBACTER PYLORI ANTIBODY 133.00 133.00 2,114 HELMINTH ANTIBODY 181.00 181.00 2,115 HEMAGGLUTINATION INHIBITION 51.00 51.00 2,116 HEMATOCRIT - 23.00 23.00 2,117 HEMATOPOIETIC NUCLEAR TX 858.00 - 2,118 Hemin, 1 mg 40.00 40.00 2,119 Hemi-wheelchair detachable a 282.00 282.00 2,120 Hemi-wheelchair fixed arms 222.00 222.00 2,121 HEMODIALYSIS ONE EVALUATION 251.00 - 2,122 HEMODIALYSIS REPEATED EVAL 359.00 - 2,123 HEMOGLOBIN - 19.00 19.00 2,124 HEMOGLOBIN CHROMOTOGRAPHY 71.00 - 2,125 HEMOGLOBIN COPPER SULFATE 18.00 18.00 2,126 HEMOGLOBIN ELECTROPHORESIS 133.00 133.00 2,127 HEMOGLOBIN FETAL 26.00 - 2,128 HEMOGLOBIN FETAL 30.00 - 2,129 HEMOGLOBIN STABILITY SCREEN 33.00 - 2,130 HEMOGLOBIN-OXYGEN AFFINITY 39.00 - 2,131 HEMOLYSIN ACID 35.00 - 2,132 HEMOLYSINS/AGGLUTININS 47.00 - 2,133 HEMOLYSINS/AGGLUTININS AUTO 32.00 - 2,134 HEMOPERFUSION 312.00 - 2,135 HEMOPHILUS INFLUENZA ANTIBDY 62.00 - 2,136 HEP A/HEP B VACC ADULT IM - 269.00 269.00 Physician Hospital Village Description # Charge Charge Charge 2,137 HEP B CORE ANTIBODY IGM 83.00 83.00 2,138 HEP B CORE ANTIBODY TOTAL - 83.00 83.00 2,139 HEP B IG IM 164.00 164.00 2,140 HEP B SURFACE ANTIBODY - 83.00 83.00 2,141 HEP C AB TEST CONFIRM 160.00 160.00 2,142 HEPA VACC PED/ADOL 2 DOSE IM - 171.00 - 2,143 HEPA VACCINE ADULT IM - 79.00 79.00 2,144 Hepagam b im injection 156.00 156.00 2,145 Hepagam b intravenous, inj 156.00 156.00 2,146 HEPARIN ASSAY 51.00 - 2,147 HEPARIN NEUTRALIZATION 46.00 - 2,148 HEPARIN-PROTAMINE TOLERANCE 56.00 - 2,149 HEPATIC FUNCTION PANEL - 83.00 83.00 2,150 HEPATITIS A ANTIBODY 83.00 83.00 2,151 HEPATITIS A IGM ANTIBODY - 83.00 83.00 2,152 HEPATITIS B DNA AMP PROBE 137.00 - 2,153 HEPATITIS B DNA QUANT - 565.00 565.00 2,154 HEPATITIS B SURFACE AG IA 40.00 - 2,155 HEPATITIS B SURFACE AG IA - 83.00 83.00 2,156 HEPATITIS BE AG IA 83.00 83.00 2,157 HEPATITIS BE ANTIBODY 83.00 83.00 2,158 HEPATITIS C AB TEST - 83.00 83.00 2,159 HEPATITIS C PROBE&RVRS TRNSC 137.00 - 2,160 HEPATITIS C REVRS TRNSCRPJ - 331.00 331.00 2,161 HEPATITIS C RNA DIR PROBE 79.00 - 2,162 HEPATITIS DELTA AG IA 64.00 - 2,163 HEPATITIS DELTA AGENT ANTBDY 67.00 - 2,164 HEPATITIS G DNA AMP PROBE 137.00 - 2,165 HEPATITIS G DNA DIR PROBE 79.00 - 2,166 HEPATITIS G DNA QUANT 164.00 - 2,167 HEPATOBIL SYST IMAGE W/DRUG 896.00 - 2,168 HEPATOBILIARY SYSTEM IMAGING 896.00 - 2,169 HEPB VACC 2 DOSE ADOLESC IM 48.00 48.00 2,170 HEPB VACC 2 DOSE ADULT IM 90.00 2,171 HEPB VACC 3 DOSE IMMUNSUP IM 239.00 2,172 HEPB VACC 3 DOSE PED/ADOL IM - 48.00 48.00 2,173 HEPB VACC 4 DOSE IMMUNSUP IM 239.00 2,174 HEPB VACCINE 3 DOSE ADULT IM - 67.00 67.00 2,175 HEROIN METABOLITE 107.00 - 2,176 HERPES SIMPLEX 1 AG IF 47.00 - 2,177 HERPES SIMPLEX 2 AG IF 47.00 - 2,178 HERPES SIMPLEX NES ANTBDY - 56.00 56.00 2,179 HERPES SIMPLEX TYPE 1 TEST - 166.00 166.00 2,180 HERPES SIMPLEX TYPE 2 TEST - 166.00 166.00 2,181 HETEROPHILE ANTIBODY ABSRBJ 29.00 - 2,182 HETEROPHILE ANTIBODY SCREEN - 51.00 51.00 2,183 HETEROPHILE ANTIBODY TITER 25.00 - 2,184 HEXAGNAL PHOSPH PLTLT NEUTRL 70.00 - 2,185 Hfo flexion glove pre ots 328.00 328.00 2,186 Hfo nontorsion jnts pre cst 247.00 247.00 2,187 Hfo w/joint(s) cf 293.00 293.00 2,188 Hfo w/o joints cf 494.00 494.00 2,189 Hfo without joints pre cst - 248.00 248.00 2,190 HGB QUANT TRANSCUTANEOUS 20.00 - 2,191 HHV-6 DNA AMP PROBE 137.00 - 2,192 HHV-6 DNA DIR PROBE 79.00 - 2,193 HHV-6 DNA QUANT 164.00 - 2,194 Hi mount flip-up ftrest repl 490.00 490.00 2,195 HIB PRP-OMP VACC 3 DOSE IM - 73.00 - 2,196 HIB-HEPB VACCINE IM 38.00 140.00 2,197 High compres band w>=3"<5"yd 27.00 27.00 2,198 High inten beh couns std 30m 80.00 135.00 - 2,199 High strength ltwt whlchr 410.00 410.00 Physician Hospital Village Description # Charge Charge Charge 2,200 Hinge ext/flex wrist finger 1,819.00 1,819.00 2,201 Hinge extension/flex wrist/f 1,475.00 1,475.00 2,202 Hip clevis/thrust bearing fr 804.00 804.00 2,203 Hip clevis/thrust bearing lo 892.00 892.00 2,204 HISTOCHEMICAL STAINS ADD-ON 67.00 - 2,205 HISTOPLASMA ANTIBODY 49.00 - 2,206 HISTOPLASMA CAPSUL AG IA 47.00 - 2,207 HISTOPLASMOSIS SKIN TEST 19.00 - 2,208 HIV-1 AG IA 51.00 51.00 2,209 HIV-1 AG W/HIV-1 & HIV-2 AB - 94.00 - 2,210 HIV-1 DNA DIR PROBE 79.00 - 2,211 HIV-1 PROBE&REVERSE TRNSCRPJ 137.00 - 2,212 HIV-1 QUANT&REVRSE TRNSCRPJ - 387.00 387.00 2,213 HIV-1/HIV-2 1 RESULT ANTBDY - 51.00 51.00 2,214 HIV-1ANTIBODY 166.00 166.00 2,215 HIV-2 AG IA 51.00 51.00 2,216 HIV-2 ANTIBODY 53.00 - 2,217 HIV-2 DNA DIR PROBE 79.00 - 2,218 HIV-2 PROBE&REVRSE TRNSCRIPJ 137.00 - 2,219 HIV-2 QUANT&REVRSE TRNSCRIPJ 168.00 - 2,220 Hizentra injection 26.00 26.00 2,221 Hkafo torsion bil rot straps 403.00 403.00 2,222 Hkafo torsion unilat rot str 391.00 391.00 2,223 HLA CLASS I HIGH DEFIN QUAL 497.00 - 2,224 HLA CLASS I PHENOTYPE QUAL 316.00 - 2,225 HLA CLASS I SEMIQUANT PANEL 1,401.00 - 2,226 HLA CLASS I&II ANTIBODY QUAL 155.00 - 2,227 HLA CLASS I/II ANTIBODY QUAL 116.00 - 2,228 HLA CLASS II HIGH DEFIN QUAL 452.00 - 2,229 HLA CLASS II PHENOTYPE QUAL 271.00 - 2,230 HLA CLASS II SEMIQUANT PANEL 1,265.00 - 2,231 HLA TYPING A B OR C - 83.00 83.00 2,232 HLA TYPING A B OR C 133.00 133.00 2,233 HLA TYPING DR/DQ 109.00 - 2,234 HLA TYPING DR/DQ 252.00 - 2,235 HLA X-MATCH NONCYTOTOXC ADDL 105.00 - 2,236 HLA X-MATH NON-CYTOTOXIC 315.00 - 2,237 Hmes filter holder or cap 44.00 44.00 2,238 Hmes or trach valve housing 21.00 21.00 2,239 Hmes/trachvalve adhesivedisk 2.00 2.00 2,240 Ho abduction hip adjustable 267.00 267.00 2,241 Ho abduction static plastic 498.00 498.00 2,242 Ho bi thighcuffs w sprdr bar 715.00 715.00 2,243 Ho flex frejka w/cov pre cst 501.00 501.00 2,244 Ho flex pavlik harns pre cst 156.00 156.00 2,245 Ho frejka cov only pre cst 172.00 172.00 2,246 Ho w/o joints cf 494.00 494.00 2,247 Hocm <=149 mg/ml iodine, 1ml 2.00 2.00 2,248 Hocm 200-249mg/ml iodine,1ml 2.00 2.00 2,249 Hocm 250-299mg/ml iodine,1ml 2.00 2.00 2,250 Hocm 350-399mg/ml iodine,1ml 2.00 2.00 2,251 HOME HEALTH CARE SUPERVISION 193.00 - 2,252 HOME HEALTH CARE SUPERVISION 305.00 - 2,253 HOME VISIT EST PATIENT 155.00 2,254 HOME VISIT EST PATIENT 226.00 2,255 HOME VISIT EST PATIENT 299.00 2,256 HOME VISIT EST PATIENT 961.00 412.00 2,257 HOME VISIT NEW PATIENT 153.00 2,258 HOME VISIT NEW PATIENT 226.00 2,259 HOME VISIT NEW PATIENT 366.00 2,260 Hook to hand cable adapter 226.00 226.00 2,261 Hosp bed fixd ht w/o mattres 233.00 233.00 2,262 Hosp bed fixed ht w/ mattres 307.00 307.00 Physician Hospital Village Description # Charge Charge Charge 2,263 Hosp bed fx ht w/o rail w/o 202.00 202.00 2,264 Hosp bed fx ht w/o rails w/m 233.00 233.00 2,265 Hosp bed hvy dty xtra wide 667.00 667.00 2,266 Hosp bed semi-elect w/ mattr 468.00 468.00 2,267 Hosp bed semi-elect w/o matt 322.00 322.00 2,268 Hosp bed semi-electr w/ matt 328.00 328.00 2,269 Hosp bed semi-electr w/o mat 454.00 454.00 2,270 Hosp bed total elec w/o matt 473.00 473.00 2,271 Hosp bed total elect w/ matt 408.00 408.00 2,272 Hosp bed total elect w/o mat 446.00 446.00 2,273 Hosp bed total electr w/ mat 533.00 533.00 2,274 Hosp bed var ht no sr no mat 256.00 256.00 2,275 Hosp bed var ht no sr w/matt 306.00 306.00 2,276 HOSPICE CARE SUPERVISION 193.00 - 2,277 HOSPICE CARE SUPERVISION 305.00 - 2,278 Hospital bed var ht w/ mattr 391.00 391.00 2,279 Hospital bed var ht w/o matt 292.00 292.00 2,280 HOSPITAL DISCHARGE DAY 259.00 - 2,281 HOSPITAL DISCHARGE DAY 359.00 - 2,282 Hospital observation per hr - 81.00 - 2,283 Hospital outpt clinic visit - 100.00 - 2,284 HOT OR COLD PACKS THERAPY - 0.01 58.00 2,285 Hot/cold h2obot/cap/col/wrap - 16.00 16.00 2,286 Housing & integrated adhesiv 13.00 13.00 2,287 HPV HIGH-RISK TYPES - 143.00 - 2,288 HPYLORI STOOL IA - 56.00 - 2,289 HSV DNA AMP PROBE 137.00 - 2,290 HSV DNA DIR PROBE 79.00 - 2,291 HSV DNA QUANT 168.00 - 2,292 HT MUSC IMAGE PLANAR MULT 1,937.00 - 2,293 HT MUSCLE IMAGE PLANAR SING 1,937.00 - 2,294 HT MUSCLE IMAGE SPECT MULT 1,937.00 - 2,295 HT MUSCLE IMAGE SPECT SING 1,937.00 - 2,296 HTLV/HIV CONFIRMJ ANTIBODY 76.00 - 2,297 HTLV-I ANTIBODY 51.00 51.00 2,298 HTLV-II ANTIBODY 55.00 - 2,299 HUMAN EPIDIDYMIS PROTEIN 4 82.00 - 2,300 Human fibrinogen conc inj 2.00 2.00 2,301 Humate-p, inj 3.00 3.00 2,302 Humidif extens supple w ippb 224.00 224.00 2,303 Humidifier for use w/ regula 12.00 12.00 2,304 Humidifier heated used w pap 675.00 675.00 2,305 Humidifier nonheated w pap 300.00 300.00 2,306 Humidifier supplemental w/ i 428.00 428.00 2,307 Hyalgan supartz visco-3 dose 225.00 225.00 2,308 Hyaluronidase injection 64.00 64.00 2,309 Hyaluronidase recombinant 2.00 2.00 2,310 Hydralazine hcl injection 11.00 11.00 2,311 HYDRATE IV INFUSION ADD-ON - 81.00 111.00 2,312 HYDRATION IV INFUSION INIT - 224.00 454.00 2,313 Hydrocolld drg <=16 in w/bdr 31.00 31.00 2,314 Hydrocolld drg <=16 w/o bdr 30.00 30.00 2,315 Hydrocolld drg > 48 in w/o b 106.00 106.00 2,316 Hydrocolld drg >16<=48 w/bdr 89.00 89.00 2,317 Hydrocolld drg >16<=48 w/o b 66.00 66.00 2,318 Hydrocolld drg filler paste 48.00 48.00 2,319 Hydrocolloid drg filler dry 12.00 12.00 2,320 Hydrocortisone sodium ph inj - 14.00 - 2,321 Hydrocortisone sodium succ i - 25.00 25.00 2,322 Hydrogel dressing >48 sq in 75.00 75.00 2,323 Hydrogel drg <= 16 in w/bdr 33.00 33.00 2,324 Hydrogel drg <=16 in w/o bdr 28.00 28.00 2,325 Hydrogel drg > 48 sq in w/b 93.00 93.00 Physician Hospital Village Description # Charge Charge Charge 2,326 Hydrogel drg >16<=48 in w/b 39.00 39.00 2,327 Hydrogel drg >16<=48 w/o bdr 48.00 48.00 2,328 Hydrogel drg >48 in w/o bdr 153.00 153.00 2,329 Hydrogel drsg gel filler 63.00 63.00 2,330 Hydrogel dsg<=16 sq in 21.00 21.00 2,331 Hydrogel dsg>16<=48 sq in 31.00 31.00 2,332 Hydromorphone injection - 6.00 6.00 2,333 HYDROTHERAPY 172.00 - 2,334 Hydroxyzine hcl injection 5.00 5.00 2,335 Hyoscyamine sulfate inj 48.00 48.00 2,336 HYPERBARIC OXYGEN THERAPY 422.00 - 2,337 HYPERTHERMIA TREATMENT 1,118.00 - 2,338 HYPERTHERMIA TREATMENT 1,118.00 - 2,339 HYPERTHERMIA TREATMENT 1,118.00 - 2,340 HYPERTHERMIA TREATMENT 1,118.00 - 2,341 HYPERTHERMIA TREATMENT 1,118.00 - 2,342 HYPNOTHERAPY 314.00 - 2,343 HYSTEROSCOPY BIOPSY 1,267.00 4,800.00 1,267.00 2,344 HZV VACCINE LIVE SUBQ - 204.00 204.00 2,345 I & D OF VULVA/PERINEUM 347.00 1,026.00 347.00 2,346 I131 iodide cap, rx 53.00 - 2,347 I131 iodide sol, rx 34.00 - 2,348 Ibandronate sodium injection 379.00 379.00 2,349 Ibutilide fumarate injection 286.00 286.00 2,350 IC INF PBW 2501-5000 G SUBSQ 412.00 - 2,351 IC LBW INF < 1500 GM SUBSQ 485.00 - 2,352 IC LBW INF 1500-2500 G SUBSQ 440.00 - 2,353 Icatibant injection 587.00 587.00 2,354 ICG ANGIOGRAPHY UNI/BI 327.00 724.00 - 2,355 ICM DEVICE INTERROGAT REMOTE 113.00 - 2,356 Idarubicin hcl injection 245.00 245.00 2,357 IDENTIFY SPERM TISSUE 172.00 - 2,358 Idursulfase injection 910.00 910.00 2,359 Ifosfamide injection 87.00 87.00 2,360 IGG 1 2 3 OR 4 EACH 83.00 83.00 2,361 IIV NO PRSV INCREASED AG IM - 62.00 62.00 2,362 IIV3 VACC NO PRSV 0.25 ML IM - 17.00 16.00 2,363 IIV3 VACC NO PRSV 0.5 ML IM 19.00 12.00 2,364 IIV3 VACCINE SPLT 0.25 ML IM 17.00 12.00 2,365 IIV3 VACCINE SPLT 0.5 ML IM - 12.00 12.00 2,366 IIV4 VACC NO PRSV 0.25 ML IM - 28.00 28.00 2,367 IIV4 VACC NO PRSV 0.5 ML IM - 24.00 - 2,368 IIV4 VACCINE SPLT 0.25 ML IM - 27.00 - 2,369 IIV4 VACCINE SPLT 0.5 ML IM - 21.00 21.00 2,370 Iloprost non-comp unit dose 221.00 221.00 2,371 ILR DEVICE INTERROGAT REMOTE 113.00 - 2,372 ILR DEVICE INTERROGATE 85.00 92.00 - 2,373 IM ADMIN 1ST/ONLY COMPONENT 70.00 2,374 IM ADMIN EACH ADDL COMPONENT 35.00 2,375 IMMUNE ADMIN ORAL/NASAL - 27.00 23.00 2,376 IMMUNE ADMIN ORAL/NASAL ADDL - 27.00 27.00 2,377 IMMUNE COMPLEX ASSAY 95.00 - 2,378 Immune globulin, powder 104.00 104.00 2,379 IMMUNFIX E-PHORSIS/URINE/CSF 115.00 - 2,380 IMMUNIZATION ADMIN - 27.00 39.00 2,381 IMMUNIZATION ADMIN EACH ADD - 27.00 35.00 2,382 IMMUNOASSAY DIPSTICK 33.00 - 2,383 IMMUNOASSAY INFECTIOUS AGENT 59.00 - 2,384 IMMUNOASSAY INFECTIOUS AGENT 80.00 80.00 2,385 IMMUNOASSAY NONANTIBODY - 166.00 166.00 2,386 IMMUNOASSAY QUANT NOS NONAB 194.00 194.00 2,387 IMMUNOASSAY TUMOR CA 125 - 145.00 145.00 2,388 IMMUNOASSAY TUMOR CA 15-3 146.00 146.00 Physician Hospital Village Description # Charge Charge Charge 2,389 IMMUNOASSAY TUMOR CA 19-9 - 157.00 157.00 2,390 IMMUNOASSAY TUMOR OTHER 133.00 133.00 2,391 IMMUNOASSAY TUMOR QUAL 77.00 - 2,392 IMMUNODIFFUSION NES 55.00 - 2,393 IMMUNODIFFUSION OUCHTERLONY 47.00 - 2,394 IMMUNOELECTROPHORESIS ASSAY 89.00 - 2,395 IMMUNOFIX E-PHORESIS SERUM - 83.00 83.00 2,396 IMMUNOFLUOR ANTB 1ST STAIN 109.00 - 2,397 IMMUNOGLOBULIN ASSAY 49.00 - 2,398 IMMUNOHISTO ANTB 1ST STAIN 109.00 - 2,399 IMMUNOTHERAPY INJECTIONS - 61.00 61.00 2,400 IMMUNOTHERAPY ONE INJECTION - 47.00 47.00 2,401 Imported lipodox inj 997.00 - 2,402 Impreg gauze no h20/sal/yard 15.00 15.00 2,403 Impression casting ft 133.00 133.00 2,404 Imuglucerase injection 126.00 126.00 2,405 INCISE & DRAIN BLADDER 2,175.00 4,800.00 - 2,406 INCISE EXTERNAL HEMORRHOID 514.00 1,026.00 514.00 2,407 INCISION OF ANAL ABSCESS 545.00 2,550.00 545.00 2,408 INCISION OF BREAST LESION 828.00 4,800.00 828.00 2,409 INCISION OF EARDRUM 593.00 624.00 593.00 2,410 INCISION OF RECTAL ABSCESS 1,540.00 3,000.00 1,540.00 2,411 Incobotulinumtoxin a 16.00 16.00 2,412 Incontinence garment anytype - 28.00 28.00 2,413 Indwelling catheter latex - 33.00 33.00 2,414 Indwelling catheter special 113.00 113.00 2,415 Indwelling trach insert 199.00 199.00 2,416 Infliximab not biosimil 10mg 411.00 411.00 2,417 INFLUENZA A AG IF 47.00 - 2,418 INFLUENZA A/B AG IA - 83.00 83.00 2,419 INFLUENZA ASSAY W/OPTIC 77.00 77.00 2,420 INFLUENZA B AG IF 47.00 - 2,421 INFLUENZA DNA AMP PROB 1+ 201.00 - 2,422 INFLUENZA DNA AMP PROB ADDL 81.00 - 2,423 INFLUENZA DNA AMP PROBE 333.00 - 2,424 INFLUENZA VIRUS ANTIBODY 51.00 51.00 2,425 Infrared ht sys replcmnt pad 746.00 746.00 2,426 INFRARED THERAPY 32.00 - 2,427 INFUSE RADIOACTIVE MATERIALS 512.00 - 2,428 Infusion supplies with pump 175.00 175.00 2,429 INHIBIN A - 120.00 120.00 2,430 INIT DAY HOSP NEONATE CARE 1,206.00 - 2,431 INIT NB EM PER DAY HOSP 378.00 - 2,432 INIT NB EM PER DAY NON-FAC 324.00 324.00 2,433 INIT PM E/M NEW PAT 1-4 YRS 300.00 300.00 2,434 INIT PM E/M NEW PAT 65+ YRS 446.00 446.00 2,435 INIT PM E/M NEW PAT INFANT 277.00 277.00 2,436 Initial foot exam pt lops 170.00 170.00 - 2,437 INITIAL HOSPITAL CARE 329.00 - 2,438 INITIAL HOSPITAL CARE 451.00 - 2,439 INITIAL HOSPITAL CARE 586.00 - 2,440 INITIAL OBSERVATION CARE 301.00 - 2,441 INITIAL OBSERVATION CARE 436.00 - 2,442 INITIAL OBSERVATION CARE 570.00 - 2,443 Initial preventive exam 360.00 - 2,444 INITIAL TREATMENT OF BURN(S) 224.00 624.00 224.00 2,445 Inj calcitriol per 0.1 mcg 2.00 2.00 2,446 Inj ceftazidime per 500 mg - 9.00 9.00 2,447 Inj cladribine per 1 mg 88.00 88.00 2,448 Inj codeine phosphate /30 mg 5.00 