CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 120 ROOM/BED: Swingbed $3,028.00 121 ROOM/BED: Semi Private $3,452.00 $2,566.00 121 ROOM/BED: T.I.C $4,656.00 $3,646.00 122 ROOM/BED: Private $2,534.00 721 Amniofusion Charge $166.00 721 INDUCTION/PER HOUR CHARGE $227.00 721 MAG SULFATE/HOUR CHARGE $119.00 761 CATH FOR SPC COLLECT SGL PT CHARGE $64.00 10021 10021 FINE NEEDLE ASPIRATION BX;W/IMAGING; 1ST LESION CCC $564.00 10060 Drain Skin Abscess, Simple/Single Charge $562.00 10061 Drain Skin Abscess, Complex/Multiple Charge $938.00 10080 I&D Pilonidal Cyst; Simple Charge $858.00 Incision & Removal of Foreign Body, Subcutaneous Tissues; Simple 10120 Charge $694.00 Incision & Removal of Foreign Body, Subcutaneous Tissues; Complicated 10121 Charge $646.56 10140 Nipple exploration.excision $794.00 10160 Puncture Aspirtn of Abscess, Hematoma, Bulla, or Cyst Charge $644.00 10180 I&D, Complex, Postoperative Wound Infectn Charge $1,308.00 Debride of Extensive Eczematous or Infected Skin; Up to 10% of Body 11000 Surface Charge $524.00 Debridement Of Extensive Eczematous Or Infected Skin; Each Additional 11001 10% Of The Body Surface $116.00 11004 Debridement of skin for necrotizing soft tissue infection $3,140.00 11005 Debridement of abdominal wall, with or without fascial closure $4,080.00 Debridement of skin, subcutaneous tissue, external genitalia, perineum 11006 and abdominal wall $5,610.00 11008 Removal of prosthetic material or mesh, abdominal wall for infection $1,438.00 11010 Debride Skin/Tissue, Fx Charge $2,208.00 Debridement Incl Removal Of Foreign Material Associated With Open 11011 Fracture(S) And/Or Dislocation(S) $2,398.00 11012 Deb skin bone at fx site $3,388.00 Debridement, subcutaneous tissue first 20 sq cm or less Technical 11042 Charge $446.00 11043 Debride Skin/Tissue/Muscle Charge $982.00 11044 Debride Skin/Tissue/Muscle/Bone Charge $1,700.00 11045 11045 Debridement, subcutaneous tissue; each additional 20 sq cm $220.00 11046 11046 Debridement Muscle/Fascia, each additional 20 sq cm $392.00 11047 Debridement Skin-Bone +20 $802.00 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 11055 single lesion $418.00 11056 11056 PARING/CUTTING LES 2-4 $288.00 11100 Biopsy of Skin Lesion Charge $526.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 11101 Biopsy, Skin Subq/Mucous, Ea Add'l Charge $154.00 Removal of Skin Tags, Mult Fibrocutaneous Tags, Any Area; Up to & w/15 11200 Lesions Charge $432.00 11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each 11201 additional ten lesions $132.00 Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam 0.5 cm > 11300 Charge $353.49 Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam 0.6 to 1.0 11301 cm Charge $474.00 11302 Shaving of epidermal or dermal lesion, single lesion, trunk, arms 11302 or legs; lesion 1.1 to 2.0cm $498.00 Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 11305 0.5 cm > Charge $353.49 Excision, benign lesion including margins, except skin tag, trunk, arms or 11400 legs; 0.5cm or less $602.00 Excision, benign lesion, trunk, arms or legs; excised diameter 0.6 to 1.0 11401 cm Technical Charge $736.00 11402 Remove Lesion, Trunk/Arm/Leg 1.1 to 2.0 cm Charge $822.00 11403 Remove Lesion, Trunk/Arm/Leg 2.1 to 3.0 cm Charge $944.00 11404 EXC TR-EXT 59+MARG 3.14-4CM $1,072.00 11406 EXC TR-EXT B9+MARG]4.0 CM-Clinic $1,530.00 11420 Remove Lesion, Scalp/Neck/Hand/Foot < .5 cm Charge $638.00 Excision, benign lesion, scalp, neck, hands, feet, genitalia; 0.6 to 1.0 cm 11421 Technical Charge $868.00 Excision, benign lesion scalp, neck, hands, feet, genitalia;1.1 to 2.0 cm 11422 Technical Charge $1,308.00 11423 Remove Lesion, Scalp/Neck/Hand/Foot 2.1 to 3.0 cm Charge $1,010.00 11424 Remove Lesion, Scalp/Neck/Hand/Foot 3.1 to 4.0 cm Charge $1,726.00 11426 Remove Lesion, Scalp/Neck/Hand/Foot >4.0 cm Charge $1,700.00 11440 Remove Lesion, Face/Lid/Ear/Nose/Lip <.5 cm Charge $458.00 11441 Remove Lesion, Face/Lid/Ear/Nose/Lip .6 to 1.0 cm Charge $1,028.00 11442 Remove Lesion, Face/Lid/Ear/Nose/Lip 1.1 to 2.0 cm Charge $1,608.00 Remove Other Benign Lesion w/Margins , Face/Ears/Eyelids/Nose/Lips; 11444 Diam 3.1 to 4.0 cm Charge $1,348.00 Excision Of Skin And Subcutaneous Tissue For Hidradenitis, Inguinal; w/ 11462 Simple Or Intermed Repair $2,080.00 Excision, malignant lesion, trunk, arms, or legs; 0.6 to 1.0 cm Technical 11601 Charge $1,140.00 Excision, malignant lesion, trunk, arms, or legs;1.1 to 2.0 cm Technical 11602 Charge $1,246.00 Excise, Malign Lesion w/Margins, Trunk, Arms, or Legs; Excised diam 2.1 11603 to 3.0 cm Charge $1,542.00 Remove Malig Lesion w/Margins, Trunk, Arms, or Legs; Diam 4.0+ cm 11606 Charge $2,302.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees Excision, malignant lesion, scalp, neck, hands, feet, genitalia; 0.6 to 1.0 11621 cm Technical Charge $996.00 Remove Malig Lesion w/Margins, Scalp, Neck, Hands, Feet, Genital; Diam 11622 1.1 to 2.0 cm Charge $1,356.00 Remove Malig Lesion w/Margins, Scalp, Neck, Hands, Feet, Genital; Diam 11626 4.0+ cm Charge $2,344.00 Excise, Malign Lesion w/Margins, Face, Ears, Eyelids, Nose, Lips; Excised 11640 diam 0.5 cm or Less Charge $1,046.00 Excise, Malign Lesion w/Margins, Face, Ears, Eyelids, Nose, Lips; Excised 11641 diam 0.6 to 1.0 cm Charge $1,238.00 Excision, malignant lesion face, ears, eyelids, nose, lips; 1.1-2.0 cm 11642 Technical Charge $1,454.00 11730 Avulsion of Nail Plate, Partial or Complete, Simple; Single Charge $524.00 11740 Evacuation of subungual hematoma Technical Charge $260.00 11750 Removal of nail Bed. $1,374.00 11765 Wedge Excise of Skin of Nail Fold (eg, For Ingrown toenail) Charge $916.00 11770 Excision of pilonidal cyst or sinus; simple $1,342.00 11900 11900 INJECT SKIN LESIONS - Clinic $288.00 11976 Removal, Implantable Contraceptive Capsules Charge $774.00 11980 Hormone Pellet Implant; Subcutaneous Charge $742.00 11981 Insertion, Non-Biodegradable Drug Delivery Implant $640.00 11982 Removal, non-biodegradable drug delivery implant $1,262.00 11983 11983 Remove w ins drug im $1,760.00 12001 Repair simple scalp, neck, axillae, ext genital $632.00 12002 Simple repair of superficial wounds of scalp, neck, axillae, external 12002 genitalia, trunk and/or $632.00 Repair Simple Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 12011 2.5 cm > Charge $588.00 Repair Simple Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 12011 2.5 cm or less Charge $588.00 Repair Simple Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 12013 2.6 cm to 5.0 cm Charge $654.00 Repair Simple Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 12014 5.1 cm to 7.5 cm Charge $654.00 12015 12015 SIMPLE REPAIR 7.6-12.5 CM FACE Clinic Charge $916.00 12020 12020 Treatment, superficial wound dehiscence; simple closure $1,486.00 Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude 12031 Hands and Feet) 2.5 cm or Less $1,202.00 Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude 12032 Hands and Feet) 2.6 cm to 07.5 $1,522.00 Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude 12032 Hands/Feet) 2.6 -07.5 Tech Chg $1,522.00 Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude 12034 Hands and Feet) 7.6 cm to 12.5 $1,638.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude 12035 Hands and Feet) 12.6 cm to 20. $2,054.00 Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude 12037 Hands and Feet) over 30.0 cm C $1,996.00 Layer Closure of Wounds of Neck, Hands, Feet and/or Ext Genitalia; 2.5 12041 cm or Less Charge Tech Chg $1,238.00 Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude 12041 Hands/Feet) 2.5 cm Tech Chg $1,238.00 Layer Closure of Wounds of Neck, Hands, Feet and/or Ext Genitalia; 2.6 12042 cm to 7.5 cm Charge $1,228.00 Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous 12051 Membrane 2.5 cm or Less Charge $1,701.32 Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous 12052 Membrane 2.6 cm to 05.0 cm Charge $1,248.00 Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous 12054 Membrane 7.6 cm to 12.5 cm Charge $1,962.00 13121 Repair Complex, Scalp, Arms, and/or Legs; 2.6 cm to 7.5 cm Charge $2,260.00 Repair Complex, Scalp, Arms, and/or Leg Each Additional 5cm or Less 13122 Charge $692.00 Repair Complex Forehead/Cheek/Mouth/Neck/Axillae/Genitalia/Hands/Feet 02.6 to 07.5 13132 cm Charge $2,972.00 13133 13133 COMPLEX REPAIR EACH ADD 5 CM FACE Clinic Charge $942.00 13160 13160 Repair, Complex, any area 2nd closure Charge $6,182.00 Adjacent Tissue Transfer or Rearrangement, Trunk; Defect 10 sq cm or 14000 Less Charge $3,980.00 Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 14001 30.0 sq cm $5,178.00 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; 14020 defect 10 sq cm or less $4,512.00 Adj tissue xfer/rearrangement,scalp,arms or legs defect 10.1cm-30.0cm 14021 Tech Chg $5,698.00 Adjacent tissue xfer/rearrangement,forehead,cheek,chin,mouth, 14040 hands/feet,<10 sq cm $5,028.00 Adj tissue xfer/rearrangement,forehead,cheek,chin,mouth,hands/ft 10.1 14041 cm-30.0cm Tech Chg $6,166.00 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or 14060 lips; defect <10 sq cm $5,354.00 Adjacent tissue xfer/rearrangement,eyelids,nose,ears or lips defect 10.1 14061 cm-30cm Tech Chg $6,594.00 14301 14301 ADJACENT TISSUE TRANS 30- Clinic Charge $7,026.00 Adjacent tissue transfer or rearrangement, any area; defect ea addtl 30 14302 sq cm $1,776.00 14350 14350 Filleted finger or toe flap, including preparation of recipient site $5,660.00 Surgical preparation or creation of recipient site by excision of open 15002 wounds, first 100 sq cm $1,832.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees Surgical preparation or creation of recipient site by excision of open 15003 wounds, each additional 100 s $366.00 15004 Surgical preparation or creation of recipient site by excision of 15004 open wounds $2,092.00 15100 Split-thickness autograft trunk arms legs first 100 sq cm or less $4,390.00 15101 Split-thickness autograft trunk, arms, legs; each additional 100 sq 15101 cm or each additional 1% o $389.07 15120 Split-thickness autograft face scalp eyelids mouth first 100 sq cm or less $4,852.00 15271 Application of skin substitute graft, trunk,arms,legs, up to 100 sq 15271 cm $1,114.00 15275 15275 SKIN SUB GRAFT FACE/NK/HF/G $1,184.00 15650 15650 Transfer, intermediate, of any pedicle flap, any location $2,616.00 15830 Excision excessive skin and subcutaneous tissue $7,776.00 Dressing Change (For Other Than Burns) Under Anesthesia (Other Than 15852 Local) Charge $5,232.00 Dressings and/or debridement of partial-thickness burns, initial or 16020 subsequent; small Tech Chg $418.00 17000 17000 DESTRUCT LESION 1ST $410.00 17003 Destruction Benign/Premalig 2-14 Lesions, each Charge $156.00 17004 17004 DESTRUCTION PRE-MALIG AK >15 Clinic Charge $916.00 Destruct benign lesions other than skin tags or cut vascular prolif lesions; 17110 up to 14 lesions Techni $560.00 Destruction (laser/electro/cryo/chemosurgery/curette), of warts; 15 or 17111 more lesions Charge $670.00 17250 Chemical cauterization of granulation tissue $296.00 Destruction, malignant lesion, scalp, neck, hands, feet, genitalia; lesion 17272 diameter 1.1 to 2.0 cm $674.03 17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue $3,924.00 19101 Breast Biopsy Open Incision Charge $1,740.00 Excision of cyst, fibroadenoma,other benign or malignant tumor, 19120 aberrant breast tis, duct lesio $3,924.00 Mastectomy partial (eg lumpectomy tylectomy quadrantectomy 19301 segmentectomy) $5,138.00 19303 Mastectomy Simple Complete $7,962.00 19304 Mastectomy, subcutaneous $4,556.00 Mastectomy modified radical w/wo pectoralis minor muscle excluding 19307 pectoralis major muscle $4,970.00 20100 Exploration of pentrating would , neck $3,714.00 Exploration of penetrating wound (separate procedure) 20102 abdomen/flank/back $2,026.00 20103 Explore of Penetrating Wound; Extremity Charge $2,782.00 20520 Removal of foreign body in muscle or endon sheath; simple $1,226.00 20526 Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal 20526 tunnel $588.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees Inj(s); Single Tendon Sheath, or Ligament, Aponeurosis (eg, Planterar 20550 ""Fascia"") Charge $332.00 20551 20551 Injection(s); single tendon origin/insertion $392.00 20552 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) $312.00 20553 Inj(s); Single or Mult Trigger Point(S), Three or More Muscle(s) Charge $348.00 Arthrocentesis, Aspirtn and/or Inj; Small Joint or Bursa (eg, Fingers, toes) 20600 Charge $406.00 Arthrocentesis, Aspirtn and/or Inj; Small Joint or Bursa (eg, Fingers, toes) 20600 Tech Chg $406.00 Arthrocentesis, aspiration and or injection; intermediate joint or bursa 20605 Technical Charge $416.00 Arthrocentesis, aspiration and or injection; major joint or bursa 20610 Technical Charge $436.00 Removal of Implanter; Deep (eg, Buried Wire, Pin, Screw, Metal Band, 20680 Nail, Rod or Plate) Charge $3,270.00 20999 Unlisted Procedure, Musculoskeletal System, General $7,848.00 Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or 21012 greater $2,656.00 21552 Exc Neck Les Sc =3Cm $3,520.00 21555 Excise Tumor, Soft Tissue of Neck or Thorax; Subcutaneous Charge $2,430.00 21931 Exc Back Les Sc >3Cm $3,738.00 22902 Excise Tumor Subq Abdom Wall <3cm $2,562.00 Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm. or 22903 greater $3,422.00 23120 Claviculectomy; Partial $4,708.00 Acromioplasty Or Acromionectomy, Partial, With Or Without 23130 Coracoacromial Ligament Release $4,708.00 23405 Tenotomy, Shoulder Area; Single Tendon $3,292.00 23430 Tenodesis Of Long Tendon Of Biceps $3,924.00 Closed tx shoulder dislocation, w/fx of greater humeral tuberosity, 23470 w/manipulation $9,610.00 23929 23929 Unlisted procedure, shoulder $7,848.00 24071 24071 Excision tumor, soft tissue upper arm/elbow, 3 cm or greater $2,196.00 24105 Excise, Olecranon Bursa Charge $3,046.00 24201 Remove foreign body, arm/elbow; deep $2,916.00 24310 24310 BICEP TENOTOMY OPEN Clinic Charge $3,924.00 24341 Repair, tendon or muscle , upper arm, or elbow, primary or 24341 secondary $5,980.00 24357 Tenotomy, elbow, lateral or medial (eg. tennis elbow, golfer's 24357 elbow); percutaneous $3,532.00 Incision, Extensor Tendon Sheath, Wrist (eg, Dequervains Disease) 25000 Charge $2,616.00 25028 Incision and drainage, forearm and/or wrist; deep abscess or hematoma $2,878.00 25076 25076 EXCISION MASS FOREARM/WRI Clinic Charge $4,112.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 25085 25085 CAPSULOTOMY WRIST Clinic Charge $2,354.00 25111 Excise of Ganglion, Wrist (Dorsal or Volar); Primary Charge $2,198.00 25447 Arthroplas Interposit-carpomet $6,410.00 Closed treatment of distal radial fracture (eg, Colles or Smith type) w/ 25605 manipualtion charge $3,008.00 25999 25999 Unlisted procedure, forearm or wrist $7,848.00 26055 Tendon Sheath Incision (Eg, For Trigger Finger) $2,904.00 Excision, tumor or vascular malformation, soft tissue of hand or finger, 26111 subcutaneous: 1.5 cm $2,616.00 26530 26530 Arthroplasty, metacarpophalangeal joint; each joint $3,466.00 Arthroplasty, Metacarpophalangeal Joint; With Prosthetic Implant, Each 26531 Joint $4,026.00 Open Trtmt of Metacarpal Fx, Single, w/ or w/o Inter or Ext Fixation, 26615 each Bone Charge $4,538.00 Percutaneous Skeletal Fixation Of Unstable Phalangeal Shaft Fracture 26727 Proximal or Mid Phalanx w/Manip $2,486.00 27327 Excise, Tumor, Thigh or Knee Area; Subcutaneous Charge $2,746.00 27337 27337 EXCISION SQ MASS UP LEG Clinic Charge $3,650.00 27347 27347 EXCISION CYST KNEE Clinic Charge $2,878.00 Excision/curettage of bone cyst or benign tumor of femur; local excision 27355 of lesion or tissue of femu $5,274.00 27590 Amputation, Thigh, Through Femur, Any Level; $6,490.00 27618 Excision, tumor, leg or ankle area; subcutaneous. $2,422.00 Suture, Primary, Torn, Ruptured Or Severed Ligament, Ankle; Both 27696 Collateral Ligaments $4,394.00 27882 Amputation leg through tibia and fibula open circular (guillotine) $3,270.00 27884 Amputation, leg, through tibia and fibula; secondary closure or 27884 scar revision $3,270.00 28054 28054 Arthrotomy with biopsy; interphalangeal joint $1,504.00 28190 Tenotomy, open, flexor tendon; foot or toe, single $1,060.00 28805 Amputa Ft; Transmetatarsal $5,882.00 28810 Amputation, Metatarsal, w/Toe, Single Charge $2,286.00 28820 Amputation, to e; Metatarsophalangeal Joint Charge $2,654.00 28825 Amputation, to e; Interphalangeal Joint Charge $2,928.00 29065 29065 CAST LONG ARM Clinic Charge $614.00 29075 29075 CAST SHORT ARM Clinic Charge $576.00 29085 Applic, Cast; Hand & Lower Forearm (Gauntlet) Charge $440.00 29105 Applic of Long Arm Splint (Shoulder to Hand) Charge $562.00 29125 29125 APPLICATION OF SHORT ARM SPLINT Clinic Charge $414.00 29130 Applic of Finger Splint; Static Charge $322.00 29345 29345 CAST LONG LEG(THIGH TO TOES) Clinic Charge $808.00 29405 29405 SHORT LEG CAST/BELOW KNEE TO TOES Clinic Charge $536.00 29445 APPLICATION RIGID TOTAL CONTACT LEG CAST $700.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 29505 29505 SPLINT LONG LEG Clinic Charge $396.00 29515 Application of short leg splint (calf to foot)- Prof $366.00 29530 29530 KNEE IMMOBLIZER Clinic Charge $386.00 29540 29540 ANKLE STRAPPING Clinic Charge $222.00 29580 29580 UNNA BOOT INCLUDING OC Clinic Charge $264.00 29700 29700 CAST REMOVAL(ORGINAL PUT ON ANOTHER Clinic Charge $420.00 Arthroscopy, Shoulder, Diagnostic, With Or Without Synovial Biopsy 29805 (Separate Procedure) $3,924.00 29806 29806 ARTHROSCOPY SHOULDER Clinic Charge $6,902.00 29807 Arthroscopy, Shoulder, Surgical; Repair Of Slap Lesion $5,232.00 29822 Arthroscopy, Shoulder, Surgical; Debridement, Limited $4,448.00 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including 29824 distal articular surface $4,394.00 29826 Arthroscopic decompression of subacromial space with partial 29826 acromioplasty $1,164.00 29827 29827 Arthroscopy, shoulder; with rotator cuff repair $7,848.00 29828 29828 ARTHRO BICEPS TENODESIS Clinic Charge $5,990.00 29862 29862 Arthroscopy, hip; debridement/shaving of articular cartilage $13,668.00 Arthroscopy, Knee, Surgical; Synovectomy, Limited (Eg Plica Or Shelf 29875 Resection) (Separate Procedure) $3,924.00 Arthroscopy, Knee, Surgical; Debridement/Shaving Of Articular Cartilage 29877 (Chondroplasty) $4,970.00 Arthroscopy, Knee, Surgical; Abrasion Arthroplasty Or Multiple Drilling 29879 Or Microfracture $5,232.00 29881 29881 Arthroscopy, knee, surgical; with meniscectomy (medial or lateral) $4,448.00 29882 Arthroscopy, Knee, Surgical; With Meniscus Repair (Medial Or Lateral) $4,538.00 Arthroscopically Aided Anterior Cruciate Ligament Repair/Augmentation 29888 Or Reconstruction $7,718.00 29897 Arthroscopy Ank Surg; Debrid L $3,140.00 29915 ARTHROSCOPY, HIP, SURGICAL, WITH ACETABULOPLASTY $15,188.00 29999 Unlisted Procedure, Arthroscopy $5,232.00 31500 Intubation, Endotracheal, Emergency Procedure Charge $562.00 Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, 32551 empyema), when performed (separ $984.00 32554 Thoracentesis w/out imaging $1,596.00 Exploration for postoperative hemorrhage thrombosis or infection 35840 abdomen $9,578.00 36415 36415 VENIPUNCTURE $26.00 $26.00 36416 Heel/finger Stick PKU $52.00 36430 36430 Transfusion, blood or blood components $274.00 36481 36481 Percutaneous portal vein catheterization by any method $4,280.00 Insert of Non-Tunneled Centrally Inserted Central Venous Catheter; Age 36556 5 Yrs or Older Charge $1,308.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees Insertion of tunneled centrally inserted cntrl venous access device w/ 36561 subcutaneous port age 5 yr+ $9,366.00 36578 Replacement, catheter, w/ subcutaneous port or pump, central or 36578 peripheral insertion site $1,726.00 Removal of tunneled central venous catheter, without subcutaneous 36589 port or pump $916.00 Removal of tunneled cntrl venous access device w/subcutaneous 36590 port/pump cntrl/peripheral insertion $1,570.00 36818 Arteriovenous anastomosis, open; by upper arm cephalic vein 36818 transposition $5,436.00 36821 36821 Arteriovenous anastomosis, open; direct, any site $3,924.00 37609 Ligation or biopsy temporal artery $1,674.00 37615 Ligation major artery (eg post-traumatic rupture) neck $4,268.00 37618 Ligation major artery (eg post-traumatic rupture) extremity $2,944.00 38120 Laparoscopy Splenectomy $6,828.00 38510 Biopsy or excision of lymph node(s); open, deep cervical node(s) $4,142.00 41017 Extraoral incision and drainage of abscess, cyst, or hematoma of 41017 floor of mouth; submandibular $2,852.00 42700 I&d Abscess; Peritonsillar $7,848.00 42999 42999 Unlisted procedure pharynx, adenoids, or tonsils $7,848.00 43235 Upper gastrointestinal endoscopy Technical Charge $1,256.00 43239 EGD, flexible, transoral; with biopsy, single or multiple $1,778.00 Upper GI endoscopy incl esophagus stomach duodenum/ejunum 43245 w/dilation of gastric outlet for obstr $1,504.00 43246 EGD, flexible, transoral; with direct placement of PEG tube $3,008.00 43247 EGD, flexible, transoral; with removal of foreign body $2,354.00 43270 Esophagogastroduodenoscopy, flexible, transoral; w/ablation of 43270 tumor(s), polyp(s), lesion(s)Â $1,488.00 43280 Laparoscopy, Fundoplasty $7,024.00 43610 Excision, local; malignant tumor of stomach Technical Charge $7,856.00 43632 43632 Gastrectomy, partial, distal; with gastrojejunostomy $10,240.00 43633 Gastrectomy, Partial, Distal; With Roux-En-Y Reconstruction $15,044.00 Change of gastrostomy tube percutaneous without imaging or 43760 endoscopic guidance $2,746.00 43771 Laparoscopy, surgical, gastric restrictive procedure; revision of 43771 adjustable gastric restricti $8,214.00 Gastrostomy open without construction of gastric tube (eg Stamm 43830 procedure) (separate procedure) $4,288.00 Gastrorrhaphy suture of perforated duodenal or gastric ulcer wound or 43840 injury $10,658.00 44005 Enterolysis (freeing of intestinal adhesion) (separate procedure) $7,848.00 44050 Reduction of volvulus intussusception internal hernia by laparotomy $7,586.00 Enterectomy resection of small intestine single resection and 44120 anastomosis $6,278.