LCMC Health Is Committed to Helping Patients Understand and Prepare for the Cost of Their Care

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LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge 17-HYDROXYPREGNENOLONE (HORMONE) LEVEL 84143 $139.00 3D REPORT WITH WORKSTATION 76377 $1,493.00 3D REPORT WITHOUT WORKSTATION 76376 $1,194.00 ABACAVIR 20 MG/ML SOLN 240 ML BOTTLE $882.80 ABACAVIR 300 MG TAB 1 EACH BLIST PACK $35.14 ABACAVIR-DOLUTEGRAVIR-LAMIVUD 600-50-300 MG TAB 30 $363.84 ABACAVIR-LAMIVUDINE 600-300 MG TAB 30 EACH BOTTLE $162.58 ABACAVIR-LAMIVUDINE-ZIDOVUDINE 300-150-300 MG TAB $112.68 ABATACEPT (WITH MALTOSE) 250 MG SOLR 1 EACH VIAL J0129 $4,394.25 ABCIXIMAB 10 MG/5 ML SOLN 5 ML VIAL J0130 $5,662.37 ABDOMINAL ASPIRATION OF FLUID SURROUNDING FETUS FO 59000 $1,073.00 ABDOMINAL ASPIRATION TO REDUCE AMOUNT OF FLUID SUR 59001 $1,119.00 ABDOMINAL INFUSION OF NORMAL SALINE INTO FETAL AMN 59070 $608.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS 76812 $824.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS (LESS THAN 76802 $818.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS SINGLE OR 76801 $1,012.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS SINGLE OR 76805 $1,049.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS SINGLE OR 76811 $1,176.00 ABDOMINAL ULTRASOUND PREGNANT UTERUS (GREATER OR E 76810 $1,238.00 ACAMPROSATE 333 MG TBEC 180 EACH BOTTLE $6.15 ACARBOSE 50 MG TAB 100 EACH BOTTLE $1.70 ACE - ANGIO CONVERTING ENZYME 82164 $173.00 ACEBUTOLOL 200 MG CAP 1 EACH BLIST PACK $3.79 ACEBUTOLOL 200 MG CAP 100 EACH BOTTLE $3.52 ACEBUTOLOL 200 MG CAP 50 EACH BLIST PACK $3.79 ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) SOLN 100 J0131 $182.70 ACETAMINOPHEN 120 MG SUPP 1 EACH BOX $1.36 ACETAMINOPHEN 120 MG SUPP 12 EACH BOX $2.04 ACETAMINOPHEN 160 MG/5 ML (5 ML) SOLN 5 ML CUP $13.83 ACETAMINOPHEN 160 MG/5 ML (5 ML) SUSP 5 ML CUP $10.10 ACETAMINOPHEN 160 MG/5 ML SUSP 30 ML DROP BTL $4.83 ACETAMINOPHEN 32 MG/ML SYRG 5 ML SYRINGE $11.41 ACETAMINOPHEN 325 MG SUPP 1 EACH BOX $0.69 ACETAMINOPHEN 325 MG SUPP 12 EACH BOX $2.29 ACETAMINOPHEN 325 MG TAB 1,000 EACH BOTTLE $0.19 ACETAMINOPHEN 325 MG TAB 100 EACH BLIST PACK $0.23 ACETAMINOPHEN 325 MG TAB 100 EACH BOTTLE $0.15 ACETAMINOPHEN 325 MG TAB 750 EACH BLIST PACK $0.22 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ACETAMINOPHEN 500 MG TAB 100 EACH BLIST PACK $0.18 ACETAMINOPHEN 500 MG TAB 100 EACH PACKAGE $0.18 ACETAMINOPHEN 500 MG TAB 500 EACH BOTTLE $0.06 ACETAMINOPHEN 500 MG/15 ML LIQD 237 ML BOTTLE $0.68 ACETAMINOPHEN 500 MG/15 ML LIQD 30 ML CUP $0.68 ACETAMINOPHEN 650 MG SUPP 1 EACH BLIST PACK $1.04 ACETAMINOPHEN 650 MG SUPP 100 EACH BOX $1.51 ACETAMINOPHEN 650 MG SUPP 12 EACH BLIST PACK $2.47 ACETAMINOPHEN 650 MG SUPP 50 EACH BOX $2.08 ACETAMINOPHEN 650 MG/20.3 ML SOLN 20.3 ML CUP $4.26 ACETAMINOPHEN-CODEINE 120 MG-12 MG /5 ML (5 ML) SO $259.77 ACETAMINOPHEN-CODEINE 300-30 MG TAB 1 EACH BLIST P $1.26 ACETAMINOPHEN-CODEINE 300-30 MG TAB 100 EACH BLIST $1.26 ACETAMINOPHEN-TYLENOL) 80307 $266.00 ACETAZOLAMIDE 250 MG TAB 100 EACH BLIST PACK $7.33 ACETAZOLAMIDE 250 MG TAB 100 EACH BOTTLE $5.05 ACETAZOLAMIDE 500 MG CPSR 100 EACH BOTTLE $15.01 ACETAZOLAMIDE 500 MG CPSR 30 EACH BLIST PACK $17.13 ACETAZOLAMIDE 500 MG SOLR 1 EACH VIAL J1120 $92.31 ACETIC ACID (BULK) 3 % LIQD 500 ML BOTTLE $89.25 ACETIC ACID (BULK) 5 % LIQD 500 ML BOTTLE $89.25 ACETIC ACID 0.25 % SOLN 1,000 ML BOTTLE $24.50 ACETIC ACID 2 % SOLN 15 ML DROP BTL $140.02 ACETONE ASSAY 82010 $140.00 ACETYLCHOLINE BINDING AB 83519 $365.00 ACETYLCHOLINE BLOCK AB 83516 $198.00 ACETYLCHOLINE MODULATING AB 83516 $198.00 ACETYLCYSTEINE 100 MG/ML (10 %) SOLN 4 ML VIAL $8.72 ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL J0132 $789.60 ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 4 ML VIAL $13.09 ACETYLCYSTEINE 600 MG CAP 100 EACH BOTTLE $0.35 ACID FAST CULTURE 87116 $230.00 ACIDOPHILUS 100 MILLION CELL GRPK 12 EACH PACKET $2.68 ACTH LEVEL 82024 $334.00 ACTIVATED CHARCOAL 25 GRAM/120 ML SUSP 120 ML BOTT $58.38 ACTIVATED CHARCOAL 25 GRAM/120 ML SUSP 120 ML TUBE $58.38 ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSP 12 $4.20 ACTIVATED PROTEIN RESISTANCE ASSAY 85307 $280.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ACTIVITY THERAPY G0176 $320.00 ACUTE DIGESTIVE TRACT BLOOD LOSS IMAGING 78278 $2,243.00 ACUTE HEPATITIS PANEL 80074 $789.00 ACYCLOVIR 200 MG CAP 100 EACH BLIST PACK $5.35 ACYCLOVIR 200 MG/5 ML SUSP 473 ML BOTTLE $8.23 ACYCLOVIR 200 MG/5 ML SUSP 5 ML CUP $16.47 ACYCLOVIR 5 % OINT 15 G TUBE $1,395.82 ACYCLOVIR 5 % OINT 30 G TUBE $1,260.00 ACYCLOVIR 50 MG/ML SOLN 10 ML VIAL J0133 $47.25 ADDING WALKER TO PREVIOUSLY APPLIED CAST 29440 $340.00 ADENOSINE (DIAGNOSTIC) 3 MG/ML SOLN 30 ML VIAL J0153 $675.99 ADENOSINE 3 MG/ML SOLN 2 ML VIAL J0153 $13.02 ADENOVIRUS AB 86603 $170.00 ADENOVIRUS ANTIGEN IMMUNOFLUORESCENT 87260 $136.00 ADH (ANTIDIURETIC HORMONE) LEVEL 84586 $433.00 ADH (ANTIDIURETIC HORMONE) LEVEL 84588 $232.00 ADMINISTRATION FLU VIRUS VACCINATION 90471 $22.00 ADMINISTRATION HEPATITIS B VACCINATION 90471 $73.00 ADMINISTRATION OF 1 VACCINE 90471 $73.00 ADMINISTRATION OF DRUG FOR HELICOBACTER PYLORI 83014 $65.00 ADMINISTRATION OF INFLUENZA VIRUS VACCINE SUBSEQUE 90472 $83.00 ADMINISTRATION OF MEDICATION THROUGH BREATHING TUB 94610 $238.00 ADMINISTRATION OF MEDICATION TO INDUCE VOMITING 99175 $198.00 ADMINISTRATION OF VACCINE 90472 $83.00 ADMINISTRATION PNEUMOCOCCAL VACCINATION 90471 $22.00 ADO-TRASTUZUMAB EMTANSINE 160 MG SOLR 1 EACH VIAL J9354 $19,782.00 ADRENAL GLAND STIMULATION PANEL 80412 $2,718.00 ADRENOCORTICOTROPIC HORMONE (ACTH) LEVEL 82024 $334.00 AFB BLOOD CULTURE 87116 $230.00 AG DETECT LEGIONELLA EIA QL MULTI 87449 $274.00 AL HYD-MG TR-ALG AC-SOD BICARB 80-14.2 MG CHEW 100 $0.25 ALBUMIN SERUM PLASMA WHOLE BLD 82040 $67.00 ALBUMIN, FLUID 82042 $95.00 ALBUMIN, HUMAN 25 % 25 % SOLP 100 ML FLEX CONT P9047 $490.00 ALBUMIN, HUMAN 25 % 25 % SOLP 50 ML FLEX CONT P9047 $245.00 ALBUMIN, HUMAN 5 % SOLP 250 ML FLEX CONT P9045 $155.75 ALBUTEROL 2.5 MG /3 ML (0.083 %) NEBU 3 ML VIAL $2.80 ALBUTEROL 5 MG/ML NEBU 20 ML BOTTLE $2.54 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ALBUTEROL 90 MCG/ACTUATION HFAA 8 G CANISTER $92.65 ALBUTEROL SULFATE 2.5 MG/0.5 ML NEBU 0.5 ML BLIST $0.79 ALCOHOL 98 % SOLN 1 ML VIAL $283.00 ALCOHOL 98 % SOLN 5 ML VIAL $543.90 ALCOHOL-ETHYL, URINE 80320 $232.00 ALCOHOLS LEVELS 80307 $232.00 ALCOHOLS LEVELS 80321 $238.00 ALCOHOLS LEVELS 80322 $259.00 ALDOLASE (ENZYME) LEVEL 82085 $165.00 ALDOSTERONE HORMONE LEVEL 82088 $465.00 ALDOSTERONE SUPPRESSION EVALUATION PANEL 80408 $1,036.00 ALENDRONATE 10 MG TAB 100 EACH BOTTLE $5.12 ALENDRONATE 10 MG TAB 20 EACH BLIST PACK $10.23 ALENDRONATE 10 MG TAB 30 EACH BOTTLE $5.12 ALENDRONATE 35 MG TAB 12 EACH BLIST PACK $10.40 ALENDRONATE 70 MG TAB 20 EACH BLIST PACK $7.48 ALENDRONATE 70 MG TAB 4 EACH BLIST PACK $71.71 ALFENTANIL 500 MCG/ML SOLN 2 ML AMPUL $14.70 ALFUZOSIN 10 MG TB24 100 EACH BOTTLE $12.38 ALISKIREN 150 MG TAB 30 EACH BOTTLE $25.19 ALKALOIDS LEVELS 80323 $292.00 ALLERGENS, EA (RAST) 86003 $65.00 ALLOPURINOL 100 MG TAB 100 EACH BLIST PACK $1.75 ALLOPURINOL 300 MG TAB 100 EACH BLIST PACK $2.65 ALPHA-1-ANTITRYPSIN (PROTEIN) BLOOD TEST 82103 $187.00 ALPHA-1-ANTITRYPSIN (PROTEIN) BLOOD TEST 82104 $232.00 ALPHA-FETOPROTEIN (AFP) ANALYSIS 82107 $636.00 ALPHA-FETOPROTEIN (AFP) LEVEL, AMNIOTIC FLUID 82106 $145.00 ALPHA-FETOPROTEIN (AFP) LEVEL, SERUM 82105 $222.00 ALPRAZOLAM 0.25 MG TAB 100 EACH BLIST PACK $2.28 ALPRAZOLAM 0.25 MG TAB 100 EACH BOTTLE $2.16 ALPRAZOLAM 0.5 MG TB24 60 EACH BOTTLE $7.90 ALPRAZOLAM 1 MG TAB 100 EACH BLIST PACK $0.79 ALPROSTADIL 500 MCG/ML SOLN 1 ML AMPUL J0270 $498.01 ALPROSTADIL 500 MCG/ML SOLN 1 ML VIAL J0270 $455.03 ALTEPLASE 100 MG SOLR 1 EACH VIAL J2997 $3,326.54 ALTEPLASE 2 MG SOLR 1 EACH VIAL J2997 $642.85 ALTEPLASE 50 MG SOLR 1 EACH VIAL J2997 $3,326.54 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ALUM, AMMONIUM POWD 340 G JAR $43.25 ALUMINUM HYDROXIDE 320 MG/5 ML SUSP 30 ML CUP $1.26 ALUMINUM HYDROXIDE 320 MG/5 ML SUSP 473 ML BOTTLE $20.16 ALUMINUM LEVEL 82108 $141.00 ALUMINUM-MAGNESIUM-HYDROXIDE-SIMETHICONE 200-200-2 $0.37 ALVIMOPAN 12 MG CAP 30 EACH BLIST PACK $693.38 AMALGAM 4 OR MORE SURFACES D2161 $227.00 AMALGAM ONE SURFACE D2140 $140.00 AMALGAM THREE SURFACES D2160 $265.00 AMALGAM TWO SURFACES D2150 $189.00 AMANTADINE HCL 100 MG CAP 1 EACH BLIST PACK $11.54 AMANTADINE HCL 100 MG CAP 100 EACH BLIST PACK $7.53 AMANTADINE HCL 100 MG TAB 100 EACH BLIST PACK $9.60 AMANTADINE HCL 50 MG/5 ML SOLN 10 ML BLIST PACK $4.50 AMANTADINE HCL 50 MG/5 ML SOLN 10 ML CUP $2.70 AMANTADINE HCL 50 MG/5 ML SOLN 473 ML BOTTLE $2.70 AMBULANCE ADVANCED LIFE SUPPORT A0426 $1,460.00 AMBULANCE ADVANCED LIFE SUPPORT A0427 $1,429.00 AMBULANCE ADVANCED LIFE SUPPORT A0433 $1,984.00 AMBULANCE ADVANCED LIFE SUPPORT MILEAGE A0390 $32.00 AMBULANCE BASIC LIFE SUPPORT EMERGENCY A0429 $1,202.00 AMBULANCE BASIC LIFE SUPPORT MILEAGE A0380 $32.00 AMBULANCE BASIC LIFE SUPPORT NON-EMERGENCY A0428 $714.00 AMBULANCE BASIC LIFE SUPPORT SUPPLIES A0382 $296.00 AMBULANCE GROUND MILEAGE A0425 $32.00 AMBULANCE MILEAGE NON-COVERED A0888 $32.00 AMBULANCE OXYGEN A0422 $199.00 AMBULANCE RESPONSE AND TREATMENT A0998 $204.00 AMBULANCE SPECIALTY CARE A0434 $2,323.00 AMBULANCE WAITING TIME A0420 $179.00 AMIKACIN - PEAK 80150 $133.00 AMIKACIN - RANDOM 80150 $133.00 AMIKACIN - TROUGH 80150 $133.00 AMIKACIN (ANTIBIOTIC) LEVEL 80150 $133.00 AMIKACIN 1,000 MG/4 ML SOLN 4 ML VIAL J0278 $102.94 AMIKACIN 500 MG/2 ML SOLN 2 ML VIAL J0278 $51.47 AMILORIDE 5 MG TAB 1 EACH BLIST PACK $4.37 AMILORIDE 5 MG TAB 100 EACH BOTTLE $0.93 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge AMILORIDE 5 MG TAB 50 EACH BLIST PACK $4.37 AMINO ACID ANALYSIS 82127 $114.00 AMINO ACID LEVEL, MULTIPLE AMINO ACIDS 82136 $139.00 AMINOCAPROIC ACID 250 MG/ML SOLN 20 ML VIAL $22.01 AMINOCAPROIC ACID 500 MG TAB 30 EACH BOTTLE $171.02 AMINOPHYLLINE 250 MG/10 ML SOLN 10 ML VIAL J0280 $47.74 AMIODARONE 200 MG TAB 1 EACH BLIST PACK $1.06 AMIODARONE 200 MG TAB 100 EACH BLIST PACK $27.80 AMIODARONE 200 MG TAB 60 EACH BOTTLE $11.63 AMIODARONE 50 MG/ML SOLN 3 ML VIAL J0282 $8.75 AMIODARONE 50 MG/ML SOLN 9 ML VIAL J0282 $7.88 AMITRIPTYLINE 10 MG TAB 100 EACH BLIST PACK $1.11 AMITRIPTYLINE 25 MG TAB 1,000 EACH BOTTLE $0.84 AMITRIPTYLINE 25 MG TAB 100 EACH BLIST PACK $2.23 AMITRIPTYLINE 50 MG TAB 1 EACH BLIST PACK $3.70 AMITRIPTYLINE 50 MG TAB 100 EACH BLIST PACK $3.70 AMLODIPINE 1 MG/ML SUSP 100 ML BOTTLE $1.01 AMLODIPINE 5 MG TAB 1 EACH BLIST PACK $0.69 AMLODIPINE 5 MG TAB 100 EACH BLIST PACK $0.17 AMLODIPINE 5 MG TAB 90 EACH BOTTLE $6.26 AMMONIA 15 % (W/V) SOLN 1 EACH AMPUL $1.80 AMMONIA LEVEL 82140 $169.00 AMMONIUM LACTATE 12 % CREA 140 G JAR $49.00 AMMONIUM LACTATE 12 % CREA 385 G JAR $175.18 AMMONIUM LACTATE 12 % LOTN 225 G BOTTLE $115.76 AMMONIUM LACTATE 12 % LOTN 227 G BOTTLE $63.56 AMOBARBITAL 500 MG SOLR 1 EACH VIAL J0300 $307.88 AMOXICILLIN 250 MG CAP 100 EACH BOTTLE $0.88 AMOXICILLIN 250 MG/5 ML SUSR 100 ML BOTTLE $21.35 AMOXICILLIN 500 MG CAP 100 EACH BOTTLE $1.52 AMOXICILLIN 500 MG CAP 500 EACH BOTTLE $1.33 AMOXICILLIN-CLAVULANATE 125-31.25 MG/5 ML SUSR 75 $1,753.50 AMOXICILLIN-CLAVULANATE 250-125 MG TAB 30 EACH BOT $20.71 AMOXICILLIN-CLAVULANATE 250-62.5 MG/5 ML SUSR 75 M $380.63 AMOXICILLIN-CLAVULANATE 500-125 MG TAB 20 EACH BOT $6.62 AMOXICILLIN-CLAVULANATE 875-125 MG TAB 100 EACH BO $17.33 AMOXICILLIN-CLAVULANATE 875-125 MG TAB 20 EACH BOT $17.68 AMPHETAMINES LEVELS 80324 $186.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge AMPHETAMINES LEVELS 80325 $111.00 AMPHETAMINES LEVELS 80326 $206.00 AMPHOTERICIN B DESOXYCHOLATE 50 MG SOLR 1 EACH VIA J0285 $159.60 AMPHOTERICIN B LIPID COMPLEX 5 MG/ML SUSP 20 ML VI J0287 $420.00 AMPICILLIN 1 GRAM SOLR 1 EACH VIAL J0290 $14.70 AMPICILLIN 2 GRAM SOLR 1 EACH VIAL J0290 $29.40 AMPICILLIN 250 MG SOLR 1 EACH VIAL J0290 $14.67 AMPICILLIN 250 MG/5 ML SUSR 100 ML BOTTLE $49.35 AMPICILLIN 500 MG CAP 100 EACH BOTTLE $2.06 AMPICILLIN 500 MG SOLR 1 EACH VIAL J0290 $9.66 AMPICILLIN-SULBACTAM 1.5 GRAM SOLR 1 EACH VIAL J0295 $14.70 AMPICILLIN-SULBACTAM 3 GRAM SOLR 1 EACH VIAL J0295 $60.25 AMPUTATION OF FINGER OR THUMB 26951 $3,856.00 AMPUTATION OF FOOT 28810 $7,018.00 AMPUTATION OF FOOT 28820 $3,601.00 AMPUTATION OF FOOT 28825 $5,723.00 AMYLASE (ENZYME) LEVEL 82150 $152.00 AMYLASE BODY FLUID 82150 $152.00 AMYLASE ISOENZYMES 82150 $152.00 AMYLASE, SERUM 82150 $152.00 ANA PROFILE 86038 $290.00 ANA SERUM SCREEN 86038 $290.00 ANABOLIC STEROIDS LEVELS 80327 $221.00 ANABOLIC STEROIDS LEVELS 80328 $259.00 ANALGESICS LEVELS 80330 $259.00 ANALGESICS LEVELS 80331 $259.00 ANALYSIS ANTIBODY FRANCISELLA TULARENSIS (BACTERIA 86668 $126.00 ANALYSIS ANTIBODY LA CROSSE (CALIFORNIA) VIRUS (EN 86651 $80.00 ANALYSIS FOR ANTIBODY (IGM) TO CHLAMYDIA (BACTERIA 86632 $124.00 ANALYSIS FOR ANTIBODY (IGM) TO CYTOMEGALOVIRUS (CM 86645 $219.00 ANALYSIS FOR ANTIBODY (IGM) TO TOXOPLASMA (PARASIT 86778 $185.00 ANALYSIS FOR ANTIBODY (IGM) TO WEST NILE VIRUS 86788 $184.00 ANALYSIS FOR ANTIBODY TO ADENOVIRUS (RESPIRATORY V 86603 $170.00 ANALYSIS FOR ANTIBODY TO ASPERGILLUS (FUNGUS) 86606 $165.00 ANALYSIS FOR ANTIBODY TO BORRELIA (RELAPSING FEVER 86619 $110.00 ANALYSIS FOR ANTIBODY TO BRUCELLA (BACTERIA) 86622 $63.00 ANALYSIS FOR ANTIBODY TO CANDIDA (YEAST) 86628 $143.00 ANALYSIS FOR ANTIBODY TO COXIELLA BURNETII (Q FEVE 86638 $151.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ANALYSIS FOR ANTIBODY TO CYTOMEGALOVIRUS (CMV) IGG 86644 $184.00 ANALYSIS FOR ANTIBODY TO DIPHTHERIA (BACTERIA) 86648 $94.00 ANALYSIS FOR ANTIBODY TO EASTERN EQUINE VIRUS (VIR 86652 $75.00 ANALYSIS FOR ANTIBODY TO EHRLICHIA (BACTERIA TRANS 86666 $246.00 ANALYSIS FOR ANTIBODY TO ENTEROVIRUS (GASTROINTEST 86658 $172.00 ANALYSIS FOR ANTIBODY TO EPSTEIN-BARR VIRUS (MONON 86663 $174.00 ANALYSIS FOR ANTIBODY TO EPSTEIN-BARR VIRUS (MONON 86664 $146.00 ANALYSIS FOR ANTIBODY TO EPSTEIN-BARR VIRUS (MONON 86665 $146.00 ANALYSIS FOR ANTIBODY TO FUNGUS 86671 $233.00 ANALYSIS FOR ANTIBODY TO HELICOBACTER PYLORI (GAST 86677 $284.00 ANALYSIS FOR ANTIBODY TO HELMINTH (INTESTINAL WORM 86682 $258.00 ANALYSIS FOR ANTIBODY TO HEPATITIS D VIRUS 86692 $261.00 ANALYSIS FOR ANTIBODY TO HERPES SIMPLEX VIRUS 86694 $156.00 ANALYSIS FOR ANTIBODY TO HERPES SIMPLEX VIRUS, TYP 86695 $122.00 ANALYSIS FOR ANTIBODY TO HERPES SIMPLEX VIRUS, TYP 86696 $161.00 ANALYSIS FOR ANTIBODY TO HIV -1 VIRUS 86701 $307.00 ANALYSIS FOR ANTIBODY TO HIV-1 AND HIV-2 VIRUS 86703 $259.00 ANALYSIS FOR ANTIBODY TO HIV-2 VIRUS 86702 $230.00 ANALYSIS FOR ANTIBODY TO JOHN CUNNINGHAM VIRUS 86711 $119.00 ANALYSIS FOR ANTIBODY TO LEISHMANIA (PARASITE) 86717 $101.00 ANALYSIS FOR ANTIBODY TO LEPTOSPIRA 86720 $220.00 ANALYSIS FOR ANTIBODY TO LYMPHOCYTIC CHORIOMENINGI 86727 $90.00 ANALYSIS FOR ANTIBODY TO MUCORMYCOSIS (FUNGUS) 86732 $109.00 ANALYSIS FOR ANTIBODY TO MUMPS VIRUS 86735 $187.00 ANALYSIS FOR ANTIBODY TO MYCOPLASMA (BACTERIA) 86738 $174.00 ANALYSIS FOR ANTIBODY TO NEISSERIA MENINGITIDIS (B 86741 $313.00 ANALYSIS FOR ANTIBODY TO PARVOVIRUS 86747 $113.00 ANALYSIS FOR ANTIBODY TO PROTOZOA (PARASITE) 86753 $188.00 ANALYSIS FOR ANTIBODY TO RESPIRATORY SYNCYTIAL VIR 86756 $186.00 ANALYSIS FOR ANTIBODY TO RICKETTSIA (BACTERIA) 86757 $136.00 ANALYSIS FOR ANTIBODY TO SALMONELLA (INTESTINAL BA 86768 $102.00 ANALYSIS FOR ANTIBODY TO SHIGELLA (INTESTINAL BACT 86771 $109.00 ANALYSIS FOR ANTIBODY TO ST. LOUIS VIRUS (VIRAL EN 86653 $83.00 ANALYSIS FOR ANTIBODY TO TETANUS BACTERIA (CLOSTRI 86774 $60.00 ANALYSIS FOR ANTIBODY TO TRICHINELLA (WORM PARASIT 86784 $289.00 ANALYSIS FOR ANTIBODY TO VARICELLA-ZOSTER VIRUS (C 86787 $133.00 ANALYSIS FOR ANTIBODY TO VIRUS 86790 $222.00 ANALYSIS FOR ANTIBODY TO WEST NILE VIRUS 86789 $184.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ANALYSIS FOR ANTIBODY TO WESTERN EQUINE VIRUS (VIR 86654 $78.00 ANALYSIS FOR ANTIBODY, TREPONEMA PALLIDUM 86780 $145.00 ANALYSIS FOR DETECTION OF TUMOR MARKER 86316 $297.00 ANALYSIS OF ANTIBODY (IGE) TO ALLERGIC SUBSTANCE 86005 $173.00 ANALYSIS OF GENETIC MATERIAL 88365 $554.00 ANALYSIS OF STONE 82355 $95.00 ANALYSIS OF SUBSTANCE USING IMMUNOASSAY TECHNIQUE 83516 $221.00 ANALYSIS OF SUBSTANCE USING IMMUNOASSAY TECHNIQUE 83518 $39.00 ANALYSIS TEST FOR HEPATITIS B VIRUS 87912 $1,241.00 ANALYSIS TEST FOR HEPATITIS C VIRUS 87902 $701.00 ANALYSIS TEST FOR HIV-1 VIRUS 87901 $1,275.00 ANALYSIS TEST FOR HIV-1 VIRUS 87903 $2,124.00 ANALYSIS TEST FOR HIV-1 VIRUS 87904 $277.00 ANALYSIS TEST FOR HIV-1 VIRUS 87906 $948.00 ANALYSIS USING CHEMILUMINESCENT TECHNIQUE (LIGHT A 82397 $219.00 ANASTROZOLE 1 MG TAB 1 EACH BLIST PACK S0170 $3.63 ANASTROZOLE 1 MG TAB 30 EACH BLIST PACK S0170 $3.63 ANASTROZOLE 1 MG TAB 30 EACH BOTTLE S0170 $46.71 ANDROSTENEDIONE (HORMONE) LEVEL 82157 $93.00 ANDROSTERONE (HORMONE) LEVEL 82160 $206.00 ANESTHESIA GENERAL 1ST 15 MINUTES $876.00 ANESTHESIA GENERAL EACH ADDITIONAL 15 MINUTES $216.00 ANESTHESIA MAC 1ST 15 MINUTES $667.00 ANESTHESIA MAC EACH ADDITIONAL 15 MINUTES $136.00 ANESTHESIA REGIONAL 1ST 15 MINUTES $334.00 ANESTHESIA REGIONAL EACH ADDITIONAL 15 MINUTES $113.00 ANESTHESIA TRAY TRAY 1 KIT KIT $129.02 ANGIO COVETING ENZYME,CSF 82164 $172.00 ANGIOGRAPHY ILIAC DURING CARDIAC CATH G0278 $936.00 ANGIOTENSIN L - CONVERTING ENZYME (ACE) LEVEL 82164 $173.00 ANGIOTENSIN LL (PROTEIN) LEVEL 82163 $169.00 ANIDULAFUNGIN 100 MG SOLR 1 EACH VIAL J0348 $756.00 ANIDULAFUNGIN 50 MG SOLR 1 EACH VIAL J0348 $756.00 ANTERIOR PITUITARY GLAND EVALUATION PANEL 80418 $4,780.00 ANTIBODY EVALUATION 88346 $273.00 ANTIBODY EVALUATION 88350 $172.00 ANTIBODY IDENTIFICATION 86870 $323.00 ANTIBODY IDENTIFICATION TEST FOR PLATELET ANTIBODI 86022 $423.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ANTIBODY IDENTIFICATION TEST FOR PLATELET ANTIBODI 86023 $335.00 ANTIDEPRESSANTS LEVELS 80333 $259.00 ANTIDEPRESSANTS LEVELS 80334 $259.00 ANTIDEPRESSANTS LEVELS 80335 $121.00 ANTIDEPRESSANTS LEVELS 80337 $259.00 ANTIEPILEPTICS LEVELS 80339 $361.00 ANTIEPILEPTICS LEVELS 80340 $259.00 ANTIEPILEPTICS LEVELS 80341 $259.00 ANTIHEMOPHIL FVIII,FULL LENGTH 1,000 (+/-) UNIT SO J7192 $4,469.60 ANTIHEMOPHIL FVIII,FULL LENGTH 250 (+/-) UNIT SOLR J7192 $1,576.43 ANTI-PHOSPHATIDYLSERINE AB IGA 86148 $167.00 ANTI-PHOSPHATIDYLSERINE AB IGG 86148 $167.00 ANTI-PHOSPHATIDYLSERINE AB IGM 86148 $167.00 ANTIPSYCHOTICS LEVELS 80343 $179.00 ANTIPSYCHOTICS LEVELS 80344 $259.00 ANTITHROMBIN III ANTIGEN (CLOTTING INHIBITOR) ACTI 85300 $283.00 APICOECTOMY D3410 $713.00 APIXABAN 2.5 MG TAB 100 EACH BLIST PACK $31.09 APIXABAN 5 MG TAB 100 EACH BLIST PACK $15.55 APOLIPOPROTEIN LEVEL 82172 $275.00 APPLICATION AND REMOVAL OF DENTAL FIXATION DEVICE 21110 $2,388.00 APPLICATION LIGHT USING ENDOSCOPE DESTRUCTION ABNO 96570 $543.00 APPLICATION MEDICATION THROUGH SKIN USING ELECTRIC 97033 $162.00 APPLICATION OF BLOOD VESSEL COMPRESSION/DECOMPRESS 97016 $93.00 APPLICATION OF CAST SHOULDER TO HAND (LONG ARM) 29065 $334.00 APPLICATION OF CAST TO HAND AND LOWER FOREARM 29085 $358.00 APPLICATION OF CAST, ELBOW TO FINGER (SHORT ARM) 29075 $305.00 APPLICATION OF CHEMICAL AGENT TO EXCESSIVE WOUND T 17250 $355.00 APPLICATION OF CHEMICAL AGENTS ACTIVATED BY ULTRAV 96912 $191.00 APPLICATION OF CYLINDER CAST (THIGH TO ANKLE) 29365 $553.00 APPLICATION OF ELECTRICAL STIMULATION TO 1 OR MORE 97032 $150.00 APPLICATION OF HOT WAX BATH TO 1 OR MORE AREAS 97018 $121.00 APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105 $441.00 APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345 $587.00 APPLICATION OF LONG LEG CAST (THIGH TO TOES), WALK 29355 $552.00 APPLICATION OF LONG LEG CAST BRACE 29358 $568.00 APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR 29505 $462.00 APPLICATION OF MECHANICAL TRACTION TO 1 OR MORE AR 97012 $160.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge APPLICATION OF MOVEABLE, HINGED FINGER SPLINT 29131 $434.00 APPLICATION OF MOVEABLE, HINGED SHORT ARM SPLINT ( 29126 $305.00 APPLICATION OF NON-MOVEABLE HINGED FINGER SPLINT 29130 $421.00 APPLICATION OF NON-MOVEABLE, SHORT ARM SPLINT (FOR 29125 $434.00 APPLICATION OF ON-BODY INJECTOR FOR INJECTION UNDE 96377 $181.00 APPLICATION OF ORGAN CAVITY RADIATION SOURCE, COMP 77763 $3,374.00 APPLICATION OF ORGAN CAVITY RADIATION SOURCE, SIMP 77761 $2,852.00 APPLICATION OF RADIATION SOURCE 77799 $2,271.00 APPLICATION OF RADIATION SOURCE, COMPLEX 77778 $6,409.00 APPLICATION OF RIGID TOTAL CONTACT LEG CAST 29445 $611.00 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405 $325.00 APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515 $341.00 APPLICATION OF SKIN SUBSTITUTE TO TRUNK ARMS OR LE 15273 $5,310.00 APPLICATION OF ULTRASOUND TO 1 OR MORE AREAS, EACH 97035 $147.00 APPLICATION OF ULTRAVIOLET LIGHT TO SKIN 96900 $91.00 APPLICATION OF WHIRLPOOL THERAPY TO 1 OR MORE AREA 97022 $230.00 APPLICATION SHORT LEG CAST (BELOW KNEE TO TOES) WA 29425 $475.00 APPLICATION SKIN SUBSTITUTE FACE SCALP EYELID MOUT 15275 $2,295.00 APPLICATION SKIN SUBSTITUTE FACE SCALP EYELID MOUT 15276 $381.00 APPLICATION SKIN SUBSTITUTE TO TRUNK ARMS OR LEGS 15271 $3,271.00 APPLICATION SKIN SUBSTITUTE TO TRUNK ARMS OR LEGS 15272 $1,006.00 APPLICATION SKIN SUBSTITUTE TO TRUNK ARMS OR LEGS 15274 $959.00 APPLICATION VEIN WOUND COMPRESSION SYST LOWER LEG 29581 $368.00 APPLY SKIN SUBSTITUTE TO FACE SCALP EYELID MOUTH N 15278 $903.00 APRACLONIDINE 0.5 % DROP 5 ML DROP BTL $303.70 APREPITANT 40 MG CAP 1 EACH BLIST PACK J8501 $495.77 APREPITANT 40 MG CAP 5 EACH BLIST PACK J8501 $495.77 AQUAPHOR 41 % OINT 396 G JAR $44.35 AQUAPORIN-4 RECEPTOR ANTIBODY 83516 $226.00 ARGATROBAN 100 MG/ML SOLN 2.5 ML VIAL J0883 $2,537.50 ARIPIPRAZOLE 10 MG TAB 100 EACH BLIST PACK $42.23 ARIPIPRAZOLE 10 MG TAB 30 EACH BOTTLE $56.19 ARIPIPRAZOLE 10 MG TAB 90 EACH BOTTLE $56.19 ARIPIPRAZOLE 15 MG TAB 1 EACH BLIST PACK $91.23 ARIPIPRAZOLE 15 MG TAB 30 EACH BOTTLE $112.39 ARIPIPRAZOLE 15 MG TAB 90 EACH BOTTLE $112.39 ARIPIPRAZOLE 2 MG TAB 1 EACH BLIST PACK $90.47 ARIPIPRAZOLE 2 MG TAB 30 EACH BLIST PACK $90.47 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARIPIPRAZOLE 2 MG TAB 30 EACH BOTTLE $100.72 ARSENIC LEVEL 82175 $258.00 ARTERIAL PUNCTURE WITHDRAWL OF BLOOD FOR DIAGNOSIS 36600 $117.00 ARTHROGRAPHY INJECTION SACROILIAC JOINT 27096 $2,222.00 ARTIFICIAL SALIVA (YERBAS-LYT) SPRA 60 ML SQUEEZ B A9155 $19.95 ARTIFICIAL TEARS(HYPROMELLOSE) 0.5 % DROP 15 ML DR $108.57 ARUP - ADENOVIRUS BY PCR QUALITATIVE 87798 $315.00 ARUP - ADENOVIRUS BY PCR QUANTITATIVE 87799 $568.00 ARUP - AMPHET CONFIRM QUANT MECONIUM 80324 $186.00 ARUP - AMPHET CONFIRM QUANT URINE 80324 $186.00 ARUP - COCAIN CONF MEC 80353 $207.00 ARUP COCAINE QUANT BLOOD 80353 $207.00 ARUP PHENYTOIN, TOTAL 80185 $154.00 ARUP 14-3-3 PROTEIN TAU/THETA CSF 86317 $241.00 ARUP A2 MACROGLOBULIN 83883 $119.00 ARUP ACETONE QUANTITATIVE SERUM 80320 $232.00 ARUP ACYLCARNITINES QUANTITATIVE 82017 $365.00 ARUP ADENOVIRUS ANTIGEN EIA 87301 $144.00 ARUP ALBUMIN OTHER SOURCE QUANTITATIVE EACH 82042 $95.00 ARUP ALBUMIN SERUM PLASMA WHOLE BLD 82040 $67.00 ARUP ALBUMIN, CSF 82042 $94.00 ARUP ALCOHOL URINE 80320 $232.00 ARUP ALDOSTERONE 82088 $465.00 ARUP ALLERGEN IGE QUANT OR SEMI 86003 $67.00 ARUP ALLERGEN SPEC IGE RECOMBINANT/PURIFIED COMPNT 86008 $13.00 ARUP ALPHA FETOPROTEIN AMNIOTIC 82106 $145.00 ARUP ALPHA FETROPROTEIN, MATERNA 82105 $222.00 ARUP AMINO ACIDS 6 OR MORE QUANTITATIVE 82139 $843.00 ARUP AMITRIPTYLINE AND NORTRIPTYLINE 80335 $121.00 ARUP ANCA TITER 86256 $203.00 ARUP ANTI MULLARIAN HORMONE 83520 $286.00 ARUP ANTITHROMBIN III ANTIGEN 85301 $306.00 ARUP ASPER GALACT AG 87305 $341.00 ARUP ASSAY C-D TRANSFER MEASURE 82373 $364.00 ARUP B2 GLYCOPROTEIN AB IGA 86146 $184.00 ARUP B2 GLYCOPROTEIN AB IGG 86146 $184.00 ARUP B2 GLYCOPROTEIN AB IGM 86146 $184.00 ARUP BARBITURATES CONF URINE 80345 $203.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARUP BARBITURATES CONFIRMATION 80345 $203.00 ARUP BCR/ABL1 TA MAJOR BREAKPOINT QL/QN 81206 $808.00 ARUP BCR/ABL1 TA MINOR BREAKPOINT QL/QN 81207 $634.00 ARUP BENZODIAZEPINES QUANT 1-12 80346 $193.00 ARUP BENZODIAZEPINES QUANT 1-12, MECONIUM 80346 $193.00 ARUP BETA-2 TRANSFERRIN 86335 $295.00 ARUP BETHESDA 85335 $403.00 ARUP BILE ACIDS 82239 $259.00 ARUP BILE ACIDS FRACTIONATED AND TOTAL 83789 $255.00 ARUP BIOTINIDASE 82261 $426.00 ARUP BK VIRUS URINE 87799 $568.00 ARUP BLASTOMYCES ANTIBODY 86612 $117.00 ARUP BUN, SERUM 84520 $100.00 ARUP BUPRENORPHINE MECONIUM 80348 $274.00 ARUP BUPRENORPHINE, SERUM/PLASMA 80348 $274.00 ARUP C DIFFICILE BY PCR 87493 $282.00 ARUP C1 ESTERASE INHIBITOR 86160 $259.00 ARUP C1-ESTERASE INHIB FUNCTION 86161 $253.00 ARUP CABAMAZEPINE THERAPEUTIC DRUG ANALYSIS 80156 $226.00 ARUP CAFFEINE THERAPUTIC DRUG ANALYSIS 80155 $233.00 ARUP CARBAMAZEPINE FREE THERAPUTIC DRUG ANALYSIS 80157 $159.00 ARUP CARBOXYHEMOGLOBIN QUANTITATIVE 82375 $131.00 ARUP CELL FUNCTION ASSAY W/STIMULATION 86352 $719.00 ARUP CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCT R 81223 $1,814.00 ARUP CHLAMYDIA ANTIBODY 86631 $139.00 ARUP CHLORIDE REGULAR STOOL 82438 $121.00 ARUP CHROMOSOME COUNT 15-20/2 88262 $1,072.00 ARUP CHROMOSOME COUNT 20-25 88264 $827.00 ARUP CHROMOSOME COUNT AMNIO IN SITU 88269 $3,766.00 ARUP CHROMOSOME COUNT AMNIO IN SITU 88237 $952.00 ARUP CLONAZEPAM LEVEL 80346 $193.00 ARUP COCAINE URINE 80353 $207.00 ARUP COCCIDIOIDES ANTIBODY 86635 $147.00 ARUP COMPLEMENT 4 86160 $260.00 ARUP COMPLEMENT C6 86160 $259.00 ARUP COMPOUND S SPECIFIC 82634 $305.00 ARUP CONCENTRATION INFECTION AGENTS ANY TYPE 87015 $95.00 ARUP CORTISOL FREE, 24 HR URINE 82530 $250.