5.00 2,449 Inj desmopressin acetate 20.00 20.00 2,450 Inj dexamethasone acetate - 4.00 4.00 2,451 Inj dobutamine hcl/250 mg 19.00 19.00 Physician Hospital Village Description # Charge Charge Charge 2,452 Inj enoxaparin sodium - 12.00 12.00 2,453 Inj estrogen conjugate 25 mg 349.00 349.00 2,454 Inj heparin sodium per 10 u - 2.00 2.00 2,455 Inj heparin sodium per 1000u - 5.00 5.00 2,456 Inj iron dextran 21.00 21.00 2,457 Inj ivig privigen 500 mg 107.00 107.00 2,458 Inj levocarnitine per 1 gm 22.00 22.00 2,459 Inj magnesium sulfate - 5.00 5.00 2,460 Inj mepivacaine hcl/10 ml 4.00 4.00 2,461 Inj midazolam hydrochloride - 5.00 5.00 2,462 Inj milrinone lactate / 5 mg 9.00 9.00 2,463 Inj multihance 8.00 8.00 2,464 Inj multihance multipack 7.00 7.00 2,465 Inj nalbuphine hydrochloride 5.00 5.00 2,466 Inj naloxone hydrochloride - 43.00 43.00 2,467 Inj octafluoropropane mic,ml 111.00 111.00 2,468 Inj pantoprazole sodium, via 9.00 9.00 2,469 Inj perflexane lip micros,ml 150.00 - 2,470 Inj perflutren lip micros,ml 167.00 167.00 2,471 Inj potassium chloride - 5.00 5.00 2,472 Inj progesterone per 50 mg 5.00 5.00 2,473 Inj prohance multipack 7.00 7.00 2,474 Inj protamine sulfate/10 mg 3.00 3.00 2,475 Inj protirelin per 250 mcg 89.00 89.00 2,476 Inj secretin synthetic human 82.00 82.00 2,477 INJ TENDON ORIGIN/INSERTION 288.00 1,026.00 288.00 2,478 INJ TENDON SHEATH/LIGAMENT 268.00 1,026.00 268.00 2,479 Inj testosterone cypionate - 0.45 - 2,480 Inj theophylline per 40 mg 2.00 2.00 2,481 INJ TRIGGER POINT 1/2 MUSCL 280.00 1,026.00 280.00 2,482 Inj, bupivacaine liposome 4.00 4.00 2,483 Inj, clevidipine butyrate 10.00 - 2,484 Inj, epirubicin hcl, 2 mg 6.00 6.00 2,485 Inj, moxifloxacin 100 mg 13.00 13.00 2,486 Inj, propofol, 10 mg - 34.00 - 2,487 Inj, rimabotulinumtoxinb 33.00 33.00 2,488 Inj., treanda 1 mg 62.00 62.00 2,489 INJECT SACROILIAC JOINT 1,465.00 - 1,465.00 2,490 INJECT SKIN LESIONS 315.00 1,026.00 315.00 2,492 Injection estrone per 1 mg 5.00 5.00 2,493 INJECTION EYE DRUG 399.00 1,026.00 - 2,494 Injection glatiramer acetate 326.00 326.00 2,495 Injection pantroprazole - 75.00 - 2,496 Injection, bupivicaine hydro - 30.00 30.00 2,497 Injection, clindamycin phosp - 36.00 5.00 2,498 Injection, doxercalciferol 3.00 3.00 2,499 Injection, fosphenytoin sodi - 36.00 2.00 2,500 Injection, fulvestrant 221.00 221.00 2,501 Injection, glucarpidase 584.00 - 2,502 Injection, metronidazole - 2.00 2.00 2,503 Injection, nafcillin sodium 30.00 30.00 2,504 Injection, piperacillin sodi 11.00 11.00 2,505 Injection, voriconazole 17.00 17.00 2,506 Injection,onabotulinumtoxina 643.00 643.00 2,507 INPATIENT CONSULTATION 258.00 - 2,508 INPATIENT CONSULTATION 318.00 - 2,509 INPATIENT CONSULTATION 391.00 - 2,510 INPATIENT CONSULTATION 572.00 - 2,511 INPATIENT CONSULTATION 702.00 - 2,512 INSEMINATION OF OOCYTES 172.00 - 2,513 INSERT AND REMOVE BONE PIN 790.00 4,800.00 790.00 2,514 INSERT BLADDER CATHETER 140.00 150.00 270.00 Physician Hospital Village Description # Charge Charge Charge 2,515 INSERT CERVICAL DILATOR 163.20 1,026.00 - 2,516 INSERT DRUG IMPLANT DEVICE 648.00 405.00 648.00 2,517 INSERT EMERGENCY AIRWAY 730.00 624.00 - 2,518 INSERT INTRAUTERINE DEVICE 490.00 624.00 490.00 2,519 INSERT NEEDLE BONE CAVITY 258.00 1,026.00 258.00 2,520 INSERT NON-TUNNEL CV CATH 1,441.00 3,000.00 - 2,521 INSERT PESSARY/OTHER DEVICE 255.00 624.00 255.00 2,522 INSERT TEMP BLADDER CATH 200.00 180.00 380.00 2,523 Insert tray w/o bag/cath 58.00 58.00 2,524 INSERT TUNNELED CV CATH 4,416.00 4,800.00 - 2,525 Insert, pneum wheel drive 425.00 425.00 2,526 INSERTION OF CATHETER VEIN 561.00 - 561.00 2,527 INSERTION OF CHEST TUBE 783.00 3,000.00 - 2,528 INSITU HYBRIDIZATION (FISH) 109.00 - 2,529 INSITU HYBRIDIZATION AUTO 109.00 - 2,530 INSITU HYBRIDIZATION MANUAL 172.00 - 2,531 INSULIN ANTIBODIES 83.00 83.00 2,532 Insulin for insulin pump use 19.00 19.00 2,533 Insulin injection - 5.00 5.00 2,534 INSULIN SUPPRESSION PANEL 529.00 - 2,535 INSULIN TOLERANCE PANEL 396.00 - 2,536 INSULIN TOLERANCE PANEL 404.00 - 2,537 Integra bmwd 56.00 56.00 2,538 Integra drt or omnigraft 41.00 41.00 2,539 Integra matrix 76.00 76.00 2,540 Integra meshed bil wound mat 74.00 - 2,541 Integrated filter & holder 12.00 12.00 2,542 Intens behave ther cardio dx 82.00 135.00 - 2,543 Interface, cough stim device 54.00 54.00 2,544 Interferon alfa-2b inj 95.00 95.00 2,545 Interferon alfacon-1 inj 51.00 51.00 2,546 Intermittent urinary cath 26.00 26.00 2,547 INTERNAL EYE PHOTOGRAPHY 167.00 - 2,548 Interphalangeal joint spacer 757.00 757.00 2,549 INTERROG DEVICE EVAL HEART 175.00 110.00 - 2,550 INTERV HLTH/BEHAV FAM NO PT 78.00 - 2,551 INTERV HLTH/BEHAV FAM W/PT 62.00 - 2,552 INTERVENE HLTH/BEHAVE GROUP 14.00 - 2,553 INTERVENE HLTH/BEHAVE INDIV 120.00 106.00 120.00 2,554 INTMD RPR FACE/MM 2.5 CM/< 758.00 1,026.00 758.00 2,555 INTMD RPR FACE/MM 2.6-5.0 CM 1,089.00 1,026.00 1,089.00 2,556 INTMD RPR FACE/MM 5.1-7.5 CM 1,089.00 1,026.00 1,089.00 2,557 INTMD RPR FACE/MM 7.6-12.5CM 1,402.00 1,026.00 1,402.00 2,558 INTMD RPR N-HF/GENIT 2.5CM/< 636.00 1,026.00 636.00 2,559 INTMD RPR N-HF/GENIT2.6-7.5 760.00 1,026.00 760.00 2,560 INTMD RPR N-HF/GENIT7.6-12.5 1,029.00 2,050.00 1,029.00 2,561 INTMD RPR S/A/T/EXT 12.6-20 1,209.00 1,026.00 1,209.00 2,562 INTMD RPR S/A/T/EXT 2.5 CM/< 562.00 1,026.00 562.00 2,563 INTMD RPR S/A/T/EXT 2.6-7.5 684.00 1,026.00 684.00 2,564 INTMD RPR S/A/T/EXT 20.1-30 1,206.00 2,050.00 1,206.00 2,565 INTMD RPR S/TR/EXT 7.6-12.5 932.00 1,026.00 932.00 2,566 Intraocular fomivirsen na 213.00 213.00 2,567 INTRAOP CYTO PATH CONSULT 1 67.00 - 2,568 INTRAOP CYTO PATH CONSULT 2 36.00 - 2,569 Intraut copper contraceptive - 518.00 518.00 2,570 INTRINSIC FACTOR ANTIBODY 59.00 - 2,571 IO RAD TX DELIVER BY ELCTRNS 2,788.00 - 2,572 IO RAD TX DELIVERY BY X-RAY 2,788.00 - 2,573 Iodine i-125 sodium iodide 63.00 - 2,574 Ipilimumab injection 313.00 313.00 2,575 Ippb all types 321.00 321.00 2,576 Ipratropium bromide non-comp - 5.00 5.00 2,577 Irinotecan injection 119.00 119.00 Physician Hospital Village Description # Charge Charge Charge 2,578 IRON BINDING TEST - 83.00 83.00 2,579 IRON STAIN PERIPHERAL BLOOD 25.00 - 2,580 Iron sucrose injection - 2.00 2.00 2,581 IRRIG DRUG DELIVERY DEVICE 160.00 72.00 2,582 IRRIGATION MAXILLARY SINUS 410.00 624.00 410.00 2,583 IRRIGATION OF BLADDER 224.00 1,026.00 - 2,584 Irrigation supply sleeve 29.00 29.00 2,585 Irrigation syringe - 14.00 14.00 2,586 Irrigation tray 22.00 22.00 2,587 ISLET CELL ANTIBODY 257.00 257.00 2,588 Itraconazole injection 2.00 2.00 2,589 Iv hanger 323.00 323.00 2,590 IV INJ RA DRUG DX STUDY 560.00 - 2,591 Iv pole 391.00 391.00 2,592 Ixabepilone injection 199.00 199.00 2,593 Jaw motion rehab system 947.00 947.00 2,594 J-cell batt for glucose mon 17.00 17.00 2,595 JOHN CUNNINGHAM ANTIBODY 56.00 - 2,596 JOINT SURVEY SINGLE VIEW 59.00 427.00 - 2,597 K FLOW/FUNCT IMAGE MULTIPLE 949.00 - 2,598 K FLOW/FUNCT IMAGE W/DRUG 949.00 - 2,599 K FLOW/FUNCT IMAGE W/O DRUG 949.00 - 2,600 Kafo plastic pediatric size 474.00 474.00 2,601 Kafo sng/dbl mechanical act 4,929.00 4,929.00 2,602 Kanamycin sulfate 500 mg inj 27.00 27.00 2,603 Kanamycin sulfate 75 mg inj 4.00 4.00 2,604 KETAMINE AND NORKETAMINE 100.00 - 2,605 Ketorolac tromethamine inj - 5.00 5.00 2,606 KIDNEY FUNCTION STUDY 560.00 - 2,607 KIDNEY IMAGING (3D) 949.00 - 2,608 KIDNEY IMAGING MORPHOL 949.00 - 2,609 KIDNEY IMAGING WITH FLOW 949.00 - 2,610 KNEE ARTHROSCOPY DX 2,826.00 4,800.00 2,826.00 2,611 KNEE ARTHROSCOPY/SURGERY 1,193.00 4,800.00 - 2,612 KNEE ARTHROSCOPY/SURGERY 1,313.00 4,800.00 - 2,613 KNEE ARTHROSCOPY/SURGERY 2,399.00 4,800.00 - 2,614 Knee cap medial or lateral p 410.00 410.00 2,615 Knee control condylar pad 330.00 330.00 2,616 Knee control full kneecap 333.00 333.00 2,617 Knee disart, sach ft, endo 4,909.00 4,909.00 2,618 Knee disc/dial lock/adj flex 359.00 359.00 2,619 Knee ext/flex w act res ctrl 279.00 279.00 2,620 Knee jnt ratchet lock ea jnt 359.00 359.00 2,621 Knee joint cam lock each joi 304.00 304.00 2,622 Knee joint drop lock ea jnt 218.00 218.00 2,623 Knee lift loop drop lock rin 296.00 296.00 2,624 Knee orth pos locking joint 295.00 295.00 2,625 Knee-shin exo variable frict 951.00 951.00 2,626 Ko adj jnt pos r sup pre cst 1,229.00 1,229.00 2,627 Ko dbl upright w/air pre cst 945.00 945.00 2,628 Ko derot ant cruciate custom 1,465.00 1,465.00 2,629 Ko double upright pre cst 1,345.00 1,345.00 2,630 Ko elas w/ condyle pads & jo - 369.00 369.00 2,631 Ko elastic with joints - 317.00 317.00 2,632 Ko immob canvas long pre ots - 423.00 423.00 2,633 Ko rigid w/o joints pre ots 134.00 134.00 2,634 Ko swedish type pre ots 859.00 859.00 2,635 Kyphosis pad 140.00 140.00 2,636 Kyphosis pad floating 492.00 492.00 2,637 L/S RATIO FETAL LUNG 133.00 133.00 2,638 LAB PATHOLOGY CONSULTATION 36.00 - 2,639 LAB PATHOLOGY CONSULTATION 67.00 - 2,640 LACTATE (LD) (LDH) ENZYME - 38.00 38.00 Physician Hospital Village Description # Charge Charge Charge 2,641 LACTOFERRIN FECAL (QUAL) 77.00 - 2,642 LACTOFERRIN FECAL (QUANT) 77.00 - 2,643 LAIV3 VACCINE INTRANASAL 23.00 2,644 LAIV4 VACCINE INTRANASAL 67.00 67.00 2,645 Lambswool sheepskin pad 302.00 302.00 2,646 LAMELLAR BDY FETAL LUNG 74.00 - 2,647 Lamination collar w/ couplin 454.00 454.00 2,648 Lancet device each 23.00 23.00 2,649 Lancets per box 13.00 13.00 2,650 Lanreotide injection 105.00 105.00 2,651 LAP PARAESOPHAG HERN REPAIR 1,676.00 4,800.00 - 2,652 LAPARO CHOLECYSTECTOMY/GRAPH 449.00 4,800.00 - 2,653 Large disposable underpad 2.00 2.00 2,654 Large size footplate each 178.00 178.00 2,655 Laronidase injection 85.00 85.00 2,656 LARYNGEAL FUNCTION STUDIES 142.00 397.00 - 2,657 LARYNGOSCOPIC SENSORY I&R 116.00 - 2,658 LARYNGOSCOPIC SENSORY VID 236.00 236.00 - 2,659 LARYNGOSCOPY WITH BIOPSY 1,247.00 4,800.00 1,247.00 2,660 LASER TX SKIN < 250 SQ CM 233.00 - 2,661 LASER TX SKIN >500 SQ CM 427.00 - 2,662 LASER TX SKIN 250-500 SQ CM 263.00 - 2,663 Lateral thoracic extension 944.00 944.00 2,664 Lateral trochanteric pad 445.00 445.00 2,665 Latex leg strap 24.00 24.00 2,666 Latex suspension sleeve each 201.00 201.00 2,667 Ldct for lung ca screen 146.00 350.00 - 2,668 Lead wires, pair 69.00 69.00 2,669 Leads any type vad, rep only 686.00 686.00 2,670 Leg strap each 82.00 82.00 2,671 Leg strap h style each 181.00 181.00 2,672 LEGION PNEUMO DNA AMP PROB 137.00 - 2,673 LEGION PNEUMO DNA DIR PROB 79.00 - 2,674 LEGION PNEUMO DNA QUANT 164.00 - 2,675 LEGION PNEUMOPHILIA AG IF 47.00 - 2,676 LEGIONELLA ANTIBODY 51.00 51.00 2,677 LEISHMANIA ANTIBODY 48.00 - 2,678 LEPTOSPIRA ANTIBODY 52.00 - 2,679 Leucovorin calcium injection 6.00 6.00 2,680 LEUKACYTE TRANSFUSION 51.00 - 2,681 LEUKOCYTE ASSESSMENT FECAL - 64.00 64.00 2,682 LEUKOCYTE HISTAMINE RELEASE 49.00 - 2,683 LEUKOCYTE PHAGOCYTOSIS 31.00 - 2,684 Leuprolide acetate injeciton 26.00 26.00 2,685 Leuprolide acetate suspnsion - 913.00 913.00 2,686 Lev 1 hosp type b ed visit 203.00 - 2,687 Lev 2 hosp type b ed visit 162.00 - 2,688 Levalbuterol non-comp con 2.00 2.00 2,689 Levalbuterol non-comp unit 2.00 2.00 2,690 LEVEEN/SHUNT PATENCY EXAM 732.00 - 2,691 Lever-activated wheel drive 664.00 664.00 2,692 Levetiracetam injection 2.00 2.00 2,693 Levofloxacin injection - 68.00 68.00 2,694 Levoleucovorin injection 6.00 6.00 2,695 Lg vol nebulizer disposable 20.00 20.00 2,696 Lidocaine injection - 5.00 5.00 2,697 Lift assist for elbow 499.00 499.00 2,698 LIGATION OF HEMORRHOID(S) 567.00 2,550.00 567.00 2,699 Lightweight wheelchair 349.00 349.00 2,700 LIMB MUSCLE TESTING MANUAL 151.00 151.00 151.00 2,701 Limited ankle motion ea jnt 252.00 252.00 2,702 Limited motion knee joint 360.00 360.00 2,703 Lincomycin injection 26.00 26.00 Physician Hospital Village Description # Charge Charge Charge 2,704 Linezolid injection 117.00 117.00 2,705 LIPID PANEL - 83.00 83.00 2,706 LIPOPRO BLD ELECTROPHORETIC 44.00 - 2,707 LIPOPROTEIN BLD HR FRACTION 97.00 - 2,708 LIPOPROTEIN BLD QUAN PART 124.00 - 2,709 LISTERIA MONOCYTOGENES 52.00 - 2,710 Lith ion batt cid, ear level 382.00 382.00 2,711 Lith ion batt cid,non-earlvl 184.00 184.00 2,712 Lithium batt for glucose mon - 10.00 10.00 2,713 LIVER & SPLEEN IMAGE/FLOW 896.00 - 2,714 LIVER AND SPLEEN IMAGING 896.00 - 2,715 LIVER IMAGE (3D) WITH FLOW 896.00 - 2,716 LIVER IMAGING 896.00 - 2,717 LIVER IMAGING (3D) 896.00 - 2,718 LIVER IMAGING WITH FLOW 896.00 - 2,719 Lo flex l1-below l5 pre ots - 166.00 166.00 2,720 Lo sag ri an/pos pnl pre cst 824.00 824.00 2,721 Lo sag rig pnl stays pre cst 195.00 195.00 2,722 Locm 100-199mg/ml iodine,1ml 3.00 3.00 2,723 Locm 200-299mg/ml iodine,1ml 2.00 2.00 2,724 Locm 300-399mg/ml iodine,1ml - 2.00 2.00 2,725 LONG CHAIN FATTY ACIDS 71.00 - 2,726 Long tongue stirrup 535.00 535.00 2,727 Loop heel 153.00 153.00 2,728 Lorazepam injection - 5.00 5.00 2,729 LOUDNESS BALANCE TEST 354.00 - 2,730 LOWER EXTREMITY STUDY 126.00 298.00 - 2,731 LOWER EXTREMITY STUDY 200.00 464.00 - 2,732 Lso corset front 376.00 376.00 2,733 Lso flex no ri stays pre ots 210.00 210.00 2,734 Lso full corset 465.00 465.00 2,735 Lso r post pnl sj-t9 pre cst 406.00 406.00 2,736 Lso s/c shell/panel prefab 1,534.00 1,534.00 2,737 Lso sag r an/pos pnl pre cst 1,235.00 1,235.00 2,738 Lso sagit rigid panel prefab 1,958.00 1,958.00 2,739 Lso sc r ant/pos pnl pre cst 1,534.00 1,534.00 2,740 Lso sc r pos/lat pnl pre cst 575.00 575.00 2,741 Lt compres band <3"/yd - 5.00 5.00 2,742 Lt compres band >=3" <5"/yd - 27.00 27.00 2,743 Lt compres band >=5"/yd - 8.00 8.00 2,744 Ltwt portbl power whlchr 825.00 825.00 2,745 Lube sterile packet 2.00 2.00 2,746 Lubricant per ounce 15.00 15.00 2,747 Lumbar bolster pad 222.00 222.00 2,748 Lumbar derotation pad 281.00 281.00 2,749 Lumbar or lumbar rib pad 315.00 315.00 2,750 Lumbar sling 319.00 319.00 2,751 Lumizyme injection 384.00 384.00 2,752 LUNG PERF&VENTILAT DIFERENTL 959.00 - 2,753 LUNG PERFUSION DIFFERENTIAL 630.00 - 2,754 LUNG PERFUSION IMAGING 630.00 - 2,755 LUNG VENTILAT&PERFUS IMAGING 959.00 - 2,756 LUNG VENTILATION IMAGING 630.00 - 2,757 Lwr ext dynamic prosth pylon 567.00 567.00 2,758 LWR XTR VASC STDY BILAT 124.00 326.00 - 2,759 LYME DIS DNA AMP PROBE 137.00 - 2,760 LYME DIS DNA DIR PROBE 79.00 - 2,761 LYME DISEASE ANTIBODY - 126.00 126.00 2,762 LYME DISEASE ANTIBODY 138.00 138.00 2,763 LYMPH CHORIOMENINGITIS AB 50.00 - 2,764 LYMPH SYSTEM IMAGING 798.00 - 2,765 LYMPH VESSEL X-RAY ARM/LEG 918.00 - 2,766 LYMPH VESSEL X-RAY ARMS/LEGS 918.00 - Physician Hospital Village Description # Charge Charge Charge 2,767 LYMPH VESSEL X-RAY TRUNK 918.00 - 2,768 LYMPH VESSEL X-RAY TRUNK 918.00 - 2,769 LYMPHOCYTE CULTURE MIXED 221.00 - 2,770 LYMPHOCYTE TRANSFORMATION 192.00 - 2,771 LYMPHOCYTOTOXICITY ASSAY 186.00 - 2,772 LYMPHOCYTOTOXICITY ASSAY 205.00 - 2,773 M.AVIUM-INTRA DNA AMP PROB 137.00 - 2,774 M.AVIUM-INTRA DNA DIR PROB 79.00 - 2,775 M.AVIUM-INTRA DNA QUANT 168.00 - 2,776 M.PNEUMON DNA AMP PROBE 137.00 - 2,777 M.PNEUMON DNA DIR PROBE 79.00 - 2,778 M.PNEUMON DNA QUANT 164.00 - 2,779 M.TUBERCULO DNA AMP PROBE 137.00 - 2,780 M.TUBERCULO DNA DIR PROBE 79.00 - 2,781 M.TUBERCULO DNA QUANT 168.00 - 2,782 MACROSCOPIC EXAM ARTHROPOD 17.00 - 2,783 MACROSCOPIC EXAM PARASITE 17.00 - 2,784 MAGNETIC IMAGE BONE MARROW 965.00 - 2,785 MAGNETIC IMAGE JAW JOINT 965.00 - 2,786 MALARIA ANTIBODY 52.00 - 2,787 Male condom 5.00 2,788 Male external catheter 37.00 37.00 2,789 Man w/ch acc seat w>=20"<24" 970.00 970.00 2,790 Man wc rim/projection rep ea 213.00 213.00 2,791 Man wc whl lock comp repl ea 159.00 159.00 2,792 Mannitol for inhaler 2.00 2.00 2,793 Mannitol injection 7.00 7.00 2,794 Man's shoe oxford brace 267.00 267.00 2,795 Manual breast pump - 93.00 93.00 2,796 MANUAL CELL COUNT EACH 17.00 - 2,797 MANUAL DIFF WBC COUNT B-COAT 15.00 - 2,798 MANUAL RETICULOCYTE COUNT 17.00 - 2,799 Manual semi-reclining back 161.00 161.00 2,800 MANUAL THERAPY 1/> REGIONS - 113.00 113.00 2,801 Manual wc accessory, handrim 127.00 127.00 2,802 MASS SPECTROMETRY QUAL/QUAN - 235.00 235.00 2,803 MASSAGE THERAPY 80.00 80.00 2,804 Mastectomy bra 178.00 178.00 2,805 Mastectomy form 556.00 556.00 2,806 Matristem micromatrix 10.00 - 2,807 Mattress foam rubber 219.00 219.00 2,808 Mattress innerspring 645.00 645.00 2,809 MCV4 MENACWY VACCINE IM - 134.00 134.00 2,810 MEASURE BLOOD OXYGEN LEVEL - 31.00 9.00 2,811 MEASURE BLOOD OXYGEN LEVEL 242.00 2,812 MEASURE BLOOD OXYGEN LEVEL - 153.00 153.00 2,813 Mech amb infusion pump <8hrs 40.00 40.00 2,814 Mech hip extension assist 788.00 788.00 2,815 MECHANICAL TRACTION THERAPY - 72.00 72.00 2,816 Mechlorethamine hcl inj 395.00 395.00 2,817 MECKELS DIVERT EXAM 732.00 - 2,818 MED NUTRITION INDIV SUBSEQ 54.00 144.00 54.00 2,819 MEDICAL NUTRITION GROUP 78.00 54.00 78.00 2,820 MEDICAL NUTRITION INDIV IN 61.00 168.00 61.00 2,821 MEDICAL SERVICES AFTER HRS 72.00 72.00 2,822 Medroxyprogesterone acetate - 2.00 2.00 2,823 Melphalan oral 2 mg 29.00 29.00 2,824 Mental health service, nos 40.00 40.00 40.00 2,825 Meperidine hydrochl /100 mg - 7.00 7.00 2,826 Meropenem 5.00 5.00 2,827 Mesna injection 13.00 13.00 2,828 METABOLIC PANEL IONIZED CA 33.00 - 2,829 METABOLIC PANEL TOTAL CA - 83.00 83.00 Physician Hospital Village Description # Charge Charge Charge 2,830 Metacarp fx orthosis pre cst - 181.00 181.00 2,831 Metacarp fx orthosis pre ots - 270.00 - 2,832 Metacarpophalangeal implant 836.00 836.00 2,833 Metaproterenol non-comp unit 2.00 2.00 2,834 Metatarsal joint implant 868.00 868.00 2,835 Methacholine chloride, neb 2.00 2.00 2,836 Methadone injection 25.00 25.00 2,837 Methocarbamol injection 109.00 109.00 2,838 Methotrexate oral 2.5 mg 2.00 2.00 2,839 Methotrexate sodium inj - 2.00 2.00 2,840 Methotrexate sodium inj - 7.00 7.00 2,841 Methyl aminolevulinate, top 209.00 209.00 2,842 Methyldopate hcl injection 127.00 127.00 2,843 METHYLENEDIOXYAMPHETAMINES 86.00 - 2,844 Methylergonovin maleate inj - 14.00 14.00 2,845 Methylnaltrexone injection 2.00 2.00 2,846 METHYLPHENIDATE 76.00 - 2,847 Methylprednisolone 20 mg inj 5.00 5.00 2,848 Methylprednisolone 40 mg inj - 10.00 10.00 2,849 Methylprednisolone 80 mg inj - 26.00 26.00 2,850 Methylprednisolone injection - 6.00 6.00 2,851 Methylprednisolone injection - 9.00 9.00 2,852 Methylprednisolone oral 1.00 1.00 2,853 Metoclopramide hcl injection - 5.00 5.00 2,854 METYRAPONE PANEL 357.00 - 2,855 Mh health assess by non-md - 300.00 300.00 2,856 Micafungin sodium injection 3.00 3.00 2,857 MICROBE SUSCEPT MACROBROTH 26.00 - 2,858 MICROBE SUSCEPT MYCOBACTERI 22.00 - 2,859 MICROBE SUSCEPTIBLE DIFFUSE 19.00 - 2,860 MICROBE SUSCEPTIBLE DISK 27.00 - 2,861 MICROBE SUSCEPTIBLE ENZYME 19.00 - 2,862 MICROBE SUSCEPTIBLE MIC - 51.00 51.00 2,863 MICROBE SUSCEPTIBLE MLC 41.00 - 2,864 MICRODISSECTION LASER 304.00 - 2,865 MICRODISSECTION MANUAL 360.00 - 2,866 MICROFLUID ANALY TEARS 65.00 - 2,867 MICROSCOPIC EXAM OF URINE 34.00 34.00 2,868 MICROSLIDE CONSULTATION 36.00 - 2,869 MICROSLIDE CONSULTATION 109.00 - 2,870 MICROSOMAL ANTIBODY EACH - 83.00 83.00 2,871 MIDDLE CEREBRAL ARTERY ECHO 184.00 - 2,872 Minocycline hydrochloride 2.00 2.00 2,873 Mirena, 52 mg - 1,000.00 - 2,874 Misc/exper non-prescript dru 3.00 3.00 2,875 Mitomycin injection 72.00 72.00 2,876 Mitoxantrone hydrochl / 5 mg 111.00 111.00 2,877 MMR VACCINE SC - 60.00 60.00 2,878 Mnt subs tx for change dx - 54.00 54.00 2,879 Mobile arm support supinator 613.00 613.00 2,880 MOD SED SAME PHYS/QHP <5 YRS 92.00 - 2,881 MOD SED SAME PHYS/QHP 5/>YRS 67.00 74.00 67.00 2,882 MOD SED SAME PHYS/QHP EA 59.00 29.00 - 2,883 Mod sedat endo service >5yrs 20.00 - 2,884 Modification diabetic shoe 101.00 101.00 2,885 MODIFICATION OF CONTACT LENS 77.00 77.00 2,886 Mon cable elec/pneum vad rep 588.00 588.00 2,887 Monitor cable elec vad, rep 706.00 706.00 2,888 MONONUCLEAR CELL ANTIGEN 105.00 - 2,889 Morphine sulfate injection - 13.00 13.00 2,890 MOTION FLUOROSCOPY/SWALLOW 308.00 - 2,891 Mouth piece 14.00 14.00 2,892 MPSV4 VACCINE SUBQ - 213.00 213.00 Physician Hospital Village Description # Charge Charge Charge 2,893 MR ANG LWR EXT W OR W/O DYE 1,388.00 - 2,894 MR ANGIO PELVIS W/O & W/DYE 1,381.00 - 2,895 MR ANGIO SPINE W/O&W/DYE 1,408.00 - 2,896 MR ANGIO UPR EXTR W/O&W/DYE 1,423.00 - 2,897 MR ANGIOGRAPH HEAD W/O&W/DYE 1,566.00 - 2,898 MR ANGIOGRAPH NECK W/O&W/DYE 1,566.00 - 2,899 MR ANGIOGRAPHY HEAD W/DYE 1,295.00 - 2,900 MR ANGIOGRAPHY HEAD W/O DYE 965.00 - 2,901 MR ANGIOGRAPHY NECK W/DYE 1,295.00 - 2,902 MR ANGIOGRAPHY NECK W/O DYE 965.00 - 2,903 MR GUIDANCE FOR NEEDLE PLACE 1,130.00 - 2,904 MR SPECTROSCOPY 1,398.00 - 2,905 MRI ABDOMEN W/DYE 1,295.00 - 2,906 MRI ABDOMEN W/O & W/DYE 1,566.00 - 2,907 MRI ABDOMEN W/O DYE 965.00 - 2,908 MRI ANGIO ABDOM W ORW/O DYE 1,380.00 - 2,909 MRI ANGIO CHEST W OR W/O DYE 1,361.00 - 2,910 MRI BOTH BREASTS 1,946.00 - 2,911 MRI BRAIN STEM W/DYE 1,295.00 - 2,912 MRI BRAIN STEM W/O & W/DYE 1,566.00 - 2,913 MRI BRAIN STEM W/O DYE 965.00 - 2,914 MRI BRAIN W/DYE 1,295.00 - 2,915 MRI BRAIN W/O & W/DYE 1,566.00 - 2,916 MRI BRAIN W/O DYE 965.00 - 2,917 MRI CHEST SPINE W/DYE 1,295.00 - 2,918 MRI CHEST SPINE W/O & W/DYE 1,566.00 - 2,919 MRI CHEST SPINE W/O DYE 965.00 - 2,920 MRI CHEST W/DYE 1,295.00 - 2,921 MRI CHEST W/O & W/DYE 1,566.00 - 2,922 MRI CHEST W/O DYE 965.00 - 2,923 MRI JNT OF LWR EXTRE W/O DYE 965.00 - 2,924 MRI JOINT LWR EXTR W/O&W/DYE 1,566.00 - 2,925 MRI JOINT OF LWR EXTR W/DYE 1,295.00 - 2,926 MRI JOINT UPR EXTR W/O&W/DYE 1,566.00 - 2,927 MRI JOINT UPR EXTREM W/DYE 1,295.00 - 2,928 MRI JOINT UPR EXTREM W/O DYE 965.00 - 2,929 MRI LOWER EXTREMITY W/DYE 1,295.00 - 2,930 MRI LOWER EXTREMITY W/O DYE 965.00 - 2,931 MRI LUMBAR SPINE W/DYE 1,295.00 - 2,932 MRI LUMBAR SPINE W/O & W/DYE 1,566.00 - 2,933 MRI LUMBAR SPINE W/O DYE 965.00 - 2,934 MRI LWR EXTREMITY W/O&W/DYE 1,566.00 - 2,935 MRI NECK SPINE W/DYE 1,295.00 - 2,936 MRI NECK SPINE W/O & W/DYE 1,566.00 - 2,937 MRI NECK SPINE W/O DYE 965.00 - 2,938 MRI ONE BREAST 1,963.00 - 2,939 MRI ORBIT/FACE/NECK W/DYE 1,295.00 - 2,940 MRI ORBIT/FACE/NECK W/O DYE 965.00 - 2,941 MRI ORBT/FAC/NCK W/O &W/DYE 1,566.00 - 2,942 MRI PELVIS W/DYE 1,295.00 - 2,943 MRI PELVIS W/O & W/DYE 1,566.00 - 2,944 MRI PELVIS W/O DYE 965.00 - 2,945 MRI PROCEDURE 965.00 - 2,946 MRI UPPER EXTREMITY W/DYE 1,295.00 - 2,947 MRI UPPER EXTREMITY W/O DYE 965.00 - 2,948 MRI UPPR EXTREMITY W/O&W/DYE 1,566.00 - 2,949 MR-STAPH DNA AMP PROBE 137.00 - 2,950 MTMS BY PHARM ADDL 15 MIN - 33.00 - 2,951 MTMS BY PHARM EST 15 MIN - 47.00 - 2,952 MTMS BY PHARM NP 15 MIN - 72.00 - 2,953 MUCOPOLYSACCHARIDES 78.00 - 2,954 MUCORMYCOSIS ANTIBODY 52.00 - 2,955 Multi den insert custom mold 126.00 126.00 Physician Hospital Village Description # Charge Charge Charge 2,956 Multi den insert direct form 84.00 84.00 2,957 MULTIPLE FAMILY GROUP PSYTX 128.00 256.00 128.00 2,958 MUMPS ANTIBODY - 51.00 51.00 2,959 MURAMIDASE 73.00 - 2,960 MUSCULOSKELETAL NUCLEAR EXAM 746.00 - 2,961 MYCOBACTERIA CULTURE - 83.00 83.00 2,962 MYCOBACTERIA DNA AMP PROBE 137.00 - 2,963 MYCOBACTERIA DNA DIR PROBE 444.00 444.00 2,964 MYCOBACTERIA DNA QUANT 168.00 - 2,965 MYCOBACTERIC IDENTIFICATION 221.00 221.00 2,966 Mycophenolate mofetil oral 4.00 4.00 2,967 Mycophenolic acid 13.00 13.00 2,968 MYCOPLASMA 60.00 - 2,969 MYCOPLASMA ANTIBODY 47.00 47.00 2,970 MYELOGPHY 2/> SPINE REGIONS 1,447.00 - 2,971 MYELOGRAPHY L-S SPINE 1,447.00 - 2,972 MYELOGRAPHY NECK SPINE 1,447.00 - 2,973 MYELOGRAPHY THORACIC SPINE 1,447.00 - 2,974 N BLOCK INJ AXILLARY 1,189.00 2,550.00 1,189.00 2,975 N BLOCK INJ OCCIPITAL 345.60 1,026.00 345.60 2,976 N BLOCK OTHER PERIPHERAL 373.00 2,050.00 373.00 2,977 N. GONORRHOEAE ASSAY W/OPTIC 47.00 - 2,978 N.GONORRHOEAE DNA AMP PROB - 164.00 164.00 2,979 N.GONORRHOEAE DNA DIR PROB 87.00 87.00 2,980 N.GONORRHOEAE DNA QUANT 168.00 - 2,981 Na ferric gluconate complex 11.00 11.00 2,982 Nabilone oral 77.00 77.00 2,983 Naltrexone, depot form - 10.00 10.00 2,984 NARCOSYNTHESIS 438.00 - 2,985 Nasal application device 329.00 329.00 2,986 NASAL ENDOSCOPY DX 677.00 624.00 677.00 2,987 NASAL FUNCTION STUDIES 100.00 - 2,988 NASAL SMEAR FOR EOSINOPHILS 51.00 51.00 2,989 NASAL/OROGASTRIC W/TUBE PLMT 218.00 1,026.00 - 2,990 NASOPHARYNGOSCOPY 436.00 436.00 2,991 Natalizumab injection 37.00 37.00 2,992 NB RESUSCITATION 1,005.00 1,005.00 2,993 Nebulizer administration set - 7.00 7.00 2,994 Nebulizer dome & mouthpiece 40.00 40.00 2,995 Nebulizer for use w/ regulat 375.00 375.00 2,996 Nebulizer not used w oxygen 435.00 435.00 2,997 Nebulizer reservoir bottle 152.00 152.00 2,998 Nebulizer ultrasonic 303.00 303.00 2,999 Nebulizer w/ compressor & he 188.00 188.00 3,000 Nebulizer water collec devic 16.00 16.00 3,001 Nebulizer with compression - 231.00 231.00 3,002 NEEDLE LOCALIZATION BY XRAY 96.00 187.00 - 3,003 Neg pres wound ther drsg set 33.00 3,004 NEG PRESS WND TX 50 CM 438.00 - 3,007 NEG PRESS WOUND TX >50 CM 175.00 265.00 175.00 3,008 NEISSERIA MENINGITIDIS 52.00 - 3,009 Nelarabine injection 309.00 309.00 3,010 NEONATE CRIT CARE INITIAL 3,292.00 - 3,011 NEONATE CRIT CARE SUBSQ 1,355.00 - 3,012 Nerve stimulator for tx n&v 273.00 273.00 3,013 NERVE TEASING PREPARATIONS 172.00 - 3,014 NERVOUS SYSTEM NUCLEAR EXAM 753.00 - 3,015 Nesiritide injection 163.00 163.00 3,016 NEUROBEHAVIORAL STATUS EXAM 293.00 532.00 - 3,017 NEUROMUSCULAR REEDUCATION 102.00 102.00 3,018 Neuromuscular stim for scoli 363.00 363.00 Physician Hospital Village Description # Charge Charge Charge 3,019 Neuromuscular stim for shock 247.00 247.00 3,020 NEUROPSYCH TESTING BY TEC 78.00 532.00 - 3,021 NEUROPSYCH TST ADMIN W/COMP 88.00 259.00 - 3,022 NEUROPSYCH TST BY PSYCH/PHYS 262.00 532.00 - 3,023 NEUTRALIZATION TEST VIRAL 137.00 137.00 3,024 NEUTRON BEAM TX COMPLEX 512.00 - 3,025 NEW EYE EXAM & TREATMENT 506.00 - 3,026 NITROBLUE TETRAZOLIUM DYE 45.00 - 3,027 NK CELLS TOTAL COUNT 148.00 - 3,028 NOCARDIA ANTIBODY 52.00 - 3,029 Non-corrosive finish 236.00 236.00 3,030 Non-cov proc, clinical trial 149.00 - 3,031 Non-cov surg proc,clin trial 149.00 - 3,032 Non-covered item or service - 56.00 56.00 3,033 Nondisposable nebulizer set 100.00 100.00 3,034 Nondisposable pump canister 108.00 108.00 3,035 Non-elastic extremity binder - 16.00 16.00 3,036 Non-elec oscillatory pep dvc 144.00 144.00 3,037 Non-electronic spirometer - 12.00 - 3,038 Noner transport lodgng escrt 99.00 - 3,039 Noner transport lodgng recip 99.00 - 3,040 Noner transport meals escort 40.00 - 3,041 Noner transport meals recip 40.00 - 3,042 Non-heu tc-99m add-on/dose 30.00 - 3,043 NON-IMAGING HEART FUNCTION 881.00 - 3,044 Non-inhalation drug for dme 1.00 1.00 3,045 Non-molded lacer 495.00 495.00 3,046 Nonpectin based ostomy paste 15.00 15.00 3,047 Non-pneum walk boot pre cst - 397.00 397.00 3,048 Nonpower mattress overlay 973.00 973.00 3,049 NON-SPEECH DEVICE SERVICE 244.00 244.00 - 3,050 Non-sterile gauze<=16 sq in 3.00 3.00 3,051 Non-sterile gloves - 27.00 27.00 3,052 NONVASCULAR SHUNT X-RAY 202.00 - 3,053 Non-waterproof tape - 31.00 31.00 3,054 Normal saline solution infus - 2.00 2.00 3,055 Normal saline solution infus - 5.00 5.00 3,056 Normal saline solution infus - 5.00 5.00 3,057 NUCLEAR ANTIGEN ANTIBODY - 133.00 133.00 3,058 NUCLEAR DIAGNOSTIC EXAM 325.00 - 3,059 NUCLEAR EXAM OF TEAR FLOW 753.00 - 3,060 NUCLEAR LOCALIZATION/ABSCESS 1,432.00 - 3,061 NUCLEAR MATRIX PROTEIN 22 63.00 - 3,062 NUCLEAR MEDICINE THERAPY 675.00 - 3,063 NUCLEAR RX INTRA-ARTERIAL 675.00 - 3,064 NUCLEAR RX INTRA-ARTICULAR 858.00 - 3,065 NUCLEAR RX INTRACAV ADMIN 858.00 - 3,066 NUCLEAR RX IV ADMIN 675.00 - 3,067 NUCLEAR RX ORAL ADMIN 675.00 - 3,068 NUCLR RX INTERSTIT COLLOID 675.00 - 3,069 Nudge control elbow lock 911.00 911.00 3,070 Nursing assessment/evaluatn 32.00 32.00 3,071 NURSING FAC CARE SUBSEQ 65.00 65.00 3,072 NURSING FAC CARE SUBSEQ 101.00 101.00 3,073 NURSING FAC CARE SUBSEQ 139.00 139.00 3,074 NURSING FAC CARE SUBSEQ 466.00 - 3,075 NURSING FAC CARE SUPERVISION 193.00 - 3,076 NURSING FAC CARE SUPERVISION 305.00 - 3,077 NURSING FAC DISCHARGE DAY 121.00 121.00 3,078 NURSING FAC DISCHARGE DAY 151.00 151.00 3,079 NURSING FACILITY CARE INIT 323.00 - 3,080 NURSING FACILITY CARE INIT 458.00 - 3,081 NURSING FACILITY CARE INIT 578.00 - Physician Hospital Village Description # Charge Charge Charge 3,082 Nutritional counseling, diet - 78.00 78.00 3,083 O shoe add felt w leath insl 96.00 96.00 3,084 O shoe add horseshoe toe tap 69.00 69.00 3,085 O shoe add instep extension 214.00 214.00 3,086 O shoe add instep velcro clo 195.00 195.00 3,087 O shoe add standard toe tap 31.00 31.00 3,088 O shoe convert to sof counte 161.00 161.00 3,089 O&p supply/accessory/service 95.00 95.00 3,090 O2/water vapor enrich w/heat 480.00 480.00 3,091 O2/water vapor enrich w/o he 487.00 487.00 3,092 Oasis burn matrix 28.00 28.00 3,093 Oasis tri-layer wound matrix 33.00 - 3,094 Oasis wound matrix 28.00 28.00 3,095 OB US < 14 WKS ADDL FETUS 143.00 270.00 - 3,096 OB US < 14 WKS SINGLE FETUS 169.00 651.00 - 3,097 OB US >/= 14 WKS ADDL FETUS 168.00 1,162.00 - 3,098 OB US >/= 14 WKS SNGL FETUS 170.00 717.00 - 3,099 OB US DETAILED ADDL FETUS 311.00 184.00 - 3,100 OB US DETAILED SNGL FETUS 330.00 441.00 - 3,101 OB US FOLLOW-UP PER FETUS 148.00 482.00 - 3,102 OB US LIMITED FETUS(S) 109.00 508.00 - 3,103 OB US NUCHAL MEAS 1 GEST 184.00 - 3,104 OB US NUCHAL MEAS ADD-ON 184.00 - 3,105 OBSERV/HOSP SAME DATE 464.00 - 3,106 OBSERV/HOSP SAME DATE 626.00 - 3,107 OBSERV/HOSP SAME DATE 772.00 - 3,108 OBSERVATION CARE DISCHARGE 256.00 - 3,109 OBSTETRIC PANEL 331.00 331.00 3,110 OBSTETRICAL CARE 4,717.00 - - 3,111 OBSTETRICAL CARE 6,984.00 - - 3,112 OBSTETRICAL CARE 4,107.00 4,800.00 4,107.00 3,113 