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees Enteroenterostomy anastomosis of intestine with or without cutaneous 44130 enterostomy $10,258.00 Mobilization (take-down) of splenic flexure performed in conjunction 44139 with partial colectomy $654.00 44140 Colectomy partial with anastomosis $7,848.00 44141 Colectomy partial with skin level cecostomy or colostomy $9,418.00 Colectomy partial with end colostomy and closure of distal segment 44143 (Hartmann type procedure) $13,306.00 44160 Colectomy partial with removal of terminal ileum with ileocolostomy $6,540.00 44180 Laparoscopy, Surgical, Enterolysis Charge $5,860.00 44188 44188 Laparoscopy, surgical, colostomy or skin level cecostomy $9,780.00 Laparoscopy surgical enterectomy resection of small intestine single 44202 resection and anastomosis $9,522.00 Laparoscopy, Surgical; Colectomy, Partial, With End Colostomy And 44206 Closure Of Distal Segment (Hartman $14,006.00 Placement enterostomy or cecostomy tube open (eg for feeding or 44300 decompression) $4,970.00 44310 Ileostomy or jejunostomy non-tube $8,218.00 44320 Colostomy or skin level cecostomy $6,084.00 44380 Ileoscpy-stoma; Dx W/wo Specmn $654.00 44799 44799 Unlisted procedure, small intestine $7,848.00 44950 44950 Appendectomy $4,488.00 44955 Appendectomy w/ Other Procedure Charge $672.00 Appendectomy for ruptured appendix with abscess or generalized 44960 peritonitis $4,896.00 44970 Laparoscopy Surgical Appendectomy Charge $4,080.00 45005 Incision and drainage of submucosal abscess, rectum $1,386.00 45100 Biopsy of anorectal wall, anal approach $1,570.00 45114 Proctectomy, partial, with anastomosis; abdominal and 45114 transsacral approach $9,680.00 Sigmoidoscopy flexible diagnostic with or without collection of specimen 45330 by brushing or washing $838.00 45331 Sigmoidoscopy, flexible with biopsy, single or multi Charge $838.00 45378 Colonoscopy, flexible; diagnostic, incl. collection of specimen(s); 45378 brushing or washing $2,040.00 45380 45380 Colonoscopy, flexible; with biopsy, single or multiple $2,438.00 Colonoscopy, flexible, removal of tumor, polyp/other lesion by hot 45384 biopsy forceps Tech Chg $2,412.00 45385 45385 Colonoscopy w/ remove polyp by snare $5,140.00 45388 Colonoscopy, flexible; w/ ablation of tumor(s), polyp(s), or other 45388 lesion(s) $3,024.00 45560 Repair Rectocele Charge $3,374.00 45915 Removal of fecal impaction or foreign body (separate procedure) 45915 under anesthesia $2,632.80 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 46020 Placement of seton $1,966.00 46030 46030 Remov Anal Seton Other Marker $724.00 46040 I&D of Ischiorectal and/or Perirectal AbscessCharge $2,578.00 46045 Incision and drainage of intramural, intramuscular, or sub mucosal 46045 abscess, trans anal, under $2,130.00 46050 I&D, Perianal Abscess, Superficial Charge $2,040.00 46080 Sphincterotomy Technical Charge $2,616.00 46083 Incise ext hemorrhoid- Clinic $840.00 46200 Fissurectomy +-Sphnctrotomy $1,146.03 46220 Papillectomy or Excise of Single Tag, AnusCharge $950.00 46221 Hemorrhoidectomy internal by rubber band ligation(s) $1,204.00 46255 46255 Hemorrhoidectomy, internal and external, simple $2,802.00 Hemorrhoidectomy, internal and external, 2 or more columns groups; 46260 Technical Charge $3,662.00 46280 46280 Surg Tx Anal Fistula; Complx/m $3,738.00 46320 46320 Enucleation or excision of external thrombotic hemorrhoid $890.00 46600 Anoscopy; diagnostic, with or without collection of specimen(s) by 46600 brushing or washing $524.00 46606 46606 Anoscopy; with biopsy, single or multiple $1,798.00 46922 Destruction of lesion(s), anus (eg, condyloma, papilloma, 46922 molluscum contagiosum, herpetic vesi $1,076.00 46999 Unlisted procedure anus $7,848.00 Biopsy of liver, when done for indicated purpose at time of other major 47001 procedure $824.00 47100 Biopsy of liver, wedge Technical Charge $4,448.00 47379 47379 Unlisted laparoscopic procedure; liver $6,540.00 47480 Cholecystotomy or cholecystostomy, open, with exploration, 47480 drainage, or removal of calculus $5,846.96 Synovectomy, tendon sheath, radical, flexor tendon, palm and/or finger, 47562 each tendon $6,122.00 47563 Laparoscopy surgical cholecystectomy with cholangiography $6,530.00 47564 Laparoscopy, surgical; cholecystectomy w/ exploration of 47564 common duct $8,752.00 47600 47600 Cholecystectomy $8,520.00 47605 Cholecystectomy with cholangiography $10,046.00 47620 47620 Cholecystectomy with exploration of common duct $7,848.00 49000 Exploratory laparotomy, exploratory celiotomy with or without 49000 biopsy(s) (separate procedure) $3,140.00 49020 Drainage of peritoneal abscess or localized peritonitis, exclusive of 49020 appendiceal abscess; ope $8,240.00 49060 Drain Retroperitoneal Abscess Open $7,038.00 49082 Paracentesis, abd, w/o image guidance $1,516.00 49083 49083 Abdominal paracentesis w/imaging guidance $876.00 49084 49084 Peritoneal lavage, including imaging guidance, when performed $524.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 49255 Omentectomy epiploectomy resection of omentum $2,786.94 49320 Laparoscopy Diagnostic Charge $3,060.00 49321 49321 Laparoscopy with biopsy $2,246.00 49322 Laparoscopy Surgical w/ Aspiration Cavity/Cyst Charge $1,962.00 49329 Unlisted laparoscopy procedure, abdomen, peritoneum and omentum $3,060.00 49402 Removal of peritoneal foreign body from peritoneal cavity (from 49402 within the abdominal cavity) $6,778.00 49422 Removal Of Permanent Intraperitoneal Cannula Or Catheter $2,550.00 49505 Repair Initial Inguinal Hernia, Age 5 Yrs or Over; Reducible Charge $2,668.00 49507 49507 Repair initial inguinal hernia age 5 or older incarcerated $3,768.00 49525 Repair inguinal hernia sliding any age $2,882.00 49560 49560 Repair initial incisional or ventral hernia; reducible $4,678.00 Hernia repair incisional or ventral hernia; incarcerated or strangulated 49561 Technical Charge $4,704.00 49568 Implantation, mesh or other prosthesis, open incisional/ventral 49568 hernia repair $1,880.00 49585 Repair umbilical hernia age 5 years or older reducible $2,512.00 49587 49587 RPR UMBIL HERNIA $2,756.00 49587 49587 Repair umbilical hernia 5 > INCAR or STRAN $3,758.00 49650 Laparoscopy surgical repair recurrent inguinal hernia $2,354.00 49652 Hernia Repair Ventral Charge $3,532.00 49653 Laparoscopy, surgical, repair ventral umbilical, spigelian or 49653 epigastric hernia, incarcerated $4,486.00 49999 Unlisted procedure abdomen peritoneum and omentum $6,540.00 51702 51702 Insertion of temporary indwelling bladder catheter $240.00 51726 Complex Cystometrogram (eg, Calibrated Electronic Equipment) Charge $1,588.00 51729 Complex cystometrogram; with voiding and urethral pressure 51727 profile studies $2,040.00 51992 Laparoscopic sling operation for stress incontinence (fascia or 51992 synthetic) $6,836.00 52000 Cystoscopy $1,104.00 53899 53899 Unlisted procedure, urinary system $7,848.00 Circumcision, Surgical Excise Other Than Clamp, Device or Dorsal Slit; 54160 Newborn Charge $524.00 Circumcision, surgical excision other than clamp, device, or dorsal slit; 54161 older than 28 days $1,056.00 54640 54640 Orchiopexy, inguinal approach, with or with out hernia repair $5,232.00 55060 Repair Of Tunica Vaginalis Hydrocele (Bottle Type) $3,018.00 Vasectomy, Unilateral or Bilateral (Separate Procedure), 55250 w/Postoperative Semen Exam(s) Charge $2,214.00 55500 Excision of hydrocele of spermatic cord unilateral (separate procedure) $2,092.00 55540 Excision of varicocele or ligation of spermatic veins for varicocele; 55540 with hernia repair $4,240.00 56405 56405 I & D Vulva/Perineum $2,424.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 56420 I&D of Bartholin's Gland Abscess Charge $734.00 56440 Bartholin's Gland/Cyst Remove Charge $1,038.00 56501 Destruct, Vulva Lesion Simple Charge $784.00 56605 56605 Biopsy of vulva or perineum (separate procedure); one lesion $484.00 56606 56606 Biopsy of vulva or perineum; each separate additional lesion $236.00 56810 Perineoplasty, repair of perineum, nonobstetrical $2,616.00 57120 57120 Colpocleisis (Le Fort type) $3,924.00 57130 57130 Excision of vaginal septum $1,046.00 57135 57135 Excision of vaginal cyst or tumor $2,092.00 57160 Fitting and insertion of pessary or other intravaginal support 57160 device $434.00 57200 57200 Colporrhaphy, suture of injury of vagina (nonobstetrical) $2,402.00 Anterior colporrhaphy, repair of cystocele with or without repair of 57220 urethrocele Technical Charge $4,562.00 57260 57260 Anterioposterior Coporrhaphy $9,008.00 57268 57268 Repair of enterocele, vaginal approach (separate procedure) $3,924.00 57280 57280 Colpopexy, abdominal approach $6,290.00 57287 57287 Removal or revision of sling for stress incontinence $4,278.00 57288 Sling operation for stress incontinence (eg fascia or synthetic) $7,128.00 57295 57295 REVISION OF PROSTHETIC VAGINAL GRAFT Clinic Charge $2,616.00 57420 Colposcopy Entire Vagina w/Cervix Charge $742.00 57452 Colposcopy Cervix Upper Vag Charge $890.00 57454 Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or 57454 endocervical curettage $976.00 57455 57455 Colpscopy of the Cervix with biopsy of the cervix $1,024.00 57460 Colposcopy (vaginoscopy); with loop electrode excision procedure 57460 of the cervix $1,644.00 57500 Biopsy, Single or Multiple, or Local Excision of Lesion $734.00 57505 Endocervical curettage (not done as part of a dilation and 57505 curettage) $728.00 57511 Cryocautery Cervix Charge $1,678.00 57520 Cervix Conization, Remove Charge $2,196.00 57522 Cervix Conization w/Loop Elec, Remove Charge $2,852.00 58100 58100 BIOPSY OF UTERUS LINING $624.00 58110 58110 Endometrial sampling performed in conjunction with colposcopy $324.00 58120 Dilation and curettage, diagnostic and/or therapeutic 58120 (nonobstetrical) $1,670.00 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural 58140 myoma(s) with total weight of $7,438.00 Total abd. hysterectomy, w/ or w/o removal of tube(s) or ovary(s) 58150 Charge $8,462.00 58150 58150 total hysterectomy with assist $2,616.00 Total abd hysterectomy, w or wo removal of tubes, w or wo removal of 58152 ovaries; w colpo-urethrocystope $7,984.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 58180 Supracervical abdominal hysterectomy, with(out) removal of tube 58180 (s), ovary(s) $8,128.00 58260 58260 Vaginal hysterectomy $6,570.00 58262 58262 Vaginal hysterectomy; with removal of tube(s), and/or ovary(s) $6,158.00 58300 58300 INSERTION OF INTRAUTERINE DEVICE Clinic Charge $784.00 58301 58301 Removal of intrauterine device (IUD) $654.00 58340 Catheterization and intro of saline contrast material 58340 hysterosonography/hysterosalpingography $692.00 58350 58350 Chromotubation of oviduct, including materials $406.00 58353 Endometrial ablation, thermal, without hysteroscopic guidance $6,540.00 Endometrial cryoablation with ultrasonic guidance, including 58356 endometrial curettage $12,884.00 Uterine Suspension, w/ or w/o Shortening of Round or Sacrouterine 58400 Ligaments Charge $2,354.00 58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 58541 g or less $6,802.00 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or 58550 less; with removal of tube(s) $8,894.00 58555 58555 Hysteroscopy, diagnositc $9,754.00 Hysteroscopy, surgical; w biposyof endometrium and or polypectomy, w 58558 and wo D and C Technical Charge $2,024.00 58559 58559 Hysteroscopy with lysis of adhesions $1,966.00 58562 58562 Hysteroscopy/ removal of foreign body $2,346.00 58563 58563 Endometrial Ablation $9,920.00 58578 58579 Unlisted hysteroscopy procedure, uterus $7,848.00 58605 Ligation of fallopian tube(s), abd.or vaginal approach, postpartum, 58605 unilateral/bilateral, duri $2,146.00 58611 Ligation/Transection Fallopian Tubes During Cesarean Delivery Charge $2,224.00 58660 58660 Laparoscopy/ lysis of adhesion $6,844.00 58662 Laparoscopy, surgical excision of lesions ovary, pelvic viscera, or 58662 peritoneal surface $5,132.00 58670 Laparoscopy Surgical w/ Fulguration Oviducts Charge $4,892.00 58679 58679 Unlist laparoscopy procedure, oviduct, ovary $4,892.00 58700 58700 Salpingectomy, complete, partial, unilateral or bilateral $4,790.00 58720 58720 Salpingo-oophorectomy, complete,partial, unilateral or bilateral $4,962.00 58740 Lysis of Adhesions (Salpingolysis, Ovariolysis) Charge $4,578.00 58925 Ovarian Cystectomy, Unilat or Bilat Charge $4,892.00 58999 58999 Unlisted procedure, female genital system; (nonobstetrical) $7,848.00 59000 Amniocentesis; diagnostic Charge $722.00 59025 Fetal Non-Stress Test Charge $610.00 59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, 59120 requiring salpingectomy and/or ooph $6,372.00 59150 Laparoscopic treatment of ectopic pregnancy; without 59150 salpingectomy and/or oophorectomy $6,008.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 59151 Laparoscopic treatment of ectopic pregnancy; with salpingectomy 59151 and/or oophorectomy $9,238.00 59160 Curettage Postpartum Charge $1,200.00 59200 Insert Cervical Dilator Charge $414.00 59300 59300 Episiotomy,vaginal repair, by other than attending physician $1,544.00 59400 Routine OB Care, Antepartum/Vaginal Delivery/Postpartum Charge $10,676.00 59409 59409 Vaginal delivery only $5,132.00 59410 Vaginal delivery only with(out) episiotomy and/or forceps; 59410 including postpartum care $6,500.00 59412 External cephalic version, with or without tocolysis Charge $1,712.00 59414 59414 Delivery of placenta $748.00 59425 Antepartum Care 4-6 Visits - 59425 $2,370.00 59426 59426 Antepartum care only; 7 or more visits $4,238.00 59430 59430 Postpartum care only $982.00 59510 Routine obstetric care including antepartum care, c-section and 59510 postpartum care $12,010.00 59514 Delivery Cesarean-Only Charge $7,562.00 59514 59514 CESAREAN DELIVERY ONLY assist Clinic Charge $3,140.00 59515 59515 Cesarean delivery only; including postpartum care $7,870.00 59612 59612 Vaginal delivery only, after previous cesarean delivery $5,132.00 59812 Treatment of incomplete abortion, any trimester, completed 59812 surgically $2,054.00 59820 Treatment of missed abortion, completed surgically; first 59820 trimester $3,078.00 59855 Induced abortion with vaginal suppositories with Dilation and Curettage $3,364.00 59899 59899 unlisted procedure maternity care/delivery $7,848.00 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy $3,794.00 60225 60225 partial removal of thyroid $7,452.00 64405 64405 Injection, anesthetic agent. greater occipital nerve $502.00 64435 64435 Injection, anesthetic agent; paracervical (uterine) nerve $1,521.57 64450 Inj, Anesthetic Agent; Other Peripheral Nerve or Branch Charge $838.00 64450 Inj, Anesthetic Agent; Other Peripheral Nerve or Branch Tech Chg $838.00 64455 64455 INJ MORTONS NEUROMA Clinic Charge $314.00 64718 Neuroplasty And/Or Transposition; Ulnar Nerve At Elbow $3,832.00 64719 Neuroplasty and/or transposition; ulnar nerve at wrist $2,092.00 Neuroplasty and/or Transposition; Median Nerve At Carpal Tunnel 64721 Charge $2,772.00 69200 Removal foreign body from external auditory canal; without 69200 general anesthesia $630.00 69209 Removal impacted cerumen, irrigation/lavage $130.00 69210 69210 Remove Impactd Ear Wax $328.00 76805 US Pregnancy, After 1st Trimester (Single or First Gestation) Charge $816.00 76830 US Transvaginal Charge $994.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 76857 76857 US Pelvic Limited $458.00 81002 Urine Dipstick POC $34.00 81025 Urine Pregnancy Test POC $92.00 82270 Stool for Occult Blood Screening POC $28.00 82948 Glucose Fingerstick POC $30.00 83037 Hemoglobin POC $35.97 83986 PH body fluid not otherwise specified $44.00 84703 84703 Gonadotropin, chorionic (hCG); qualitative $156.00 85014 Hematocrit POC $8.79 85610 Prothrombin/INR POC $78.00 86580 PPD Admin POC $76.00 87210 Wet Mount POC $52.00 87650 Strep A DNA DIR Probe $162.00 88142 Pap Wet Mount POC $74.00 90471 90471 Immunization administration; 1 vaccine $130.00 90472 90472 Each additional vaccine $66.00 90473 90473 Immunization administration, oral $196.00 90632 90632 Hepatitis A vaccine, adult dosage, for intramuscular use $250.00 90633 58160-0825-52 Hepatitis A Peds/Adol Vaccine 2 Dose Sched Charge $394.00 90633 VFC - Hep A vaccine, pediatric/adolescent dosage-2 dose 90633 schedule, IM $120.00 90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose 90648 schedule), for intramuscular use $130.00 90648 Haemophilus influenzae type b vaccine (Hib), PRP-T conjugate $172.00 90649 90649 Human Papilloma virus (HPV) $838.00 90649 90649 THS Gardasil Sd Hpv Vacci $796.00 90657 90657 Influenza vaccine pediatric $49.14 90658 90658 Influenza virus vaccine, adult $49.14 90658 90658 THS Flu Vaccine 3Yrs & > $66.00 90660 90660 Influenza virus vaccine, live, for intranasal use $148.00 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use $510.09 90670 90670 VFC- Pneumococcal conjugate vaccine, 13 valent, IM $546.00 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use $818.00 90675 Rabies Vaccine IM Charge $1,322.00 90680 Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for 90680 oral use $392.00 90685 90685 Injection Fluzone prefilled 6-35 mo $96.00 90696 90696 DTaP-IPV Vaccine IM $314.00 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus 90698 influenza Type B, and poliovir $430.00 90707 MMR Measles/Mumps/Rubella Virus Vaccine POC $350.00 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for 90710 subcutaneous use POC $654.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 90713 Poliovirus vaccine, inactivated (IPV), for subcutaneous or 90713 intramuscular use $162.00 90713 90713 VFC- Poliovirus vaccine, inactivated (IPV), SQ or IM $198.00 90715 90714 Tetanus Vaccine IM $128.00 90715 90715 TDaP Vaccine $228.00 90715 TDAP Vaccine 0.5ML $64.00 90716 90716 Varicella virus vaccine, live, for subcutaneous use $40.00 90716 90716 VFC- Varicella virus vaccine, live, SQ $468.00 90723 DTaP, Diphtheria, tetanus, acellular pertussis vac, hep B, 90723 poliovirus vac, IM $430.00 90732 90732 - NO CHARGE - Pneumococcal 23 vaccine $214.00 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 90734 (tetravalent), for IM $512.00 90736 Zoster (shingles) vaccine (HZV), live, for subcutaneous injection $1,063.34 90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose 90744 schedule), for intramuscular use $104.00 90744 VFC- Hep B vaccine, pediatric/adolescent dosage-3 dose schedule, 90744 IM $162.00 90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for 90746 intramuscular use $340.00 90746 Hepatitis B Vaccine, Adult $328.00 93005 EKG POC $226.00 94640 Airway Inhalation Treatment. $80.00 Noninvasive Ear or Pulse Oximetry For O2 Saturation; Single 94760 Determination Charge $42.00 95115 Allergy Injection Single POC $66.00 95117 Allergy Injection Multi POC $76.00 96360 IV Hydration 1ST Hour Charge $277.20 96361 IV HYDRA ADDITITIONAL HOUR Charge $92.61 96365 IV infusion INITIAL <91 min TX RM $405.50 96366 IV Infusion EA Addition HR TX RM $250.00 96367 IV Infusion Sequential Addl Hour Tech Chg $400.00 96368 IV Infusion Concurrent Diff DrugsTech Chg $400.00 96372 Therapeutic, prophylactic, or diagnostic injection; subcutaneous 96372 or intramuscular $148.00 96374 96374 Therapeutic, prophylactic, or diagnostic injection; IV push, $262.00 97597 Wound Debridement Less than 20 cm Charge $654.00 97598 97598 Debride Add 20 Sq Cm $92.00 97602 Removal of devitalized tissue from wound(s), non-selective 97602 debridement $506.85 Negative pressure wound therapy (e.g., vacuum-assisted drainage 97605 collection)<50 sq cm $196.00 97606 Negative pressure wound treatment> 50 sq. cm $238.00 97610 97610 Low Frequency non-thermal ultrasound per $800.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees Osteopathic Manipulative Treatment (Omt); One To Two Body Regions 98925 Involved $236.00 Handling and/or Conveyance of Specimen For Transfer From The 99000 Physician's Office to A Lab Charge $52.00 99188 99188 Application of topical fluoride clear varnish $18.58 99201 Office/Outpatient Visit Level 1 New - 992011 $212.00 99202 Office/OP New Visit Level 2 99202 $402.00 99203 Office/OP New Visit Level 3 99203 $578.00 99204 Office/OP New Visit Level 4 99204 $892.00 99205 Office/OP New Visit Level 5 99205 $1,020.00 99205 Office/OP New Visit Level 5 99205 Tech Chg $1,020.00 99211 99211 Established Patient - Brief $114.00 99212 99212 Established Patient - Limited $234.00 99213 99213 Established Patient - Intermediate $356.00 99214 99214 Established Patient - Extended $578.00 99215 99215 Established Patient - Comprehensive $774.00 99241 Office/Other Outpatient Consultation Level 1 - 99241 $356.00 99242 Office/Other Outpatient Consultation Level 2 - 99242 $558.00 99243 Office/Other Outpatient Consultation Level 3 - 99243 $786.00 Initial eval mgmnt of pt an annual nsg facility assessment. Physician 99306 spends 45 minutes $575.22 99347 Home Visit Level 1 Established - 99347 $218.00 99348 Home Visit Level 2 Established - 99348 $329.00 99349 Home Visit Level 3 Established - 99349 $502.00 Hm Vis For E&M Of Estab Pat,Req At Least 2:Comp Inter Hx,Exam;Med 99350 Dec Making Mod-High Complx;Care $695.00 99381 Preventive Medicine < 1 year New - 99381 $558.00 99382 Preventive Medicine 1-4 years New - 99382 $644.00 99383 Preventive Medicine 5-11 years New - 99383 $646.00 99384 Preventive Medicine 12-17 years New - 99384 $734.00 99385 Preventive Medicine 18-39 years New - 99385 $692.00 99386 Preventive Medicine 40-64 years New - 99386 $868.00 99387 Preventive Medicine 65+ years New - 99387 $868.00 99391 99391 Preventive Medicine Established Patient - Under 1 year $536.00 99392 99392 Preventive Medicine Established Patient - 1 to 4 years $470.00 99393 99393 Preventive Medicine Established Patient - 5 to 11 years $468.00 99394 99394 Preventive Medicine Established Patient - 12 to 17 years $514.00 99395 99395 Preventive Medicine Established Patient - 18 to 39 years $518.00 99396 99396 Preventive Medicine Established Patient - 40 to 64 years $566.00 99397 99397 Preventive Medicine Established Patient - 65 and over $640.00 99441 99441 Telephone Services 5-10 minutes $102.00 99442 99442 Telephone Service $200.00 99443 Phone E&M by Physician 21 to 31 minutes of medical discussion $306.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 99466 99466 Critical Care During Transport, 24 Months $719.00 99467 99467 Pediatric Critical Care Transport Addl $327.00 310286 Direct Coombs $152.00 2240300 Newborn Screening Test 3 $132.00 2254610 Fetal Screen $327.00 2254610 Fetal Screen $327.00 2254610 Fetal Screen1 $327.00 2286870 Antibody Identification $589.00 2286870 Bill ABID $589.00 2289016 Aph ARBC ACDA AS3 1 LR $262.00 2289016 Aph ARBC ACDA AS3 2 LR $262.00 2289016 Aph ARBC ACDA AS3 LR $262.00 2289016 Aph ARBC ACDA AS3 LR Irr 1 $262.00 2289016 Aph RBC ACDA AS1 LR $262.00 2289016 Aph RBC ACDA AS1 LR 1 $262.00 2289016 Aph RBC ACDA AS1 LR 2 $262.00 2289016 Aph RBC ACDA AS1 LR Irr $262.00 2289016 Aph RBC ACDA AS1 LR Irr 1 $262.00 2289016 Aph RBC ACDA AS1 LR Irr 2 $262.00 2289016 Aph RBC ACDA AS3 LR Irr $262.00 2289016 Aph RBC ACDA AS3 LR Irr 2 $262.00 2289016 Aph RBC CP2D AS3 LR 1 $262.00 2289016 Aph RBC CP2D AS3 LR 2 $262.00 2289016 Aph RBC CP2D AS3 LR Irr 1 $262.00 2289016 Aph RBC CP2D AS3 LR Irr 2 $262.00 2289016 RBC CP2D 500 LR $262.00 2289016 RBC CP2D 500 LR Irr $262.00 2289016 RBC CP2D AS3 500 LR $262.00 2289016 RBC CP2D AS3 500 LR Irr $262.00 2289016 RBC CPD AS1 500 LR $262.00 2500001 SEVOFLURANE PER 30 MIN $45.25 2860680 Compatible - Computer XM Interp $262.00 2860680 Compatible - X-Match AHG Interp $262.00 2860680 Incompatible - X-Match AHG Interp $262.00 2860680 Least Incompat - X-Match AHG Interp $262.00 2869000 ABO/Rh. $108.00 2869000 ABO/Rh. Neonatal $108.00 2869010 Rh $108.00 2869010 Rh Type 1 $108.00 3060170 Aph Plt ACDA LR $1,586.00 3060170 Aph Plt ACDA LR 1 $1,586.00 3060170 Aph Plt ACDA LR 2 $1,586.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 3060170 Aph Plt ACDA LR <3 X log 11 $1,586.00 3060170 Aph Plt ACDA LR Irr $1,586.00 3060170 Aph Plt ACDA LR Irr 1 $1,586.00 3060170 Aph Plt ACDA LR Irr 2 $1,586.00 3060170 Aph Plt ACDA LR Irr 3 $1,586.00 3060170 Aph Plt ACDA LR Irr Var Con $1,586.00 3060810 Cryo AHF $117.00 3060810 Cryo Pooled $117.00 3060810 Plasma CP2D Cryo Red $117.00 3060810 Plasma CPD Cryo Red $117.00 3060810 Thawed Cryo AHF $117.00 3060810 Thawed Pooled Cryo $117.00 3061310 RhIG. $346.00 3090170 Aph FFP ACDA $147.00 3090170 Aph FFP ACDA RT<=24h $147.00 3090170 Aph FFP ACDA RT<=24h 1st Cont. $147.00 3090170 Aph FFP ACDA RT<=24h 2nd Cont. $147.00 3090170 Aph FFP ACDA RT<=24h 3rd Cont. $147.00 3090170 Aph FFP ACDA Thawed $147.00 3090170 Aph FFP Thawed ACDA RT<=24h $147.00 3090170 Aph Plasma ACDA <-18C RT <24h Frz <24h 4 $147.00 3090170 FFP CP2D $147.00 3090170 Frz Plasma CP2D <24 hrs $147.00 3090170 Frz Plasma CPD Frozen<=24h $147.00 3090170 Plasma CPD Cryo Red Thawed $147.00 3090170 Plasma Thawed CP2D $147.00 3090170 Plasma Thawed CP2D <24 Hrs $147.00 3090170 Plasma Thawed CP2D Cryo Red $147.00 3090170 Plasma Thawed CPD $147.00 3090170 Thawed Aph FFP ACDA RT<=24h 1st Cont. $147.00 3090170 Thawed Aph FFP ACDA RT<=24h 2nd Cont. $147.00 3090170 Thawed Aph FFP ACDA RT<=24h 3rd Cont. $147.00 3090170 Thawed Aph Plasma ACDA <24H Frz <24H 4 $147.00 3090170 Thawed Plasma CP2D Cryo Red $147.00 3090170 Thawed Plasma CPD <24h $147.00 25000001 SEVOFLURANE PER 30 MINUTES $45.25 25000002 DESFLURANE PER 30 MINUTES $33.55 25000002 DESFLURANE PER 30 MIN $33.55 25090700 DTAP VACCINE (LCMC) $65.83 26096360 96360 IV INFUSION, HYDRATION 31 TO 60 MINS $654.00 26096361 96361 IN INFUSION, HYDRATION EACH ADD HOUR $458.00 26096365 96365 IV INFUSION THERAPY, 1ST HOUR CHARGE INF $531.