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARUP CORTISOL FREE, SERUM 82530 $250.00 ARUP CREATININE OTHER SOURCE 82570 $103.00 ARUP CRYPTOCOCCUS ANTIGEN 87327 $244.00 ARUP CULTURE FUNGUS DEFINITIVE ID MOLD 87107 $155.00 ARUP CULTURE VIRUS DEFINITIVE ID 87253 $313.00 ARUP CULTURE VIRUS SHELL VIAL 87254 $239.00 ARUP CYCLIC CITRULLINATED PEPTIDE TEST 86200 $190.00 ARUP CYSTINE URINE 24 HOUR 82131 $145.00 ARUP CYTO MOLECULAR INTERP & REPORT MM FISH 88291 $250.00 ARUP CYTOGENETICS AND MOLECULAR CYTOGENETICS INTER 88291 $250.00 ARUP CYTOGENOMIC CONSTITUTIONAL (GENOME-WIDE) MICR 81229 $5,957.00 ARUP DEOXYRIBONUCLEASE ANTIBODY 86215 $213.00 ARUP DESOXYCORTICOSTERONE-11 82633 $391.00 ARUP DHEA (DEHYDROEPIANDROSTERONE) 82626 $295.00 ARUP DHEA-SULFATE DHEA 82627 $303.00 ARUP DIPHTHERIA ANTIBODY, IGG 86317 $190.00 ARUP ENCEPHALITIS AB WEST NILE IGM, CSF 86788 $184.00 ARUP ENDOMYSIAL ANTIBODY, IGA 86256 $203.00 ARUP EPSTEIN BARR VIRUS QUANT PCR 87799 $568.00 ARUP ESTRADIOL ULTRASENSITIVE 82670 $409.00 ARUP ETHOSUXIMIDE 80168 $180.00 ARUP EVB AB EARLY (D) AG,IGG 86663 $174.00 ARUP EXTRACTABLE NUC ANTIGENS, SMITH-IGG 86235 $221.00 ARUP FACTOR 9 ACTIVITY 85250 $434.00 ARUP FACTOR II PROTHROMBIN 85210 $330.00 ARUP FACTOR V ASSAY 85220 $339.00 ARUP FACTOR VII STABLE FACTOR 85230 $321.00 ARUP FACTOR VIII VON WILLEBRAND FACTOR MULTIMETRIC 85247 $462.00 ARUP FACTOR X STUART PROWER 85260 $357.00 ARUP FAT QUANTITATIVE FECES 82710 $272.00 ARUP FATTY ACIDS VERY LONG CHAIN 82726 $373.00 ARUP FELBAMATE 80339 $361.00 ARUP FETAL CONGENITAL ABNORMALITIES FOUR ANALYTES 81511 $623.00 ARUP FIBROBLAST GROWTH FACTOR 23 83520 $286.00 ARUP FLECAINIDE 80299 $182.00 ARUP FLUCONAZOLE 80299 $182.00 ARUP FLUCONAZOLE SUSCEPTIBILITY 87181 $182.00 ARUP FLUNITRAZEPAM URINE 80307 $180.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARUP FLUORESCENT ANTIBODY SCREEN 86255 $316.00 ARUP FLUOXETINE 80332 $259.00 ARUP FMR1 (FRAGILE X MENTAL RETARDATION 1) GENE DE 81243 $1,092.00 ARUP FSH, SERUM 83001 $326.00 ARUP GABAPENTIN 80171 $204.00 ARUP GHB CONFIRMATION, URINE 80375 $259.00 ARUP GHB SCREEN, URINE 80307 $180.00 ARUP HAEMOPHILIUS INFLUENZA B AB IGG 86317 $241.00 ARUP HAPTOGLOBIN QUANT 83010 $243.00 ARUP HBA1/HBA2 (ALPHA GLOBIN 1 AND 2) GENE COMMON 81257 $510.00 ARUP HEP C GENOTYP SEQ #55593 87902 $701.00 ARUP HEP C VIR NS5A RES #2014139 87902 $701.00 ARUP HEPARIN ASSAY 85520 $112.00 ARUP HEPATITIS C AB 86803 $293.00 ARUP HERPES 6 QUANTIFICATION NUCLEIC ACID PROBE 87533 $607.00 ARUP HETEROPHILE AB SCREEN (INFECTIOUS MONO) 86308 $176.00 ARUP HFE (HEMOCHROMATOSIS) GENE COMMON VARIANTS 81256 $613.00 ARUP HGB ELP 83020 $216.00 ARUP HISTAMINE 83088 $239.00 ARUP HISTOPLASMA AG 87385 $292.00 ARUP HIT PF4 IGG 86022 $423.00 ARUP HIV 2 ANTIBODY 86702 $171.00 ARUP HIV-1 QUANTIFICATION NUCLEIC ACID PROBE 87536 $649.00 ARUP HIV1-2 W/RFLX HIV 1 WESTERN BLOT 86703 $259.00 ARUP HLA-B5701 81381 $832.00 ARUP HSV 1&2 BY NUCLEIC ACID AMPLIFICATION 87529 $391.00 ARUP IA-2 AUTOANTIBODY 86341 $219.00 ARUP IFE FLUID 86355 $309.00 ARUP IGA IGG IGM GAMMAGLOBULIN 82784 $229.00 ARUP IGF BINDING PROTEIN 3 82397 $219.00 ARUP IGHV MUTATION ANALYSIS 81263 $1,649.00 ARUP IL28B UNLISTED MOLECULARE PATH 81479 $740.00 ARUP IMMUNOASSAY NON INF AGENT QUALITATIVE/SEMIQUA 83516 $221.00 ARUP IMMUNOGLOBULIN D 82784 $229.00 ARUP IMMUNOGLOBULIN E 82785 $256.00 ARUP IMMUNOGLOBULIN G 82784 $229.00 ARUP IMMUNOGLOBULIN G CSF 82787 $296.00 ARUP IMMUNOGLOBULIN G CSF 82784 $175.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARUP IN SITU HYBRIDIZATION PER SPECIMEN MAN EA ADD 88377 $1,082.00 ARUP INDIA INK 87210 $74.00 ARUP INHIBIN B 83520 $286.00 ARUP INSULIN FASTING 83525 $135.00 ARUP INSULIN FREE 83527 $174.00 ARUP IRON 83540 $108.00 ARUP JAK2 EXON 12 MUT ANALYS PCR 81403 $518.00 ARUP JAK2 GENE V671F MUT QUAL 81270 $656.00 ARUP LACTOFERRIN FECES QUALITATIVE 83630 $156.00 ARUP LD BLOOD 83615 $101.00 ARUP LD ISOENZYME 83625 $168.00 ARUP LDH 83615 $101.00 ARUP LEAD URINE 83655 $184.00 ARUP LEAD, WHOLE BLOOD 83655 $184.00 ARUP LEGIONELLA ABS 86713 $246.00 ARUP LIVER KIDNEY MICROSOME AB 86376 $182.00 ARUP LUTENIZING HORMONE 83002 $306.00 ARUP LYME DISEASE AB 86618 $213.00 ARUP LYME DISEASE AB CONFIRM, IGG 86617 $201.00 ARUP LYME DISEASE AB CONFIRM, IGG CSF 86617 $201.00 ARUP LYME DISEASE AB CONFIRM, IGM CSF 86617 $201.00 ARUP LYME DISEASE AB, CSF 86618 $213.00 ARUP LYME DISEASE ANTIBODY CONFIRM, IGM 86617 $201.00 ARUP MANGANESE 83785 $180.00 ARUP MDA/MDEA/MDMA DEFIN ASSAY MECONIUM 80359 $259.00 ARUP METANEPHRINES, URINE 83835 $212.00 ARUP METHADONE CONF URINE 80358 $161.00 ARUP METHOADONE CONF MECONIUM 80358 $161.00 ARUP MIC PER PLATE 87186 $188.00 ARUP MOLECULAR CYTO DNA PROBE FISH 88271 $315.00 ARUP MOLECULAR CYTO DNA PROBE FISH PML-RARA 88271 $315.00 ARUP MOLECULAR CYTO HER-2/NEU 88271 $315.00 ARUP MOLECULAR CYTO INSITU 100-300 MDS PANEL 88275 $466.00 ARUP MOLECULAR CYTO MDS PANEL 88271 $315.00 ARUP MOLECULAR CYTO MM FISH 88271 $315.00 ARUP MOLECULAR CYTOGENETICS IN SITU HYBRIDIZATION 88275 $466.00 ARUP MUSK ANTIBODY 83519 $353.00 ARUP MYCOBACTERIA TB NUCLEIC ACID PROBE AMPLIFIED 87556 $462.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARUP MYCOPHENOLIC ACID THERAPUTIC DRUG ANALYSIS 80180 $179.00 ARUP MYELOPEROXIDASE AB 83520 $286.00 ARUP NEURONAL NUCLEAR ANTIBODIES 83516 $221.00 ARUP NORTRIPTYLINE 80335 $121.00 ARUP NUCLEOTIDASE 5 83915 $112.00 ARUP OPIATES CONFIRM MECONIUM 80361 $214.00 ARUP OPIATES CONFIRM/QUANT URINE 80361 $214.00 ARUP ORGANIC ACIDS PLASMA 83918 $603.00 ARUP ORGANIC ACIDS QUANT URINE 83918 $603.00 ARUP OXYCODONE CONFIRM MECONIUM 80365 $259.00 ARUP OXYCODONE CONFIRM URINE 80365 $259.00 ARUP P JIROVECI QNT PCR 87798 $315.00 ARUP PANCREATIC POLYPEPTIDE 83519 $353.00 ARUP PARTIAL PROTHROMBIN TIME LA 85730 $122.00 ARUP PARTIAL THROMBOPLASTIN 85730 $122.00 ARUP PARTIAL THROMBOPLASTIN SUBSTITUTION 85732 $144.00 ARUP PARVOVIRUS B19 IGG 86747 $113.00 ARUP PARVOVIRUS B19 IGM 86747 $113.00 ARUP PHENCYCLIDINE CONF URINE 83992 $182.00 ARUP PINWORM EXAM 87172 $108.00 ARUP PLASMINOGEN ACTIVATOR INHIBITORS 85415 $310.00 ARUP PLASMINOGEN ASSAY 85420 $292.00 ARUP PLATELET AGGREGATION 85576 $341.00 ARUP PROGESTERONE 84144 $253.00 ARUP PROTEIN TOTAL URINE 84156 $213.00 ARUP PROTEIN TOTAL XCPT REFRACTOMETRY URINE 84156 $100.00 ARUP PROTEIN WESTERN BLOT BAND ID 84182 $441.00 ARUP PROTEIN-QUANT 84156 $100.00 ARUP PROTHROMBIN TIME 85610 $86.00 ARUP PYRUVATE 84210 $153.00 ARUP RAST ALLERGEN QUALITATIVE MULTI SCR 86005 $173.00 ARUP REPTILASE TEST 85635 $143.00 ARUP RESPIRATORY VIRUS DNA/RNA 3-5 TARGETS 87631 $756.00 ARUP RNP IGG 86235 $221.00 ARUP ROTAVIRUS ANTIGEN INFECTIOUS AGENT IMMUNOASSA 87425 $138.00 ARUP RPR TITER 86593 $136.00 ARUP RPR TITER CSF 86593 $136.00 ARUP RUFINAMIDE 80339 $361.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARUP SEROTONIN 84260 $267.00 ARUP SEROTONIN RELEASE HEPARIN DEPENDENT PLT AB 86022 $258.00 ARUP SEX HORMONE BINDING GLOBULIN 84270 $255.00 ARUP SICKLE CELL RBC 85660 $86.00 ARUP SMEAR FLUOURESCENT/ACID STAIN 87206 $121.00 ARUP SMEAR SPECIAL STAIN INCLUSION BODIES 87207 $129.00 ARUP SMITH IGG 86235 $221.00 ARUP SMRNP IGG 86235 $221.00 ARUP SS-A IGG 86235 $220.00 ARUP SS-B IGG 86235 $220.00 ARUP SSDNA AB 84156 $100.00 ARUP STREP PNEUMONIAE ANTIGEN URINE 87899 $197.00 ARUP STRONGYLOIDES ANTIBODY 86682 $258.00 ARUP T GONDII AB IGG 86777 $195.00 ARUP T GONDII AB IGM 86778 $185.00 ARUP T3 UPTAKE 84479 $117.00 ARUP T4 TOTAL 84436 $146.00 ARUP TAY-SACHS DISEASE 81255 $257.00 ARUP TCA CONFIRMATION 80337 $259.00 ARUP TELOPEPTIDE BETA 82523 $203.00 ARUP TESTOSTERONE TOTAL 84403 $283.00 ARUP TETANUS ANTIBODY IGG 86317 $190.00 ARUP THC METABOLITE SERUM QUANT 80349 $232.00 ARUP THROMBIN CLOTTING TIME 85670 $107.00 ARUP THROMBIN MIXING STUDY 85670 $107.00 ARUP THYROGLOBULIN ANTIBODY 86800 $141.00 ARUP THYROID PEROXIDASE TPO AB 86376 $182.00 ARUP THYROID STIM HORMONE RECE AB 83520 $286.00 ARUP TIS TRANSGLUTAMINASE AB IGA 83516 $221.00 ARUP TISSUE CULTURE AMNIOTIC 88235 $1,224.00 ARUP TISSUE CULTURE AMNIOTIC 88264 $827.00 ARUP TISSUE CULTURE LYMPHOCYTE 88230 $661.00 ARUP TISSUE CULTURE NEOPLASTIC DISORDERS 88237 $952.00 ARUP TISSUE CULTURE SKIN 88230 $1,047.00 ARUP TISSUE CULTURE SOLID TUMOR 88239 $734.00 ARUP TSH 84443 $196.00 ARUP TYROSINE 84510 $86.00 ARUP UREA NITROGEN URINE 84540 $77.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARUP URINE DRUG SCREEN 80307 $180.00 ARUP VANILLYMANDELIC ACID VMA URINE 84585 $214.00 ARUP VARICELLA ZOSTER AG IMMUNOFLUORESCENT 87290 $117.00 ARUP VARICELLA ZOSTER VIRUS, PCR 87798 $315.00 ARUP VIMPAT (LACOSAMIDE) 80339 $361.00 ARUP VIRAL CULTURE NON-RESP 87252 $313.00 ARUP VIRUS ISOLATION, HERPES 87252 $313.00 ARUP VOLATILES GC QUANT 84600 $232.00 ARUP WEST NILE AB CSF 86789 $141.00 ARUP ZIKA VIRUS NUCLEIC ACID PROBE AMPLIFIED 87798 $315.00 ARUP-ANTI-MAG AB 83516 $175.00 ARUP-BILIRUBIN 82247 $105.00 ARUP-BK VIRUS 87799 $568.00 ARUP-BORDETALLA PERT/PARAPERT B/F 87798 $315.00 ARUP-CALCIUM,URINE 24HR 82340 $150.00 ARUP-CF 165 PATH VARIANTS WB 81220 $748.00 ARUP-CFTR GENE ANAL,COMMON VAR 81220 $748.00 ARUP-CHYMOTRYPSIN FECAL 84311 $253.00 ARUP-COMPLEMENT COMP 4 86160 $260.00 ARUP-CORTISOL,SALIVA 82533 $326.00 ARUP-DRG PAN 9 SER/PLA 80307 $180.00 ARUP-DRG SCRN MULT CLASS 80307 $342.00 ARUP-EBV AB CAPSID IGG 86665 $147.00 ARUP-EBV CAP IGM 86665 $147.00 ARUP-EBV NUCLEAR AG,IGG 86664 $146.00 ARUP-GBM AB,IGA 86255 $243.00 ARUP-GLUCAN (FUNGITELL) 87449 $274.00 ARUP-HEAT SHOCK PROTEIN 70 IGG 83516 $221.00 ARUP-HEMOGLOBIN A1C 83036 $170.00 ARUP-HTLV WB INTERP 86689 $355.00 ARUP-IL2 RECEPT (CD25) 83520 $252.00 ARUP-INF AGT ASPERGILLUS 87305 $341.00 ARUP-MATERNAL SCREEN INTEG 1 84163 $136.00 ARUP-MATERNAL SCREEN INTEG 2 81511 $623.00 ARUP-PHENCYCLIDINE CONF MEC 83992 $182.00 ARUP-PHOSPHOLIPIDS,SERUM/PLAS 84311 $269.00 ARUP-RHEUMATOID FACTOR IGG 83516 $221.00 ARUP-RHRUMATOID FACTOR IGM 83516 $221.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ARUP-RPR TITER 86593 $136.00 ARUP-SMOOTH MUSCLE IGG TITER 86256 $203.00 ARUP-SOL LIVER ANT ANTIBODY IGG 83516 $198.00 ARUP-SULFONYLUREAS,QUAL,BLD 83789 $225.00 ARUP-TISSUE TRANSGLUT TTG IGA 83516 $198.00 ARUP-TRIGLYCERIDES,FLUID 84478 $124.00 ARUP-UREA NITROGEN,URINE 24HR 84540 $67.00 ASCORBIC ACID (VITAMIN C) 250 MG TAB 1 EACH BLIST $0.98 ASCORBIC ACID (VITAMIN C) 250 MG TAB 100 EACH BOTT $0.09 ASCORBIC ACID (VITAMIN C) 250 MG TAB 50 EACH BLIST $0.98 ASCORBIC ACID (VITAMIN C) 500 MG TAB 100 EACH BLIS $0.23 ASCORBIC ACID (VITAMIN C) 500 MG TAB 100 EACH BOTT $0.22 ASCORBIC ACID (VITAMIN C) 500 MG/5 ML SYRP 118 ML $16.93 ASCORBIC ACID (VITAMIN C) 500 MG/ML SOLN 50 ML VIA $357.35 ASCORBIC ACID (VITAMIN C) LEVEL, BLOOD 82180 $182.00 ASENAPINE 5 MG SUBL 60 EACH BLIST PACK $84.04 ASPIRATION AND/OR INJECT OF MAJOR JOINT OR JOINT C 20611 $785.00 ASPIRATION AND/OR INJECT OF SMALL JOINT OR JOINT C 20604 $1,106.00 ASPIRATION AND/OR INJECTION KIDNEY CYST, ACCESSED 50390 $2,115.00 ASPIRATION AND/OR INJECTION OF CYSTS 20612 $335.00 ASPIRATION AND/OR INJECTION OF LARGE JOINT OR JOIN 20610 $585.00 ASPIRATION AND/OR INJECTION OF MEDIUM JOINT OR JOI 20605 $378.00 ASPIRATION AND/OR INJECTION OF SMALL JOINT OR JOIN 20600 $812.00 ASPIRATION AND/OR INJECTION OF THYROID CYST 60300 $994.00 ASPIRATION INJECTION INTERMEDIATE JOINT OR JOINT C 20606 $1,106.00 ASPIRATION OF ABDOMINAL CAVITY OR CYST USING AN EN 49322 $9,711.00 ASPIRATION OF ABSCESS, BLOOD ACCUMULATION, BLISTER 10160 $435.00 ASPIRATION OF BLADDER WITH INSERTION OF BLADDER TU 51102 $3,126.00 ASPIRATION OF BLOOD FROM EYE 65815 $6,775.00 ASPIRATION OF BLOOD FROM FETAL UMBILICAL CORD 59012 $1,482.00 ASPIRATION OF BREAST CYST 19000 $876.00 ASPIRATION OF BREAST CYST 19100 $1,739.00 ASPIRATION OF EYE FLUID 65800 $4,173.00 ASPIRATION OF EYE FLUID 65810 $5,360.00 ASPIRATION OF FETAL FLUID USING ULTRASOUND GUIDANC 59074 $1,571.00 ASPIRATION OF FLUID FROM SAC THAT COVERS THE HEART 33010 $2,751.00 ASPIRATION OF LUNG SECRETIONS FROM LUNG AIRWAYS US 31645 $1,987.00 ASPIRATION OR INJECTION OF CEREBROSPINAL FLUID SHU 61070 $1,294.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ASPIRATION OR RELEASE OF EYE FLUID BETWEEN THE LEN 67015 $6,952.00 ASPIRIN 300 MG SUPP 12 EACH BOX $1.98 ASPIRIN 325 MG TAB 100 EACH BOTTLE $0.06 ASPIRIN 325 MG TAB 500 EACH BLIST PACK $0.23 ASPIRIN 325 MG TBEC 1,000 EACH BOTTLE $0.15 ASPIRIN 325 MG TBEC 100 EACH BOTTLE $0.10 ASPIRIN 325 MG TBEC 750 EACH BLIST PACK $0.05 ASPIRIN 600 MG SUPP 12 EACH BOX $5.28 ASPIRIN 81 MG CHEW 36 EACH BOTTLE $0.14 ASPIRIN 81 MG CHEW 500 EACH BLIST PACK $0.25 ASPIRIN 81 MG CHEW 750 EACH BLIST PACK $0.33 ASPIRIN 81 MG TBEC 1,000 EACH BOTTLE $0.07 ASPIRIN 81 MG TBEC 100 EACH BLIST PACK $0.35 ASPIRIN 81 MG TBEC 100 EACH BOTTLE $0.14 ASPIRIN 81 MG TBEC 120 EACH BOTTLE $0.17 ASPIRIN 81 MG TBEC 500 EACH BOTTLE $0.03 ASPIRIN 81 MG TBEC 750 EACH BLIST PACK $0.35 ASPIRIN-DIPYRIDAMOLE 25-200 MG CM12 1 EACH BLIST P $44.10 ASPIRIN-DIPYRIDAMOLE 25-200 MG CM12 20 EACH BLIST $44.10 ASPIRIN-DIPYRIDAMOLE 25-200 MG CM12 60 EACH BOTTLE $24.24 ASSESSMENT ANTIBODIES CLASS I & II HUMAN LEUKOCYTE 86828 $292.00 ASSESSMENT ANTIBODIES CLASS I & II HUMAN LEUKOCYTE 86829 $245.00 ASSESSMENT ANTIBODY HUMAN LEUKOCYTE ANTIGENS W/ANT 86830 $666.00 ASSESSMENT ANTIBODY HUMAN LEUKOCYTE ANTIGENS W/ANT 86831 $571.00 ASSESSMENT ANTIBODY HUMAN LEUKOCYTE ANTIGENS W/HIG 86832 $1,047.00 ASSESSMENT ANTIBODY HUMAN LEUKOCYTE ANTIGENS W/HIG 86833 $952.00 ASSESSMENT EXPRESSIVE & RECEPTIVE SPEECH W/INTERP 96105 $511.00 ASSESSMENT FOR PRESCRIPTIVE EYE WEAR USING A RANGE 92015 $391.00 ATAZANAVIR 200 MG CAP 60 EACH BOTTLE $102.43 ATAZANAVIR 300 MG CAP 30 EACH BOTTLE $96.39 ATENOLOL 100 MG TAB 1 EACH BLIST PACK $5.23 ATENOLOL 100 MG TAB 100 EACH BOTTLE $4.38 ATENOLOL 25 MG TAB 100 EACH BLIST PACK $2.50 ATENOLOL 50 MG TAB 1 EACH BLIST PACK $3.12 ATENOLOL 50 MG TAB 100 EACH BLIST PACK $3.12 ATENOLOL 50 MG TAB 100 EACH BOTTLE $2.92 ATENOLOL-CHLORTHALIDONE 100-25 MG TAB 100 EACH BOT $9.26 ATENOLOL-CHLORTHALIDONE 50-25 MG TAB 100 EACH BOTT $6.59 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) SOLN 20 ML $25,722.94 ATHERECT CORONOARY W/ DRUG ELUTING STENT C9602 $28,608.00 ATOMOXETINE 40 MG CAP 30 EACH BOTTLE $13.52 ATORVASTATIN 10 MG TAB 1 EACH BLIST PACK $2.21 ATORVASTATIN 10 MG TAB 100 EACH BLIST PACK $1.75 ATORVASTATIN 40 MG TAB 1 EACH BLIST PACK $0.46 ATORVASTATIN 40 MG TAB 100 EACH BLIST PACK $0.60 ATOVAQUONE 750 MG/5 ML SUSP 210 ML BOTTLE $4,823.81 ATOVAQUONE 750 MG/5 ML SUSP 5 ML BLIST PACK $132.62 ATOVAQUONE 750 MG/5 ML SUSP 5 ML CUP $123.90 ATRACURIUM 10 MG/ML SOLN 5 ML VIAL $26.46 ATROPINE 0.1 MG/ML SYRG 10 ML SYRINGE J0461 $3.89 ATROPINE 0.4 MG/ML SOLN 1 ML VIAL J0461 $15.31 ATROPINE 1 % DROP 5 ML DROP BTL $204.33 ATROPINE 1 % OINT 3.5 G TUBE $69.65 ATROPINE 1 MG/ML SOLN 1 ML VIAL J0461 $24.06 ATROPINE-PHENOBARBITAL-SCOPOLAMINE-HYOSCYAMINE 16. $39.91 ATTEMPT TO RESTART HEART AND LUNGS 92950 $1,042.00 ATTENTION FUNCTIONAL LIMIT CURRENT STATUS AT THERA G9165 $0.01 ATTENTION FUNCTIONAL LIMITED DISCHARGE STATUS G9167 $0.01 ATTENTION FUNCTIONAL LIMITED PROJECTED GOAL STATUS G9166 $0.01 AUTOMATED URINALYSIS TEST 81003 $76.00 AUTOPSY FOR FORENSIC INVESTIGATIVE EXAMINATION 88040 $945.00 AZACITIDINE 100 MG SOLR 1 EACH VIAL J9025 $1,680.00 AZATHIOPRINE 50 MG TAB 100 EACH BLIST PACK J7500 $2.84 AZELASTINE 0.15 % (205.5 MCG) SPRY 30 ML SQUEEZ BT $481.95 AZELASTINE 137 MCG (0.1 %) SPRA 30 ML SQUEEZ BTL $368.03 AZITHROMYCIN 200 MG/5 ML SUSR 22.5 ML BOTTLE $122.06 AZITHROMYCIN 250 MG TAB 1 EACH BLIST PACK $25.87 AZITHROMYCIN 250 MG TAB 100 EACH BLIST PACK $14.75 AZITHROMYCIN 250 MG TAB 30 EACH BOTTLE $27.24 AZITHROMYCIN 250 MG TAB 50 EACH BLIST PACK $25.87 AZITHROMYCIN 500 MG SOLR 1 EACH VIAL J0456 $25.20 AZITHROMYCIN 600 MG TAB 30 EACH BOTTLE $65.39 AZTREONAM 1 GRAM SOLR 1 EACH VIAL S0073 $60.90 AZTREONAM 2 GRAM SOLR 1 EACH VIAL S0073 $70.30 B CELLS TOTAL COUNT 86355 $551.00 B COMPLEX WITH C 20-FOLIC ACID 1 MG CAP 100 EACH B $3.80 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge B. PERTUSSIS CULTURE 87081 $186.00 B12-LEVOMEFOLATE CALCIUM-B6 2-1.13-25 MG TAB 90 EA $6.42 BACITRACIN 50,000 UNIT SOLR 1 EACH VIAL $46.59 BACITRACIN 500 UNIT/GRAM OINT 14 G TUBE $16.42 BACITRACIN 500 UNIT/GRAM OINT 14.17 G TUBE $12.45 BACITRACIN 500 UNIT/GRAM OINT 15 G TUBE $7.25 BACITRACIN 500 UNIT/GRAM OINT 3.5 G TUBE $414.54 BACITRACIN-POLYMYXIN B 500-10,000 UNIT/GRAM OINT 2 $11.89 BACITRACIN-POLYMYXIN B 500-10,000 UNIT/GRAM OINT 3 $100.28 BACLOFEN 10 MG TAB 100 EACH BLIST PACK $1.94 BACLOFEN 2,000 MCG/ML SOLN 20 ML AMPUL J0475 $3,612.00 BACLOFEN 20 MG TAB 1 EACH BLIST PACK $0.99 BACLOFEN 20 MG TAB 100 EACH BLIST PACK $0.75 BACLOFEN 20 MG TAB 100 EACH BOTTLE $4.49 BACLOFEN 50 MCG/ML SOLN 1 ML AMPUL J0476 $63.00 BACLOFEN 500 MCG/ML SOLN 20 ML AMPUL J0475 $903.00 BACLOFEN 500 MCG/ML SOLN 40 ML AMPUL J0475 $0.14 BACTERIAL CULTURE 87070 $211.00 BACTERIAL CULTURE 87075 $253.00 BACTERIAL CULTURE AND COLONY COUNT 87071 $271.00 BACTERIAL CULTURE AND COLONY COUNT FOR ANAEROBIC B 87073 $65.00 BALANCED SALT SOLUTION (REGULAR) SOLN 15 ML BOTTLE $41.63 BALANCED SALT SOLUTION (REGULAR) SOLN 500 ML BAG $19.25 BALLOON CATHETER ENLARGEMENT OF OPENING BETWEEN TW 92992 $3,882.00 BALLOON DILAT INTRACRANIAL VASOSPASM 61640 $3,842.00 BALLOON DILATION OF ADDITIONAL VEIN ACCESSED THROU 37249 $1,770.00 BALLOON DILATION OF ARTERIES IN ONE LEG ENDOVASCUL 37224 $8,142.00 BALLOON DILATION OF ARTERY ACCESSED THROUGH THE SK 37246 $6,928.00 BALLOON DILATION OF ARTERY ACCESSED THROUGH THE SK 37247 $6,928.00 BALLOON DILATION OF ARTERY IN ONE LEG ENDOVASCULAR 37232 $4,684.00 BALLOON DILATION OF ARTERY IN ONE SIDE OF GROIN EN 37220 $7,752.00 BALLOON DILATION OF ARTERY OF ONE LEG ENDOVASCULAR 37228 $19,645.00 BALLOON DILATION OF DIALYSIS SEGMENT ACCESSED THRO 36907 $9,079.00 BALLOON DILATION OF ESOPHAGUS STOMACH/UPPER SMALL 43233 $4,607.00 BALLOON DILATION OF ESOPHAGUS USING AN ENDOSCOPE 43214 $4,842.00 BALLOON DILATION OF ESOPHAGUS USING AN ENDOSCOPE 43220 $4,138.00 BALLOON DILATION OF ESOPHAGUS USING AN ENDOSCOPE 43249 $2,897.00 BALLOON DILATION OF FIRST VEIN ACCESSED THROUGH TH 37248 $1,770.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge BALLOON DILATION OF GROIN ARTERY ENDOVASCULAR OPEN 37222 $5,932.00 BALLOON DILATION OF LARGE BOWEL USING AN ENDOSCOPE 45386 $2,055.00 BALLOON DILATION OF NARROWED OR BLOCKED MAJOR CORO 92920 $20,845.00 BALLOON DILATION OF NARROWED OR BLOCKED MAJOR CORO 92921 $18,293.00 BALLOON DILATION OF PANCREATIC OR BILE DUCT USING 43277 $7,693.00 BALLOON OCCLUSION OF HEAD OR NECK ARTERY 61623 $17,547.00 BALSAM PERU-CASTOR OIL OINT 60 G TUBE $131.25 BARBITURATES LEVELS 80345 $203.00 BARIUM 2.1 % (W/V), 2.0 % (W/W) SUSP 450 ML BOTTLE $37.80 BARIUM SULFATE 2 % (W/V) SUSP 450 ML BOTTLE $18.90 BARTONELLA AB IGG 86611 $125.00 BARTONELLA AB IGM 86611 $125.00 BCG VACCINE 50 MG SUSR 1 EACH VIAL J9030 $659.68 BECLOMETHASONE 42 MCG (0.042 %) SPRY 25 G AER W/AD $1,173.46 BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION FIRS 0373T $605.00 BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND R 92524 $289.00 BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG SUPP 12 EACH $96.31 BENAZEPRIL 20 MG TAB 1 EACH BLIST PACK $3.32 BENAZEPRIL 20 MG TAB 100 EACH BOTTLE $3.68 BENAZEPRIL 20 MG TAB 50 EACH BLIST PACK $3.32 BENAZEPRIL 5 MG TAB 100 EACH BOTTLE $3.68 BENAZEPRIL-HYDROCHLOROTHIAZIDE 10-12.5 MG TAB 100 $7.23 BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG TAB 100 $7.23 BENDAMUSTINE 25 MG/ML SOLN 4 ML VIAL J9034 $10,186.26 BENRALIZUMAB 30 MG/ML SYRG 1 ML SYRINGE C9466 $19,958.86 BENZOCAINE 10 % GEL 7 G JAR $1.47 BENZOCAINE 20 % GEL 11.9 G JAR $17.49 BENZOCAINE 20 % SPRY 1 EACH PF APPLI $43.03 BENZOCAINE-LANOLIN-ALOE VERA 20-0.5 % AERO 56 G CA $19.80 BENZOCAINE-LANOLIN-ALOE VERA 20-0.5 % AERO 78 G CA $630.63 BENZOCAINE-MENTHOL 15-3.6 MG LOZG 16 EACH BLIST PA $0.72 BENZOCAINE-MENTHOL 15-3.6 MG LOZG 18 EACH BLIST PA $0.57 BENZOCAINE-MENTHOL 6-10 MG LOZG 18 EACH BLIST PACK $0.58 BENZODIAZEPINES LEVELS 80346 $193.00 BENZODIAZEPINES LEVELS 80347 $220.00 BENZOIN (BULK) TINC 60 ML BOTTLE $19.60 BENZOIN COMPOUND 10-2-8-4 % TINC 60 ML BOTTLE $18.69 BENZONATATE 100 MG CAP 1 EACH BLIST PACK $2.55 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge BENZONATATE 100 MG CAP 100 EACH BLIST PACK $2.55 BENZONATATE 100 MG CAP 100 EACH BOTTLE $8.76 BENZOYL PEROXIDE 10 % GEL 42.5 G TUBE $24.25 BENZTROPINE 1 MG TAB 1 EACH BLIST PACK $1.03 BENZTROPINE 1 MG TAB 100 EACH BLIST PACK $1.03 BENZTROPINE 1 MG TAB 100 EACH BOTTLE $0.72 BENZTROPINE 2 MG TAB 1 EACH BLIST PACK $0.59 BENZTROPINE 2 MG TAB 100 EACH BLIST PACK $0.59 BENZTROPINE MESYLATE 2 MG/2 ML SOLN 2 ML AMPUL J0515 $65.63 BENZTROPINE MESYLATE 2 MG/2 ML SOLN 2 ML VIAL J0515 $51.41 BERACTANT 25 MG/ML SUSP 4 ML VIAL $1,608.60 BETA 2 GLYCOPROTEIN 1 ANTIBODY (AUTOANTIBODY) MEAS 86146 $184.00 BETA-2 MICROGLOBULIN 82232 $197.00 BETAMETHASONE ACETATE-BETAMETHASONE SODIUM PHOSPHA J0702 $31.42 BETAMETHASONE DIPROPIONATE 0.05 % CREA 15 G TUBE $184.91 BETAMETHASONE DIPROPIONATE 0.05 % OINT 15 G TUBE $215.20 BETAMETHASONE VALERATE 0.1 % CREA 15 G TUBE $97.91 BETAMETHASONE VALERATE 0.1 % OINT 45 G TUBE $149.31 BETAXOLOL 0.25 % DRPS 10 ML DROP BTL $1,304.24 BETAXOLOL 0.5 % DROP 5 ML DROP BTL $221.94 BETHANECHOL 10 MG TAB 100 EACH BLIST PACK $3.50 BETHANECHOL 25 MG TAB 1 EACH BLIST PACK $6.24 BETHANECHOL 25 MG TAB 100 EACH BLIST PACK $9.35 BETHANECHOL 50 MG TAB 100 EACH BOTTLE $1.49 BEVACIZUMAB 25 MG/ML SOLN 16 ML VIAL J9035 $40.82 BEVACIZUMAB 25 MG/ML SOLN 4 ML VIAL J9035 $40.82 BEVACIZUMAB-AWWB 25 MG/ML SOLN 16 ML VIAL Q5107 $35.56 BEVACIZUMAB-AWWB 25 MG/ML SOLN 4 ML VIAL Q5107 $35.56 BICALUTAMIDE 50 MG TAB 100 EACH BOTTLE $64.96 BICALUTAMIDE 50 MG TAB 30 EACH BOTTLE $64.24 BILE ACIDS LEVEL 82240 $219.00 BILIRUBIN LEVEL 82247 $105.00 BILIRUBIN LEVEL 82248 $102.00 BILIRUBIN, FLD 82247 $105.00 BIMATOPROST 0.01 % DROP 2.5 ML DROP BTL $827.26 BIOPSIES OF LARGE BOWEL 44389 $2,762.00 BIOPSY AND SCRAPING OF THE CERVIX USING AN ENDOSCO 57454 $1,883.00 BIOPSY AND/OR REMOVAL OF POLYP OF THE UTERUS USING 58558 $6,643.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge BIOPSY OF ABDOMEN USING AN ENDOSCOPE 49321 $11,735.00 BIOPSY OF ANUS USING AN ENDOSCOPE 46606 $1,040.00 BIOPSY OF BACK OF THROAT 42800 $3,179.00 BIOPSY OF BLOOD VESSEL VIA CATHETER 37200 $4,913.00 BIOPSY OF BONE USING NEEDLE OR TROCAR 20220 $1,360.00 BIOPSY OF BONE, OPEN PROCEDURE 20240 $5,988.00 BIOPSY OF BREAST ACCESSED THROUGH THE SKIN WITH ST 19081 $2,727.00 BIOPSY OF BREAST ACCESSED THROUGH THE SKIN WITH UL 19083 $2,249.00 BIOPSY OF BREAST ACCESSED THROUGH THE SKIN WITH UL 19084 $1,437.00 BIOPSY OF CERVIX OR EXCISION OF LOCAL GROWTHS 57500 $2,874.00 BIOPSY OF CERVIX USING AN ENDOSCOPE 57455 $768.00 BIOPSY OF CERVIX USING AN ENDOSCOPE 57460 $3,861.00 BIOPSY OF EAR 69100 $1,115.00 BIOPSY OF EAR CANAL 69105 $2,669.00 BIOPSY OF ESOPHAGUS USING AN ENDOSCOPE 43198 $3,391.00 BIOPSY OF ESOPHAGUS USING AN ENDOSCOPE 43202 $2,405.00 BIOPSY OF ESOPHAGUS USING AN ENDOSCOPE 43193 $4,842.00 BIOPSY OF EXTERNAL FEMALE GENITALS 56605 $1,143.00 BIOPSY OF EXTERNAL FEMALE GENITALS 56606 $666.00 BIOPSY OF EYELID 67810 $1,309.00 BIOPSY OF FINGER OR TOE NAIL 11755 $580.00 BIOPSY OF GALLBLADDER, PANCREATIC, LIVER, AND BILE 43261 $3,930.00 BIOPSY OF LARGE BOWEL USING AN ENDOSCOPE 45331 $1,242.00 BIOPSY OF LARGE BOWEL USING AN ENDOSCOPE 45380 $4,065.00 BIOPSY OF LINING OF NOSE 30100 $1,954.00 BIOPSY OF LIP 40490 $692.00 BIOPSY OF LUNG AIRWAYS USING AN ENDOSCOPE 31625 $2,284.00 BIOPSY OF LUNG USING AN ENDOSCOPE 31632 $1,516.00 BIOPSY OF MOUTH 40808 $2,438.00 BIOPSY OF ONE LOBE OF LUNG USING AN ENDOSCOPE 31628 $2,650.00 BIOPSY OF PROSTATE GLAND 55700 $4,013.00 BIOPSY OF RECTUM 45100 $4,320.00 BIOPSY OF RECTUM AND LARGE BOWEL USING AN ENDOSCOP 45305 $5,375.00 BIOPSY OF ROOF OF MOUTH 42100 $2,453.00 BIOPSY OF SALIVARY GLAND 42405 $5,582.00 BIOPSY OF SMALL BOWEL USING AN ENDOSCOPE 44361 $2,515.00 BIOPSY OF SMALL BOWEL USING AN ENDOSCOPE 44377 $2,490.00 BIOPSY OF SOFT TISSUE OF NECK OR CHEST 21550 $2,692.