Obtaining screen pap smear 25.00 - 3,114 OCCULT BLD FECES 1-3 TESTS 41.00 41.00 3,115 OCCULT BLOOD FECES - 51.00 51.00 3,116 OCCULT BLOOD OTHER SOURCES 13.00 - 3,117 Octagam injection 95.00 95.00 3,118 Octreotide inj, non-depot 5.00 5.00 3,119 Octreotide injection, depot 324.00 324.00 3,120 Ofatumumab injection 136.00 136.00 3,121 OFFICE CONSULTATION 234.00 234.00 3,122 OFFICE CONSULTATION 333.00 333.00 3,123 OFFICE CONSULTATION 433.00 433.00 3,124 OFFICE CONSULTATION 579.00 579.00 3,125 OFFICE CONSULTATION 756.00 756.00 3,126 OFFICE EMERGENCY CARE 210.00 210.00 3,127 OFFICE/OUTPATIENT VISIT EST 80.00 70.00 80.00 3,128 OFFICE/OUTPATIENT VISIT EST 122.00 80.00 122.00 3,129 OFFICE/OUTPATIENT VISIT EST 165.00 90.00 165.00 3,130 OFFICE/OUTPATIENT VISIT EST 246.00 130.00 246.00 3,131 OFFICE/OUTPATIENT VISIT EST 373.00 202.00 373.00 3,132 OFFICE/OUTPATIENT VISIT NEW 145.00 145.00 3,133 OFFICE/OUTPATIENT VISIT NEW 202.00 202.00 3,134 OFFICE/OUTPATIENT VISIT NEW 284.00 284.00 3,135 OFFICE/OUTPATIENT VISIT NEW 406.00 406.00 3,136 OFFICE/OUTPATIENT VISIT NEW 515.00 515.00 3,137 Offset knee joint each 433.00 433.00 3,138 Offset knee joint heavy duty 477.00 477.00 3,139 Offset/lat rocker arm w/ela 613.00 613.00 3,140 Olanzapine long-acting inj 10.00 10.00 3,141 OLIGOCLONAL BANDS 146.00 146.00 3,142 Omalizumab injection 71.00 71.00 3,143 ONCOPROTEIN DCP 252.00 - 3,144 ONCOPROTEIN HER-2/NEU 252.00 - Physician Hospital Village Description # Charge Charge Charge 3,145 Ondansetron hcl injection - 5.00 5.00 3,146 Ondansetron oral 2.00 2.00 3,147 One way chest drain valve 133.00 133.00 3,148 OOCYTE IDENTIFICATION 172.00 - 3,149 OPHTH US B & QUANT A 340.00 413.00 - 3,150 OPHTH US B W/NON-QUANT A 190.00 283.00 - 3,151 OPHTH US QUANT A ONLY 185.00 283.00 - 3,152 OPHTHALMIC BIOMETRY 159.00 185.00 - 3,153 OPHTHALMOSCOPY/DYNAMOMETRY 40.00 - 3,154 OPIATES 1 OR MORE - 107.00 - 3,155 OPIOID &OPIATE ANALOG 5/MORE 107.00 - 3,156 OPIOIDS & OPIATE ANALOGS 1/2 107.00 - 3,157 OPIOIDS & OPIATE ANALOGS 3/4 107.00 - 3,158 Oprelvekin injection 526.00 526.00 3,159 OPTICAL ENDOMICROSCPY INTERP 36.00 - 3,160 OPTOKINETIC NYSTAGMUS TEST 48.00 - 3,161 Oral aprepitant 23.00 23.00 3,162 Oral busulfan 19.00 19.00 3,163 Oral dexamethasone 2.00 2.00 3,164 Oral everolimus 22.00 22.00 3,165 Oral fludarabine phosphate 204.00 204.00 3,166 ORAL FUNCTION THERAPY 430.00 430.00 3,167 Oral hiv-1/hiv-2 screen 47.00 47.00 3,168 Oral med adm direct observe 30.00 - 3,169 Oral mr contrast, 100 ml 35.00 35.00 3,170 Oral prescrip drug non chemo 3.00 3.00 3,171 ORAL SPEECH DEVICE EVAL 355.00 - 3,172 ORGANIC ACID SINGLE QUANT 277.00 277.00 3,173 ORGANIC ACIDS QUAL EACH 64.00 - 3,174 ORGANIC ACIDS TOTAL QUANT - 83.00 83.00 3,175 Oropharyngeal suction cath 17.00 17.00 3,176 Orphenadrine injection 23.00 23.00 3,177 Orth dev repair/repl minor p 11.00 11.00 3,178 ORTHC/PROSTC MGMT SBSQ ENC 164.00 - 3,179 Ortho dvc repair per 15 min 27.00 27.00 3,180 Ortho shoe add full sole 153.00 153.00 3,181 Ortho shoe add half sole 96.00 96.00 3,182 Ortho shoe add leather insol 88.00 88.00 3,183 Ortho shoe add march bar 126.00 126.00 3,184 Ortho sidebar disconnect 326.00 326.00 3,185 Orthopedic shoe add rub insl 88.00 88.00 3,186 ORTHOPTIC/PLEOPTIC TRAINING 91.00 121.00 - 3,187 ORTHOTIC MGMT&TRAINJ 1ST ENC - 58.00 58.00 3,188 Orthovisc inj per dose 419.00 419.00 3,189 Os pch urine w bar/fange/tap 52.00 52.00 3,190 OSCILLATING TRACKING TEST 44.00 - 3,191 Ossicular implant 636.00 636.00 3,192 Ost pch clsd w barrier/filtr 12.00 12.00 3,193 Ost pch clsd w/o bar w filtr 8.00 8.00 3,194 Ost pch drain 2 piece system 12.00 12.00 3,195 Ost pch drain for barrier fl 15.00 15.00 3,196 Ost pch drain w bar & filter 20.00 20.00 3,197 Ost pch drain/barr lk flng/f 13.00 13.00 3,198 Ost pch for bar w flange/flt 7.00 7.00 3,199 Ost pch for bar w lk fl/fltr 9.00 9.00 3,200 Ost pch urine w barrier/tapv 28.00 28.00 3,201 Ost pch urine w lock flng/ft 16.00 16.00 3,202 Ost pch w bar/bltinconv/fltr 15.00 15.00 3,203 Ost pouch absorbent material 2.00 2.00 3,204 Ost pouch drain high output 12.00 12.00 3,205 Ost skn barr convex <=4 sq i 67.00 67.00 3,206 Ost skn barr extnd =4sq 23.00 23.00 3,207 Ost skn barr extnd >4 sq 35.00 35.00 Physician Hospital Village Description # Charge Charge Charge 3,208 Ost skn barr w/o conv >4 sqi 27.00 27.00 3,209 Ost skn barrier sld ext wear - 202.00 202.00 3,210 Ost sknbar w/o conv<=4 sq in 44.00 44.00 3,211 Ost urine pch w b/bltin conv 30.00 30.00 3,212 OSTEOPATH MANJ 1-2 REGIONS 117.00 117.00 117.00 3,213 OSTEOPATH MANJ 3-4 REGIONS 158.00 158.00 158.00 3,214 OSTEOPATH MANJ 5-6 REGIONS 162.00 162.00 - 3,215 OSTEOPATH MANJ 7-8 REGIONS 206.00 206.00 - 3,216 OSTEOPATH MANJ 9-10 REGIONS 268.00 268.00 268.00 3,217 Ostomy accessory convex inse 8.00 8.00 3,218 Ostomy belt - 20.00 20.00 3,219 Ostomy clamp, replacement - 8.00 8.00 3,220 Ostomy face plate 94.00 94.00 3,221 Ostomy faceplt/silicone ring 34.00 34.00 3,222 Ostomy filter 2.00 2.00 3,223 Ostomy irrig cone/cath w brs 46.00 46.00 3,224 Ostomy irrigation bag 51.00 51.00 3,225 Ostomy irrigation set 207.00 207.00 3,226 Ostomy pouch liq deodorant 11.00 11.00 3,227 Ostomy pouch solid deodorant 2.00 2.00 3,228 Ostomy ring each 7.00 7.00 3,229 Ostomy vent 6.00 6.00 3,230 OT EVAL HIGH COMPLEX 60 MIN 276.00 - 3,231 OT EVAL LOW COMPLEX 30 MIN - 221.00 - 3,232 OT EVAL MOD COMPLEX 45 MIN - 242.00 - 3,233 OT RE-EVAL EST PLAN CARE - 154.00 - 3,234 OTHER IMMUNOELECTROPHORESIS 88.00 - 3,235 OTHER SOURCE ALBUMIN QUAN EA 20.00 - 3,236 Outrigger 188.00 188.00 3,237 Outrigger bil w/ vert extens 459.00 459.00 3,238 OVA AND PARASITES SMEARS - 133.00 133.00 3,239 Ovine, up to 999 usp units 2.00 2.00 3,240 OVULATION TESTS 39.00 - 3,241 Oxacillin sodium injeciton 10.00 10.00 3,242 Oxaliplatin 118.00 118.00 3,243 Oxy suppl heater for nebuliz 473.00 473.00 3,244 Oxygen concentrator 443.00 443.00 3,245 Oxygen concentrator, dual 443.00 443.00 3,246 Oxygen probe used w oximeter 54.00 54.00 3,247 Oxygen supplies regulator 204.00 204.00 3,248 Oxygen supplies stand/rack 83.00 83.00 3,249 Oxymorphone hcl injection 8.00 8.00 3,250 Oxytocin injection - 6.00 6.00 3,251 P32 chromic phosphate 287.00 - 3,252 P32 na phosphate 425.00 - 3,253 Packing strips, non-impreg - 21.00 21.00 3,254 Paclitaxel protein bound 33.00 33.00 3,255 Pad band w>=3" <5"/yd 3.00 3.00 3,256 Pad water circulating heat u 416.00 416.00 3,257 Palifermin injection 39.00 39.00 3,258 Paliperidone palmitate inj - 25.00 25.00 3,259 Palonosetron hcl 57.00 57.00 3,260 Pamidronate disodium /30 mg 927.00 927.00 3,261 PANCREATIC ELASTASE FECAL 45.00 - 3,262 Panitumumab injection 223.00 223.00 3,263 PANORAMIC X-RAY OF JAWS 102.00 - 3,264 Pap oral interface 338.00 338.00 3,265 Papaverin hcl injection 3.00 3.00 3,266 PAPPA SERUM 59.00 - 3,267 Paraffin 15.00 15.00 3,268 PARAFFIN BATH THERAPY 81.00 81.00 3,269 Paraffin bath unit portable 114.00 114.00 3,270 PARAINFLUENZA AG IF 47.00 - Physician Hospital Village Description # Charge Charge Charge 3,271 PARATHYRD PLANAR W/SPECT&CT 918.00 - 3,272 PARATHYRD PLANAR W/WO SUBTRJ 918.00 - 3,273 PARATHYROID PLANAR IMAGING 664.00 - 3,274 Parenteral 50% dextrose solu 57.00 - 3,275 Parenteral administration ki 84.00 - 3,276 Parenteral infusion pump sta 739.00 739.00 3,277 Parenteral nutrition additiv 30.00 - 3,278 Parenteral sol > 100gm prote 719.00 - 3,279 Parenteral sol 10 gm lipids 38.00 - 3,280 Parenteral sol 52-73 gm prot 516.00 - 3,281 Parenteral sol 74-100 gm pro 629.00 - 3,282 Parenteral sol amino acid & 500.00 - 3,283 Parenteral sol amino acid > 194.00 - 3,284 Parenteral sol amino acid 3. 84.00 - 3,285 Parenteral sol amino acid 7- 162.00 - 3,286 Parenteral sol carb > 50% 82.00 - 3,287 Parenteral sol renal-amirosy 40.00 - 3,288 Parenteral solution hepatic 18.00 - 3,289 Parenteral supply kit homemi 33.00 - 3,290 Parenteral supply kit premix 32.00 - 3,291 Paricalcitol 6.00 6.00 3,292 PARTIAL REMOVAL FINGER BONE 2,408.00 4,800.00 - 3,293 PARTICLE AGGLUT ANTBDY SCRN 51.00 51.00 3,294 PARTICLE AGGLUT ANTBDY TITR 42.00 - 3,295 PARVOVIRUS ANTIBODY 51.00 51.00 3,296 Patch, lidocaine/tetracaine 40.00 - 3,297 PATH CONSULT INTRAOP 1 BLOC 67.00 - 3,298 PATH CONSULT INTRAOP ADDL 36.00 - 3,299 PATH CONSULT INTROP 36.00 - 3,300 PATHOLOGY LAB PROCEDURE 83.00 - 3,301 Patient lift electric 450.00 450.00 3,302 Patient lift hydraulic 276.00 276.00 3,303 Patient lift sling or seat 263.00 263.00 3,304 PCV13 VACCINE IM - 274.00 274.00 3,305 Pectin based ostomy paste 25.00 25.00 3,306 PED CRIT CARE AGE 2-5 INIT 1,940.00 - 3,307 PED CRIT CARE AGE 2-5 SUBSQ 1,202.00 - 3,308 PED CRIT CARE TRANSPORT 929.00 - 3,309 PED CRIT CARE TRANSPORT ADDL 421.00 - 3,310 PED CRITICAL CARE INITIAL 2,940.00 - 3,311 PED CRITICAL CARE SUBSQ 1,398.00 - 3,312 Ped size brief/diaper lg 14.00 14.00 3,313 Ped size brief/diaper sm/med - 20.00 20.00 3,314 Pegademase bovine, 25 iu 536.00 536.00 3,315 Peginesatide injection 32.00 32.00 3,316 Pegloticase injection 713.00 713.00 3,317 Pelv & thor control gluteal 349.00 349.00 3,318 Pelvic belt/harness/boot 60.00 60.00 3,319 Pelvic control hip heavy dut 848.00 848.00 3,320 Pelvic control pelvic sling - 706.00 - 3,321 PELVIC EXAMINATION 639.00 4,800.00 - 3,322 Pemetrexed injection 174.00 174.00 3,323 Peng benzathine/procaine inj 13.00 13.00 3,324 Penicillin g benzathine inj - 8.00 38.00 3,325 Penicillin g potassium inj - 48.00 48.00 3,326 PENILE VASCULAR STUDY 110.00 464.00 - 3,327 PENILE VASCULAR STUDY 312.00 464.00 - 3,328 Pentamidine non-comp unit 191.00 191.00 3,329 Pentazocine injection 74.00 74.00 3,330 Pentobarbital sodium inj 99.00 99.00 3,331 PER PM REEVAL EST PAT 65+ YR 378.00 226.00 378.00 3,332 PER PM REEVAL EST PAT INFANT 226.00 133.00 226.00 3,333 Percussor elect/pneum home m 151.00 151.00 Physician Hospital Village Description # Charge Charge Charge 3,334 Percutaneous catheter anchor 44.00 44.00 3,335 Peristomal hernia supprt blt 158.00 158.00 3,336 PERITONEAL LAVAGE 602.00 2,550.00 - 3,337 Permanent tear duct plug 74.00 74.00 3,338 Peroneal straps pair pre ots 61.00 61.00 3,339 PERTUSSIS AG IF 47.00 - 3,340 Pessary rubber, any type 67.00 67.00 3,341 Pessary, non rubber,any type - 120.00 120.00 3,342 PET IMAGE FULL BODY 3,010.00 - 3,343 PET IMAGE LTD AREA 3,010.00 - 3,344 PET IMAGE SKULL-THIGH 3,010.00 - 3,345 PET IMAGE W/CT FULL BODY 3,010.00 - 3,346 PET IMAGE W/CT LMTD 3,010.00 - 3,347 PET IMAGE W/CT SKULL-THIGH 3,010.00 - 3,348 PHARMACOLOGIC MGMT W/PSYTX 0.01 25.00 - 3,349 Phenobarbital sodium inj - 49.00 49.00 3,350 PHENOTYPE DNA HIV W/CLT ADD 102.00 - 3,351 PHENOTYPE DNA HIV W/CULTURE 1,914.00 - 3,352 PHENOTYPE INFECT AGENT DRUG 511.00 - 3,353 Phentolaine mesylate inj 265.00 265.00 3,354 Phenylephrine hcl injection 4.00 4.00 3,355 Phenytoin sodium injection 2.00 2.00 3,356 PHLEBOTOMY - 300.00 - 3,357 PHOSPHOLIPID PLTLT NEUTRALIZ 70.00 - 3,358 PHOTODYNAMIC TX ADDL 15 MIN 92.00 - 3,359 PHOTODYNMC TX 30 MIN ADD-ON 200.00 - 3,360 Phototherapy light w/ photom 487.00 487.00 3,361 PHYS BLOOD BANK SERV AUTHRJ 67.00 - 3,362 PHYS BLOOD BANK SERV REACTJ 67.00 - 3,363 PHYS BLOOD BANK SERV XMATCH 36.00 - 3,364 PHYSICAL MEDICINE PROCEDURE 27.00 3,365 PHYSICAL PERFORMANCE TEST 124.00 124.00 3,366 PHYSICAL THERAPY TREATMENT 78.00 3,367 PHYSICIAN STANDBY SERVICES 211.00 - 3,368 PINWORM EXAM 61.00 61.00 3,369 Pinworm examinations 21.00 21.00 3,370 Piperacillin/tazobactam - 10.00 10.00 3,371 PITUITARY EVALUATION PANEL 2,271.00 - 3,372 PLACE NEEDLE IN VEIN 177.00 - 177.00 3,373 PLACENTAL LACTOGEN 79.00 - 3,374 Plaelet rich plasma unit 439.00 439.00 3,375 Plas shoe insert w ank joint 419.00 419.00 3,376 Plasma 1 donor frz w/in 8 hr 197.00 197.00 3,377 PLASMA FRESH FROZEN 51.00 - 3,378 Plasma protein fract,5%,50ml 29.00 29.00 3,379 PLASMA VOLUME MULTIPLE 1,242.00 - 3,380 PLASMA VOLUME SINGLE 1,242.00 - 3,381 Plasma, frz between 8-24hour 189.00 189.00 3,382 Plasmaprotein fract,5%,250ml 125.00 125.00 3,383 Plastic mod low ext pad/line 403.00 403.00 3,384 Plate pheres leukoredu irrad 1,011.00 1,011.00 3,385 PLATELET ANTIBODIES 72.00 - 3,386 Platelet pheres leukoreduced 767.00 767.00 3,387 Platelet pheresis irradiated 1,014.00 1,014.00 3,388 PLATELET SURVIVAL 560.00 - 3,389 Platelets leukocytes reduced 296.00 296.00 3,390 Platelets leukoreduced irrad 391.00 391.00 3,391 Platelets, each unit 229.00 229.00 3,392 Platelets, irradiated 336.00 336.00 3,393 Platelets, pheresis 864.00 864.00 3,394 Plating chrome/nickel pr bar 243.00 243.00 3,395 Plerixafor injection 583.00 583.00 3,396 PM DEVICE EVAL IN PERSON 84.00 101.00 - Physician Hospital Village Description # Charge Charge Charge 3,397 PM DEVICE INTERROGATE REMOTE 144.00 - 3,398 Pneum drive wheel tire 213.00 213.00 3,399 Pneum full leg splnt pre ots 440.00 440.00 3,400 Pneumat walking boot pre cst 516.00 516.00 3,401 Pneumatic appliance full arm 371.00 371.00 3,402 Pneumatic appliance full leg 472.00 472.00 3,403 Pneumatic appliance half arm 316.00 316.00 3,404 Pneumatic appliance half leg 374.00 374.00 3,405 Pneumatic caster tire 226.00 226.00 3,406 Pneumatic caster tire each 161.00 161.00 3,407 Pneumatic caster tire tube 37.00 37.00 3,408 Pneumatic compression device 833.00 833.00 3,409 Pneumatic prop tire insert 118.00 118.00 3,410 Pneumatic prop tire tube 27.00 27.00 3,411 Pneumatic propulsion tire 340.00 340.00 3,412 PNEUMOCYSTIS CARINII AG IF 166.00 166.00 3,413 POLIOVIRUS IPV SC/IM - 97.00 - 3,414 Polycentric hinge pair 622.00 622.00 3,415 POOLING BLOOD PLATELETS 71.00 - 3,416 Portable 02 contents, gas 194.00 194.00 3,417 Portable 02 contents, liquid 194.00 194.00 3,418 Portable gas oxygen system 155.00 155.00 3,419 Portable gaseous 02 89.00 89.00 3,420 Portable liquid 02 89.00 89.00 3,421 Portable liquid oxygen sys 155.00 155.00 3,422 Portable oxygen concentrator 155.00 155.00 3,423 Portable peak flow meter - 33.00 - 3,424 Pos airway press chinstrap 51.00 51.00 3,425 Pos airway press headgear 117.00 117.00 3,426 POS AIRWAY PRESSURE CPAP 330.00 330.00 330.00 3,427 Pos airway pressure filter 20.00 20.00 3,428 Pos airway pressure tubing 129.00 129.00 3,429 Position back cush wd <22in 880.00 880.00 3,430 Position wc cush wdth <22 in 603.00 603.00 3,431 Position wc cush wdth>=22 in 940.00 940.00 3,432 POSITIONAL NYSTAGMUS TEST 84.00 - 3,433 Positioning cushion - 102.00 102.00 3,434 Post-coital mucous exam 39.00 39.00 3,435 Potassium hydroxide preps 17.00 17.00 3,436 Pouch clsd w barr attached 9.00 9.00 3,437 Pouch drainable w barrier at - 53.00 53.00 3,438 Power adapter, combo vad 435.00 435.00 3,439 PPSV23 VACC 2 YRS+ SUBQ/IM - 66.00 66.00 3,440 Pralatrexate injection 457.00 457.00 3,441 Pralidoxime chloride inj 225.00 225.00 3,442 Prednisolone oral per 5 mg 2.00 2.00 3,443 PREPARE EMBRYO FOR TRANSFER 172.00 - 3,444 PREPUTIAL