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 26096365 96365 IV INFUSION THERAPY, 1ST HOUR CHARGE $531.00 26096366 96366 IV INFUSION, EACH ADD HOUR $327.00 26096367 96367 IV INFUSION, SEQUENTIAL UP TO 1HR CHARGE $523.00 26096368 96368 IV INFUSION, CONCURRENT CHARGE $523.00 26096372 96372 INJECTION SUB Q OR IM $74.00 26096374 96374 IV INJECTION CHARGE $265.00 26096375 96375 IV INJ EA ADD NEW DRUG $131.00 26096376 96376 IV INJ EA ADD SAME DRUG $98.00 27000001 OB PACK CUSTOM MADE $258.47 27000002 BONE WAX ETH#W31G $109.09 27000003 BALL ELECTRODE 5MM THOMAS#LE-14-005 $179.20 27000004 BALL ELECTRODE 5MM COOPER#B0512 $296.49 27000005 CAUTERY PENCIL, HAND CONMD#130309A $60.13 27000007 ABLATION THERMACHOICE KIT,CATH ETH#TC003 $7,817.74 27000008 CARDIOVASCULAR PATCH GORTEX .4MM 3CMX6CM $1,854.96 27000009 CLOSE SURE PROCEDURE KIT COOP#CTI512N $1,269.00 27000010 CLOSE SURE PILOT GUIDE 15MM #PG-15S $354.27 27000011 CHLORAPREP 26ML APPLICATOR ORANGE#260815 $145.22 27000012 CATHETER FLEX NECK REPAIR KIT #CE-1400 $799.00 27000013 CATHETER IMPRESS MINI RIM #56535MRMIST $215.04 27000014 CIRCULAR STAPLER 25MM ETH#ECS25A $2,920.50 27000015 CIRCULAR STAPLER 29MM ETH#ECS29 $2,920.50 27000016 CIRCULAR STAPLER 33MM ETH#ECS33A $2,920.50 27000017 COMMON BILE DUCT SET #G26908 $6,343.68 27000018 DRAPE, MAGNETIC KEND#31140612 $80.53 27000019 BASIC SET UP PACK I ALLEG#114 $38.37 27000020 BASIN PACK, SINGLE DEVON#7693-T4 $263.01 27000021 BASIN PACK, DOUBLE DEVON#7897-T8 $368.73 27000022 BITE BLOCK, ENDOSCOPE $72.59 27000024 BLADE ELECTRODE, 6 INCH CONMD#138107 $55.19 27000025 CATH PERITONEAL MONCRIEF-POPOVICH $1,871.64 27000026 CATH REPAIR KIT W/CONNECTORS #5587000 $1,398.72 27000027 CHOLANGIOGRAM CATH 4FR 2LUMEN TELE#01701 $1,034.00 27000028 CHOLANGIOGRAM CATH 4FR #COECS400 $518.15 27000030 DECANTER VIAL STERILE #10-106 $59.57 27000031 DRAIN, 10MM FLAT JP#JPHUF100 $295.05 27000032 DRAIN 7MM FLAT BARD#0070430 $297.89 27000033 DRAINAGE CATHETER 14FR MALECOTS #086014 $295.51 27000034 FORCEP, HOT BIOPSY OLYMPUS#FD-230U $273.66 27000035 FORCEP, BIOPSY OLYMPUS #FB240U $201.20 27000036 FOGARTY ARTERIAL CATH 4FR 40CM #120404FF $836.60 27000037 FOGARTY ARTERIAL EMB CATH 3FR ED#120803F $522.05 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000038 FOGARTY ARTERIAL EMB CATH 4FR ED#120804F $522.05 27000039 FOGARTY ARTERIAL EMB CATH 5FR ED#120805F $512.20 27000040 FOREIGN BODY ROTH NET USEND#711052 $883.60 27000041 GOWNS, LARGE DISPOSABLE STERILE#9511 $41.43 27000042 GROUNDING PADS $54.33 27000043 HERNIA MESH, PROLENE ETH#PML $2,841.42 27000044 FOGARTY EMB CATH 5.5FR 40CM #12TLW405F35 $848.35 27000045 HICKMAN CATH DUAL LUMEN 10FR #0600634 $1,345.20 27000046 GUIDE WIRE HYDROPHILIC FIRM #G07518 $679.65 27000047 HYSTEROSCOPY/DC DRAPE $205.42 27000048 INJECTION NEEDLE OLYMPUS#NM-200U-0425 $398.09 27000049 IOBAN 2 FILM, 23X17 INCH 3M#6650EZ $114.63 27000050 LAP SHEET, CHEST/BREAST ALLEG#29420 $100.24 27000051 LAPAROSCOPIC CUSTOM PACK $423.44 27000052 LAP CHOLY DRAPE DR J KC#89225 $260.63 27000053 LAP LAPAROSCOPY DRAPE PACK I #29242 $108.71 27000054 LAP SHEET, W/ARMBRD CVR LAPAROTOMY#29410 $69.47 27000055 LAP SHEET, TRNSV W/AB COV ALLEG#29421 $88.91 27000057 LEGGINGS, CONVERTORS ALLEG#8420 $36.88 27000059 LITHOTOMY SHEET, 105X144 ALLEG#29450 $87.86 27000060 PERCUTANEOUS ENTRY NEEDLE #G00166 $136.36 27000061 PERFIX PLUG, SMALL $2,651.46 27000062 PERFIX PLUG, MEDIUM $2,676.24 27000063 PERFIX PLUG, LARGE $2,704.56 27000064 MIMEDX EPIFIX GRAFT #ES-4400 $7,868.00 27000065 MALECOT CATHETER 18FR BARD#086018 $302.89 27000066 MALECOT CATHETER 20FR BARD#086020 $302.89 27000067 NOVASURE DEVICE #NS2000US $7,420.00 27000070 PEG GASTROSCOPY KIT 24FR WC#PEG24-PULL $1,359.36 27000071 PERITONEAL DIALYSIS FLURO KIT CUSTOM $1,309.80 27000072 PLASMASORD GYRUS#962000PK $5,210.88 27000075 PLEDGET POLYMER TFE ETH#PCP40 $99.80 27000076 PORT-A-CATH TITANIUM BARD#0602230 $1,699.20 27000078 PREOP SKIN PREP TR W/B LF ALL#4468 $69.44 27000079 PREOP SKIN PREP TRAY W/O ALLEG#4461A $54.09 27000080 PRESTO INFLATION DEVICE #ID4030 $337.40 27000081 PERITONEAL DIALYSIS PACK CUSTOM $480.19 27000082 RETRACTOR, CSECTION ALEXIS-O XLG #G6314 $893.00 27000083 RETICULATING SHEER,CURVED ETH#5DCS $691.14 27000084 RETRACTOR WOUND SMALL #C8401 $531.90 27000085 SCISSORS SWITCH BLADE HOOK CVM#89-5200B $570.85 27000086 SCREW HI-TORQUE BONE 1.2 $115.76 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000087 SCREW HI-TORQUE BONE 1.4 $99.08 27000088 SCREW HI-TORQUE BONE 3.8 $99.08 27000089 SCREW 2.7 CORTICAL 20MM S&N#71149420 $244.50 27000090 SCREW 2.7 CORTICAL 22MM S&N#71149422 $244.50 27000091 SCREW 2.7 CORTICAL 24MM S&N#71149424 $244.50 27000092 SCREW 2.7 CORTICAL 18MM S&N#71149418 $244.50 27000093 SCREW 2.7 CORTICAL 16MM S&N#71220016 $244.50 27000094 SCREW 2.7 CORTICAL 10MM S&N#71149410 $244.50 27000095 SCREW 2.7 CORTICAL 12MM S&N#71149412 $244.50 27000096 SCREW 2.7 CORTICAL 14MM S&N#71149414 $244.50 27000097 SCREW KEY LOK LAG 3.75 INCH $758.67 27000098 SCREW KEY LOK LAG 4 3/4TH $610.70 27000099 SCREW 4.0 CANCELLOUS 10MM $84.37 27000101 SCREW 4.0 CANCELLOUS 30MM $84.37 27000102 SCREW 4.0 CANCELLOUS 35MM $84.37 27000103 SHEET, EXTREMITY CARD#29414 $104.38 27000104 SHEATH 6FR TERUMO #RSS602 $152.32 27000105 SHEATH 7FR TERUMO #RSS702 $152.32 27000106 SHEATH 8FR TERUMO #RSS802 $279.75 27000107 SHEATH 9FR TERUMO #RSS902 $279.75 27000108 SHEATH INTRODUCER & GUIDEWIRE #15-718B $308.48 27000109 SNARE,STANDARD HOT SHEARS OLYMPUS#SD210U $214.14 27000110 SNARE, LARGE OVAL POLYPECTOMY #472 $239.55 27000111 LAPRSCP SPATULA 32CM CONMED#605272032 $302.50 27000113 SNARE MED OVAL POLYPECTOMY $239.55 27000114 STAPLER, ENDO UNIVERSAL 65DEG AS#173054 $1,333.23 27000115 STAPLER, ENDO UNIVERSAL MULTIFIRE#174015 $578.28 27000116 STERILE TOWEL 6/PK KENDALL#77706 $69.24 27000118 STERI-DRAPE, LARGE 3M#1010 $54.13 27000119 ENDO CUTTER 35MM POWERED VASCULAR#PVE35A $1,864.35 27000120 SUCTION COAGULATOR 10FR AS#E250510FR $157.70 27000121 SUCTION INSTRUMENT, POOLE CONMD#0035040 $37.55 27000122 SUCTION RESERVOIR, JACKSN ALL#SU1301305 $85.15 27000123 STONE RETRIEVAL BASKET BOST#M0063901040 $2,734.65 27000124 SURGIMESH 10X15 CM FLAT SHEET #T1015 $3,009.00 27000125 SURGIMESH WN OVOIDE 11X15CM #T1115-8 $2,832.00 27000126 SURGIFOAM 8CMX6.25CMX10MM ETH#1973 $280.19 27000127 SUTURE AID BOOTIES YELLOW ASPN#051003PBX $115.58 27000128 SUTURE, 0 VICRYL CTX ETH#J978H $44.20 27000129 T-TUBE 10FR, DEAVER #99800 $211.42 27000132 T-TUBE 16FR, DEAVER #99830 $210.38 27000133 T-TUBE 18FR, DEAVER #99840 $210.38 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000134 TONSIL SPONGES, MEDIUM $141.57 27000135 TONSIL SPONGE 1 1/4 #23275-630 $78.48 27000136 TEFLON BOVIE TIPS CONMED#139100 $73.22 27000137 TEFLON BOVIE PENCILS CONMED#131309A $105.58 27000138 TRANSDUCER COVER CIV-FLEX #610-1119 $216.53 27000139 TRIPOD OLYMPUS#FG600U $731.50 27000140 TUBING, FLOW STUDY TUBE SET #350-800-006 $542.25 27000141 TUBING, INSUFFLATION CONMD#606050097 $125.29 27000142 TVT ABBREVO SYSTEM #TVTOML $8,066.64 27000143 UMBILICAL TAPE 1/8X24 2/P ETH#U16G $71.35 27000144 URETERAL CATH 6FR CONE TIP COOK#G14665 $239.25 27000145 URETERAL CATH 8FR FLEX TIP COOK#G14925 $285.00 27000146 URETERAL CATH 5FR SPIRAL TIP #G14873 $239.25 27000147 VASCULAR GRAFT 20MMX30CM GORE#SA2003 $4,481.64 27000148 WIRE, KIRSCHNER 7 .35"X9" #00018600179 $215.04 27000149 WIRE GUIDE ROADRUNNER FLOPPY #G07937 $679.65 27000150 WIRE GUIDE ROADRUNNER #G09105 $764.41 27000151 WIRE GUIDE AMPLATZ #G03330 $600.09 27000152 HERNIA TROCAR BALON DISCT KIDNY#OMSPDBS2 $2,044.85 27000153 SURGICAL SPEARS $68.70 27000154 BALLOON DILATATION CATHETER PTA 14X4 $2,088.60 27000155 BALLOON DILATATION CATHETER PTA 10X4 $1,309.80 27000156 BALLOON DILATATION CATHETER PTA 12X4 $1,309.80 27000157 BALLOON DILATATION CATHETER PTA 5X4 $752.00 27000158 BALLOON DILATATION CATHETER PTA 6X4 $752.00 27000159 BALLOON DILATATION CATHETER PTA 7X4 $1,309.80 27000160 BALLOON DILATATION CATHETER PTA 8X4 $1,309.80 27000161 BALLOON DILATATION CATHETER PTA 9X4 $1,309.80 27000162 BALLOON DILATATION CATHETER PTA 4X4 $752.00 27000163 BALLOON DILATATION CATHETER PTA 5X4 U357554 $752.00 27000164 BALLOON DILATATION CATHETER PTA 6X4 U357564 $752.00 27000165 BALLOON DILATATION CATHETER 3X4 $752.00 27000166 CUFF, TOURNIQUET 18 IN DOUBLE BLADDER $548.03 27000167 CUFF, TOURNIQUET 24 IN DOUBLE BLADDER $505.63 27000168 CUFF, TOURNIQUET 34 IN SINGLE BLADDER $505.23 27000169 CUFF, TOURNIQUET 42 IN SINGLE BLADDER $542.08 27000170 CUFF, TOURNIQUET SNGL BLADDER DUAL 18X4 $321.88 27000171 CUFF, TOURNIQUET SNGL BLADDER DUAL 24X4 $337.40 27000172 E TRAP POLYP TRAP US#00711099 $197.12 27000173 ELECTRODE COAGULATION BARREL 3MM 24/26FR $1,346.32 27000174 ENDO GIA HANDLE #EGIAUSTND $2,829.38 27000175 ENDO GIA 45MM RELOAD TAN #EGIA45AVM $3,516.57 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000176 ENDOSCPC RELOAD POWERD VASCULAR#VASECR35 $1,066.36 27000177 ENDOSCOPIC KITTNER CARDVM#LZKT01 $451.88 27000178 ESOPHOGEAL DILATOR INFLTR COOK#QID-1 $1,325.40 27000179 ESOPHOGEAL DILATOR 6X8 WC#QD6X8 $1,961.16 27000180 ESOPHOGEAL DILATOR 8X8 WC#QD8X8 $1,961.16 27000181 ESOPHOGEAL DILATOR 10X8 WC#QD10X8 $1,961.16 27000182 ESOPHOGEAL DILATOR 12X8 COOK#QD12X8 $1,961.16 27000183 ESOPHOGEAL DILATOR 14X8 COOK#QD14X8 $799.00 27000184 ESOPHOGEAL DILATOR 16X8 COOK#QD16X8 $1,175.00 27000185 FLEXIBLE HINGE TOE IMPLANT #G4260105 $6,690.60 27000186 GEL PORT LAPAROSCOPIC SYSTEM #C8XX2 $4,779.00 27000187 GUIDE WIRE .9MMX120CM SCHON $300.00 27000188 GUIDE WIRE HI HIRE HYDROPHILIC #G36277 $732.84 27000189 GLIDE WIRE .035X180CM #GR3508 $579.67 27000190 GUIDE WIRE .035X180CM ANGLED #GS08 $682.61 27000191 WIRE GUIDE FIXED CORE #G00527 $265.10 27000192 GLIDE CATH STRAIGHT TAPER 5FR 65CM#CG505 $704.28 27000193 GUIDE WIRE BENTSON STRAIGHT #49-145 $291.00 27000194 HEMODIALYSIS CATH 13.5 DUAL LUMEN $1,578.84 27000195 HEMODIALYSIS CATH 14.5F 42CM #5103420 $4,233.84 27000196 HEMODIALYSIS CATHETER 19CM #DF19SH24K $2,371.80 27000197 HEMODIALYSIS CATHETER 23CM #DF23SH28K $2,371.80 27000198 HEMODIALYSIS CATHETER 27CM #DF27SH32K $2,371.80 27000199 HEMODIALYSIS CATHETER 31CM #DF31SH36K $2,371.80 27000200 HEMODIALYSIS CATHETER 50CM #DF50SH55K $2,116.92 27000201 HEMODIALYSIS CATHETER 10X4 #VA80104 $2,336.40 27000202 HEMODIALYSIS CATHETER 5X4 #VA8054 $2,548.80 27000203 HEMODIALYSIS CATHETER 6X4 #VA8064 $2,548.80 27000204 HEMODIALYSIS CATHETER 6X8 #VA8068 $2,336.40 27000205 HEMODIALYSIS CATHETER 7X4 #VA8074 $2,336.40 27000206 HEMODIALYSIS CATHETER 7X8 #VA8078 $2,548.80 27000207 HEMODIALYSIS CATHETER 8X4 #VA8084 $2,548.80 27000208 HEMODIALYSIS CATHETER 8X8 #VA8088 $2,548.80 27000209 HEMODIALYSIS CATHETER 9X4 #VA8094 $2,336.40 27000210 HEMODIALYSIS CATHETER 12X4 #VA80124 $2,548.80 27000211 HEMOVAC DRAIN MED #DC4361 $278.89 27000212 HEMOVAC DRAIN LARGE #DC4362 $279.70 27000213 HERNIA MESH 3D MAX RT LG DAVOL#0115321 $2,442.60 27000214 HERNIA MESH 3D MAX LFT LG DAVOL#0115311 $2,442.60 27000215 HERNIA MESH 3DMAX RT MED DAVOL#0115320 $2,265.60 27000216 HERNIA MESH 3DMAX LFT MED DAVOL#0115310 $2,265.60 27000217 HERNIA DUALMESH 10X15CM GORTX#1DLMC03 $4,375.44 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000218 HERNIA DUALMESH+10X15X1MM THICK#1DLMCP03 $3,745.32 27000219 HERNIA DUALMESH+15X19X1MM THICK#1DLMCPOR $7,094.00 27000220 HERNIA DUALMESH+ 20CMX30CM #1DLMCP07 $8,608.00 27000221 HERNIA DUALMESH 10X15X2MMTHICK#1DLMCP200 $5,989.68 27000222 HERNIA DUALMESH 15X19X2MMTHICK#1DLMCP201 $8,462.00 27000223 HERNIA MESH PROLENE 3X6 ETH#PMII $1,131.20 27000224 HERNIA MESH PROLENE 6X6 ETH#PMH $548.86 27000225 HERNIA MESH/VICRYL WOVEN 6X6 ETH#VWMM $5,280.59 27000226 HERNIA MESH VNTRLX LG 8CM DAVL#10303 $6,814.50 27000227 HERNIA MESH VNTRLX MD 6.4X6.4 DAVL#10302 $6,124.20 27000228 HERNIA MESH VNTRLX SM 4.3X4.3 DAVL#10301 $4,216.14 27000229 HICKMAN CATH SINGLE LUMEN 5FR #0600710 $469.95 27000230 HICKMAN DIALYSIS CATH 13.5 36CM #0600662 $1,348.15 27000231 INTERCEED ADHESN BARRIER GYNECARE#4350 $2,176.14 27000232 INTERPULSE W/TUBNG STRYKER#210100 $810.23 27000233 IOBAN 2 FILM, 13X13 INCH 3M#6640EZ $87.68 27000234 KUMAR CHOLANGIOGRAPHY CATHETER #CC019 $406.69 27000235 LAP JHOOK ELECT COAT 32CM CM#60-5274-232 $363.81 27000236 LAP CLIP HEMOLOK LG POLYMER CLIP $344.29 27000237 LAP CLIP APPLIER FEFLEX/HEMOLOK 5MM $1,165.60 27000238 LAP LIGACLIP APPLIER LARGE ETH#MCL20 $678.34 27000239 LAP CHOLY DRAPE DR P #9458 $188.30 27000240 LAP CLIP APPLIER SMALL ETH#MCS20 $667.93 27000241 LAP CLIP APPLIER MED ETH#MSM20 $670.92 27000242 LAP ENDO CLIP APPLIER LIGAMAX ETH#EL5ML $1,375.57 27000243 LAP HARMONIC ACE 36MM W/HANDLE ET#ACE36E $4,091.26 27000244 LAP HARMONIC FOCUS ETH#FCS9 $2,816.77 27000245 LAP ENDOLOOP, W/VCL CT ETH#EJ10G $508.20 27000246 LAP CLIP APPLIER 10MM M/L ETH#ER320 $1,042.87 27000247 LAP SUMP CANNULA 10MM 32CM #606001110 $295.98 27000248 LAP SUMP CANNULA 5MM 32CM #606001203 $263.34 27000249 LAP MULTIFUNCTION INST CONTROL $658.72 27000250 LAP TROCAR BLUNTPRT/FOAMGRP ETH#H12LP $579.21 27000251 LAP TROCAR ENDOPATH BLADLESS 12MM #B12LT $550.42 27000252 LAP TROCAR 5MM XCEL BLADELESS ETH#B5LT $415.87 27000253 LAP VERRESS NEEDLE 120MM AS#172015 $240.00 27000254 LAP VERRESS NEEDLE 150MM LONG AS#172016 $240.00 27000255 LAP VERSA STEP EXP SLEEVE ETH#CB-5LT $242.87 27000256 LIGASURE HAND HELD #LS1020 $3,044.40 27000257 LIGASURE IMPACT SEALER/DIVIDER $5,156.22 27000258 LIGASURE 5MM 37CM SEALER/DIVIDER#LF1837 $4,473.85 27000259 LINEAR CUTTER RELOAD 45MM BLUE #6R45B $1,174.28 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000260 LINEAR CUTTER RELOAD 45MM WHITE #TR45W $1,196.79 27000261 LINEAR CUTTER 55MM ETH#TLC55 $925.56 27000262 LINEAR CUTTER 45MM #ATS45 $2,068.78 27000263 LINEAR CUTTER 75MM ETH#TLC75 $1,280.82 27000264 LINEAR CUTTER 75MM REFILL ETH#TCR75 $906.83 27000265 LINEAR CTR RELOAD BLU/REG ETH#TRC55 $519.79 27000266 LINEAR STAPLER 60MMX3.5MM ETH#TX60B $1,125.96 27000267 LINEAR STAPLER RELOAD 60X3.5 ETH#XR60B $589.88 27000268 LINEAR STAPLER 30MM ETH#TX30B $1,109.89 27000269 LINEAR STAPLER RELOAD 30MM ETH#XR30B $547.68 27000270 LINEAR STAPLER 90MM ETH#TL90 $997.06 27000271 LINEAR STAPLER RELOAD 90MM ETH#TR90 $517.22 27000272 LEEP ELECTRODE 2X1.0 COOPER#R2010 $255.15 27000273 LEEP ELECTRODE RND 2X2CM COOPER#R2020 $255.15 27000274 LEEP REDIKIT COOP#60604 $475.83 27000275 LOOP ELECTRODE 15X15X13MM #LE08151 $179.20 27000276 LOOPS RED MINI.8X762 DBL ASPEN#011301PBX $130.92 27000277 LOOPS BLUE MINI.8X762 DBL ASPN#011302PBX $130.92 27000278 FOG REDUCER KIT $43.09 27000279 LAPRASCOPE SPECIMEN BAG ETH#POUCH $650.10 27000280 MARKER, ENDOSCOPIC SPOT #GIS-45 $433.80 27000281 MARGIN MARKER TISSUE ORIENTATION $1,405.30 27000282 METZ TIP MINI CVM#895300B $634.96 27000283 METZ TIP REGULAR SCISSORS SWITCH#895100B $497.43 27000284 MESH SOFT FLAT 3X6 #0117009 $1,163.48 27000285 MESH SOFT FLAT 4X6 #0117010 $1,298.00 27000286 MICRO INTRODUCER SET 5FR #065797016 $782.08 27000287 PROTACK MESH FIXATION DEVICE AS#PTACK30 $2,345.79 27000288 PULSAVAC PLUS KIT #00515047500 $469.95 27000289 PULSAVAC + MULTI ORIFICE TIP #00515017500 $179.20 27000290 SMOKE EVAC FILTER ASSEMBLY $584.93 27000292 SMOKE EVAC TUBING W/ATT SPECULUM $235.82 27000293 TROCAR XCEL BLADELESS 5MMX150MM #B5XT $482.42 27000294 TROCAR EXCEL BLADELESS 12MMX150MM #B12XT $521.85 27000295 TROCAR OPTICAL BLADELESS 5MM #ONB5STF $1,013.51 27000296 ARGON DISSECTING BLUNT NEEDLE ELECTRODE $777.26 27000297 ARGON GROUNDING PAD ADULT CONM#7382 $99.55 27000298 ARGON LAP PROBE 5MM FOOTSWITCH CM#160655 $1,284.74 27000299 ARGON SINGLE FUNCTION HANDCONTROL HANDPC $713.50 27000300 ARGON ABCFLEX PROBE 7FR #133327 $2,210.84 27000301 BLADE MICRO 7X.38X20 #2296003194 $670.69 27000302 BLADE SAGITAL SAW 15X10MM BRSLR#KMT90124 $133.42 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000303 BLADE AVERAGE MEDIUM 9X.38X25#2296003111 $285.59 27000304 DERMA CARRIER 1.5:1 #2195012 $313.30 27000305 DERMA CARRIER 3:1 #2195013 $313.30 27000306 DERMATOME BLADES #8800000 $444.95 27000307 DERMATOME CUTTING HEAD BARD#0032950 $335.43 27000308 IMAGING SONY PRINTER PACK #UPC-5010A $723.80 27000309 INTRODUCER CAP $127.53 27000310 PEG TUBE, FLOW 20 PULL COOK#G22638 $1,359.36 27000311 PURSTRING 45 #020730 $1,233.12 27000312 PURSTRING 65 #020242 $1,233.12 27000313 SEPRAFILM ADHESION BARRIER GENZ#430102 $1,759.38 27000314 VIABAHN STENT 6X5 #VBCR060501A $10,740.00 27000315 KWIRE SMOOTH .045 STERILE #47-0186-062-0 $199.13 27000316 KWIRE SMOOTH .063 STERILE #47-0186-078-0 $199.13 27000317 KWIRE THREADED .045 STERILE #47-0262-012 $300.72 27000318 KWIRE THREADED .063 STERILE #47-0262-013 $300.72 27000319 SCREW CORTICAL 2.7X8MM SELF CUTTING $261.27 27000320 SCREW CORTICAL 2.7X10MM SELF CUTTING $261.27 27000321 SCREW CORTICAL 2.7X12MM SELF CUTTING $261.27 27000322 SCREW CORTICAL 2.7X14MM SELF CUTTING $261.27 27000323 SCREW CORTICAL 2.7X16MM SELF CUTTING $349.45 27000324 SCREW CORTICAL 2.7X18MM SELF CUTTING $349.45 27000325 SCREW CORTICAL 2.7X20MM SELF CUTTING $261.27 27000326 SCREW CORTICAL 2.7X22MM SELF CUTTING $261.27 27000327 SCREW CORTICAL 2.7X24MM SELF CUTTING $261.27 27000328 SCREW CORTICAL 2.7X26MM SELF CUTTING $261.27 27000329 SCREW CORTICAL 2.7X28MM SELF CUTTING $261.27 27000330 SCREW CORTICAL 2.7X30MM SELF CUTTING $261.27 27000331 SCREW CORTICAL 3.0X12MM $1,193.80 27000332 SCREW CORTICAL 3.5X10MM SELF CUTTING $261.27 27000333 SCREW CORTICAL 3.5X12MM SELF CUTTING $261.27 27000334 SCREW CORTICAL 3.5X14MM SELF CUTTING $261.27 27000335 SCREW CORTICAL 3.5X16MM SELF CUTTING $261.27 27000336 SCREW CORTICAL 3.5X18MM SELF CUTTING $261.27 27000337 SCREW CORTICAL 3.5X20MM SELF CUTTING $261.27 27000338 SCREW CORTICAL 3.5X22MM SELF CUTTING $261.27 27000339 SCREW CORTICAL 3.5X24MM SELF CUTTING $261.27 27000340 SCREW CORTICAL 3.5X26MM SELF CUTTING $261.27 27000341 SCREW CORTICAL 3.5X28MM SELF CUTTING $261.27 27000342 SCREW CORTICAL 3.5X30MM SELF CUTTING $261.27 27000343 SCREW CORTICAL 3.5X32MM SELF CUTTING $261.27 27000344 SCREW CORTICAL 3.5X34MM SELF CUTTING $261.27 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000345 SCREW CORTICAL 3.5X36MM SELF CUTTING $261.27 27000346 SCREW CORTICAL 3.5X38MM SELF CUTTING $261.27 27000347 SCREW CORTICAL 3.5X40MM SELF CUTTING $261.27 27000348 SCREW CORTICAL 3.5X42MM SELF CUTTING $261.27 27000349 SCREW CORTICAL 3.5X44MM SELF CUTTING $261.27 27000350 SCREW CORTICAL 3.5X46MM SELF CUTTING $261.27 27000351 SCREW CORTICAL 3.5X48MM SELF CUTTING $261.27 27000352 SCREW CORTICAL 3.5X50MM SELF CUTTING $261.27 27000353 SCREW CORTICAL 3.5X55MM SELF CUTTING $261.27 27000354 SCREW CORTICAL 3.5X60MM SELF CUTTING $261.27 27000355 SCREW 4.0 CANCELLOUS FULL THREAD X 10 $261.27 27000356 SCREW 4.0 CANCELLOUS FULL THREAD X 12 $261.27 27000357 SCREW 4.0 CANCELLOUS FULL THREAD X 14 $261.27 27000358 SCREW 4.0 CANCELLOUS FULL THREAD X 16 $261.27 27000359 SCREW 4.0 CANCELLOUS FULL THREAD X 18 $261.27 27000360 SCREW 4.0 CANCELLOUS FULL THREAD X 20 $261.27 27000361 SCREW 4.0 CANCELLOUS FULL THREAD X 22 $261.27 27000362 SCREW 4.0 CANCELLOUS FULL THREAD X 24 $261.27 27000363 SCREW 4.0 CANCELLOUS FULL THREAD X 26 $261.27 27000364 SCREW 4.0 CANCELLOUS FULL THREAD X 28 $261.27 27000365 SCREW 4.0 CANCELLOUS FULL THREAD X 30 $261.27 27000366 SCREW 4.0 CANCELLOUS FULL THREAD X 32 $261.27 27000367 SCREW 4.0 CANCELLOUS FULL THREAD X 34 $261.27 27000368 SCREW 4.0 CANCELLOUS FULL THREAD X 36 $261.27 27000369 SCREW 4.0 CANCELLOUS FULL THREAD X 38 $261.27 27000370 SCREW 4.0 CANCELLOUS FULL THREAD X 40 $261.27 27000371 SCREW 4.0 CANCELLOUS FULL THREAD X 45 $261.27 27000372 SCREW 4.0 CANCELLOUS FULL THREAD X 50 $261.27 27000373 SCREW 4.0 CANCELLOUS FULL THREAD X 55 $261.27 27000374 SCREW 4.0 CANCELLOUS FULL THREAD X 60 $261.27 27000375 SCREW 4.0 CANCELLOUS PARTIAL THREAD X 14 $261.27 27000376 SCREW 4.0 CANCELLOUS PARTIAL THREAD X 18 $261.27 27000377 SCREW 4.0 CANCELLOUS PARTIAL THREAD X 24 $261.27 27000378 SCREW 4.0 CANCELLOUS PARTIAL THREAD X 28 $261.27 27000379 SCREW 4.0 CANCELLOUS PARITAL THREAD X 32 $261.27 27000380 SCREW 4.0 CANCELLOUS PARTIAL THREAD X 38 $261.27 27000381 SCREW 4.0 CANCELLOUS PARTIAL THREAD X 50 $261.27 27000382 SCREW 4.0 CANCELLOUS PARTIAL THREAD X 55 $261.27 27000383 SCREW 4.0 CANCELLOUS PARTIAL THREAD X 60 $261.27 27000384 SCREW CANNULATED 3.0X24MM PT $1,297.20 27000385 SCREW CANNULATED 4.0X14MM 1/3 THREAD $1,056.09 27000386 SCREW CANNULATED 4.0X16MM 1/3 THREAD $1,056.09 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000387 SCREW CANNULATED 4.0X18MM 1/3 THREAD $1,056.09 27000388 SCREW CANNULATED 4.0X20MM 1/3 THREAD $1,056.09 27000389 SCREW CANNULATED 4.0X22MM 1/3 THREAD $1,056.09 27000390 SCREW CANNULATED 4.0X24MM 1/3 THREAD $1,056.09 27000391 SCREW CANNULATED 4.0X26MM 1/3 THREAD $1,056.09 27000392 SCREW CANNULATED 4.0X28MM 1/3 THREAD $1,056.09 27000393 SCREW CANNULATED 4.0X30MM 1/3 THREAD $1,056.09 27000394 SCREW CANNULATED 4.0X32MM 1/3 THREAD $1,056.09 27000395 SCREW CANNULATED 4.0X34MM 1/3 THREAD $1,080.25 27000396 SCREW CANNULATED 4.0X36MM 1/3 THREAD $1,080.25 27000397 SCREW CANNULATED 4.0X38MM 1/3 THREAD $1,080.25 27000398 SCREW CANNULATED 4.0X40MM 1/3 THREAD $1,080.25 27000399 SCREW CANNULATED 4.0X42MM 1/3 THREAD $1,080.25 27000400 SCREW CANNULATED 4.0X44MM 1/3 THREAD $1,080.25 27000401 SCREW CANNULATED 4.0X46MM 1/3 THREAD $1,080.25 27000402 SCREW CANNULATED 4.0X48MM 1/3 THREAD $1,080.25 27000403 SCREW CANNULATED 4.0X50MM 1/3 THREAD $1,080.25 27000404 SCREW CANNULATED 4.0X55MM 1/3 THREAD $1,080.25 27000405 SCREW CANNULATED 4.0X60MM 1/3 THREAD $1,080.25 27000406 SCREW AXSOS 4.0MM LOCKING L14MM $800.50 27000407 SCREW AXSOS 4.0MM LOCKING L16MM $800.50 27000408 SCREW AXSOS 4.0MM LOCKING L18MM $800.50 27000409 SCREW AXSOS 4.0MM LOCKING L20MM $800.50 27000410 SCREW AXSOS 4.0MM LOCKING L22MM $800.50 27000411 SCREW AXSOS 4.0MM LOCKING L24MM $800.50 27000412 SCREW AXSOS 4.0MM LOCKING L26MM $800.50 27000413 SCREW AXSOS 4.0MM LOCKING L28MM $800.50 27000414 SCREW AXSOS 4.0MM LOCKING L30MM $800.50 27000415 SCREW AXSOS 4.0MM LOCKING L32MM $800.50 27000416 SCREW AXSOS 4.0MM LOCKING L34MM $800.50 27000417 SCREW AXSOS 4.0MM LOCKING L36MM $800.50 27000418 SCREW AXSOS 4.0MM LOCKING L38MM $800.50 27000419 SCREW AXSOS 4.0MM LOCKING L40MM $800.50 27000420 SCREW AXSOS 4.0MM LOCKING L42MM $800.50 27000421 SCREW AXSOS 4.0MM LOCKING L44MM $800.50 27000422 SCREW AXSOS 4.0MM LOCKING L46MM $800.50 27000423 SCREW AXSOS 4.0MM LOCKING L48MM $800.50 27000424 SCREW ASXOX 4.0MM LOCKING L50MM $800.50 27000425 SCREW AXSOS 4.0MM LOCKING L55MM $800.50 27000426 SCREW AXSOS 4.0MM LOCKING L60MM $800.50 27000427 SCREW AXSOS 3.0MM LOCKING L8MM $555.84 27000428 SCREW AXSOS 3.0MM LOCKING L10MM $555.84 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000429 SCREW AXSOS 3.0MM LCOKING L12MM $555.84 27000430 SCREW AXSOS 3.0MM LOCKING L14MM $555.84 27000431 SCREW AXSOS 3.0MM LOCKING L16MM $555.84 27000432 SCREW AXSOS 3.0MM LOCKING L18MM $555.84 27000433 SCREW AXSOS 3.0MM LOCKING L20MM $555.84 27000434 SCREW AXSOS 3.0MM LOCKING L22MM $555.84 27000435 SCREW AXSOS 3.0MM LOCKING L24MM $555.84 27000436 SCREW AXSOS 3.0MM LOCKING L26MM $555.84 27000437 SCREW AXSOS 3.0MM LOCKING L28MM $555.84 27000438 SCREW, LOCKING 3.0X12MM #AR-8933L-12 $1,193.80 27000439 SCREW AXSOS 3.0MM LOCKING L30MM $555.84 27000440 SCREW, LOCKING 3.0X14MM #AR-8933L-14 $1,193.80 27000441 SUTURE FORCE FIBER#2 HC5 1/2 CIRCLE TAPR $301.25 27000442 PLATE LOCKING 1/3 TUBULAR 4HOLE L50MM $863.20 27000443 PLATE LOCKING 1/3 TUBULAR 6HOLE L76MM $863.20 27000444 PLATE LOCKING 1/3 TUBULAR 8HOLE L102MM $863.20 27000445 PLATE LOCKING 1/3 TUBULAR 10HOLE L128MM $863.20 27000446 PLATE LOCKING COMPRESSION 4HOLE L58MM $776.44 27000447 PLATE LOCKING COMPRESSION 6HOLE L84MM $950.06 27000448 PLATE LOCKING COMPRESSION 7HOLE L97MM $950.06 27000449 PLATE LOCKING COMPRESSION 8HOLE L110MM $1,123.58 27000450 PLATE LOCKING COMPRESSION 10HOLE L136MM $1,123.58 27000451 PLATE LOCKING RECON 6HOLE L172MM $2,262.77 