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge BIOPSY OF SOFT TISSUE OF UPPER ARM OR ELBOW 24065 $4,147.00 BIOPSY OF THE BLADDER USING AN ENDOSCOPE 52204 $3,731.00 BIOPSY OF THE WALL DIVIDING THE LEFT AND RIGHT HEA 93505 $5,942.00 BIOPSY OF TISSUE OF FOREARM AND/OR WRIST 25065 $3,053.00 BIOPSY OF TISSUE OR MUSCLE OF LOWER LEG OR ANKLE 27614 $3,130.00 BIOPSY OF TONGUE 41100 $1,813.00 BIOPSY OF URINARY DUCT USING IMAGING GUIDANCE 50606 $664.00 BIOPSY OF UTERINE LINING 58100 $326.00 BIOPSY OF VAGINA AND CERVIX USING AN ENDOSCOPE 57421 $892.00 BIOPSY OF VAGINAL MUCOUS MEMBRANE 57100 $784.00 BIOPSY OF VOICE BOX USING A FLEXIBLE ENDOSCOPE 31576 $6,401.00 BIOPSY OR REMOVAL OF LYMPH NODES OF NECK, OPEN PRO 38510 $7,545.00 BIOPSY OR REMOVAL OF LYMPH NODES OF UNDER THE ARM, 38525 $7,040.00 BIOPSY OR REMOVAL OF LYMPH NODES, OPEN PROCEDURE 38500 $6,275.00 BIOPSY OR REMOVAL OF NASAL POLYP OR TISSUE USING A 31237 $3,797.00 BIOPSY THE ESOPHAGUS, STOMACH, AND/OR UPPER SMALL 43239 $3,228.00 BIOPSY VOICE BOX USING AN ENDOSCOPE WITH OPERATING 31536 $5,144.00 BISACODYL 10 MG SUPP 100 EACH BOX $0.63 BISACODYL 10 MG SUPP 12 EACH BOX $1.48 BISACODYL 10 MG SUPP 50 EACH BOX $0.57 BISACODYL 5 MG TBEC 100 EACH BLIST PACK $0.25 BISACODYL 5 MG TBEC 100 EACH BOTTLE $0.21 BISMUTH SUBSALICYLATE 262 MG/15 ML SUSP 15 ML CUP $0.68 BISMUTH SUBSALICYLATE 262 MG/15 ML SUSP 236 ML BOT $10.74 BISOPROLOL 5 MG TAB 100 EACH BOTTLE $4.27 BISOPROLOL 5 MG TAB 30 EACH BLIST PACK $4.73 BIVALIRUDIN 250 MG SOLR 1 EACH VIAL J0583 $3,980.44 BLADDER INSTILLATION OF CANCER PREVENTIVE, INHIBIT 51720 $587.00 BLADDER IRRIGATION AND/OR INSTILLATION 51700 $318.00 BLEOMYCIN 15 UNIT SOLR 1 EACH VIAL J9040 $27.84 BLOOD ADMINISTRATION ? REVENUE CODE 391 DEDUCT 2 H G0378 $90.00 BLOOD BANK PHYSICIAN SERVICES INVESTIGATION TRANSF 86078 $145.00 BLOOD CLOT EVALUATION, (RETRACTION TIME) 85170 $46.00 BLOOD CREATININE LEVEL 82565 $104.00 BLOOD CULTURE 87040 $211.00 BLOOD CULTURE - PEDIATRIC 87040 $211.00 BLOOD DRAW VENIPUNCTURE 36415 $31.00 BLOOD GASES MEASUREMENT 82803 $286.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge BLOOD GLUCOSE (SUGAR) LEVEL 82947 $82.00 BLOOD GLUCOSE (SUGAR) MEASUREMENT USING REAGENT ST 82948 $44.00 BLOOD GLUCOSE (SUGAR) TOLERANCE TEST 82951 $221.00 BLOOD GLUCOSE (SUGAR) TOLERANCE TEST 82952 $41.00 BLOOD GROUP TYPING (ABO) 86900 $76.00 BLOOD PRODUCT BLOOD P9010 $553.00 BLOOD PRODUCT BLOOD P9016 $484.00 BLOOD PRODUCT BLOOD P9021 $475.00 BLOOD PRODUCT BLOOD P9022 $674.00 BLOOD PRODUCT BLOOD P9038 $440.00 BLOOD PRODUCT BLOOD P9039 $893.00 BLOOD PRODUCT BLOOD P9040 $559.00 BLOOD PRODUCT BLOOD P9051 $512.00 BLOOD PRODUCT CRYOPRECIPITATE P9012 $142.00 BLOOD PRODUCT PLASMA P9017 $307.00 BLOOD PRODUCT PLASMA P9023 $394.00 BLOOD PRODUCT PLASMA P9044 $265.00 BLOOD PRODUCT PLATELETES P9019 $323.00 BLOOD PRODUCT PLATELETS P9031 $250.00 BLOOD PRODUCT PLATELETS P9033 $414.00 BLOOD PRODUCT PLATELETS P9034 $1,403.00 BLOOD PRODUCT PLATELETS P9035 $2,718.00 BLOOD PRODUCT PLATELETS P9036 $1,143.00 BLOOD PRODUCT PLATELETS P9037 $2,719.00 BLOOD PRODUCT PLATELETS P9053 $2,549.00 BLOOD PRODUCT PLATELETS P9055 $2,004.00 BLOOD SMEAR FOR IRON 85536 $50.00 BLOOD SMEAR PERIPHERAL INTERPRETATION BY PHYSICIAN 85060 $144.00 BLOOD TEST PANEL FOR ELECTROLYTES 80051 $237.00 BLOOD TEST, BASIC GROUP OF BLOOD CHEMICALS 80048 $298.00 BLOOD TEST, CLOTTING TIME 85610 $86.00 BLOOD TEST, COMPREHENSIVE GROUP OF BLOOD CHEMICALS 80053 $453.00 BLOOD TEST, LIPIDS (CHOLESTEROL AND TRIGLYCERIDES) 80061 $237.00 BLOOD TEST, THYROID STIMULATING HORMONE (TSH) 84443 $196.00 BLOOD TYPING FOR PATERNITY TESTING 86910 $137.00 BLOOD TYPING FOR PATERNITY TESTING EACH ADDITIONAL 86911 $366.00 BLOOD TYPING FOR RED BLOOD CELL ANTIGENS 86905 $130.00 BLOOD TYPING FOR RH (D) ANTIGEN 86901 $75.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge BLOOD UNIT COMPATIBILITY TEST 86920 $138.00 BLOOD UNIT COMPATIBILITY TEST 86921 $174.00 BLOOD UNIT COMPATIBILITY TEST 86922 $122.00 BLOOD VISCOSITY MEASUREMENT 85810 $154.00 BODY FLUID CELL COUNT 89050 $184.00 BODY FLUID CELL COUNT WITH CELL IDENTIFICATION 89051 $244.00 BODY POSITION CURRENT STATUS G8981 $0.01 BODY POSITION DISCHARGE STATUS G8983 $0.01 BODY POSITION GOAL STATUS G8982 $0.01 BONE AND/OR JOINT IMAGING 78300 $1,519.00 BONE AND/OR JOINT IMAGING, 3 PHASE STUDY 78315 $3,296.00 BONE AND/OR JOINT IMAGING, MULTIPLE AREAS 78305 $1,335.00 BONE AND/OR JOINT IMAGING, WHOLE BODY 78306 $2,502.00 BONE DENSITY MEASUREMENT USING DEDICATED X-RAY MAC 77080 $854.00 BONE DENSITY MEASUREMENT USING DEDICATED X-RAY MAC 77081 $475.00 BONE MARROW ASPIRATION 38220 $2,738.00 BONE MARROW BIOPSY AND ASPIRATION 38222 $3,708.00 BONE MARROW, SMEAR INTERPRETATION 85097 $435.00 BORDATELLA PERTUSDSSIS P C R 87798 $315.00 BORDETELLA PERTUS ANTIBODY IGG 86615 $480.00 BORTEZOMIB 3.5 MG SOLR 1 EACH VIAL J9041 $6,732.60 BOUDREAUX'S BUTT PASTE 16 % OINT 113 G TUBE $22.94 BOUDREAUX'S BUTT PASTE 16 % OINT 454 G TUBE $9.53 BREATH ALCOHOL LEVEL 82075 $136.00 BREATH TEST ANALYSIS FOR HELICOBACTER PYLORI 83013 $555.00 BRENTUXIMAB VEDOTIN 50 MG SOLR 1 EACH VIAL J9042 $30,975.00 BRIEF EMOTIONAL OR BEHAVIORAL ASSESSMENT 96127 $153.00 BRIMONIDINE 0.2 % DROP 5 ML DROP BTL $114.28 BRIMONIDINE-TIMOLOL 0.2-0.5 % DROP 5 ML DROP BTL $740.60 BRINZOLAMIDE 1 % DRPS 10 ML DROP BTL $1,295.21 BROMOCRIPTINE 2.5 MG TAB 100 EACH BOTTLE $21.94 BROMOCRIPTINE 2.5 MG TAB 30 EACH BOTTLE $14.48 BROMOCRIPTINE 5 MG CAP 30 EACH BOTTLE $32.59 BUDESONIDE 0.25 MG/2 ML NBSP 2 ML AMPUL $65.90 BUDESONIDE 0.5 MG/2 ML NBSP 2 ML AMPUL $38.80 BUDESONIDE 0.5 MG/2 ML NBSP 2 ML AMPUL/KIT $43.08 BUDESONIDE 0.5 MG/2 ML NBSP 2 ML VIAL $38.78 BUDESONIDE 3 MG CECX 1 EACH BLIST PACK $79.81 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge BUDESONIDE 3 MG CECX 100 EACH BOTTLE $65.96 BUDESONIDE 3 MG CECX 30 EACH BLIST PACK $79.81 BUDESONIDE 9 MG TADE 30 EACH BOTTLE $83.67 BUDESONIDE-FORMOTEROL 160-4.5 MCG/ACTUATION HFAA 6 $989.88 BUDESONIDE-FORMOTEROL 80-4.5 MCG/ACTUATION HFAA 6. $860.44 BUMETANIDE 0.25 MG/ML SOLN 10 ML VIAL $2.28 BUMETANIDE 0.25 MG/ML SOLN 4 ML VIAL $5.25 BUMETANIDE 0.5 MG TAB 100 EACH BOTTLE $3.79 BUMETANIDE 1 MG TAB 100 EACH BOTTLE $3.82 BUN, SERUM 84520 $100.00 BUPIVACAINE 0.25 % (2.5 MG/ML) SOLN 30 ML VIAL $1.16 BUPIVACAINE 0.5 % (5 MG/ML) SOLN 30 ML VIAL $1.28 BUPIVACAINE 0.5 % (5 MG/ML) SOLN 50 ML VIAL $1.02 BUPIVACAINE 0.75 % (7.5 MG/ML) SOLN 30 ML VIAL $2.29 BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) $9.74 BUPIVACAINE LIPOSOME (PF) 1.3 % (13.3 MG/ML) SUSP C9290 $735.42 BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 SOLN 30 M $2.00 BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 SOLN 50 M $5.18 BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 SOLN 30 ML $1.70 BUPRENORPHINE DEFINITIVE ASSY 80348 $274.00 BUPRENORPHINE HCL 8 MG SUBL 30 EACH BOTTLE $19.46 BUPRENORPHINE,URINE 80348 $295.00 BUPRENORPHINE-NALOXONE 8-2 MG SUBL 15 EACH BLIST P $36.52 BUPRENORPHINE-NALOXONE 8-2 MG SUBL 30 EACH BLIST P $36.52 BUPRENORPHINE-NALOXONE 8-2 MG SUBL 30 EACH BOTTLE $28.42 BUPROPION 100 MG SR12 1 EACH BLIST PACK $2.83 BUPROPION 100 MG TAB 100 EACH BLIST PACK $6.87 BUPROPION 100 MG TAB 100 EACH BOTTLE $3.36 BUPROPION 150 MG SR12 1 EACH BLIST PACK $4.22 BUPROPION 150 MG SR12 100 EACH BLIST PACK $1.64 BUPROPION 150 MG SR12 100 EACH BOTTLE $4.52 BUPROPION 150 MG SR12 30 EACH BLIST PACK $1.71 BUPROPION 150 MG TB24 1 EACH BLIST PACK $18.27 BUPROPION 150 MG TB24 100 EACH BLIST PACK $18.27 BUPROPION 75 MG TAB 1 EACH BLIST PACK $5.41 BUPROPION 75 MG TAB 100 EACH BLIST PACK $5.41 BURN TREATMENT 16000 $441.00 BUSPIRONE 10 MG TAB 100 EACH BLIST PACK $4.71 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge BUSPIRONE 10 MG TAB 100 EACH BOTTLE $1.18 BUSPIRONE 5 MG TAB 100 EACH BLIST PACK $2.70 BUSPIRONE 5 MG TAB 100 EACH BOTTLE $1.35 BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50-325-40 MG TAB $6.83 BUTALBITAL-ASPIRIN-CAFFEINE 50-325-40 MG CAP 100 E $5.95 BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 M $242.97 BUTORPHANOL 1 MG/ML SOLN 1 ML VIAL J0595 $8.38 C BLOOD ACID FAST 87116 $230.00 C. DIFF TOXIN AG 87324 $250.00 C1 ESTERASE INHIBITOR 86160 $260.00 CA 125, BODY FLUID 86304 $376.00 CA-125 86304 $376.00 CA-19-9 86301 $315.00 CABAZITAXEL 10 MG/ML (FIRST DILUTION) SOLN 6 ML VI J9043 $42,766.44 CADEXOMER IODINE 0.9 % GEL 40 G TUBE $364.70 CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) SOLN 3 ML V J0706 $78.75 CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) SOLN 3 ML V $169.54 CAFFEINE LEVEL 80155 $233.00 CALAMINE-ZINC OXIDE 8-8 % LOTN 177 ML BOTTLE $5.58 CALCITONIN (HORMONE) LEVEL 82308 $236.00 CALCITONIN (SALMON) 200 UNIT/ACTUATION SPRY 3.7 ML $414.89 CALCITONIN 200 UNIT/ML SOLN 2 ML VIAL J0630 $28.38 CALCITONIN STIMULATION PANEL 80410 $448.00 CALCITRIOL 0.25 MCG CAP 100 EACH BOTTLE $4.24 CALCITRIOL 0.25 MCG CAP 30 EACH BOTTLE $4.48 CALCITRIOL 0.5 MCG CAP 100 EACH BOTTLE $3.38 CALCITRIOL 1 MCG/ML SOLN 1 ML CUP $10.44 CALCITRIOL 1 MCG/ML SOLN 15 ML BOTTLE $626.48 CALCIUM ACETATE 667 MG CAP 100 EACH BLIST PACK $5.08 CALCIUM ACETATE 667 MG CAP 200 EACH BOTTLE $3.59 CALCIUM ACETATE-ALUMINUM SULF 952-1,347 MG PWPK 12 $3.97 CALCIUM CARBONATE 1250 MG/5 ML (ELEMENTAL CALCIUM $4.89 CALCIUM CARBONATE 1500 MG (ELEMENTAL CA 600 MG) TA $0.39 CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW 150 $0.12 CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW 500 $0.27 CALCIUM CARBONATE-VITAMIN D3 250-125 MG-UNIT TAB 1 $0.27 CALCIUM CHLORIDE 100 MG/ML (10 %) SOLN 10 ML VIAL $40.58 CALCIUM CHLORIDE 100 MG/ML (10 %) SYRG 10 ML SYRIN $28.49 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 10 ML VIAL J0610 $29.47 CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 100 ML VIAL J0610 $19.15 CALCIUM LEVEL 82310 $80.00 CALCIUM LEVEL 82331 $43.00 CALCIUM URINE 82340 $80.00 CALCIUM-VITAMIN D3 500 MG(1,250MG) -200 UNIT TAB 1 $0.35 CALCIUM-VITAMIN D3 500 MG(1,250MG) -200 UNIT TAB 7 $0.34 CALCULATION OF RADIATION THERAPY DOSE 77300 $333.00 CAMPHOR-MENTHOL 0.5-0.5 % LOTN 222 ML BOTTLE $14.76 CAMPYLOBACTER; STOOL CULTR EA 87046 $86.00 CANAGLIFLOZIN 100 MG TAB 30 EACH BOTTLE $65.04 CANAKINUMAB (PF) 150 MG/ML SOLN 1 ML VIAL $10,114,655.25 CANDESARTAN 8 MG TAB 1 EACH BLIST PACK $8.32 CANDESARTAN 8 MG TAB 90 EACH BOTTLE $5.55 CANDIDA ALBICANS SKIN TEST FDA STANDARD ALRG 1 ML $76.63 CANDIDA NUCLEIC ACID PROBE DIRECT 87480 $127.00 CANGRELOR 50 MG SOLR 1 EACH VIAL $3,145.80 CANNABINOIDS DEFINITIVE ASSAY, URINE 80349 $232.00 CANNABINOIDS LEVELS 80350 $259.00 CANNABINOIDS LEVELS 80351 $259.00 CANNABINOIDS LEVELS 80352 $259.00 CAPSAICIN 0.025 % CREA 60 G TUBE $34.86 CAPTOPRIL 12.5 MG TAB 100 EACH BLIST PACK $6.01 CAPTOPRIL 25 MG TAB 1,000 EACH BOTTLE $5.84 CAPTOPRIL 25 MG TAB 100 EACH BLIST PACK $6.52 CAPTOPRIL 50 MG TAB 100 EACH BOTTLE $10.15 CAR SEAT OR BED AIRWAY TESTING OF NEONATE 94781 $274.00 CAR SEAT OR BED AIRWAY TESTING OF NEONATE, MINIMUM 94780 $274.00 CARBACHOL 0.01 % SOLN 1.5 ML VIAL $49.50 CARBAMAZEPINE 100 MG CHEW 100 EACH BLIST PACK $2.31 CARBAMAZEPINE 100 MG CHEW 100 EACH BOTTLE $2.31 CARBAMAZEPINE 100 MG CM12 120 EACH BOTTLE $6.87 CARBAMAZEPINE 100 MG TB12 100 EACH BOTTLE $4.01 CARBAMAZEPINE 200 MG TAB 100 EACH BLIST PACK $3.92 CARBAMAZEPINE 200 MG/10 ML SUSP 10 ML CUP $15.93 CARBAMAZEPINE 400 MG TB12 30 EACH BLIST PACK $6.09 CARBAMAZEPINE LEVEL 80156 $226.00 CARBAMIDE PEROXIDE 6.5 % DROP 15 ML DROP BTL $13.07 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CARBIDOPA-LEVODOPA 10-100 MG TAB 100 EACH BLIST PA $4.01 CARBIDOPA-LEVODOPA 10-100 MG TAB 100 EACH BOTTLE $2.70 CARBIDOPA-LEVODOPA 25-100 MG TAB 1 EACH BLIST PACK $2.79 CARBIDOPA-LEVODOPA 25-100 MG TAB 100 EACH BLIST PA $2.79 CARBIDOPA-LEVODOPA 25-100 MG TBSR 1 EACH BLIST PAC $3.26 CARBIDOPA-LEVODOPA 25-100 MG TBSR 100 EACH BLIST P $2.92 CARBIDOPA-LEVODOPA 25-100 MG TBSR 100 EACH BOTTLE $3.45 CARBIDOPA-LEVODOPA 25-250 MG TAB 100 EACH BLIST PA $3.31 CARBIDOPA-LEVODOPA 25-250 MG TAB 100 EACH BOTTLE $3.89 CARBOHYDRATE ANALYSIS 84376 $93.00 CARBOHYDRATE ANALYSIS 84378 $54.00 CARBON DIOXIDE (BICARBONATE) LEVEL 82374 $111.00 CARBOPLATIN 10 MG/ML SOLN 45 ML VIAL J9045 $272.95 CARBOPROST 250 MCG/ML SOLN 1 ML AMPUL $1,488.62 CARBOXYHEMOGLOBIN (PROTEIN) ANALYSIS 82376 $50.00 CARCINOEMBRYONIC ANTIGEN (CEA) PROTEIN LEVEL 82378 $279.00 CARDIAC OUTPUT MEASUREMENTS 93561 $85.00 CARDIAC OUTPUT MEASUREMENTS 93562 $80.00 CARDIAC REHAB PHASE II W/ MONITORING 93798 $164.00 CARDIAC REHAB PHASE II W/O MONITORING 93797 $216.00 CARDIOLIPIN ANTIBODY IGA 86147 $269.00 CARDIOLIPIN ANTIBODY IGG 86147 $269.00 CARDIOLIPIN ANTIBODY, IGA 86147 $228.00 CARDIOPLEGIA - DEL NIDO 1050 ML SOLN 1,050 ML BAG $874.65 CARDIOPLIPIN IGG IGM IGA EXPL 86147 $228.00 CARFILZOMIB 10 MG SOLR 1 EACH VIAL J9047 $1,625.16 CARFILZOMIB 30 MG SOLR 1 EACH VIAL J9047 $4,733.47 CARFILZOMIB 60 MG SOLR 1 EACH VIAL J9047 $9,466.98 CARINITINE-CARINITINE 82379 $417.00 CARISOPRODOL 350 MG TAB 100 EACH BLIST PACK $2.48 CARISOPRODOL 350 MG TAB 100 EACH BOTTLE $2.09 CARNITINE LEVEL 82379 $417.00 CARRYING CURRENT STATUS G8984 $0.01 CARRYING DISCHARGE STATUS G8986 $0.01 CARRYING GOAL STATUS G8985 $0.01 CARVEDILOL 12.5 MG TAB 1 EACH BLIST PACK $1.71 CARVEDILOL 12.5 MG TAB 100 EACH BLIST PACK $1.84 CARVEDILOL 20 MG CM24 30 EACH BOTTLE $19.27 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CARVEDILOL 3.125 MG TAB 100 EACH BLIST PACK $7.35 CATARACT PRE-OP DILATION GEL EYE DROPS - (WJ) 1 ML $100.00 CATECHOLAMINES-PLASMA 82384 $344.00 CATECHOLAMINES-URINE 82384 $344.00 CATHEPSIN-D (ENZYME) LEVEL 82387 $63.00 CATHETER BASED CLOSURE OF CONGENITAL HEART DEFECT 93580 $23,514.00 CATHETER BASED REPAIR OF HEART VALVE (PULMONARY) T 92990 $16,235.00 CATHETER INSERT STENTS IN MAJOR CORONARY ARTERY OR 92928 $22,381.00 CATHETER PLACEMENT STENTS IN MAJOR CORONARY ARTERY 92929 $19,226.00 CATHETER REMOVAL OF PLAQUE FROM GROIN ARTERY ACCES 0238T $21,674.00 CATHETER REPLACEMENT OF CENTRAL VENOUS ACCESS DEVI 36578 $5,296.00 CATHETER TIP CULTURE 87070 $211.00 CCP ANTIBODY 86200 $190.00 CD4 COUNT LYMPHOCYTE SUBSET PANEL 2 86361 $284.00 CEA CARCINOEMBRYONIC ANTIGEN 82378 $279.00 CEFADROXIL 500 MG CAP 100 EACH BOTTLE $12.60 CEFAZOLIN 1 GRAM SOLR 1 EACH VIAL J0690 $1.10 CEFAZOLIN 10 GRAM SOLR 1 EACH VIAL J0690 $2.10 CEFAZOLIN 500 MG SOLR 1 EACH VIAL J0690 $6.72 CEFAZOLIN IN D5W 1 GRAM/50 ML PGBK 50 ML BAG J0690 $25.73 CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/100 ML PGBK J0690 $51.10 CEFEPIME 1 GRAM SOLR 1 EACH VIAL J0692 $25.20 CEFEPIME 2 GRAM SOLR 1 EACH VIAL J0692 $141.26 CEFOTAXIME 1 GRAM SOLR 1 EACH VIAL J0698 $22.75 CEFOTAXIME 2 GRAM SOLR 1 EACH VIAL J0698 $22.75 CEFOTAXIME 500 MG SOLR 1 EACH VIAL J0698 $11.17 CEFOXITIN 1 GRAM SOLR 1 EACH VIAL J0694 $50.40 CEFOXITIN 2 GRAM SOLR 1 EACH VIAL J0694 $42.00 CEFTAROLINE FOSAMIL 400 MG SOLR 1 EACH VIAL J0712 $1,210.36 CEFTAROLINE FOSAMIL 600 MG SOLR 1 EACH VIAL J0712 $806.91 CEFTAZIDIME 1 GRAM SOLR 1 EACH VIAL J0713 $17.64 CEFTAZIDIME 2 GRAM SOLR 1 EACH VIAL J0713 $46.20 CEFTAZIDIME 500 MG SOLR 1 EACH VIAL J0713 $27.72 CEFTRIAXONE 1 GRAM SOLR 1 EACH VIAL J0696 $30.63 CEFTRIAXONE 2 GRAM SOLR 1 EACH VIAL J0696 $11.97 CEFTRIAXONE 250 MG SOLR 1 EACH VIAL J0696 $3.15 CEFTRIAXONE 500 MG SOLR 1 EACH VIAL J0696 $3.99 CEFUROXIME 125 MG/5 ML SUSR 100 ML BOTTLE $30.50 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CEFUROXIME 250 MG TAB 60 EACH BOTTLE $19.90 CEFUROXIME 500 MG TAB 60 EACH BOTTLE $19.42 CEFUROXIME 750 MG SOLR 1 EACH VIAL J0697 $22.40 CEFUROXIME SODIUM 1.5 GRAM SOLR 1 EACH VIAL J0697 $70.56 CELECOXIB 100 MG CAP 1 EACH BLIST PACK $16.16 CELECOXIB 100 MG CAP 100 EACH BLIST PACK $9.86 CELECOXIB 100 MG CAP 100 EACH BOTTLE $16.18 CELIAC DIS SCREEN 83516 $198.00 CELL COUNT W/DIFF CSF 89051 $184.00 CELL EXAMINATION OF BODY FLUID 88104 $167.00 CELL EXAMINATION OF BODY FLUID 88106 $219.00 CELL EXAMINATION OF SPECIMEN 88108 $148.00 CELL EXAMINATION OF SPECIMEN 88112 $227.00 CENTROMERE B AB IGG 86235 $221.00 CEPHALEXIN 250 MG CAP 100 EACH BLIST PACK $1.36 CEPHALEXIN 250 MG CAP 100 EACH BOTTLE $2.43 CEPHALEXIN 250 MG/5 ML SUSR 100 ML BOTTLE $100.80 CEPHALEXIN 500 MG CAP 100 EACH BLIST PACK $0.76 CEPHALEXIN 500 MG CAP 100 EACH BOTTLE $4.82 CEPHALEXIN 500 MG CAP 50 EACH BLIST PACK $2.14 CEPHALEXIN 500 MG CAP 500 EACH BOTTLE $4.72 CERULOPLASMIN 82390 $175.00 CERULOPLASMIN (PROTEIN) LEVEL 82390 $174.00 CERVICOVAGINAL SECRETION OF PLACENTA PROTEIN 84112 $150.00 CETIRIZINE 10 MG TAB 1 EACH BLIST PACK $4.34 CETIRIZINE 10 MG TAB 100 EACH BLIST PACK $8.73 CETIRIZINE 10 MG TAB 100 EACH BOTTLE $8.73 CETUXIMAB 100 MG/50 ML SOLN 50 ML VIAL J9055 $2,547.30 CETUXIMAB 200 MG/100 ML SOLN 100 ML VIAL J9055 $5,094.95 CHANGE OF BREATHING TUBE OF WINDPIPE IN NECK 31502 $729.00 CHEMICAL ANALYSIS FOR GENETIC DISORDER 82016 $114.00 CHEMICAL ANALYSIS USING CHROMATOGRAPHY TECHNIQUE 82542 $331.00 CHEMICAL RECEPTOR ANALYSIS 84238 $365.00 CHEMOTHERAPY ADMINISTRATION INTO SPINAL CANAL REQU 96450 $1,039.00 CHEMOTHERAPY INFUSION INTO ABDOMINAL CAVITY 96446 $991.00 CHEMOTHERAPY INJECTION INTO BRAIN THROUGH RESERVOI 96542 $452.00 CHEST ULTRASOUND EXAMINATION OF HEART W/CONTRAST 93307 $1,091.00 CHEST ULTRASOUND EXAMINATION OF HEART W/O CONTRAST 93307 $1,091.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CHIMERISM ANALYSIS POST TRANSPLANTATION 81268 $32.00 CHLAMYDIA CULTURE 87110 $263.00 CHLORDIAZEPOXIDE 10 MG CAP 100 EACH BLIST PACK $2.17 CHLORDIAZEPOXIDE 25 MG CAP 100 EACH BLIST PACK $2.34 CHLORDIAZEPOXIDE 25 MG CAP 100 EACH BOTTLE $1.50 CHLORDIAZEPOXIDE 5 MG CAP 1 EACH BLIST PACK $2.84 CHLORHEXIDINE 0.12 % MWSH 15 ML BOTTLE A4248 $6.98 CHLORHEXIDINE 0.12 % MWSH 15 ML CUP A4248 $1.16 CHLORHEXIDINE 0.12 % MWSH 473 ML BOTTLE A4248 $36.42 CHLORIDE - CSF 82438 $121.00 CHLORIDE BODY FLUID 82438 $121.00 CHLORIDE URINE 82436 $142.00 CHLORIDE, URINE, RANDOM 82436 $114.00 CHLORIDE-QUANT, URINE, 24HRS 82436 $142.00 CHLOROPROCAINE 30 MG/ML (3 %) SOLN 20 ML VIAL J2400 $94.01 CHLOROTHIAZIDE 250 MG TAB 100 EACH BOTTLE $2.42 CHLOROTHIAZIDE 250 MG/5 ML SUSP 237 ML BOTTLE $289.50 CHLOROTHIAZIDE 250 MG/5 ML SUSP 5 ML CUP $6.11 CHLOROTHIAZIDE 50 MG/ML SUSP 1 ML ORAL SYRINGE $1.23 CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL J1205 $700.00 CHLORPROMAZINE 10 MG TAB 100 EACH BLIST PACK Q0161 $23.20 CHLORPROMAZINE 100 MG TAB 100 EACH BLIST PACK Q0161 $37.78 CHLORPROMAZINE 100 MG TAB 100 EACH BOTTLE Q0161 $52.10 CHLORPROMAZINE 25 MG TAB 1 EACH BLIST PACK Q0161 $15.51 CHLORPROMAZINE 25 MG TAB 100 EACH BLIST PACK Q0161 $15.51 CHLORPROMAZINE 25 MG TAB 100 EACH BOTTLE Q0161 $26.74 CHLORPROMAZINE 25 MG/ML SOLN 2 ML AMPUL J3230 $60.30 CHLORPROMAZINE 50 MG TAB 1 EACH BLIST PACK Q0161 $10.53 CHLORTHALIDONE 25 MG TAB 1 EACH BLIST PACK $8.03 CHLORTHALIDONE 25 MG TAB 100 EACH BLIST PACK $8.03 CHLORTHALIDONE 25 MG TAB 100 EACH BOTTLE $4.22 CHLORZOXAZONE 500 MG TAB 100 EACH BOTTLE $3.82 CHOLECALCIFEROL (VITAMIN D3) 1000 UNITS TAB 100 EA $0.20 CHOLESTEROL LEVEL 82465 $151.00 CHOLESTYRAMINE 4 GRAM PWPK 60 EACH PACKET $11.79 CHOLESTYRAMINE-ASPARTAME 4 GRAM PWPK 1 EACH PACKET $11.79 CHOLESTYRAMINE-ASPARTAME 4 GRAM PWPK 60 EACH PACKE $11.79 CHONDROITIN B SULFATE (PROTEIN) LEVEL 82485 $170.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CHONDROITIN-SODIUM HYALURONATE 4-3 % (40-30 MG/ML) $633.75 CHROMATIN IGG 86235 $221.00 CHROMATOGRAPHY(HGB,EVAL) 83021 $181.00 CHROMIUM LEVEL TO TEST FOR POISONING OR DEFICIENCY 82495 $161.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88245 $527.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88262 $1,072.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88263 $1,068.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88264 $827.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88272 $221.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88273 $372.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88280 $296.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88285 $252.00 CHROMOSOME ANALYSIS FOR GENETIC DEFECTS 88289 $314.00 CHROMOSOME ANALYSIS OF AMNIOTIC FLUID OR PLACENTA 88267 $1,228.00 CICLOPIROX 0.77 % CREA 15 G TUBE $110.78 CICLOPIROX 8 % SOLN 6.6 ML BOTTLE $589.95 CILOSTAZOL 100 MG TAB 1 EACH BLIST PACK $3.94 CILOSTAZOL 100 MG TAB 60 EACH BOTTLE $3.19 CINACALCET 30 MG TAB 30 EACH BOTTLE $112.94 CINACALCET 60 MG TAB 30 EACH BOTTLE $112.94 CIPROFLOXACIN HCL 0.3 % DROP 10 ML DROP BTL $330.54 CIPROFLOXACIN HCL 0.3 % DROP 2.5 ML DROP BTL $87.61 CIPROFLOXACIN HCL 0.3 % DROP 5 ML DROP BTL $507.85 CIPROFLOXACIN HCL 250 MG TAB 100 EACH BLIST PACK $0.86 CIPROFLOXACIN HCL 250 MG TAB 100 EACH BOTTLE $15.53 CIPROFLOXACIN HCL 500 MG TAB 1 EACH BLIST PACK $17.85 CIPROFLOXACIN HCL 500 MG TAB 100 EACH BLIST PACK $17.85 CIPROFLOXACIN HCL 750 MG TAB 1 EACH BLIST PACK $26.81 CIPROFLOXACIN HCL 750 MG TAB 100 EACH BLIST PACK $26.81 CIPROFLOXACIN HCL 750 MG TAB 50 EACH BOTTLE $19.06 CIPROFLOXACIN IN 5 % DEXTROSE 400 MG/200 ML PGBK 2 J0744 $12.60 CIPROFLOXACIN IN 5% DEXTROSE 100 ML BAG J0744 $10.15 CIPROFLOXACIN IN 5% DEXTROSE 200 ML BAG J0744 $16.80 CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML $991.62 CIRC IMM COMP 86332 $318.00 CISATRACURIUM 2 MG/ML SOLN 5 ML VIAL $17.01 CISPLATIN 1 MG/ML SOLN 50 ML VIAL J9060 $75.78 CITALOPRAM 10 MG TAB 100 EACH BLIST PACK $8.49 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CITALOPRAM 20 MG TAB 100 EACH BLIST PACK $9.43 CITALOPRAM 40 MG TAB 100 EACH BOTTLE $9.73 CITRATE (RANDOM URINE) 82507 $194.00 CITRATE LEVEL 82507 $222.00 CITRATE, 24HR 82507 $222.00 CITRIC ACID-SODIUM CITRATE 500-334 MG/5 ML SOLN 15 $9.61 CITRIC ACID-SODIUM CITRATE 500-334 MG/5 ML SOLN 30 $5.20 CLADRIBINE 10 MG/10 ML SOLN 10 ML VIAL J9065 $1,827.00 CLARITHROMYCIN 500 MG TAB 1 EACH BLIST PACK $12.24 CLARITHROMYCIN 500 MG TAB 30 EACH BLIST PACK $12.24 CLARITHROMYCIN 500 MG TAB 60 EACH BOTTLE $21.05 CLIDINIUM-CHLORDIAZEPOXIDE 5-2.5 MG CAP 100 EACH B $17.74 CLINDAMYCIN 150 MG CAP 100 EACH BLIST PACK $2.19 CLINDAMYCIN 150 MG/ML SOLN 2 ML VIAL S0077 $20.58 CLINDAMYCIN 150 MG/ML SOLN 4 ML VIAL S0077 $12.18 CLINDAMYCIN 150 MG/ML SOLN 6 ML VIAL S0077 $13.72 CLINDAMYCIN 300 MG/50 ML PGBK 50 ML BAG S0077 $29.75 CLINDAMYCIN 600 MG/50 ML PGBK 50 ML BAG S0077 $73.33 CLINDAMYCIN 75 MG/5 ML SOLR 100 ML BOTTLE $217.00 CLINDAMYCIN 900 MG/50 ML PGBK 50 ML BAG S0077 $54.78 CLINICAL PATHOLOGY CONSULTATION 80500 $113.00 CLO TEST 87081 $186.00 CLOBETASOL 0.05 % CREA 15 G TUBE $430.82 CLOBETASOL 0.05 % OINT 15 G TUBE $544.06 CLONAZEPAM 0.5 MG TAB 100 EACH BLIST PACK $1.26 CLONAZEPAM 0.5 MG TAB 100 EACH BOTTLE $1.31 CLONAZEPAM 1 MG TAB 1 EACH BLIST PACK $3.17 CLONAZEPAM 1 MG TAB 100 EACH BLIST PACK $3.17 CLONAZEPAM 1 MG TAB 100 EACH BOTTLE $2.99 CLONAZEPAM 2 MG TAB 1 EACH BLIST PACK $0.54 CLONAZEPAM 2 MG TAB 100 EACH BLIST PACK $0.52 CLONIDINE 0.1 MG/24 HR PTWK 4 EACH BOX $115.93 CLONIDINE 0.2 MG/24 HR PTWK 4 EACH BOX $195.18 CLONIDINE 0.3 MG/24 HR PTWK 4 EACH BOX $270.76 CLONIDINE 1,000 MCG/10 ML (100 MCG/ML) SOLN 10 ML J0735 $15.75 CLONIDINE HCL 0.1 MG TAB 1 EACH BLIST PACK $0.83 CLONIDINE HCL 0.1 MG TAB 100 EACH BLIST PACK $0.82 CLONIDINE HCL 0.2 MG TAB 100 EACH BLIST PACK $1.14 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CLONIDINE HCL 0.3 MG TAB 100 EACH BLIST PACK $1.65 CLOPIDOGREL 75 MG TAB 1 EACH BLIST PACK $1.09 CLOPIDOGREL 75 MG TAB 100 EACH BLIST PACK $1.44 CLORAZEPATE 3.75 MG TAB 100 EACH BOTTLE $7.11 CLORAZEPATE 7.5 MG TAB 100 EACH BOTTLE $4.98 CLOSED TREATMENT BROKEN & DISLOCATED FOREARM BONES 24620 $2,842.00 CLOSED TREATMENT BROKEN JAW BONE WITH INSERTION OF 21453 $10,744.00 CLOSED TREATMENT BROKEN UPPER ARM BONE AT SHOULDER 23625 $3,312.00 CLOSED TREATMENT BROKEN/GROWTH PLATE SEPARATE FORE 25605 $2,086.00 CLOSED TREATMENT COLLAR BONE AND SHOULDER JOINT DI 23545 $453.00 CLOSED TREATMENT DISLOCATION JOINT BETWEEN COLLAR 23525 $826.00 CLOSED TREATMENT OF ANKLE DISLOCATION 27840 $724.00 CLOSED TREATMENT OF ANKLE JOINT BONE DISLOCATION 28540 $583.00 CLOSED TREATMENT OF BROKE FOREARM BONE AT ELBOW 24670 $552.00 CLOSED TREATMENT OF BROKEN ANKLE 27780 $523.00 CLOSED TREATMENT OF BROKEN ANKLE 27786 $832.00 CLOSED TREATMENT OF BROKEN ANKLE 27760 $832.00 CLOSED TREATMENT OF BROKEN ANKLE 27767 $453.00 CLOSED TREATMENT OF BROKEN ANKLE 27808 $832.00 CLOSED TREATMENT OF BROKEN ANKLE 27816 $523.00 CLOSED TREATMENT OF BROKEN ANKLE JOINT BONE 28430 $570.00 CLOSED TREATMENT OF BROKEN ANKLE JOINT BONE WITH M 28435 $1,929.00 CLOSED TREATMENT OF BROKEN ANKLE WITH MANIPULATION 27818 $1,839.00 CLOSED TREATMENT OF BROKEN ANKLE WITH MANIPULATION 27762 $3,023.00 CLOSED TREATMENT OF BROKEN ANKLE WITH MANIPULATION 27781 $3,838.00 CLOSED TREATMENT OF BROKEN ANKLE WITH MANIPULATION 27788 $795.00 CLOSED TREATMENT OF BROKEN ANKLE WITH MANIPULATION 27810 $1,893.00 CLOSED TREATMENT OF BROKEN CHEST BONE 21820 $462.00 CLOSED TREATMENT OF BROKEN EYE SOCKET BONE 21400 $939.00 CLOSED TREATMENT OF BROKEN FINGER OR THUMB WITH MA 26755 $699.00 CLOSED TREATMENT OF BROKEN FINGER OR THUMB WITH MA 26725 $786.00 CLOSED TREATMENT OF BROKEN FOOT BONE 28470 $570.00 CLOSED TREATMENT OF BROKEN FOOT BONE 28530 $380.00 CLOSED TREATMENT OF BROKEN FOREARM AND DISLOCATED 25520 $1,831.00 CLOSED TREATMENT OF BROKEN FOREARM AT WRIST BONE 25650 $366.00 CLOSED TREATMENT OF BROKEN FOREARM BONE 25500 $472.00 CLOSED TREATMENT OF BROKEN FOREARM BONE 25530 $472.00 CLOSED TREATMENT OF BROKEN FOREARM BONE AT ELBOW 24650 $465.