STRETCHING 249.00 1,026.00 - 3,445 Prescription drug, generic 1.00 1.00 3,446 Prescription drug,brand name 21.00 21.00 3,447 PRESCRIPTION OF CONTACT LENS 150.00 100.00 150.00 3,448 Press pad alternating w/ pum 103.00 103.00 3,449 Pressure pneum appl full arm 839.00 839.00 3,450 Pressure pneum appl half leg 697.00 697.00 3,451 PREV VISIT EST AGE 12-17 279.00 245.00 279.00 3,452 PREV VISIT EST AGE 1-4 246.00 153.00 246.00 3,453 PREV VISIT EST AGE 18-39 325.00 180.00 325.00 3,454 PREV VISIT EST AGE 40-64 353.00 202.00 353.00 3,455 PREV VISIT EST AGE 5-11 255.00 154.00 255.00 3,456 PREV VISIT NEW AGE 12-17 340.00 340.00 3,457 PREV VISIT NEW AGE 18-39 391.00 391.00 3,458 PREV VISIT NEW AGE 40-64 430.00 430.00 3,459 PREV VISIT NEW AGE 5-11 306.00 306.00 Physician Hospital Village Description # Charge Charge Charge 3,460 PREVENTIVE COUNSELING GROUP 53.00 53.00 3,461 PREVENTIVE COUNSELING GROUP 105.00 105.00 3,462 PREVENTIVE COUNSELING INDIV 110.00 110.00 3,463 PREVENTIVE COUNSELING INDIV 187.00 187.00 3,464 PREVENTIVE COUNSELING INDIV 216.00 216.00 3,465 PREVENTIVE COUNSELING INDIV 298.00 298.00 3,466 Primatrix 103.00 103.00 3,467 Procainamide hcl injection 41.00 41.00 3,468 PROCALCITONIN (PCT) 105.00 - 3,469 Prochlorperazine injection - 7.00 7.00 3,470 Prochlorperazine maleate 5mg 2.00 2.00 3,471 PROCTOSIGMOIDOSCOPY REMOVAL 800.00 3,000.00 800.00 3,472 Program intake assessment 35.00 35.00 35.00 3,473 PROLONG E&M/PSYCTX SERV O/P 330.00 330.00 3,474 PROLONG E&M/PSYCTX SERV O/P 397.00 397.00 3,475 PROLONG SERV W/O CONTACT ADD 182.00 - 3,476 PROLONG SERVICE W/O CONTACT 376.00 - 3,477 PROLONGED SERVICE INPATIENT 313.00 - 3,478 PROLONGED SERVICE INPATIENT 316.00 - 3,479 Prolotherapy 300.00 - 3,480 Promethazine hcl 12.5mg oral 2.00 2.00 3,481 Promethazine hcl injection - 6.00 6.00 3,482 Propranolol injection 21.00 21.00 3,483 Propulsion whl excl tire rep 334.00 334.00 3,484 Pros sheath/sock w gel cushn 189.00 189.00 3,485 Pros sock multi ply upper lm 80.00 80.00 3,486 Pros sock single ply ak 34.00 34.00 3,487 Pros sock single ply bk 32.00 32.00 3,488 Pros sock single ply upper l 41.00 41.00 3,489 Prostate ca screening; dre 44.00 44.00 - 3,490 Prosthetic sock multi ply ak 109.00 109.00 3,491 Prosthetic sock multi ply bk 109.00 109.00 3,492 PROSTHETIC TRAINJ 1ST ENC 172.00 - 3,493 Protect body sock ea pre ots 206.00 206.00 3,494 Protector heel or elbow 54.00 54.00 3,495 PROTEIN ANALYSIS W/PROBE 89.00 - 3,496 Protein c concentrate 41.00 41.00 3,497 PROTEIN E-PHORESIS SERUM - 83.00 83.00 3,498 PROTEIN E-PHORESIS/URINE/CSF - 132.00 132.00 3,499 PROTEIN WESTERN BLOT TEST 71.00 - 3,500 PROTEIN WESTERN BLOT TISSUE 87.00 - 3,501 PROTHROMBIN TEST 15.00 - 3,502 PROTHROMBIN TIME - 83.00 83.00 3,503 PROTON TREATMENT COMPLEX 1,945.00 - 3,504 PROTON TRMT INTERMEDIATE 1,945.00 - 3,505 PROTON TRMT SIMPLE W/COMP 3,239.00 - 3,506 PROTON TRMT SIMPLE W/O COMP 3,239.00 - 3,507 PROTOZOA ANTIBODY NOS 49.00 - 3,508 Psa screening 72.00 72.00 3,509 PSY EVALUATION OF RECORDS 172.00 - 3,510 PSYCH DIAG EVAL W/MED SRVCS 426.00 330.00 - 3,511 PSYCH DIAGNOSTIC EVALUATION 413.00 330.00 - 3,512 PSYCHIATRIC SERVICE/THERAPY 20.00 - 3,513 PSYCHO TESTING ADMIN BY COMP 90.00 259.00 - 3,514 PSYCHO TESTING BY PSYCH/PHYS 263.00 532.00 - 3,515 PSYCHO TESTING BY TECHNICIAN 79.00 259.00 - 3,516 PSYCHOANALYSIS 263.00 - 3,517 PSYCHOPHYSIOLOGICAL THERAPY 211.00 - 3,518 PSYCHOPHYSIOLOGICAL THERAPY 335.00 - 3,519 Psysoc rehab svc, per 15 min 9.00 10.00 10.00 3,520 PSYTX COMPLEX INTERACTIVE 17.00 25.00 - 3,521 PSYTX CRISIS EA ADDL 30 MIN 200.00 250.00 - 3,522 PSYTX CRISIS INITIAL 60 MIN 450.00 330.00 - Physician Hospital Village Description # Charge Charge Charge 3,523 PSYTX W PT 30 MINUTES 173.00 83.00 - 3,524 PSYTX W PT 45 MINUTES 259.00 330.00 - 3,525 PSYTX W PT 60 MINUTES 391.00 110.00 - 3,526 PSYTX W PT W E/M 30 MIN 145.00 - 3,527 PSYTX W PT W E/M 45 MIN 238.00 - 3,528 PSYTX W PT W E/M 60 MIN 382.00 - 3,529 PT EVAL HIGH COMPLEX 45 MIN - 285.00 - 3,530 PT EVAL LOW COMPLEX 20 MIN - 228.00 - 3,531 PT EVAL MOD COMPLEX 30 MIN - 255.00 - 3,532 PT RE-EVAL EST PLAN CARE - 155.00 - 3,533 Pulmonary rehab w exer 118.00 - 3,534 Pulse gen sys tx endolymp fl 737.00 737.00 3,535 Pump for water circulating p 201.00 201.00 3,536 Pump uninterrupted infusion 735.00 735.00 3,537 PUNCTURE DRAINAGE OF LESION 299.00 1,026.00 299.00 3,538 PURE TONE AUDIOMETRY AIR - 354.00 77.00 3,539 PURE TONE HEARING TEST AIR - 65.00 63.00 3,540 Pwc gp 1 std port cap chair 951.00 951.00 3,541 Pwc gp 1 std port seat/back 743.00 743.00 3,542 Pwc gp 2 std port seat/back 793.00 793.00 3,543 Pwc harness, expand control 711.00 711.00 3,544 Pyridoxine hcl 100 mg 22.00 22.00 3,545 Q FEVER ANTIBODY 96.00 96.00 3,546 Quadrilateral brim 697.00 697.00 3,547 QUANTITATIVE ASSAY DRUG - 166.00 166.00 3,548 Quinupristin/dalfopristin 468.00 468.00 3,549 RABIES IG HEAT TREATED 395.00 3,550 RABIES IG IM/SC 471.00 413.00 3,551 RABIES VACCINE IM 381.00 381.00 3,552 Rad w/o backup non-inv intfc 497.00 497.00 3,553 RADIATION HANDLING 152.00 - 3,554 RADIATION PHYSICS CONSULT 313.00 - 3,555 RADIATION PHYSICS CONSULT 313.00 - 3,556 RADIATION THERAPY DOSE PLAN 313.00 - 3,557 RADIATION THERAPY PLANNING 313.00 - 3,558 RADIATION TREATMENT AID(S) 575.00 - 3,559 RADIATION TREATMENT AID(S) 575.00 - 3,560 RADIATION TREATMENT AID(S) 575.00 - 3,561 RADIATION TREATMENT DELIVERY 272.00 - 3,562 RADIATION TREATMENT DELIVERY 272.00 - 3,563 RADIATION TREATMENT DELIVERY 272.00 - 3,564 RADIATION TREATMENT DELIVERY 512.00 - 3,565 RADIOGRAPHIC PROCEDURE 131.00 - 3,566 RADIOTHERAPY DOSE PLAN IMRT 2,806.00 - 3,567 RADIUM/RADIOISOTOPE THERAPY 1,171.00 - 3,568 Rails bed side full length 480.00 480.00 3,569 Rails bed side half length 59.00 59.00 3,570 RANGE OF MOTION MEASUREMENTS 30.00 - 3,571 RANGE OF MOTION MEASUREMENTS 131.00 131.00 131.00 3,572 Ranibizumab injection 796.00 796.00 3,573 Ranitidine hydrochloride inj - 5.00 5.00 3,574 Rasburicase 416.00 416.00 3,575 Ratchet assembly replacement 109.00 109.00 3,576 RBC ANTIBODY ELUTION 71.00 - 3,577 RBC ANTIBODY IDENTIFICATION 98.00 - 3,578 RBC ANTIBODY SCREEN - 51.00 - 3,579 Rbc deglycerolized 959.00 959.00 3,580 Rbc irradiated 505.00 505.00 3,581 Rbc leukocytes reduced 483.00 483.00 3,582 Rbc leukoreduced irradiated 546.00 546.00 3,583 RBC MECHANICAL FRAGILITY 34.00 - 3,584 RBC OSMOTIC FRAGILITY 26.00 - 3,585 RBC OSMOTIC FRAGILITY 52.00 - Physician Hospital Village Description # Charge Charge Charge 3,586 RBC PRETREATMENT SERUM 71.00 - 3,587 RBC PRETX INCUBATJ W/CHEMICL 51.00 - 3,588 RBC PRETX INCUBATJ W/DENSITY 51.00 - 3,589 RBC PRETX INCUBATJ W/ENZYMES 51.00 - 3,590 RBC SED RATE AUTOMATED - 51.00 51.00 3,591 RBC SED RATE NONAUTOMATED 51.00 51.00 3,592 RBC SERUM PRETX ID DILUTION 51.00 - 3,593 RBC SERUM PRETX INCUBJ DRUGS 98.00 - 3,594 RBC SERUM PRETX INCUBJ/INHIB 98.00 - 3,595 RBC SICKLE CELL TEST 22.00 - 3,596 REAGENT STRIP/BLOOD GLUCOSE 21.00 21.00 3,597 Reclining back add ped w/c 949.00 949.00 3,598 RECONSTRUCTION KNEE 1,273.00 4,800.00 - 3,599 RECONSTRUCTION KNEE 1,977.00 4,800.00 - 3,600 Red blood cells unit - 368.00 368.00 3,601 RED CELL MASS MULTIPLE 1,242.00 - 3,602 RED CELL MASS SINGLE 1,242.00 - 3,603 RED CELL SEQUESTRATION 1,242.00 - 3,604 RED CELL SURVIVAL KINETICS 1,242.00 - 3,605 RED CELL SURVIVAL STUDY 1,242.00 - 3,606 REDUCTION OF RECTAL PROLAPSE 882.00 2,550.00 - 3,607 Regadenoson injection 161.00 161.00 3,608 REMOTE 30 DAY ECG REV/REPORT - 101.00 219.00 3,609 REMOTE 30 DAY ECG REV/REPORT 310.00 310.00 3,610 Removable soft interface le 213.00 213.00 3,611 REMOVAL FOREIGN BODY MOUTH 895.00 2,550.00 895.00 3,612 REMOVAL OF ARM FOREIGN BODY 840.00 4,800.00 840.00 3,613 REMOVAL OF BREAST LESION 1,902.00 4,800.00 1,902.00 3,614 REMOVAL OF FOOT FOREIGN BODY 897.00 2,050.00 897.00 3,615 REMOVAL OF FOOT LESION 1,128.00 4,800.00 1,128.00 3,616 REMOVAL OF FOREIGN BODY 649.00 4,800.00 649.00 3,617 REMOVAL OF FOREIGN BODY 2,587.00 4,800.00 2,587.00 3,618 REMOVAL OF KNEE CARTILAGE 3,635.00 4,800.00 - 3,619 REMOVAL OF NAIL BED 859.00 1,026.00 859.00 3,620 REMOVAL OF NAIL PLATE 283.00 624.00 283.00 3,621 REMOVAL OF SKIN TAGS 235.00 - 3,709 REPTILASE TEST 39.00 - 3,710 Residual limb support system 545.00 545.00 3,711 RESP SYNCYTIAL AG IA - 83.00 83.00 Physician Hospital Village Description # Charge Charge Charge 3,712 RESP VIRUS 12-25 TARGETS - 1,633.00 - 3,713 RESP VIRUS 3-5 TARGETS 503.00 - 3,714 RESP VIRUS 6-11 TARGETS 836.00 - 3,715 RESPIRATORY NUCLEAR EXAM 630.00 - 3,716 RESPIRATORY SYNCYTIAL AG IF 47.00 - 3,717 RESPIRATORY VIRUS ANTIBODY 51.00 51.00 3,718 Restraints any type - 2.00 - 3,719 RETICULATED PLATELET ASSAY 105.00 - 3,720 RETICYTE/HGB CONCENTRATE 22.00 - 3,721 RETROGRADE EJACULATION ANAL 77.00 - 3,722 Reusable nipple prosthesis 118.00 118.00 3,723 Reusable oral thermometer 29.00 29.00 3,724 Reusable rectal thermometer - 29.00 29.00 3,725 REVISE EYELASHES 297.00 405.00 297.00 3,726 REVISE/REPLACE KNEE JOINT 5,604.00 - - 3,727 REVISION OF CORNEA 971.00 - - 3,728 RH IG FULL-DOSE IM 10.00 - 3,729 RH IG MINIDOSE IM 12.00 3,730 RHEUMATOID FACTOR QUANT - 133.00 133.00 3,731 RHEUMATOID FACTOR TEST QUAL 133.00 133.00 3,732 Rho d immune globulin 50 mcg 74.00 74.00 3,733 Rho d immune globulin inj 211.00 211.00 3,734 Rho(d) immune globulin h, sd 55.00 55.00 3,735 Rhophylac injection 18.00 18.00 3,736 RHYTHM ECG REPORT 54.00 54.00 3,737 RHYTHM ECG TRACING 44.00 44.00 3,738 RHYTHM ECG WITH REPORT 98.00 3,739 RIA NONANTIBODY - 91.00 91.00 3,740 Rib gusset (elastic) each 317.00 317.00 3,741 RICKETTSIA ANTIBODY 83.00 83.00 3,742 Rigid wheeled walker adj/fix 340.00 340.00 3,743 Rilonacept injection 72.00 72.00 3,744 Ring flange plas/leather mol 796.00 796.00 3,745 Ring flange plastic/leather 406.00 406.00 3,746 Ringers lactate infusion - 5.00 5.00 3,747 Risperidone, long acting - 20.00 20.00 3,748 RMVL DEVITAL TIS 20 CM/< 311.00 294.00 311.00 3,749 RMVL DEVITAL TIS ADDL 20CM/< 315.00 150.00 315.00 3,750 Rocker bottom, contact afo 227.00 227.00 3,751 Rocking bed w/ or w/o side r 868.00 868.00 3,752 Rollabout chair with casters 177.00 177.00 3,753 Romidepsin injection 485.00 485.00 3,754 Romiplostim injection 148.00 148.00 3,755 Ropivacaine hcl injection 2.00 2.00 3,756 ROTAVIRUS AG IA 83.00 83.00 3,757 ROTAVIRUS ANTIBODY 52.00 - 3,758 Round caliper and plate atta 417.00 417.00 3,759 Rout foot care per visit 113.00 113.00 3,760 Routine footcare pt w lops 93.00 93.00 - 3,761 ROUTINE VENIPUNCTURE - 33.00 33.00 3,762 RPR F/E/E/N/L/M 2.5 CM/< 522.00 624.00 522.00 3,763 RPR F/E/E/N/L/M 2.6-5.0 CM 627.00 624.00 627.00 3,764 RPR F/E/E/N/L/M 5.1-7.5 CM 747.00 624.00 747.00 3,765 RPR F/E/E/N/L/M 7.6-12.5 CM 978.00 624.00 978.00 3,766 RPR FE/E/EN/L/M 12.6-20.0 CM 1,141.00 1,026.00 1,141.00 3,767 RPR FE/E/EN/L/M 20.1-30.0 CM 1,052.00 1,026.00 - 3,768 RPR S/N/A/GEN/TRK12.6-20.0CM 848.00 1,026.00 848.00 3,769 RPR S/N/A/GEN/TRK20.1-30.0CM 921.00 1,026.00 921.00 3,770 RPR S/N/AX/GEN/TRK7.6-12.5CM 672.00 624.00 672.00 3,771 RPR S/N/AX/GEN/TRNK >30.0 CM 635.00 624.00 - 3,772 RPR S/N/AX/GEN/TRNK 2.5CM/< 445.00 624.00 445.00 3,773 RPR S/N/AX/GEN/TRNK2.6-7.5CM 537.00 624.00 537.00 3,774 Rr whl compl pne tire rep ea 476.00 476.00 Physician Hospital Village Description # Charge Charge Charge 3,775 Rr whl compl sol tire rep ea 324.00 324.00 3,776 RSV ASSAY W/OPTIC 47.00 - 3,777 RSV MAB IM 50MG - 2,675.00 2,675.00 3,778 RUBELLA ANTIBODY - 51.00 51.00 3,779 RUBEOLA AG IF 47.00 - 3,780 RUBEOLA ANTIBODY - 51.00 51.00 3,781 RUSSELL VIPER VENOM DILUTED - 133.00 133.00 3,782 RV5 VACC 3 DOSE LIVE ORAL - 208.00 208.00 3,783 RX CNTACT LENS APHAKIA 1 EYE 88.00 - 3,784 RX CNTACT LENS APHAKIA 2 EYE 140.00 - 3,785 RX CORNEOSCLERAL CNTACT LENS 76.00 - 3,786 Sach foot, replacement 530.00 530.00 3,787 SALIVARY GLAND FUNCTION EXAM 732.00 - 3,788 SALIVARY GLAND IMAGING 732.00 - 3,789 SALMONELLA ANTIBODY 52.00 - 3,790 SAME DAY NB DISCHARGE 457.00 - 3,791 Sargramostim injection 89.00 89.00 3,792 SBSQ NB EM PER DAY HOSP 189.00 - 3,793 SBSQ PSYC COLLAB CARE MGMT 216.00 - 3,794 SC THER INFUSION UP TO 1 HR 86.00 3,795 Scr c/v cyto, automated sys 45.00 45.00 3,796 Scr c/v cyto, autosys, rescr 60.00 60.00 3,797 Scr c/v cyto,thinlayer,rescr 79.00 79.00 3,798 Scr c/v cyto,thinlayer,rescr 84.00 84.00 3,799 Scr c/v cyto,thinlayer,rescr 104.00 104.00 3,800 SCR MAMMO BI INCL CAD 122.00 327.00 - 3,801 Screen cerv/vag thin layer 79.00 79.00 3,802 Screen pap by tech w md supv 41.00 41.00 3,803 Seat ht <17 or >=21 ltwt wc 309.00 309.00 3,804 Seat lift mech, electric any 859.00 859.00 3,805 Seat lift mech, non-electric 859.00 859.00 3,806 Seat upholstery, replacement 216.00 216.00 3,807 SEDATIVE HYPNOTICS 76.00 - 3,808 Seg pneumatic appli half leg 452.00 452.00 3,809 SELECT PICTURE AUDIOMETRY - 102.00 - 3,810 SELF CARE MNGMENT TRAINING - 83.00 83.00 3,811 Self-adher band >=5"/yd 6.00 6.00 3,812 Self-adher band w <3"/yd - 10.00 10.00 3,813 Self-adher band w>=3" <5"/yd - 3.00 3.00 3,814 SELF-MGMT EDUC & TRAIN 1 PT - 85.00 32.00 3,815 SELF-MGMT EDUC/TRAIN 2-4 PT 41.00 - 3,816 SELF-MGMT EDUC/TRAIN 5-8 PT 30.00 228.00 3,817 SEMEN ANAL SPERM DETECTION - 83.00 83.00 3,818 SEMEN ANAL STRICT CRITERIA 61.00 - 3,819 SEMEN ANAL VOL/COUNT/MOT 249.00 249.00 3,820 Semen analysis 25.00 25.00 3,821 SEMEN ANALYSIS W/COUNT 34.00 - 3,822 SEMEN ANALYSIS W/HUHNER 35.00 - 3,823 SENSORINEURAL ACUITY TEST 130.00 - 3,824 SENSORY INTEGRATION 149.00 - 3,825 SERIAL SALIVARY IMAGING 732.00 - 3,826 SERIAL TONOMETRY EXAM(S) 119.00 - 3,827 Sermorelin acetate injection 6.00 6.00 3,828 SERUM IMMUNOELECTROPHORESIS 88.00 - 3,829 SET RADIATION THERAPY FIELD 313.00 - 3,830 SET RADIATION THERAPY FIELD 829.00 - 3,831 SET RADIATION THERAPY FIELD 829.00 - 3,832 Sewho airplan desig abdu pos 973.00 973.00 3,833 Sewho cap design w/o jnts cf 1,533.00 1,533.00 3,834 Sewho erbs palsey design abd 886.00 886.00 3,835 SEX CHROMATIN IDENTIFICATION 31.00 - 3,836 SEX CHROMATIN IDENTIFICATION 48.00 48.00 3,837 SHAVE SKIN LESION >2.0 CM 517.00 1,026.00 517.00 Physician Hospital Village Description # Charge Charge Charge 3,838 SHAVE SKIN LESION >2.0 CM 518.00 1,026.00 518.00 3,839 SHAVE SKIN LESION 0.5 CM/< 235.00 624.00 235.00 3,840 SHAVE SKIN LESION 0.5 CM/< 240.00 624.00 240.00 3,841 SHAVE SKIN LESION 0.5 CM/< 289.00 624.00 289.00 3,842 SHAVE SKIN LESION 0.6-1.0 CM 296.00 624.00 296.00 3,843 SHAVE SKIN LESION 0.6-1.0 CM 329.00 624.00 329.00 3,844 SHAVE SKIN LESION 1.1-2.0 CM 360.00 624.00 360.00 3,845 SHAVE SKIN LESION 1.1-2.0 CM 424.00 1,026.00 - 3,846 Sheath above knee 82.00 82.00 3,847 Sheath below knee 71.00 71.00 3,848 Sheath upper limb 80.00 80.00 3,849 SHIGA-LIKE TOXIN AG IA 47.00 - 3,850 SHIGELLA ANTIBODY 52.00 - 3,851 Sho heel count plast reinfor 402.00 402.00 3,852 Sho lift taper to metatarsal - 52.00 52.00 