27000452 PLATE LOCKING RECON 8HOLE L96MM $2,480.69 27000453 PLATE LOCKING RECON 10HOLE L120MM $2,560.62 27000454 BUR, BARREL ROUND 4.0MM $590.45 27000455 CANNULA DRI LOK THREADED STANDARD 5.0MM $301.25 27000456 CANNULA DRI LOK THREADED STANDARD 6.5MM $301.25 27000457 CUTTER, RESECTOR 4.0MM $590.45 27000458 CUTTER, TOMCAT 4.0MM $590.45 27000459 DRILL BIT CANNULATED 4.5X150 $2,301.00 27000460 DRILL BIT CANNULATED 5.5X230 $2,301.00 27000461 GUIDE WIRE 230X2.0 $591.00 27000462 SCREW DUAL THREAD 6.5X75 $3,950.64 27000463 SCREW DUAL THREAD SHORT THREAD#F6575TS $3,950.64 27000464 SCREW DUAL THREAD SHORT THREAD#F6580TS $3,950.64 27000465 TIBIALIS TENDON $9,880.00 27000466 BLADE MICRO 16.5X.38X34.5 #22963104 $670.69 27000467 BLADE MICRO 16.5X.38X18.5 #22963102 $670.69 27000468 DRILL BIT, CANNULATED 2.2MM #2402-100-22 $1,663.80 27000469 DRILL BIT, STAPLE 2.5 #DA2520 $1,734.60 27000470 K WIRE, 1.1MM #K100-11 $421.75 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000471 SCREW, HEADLESS 3.0X14 #F30-14T $2,180.64 27000472 SCREW, HEADLESS 3.0X16 #F30-16T $2,180.64 27000473 STAPLE 15X15X15 #ST-151515 $7,330.00 27000474 STAPLE, 18X14X14 #ST-181414 $7,330.00 27000475 STAPLE 20X16X16 #ST#201616 $7,330.00 27000476 SCREW, HEADLESS 4.0X26 #F40-26T $2,605.44 27000477 SCREW, HEADLESS 4.0X30 #F40-30T $2,605.44 27000478 SCREW, HEADLESS 4.0X34 #F40-34T $2,605.44 27000479 SCREW, HEADLESS 4.0X36 #F40-36T $2,605.44 27000480 DRILL BIT W/QC 2.0MM 157MM #71173588 $1,279.62 27000481 DRILL BIT W/QC 2.7MM SHORT #71173502 $1,135.05 27000482 PERI LOC K WIRE 1.25MM #71161012 $1,904.80 27000483 PERI LOC VLP 2.7MM X 14MM #71171228 $1,333.66 27000484 P-L VLP 3.5MM L-D FIB LK PL 7H #72821007 $6,777.33 27000485 PER LOC VLP 3.5MM X 16MM LCK SCRW $1,181.79 27000486 PERI LOC VLP 3.5MM X 14MM LCK SCRW $1,181.79 27000487 PERI LOC VLP 3.5MM X 12MM CRTX SCRW $359.93 27000488 PERI LOC VLP 3.5MM X 18MM LCK SCRW $1,181.79 27000489 PERI LOC VLP 3.5MM X 14MM CRTX SCRW $359.93 27000490 2.7 MM S-T CRTX SCRW 26MM #71823026 $363.55 27000491 2.7 MM S-T CRTX SCRW 24MM #71823024 $363.55 27000492 K WIRE 0.9MM #K100-09 $301.25 27000493 SCREW HEADLESS 2.0X18 #F20-18T $2,109.84 27000494 DRILL BIT CANNULATED 1.7MM #2402-100-17 $1,593.00 27000495 EXTENSION SET #050-95004 $337.40 27000496 BLANKET, WARMING UPPER BODY FULL ACCESS $312.81 27000497 BLANKET, WARMING MULTIPOSITON UPPER BODY $126.08 27000498 BLANKET, WARMING UPPER BODY PEDS LARGE $259.91 27000499 BLANKET, WARMING FULL BODY W/HEAD DRAPE $127.90 27000500 ENDOBRONCHIAL 35FR L R.SHAW #116100350 $581.25 27000501 ENDOBRONCHIAL 37FR L R.SHAW #116100370 $581.25 27000502 ENDOBRONCHIAL 39FR L R.SHAW #116100390 $564.31 27000503 ENDO TUBE, 4.5MM CUFFED MALLINCT#86106 $33.12 27000506 ENDO TUBE, 6.0 ORALRAE TAPERGUARD CUFFED $146.40 27000507 ENDO TUBE, 6.5 ORALRAE TAPERGUARD CUFFED $146.40 27000508 ENDO TUBE, 7.0 ORALRAE TAPERGUARD CUFFED $146.40 27000509 EPIDURAL CATHETER #4910-16/17 $132.12 27000510 EPIDURAL CATHETER 19GX12 INCH #NT-12-19 $541.75 27000511 EPIDURAL TRAY $301.27 27000512 EPIDURAL PUMP TUBING SAPPHIRE #16339-02 $187.08 27000513 EPIDURAL NEEDLE 17G 5INCH BD#405193 $134.71 27000514 EPIDURAL NEEDLE 20G 3.5INCH BD#405186 $77.85 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000515 ESOPHAGEAL STETHOSCOPE/TEMP PROBE 18FR $76.52 27000516 HUMID-VENT 1200 HUDSON#14412 $47.34 27000517 IV PRIMARY TUBING SAPPHIRE #16385-01 $97.51 27000518 SPINAL TRAY $253.19 27000519 MASK, ANESTHESIA SM ADULT/CHILD $42.95 27000520 MASK, ANESTHESIA TODDLER BM#4-3351-23 $47.45 27000521 MASK, ANESTHESIA INFANT BM#4-3351-22 $46.75 27000522 MICRODRIP PIGGYBACK SET #20671-28 $97.92 27000523 NEEDLE,BRACHIAL PLEX BLCK BD#408348 $56.00 27000524 NERVE BLOCK SET BRAUN#331674 $455.37 27000525 RADIAL ARTERY CATH SET #RA-04020 $169.01 27000526 SPINAL NEEDLE QUINCKE 22GX5 BD#405148 $72.00 27000527 SPINAL NEEDLE QUINCKE 22GX7 BD#405149 $77.13 27000528 SPINAL NEEDLE WHITACRE 25GX3.5 BD#405138 $84.44 27000529 SPINAL NEEDLE WHITACRE 22GX3.5 BD#405010 $88.08 27000530 SPINAL NEEDLE WHITACRE 25GX5 BD#405140 $101.76 27000531 SPINAL & EPIDURAL NEEDLE SET BD#405139 $178.72 27000532 ENDOTRACHEAL TUBE INTRDCR SUNMED#9021270 $125.47 27000533 LARYNGOSCOPE BLADE MCGRATH MAC #3 $258.05 27000534 LARYNGOSCOPE BLADE MCGRATH MAC #4 $258.05 27000535 LMA UNIQUE #4 #125040 $241.92 27000536 LMA UNIQUE #5 #125050 $241.92 27000537 LMA UNIQUE #3 #125030 $157.70 27000538 LMA UNIQUE #2 #125020 $241.92 27000539 LMA UNIQUE #2.5 #125025 $241.92 27000540 NEEDLE, TOUHY 17GX3.5 INCH #WC-17-35 $268.80 27000541 UNIVERSAL ANESTHESIA SET BAXT#2C9218 $52.23 27000542 AMNIHOOK $34.48 27000543 ABDOMINAL BINDER, SMALL DJ#79-89043 $176.51 27000544 ABDOMINAL BINDER, MEDIUM DJ#79-89045 $176.51 27000545 ABDOMINAL BINDER, LARGE DJ#79-89047 $176.51 27000546 ABDOMINAL BINDER, X-LRGE DJ#79-89048 $176.51 27000547 ABDOMINAL BINDER, XX-LGE DJ#79-89049 $176.51 27000548 AEROSOL CANAPY, PEDIATRIC $189.06 27000549 AMBU BAG DISP INFANT PORTEX#8528M $220.67 27000550 AMBU BAG DISP CHILD'S HUDSON#5367 $240.89 27000551 AMBU BAG DISP ADULT HUDSON#5372 $182.97 27000552 ADAPTIC, 3 X 16 J&J#2014B $37.12 27000553 ADAPTIC PKNG STRIP 1/2X4Y $74.75 27000554 AIRWAY, NASO 30FR ARGYLE#247049 $67.52 27000555 AIRWAY, NASO 32FR ARGYLE#247056 $67.52 27000556 AIRWAY, NASO 34FR ARGYLE#247064 $67.52 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000557 AMNIOCENTESIS TRAYS ALLEG#4545A $228.02 27000558 ANALSCOPE, DISPOSABLE WA#53110 $69.14 27000559 ANES BREATH CIRCUIT ADULT KING#DF37061Z $105.95 27000560 ANES BREATH CIRCUIT PEDS KING #PDB16061 $109.48 27000561 ANGIOCATH, 14GX2 MED#3358 $36.96 27000562 ANGIOCATH, 16GX1.25 MEDEX#3342 $36.96 27000563 ANGIOCATH, 16X1.88 BD#381157 $85.45 27000564 ANGIOCATH, 18X1.16 #381144 $81.94 27000565 ANGIOCATH, 18X1.16 BD#381705 $36.57 27000566 ANGIOCATH, 18G X 1.88 BD#381447 $36.57 27000567 ANGIOCATH, 20X1 1/4 SMITHS#3066 $38.34 27000568 ANGIOCATH, 20X1 1/4 NON SAFE BD#381134 $88.95 27000569 ANGIOCATH, 22GX1 MEDEX#3350 $37.36 27000570 ANGIOCATH, 22X1 NON SAFE BD#381123 $94.87 27000571 ANGIOCATH, 22X1 BD#381423 $34.74 27000572 ANGIOCATH, 24GX5/8 MEDEX#3353 $36.96 27000573 ANKLE STABILIZED SUPPORT MED #79-81355 $225.25 27000574 ANKLE STABLIZED SUPPORT LG #79-81357 $225.25 27000575 ANKLE STABILIZED SUPPORT XL #79-81358 $225.25 27000576 ARMBOARD, INFANT TARRY#T92641VS $34.15 27000578 ARMBOARD, ADULT TARRY#T52843VS $54.00 27000579 ARM/SHLDR IMMOB UNIVERSAL DJ#79-84100 $145.33 27000580 ARM SLING SMALL DJ#79-99153 $62.85 27000581 ARM SLING MEDIUM DJ#79-99155 $62.85 27000582 ARM SLING LARGE DJ#79-99157 $62.85 27000583 ARM SLING ULTRA III MEDIUM #11-0449-3 $603.81 27000584 ARM SLING ULTRA III LARGE #11-0449-4 $603.81 27000585 ARM SLING ULTRA III XLARGE #11-0449-5 $603.81 27000586 ATHLETIC SUPPORTER MEDIUM YOUTH $70.18 27000587 ATHLETIC SUPPORTER LARGE ADULT $173.11 27000588 ATHLETIC SUPPORTER MEDIUM ADULT $70.18 27000589 ATHLETIC SUPPORTER XLARGE ADULT $70.18 27000590 ANTI-EMB THIGH SM/REG KENDALL#3130 $145.93 27000591 ANTI-EMB THIGH MED/REG KENDALL#3416 $146.64 27000592 ANTI-EMB THIGH LG/REG KENDALL#3728 $146.65 27000593 ANTI-EMB KNEE SMALL #KC7071 $98.01 27000594 ANTI-EMB KNEE MEDIUM #KC7115 $97.07 27000595 ANTI-EMB KNEE LARGE #KC7203 $97.35 27000596 ANTI-EMB KNEE XLARGE #KC7604 $97.35 27000597 BALLOON TAMPONADE CATH UTAH#BTC-100 $1,090.40 27000598 BARTHOLIN GLAND CATHETER #53404 $243.93 27000599 BASIC PACK CUSTOM MADE #SBA54BPLCA $314.14 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000600 BILI MASK $70.80 27000601 BIOPATCH, DRESSING JJ#4150 $196.94 27000602 BLANKET, WARMING FULL BODY #300 $88.08 27000603 BLANKET, WARMING LOWER BODY #525 $128.66 27000604 BLOOD PUMP W/INJ SITE ABBOTT#1271865 $130.79 27000605 BLOOD COLLECT SET #BO-16S1 $54.81 27000606 BLOOD/FLUID WARMER CUFF ARZ#24200 $161.16 27000607 BONE MARROW TRAY ALLEG#BEK3411 $261.50 27000608 BREAST PUMPING SYSTEM MEDELA $369.49 27000609 BREAST SHIELD MEDELA#67203 $97.12 27000610 BURETROL ADD-ON F/PUMP SET #12425-28 $85.35 27000611 BURN SHEET, STER 60 X90 ROEHAMPTON#514 $254.85 27000612 BURN GEL DRESSING 4 X 4 INCH $266.11 27000613 BURN GEL DRESSING 4 X 16 INCH $285.75 27000614 ANKLE BRACE AIRSTIRRUP SM-LEFT #02CL $274.62 27000615 ANKLE BRACE AIRSTIRRUP SM-RIGHT #02CR $274.62 27000616 ANKLE BRACE AIRSTIRRUP STANDARD-L #02AL $274.62 27000617 ANKLE BRACE AIRSTIRRUP STANDARD-R #02AR $274.62 27000618 ANKLE SUPPORT X-LARGE DJ#79-81378 $168.63 27000619 C-SECTION PACK $626.17 27000621 CO2 CAPNOFLEX SYSTEM ADULT/PEDS $271.95 27000622 CO2 CAPNOFLEX SYSTEM PEDS/INFANT $139.24 27000623 C02 CAPNOFLEX DELIVERY CANNUAL NEONATAL $273.00 27000624 CATHETER DRESSING TRAY $300.65 27000625 CATHETER SECRMNT DEVICE STANDARD#3300MVA $64.32 27000626 CATHETER SHEATH INTRODUCER 5FR #402605X $152.32 27000627 CATHETER SHEATH INTRODUCER 6FR #402606X $152.32 27000628 CATH KIT F/STERILE SPECMN ML#DYND10805 $54.15 27000629 CATHETER SHEATH INTRODUCER 7FR #402607X $152.32 27000630 CATH STRAP SM/MED/LG B&C#8214 $37.43 27000631 CATHETER SHEATH INTRODUCER 7FR 45CM $289.20 27000632 CATHETER SHEATH INTRODUCER 7FR #504657X $145.15 27000633 CATHETER SHEATH INTRODUCER 8FR #504658X $313.30 27000634 CATHETER SHEATH INTRODUCER 9FR #402609X $152.32 27000635 CATH, SUPRAPUBIC BONNANO BD#408289 $803.39 27000636 CATH TRAY 13.5X16CM NON CUFFED DIALYSIS $1,395.04 27000637 CATH TRAY 13.5X24CM NON CUFFED DIALYSIS $1,395.04 27000638 CATHETER SHEATH INTRODUCER 8FR #402608X $152.32 27000639 CATHETER KIT INFANT BARD#0035630 $49.44 27000640 CATHETER TRAY 14FR ML#DYND18200 $47.09 27000641 CATH, SWAN NECK CURL LEFT 2 CUFF $2,370.88 27000642 CATH, SWAN NECK CURL RIGHT 2 CUFF $2,370.88 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000643 CATHETER SHEATH INTRODUCER 7FR 90CM $289.20 27000644 CATHETER TRAY 16FR ML#DYND11860 $157.14 27000645 CATHETER TRAY 18FR ML#DYND11865 $164.24 27000646 CVC KIT PRESSURE INJECTABLE MULTI LUMEN $1,277.12 27000647 CVP TRAY, THREE LUMEN ARROW#AK15703 $687.53 27000648 CERVIC COLLAR SMALL DJ#79-83013 $81.03 27000649 CERVIC COLLAR MEDIUM DJ#79-83014 $249.09 27000650 CERVIC COLLAR LARGE DJ#79-83016 $249.09 27000651 CERVIC COLLAR X-LARGE DJ#79-83508S $81.03 27000652 COLLAR, VISTA TX SET #79-83360 $593.46 27000653 COLLAR, STIFFNECK ADULT #472001000 $149.33 27000654 COLLAR, STIFFNECK ASST SIZES $125.37 27000655 COLLAR, STIFFNECK INFANT/PEDS #472002000 $188.95 27000656 CAUTERY DIAGNOSTICK $138.72 27000657 CO2 DETECTOR, ADULT EASY CAP $163.51 27000658 CO2 DETECTOR, PEDIATRICS $161.28 27000660 COMPRESSION CUFF CALF AIRCST#3010 $336.80 27000661 COMPRESSION CUFF THIGH AIRCST#3015 $433.80 27000662 COMPRESSION CUFF XLARGE AIRCST#3012 $360.90 27000663 COMPRESSION CUFF FOOT AIRCST#3016 $469.95 27000664 CLAVICL STRAP SMALL DJ#79-85003 $88.29 27000665 CLAVICL STRAP MEDIUM DJ#79-85005 $88.29 27000666 CLAVICL STRAP LARGE DJ#79-85007 $88.29 27000667 CLAVICL STRAP X-LARGE DJ#79-85008 $88.29 27000668 CRICOTHYROTOM CATH SET 3.5MM #CTCCS350 $1,108.94 27000669 CRICOTHYROIDOTOMY KIT #100/465/060 $1,359.05 27000670 CLOSED DRAINAGE BAG/BOT ML#DYND15207 $73.77 27000671 COLLECTION TUBING SET, VACCUUM $122.63 27000672 CURRETTE, CRVD RIGID 8MM BERKLEY#611 $74.56 27000673 CURRETTE, CRVD RIGID 10MM BERKLEY#613 $74.56 27000674 CURRETTE, CRVD SEMIRIGID 6MM $70.18 27000675 CURRETTE, CRVD RIGID 12MM $74.56 27000676 CURRETTE, CRVD RIGID 7MM $74.56 27000677 CURRETTE, CRVD RIGID 14MM BERKLEY#616 $77.50 27000678 CURRETTE, CRVD RIGID 9MM BERKLEY#612 $74.56 27000679 CURRETTE, CRVD RIGID 16MM BERKLEY#617 $77.50 27000680 CURRETTE, CRVD RIGID 11MM BERKLEY#614 $74.56 27000681 CURRETTE, STRAIGHT 8MM $70.18 27000682 CURRETTE, STRAIGHT 10MM $70.18 27000683 CURRETTE, STRAIGHT 12MM $70.18 27000684 CURRETTE, STRAIGHT 7MM BERKELEY#608 $70.18 27000685 CURRETTE, STRAIGHT 9MM BERKELEY#602 $70.18 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000686 CURRETTE, STRAIGHT 11MM BERKELEY#604 $70.18 27000687 CURRETTE, FLEXIBLE 6MM BERKELEY#623 $51.33 27000688 DERMABOND TOPICAL SKIN ADHESIVE #DNX12 $269.25 27000689 INDERMIL LACERTN ADH AS#IND012 $313.30 27000690 DERMABOND SKIN ADHESIVE TOPICAL #ETDHV12 $423.76 27000691 DRESSING AQUACEL AG SURGICAL 3.5X12 $466.80 27000692 DRESSING AQUACEL AG SURGICAL 3.5X14 $500.98 27000693 DRESSING, ACTICOAT 7 4X5 #20141 $256.52 27000694 DRESSING, DUODERM 2.5X2.5 CONVATC#187970 $71.52 27000695 DRESSING, QUIK CLOT 4X4 ZMED#197 $278.84 27000696 DRESSING, MEPILEX LITE 2.4X3.4 #284090 $52.71 27000697 DRESSING, MEPILEX 4X4 #294199 $70.60 27000698 DRESSING, MEPILEX AG 4X4 #287100 $150.53 27000699 DRESSING TIPSTOP #114555 $52.58 27000700 EKG PACING PAD,QUIK COMBO #3010107-003 $378.97 27000701 EKG PACING PAD, PEDIATRIC #3010107-003 $460.91 27000702 ELECTRODE PACING BPLR BALLOON 5FR #8556P $1,104.48 27000703 ENEMA FLEETS MINERAL OIL $44.00 27000704 EVACUATED CONTAINER 250ML $70.53 27000705 EVACUATED CONTAINER 500ML $70.66 27000706 EVACUATED CONTAINR 1000ML $222.92 27000707 ENDOTRACH TUBE HOLDER DALE#270 $185.33 27000708 EZ-IO FLUID TRANSFER SET #9013 $93.20 27000709 EZ-IO NEEDLE SET 15X15MM #9018 $1,175.00 27000710 EZ-IO NEEDLE SET 15X25MM #9001 $1,211.35 27000711 EZ-IO NEEDLE SET 15X45MM #9079 $1,284.04 27000712 EZ-IO STABILIZER #9066 $259.69 27000713 INTUBATION SYSTEM 2.5 ENDOTRACH #H4001S $138.58 27000714 INTUBATION SYSTEM 3.0 ENDOTRACH #H4002S $144.17 27000715 INTUBATION SYSTEM 3.5 ENDOTRACH #H4003S $144.17 27000716 INTUBATION SYSTEM 4.0 ENDOTRACH #H4004S $144.17 27000717 INTUBATION SYSTEM 4.5 ENDOTRACH #H4004S $144.17 27000718 ENDO TUBE, 4.5 UNCUFFED NASAL RAE #86286 $82.05 27000719 ENDO TUBE, 5.0 UNCUFFED NASAL RAE #86287 $82.05 27000720 ENDO TUBE, 5.5 UNCUFFED NASAL RAE #86288 $80.05 27000721 ENDO TUBE, 6.0 UNCUFFED NASAL RAE #86289 $72.32 27000722 ENDO TUBE, 6.0 CUFFED NASAL RAE $145.70 27000723 ENDO TUBE, 2.0MM UNCUFF MALLINCT#86221 $34.46 27000724 ENDO TUBE, 2.5MM UNCUFF SMITHS#H4021S $79.62 27000725 ENDO TUBE, 4.0MM UNCUFF MALLINCT#86225 $34.36 27000726 ENDO TUBE, 4.5MM UNCUFF MALLINCT#86226 $34.36 27000727 ENDO TUBE, 5.0MM CUFFED MALLINCT#86107 $52.19 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000728 ENDO TUBE, 5.5MM CUFFED MALLINCT#86108 $52.35 27000729 ENDO TUBE, 6.0MM CUFFED MALLINCT#86109 $52.35 27000730 ENDO TUBE, 6.5MM CUFFED MALLINCT#86110 $52.35 27000731 ENDO TUBE, 7.0MM CUFFED MALLINCT#86111 $52.22 27000732 ENDO TUBE, 7.5MM CUFFED MALLINCT#86112 $52.19 27000733 ENDO TUBE, 8.0MM CUFFED MALLINCT#86113 $52.27 27000734 ENDO TUBE, 4.0 UNCUFFED NASAL RAE #86285 $82.05 27000735 ENDOTRACHEAL TUBE INTRDCR PEDS #9021170 $125.47 27000736 ENDOTRACHEAL TUBE INTRDCR ADULT #9021270 $125.47 27000737 EXTENSION SET FASTFLOW RAPID INFUSER#X36 $72.60 27000738 EXTRACTOR KATZ FOREIGN BODY REMOVAL $956.88 27000739 FEEDING TUBE 10FR 43 #8884721088 $191.95 27000741 FEEDING TUBE 5FR 36 DAVOL#0036430 $38.64 27000742 FEEDING TUBE 8FR 15 DAVOL#0036410 $34.30 27000743 FIBERGLASS CAST BNDGE 2 INCH $43.95 27000744 FIBERGLASS CAST BNDGE 3 INCH $53.58 27000745 FIBERGLASS CAST BNDGE 4 INCH $77.87 27000746 ENTERNAL NUTRITION PUMP SET #773662 $107.64 27000747 ENTERAL NUTRITION BAG/GRAVITY #702520 $49.76 27000748 FOLEY CATH COUDE 16FR $76.04 27000749 FOLEY CATH COUDE 18FR $75.82 27000750 FOLEY CATH COUDE 20FR $76.04 27000751 FOLEY CATH 8FR 3CC #8887654088 $125.06 27000752 FOLEY CATH 20FR 30CC #0167L20 $162.01 27000753 FOLEY CATH 3-WAY 18FR BARD#0167L18 $161.96 27000754 FOLEY CATH 3-WAY 24FR BARD#0167L24 $162.01 27000755 FOLEY CATH COUDE 16FR 5CCBALLOON#0102L16 $258.92 27000756 FOLEY CATH COUDE 18FR 5CCBALLOON#0102L18 $202.23 27000757 FOLEY CATH COUDE 20FR 5CCBALLOON#0102L20 $202.23 27000758 FOLEY CATH LATEXFREE 16FR 5CC BRD#165816 $70.10 27000759 FOLEY CATH LATEXFREE 18FR 5CC BRD#165818 $70.10 27000760 GAS VENT/FILTER RAPID INFUSER #F-30 $246.23 27000761 GASTRIC LAVAGE SYSTEM $274.98 27000762 GASTROSTOMY TUBE 24FR 7-10ML BALLON $487.63 27000763 GASTROSTOMY TUBE 20FR 7-10ML BALLON $487.63 27000764 GASTROSTOMY TUBE 18FR $748.64 27000765 GASTROSTOMY TUBE 24FR WC#PEG24-BRT-S $752.00 27000766 GASTROSTOMY TUBE 22FR 7-10ML BALLON $504.42 27000767 GASTROSTOMY TUBE 24FR JEJUNAL#8884790240 $785.37 27000768 GLYCINE 3000ML ABBOTT#7974-08 $224.99 27000769 GOWNS, X-LARGE DISPOSABLE STERILE#9541 $45.45 27000770 HEAD IMMOBILIZER BNDTREE#660400 $139.60 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000771 GOWNS, XXLARGE DISPOSABLE STERILE#9571 $62.44 27000772 HYDROGEL, 4OZ SKINTEGRITY #MSC6104 $136.34 27000773 HEARING SCREENING ELECTRODES ONLY $50.80 27000774 HEARING SCREENING SUPPLIES $225.99 27000775 HYDROGEL WOUND DRESSING W/ZINC+B6 #DH03 $72.64 27000776 HYPERINFLATION BAG 1/2 LT $131.27 27000777 HEIMLICH CHEST DRAIN VALVE BD#373460 $352.38 27000778 HUMIDIFIER PREFILLED 500ML W/ADAPT #2620 $34.79 27000780 HOLLIHESIVE SKIN BARRIER HOLLSTR#7700 $42.44 27000781 HYPO/HYPERTHERMIA BLANKET GAYMAR#DHP810 $260.40 27000782 IODOFORM GAUZE 1/4 INCH KENDAL#KC7831 $60.86 27000783 IODOFORM GAUZE 1/2 INCH #7832 $63.53 27000784 IODOFORM GAUZE 1 INCH $72.54 27000785 IODOFORM GAUZE 2 INCH #KC7834 $96.34 27000786 INTRAUTERN PRESSURE CATH KENDL#56300 $324.93 27000788 INTUBATING LMA AIR Q 1.5 #3015 $177.41 27000789 INTUBATING LMA AIR Q 2.5 #3025 $177.41 27000790 INTUBATING LMA AIR Q 3.5 #3035 $177.41 27000791 INTUBATING LMA AIR Q 4.5 #3045 $177.41 27000792 INFUSION SET F/LIFE PORT #LPS3009 $155.01 27000793 IRRIGATION SPLASH GUARD SM ETHOX#10222 $40.35 27000794 IRRIGATION SPLASH GUARD LG COOPER#556100 $76.71 27000795 IRRIGATION TRAY ML#DYND20300 $38.27 27000796 IRRIGATION TUR SET $206.68 27000797 IV CATH SYSTEM 18GX1.25 NEXIVA BD#383539 $105.07 27000799 IV CATH SYSTEM 20G NEXIVA BD#383536 $105.07 27000800 IV CATH SYSTEM 18GX1.75 BRACHIAL#383540 $100.41 27000801 IV CATH SYSTEM 22G NEXIVA BD#383532 $99.41 27000802 IV CATH SYSTEM 24G NEXIVA BD#383531 $105.07 27000803 IV ADMINISTRATION SET RAPID INFUSER#D300 $896.59 27000804 IV NITRO PUMP SET ABBOT#11878-12 $122.23 27000805 IV PRIMARY HIGH PRESSURE FILTER #1645-48 $173.47 27000806 IV PRIMARY 15DP CASSETTE HOSP#12538-28 $103.01 27000807 IV PRIMARY 15DP PIGGYBCK ABBOT#12662-28 $88.03 27000808 IV PUMP BLOOD TUBING HOSP#1225902 $247.99 27000809 IV NON-CORING W/9IN TUBING AL-MED#502032 $83.39 27000810 IV EXT SET W/TWIN SITE HOSP#12678-28 $63.13 27000811 IV EXT SET .2 MICRON FILTER #20668-28 $74.84 27000812 IV EXT SET 1.2 MICRON FILTER #12354-05 $90.81 27000814 IV MICROBORE EXT SET ABBOT#1267728 $48.19 27000815 IV MICROBORE EXT SET PEDS #12545 $59.50 27000816 IV TUBING,PCA SET, LONG ABBOTT#6516-03 $95.55 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000817 K-PAD DISPOS PAD 15X22 GAYMAR#TP622E $103.46 27000818 JEJUNOSTOMY KIT ABBOT#51442 $1,331.04 27000819 JEJUNOSTOMY BAKER CATH 16FR BARD#42510 $2,402.95 27000820 KNEE BRACE KNEERANGER LITE DJ#79-94040 $541.41 27000821 KNEE BRACE X-ACT ROM #11-2151-9 $977.13 27000822 KNEE BRACE HINGED WEEKENDER MED RIGHT DJ $905.60 27000823 KNEE BRACE HINGED WEEKENDER LG RIGHT DJ $905.60 27000824 KNEE IMMOBILIZER SM #79-80053 $235.65 27000825 KNEE IMMOBILIZER MD #79-80045 $266.70 27000826 KNEE IMMOBILIZER LG #79-80037 $308.96 27000827 KNEE STABILIZER SMALL DJ#79-94483 $290.41 27000828 KNEE STABILIZER MEDIUM DJ#79-94485 $290.41 27000829 KNEE STABILIZER LARGE DJ#79-94487 $290.41 27000830 KNEE STABILIZER X-LARGE DJ#79-94488 $290.41 27000831 KNEE STABILIZER XX-LARGE DJ#79-94489 $309.08 27000832 LAP SPONGE, 18X18 STERILE ML#MDS251518 $38.90 27000833 LAVACUATOR TB 28FR KC#15028 $230.49 27000834 LAVACUATOR TB 34FR KC#15034 $196.77 27000835 LARYNGOSCOPE 0 MAC DISP BLADE #004651000 $112.74 27000836 LARYNGOSCOPE 1 MAC DISP BLADE #004651001 $112.74 27000837 LARYNGOSCOPE 2 MAC DISP BLADE #004651002 $112.74 27000838 LARYNGOSCOPE 3 MAC DISP BLADE #004651003 $112.74 27000839 LARYNGOSCOPE 4 MAC DISP BLADE #004651004 $112.73 27000840 LARYNGOSCOPE 0 MILL DISP BLADE#004650000 $112.74 27000841 LARYNGOSCOPE 1 MILL DISP BLADE#004650001 $112.74 27000842 LARYNGOSCOPE 2 MILL DISP BLADE#004650002 $112.74 27000843 LARYNGOSCOPE 3 MILL DISP BLADE#004650003 $112.74 27000844 LARYNGOSCOPE 4 MILL DISP BLADE#004650004 $112.74 27000845 LIMB HOLDER, PAIR DISPOS ML#MDT829020C $70.29 27000846 LUMBAR PUNCTURE TRAY,ADLT ALLEG#4306C $168.60 27000847 LUMBAR PUNCTURE TRAY, PED ALLEG#4304C $147.15 27000848 LUMBOSACRAL SUPPORT UNIV DJ#79-89980 $255.00 27000849 MASK, ANESTHESIA REG ADLT SIMMS#5045 $37.96 27000850 MASK,CO2 W/O2 CANNULA ADULT #2013067-003 $201.96 27000851 MASK,CO2 W/O2 CANNULA PEDS #2013067-004 $204.22 27000852 MONTGOMERY STRAPS #5129 $43.90 27000853 MORGAN LENS EYE IRRIGATN $288.00 27000854 MUCUS SPECIMEN TRAP, 8FR TRIST#SMT80855 $175.37 27000855 MECONIUM ASPIRATOR $73.33 27000856 NASAL ATOMIZER TELEFLEX#MAD300 $102.56 27000857 NASAL CANNULA W/CO2 SAMPLE ADULT $129.10 27000858 NASAL CANNULA ADULT HIGH FLOW #1600HF $72.02 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000859 NOZ STOP KIT S&N#890912 $538.30 27000860 NEEDLE, CHIBA 22G X 6 $180.71 27000861 NEEDLE, TENSION PNEUMOTHORAX 14X3.25 $137.73 27000862 NEEDLE, TRU-CUT BIOPSY 14X6 CARD#2N2704X $321.33 27000863 NEEDLE, TRU CUT BIOPSY 12FR BARD#121816 $530.20 27000864 NEEDLE,18G JAM/ILL ASPIRT $436.21 27000865 NEEDLE,15G JAM/ILL ASPIRT $241.74 27000866 NEEDLE, JAMSHIDI 11GX4 ALLEG#PDJ4011 $260.40 27000868 NEEDLE,SPINAL 18GX6 BD#408360 $109.07 27000869 NEEDLE STIMUPLEX ULTRA 360 20GX4 #333648 $230.72 27000870 NEEDLE, STIMUPLEX 30DEGREE 22X50MM333652 $212.27 27000871 NEEDLE, STIMUPLEX D+ 22X3 1/8 #333688 $204.02 27000872 NEONATAL PROCEDURE TRAY ARGYLE#160408 $623.17 27000873 O2 MASK, INFANT 7'TUBING ALLEG#2D4823 $50.46 27000875 O2 MASK, PREEMIE SIZE 0 CUSHION #6800 $69.85 27000876 ORTHOPEDIC EXTREMITY DRAPE ARTHROSCOPY $250.88 27000877 ORTHOPEDIC SPLIT SHEET DRAPE 77X108 $99.64 27000878 ORTHOPEDIC SPLIT SHEET DRAPE 88X116 $243.51 27000879 OP SITE DRESSING, 5X7 3M#9548HP $33.05 27000880 ORTHOPEDIC SPLIT U DRAPE 60X72 #8476 $50.99 27000881 ORTHOPEDIC STERI U DRAPE 47X51 #M1015 $71.37 27000882 BARRIER FILM 3M#3346 $141.57 27000884 OSTOMY 1 3/4 INCH BARRIER FLAT GRE#14602 $38.63 27000885 OSTOMY 1 3/4 IN BARRIER CONVEX GRE#14802 $66.91 27000886 ORTHOPEDIC PACK GENERAL #29181 $290.90 27000888 OSTOMY 2.75 IN BARRIER HOLLSTR#3704 $34.27 27000890 OSTOMY 2 1/4 INCH BARRIER FLAT RED#14603 $38.63 27000891 OSTOMY 2 1/4 IN BARRIER CONVEX RED#14803 $66.91 27000893 OSTOMY 2 3/4 BARRIER FLAT BLU#14604 $38.63 27000894 OSTOMY 2 3/4 IN BARRIER CONVEX BLU#14804 $66.91 27000895 OSTOMY 4 INCH BAG HOLLSTR#3806 $38.80 27000896 OSTOMY 4 INCH BARRIERS HOLLSTR#3726 $59.41 27000897 PACKING STRIP 1/2X 5YDS KENDALL#7632 $54.78 27000898 PACKING STRIP 1/4X 5YDS KENDALL#7631 $56.73 27000899 PACKING STRIP 1 X 5YDS KENDALL#7633 $62.83 27000900 PACKING STRIP 2 X 5YD KENDALL#7634 $80.95 27000901 PARACENTESIS TRAY #TPT1000 $334.92 27000902 PELVIC BINDER YELLOW #Y-3000 $1,348.74 27000903 PNEUMOTHORAX SET 9 FR COOK#CTPT100 $1,259.46 27000904 PUDENDAL BLOCK TRAY ALLEG#4542 $215.27 27000905 PEG KIT 16FR #761610 $1,057.50 27000906 PED KIT 20FR #762010 $1,175.