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CLOSED TREATMENT OF BROKEN FOREARM BONE AT ELBOW W 24675 $2,129.00 CLOSED TREATMENT OF BROKEN FOREARM BONE WITH MANIP 25535 $1,398.00 CLOSED TREATMENT OF BROKEN FOREARM BONE WITH MANIP 25505 $1,613.00 CLOSED TREATMENT OF BROKEN FOREARM BONES 25600 $859.00 CLOSED TREATMENT OF BROKEN FOREARM BONES 25560 $472.00 CLOSED TREATMENT OF BROKEN FOREARM BONES WITH MANI 25565 $2,795.00 CLOSED TREATMENT OF BROKEN GREAT TOE 28490 $906.00 CLOSED TREATMENT OF BROKEN GREAT TOE WITH MANIPULA 28495 $821.00 CLOSED TREATMENT OF BROKEN HAND OR FINGER 26740 $682.00 CLOSED TREATMENT OF BROKEN HEEL BONE 28400 $906.00 CLOSED TREATMENT OF BROKEN JAW BONE 21450 $2,078.00 CLOSED TREATMENT OF BROKEN JAW OR CHEEK BONE 21440 $2,855.00 CLOSED TREATMENT OF BROKEN NASAL BONE 21310 $1,731.00 CLOSED TREATMENT OF BROKEN NASAL BONE 21315 $1,297.00 CLOSED TREATMENT OF BROKEN NASAL BONE WITH STABILI 21320 $2,322.00 CLOSED TREATMENT OF BROKEN OF UPPER ARM BONE AT SH 24577 $1,577.00 CLOSED TREATMENT OF BROKEN SHIN BONE 27750 $523.00 CLOSED TREATMENT OF BROKEN SHIN BONE WITH MANIPULA 27752 $3,620.00 CLOSED TREATMENT OF BROKEN SHIN BONES 27538 $761.00 CLOSED TREATMENT OF BROKEN TAILBONE 27200 $360.00 CLOSED TREATMENT OF BROKEN THIGH BONE 27246 $587.00 CLOSED TREATMENT OF BROKEN THIGH BONE 27501 $1,056.00 CLOSED TREATMENT OF BROKEN THIGH BONE 27508 $919.00 CLOSED TREATMENT OF BROKEN THIGH BONE WITH MANIPUL 27502 $1,402.00 CLOSED TREATMENT OF BROKEN TOE 28510 $604.00 CLOSED TREATMENT OF BROKEN TOE WITH MANIPULATION 28515 $423.00 CLOSED TREATMENT OF BROKEN UPPER ARM BONE AT SHOUL 24560 $480.00 CLOSED TREATMENT OF BROKEN UPPER ARM BONE AT SHOUL 24576 $497.00 CLOSED TREATMENT OF BROKEN UPPER ARM BONE WITH MAN 23605 $4,248.00 CLOSED TREATMENT OF BROKEN UPPER ARM BONE WITH MAN 24505 $1,681.00 CLOSED TREATMENT OF BROKEN WRIST BONE 25622 $753.00 CLOSED TREATMENT OF BROKEN WRIST BONE 25630 $753.00 CLOSED TREATMENT OF COLLAR BONE AND SHOULDER JOINT 23540 $329.00 CLOSED TREATMENT OF DISLOCATED FINGER JOINT WITH M 26770 $798.00 CLOSED TREATMENT OF DISLOCATED FOOT BONE 28630 $612.00 CLOSED TREATMENT OF DISLOCATED FOOT JOINT 28570 $510.00 CLOSED TREATMENT OF DISLOCATED FOOT JOINT 28600 $411.00 CLOSED TREATMENT OF DISLOCATED HAND BONE WITH MANI 26670 $725.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CLOSED TREATMENT OF DISLOCATED HAND JOINT WITH MAN 26700 $525.00 CLOSED TREATMENT OF DISLOCATED HIP PROSTHESIS 27265 $919.00 CLOSED TREATMENT OF DISLOCATED HIP PROSTHESIS UNDE 27266 $4,005.00 CLOSED TREATMENT OF DISLOCATED WRIST WITH MANIPULA 25675 $753.00 CLOSED TREATMENT OF DISLOCATED WRIST WITH MANIPULA 25660 $472.00 CLOSED TREATMENT OF DISLOCATION OF KNEE CAP 27560 $973.00 CLOSED TREATMENT OF DISLOCATION OF TOE JOINT 28660 $441.00 CLOSED TREATMENT OF FINGER TENDON 26432 $4,767.00 CLOSED TREATMENT OF FRACTURE AND/OR DISLOCATION OF 27197 $593.00 CLOSED TREATMENT OF FRACTURE BELOW NECK OF UPPER T 27238 $1,772.00 CLOSED TREATMENT OF FRACTURE HAND BONE 26600 $825.00 CLOSED TREATMENT OF FRACTURE OF BONE OF HAND WITH 26605 $832.00 CLOSED TREATMENT OF FRACTURE OF FOOT WITH MANIPULA 28475 $776.00 CLOSED TREATMENT OF FRACTURE OF LOWER WEIGHT BEARI 27825 $4,086.00 CLOSED TREATMENT OF FRACTURE OF LOWER WEIGHT BEARI 27824 $832.00 CLOSED TREATMENT OF FRACTURE OF SHIN BONE 27530 $717.00 CLOSED TREATMENT OF FRACTURE OF SHIN BONE WITH TRA 27532 $5,325.00 CLOSED TREATMENT OF FRACTURE OF UPPER ARM BONE AT 23620 $436.00 CLOSED TREATMENT OF GROWTH PLATE OR BROKEN UPPER A 24530 $585.00 CLOSED TREATMENT OF GROWTH PLATE OR BROKEN UPPER A 24535 $2,540.00 CLOSED TREATMENT OF GROWTH PLATE SEPARATION AT END 27516 $455.00 CLOSED TREATMENT OF HIP DISLOCATION UNDER ANESTHES 27252 $3,894.00 CLOSED TREATMENT OF HIP SOCKET FRACTURES 27220 $884.00 CLOSED TREATMENT OF JAW TEMPOROMANDIBULAR JOINT (T 21480 $466.00 CLOSED TREATMENT OF KNEE CAP FRACTURE 27520 $663.00 CLOSED TREATMENT OF KNEE DISLOCATION 27550 $662.00 CLOSED TREATMENT OF KNEE DISLOCATION UNDER ANESTHE 27552 $5,099.00 CLOSED TREATMENT OF KNEE JOINT DISLOCATION 27830 $523.00 CLOSED TREATMENT OF NASAL CARTILAGE DIVIDING NASAL 21337 $4,874.00 CLOSED TREATMENT OF SHOULDER BLADE FRACTURE 23570 $826.00 CLOSED TREATMENT OF SHOULDER DISLOCATION AND BROKE 23675 $2,042.00 CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANI 23655 $3,498.00 CLOSED TREATMENT OF SHOULDER DISLOCATION WITH MANI 23650 $619.00 CLOSED TREATMENT OF THIGH BONE FRACTURE 27500 $1,005.00 CLOSED TREATMENT OF THUMB DISLOCATION WITH MANIPUL 26641 $1,023.00 CLOSED TREATMENT OF UPPER ARM FRACTURE 23600 $346.00 CLOSED TREATMENT OF UPPER ARM FRACTURE 24500 $551.00 CLOSED TREATMENT OF UPPER THIGH BONE FRACTURE 27230 $583.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CLOSED TREATMENT SHOULDER DISLOCATION AND BROKEN O 23665 $1,432.00 CLOSURE OF PERMANENT WINDPIPE OPENING OR ABNORMAL 31820 $8,408.00 CLOSURE OF SKIN OPENING TO STOMACH 43870 $8,521.00 CLOTRIMAZOLE 1 % CREA 14.17 G TUBE $18.50 CLOTRIMAZOLE 1 % CREA 45 G TUBE/KIT $42.05 CLOTRIMAZOLE 10 MG TROC 70 EACH BOTTLE $11.25 CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE $119.70 CLOTTING FACTOR IX (PTC OR CHRISTMAS) MEASUREMENT 85250 $434.00 CLOTTING FACTOR VII (PROCONVERTIN, STABLE FACTOR) 85230 $321.00 CLOTTING FACTOR VIII (AHG) MEASUREMENT 85240 $382.00 CLOTTING FACTOR VIII (VW FACTOR) ANTIGEN 85246 $256.00 CLOTTING FACTOR VIII (VW FACTOR) MEASUREMENT 85245 $292.00 CLOTTING FACTOR X ASSESSMENT TEST 85612 $73.00 CLOTTING FACTOR X ASSESSMENT TEST 85613 $175.00 CLOTTING FACTOR XI (PTA) MEASUREMENT 85270 $325.00 CLOTTING FACTOR XII (HAGEMAN) MEASUREMENT 85280 $301.00 CLOVE OIL (BULK) OIL 3.5 ML BOTTLE $3.06 CLOZAPINE 100 MG TAB 100 EACH BLIST PACK S0136 $12.00 CLOZAPINE 25 MG TAB 100 EACH BLIST PACK S0136 $4.63 CLOZAPINE LEVEL 80159 $240.00 CMV AB,IGM 86645 $219.00 COAGULATION ASSESSMENT BLOOD TEST 85732 $144.00 COAGULATION FUNCTION MEASUREMENT 85379 $138.00 COAGULATION FUNCTION MEASUREMENT 85380 $77.00 COAGULATION TIME MEASUREMENT 85348 $28.00 COAL TAR 0.5 % SHAM 130 ML BOTTLE $21.84 COCAINE DEFINITIVE ASSAY, URINE 80353 $207.00 CODEINE 30 MG TAB 100 EACH BLIST PACK $2.41 COLCHICINE 0.6 MG CAP 1 EACH BLIST PACK $23.36 COLCHICINE 0.6 MG CAP 100 EACH BOTTLE $22.88 COLCHICINE 0.6 MG TAB 100 EACH BOTTLE $28.47 COLISTIMETHATE 150 MG SOLR 1 EACH VIAL J0770 $38.73 COLLAGEN CROSS LINKS TEST, (URINE TEST TO EVALUATE 82523 $203.00 COLLAGENASE 250 UNIT/GRAM OINT 30 G TUBE $995.40 COLLECTION BLOOD SPECIMEN FROM COMPLETELY IMPLANTA 36591 $147.00 COLLECTION OF BLOOD SPECIMEN FROM CENTRAL OR PERIP 36592 $193.00 COLLECTION OF STEM CELLS FOR TRANSPLANTATION 38206 $6,310.00 COLORECTAL CANCER SCREENING HIGH RISK 45378 $3,678.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge COMMUNITY OR WORK REINTEGRATION TRAINING, EACH 15 97537 $122.00 COMPLEMENT C-4 86160 $259.00 COMPLEMENT C-5 86160 $259.00 COMPLETE BLOOD CELL COUNT AUTOMATED TEST 85025 $213.00 COMPLETE BLOOD CELL COUNT AUTOMATED TEST 85027 $143.00 COMPLEX CONTROL OF NOSE BLEED 30903 $503.00 COMPOUNDING VEHICLE SYRUP NO15 SYRP 1 ML BOTTLE $2.21 COMPREHENSIVE SURGICAL PATHOLOGY CONSULTATION AND 88325 $262.00 COMPUTED TOMOGRAPHY OF BRAIN BLOOD FLOW VOLUME & T 0042T $3,025.00 CONCENTRATION OF SPECIMEN FOR INFECTIOUS AGENTS 87015 $95.00 CONE BIOPSY OF THE CERVIX AND VAGINA USING AN ENDO 57461 $4,220.00 CONFIRMATION TEST FOR ANTIBODY TO HUMAN T-CELL LYM 86689 $355.00 CONJUGATED ESTROGENS 0.625 MG/GRAM CREA 30 G TUBE/ $1,568.91 CONJUGATED ESTROGENS 25 MG SOLR 1 EACH VIAL J1410 $1,246.56 CONNECTION OF TUBE GRAFT TO VEIN AND ARTERY FOR DI 36830 $17,080.00 CONNECTIVE TISSUE HUMAN C1762 $7,401.00 CONTINUOUS MONITORING OF NERVOUS SYSTEM DURING OPE 95940 $163.00 CONTINUOUS MONITORING OF NERVOUS SYSTEM DURING OPE 95941 $114.00 CONTRAST INJECTION FOR X-RAY IMAGING PROCEDURE TO 36598 $625.00 CONTRAST INJECTS X-RAY IMAGING THRU EXIST TUBE STO 49465 $2,153.00 CONTROL OF ANAL BLEEDING USING AN ENDOSCOPE 46614 $1,935.00 CONTROL OF BLEEDING IN LARGE BOWEL USING AN ENDOSC 45334 $1,649.00 CONTROL OF BLEEDING IN LARGE BOWEL USING AN ENDOSC 45382 $4,517.00 CONTROL OF BLEEDING IN RECTUM AND LARGE BOWEL USIN 45317 $1,060.00 CONTROL OF BLEEDING IN SMALL BOWEL USING AN ENDOSC 44366 $4,153.00 CONTROL OF BLEEDING OF ESOPHAGUS STOMACH AND/OR UP 43255 $3,432.00 CONTROL OF BLEEDING OF THROAT 42960 $942.00 CONTROL OF BLEEDING OF THROAT WITH INSERTION OF PA 42972 $4,736.00 CONTROL OF NOSE BLEED AND INSERTION OF PACKING 30905 $900.00 CONVERSION OF STOMACH TUBE TO SMALL BOWEL TUBE 49446 $2,436.00 CONVERSION TO TWO CHAMBER PACEMAKER SYSTEM 33214 $17,864.00 CONVERT EXTERNAL BILIARY DRAIN CATH TO INTERNAL-EX 47535 $6,955.00 CONVERT STOMACH TUBE TO SMALL BOWEL TUBE (ACCESSED 44373 $1,526.00 COPPER INTRAUTERINE DEVICE (IUD) 380 SQUARE MM IUD J7300 $3,395.70 COPPER LEVEL 82525 $212.00 COPPER-COPPER 82525 $212.00 COPPER-URINE 82525 $212.00 CORN STARCH PACK 1 EACH PACKET $1.06 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CORN STARCH POWD 15 OZ $8.40 CORTISOL (HORMONE) MEASUREMENT 82533 $326.00 CORTISOL (HORMONE) MEASUREMENT 82530 $250.00 CORTISOL PM 82533 $326.00 CORTISOL, TOTAL, SERUM 82533 $326.00 CORTISONE 25 MG TAB 100 EACH BOTTLE $5.47 COSYNTROPIN 0.25 MG SOLR 1 EACH VIAL J0834 $447.64 COUNSELING VISIT FOR LUNG CANCER SCREENING G0296 $332.00 COXSACKIE A VIRUS 86658 $172.00 C-PEPTIDE (PROTEIN) LEVEL 84681 $139.00 CREATE OPENINGS IN IRIS FOR EYE FLUID DRAIN USING 66762 $1,862.00 CREATINE KINASE (CARDIAC ENZYME) LEVEL 82550 $121.00 CREATINE KINASE (CARDIAC ENZYME) LEVEL 82553 $202.00 CREATINE KINASE (CARDIAC ENZYME) LEVEL 82552 $206.00 CREATINE KINASE (CARDIAC ENZYME) LEVEL 82554 $97.00 CREATINE MEASUREMENT 82540 $39.00 CREATININE CLEARANCE MEASUREMENT TO TEST FOR KIDNE 82575 $203.00 CREATININE LEVEL TO TEST FOR KIDNEY FUNCTION OR MU 82570 $103.00 CREATININE, BODY FLD 82570 $103.00 CREATININE, URINE 24 HR 82570 $103.00 CREATION OF BLOOD FLOW TRACT FROM PENIS TO GROIN V 54420 $6,826.00 CREATION OF DRAINAGE TRACT FOR FEMALE GENITAL GLAN 56440 $3,703.00 CREATION OF DRAINAGE TRACT FOR SPINAL FLUID 62180 $7,873.00 CREATION OF MULTIPLE TISSUE SKIN GRAFT 15760 $3,861.00 CREATION OF PERMANENT EYELID MARGIN SCARRING 67880 $4,284.00 CREATION OF SKIN AND TISSUE GRAFT 15740 $3,485.00 CREATION OF STOMACH FEEDING TUBE USING AN ENDOSCOP 43653 $5,801.00 CREATION OF TRACT TO DRAIN SALIVARY GLAND CYST 42409 $5,019.00 CRITICAL CARE EACH ADDL 30 MINUTES 99292 $408.00 CRITICAL CARE FIRST 30-74 MINUTE 99291 $3,415.00 CROMOLYN 5.2 MG/SPRAY (4 %) SPRY 13 ML SQUEEZ BTL $50.73 CROMOLYN 5.2 MG/SPRAY (4 %) SPRY 26 ML SQUEEZ BTL $45.14 CROTALIDAE POLYVALENT IMMUNE FAB SOLR 1 EACH VIAL $26,863.20 CRRT DIALYSIS 90945 $1,936.00 CRUSHING OF STONE IN URINARY DUCT (URETER) USING A 52353 $9,836.00 CRYOFIBRINOGEN (PROTEIN) LEVEL 82585 $110.00 CRYOGLOBULIN (PROTEIN) MEASUREMENT 82595 $158.00 CRYPTOCOCCUS ANTIG, CSF 87327 $244.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CRYPTOSPORIDIUM AG EIA 87328 $129.00 CRYSTAL IDENTIFICATION FROM TISSUE OR BODY FLUID 89060 $95.00 C-SECTION / L&D OR LEVEL 1 EACH ADDITIONAL 15 MINU $331.00 C-SECTION / L&D OR LEVEL 1 FIRST 15 MINUTES $2,379.00 C-SECTION / L&D OR LEVEL 2 EACH ADDITIONAL 15 MINU $2,186.00 C-SECTION / L&D OR LEVEL 2 FIRST 15 MINUTES $7,563.00 C-SECTION / L&D OR LEVEL 3 EACH ADDITIONAL 15 MINU $3,585.00 C-SECTION / L&D OR LEVEL 3 FIRST 15 MINUTES $8,356.00 CSF CULT 87070 $211.00 CT ? REVENUE CODE 35X G0378 $90.00 CT SCAN ABDOMEN 74150 $3,264.00 CT SCAN ABDOMEN BEFORE AND AFTER CONTRAST 74170 $3,831.00 CT SCAN ABDOMEN WITH CONTRAST 74160 $3,286.00 CT SCAN CHEST 71250 $2,750.00 CT SCAN CHEST BEFORE AND AFTER CONTRAST 71270 $4,665.00 CT SCAN CHEST WITH CONTRAST 71260 $3,776.00 CT SCAN GUIDANCE FOR AND MONITORING OF TISSUE DEST 77013 $1,971.00 CT SCAN GUIDANCE FOR INSERTION OF RADIATION THERAP 77014 $380.00 CT SCAN GUIDANCE FOR STEREOTACTIC LOCALIZATION 77011 $3,051.00 CT SCAN HEAD OR BRAIN 70450 $2,431.00 CT SCAN HEAD OR BRAIN BEFORE AND AFTER CONTRAST 70470 $3,202.00 CT SCAN HEAD OR BRAIN WITH CONTRAST 70460 $2,909.00 CT SCAN LEG 73700 $2,351.00 CT SCAN LEG WITH CONTRAST INJECTION 73701 $2,956.00 CT SCAN LIMITED OR FOLLOW-UP STUDY 76380 $1,308.00 CT SCAN OF ABDOMEN AND PELVIS 74176 $2,928.00 CT SCAN OF ABDOMEN AND PELVIS BEFORE AND AFTER CON 74178 $3,044.00 CT SCAN OF ABDOMEN AND PELVIS WITH CONTRAST 74177 $2,965.00 CT SCAN OF ABDOMINAL AND PELVIC BLOOD VESSELS WITH 74174 $3,445.00 CT SCAN OF ABDOMINAL AORTA AND BOTH LEG ARTERIES W 75635 $3,944.00 CT SCAN OF ABDOMINAL BLOOD VESSELS WITH CONTRAST 74175 $3,719.00 CT SCAN OF ARM 73200 $1,715.00 CT SCAN OF ARM BEFORE AND AFTER CONTRAST 73202 $3,367.00 CT SCAN OF ARM BLOOD VESSELS WITH CONTRAST 73206 $2,169.00 CT SCAN OF ARM WITH CONTRAST 73201 $2,136.00 CT SCAN OF BLOOD VESSEL OF HEAD WITH CONTRAST 70496 $3,499.00 CT SCAN OF BLOOD VESSELS IN CHEST WITH CONTRAST 71275 $3,342.00 CT SCAN OF CONGENITAL HEART STRUCTURE DEFECT WITH 75573 $2,205.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CT SCAN OF CRANIAL CAVITY 70480 $1,996.00 CT SCAN OF CRANIAL CAVITY BEFORE AND AFTER CONTRAS 70482 $2,239.00 CT SCAN OF CRANIAL CAVITY WITH CONTRAST 70481 $2,118.00 CT SCAN OF FACE 70486 $2,060.00 CT SCAN OF FACE BEFORE AND AFTER CONTRAST 70488 $3,410.00 CT SCAN OF FACE WITH CONTRAST 70487 $1,825.00 CT SCAN OF HEART BLOOD VESSELS AND GRAFTS WITH CON 75574 $3,730.00 CT SCAN OF HEART STRUCTURE WITH CONTRAST 75572 $1,857.00 CT SCAN OF HEART WITH EVALUATION OF BLOOD VESSEL C 75571 $1,279.00 CT SCAN OF LEG BEFORE AND AFTER CONTRAST INJECTION 73702 $3,215.00 CT SCAN OF LOWER LEG BLOOD VESSELS WITH CONTRAST 73706 $2,363.00 CT SCAN OF LOWER SPINE 72131 $2,766.00 CT SCAN OF LOWER SPINE BEFORE AND AFTER CONTRAST 72133 $3,764.00 CT SCAN OF LOWER SPINE WITH CONTRAST 72132 $3,742.00 CT SCAN OF MIDDLE SPINE 72128 $2,815.00 CT SCAN OF MIDDLE SPINE BEFORE AND AFTER CONTRAST 72130 $2,256.00 CT SCAN OF MIDDLE SPINE WITH CONTRAST 72129 $3,152.00 CT SCAN OF NECK 70490 $2,532.00 CT SCAN OF NECK BEFORE AND AFTER CONTRAST 70492 $3,536.00 CT SCAN OF NECK BLOOD VESSELS WITH CONTRAST 70498 $2,348.00 CT SCAN OF NECK WITH CONTRAST 70491 $2,445.00 CT SCAN OF PELVIC BLOOD VESSELS WITH CONTRAST 72191 $3,502.00 CT SCAN OF PELVIS BEFORE AND AFTER CONTRAST 72194 $3,628.00 CT SCAN OF UPPER SPINE 72125 $2,574.00 CT SCAN OF UPPER SPINE BEFORE AND AFTER CONTRAST 72127 $3,724.00 CT SCAN OF UPPER SPINE WITH CONTRAST 72126 $3,205.00 CT SCAN PELVIS 72192 $2,186.00 CT SCAN PELVIS WITH CONTRAST 72193 $3,108.00 CULT BACT, EYE 87070 $211.00 CULT BACT, GENITAL 87070 $211.00 CULT BACT, THROAT 87070 $211.00 CULT BACT, TISSUE, AEROBIC 87070 $211.00 CULT BACT, WOUND, AEROBIC 87070 $211.00 CULT, GC SCREEN 87081 $186.00 CULT, STREP GRP B SCREEN 87081 $186.00 CULTURE AEROBIC ADD DEF EACH 87077 $100.00 CULTURE ANAEROBIC ADD DEF EACH 87076 $77.00 CULTURE FOR ACID-FAST BACILLI 87116 $230.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CULTURE FOR CHLAMYDIA 87110 $263.00 CULTURE FUNGUS DEFINITIVE ID MOLD 87107 $155.00 CULTURE STOOL AEROBIC ADDL PATHOGENS AND ID EACH 87046 $86.00 CULTURE, URINE EACH ISOLATE 87088 $119.00 CYANIDE MEASUREMENT 82600 $142.00 CYANOCOBALAMIN (VITAMIN B-12) 2,500 MCG SUBL 100 E $0.32 CYANOCOBALAMIN (VITAMIN B-12) LEVEL 82607 $206.00 CYANOCOBALAMIN (VITAMIN B-12) LEVEL 82608 $165.00 CYANOCOBALAMIN 1,000 MCG/ML SOLN 1 ML VIAL J3420 $2.91 CYANOCOBALAMIN 100 MCG TAB 1 EACH BLIST PACK $1.07 CYANOCOBALAMIN 1000 MCG TAB 100 EACH BOTTLE $0.58 CYANOCOBALAMIN 250 MCG TAB 1 EACH BLIST PACK $1.08 CYANOCOBALAMIN 250 MCG TAB 100 EACH BOTTLE $0.16 CYANOCOBALAMIN 250 MCG TAB 50 EACH BLIST PACK $1.08 CYCLOBENZAPRINE 10 MG TAB 100 EACH BLIST PACK $4.24 CYCLOPENTOLATE 0.5 % DROP 15 ML DROP BTL $319.57 CYCLOPENTOLATE 1 % DROP 15 ML DROP BTL $122.33 CYCLOPENTOLATE 1 % DROP 2 ML DROP BTL $51.70 CYCLOPENTOLATE 2 % DROP 2 ML DROP BTL $103.29 CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % DROP 2 ML DRO $116.89 CYCLOPHOSPHAMIDE 1 GRAM SOLR 1 EACH VIAL J9070 $2,884.21 CYCLOPHOSPHAMIDE 2 GRAM SOLR 1 EACH VIAL J9070 $5,768.46 CYCLOSPORINE 0.05 % DPET 30 EACH BLIST PACK $35.65 CYCLOSPORINE 25 MG CAP 30 EACH BOTTLE J7515 $11.64 CYCLOSPORINE LEVEL 80158 $354.00 CYCLOSPORINE MODIFIED 25 MG CAP 30 EACH BLIST PACK J7515 $8.97 CYPROHEPTADINE 2 MG/5 ML SYRP 473 ML BOTTLE $225.15 CYPROHEPTADINE 2 MG/5 ML SYRP 5 ML CUP $2.38 CYPROHEPTADINE 4 MG TAB 100 EACH BOTTLE $3.73 CYSTATIN C (ENZYME INHIBITOR) LEVEL 82610 $191.00 CYSTEINE (L-CYSTEINE) 50 MG/ML SOLN 10 ML VIAL $97.93 CYSTINE AND HOMOCYSTINE (AMINO ACIDS) ANALYSIS 82615 $67.00 CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) SOLN 20 M J9100 $15.47 CYTARABINE (PF)(20 MG/ML) 100 MG/5 ML (20 MG/ML) S J9100 $26.25 CYTOLOGY FL BRUSH 88104 $167.00 CYTOMEGALOVIRUS AB,IGG 86644 $197.00 D&C FOR DIAGNOSIS AND/OR THERAPY (NON-OBSTETRICAL) 58120 $3,384.00 DABIGATRAN ETEXILATE 150 MG CAP 60 EACH BLIST PACK $28.04 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DABIGATRAN ETEXILATE 75 MG CAP 60 EACH BLIST PACK $28.04 DACARBAZINE 200 MG SOLR 1 EACH VIAL J9130 $50.40 DACTINOMYCIN 0.5 MG SOLR 1 EACH VIAL J9120 $7,805.32 DALTEPARIN 2,500 ANTI-XA UNIT/0.2 ML SYRG 0.2 ML S J1645 $106.24 DALTEPARIN 5,000 ANTI-XA UNIT/0.2 ML SYRG 0.2 ML S J1645 $172.36 DANTROLENE 20 MG SOLR 1 EACH VIAL $387.80 DANTROLENE 25 MG CAP 100 EACH BOTTLE $3.74 DANTROLENE 25 MG CAP 30 EACH BLIST PACK $6.78 DAPSONE 100 MG TAB 30 EACH BLIST PACK $2.65 DAPTOMYCIN 500 MG SOLR 1 EACH VIAL J0878 $1,870.86 DAPTOMYCIN 500 MG SOLR 10 ML VIAL J0878 $1,869.00 DARATUMUMAB 20 MG/ML SOLN 20 ML VIAL J9145 $8,165.15 DARATUMUMAB 20 MG/ML SOLN 5 ML VIAL J9145 $2,041.27 DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML SYRG $3,250.80 DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/ML SOLN 1 M $3,251.50 DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/ML SOLN 1 M $6,501.60 DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/ML SOLN 1 ML $1,950.48 DARBEPOETIN ALFA-POLYSORBATE 25 MCG/ML SOLN 1 ML V $812.70 DARBEPOETIN ALFA-POLYSORBATE 40 MCG/ML SOLN 1 ML V $1,300.32 DARBEPOETIN ALFA-POLYSORBATE 500 MCG/ML SYRG 1 ML $4,876.20 DARK FIELD MICROSCOPIC EXAMINATION FOR ORGANISM 87164 $41.00 DARUNAVIR ETHANOLATE 600 MG TAB 60 EACH BOTTLE $110.65 DARUNAVIR ETHANOLATE 800 MG TAB 30 EACH BOTTLE $221.29 DARUNAVIR-COBICISTAT 800-150 MG-MG TAB 30 EACH BOT $252.93 DECITABINE 50 MG SOLR 1 EACH VIAL J0894 $6,826.89 DECLOTTING INFUSION OF IMPLANTED CENTRAL VENOUS AC 36593 $708.00 DECOMPRESSION OF LARGE BOWEL USING AN ENDOSCOPE 45393 $3,214.00 DEEP BIOPSY OF BONE USING NEEDLE OR TROCAR 20225 $2,107.00 DEEP BIOPSY OF MUSCLE 20205 $3,247.00 DEFEROXAMINE 500 MG SOLR 1 EACH VIAL J0895 $52.50 DEFEROXAMINE 500 MG SOLR 4 EACH VIAL J0895 $142.97 DEGARELIX 120 MG SOLR 2 EACH KIT J9155 $6,401.57 DEGARELIX 80 MG SOLR 1 EACH KIT J9155 $2,051.49 DEMECLOCYCLINE 150 MG TAB 100 EACH BLIST PACK $37.21 DEMECLOCYCLINE 300 MG TAB 50 EACH BLIST PACK $37.21 DEMONSTRATION EVALUATION OF PATIENT USE OF AEROSOL 94664 $117.00 DEMONSTRATION/EVALUATION MANUAL MANEUVERS CHEST WA 94667 $186.00 DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SOLN 1.7 ML VIA J0897 $9,591.71 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DENOSUMAB 60 MG/ML SYRG 1 ML SYRINGE J0897 $4,970.91 DENTAL PROPHYLAXIS CHILD D1120 $137.00 DEOXYCORTISOL, 11 (HORMONE) LEVEL 82634 $305.00 DESFLURANE 100 % LIQD 240 ML BOTTLE $672.84 DESIGN AND CONSTRUCTION OF DEVICE FOR RADIATION TH 77338 $1,063.00 DESIPRAMINE 25 MG TAB 100 EACH BOTTLE $7.02 DESMOPRESSIN 0.1 MG TAB 1 EACH BLIST PACK $5.29 DESMOPRESSIN 0.1 MG TAB 100 EACH BOTTLE $15.47 DESMOPRESSIN 0.1 MG TAB 30 EACH BLIST PACK $5.29 DESMOPRESSIN 0.2 MG TAB 1 EACH BLIST PACK $4.21 DESMOPRESSIN 0.2 MG TAB 30 EACH BLIST PACK $4.21 DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) SPRP 5 ML AER W $827.40 DESMOPRESSIN 4 MCG/ML SOLN 1 ML AMPUL J2597 $83.39 DESONIDE 0.05 % CREA 15 G TUBE $75.60 DESONIDE 0.05 % LOTN 59 ML BOTTLE $1,036.42 DESONIDE 0.05 % OINT 15 G TUBE $210.37 DESOXIMETASONE 0.25 % CREA 15 G TUBE $203.96 DESOXIMETASONE 0.25 % OINT 15 G TUBE $371.86 DESTRUCTION LOWER OR SACRAL SPINAL FACET JOINT NER 64635 $5,267.00 DESTRUCTION LOWER OR SACRAL SPINAL FACET JOINT NER 64636 $3,117.00 DESTRUCTION OF 1 OR MORE BONE GROWTHS ACCESSED THR 20982 $11,530.00 DESTRUCTION OF 1 OR MORE GROWTHS IN LIVER, ACCESSE 47382 $11,253.00 DESTRUCTION OF 1 OR MORE GROWTHS IN ONE KIDNEY, AC 50592 $11,727.00 DESTRUCTION OF 15 OR MORE SKIN GROWTHS 17004 $913.00 DESTRUCTION OF 15 OR MORE SKIN GROWTHS 17111 $358.00 DESTRUCTION OF 2-14 SKIN GROWTHS 17003 $130.00 DESTRUCTION OF ANAL GROWTHS USING ELECTRIC CURRENT 46910 $4,086.00 DESTRUCTION OF ANAL POLYPS OR GROWTHS USING AN END 46615 $3,850.00 DESTRUCTION OF EXTERNAL FEMALE GENITAL GROWTHS 56501 $2,261.00 DESTRUCTION OF GROWTHS IN ONE KIDNEY, ACCESSED THR 50593 $11,843.00 DESTRUCTION OF GROWTHS OF ESOPHAGUS USING AN ENDOS 43229 $5,661.00 DESTRUCTION OF GROWTHS ON ESOPHAGUS STOMACH AND/OR 43270 $3,024.00 DESTRUCTION OF INTERNAL ANAL HEMORRHOIDS 46930 $3,912.00 DESTRUCTION OF KIDNEY CYSTS USING AN ENDOSCOPE 50541 $11,378.00 DESTRUCTION OF KIDNEY GROWTHS USING AN ENDOSCOPE 50542 $17,186.00 DESTRUCTION OF LARGE BOWEL GROWTHS USING AN ENDOSC 45388 $3,292.00 DESTRUCTION OF LINING OF UTERUS USING ULTRASOUND G 58356 $8,741.00 DESTRUCTION OF MULTIPLE PENILE GROWTHS 54065 $3,601.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DESTRUCTION OF MULTIPLE VAGINAL GROWTHS 57065 $5,342.00 DESTRUCTION OF PERIPHERAL NERVE OR BRANCH 64640 $1,890.00 DESTRUCTION OF RECTAL GROWTH 45190 $4,955.00 DESTRUCTION OF SKIN GROWTH 17000 $280.00 DESTRUCTION OF SOFT TISSUE IN NASAL PASSAGES 30802 $3,365.00 DESTRUCTION OF STONE IN BILE OR PANCREATIC DUCT US 43265 $5,331.00 DESTRUCTION OF UP TO 14 SKIN GROWTHS 17110 $263.00 DESTRUCTION OF VAGINAL GROWTHS 57061 $5,309.00 DESTRUCTION TISSUE RT/LT UPPER HEART CHAMBER VIA C 93657 $16,281.00 DESTRUCTION UPPER OR MIDDLE SPINAL FACET JOINT NER 64633 $4,338.00 DESTRUCTION UPPER OR MIDDLE SPINAL FACET JOINT NER 64634 $943.00 DESVENLAFAXINE SUCCINATE 50 MG TB24 30 EACH BOTTLE $53.44 DESVENLAFAXINE SUCCINATE 50 MG TB24 90 EACH BOTTLE $53.44 DETECT INF AGT NUC ACID NOS 87798 $315.00 DETECTION BARTONELLA HENSELAE AND BARTONELLA QUINT 87471 $495.00 DETECTION OF INFECTIOUS AGENT ANTIBODY 86318 $107.00 DETECTION TEST FOR ADENOVIRUS 87809 $99.00 DETECTION TEST FOR ASPERGILLUS (FUNGUS) 87305 $341.00 DETECTION TEST FOR BACTERIA TOXIN (SHIGA-LIKE TOXI 87427 $123.00 DETECTION TEST FOR BARTONELLA HENSELAE AND BARTONE 87472 $353.00 DETECTION TEST FOR BORRELIA BURGDORFERI (BACTERIA) 87476 $540.00 DETECTION TEST FOR BORRELIA BURGDORFERI, (BACTERIA 87475 $165.00 DETECTION TEST FOR CANDIDA SPECIES (YEAST) 87482 $344.00 DETECTION TEST FOR CHLAMYDIA 87490 $165.00 DETECTION TEST FOR CHLAMYDIA 87491 $223.00 DETECTION TEST FOR CHLAMYDIA 87320 $99.00 DETECTION TEST FOR CHLAMYDIA 87492 $289.00 DETECTION TEST FOR CHLAMYDIA 87810 $99.00 DETECTION TEST FOR CHLAMYDIA PNEUMONIAE 87485 $165.00 DETECTION TEST FOR CHLAMYDIA PNEUMONIAE 87486 $75.00 DETECTION TEST FOR CHLAMYDIA PNEUMONIAE 87487 $353.00 DETECTION TEST FOR CLOSTRIDIUM DIFFICILE 87493 $282.00 DETECTION TEST FOR CLOSTRIDIUM DIFFICILE TOXIN A ( 87803 $99.00 DETECTION TEST FOR CLOSTRIDIUM DIFFICILE TOXINS (S 87324 $250.00 DETECTION TEST FOR CRYPTOCOCCUS NEOFORMANS (YEAST) 87327 $244.00 DETECTION TEST FOR CRYPTOSPORIDIUM (PARASITE) 87328 $129.00 DETECTION TEST FOR CRYPTOSPORIDIUM (PARASITE) 87272 $99.00 DETECTION TEST FOR CYTOMEGALOVIRUS 87332 $99.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DETECTION TEST FOR CYTOMEGALOVIRUS (CMV) 87495 $165.00 DETECTION TEST FOR CYTOMEGALOVIRUS (CMV) 87496 $410.00 DETECTION TEST FOR CYTOMEGALOVIRUS, QUANTIFICATION 87497 $617.00 DETECTION TEST FOR E. COLI, (ESCHERICHIA COLI 0157 87335 $99.00 DETECTION TEST FOR ENTAMOEBA HISTOLYTICA DISPAR GR 87336 $99.00 DETECTION TEST FOR ENTAMOEBA HISTOLYTICA GROUP (PA 87337 $145.00 DETECTION TEST FOR ENTEROVIRUS (INTESTINAL VIRUS) 87498 $525.00 DETECTION TEST FOR GARDNERELLA VAGINALIS (BACTERIA 87511 $289.00 DETECTION TEST FOR GARDNERELLA VAGINALIS (BACTERIA 87512 $282.00 DETECTION TEST FOR GIARDIA (INTESTINAL PARASITE) 87329 $99.00 DETECTION TEST FOR HELICOBACTER PYLORI (GI TRACT B 87339 $99.00 DETECTION TEST FOR HEPATITIS B SURFACE ANTIGEN 87340 $210.00 DETECTION TEST FOR HEPATITIS B SURFACE ANTIGEN 87341 $179.00 DETECTION TEST FOR HEPATITIS B VIRUS 87517 $564.00 DETECTION TEST FOR HEPATITIS B VIRUS 87516 $332.00 DETECTION TEST FOR HEPATITIS BE SURFACE ANTIGEN 87350 $126.00 DETECTION TEST FOR HEPATITIS C VIRUS 87520 $165.00 DETECTION TEST FOR HEPATITIS C VIRUS 87521 $500.00 DETECTION TEST FOR HEPATITIS G VIRUS 87527 $344.00 DETECTION TEST FOR HEPATITIS G VIRUS 87525 $165.00 DETECTION TEST FOR HERPES SIMPLEX VIRUS 87529 $391.00 DETECTION TEST FOR HERPES SIMPLEX VIRUS 87528 $165.00 DETECTION TEST FOR HERPES SIMPLEX VIRUS TYPE 1 87274 $121.00 DETECTION TEST FOR HERPES SIMPLEX VIRUS TYPE 2 87273 $127.00 DETECTION TEST FOR HISTOPLASMA CAPSULATUM (PARASIT 87385 $292.00 DETECTION TEST FOR HIV-1 AND HIV-2 87389 $211.00 DETECTION TEST FOR HIV-1 VIRUS 87534 $165.00 DETECTION TEST FOR HIV-1 VIRUS 87535 $514.00 DETECTION TEST FOR HIV-2 87391 $145.00 DETECTION TEST FOR HIV-2 VIRUS 87537 $165.00 DETECTION TEST FOR HIV-2 VIRUS 87538 $289.00 DETECTION TEST FOR HIV-2 VIRUS 87539 $353.00 DETECTION TEST FOR HUMAN PAPILLOMAVIRUS (HPV) 87624 $189.00 DETECTION TEST FOR HUMAN PAPILLOMAVIRUS (HPV) 87623 $231.00 DETECTION TEST FOR INFLUENZA A VIRUS 87276 $313.00 DETECTION TEST FOR INFLUENZA B VIRUS 87275 $313.00 DETECTION TEST FOR INFLUENZA VIRUS 87501 $424.00 DETECTION TEST FOR INFLUENZA VIRUS 87804 $121.