3,853 Shock absorber for man w/c 373.00 373.00 3,854 Shock absorber for power w/c 368.00 368.00 3,855 Shoe clubfoot wedge 149.00 149.00 3,856 Shoe dennis browne splint bo 130.00 130.00 3,857 Shoe heel new leather standa 122.00 122.00 3,858 Shoe heel new rubber standar 103.00 103.00 3,859 Shoe heel pad & depress for 187.00 187.00 3,860 Shoe heel pad removable for 37.00 37.00 3,861 Shoe heel sach cushion type 265.00 265.00 3,862 Shoe heel thomas extend to b 187.00 187.00 3,863 Shoe heel thomas with wedge 176.00 176.00 3,864 Shoe heel wedge 69.00 69.00 3,865 Shoe lift elev heel/sole cor 27.00 27.00 3,866 Shoe lift elev heel/sole neo 204.00 204.00 3,867 Shoe lifts elevation heel /i 38.00 38.00 3,868 Shoe lifts tapered to one-ha - 74.00 74.00 3,869 Shoe metatarsal bar between 233.00 233.00 3,870 Shoe metatarsal bar wedge ro 122.00 122.00 3,871 Shoe outflare wedge 149.00 149.00 3,872 Shoe sole wedge between sole 149.00 149.00 3,873 Shoe sole wedge outside sole 107.00 107.00 3,874 Shoe wedge sach 214.00 214.00 3,875 Should sling/vest/abrestrain 42.00 42.00 3,876 Shoulder abduction joint pai 695.00 695.00 3,877 Shoulder flexion-abduction j 905.00 905.00 3,878 Shoulder harness 646.00 646.00 3,879 Shoulder universal joint 945.00 945.00 3,880 Shrinker above knee 351.00 351.00 3,881 Shrinker below knee 188.00 188.00 3,882 Shrinker upper limb 181.00 181.00 3,883 SIALIDASE ENZYME ASSAY 48.00 - 3,884 SIGMOIDOSCOPY & POLYPECTOMY 1,073.00 2,550.00 1,073.00 3,885 SIGMOIDOSCOPY AND BIOPSY 718.00 2,550.00 718.00 3,886 SIGMOIDOSCOPY W/TUMR REMOVE 1,147.00 3,000.00 1,147.00 3,887 Silvr oxide batt glucose mon 8.00 8.00 3,888 Sincalide injection 166.00 166.00 3,889 Single energy x-ray study 84.00 - 3,890 Single pivot hinge pair 646.00 646.00 3,891 SINUSOIDAL ROTATIONAL TEST 50.00 - 3,892 Sio flex pelvic/sacr pre ots - 281.00 281.00 3,893 Sio flex pelvisacral custom 373.00 373.00 3,894 Sio rig pnl pelv/sac pre ots 1,020.00 1,020.00 3,895 Sirolimus, oral 37.00 37.00 3,896 Sitz bath chair 552.00 552.00 3,897 Sitz bath/equipment w/faucet 96.00 96.00 3,898 Sitz type bath or equipment 80.00 80.00 3,899 Six volt bat otto bock/eq ea 738.00 738.00 3,900 SKEL MUSC RELAXANT 3 OR MORE 97.00 - Physician Hospital Village Description # Charge Charge Charge 3,901 SKELETAL MUSCLE RELAXANT 1/2 97.00 - 3,902 Skills train and dev, 15 min 20.00 20.00 3,903 Skin barrier liquid per oz 11.00 11.00 3,904 Skin barrier powder per oz - 18.00 18.00 3,905 Skin barrier solid 4x4 equiv 17.00 17.00 3,906 Skin barrier with flange 26.00 26.00 3,907 Skin barrier, wipe or swab - 15.00 15.00 3,908 SKIN FUNGI CULTURE 83.00 83.00 3,909 Skin pro/pos wc cus wd <22in 649.00 649.00 3,910 Skin pro/pos wc cus wd>=22in 780.00 780.00 3,911 Skin protect wc cus wd <22in 424.00 424.00 3,912 Skin protect wc cus wd>=22in 422.00 422.00 3,913 Skin seal protect moisturizr - 14.00 - 3,914 SKIN TEST CANDIDA 19.00 - 3,915 SKIN TEST NOS ANTIGEN 19.00 - 3,916 Slings - 25.00 25.00 3,917 SMALL ANIMAL INOCULATION 66.00 - 3,918 SMALL BOWEL ENDOSCOPY 1,038.00 2,550.00 - 3,919 SMEAR COMPLEX STAIN - 90.00 90.00 3,920 SMEAR FLUORESCENT/ACID STAI 42.00 42.00 3,921 SMEAR GRAM STAIN - 51.00 51.00 3,922 SMEAR SPECIAL STAIN 23.00 - 3,923 SMEAR WET MOUNT SALINE/INK - 29.00 29.00 3,924 So 8 ab rstr can/web pre ots - 293.00 293.00 3,925 So 8 abd restraint pre ots - 201.00 201.00 3,926 So acro/clav can web pre ots 409.00 409.00 3,927 So airplane w/wo joint cf 1,294.00 1,294.00 3,928 So hard plas stabili pre cst 27.00 27.00 3,929 So vest canvas/web pre ots 437.00 437.00 3,930 Sock fracture or equal each 130.00 130.00 3,931 Socket insert symes 823.00 823.00 3,932 Soft interface above knee se 607.00 607.00 3,933 Soft interface below knee se 607.00 607.00 3,934 Soft interface material 274.00 274.00 3,935 Soft protect helmet prefab 498.00 498.00 3,936 Solid caster integ whl, repl 82.00 82.00 3,937 Solid caster tire 63.00 63.00 3,938 Solid caster tire repl, each 100.00 100.00 3,939 Solid caster tire, integrate 181.00 181.00 3,940 Solid drive wheel tire 132.00 132.00 3,941 Solid propuls tire, repl, ea 117.00 117.00 3,942 Solid seat support base 499.00 499.00 3,943 Solid skin barrier 10.00 10.00 3,944 Solid skin barrier 6x6 35.00 35.00 3,945 Solid skin barrier 8x8 49.00 49.00 3,946 Somatropin injection 195.00 195.00 3,947 Spacer bag/reservoir 62.00 62.00 3,948 Spacer without mask 23.00 23.00 3,949 Special casting material - 158.00 158.00 3,950 SPECIAL EYE EVALUATION 139.00 139.00 3,951 SPECIAL EYE EVALUATION 198.00 121.00 - 3,952 SPECIAL EYE EXAM INITIAL 77.00 121.00 - 3,953 SPECIAL EYE EXAM SUBSEQUENT 66.00 121.00 - 3,954 Special joystick handle 194.00 194.00 3,955 SPECIAL RADIATION DOSIMETRY 313.00 - 3,956 SPECIAL RADIATION TREATMENT 1,118.00 - 3,957 SPECIAL REPORTS OR FORMS 102.00 102.00 3,958 SPECIAL STAINS GROUP 1 67.00 - 3,959 SPECIAL STAINS GROUP 2 67.00 - 3,960 SPECIAL SUPPLIES PHYS/QHP 50.00 50.00 3,961 SPECIAL TELETX PORT PLAN 829.00 - 3,962 SPECIMEN FAT STAIN 17.00 - 3,963 SPECIMEN HANDLING OFFICE-LAB 56.00 56.00 56.00 Physician Hospital Village Description # Charge Charge Charge 3,964 SPECIMEN HANDLING PT-LAB 93.00 93.00 3,965 SPECIMEN INFECT AGNT CONCNTJ 42.00 42.00 3,966 SPECTROPHOTOMETRY 27.00 - 3,967 SPEECH AUDIOMETRY COMPLETE 130.00 119.00 3,968 SPEECH EVALUATION COMPLEX 326.00 - 3,969 SPEECH SOUND LANG COMPREHEN - 650.00 650.00 3,970 SPEECH THRESHOLD AUDIOMETRY 130.00 75.00 3,971 SPEECH/HEARING THERAPY - 107.00 - 3,972 SPEECH/HEARING THERAPY - 270.00 270.00 3,973 SPERM ANTIBODY TEST 42.00 - 3,974 SPERM EVALUATION TEST 82.00 - 3,975 SPERM IDENTIFICATION 67.00 - 3,976 SPERM ISOLATION COMPLEX 109.00 - 3,977 SPERM ISOLATION SIMPLE 109.00 - 3,978 SPINAL FLUID TAP DIAGNOSTIC 536.00 2,050.00 536.00 3,979 Spinal orthosis nos - 11.00 11.00 3,980 SPLEEN IMAGING 798.00 - 3,981 Splint - 131.00 131.00 3,982 Splint digit - 1.00 - 3,983 Splint supplies misc 27.00 27.00 3,984 Splint wrist or ankle - 51.00 51.00 3,985 SPLIT BLOOD OR PRODUCTS 51.00 - 3,986 Split flat caliper stirr & p 420.00 420.00 3,987 Spoke protectors 173.00 173.00 3,988 SPONTANEOUS NYSTAGMUS TEST 71.00 - 3,989 Sps ankle device 432.00 432.00 3,990 Sps elbow device 410.00 410.00 3,991 Sps forearm device 442.00 442.00 3,992 Sps knee device 426.00 426.00 3,993 Sps wrist device 336.00 336.00 3,994 SPUN MICROHEMATOCRIT 9.00 - 3,995 SPUTUM SPECIMEN COLLECTION 67.00 - 3,996 Stainless steel any wrist 535.00 535.00 3,997 Standard control cable extra 297.00 297.00 3,998 Standard size ftplate rep ea 193.00 193.00 3,999 Standard wheelchair 173.00 173.00 4,000 STAPH A DNA AMP PROBE 137.00 - 4,001 Static or dynami afo pre cst 459.00 459.00 4,002 Static str toe dev ext/flex 206.00 206.00 4,003 Stationary compressed gas 02 443.00 443.00 4,004 Stationary liquid 02 443.00 443.00 4,005 Stationary o2 contents, gas 194.00 194.00 4,006 Stationary o2 contents, liq 194.00 194.00 4,007 STEM CELLS TOTAL COUNT 148.00 - 4,008 STENGER TEST PURE TONE 130.00 95.00 4,009 STENGER TEST SPEECH 333.00 - 4,010 Sterile eye pad - 3.00 3.00 4,011 Sterile gauze <= 16 sq in - 3.00 3.00 4,012 Sterile gauze>16 <= 48 sq in 11.00 11.00 4,013 Sterile needle - 1.00 58.00 4,014 Sterile saline or water - 2.00 - 4,015 Sterile water/saline, 10 ml 3.00 3.00 4,016 Sterile water/saline, 500 ml 13.00 13.00 4,017 Sterile, gloves per pair 13.00 13.00 4,018 Sternal pad 270.00 270.00 4,019 STIMULANTS SYNTHETIC 100.00 - 4,020 Stnd hemi (low seat) whlchr 281.00 281.00 4,021 Stocking sup grips 4 pre ots 57.00 57.00 4,022 Stoma absorptive cover 3.00 3.00 4,023 Stoma cap 6.00 6.00 4,024 Stoma plug or seal, any type 15.00 15.00 4,025 Stool collection pouch 28.00 28.00 4,026 STOOL CULTR AEROBIC BACT EA - 51.00 51.00 Physician Hospital Village Description # Charge Charge Charge 4,027 STORAGE/YEAR EMBRYO(S) 172.00 - 4,028 STORAGE/YEAR OOCYTE(S) 172.00 - 4,029 STORAGE/YEAR REPROD TISSUE 172.00 - 4,030 STORAGE/YEAR SPERM/SEMEN 172.00 - 4,031 Straight knee joint heavy du 429.00 429.00 4,032 Straight tip urine catheter - 4.00 4.00 4,033 STRAPPING OF ANKLE AND/OR FT 153.00 624.00 153.00 4,034 STRAPPING OF CHEST 113.00 624.00 113.00 4,035 STRAPPING OF ELBOW OR WRIST 159.00 - 159.00 4,036 STRAPPING OF HAND OR FINGER - 84.00 84.00 4,037 STRAPPING OF KNEE - 198.00 105.00 4,038 STRAPPING OF SHOULDER 183.00 405.00 183.00 4,039 STRAPPING OF TOES 65.00 405.00 55.00 4,040 STREP A AG IA 83.00 83.00 4,041 STREP A ASSAY W/OPTIC - 45.00 45.00 4,042 STREP A DNA AMP PROBE 137.00 - 4,043 STREP A DNA DIR PROBE 79.00 - 4,044 STREP A DNA QUANT 164.00 - 4,045 STREP B ASSAY W/OPTIC 72.00 72.00 4,046 STREP B DNA AMP PROBE 137.00 - 4,047 STREPTOKINASE ANTIBODY 43.00 - 4,048 Streptomycin injection 45.00 45.00 4,049 Streptozocin injection 542.00 542.00 4,050 STRESS TTE ONLY 359.00 1,171.00 - 4,051 SUBSEQUENT HOSPITAL CARE 165.00 - 4,052 SUBSEQUENT HOSPITAL CARE 230.00 - 4,053 SUBSEQUENT HOSPITAL CARE 348.00 - 4,054 SUBSEQUENT OBSERVATION CARE 317.00 - 4,055 SUBSEQUENT OBSERVATION CARE 317.00 - 4,056 SUBSEQUENT OBSERVATION CARE 356.00 - 4,057 Succinycholine chloride inj - 2.00 2.00 4,058 Suction pump portab hom modl 221.00 221.00 4,059 SUGARS MULTIPLE QUAL 22.00 - 4,060 SUGARS MULTIPLE QUANT 45.00 - 4,061 SUGARS SINGLE QUAL 22.00 - 4,062 SUGARS SINGLE QUANT 45.00 - 4,063 Sumatriptan succinate / 6 mg - 214.00 214.00 4,064 Sup/ext non-ins inf pump syr 12.00 12.00 4,065 Supp for self-adm injections 102.00 102.00 4,066 Supp non-insulin inf cath/wk 88.00 88.00 4,067 Supply/accessory/service 27.00 27.00 4,068 SUPRV INTERFAC TRNSPORT ADDL 228.00 - 4,069 SUPRV INTERFACILTY TRANSPORT 262.00 - 4,070 SURFACTANT ADMIN THRU TUBE 264.00 - 4,071 Surgical dress holder reuse 48.00 48.00 4,072 Surgical mask - 2.00 - 4,073 SURGICAL PATH GROSS 70.00 - 4,074 SURGICAL PATHOLOGY PROCEDURE 36.00 - 4,075 Surgical supplies - 8.00 8.00 4,076 Surgical trays - 53.00 53.00 4,077 Surgicl dress hold non-reuse 15.00 15.00 4,078 Surgimend, fetal 35.00 - 4,079 Surgimend, neonatal 36.00 - 4,080 Suspension sleeve lower ext 315.00 315.00 4,081 Swingaway detach ftrest repl 259.00 259.00 4,082 Symes type medial opening so 632.00 632.00 4,083 Symes type ptb brim design s 551.00 551.00 4,084 Synthetic implnt urinary 1ml 428.00 428.00 4,085 Synthetic sheepskin pad 151.00 151.00 4,086 Synvisc or synvisc-one - 181.00 181.00 4,087 SYPHILIS TEST NON-TREP QUAL - 35.00 35.00 4,088 SYPHILIS TEST NON-TREP QUANT 33.00 33.00 4,089 Syringe w/wo needle - 2.00 - Physician Hospital Village Description # Charge Charge Charge 4,090 T CELL ABSOLUTE COUNT 174.00 174.00 4,091 T CELL ABSOLUTE COUNT/RATIO - 166.00 166.00 4,092 T CELLS TOTAL COUNT 148.00 - 4,093 T3 REVERSE - 62.00 - 4,094 Tacrolimus imme rel oral 1mg 6.00 6.00 4,095 Tacrolimus injection 347.00 347.00 4,096 Targeted case mgmt per month - 287.00 287.00 4,097 TB AG RESPONSE T-CELL SUSP 294.00 - 4,098 TB INTRADERMAL TEST - 41.00 41.00 4,099 TB TEST CELL IMMUN MEASURE - 243.00 - 4,100 TD VACC NO PRESV 7 YRS+ IM - 163.00 40.00 4,101 TDAP VACCINE 7 YRS/> IM - 46.00 46.00 4,102 TEAM CONF W/O PAT BY HC PRO 126.00 210.00 - 4,103 TEAM CONF W/O PAT BY PHYS 193.00 - 4,104 TEAM CONF W/PAT BY HC PROF 144.00 240.00 - 4,105 Teflon or equal cable lining 171.00 171.00 4,106 Telavancin injection 9.00 9.00 4,107 Telehealth facility fee - 50.00 50.00 4,108 Temozolomide 32.00 32.00 4,109 Temozolomide injection 17.00 17.00 4,110 TEMPORARY EXTERNAL PACING 37.00 - 4,111 Temporary tear duct plug 48.00 - 4,112 Temsirolimus injection 168.00 168.00 4,113 Tenecteplase injection 212.00 212.00 4,114 Teniposide, 50 mg 644.00 - 4,115 Tens four lead - 577.00 577.00 4,116 Tens suppl 2 lead per month 53.00 4,117 Tens two lead 528.00 528.00 4,118 Terbutaline sulfate inj - 13.00 13.00 4,119 Term dev mech hand vol close 2,223.00 2,223.00 4,120 Term dev mech hand vol open 1,461.00 1,461.00 4,121 Term dev mech hook vol close 1,998.00 1,998.00 4,122 Term dev mech hook vol open 865.00 865.00 4,123 Term dev modifier wrist unit 843.00 843.00 4,124 Term dev precision pinch dev 463.00 463.00 4,125 Term dev, passive hand mitt 806.00 806.00 4,126 Term dev, sport/rec/work att 1,233.00 1,233.00 4,127 Term device, multi art digit 3,805.00 3,805.00 4,128 TEST FECES FOR TRYPSIN 29.00 - 4,129 TEST FOR ACETONE/KETONES 51.00 51.00 4,130 TEST FOR CHLOROHYDROCARBONS 24.00 - 4,131 TEST FOR G6PD ENZYME 24.00 - 4,132 TEST FOR PORPHOBILINOGEN 17.00 - 4,133 TEST FOR URINE CYSTINES 32.00 - 4,134 TEST RBC PROTOPORPHYRIN 34.00 - 4,135 Test socket below knee 735.00 735.00 4,136 Test socket symes 698.00 698.00 4,137 TEST URINE FOR LACTOSE 22.00 - 4,138 TEST URINE FOR PORPHYRINS 34.00 - 4,139 TEST URINE UROBILINOGEN 13.00 - 4,140 TESTICULAR IMAGING W/FLOW 949.00 - 4,141 TESTOSTERONE RESPONSE 202.00 - 4,142 TETANUS ANTIBODY 58.00 - 4,143 THAW CRYOPRSVRD REPROD TISS 172.00 - 4,144 THAWING CRYOPRESRVED EMBRYO 172.00 - 4,145 THAWING CRYOPRESRVED OOCYTE 172.00 - 4,146 THAWING CRYOPRESRVED SPERM 172.00 - 4,147 Ther behav svc, per 15 min 9.00 17.00 17.00 4,148 THER INJECTION CARP TUNNEL 312.00 1,026.00 312.00 4,149 THER IVNTJ W/FOCUS COG FUNCJ 243.00 - 4,150 THER/DIAG CONCURRENT INF - 114.00 158.00 4,151 THER/PROPH/DIAG INJ IA 105.00 - 4,152 THER/PROPH/DIAG INJ IV PUSH - 175.00 103.00 Physician Hospital Village Description # Charge Charge Charge 4,153 THER/PROPH/DIAG INJ SC/IM - 75.00 47.00 4,154 THER/PROPH/DIAG IV INF ADDON - 158.00 158.00 4,155 THER/PROPH/DIAG IV INF INIT - 454.00 454.00 4,156 THERAPEUTIC ACTIVITIES - 102.00 102.00 4,157 THERAPEUTIC EXERCISES - 102.00 102.00 4,158 Theraskin 66.00 66.00 4,159 Thi/glut/ischia wgt bearing 856.00 856.00 4,160 Thiamine hcl 100 mg - 13.00 13.00 4,161 Thigh length surg stocking - 54.00 54.00 4,162 Thigh/wght bear high roll cu 925.00 925.00 4,163 Thigh/wght bear lacer non-mo 836.00 836.00 4,164 Thiotepa injection 439.00 439.00 4,165 Thor rib belt custom fabrica 356.00 356.00 4,166 Thorac cont lat support upri 455.00 455.00 4,167 Thorac cont paraspinal uprig 497.00 497.00 4,168 Thoracic control thoracic ba 467.00 467.00 4,169 Thoracic pad 325.00 325.00 4,170 THROAT SURGERY PROCEDURE 525.00 624.00 - 4,171 THROAT X-RAY & FLUOROSCOPY 326.00 - 4,172 THROMBIN TIME PLASMA 23.00 - 4,173 THROMBIN TIME TITER 27.00 - 4,174 THROMBOMODULIN 41.00 - 4,175 THROMBOPLASTIN INHIBITION 38.00 - 4,176 THROMBOPLASTIN TIME PARTIAL 25.00 - 4,177 THROMBOPLASTIN TIME PARTIAL - 47.00 47.00 4,178 THROMBOXANE URINE 66.00 - 4,179 THYROGLOBULIN ANTIBODY - 83.00 83.00 4,180 THYROID IMAGING W/BLOOD FLOW 428.00 - 4,181 THYROID IMAGING W/BLOOD FLOW 664.00 - 4,182 THYROID MET IMAGING 855.00 - 4,183 THYROID MET IMAGING BODY 855.00 - 4,184 THYROID MET IMAGING/STUDIES 855.00 - 4,185 THYROID MET UPTAKE 205.00 - 4,186 THYROID UPTAKE MEASUREMENT 325.00 - 4,187 TIBIAL ARTHROSCOPY/SURGERY 2,968.00 4,800.00 - 4,188 