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000907 PLASTIBELL 1.2 F/CIRCUMSN $69.41 27000908 PLASTIBELL 1.3 F/CIRCUMSN $70.90 27000909 PLASTIBELL 1.5 F/CIRCUMCISN $70.90 27000910 PERITONEAL LAVAGE TRAY ALLEG#LNT9000 $324.54 27000911 PEAK-FLOW METER, ADT/PED HUDSON#1801 $149.77 27000912 PERI COLD PACK KENDALL#52000024 $39.54 27000913 PERI WIPE WITCH HAZEL PAD $90.45 27000914 PICC CATHETER INTERMEDIATE TRAY #4132100 $997.34 27000915 PICC LINE 4FR TRAY BARD#3154108 $1,230.84 27000916 PICC LINE 5FR TRAY BARD#3175108 $1,072.76 27000917 PICC LINE 5FR DUAL LUMEN TRAY #3255108 $1,355.48 27000918 PICC LINE 5FR SINGLE LUMEN #3155108 $1,272.98 27000919 POST-OP SHOE, MEN'S SMALL #79-90183 $113.60 27000920 POST-OP SHOE, MEN'S MEDIUM #79-90185 $113.60 27000921 POST-OP SHOE, MEN'S LARGE #79-90187 $113.60 27000922 POST-OP SHOE, WMN'S MED #79-90195 $113.60 27000923 POST-OP SHOE, WMN'S LARGE #79-90197 $113.60 27000924 PRESSURE MONITORING KIT #PXVP2X2AT3 $543.46 27000925 POSEY VEST, MEDIUM $98.10 27000926 POSEY VEST, LARGE $93.20 27000927 PROBE F/HYPO/HYPERTHERMIA GAYMAR#DP400 $127.33 27000928 RAPID RHINO POSTERIOR/ANTERIOR ART#RR750 $456.70 27000929 RIB BELT MENS MED. 30-36 DJ#79-89065 $85.15 27000930 RIB BELT MENS LARGE 36-42 DJ#79-89067 $85.15 27000931 RIB BELT MENS X-LG 42-48 #79-89068 $85.15 27000932 RIB BELT MENS XX-LARGE 89069/89151 $101.83 27000933 RAPID RHINO 5.5CM UNILATERAL #RR551 $468.75 27000934 RAPID RHINO 4.5CM UNILATERAL #RR450 $442.24 27000935 RAPID RHINO 9.0CM POSTERIOR #RR900 $668.82 27000936 RESUSCITATOR T PIECT INFANT #MERC1050814 $284.85 27000937 RIB BELT WOMENS MED #79-89075 $85.15 27000938 RIB BELT WOMENS LG DJ#7989077 $85.15 27000939 RIB BELT WOMENS X-LG DJ#79-89078 $85.15 27000940 RIB BELT WOMENS XX-LG #79-89079 $85.15 27000941 SCALPEL #10 STER, SAFETY AMER#73-0610 $32.62 27000942 SCALPEL #11 STER SAFETY AMER#73-0611 $34.14 27000943 SCALPEL #15 STER SAFETY AMER#73-0615 $34.26 27000944 SALEM SUMP, ANTI REFLUX VALVE #8888266197 $92.24 27000945 SALEM SUMP 16FR RIGID ARGYLE#264960 $32.87 27000946 SALEM SUMP, 18FR RIGID ARGYLE#264986 $32.87 27000947 SENGSTAKEN TUBE ADULT 20FR BLAKMOR#92030 $2,628.59 27000948 SHOULDER ABDUCTION KIT DJ#79-84500 $339.09 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000949 SHOLDER ORTHO PACK CUSTOM MADE $566.30 27000950 SHOULDER PACK #9183 $425.79 27000951 SILVASORB GEL ANTIMICROBAL 1.5OZ#MSC9301 $269.38 27000952 SKIN TEMPERATURE PROBE $397.92 27000953 SKIN TEMPERATURE PROBE DISP #M1024222 $62.82 27000954 SPIRAL FETAL SCALP ELECTRODE SAFELINK $58.66 27000955 SODIUM CHLORIDE 1000ML ABBOTT#7138-09 $56.17 27000956 SODIUM CHLORIDE 3000CC $142.35 27000957 SODIUM CHLORIDE 500ML ABBOTT#6138-03 $53.82 27000958 SPLINT, FRARM META SML RT DJ#79-72123 $92.80 27000959 SPLINT, FRARM META SML LT DJ#79-72113 $92.80 27000960 SPLINT, FRARM META MED RT DJ#79-72125 $92.80 27000961 SPLINT, FRARM META MED LT DJ#79-72115 $92.80 27000962 SPLINT, FRARM META LRG RT DJ#79-72127 $92.80 27000963 SPLINT, FRARM META LRG LT DJ#79-72117 $92.80 27000964 SPLINT, 2 IN ORTHOGLASS S&N#OG-2L2 $64.95 27000965 SPLINT, 3 IN ORTHOGLASS S&N#OG-3L2 $83.64 27000966 SPLINT, 4 IN ORTHOGLASS S&N#OG-4L2 $100.40 27000967 SPLINT, 6 IN ORTHOGLASS S&N#OG-6L2 $141.81 27000968 STAPLER, SKIN 35R ETH#PMR35 $106.96 27000969 STAPLER, SKIN 35W ETH#PMW35 $109.73 27000970 STAT LOCK ADULT BARD#VPPCSP $86.72 27000971 STERILE WATER IRRIG 1000M ABBOTT#7139-09 $53.93 27000972 STERILE TOWEL 4/PK #77704 $45.52 27000973 STERILE WATER IRRIG 500ML ABBOTT#6139-03 $53.52 27000974 STOMA PASTE #183910 $105.89 27000975 STOMA POWDER 1 OZ #7906 $69.85 27000976 STOPCOCK, 3-WAY RAPID INFUSER #SC-3 $61.41 27000977 STYLET, ENDOTRACH 6F PEDS #IS6FRL $64.73 27000978 STYLET, ENDOTRACH 14F ADT MALLINCT#85865 $72.78 27000979 SUCTION CANISTER 800CC #424410 $125.49 27000980 SUCTION FRAZIER 7FR #0031070 $58.01 27000981 SUCTION FRAZIER 8FR #0033080 $44.30 27000982 SUCTION FRAZIER 10FR #0033100 $44.30 27000983 SUCTION TUBE ATTCHMT DEVC HOLLSTR#9785 $47.42 27000984 SURGICEL HEMOSTAT 2X14 J&J#1951 $1,043.31 27000985 SURGICEL SNOW ABS 2X4 #2082-33 $1,210.96 27000986 SUTURE, CVO NEEDLE THX-26 GORE#0N05 $309.28 27000987 SUTURE, 0 CHROMIC CT-1 ETH#924H $74.59 27000988 SUTURE, SZ0 VICRYL ETH#J764D $238.77 27000989 SUTURE, SZ0 PDS ETH#Z334H $68.31 27000990 SUTURE, SZ1 PDS II TP1 ETH#Z880G $112.41 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27000991 SUTURE, PDS II 1-0 CT ETH#Z359T $59.38 27000992 SUTURE, ETHIBOND 0 CT2 ETH#X412H $37.90 27000993 SUTURE 2-0 VICRYL #J911T $136.26 27000994 SUTURE, SZ0 VICRYL CT-2 ETH#J334H $36.21 27000995 SUTURE, SZ0 CHROMIC GS-25 ETH#904H $80.54 27000996 SUTURE, SZO PROLENE CT-2 ETH#8412H $62.64 27000997 SUTURE SZ1 ETHILON NYLON ETH#489T $185.31 27000998 SUTURE, SZ0 PLAIN REEL ETH#L104G $78.56 27000999 SUTURE, SZ0 CHROMIC ETH#914H $73.44 27001000 SUTURE SZ 2 ETHIBOND TICRON ETH#PX83H $139.36 27001001 SUTURE, 2-0 PLAIN ETH#53T $149.98 27001002 SUTURE, 2-0 CHROMIC SH ETH#G123H $71.03 27001003 SUTURE, 2-0 PDS CT2 ETH#Z333H $68.93 27001004 SUTURE, 3-0 NYLON ETHILON FSLX #1673H $42.36 27001005 SUTURE, 3-0 CHROMIC FS-2 ETH#636H $69.34 27001006 SUTURE, 2-0 CHROMIC ETH#923H $75.44 27001007 SUTURE, 3-0 CHROMIC V20 EHT#G122H $69.90 27001008 SUTURE, 4-0 CHROMIC SH NEEDLE #G121H $72.32 27001009 SUTURE, 3-0 CHROMIC GS24 ETH#912H $69.99 27001010 SUTURE, 4-0 CHROMIC C13 ETH#635H $64.67 27001011 SUTURE, 3-0 PLAINGUT ETH#52T $142.17 27001012 SUTURE, 3-0 CHROMIC GS21 ETH#922H $74.98 27001013 SUTURE, 3-0 VICRYL SH TAPER PT ETH#J416H $39.50 27001014 SUTURE, 3-0 NYLON ETH#669H $46.79 27001015 SUTURE, 4-0 MONOCRYL PS-2 ETH#Y426H $242.48 27001016 SUTURE, 4-0 MONOCRYL PC5 ETH#Y823G $113.22 27001017 SUTURE, 2-0 NYLON ETH#585H $89.70 27001018 SUTURE, 3-0 NYLON C14 ETH#1663G $135.95 27001019 SUTURE, 3-0 NYLON C16 ETH#1671H $50.63 27001020 SUTURE, 4-0 NYLON C13 ETH#1894G $96.65 27001021 SUTURE, 4-0 NYLON C14 ETH#1629H $44.78 27001022 SUTURE, 4-0 NYLON P13 ETH#699G $135.43 27001023 SUTURE, 5-0 NYLON P13 ETH#698H $80.25 27001024 SUTURE, 5-0 NYLON C13 ETH#661G $49.03 27001025 SUTURE, 6-0 NYLON P13 ETH#1698G $100.09 27001026 SUTURE,4-0 PROLENE C-1 NEEDLE ETH#9706H $264.56 27001027 SUTURE, 4-0 VICRYL UNDYED ETH#J422H $114.37 27001028 SUTURE, 4-0 PROLENE PS2 #8682G $133.56 27001029 SUTURE, 7-0 NYLON P16 #1696G $106.95 27001030 SUTURE, 7-0 PROLENE #M8600 $778.01 27001031 SUTURE, 6-0 NYLON P-10 EHT#697G $88.22 27001032 SUTURE, 3-0 PROLENE ETH#8832H $54.76 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27001033 SUTURE, 4-0 PROLENE C13 ETH#8683G $61.83 27001034 SUTURE, 5-0 PROLENE P13 ETH#8618G $127.49 27001035 SUTURE, 2-0 VICRYL CT-1 36INCH #J945H $37.40 27001036 SUTURE, SZ1 PROLENE CT1 ETH#8425H $59.20 27001037 SUTURE, SZ0 PROLENE FSLX #8690H $64.35 27001038 SUTURE, SZ0 PROLENE GS24 EHT#8424H $57.78 27001039 SUTURE, 2-0 PROLENE/SURGIPRO GS22 #8411H $138.24 27001040 SUTURE, 2-0 NYLON ETH#628H $39.09 27001041 SUTURE, 3-0 VICRYL PS-1 ETH#J936H $81.85 27001042 SUTURE, 4-0 SILK TIES ETH#A183H $52.20 27001044 SUTURE, 4-0 SILK POPOFFS ETH#C0145 $136.65 27001045 SUTURE, 3-0 SILK ETH#CO13D $164.90 27001046 SUTURE, SZ0 SILK TIE NO/NDL ETH#SA76G $48.76 27001047 SUTURE, SZ0 SILK FSL ETH#680H $42.77 27001048 SUTURE, 1-0 SILK #S187 $39.96 27001049 SUTURE, 2-0 SILK FS CUTTNG NDLE ETH#685G $41.42 27001050 SUTURE, 2-0 SILK TIES ETH#A185H $36.77 27001051 SUTURE, 2-0 SILK SH ETH#K833H $69.23 27001052 SUTURE, 2-0 VICRYL TIES #J645H $121.81 27001053 SUTURE, 3-0 SILK ETH#SA84H $53.03 27001054 SUTURE, 3-0 SILK SH #K832H $32.68 27001055 SUTURE, 4-0 SILK ETH#683G $37.64 27001056 SUTURE, 5-0 PLAIN PC1 #1915G $141.71 27001057 SUTURE, 3-0 VICRYL TIE #J606H $44.84 27001059 SUTURE, SZ0 VICRYL SH ETH#J418H $84.19 27001060 SUTURE, SZ1 VICRYL CT1 ETH#J341H $40.18 27001061 SUTURE, 2-0 VICRYL V20 ETH#J417H $39.79 27001062 SUTURE, SZ0 VICRYL REEL ETH#J287G $54.23 27001063 SUTURE, SZ0 VICRYL CT-1 ETH#J946H $36.75 27001064 SUTURE, 1-0 VICRYL ETH#J347H $43.15 27001065 SUTURE, 3-0 VICRYL GS24 ETH#J356H $59.13 27001066 SUTURE,2-0 POLYSRB/VICRYL ETH#J269H $42.01 27001067 SUTURE, SZ0 VICRYL CT GS24 ETH#J958H $61.47 27001068 SUTURE,2-0 VICRYL CT-1 NEEDLE #J259H $34.71 27001069 SUTURE, 2-0 VICRYL GS24 ETH#ETVCP357H $44.00 27001070 SUTURE,3-0 VICRYL FS2 ETH#J393H $53.15 27001071 SUTURE,3-0 VICRYL CT-1 NEEDLE #J258H $35.95 27001072 SUTURE, 3-0 VICRYL CT2 #J232H $40.07 27001073 SUTURE, 4-0 VICRYL C14 ETH#J441H $55.36 27001074 SUTURE, SZ2 VICRYL ETH#J618H $43.65 27001075 SUTURE, 3-0 VICRYL CT-1 #J944H $37.27 27001076 SUTURE, 4-0 VICRYL V20 ETHE#J415H $35.78 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27001077 SUTURE, 5-0 VICRYL CV23 ETH#J213H $39.12 27001078 SUTURE, STEEL 5 ETH#ETM653G $286.46 27001079 SUTURE, 4-0 POLYSORB/VICRYL ETH#J662H $49.97 27001080 SYRINGE,140CC PISTON,CATH MONOJ#114055 $54.61 27001082 EZ HOLD MINI #N756 100/BX $893.00 27001083 EZ HOLD STANDARD #N757 100/BX $916.50 27001084 T-PIECE CIRCUIT KIT SIZE 0 $249.09 27001085 T-PIECE CIRCUIT KIT SIZE 1 $243.84 27001086 THORACENTESIS/PARACENTES SET #4653-48 $60.37 27001087 THORACENTESIS W/CATHETER ALLEG#4341B $274.72 27001088 THORACIC CATHETER 20FR KEN#8888570523 $105.36 27001089 THORACIC CATHETER 24FR KEN#8888570531 $101.74 27001090 THORACIC CATHETER 28FR KEN#8888570549 $105.17 27001091 THORACIC CATHETER 36FR KEN#8888570564 $102.94 27001092 THORACIC CATH TROCAR 10FR KEN#8888561019 $264.08 27001093 THORACIC CATH TROCAR 16FR KEN#8888561035 $262.79 27001094 THORACIC CATH TROCAR 12FR KEN#8888561027 $264.08 27001095 THORACIC CATH TROCAR 20FR KEN#8888561043 $265.11 27001096 THORACIC CATH TROCAR 24FR KEN#8888561050 $265.11 27001097 THORACIC CATH TROCAR 28FR KEN#8888561068 $263.47 27001098 THORACIC CATH TROCAR 32FR KEN#8888561076 $263.65 27001099 TOURNIQUET DIGITAL T-RING $142.46 27001100 TOURNIQUET APPLICATION CAT#30-0001 $339.33 27001102 TRACHEOSTOMY TUBE 26FR #4LPC $604.52 27001103 TRACHEOSTOMY TUBE 30FR #6LPC $592.67 27001104 TRACHEOSTOMY TUBE 36FR #8LPC $604.52 27001105 TRACHEOSTOMY TUBE 39FR #10LPC $592.67 27001106 TRACHEOSTOMY TUBE #4.0 PED $449.00 27001107 TRANSDUCER COVER STERILE CIVCO#610367 $212.05 27001108 TRAUMA DRESSING KENDALL#1967 $50.59 27001109 UNDERWATER DRAINAGE SET SINGLE CHAMBER $278.46 27001110 UNDERWATER DRAINAGE SET DUAL CHAMBER $594.47 27001111 UMBILICAL CATHETER 3.5FR #S1UVC-3540 $262.78 27001112 UMBILICAL CATHETER 5FR #S1UVC-540 $233.72 27001113 UNNA BOOT BANDAGE BSN#1053-01 $127.50 27001114 UROMETER, PEDIATRIC 5FR ALLEG#895605 $236.69 27001115 UROMETER W/CL DRAINAGE ML#DYND17403 $147.05 27001116 VACUUM EXTRACTOR KIT $292.50 27001117 VACUUM EXTRACTOR KIWI OMNICUP #6000MT $392.23 27001118 VACUUM EXTRACTOR KIWI PROCUP #6000S $322.70 27001119 VACUTAINERS BLOOD COLLECTION RED/LAVENDR $75.10 27001120 VAGINAL SPECULUM, SMALL WA#59000 $31.93 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27001122 VAGINAL SPECULAM, LARGE WA#59004 $38.36 27001123 VALVE PEEP AMBU#199003020 $52.44 27001124 WALKING PNEU BRACE SM AIRCST#01P-S $784.62 27001125 WALKING PNEU BRACE MD AIRCST#01P-M $784.62 27001126 WALKING PNEU BRACE LG AIRCST#01P-L $784.62 27001127 WOUND DRESSG MAXORB 1X12 ROPE #MSC9412EP $120.53 27001128 WOUND VAC GRANUFOAM SMALL KC#M8275051/10 $401.06 27001129 WOUND VAC GRANUFOAM MED KCI#M8275052/10 $505.70 27001130 WOUND VAC CANISTR W/O GEL KC#M6275071/10 $376.51 27001131 WOUND VAC FREEDOM CANSTR 300ML#320058/10 $391.97 27001132 WOUND VAC Y-CONNECTOR KCI#M6275066/10 $39.66 27001133 WRIST SPLINT, SMALL RIGHT DJ#79-87363 $119.09 27001134 WRIST SPLINT, SMALL LEFT DJ#79-87373 $119.09 27001135 WRIST SPLINT, SM RIGHT W/THUMB #79-87303 $239.25 27001136 WRIST SPLINT, SM LEFT W/THUMB #79-87313 $239.25 27001137 WRIST SPLINT, MED RIGHT DJ#79-87075 $83.78 27001138 WRIST SPLINT, MED LEFT DJ#79-87085 $83.78 27001139 WRIST SPLINT, MED RIGHT W/THUMB#79-87305 $239.25 27001140 WRIST SPLINT, MED LEFT W/THUMB #79-87315 $239.25 27001141 WRIST SPLINT, LG RIGHT DJ#79-87077 $83.78 27001142 WRIST SPLINT, LG LEFT DJ#79-87087 $91.07 27001143 WRIST SPLINT, LG RIGHT W/THUMB #79-87307 $239.25 27001144 WRIST SPLINT, LG LEFT W/THUMB #79-87317 $239.25 27001145 WRIST SPLINT, XLG RIGHT W/THUMB#79-87308 $239.25 27001146 WRIST SPLINT, XLG LEFT W/THUMB #79-87318 $239.25 27001147 WRIST SUPPORT ARTERIAL #29980 $223.90 27001148 XEROFORM DRESSING 5X9 #84-437100 $41.29 27001149 STOCKINETTE IMPERVIOUS MED 8X38 #1585 $63.47 27001150 STOCKINETTE IMPERVIOUS LG 9X48 #1586 $82.87 27001151 CAST PADDING 6 INCH STERILE #KC2944 $72.34 27001152 AERO CHAMBER $160.56 27001153 BIPAP CIRCUIT #582073 $127.14 27001154 ENDOTRACH TUBE HOLDER PEDS#3.5 #H4053 $57.44 27001155 ENDOTRACH TUBE HOLDER PEDS#4 #H4054 $57.44 27001156 ENDOTRACH TUBE HOLDER PEDS#4.5 #H4055 $57.44 27001157 MASK, BIPAP FULL FACE SMALL #1012623 $311.93 27001158 MASK, BIPAP FULL FACE MEDIUM #1012624 $311.93 27001159 MASK, BIPAP FULL FACE LARGE #1012572 $311.93 27001160 MASK, BIPAP NASAL PETITE #1048706 $289.35 27001161 MASK, BIPAP NASAL SMALL #1048705 $289.35 27001162 MASK, BIPAP NASAL MED/LG #1048707 $298.04 27001163 ANGIOGRAPHIC CATHETER SOFT VU#10732703 $414.52 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27001164 ANGIOGRAPHIC CATHETER SOFT VU#10733401 $414.52 27001165 ANGIO PACK CUSTOM $277.15 27001166 ANGIOGRAPHIC CATHETER 5FR #10732701 $414.52 27001167 ABSORBATACK 30 TACK 5MM $3,871.86 27001168 SUTURE PDS PLUS 1 #PDP347H $77.35 27001169 CATHETER STRAIGHT 5FR #H757507229745 $397.65 27001170 SUTURE 2-0 MONOCRYL CT-1 #MCP945H $131.34 27001171 SUTURE 4-0 MONOCRYL PS-1 #MCP935H $150.92 27001172 SUTURE 1 PDS XLH #PDP877G $122.07 27001173 VLOC WOUND CLOSURE 2-0 V20 VIOLET $389.70 27001174 SUTURE, SZ0 VICRYL CT-1 #J946H $40.82 27001175 SUTURE, SZ0 VICRYL CT-2 #J334H $39.51 27001176 SUTURE, 4-0 SILK POPOFFS #C0145 $136.65 27001177 ANTEGRADE TUNNELER CUSTOM KIT #K14-00046 $1,295.64 27001178 CATHETER MINI RIM 5FR #H787507229975 $397.65 27001179 CATHETER HEADHUNTER 4FR #H787107140275 $414.52 27001180 CATHETER VAN ANDEL DILATION #G01391 $597.40 27001181 CATHETER PERITONEAL DIALYSIS SMALL #CF-5250 $1,231.92 27001182 COBAN, 4 INCH STERILE 3M#M2084S $53.49 27001183 LINEAR STAPLER #TA9035S $2,601.83 27001184 LINEAR STAPLER RELOAD #TA9035L $1,382.83 27001185 FIBULAR PLATE CLUSTER 9 HOLE ANATOMICAL LEFT $9,322.00 27001186 DRILL 2.4X140MM SOLID MEASURING LONG AO $1,775.31 27001187 OLIVE WIRE SMOOTH 1.4MM $1,278.40 27001188 R3CON LOCKING PLATE SCREW 3.5X12MM $1,865.58 27001189 R3CON LOCKING PLATE SCREW 3.5X14MM $1,865.58 27001190 FLEX NECK CLASSIC PD CATHETER #CF-5260 $1,231.92 27001191 UNIVERSAL TUBING ADAPTER #4992307 $494.05 27001192 SUTURE, 3-0 MONOCRYL PS-2 #Y427H $133.25 27001194 ESMARK BANDAGE 6INX3YD STERILE #820-3609 $48.76 27001195 BALLOON DILATATION CATHETER PTA 16X4 $2,407.20 27001196 VIABAHN STENT 7X100MM #VBCR071002A $11,742.00 27001197 VIABAHN STENT 7X50MM #VBCR070502A $10,882.00 27001198 Salem Sump 10fr $32.76 27001199 SALEM SUMP, 12FR #8888264929 $32.76 27001201 ENDO GIA 45MM RELOAD MED THICK PURPLE #EGIA45AMT $3,637.77 27001202 ENDO GIA 60MM RELOAD MED THICK PURPLE #EGIA60AMT $3,961.12 27001203 LINEAR STAPLER RELOAD THICK #XR30G $547.68 27001206 LARYNGOSCOPE BLADE 4 GLIDESCOPE $482.00 27001207 LARYNGOSCOPE BLADE 3 GLIDESCOPE $482.00 27001208 LARYNGOSCOPE BLADE 2 GLIDESCOPE $512.20 27001209 LARYNGOSCOPE BLADE 1 GLIDESCOPE $512.20 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 27001210 HIGH FLOW CIRCUIT VAPOTHERM $958.80 27001211 LOW FLOW CIRCUIT VAPOTHERM $958.80 27001212 HIGH FLOW ADULT CANNULA VAPOTHERM $113.01 27001213 PEDIATRIC/ADULT SMALL CANNULA VAPOTHERM $113.01 27001214 PEDIATRIC SMALL CANNULA VAPOTHERM $113.01 27001215 INFANT CANNULA VAPOTHERM $141.26 27001216 NEONATAL CANNULA VAPOTHERM $141.26 27001217 STERILE WATER 1000ML BAG $35.31 27099999 OXYGEN PER DAY CHARGE $471.00 30036415 COLLECTION: Venous Draw $99.00 $99.00 $26.00 30080183 Oxcarbazepine Level Lab NAH $196.00 30080320 Ethanol Level $120.00 $74.70 30080320 Ethanol Level Lab NAH $120.00 30080329 Acetaminophen Level $481.00 $70.40 30080329 Acetaminophen Level Lab NAH $481.00 30082024 Adrenocorticotropic Hormone NAH $458.00 30082040 Albumin Level $120.00 $25.09 30082040 Albumin Level NAH $120.00 30082042 Albumin CSF NAH $31.00 30082042 Albumin Pericardial Fluid NAH $31.00 30082042 Albumin Peritoneal Fluid NAH $31.00 30082042 Albumin Pleural Fluid NAH $31.00 30082042 Albumin Synovial Fluid NAH $31.00 30082088 Aldosterone NAH $327.00 30082274 Occult Blood Screening 1 - 3 Standard $93.00 $70.77 30082375 Carboxyhemoglobin NAH $98.00 30082525 Copper Level NAH $150.00 30082803 Arterial Blood Gas Standard $275.00 $75.00 30082803 Arterial Cord Blood Gas Standard $275.00 30082803 Capillary Blood Gas Standard $275.00 30082803 Venous Cord Blood Gas Standard $275.00 30082805 Venous Blood Gas Standard $112.77 $75.00 30082945 Glucose Body Fluid $120.00 30083010 Haptoglobin NAH $123.00 30083516 Centromere Ab IgG NAH $110.00 30083520 Antiglomerular Basement Membrane Ab NAH $327.00 30083520 Antimullerian Hormone NAH $294.00 30083986 pH Body Fluid $71.00 $25.46 30084146 Prolactin Level NAH $55.53 30084165 84165 NAH $196.00 30084165 Protein Electrophoresis NAH $196.00 30084207 Vitamin B6 Level NAH $314.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30084244 Renin Activity NAH $327.00 30084445 Thyroid Stimulating Immunoglobulin NAH $188.00 30084633 Flu A & B $74.00 30085007 .Manual Differential (57) $98.00 30085007 Manual Differential NAH $98.00 30085007 Manual Differential Standard $98.00 $25.09 30085009 FLUID DIFFERENTIAL $98.00 30085018 HEMOGLOBIN REF LAB ADD-ON $50.00 30085018 Hemoglobin $50.00 $19.68 30085025 CBC Peds-Neonate NAH $232.00 30085025 CBC Standard $232.00 $27.51 30085025 Complete Blood Count with Diff NAH $232.00 30085027 Hemogram NAH $232.00 30085027 Hemogram Standard $232.00 $23.62 30085032 BLOOD COUNT, MANUAL CELL COUNT $162.00 30085032 CSF Cell Count 10 $50.00 30085032 WBC Manual $50.00 $19.68 30085045 Reticulocyte Count, Auto NAH $196.00 30085048 White Blood Count $39.00 $19.68 30085230 Factor VII Assay NAH $66.00 30085250 Factor IX Assay NAH $71.00 30085300 Antithrombin III Assay NAH $210.00 30085384 Fibrinogen $320.00 $55.07 30085384 Fibrinogen Level Lab NAH $320.00 30085610 PT with INR NAH $187.00 30085610 Prothrombin Time $187.00 $25.14 30085730 Partial Thromboplastin Time $132.00 $40.79 30085730 Partial Thromboplastin Time NAH $132.00 30086021 Antineutrophil Cytoplasmic Antigen NAH $436.00 30086038 ANA Cascade NAH $109.00 30086038 Antinuclear Antibody Screen NAH $109.00 30086038 Antinuclear Antibody Screen w/ Reflex to Complete NAH $109.00 30086039 86039 NAH $109.00 30086140 C-Reactive Protein NAH $234.00 30086141 C Reactive Protein HS NAH $97.00 30086160 C3 Complement NAH $166.00 30086225 Double Stranded DNA Ab NAH $144.00 30086225 dsDNA Ab with Reflex IgG NAH $325.00 30086235 RNP Ab IgG NAH $164.00 30086235 Sm Ab IgG NAH $164.00 30086300 Cancer Antigen 15 3 NAH $157.00 30086301 Carbohydrate Antigen 19 9 NAH $170.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30086304 Cancer Antigen 125 NAH $172.00 30086334 86334 NAH $157.00 30086334 Immunofixation NAH $157.00 30086335 Immunofixation Urine NAH $211.00 30086336 86336 NAH $55.00 30086361 Lymphocyte Subset Panel 5 NAH $262.00 30086430 Rheumatoid Factor. $202.09 30086431 Rheumatoid Factor NAH $65.00 30086480 Quantiferon TB Gold NAH $392.00 30086592 Rapid Plasma Reagin Test NAH $69.00 30086592 Rapid Plasma Reagin Titer NAH $413.40 30086648 Diphtheria Toxoid IgG Antibody NAH $392.00 30086703 HIV 1/2, Rapid $242.00 $125.00 30086756 Respiratory Syncytial Virus $268.00 $141.75 30086778 86778 NAH $196.00 30086850 Antibody Screen Gel $218.00 30086900 BB ABORH Pt NAH $108.00 30087040 Bld Cult Aero Peds $210.00 30087040 Blood Culture Bactec $210.00 30087040 Blood Culture NAH $210.00 30087040 Body Fluid Culture Extended NAH $284.00 30087040 Body Fluid Culture NAH $284.00 30087070 CSF Culture NAH $284.00 30087070 Environmental Culture NAH $284.00 30087070 Respiratory Culture Lower NAH $284.00 30087070 Respiratory Culture Upper NAH $284.00 30087070 Tissue/Bone Culture Extended NAH $284.00 30087070 Tissue/Bone Culture NAH $284.00 30087070 Wound Culture Deep NAH $284.00 30087081 Group A Beta Strept Culture NAH $284.00 30087081 Group B Beta Strept Culture NAH $109.00 30087081 Rapid Urease $109.00 $43.68 30087101 Fungal Culture (Hair, Skin, Nails) NAH $327.00 30087102 Fungal Culture (Tissue, Resp, Body Fluid) NAH $78.00 30087116 Mycobacterium Culture Blood NAH $52.00 30087116 Mycobacterium Culture Misc source NAH $52.00 30087172 Pinworm Prep $85.00 $35.38 30087177 Ova and Parasites Stool NAH $171.00 30087206 AFB Direct Smear NAH $61.00 30087210 Wet Mount $71.00 30087255 Herpes Simplex Culture NAH $183.00 30087327 Cryptococcal Antigen NAH $209.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30087425 Rotaviral Antigen NAH $185.00 30087449 Legionella Antigen Urine NAH $262.00 30087486 87486 $52.00 30087486 Respiratory Panel NAH $52.00 30087500 87500 NAH $57.00 30087507 87507 $52.00 30087507 C diff Toxin by PCR NAH $70.00 30087522 Hepatitis C RNA PCR Quantitative NAH $474.00 30087529 87529 $57.00 30087532 87532 $57.00 30087536 HIV 1 RNA PCR Quantitative NAH $315.00 30087581 87581 NAH $52.00 30087633 87633 $52.00 30087640 87640 NAH $196.00 30087640 NON-MRSA SCREEN $196.00 30087640 MRSA Nasal PCR $196.00 $39.31 30087640 MRSA/SA Nasal Screen $196.00 30087641 87641 NAH $57.00 30087650 Streptococcus Group A DNA NAH $81.00 30087651 87651 NAH $57.00 30087653 87653 NAH $57.00 30087653 Strep Group B by PCR NAH $57.00 30087798 87498 $57.00 30087798 87798 NAH $57.00 30087798 Blood Culture PCR - GPC NAH $130.00 30087798 Blood Culture PCR - Yeasts NAH $130.00 30087798 Blood Culture PCR-GNR NAH $130.00 30087801 87801 NAH $57.00 30087880 Group A Strep by PCR $120.00 30087880 Rapid Strep Test Standard $120.00 $68.82 30089051 Body Fluid Cell Count Manual $22.50 30089051 Body Fluid Cell Count Standard $22.50 $25.09 30089051 Cell Count Body Fluid NAH $22.50 30089055 Fecal Leukocytes $111.00 $25.09 30089060 Body Fluid Crystals $202.00 30089060 Crystal Exam Synovial Fluid NAH $202.00 30089190 Eosinophil Count- Nasal $71.00 30089310 Sperm Count (post vasectomy) $71.00 $57.01 30099000 Bill Urine Drug Scrn Legal $98.00 30099001 Bill Handling Charge $98.00 30180048 Basic Metabolic Panel NAH $409.00 30180048 Basic Metabolic Panel Standard $409.00 $29.19 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30180051 Electrolyte Panel NAH $314.00 30180051 Electrolyte Panel Standard $314.00 $26.82 30180053 Comprehensive Metabolic Panel Standard $601.00 $31.76 30180053 Comprehensive Metabolic Panel NAH $601.00 30180061 Lipid Panel NAH $280.00 30180061 Lipid Panel Standard $280.00 $69.93 30180061 Lipid Panel Standard, Non-Fasting $280.00 30180069 Renal Function Panel Standard $458.00 $30.56 30180069 Renal Panel NAH $458.00 30180074 Hepatitis Acute Panel NAH $484.00 30180076 Hepatic Function Panel NAH $589.00 30180076 Hepatic Function Panel Standard $589.00 $28.61 30180156 Carbamazepine Level $306.00 $78.64 30180156 Carbamazepine Level Lab NAH $306.00 30180162 Digoxin Level $254.00 $73.02 30180162 Digoxin Level Lab NAH $254.00 30180164 Valproic Acid Level $373.00 $118.75 30180164 Valproic Acid Level Lab NAH $373.00 30180170 Gent Lvl Peak $196.00 30180170 Gent Lvl Trough $196.00 30180170 Gentamicin Level Lab NAH $196.00 30180170 Gentamicin Level Peak Lab NAH $196.00 30180170 Gentamicin Level Trough Lab NAH $196.00 30180170 Gentamicin Lvl Random $196.00 $112.03 30180177 Levetiracetam Level NAH $104.48 30180178 Lithium Level $187.00 $51.13 30180178 Lithium Level Lab NAH $187.00 30180184 Phenobarbital Level $280.00 $88.46 30180184 Phenobarbital Level Lab NAH $280.00 30180185 Phenytoin Lvl $280.00 $80.01 30180197 FK506 NAH $327.00 30180198 Theophylline Level $228.00 $70.77 30180200 Tobramycin Level NAH $146.00 30180200 Tobramycin Level Peak NAH $146.00 30180200 Tobramycin Level Trough NAH $146.00 30180200 Topiramate Level Lab NAH $146.00 30180202 Vancomycin Level Lab NAH $501.00 30180202 Vancomycin Level Peak NAH $501.00 30180202 Vancomycin Level Trough NAH $501.00 30180202 Vancomycin Lvl Peak 1 $501.00 30180202 Vancomycin Lvl Random $501.00 30180202 Vancomycin Lvl Trough 1 $501.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30180299 Lamotrigine Level Lab NAH $302.00 30180307 Drug Screen Meconium NAH $259.50 30180307 Urine Drug Screen Standard $13.00 $74.77 30180329 Salicylate Level $120.00 $75.60 30180329 Salicylate Level Lab NAH $120.00 30182009 Ketone Serum $97.00 $27.51 30182043 Microalbumin 24 Hour Urine NAH $98.00 30182043 Microalbumin Urine NAH $98.00 30182105 82105 NAH $196.00 30182105 AFP Maternal Serum Screen 4 NAH $196.00 30182105 Alpha Fetoprotein Tumor Marker NAH $306.00 30182140 Ammonia Level $169.00 $112.03 30182140 Ammonia Level NAH $169.00 30182150 Amylase Level $187.00 $39.32 30182150 Amylase NAH $187.00 30182232 Beta 2 Microglobulin NAH $159.00 30182247 Bilirubin Total $120.00 $25.09 30182247 Bilirubin Total NAH $120.00 30182247 Neonatal Bilirubin 1 $120.00 30182248 82248 NAH $120.00 30182248 Bilirubin Direct $120.00 $25.09 30182248 Bilirubin Direct NAH $120.00 30182274 Fecal Occult Blood, Immunochemical NAH $196.00 30182310 Calcium Level Lab NAH $120.00 30182310 Calcium Level Total $120.00 $25.09 30182374 Carbon Dioxide Level $120.00 $25.09 30182378 Carcinoembryonic Antigen NAH $361.00 30182435 Chloride Level $110.00 $25.09 30182436 82436 NAH $120.00 30182436 Chloride Level Urine $120.00 $25.09 30182465 Cholesterol Total $120.00 $25.09 30182465 Cholesterol Total NAH $120.00 30182523 Beta-CTx NAH $250.00 30182533 Cortisol NAH $168.00 30182550 Cardiac Panel Standard $187.00 30182550 Creatine Kinase $187.00 $25.46 30182550 Creatine Kinase NAH $187.00 30182553 CPK-MB $271.00 30182553 CPK MB Isoenzyme NAH $271.00 30182553 Creatine Kinase-MB $271.00 $76.65 30182565 Creatinine $120.00 $25.09 30182565 Creatinine NAH $120.