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DETECTION TEST FOR LEGIONELLA PNEUMOPHILA (WATER B 87540 $165.00 DETECTION TEST FOR LEGIONELLA PNEUMOPHILA (WATER B 87542 $344.00 DETECTION TEST FOR MULTIPLE ORGANISMS 87800 $238.00 DETECTION TEST FOR MULTIPLE ORGANISMS 87801 $537.00 DETECTION TEST FOR MULTIPLE TYPES INFLUENZA VIRUS 87502 $407.00 DETECTION TEST FOR MULTIPLE TYPES OF RESPIRATORY V 87633 $1,246.00 DETECTION TEST FOR MYCOBACTERIA AVIUM-INTRACELLULA 87560 $165.00 DETECTION TEST FOR MYCOBACTERIA AVIUM-INTRACELLULA 87561 $214.00 DETECTION TEST FOR MYCOBACTERIA AVIUM-INTRACELLULA 87562 $353.00 DETECTION TEST FOR MYCOBACTERIA SPECIES (BACTERIA) 87550 $165.00 DETECTION TEST FOR MYCOBACTERIA SPECIES (BACTERIA) 87551 $289.00 DETECTION TEST FOR MYCOBACTERIA SPECIES (BACTERIA) 87552 $353.00 DETECTION TEST FOR MYCOBACTERIA TUBERCULOSIS (TB B 87556 $462.00 DETECTION TEST FOR MYCOBACTERIA TUBERCULOSIS (TB B 87557 $353.00 DETECTION TEST FOR MYCOBACTERIA TUBERCULOSIS (TB B 87555 $165.00 DETECTION TEST FOR MYCOPLASMA PNEUMONIAE (BACTERIA 87580 $165.00 DETECTION TEST FOR MYCOPLASMA PNEUMONIAE (BACTERIA 87581 $415.00 DETECTION TEST FOR NEISSERIA GONORRHOEAE (GONORRHO 87591 $206.00 DETECTION TEST FOR NEISSERIA GONORRHOEAE (GONORRHO 87590 $97.00 DETECTION TEST FOR NEISSERIA GONORRHOEAE (GONORRHO 87592 $353.00 DETECTION TEST FOR NEISSERIA GONORRHOEAE (GONORRHO 87850 $99.00 DETECTION TEST FOR ORGANISM 87299 $194.00 DETECTION TEST FOR PARAINFLUENZA VIRUS 87279 $313.00 DETECTION TEST FOR PNEUMOCYSTIS CARINII (RESPIRATO 87281 $228.00 DETECTION TEST FOR RESPIRATORY SYNCYTIAL VIRUS (RS 87280 $313.00 DETECTION TEST FOR STREP (STREPTOCOCCUS, GROUP A) 87430 $193.00 DETECTION TEST FOR STREP (STREPTOCOCCUS, GROUP A) 87650 $165.00 DETECTION TEST FOR STREP (STREPTOCOCCUS, GROUP A) 87651 $289.00 DETECTION TEST FOR STREP (STREPTOCOCCUS, GROUP A) 87652 $344.00 DETECTION TEST FOR TREPONEMA PALLIDUM (SYPHILIS OR 87285 $99.00 DETECTION TEST FOR TRICHOMONAS VAGINALIS (GENITAL 87661 $380.00 DETECTION TEST FOR VANCOMYCIN RESISTANCE STREP (VR 87500 $289.00 DETECTION TEST FOR VARICELLA (CHICKEN POX) ZOSTER 87290 $313.00 DETERMINATION OF LUNG VOLUMES USING GAS DILUTION O 94727 $205.00 DETERMINATION OF LUNG VOLUMES USING PLETHYSMOGRAPH 94726 $638.00 DEXA FOR FAT COMPOSITION 76499 $751.00 DEXAMETHASONE (STEROID) SUPPRESSION EVALUATION PAN 80420 $594.00 DEXAMETHASONE 0.1 % DROP 5 ML DROP BTL $204.42 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DEXAMETHASONE 0.5 MG TAB 100 EACH BLIST PACK J8540 $0.72 DEXAMETHASONE 0.5 MG TAB 100 EACH BOTTLE J8540 $0.48 DEXAMETHASONE 0.5 MG/5 ML SOLN 240 ML BOTTLE J8540 $1.75 DEXAMETHASONE 0.75 MG TAB 100 EACH BLIST PACK J8540 $0.93 DEXAMETHASONE 1 MG/ML DROP 30 ML DROP BTL J8540 $3.75 DEXAMETHASONE 1.5 MG TAB 100 EACH BLIST PACK J8540 $1.92 DEXAMETHASONE 10 MG/ML SOLN 1 ML VIAL J1100 $2.73 DEXAMETHASONE 4 MG TAB 100 EACH BLIST PACK J8540 $4.22 DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL J1100 $5.19 DEXAMETHASONE 4 MG/ML SOLN 5 ML VIAL J1100 $6.91 DEXAMETHASONE SODIUM PHOS (PF) 10 MG/ML SOLN 1 ML J1100 $8.82 DEXMEDETOMIDINE 100 MCG/ML SOLN 2 ML VIAL $176.40 DEXRAZOXANE HCL 500 MG SOLR 1 EACH VIAL J1190 $2,303.74 DEXROSE 5 % AND 0.45 % NACL WITH KCL 30 MEQ 30 MEQ J3480 $8.75 DEXTROAMPHETAMINE 5 MG TAB 100 EACH BOTTLE $10.15 DEXTROMETHORPHAN 30 MG/5 ML SU12 148 ML BOTTLE $0.87 DEXTROMETHORPHAN 30 MG/5 ML SU12 89 ML BOTTLE $1.06 DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML SYRP 5 $3.15 DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG TB12 40 EAC $2.19 DEXTROMETHORPHAN-QUINIDINE 20-10 MG CAP 60 EACH BO $76.86 DEXTROSE 10 % 10 % SOLP 1,000 ML BAG $2.80 DEXTROSE 10% SOLN 1,000 ML BAG $21.00 DEXTROSE 10% SOLN 250 ML BAG $20.13 DEXTROSE 10% SOLN 500 ML BAG $21.00 DEXTROSE 15 GRAM/59 ML LIQD 54 ML BOTTLE $5.29 DEXTROSE 15 GRAM/59 ML LIQD 59 ML BOTTLE $7.02 DEXTROSE 25 % SYRG 10 ML SYRINGE $87.76 DEXTROSE 40 % GEL 37.5 G TUBE $13.78 DEXTROSE 5 % AND 0.2 % NACL WITH KCL 20 MEQ 20 MEQ J3480 $17.50 DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE SOLP 1,000 J7042 $10.50 DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE SOLP 500 ML J7042 $19.25 DEXTROSE 5 % AND 0.45 % NACL WITH KCL 10 MEQ 10 ME J3480 $17.50 DEXTROSE 5 % AND 0.45 % NACL WITH KCL 20 MEQ 20 ME J3480 $5.25 DEXTROSE 5 % AND 0.45 % NACL WITH KCL 40 MEQ 40 ME J3480 $8.75 DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE SOLP 1,000 J7042 $5.25 DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE SOLP 500 M J7042 $8.75 DEXTROSE 5 % AND 0.9 % NACL WITH KCL 20 MEQ 20 MEQ J3480 $8.75 DEXTROSE 5 % AND SODIUM CHLORIDE 0.9% SOLP 1,000 M J7042 $1.75 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DEXTROSE 5 % AND SODIUM CHLORIDE 0.9% SOLP 500 ML J7042 $8.75 DEXTROSE 5 % PGBK 100 ML BAG ABCDE $21.00 DEXTROSE 5 % PGBK 50 ML BAG ABCDE $20.83 DEXTROSE 5 % SOLP 1,000 ML BAG J7070 $4.38 DEXTROSE 5 % SOLP 100 ML BAG ABCDE $24.50 DEXTROSE 5 % SOLP 250 ML BAG J7060 $14.00 DEXTROSE 5 % SOLP 250 ML FLEX CONT ABCDE $21.88 DEXTROSE 5 % SOLP 50 ML BAG ABCDE $60.00 DEXTROSE 5 % SOLP 500 ML BAG J7060 $7.00 DEXTROSE 5 % WITH KCL 20 MEQ 20 MEQ/L SOLP 1,000 M J3480 $38.50 DEXTROSE 5% LACTATED RINGERS SOLP 1,000 ML BAG J7121 $5.25 DEXTROSE 5% LACTATED RINGERS WITH KCL 20 MEQ 20 ME J3480 $21.00 DEXTROSE 50 % 50 % SOLP 50 ML VIAL $11.38 DEXTROSE 50 % SYRG 50 ML SYRINGE $16.80 DEXTROSE 70% SOLP 2,000 ML BAG $70.00 DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM GEL 31 G $15.62 DIAG COLONOSCOPY W/SPEC COLLECTION 45378 $3,678.00 DIAGNOSTIC ASPIRATION OF SPINAL DISC OR TISSUE, AC 62267 $1,733.00 DIAGNOSTIC CT SCAN OF LARGE BOWEL 74261 $1,960.00 DIAGNOSTIC EXAM GALLBLADDER PANCREATIC LIVER & BIL 0397T $3,560.00 DIAGNOSTIC EXAM OF BILE DUCTS USING ENDOSCOPE ACCE 47552 $5,325.00 DIAGNOSTIC EXAM OF ESOPHAGUS STOMACH/UPPER SMALL B 43235 $2,241.00 DIAGNOSTIC EXAM OF GALLBLADDER AND PANCREATIC LIVE 43260 $3,784.00 DIAGNOSTIC EXAM OF LARGE BOWEL 44388 $2,489.00 DIAGNOSTIC EXAM OF THE BLADDER AND BLADDER CANAL ( 52000 $2,871.00 DIAGNOSTIC EXAM OF VOICE BOX USING ENDOSCOPE WITH 31526 $1,949.00 DIAGNOSTIC EXAMINATION OF ANUS AND RECTUM UNDER AN 45990 $5,437.00 DIAGNOSTIC EXAMINATION OF ESOPHAGUS USING AN ENDOS 43200 $2,182.00 DIAGNOSTIC EXAMINATION OF ESOPHAGUS USING AN ENDOS 43191 $3,049.00 DIAGNOSTIC EXAMINATION OF ESOPHAGUS USING AN ENDOS 43197 $2,659.00 DIAGNOSTIC EXAMINATION OF LARGE BOWEL USING AN END 45330 $997.00 DIAGNOSTIC EXAMINATION OF LUNG AIRWAYS USING AN EN 31622 $1,888.00 DIAGNOSTIC EXAMINATION OF NASAL PASSAGES USING AN 31231 $1,261.00 DIAGNOSTIC EXAMINATION OF RECTUM AND LARGE BOWEL U 45300 $3,333.00 DIAGNOSTIC EXAMINATION OF SMALL BOWEL USING AN END 44376 $3,079.00 DIAGNOSTIC EXAMINATION OF THE ANUS USING AN ENDOSC 46600 $700.00 DIAGNOSTIC EXAMINATION OF UTERUS USING AN ENDOSCOP 58555 $3,417.00 DIAGNOSTIC EXAMINATION OF VOICE BOX USING AN ENDOS 31505 $375.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DIAGNOSTIC EXAMINATION OF VOICE BOX USING AN ENDOS 31525 $5,016.00 DIAGNOSTIC EXAMINATION OF VOICE BOX USING FLEXIBLE 31575 $826.00 DIAGNOSTIC EYE EXAMINATION UNDER GENERAL ANESTHESI 92018 $4,726.00 DIAGNOSTIC IMAGING OF RETINA 92227 $103.00 DIAGNOSTIC TEST FOR SLEEP DISORDER 95805 $3,583.00 DIATRIZOATE MEGLUMINE 30 % SOLN 300 ML BOTTLE Q9958 $232.05 DIATRIZOATE MEGLUMINE-SODIUM 66-10 % SOLN 120 ML B Q9963 $322.14 DIATRIZOATE MEGLUMINE-SODIUM 66-10 % SOLN 30 ML BO Q9963 $86.63 DIAZEPAM 10 MG TAB 1 EACH BLIST PACK $0.30 DIAZEPAM 10 MG TAB 100 EACH BLIST PACK $0.30 DIAZEPAM 2 MG TAB 1 EACH BLIST PACK $0.85 DIAZEPAM 2 MG TAB 100 EACH BLIST PACK $0.85 DIAZEPAM 2.5 MG KIT 1 EACH KIT $1,140.69 DIAZEPAM 5 MG TAB 1 EACH BLIST PACK $1.12 DIAZEPAM 5 MG TAB 100 EACH BLIST PACK $1.12 DIAZEPAM 5 MG TAB 100 EACH BOTTLE $0.70 DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) SOLN 5 ML CUP $3.22 DIAZEPAM 5 MG/ML SYRG 2 ML CARTRIDGE J3360 $28.72 DIAZEPAM 5-7.5-10 MG KIT 1 EACH KIT $1,415.96 DIAZOXIDE 50 MG/ML SUSP 30 ML BOTTLE $1,242.78 DICLOFENAC 0.1 % DROP 2.5 ML DROP BTL $156.70 DICLOFENAC 0.1 % DROP 5 ML DROP BTL $255.61 DICLOFENAC 25 MG TBEC 100 EACH BOTTLE $4.98 DICLOFENAC 50 MG TAB 100 EACH BOTTLE $9.66 DICLOFENAC 50 MG TBEC 100 EACH BLIST PACK $2.58 DICLOFENAC 50 MG TBEC 100 EACH BOTTLE $1.66 DICLOFENAC 75 MG TBEC 100 EACH BLIST PACK $0.76 DICLOFENAC 75 MG TBEC 60 EACH BOTTLE $1.34 DICLOFENAC SODIUM 1 % GEL 100 G TUBE $184.10 DICLOXACILLIN 250 MG CAP 100 EACH BOTTLE $4.82 DICYCLOMINE 10 MG CAP 1 EACH BLIST PACK $2.09 DICYCLOMINE 10 MG CAP 100 EACH BLIST PACK $2.09 DICYCLOMINE 10 MG CAP 100 EACH BOTTLE $0.92 DICYCLOMINE 10 MG/5 ML SOLN 473 ML BOTTLE $2.63 DICYCLOMINE 10 MG/5 ML SOLN 5 ML CUP $2.63 DICYCLOMINE 10 MG/ML SOLN 2 ML AMPUL J0500 $176.52 DICYCLOMINE 10 MG/ML SOLN 2 ML VIAL J0500 $85.31 DICYCLOMINE 20 MG TAB 100 EACH BLIST PACK $2.09 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DICYCLOMINE 20 MG TAB 100 EACH BOTTLE $1.24 DIGITAL ANALYSIS OF ELECTRICAL BRAIN WAVE ACTIVITY 95957 $1,236.00 DIGITAL TOMOGRAPHY OF BOTH BREASTS 77062 $177.00 DIGITAL TOMOGRAPHY OF ONE BREAST 77061 $144.00 DIGOXIN 0.125 MG TAB 1 EACH BLIST PACK $8.70 DIGOXIN 0.125 MG TAB 100 EACH BLIST PACK $8.70 DIGOXIN 0.25 MG TAB 100 EACH BLIST PACK $5.90 DIGOXIN 0.25 MG TAB 100 EACH BOTTLE $4.03 DIGOXIN 250 MCG/ML (0.25 MG/ML) SOLN 2 ML AMPUL J1160 $11.55 DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL J1162 $76,419.00 DIGOXIN LEVEL 80162 $137.00 DIGOXIN LEVEL 80163 $107.00 DILATION OF ANAL MUSCLE UNDER ANESTHESIA 45905 $3,702.00 DILATION OF BLADDER CANAL (URETHRA) USING AN ENDOS 52281 $3,461.00 DILATION OF ESOPHAGUS 43450 $2,033.00 DILATION OF ESOPHAGUS USING AN ENDOSCOPE 43213 $3,549.00 DILATION OF LARGE BOWEL STRICTURE USING AN ENDOSCO 45340 $1,531.00 DILATION OF NARROWING OF BLADDER CANAL 53605 $4,986.00 DILATION OF NARROWING OF BLADDER CANAL (URETHRA), 53620 $3,367.00 DILATION OF NARROWING OF BLADDER CANAL (URETHRA), 53600 $1,195.00 DILATION OF RECTAL SCAR TISSUE UNDER ANESTHESIA 45910 $4,005.00 DILATION OF RECTUM AND LARGE BOWEL USING AN ENDOSC 45303 $2,584.00 DILATION OF STOMACH OUTLET USING AN ENDOSCOPE 43245 $2,601.00 DILATION OF TEAR-DRAINAGE OPENING 68801 $739.00 DILATION OF THE VOICE BOX USING AN ENDOSCOPE 31528 $5,968.00 DILATION OF TISSUE AT UTERINE OPENING (CERVIX) 57800 $2,488.00 DILATION TO IMPROVE EYE FLUID FLOW 66174 $11,475.00 DILATION WITH INSERTION OF DEVICE OR STENT TO IMPR 66175 $8,526.00 DILTIAZEM 100 MG SOLR 1 EACH VIAL J3490 $84.54 DILTIAZEM 120 MG CDCR 100 EACH BOTTLE $3.98 DILTIAZEM 120 MG CP12 1 EACH BLIST PACK $11.41 DILTIAZEM 120 MG CP12 100 EACH BOTTLE $8.27 DILTIAZEM 120 MG CP24 1 EACH BLIST PACK $1.52 DILTIAZEM 120 MG CP24 100 EACH BLIST PACK $1.52 DILTIAZEM 120 MG CP24 30 EACH BOTTLE $4.28 DILTIAZEM 180 MG CP24 1 EACH BLIST PACK $1.19 DILTIAZEM 180 MG CP24 100 EACH BLIST PACK $6.32 DILTIAZEM 180 MG CP24 90 EACH BOTTLE $2.10 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DILTIAZEM 240 MG CP24 1 EACH BLIST PACK $1.41 DILTIAZEM 240 MG CP24 100 EACH BLIST PACK $1.41 DILTIAZEM 30 MG TAB 1 EACH BLIST PACK $1.57 DILTIAZEM 30 MG TAB 100 EACH BLIST PACK $1.57 DILTIAZEM 300 MG CP24 1 EACH BLIST PACK $4.03 DILTIAZEM 5 MG/ML SOLN 10 ML VIAL $1.67 DILTIAZEM 5 MG/ML SOLN 25 ML VIAL $1.39 DILTIAZEM 5 MG/ML SOLN 5 ML VIAL $2.61 DILTIAZEM 60 MG CP12 100 EACH BOTTLE $15.86 DILTIAZEM 60 MG TAB 1 EACH BLIST PACK $2.46 DILTIAZEM 60 MG TAB 100 EACH BLIST PACK $2.46 DILTIAZEM 90 MG CP12 1 EACH BLIST PACK $10.90 DILTIAZEM 90 MG TAB 1 EACH BLIST PACK $3.00 DIMENHYDRINATE 50 MG TAB 100 EACH BOTTLE $0.19 DIMETHYL SULFOXIDE 50 % SOLN 50 ML BOTTLE J1212 $2,387.88 DINOPROSTONE 10 MG INSR 1 EACH BOX $1,724.49 DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0 90700 $131.69 DIPHENHYDRAMINE 12.5 MG/5 ML ELIX 5 ML CUP Q0163 $4.56 DIPHENHYDRAMINE 12.5 MG/5 ML LIQD 473 ML BOTTLE Q0163 $19.95 DIPHENHYDRAMINE 25 MG CAP 100 EACH BLIST PACK Q0163 $0.44 DIPHENHYDRAMINE 50 MG CAP 100 EACH BLIST PACK Q0163 $1.01 DIPHENHYDRAMINE 50 MG/ML SOLN 1 ML VIAL J1200 $0.56 DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % CREA 28 G TUB $13.72 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TAB 100 EACH B $3.06 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5 ML LIQD 5 ML $24.50 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5 ML LIQD 60 M $294.00 DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5 90715 $173.00 DIPYRIDAMOLE 25 MG TAB 100 EACH BOTTLE $3.71 DIPYRIDAMOLE 75 MG TAB 100 EACH BOTTLE $8.00 DISOPYRAMIDE PHOSPHATE 100 MG CAP 100 EACH BOTTLE $10.00 DISOPYRAMIDE PHOSPHATE 150 MG CAP 100 EACH BOTTLE $7.88 DIVALPROEX 125 MG CDRS 100 EACH BLIST PACK $4.97 DIVALPROEX 250 MG TB24 1 EACH BLIST PACK $8.59 DIVALPROEX 250 MG TB24 100 EACH BLIST PACK $9.12 DIVALPROEX 250 MG TBEC 1 EACH BLIST PACK $3.76 DIVALPROEX 250 MG TBEC 100 EACH BLIST PACK $3.76 DIVALPROEX 500 MG TB24 1 EACH BLIST PACK $7.52 DIVALPROEX 500 MG TB24 80 EACH BLIST PACK $14.26 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DIVALPROEX 500 MG TBEC 1 EACH BLIST PACK $2.49 DIVALPROEX 500 MG TBEC 100 EACH BLIST PACK $2.49 DIVISION OF MUSCLE OF ANUS 46080 $5,953.00 DNA ANTIBODY NATIVE 86225 $164.00 DNA ON BLOCK 88182 $474.00 DNA TESTING FOR GENETIC DEFECTS 88271 $315.00 DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN 20 ML VI J1250 $24.78 DOBUTAMINE 250 MG/250 ML (1 MG/ML) SOLP 250 ML BAG J1250 $80.50 DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) SOLP 250 M J1250 $146.13 DOCETAXEL 20 MG/ML (1 ML) SOLN 1 ML VIAL J9171 $288.75 DOCETAXEL 80 MG/4 ML (20 MG/ML) SOLN 4 ML VIAL J9171 $1,155.00 DOCUSATE 50 MG/5 ML LIQD 10 ML BLIST PACK $1.23 DOCUSATE 50 MG/5 ML LIQD 10 ML CUP $1.12 DOCUSATE 50 MG/5 ML LIQD 473 ML BOTTLE $23.18 DOCUSATE CALCIUM 240 MG CAP 1 EACH BLIST PACK $1.24 DOCUSATE CALCIUM 240 MG CAP 100 EACH BOTTLE $0.32 DOCUSATE CALCIUM 240 MG CAP 50 EACH BLIST PACK $1.24 DOCUSATE SODIUM 100 MG CAP 100 EACH BLIST PACK $0.61 DOCUSATE SODIUM 100 MG CAP 100 EACH BOTTLE $0.21 DOCUSATE SODIUM 100 MG CAP 750 EACH BLIST PACK $0.13 DOCUSATE SODIUM 283 MG/5 ML ENEM 5 ML TUBE $8.16 DOFETILIDE 125 MCG CAP 60 EACH BOTTLE $29.97 DOFETILIDE 250 MCG CAP 60 EACH BOTTLE $14.99 DOLUTEGRAVIR 50 MG TAB 30 EACH BOTTLE $243.67 DONEPEZIL 23 MG TAB 30 EACH BOTTLE $39.75 DONEPEZIL 5 MG TAB 1 EACH BLIST PACK $2.72 DONEPEZIL 5 MG TAB 100 EACH BLIST PACK $27.26 DONNATAL 16.2-0.1037 -0.0194 MG/5 ML ELIX 480 ML B $5,974.08 DOPAMINE 200 MG/5 ML (40 MG/ML) SOLN 5 ML VIAL J1265 $11.17 DOPAMINE 400 MG/250 ML (1,600 MCG/ML) SOLN 250 ML J1265 $50.75 DOPPLER ULTRASOUND STUDY OF COLOR-DIRECTED HEART B 93325 $713.00 DOPPLER ULTRASOUND STUDY OF HEART BLOOD FLOW, VALV 93320 $961.00 DORZOLAMIDE 2 % DROP 10 ML DROP BTL $318.36 DORZOLAMIDE-TIMOLOL (PF) 2-0.5 % DPET 60 EACH BLIS $10.99 DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML DROP 10 ML DROP $430.50 DOXAPRAM 20 MG/ML SOLN 20 ML VIAL $193.90 DOXAZOSIN 1 MG TAB 100 EACH BLIST PACK $13.18 DOXAZOSIN 1 MG TAB 100 EACH BOTTLE $4.72 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DOXAZOSIN 4 MG TAB 100 EACH BLIST PACK $13.81 DOXAZOSIN 4 MG TAB 100 EACH BOTTLE $4.96 DOXEPIN 10 MG CAP 100 EACH BLIST PACK $2.24 DOXEPIN 25 MG CAP 100 EACH BOTTLE $2.88 DOXEPIN 50 MG CAP 100 EACH BLIST PACK $4.09 DOXEPIN 50 MG CAP 100 EACH BOTTLE $4.12 DOXORUBICIN 2 MG/ML SOLN 100 ML VIAL J9000 $591.50 DOXORUBICIN 50 MG SOLR 1 EACH VIAL J9000 $624.51 DOXORUBICIN LIPOSOME 2 MG/ML SUSP 10 ML VIAL Q2050 $4,930.10 DOXYCYCLINE 100 MG SOLR 1 EACH VIAL $110.59 DOXYCYCLINE 100 MG TAB 1 EACH BLIST PACK $9.36 DOXYCYCLINE 100 MG TAB 50 EACH BOTTLE $10.76 DOXYCYCLINE 50 MG CAP 1 EACH BLIST PACK $9.74 DOXYCYCLINE 50 MG CAP 50 EACH BLIST PACK $9.74 DOXYCYCLINE 50 MG CAP 50 EACH BOTTLE $5.04 DRAINAGE BSCESS CYST OR BLOOD ACCUMULATION UNDER T 41007 $7,065.00 DRAINAGE OF ABSCESS CYST OR BLOOD ACCUMULATION OF 41800 $408.00 DRAINAGE OF ABSCESS OR BLOOD ACCUMULATION AT UPPER 23930 $4,276.00 DRAINAGE OF ABSCESS OR BLOOD ACCUMULATION IN NASAL 30020 $1,963.00 DRAINAGE OF ABSCESS OR BLOOD ACCUMULATION IN NOSE 30000 $458.00 DRAINAGE OF ABSCESS OR BLOOD ACCUMULATION IN PELVI 26990 $5,705.00 DRAINAGE OF ABSCESS OR CYST OF SKENE'S GLANDS, MAL 53060 $3,952.00 DRAINAGE OF ABSCESS SIMPLE 10060 $482.00 DRAINAGE OF ABSCESS, CYST, OR BLOOD ACCUMULATION U 41005 $960.00 DRAINAGE OF ABSCESS, CYST, OR BLOOD ACCUMULATION U 41008 $4,505.00 DRAINAGE OF BLOOD OR FLUID ACCUMULATION 10140 $1,472.00 DRAINAGE OF CYST OF THE ESOPHAGUS STOMACH AND/OR U 43240 $2,999.00 DRAINAGE OF FINGER ABSCESS COMPLICATED 26011 $1,943.00 DRAINAGE OF FINGER ABSCESS SIMPLE 26010 $503.00 DRAINAGE OF FLUID FROM ABDOMINAL CAVITY 49082 $1,668.00 DRAINAGE OF FLUID FROM ABDOMINAL CAVITY USING IMAG 49083 $2,525.00 DRAINAGE OF FLUID-FILLED SAC (BURSA) OF UPPER ARM 23931 $1,570.00 DRAINAGE OF LYMPH NODE ABSCESS OR INFLAMMATION 38300 $3,960.00 DRAINAGE OF MULTIPLE ABSCESS 10061 $646.00 DRAINAGE OF RECTAL ABSCESS 45005 $3,288.00 DRAINAGE OF RECTAL ABSCESS 46040 $5,035.00 DRAINAGE OF RECTAL ABSCESS 46050 $2,552.00 DRAINAGE OF TAILBONE CYST COMPLICATED 10081 $1,398.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge DRAINAGE OF TAILBONE CYST SIMPLE 10080 $814.00 DRAINAGE OF TEAR-PRODUCING GLAND 68400 $2,762.00 DRAINAGE OF TONSIL ABSCESS 42700 $836.00 DRAINAGE OF WOUND INFECTION AFTER SURGERY 10180 $7,190.00 DRESSING CHANGE AND/OR REMOVAL BURN TISSUE (5% TO 16025 $198.00 DRESSING CHANGE AND/OR REMOVAL OF BURN TISSUE 16030 $935.00 DRESSING CHANGE AND/OR REMOVE BURN TISSUE (LESS TH 16020 $214.00 DRESSING CHANGE UNDER ANESTHESIA 15852 $4,327.00 DRONABINOL 2.5 MG CAP 100 EACH BLIST PACK Q0167 $20.63 DRONEDARONE 400 MG TAB 100 EACH BLIST PACK $46.09 DRONEDARONE 400 MG TAB 60 EACH BOTTLE $44.15 DRUG ABUSE SCREEN 80307 $249.00 DRUG ELUTING STENT C9601 $22,937.00 DRUG ELUTING STENT PLACEMENT C9600 $26,107.00 DRUG INFUSION DURING CARDIAC CATHETERIZATION 93463 $1,071.00 DRUG QUANT NOT ELSEWHERE SPEC 80299 $207.00 DRUG SCREEN URINE 80307 $331.00 DRUG SCREEN, ACETOMINOPHEN 80307 $198.00 DRUG SCREEN, SALICYLATES 80307 $198.00 DRUG SCREENING PREGABALIN 80366 $134.00 DRUGS OR SUBSTANCES MEASUREMENT 80375 $259.00 DRUGS OR SUBSTANCES MEASUREMENT 80377 $247.00 DS DNA ANTIBODY IGG BY IFA 86256 $203.00 DULOXETINE 20 MG CPDR 1 EACH BLIST PACK $28.58 DULOXETINE 20 MG CPDR 30 EACH BLIST PACK $13.48 DULOXETINE 30 MG CPDR 100 EACH BLIST PACK $13.07 DULOXETINE 30 MG CPDR 90 EACH BOTTLE $33.56 DURVALUMAB 50 MG/ML SOLN 10 ML VIAL J9173 $17,005.38 DURVALUMAB 50 MG/ML SOLN 2.4 ML VIAL J9173 $4,081.31 EAR CULTURE 87070 $211.00 EBV CAP IGG 86665 $147.00 EBV CAP IGM 86665 $129.00 EBV DNA PCR QT 87799 $568.00 EBV NUC AG 86664 $146.00 EBV-EARLY ANTIGEN 86663 $175.00 ECONAZOLE NITRATE 1 % CREA 15 G TUBE $380.63 ED VISIT, LVL 1 99281 $196.00 ED VISIT, LVL 2 99282 $555.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ED VISIT, LVL 3 99283 $918.00 ED VISIT, LVL 4 99284 $1,420.00 ED VISIT, LVL 5 99285 $2,137.00 EDUCATION AND TRAINING FOR PATIENT SELF-MANAGEMENT 98960 $159.00 EDUCATION TRAINING SESSION G0177 $280.00 EFAVIRENZ 600 MG TAB 30 EACH BOTTLE $137.29 EFAVIRENZ-EMTRICTABINE-TENOFOVIR 600-200-300 MG TA $400.06 ELECTRICAL STIMULATION UNATTENDED TO ONE OR MORE A 97014 $157.00 ELECTROLYTE-A SOLP 1,000 ML BAG $52.50 ELECTRON MICROSCOPY FOR DIAGNOSIS 88348 $1,067.00 ELECTRONIC ANALYSIS & PROGRAM IMPLANT CMPLX NEUROS 95972 $704.00 ELECTRONIC ANALYSIS & PROGRAM IMPLANT SMPL NEUROST 95971 $620.00 ELECTRONIC ANALYSIS AND REPROGRAMMING OF SPINAL CA 62368 $656.00 ELECTRONIC ANALYSIS IMPLANT BRAIN SPINAL CORD/PERI 95970 $267.00 ELECTRONIC ANALYSIS REPROGRAM AND REFILL OF SPINAL 62370 $1,031.00 ELECTRONIC ASSESSMENT OF BLADDER EMPTYING 51741 $381.00 ELOTUZUMAB 300 MG SOLR 1 EACH VIAL J9176 $7,799.96 ELOTUZUMAB 400 MG SOLR 1 EACH VIAL J9176 $10,399.87 ELVITEG-COB-EMTRI-TENOFO DISOP 150-150-200-300 MG $432.60 EMERGENCY DIALYSIS ESRD PATIENT 90935 $2,007.00 EMERGENT INSERTION BREATHING TUBE INTO WINDPIPE CA 31500 $806.00 EMERGENT SURGICAL OPENING OF WINDPIPE FOR INSERTIO 31605 $2,443.00 EMOLLIENT COMBINATION NO.108 LOTN 237 ML BOTTLE $7.47 EMPTY VIAL MISC 1 EACH VIAL $4.17 EMTRICITABINE-TENOFOVIR (TDF) 100-150 MG TAB 30 EA $234.61 EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG TAB 30 EA $246.11 EMTRICITABINE-TENOFOVIR ALAFEN 200-25 MG TAB 30 EA $246.11 ENALAPRIL 5 MG TAB 100 EACH BLIST PACK $5.40 ENALAPRIL 5 MG TAB 100 EACH BOTTLE $6.48 ENALAPRILAT 1.25 MG/ML SOLN 1 ML VIAL $8.40 ENALAPRILAT 1.25 MG/ML SOLN 2 ML VIAL $7.50 ENCEPHALITIS AB, ST LOUIS 86653 $83.00 ENDODONTIC THERAPY D3330 $1,016.00 ENDOMYSIAL AB 83516 $198.00 ENDOVASCULAR REPAIR DEPLOY AORTO-BIL-ILIAC ENDOGRA 34705 $4,551.00 ENDOVASCULAR REPAIR DEPLOY AORTO-UNI-ILIAC ENDOGRA 34703 $4,146.00 ENDOVASCULAR REPAIR DEPLOYMENT AORTO-UNI-ILIAC END 34704 $6,908.00 ENLARGEMENT OF EYELID MARGIN 67950 $5,215.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ENOXAPARIN 100 MG/ML SYRG 1 ML SYRINGE J1650 $347.70 ENOXAPARIN 30 MG/0.3 ML SYRG 0.3 ML SYRINGE J1650 $104.19 ENOXAPARIN 300 MG/3 ML SOLN 3 ML VIAL J1650 $1,041.95 ENOXAPARIN 40 MG/0.4 ML SYRG 0.4 ML SYRINGE J1650 $138.92 ENOXAPARIN 60 MG/0.6 ML SYRG 0.6 ML SYRINGE J1650 $208.63 ENOXAPARIN 80 MG/0.8 ML SYRG 0.8 ML SYRINGE J1650 $104.31 ENZYME ACTIVITY MEASUREMENT 82657 $431.00 EPHEDRINE 50 MG/ML SOLN 1 ML AMPUL $18.47 EPHEDRINE SULFATE 50 MG/ML SOLN 1 ML AMPUL $19.86 EPHEDRINE SULFATE 50 MG/ML SOLN 1 ML VIAL $20.69 EPINEPHRINE 0.1 MG/ML SYRG 10 ML SYRINGE J0171 $1.91 EPINEPHRINE 1 MG/ML (1 ML) SOLN 1 ML AMPUL J0171 $13.86 EPINEPHRINE 1 MG/ML (1 ML) SOLN 1 ML VIAL J0171 $18.85 EPINEPHRINE 1 MG/ML SOLN 30 ML BOTTLE $469.25 EPINEPHRINE 1 MG/ML SOLN 30 ML VIAL J0171 $8.77 EPOETIN ALFA 10,000 UNIT/ML SOLN 1 ML VIAL $696.36 EPOETIN ALFA 20,000 UNIT/ML SOLN 1 ML VIAL $1,392.72 EPOETIN ALFA 4,000 UNIT/ML SOLN 1 ML VIAL $278.54 EPOETIN ALFA 40,000 UNIT/ML SOLN 1 ML VIAL $4,489.80 EPOETIN ALFA-EPBX 10,000 UNIT/ML SOLN 1 ML VIAL $92.65 EPOETIN ALFA-EPBX 2,000 UNIT/ML SOLN 1 ML VIAL $92.65 EPOETIN ALFA-EPBX 3,000 UNIT/ML SOLN 1 ML VIAL $92.65 EPOETIN ALFA-EPBX 4,000 UNIT/ML SOLN 1 ML VIAL $92.65 EPOETIN ALFA-EPBX 40,000 UNIT/ML SOLN 1 ML VIAL $92.65 EPTIFIBATIDE 0.75 MG/ML SOLN 100 ML VIAL J1327 $1,260.00 EPTIFIBATIDE 2 MG/ML SOLN 10 ML VIAL J1327 $730.14 ERGOCALCIFEROL 50,000 UNIT CAP 100 EACH BOTTLE $6.90 ERGOCALCIFEROL 8,000 UNIT/ML DROP 60 ML BOTTLE $350.70 ERGOCALCIFEROL 8,000 UNIT/ML DROP 60 ML DROP BTL $350.70 ERIBULIN 1 MG/2 ML (0.5 MG/ML) SOLN 2 ML VIAL J9179 $4,569.60 ERTAPENEM 1 GRAM SOLR 1 EACH VIAL J1335 $540.33 ERY-OSMOT-FRAGIL 85555 $220.00 ERYTHROMYCIN 250 MG TAB 100 EACH BOTTLE $45.94 ERYTHROMYCIN 333 MG TBEC 100 EACH BOTTLE $29.21 ERYTHROMYCIN 400 MG/5 ML SUSR 100 ML BOTTLE $138.93 ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 1 G TUBE $30.44 ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 3.5 G TUBE $62.85 ERYTHROMYCIN 500 MG SOLR 1 EACH VIAL J1364 $312.49 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ERYTHROMYCIN BASE 250 MG TAB 100 EACH BOTTLE $48.74 ERYTHROMYCIN BASE 500 MG TAB 100 EACH BOTTLE $36.74 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML SUSR 100 M $1,418.90 ERYTHROPOIETIN (PROTEIN) LEVEL 82668 $230.00 ESCITALOPRAM OXALATE 10 MG TAB 100 EACH BLIST PACK $8.69 ESMOLOL 100 MG/10 ML (10 MG/ML) SOLN 10 ML VIAL $51.07 ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP 250 ML FLE $1,964.38 ESMOLOL IN STERILE WATER 2,500 MG/250 ML (10 MG/ML $739.38 ESOPHAGOSCOPY FLEXIBLE W/BLEEDING CONTROL 43227 $4,236.00 ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT VIS 99211 $150.00 ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT VIS 99212 $150.00 ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT VIS 99213 $150.00 ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT, VI 99214 $150.00 ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT, VI 99215 $150.00 ESTRADIOL 0.05 MG/24 HR PTWK 1 EACH BOX $77.35 ESTRADIOL 0.05 MG/24 HR PTWK 4 EACH BOX $77.35 ESTRADIOL 0.1 MG/24 HR PTWK 1 EACH BOX $77.35 ESTRADIOL 0.1 MG/24 HR PTWK 4 EACH BOX $77.35 ESTRADIOL 1 MG TAB 100 EACH BOTTLE $2.38 ESTRADIOL CYPIONATE 5 MG/ML OIL 5 ML VIAL J1000 $88.45 ESTRADIOL VALERATE 20 MG/ML OIL 5 ML VIAL J1380 $50.51 ESTRIOL (HORMONE) LEVEL 82677 $147.00 ESTROGEN ANALYSIS 82671 $443.00 ESTROGEN ANALYSIS 82672 $230.00 ESTROGEN RECEPTOR ANALYSIS 84233 $605.00 ESTROGENS (CONJUGATED) 0.3 MG TAB 100 EACH BOTTLE $22.49 ESTROGENS (CONJUGATED) 0.625 MG TAB 100 EACH BOTTL $22.49 ESTROGENS (CONJUGATED) 1.25 MG TAB 100 EACH BOTTLE $23.62 ESTROGENS (CONJUGATED)-METHYLTESTOSTERONE 1.25-2.5 $16.80 ESZOPICLONE 1 MG TAB 100 EACH BOTTLE $40.86 ESZOPICLONE 1 MG TAB 30 EACH BOTTLE $42.56 ETHAMBUTOL 400 MG TAB 100 EACH BLIST PACK $1.62 ETHOSUXIMIDE LEVEL 80168 $180.00 ETHYL CHLORIDE 100 % SPRA 103.5 ML SQUEEZ BTL $115.20 ETHYLENE GLYCOL (ANTIFREEZE) MEASUREMENT 82693 $210.00 ETIOCHOLANOLONE (TESTOSTERONE BYPRODUCT) LEVEL 82696 $195.00 ETOMIDATE 2 MG/ML SOLN 10 ML VIAL $26.11 ETONOGESTREL 68 MG IMPL 1 EACH PF APPLI J7307 $3,150.