Tibial length sock fx or equ 153.00 153.00 4,189 Tigecycline injection 6.00 6.00 4,190 TINNITUS ASSESSMENT 216.00 216.00 - 4,191 Tirofiban hcl 28.00 28.00 4,192 TISS EX MOLECUL STUDY ADD-ON 34.00 - 4,193 TISS EXAM MOLECULAR STUDY 22.00 - 4,194 TISSUE CULTURE BONE MARROW 495.00 - 4,195 TISSUE CULTURE LYMPHOCYTE 441.00 441.00 4,196 TISSUE CULTURE PLACENTA 577.00 - 4,197 TISSUE CULTURE SKIN/BIOPSY 551.00 - 4,198 TISSUE CULTURE TUMOR 578.00 - 4,199 TISSUE EXAM BY PATHOLOGIST 67.00 - 4,200 TISSUE EXAM BY PATHOLOGIST 67.00 - 4,201 TISSUE EXAM BY PATHOLOGIST - 109.00 - 4,202 TISSUE EXAM BY PATHOLOGIST 172.00 - 4,203 TISSUE EXAM BY PATHOLOGIST 448.00 - 4,204 TISSUE EXAM FOR FUNGI - 51.00 51.00 4,205 TISSUE HOMOGENIZATION CULTR 23.00 - 4,206 Tlso 3 piece rigid shell 984.00 984.00 4,207 Tlso corset front 421.00 421.00 4,208 Tlso flex trunk/thor pre ots 367.00 367.00 4,209 Tlso full corset 434.00 434.00 4,210 Tlso r fram soft ant pre cst 949.00 949.00 4,211 Tlso rigid plastic pre one 619.00 619.00 4,212 Tlso trnk sj-t9 pre cst 695.00 695.00 4,213 Tobramycin non-comp unit 235.00 235.00 4,214 Tobramycin sulfate injection 6.00 6.00 4,215 Tocilizumab injection 12.00 12.00 Physician Hospital Village Description # Charge Charge Charge 4,216 Toe loop/holder, each 115.00 115.00 4,217 Tomosynthesis, mammo 103.00 - 4,218 TONE DECAY HEARING TEST 130.00 - 4,219 Topotecan injection 11.00 11.00 4,220 Topotecan oral 211.00 211.00 4,221 Torsion ank & half solid sti 391.00 391.00 4,222 Torsion straight knee joint 462.00 462.00 4,223 TOTAL CORTISOL - 133.00 133.00 4,224 TOXOPLASMA ANTIBODY 56.00 - 4,225 TOXOPLASMA ANTIBODY IGM 51.00 51.00 4,226 Trac stand free stand extrem 379.00 379.00 4,227 Trac stand free stand pelvic 444.00 444.00 4,228 Trach care kit for new trach 144.00 144.00 4,229 Trach pros cleaning device 20.00 20.00 4,230 Trach suction cath close sys 64.00 64.00 4,231 Trach/laryn tube cuffed 183.00 183.00 4,232 Trach/laryn tube non-cuffed 185.00 185.00 4,233 Trach/laryn tube plug/stop 16.00 16.00 4,234 Trach/laryn tube stainless 176.00 176.00 4,235 Tracheal suction tube 11.00 11.00 4,236 Tracheostoma filter 2.00 2.00 4,237 Tracheostoma hmes filter 3.00 3.00 4,238 Tracheostoma stent/stud/bttn 251.00 251.00 4,239 Tracheostoma valve w diaphra 341.00 341.00 4,240 Tracheostomy care kit 21.00 21.00 4,241 Tracheostomy cleaning brush 12.00 12.00 4,242 Tracheostomy inner cannula 25.00 25.00 4,243 Tracheostomy mask 9.00 9.00 4,244 Tracheostomy speaking valve 375.00 375.00 4,245 Tracheostomy tube collar 15.00 15.00 4,246 Trach-esoph voice pros md in 274.00 274.00 4,247 Trach-esoph voice pros pt in 126.00 126.00 4,248 Tract equip cervical tract - 201.00 57.00 4,249 Tract frame attach footboard 411.00 411.00 4,250 Tract frame attach headboard 317.00 317.00 4,251 Traction frame attach pelvic 326.00 326.00 4,252 Traction stand free standing 311.00 311.00 4,253 TRANS CARE MGMT 14 DAY DISCH 475.00 - 4,254 TRANS CARE MGMT 7 DAY DISCH 697.00 - 4,255 Trans shoe calip plate exist 191.00 191.00 4,256 Trans shoe caliper plate new 252.00 252.00 4,257 Trans shoe solid stirrup exi 191.00 191.00 4,258 Trans shoe solid stirrup new 252.00 252.00 4,259 TRANSCUTANEOUS CARBOXYHB 20.00 - 4,260 TRANSCUTANEOUS METHB 20.00 - 4,261 Transfer device 256.00 256.00 4,262 TRANSFERASE (AST) (SGOT) - 51.00 51.00 4,263 TRANSFUSION PROCEDURE 51.00 - 4,264 Transparent film <= 16 sq in - 7.00 7.00 4,265 Transparent film > 48 sq in 14.00 14.00 4,266 Transparent film >16<=48 in 13.00 13.00 4,267 Transport chair pt wt >300lb 133.00 133.00 4,268 Transport chair pt wt<=300lb 70.00 70.00 4,269 Transport chair, ped size 352.00 352.00 4,270 Transtracheal oxygen cath 195.00 195.00 4,271 TRANSVAGINAL US NON-OB 119.00 647.00 - 4,272 TRANSVAGINAL US OBSTETRIC 130.00 318.00 - 4,273 Trapeze bar attached to bed 56.00 56.00 4,274 Trapeze bar free standing 105.00 105.00 4,275 Trapezius sling 275.00 275.00 4,276 Trastuzumab injection 191.00 191.00 4,277 Tray 429.00 429.00 4,278 TREAT BIG TOE FRACTURE 460.00 1,026.00 460.00 Physician Hospital Village Description # Charge Charge Charge 4,279 TREAT BIG TOE FRACTURE 467.00 1,026.00 467.00 4,280 TREAT CLAVICLE DISLOCATION 908.00 1,026.00 908.00 4,281 TREAT CLAVICLE DISLOCATION 1,722.00 1,026.00 1,722.00 4,282 TREAT CLAVICLE DISLOCATION 4,429.00 4,800.00 - 4,283 TREAT CLAVICLE FRACTURE 908.00 1,026.00 908.00 4,284 TREAT CLAVICLE FRACTURE 1,451.00 4,800.00 1,451.00 4,285 TREAT DISLOCATION/FRACTURE 2,448.00 4,800.00 2,448.00 4,286 TREAT DISLOCATION/FRACTURE 2,477.00 4,800.00 2,477.00 4,287 TREAT ELBOW DISLOCATION 502.00 1,026.00 502.00 4,288 TREAT ELBOW DISLOCATION 1,209.00 1,026.00 1,209.00 4,289 TREAT ELBOW DISLOCATION 1,832.00 4,800.00 - 4,290 TREAT FINGER DISLOCATION 803.00 1,026.00 803.00 4,291 TREAT FINGER DISLOCATION 1,558.00 1,026.00 1,558.00 4,292 TREAT FINGER FRACTURE EACH 628.00 1,026.00 628.00 4,293 TREAT FINGER FRACTURE EACH 703.00 1,026.00 703.00 4,294 TREAT FINGER FRACTURE EACH 953.00 1,026.00 953.00 4,295 TREAT FINGER FRACTURE EACH 1,212.00 1,026.00 1,212.00 4,296 TREAT FINGER FRACTURE EACH 1,931.00 4,800.00 - 4,297 TREAT FOOT DISLOCATION 760.00 1,026.00 - 4,298 TREAT FOOT DISLOCATION 1,175.00 1,026.00 1,175.00 4,299 TREAT FRACTURE OF RADIUS 1,113.00 1,026.00 1,113.00 4,300 TREAT FRACTURE OF RADIUS 2,053.00 4,800.00 2,053.00 4,301 TREAT FRACTURE OF ULNA 1,206.00 1,026.00 1,206.00 4,302 TREAT FRACTURE OF ULNA 1,212.00 4,800.00 - 4,303 TREAT FRACTURE RADIUS & ULNA 1,343.00 1,026.00 1,343.00 4,304 TREAT FRACTURE RADIUS & ULNA 2,728.00 4,800.00 2,728.00 4,305 TREAT FRACTURE RADIUS/ULNA 1,373.00 1,026.00 1,373.00 4,306 TREAT FRACTURE RADIUS/ULNA 2,272.00 4,800.00 2,272.00 4,307 TREAT HAND DISLOCATION 1,233.00 1,026.00 - 4,308 TREAT HIP DISLOCATION 1,679.00 1,026.00 - 4,309 TREAT HIP DISLOCATION 2,083.00 1,026.00 - 4,310 TREAT HIP DISLOCATION 2,929.00 4,800.00 - 4,311 TREAT HIP SOCKET FRACTURE 2,186.00 1,026.00 2,186.00 4,312 TREAT HUMERUS FRACTURE 1,278.00 1,026.00 1,278.00 4,313 TREAT HUMERUS FRACTURE 1,315.00 1,026.00 1,315.00 4,314 TREAT HUMERUS FRACTURE 1,413.00 1,026.00 1,413.00 4,315 TREAT HUMERUS FRACTURE 1,488.00 1,026.00 1,488.00 4,316 TREAT HUMERUS FRACTURE 1,587.00 1,026.00 1,587.00 4,317 TREAT HUMERUS FRACTURE 1,619.00 1,026.00 1,619.00 4,318 TREAT HUMERUS FRACTURE 2,765.00 4,800.00 2,765.00 4,319 TREAT KNEE FRACTURE 1,736.00 1,026.00 1,736.00 4,320 TREAT KNEECAP DISLOCATION 1,575.00 1,026.00 1,575.00 4,321 TREAT KNEECAP FRACTURE 1,478.00 1,026.00 1,478.00 4,322 TREAT KNUCKLE DISLOCATION 1,381.00 1,026.00 1,381.00 4,323 TREAT KNUCKLE DISLOCATION 1,711.00 4,800.00 1,711.00 4,324 TREAT LOWER JAW FRACTURE 1,408.00 2,050.00 1,408.00 4,325 TREAT LOWER LEG FRACTURE 1,675.00 1,026.00 1,675.00 4,326 TREAT LOWER LEG FRACTURE 3,407.00 4,800.00 3,407.00 4,327 TREAT METACARPAL FRACTURE 945.00 1,026.00 945.00 4,328 TREAT METACARPAL FRACTURE 1,411.00 1,026.00 1,411.00 4,329 TREAT METACARPAL FRACTURE 2,446.00 4,800.00 - 4,330 TREAT METACARPAL FRACTURE 2,707.00 4,800.00 - 4,331 TREAT METATARSAL FRACTURE 1,035.00 1,026.00 1,035.00 4,332 TREAT METATARSAL FRACTURE 1,567.00 1,026.00 1,567.00 4,333 TREAT MIDFOOT FRACTURE EACH 995.00 1,026.00 995.00 4,334 TREAT RADIUS FRACTURE 656.00 1,026.00 656.00 4,335 TREAT RADIUS FRACTURE 1,710.00 4,800.00 1,710.00 4,336 TREAT SHOULDER BLADE FX 966.00 1,026.00 966.00 4,337 TREAT SHOULDER DISLOCATION 1,155.00 1,026.00 1,155.00 4,338 TREAT SHOULDER DISLOCATION 1,646.00 4,800.00 - 4,339 TREAT SPINAL CANAL LESION 1,488.00 2,550.00 1,488.00 4,340 TREAT SPINAL CORD LESION 2,682.00 2,550.00 2,682.00 4,341 TREAT THIGH FRACTURE 1,226.00 1,026.00 1,226.00 Physician Hospital Village Description # Charge Charge Charge 4,342 TREAT THIGH FRACTURE 1,869.00 1,026.00 1,869.00 4,343 TREAT THIGH FRACTURE 2,274.00 4,800.00 - 4,344 TREAT THUMB DISLOCATION 1,439.00 1,026.00 1,439.00 4,345 TREAT TOE DISLOCATION 554.00 1,026.00 554.00 4,346 TREAT ULNAR FRACTURE 1,316.00 1,026.00 1,316.00 4,347 TREAT ULNAR FRACTURE 3,489.00 4,800.00 - 4,348 TREAT WRIST BONE FRACTURE 1,286.00 1,026.00 1,286.00 4,349 TREAT WRIST BONE FRACTURE 1,373.00 1,026.00 1,373.00 4,350 TREAT WRIST BONE FRACTURE 1,521.00 1,026.00 1,521.00 4,351 TREAT WRIST BONE FRACTURE 1,864.00 4,800.00 1,864.00 4,352 TREAT WRIST DISLOCATION 2,141.00 1,026.00 2,141.00 4,353 TREAT WRIST FRACTURE 2,139.00 1,026.00 - 4,354 TREATMENT OF ANKLE FRACTURE 1,299.00 1,026.00 1,299.00 4,355 TREATMENT OF ANKLE FRACTURE 1,566.00 1,026.00 1,566.00 4,356 TREATMENT OF ANKLE FRACTURE 1,643.00 1,026.00 1,643.00 4,357 TREATMENT OF ANKLE FRACTURE 2,005.00 1,026.00 2,005.00 4,358 TREATMENT OF ANKLE FRACTURE 2,071.00 1,026.00 2,071.00 4,359 TREATMENT OF ANKLE FRACTURE 1,839.00 4,800.00 - 4,360 TREATMENT OF ANKLE FRACTURE 1,446.00 4,800.00 1,446.00 4,361 TREATMENT OF BLADDER LESION 569.00 1,026.00 569.00 4,362 TREATMENT OF FIBULA FRACTURE 1,155.00 1,026.00 1,155.00 4,363 TREATMENT OF HEEL FRACTURE 1,368.00 1,026.00 1,368.00 4,364 TREATMENT OF HEEL FRACTURE 2,268.00 4,800.00 - 4,365 TREATMENT OF MISCARRIAGE 1,023.00 4,800.00 1,023.00 4,366 TREATMENT OF THIGH FRACTURE 2,287.00 1,026.00 2,287.00 4,367 TREATMENT OF THIGH FRACTURE 2,565.00 1,026.00 2,565.00 4,368 TREATMENT OF THIGH FRACTURE 2,430.00 4,800.00 - 4,369 TREATMENT OF THIGH FRACTURE 3,103.00 1,026.00 3,103.00 4,370 TREATMENT OF THIGH FRACTURE 1,955.00 4,800.00 1,955.00 4,371 TREATMENT OF TIBIA FRACTURE 1,903.00 1,026.00 1,903.00 4,372 TREATMENT OF TIBIA FRACTURE 2,684.00 4,800.00 - 4,373 TREATMENT OF TOE FRACTURE 497.00 1,026.00 497.00 4,374 TREATMENT OF TOE FRACTURE 665.00 1,026.00 665.00 4,375 Treatment plan development 79.00 79.00 4,376 TREPONEMA PALLIDUM - 52.00 - 4,377 TREPONEMA PALLIDUM AG IF 47.00 - 4,378 Treprostinil injection 184.00 184.00 4,379 Treprostinil, non-comp unit 878.00 878.00 4,380 TRH STIMULATION PANEL 198.00 - 4,381 TRH STIMULATION PANEL 263.00 - 4,382 Triamcinolone a inj prs-free 13.00 13.00 4,383 Triamcinolone acet inj nos - 14.00 14.00 4,384 Triamcinolone diacetate inj 2.00 2.00 4,385 Triamcinolone hexacetonl inj 6.00 6.00 4,386 TRICHINELLA ANTIBODY 49.00 - 4,387 TRICHOGRAM 73.00 - 4,388 TRICHOMONAS ASSAY W/OPTIC 47.00 - 4,389 TRICHOMONAS VAGIN DIR PROBE 79.00 - 4,390 TRICHOMONAS VAGINALIS AMPLIF - 245.00 - 4,391 TRICYCLIC & CYCLICALS 6/MORE 99.00 - 4,392 Trim nail(s) 72.00 72.00 - 4,393 TRIM NAIL(S) ANY NUMBER 72.00 405.00 72.00 4,394 TRIM SKIN LESION 123.00 624.00 123.00 4,395 TRIM SKIN LESIONS 2 TO 4 143.00 624.00 143.00 4,396 TRIM SKIN LESIONS OVER 4 160.00 624.00 160.00 4,397 Trimethobenzamide hcl inj 31.00 31.00 4,398 Triptorelin pamoate 439.00 439.00 4,399 Truss add to std pad scrotal 188.00 188.00 4,400 Truss addition to std pad wa 201.00 201.00 4,401 Truss double w/ standard pad 426.00 426.00 4,402 Truss single w/ standard pad 496.00 496.00 4,403 TTE F-UP OR LMTD 128.00 638.00 - 4,404 TTE W/DOPPLER COMPLETE 1,171.00 1,171.00 - Physician Hospital Village Description # Charge Charge Charge 4,405 TTE W/O DOPPLER COMPLETE 228.00 976.00 - 4,406 Tube, pneum wheel drive tire 70.00 70.00 4,407 Tube, pneumatic caster tire 192.00 192.00 4,408 Tubing (oxygen) per foot 4.00 4.00 4,409 Tubing used w suction pump 15.00 15.00 4,410 Tubing with heating element 224.00 224.00 4,411 Tubular dressing 14.00 14.00 4,412 TUMOR IMAGING (3D) 1,432.00 - 4,413 TUMOR IMAGING LIMITED AREA 855.00 - 4,414 TUMOR IMAGING MULT AREAS 1,432.00 - 4,415 TUMOR IMAGING WHOLE BODY 1,432.00 - 4,416 TUMOR IMAGING WHOLE BODY 2,723.00 - 4,417 TUMOR IMMUNOHISTOCHEM/COMPUT 109.00 - 4,418 TUMOR IMMUNOHISTOCHEM/MANUAL 109.00 - 4,419 TX GASTRO INTUB W/ASP 95.00 1,026.00 - 4,420 TX/PRO/DX INJ NEW DRUG ADDON - 103.00 103.00 4,421 TX/PRO/DX INJ SAME DRUG ADON - 103.00 47.00 4,422 TX/PROPH/DG ADDL SEQ IV INF - 158.00 158.00 4,423 TYMPANOMETRY 93.00 130.00 93.00 4,424 TYMPANOMETRY & REFLEX THRESH 354.00 - 4,425 TYPHOID VACCINE IM 137.00 4,426 U1 sealed leadacid battery 314.00 314.00 4,427 U1nonsealed leadacid battery 367.00 367.00 4,428 Ue triple control harness 596.00 596.00 4,429 Ultrasonic generator w svneb 154.00 154.00 4,430 ULTRASOUND BREAST COMPLETE 126.00 261.00 - 4,431 ULTRASOUND BREAST LIMITED 118.00 261.00 - 4,432 ULTRASOUND EXAM FOLLOW-UP 71.00 184.00 - 4,433 ULTRASOUND THERAPY - 80.00 80.00 4,434 ULTRAVIOLET LIGHT THERAPY 66.00 4,435 ULTRAVIOLET THERAPY - 70.00 70.00 4,436 UMBILICAL ARTERY ECHO 184.00 - 4,437 Unclassified drugs or biolog 2.00 2.00 4,438 Underarm crutch pad - 26.00 26.00 4,439 Underarm springassist crutch 501.00 501.00 4,440 UNLISTED E&M SERVICE 111.00 111.00 4,441 UNLISTED PROCEDURE COLON - 2,370.00 - 4,442 UNLISTED REPROD MED LAB PROC 36.00 - 4,443 Up ext fx orthos humeral nos 1,464.00 1,464.00 4,444 Upper ext fx orthosis rad/ul 1,464.00 1,464.00 4,445 Upper ext fx orthosis wrist 890.00 890.00 4,446 UPPER EXTREMITY STUDY 77.00 298.00 - 4,447 UPPER EXTREMITY STUDY 116.00 464.00 - 4,448 Upper limb orthosis nos - 27.00 27.00 4,449 UPPR GI SCOPE W/SUBMUC INJ 626.00 2,550.00 - 4,450 UPR/L XTREMITY ART 2 LEVELS 61.00 200.00 - 4,451 UPR/LXTR ART STDY 3+ LVLS 112.00 326.00 - 4,452 UR ALBUMIN QUANTITATIVE - 133.00 133.00 4,453 UR ALBUMIN SEMIQUANTITATIVE 18.00 - 4,454 UREA NITROGEN SEMI-QUANT 15.00 - 4,455 UREA-N CLEARANCE TEST 26.00 - 4,456 URETERAL REFLUX STUDY 949.00 - 4,457 Urethral insert 6.00 6.00 4,458 Urinal female jug-type 57.00 57.00 4,459 Urinal male jug-type - 12.00 12.00 4,460 URINALYSIS 8.00 - 4,461 URINALYSIS AUTO W/O SCOPE - 37.00 37.00 4,462 URINALYSIS AUTO W/SCOPE - 53.00 53.00 4,463 URINALYSIS GLASS TEST 14.00 - 4,464 URINALYSIS NONAUTO W/O SCOPE - 29.00 29.00 4,465 URINALYSIS NONAUTO W/SCOPE 44.00 44.00 4,466 URINALYSIS VOLUME MEASURE - 36.00 36.00 4,467 URINARY BLADDER RETENTION 325.00 - Physician Hospital Village Description # Charge Charge Charge 4,468 Urinary cath anchor device 12.00 12.00 4,469 Urinary cath leg strap - 27.00 27.00 4,470 Urinary hvy plstc pch w/o fp 88.00 88.00 4,471 Urinary leg bag 141.00 141.00 4,472 Urinary leg or abdomen bag - 44.00 44.00 4,473 Urinary plastic pouch w fcpl 54.00 54.00 4,474 Urinary plastic pouch w/o fp 19.00 19.00 4,475 Urinary pouch on barr w/flng 13.00 13.00 4,476 Urinary pouch w ex wear barr 29.00 29.00 4,477 Urinary pouch w st wear barr 32.00 32.00 4,478 Urinary pouch w/barrier 27.00 27.00 4,479 Urinary pouch w/o barrier 16.00 16.00 4,480 Urinary rubber pouch w fcplt 133.00 133.00 4,481 Urinary rubber pouch w/o fp 101.00 101.00 4,482 Urinary suspensory 208.00 208.00 4,483 URINE BACTERIA CULTURE 139.00 139.00 4,484 URINE CULTURE/COLONY COUNT - 83.00 83.00 4,485 Urine ost pch bar w lock fln 14.00 14.00 4,486 Urine ost pouch w bltinconv 32.00 32.00 4,487 Urine ost pouch w faucet/tap - 110.00 110.00 4,488 Urine pch w ex wear bar conv 35.00 35.00 4,489 URINE PREGNANCY TEST - 51.00 