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30182570 Creatinine Level 24 Hr Ur Standard $120.00 $39.32 30182570 Creatinine Level Urine $120.00 $37.38 30182575 Creatinine Clearance 12 Hour Urine NAH $120.00 30182575 Creatinine Clearance Corrected NAH $120.00 30182575 Creatinine Clearance Standard $120.00 $59.37 30182607 Vitamin B12 Level NAH $149.00 30182652 Vitamin D 25 Hydroxy Total NAH $523.00 30182670 Estradiol Level Lab NAH $157.00 30182672 Estrogen Level Lab NAH $392.00 30182677 82677 NAH $262.00 30182677 Estriol Level Lab NAH $262.00 30182728 Ferritin Level Lab NAH $201.00 30182731 Fetal Fibronectin 2 $640.00 30182746 Folate Level NAH $144.00 30182747 Red Blood Cell Folate NAH $131.00 30182784 Immunoglubulin Panel NAH $78.00 30182785 82785 NAH $164.00 30182947 .GTT 2Hr Post Prandial $120.00 30182947 Glucose 1 Hour $120.00 30182947 Glucose 2 Hour $120.00 30182947 Glucose 3 Hour $120.00 30182947 Glucose 30 Minutes $120.00 30182947 Glucose 4 Hour $120.00 30182947 Glucose Cerebrospinal Fluid $120.00 30182947 Glucose Fasting $120.00 30182947 Glucose Fasting NAH $120.00 30182947 Glucose Level $120.00 $25.09 30182947 Glucose Level Lab NAH $120.00 30182948 82962 ACCU CHECK CHARGE $22.00 30182948 Blood Glucose Monitoring POC $22.00 30182977 Gamma Glutamyl Transferase $120.00 $25.09 30182977 Gamma Glutamyl Transferase NAH $120.00 30183001 Follicle Stimulating Hormone NAH $138.00 30183002 Luteinizing Hormone NAH $142.00 30183036 Hemoglobin A1c. $167.00 30183036 Hemoglobin A1c $167.00 $70.40 30183036 Hemoglobin A1c NAH $167.00 30183090 Homocysteine Total NAH $196.00 30183516 Celiac Disease AB Panel NAH $247.00 30183519 IGF Binding Protein-3 NAH $209.00 30183525 Insulin Level NAH $105.00 30183540 Iron Level Lab NAH $26.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30183540 Iron Sat Panel NAH $26.00 30183550 83550 NAH $39.00 30183550 Iron Binding Capacity Total NAH $39.00 30183605 Lactic Acid $330.00 $102.06 30183605 Lactic Acid NAH $330.00 30183615 Lactate Dehydrogenase $120.00 $25.09 30183615 Lactate Dehydrogenase NAH $120.00 30183630 Lactoferrin Fecal Qualitative NAH $327.00 30183690 Lipase Level $161.00 $47.67 30183690 Lipase Level NAH $161.00 30183718 Cholesterol High Density Lipid $120.00 $47.25 30183718 Cholesterol High Density Lipid NAH $120.00 30183721 Cholesterol Low Density Lipids $78.00 $49.14 30183721 Cholesterol Low Density Lipid Direct NAH $78.00 30183735 Magnesium Level $120.00 $25.46 30183735 Magnesium Level Lab NAH $120.00 30183789 Iodine, Serum NAH $298.65 30183880 Blood Urea Nitrogen NAH $120.00 30183880 Brain Natriuretic Peptide (BNP) $310.00 $171.46 30183880 NT Pro-BNP $310.00 30183880 NT proBNP NAH $310.00 30183883 83883 NAH $327.00 30183883 Kappa Lambda Light Chains Free/Ratio NAH $895.00 30183921 Methylmalonic Acid Serum NAH $327.00 30183930 Osmolality Urine NAH $98.00 30183970 PTH Intact NAH $392.00 30184075 Alkaline Phosphatase $140.00 30184080 Alkaline Phosphatase Isoenzymes NAH $165.00 30184100 Phosphorus Level $120.00 $25.09 30184100 Phosphorus Level Lab NAH $120.00 30184112 ROM Test $294.33 30184132 Potassium Level $120.00 $25.09 30184132 Potassium Level Lab NAH $120.00 30184133 Potassium Level Urine $120.00 $25.09 30184134 Pre Albumin NAH $196.00 30184144 Progesterone Level Lab NAH $196.00 30184145 Procalcitonin NAH $458.00 30184153 PSA Annual Screen $330.00 $99.75 30184153 PSA Total NAH $330.00 30184153 Prostate Specific Antigen $330.00 $99.75 30184154 Prostate Specific Antigen Free/Total NAH $279.00 30184155 84155 NAH $120.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30184155 Protein Body Fluid $120.00 30184155 Protein Total $120.00 $25.09 30184155 Protein Total NAH $120.00 30184156 Protein 24 Hr Ur Standard $120.00 30184156 U Protein Level $120.00 $25.09 30184157 Protein Cerebrospinal Fluid $196.00 30184166 84166 NAH $131.00 30184166 Protein Electrophoresis Urine NAH $131.00 30184295 Sodium Level $120.00 $25.09 30184295 Sodium Level Lab NAH $120.00 30184300 84300 NAH $76.00 30184300 Sodium Level 24 Hour Urine NAH $55.00 30184300 Sodium Level Urine $76.00 $25.09 30184305 Insulin-Like Growth Factor-1 LC-MS NAH $471.00 30184402 Testos Free and Total NAH $93.00 30184403 Testosterone Total NAH $294.00 30184425 Thiamine Level Lab NAH $392.00 30184432 Thyroglobulin NAH $131.00 30184436 T4 NAH $250.80 $250.80 30184439 Free T4 $330.00 $98.28 30184439 Thyroxine Free NAH $330.00 30184443 TSH w/ Reflex to Free T4 $232.00 30184443 Thyroid Stimulating Hormone $232.00 $56.70 30184443 Thyroid Stimulating Hormone NAH $120.00 30184443 Thyroid-stimulating Hormone NAH $232.00 30184450 Aspartate Aminotransferase $120.00 $25.09 30184450 Aspartate Aminotransferase NAH $120.00 30184460 Alanine Aminotransferase $120.00 $25.09 30184466 Transferrin NAH $129.00 30184478 Triglyceride NAH $120.00 30184478 Triglycerides $120.00 $25.09 30184480 T3 (Triiodothyronine), Total, Serum NAH $44.40 30184481 T3 Free NAH $320.00 30184482 T3 Reverse NAH $425.00 30184484 TROPONIN I $261.00 30184484 Troponin I $261.00 $75.60 30184520 Blood Urea Nitrogen $120.00 $25.09 30184540 Urea Level Urine $120.00 $37.38 30184550 Uric Acid $120.00 $25.09 30184550 Uric Acid NAH $120.00 30184681 C Peptide NAH $147.00 30184702 BHCG Quantitative NAH $301.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30184702 hCG Quantitative $301.00 $52.42 30184703 BHCG Qualitative NAH $294.00 30184703 Pregnancy Test Serum Reflex Quant $294.00 30184703 Serum Pregnancy Test $294.00 $57.80 30186645 Cytomegalovirus Antibody NAH $235.00 30187798 Rapid Strep C/G Ag Screen $120.00 30286200 Cyclic Citrullinated Peptide Antibody NAH $196.00 30286235 86235 NAH $196.00 30286235 Sjogrens Ab SSA SSB NAH $170.00 30286300 CA 27 29 NAH $183.00 30286318 Mono Spot $160.00 $40.32 30286318 Mononucleosis Screen NAH $160.00 30286318 Rapid Mono Screen Standard $160.00 30286376 Antithyroid Peroxidase Antibody NAH $136.00 30286635 86635 NAH $123.00 30286635 Coccidioides Antibodies NAH $123.00 30286635 Coccidioides Antibody NAH $123.00 30286665 86665 NAH $294.00 30286665 Epstein Barr Panel NAH $294.00 30286694 HSV Ab IgM by IFA NAH $262.00 30286695 86695 NAH $49.00 30286696 86696 NAH $71.70 30286704 Hepatitis B Core Antibody (Total) NAH $116.00 30286705 Hepatitis B Core Ab IgM Acute Titer NAH $116.00 30286706 Hepatitis B Surface Antibody NAH $110.00 30286707 Hepatitis Be Antibody NAH $131.00 30286708 Hepatitis A Antibody (Total) NAH $141.00 30286709 Hepatitis A Antibody IgM Acute Titer NAH $116.00 30286735 Mumps IgG Level NAH $164.00 30286762 Rubella IgG Level NAH $131.00 30286765 Rubeola IgG Level NAH $177.00 30286777 Toxoplasmosis Antibodies NAH $392.00 30286787 Varicella Zoster IgG NAH $131.00 30286803 Hepatitis C Antibody NAH $209.00 30585014 HEMATOCRIT (HCT) ADD-ON $50.00 30585014 Hematocrit $50.00 $19.68 30585014 Hematocrit NAH $50.00 30585018 Hemoglobin NAH $50.00 30585032 RBC Count $50.00 $19.68 30585041 Red Blood Cell Count NAH $26.00 30585049 Platelet Count $68.00 $19.68 30585049 Platelet Count, auto NAH $68.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 30585379 D-Dimer $320.00 $103.95 30585461 Fetal Fibronectin NAH $640.00 30585651 Sed Rate (ESR) $100.00 $27.51 30585651 Sedimentation Rate NAH $100.00 30687040 Blood Culture Positive NAH $133.00 30687045 Stool Culture NAH $131.00 30687070 Wound Culture Superficial NAH $284.00 30687081 MRSA Culture Screen NAH $284.00 30687086 Urine Culture NAH $274.00 30687205 Gram Stain 2 $104.00 $29.50 30687210 KOH Prep $71.00 $25.09 30687329 Giardia Crypto Ag Fecal NAH $209.00 30687338 Helicobacter Pylori Antigen Stool NAH $327.00 30687340 Hepatitis B Surface Antigen NAH $223.00 30687493 C Diff Toxin B $196.00 30687502 87502 NAH $196.00 30687517 Hepatitis B Virus DNA Quant NAH $325.00 30687529 Herpes Simplex Virus By PCR NAH $491.00 30687556 87556 $157.00 30687556 Mycobacterium tuberculosis PCR NAH $273.00 30687591 87591 NAH $249.00 30687591 Gonorrhea/Chlamydia Panel NAH $249.00 30687641 MRSA Nares by PCR NAH $196.00 30687641 MRSA PCR $196.00 $46.80 30687641 MRSA Screen (GeneXpert) $196.00 30687641 MRSA/SA Skin and Soft Tissue Infection (GeneXpert) $196.00 30687798 B Pertussis DNA NAH $222.00 30687902 Hepatitis C Genotyping NAH $1,059.00 30781000 UA Micro Standard $132.00 30781000 Urinalysis Standard $132.00 $31.07 30781000 Urinalysis w Mandatory Microscopic $132.00 30781000 Urinalysis with Culture, if indicated Standard $132.00 30781000 Urinalysis with Microscopic, if indicated Standard $132.00 30781002 Urinalysis Dipstick Only Standard $66.00 $24.09 30781025 BHCG Qualitative (U) NAH $228.00 30781025 Pregnancy Test Urine Reflex Quant $228.00 30781025 Urine Pregnancy Test $228.00 $45.20 30981256 Hemochromatosis DNA NAH $545.00 30986807 REF Antibody ID $346.25 31288331 88331 Bill SPEC A SECTION 1 $100.00 31288331 88331 Bill SPEC B SECTION 1 $100.00 31288332 88332 Bill SPEC A SECTION 2 $83.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 31288332 88332 Bill SPEC B SECTION 2 $83.00 32070030 XR Eye for Foreign Body $438.00 32070100 XR Mandible Partial Less Than 4 Views $586.00 32070110 XR Mandible Complete Minimum 4 Views $753.00 32070150 XR Facial Bones Minimum 3 Views $753.00 32070160 XR Nasal Bones Minimum 3 Views $528.00 32070220 XR Sinuses Paranasal Complete $826.00 32070250 XR Skull < 4 Views $564.00 32070360 XR Neck Soft Tissue $462.00 32071101 XR Ribs Min 3 Views Left w/ PA Chest $623.00 32071101 XR Ribs Min 3 Views Right w/ PA Chest $623.00 32071111 XR Ribs Min 4 Views Bilateral $798.00 32071120 XR Sternum Minimum 2 Views $471.00 32072020 XR Spine 1 View Lumbar $274.00 32072020 XR Spine Single View Specify Level $274.00 32072040 XR Spine Cervical 2 or 3 Views $469.00 32072050 XR Spine Cervical 4 or 5 Views $621.00 32072052 XR Spine Cervical 6 or More Views $763.00 32072070 XR Spine Thoracic 2 Views $588.00 32072074 XR Spine Thoracic Minimum 4 Views $957.00 32072080 XR Spine Thoracolumbar 2 Views $469.00 32072081 XR Spine Thoracolumbar Standing $248.48 32072100 XR Spine Lumbosacral 2 or 3 Views $623.00 32072110 XR Spine Lumbosacral Minimum 4 Views $957.00 32072114 XR Spine Lumbosacral Complete w/ Bending $1,313.00 32072120 XR Spine Lumbosacral Bending Only $338.00 32072170 XR Pelvis 1 or 2 Views $462.00 32072190 XR Pelvis Complete Minimum 3 Views $457.84 32072202 XR Sacroiliac Joints Minimum 3 Views $457.84 32072220 XR Sacrum/Coccyx Minimum 2 Views $509.00 32073000 XR Clavicle Left $425.00 32073000 XR Clavicle Right $425.00 32073010 XR Scapula Left $488.00 32073010 XR Scapula Right $488.00 32073020 XR Shoulder 1 View Left $456.00 32073020 XR Shoulder 1 View Right $456.00 32073030 XR Shoulder 3 Views Left $462.00 32073030 XR Shoulder 3 Views Right $462.00 32073050 XR AC Joints w/ or w/o weights Bilateral $619.00 32073060 XR Humerus Left $462.00 32073060 XR Humerus Right $462.00 32073070 XR Elbow 2 Views Left $259.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 32073070 XR Elbow 2 Views Right $259.00 32073080 XR Elbow Complete Right $462.00 32073080 XR Elbow Complete Right $462.00 32073090 XR Forearm 2 Views Left $264.00 32073090 XR Forearm 2 Views Right $264.00 32073100 XR Wrist 2 Views Left $391.00 32073100 XR Wrist 2 Views Right $391.00 32073110 XR Wrist Complete Left $395.00 32073110 XR Wrist Complete Right $395.00 32073120 XR Hand 2 Views Left $391.00 32073120 XR Hand 2 Views Right $391.00 32073130 XR Hand Complete Left $395.00 32073130 XR Hand Complete Right $395.00 32073140 XR Finger Left $256.00 32073140 XR Finger Right $256.00 32073501 XR Hip 1 View Left $387.00 32073501 XR Hip 1 View Right $387.00 32073502 XR Pelvis/Hip Unilateral Left $537.00 32073502 XR Pelvis/Hip Unilateral Right $537.00 32073551 XR Femur 1 View Left $344.00 32073551 XR Femur 1 View Right $344.00 32073552 XR Femur 2 Views Left $517.00 32073552 XR Femur 2 Views Right $517.00 32073560 XR Knee One or Two Views Left $375.00 32073560 XR Knee One or Two Views Right $375.00 32073562 XR Knee 3 Views Left $524.00 32073562 XR Knee 3 Views Right $524.00 32073564 XR Knee Complete Left $883.00 32073564 XR Knee Complete Right $883.00 32073565 XR Knee Standing AP Bilateral $292.00 32073590 XR Tibia/Fibula 2 Views $375.00 32073590 XR Tibia/Fibula 2 Views $375.00 32073600 XR Ankle 2 Views Left $434.00 32073600 XR Ankle 2 Views Right $434.00 32073610 XR Ankle Complete Left $608.00 32073610 XR Ankle Complete Right $608.00 32073620 XR Foot 2 Views Left $375.00 32073620 XR Foot 2 Views Right $375.00 32073630 XR Foot Complete Left $449.00 32073630 XR Foot Complete Right $449.00 32073650 XR Calcaneus Left $375.00 32073650 XR Calcaneus Right $375.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 32073660 XR Toes Left $347.00 32073660 XR Toes Right $347.00 32074000 XR Abdomen 1 View $608.00 32074019 XR Abdomen 2 View $656.00 32074022 XR Abdomen Series w/ Chest1 View $804.00 32074300 XR Cholangiogram in OR $1,091.00 32076000 XR Fluoroscopy Up to 1 Hour $273.00 32076000 XR Fluoroscopy Up to 1 Hour EO $273.00 32076001 XR Fluoroscopy Over 1 Hour $196.00 32076001 XR Fluoroscopy Over 1 Hour EO $196.00 32077072 XR Bone Age Studies $392.00 32077075 XR Bone Survey Complete $704.00 32077076 XR Bone Survey Infant $704.00 32471035 XR Chest Special Views $509.00 32471045 XR Chest 1 View $456.00 32471046 XR Chest 2 Views $477.00 35070492 CT Soft Tissue Neck w/ + w/o Contrast $4,433.00 35071275 CT PE Chest w/ Contrast $4,259.00 35074175 CT Angiography Abdomen w/ + w/o Contrast $2,224.00 35074176 74176 ADD-ON $6,416.00 35074176 CT Abdomen/Pelvis w/o Contrast $6,416.00 35074177 74177 ADD-ON $6,416.00 35074177 CT Abdomen/Pelvis w/ Contrast $6,416.00 35074178 CT Abdomen/Pelvis w + w/o Contrast $6,416.00 35170450 CT Head or Brain w/o Contrast $3,657.00 35170460 CT Head or Brain w/ Contrast $3,834.00 35170470 CT Head or Brain w/ + w/o Contrast $4,446.00 35170480 CT Orbit Sella etc. w/o Contrast $3,597.00 35170481 CT Orbit Sella etc. w/ Contrast $3,771.00 35170482 MRI Brain w/ + w/o Contrast $4,397.00 35170486 CT Maxillofacial w/o Contrast $3,665.00 35170486 CT Sinus $3,665.00 35170487 CT Maxillofacial w/ Contrast $3,771.00 35170488 CT Maxillofacial w/ + w/o Contrast $4,393.00 35170496 CT Angiography Head w/ + w/o Contrast $2,224.00 35170498 CT Angiography Neck W/WO Contrast $2,224.00 35270490 CT Soft Tissue Neck w/o Contrast $4,211.00 35270491 CT Soft Tissue Neck w/ Contrast $4,658.00 35271250 71250 ADD-ON $4,211.00 35271250 CT Chest W/O Contrast $4,211.00 35271250 CT Chest/Abd/Pel w/o Contrast $4,211.00 35271250 CT Chest/Abdomen w/o Contrast $4,211.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 35271260 71260 ADD-ON $4,421.00 35271260 CT Chest W/Contrast $4,421.00 35271260 CT Chest/Abdomen w/Contrast $4,421.00 35271270 CT Chest W/WO Contrast $5,060.00 35271275 CT Angiography Chest W/WO Contrast $4,259.00 35272125 CT Spine Cervical w/o Contrast $4,550.00 35272126 CT Spine Cervical w/ Contrast $4,579.00 35272127 CT Spine Cervical w/ + w/o Contrast $4,874.00 35272128 CT Spine Thoracic w/o Contrast $4,874.00 35272129 CT Spine Thoracic w/ Contrast $4,579.00 35272130 CT Spine Thoracic w/ + w/o Contrast $4,874.00 35272131 CT Spine Lumbar w/o Contrast $4,646.00 35272132 CT Spine Lumbar w/ Contrast $4,579.00 35272133 CT Spine Lumbar w/ + w/o Contrast $4,646.00 35272192 CT Pelvis w/o Contrast $4,622.00 35272193 CT Pelvis w/ Contrast $4,833.00 35272194 CT PELVIS; W & WO CONTR $758.20 35273200 CT Elbow w/o Contrast Left $2,978.00 35273200 CT Elbow w/o Contrast Right $2,978.00 35273200 CT Forearm w/o Contrast Left $2,978.00 35273200 CT Forearm w/o Contrast Right $2,978.00 35273200 CT Hand w/o Contrast Left $2,978.00 35273200 CT Hand w/o Contrast Right $2,978.00 35273200 CT Humerus w/o Contrast Left $2,978.00 35273200 CT Humerus w/o Contrast Right $2,978.00 35273200 CT Shoulder w/o Contrast Left $2,978.00 35273200 CT Shoulder w/o Contrast Right $2,978.00 35273200 CT Upper Extremity w/o Contrast Left $2,978.00 35273200 CT Upper Extremity w/o Contrast Right $2,978.00 35273200 CT Wrist w/o Contrast Left $2,978.00 35273200 CT Wrist w/o Contrast Right $2,978.00 35273201 CT Elbow w/ Contrast Left $3,756.00 35273201 CT Elbow w/ Contrast Right $3,756.00 35273201 CT Forearm w/ Contrast Left $3,756.00 35273201 CT Forearm w/ Contrast Right $3,756.00 35273201 CT Hand w/ Contrast Left $3,756.00 35273201 CT Hand w/ Contrast Right $3,756.00 35273201 CT Humerus w/ Contrast Left $3,756.00 35273201 CT Humerus w/ Contrast Right $3,756.00 35273201 CT Shoulder w/ Contrast Left $3,756.00 35273201 CT Shoulder w/ Contrast Right $3,756.00 35273201 CT Upper Extremity w/ Contrast Left $3,756.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 35273201 CT Upper Extremity w/ Contrast Right $3,756.00 35273201 CT Wrist w/ Contrast Left $3,756.00 35273201 CT Wrist w/ Contrast Right $3,756.00 35273700 CT Ankle w/o Contrast Left $2,991.00 35273700 CT Ankle w/o Contrast Right $2,991.00 35273700 CT Femur w/o Contrast Left $2,991.00 35273700 CT Femur w/o Contrast Right $2,991.00 35273700 CT Foot w/o Contrast Left $2,991.00 35273700 CT Foot w/o Contrast Right $2,991.00 35273700 CT Knee w/o Contrast Left $2,991.00 35273700 CT Knee w/o Contrast Right $2,991.00 35273700 CT Lower Extremity w/o Contrast Left $2,991.00 35273700 CT Lower Extremity w/o Contrast Right $2,991.00 35273700 CT Tibia/Fibula w/o Contrast Left $2,991.00 35273700 CT Tibia/Fibula w/o Contrast Right $2,991.00 35273701 CT Ankle w/ Contrast Left $3,755.00 35273701 CT Ankle w/ Contrast Right $3,755.00 35273701 CT Femur w/ Contrast Left $3,755.00 35273701 CT Femur w/ Contrast Right $3,755.00 35273701 CT Foot w/ Contrast Left $3,755.00 35273701 CT Foot w/ Contrast Right $3,755.00 35273701 CT Knee w/ Contrast Left $3,755.00 35273701 CT Knee w/ Contrast Right $3,755.00 35273701 CT Lower Extremity w/ Contrast Left $3,755.00 35273701 CT Lower Extremity w/ Contrast Right $3,755.00 35273701 CT Tibia/Fibula w/ Contrast Left $3,755.00 35273701 CT Tibia/Fibula w/ Contrast Right $3,755.00 35274150 CT Abdomen w/o Contrast $4,658.00 35274160 CT Abdomen w/ Contrast $4,851.00 35274170 CT Abdomen w/ + w/o Contrast $5,848.00 35274175 CT Angiography Abdomen/Pelvis w/ + w/o C $2,616.00 39136430 36430 BLOOD ADMIN < 2 HOUR CHARGE $1,728.00 39136430 BLOOD ADMINISTRATION 3 HR CHARGE $2,592.00 39136430 BLOOD ADMINISTRATION 4 HR CHARGE $3,455.00 39136430 BLOOD ADMINISTRATION 5 HR CHARGE $4,320.00 39136430 BLOOD ADMINISTRATION 6 HR CHARGE $4,756.00 $5,184.00 40249083 US Paracentesis w/ Imaging Guidance $743.49 40276536 US Thyroid $1,173.00 40276604 US Chest $960.00 40276700 US Abdomen Complete $1,045.00 40276705 US Abdomen Limited $700.00 40276705 US Spleen $700.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 40276706 US Abdominal Aortic Aneurysm Screening $563.65 40276770 US Renal $1,173.00 40276801 US Pregnancy < 14 weeks $1,156.00 40276802 US Pregnancy Multi Gest < 14 weeks $1,813.00 40276805 US Pregnancy > 14 weeks $1,227.00 40276810 US Pregnancy Multi Gest > 14 weeks $1,860.00 40276815 US OB Limited (AFI) $704.00 40276816 US OB Follow-Up/Repeat $704.00 40276818 US Biophysical Profile $1,240.00 40276818 US Fetal Biophysical Profile $1,240.00 40276830 76830 ADD-ON $1,490.00 40276830 US Pelvic/Transvag $1,490.00 40276830 US TRANSVAGINAL $1,490.00 40276856 76856 ADD-ON $1,186.00 40276856 US Pelvic Complete $1,163.00 40276870 US Scrotum (Contents) $1,173.00 40276881 US Superficial Mass $1,152.00 40276882 US Extremity Nonvascular Ltd Lt $598.60 40276882 US Extremity Nonvascular Ltd Rt $598.60 40276882 US Soft Tissue Other Than Neck $598.60 40293970 US LE Venous Doppler Bilateral $1,328.00 40293970 US LE Venous Duplex Bilateral $1,328.00 40293971 US LE Venous Duplex Left $1,328.00 40293971 US LE Venous Duplex Right $1,328.00 40293971 US UE Venous Doppler Left $1,328.00 40293971 US UE Venous Doppler Right $1,328.00 41094002 VENTILATOR 1ST DAY $5,028.00 41094002 Ventilator Services Initial $5,028.00 41094003 RT Ventilator Services - Subs Charge $1,371.33 41094003 VENTILATOR SUBSEQUENT DAY $1,371.33 41094644 AEROSOL INITIAL THERAPY CHARGE $392.00 41094644 Aerosol Initial $392.00 41094645 AEROSOL SUBSEQUENT CHARGE $72.00 41094645 Aerosol Subsequent $72.00 41094660 BiPAP/CPAP Initial $496.00 41094660 CPAP/BIPAP CIRCUIT CHARGE $496.00 41094667 CPT INITIAL $220.00 41094667 CPT Initial RT Charge $220.00 41094668 CPT SUBSEQUENT $167.82 41094668 CPT Subsequent $167.82 41994640 RT Pulse Oximetry; Exercise Charge $94.00 41994664 PULSE OXIMETRY EXERCISE CHARGE $94.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 42097001 PT Evaluation Charge $656.00 42097002 Reevaluation Charge $228.00 42097014 Unattended Electrical Therapy Charge $228.00 42097035 Ultrasound Charges $228.00 42097110 Therapeutic Exercise Charges $228.00 42097112 Neuromuscular Reeducation Charges $228.00 42097116 Gait Training Charges $228.00 42097140 Manual Therapy Charge Units $228.00 42097530 Therapeutic Activities Charge $228.00 42097535 ADL Training Charge $228.00 42097542 Wheelchair Management Charges $92.00 42097597 Selective Debridement Charge $228.00 42097598 Selective Debridement Addition Charge $228.00 42497161 PT Low Complex Units $225.00 42497162 PT Moderate Complex Units $345.00 42497163 PT High Complex Units $550.00 42497164 PT ReEval Units $135.00 45010060 10060 INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE TechFee $2,172.00 45010060 10060 DRAINAGE OF SKIN ABSCESS ED Charge $2,172.00 45010080 10080 INCISION & DRAINAGE PILONIDAL CYST SIMPLE TechFee $429.00 45010120 10120 INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE TechFee $1,413.00 45010140 10140 I&D HEMATOMA SEROMA/FLUID COLLECTION TechFee $1,312.00 45010160 10160 ASPIRATION HEMATOMA/CYST TechFee $714.00 11000 DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF 45011000 TechFee $633.00 45011010 11010 DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS TechFee $714.00 45011042 11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< TechFee $82.00 45011043 11043 DEBRIDE TISSUE/MUSCLE TechFee $491.00 45011044 11044 DEBRIDE TISSUE/MUSCLE/BONE $850.00 45011720 11720 DEBRIDEMENT NAIL ANY METHOD 1-5 TechFee $269.00 45011750 11750 EXCISION NAIL MATRIX PERMANENT REMOVAL TechFee $643.00 45011750 11750 PROC EXCISION ED Charge $322.00 45011765 11765 WEDGE EXCISION SKIN NAIL FOLD TechFee $633.00 45016000 16000 BURN-INITIAL TREATMENT,SM TechFee $633.00 45017000 17000 DESTRUCTION PREMALIGNANT LESION 1ST TechFee $205.00 45017250 17250 CHEMICAL CAUTERIZATION GRANULATION TISSUE TechFee $789.00 20520 REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE 45020520 TechFee $643.00 45020550 20550 INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS TechFee $763.00 45020610 20610 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US TechFee $799.00 45020999 20999 UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL TechFee $3,924.00 45021315 21315 CLOSED TX NASAL FRACTURE W/O STABILIZATION TechFee $610.