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL J9181 $39.80 ETOPOSIDE 20 MG/ML SOLN 50 ML VIAL J9181 $522.38 EUGLOBULIN LYSIS (CLOT DISSOLVING) MEASUREMENT 85360 $130.00 EVALUATION & INSERT CATHETERS REC PACING & ATTEMPT 93654 $50,682.00 EVALUATION & INSERT CATHETERS REC PACING & TREATME 93656 $55,271.00 EVALUATION & PRESCRIPTION SPEECH-GENERAT & ALTERN 92608 $69.00 EVALUATION AND INSERTION OF CATHETERS FOR CREATION 93653 $55,009.00 EVALUATION IMPLANTABLE DEFIBRILLATOR 93644 $3,462.00 EVALUATION OF ANTIMICROBIAL DRUG (ANTIBIOTIC, ANTI 87181 $182.00 EVALUATION OF ANTIMICROBIAL DRUG (ANTIBIOTIC, ANTI 87184 $139.00 EVALUATION OF ANTIMICROBIAL DRUG (ANTIBIOTIC, ANTI 87185 $40.00 EVALUATION OF ANTIMICROBIAL DRUG (ANTIBIOTIC, ANTI 87186 $188.00 EVALUATION OF ANTIMICROBIAL DRUG (ANTIBIOTIC, ANTI 87188 $170.00 EVALUATION OF DEFIBRILLATOR INCLUDING CONNECTION R 93289 $155.00 EVALUATION OF DEFIBRILLATOR WITH ANALYSIS, REVIEW, 93261 $144.00 EVALUATION OF FINE NEEDLE ASPIRATE 88172 $178.00 EVALUATION OF FINE NEEDLE ASPIRATE WITH INTERPRETA 88173 $275.00 EVALUATION OF HEARING FUNCTION BRAIN RESPONSES 92521 $295.00 EVALUATION OF HEART FUNCTION USING TILT TABLE 93660 $1,987.00 EVALUATION OF IMPLANTABLE HEART RECORDER SYSTEM 93291 $174.00 EVALUATION OF NON-CARDIAC CHEST PAIN USING ESOPHAG 91040 $1,353.00 EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLA 97167 $257.00 EVALUATION OF OCCUPATIONAL THERAPY TYPICALLY 30 MI 97165 $257.00 EVALUATION OF OCCUPATIONAL THERAPY TYPICALLY 45 MI 97166 $256.00 EVALUATION OF ORTHOTIC OR PROSTHETIC USE, EACH 15 97763 $136.00 EVALUATION OF PHYSICAL THERAPY TYPICALLY 20 MINUTE 97161 $324.00 EVALUATION OF PHYSICAL THERAPY TYPICALLY 30 MINUTE 97162 $322.00 EVALUATION OF PHYSICAL THERAPY TYPICALLY 45 MINUTE 97163 $323.00 EVALUATION OF SPECIMEN ENZYMES 88319 $504.00 EVALUATION OF SPEECH SOUND PRODUCTION 92522 $298.00 EVALUATION OF SWALLOWING FUNCTION 92610 $433.00 EVALUATION PARAMETERS SNGL/DUAL/MULT LD CARD-DEFIB 93290 $231.00 EVALUATION PARAMETERS SNGL/DUAL/MULT LD PACEMKR W/ 93288 $304.00 EVALUATION PATIENT W/PRESCRIPTION SPEECH-GENERAT & 92607 $651.00 EVALUATION SNGL/DUAL CHAMBER PACING CARD-DEFIB & G 93641 $1,654.00 EVALUATION SNGL/DUAL CHAMBER PACING CARD-DEFIB AT 93640 $3,046.00 EVALUATION SNGL/DUAL CHAMBER PACING CARD-DEFIB W/P 93642 $4,564.00 EVALUATION SPEECH SOUND PRODUCTION W/EVAL LANGUAGE 92523 $299.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge EVALUATION TEST & PROGRAM ADJUST IMPLANT PATIENT A 93285 $155.00 EVALUATION TEST & PROGRAM ADJUSTMENT PERMANENT MUL 93281 $174.00 EVALUATION TESTING & PROGRAM ADJUST PERMANENT SNGL 93279 $76.00 EVALUATION TESTING & PROGRAMMING ADJUST PERMANENT 93280 $90.00 EVALUATION TESTING AND PROGRAMMING ADJUSTMENT OF D 93282 $155.00 EVALUATION TESTING AND PROGRAMMING ADJUSTMENT OF D 93283 $155.00 EVALUATION TESTING AND PROGRAMMING ADJUSTMENT OF D 93284 $155.00 EVALUATION WEARABLE DEFIBRILLATOR SYSTEM INCLUDE C 93292 $155.00 EVEROLIMUS LEVEL 80169 $332.00 EXAM OF WINDPIPE & LUNG AIRWAYS THROUGH PERMANENT 31615 $2,242.00 EXAM WITH INJECTIONS OF CHEMICAL FOR DESTRUCTION O 52287 $5,109.00 EXAMINATION AND BIOPSY OF EXTERNAL FEMALE GENITALS 56821 $674.00 EXAMINATION OF CERVIX USING AN ENDOSCOPE WITH BIOP 58110 $534.00 EXAMINATION OF COMMON BILE AND/OR PANCREATIC DUCTS 43273 $5,110.00 EXAMINATION OF EXTERNAL FEMALE GENITALS USING AN E 56820 $544.00 EXAMINATION OF LUNG AIRWAYS USING AN ENDOSCOPE 31623 $2,178.00 EXAMINATION OF NASAL PASSAGE AND SINUS USING AN EN 31233 $1,500.00 EXAMINATION OF SMALL BOWEL USING AN ENDOSCOPE 44360 $2,195.00 EXAMINATION OF THE NOSE AND THROAT USING AN ENDOSC 92511 $479.00 EXAMINATION OF THE VAGINA AND CERVIX USING AN ENDO 57452 $684.00 EXAMINATION OF THE VAGINA USING AN ENDOSCOPE 57420 $654.00 EXAMINATION OF UTERUS WITH DESTRUCTION OF UTERINE 58563 $10,544.00 EXCHANGE BLOOD TRANSFUSION 36455 $1,024.00 EXCHANGE BLOOD TRANSFUSION, NEWBORN 36450 $1,036.00 EXCISION OF BLOOD CLOT AND/OR INFUS TO DISSOLVE BL 36904 $7,539.00 EXCISION OF BLOOD CLOT AND/OR INFUS TO DISSOLVE BL 36905 $9,079.00 EXCISION OF BLOOD CLOT AND/OR INFUS TO DISSOLVE BL 36906 $3,008.00 EXCISIONAL DESTRUCTION OF ANAL GROWTHS 46922 $4,095.00 EXCISIONAL DESTRUCTION OF PENILE GROWTHS 54060 $3,404.00 EXENATIDE 10 MCG/DOSE(250 MCG/ML) 2.4 ML PNIJ 2.4 $3,064.46 EXENATIDE 5 MCG/DOSE (250 MCG/ML) 1.2 ML PNIJ 1.2 $3,064.46 EXERCISE OR DRUG-INDUCED HEART AND BLOOD VESSEL ST 93017 $1,406.00 EXPLORATION DRAINAGE OR REMOVAL OF FOREIGN BODY OF 26075 $5,667.00 EXPLORATION OF PENETRATING WOUND OF ABDOMEN, FLANK 20102 $3,499.00 EXPLORATION OF PENETRATING WOUND OF ARM OR LEG 20103 $2,580.00 EXPLORATION OF PENETRATING WOUND OF CHEST 20101 $3,610.00 EXPLORATION OF PENETRATING WOUND OF NECK 20100 $460.00 EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY 26080 $3,185.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY 28024 $3,179.00 EXPOSURE OF SKIN SURFACE BY CREATION OF AN OPENING 29730 $313.00 EXTENDED RECOVERY $90.00 EXTERNAL SHOCK TO HEART TO REGULATE HEART BEAT 92960 $1,766.00 EXTRACTION ERUPTED TOOTH D7140 $3,014.00 EYE AND MEDICAL EXAMINATION FOR DIAGNOSIS AND TREA 92002 $381.00 EYE CHART TESTING OF VISUAL ACUITY OF BOTH EYES 99173 $93.00 EZETIMIBE 10 MG TAB 1 EACH BLIST PACK $43.39 EZETIMIBE 10 MG TAB 90 EACH BOTTLE $39.54 F-ACTIN SM MUSCLE AB IGG 83516 $226.00 FACTOR 8 INHIBITOR 85335 $403.00 FACTOR V ASSAY 85220 $339.00 FAMOTIDINE 20 MG TAB 100 EACH BLIST PACK $6.09 FAMOTIDINE 20 MG TAB 100 EACH BOTTLE $6.09 FAMOTIDINE 20 MG/2 ML SOLN 2 ML VIAL $1.66 FAT EMULSION 20% 20 % EMUL 1,000 ML BAG $67.38 FAT EMULSION 20% 20 % EMUL 100 ML BAG $282.63 FAT EMULSION 20% 20 % EMUL 250 ML BAG $173.25 FATTY ACIDS MEASUREMENT 82725 $179.00 FEBUXOSTAT 40 MG TAB 30 EACH BOTTLE $46.20 FELODIPINE 2.5 MG TB24 100 EACH BOTTLE $5.29 FELODIPINE 5 MG TB24 1 EACH BLIST PACK $2.64 FENOFIBRATE 145 MG TAB 1 EACH BLIST PACK $5.97 FENOFIBRATE 145 MG TAB 90 EACH BOTTLE $1.29 FENOFIBRATE 48 MG TAB 1 EACH BLIST PACK $6.69 FENOFIBRIC ACID (CHOLINE) 135 MG CPDR 90 EACH BOTT $18.67 FENOFIBRIC ACID (CHOLINE) 45 MG CPDR 90 EACH BOTTL $6.65 FENTANYL 12 MCG/HR PT72 5 EACH BOX $71.06 FENTANYL 25 MCG/HR PT72 1 EACH BOX $74.43 FENTANYL 25 MCG/HR PT72 5 EACH BOX $50.47 FENTANYL 50 MCG/HR PT72 1 EACH BOX $136.09 FENTANYL 50 MCG/HR PT72 5 EACH BOX $92.26 FENTANYL 50 MCG/ML SOLN 2 ML AMPUL J3010 $6.13 FENTANYL 50 MCG/ML SOLN 2 ML VIAL J3010 $5.29 FENTANYL 50 MCG/ML SOLN 20 ML VIAL J3010 $26.67 FENTANYL 50 MCG/ML SOLN 5 ML AMPUL J3010 $8.19 FENTANYL 50 MCG/ML SOLN 5 ML AMPULE J3010 $8.23 FENTANYL 50 MCG/ML SOLN 5 ML VIAL J3010 $7.95 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge FENTANYL 75 MCG/HR PT72 1 EACH BOX $207.57 FENTANYL 75 MCG/HR PT72 5 EACH BOX $207.57 FERRIC CARBOXYMALTOSE 50 IRON MG/ML SOLN 15 ML VIA J1439 $4,216.75 FERRIC GLUCONATE 62.5 MG/5 ML SOLN 5 ML VIAL J2916 $133.56 FERRITIN (BLOOD PROTEIN) LEVEL 82728 $161.00 FERROUS FUMARATE-VITAMIN C 200 MG (65 MG IRON)-25 $0.62 FERROUS GLUCONATE 324 MG (37.5 MG IRON) TAB 100 EA $0.25 FERROUS GLUCONATE 324 MG TAB 100 EACH BOTTLE $0.21 FERROUS SULFATE 15 MG IRON (75 MG)/ML DROP 50 ML D $37.45 FERROUS SULFATE 300 MG (60 MG IRON)/5 ML LIQD 5 ML $0.05 FERROUS SULFATE 325 (65 FE) MG TAB 100 EACH BLIST $0.23 FERROUS SULFATE 325 (65 FE) MG TAB 100 EACH BOTTLE $0.09 FERROUS SULFATE 325 (65 FE) MG TBEC 100 EACH BLIST $4.10 FERUMOXYTOL 510 MG/17 ML (30 MG/ML) SOLN 17 ML VIA Q0138 $3,484.32 FETAL CONTRACTION STRESS TEST 59020 $976.00 FETAL FIBRONECTIN (PROTEIN) ANALYSIS 82731 $492.00 FETAL HEMOGLOBIN/RED BLOOD CELLS MEASURE ASSESS FE 85460 $176.00 FETAL HEMOGLOBIN/RED BLOOD CELLS MEASURE ASSESS FE 85461 $123.00 FETAL LUNG MATURITY ASSESSMENT 83662 $156.00 FETAL LUNG MATURITY ASSESSMENT 83664 $139.00 FETAL NON-STRESS TEST 59025 $751.00 FEXOFENADINE 180 MG TAB 1 EACH BLIST PACK $1.39 FEXOFENADINE 180 MG TAB 100 EACH BLIST PACK $1.42 FEXOFENADINE 180 MG TAB 30 EACH BOTTLE $0.38 FEXOFENADINE 180 MG TAB 45 EACH BOTTLE $0.33 FEXOFENADINE 180 MG TAB 50 EACH BLIST PACK $1.39 FEXOFENADINE 60 MG TAB 1 EACH BLIST PACK $2.65 FEXOFENADINE 60 MG TAB 100 EACH BLIST PACK $2.65 FIBRINOGEN (FACTOR 1) ACTIVITY MEASUREMENT 85384 $173.00 FIDAXOMICIN 200 MG TAB 20 EACH BOTTLE $773.14 FINASTERIDE 5 MG TAB 1 EACH BLIST PACK $10.94 FINASTERIDE 5 MG TAB 100 EACH BLIST PACK $10.94 FINASTERIDE 5 MG TAB 90 EACH BOTTLE $10.90 FINE NEEDLE ASPIRATION 10021 $1,287.00 FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL 10010 $5,308.00 FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION 10007 $1,594.00 FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL 10008 $5,308.00 FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION 10005 $1,594.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL 10006 $432.00 FITTING AND INSERTION OF VAGINAL SUPPORT DEVICE 57160 $466.00 FITZGERALD FACTOR (CLOTTING FACTOR) MEASUREMENT 85293 $433.00 FLECAINIDE 100 MG TAB 1 EACH BLIST PACK $10.46 FLEX SIGMOIDOSCOPY W/ STENT INSERTION SIG COLON 45347 $5,506.00 FLOW CYTOMETRY TECHNIQUE FOR DNA OR CELL ANALYSIS 88182 $474.00 FLOW CYTOMETRY TECHNIQUE FOR DNA OR CELL ANALYSIS 88184 $289.00 FLOW CYTOMETRY TECHNIQUE FOR DNA OR CELL ANALYSIS 88185 $240.00 FLU VAC QS 2018(4 YR UP)CD(PF) 60 MCG (15 MCG X 4) 90674 $67.24 FLU VAC QS 2018-19(6-35MO)(PF) 30 MCG (7.5 MCG X 4 90685 $58.24 FLU VAC QS 2019(4 YR UP)CD(PF) 60 MCG (15 MCG X 4) 90674 $78.58 FLU VAC QV 2019(18YR UP)RC(PF) 180 MCG (45 MCG X 4 90682 $206.91 FLU VACC QS2019-20 6MOS UP(PF) 60 MCG (15 MCG X 4) 90686 $75.59 FLU VACC QUAD 2018-19(6MOS UP) 60 MCG (15 MCG X 4) $33.11 FLUCICLOVINE F18 10 MCI (370 MBQ) SOLN 1 EACH VIAL a9588 $35,367.50 FLUCONAZOLE 100 MG TAB 1 EACH BLIST PACK $16.68 FLUCONAZOLE 100 MG TAB 100 EACH BLIST PACK $3.93 FLUCONAZOLE 40 MG/ML SUSR 35 ML BOTTLE $439.41 FLUCONAZOLE IN 0.9% SODIUM CHLORIDE 200 ML FLEX CO J1450 $58.80 FLUCONAZOLE IN SODIUM CHLORIDE 200 MG/100 ML PGBK J1450 $37.80 FLUCONAZOLE IN SODIUM CHLORIDE 400 MG/200 ML PGBK J1450 $29.40 FLUDROCORTISONE 0.1 MG TAB 1 EACH BLIST PACK $2.80 FLUDROCORTISONE 0.1 MG TAB 100 EACH BLIST PACK $2.81 FLUDROCORTISONE 0.1 MG TAB 100 EACH BOTTLE $2.62 FLUDROCORTISONE 0.1 MG TAB 50 EACH BLIST PACK $2.80 FLUID COLLECTION DRAINAGE BY CATHETER ACCESSED THR 10030 $2,491.00 FLUID COLLECTION DRAINAGE BY CATHETER USING IMAGIN 49405 $4,106.00 FLUID COLLECTION DRAINAGE BY CATHETER USING IMAGIN 49406 $3,257.00 FLUMAZENIL 0.1 MG/ML SOLN 5 ML VIAL $11.38 FLUNISOLIDE 25 MCG (0.025 %) SPRY 25 ML SQUEEZ BTL $209.83 FLUOCINOLONE 0.01 % CREA 15 G TUBE $157.08 FLUOCINOLONE 0.01 % SOLN 60 ML BOTTLE $942.50 FLUOCINOLONE 0.025 % OINT 15 G TUBE $118.18 FLUOCINONIDE 0.05 % CREA 15 G TUBE $159.44 FLUOCINONIDE 0.05 % OINT 15 G TUBE $247.64 FLUOCINONIDE 0.05 % SOLN 60 ML BOTTLE $340.20 FLUOR NONIF AGT ANTI SCRN EA AB 86256 $203.00 FLUORESCEIN 0.6 MG STRP 300 EACH BOX $0.43 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge FLUORESCEIN 1 MG STRP 1 EACH PACKET $1.43 FLUORESCEIN 1 MG STRP 100 EACH BOX $1.43 FLUORESCEIN 500 MG/5 ML (10 %) SOLN 5 ML VIAL $97.09 FLUOROSCOPIC AND VIDEO RECORDED MOTION EVALUATION 92611 $440.00 FLUOROSCOPIC GUIDANCE FOR INJECTION INTO SPINE OR 77003 $900.00 FLUOROSCOPIC GUIDANCE FOR INSERTION OF NEEDLE 77002 $901.00 FLUOROSCOPIC GUIDE INSERTION REPLACE OR REMOVAL OF 77001 $789.00 FLUOROURACIL 5 GRAM/100 ML SOLN 100 ML BOTTLE J9190 $231.00 FLUOROURACIL 5 GRAM/100 ML SOLN 100 ML VIAL J9190 $140.00 FLUOROURACIL 500 MG/10 ML SOLN 10 ML VIAL J9190 $53.62 FLUOXETINE 10 MG CAP 100 EACH BLIST PACK $8.47 FLUOXETINE 20 MG CAP 1,000 EACH BOTTLE $9.15 FLUOXETINE 20 MG CAP 100 EACH BLIST PACK $8.69 FLUOXETINE 20 MG CAP 100 EACH BOTTLE $4.40 FLUOXETINE 20 MG/5 ML (4 MG/ML) SOLN 120 ML BOTTLE $0.88 FLUOXETINE 20 MG/5 ML (4 MG/ML) SOLN 5 ML CUP $11.97 FLUPHENAZINE 2.5 MG TAB 100 EACH BOTTLE $3.15 FLUPHENAZINE 2.5 MG/ML SOLN 10 ML VIAL J2680 $768.25 FLUPHENAZINE 5 MG TAB 1 EACH BLIST PACK $7.47 FLUPHENAZINE 5 MG TAB 100 EACH BLIST PACK $2.80 FLUPHENAZINE 5 MG TAB 100 EACH BOTTLE $4.27 FLUPHENAZINE DECANOATE 25 MG/ML SOLN 5 ML VIAL J2680 $50.82 FLURBIPROFEN 0.03 % DROP 2.5 ML DROP BTL $30.56 FLUTAMIDE 125 MG CAP 180 EACH BOTTLE $7.32 FLUTICASONE FUROATE-VILANTEROL 100-25 MCG/DOSE DSD $18.59 FLUTICASONE FUROATE-VILANTEROL 200-25 MCG/DOSE DSD $18.59 FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFAA 12 G $1,052.48 FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFAA 12 G $1,634.77 FLUTICASONE PROPIONATE 50 MCG/ACTUATION SPSN 16 G $263.42 FLUTICASONE PROPION-SALMETEROL 100-50 MCG/DOSE DSD $41.76 FLUTICASONE PROPION-SALMETEROL 250-50 MCG/DOSE DSD $41.76 FLUTICASONE PROPION-SALMETEROL 500-50 MCG/DOSE DSD $33.27 FLUVOXAMINE 50 MG TAB 100 EACH BOTTLE $4.50 FOLIC ACID 1 MG TAB 1 EACH BLIST PACK $1.26 FOLIC ACID 1 MG TAB 100 EACH BLIST PACK $0.67 FOLIC ACID 1 MG TAB 100 EACH BOTTLE $1.26 FOLIC ACID 5 MG/ML SOLN 10 ML VIAL $189.49 FOLIC ACID LEVEL 82746 $184.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge FOLIC ACID LEVEL 82747 $154.00 FOLLOW-UP OR LIMITED ULTRASOUND EXAMINATION OF HEA 93308 $976.00 FOLLOW-UP OR REPEAT ULTRASOUND OF FETAL HEART 76828 $227.00 FOLLOW-UP OR REPEAT ULTRASOUND OF FETAL HEART BLOO 76826 $773.00 FOLLOW-UP/LIMITED HEART DOPPLER US STUDY HEART BLO 93321 $424.00 FONDAPARINUX 2.5 MG/0.5 ML SYRG 0.5 ML SYRINGE J1652 $201.95 FOSAPREPITANT 150 MG SOLR 1 EACH VIAL J1453 $1,405.46 FOSFOMYCIN 3 GRAM PACK 1 EACH PACKET $333.41 FOSINOPRIL 10 MG TAB 90 EACH BOTTLE $7.08 FOSINOPRIL 20 MG TAB 90 EACH BOTTLE $7.08 FOSPHENYTOIN 100 MG PE/2 ML SOLN 2 ML VIAL Q2009 $12.85 FOSPHENYTOIN 500 MG PE/10 ML SOLN 10 ML VIAL Q2009 $105.00 FREE LIGHT CHAIN, SERUM 83883 $119.00 FRUCTOSAMINE-FRUCTOSAMINE 82985 $120.00 FTA/ABS 86780 $145.00 FULVESTRANT 250 MG/5 ML SYRG 5 ML SYRINGE J9395 $4,011.84 FUNGAL BLOOD CULTURE (MOLD OR YEAST) 87103 $270.00 FUNGAL CULTURE (MOLD OR YEAST) 87102 $202.00 FUNGAL CULTURE, YEAST 87106 $104.00 FUROSEMIDE 10 MG/ML SOLN 10 ML VIAL J1940 $4.83 FUROSEMIDE 10 MG/ML SOLN 2 ML VIAL J1940 $17.30 FUROSEMIDE 10 MG/ML SOLN 4 ML VIAL J1940 $6.07 FUROSEMIDE 10 MG/ML SOLN 60 ML BOTTLE $36.33 FUROSEMIDE 20 MG TAB 100 EACH BLIST PACK $1.80 FUROSEMIDE 20 MG TAB 100 EACH BOTTLE $0.25 FUROSEMIDE 40 MG TAB 1,000 EACH BOTTLE $0.56 FUROSEMIDE 40 MG TAB 100 EACH BLIST PACK $2.05 G6PD (ENZYME) LEVEL 82955 $173.00 GABAPENTIN 100 MG CAP 100 EACH BLIST PACK $2.42 GABAPENTIN 300 MG CAP 100 EACH BLIST PACK $0.23 GABAPENTIN 300 MG CAP 100 EACH BOTTLE $1.55 GABAPENTIN 400 MG CAP 100 EACH BLIST PACK $1.74 GABAPENTIN 400 MG CAP 100 EACH BOTTLE $1.40 GABAPENTIN LEVEL NON-BLOOD 80355 $165.00 GAD AB (GLTAMIC ACID DECRBXYLASE) 83519 $353.00 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) S A9577 $249.06 GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML (469.01 MG A9579 $522.90 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE (ENZYME) 82775 $305.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE SCREENING 82776 $69.00 GALECTIN-3 LEVEL 82777 $107.00 GAMMAGLOBULIN, IGA, QUANT 82784 $229.00 GAMMAGLOBULIN, IGG SUBCLASSES 82787 $294.00 GAMMAGLOBULIN, IGG, CSF 82784 $229.00 GAMMAGLOBULIN, IGG, QUANT 82784 $229.00 GAMMAGLOBULIN, IGM, QUANT 82784 $229.00 GANCICLOVIR 500 MG SOLR 1 EACH VIAL J1570 $408.53 GANCICLOVIR SODIUM 50 MG/ML SOLN 10 ML VIAL $252.00 GARDNERELLA NUCLEIC ACID PROBE DIRECT 87510 $127.00 GASTRIC ACID ANALYSIS 82930 $39.00 GASTRIN (GI TRACT HORMONE) LEVEL 82941 $184.00 GBM AB IGG 86255 $246.00 GEMCITABINE 1 GRAM SOLR 1 EACH VIAL J9201 $588.00 GEMCITABINE 200 MG SOLR 1 EACH VIAL J9201 $168.00 GEMFIBROZIL 600 MG TAB 1 EACH BLIST PACK $4.05 GEMFIBROZIL 600 MG TAB 100 EACH BLIST PACK $4.05 GEMFIBROZIL 600 MG TAB 60 EACH BOTTLE $6.76 GENE ANALYSIS (5, 10-METHYLENETETRAHYDROFOLATE RED 81291 $559.00 GENE ANALYSIS (ABL PROTO-ONCOGENE 1, NON-RECEPTOR 81170 $1,306.00 GENE ANALYSIS (ADENOMATOUS POLYPOSIS COLI) DUPLICA 81203 $906.00 GENE ANALYSIS (ADENOMATOUS POLYPOSIS COLI), FULL G 81201 $906.00 GENE ANALYSIS (ADENOMATOUS POLYPOSIS COLI), KNOWN 81202 $906.00 GENE ANALYSIS (BREAST CANCER 1 & 2) FULL SEQUENCE 81162 $11,007.00 GENE ANALYSIS (CALRETICULIN), COMMON VARIANTS 81219 $657.00 GENE ANALYSIS (COAGULATION FACTOR V) LEIDEN VARIAN 81241 $461.00 GENE ANALYSIS (CYSTIC FIBROSIS TRANSMEMBRANE CONDU 81220 $748.00 GENE ANALYSIS (CYTOCHROME P450 FAMILY 2 SUBFAMILY 81226 $1,092.00 GENE ANALYSIS (CYTOCHROME P450 FAMILY 2 SUBFAMILY 81225 $937.00 GENE ANALYSIS (CYTOCHROME P450 FAMILY 2 SUBFAMILY 81227 $639.00 GENE ANALYSIS (FRAGILE X MENTAL RETARDATION) ABNOR 81243 $1,092.00 GENE ANALYSIS (GAP JUNCTION PROTEIN BETA 2 26KDA C 81252 $1,186.00 GENE ANALYSIS (HEMOGLOBIN, SUBUNIT BETA) FOR COMMO 81361 $481.00 GENE ANALYSIS (HEXOSAMINIDASE A) COMMON VARIANTS 81255 $257.00 GENE ANALYSIS (JANUS KINASE 2) VARIANT 81270 $656.00 GENE ANALYSIS (MUTL HOMOLOG 1 COLON CANCER NONPOLY 81292 $2,563.00 GENE ANALYSIS (MUTL HOMOLOG 1 COLON CANCER NONPOLY 81294 $756.00 GENE ANALYSIS (MUTS HOMOLOG 2 COLON CANCER NONPOLY 81297 $602.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge GENE ANALYSIS (MUTS HOMOLOG 6 [E COLI]) DUPLICATIO 81300 $641.00 GENE ANALYSIS (PHOSPHATASE AND TENSIN HOMOLOG), FU 81321 $32.00 GENE ANALYSIS (PROTHROMBIN, COAGULATION FACTOR II) 81240 $461.00 GENE ANALYSIS COMMON DELETIONS OR VARIANT 81257 $510.00 GENE ANALYSIS COMMON VARIANTS 81254 $850.00 GENE ANALYSIS COMMON VARIANTS 81355 $215.00 GENE ANALYSIS DUPLICATION OR DELETION ANALYSIS 81324 $32.00 GENE ANALYSIS(SERP PEPTIDASE INHIB CLADE A ALPH1 A 81332 $415.00 GENE REARRANGEMENT ANALYSIS (IMMUNOGLOB HEAVY CHAI 81261 $708.00 GENE REARRANGEMENT ANALYSIS (IMMUNOGLOB KAPPA LT C 81264 $1,196.00 GENE REARRANGEMENT ANALYSIS DETECT ABN CLONAL POP( 81342 $874.00 GENERAL HEALTH PANEL 80050 $323.00 GENETIC TESTING 88275 $466.00 GENOME-WIDE MICROARRAY ANALYSIS COPY NUMBR & SNGL 81229 $5,957.00 GENTAMICIN (ANTIBIOTIC) LEVEL 80170 $239.00 GENTAMICIN 0.1 % CREA 15 G TUBE $172.83 GENTAMICIN 0.1 % OINT 15 G TUBE $172.83 GENTAMICIN 0.3 % (3 MG/GRAM) OINT 3.5 G TUBE $68.85 GENTAMICIN 0.3 % DROP 5 ML DROP BTL $149.98 GENTAMICIN 100 MG/100 ML PGBK 100 ML BAG J1580 $15.40 GENTAMICIN 40 MG/ML SOLN 2 ML VIAL J1580 $4.66 GENTAMICIN 60 MG/50 ML PGBK 50 ML BAG J1580 $13.83 GENTAMICIN 80 MG/100 ML PGBK 100 ML BAG J1580 $14.35 GENTAMICIN 80 MG/50 ML PGBK 50 ML BAG J1580 $14.70 GENTAMICIN SULFATE (PED) (PF) 10 MG/ML SOLN 2 ML V J1580 $16.55 GENTAMYCIN-PEAK 80170 $239.00 GENTAMYCIN-RANDOM 80170 $239.00 GENTAMYCIN-TROUGH 80170 $239.00 GENTIAN VIOLET 1 % SOLN 59 ML BOTTLE $26.85 GENTIAN VIOLET 2 % SOLN 59 ML BOTTLE $27.88 GGT (GLUTAMYLTRANSFERASE GAMMA) 82977 $154.00 GI COCKTAIL (MAALOX-PLUS, LIDOCAINE VISCOUS 2%, HY $71.75 GINGER (ZINGIBER OFFICINALIS) 250 MG CAP 60 EACH B $0.35 GLIADIN AB, IGA 83516 $221.00 GLIADIN AB, IGG 83516 $221.00 GLIMEPIRIDE 2 MG TAB 1 EACH BLIST PACK $4.31 GLIMEPIRIDE 2 MG TAB 100 EACH BLIST PACK $4.31 GLIMEPIRIDE 4 MG TAB 1 EACH BLIST PACK $2.15 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge GLIMEPIRIDE 4 MG TAB 100 EACH BLIST PACK $2.15 GLIPIZIDE 10 MG TAB 1 EACH BLIST PACK $2.65 GLIPIZIDE 10 MG TAB 100 EACH BLIST PACK $2.65 GLIPIZIDE 2.5 MG TR24 1 EACH BLIST PACK $4.17 GLIPIZIDE 2.5 MG TR24 30 EACH BLIST PACK $4.17 GLIPIZIDE 5 MG TAB 100 EACH BLIST PACK $1.31 GLIPIZIDE 5 MG TR24 100 EACH BLIST PACK $2.52 GLIPIZIDE 5 MG TR24 100 EACH BOTTLE $1.42 GLUCAGON (HORMONE) TOLERANCE PANEL TO EVALUATE FOR 80422 $380.00 GLUCAGON (HORMONE) TOLERANCE PANEL TO EVALUATE FOR 80424 $417.00 GLUCAGON (HUMAN RECOMBINANT) 1 MG/ML SOLR 1 EACH V J1610 $720.72 GLUCAGON (PANCREATIC HORMONE) LEVEL 82943 $249.00 GLUCAGON (PANCREATIC HORMONE) TOLERANCE TEST 82946 $96.00 GLUCAGON HCL 1 MG SOLR 1 EACH VIAL J1610 $358.05 GLUCOSE - 2HR PP 82947 $82.00 GLUCOSE TOLERANCE TEST (GTT) G0410 $275.00 GLUCOSE, FLUID 82945 $110.00 GLUCOSE, URINE 82945 $110.00 GLUTAMATE DEHYDROGENASE (ENZYME) MEASUREMENT 82965 $63.00 GLUTAMIC ACID DECARBOXY AB 83516 $226.00 GLUTATHIONE (PROTEIN) LEVEL 82978 $118.00 GLYBURIDE 2.5 MG TAB 100 EACH BLIST PACK $1.07 GLYBURIDE 5 MG TAB 1 EACH BLIST PACK $1.84 GLYBURIDE 5 MG TAB 100 EACH BLIST PACK $2.89 GLYBURIDE MICRONIZED 3 MG TAB 100 EACH BOTTLE $1.07 GLYBURIDE-METFORMIN 1.25-250 MG TAB 100 EACH BOTTL $3.10 GLYBURIDE-METFORMIN 5-500 MG TAB 100 EACH BOTTLE $3.70 GLYCATED PROTEIN LEVEL 82985 $120.00 GLYCERIN 99.5 % SOLN 177 ML BOTTLE $27.26 GLYCERIN ADULT SUPP 10 EACH BOX $2.73 GLYCERIN PEDIATRIC SUPP 12 EACH BOX $0.46 GLYCERIN PEDIATRIC SUPP 25 EACH BOX $1.53 GLYCERIN-DIMETHICONE-PETRO, WH CREA 453 G JAR $49.15 GLYCERIN-WITCH HAZEL 12.5-50 % PADM 40 EACH BOX $0.21 GLYCOPYRROLATE 0.5 MG/ML SOLN 1 ML VIAL $29.40 GLYCOPYRROLATE 1 MG TAB 1 EACH BLIST PACK $4.37 GLYCOPYRROLATE 1 MG TAB 100 EACH BLIST PACK $4.37 GLYCOPYRROLATE 1 MG TAB 100 EACH BOTTLE $4.60 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge GONADOTROPIN (REPRODUCTIVE HORMONE) ANALYSIS 84703 $224.00 GONADOTROPIN CHORIONIC QUANTITATIVE HCG 84702 $253.00 GONADOTROPIN RELEASING HORMONE (REPRODUCTIVE HORMO 80426 $1,224.00 GONADOTROPIN, CHORIONIC (REPRODUCTIVE HORMONE) MEA 84704 $125.00 GONADOTROPIN, FOLLICLE STIMULATING (REPRODUCTIVE H 83001 $326.00 GONADOTROPIN, LUTEINIZING (REPRODUCTIVE HORMONE) L 83002 $306.00 GRAM STAIN FOR CC 87205 $66.00 GREEN SOAP TINC 120 ML BOTTLE $12.29 GREEN SOAP TINC 3,840 ML BOTTLE $137.22 GROUP PREVENTIVE MEDICINE COUNSELING, APPROXIMATEL 99411 $19.00 GROUP PREVENTIVE MEDICINE COUNSELING, APPROXIMATEL 99412 $25.00 GROUP TREATMENT SPEECH LANGUAGE COMMUNICATION/HEAR 92508 $182.00 GROWTH HORMONE STIMULATION PANEL 80428 $551.00 GROWTH HORMONE SUPPRESSION PANEL 80430 $647.00 GUAIFENESIN 100 MG/5 ML LIQD 240 ML BOTTLE $0.07 GUAIFENESIN 100 MG/5 ML LIQD 5 ML CUP $1.05 GUAIFENESIN 600 MG TA12 1 EACH BLIST PACK $3.65 GUAIFENESIN 600 MG TA12 100 EACH BLIST PACK $3.65 GUAIFENESIN-CODEINE 10-100 MG/5 ML LIQD 5 ML CUP $1.14 GUANFACINE 1 MG TAB 1 EACH BLIST PACK $3.38 GUANFACINE 1 MG TAB 100 EACH BOTTLE $3.05 GUIDANCE FOR LOCALIZATION TARGET DELIVERY OF RADIA 77387 $445.00 HAEMOPHILUS B POLYSAC-TETANUS TOXOID (HIB) 10 MCG/ 90648 $70.72 HALOPERIDOL 0.5 MG TAB 100 EACH BLIST PACK $2.07 HALOPERIDOL 1 MG TAB 1 EACH BLIST PACK $1.72 HALOPERIDOL 1 MG TAB 100 EACH BLIST PACK $1.59 HALOPERIDOL 10 MG TAB 100 EACH BLIST PACK $6.28 HALOPERIDOL 2 MG TAB 1 EACH BLIST PACK $2.36 HALOPERIDOL 2 MG TAB 100 EACH BLIST PACK $2.36 HALOPERIDOL 2 MG TAB 100 EACH BOTTLE $2.21 HALOPERIDOL 2 MG/ML CONC 120 ML BOTTLE $189.84 HALOPERIDOL 5 MG TAB 100 EACH BLIST PACK $3.41 HALOPERIDOL 5 MG TAB 100 EACH BOTTLE $0.72 HALOPERIDOL DECANOATE 100 MG/ML SOLN 1 ML VIAL J1631 $42.00 HALOPERIDOL DECANOATE 50 MG/ML SOLN 1 ML AMPUL J1631 $182.85 HALOPERIDOL DECANOATE 50 MG/ML SOLN 1 ML VIAL J1631 $50.40 HALOPERIDOL LACTATE 5 MG/ML SOLN 1 ML AMPUL J1630 $10.32 HALOPERIDOL LACTATE 5 MG/ML SOLN 1 ML VIAL J1630 $2.69 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFE 99001 $62.00 HAPTOGLOBIN (SERUM PROTEIN) LEVEL 83010 $242.00 HAPTOGLOBIN (SERUM PROTEIN) MEASUREMENT 83012 $142.00 HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS 81269 $557.00 HC 3D TOMO BX 19499 $4,933.00 HC ADMINISTRATION OF HEPATITIS B VACCINE SUBSEQUEN 90472 $83.00 HC ADMINISTRATION OF PNEUMOCOCCAL VACCINE SUBSEQUE 90472 $83.00 HC ARUP BORRLIEA BURGDORFERI (LYME) NUCLEIC ACID P 87476 $541.00 HC ARUP IFE, TOT PROT 84160 $59.00 HC ENDOVASC VISC AORTA 2 GRAFT 34842 $5,257.00 HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION 10009 $1,594.00 HC L&D TRIAGE LEVEL I 99281 $196.00 HC L&D TRIAGE LEVEL II 99282 $555.00 HC L&D TRIAGE LEVEL III 99283 $918.00 HC L&D TRIAGE LEVEL IV 99284 $1,420.00 HC L&D TRIAGE LEVEL V 99285 $2,137.00 HC PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION 11105 $79.00 HC PUNCH BIOPSY SKIN SINGLE LESION 11104 $486.00 HCG, TUMOR MARKER, QUANT 84702 $252.00 HDL CHOLESTEROL LEVEL 83718 $213.00 HEART RHYTHM ANALYSIS, INTERPRETATION AND REPORT O 93226 $1,433.00 HEART RHYTHM SYMPTOM-RELATED TRACING 24-HOUR EKG M 93270 $466.00 HEART RHYTHM TRACING OF 48-HOUR EKG 93225 $1,113.00 HEART RHYTHM TRACING OF 48-HOUR EKG 93224 $1,835.00 HEAT DELIVERY TO MUSCLE AT ESOPHAGUS AND/OR STOMAC 43257 $7,673.00 HEAVY METAL LEVEL 83018 $521.00 HELICOBACTER PYLORI ANTIGEN INFECTIOUS AGENT TECH 87338 $270.00 HEMIN 313 MG SOLR 1 EACH VIAL J1640 $30,372.51 HEMIN 350 MG SOLR 1 EACH VIAL J1640 $31,283.70 HEMODIALYSIS 90935 $1,531.00 HEMOGLOBIN A1C 83036 $193.00 HEMOGLOBIN A1C LEVEL 83036 $193.00 HEMOGLOBIN ANALYSIS AND MEASUREMENT 83020 $216.00 HEMOGLOBIN ANALYSIS AND MEASUREMENT 83021 $181.00 HEMOGLOBIN MEASUREMENT 85018 $17.00 HEMOGLOBIN MEASUREMENT, PER DAY 88740 $28.00 HEMOGLOBIN MEASUREMENT, PER DAY 88741 $28.00 HEMOGLOBIN S (IN HOUSE) 85660 $86.