51.00 4,490 URINE SCREEN FOR BACTERIA 10.00 - 4,491 Urine specimen collect mult 9.00 9.00 4,492 Urofollitropin, 75 iu 199.00 199.00 4,493 Urokinase 250,000 iu inj 915.00 915.00 4,494 US ABDL AORTA SCREEN AAA 171.00 171.00 - 4,495 US BONE DENSITY MEASURE 10.00 162.00 - 4,496 US COMPL JOINT R-T W/IMG 109.00 628.00 - 4,497 US EXAM ABDO BACK WALL COMP 126.00 702.00 - 4,498 US EXAM ABDO BACK WALL LIM 98.00 447.00 - 4,499 US EXAM ABDOM COMPLETE 138.00 756.00 - 4,500 US EXAM CHEST 94.00 603.00 - 4,501 US EXAM INFANT HIPS DYNAMIC 127.00 184.00 - 4,502 US EXAM INFANT HIPS STATIC 103.00 184.00 - 4,503 US EXAM K TRANSPL W/DOPPLER 130.00 696.00 - 4,504 US EXAM OF HEAD AND NECK 96.00 651.00 - 4,505 US EXAM PELVIC COMPLETE 118.00 657.00 - 4,506 US EXAM PELVIC LIMITED 66.00 415.00 - 4,507 US EXAM SCROTUM 109.00 642.00 - 4,508 US EXAM SPINAL CANAL 191.00 779.00 - 4,509 US GUIDE VASCULAR ACCESS 52.00 78.00 - 4,510 US LMTD JT/NONVASC XTR STRUX 84.00 164.00 - 4,511 US TRANSRECTAL 118.00 283.00 - 4,512 USE OF SPEECH DEVICE SERVICE 347.00 - 4,513 Ustekinumab sub cu inj, 1 mg 335.00 335.00 4,514 Uvl replacement bulb 160.00 160.00 4,515 Vancomycin hcl injection - 8.00 8.00 4,516 VANOMYCIN DNA AMP PROBE 137.00 - 4,517 Vaporizer room type 205.00 205.00 4,518 VAR VACCINE LIVE SUBQ - 232.00 232.00 4,519 Variable concentration mask - 7.00 7.00 4,520 VARICELLA ZOSTER AG IF 47.00 - 4,521 VARICELLA-ZOSTER ANTIBODY 83.00 83.00 4,522 Varus/valgus strap padded/li 307.00 307.00 4,523 VASCULAR FLOW IMAGING 943.00 - 4,524 VASCULAR STUDY 109.00 298.00 - 4,525 VASCULAR STUDY 165.00 464.00 - 4,526 VASCULAR STUDY 303.00 464.00 - 4,527 VASCULAR STUDY 450.00 464.00 - 4,528 VASOPNEUMATIC DEVICE THERAPY 100.00 - 4,529 VBAC CARE AFTER DELIVERY 5,591.00 - - 4,530 VBAC DELIVERY ONLY 4,683.00 4,800.00 - Physician Hospital Village Description # Charge Charge Charge 4,531 VEIN X-RAY ADRENAL GLAND 6,326.00 - 4,532 VEIN X-RAY ADRENAL GLANDS 6,326.00 - 4,533 VEIN X-RAY ARM/LEG 2,041.00 - 4,534 VEIN X-RAY ARMS/LEGS 2,041.00 - 4,535 VEIN X-RAY CHEST 2,041.00 - 4,536 VEIN X-RAY EYE SOCKET 2,041.00 - 4,537 VEIN X-RAY KIDNEY 6,326.00 - 4,538 VEIN X-RAY KIDNEYS 6,326.00 - 4,539 VEIN X-RAY LIVER 6,326.00 - 4,540 VEIN X-RAY LIVER W/HEMODYNAM 6,326.00 - 4,541 VEIN X-RAY LIVER W/HEMODYNAM 6,326.00 - 4,542 VEIN X-RAY LIVER W/O HEMODYN 2,041.00 - 4,543 VEIN X-RAY NECK 2,041.00 - 4,544 VEIN X-RAY SKULL 2,041.00 - 4,545 VEIN X-RAY SKULL EPIDURAL 2,041.00 - 4,546 VEIN X-RAY SPLEEN/LIVER 6,326.00 - 4,547 VEIN X-RAY TRUNK 6,326.00 - 4,548 Velaglucerase alfa 698.00 698.00 4,549 VEN THROMBOSIS IMAGES BILAT 943.00 - 4,550 VENOUS SAMPLING BY CATHETER 6,326.00 - 4,551 VENOUS THROMBOSIS IMAGING 943.00 - 4,552 VENT MGMT INPAT INIT DAY 315.00 1,123.00 - 4,553 VENT MGMT INPAT SUBQ DAY 359.00 1,123.00 - 4,554 Verteporfin injection 31.00 31.00 4,555 Vessel mapping hemo access 739.00 - 4,556 Vinblastine sulfate inj 4.00 4.00 4,557 Vincristine sulfate 1 mg inj 13.00 13.00 4,558 Vinorelbine tartrate inj 33.00 33.00 4,559 VIPER VENOM PROTHROMBIN TIME 38.00 - 4,560 VIRUS ANTIBODY NOS 83.00 83.00 4,561 VIRUS INOCULATE EGGS/ANIMAL 77.00 - 4,562 VIRUS INOCULATE TISSUE ADDL 83.00 83.00 4,563 VIRUS INOCULATION SHELL VIA - 77.00 - 4,564 VIRUS INOCULATION TISSUE - 83.00 83.00 4,565 Visit to determ ldct elig 90.00 - 4,566 VISUAL ACUITY SCREEN 55.00 4,567 VISUAL AUDIOMETRY (VRA) 158.00 222.00 158.00 4,568 VISUAL FIELD EXAMINATION(S) 59.00 121.00 - 4,569 VISUAL FIELD EXAMINATION(S) 188.00 145.00 - 4,570 VISUAL FIELD EXAMINATION(S) 268.00 222.00 - 4,571 Visualization adjunct 4.00 4.00 4,572 VIT B-12 ABSORP COMBINED 560.00 - 4,573 VIT B-12 ABSORPTION EXAM 560.00 - 4,574 VIT B-12 ABSRP EXAM INT FAC 560.00 - 4,575 VIT D 1 25-DIHYDROXY - 344.00 344.00 4,576 VITAL CAPACITY TEST 362.00 - 4,577 VITAMIN B-12 - 102.00 102.00 4,578 Vitamin b12 injection - 5.00 5.00 4,579 VITAMIN D 25 HYDROXY - 263.00 263.00 4,580 Vitamin k phytonadione inj - 9.00 9.00 4,581 Vivaglobin, inj 38.00 38.00 4,582 Voice amplifier 508.00 508.00 4,583 VOL REDUCTION OF BLOOD/PROD 51.00 - 4,584 W/c acc,saf belt pelv strap 156.00 156.00 4,585 W/c lateral trunk/hip suppor 276.00 276.00 4,586 W/c manual swingaway 463.00 463.00 4,587 W/c medial thigh support 386.00 386.00 4,588 W/c seat lift mechanism 527.00 527.00 4,589 W/c shoulder harness/straps 255.00 255.00 4,590 W/c vent tray fixed 828.00 828.00 4,591 W/c wdth 20-23 in seat frame 931.00 931.00 4,592 W/ch access anti-rollback 212.00 212.00 4,593 W/ch access det adj armrest 268.00 268.00 Physician Hospital Village Description # Charge Charge Charge 4,594 Waist belt 254.00 254.00 4,595 Walker crutch attachment 191.00 191.00 4,596 Walker folding adjust/fixed 226.00 142.00 4,597 Walker folding wheeled w/o s - 355.00 142.00 4,598 Walker leg extenders set of4 112.00 112.00 4,599 Walker platform attachment 242.00 242.00 4,600 Walker rigid adjust/fixed ht - 212.00 212.00 4,601 Walker seat attachment 291.00 291.00 4,602 Walker w trunk support 808.00 808.00 4,603 Walker wheel attachment,pair - 126.00 126.00 4,604 Warfarin respon genetic test 473.00 473.00 4,605 Washed red blood cells unit 593.00 593.00 4,606 Water distilled w/nebulizer 2.00 2.00 4,607 Water pressure mattress 157.00 157.00 4,608 Water seal drain container 208.00 208.00 4,609 Waterproof tape - 14.00 14.00 4,610 WBC ALKALINE PHOSPHATASE 83.00 83.00 4,611 WBC ANTIBODY IDENTIFICATION - 261.00 261.00 4,612 Wc calf rest, pad replacemnt 243.00 243.00 4,613 WEST NILE VIRUS AB IGM 66.00 - 4,614 WEST NILE VIRUS ANTIBODY 56.00 - 4,615 WESTERN BLOT TEST 67.00 - 4,616 Wet mounts/ w preparations 17.00 17.00 4,617 Whchr h-duty det arm leg res 450.00 450.00 4,618 Whchr litwt det arm leg rest 299.00 299.00 4,619 Whchr s-recl fxd arm leg res 347.00 347.00 4,620 Wheelchair amputee detach ar 343.00 343.00 4,621 Wheelchair amputee fixed arm 341.00 341.00 4,622 Wheelchair amputee heavy dut 400.00 400.00 4,623 Wheelchair amputee w/ foot r 330.00 330.00 4,624 Wheelchair amputee w/ leg re 413.00 413.00 4,625 Wheelchair amputee w/o leg r 320.00 320.00 4,626 Wheelchair anti-tipping devi 169.00 169.00 4,627 Wheelchair arm rest 107.00 107.00 4,628 Wheelchair bearings 23.00 23.00 4,629 Wheelchair brake extension 97.00 97.00 4,630 Wheelchair commode seat 72.00 72.00 4,631 Wheelchair detachable arms 364.00 364.00 4,632 Wheelchair detachable foot r 431.00 431.00 4,633 Wheelchair elevating leg res 424.00 424.00 4,634 Wheelchair fixed arms 214.00 214.00 4,635 Wheelchair head rest extensi 325.00 325.00 4,636 Wheelchair heavy duty fixed 467.00 467.00 4,637 Wheelchair lightweight det a 451.00 451.00 4,638 Wheelchair lightweight leg r 236.00 236.00 4,639 Wheelchair lightwt fixed arm 468.00 468.00 4,640 WHEELCHAIR MNGMENT TRAINING - 72.00 72.00 4,641 Wheelchair narrowing device 438.00 438.00 4,642 Wheelchair safety vest 111.00 111.00 4,643 Wheelchair semi-recl detach 289.00 289.00 4,644 Wheelchair solid seat insert 531.00 531.00 4,645 Wheelchair spec seat depth/w 939.00 939.00 4,646 Wheelchair spec size w foot 200.00 200.00 4,647 Wheelchair spec size w foot 233.00 233.00 4,648 Wheelchair spec size w/ leg 246.00 246.00 4,649 Wheelchair spec size w/ leg 264.00 264.00 4,650 Wheelchair spec sz spec ht a 721.00 721.00 4,651 Wheelchair spec sz spec ht b 95.00 95.00 4,652 Wheelchair special seat dept 316.00 316.00 4,653 Wheelchair standard w/ leg r 277.00 277.00 4,654 Wheelchair wide w/ foot rest 424.00 424.00 4,655 Wheelchair wide w/ leg rests 462.00 462.00 4,656 Whelchr fxd full length arms 495.00 495.00 Physician Hospital Village Description # Charge Charge Charge 4,657 Whfo nontorsion joint prefab 424.00 424.00 4,658 Whfo w/joint(s) custom fab 829.00 829.00 4,659 Whfo w/o joints pre cst - 498.00 498.00 4,660 Whfo w/o joints pre ots - 515.00 - 4,661 Whfo, rigid w/o joints 959.00 959.00 4,662 WHIRLPOOL THERAPY - 93.00 93.00 4,663 Whlchr ampu fxd arm leg rest 400.00 400.00 4,664 Whlchr att- conv 1 arm drive 175.00 175.00 4,665 Who cock-up nonmolde pre ots - 239.00 239.00 4,666 Who nontorsion jnts pre cst 970.00 970.00 4,667 Who w/o joints cf - 988.00 988.00 4,668 Whole blood for transfusion 425.00 425.00 4,669 Wilate injection 3.00 3.00 4,670 WINDOWING OF CAST 204.00 624.00 204.00 4,671 WITHDRAWAL OF ARTERIAL BLOOD - 67.00 - 4,672 Woman's shoe oxford brace 289.00 289.00 4,673 WORK HARDENING 364.00 364.00 4,674 WORK HARDENING ADD-ON 182.00 - 4,675 Wound cleanser any type/size - 9.00 9.00 4,676 Wound closure by adhesive 388.00 388.00 4,677 Wound pouch each 51.00 51.00 4,678 WOUND(S) CARE NON-SELECTIVE - 120.00 - 4,679 XM ARCHIVE TISSUE MOLEC ANAL 36.00 - 4,680 X-RAY AORTA LEG ARTERIES 6,326.00 - 4,681 X-RAY ASSAY CALCULUS 133.00 133.00 4,682 X-RAY BEND ONLY L-S SPINE 42.00 330.00 - 4,683 X-RAY CONSULTATION 118.00 - 4,684 XRAY CONTROL CATHETER CHANGE 282.00 - 4,685 X-RAY EXAM ABDOMEN 1 VIEW 31.00 212.00 - 4,686 X-RAY EXAM ABDOMEN 2 VIEWS 40.00 391.00 - 4,687 X-RAY EXAM ABDOMEN 3+ VIEWS 47.00 391.00 - 4,688 X-RAY EXAM BREASTBONE 2/>VWS 35.00 246.00 - 4,689 X-RAY EXAM CHEST 1 VIEW 31.00 212.00 - 4,690 X-RAY EXAM CHEST 2 VIEWS 37.00 212.00 - 4,691 X-RAY EXAM CHEST 3 VIEWS 48.00 212.00 - 4,692 X-RAY EXAM CHEST 4+ VIEWS 55.00 391.00 - 4,693 X-RAY EXAM ENTIRE SPI 1 VW 46.00 182.00 - 4,694 X-RAY EXAM ENTIRE SPI 2/3 VW 56.00 302.00 - 4,695 X-RAY EXAM ENTIRE SPI 4/5 VW 60.00 576.00 - 4,696 X-RAY EXAM ENTIRE SPI 6/> VW 70.00 576.00 - 4,697 X-RAY EXAM HIP UNI 1 VIEW 33.00 182.00 - 4,698 X-RAY EXAM HIP UNI 2-3 VIEWS 38.00 182.00 - 4,699 X-RAY EXAM HIP UNI 4/> VIEWS 50.00 302.00 - 4,700 X-RAY EXAM HIPS BI 2 VIEWS 40.00 302.00 - 4,701 X-RAY EXAM HIPS BI 3-4 VIEWS 52.00 302.00 - 4,702 X-RAY EXAM HIPS BI 5/> VIEWS 56.00 576.00 - 4,703 X-RAY EXAM KNEE 4 OR MORE 42.00 255.00 - 4,704 X-RAY EXAM L-2 SPINE 4/>VWS 55.00 369.00 - 4,705 X-RAY EXAM L-S SPINE 2/3 VWS 41.00 246.00 - 4,706 X-RAY EXAM L-S SPINE BENDING 59.00 441.00 - 4,707 X-RAY EXAM NECK SPINE 2-3 VW 41.00 219.00 - 4,708 X-RAY EXAM NECK SPINE 4/5VWS 55.00 340.00 - 4,709 X-RAY EXAM NECK SPINE 6/>VWS 64.00 410.00 - 4,710 X-RAY EXAM OF ANKLE 29.00 173.00 - 4,711 X-RAY EXAM OF ANKLE 30.00 248.00 - 4,712 X-RAY EXAM OF ARM INFANT 29.00 177.00 - 4,713 X-RAY EXAM OF BODY SECTION 202.00 - 4,714 X-RAY EXAM OF COLLAR BONE 29.00 189.00 - 4,715 X-RAY EXAM OF ELBOW 28.00 182.00 - 4,716 X-RAY EXAM OF ELBOW 30.00 214.00 - 4,717 X-RAY EXAM OF EYE SOCKETS 37.00 307.00 - 4,718 X-RAY EXAM OF EYE SOCKETS 48.00 355.00 - 4,719 X-RAY EXAM OF FACIAL BONES 35.00 262.00 - Physician Hospital Village Description # Charge Charge Charge 4,720 X-RAY EXAM OF FACIAL BONES 46.00 345.00 - 4,721 X-RAY EXAM OF FEMUR 1 29.00 182.00 - 4,722 X-RAY EXAM OF FEMUR 2/> 33.00 182.00 - 4,723 X-RAY EXAM OF FINGER(S) 24.00 155.00 - 4,724 X-RAY EXAM OF FISTULA 728.00 - 4,725 X-RAY EXAM OF FOOT 26.00 165.00 - 4,726 X-RAY EXAM OF FOOT 29.00 204.00 - 4,727 X-RAY EXAM OF FOREARM 29.00 189.00 - 4,728 X-RAY EXAM OF HAND 29.00 167.00 - 4,729 X-RAY EXAM OF HAND 30.00 240.00 - 4,730 X-RAY EXAM OF HEEL 28.00 173.00 - 4,731 X-RAY EXAM OF HUMERUS 30.00 240.00 - 4,732 X-RAY EXAM OF JAW <4VIEWS 31.00 296.00 - 4,733 X-RAY EXAM OF JAW 4/> VIEWS 43.00 319.00 - 4,734 X-RAY EXAM OF JAW JOINT 32.00 131.00 - 4,735 X-RAY EXAM OF JAW JOINT 851.00 - 4,736 X-RAY EXAM OF JAW JOINTS 43.00 321.00 - 4,737 X-RAY EXAM OF KIDNEY LESION 728.00 - 4,738 X-RAY EXAM OF KNEE 1 OR 2 34.00 187.00 - 4,739 X-RAY EXAM OF KNEE 3 35.00 214.00 - 4,740 X-RAY EXAM OF KNEES 34.00 199.00 - 4,741 X-RAY EXAM OF LEG INFANT 28.00 207.00 - 4,742 X-RAY EXAM OF LOWER LEG 30.00 199.00 - 4,743 X-RAY EXAM OF MASTOIDS 31.00 349.00 - 4,744 X-RAY EXAM OF MASTOIDS 59.00 325.00 - 4,745 X-RAY EXAM OF MIDDLE EAR 328.00 - 4,746 X-RAY EXAM OF NASAL BONES 30.00 250.00 - 4,747 X-RAY EXAM OF NECK 29.00 194.00 - 4,748 X-RAY EXAM OF PELVIS 32.00 192.00 - 4,749 X-RAY EXAM OF PELVIS 40.00 308.00 - 4,750 X-RAY EXAM OF PENIS 597.00 - 4,751 X-RAY EXAM OF PERINEUM 597.00 - 4,752 X-RAY EXAM OF PERITONEUM 728.00 - 4,753 X-RAY EXAM OF SALIVARY DUCT 728.00 - 4,754 X-RAY EXAM OF SALIVARY GLAND 131.00 - 4,755 X-RAY EXAM OF SHOULDER 26.00 167.00 - 4,756 X-RAY EXAM OF SHOULDER 35.00 218.00 - 4,757 X-RAY EXAM OF SHOULDER BLADE 34.00 238.00 - 4,758 X-RAY EXAM OF SHOULDERS 38.00 230.00 - 4,759 X-RAY EXAM OF SINUSES 30.00 188.00 - 4,760 X-RAY EXAM OF SINUSES 43.00 321.00 - 4,761 X-RAY EXAM OF SKULL 43.00 262.00 - 4,762 X-RAY EXAM OF SKULL 59.00 362.00 - 4,763 X-RAY EXAM OF SMALL BOWEL 236.00 - 4,764 X-RAY EXAM OF SMALL BOWEL 350.00 - 4,765 X-RAY EXAM OF SMALL BOWEL 457.00 - 4,766 X-RAY EXAM OF SPINE 1 VIEW 26.00 151.00 - 4,767 X-RAY EXAM OF TEAR DUCT 728.00 - 4,768 X-RAY EXAM OF TEETH 20.00 102.00 - 4,769 X-RAY EXAM OF TEETH 28.00 102.00 - 4,770 X-RAY EXAM OF TOE(S) 23.00 155.00 - 4,771 X-RAY EXAM OF WRIST 32.00 175.00 - 4,772 X-RAY EXAM OF WRIST 30.00 206.00 - 4,773 X-RAY EXAM PITUITARY SADDLE 221.00 - 4,774 X-RAY EXAM RIBS BIL 3 VIEWS 47.00 282.00 - 4,775 X-RAY EXAM RIBS UNI 2 VIEWS 38.00 267.00 - 4,776 X-RAY EXAM RIBS/CHEST4/> VWS 55.00 338.00 - 4,777 X-RAY EXAM SACRUM TAILBONE 30.00 216.00 - 4,778 X-RAY EXAM SERIES ABDOMEN 54.00 325.00 - 4,779 X-RAY EXAM SI JOINTS 30.00 204.00 - 4,780 X-RAY EXAM SI JOINTS 3/> VWS 32.00 238.00 - 4,781 X-RAY EXAM SURGICAL SPECIMEN 918.00 - 4,782 X-RAY EXAM THORAC SPINE 2VWS 38.00 255.00 - Physician Hospital Village Description # Charge Charge Charge 4,783 X-RAY EXAM THORAC SPINE 3VWS 37.00 284.00 - 4,784 X-RAY EXAM THORAC SPINE4/>VW 37.00 131.00 - 4,785 X-RAY EXAM THORACOLMB 2/> VW 41.00 252.00 - 4,786 X-RAY EXAM UNILAT RIBS/CHEST 46.00 267.00 - 4,787 X-RAY EYE FOR FOREIGN BODY 29.00 234.00 - 4,788 X-RAY FEMALE GENITAL TRACT 489.00 - 4,789 X-RAY GUIDE GU DILATION 3,224.00 - 4,790 X-RAY HEAD FOR ORTHODONTIA 35.00 131.00 - 4,791 X-RAY MALE GENITAL TRACT 597.00 - 4,792 X-RAY MEASUREMENT OF PELVIS 364.00 - 4,793 X-RAY NOSE TO RECTUM 31.00 122.00 - 4,794 X-RAY OF LOWER SPINE DISK 4,933.00 - 4,795 X-RAY OF MAMMARY DUCT 728.00 - 4,796 X-RAY OF MAMMARY DUCTS 728.00 - 4,797 X-RAY STRENOCLAVIC JT 3/>VWS 38.00 242.00 - 4,798 X-RAY STRESS VIEW 131.00 - 4,799 X-RAY UPPER GI DELAY W/KUB 350.00 - 4,800 X-RAY UPPER GI DELAY W/O KUB 542.00 - 4,801 X-RAY UPPER GI&SMALL INTEST 837.00 - 4,802 X-RAY URETHRA/BLADDER 454.00 - 4,803 X-RAY URETHRA/BLADDER 518.00 - 4,804 X-RAYS BONE LENGTH STUDIES 77.00 257.00 - 4,805 X-RAYS BONE SURVEY COMPLETE 116.00 659.00 - 4,806 X-RAYS BONE SURVEY INFANT 120.00 243.00 - 4,807 X-RAYS BONE SURVEY LIMITED 527.00 - 4,808 X-RAYS FOR BONE AGE 257.00 - 4,809 XYLOSE TOLERANCE TEST 51.00 51.00 4,810 Xyntha inj 4.00 4.00 4,811 YELLOW FEVER VACCINE SUBQ 143.00 4,812 YERSINIA ANTIBODY 52.00 - 4,813 Ziconotide injection 23.00 23.00 4,814 Zidovudine 5.00 5.00 4,815 Zinc paste band w >=3"<5"/yd - 6.00 6.00 4,816 Ziprasidone mesylate 31.00 31.00