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 45021480 21480 DISLOCATION JAW TechFee $594.00 45023650 23650 DISLOCATION SHOULDER TechFee $594.00 45024505 24505 CLOSED REDUCTION UPPER EXTREMITY TechFee $784.00 45024600 24600 DISLOCATION ELBOW REDUCTION TechFee $784.00 45024605 24605 DISLOCATION ELBOW W/ANES TechFee $4,229.00 45026641 26641 DISLOCATION THUMB(CARPAL) TechFee $763.00 45026670 26670 DISLOCATION FINGER REDUCTION TechFee $920.00 45026675 26675 DISLOC FINGER W/ANES TechFee $2,212.00 45027197 27197 CLSD TX PELVIC RING FX W/O MANIPULATION TechFee $784.00 45027198 27198 CLSD TX PELVIC RING FX W/O MANIPULATION TechFee $784.00 45027250 27250 DISLOCATION HIP TechFee $784.00 45027550 27550 DISLOCATION KNEE REDUCTION TechFee $784.00 45027824 27824 CLOSED REDUCTION LOWER EXTREMITY TechFee $784.00 45027840 27840 DISLOCATION ANKLE REDUCTION TechFee $422.00 45027842 27842 CLTX ANKLE DISLC REQ ANES W $422.00 45028190 28190 REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS TechFee $530.00 45028510 28510 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ TechFee $584.00 45028540 28540 DISLOCATION TOE REDUCTION TechFee $584.00 45028545 28545 DISLOC TOE W/ANES TechFee $1,765.00 45029505 29505 APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES TechFee $392.00 45029799 29799 UNLISTED PROCEDURE CASTING/STRAPPING TechFee $627.00 30300 REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE 45030300 TechFee $594.00 45032554 32554 THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING TechFee $1,300.00 45033010 33010 PERICARDIOCENTESIS INITIAL TechFee $2,263.00 45036430 36430 TRANSFUSION BLOOD/BLOOD COMPONENTS TechFee $526.00 45042700 42700 I&D ABSCESS PERITONSILLAR TechFee $595.00 45043753 43753 GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE TechFee $639.00 Change of gastrostomy tube percutaneous without imaging or 45043760 endoscopic guidance Tech Chg $688.59 45045020 45020 I&D DP SUPRALEVATOR PELVIRCT/RETRORCT ABSC TechFee $741.00 45046320 46320 EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL. TechFee $294.00 46600 ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD 45046600 TechFee $273.54 45049084 49084 PERITONEAL LAVAGE W/WO IMAGING GUIDANCE TechFee $262.00 45056420 56420 I&D OF BARTHOLINS GLAND ABSCESS TechFee $1,312.00 45057558 57558 DILATION & CURETTAGE CERVICAL STUMP TechFee $458.00 45062270 62270 SPINAL PUNCTURE LUMBAR DIAGNOSTIC TechFee $1,071.00 45064455 64455 NJX ANES&/STEROID PLANTAR COMMON DIGITAL NERVE TechFee $1,185.00 45065205 65205 FOREIGN BODY REMOVAL-EYE TechFee $948.00 45069200 69200 RMVL FB XTRNL AUDITORY CANAL W/O ANES TechFee $375.00 45092235 92235 FLORESCEIN DYE STUDY TechFee $370.00 45092950 92950Â Â CARDIOPULMONARY RESUSCITATION TechFee $1,660.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 45092960 92960Â Â CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL TechFee $2,429.00 93503Â Â INSERTION FLOW DIRECTED CATHETER FOR MONITORING 45093503 TechFee $2,587.53 94640Â Â PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT 45094664 TechFee $431.00 45096360 96360 - HYDRATION, FIRST HOUR $654.00 45096361 IV THERAPY HYDRATION, EACH ADDITIONAL HOUR $458.00 45096365 ZZZ96365 - IV TX, FIRST HOUR $531.00 45096366 ZZZ96366 - IV TX, EACH ADDITIONAL HOUR/CRITICAL CARE $327.00 45096367 96367 - IV tx, sequential infusion $523.00 45096368 ZZZ96368 - IV tx, concurrent infusion $523.00 45096372 zzz96372 - Subq/IM Injection $74.00 45096374 IVP INJECTION therapeutic or diagnostic ER $265.00 45096375 IV Injection, add new drug THERAPEUTIC OR DIAGNOSTIC $131.00 45096376 96376 - IV Push, add same drug $98.00 45098925 98925Â Â OSTEOPATHIC MANIPULATIVE TX 1-2 BODY REGIONS TechFee $118.00 99184Â Â INITIAT SELECTIVE HEAD/BODY HYPOTHERMIA NEONATE 45099184 TechFee $323.73 45099281 99281 - ED Level 1 $374.00 45099282 99282 - ED Level 2 $557.00 45099283 99283 - ED Level 3 $1,071.00 45099284 99284 - ED Level 4 $1,261.00 45099285 99285 - ED Level 5 $2,833.00 45099291 H: 99291 - ED Critical Care $2,833.00 45099292 Critical Care, each 30 min $403.00 46094060 BRONCHOSPSM PRE/POST EVAL Respiratory Therapy Charges $661.05 46094060 RT Pre & Post Spiro Charge $661.05 46094760 PULSE OXIMETERY SINGLE $194.00 46094760 RT Pulse Oximetry; Single Day Charge $194.00 46094762 PULSE OXIMETRY CONTINUOUS CHARGE $389.25 46094762 RT Oximetry - Continuous Charge $389.25 48093320 US Echo Transesophageal, TEE $1,783.00 48293017 Stress Echocardiogram, Exercise, Treadmill $2,480.00 48293017 Cardiac Stress Test $2,480.00 48293350 Stress Echocardiogram, Dobutamine $2,480.00 48393306 US Echo Color Flow Doppler $2,297.00 48393308 US Echocardiogram Limited $973.00 48393350 US Echo Exercise Stress $1,783.00 52100001 1 cc 1% Lidocaine w/o epi $2.46 52100002 2 cc 1% Lidocaine w/o epi $2.50 52110140 NIPPLE EXPL W/WO EXC DUCT $1,033.41 52169209 Ear Irrigation POC $167.88 52182140 Ammonia, Plasma LC $53.97 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 52183010 HAPTOGLOBIN; QUAN $46.59 52184140 Pregnenolone MS LC $76.56 52186300 Cancer Antigen (CA) 15-3 LC $77.10 52187650 Rapid Strep POC $74.80 61070543 MRI Face Neck Orbit w/ + w/o Contrast $6,580.00 61070544 MRA Head w/o Contrast $3,124.00 61070544 MRV Head w/o Contrast $3,124.00 61070545 MRA Head w/ Contrast $5,652.00 61070546 MRA Head w/ + w/o Contrast $3,644.00 61070547 MRA Neck w/o Contrast $5,652.00 61070548 MRA Neck w/ Contrast $6,580.00 61070549 MRA Neck w/ + w/o Contrast $1,420.00 61071550 MRI Chest w/o Contrast $5,090.00 61071551 MRI Chest w/ Contrast $5,542.00 61071552 MRI Chest w/ + w/o Contrast $6,273.00 61072142 MRI Spine Cervical w/ Contrast $5,874.00 61072147 MRI Spine Thoracic w/ Contrast $5,874.00 61072149 MRI Spine Lumbar w/ Contrast $5,874.00 61072195 MRI Pelvis w/o Contrast $5,090.00 61072197 MRI Pelvis w/ + w/o Contrast $5,755.00 61072198 MRA Pelvis w/ Contrast $6,580.00 61073218 MRI Forearm w/o Contrast Left $3,774.00 61073218 MRI Forearm w/o Contrast Right $3,774.00 61073218 MRI Hand w/o Contrast Left $3,774.00 61073218 MRI Hand w/o Contrast Right $3,774.00 61073218 MRI Humerus w/o Contrast Left $3,774.00 61073218 MRI Humerus w/o Contrast Right $3,774.00 61073218 MRI UE Non Joint w/o Contrast Left $3,774.00 61073218 MRI UE Non Joint w/o Contrast Right $3,774.00 61073219 MRI Forearm w/ Contrast Left $3,957.00 61073219 MRI Forearm w/ Contrast Right $3,957.00 61073219 MRI Hand w/ Contrast Left $3,957.00 61073219 MRI Hand w/ Contrast Right $3,957.00 61073219 MRI Humerus w/ Contrast Left $3,957.00 61073219 MRI Humerus w/ Contrast Right $3,957.00 61073219 MRI Tibia/Fibula w/ Contrast Left $3,957.00 61073219 MRI Tibia/Fibula w/ Contrast Right $3,957.00 61073220 MRI Forearm w/ + w/o Contrast Left $4,192.00 61073220 MRI Hand w/ + w/o Contrast Left $4,192.00 61073220 MRI Hand w/ + w/o Contrast Right $4,192.00 61073220 MRI Humerus w/ + w/o Contrast Left $4,192.00 61073220 MRI Humerus w/ + w/o Contrast Right $4,192.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 61073221 MRI Elbow w/o Contrast Left $4,591.00 61073221 MRI Elbow w/o Contrast Right $4,591.00 61073221 MRI Shoulder w/o Contrast Left $4,591.00 61073221 MRI Shoulder w/o Contrast Right $4,591.00 61073221 MRI UE Joint w/o Contrast Left $4,591.00 61073221 MRI UE Joint w/o Contrast Right $4,591.00 61073221 MRI Wrist w/o Contrast Left $4,591.00 61073221 MRI Wrist w/o Contrast Right $4,591.00 61073222 MRI Elbow w/ Contrast Left $4,815.00 61073222 MRI Elbow w/ Contrast Right $4,815.00 61073222 MRI Shoulder w/ Contrast Left $4,815.00 61073222 MRI Shoulder w/ Contrast Right $4,815.00 61073222 MRI Wrist w/ Contrast Left $4,815.00 61073222 MRI Wrist w/ Contrast Right $4,815.00 61073223 MRI Elbow w/ + w/o Contrast Left $4,815.00 61073223 MRI Elbow w/ + w/o Contrast Right $4,815.00 61073223 MRI Shoulder w/ + w/o Contrast Left $4,815.00 61073223 MRI Shoulder w/ + w/o Contrast Right $4,815.00 61073223 MRI UE Joint w/ + w/o Contrast Left $4,815.00 61073223 MRI UE Joint w/ + w/o Contrast Right $4,815.00 61073718 MRI Femur w/o Contrast Left $3,774.00 61073718 MRI Femur w/o Contrast Right $3,774.00 61073718 MRI Foot w/o Contrast Left $3,774.00 61073718 MRI Foot w/o Contrast Right $3,774.00 61073718 MRI LE Non Joint w/o Contrast Left $3,774.00 61073718 MRI LE Non Joint w/o Contrast Right $3,774.00 61073718 MRI Tibia/Fibula w/o Contrast Left $3,774.00 61073718 MRI Tibia/Fibula w/o Contrast Right $3,774.00 61073719 MRI Femur w/ Contrast Left $4,192.00 61073719 MRI Femur w/ Contrast Right $4,192.00 61073720 MRI Femur w/ + w/o Contrast Left $4,192.00 61073720 MRI Femur w/ + w/o Contrast Right $4,192.00 61073720 MRI Foot w/ + w/o Contrast Left $4,192.00 61073720 MRI Foot w/ + w/o Contrast Right $4,192.00 61073720 MRI LE Non Joint w/ + w/o Contrast Left $4,192.00 61073720 MRI LE Non Joint w/ + w/o Contrast Right $4,192.00 61073721 MRI Ankle w/o Contrast Left $4,591.00 61073721 MRI Ankle w/o Contrast Right $4,591.00 61073721 MRI Hip w/o Contrast Left $4,591.00 61073721 MRI Hip w/o Contrast Right $4,591.00 61073721 MRI Knee w/o Contrast Left $4,591.00 61073721 MRI Knee w/o Contrast Right $4,591.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 61073721 MRI LE Joint w/o Contrast Left $4,591.00 61073721 MRI LE Joint w/o Contrast Right $4,591.00 61073722 MRI Ankle w/ Contrast Left $4,815.00 61073722 MRI Ankle w/ Contrast Right $4,815.00 61073722 MRI Hip w/ Contrast Left $4,815.00 61073722 MRI Hip w/ Contrast Right $4,815.00 61073722 MRI Knee w/ Contrast Left $4,815.00 61073722 MRI Knee w/ Contrast Right $4,815.00 61073723 MRI Ankle w/ + w/o Contrast Left $5,184.00 61073723 MRI Ankle w/ + w/o Contrast Right $5,184.00 61073723 MRI Hip w/ + w/o Contrast Left $5,184.00 61073723 MRI Hip w/ + w/o Contrast Right $5,184.00 61073723 MRI Knee w/ + w/o Contrast Left $5,184.00 61073723 MRI Knee w/ + w/o Contrast Right $5,184.00 61073723 MRI LE Joint w/ + w/o Contrast Left $5,184.00 61073723 MRI LE Joint w/ + w/o Contrast Right $5,184.00 61074181 MRI Abdomen w/o Contrast $4,670.00 61074182 MRI Abdomen w/ Contrast $5,542.00 61074183 MRI Abdomen w/ + w/o Contrast $6,273.00 61170551 MRI Brain w/o Contrast $4,591.00 61170553 MRI Brain w/ + w/o Contrast $6,580.00 61272141 MRI Spine Cervical w/o Contrast $5,652.00 61272146 MRI Spine Thoracic w/o Contrast $5,652.00 61272148 MRI Spine Lumbar w/o Contrast $5,652.00 61272156 MRI Spine Cervical w/ + w/o Contrast $6,580.00 61272157 MRI Spine Thoracic w/ + w/o Contrast $6,580.00 61272158 MRI Spine Lumbar w/ + w/o Contrast $6,580.00 72059025 59025 FETAL MONITORING CHARGE $718.00 72059025 Fetal Nonstress Test $718.00 72192700 REPEAT NEWBORN HEARING SCREEN CHARGE $142.00 72200001 LABOR\\DELIVERY\\RECOVERY CHARGE $4,059.00 73093005 ECG 12-Lead Acquisition $778.00 73093005 ECG 12-Lead Acquisition $778.00 $226.00 73093005 EKG 12 Lead, Tracing Only Charge $778.00 73193226 Holter 48 $1,408.00 76100000 ER VISIT L-1 $142.00 76131500 31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE TechFee $1,186.00 76131500 INTUBATION CHARGE $1,186.00 $386.10 76136400 36400 BL DRAW < 3 YRS FEM/JUGULAR TechFee $63.51 76136400 36400 BL DRAW < 3 YRS FEM/JUGULAR CHARGE $63.51 $70.89 76136400 36400 BL DRAW < 3 YRS FEM/JUGULAR $63.51 76136410 36410 VENIPNCTR >= 3 YRS NON ROUTINE CHARGE $425.00 $33.06 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 36556 INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> 76136556 TechFee $1,949.00 76136591 36591 DRAW BLOOD OFF VENOUS DEVICE CHARGE $273.54 $15.00 76136592 36592 COLLECT BLOOD FROM PICC CHARGE $273.54 $15.00 76151702 51702 CATHETER INSERTION FOLEY CHARGE $227.00 76151703 51703 INSERTION BLADDER CATH COMPLEX CHARGE $389.25 76199211 OB TRIAGE NON-ADMISSION CHARGE $1,191.00 92093880 US Carotid Doppler Bilateral $1,856.00 92093880 US Carotid Duplex Bilateral $1,856.00 94099195 Therapeutic Phlebotomy. $335.00 $75.00 94297802 97802 MED NUTRITION THERAPY CHARGE $85.00 94297802 97802 MEDICAL NUTRITIONAL THERAPY EA 15 MIN CHARGE $85.00 94297803 97803 MED NUTRITION REASSESS CHARGE $41.00 94297803 97803 NUTRITION RE ASSESSMENT EA 15 MIN CHARGE $41.00 96011055 11055 PARING AND CUTTING $209.00 96011442 11442 EX BEN LESN F,E,E,N, $804.00 96011462 11462 EXCISION OF SKIN AND SUB $1,040.00 96013101 13101 Rpr Complex Trunk 2.6-7.5 $1,286.01 96013102 13102 Rpr Complx Trnk Eaadd<5Cm $262.23 96032551 32551 TUBE THORACOSTOMY $1,448.49 96032556 32556 Insert Cath Pleura W/O Im $3,623.25 96036569 36569 Insert Picc Line W/O >5Yo $324.09 96036578 36578 REPLACE CATH ONLY CV DEVICE ProFee $863.00 96044604 44604 SUTURE LG INTESTINE W/O COLOST ProFee $3,727.32 96045337 45337 SIGMOIDOSCOPY & DECOMPRESS $2,258.28 96062270 SPINAL PUNCTURE LUMBAR DIAGNOSTIC $142.70 96076801 76801 OB US < 14 WKS SINGLE FETUS $338.19 96076805 76805 OB US>/=14 WKS SNGL FETUS $408.00 96076817 76817 US Preg Utrus Transvag ProFee $286.00 96076830 76830 US Transvaginal ProFee $497.00 96076857 76857 US EXAM PELVIC LIMITED $229.00 96097605 97605 Neg Pres Wnd Tx Per Sessn <=50 cm $98.00 96097610 97610 LOW FREQUENCY NON-THERMAL ULTRASOUND PER $400.00 96099245 99245 Outpt Comp/High Consult80Min $640.00 96099304 Initial Nursing facility care (History, Examination and MDM) $317.00 96099305 99305 INITIAL SWING CARE MODERATE $451.05 96099307 99307 SUBSEQUENT SWING CARE STRAIGHTFORWARD $103.24 96099308 99308 Nursing Facility Subsequent Care - Minor Complications $239.67 96099309 99309 Nursing Facility Susequent Care - Significant Complications $315.96 96099310 99310 Nursing Facility Subsequent Care - Unstable/New Complications $469.44 96099315 Nursing facility discharge day management; 30 minutes or less $253.20 96099316 Nursing Facility Discharge Management More Than 30 min - 99316 $318.63 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 96400000 ANESTHETIST FEE/UNIT $431.00 96431500 31500 Intubation, Endotracheal, Emergency $281.00 96432551 32551 Tube Thoracostomy Includes Water Seal $599.67 96436400 36400 VENIPUNCTURE <3 YRS FEMORAL OR JUGULAR $74.00 96436410 36410 Venipuncture >3Yr Diag/Therapeutic $35.00 96462320 62320 INJS EPI/SUB CERV/THOR PRO $1,436.00 96464490 64490 MEDIAL BLOCK CRV/THRC L1 $2,545.00 96464491 64491 MEDIAL BLOCK CRV/THRC L2 $1,250.00 96499100 99100 Anes Extreme Age <1&>70Yr $431.00 96499140 99140 Emergency Conditions $431.00 97510021 10021 Fine Needl Aspir W/O Imag $564.00 97510060 10060 I & D ABSCESS, SIMPLE OR SINGLE $562.00 97510061 10061 DRAIN SKIN ABCESS $938.00 97510080 10080 I & D PIDONIDAL CYST $429.00 97510120 10120 REM FB W INCISION $347.00 97510121 10121 Inc&Rem Fb Subq Tiss Cmpl $646.56 97510140 10140 I & D HEMATOMA $794.00 97510160 10160 PUNCTURE ASPIRATION $644.00 97510180 10180 I&D Complx Postop Wnd Inf $654.00 97511000 11000 DEBRIDEMENT INFECTED SKIN ProFee. $262.00 97511001 11001 DBRDMT EXTNS ECZE/INFCT SKN EA10%BDY SUR $116.00 97511004 11004 DEBRIDEMENT SKIN SUBCU TISSUE/MUSCLE $1,570.00 97511005 11005 DEBRIDEMENT, ABD WALL W OR W/O FASCIAL C $2,040.00 97511006 11006 DBRDMT SKN SUBQ T/M/F NEC INFCTJ GENT/AB $2,805.00 97511008 11008 Remov Mesh Abdominal Wall $719.00 97511010 11010 DEBRIDEMENRT W FB $1,104.00 97511011 11011 Debrid Skin-Subq-Tis-Musc $1,199.00 97511012 11012 DEBRID SKIN MUS BONE $1,694.00 97511042 11042 DEBRIDEMENT SKIN SUB $223.00 97511043 11043 WOUND DEBRIDEMENT-MUSCLE $491.00 97511044 11044 Wound debridement, to and including bone $850.00 97511045 11045 DEB SUBQ TISSUE/ADD ON ProFee $110.00 97511046 11046 Debride Muscl/Fas Eaadd20Sqcm $196.00 97511047 11047 Debride Bone Ea Add20Sqcm Or Part $401.00 97511056 11056 REMOVE CALLOUS $144.00 11101 BIOPSY OF SKIN, SUBC TISSUE/MUCCOUS MEMB EACH 97511101 ADDITIONAL LESION $154.00 97511300 11300 SHAVE LES T/A/L; 0.5CM/< $353.49 97511305 11305 SHAVE LES S/N/H/F/G; 0.5CM/< $353.49 97511400 11400 EXC BENIGN LES T/A/L $301.00 97511401 11401 EXC BENIGN LES T/A/L $368.00 97511402 11402 Excise Les Ben 1.1 To 2Cm $411.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97511403 11403 EXC BENIGN LESN $472.00 97511404 11404 EXC BENIGN LES T.A.L $536.00 97511406 11406 EXC BEN LESN >4.0 CM $765.00 97511420 11420 EX BENIGN LES S/H/FT/G 0.5 CM OR LESS CHARGE $319.00 97511421 11421 EXC BEN LESN S,N,H,F $434.00 97511422 11422 Excise Les Ben 1.1 To 2Cm $654.00 97511423 11423 Excise Les Ben 2.1 To 3Cm $505.00 97511424 11424 EXC BEN LESN S,N,H,F $863.00 97511426 11426 EXC BEN LES>4 CM $850.00 97511440 11440 LESION-BENIGN FACE $229.00 97511441 11441 LES BEN FACE/EARS/ O $514.00 97511443 MD Remove Lesion, Face/Lid/Ear/Nose/Lip 2.1 to 3.0 cm Charge $538.00 97511444 11444 EXCISE FACIAL CYST 3.1-CM $674.00 Exc, benign lesion, face, ears, eyelids, nose, lips, mm; >4.0 cm Technical 97511446 Charge $983.10 97511730 11730 AVULSION NAIL PARTIA $262.00 97511752 11752 AMPU TUFT DIS PHALAN $988.00 97511765 11765 EXCISION OF NAIL FOL $458.00 97511770 11770-REMOVE PILONIDAL CYST SIMPLE-SC PF $671.00 97511900 11900 INJ,INTRALESIONAL,UP TO 7 $144.00 97511976 11976 REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSUL $387.00 97511980 11980 SUBCUTANEIOUS HORMONE PELLET IMPLANTATIO $371.00 97511981 11981 INSJ NON-BIODEGRADABLE DRUG DELIVERY IMP $320.00 97511982 11982 Rem Nonbio Rx Del Implnt $631.00 97511983 11983 RMVL W/RINSJ NON-BIODGRDBLE DRUG DLVR IM $880.00 97512005 12005 SIM LAC 12.6 TO 20.0 $331.71 97512011 12011 SIM SPRFL F,E,E,N,L $588.00 97512013 12013 SIM SPRFCL F,E,E,N,L $654.00 97512014 12014 SIM SPRFL F,E,E,N,L $654.00 97512015 12015 SIM SPRF F,E,E,M,L,M $458.00 97512020 12020 TRT WOUND DEHIS SIMP $1,486.00 97512031 12031 LAC LAYER SCALP AXI $601.00 97512032 12032 LAC LAYER SCALP AXIL $761.00 97512034 12034 LAC LAYER SCALP AXIL $819.00 97512035 12035 Sclp/Trk/Ext Int 12.6-20 $1,027.00 97512037 12037 LAC RPR INTMD, SCALP, AXILLAE, TRUNK, >30CM- PROF CHG $1,996.00 97512041 12041 LAYER CLOS <=2.5CM $619.00 97512042 12042 LAYER CLOSR N,H,F,G $1,228.00 97512051 12051 LAYER CLOS <2.5CM $1,701.32 97512052 12052 LAYER CLOS F,E,E,N,L $1,248.00 97512054 12054 LAY CLS LAC 7.6-12.5 $981.00 97513122 13122 COMPL REPR > 7.5 CM $346.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97513133 13133 EA ADD 5 CM OR LESS $471.00 97513152 CREP E/N/E/L; 2.6-7.5CM $1,057.74 97513160 13160 Secndry Clo Surg Wnd-Exte $3,091.00 97514000 14000 ADJ TISS TRNSFR/REARGMT TRUNK 10SQCM/< $1,990.00 97514001 14001 ADJ TISS XFER TRNK10.1-30SQCM $2,589.00 97514020 14020 Adj Tiss Xfer Sclp/Ar/Le $2,256.00 97514021 14021 TISSXFERSCLP/ARM 10.1-30 SQCM $2,849.00 97514040 14040 ADJACENT TISSUE TRANS FLAP/CLO ProFee $2,514.00 97514041 Adjacent tissue transfer or rearrangement, forehead, cheeks, $3,083.00 97514060 14060 TIS TRNSFR E/N/E/L 10 SQ CM/< - SC $2,677.00 97514061 14061 ATT E/N/E/L; D 10.1-30 $3,297.00 97514301 14301 ADJT TIS TRNFR/RERGMT ANYAREA30.1-60SQCM $3,513.00 97514302 14302 SKIN TISSUE REARRANGE ADDL 30.0SQCM $888.00 97514350 14350 FILLETED FGR/TOE FLAP $2,830.00 97515002 15002 SURG PREP BY EXCISE WOUND $916.00 97515003 15003 PREP SITE TRNK/ARM/LEG ADDL 100SQCM/1PCT $183.00 97515004 15004 Wound Prep F/N/Hf/G 100Sq $1,046.00 97515100 15100 SPLIT THICK AUTOGRAFT 1ST $2,195.00 97515101 15101 SKIN SPLT GRFT T/A/L ADDL 100 SQ $389.07 97515120 15120 SPLIT THCKNS AUTOGFT FACE $2,426.00 97515271 15271 Application of skin substitute graft to trunk, arms, legs, $557.00 15275 application of skin substitute graft to face, scalp, eyelids, mouth, 97515275 neck, ears, orbits, genit $592.00 97515650 15650 TRANS SKIN PEDICLE FLAP $1,308.00 97515830 15830 Excise Excess Skin Abdomen $3,888.00 97516020 16020 DEBRIDEMENT BURN W O $418.00 97517000 17000 DESTRUCTION LESION (FIRST LESION) CHARGE $205.00 97517003 17003 DESTRUCTION LESION (2-14 LESIONS) ADD ON CHARGE $78.00 17004 Destruction (Eg, Laser Surgery, Electrosurgery, Cryosurgery, 97517004 Chemosurgery, Surgical Curettemen $458.00 97517110 17110 DEST WARTS MOLLUS $280.00 97517111 17111 DESTRUCTION BGN LES 15 OR > ProFee $335.00 97517250 17250 CAUTERIZATION $148.00 97517272 17272 DESTRUCTION OF SKIN LESIONS -SC $674.03 97517999 17999 Unlisted Proc Skin/Mus/Su $1,962.00 97519101 19101 OPEN BREAST BIOPSY $870.00 97519120 19120 Excise Cyst/Tmr/Les breast $1,962.00 97519301 19301Mastectomy part/lumpectomy $2,569.00 97519303 19303 MASTECTOMY SIMPLE COMPLETE ProFee $3,981.00 97519304 19304 MASTECTOMY SUBCUTANEOUS $2,278.00 97519307 19307 MASTECTOMY RAD INCL LYMPH NODE ProFee $4,578.00 97520100 20100 EXP PENETRATING WOUND, NECK $3,714.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97520102 20102 Wound Explore Ab/Flnk/Bck $1,013.00 97520103 20103 WOUND EXPLORA EXTREM $1,391.00 97520520 20520 Rem Fb Muscle/Tend Simple $613.00 97520526 20526 INJ THERAPEUTIC CARPL TUNNEL WRIST $588.00 97520550 20550 INJECT TENDON $332.00 97520551 20551 INJECTION SINGLE TENDON ORIGIN $392.00 97520552 20552 INJ TRIGGER POINT 1/2 MUSCL-SC PF $312.00 97520553 20553 Inj Trigger Point 3 Or Mo $348.00 97520600 20600 Arthrocent/Aspir/Inj Smjt $406.00 97520605 20605 ASP INJ INT JOINT $416.00 97520610 20610 DRAIN/INJ JOINT/BURSA OP CCCPF $436.00 97520680 20680 Removal Implant Deep $1,635.00 97520999 20999 UNLISTED PROCEDURE MUSCSKELETAL SYSTEM G $3,924.00 97521012 21012 EXC TUMOR SOFT TIS FACE/SCALP SUBQ 2CM/> $1,328.00 97521552 21552 EXCISION,NECK/THORAX 3 CM OR> ProFee $1,760.00 97521555 21555 Excise Tumor/Neck Sub<3Cm $1,215.00 97521931 21931 EXCISION LIPOMA FLANK $1,869.00 97522902 22902 EXC TUMOR SOFT TISSUE ABD WALL SUBQ<3CM $1,281.00 97522903 22903 Excise Tumor Abdominal Wa $1,711.00 97523120 23120-PARTIAL REMOVAL COLLAR BONE-SC $2,354.00 97523130 23130 Acromioplasty/Ectomy Part $2,354.00 97523405 23405 TENOTOMY, SHOULDER AREA SINGLE TENDON $3,292.00 97523430 23430 Bicep Tenodesis;Long Tndn $1,962.00 97523470 23470- Hemiarthroplasty Glenohum Joint $4,805.00 97523929 23929 Unlisted Proc Shoulder $3,924.00 97524071 24071 EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ $1,098.00 97524105 24105 Excision Olecranon Bursa $3,046.00 97524201 24201 REMOV FOREIGN BODY UPPER ARM/ELBOW DEEP $1,458.00 97524310 24310 TENOTOMY ELBOW/SHLDR TNDN $1,962.00 97524341 24341 REPAIR ARM TENDON/MUSCLE PF $2,990.00 97524357 24357 REPAIR ELBOW PERC $1,766.00 97525000 25000 Inc Exten Tendn Shth Wrst $1,308.00 97525028 25028 I&D Forearm & Or Wrist $1,439.00 97525076 25076 EXC TMR SFT TISS FARM&/WRIST SUBFAC <3CM $2,056.00 97525085 25085 CAPSULOTOMY, WRIST $1,177.00 97525111 25111 EXC GANGLION WRIST DOR/VOL ProFee $1,099.00 97525260 25260 REPR FRARM WRST TEND $2,191.44 97525447 25447 Arthroplasty Interposition $3,205.00 97525605 25605 CLOS TRTMT DSTL RAD $1,504.00 97525999 25999 Unlisted F/Arm/Wrist $3,924.00 97526055 26055 INCISE FINGER TENDON SHEATH $1,452.00 97526111 26111 EXC OF SOFT TISSUE HAND $1,308.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97526530 26530 ARTHOPL METACARP EA JT $1,733.00 97526531 26531 Mcp Arthropl W/Impl Each Jt $2,013.00 97526615 26615 Orif Metacarpal Fx Single $2,269.00 97526727 26727 Percut Fix Fx Prox/Mid W/ $1,243.00 97527043 27043 Exc Hip Pelvis Les Sc 3Cm $1,435.00 97527327 27327 Excisetumr Thigh/Knee<3Cm $2,746.00 97527337 27337 EXC LIMPOMA THIGH/KNEE > 3 CM ProFee $1,825.00 97527347 27347 REMOVAL KNEE CYST GANGLION ProFee $1,439.00 97527355 27355 REMOVE FEMUS LESION $2,637.00 97527590 27590 AMPUTATION THIGH THROUGH FEMUR ANY LEVEL $3,245.00 97527618 27618 Excise Tumr Sft Leg/Ankl <3Cm $1,211.00 97527696 27696 REPAIR OF ANKLE $2,197.00 97527882 27882 AMP, LEG, THROUGH TIB/FIB GUILLOTINE $1,635.00 97527884 27884 AMP, LEG THROUGH TIB/FIB SEC CLOSE OR SC $1,635.00 97528054 28054 ARTHROTOMY W/BIOPSY INTERPHALANGEAL JNT $1,504.00 97528122 28122 Partial Exc Bone/Tar/Meta $1,547.58 97528190 28190 Remove Fb Foot Subq $530.00 97528805 28805 Amputate Transmetatarsal $2,941.00 97528810 28238 Revision of foot tendon $1,143.00 97528820 28820 Amputa Toe Metatarso Jt $1,327.00 97528825 28825 PARTIAL AMPUTATION TOE ProFee $1,464.00 97529065 29065 LONG ARM CAST $614.00 97529105 29105 LONG ARM SPLINT $562.00 97529125 29125 SHORT ARM SPLINT $414.00 97529130 28297 Correction hallux valgus $322.00 97529345 29345 CAST LONG LEG $808.00 97529405 29405 Cast Applic Short Leg $536.00 97529445 29445 APPLICATION RIGID TOTAL CONTACT LEG CAST $700.00 97529505 29505 Splint Applic Long Leg $396.00 97529515 29515 SHORT LEG SPLINT $366.00 97529530 29530 STRAPPING KNEE $386.00 97529700 29700 REMOVAL CAST BODY OR BOOT $420.00 97529805 29805 Arthroscopy Shldr Dx W/Wo $1,962.00 97529806 29806 Scope Shldr Capsulorrhapy $3,451.00 97529807 29807 SHOULDER ARTHROSCOPY/SURGERY - SC $2,616.00 97529822 29822 Scope Shldr Debride Ltd $2,224.00 97529824 29824 SHOULDER ARTHROSCOPY/DISTAL CLAVI -SC $2,197.00 97529826 29826 SHOULDER ARTHROSCOPY/SURGERY-SC PF $582.00 97529827 29827 Scope Shldr Rt Cuff Repr $3,924.00 97529828 29828 Biceps Tenodesis $2,995.00 97529862 29862 Arthr Debrid/Shv Art Cart $6,834.00 97529875 29875 Arthro Knee Synovect Ltd $1,962.