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge HEMOGLOBIN-OXYGEN AFFINITY MEASUREMENT 82820 $83.00 HEMOSIDERIN (HEMOGLOBIN BREAKDOWN PRODUCT) ANALYSI 83070 $56.00 HEP B SURFACE AB 86317 $318.00 HEP B-DP(A)T-POLIO VAC (PF) 10 MCG-25LF-25 MCG-10L 90723 $332.43 HEPARIN (PORCINE) 1,000 UNIT/ML SOLN 1 ML VIAL J1644 $6.68 HEPARIN (PORCINE) 1,000 UNIT/ML SOLN 30 ML VIAL J1644 $29.82 HEPARIN (PORCINE) 10,000 UNIT/ML SOLN 1 ML VIAL J1644 $11.84 HEPARIN (PORCINE) 2 UNITS/ML 1,000 UNIT/500 ML SOL J1644 $17.50 HEPARIN (PORCINE) 25,000 UNIT/250 ML(100 UNIT/ML) J1644 $58.63 HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) J1644 $82.25 HEPARIN (PORCINE) 5,000 UNIT/ML SOLN 1 ML VIAL J1644 $7.27 HEPARIN ASSAY 85520 $112.00 HEPARIN LOCK FLUSH 100 UNIT/ML SYRG 5 ML SYRINGE J1642 $0.62 HEPARIN NEUTRALIZATION TEST 85525 $125.00 HEPARIN THERAPY ASSESSMENT 85530 $108.00 HEPARIN, PORCINE (PF) 10 UNIT/ML SYRG 3 ML SYRINGE J1642 $4.01 HEPARIN, PORCINE (PF) 10 UNIT/ML SYRG 5 ML SYRINGE J1642 $40.67 HEPARIN, PORCINE (PF) 10 UNIT/ML SYRG 6 ML SYRINGE J1642 $3.15 HEPATITIS A (HAAB) ANTIBODY 86708 $128.00 HEPATITIS A VACCINE 50 UNIT/ML SUSP 1 ML VIAL 90632 $281.01 HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML SUSP 90632 $204.19 HEPATITIS B CORE ANTIBODY (IGM) MEASUREMENT 86705 $244.00 HEPATITIS B CORE ANTIBODY TOTAL 86704 $113.00 HEPATITIS B IMMUNE GLOBULIN GREATER THAN 1,560 UNI 90371 $1,689.32 HEPATITIS B IMMUNE GLOBULIN GREATR THAN 312 UNIT/M 90371 $617.19 HEPATITIS B SURFACE AG 87340 $210.00 HEPATITIS B SURFACE ANTIBODY MEASUREMENT 86706 $174.00 HEPATITIS B VIRUS VACC.REC(PF) 10 MCG/0.5 ML SYRG 90744 $99.62 HEPATITIS B VIRUS VACC.REC(PF) 20 MCG/ML SYRG 1 ML 90746 $247.59 HEPATITIS B VIRUS VACC.REC(PF) 5 MCG/0.5 ML SYRG 0 90744 $97.44 HEPATITIS BE ANTIBODY MEASUREMENT 86707 $121.00 HEPATITIS C ANTIBODY MEASUREMENT 86803 $293.00 HEPATITIS C QUANTATIVE NUCLEIC ACID PROBE 87522 $666.00 HER-2 ONCOPROTEIN (CANCER RELATED GENE) MEASUREMEN 83950 $419.00 HETASTARCH 6% IN 0.9% NACL 6 % SOLN 500 ML BAG $68.25 HIGH DOSE BRACHYTHERAPY , 1 CHANNEL 77770 $2,907.00 HIGH DOSE BRACHYTHERAPY , 2- 12 CHANNELS 77771 $2,907.00 HIGH DOSE BRACHYTHERAPY , MORE THAN 12 CHANNELS 77772 $2,907.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge HISTOPLASMA AB BY ID 86698 $130.00 HIV 1 ANTIBODY 86701 $218.00 HIV RAPID 1 AND 2 COMBO 86703 $260.00 HLA CLASS I TYPING HIGH RESOLUTION ONE LOCUS 81380 $1,196.00 HLA CLASS I TYPING LOW RESOLUTION 81372 $146.00 HLA CLASS II TYPING HIGH RESOLUTION ONE ALLELE OR 81383 $1,030.00 HLA CLASS II TYPING HIGH RESOLUTION ONE LOCUS 81382 $1,114.00 HLA CLASS II TYPING LOW RESOLUTION ONE LOCUS 81376 $889.00 HOMATROPINE 5 % DROP 5 ML DROP BTL $146.79 HOMOCYSTEINE 83090 $224.00 HOMOVANILLIC ACID (ORGANIC ACID) LEVEL 83150 $160.00 HORMONAL ANTI-NEOPLASTIC CHEMOTHERAPY ADMIN BENEAT 96402 $407.00 HORMONE PANEL ADRENAL GLAND ASSESSMENT 80406 $646.00 HORMONE PANEL FOR ADRENAL GLAND ASSESSMENT (21 HYD 80402 $717.00 HOSPITAL OBSERVATION SERVICE G0378 $90.00 HPV VACCINE 9-VALENT 0.5 ML SUSP 0.5 ML VIAL 90651 $860.44 HSV-1/2 AB,IGG,CSF 86694 $120.00 HSV-1/2 AB,IGG,SERUM 86694 $156.00 HSV-1/2 AB,IGM,CSF 86694 $158.00 HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT (400-620 U C9132 $4,088.90 HUMAN GROWTH HORMONE LEVEL 83003 $197.00 HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML SYRG 0.5 ML 90651 $860.44 HUMAN T-LYMPHTROPHIC VIRUS 1/11 86790 $265.00 HYALURONIDASE (OVINE) 200 UNIT/ML SOLN 1.2 ML VIAL J3471 $344.63 HYDRALAZINE 10 MG TAB 100 EACH BLIST PACK $1.45 HYDRALAZINE 20 MG/ML SOLN 1 ML VIAL J0360 $9.84 HYDRALAZINE 25 MG TAB 1 EACH BLIST PACK $1.78 HYDRALAZINE 25 MG TAB 100 EACH BLIST PACK $1.78 HYDRALAZINE 25 MG TAB 100 EACH BOTTLE $1.78 HYDRALAZINE 50 MG TAB 100 EACH BLIST PACK $1.97 HYDRALAZINE 50 MG TAB 100 EACH BOTTLE $1.97 HYDRATION INFUSION INTO A VEIN 96361 $229.00 HYDRATION INFUSION INTO A VEIN 31 MINUTES TO 1 HOU 96360 $534.00 HYDROCHLOROTHIAZIDE 12.5 MG CAP 1 EACH BLIST PACK $1.49 HYDROCHLOROTHIAZIDE 12.5 MG CAP 100 EACH BLIST PAC $1.49 HYDROCHLOROTHIAZIDE 12.5 MG CAP 100 EACH BOTTLE $1.49 HYDROCHLOROTHIAZIDE 5 MG/ML SUSP 1 ML SYRINGE $3.50 HYDROCHLOROTHIAZIDE 5 MG/ML SUSP 100 EACH BLIST PA $0.44 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge HYDROCHLOROTHIAZIDE 5 MG/ML SUSP 100 EACH BOTTLE $0.30 HYDROCHLOROTHIAZIDE 50 MG TAB 100 EACH BOTTLE $0.58 HYDROCODONE-ACETAMINOPHEN 10-325 MG TAB 100 EACH B $3.80 HYDROCODONE-ACETAMINOPHEN 10-325 MG TAB 50 EACH BL $5.48 HYDROCODONE-ACETAMINOPHEN 5-325 MG TAB 1 EACH BLIS $3.48 HYDROCODONE-ACETAMINOPHEN 5-325 MG TAB 100 EACH BL $2.78 HYDROCODONE-ACETAMINOPHEN 5-325 MG TAB 100 EACH BO $1.61 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG TAB 1 EACH BL $2.16 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG TAB 100 EACH $3.10 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML SOLN 47 $10.33 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML SOLN 5 $61.71 HYDROCODONE-HOMATROPINE 5-1.5 MG/5 ML (5 ML) SYRP $6.56 HYDROCORTISONE 0.2 % CREA 15 G TUBE $313.37 HYDROCORTISONE 0.5 % CREA 28.35 G TUBE $11.31 HYDROCORTISONE 0.5 % CREA 28.4 G TUBE $19.28 HYDROCORTISONE 1 % CREA 28 G TUBE $12.15 HYDROCORTISONE 1 % CREA 28.35 G TUBE $25.20 HYDROCORTISONE 1 % LOTN 118 ML BOTTLE $47.91 HYDROCORTISONE 1 % OINT 28.4 G TUBE $22.76 HYDROCORTISONE 10 MG TAB 100 EACH BLIST PACK $6.09 HYDROCORTISONE 10 MG TAB 100 EACH BOTTLE $1.00 HYDROCORTISONE 100 MG/60 ML ENEM 60 ML SQUEEZ BTL $42.42 HYDROCORTISONE 2.5 % CREA 20 G TUBE $29.05 HYDROCORTISONE 2.5 % CREA 30 G TUBE $13.86 HYDROCORTISONE 2.5 % CRPE 28.35 G TUBE $305.61 HYDROCORTISONE 2.5 % CRPE 30 G TUBE $305.66 HYDROCORTISONE 2.5 % LOTN 59 ML BOTTLE $187.09 HYDROCORTISONE 2.5 % OINT 20 G TUBE $17.36 HYDROCORTISONE 20 MG TAB 1 EACH BLIST PACK $1.82 HYDROCORTISONE 20 MG TAB 100 EACH BOTTLE $3.80 HYDROCORTISONE 20 MG TAB 30 EACH BLIST PACK $1.82 HYDROCORTISONE 25 MG SUPP 1 EACH BOX $48.30 HYDROCORTISONE 25 MG SUPP 12 EACH BOX $50.49 HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML SOLR 1 EA J1720 $28.21 HYDROCORTISONE SOD SUCC (PF) 250 MG/2 ML SOLR 1 EA J1720 $104.34 HYDROCORTISONE SODIUM SUCCINATE 1,000 MG/8 ML SOLR J1720 $208.68 HYDROCORTISONE VALERATE 0.2 % OINT 15 G TUBE $344.40 HYDROCORTISONE-PRAMOXINE 1-1 % FOAM 10 G CAN $628.29 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge HYDROCORTISONE-PRAMOXINE 1-1 % OINT 28.4 G TUBE $740.53 HYDROMORPHONE 10 MG/ML SOLN 1 ML VIAL J1170 $0.73 HYDROMORPHONE 10 MG/ML SOLN 5 ML VIAL J1170 $0.45 HYDROMORPHONE 2 MG TAB 100 EACH BLIST PACK $2.50 HYDROMORPHONE 2 MG/ML SOLN 1 ML VIAL J1170 $0.66 HYDROXOCOBALAMIN 5 GRAM/200 ML SOLR 1 EACH VIAL J3420 $3,449.54 HYDROXYCHLOROQUINE 200 MG TAB 100 EACH BLIST PACK $15.37 HYDROXYCHLOROQUINE 200 MG TAB 100 EACH BOTTLE $14.31 HYDROXYCHLOROQUINE 200 MG TAB 50 EACH BLIST PACK $12.22 HYDROXYCORTICOSTEROIDS, 17 (ADRENAL GLAND HORMONE) 83491 $155.00 HYDROXYINDOLACETIC ACID (PRODUCT OF METABOLISM) LE 83497 $169.00 HYDROXYPROGESTERONE, 17-D (SYNTHETIC HORMONE) LEVE 83498 $294.00 HYDROXYUREA 500 MG CAP 100 EACH BLIST PACK S0176 $3.86 HYDROXYZINE 10 MG/5 ML SOLN 473 ML BOTTLE $139.06 HYDROXYZINE 10 MG/5 ML SOLN 5 ML CUP $1.47 HYDROXYZINE 50 MG/ML SOLN 1 ML VIAL J3410 $46.73 HYDROXYZINE 50 MG/ML SOLN 2 ML VIAL J3410 $37.11 HYDROXYZINE HCL 10 MG TAB 100 EACH BLIST PACK $2.18 HYDROXYZINE HCL 25 MG TAB 1 EACH BLIST PACK $2.17 HYDROXYZINE HCL 25 MG TAB 100 EACH BLIST PACK $2.17 HYDROXYZINE HCL 50 MG TAB 100 EACH BLIST PACK $0.33 HYDROXYZINE PAMOATE 100 MG CAP 100 EACH BOTTLE Q0177 $1.04 HYDROXYZINE PAMOATE 25 MG CAP 100 EACH BLIST PACK Q0177 $1.05 HYDROXYZINE PAMOATE 25 MG CAP 100 EACH BOTTLE Q0177 $1.05 HYDROXYZINE PAMOATE 50 MG CAP 100 EACH BLIST PACK Q0177 $1.13 HYOSCYAMINE 0.125 MG SUBL 100 EACH BOTTLE $1.49 HYOSCYAMINE 0.125 MG TAB 100 EACH BOTTLE $2.98 HYOSCYAMINE 0.125 MG/5 ML ELIX 473 ML BOTTLE $0.96 HYOSCYAMINE 0.125 MG/5 ML ELIX 5 ML CUP $0.98 HYOSCYAMINE 0.375 MG TB12 100 EACH BOTTLE $5.60 HYOSCYAMINE 0.5 MG/ML SOLN 1 ML AMPUL J1980 $125.19 HYOSCYAMINE SULFATE 0.125 MG TBDL 100 EACH BOTTLE $0.90 HYPERSENSITIVITY PNEUMONITIS I 86331 $113.00 HYPERSENSITIVITY PNEUMONITIS II 86331 $113.00 IBANDRONATE 3 MG/3 ML SYRG 3 ML SYRINGE J1740 $1,750.00 IBUPROFEN 100 MG/5 ML SUSP 120 ML BOTTLE $0.07 IBUPROFEN 100 MG/5 ML SUSP 5 ML CUP $6.09 IBUPROFEN 200 MG TAB 100 EACH BLIST PACK $0.28 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge IBUPROFEN 400 MG TAB 100 EACH BLIST PACK $0.76 IBUPROFEN 600 MG TAB 100 EACH BLIST PACK $1.07 IBUPROFEN 600 MG TAB 100 EACH BOTTLE $0.64 IBUPROFEN 600 MG TAB 500 EACH BOTTLE $0.84 IBUPROFEN 600 MG TAB 750 EACH BLIST PACK $0.22 IBUPROFEN 800 MG TAB 100 EACH BLIST PACK $0.10 IBUPROFEN 800 MG TAB 500 EACH BOTTLE $0.25 IBUPROFEN LYSINE (PF) 20 MG/2 ML SOLN 2 ML VIAL J1741 $2,565.07 IBUTILIDE 0.1 MG/ML SOLN 10 ML VIAL J1742 $1,899.52 ICOSAPENT ETHYL 1 GRAM CAP 120 EACH BOTTLE $19.50 ICTOTEST BILIRUBIN CONF, URINE 81002 $18.00 IDARUCIZUMAB 2.5 GRAM/50 ML SOLN 50 ML VIAL $14,700.00 IDENTIFICATION OF MYCOBACTERIA (TB OR TB LIKE ORGA 87118 $92.00 IDENTIFICATION OF ORGANISM BY PULSE FIELD GEL TYPI 87152 $43.00 IDENTIFICATION OF ORGANISMS BY GENETIC ANALYSIS 87149 $254.00 IDENTIFICATION OF ORGANISMS BY GENETIC ANALYSIS 87153 $322.00 IDENTIFICATION OF ORGANISMS BY GENETIC ANALYSIS 87150 $295.00 IDENTIFICATION OF ORGANISMS BY IMMUNOLOGIC ANALYSI 87140 $313.00 IDENTIFICATION OF ORGANISMS BY IMMUNOLOGIC ANALYSI 87147 $35.00 IDENTIFICATION OF RED BLOOD CELL ANTIBODIES 86870 $323.00 IF INDIRECT EA AB 88346 $273.00 IFOSFAMIDE 1 GRAM SOLR 1 EACH VIAL J9208 $243.81 IFOSFAMIDE 3 GRAM SOLR 1 EACH VIAL J9208 $439.46 IGE (IMMUNE SYSTEM PROTEIN) LEVEL 82785 $256.00 IGF 1 INSULIN GROWTH FAC 1 84305 $250.00 IMAGING AND EVALUATION OF DEEP CELLS OF THE EYE 92287 $381.00 IMAGING FOR ABSCESS OR ABNORMAL DRAINAGE TRACT PRO 76080 $723.00 IMAGING FOR BONE AGE ASSESSMENT 77072 $433.00 IMAGING FOR BONE LENGTH ASSESSMENT 77073 $530.00 IMAGING FOR EVALUATION OF SWALLOWING FUNCTION 74230 $987.00 IMAGING FROM NOSE TO RECTUM, SINGLE VIEW, CHILD 76010 $380.00 IMAGING GUIDANCE FOR PROCEDURE, UP TO 1 HOUR 76000 $715.00 IMAGING OF BLOOD VESSEL 75898 $1,075.00 IMAGING OF BLOOD VESSEL OF GLAND OF KIDNEY 78075 $2,298.00 IMAGING OF BONE MARROW LIMITED AREA 78102 $2,102.00 IMAGING OF BRAIN AND SPINAL CORD FLUID FLOW AT BAS 78630 $1,297.00 IMAGING OF BRAIN AND SPINAL CORD FLUID FLOW SHUNT 78645 $1,936.00 IMAGING OF BRAIN AND SPINAL CORD FLUID LEAKAGE DET 78650 $2,048.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge IMAGING OF BRAIN WITH BLOOD FLOW, LESS THAN 4 STAT 78601 $802.00 IMAGING OF BRAIN WITH BLOOD FLOW, MINIMUM OF 4 STA 78606 $1,439.00 IMAGING OF COLON USING ENEMA 74283 $527.00 IMAGING OF DIGESTIVE TRACT DONE FROM THE INSIDE OF 91110 $2,623.00 IMAGING OF ESOPHAGUS DONE FROM THE INSIDE OF THE E 91111 $3,525.00 IMAGING OF ESOPHAGUS USING RADIOISOTOPES 78258 $1,781.00 IMAGING OF GALLBLADDER WITH CONTRAST 74290 $612.00 IMAGING OF KIDNEY 78700 $1,053.00 IMAGING OF LIVER AND BILE DUCT SYSTEM 78226 $2,403.00 IMAGING OF LIVER AND BILE DUCT SYSTEM WITH USE OF 78227 $1,164.00 IMAGING OF LIVER AND SPLEEN WITH BLOOD FLOW 78216 $2,488.00 IMAGING OF LYMPHATIC TISSUE AND LYMPH NODE 78195 $1,888.00 IMAGING OF ORGAN 76120 $288.00 IMAGING OF ORGAN 76125 $288.00 IMAGING OF PARATHYROID 78070 $1,850.00 IMAGING OF SALIVARY GLAND 78231 $1,165.00 IMAGING OF SMALL INTESTINE 74260 $426.00 IMAGING OF SURGICAL SPECIMEN 76098 $910.00 IMAGING OF URINARY TRACT 74420 $1,040.00 IMAGING OF URINARY TRACT WITH INJECTION OF CONTRAS 74400 $1,525.00 IMAGING URINARY TRACT USING INFUSION TECHNIQUE WIT 74415 $664.00 IMATINIB 100 MG TAB 1 EACH BLIST PACK $1,489.60 IMATINIB 100 MG TAB 90 EACH BOTTLE $1,573.12 IMIPENEM-CILASTATIN 500 MG SOLR 1 EACH VIAL J0743 $137.14 IMIPRAMINE 25 MG TAB 100 EACH BOTTLE $2.51 IMM NON INFCT AB OR AG QUAL/SEMI MULT 83516 $159.00 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % SOLN 100 ML VI J1569 $4,573.10 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % SOLN 200 ML VI J1569 $9,146.20 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % SOLN 300 ML VI J1569 $12,820.50 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % SOLN 50 ML VIA J1569 $2,286.55 IMMUNOASSAY NI AGENT AB/AG NOS 83520 $286.00 IMMUNOASSAY NONANTIBODY 83516 $221.00 IMMUNOASSAY QN TRYPTASE 83520 $287.00 IMMUNOFIX ELECTROPHORESIS 86334 $380.00 IMMUNOFLUORESCENCE PER SPECIMEN 88346 $273.00 IMMUNOLOGIC ANALYSIS FOR AUTOIMMUNE DISEASE 86806 $392.00 IMMUNOLOGIC ANALYSIS FOR AUTOIMMUNE DISEASE 86812 $301.00 IMMUNOLOGIC ANALYSIS FOR AUTOIMMUNE DISEASE 86816 $230.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge IMMUNOLOGIC ANALYSIS FOR DETECTION OF ANTIGEN OR A 86331 $88.00 IMMUNOLOGIC ANALYSIS FOR DETECTION OF ORGANISM 87449 $274.00 IMMUNOLOGIC ANALYSIS FOR DETECTION OF ORGANISM 87450 $39.00 IMMUNOLOGIC ANALYSIS FOR DETECTION OF ORGANISM 87451 $39.00 IMMUNOLOGIC ANALYSIS FOR DETECTION OF TUMOR ANTIGE 86300 $229.00 IMMUNOLOGIC ANALYSIS FOR DETECTION OF TUMOR ANTIGE 86294 $95.00 IMMUNOLOGIC ANALYSIS FOR ORGAN TRANSPLANT 86825 $606.00 IMMUNOLOGIC ANALYSIS FOR ORGAN TRANSPLANT 86826 $247.00 IMMUNOLOGIC ANALYSIS TECHNIQUE 86327 $187.00 IMMUNOLOGIC ANALYSIS TECHNIQUE ON BODY FLUID 86325 $284.00 IMMUNOLOGIC ANALYSIS TECHNIQUE ON BODY FLUID 86335 $295.00 IMMUNOLOGIC ANALYSIS TECHNIQUE ON SERUM 86334 $380.00 IMPLANTATION SPINAL NEUROSTIMULATOR ELECTRODES, AC 63650 $12,157.00 INCISION AND DRAINAGE OF ABSCESS IN SCROTAL SAC OF 55100 $1,490.00 INCISION AND DRAINAGE OF EXTERNAL EAR ABSCESS OR B 69000 $859.00 INCISION AND DRAINAGE OF EXTERNAL EAR ABSCESS OR B 69005 $1,744.00 INCISION AND DRAINAGE OF EYE CYST 68020 $2,419.00 INCISION AND DRAINAGE OF EYELID ABSCESS 67700 $295.00 INCISION AND DRAINAGE OF FEMALE GENITAL GLAND ABSC 56420 $420.00 INCISION AND DRAINAGE OF FEMALE GENITALS ABSCESS 56405 $487.00 INCISION AND DRAINAGE OF ROOF OF MOUTH OR ITS SOFT 42000 $544.00 INCISION AND DRAINAGE OF SPERM RESERVOIR, TESTIS, 54700 $2,951.00 INCISION AND EXPLORATION OF CHEST CAVITY 32100 $15,759.00 INCISION OF ABSCESS, CYST, OR BLOOD ACCUMULATION I 40800 $579.00 INCISION OF ABSCESS, CYST, OR BLOOD ACCUMULATION I 40801 $931.00 INCISION OF BLADDER WITH DRAINAGE 51040 $3,749.00 INCISION OF BURN TISSUE 16035 $1,433.00 INCISION OF EARDRUM WITH INSERT EARDRUM TUBE UNDER 69433 $1,317.00 INCISION OF ENGORGED EXTERNAL HEMORRHOID 46083 $516.00 INCISION OF EXTERNAL URINARY OPENING 53020 $3,728.00 INCISION OF FLUID CANALS OF INNER EAR WITH INFUSIO 69801 $2,896.00 INCISION OF PANCREATIC OUTLET MUSCLE USING AN ENDO 43262 $5,895.00 INCISION OF PENILE FORESKIN 54001 $3,805.00 INCISION OF TENDON TO REPAIR ELBOW JOINT, ACCESSED 24357 $7,149.00 INCISION OF TISSUE CONNECTING TONGUE AND FLOOR OF 41010 $2,193.00 INCISION OF VEIN FOR INSERTION OF NEEDLE/CATHETER 36420 $119.00 INCISION TO RELEASE TISSUE AND MUSCLE OF SOLE OF F 28250 $6,175.00 INCISION, STRETCHING, AND SUTURE OF FOREHEAD SKIN 15824 $4,969.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INCISION, STRETCHING, AND SUTURE OF SKIN 15828 $5,663.00 INDAPAMIDE 2.5 MG TAB 1 EACH BLIST PACK $2.71 INDAPAMIDE 2.5 MG TAB 100 EACH BOTTLE $2.71 INDIA INK 87210 $74.00 INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) SOLN 5 $693.00 INDOCYANINE GREEN 25 MG SOLR 1 EACH VIAL $19.95 INDOMETHACIN 1 MG SOLR 1 EACH VIAL $1,932.00 INDOMETHACIN 25 MG CAP 1 EACH BLIST PACK $1.39 INDOMETHACIN 25 MG CAP 100 EACH BLIST PACK $1.41 INDOMETHACIN 50 MG CAP 1 EACH BLIST PACK $2.38 INDOMETHACIN 50 MG CAP 100 EACH BLIST PACK $2.38 INDOMETHACIN 50 MG CAP 100 EACH BOTTLE $2.23 INDOMETHACIN 50 MG SUPP 30 EACH BOX $357.00 INDOMETHACIN 75 MG CPSR 1 EACH BLIST PACK $10.77 INFECTIOUS AGENT ANTIBODY QUANTITATIVE PNEUMO AB I 86317 $241.00 INFECTIOUS AGENT DRUG SUSCEPTIBILITY ANALYSIS 87900 $815.00 INFECTIOUS AGENT ENZYMATIC ACTIVITY TO DETECT ORGA 87905 $70.00 INFLIXIMAB 100 MG SOLR 1 EACH VIAL J1745 $4,904.83 INFLIXIMAB-DYYB 100 MG SOLR 1 EACH VIAL Q5103 $3,974.39 INFLUENZA A ANTIBODIES, RAPID 86710 $92.00 INFLUENZA A ASSAY W/OPTIC 87804 $121.00 INFLUENZA B ASSAY W/OPTIC 87804 $121.00 INFUSION DIFFERENT CHEMOTHERAPY DRUG OR SUBSTANCE 96417 $497.00 INFUSION FOR THERAPY OR PREVENTION, BENEATH THE SK 96371 $202.00 INFUSION INTO A VEIN FOR THERAPY, PREVENTION, OR D 96366 $310.00 INFUSION INTO A VEIN FOR THERAPY, PREVENTION, OR D 96365 $527.00 INFUSION INTO TISSUE FOR THERAPY OR PREVENTION UP 96369 $752.00 INFUSION INTO TISSUE FOR THERAPY OR PREVENTION, BE 96370 $154.00 INFUSION INTO VEIN THERAPY PREVENTION/DIAGNOSIS AD 96367 $448.00 INFUSION INTO VEIN THERAPY PREVENTION/DIAGNOSIS CO 96368 $289.00 INFUSION OF CHEMICAL AGENT INTO THE ARTERY OF BRAI 61650 $2,985.00 INFUSION OF CHEMOTHERAPY INTO A VEIN 96415 $442.00 INFUSION OF CHEMOTHERAPY INTO A VEIN UP TO 1 HOUR 96413 $908.00 INFUSION OF CHEMOTHERAPY INTO A VEIN USING PUSH TE 96409 $582.00 INFUSION OF DIFFERENT CHEMOTHERAPY DRUG OR SUBSTAN 96411 $482.00 INFUSION OF DRUG INTO VEIN TO DISSOLVE BLOOD CLOT 37195 $1,651.00 INFUSION OF DRUG INTO VEIN TO DISSOLVE CORONARY BL 92977 $1,153.00 INFUSION OF HEART ARTERY TO DISSOLVE BLOOD CLOT WI 92975 $2,972.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INFUSION/INSTILLATION OF RADIOELEMENT SOLUTION W/3 77750 $767.00 INHALATION OF MEDICATIONS WITH ALLERGIC REACTION A 95070 $701.00 INHIBIN A (REPRODUCTIVE ORGAN HORMONE) MEASUREMENT 86336 $194.00 INITIATION & MANAGEMENT CONTINUED PRESSURED RESPIR 94660 $438.00 INJECT BONE CEMENT INTO BODY OF LOWER SPINE BONE A 22514 $11,708.00 INJECT BONE CEMENT INTO BODY OF MIDDLE OR LOWER SP 22512 $4,736.00 INJECT BONE CEMENT INTO BODY OF MIDDLE OR LOWER SP 22515 $8,103.00 INJECT BONE CEMENT INTO BODY OF MIDDLE SPINE BONE 22510 $5,594.00 INJECT BONE CEMENT INTO BODY OF MIDDLE SPINE BONE 22513 $11,708.00 INJECT CHEMICAL FOR DESTRUCTION OF NERVE MUSCLES O 64647 $1,536.00 INJECT DIAGNOSTIC OR THERAPEUTIC SUBSTANCES OR MAR 43253 $4,495.00 INJECT FOR X-RAY IMAGE OF HEART VESSEL GRAFTS DURI 93564 $983.00 INJECT FOR X-RAY IMAGING HEART BLOOD VESSEL DEFECT 93563 $852.00 INJECT OF BILE DUCT FOR X-RAY IMAGING PROCEDURE AC 47531 $1,842.00 INJECT OF BILE DUCT FOR X-RAY IMAGING PROCEDURE AC 47532 $5,124.00 INJECT OF DIFFERENT DRUG/SUBSTANCE INTO VEIN THERA 96375 $249.00 INJECT OF DRUG/SUBSTANCE INTO VEIN THERAPY/DIAGNOS 96376 $263.00 INJECT PROCEDURE FOR X-RAY IMAGING OF BLADDER AND 51605 $808.00 INJECT PROCEDURE FOR X-RAY IMAGING OF KIDNEY AND U 50430 $1,155.00 INJECT PROCEDURE THROUGH THE BLADDER AND BLADDER C 51610 $896.00 INJECTION BENEATH SKIN OR INTO MUSCLE FOR THERAPY 96372 $195.00 INJECTION DRUG OR SUBSTANCE INTO A VEIN FOR THERAP 96374 $270.00 INJECTION FOR X-RAY IMAGING OF AORTA ABOVE HEART V 93567 $687.00 INJECTION FOR X-RAY IMAGING OF BREAST DUCT 19030 $770.00 INJECTION FOR X-RAY IMAGING OF LEFT UPPER OR LOWER 93565 $827.00 INJECTION FOR X-RAY IMAGING OF PULMONARY (LUNG) AR 93568 $985.00 INJECTION FOR X-RAY IMAGING OF RIGHT UPPER OR LOWE 93566 $948.00 INJECTION FOR X-RAY IMAGING PROCEDURE ON VEINS OF 36005 $1,569.00 INJECTION INTO ARTERY FOR THERAPY, DIAGNOSIS, OR P 96373 $213.00 INJECTION INTO CONJUNCTIVA 68200 $317.00 INJECTION OF 5.1 TO 10.0 CC FILLING MATERIAL INTO 11954 $1,357.00 INJECTION OF ABNORMAL FLUID ACCUMULATION 49185 $2,138.00 INJECTION OF ABNORMAL MUSCLE DRAINAGE TRACT FOR X- 20501 $784.00 INJECTION OF AGENT TO DESTROY ABDOMINAL SYMPATHETI 64680 $2,386.00 INJECTION OF AIR OR X-RAY CONTRAST MATERIAL INTO A 49400 $611.00 INJECTION OF ALCOHOL INTO CAVITY BEHIND EYE 67505 $1,735.00 INJECTION OF ANESTHETIC AGENT OF MULTIPLE RIB NERV 64421 $1,438.00 INJECTION OF ANESTHETIC AGENT UNDERARM (AXILLARY) 64417 $1,004.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INJECTION OF ANESTHETIC AGENT, ABDOMINAL SYMPATHET 64530 $1,072.00 INJECTION OF ANESTHETIC AGENT, BRACHIAL (ARM) NERV 64415 $1,428.00 INJECTION OF ANESTHETIC AGENT, FACIAL NERVE 64402 $468.00 INJECTION OF ANESTHETIC AGENT, GREATER OCCIPITAL N 64405 $1,424.00 INJECTION OF ANESTHETIC AGENT, MIDDLE OR LOWER SPI 64520 $2,405.00 INJECTION OF ANESTHETIC AGENT, OF RIB NERVE 64420 $773.00 INJECTION OF ANESTHETIC AGENT, OTHER PERIPHERAL NE 64450 $747.00 INJECTION OF ANESTHETIC AGENT, SYMPATHETIC NERVE B 64510 $1,237.00 INJECTION OF ANESTHETIC AGENT, THIGH NERVE 64447 $2,105.00 INJECTION OF ANESTHETIC AGENT, TRIGEMINAL NERVE 64400 $752.00 INJECTION OF BLADDER AND URINARY DUCT (URETER) FOR 50690 $631.00 INJECTION OF BLOOD OR BLOOD CLOT INTO SPINAL CANAL 62273 $1,189.00 INJECTION OF CARPAL TUNNEL 20526 $466.00 INJECTION OF CHEMICAL AGENT INTO MULTIPLE VEINS OF 36471 $847.00 INJECTION OF CHEMICAL AGENT INTO SINGLE VEIN 36470 $1,127.00 INJECTION OF CHEMICAL AGENT INTO SPIDER VEINS OF A 36468 $435.00 INJECTION OF CHEMICAL FOR DESTRUCTION OF EYE MUSCL 67345 $921.00 INJECTION OF CHEMOTHERAPY USING PUSH TECHNIQUE INT 96420 $744.00 INJECTION OF CONTRAST FOR X-RAY IMAGING OF TEAR SA 68850 $363.00 INJECTION OF CONTRAST THROUGH ABDOMINAL CAVITY CAT 49424 $556.00 INJECTION OF DILATED VEINS OF STOMACH AND/OR ESOPH 43243 $3,449.00 INJECTION OF DRUG INTO ERECTILE TISSUE AT SIDES AN 54220 $722.00 INJECTION OF DRUG INTO EYE 67028 $1,310.00 INJECTION OF DYE FOR X-RAY IMAGING AND/OR CT OF LO 62284 $1,685.00 INJECTION OF DYE FOR X-RAY IMAGING OF ELBOW JOINT 24220 $696.00 INJECTION OF DYE FOR X-RAY IMAGING OF HIP JOINT 27093 $953.00 INJECTION OF DYE FOR X-RAY IMAGING OF SHOULDER JOI 23350 $803.00 INJECTION OF DYE FOR X-RAY IMAGING OF SPINE DISC 62290 $1,899.00 INJECTION OF DYE FOR X-RAY IMAGING OF SPINE DISC 62291 $987.00 INJECTION OF DYE FOR X-RAY IMAGING OF WRIST JOINT 25246 $577.00 INJECTION OF DYE FOR X-RAY OF SALIVARY GLANDS 42550 $385.00 INJECTION OF MEDICATION INTO EYE 66030 $2,431.00 INJECTION OF MEDICATION OR SUBSTANCE INTO MEMBRANE 67515 $1,366.00 INJECTION OF RADIOACTIVE DYE FOR X-RAY IDENTIFICAT 38792 $1,160.00 INJECTION OF SPINAL CANAL TO DESTROY NERVE 62281 $2,179.00 INJECTION OF SPINAL CANAL TO DESTROY NERVE 62282 $1,104.00 INJECTION OF SUBSTANCE INTO SPINAL CANAL OF LOWER 62322 $1,816.00 INJECTION OF SUBSTANCE INTO SPINAL CANAL OF LOWER 62323 $1,896.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INJECTION OF SUBSTANCE INTO SPINAL CANAL OF UPPER 62320 $1,908.00 INJECTION OF SUBSTAND INTO SPINAL CANAL OF UPPER O 62321 $1,641.00 INJECTION OF SYNTHETIC EYE FLUID 67025 $6,881.00 INJECTION OF UP TO 7 SKIN GROWTHS 11900 $204.00 INJECTION PROCEDURE FOR X-RAY IMAGING OF HIP UNDER 27095 $1,272.00 INJECTION PROCEDURE FOR X-RAY IMAGING OF PENILE ER 54230 $3,884.00 INJECTION PROCEDURE FOR X-RAY IMAGING OF THE BLADD 51600 $868.00 INJECTION PROCEDURE FOR X-RAY IMAGING OF THE SPLEE 38200 $544.00 INJECTION PROCEDURE TO INDUCE ERECTION 54235 $266.00 INJECTION SACROILIAC JOINT THERAPEUTIC AGENT 27096 $2,222.00 INJECTION TO CAUSE BLOOD CLOT IN A DISEASED OR BUL 36002 $937.00 INJECTIONS ESOPHAGUS, STOMACH, AND/OR UPPER SMALL 43236 $2,008.00 INJECTIONS INTO ESOPHAGUS USING AN ENDOSCOPE 43201 $2,578.00 INJECTIONS INTO LARGE BOWEL USING AN ENDOSCOPE 45335 $2,603.00 INJECTIONS OF ANESTHETIC AND/OR STEROID DRUG INTO 64455 $752.00 INJECTIONS OF LARGE BOWEL USING AN ENDOSCOPE 45381 $2,988.00 INJECTIONS OF LOWER OR SACRAL SPINE FACET JOINT US 64493 $2,133.00 INJECTIONS OF LOWER OR SACRAL SPINE FACET JOINT US 64494 $1,794.00 INJECTIONS OF LOWER OR SACRAL SPINE FACET JOINT US 64495 $1,813.00 INJECTIONS OF TENDON ATTACHMENT TO BONE 20551 $414.00 INJECTIONS OF TENDON SHEATH, LIGAMENT, OR MUSCLE M 20550 $551.00 INJECTIONS OF TRIGGER POINTS IN 1 OR 2 MUSCLES 20552 $630.00 INJECTIONS OF TRIGGER POINTS IN 3 OR MORE MUSCLES 20553 $578.00 INJECTIONS OF UPPER OR MIDDLE SPINE FACET JOINT US 64490 $2,999.00 INJECTIONS OF UPPER OR MIDDLE SPINE FACET JOINT US 64491 $1,835.00 INJECTIONS OF UPPER OR MIDDLE SPINE FACET JOINT US 64492 $1,787.00 INJECTS OF ANESTHETIC/STEROID DRUG INTO LOWER OR S 64483 $1,669.00 INJECTS OF ANESTHETIC/STEROID DRUG INTO LOWER OR S 64484 $1,632.00 INJECTS OF ANESTHETIC/STEROID DRUG INTO UPPER OR M 64479 $1,782.00 INJECTS OF ANESTHETIC/STEROID DRUG INTO UPPER OR M 64480 $1,869.00 INSERT ARTERIAL CATHETER FOR BLOOD SAMPLE OR INFUS 36620 $1,437.00 INSERT CATHETER FOR RECORDING AND PACING RIGHT UPP 93619 $11,770.00 INSERT CATHETER IN RIGHT HEART FOR X-RAY IMAGING O 93456 $22,645.00 INSERT CATHETER INTO ARTERY ON ONE SIDE OF CHEST F 36225 $11,502.00 INSERT CATHETER INTO ARTERY ON ONE SIDE OF NECK FO 36222 $11,502.00 INSERT CATHETER INTO ARTERY ON ONE SIDE OF NECK FO 36223 $11,502.00 INSERT CATHETER INTO ARTERY ON ONE SIDE OF NECK FO 36224 $18,811.00 INSERT CATHETER INTO ARTERY ON ONE SIDE OF NECK FO 36227 $3,433.