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97529877 29877 Arthros Debrid/Shave Cart $2,485.00 97529879 29879 Arthros Knee Abras Plasty $2,616.00 97529881 29881 Arthro W/Menis Med Or Lat $2,224.00 97529882 29882 Arthr Knee Surg W/Men Rpr $2,269.00 97529888 29888 Arthro Aided Acl Recn/Rpr $3,859.00 97529897 29897 ARTHOSCOPY ANKLE $1,570.00 97529915 29915 Arth,Hip Surg Acetabuloplasty $7,594.00 97529999 29999 Unlisted Proc Arthroscopy $2,616.00 97532554 32554 THOURACENTESIS W/O IMAGING GUIDANCE $1,596.00 97535840 35840 Explor Postop Hemorrhage Abdomen $4,789.00 97536481 36481 CENTRAL LINE PLACEMENT $2,140.00 97536558 36558 CENTRAL LINE $983.10 97536589 36589 Rem Tunneled Cvc W/O Pump $458.00 97536590 36590 Rmvl Tun Ctr Vad W/Subq $785.00 97536818 36818 Arteriov Anastomosis Opn $2,718.00 97536821 36821 Hemodyls Acc Jng Art&Vein $3,924.00 97537609 37609 LIGATION/BIOPSY TEMPORAL ARTERY $837.00 97537615 37615 LIGATION MAJOR ARTERY NECK $2,134.00 97537618 37618 Ligation Extremity $1,472.00 97538120 38120 LAP SPLEN TOTAL $3,414.00 97538510 38510 LYMPH NODE BIOPSY-DEEP/REMOVAL ProFee. $2,071.00 97542960 42960 Control Oropharyngeal Hem $634.75 97542999 42999 UNLISTED PROC, SALIVARY GLANDS OR DUCTS $3,924.00 97543235 43235 EGD $628.00 97543239 43239 EGD WITH BIOPSY $889.00 97543245 43245 EGD DILATION GASTRIC/DUODENAL STRICTURE $752.00 97543246 43246 GASTROSTOMY TUBE PLACEMENT ProFee $1,504.00 97543247 43247 EGD REMOVE FOREIGN BODY- CCC PF $2,354.00 97543270 43270 EGD LESION ABLATION ProFee $1,488.00 97543280 43280 Laps Surg Esopg/Gstr Fndo $3,512.00 97543610 43610 EXCISION, LOCAL; ULCER OR BENIGN TUMOR $7,856.00 97543632 43632 GASTRCTMY PRTL W/GASTROJE $5,120.00 97543633 43633 GSTRCT,PRTL,DSTL;W/ROUX-EN-Y RCNST J $7,522.00 97543760 43760 CHANGE G TUBE $2,746.00 97543771 43771 Laps Gastric Rstrc Px Rev $4,107.00 97543830 43775 LAP SLEEVE GASTRECTOMY $4,288.00 97543840 43840 Gastrorrhaphy Perf Duodnl $5,329.00 97544005 44005 LYSIS OF ADHESIONS $3,924.00 97544050 44050 RELEASE OF SMALL BOWEL OBSTRUCTION $3,793.00 97544120 44120 ENTERECTOMY,RESECT SM INTESTIN ProFee. $3,139.00 97544121 44121 RESECT SM INTEST; EA ADDTL RESECTION $855.36 97544130 44130 Entrontrstm Anast Int Cut $5,219.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97544139 44139 MOBILIZ SPLENIC FLEX $327.00 97544140 44140 COLECTOMY PARTIAL $3,924.00 97544141 44141 Colectomy Part W/Cecostom $4,709.00 97544143 44143 Colct Prtl W/End Clst&Cls $6,653.00 97544180 44180 LAPAROSCOPY SURG ENTEROLYSIS ProFee. $2,930.00 97544188 44188 Laparoscpy Surg Colostmy $4,890.00 97544202 44202 Laparoscpy Enterectmysngl $4,761.00 97544206 44206 LAPS COLECTOMY PRTL W/END CLST & CLSR DS $7,003.00 97544300 44300 OPEN BOWEL TO SKIN $2,485.00 97544310 44310 ILEOSTOMY/JEJUNOSTOMY,NON-TUBE $4,109.00 97544320 44320 Colostomy Or Skin Lev Cec $3,042.00 97544380 44380 ILEOSCOPY $327.00 97544388 44388 COLONOSCOPY THRU STOMA SPX -SC $2,258.28 97544620 44620 CLOS ENTEROSTOMY INT $3,063.34 97544625 Close Enterostomy; W Resect & Anastom $3,556.00 97544799 44799 UNLISTED PROCEDURE INTESTINE ProFee $3,924.00 97544950 44950 APENDECTOMY ProFee $2,244.00 97544955 44955 APPENDCTMY WITH SURG $336.00 97544960 44960 APPENDECTOMY FOR RUP $2,448.00 97544970 44970 LAPAROSCOP APPENDECTOMY ProFee. $2,040.00 97545005 45005 I&D SUBMUCOSAL ABS,RECTUM $693.00 97545100 45100 BIOPSY OF RECTUM ProFee $785.00 97545114 45114 PROCTECTOMY PARTIAL WITH ANASTOMOSIS $4,840.00 97545330 45303 Proctosigmoidoscopy dilate $419.00 97545331 45331 SIGMOIDOSCOPY W BIOP $419.00 97545378 45378 DIAGNOSTIC COLONOSCOPY $1,020.00 97545380 45380 COLONOSCOPY WITH BIOPSY $1,219.00 97545388 45388 HOT BIOPSY POLYP ProFee $969.15 97545398 45398 COLONOSCOPY W/BAND LIGATION. $840.48 97545399 45399 UNLISTED PROCEDURE COLON $2,003.01 97545560 45560 REPAIR OF RECTOCELE ProFee $1,687.00 97545915 45915 REMOVAL RECTUM FOREIGN BODY $2,632.80 97546020 46020 Plmt Seton $933.00 97546030 46030 Rmvl Anal Seton Oth Marka $362.00 97546040 46040 I&D PERIRECTAL ABSCE $1,289.00 97546045 46045 INC&DRAIN INTRAMURAL ABSC $1,065.00 97546050 46050 I&D PERIANAL ABSCESS $1,020.00 97546080 46080 Sphincterotomy Anal Divid $1,308.00 97546083 46083 INCISE EXTRNL HEMORR $420.00 97546220 46220 EXC SINGLE ANAL TAG $475.00 97546221 46221 HEMORRHOIDECTOMY INT,RB LIGATION ProFee $602.00 97546255 46255 REMOVE INT/EXT HEM 1 GROUP - SC $1,401.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97546257 REMOVE IN/EX HEM GRP & FISS $1,287.75 97546260 46260 HEMORRHOIDECTOMY INT/EXT COMP ProFee $1,831.00 97546270 46270 Surg Tx Anal Fistula $1,194.00 97546280 46280 Transsphinct Supra/Extra $1,869.00 97546320 46320 Excise Thrombos Hemorrhoi $445.00 97546999 46999 ANUS UNLISTED PROCEDURE ProFee $3,924.00 97547001 47001 NEEDLE BIOPSY LIVER ADD ON SC PF $412.00 97547100 47100 BIOPSY OF LIVER WEDGE $2,224.00 97547379 47379 UNLISTED LAP PROCEDURE-LIVER ProFee $3,270.00 97547480 47480 INCISION OF GALLBLADDER $5,846.96 97547562 47562 LAP CHOLECYSTECTOMY $3,061.00 97547563 47563 LAPARO CHOLECYSTECTOMY/GRAPH ProFee $3,265.00 97547564 47564 LAP CHOLE W/EXP COMMON BILE DU ProFee $4,376.00 97547600 47600 CHOLECYSTECTOMY $4,260.00 97547605 47605 CHOLECYSTECTOMY W CH $5,023.00 97547620 47620 GALLBLADDER REM W/EXP $3,924.00 97549000 49000 EXPLORATY LAPAROTOMY $2,485.00 97549020 49020 Drainage Of Peritoneal Ab $4,120.00 97549060 49060 DRAIN OF RETROPTL ABSCESS $3,519.00 97549082 49082 PARACENTESIS W/O IMAGING $758.00 97549083 49083 ABD PARACENTESIS WITH IMAGING GUIDANCE $438.00 97549084 49084 Peritoneal Lavagew/Image Guidnc Pro $524.00 97549255 49255 DEST.PERITONEAL TISSUE ProFee $2,786.94 97549320 49320 DIAGNOSTIC LAPAROSCO $1,530.00 49321 LAPAROSCOPY BIOPSY ProFee49321 LAPAROSCOPY BIOPSY 97549321 ProFee $1,123.00 97549322 49322 LAPAROSCOPY ASPIRATION ProFee $981.00 97549329 49329 UNLISTED LAPAROSCOPY PROCEDURE ProFee $1,530.00 97549402 49402 REMOV PERITONEAL FOREIGN BODY FRM CAVITY $3,389.00 97549422 49422 REMOV INTRAPER CATH $1,275.00 97549505 49505 REP INGU HERN 5 UP W $1,334.00 97549507 49507 HERNIA REP INCARCER/STRANGULAT ProFee $1,884.00 97549520 49520 REPAIR RECURRENT ING HERNIA ProFee $2,209.92 97549521 49521 Rpr Inguinl Hernia Incarc $2,520.57 97549525 49525 Rpr Inguinal Hernia Slidi $1,441.00 97549560 49560 HERNIA REP INIT VENTRAL REDUCE ProFee. $2,339.00 97549561 49561 INCARCERATED INCISCIONAL HERNIA $2,352.00 97549565 49565 HERNIA INC/VENT RECUR/REDUCED ProFee $2,688.24 97549568 49568 IMPLANTATION OF MESH $940.00 97549585 49585 HERNIA UMBILICAL REDUCED ProFee $1,256.00 97549587 49587 HERNIA REPAIR INCAR/STRANG ProFee. $2,756.00 97549650 49650 LAP ING HERNIA REP INTIAL ProFee $1,177.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97549652 49652 Laparoscpy Surg Rprhernia $1,766.00 97549653 49653 Hernia repair w/mesh-incarcerated/strangulated $2,243.00 MD Pro Suture, secondary, of abdominal wall for evisceration or 97549900 dehiscence $2,470.00 97549999 49999 ABDOMEN SURGERY PROCEDURE $3,270.00 97551727 51727 COMPLEX CYSTOURET PRESSURE $2,040.00 97551860 51860 Rpr of bladder wound -CCCPF $2,621.22 97552000 52000 CYSTOSCOPY $552.00 97553899 53899 Unlisted Urinary System $3,924.00 97554520 54520 Orchiectomy Sim Scro/Ingu $1,148.58 97554640 54640 ORCHIOPEXY INGUIN W/WO HERN RE ProFee $2,616.00 97554700 54700 I & D ABSCESS EPID/TESTIS/SCRO ProFee $864.00 97555060 55060 Rpr Tunica Vagis Hydrocel $1,509.00 97555500 55500 Excis Hydrocele Spermcord $1,046.00 97555540 55540 EXC VARICOCELE/LIGATION VEINS W/HERNIA $2,120.00 97556405 56405 I & D PERINEAL ABSCESS $1,212.00 97556420 56420 BARTHOLIN GLAND REMOVAL $367.00 97556440 56440 MARSUPIALIZATION BART CYS $519.00 97556501 56501 DESTRUCTN LESION VULVA SM $392.00 97556605 56605 BIOPSY VULVA/PERINEUM 1 LESION SPX $242.00 97556606 56606 BIOPSY VULVA/PERINEUM EACH ADDL LESION $118.00 97556620 56620 VULVECTOMY (LABIOPLASTY)- SIMPLE/PARTIAL $1,812.45 97556810 56810 PERINEOPLASTY,RPR PERINUM $1,308.00 97557120 57120 COLPOCLEISIS (LE FORT TYPE) $1,962.00 97557130 57130 EXCISION OF VAGINAL SEPTUM $523.00 97557135 57135 Exc Vaginal Cyst/Tumor $1,046.00 97557200 57200 REPAIR OF VAGINA ProFee $1,201.00 97557220 57220 REV OF URETHREAL SPHINTER $850.00 97557240 57240 ANTERIOR COLPORRAPHY ProFee $2,281.00 97557260 57260 COLPORRHAPHY A & P $4,504.00 97557265 57265 COLPO A&P ENTERO REP $3,164.04 97557267 57267 Insert Mesh/Pelvic Flr $891.84 97557268 57268 Rpr Enterocele Vag Approach $1,962.00 97557270 57270 Rpr Enterocele Abd Approach $2,779.14 97557280 57280 ABDOMINAL SACRAL COLPOPLASTY/COLPOPEXY $3,145.00 97557287 57287 Remov Sling 4 Stress Inco $2,139.00 97557288 57288 SLING PROCEDURE $3,564.00 97557295 57295 REVISION OF VAGINAL GRAFT $1,308.00 97557420 57420 COLPOSCOPY ENTIRE VAGINAL W/CERVIX $371.00 97557425 57425 COLPOPEXY LAPAROSCOPY $3,369.81 97557452 57452 EXAM OF CERVIX W/SCOPE $445.00 97557454 57454 COLPOSCOPY W BX CERV $488.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97557455 57455 COLPOLOSCOPY OF CERVIX WITH BIOPSY $512.00 97557460 57460 COLPOLOSCOPY WITH LOOP ELECTRODE BIOPSY $822.00 97557500 57500 BIOPSY OF CERVIX. $367.00 97557505 57505 Endocervical Curettage $364.00 97557511 57511 CRYOCAUTERY OF CERVIX $839.00 97557520 57520 CONIZATION CERVIX W/WO D&C RPR KNIFE/LAS $1,098.00 97557522 57522 CONIZATION OF CERVIX LOOP $1,426.00 97557720 57720 Trachelorrhaphy Rprcervix $1,065.99 97558100 58100 ENDOMETRIAL ASPIRATI $312.00 97558110 58110 ENOOMETRIAL BIOPSY PERFORMED WITH COLPOSCOPY $162.00 97558120 58120 D & C DIAGNOSTIC $835.00 97558140 58140 HYSTEROSCOPY (ABD) $3,719.00 97558150 58150 HYSTERECTOMY ABDOM $4,231.00 97558152 58152 HYSTERECTOMY $3,992.00 97558180 58180 SUPRACERVICAL ABDOMINAL HYSTERECTOMY $4,064.00 97558260 58260 HYSTER VAGINAL $3,285.00 97558262 58262 HYSTER VAG TUBE OVAR $3,079.00 97558340 58340 INJECT PROC HSG $346.00 97558350 58350 CHROMOTUBATION $203.00 58353 ENDOMETRIAL ABLATION THERMAL WOUT HYSTEROSCOPIC 97558353 GUIDANCE $3,270.00 97558356 58356 ENDOMETRAIL CRYOABLATION $6,442.00 97558400 58400 UTERINE SUSPENSION $1,177.00 97558541 58541 LAPARO SUPRACERVIC HYSTER $3,401.00 97558550 58550 LAP VAG HYSTERECTOMY $4,447.00 97558552 58552 LAP VAG HYS W SAL OO $4,448.00 97558555 58555 HYSTEROSCOPY diagnostic $4,877.00 97558558 58558 HYSTEROSCOPY SURGICAL; WITH SAMPLING OF ENDOMETRIUM $2,024.00 97558559 58559 HYS W/LYSIS UTERINE ADH $983.00 97558561 58561 Hysteroscopy W/Rem Leiomy $1,527.36 97558562 58562 Hysteroscopy W/Rem Fb $1,173.00 97558563 58563 Hysteroscopy W/Endo Ablat $4,960.00 97558578 58578 LAP PROCEDURE, UTERUS $3,924.00 97558579 58579 UNLIST HYSTERSCOPE UTERUS $3,270.00 97558600 58600 Tubal Ligation CHARGE $1,083.00 97558600 LIGATE FALLOP TUBE ABD OR VAG; INIT/BIL $1,083.18 97558605 58605 Tubal w/postpartum CHARGE $1,073.00 97558611 58611 TUBAL LIGATION/C-SECTION CHARGE $1,112.00 97558660 58660 LAP LYSIS ADHISIONS $3,422.00 97558661 58661 LAP W REM ADNEXAL ST $3,336.00 97558662 58662 CAUTERIZE ENDOMETRI $2,566.00 97558670 58670 LAPAROSCOPIC TUBAL LIGATION ProFee $2,446.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97558679 58679 UNLIST LAPAROSCOPY PROCED,OVIDUCT,OVARY $2,446.00 97558700 58700 REMOVAL OF FALLOPIAN TUBE $2,395.00 97558720 58720 SALPINGO-OOPHORECTOMY COMP/PAR ProFee $2,481.00 97558740 58740 LYSIS OF ADHESIONS (SALPINGOLY ProFee $2,289.00 97558920 58920 OVARION WEDGE RESECTION ProFee $17,096.85 97558925 58925 OVARIAN CYSTECTOMY UNIL/BIL ProFee $2,446.00 97558940 58940 OOPHORECTOMY PART TO $1,592.00 97558999 58999 UNLISTED FEMALE GENITAL PROCED ProFee. $3,924.00 97559025 59025 FETAL NON STRESS TEST $610.00 97559120 59120 Surg Tx Ectopic Pregnancy $3,186.00 97559150 59150 LAPS TX ECTOPIC PREG W/O SALPING&/OOPHOR $3,004.00 97559151 59151 SALPINGECTOMY $4,619.00 97559160 59160 Curettage, postpartum CHARGE $600.00 97559200 59200 Insertion Cervical Dilator $207.00 97559300 59300 EPISIOTOMY VAGINAL $772.00 97559400 59400 OB CARE -CCCPF $10,676.00 97559425 59425 ANTEPARTUM CARE 4-5 $2,370.00 97559426 59426 ANTEPARTUM CARE $4,238.00 97559430 59430 POSTPARTUM CARE ONLY $982.00 97559510 59510 C-SECTION CHARGE $12,010.00 97559514 59514 Caesarean Delivery Only CHARGE $3,781.00 97559515 59515 C-SECTION DELIVERY WITH POSTPARTUM CARE $3,935.00 97559612 59612 VBAC DELIVERY ONLY $2,566.00 59821 Treatment of missed abortion, completed surgically; second 97559821 trimester $1,072.50 97559855 59855 INDUCED ABORT 1/> VAGINAL SUPPOSITORIES $3,364.00 97559899 59899 Unlisted procedure, maternity care and delivery $7,848.00 97560220 60220 THYROID LOBECTOMY W/WO ISTHM ProFee $1,897.00 97560225 60225 PARTIAL REMOVAL OF THYROID $3,726.00 97564405 64405 N BLOCK INJ OCCIPITAL $251.00 97564435 64435 INJ ANESTH; PARACERVICAL NERVE $1,521.57 97564450 64450 Nerv Blck Oth Periph Nerv $838.00 97564455 64455 N BLOCK INJ PLANTAR DIGIT SC PF $314.00 97564718 64718 Neuroplasty Ulnar Nrv Elb $1,916.00 97564719 64719 Neuroplsty Ulnar Nrv Wrst $1,046.00 97564721 64721 Neuroplasty Median Nerve $1,386.00 97569200 69200 REMOVAL FB EAR $315.00 97569209 69209 Remove Impacted Ear Wax Unilateral $130.00 97569210 69210 EAR IRRIGATION $328.00 97596374 96374 IV PUSH,SNGL/INIT SUB/DRG $262.00 97597597 97597 WOUND DEBRIDEMENT $654.00 97597598 97598 Debrid Selct Ea Add20Sqcm $92.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 97602 REMOVE DEVITALIZED TISSUE, NON-SELECT W/O ANES, INCL TOP 97597602 APPL, WND ASMT/SESS- PROF CHG $3,924.00 97597606 97606 Neg Pres Wnd Ther>50Sqcm $119.00 97598925 98925 OSTEOPATHIC MANIPULATION $236.00 98199281 99281 BRIEF SERVICE $90.00 98199282 99282 LIMITED SERVICE $122.00 98199283 99283 INTERMEDIATE SERVICE $222.00 98199284 99284 EXTENDED SERVICE $346.00 98211100 11100 BIOPSY OF SKIN, SUBC TISSUE/MUCCOUS MEMB SINGLE LESION $263.00 98211200 11200 SKIN TAG UP TO 15 $216.00 98211201 11201 Skin Tag Removl Add'L 10 $66.00 98211301 11301 SHAVE SKIN LESION .6/1.0 $237.00 98211302 11302 SHVG SKN LESION1 TRNK/ARM/LEG DIAM1.1-2. $249.00 98211601 11601 Excise Les Mal .6 To 1 Cm $570.00 98211602 11602 Excise Les Mal 1.1 To 2Cm $623.00 98211603 11603 EXC TR-EXT MAL+MARG 2.1-3 CM -SC $771.00 98211606 11606 EXC TR-EXT MLG+MRG > 4 CM $1,151.00 98211621 11621 EXC MAL SCL/NK/HDS 0.6-1.0 CM ProFee $498.00 98211622 11622 EXC MALIGNANT LESIONS S/N/H/F/G 1.1-2 CM $678.00 98211626 11626 EXC MALIGNANT LESIONS S/N/H/F/G >4.0 CM $1,172.00 98211640 11640 EXC FACE-MM MLG_MRG 0.5< $523.00 98211641 11641 LES MAL FACE ER EY N $619.00 98211642 11642 EXCIS MALIGNANT LES F/E/E/N/L 1.1-2.0 CM $727.00 98211740 11740 EVACUATION SUB HEMAT $130.00 98211750 11750 Exc Nail/Matrix Part/Comp $687.00 98212001 12001 SIM SPRFCL S,N,A,G,T $316.00 98212002 12002 Smp Rpr Sclp/Trk 2.6-7.5 $316.00 98213121 13121 COMPLEX REPAIR S,A,L $1,130.00 98213132 13132 CMPX F,C,C,M,N,A,G,H $1,486.00 98215852 15852 DRESSING CHNG W/ANES $2,616.00 98229075 29075 Short Arm Cast $288.00 98229085 29085 Cast Hand/Lower Forearmt $220.00 98229540 29540 ANKLE STRAPPING $111.00 98229580 29580 STRAPPING UNNA BOOT CHARGE $132.00 98236556 36556 INSERT NON T CV CATH $654.00 98236561 36561 Insert Tunn Cntrl Ven >5 $4,683.00 98241017 41017 XTRORAL I&D ABSC CST/HMTMA FLOOR OF MOUT $1,426.00 98244160 44160 COLECTOMY W REMOVAL $3,270.00 45384 COLON W/REMOVAL OF TUMOR,POLYP OR OTHER LES BY HOT 98245384 BIOPSY FORCEPS $1,206.00 98245385 45385 COLON W/REMOVAL OF TUMOR,POLYP, OR OTHER LES BY SNARE $2,570.00 98246600 46600 Anoscopy Diagnostic $262.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 98246606 46606 Anoscopy W/Biopsy $899.00 98246922 46922 EXC ANUS LESION ProFee $538.00 98251702 51702 INSERT FOLEY CATHETE ED Charge $120.00 98251726 51726 COMPLEX CYSTOMETROGRAM $794.00 98251992 51992 Lap Sling 4 Stress Incont $3,418.00 98254160 54160 Circmcis Surg 28Dayorless $262.00 98254161 54161 CIRCUMCISION ]28 DAYS $528.00 98255250 55250 VASECTOMY $1,107.00 98257160 57160 INSERT PESSARY/OTHER DEVI $217.00 98258300 58300 Insertion IUD $392.00 98258301 58301 Removal Iud $327.00 98259000 59000 AMNIOCENTESIS DIAGNOSITC $361.00 98293000 93000 EKG W/INTERPRETATION/REPT $129.00 98296372 96372 Inj Im/Sub Theraputic/Diagnos $74.00 98299226 SUBSEQUENT OBSERVATION Care $315.78 98354150 54150 CIRCUMCISION NEWBORN $300.00 98742700 42700 Peritonsillar Absc/Drain $3,924.00 98759409 59409 Vaginal Delivery only CHARGE $2,566.00 98759410 59410 VAGINAL DELIVERY WITH POSTPARTUM CARE $3,250.00 98759412 59412 External Cephalic Version $856.00 98759414 59414 DELIVERY OF PLACENTA $374.00 98759812 59812 D and C CHARGE $1,027.00 98759820 59820 Tx of missed abortion -CCCPF $1,539.00 98799217 99217 OBSERVATION CARE DISCHARGE $231.00 98799218 99218 INITIAL OBSERVATION CARE $320.00 98799219 99219 INITIAL OBS CARE MODERATE COMPLEX $424.00 98799220 99220 INITIAL OBS CARE HIGH COMPLEX $535.00 98799221 99221 INITIAL HOSP. FOCUSED CHARGE $274.00 98799222 99222 Initital Hosp. Detailed CHARGE $424.00 98799223 99223 Initial Hosp. CHARGE $549.00 98799224 99224 SUBSEQUENT OBS CARE LOW $129.00 98799225 99225 SUB OPO CARE,LEVEL 2 -CCCPF $233.00 98799231 99231 SUBSEQUENT HOSPITAL CARE - LOW COMPLEX $133.00 98799232 99232 SUBSEQUENT HOSPITAL CARE - MODERATE COMPLEX $202.00 98799233 99233 SUBSEQUENT HOSPITAL CARE - HIGH COMPLEX $281.00 98799234 99234 S/D Hospital Care CHARGE $424.00 98799235 99235 S/D Hospital Care CHARGE $580.00 98799236 99236 S/D Hospital Care CHARGE $856.00 98799238 99238 SUBSEQUENT HOSPITAL CARE - DISCHARGE -CCCPF $235.00 98799239 99239 SUBSEQUENT HOSPITAL CARE - DISCHARGE OVER 30 MINS $289.00 98799460 Initial Newborn EM Per Day $288.00 98799462 99462 SUBSEQUENT HOSP CARE NEWBORN $189.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 98799463 99463 NEWBORN CARE ADM/DISC SAME DAY $256.00 98799464 99464 ATTENDANCE AT DELIVERY OF NEWBORN $293.00 98799465 99465 Neonatal Resuscitation $439.00 98799468 99468 INT IP NEONAT CC<28D $2,771.00 98831500 Scope Plantar Fasciotomy $1,186.00 $398.00 98899241 99241 Outpt Focused Consult 15Min $178.00 98899242 99242 Outpt Expanded Consult 30Min $279.00 98899243 99243 DETAILED OP/ER CONSULTATIONS $393.00 98899244 99244 Outpt Comp/Mod Consult60Min $512.00 98899245 Office consultation for a new or established patient $950.00 98899251 99251 INPT CONSULT LEVEL 1 CHARGE $178.00 98899252 99252 INPT CONSULT LEVEL 2 CHARGE $279.00 98899253 99253 INPT CONSULT LEVEL 3 CHARGE $367.00 731932261 Holter Monitor 24 hr $1,408.00 2700119293 ESMARK BANDAGE 4INX3YD STERILE #820-3409 $34.83 7619921111 99211 LDR OB TRIAGE HOSP LV 1 CHARGE $142.00 0249T 0249T ligation hemorrhoid bundle W/US $1,980.00 30036415BO 36415 BO $99.00 $26.00 350G0297 CT Low Dose Lung Screening $337.47 521J1030 DEPO_MEDROL 40 MG INJ $19.80 521J1885 Injection, ketorolac tromethamine charge. $2.67 521J7327 MONOVISC INJ PER DOSE $2,234.76 521Q4038 Cast Supplies, Short Leg Cast, Adult (11 Years +), Fiberglass $124.32 521S0020 0.25% Marcaine injection $13.56 540A0425 A0425 Ground mileage TechFee $20.91 540A0428 A0428 Bls TechFee $1,301.54 540A0428 BLS NON-EMERGENCY $1,301.54 684G0390 G0390 TRAUMA TEAM ACTIVATION LCMC $3,388.00 684G0390 TRAUMA TEAM ACTIVATION $3,388.00 762G0378 OBSV BED HOUR 1-2 HRS CHARGE $1,037.00 762G0378 OBSV W/TELEMETRY 25+ HOURS CHARGE $154.00 762G0378 OBSV W/TELEMETRY HOUR 1 CHARGE $1,107.00 762G0378 OBSV W/TELEMETRY HOUR 2 CHARGE $1,107.00 762G0378 OBSV W/TELEMETRY HOUR 3 CHARGE $554.00 762G0378 OBSV W/TELEMETRY HR 4-24 CHARGE $45.00 762G0378 OBVS BED HOUR 1 CHARGE $1,037.00 762G0378 OBVS BED HOUR 2 CHARGE $1,037.00 762G0378 OBVS BED HOUR 3 CHARGE $533.00 762G0378 OBVS BED HOURLY 25+ HOURS CHARGE $133.00 762G0378 OBVS BED PER HR 4-24 CHARGE $40.00 9750249T 0249T LIGATION HEMORRHOID BUNDLE W/US $990.00 975G0121 G0121 SCREENING COLONOSCOPY $1,059.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees 975G0289 G0289 ARTHRO, LOOSE BODY + CHONDRO $349.00 975J7300 J7300 INTRAUTERINE COPPER CONTR $1,962.00 A4565 A4565 Sling $30.00 A6456 A6456 Una Boot Zinc Bandage $41.42 A9270 A9270 Bisacodyl $14.00 G0008 G0008 Admin Influenza Virus Vaccine POC $42.00 G0009 Admin Pneumococcal Vaccine Medicare POC $62.00 G0010 Admin Hepatitis B Vaccine Medicare POC $253.86 G0101 G0101 Cervical or vaginal cancer screening $192.00 Colorectal cancer screening; colonoscopy on indiv meeting criteria for G0105 high risk Technical Charge $2,106.00 Colorectal cancer screening; colonoscopy on indiv not meeting criteria G0121 for high risk Tech Chg $2,118.00 G0123 G0123 Medicare pap smear $130.00 G0289 G0289 Medicare Chondroplasty Clinic Charge $698.00 G0402 G0402 Initial preventive physical examination Medicare $215.00 G0438 Advanced care planning for 30 minutes $592.68 G0439 Annual Wellness Visit, Subsequent (AWV) $294.00 G0463 G0463 hospital outpatient clinic visit $250.00 J0500 INJ BENTYL 50mg $48.00 J0561 INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS $33.00 J0561 J0561 PCN 1,000,000 units injection $92.00 J0696 CEFTRIAXONE PER 250MG $14.00 J0696 Injection, Ceftriaxone Sodium, Per 1 G Charge $34.00 J0696 Injection, Ceftriaxone Sodium, Per 250 MG Charge $38.00 J0834 Cosyntropin Injection 0.25 mg Charge $50.00 J0885 Epoetin alfa, non-esrd $80.00 J0885 INJ EPOETIN ALFA 1000 UNITS ESRD $56.00 J0897 J0897 (Prolia) Injection, denosumab, 60 mg $142.00 J1000 Depo-Estradiol Injection, up to 5 mg $74.00 J1071 J1071 Testosterone cypionate, 1 mg $26.91 J1094 Injection, Dexamethasone sodium phosphate 10mg/1ml #25 $56.00 J1100 DEXAMETH SOD INJ TO 1 MG $2.64 J1200 J1200 Injection, diphenhydramine HCl, up to 50 mg $14.00 J1200 Diphenhydramine, up to 50mg $1.71 J1740 J1740 Ibandronate sodium injection $1,570.00 J2357 J2357 Injection, omalizumab, 5 mg $4,344.00 J2357 J2357 Xolair $152.00 J2550 J2550 Phenegran Shot $30.00 J2550 Injection, Promethazine HCL, up to 50 mg Charge $68.00 J2790 Injection, RhoGam 300 mcg charge $314.00 J2930 Injection, Methylprednisolone 125mg/2ml #25 $42.00 CDM # Description Clinic Price Hopital Price Emergency Room Price Ancillary OP Price Nursery Price Professional Fees J3301 J3301 Kenalog 40mg injection $57.00 J3301 Injection, Kenalog, triamcinolone acetonide, 40mg/1ml #1 $114.00 J3303 J3303 Injection, triamcinolone hexacetonide, per 5mg $114.00 J3420 Injection, Vitamin B-12 Cyanocobalamin, 1ml/1000 mcg $25.26 J3420 Vitamin B-12 Injection 1000 mcg Charge $30.00 J7298 Levonorgestrel-Releasing Intrauterine Contraceptive System, 52 J7298 Mg, 5 Year $5,232.00 J7300 Intrauterine Copper Contraceptive Charge $3,924.00 J7301 J7301 Levonorgestrel releasing IUD 13.5mg $5,103.38 J7301 IUD Skyla $3,745.86 J7307 Nexplanon $3,250.00 J7325 J7325 Hyaluronate SOD Synvic 1mg $3,676.00 J7325 Synvisc per 1 mg $1,920.00 J7325 Synvisc or Synvisc-One, for intra-articular injection, 1mg $82.00 J7607 Levalbuterol (Xopenex), inhalation solution, compounded product, J7607 administered through dme, con $26.00 J7609 J7609 Albuterol $92.00 J7613 albuterol svn 2.5mg/3ml $14.00 J7613 albuterol/IPR 3mg/0.5mg $16.00 J7613 J7613 Albuterol, inhalation solution, non-compounded, unit dose, 1 mg $46.00 J7626 PULMICORT .25+ MG IN $42.00 L1820 L1820 walking pneumatic brace $392.00 L4360 Air Walker Boot Charge $1,178.00 Q2038 Influenza virus vaccine, split virus, when administered to Q2038 individuals 3 year of age and older $138.00 Q4009 Cast Supplies, Short Arm Cast, Adult (11 Years +), Plaster $26.13 Q4045 Q4045 cast supplies, short leg, plaster $106.00 Q4131 Q4131 epifix, per SQ CM $1,212.00 S0020 0.5% Marcaine injection $11.30