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INSERT CATHETER INTO ARTERY ON ONE SIDE OF NECK OR 36228 $1,000.00 INSERT CATHETER INTO HEART CHAMBERS FOR EVAL OF CO 93531 $14,791.00 INSERT CATHETER INTO RIGHT UPPER HEART CHAMBER AND 93503 $3,073.00 INSERT CATHETER LEFT HEART IMAGING BLOOD VESSELS/G 93458 $22,476.00 INSERT CATHETER LEFT HEART IMAGING BLOOD VESSELS/G 93459 $25,006.00 INSERT CATHETER RIGHT & LEFT HEART IMAG BLOOD VESS 93460 $23,915.00 INSERT CATHETER RIGHT & LEFT HEART IMAG BLOOD VESS 93461 $14,130.00 INSERT CATHETER RIGHT UPPER HEART CHAMBER EVALUATI 93530 $8,538.00 INSERT CATHETERS ASSESS HEART PACING REC OR ATTEMP 93624 $12,477.00 INSERT CATHETERS FOR RECORD PACE & ATTEMPTED INDUC 93620 $11,366.00 INSERT CATHETERS FOR RECORD PACE & ATTEMPTED INDUC 93621 $6,545.00 INSERT CATHETERS FOR RECORDING PACE & ATTEMPTED IN 93622 $4,756.00 INSERT CATHETERS INTO MAIN & ACCESSORY ARTERIES OF 36252 $10,811.00 INSERT CATHETERS INTO MAIN & ACCESSORY ARTERIES OF 36254 $8,274.00 INSERT CATHETERS INTO MAIN AND ACCESSORY ARTERIES 36251 $9,488.00 INSERT CATHETERS INTO MAIN AND ACCESSORY ARTERIES 36253 $9,696.00 INSERT CENTRAL VENOUS CATHETER & IMPLANTED DEVICE 36561 $7,928.00 INSERT CENTRAL VENOUS CATHETER & IMPLANTED DEVICE 36563 $6,009.00 INSERT CENTRAL VENOUS CATHETER & IMPLANTED DEVICE 36566 $11,638.00 INSERT CENTRAL VENOUS CATHETER & IMPLANTED DEVICE 36560 $10,583.00 INSERT CENTRAL VENOUS CATHETER FOR INFUSION W/PORT 36571 $5,636.00 INSERT CENTRAL VENOUS CATHETER FOR INFUSION W/PORT 36570 $8,332.00 INSERT DEVICE INTO ABDOMEN WITH MEASUREMENT OF PRE 51797 $706.00 INSERT DEVICES FOR RADIATION THERAPY GUIDANCE IN A 49412 $315.00 INSERT DEVICES IN ABDOMINAL CAVITY FOR RADIATION T 49411 $4,057.00 INSERT ELECTRONIC DEVICE INTO BLADDER W/MEASUREMEN 51726 $1,439.00 INSERT ELECTRONIC DEVICE INTO BLADDER W/VOID & BLA 51729 $1,057.00 INSERT GUIDE WIRE THROUGH KIDNEY INTO URINARY DUCT 52334 $5,612.00 INSERT INTRAVASCULAR STENTS IN ARTERY OPEN OR ACCE 37236 $24,189.00 INSERT INTRAVASCULAR STENTS IN ARTERY OPEN OR ACCE 37237 $10,879.00 INSERT INTRAVASCULAR STENTS IN VEIN OPEN OR ACCESS 37238 $22,800.00 INSERT INTRAVASCULAR STENTS IN VEIN OPEN OR ACCESS 37239 $3,702.00 INSERT LARGE BOWEL TUBE 49442 $2,152.00 INSERT LEFT HEART ELECTRODE W/ATTACHMENT PACEMKR/P 33224 $15,012.00 INSERT NEEDLES & SKIN ELECTRODES FOR MEASUREMENT & 95938 $734.00 INSERT NEEDLES & SKIN ELECTRODES MEASURE & REC STI 95925 $1,576.00 INSERT NEEDLES & SKIN ELECTRODES MEASURE & REC STI 95926 $1,576.00 INSERT NEEDLES & SKIN ELECTRODES MEASURE & REC STI 95927 $946.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INSERT NEW/REPLACEMENT PERMANENT PACEMKR W/UPPER & 33208 $29,848.00 INSERT PROBE ESOPHAGUS CONTINUOUS HEART US MONIT & 93318 $2,898.00 INSERT PROBE IN ESOPHAGUS FOR HEART ULTRASOUND EXA 93312 $2,480.00 INSERT STENT & BLOOD CLOT PROTECTION DEVICE IN NEC 37215 $6,689.00 INSERT STENT REMOVAL OF PLAQUE AND/OR BALLOON DILA 92937 $33,617.00 INSERT STENT REMOVAL OF PLAQUE AND/OR BALLOON DILA 92938 $22,824.00 INSERT STENT REMOVAL OF PLAQUE AND/OR BALLOON DILA 92943 $25,249.00 INSERT STENT REMOVAL PLAQUE/BALLOON DIL CORONARY V 92941 $29,942.00 INSERT STENTS IN ARTERY IN ONE SIDE OF GROIN ENDOV 37221 $26,442.00 INSERT STENTS INTO ARTERIES IN ONE LEG ENDOVASCULA 37226 $35,643.00 INSERT STENTS INTO GROIN ARTERY ENDOVASCULAR 37223 $11,159.00 INSERT STOMACH TUBE (ACCESSED THROUGH THE SKIN) US 49440 $2,029.00 INSERTION ABDOMINAL CAVITY CATHETER FOR DRAINAGE O 49421 $8,268.00 INSERTION AND REMOVAL OF WIRE OR PIN WITH BONE TRA 20650 $3,389.00 INSERTION BRAIN DRAIN CATHETER OR FLUID PRESSURE R 61107 $2,017.00 INSERTION CATHETER FOR RECORDING TO IDENTIFY ORIGI 93609 $8,925.00 INSERTION CATHETERS FOR 3D MAPPING OF ELECTRICAL I 93613 $10,449.00 INSERTION CENTRAL VENOUS CATHETER FOR INFUSION PAT 36555 $1,566.00 INSERTION CENTRAL VENOUS CATHETER FOR INFUSION PAT 36568 $1,829.00 INSERTION CENTRAL VENOUS CATHETERS FOR INFUSION TW 36565 $5,065.00 INSERTION DILATOR DEVICE INTO CERVIX 59200 $641.00 INSERTION ELECTRODE FOR PERMANENT PACEMAKER OR PAC 33216 $8,359.00 INSERTION HARDWARE TO BROKEN FINGER OR THUMB W/MAN 26727 $6,051.00 INSERTION NEEDLE INTO UPPER LEG OR NECK VEIN, PATI 36400 $205.00 INSERTION OF ABDOMINAL CATHETER THROUGH THE SKIN U 49418 $8,468.00 INSERTION OF ARTERIAL CATHETER FOR BLOOD SAMPLING 36625 $2,815.00 INSERTION OF ASSISTIVE HEART BLOOD FLOW DEVICE INT 33967 $2,894.00 INSERTION OF CATHETER (ACCESSED THROUGH THE SKIN) 47490 $3,240.00 INSERTION OF CATHETER FOR DIAGNOSTIC EVALUATION OF 93451 $4,331.00 INSERTION OF CATHETER FOR IMAGING OF HEART BLOOD V 93454 $3,840.00 INSERTION OF CATHETER FOR IMAGING OF HEART BLOOD V 93455 $14,190.00 INSERTION OF CATHETER FOR RECORDING UPPER HEART RH 93600 $5,600.00 INSERTION OF CATHETER FOR SUCTION OF SECRETIONS 31720 $201.00 INSERTION OF CATHETER IN RIGHT HEART FOR IMAGING O 93457 $18,885.00 INSERTION OF CATHETER INTO ABDOMINAL PELVIC OR LEG 36245 $3,754.00 INSERTION OF CATHETER INTO ABDOMINAL PELVIC OR LEG 36246 $1,966.00 INSERTION OF CATHETER INTO ABDOMINAL PELVIC OR LEG 36247 $2,234.00 INSERTION OF CATHETER INTO AN ARTERY IN NAVEL, NEW 36660 $427.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INSERTION OF CATHETER INTO AN ARTERY OF A LOBE OF 36015 $2,403.00 INSERTION OF CATHETER INTO AORTA 36200 $1,513.00 INSERTION OF CATHETER INTO ARTERY FOR DRUG INFUSIO 37211 $8,244.00 INSERTION OF CATHETER INTO ARTERY/VEIN FOR DRUG IN 37213 $9,089.00 INSERTION OF CATHETER INTO CHEST AORTA FOR DIAGNOS 36221 $10,030.00 INSERTION OF CATHETER INTO CHEST ARTERY FOR DIAGNO 36226 $17,971.00 INSERTION OF CATHETER INTO CHEST OR ARM ARTERY 36215 $2,678.00 INSERTION OF CATHETER INTO CHEST OR ARM ARTERY 36216 $1,714.00 INSERTION OF CATHETER INTO CHEST OR ARM ARTERY 36217 $1,807.00 INSERTION OF CATHETER INTO CHEST OR ARM ARTERY 36218 $1,524.00 INSERTION OF CATHETER INTO EACH ADDITIONAL ABDOMIN 36248 $1,054.00 INSERTION OF CATHETER INTO LEFT HEART FOR DIAGNOSI 93452 $18,071.00 INSERTION OF CATHETER INTO LEFT HEART FOR DIAGNOSI 93462 $13,036.00 INSERTION OF CATHETER INTO LEFT OR RIGHT PULMONARY 36014 $2,096.00 INSERTION OF CATHETER INTO PORTAL VEIN OF LIVER, A 36481 $6,331.00 INSERTION OF CATHETER INTO RIGHT AND LEFT HEART FO 93453 $10,512.00 INSERTION OF CATHETER INTO RIGHT HEART OR MAIN PUL 36013 $2,225.00 INSERTION OF CATHETER INTO URINARY DUCT (URETER) U 52005 $3,393.00 INSERTION OF CATHETER INTO VEIN 36011 $2,792.00 INSERTION OF CATHETER INTO VEIN 36012 $2,008.00 INSERTION OF CATHETER INTO VEIN FOR DRUG INFUSION 37212 $4,073.00 INSERTION OF CATHETER INTO VEIN OF NAVEL, NEWBORN 36510 $214.00 INSERTION OF CATHETER INTO VEIN WITH COLLECTION OF 36500 $1,591.00 INSERTION OF CATHETER OR TUBE IN ESOPHAGUS STOMACH 43241 $2,259.00 INSERTION OF CATHETERS FOR CREATION OF COMPLETE HE 93650 $9,040.00 INSERTION OF CATHETERS FOR TREATMENT OF ABNORMAL H 93655 $16,993.00 INSERTION OF CENTRAL VENOUS CATHETER FOR INFUSION, 36556 $2,230.00 INSERTION OF CENTRAL VENOUS CATHETER FOR INFUSION, 36558 $4,538.00 INSERTION OF CENTRAL VENOUS CATHETER FOR INFUSION, 36569 $2,227.00 INSERTION OF DEFIBRILLATOR ELECTRODE 33271 $18,249.00 INSERTION OF DEVICE INTO BLADDER TO MEASURE PRESSU 51725 $910.00 INSERTION OF DRUG AGENT OR PACKING TO CONTROL VAGI 57180 $587.00 INSERTION OF DRUG DELIVERY IMPLANT INTO TISSUE 11981 $150.00 INSERTION OF ELECTRONIC DEVICE INTO BLADDER WITH V 51728 $1,458.00 INSERTION OF FEEDING TUBE (ACCESSED BENEATH THE SK 44372 $2,541.00 INSERTION OF FEEDING TUBE OR CATHETER INTO UPPER S 44015 $1,150.00 INSERTION OF GUIDE WIRE FOR DILATION OF ESOPHAGUS 43226 $5,378.00 INSERTION OF GUIDE WIRE WITH DILATION OF ESOPHAGUS 43248 $2,473.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INSERTION OF HARDWARE TO BROKEN FINGER, ACCESSED T 26608 $6,995.00 INSERTION OF IMPLANTS TO BLOCK BOTH FALLOPIAN TUBE 58565 $10,379.00 INSERTION OF INDWELLING BLADDER CATHETER 51702 $359.00 INSERTION OF INDWELLING BLADDER CATHETER 51703 $426.00 INSERTION OF INDWELLING CATHETER ADMIN OF SUBSTANC 62324 $1,379.00 INSERTION OF INDWELLING CATHETER ADMIN OF SUBSTANC 62326 $1,351.00 INSERTION OF LEFT HEART ELECTRODE FOR PACING DEFIB 33225 $28,247.00 INSERTION OF LENS PROSTHESIS 66985 $9,631.00 INSERTION OF LOWER HEART CHAMBER BLOOD FLOW ASSIST 33990 $14,491.00 INSERTION OF NASAL OR ORAL STOMACH TUBE USING FLUO 43752 $825.00 INSERTION OF NEEDLE AND/OR CATHETER INTO DIALYSIS 36901 $3,008.00 INSERTION OF NEEDLE AND/OR CATHETER INTO DIALYSIS 36902 $9,079.00 INSERTION OF NEEDLE AND/OR CATHETER INTO DIALYSIS 36903 $3,008.00 INSERTION OF NEEDLE FOR INFUSION INTO BONE 36680 $683.00 INSERTION OF NEEDLE INTO SCALP VEIN, PATIENT YOUNG 36405 $84.00 INSERTION OF NEEDLE INTO VEIN, PATIENT 3 YEARS OR 36410 $150.00 INSERTION OF NEEDLE INTO VEIN, PATIENT YOUNGER THA 36406 $76.00 INSERTION OF NEEDLE OR CATHETER INTO A VEIN 36000 $184.00 INSERTION OF NEEDLE OR CATHETER INTO AN ARTERY OF 36140 $1,783.00 INSERTION OF NEEDLE OR CATHETER INTO AORTA 36160 $1,925.00 INSERTION OF NEEDLE OR CATHETER INTO THE CAROTID O 36100 $1,679.00 INSERTION OF PACEMAKER PULSE GENERATOR WITH EXISTI 33213 $13,929.00 INSERTION OF PACING DEFIBRILLATOR PULSE GENERATOR 33240 $99,210.00 INSERTION OF PERMANENT CATHETER FOR DRAINAGE OF LU 32550 $6,795.00 INSERTION OF PROBE IN ESOPHAGUS FOR HEART ULTRASOU 93313 $2,791.00 INSERTION OF RADIATION DELIVERY DEVICE INTO HEART 92974 $8,708.00 INSERTION OF SHUNT FROM JUGULAR VEIN TO ABDOMINAL 49425 $3,726.00 INSERTION OF SHUNTS TO BYPASS BLOOD FLOW TO LIVER 37182 $10,412.00 INSERTION OF STENT IN DIALYSIS SEGMENT WITH IMAGIN 36908 $2,833.00 INSERTION OF STENT IN URINARY DUCT (URETER) USING 52332 $3,999.00 INSERTION OF STENTS IN NECK ARTERY, OPEN OR ACCESS 37216 $5,870.00 INSERTION OF STENTS INTO ARTERY IN ONE LEG ENDOVAS 37230 $28,368.00 INSERTION OF STENTS INTO ARTERY IN ONE LEG ENDOVAS 37234 $23,894.00 INSERTION OF STENTS INTO VERTEBRAL ARTERY VIA CATH 0075T $9,515.00 INSERTION OF STENTS INTO VERTEBRAL ARTERY VIA CATH 0076T $10,016.00 INSERTION OF STOMACH FEEDING TUBE, OPEN PROCEDURE 43830 $7,334.00 INSERTION OF STOMACH TUBE AND ASPIRATIONS OF GASTR 43753 $623.00 INSERTION OF STOMACH TUBE USING AN ENDOSCOPE 43246 $2,076.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INSERTION OF TEMPORARY BLADDER CATHETER 51701 $194.00 INSERTION OF VENA CAVA FILTER BY ENDOVASCULAR APPR 37191 $15,472.00 INSERTION OR REPLACEMENT OF DEFIBRILLATOR WITH ELE 33270 $47,502.00 INSERTION OR REPLACEMENT PERMANENT PACEMAKER AND L 33207 $16,328.00 INSERTION OR REPLACEMENT PERMANENT PACEMAKER AND U 33206 $20,340.00 INSERTION OR REPLACEMENT SINGLE OR DUAL CHAMBER PA 33249 $49,973.00 INSERTION PICC W/RS&I 5 YR/> 31648 $6,173.00 INSERTION SUBQ CARDIAC RHYTHM MONITOR W/PRGRMG 33285 $20,362.00 INSULIN ANTIBODY MEASUREMENT 86337 $265.00 INSULIN ASPART PROTAMINE-INSULIN ASPART 70-30 100 J1815 $1,260.49 INSULIN ASPART U-100 100 UNIT/ML SOLN 10 ML VIAL J1815 $1,215.31 INSULIN DETEMIR U-100 100 UNIT/ML SOLN 10 ML VIAL J1815 $1,294.20 INSULIN GLARGINE 100 UNIT/ML SOLN 10 ML VIAL J1815 $1,190.95 INSULIN LISPRO 100 UNIT/ML SOLN 10 ML VIAL J1815 $1,153.74 INSULIN MEASUREMENT 83525 $135.00 INSULIN NPH 100 UNIT/ML SUSP 10 ML VIAL J1815 $578.34 INSULIN NPH-INSULIN REGULAR 70/30 100 UNIT/ML (70- J1815 $624.54 INSULIN REGULAR 100 UNIT/ML SOLN 10 ML VIAL J1815 $624.54 INSULIN TOLERANCE PANEL FOR ACTH (ADRENAL GLAND HO 80434 $834.00 INSULIN TOLERANCE PANEL FOR GROWTH HORMONE DEFICIE 80435 $850.00 INSULIN-INDUCED C-PEPTIDE (PROTEIN) SUPPRESSION PA 80432 $1,114.00 INTACT PARATHYROID 83970 $280.00 INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML PNIJ 0. Q3028 $2,548.01 INTERNAL SHOCK TO HEART TO REGULATE HEART BEAT 92961 $1,971.00 INTERPRETATION AND REPORT OF GENETIC TESTING 88291 $250.00 INTESTINE IMAGING 78290 $1,726.00 INTRACRAN ANGIOPLSTY W/STENT 61635 $14,191.00 INTRA-OPERATIVE HEART PACING & MAPPING ABNORM HEAR 93631 $6,490.00 INTRAOPERATIVE NEUROPHYSIOLOGY MONITORING G0453 $303.00 INTRINSIC FACTOR (STOMACH PROTEIN) ANTIBODY MEASUR 86340 $211.00 INTRINSIC FACTOR (STOMACH PROTEIN) LEVEL 83528 $131.00 INTRODUCTION CONTRAST MATERIAL FOR X-RAY IMAGING O 58340 $629.00 INTRODUCTION OF CATHETER INTO THE UPPER OR LOWER M 36010 $1,954.00 IOHEXOL 12 MG IODINE/ML SOLN 500 ML BOTTLE $35.00 IOHEXOL 240 MG IODINE/ML SOLN 20 ML VIAL Q9966 $483.18 IOHEXOL 300 MG IODINE/ML SOLN 100 ML BOTTLE Q9967 $190.58 IOHEXOL 300 MG IODINE/ML SOLN 50 ML BOTTLE Q9967 $194.60 IOHEXOL 350 MG IODINE/ML SOLN 100 ML BOTTLE Q9967 $211.93 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge IOHEXOL 350 MG IODINE/ML SOLN 200 ML BOTTLE Q9967 $180.08 IOHEXOL 350 MG IODINE/ML SOLN 50 ML BOTTLE Q9967 $211.93 IOPAMIDOL 41 % SOLN 10 ML VIAL Q9966 $271.43 IOPAMIDOL 41 % SOLN 20 ML VIAL Q9966 $185.96 IOPAMIDOL 51 % SOLN 100 ML BOTTLE Q9966 $161.53 IOPAMIDOL 51 % SOLN 50 ML VIAL Q9966 $182.18 IOPAMIDOL 61 % SOLN 100 ML BOTTLE Q9967 $184.98 IOPAMIDOL 61 % SOLN 15 ML VIAL Q9967 $360.68 IOPAMIDOL 61 % SOLN 200 ML BOTTLE Q9967 $99.58 IOPAMIDOL 61 % SOLN 30 ML VIAL Q9967 $296.80 IOPAMIDOL 61 % SOLN 50 ML VIAL Q9967 $189.35 IOPAMIDOL 76 % SOLN 100 ML BOTTLE Q9967 $205.28 IOPAMIDOL 76 % SOLN 200 ML BOTTLE Q9967 $181.13 IOPAMIDOL 76 % SOLN 50 ML VIAL Q9967 $214.38 IPILIMUMAB 50 MG/10 ML (5 MG/ML) SOLN 10 ML VIAL J9228 $42,456.20 IPRATROPIUM 0.02 % SOLN 2.5 ML VIAL $4.62 IPRATROPIUM 0.03 % SPRY 30 ML CANISTER $390.81 IPRATROPIUM 17 MCG/ACTUATION HFAA 12.9 G AER W/ADA $1,509.27 IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 M $3.83 IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION MIST 4 $1,564.54 IRBESARTAN 150 MG TAB 1 EACH BLIST PACK $5.88 IRBESARTAN 150 MG TAB 30 EACH BLIST PACK $1.65 IRBESARTAN 150 MG TAB 50 EACH BLIST PACK $5.88 IRINOTECAN 100 MG/5 ML SOLN 5 ML VIAL J9206 $156.75 IRINOTECAN 40 MG/2 ML SOLN 2 ML VIAL J9206 $90.30 IRINOTECAN LIPOSOMAL 4.3 MG/ML DISP 10 ML VIAL J9205 $8,223.60 IRON BINDING CAPACITY 83550 $109.00 IRON DEXTRAN 50 MG/ML SOLN 2 ML VIAL J1750 $27.85 IRON SUCROSE 100 MG IRON/5 ML SOLN 5 ML VIAL J1756 $210.00 IRON, SERUM 83540 $108.00 IRRADIATION OF BLOOD PRODUCT, EACH UNIT 86945 $150.00 IRRIGATION AND SUCTION OF LUNG AIRWAYS TO OBTAIN C 31624 $2,480.00 IRRIGATION OF ABDOMINAL CAVITY 49084 $3,089.00 IRRIGATION OF IMPLANTED VENOUS ACCESS DRUG DELIVER 96523 $255.00 IRRIGATION OF NASAL SINUS 31000 $800.00 ISLET CELL AB, IGG 86341 $223.00 ISOCITRIC DEHYDROGENASE (ENZYME) LEVEL 83570 $73.00 ISOFLURANE 99.9 % LIQD 100 ML BOTTLE $100.80 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ISOFLURANE 99.9 % LIQD 250 ML BOTTLE $241.50 ISONIAZID 300 MG TAB 100 EACH BLIST PACK $4.51 ISONIAZID 300 MG TAB 100 EACH BOTTLE $1.09 ISOPROTERENOL 0.2 MG/ML SOLN 5 ML AMPUL $150.37 ISOPROTERENOL 0.2 MG/ML SOLN 5 ML VIAL $109.20 ISOSORBIDE DINITRATE 10 MG TAB 1 EACH BLIST PACK $6.72 ISOSORBIDE DINITRATE 10 MG TAB 100 EACH BLIST PACK $6.72 ISOSORBIDE DINITRATE 20 MG TAB 100 EACH BLIST PACK $3.36 ISOSORBIDE DINITRATE 40 MG TBSR 100 EACH BOTTLE $8.32 ISOSORBIDE DINITRATE 5 MG TAB 1 EACH BLIST PACK $7.44 ISOSORBIDE MONONITRATE 20 MG TAB 100 EACH BOTTLE $0.36 ISOSORBIDE MONONITRATE 30 MG TB24 100 EACH BLIST P $5.87 ISOSORBIDE MONONITRATE 30 MG TB24 100 EACH BOTTLE $1.81 ISOSORBIDE MONONITRATE 60 MG TB24 1 EACH BLIST PAC $3.60 ISOSORBIDE MONONITRATE 60 MG TB24 100 EACH BLIST P $3.60 ISOSORBIDE-HYDRALAZINE 20-37.5 MG TAB 180 EACH BOT $14.25 ISOSULFAN BLUE 1 % SOLN 5 ML VIAL Q9968 $371.46 ISRADIPINE 2.5 MG CAP 1 EACH BLIST PACK $8.34 ISRADIPINE 2.5 MG CAP 50 EACH BLIST PACK $8.34 IVABRADINE 7.5 MG TAB 60 EACH BOTTLE $30.07 JO1 (ENA) AB 86235 $193.00 KETAMINE 10 MG/ML SOLN 20 ML VIAL $1.89 KETAMINE 100 MG/ML SOLN 5 ML VIAL $0.34 KETAMINE 50 MG/ML SOLN 10 ML VIAL $14.70 KETOCONAZOLE 2 % CREA 30 G TUBE $182.39 KETOCONAZOLE 2 % SHAM 120 ML BOTTLE $105.84 KETOCONAZOLE 200 MG TAB 100 EACH BOTTLE $13.27 KETONE BODIES ANALYSIS 82010 $140.00 KETOROLAC 0.5 % DROP 5 ML DROP BTL $374.05 KETOROLAC 10 MG TAB 100 EACH BOTTLE $7.55 KETOROLAC 30 MG/ML (1 ML) SOLN 1 ML VIAL J1885 $7.35 KETOROLAC 60 MG/2 ML SOLN 2 ML VIAL J1885 $5.25 KIDNEY BIOPSY, LEV 6 88309 $925.00 KIDNEY FUNCTION BLOOD TEST PANEL 80069 $322.00 L&D RECOVERY $1,720.00 LABCORP 5-HIAA 83497 $169.00 LABCORP ACTIVATED PROTEIN C RESISTANCE ASSAY 85307 $280.00 LABCORP ADENOSINE CYLIC AMP 82030 $103.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP ADENOVIRUS ANTIGEN INFECTIOUS AGENT IMMUNO 87301 $144.00 LABCORP AFB BY ID DNA PROBE 87149 $95.00 LABCORP AG DETECT LEGIONELLA EIA, URINE 87449 $274.00 LABCORP ALDOLASE 82085 $165.00 LABCORP ALKALINE PHOSPHATASE 84075 $222.00 LABCORP ALKALINE PHOSPHATASE ISOENZYME 84080 $101.00 LABCORP ALLERGEN 86003 $67.00 LABCORP ALPHA FETOPROTEIN AMNIOTIC 82106 $145.00 LABCORP ALPHA FETOPROTEIN, TUMOR MARKER 82105 $222.00 LABCORP ALPHA-1 ANTITRYPSIN 82103 $187.00 LABCORP ALPHA-1 ANTITRYPSIN 82104 $232.00 LABCORP ALUMINUM 82108 $141.00 LABCORP AMIKACIN - PEAK 80150 $133.00 LABCORP AMIKACIN - RANDOM 80150 $133.00 LABCORP AMIKACIN - TROUGH 80150 $133.00 LABCORP AMIODARONE 80299 $182.00 LABCORP AMITRIPTYLINE AND NORTRIPTYLINE 80335 $121.00 LABCORP AMYLASE ISOENZYMES 82150 $152.00 LABCORP ANDROSTENEDIONE 82157 $93.00 LABCORP ANTIMYOCARDIAL AB 86256 $203.00 LABCORP ANTINUCLEAR ANTIBODY SCREEN 86038 $290.00 LABCORP ANTISTREPTOLYSIN O 86060 $175.00 LABCORP ANTITHROMBIN III ACTIVITY 85300 $283.00 LABCORP ARSENIC 82175 $258.00 LABCORP ARSENIC URINE 82175 $258.00 LABCORP B2 GLYCOPROTEIN AB IGA 86146 $184.00 LABCORP B2 GLYCOPROTEIN AB IGG 86146 $184.00 LABCORP B2 GLYCOPROTEIN AB IGM 86146 $184.00 LABCORP BARTONELLA ANTIBODY (CAT SCRATCH) 86611 $125.00 LABCORP BETA-2 MICROGLOBULIN 82232 $197.00 LABCORP BILE ACIDS 82239 $259.00 LABCORP BK VIRUS 87799 $568.00 LABCORP BK VIRUS URINE 87799 $568.00 LABCORP BLASTOMYCES ANTIBODY 86612 $117.00 LABCORP BRUCELLA ANTIBODY 86622 $63.00 LABCORP C. DIFF TOXIN AG 87324 $250.00 LABCORP C1 ESTERASE INHIBITOR 86160 $259.00 LABCORP CA 125 86304 $376.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP CA 19 9 86301 $315.00 LABCORP CADMIUM 82300 $191.00 LABCORP CADMIUM URINE 82300 $191.00 LABCORP CAFFEINE THERAPUTIC DRUG ANALYSIS 80155 $233.00 LABCORP CALCITONIN 82308 $236.00 LABCORP CALCIUM IONIZED 82330 $152.00 LABCORP CARBAMAZEPINE 80156 $226.00 LABCORP CAROTENE 82380 $294.00 LABCORP CATECHOLAMINES FRACTION 82384 $344.00 LABCORP CATECHOLAMINES FRACTION URINE 82384 $344.00 LABCORP CEA CARCINOEMBRYONIC ANTIG 82378 $279.00 LABCORP CHLAMYDIA ANTIBODY IGG 86631 $139.00 LABCORP CHLAMYDIA ANTIBODY IGM 86632 $124.00 LABCORP CLOMIPRAMINE 80335 $121.00 LABCORP CLONAZEPAM LEVEL 80346 $193.00 LABCORP CLOZAPINE (CLOZARIL) 80159 $240.00 LABCORP COAGULATION/FIBRINOLYSIS EA ANALYTE 85397 $176.00 LABCORP COLD AGGLUTININ TITER 86157 $151.00 LABCORP COMPLEMENT C1Q 86160 $259.00 LABCORP COMPLEMENT C2 86160 $259.00 LABCORP COMPLEMENT C3 86160 $259.00 LABCORP COMPLEMENT C5 86160 $259.00 LABCORP COMPLEMENT C6 86160 $259.00 LABCORP COMPLEMENT TOTAL 86162 $281.00 LABCORP COMPLIMENT C8 86160 $259.00 LABCORP CORTISOL FREE, URINE 82530 $250.00 LABCORP CORTISOL LC/MS 82533 $326.00 LABCORP CORTISOL, AM 82533 $326.00 LABCORP CORTISOL, PM 82533 $326.00 LABCORP C-PEPTIDE 84681 $139.00 LABCORP C-REACTIVE PROTEIN 86140 $131.00 LABCORP C-REACTIVE PROTEIN HIGH SENSITIVITY 86141 $131.00 LABCORP CREATINE KINASE (CK) ISOENZYME 82552 $206.00 LABCORP CREATINE KINASE (CPK) 82550 $121.00 LABCORP CREATININE URINE 82570 $103.00 LABCORP CRYOGLOBULIN 82595 $158.00 LABCORP CRYPTOCOCCUS ANTIGEN CSF 87899 $197.00 LABCORP CRYPTOCOCCUS ANTIGEN TITER CSF 87449 $274.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP CULTURE AFB 87116 $239.00 LABCORP CULTURE CMV 87254 $239.00 LABCORP CULTURE FUNGUS 87101 $104.00 LABCORP CULTURE FUNGUS BLOOD 87103 $270.00 LABCORP CULTURE STOOL 87045 $202.00 LABCORP CULTURE STOOL ADDITIONAL 87046 $86.00 LABCORP CULTURE VIRUS 87252 $313.00 LABCORP CYCLIC CITRUL PEPTIDE (CCP) ANTIBODY 86200 $190.00 LABCORP CYCLOSPORA SMEAR 87206 $121.00 LABCORP CYCLOSPORINE 80158 $354.00 LABCORP CYSTINE URINE 24 HOUR 82131 $145.00 LABCORP CYTOMEGALOVIRUS AB IGG 86644 $184.00 LABCORP CYTOMEGALOVIRUS AB IGM 86645 $219.00 LABCORP CYTOMEGALOVIRUS NUCLEIC ACID PROBE AMPLIFI 87496 $410.00 LABCORP CYTOMEGALOVIRUS QUANTITATIVBE NUCLEIC ACID 87497 $617.00 LABCORP DEOXYRIBONUCLEASE ANTIBODY 86215 $213.00 LABCORP DHEA-S 82627 $303.00 LABCORP DRUG TEST PRESUMPTIVE 80307 $180.00 LABCORP DS DNA AB 86225 $164.00 LABCORP EBV AB VCA IGG 86665 $146.00 LABCORP EBV AB VCA IGM 86665 $146.00 LABCORP ECHINOCOCCUS AB IGG 86682 $258.00 LABCORP EOSINOPHIL URINE 87205 $66.00 LABCORP ERYTHROPOIETIN 82668 $230.00 LABCORP ESTRADIOL 82670 $409.00 LABCORP ESTRIOL 82677 $147.00 LABCORP ESTRONE 82679 $367.00 LABCORP ETHOSUXIMIDE 80168 $180.00 LABCORP F5 (COAGULATION FACTOR V) GENE LEIDEN VARI 81241 $461.00 LABCORP F-ACTIN AB IGG 83516 $221.00 LABCORP FACTOR 9 ASSAY 85250 $434.00 LABCORP FACTOR VII STABLE FACTOR 85230 $321.00 LABCORP FACTOR VIII ASSAY 85240 $382.00 LABCORP FACTOR X STUART PROWER 85260 $357.00 LABCORP FACTOR XI ASSAY 85270 $325.00 LABCORP FAT QUALITATIVE FECES 82705 $121.00 LABCORP FAT QUANTITATIVE FECES 82710 $272.00 LABCORP FDP/FSP AGGLUTINATION SEMIQUANTITATIVE 85362 $225.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP FELBAMATE 80339 $361.00 LABCORP FERRITIN 82728 $161.00 LABCORP FLUOR AB SCR ADRENAL AB 86255 $246.00 LABCORP FLUOXETINE 80332 $259.00 LABCORP FOLIC ACID 82746 $184.00 LABCORP FOLIC ACID RBC 82747 $53.00 LABCORP FREE LIGHT CHAIN, SERUM 83883 $119.00 LABCORP FSH 83001 $326.00 LABCORP G6-PD QUANT 82955 $23.00 LABCORP GABAPENTIN BLD/SRM/PLASMA THERAPUTIC DRUG 80171 $204.00 LABCORP GASTRIN 82941 $184.00 LABCORP GENTAMICIN THERAPEUTIC DRUG ANALYSIS - PEA 80170 $239.00 LABCORP GENTAMICIN THERAPEUTIC DRUG ANALYSIS - TRO 80170 $239.00 LABCORP GGT (GLUTAMYLTRANSFERASE GAMMA) 82977 $154.00 LABCORP GIARDIA ANTIGEN 87329 $99.00 LABCORP GLUCAGON 82943 $249.00 LABCORP GLUCOSE BODY FLUID 82945 $110.00 LABCORP GLUTAMIC ACID DECARBOXYLASE AB 83516 $221.00 LABCORP GROWTH HORMONE 83003 $197.00 LABCORP H PYLORI ANTIBODY IGA 86677 $284.00 LABCORP H PYLORI ANTIBODY IGG 86677 $284.00 LABCORP H PYLORI ANTIBODY IGM 86677 $284.00 LABCORP HAPTOGLOBIN QUANT 83010 $242.00 LABCORP HCG QUANTITATIVE TUMOR MARKER 84702 $253.00 LABCORP HEMATOCRIT 85014 $154.00 LABCORP HEMOGLOBIN CHROMATOGRAPHY 83021 $181.00 LABCORP HEP A AB, IGM 86709 $205.00 LABCORP HEP B SURF ANTIGEN CONFIRM 87341 $179.00 LABCORP HEP B SURFACE AB 86706 $125.00 LABCORP HEPARIN ASSAY 85520 $112.00 LABCORP HEPATITIS A (HAAB) ANTIBODY 86708 $128.00 LABCORP HEPATITIS B CORE AB IGM 86705 $244.00 LABCORP HEPATITIS B CORE ANTIBODY TOTAL 86704 $170.00 LABCORP HEPATITIS B QUANTATIVE NUCLEIC ACID PROBE 87517 $564.00 LABCORP HEPATITIS BE ANTIBODY 86707 $125.00 LABCORP HEPATITIS BE ANTIGEN INFECTIOUS AGENT IMMU 87350 $126.00 LABCORP HEPATITIS C AB 86803 $293.00 LABCORP HERPES (HSV) NUCLEIC ACID PROBE AMPLIFIED 87529 $391.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP HERPES SIMPLEX TYPE 2 ANTIBODY 86696 $161.00 LABCORP HGB A2 83021 $181.00 LABCORP HGB LCA INTERP 85660 $86.00 LABCORP HISTOPLASMA AG 87385 $292.00 LABCORP HISTOPLASMA ANTIBODY 86698 $150.00 LABCORP HIV 1 ANTIBODY???????????????????????????? 86701 $307.00 LABCORP HIV 2 ANTIBODY???????????????????????????? 86702 $230.00 LABCORP HIV GENOTYPE ANALYSIS BY DNA OR RNA 87901 $1,275.00 LABCORP HIV PHENOTYPE W/CULTURE 87903 $2,124.00 LABCORP HIV PHENOTYPE W/CULTURE ADDITIONAL 87904 $277.00 LABCORP HIV1 NUCLEIC ACID PROBE AMPLIFIED 87535 $514.00 LABCORP HIV1 QNT PCR 87536 $649.00 LABCORP HLA-B5701 81381 $832.00 LABCORP HOMOCYSTEIN 83090 $224.00 LABCORP HSV 1 AB IGG 86695 $122.00 LABCORP HSV 1/2 AB IGM 86694 $156.00 LABCORP HSV 1/2 AB IGM CSF 86694 $156.00 LABCORP IGE GAMMAGLOBULIN 82785 $256.00 LABCORP IGH/BCL2 FISH 88366 $2,051.00 LABCORP IMIPRAMINE 80335 $121.00 LABCORP IMMUNOGLOBULIN A 82784 $229.00 LABCORP IMMUNOGLOBULIN G 82784 $229.00 LABCORP IMMUNOGLOBULIN M 82784 $229.00 LABCORP INSULIN ANTIBODY 86337 $265.00 LABCORP INTRINSIC FACTOR ANTIBODY 86340 $211.00 LABCORP IRON 83540 $108.00 LABCORP KOH SMEAR FLUORESCENT/ACID STAIN 87206 $121.00 LABCORP LACTATE DEHYDROGENASE (LDH) 83615 $101.00 LABCORP LAMOTRIGINE (LAMICTAL) 80175 $233.00 LABCORP LD BLOOD 83615 $101.00 LABCORP LD ISOENZYME 83625 $168.00 LABCORP LEAD BLOOD 83655 $184.00 LABCORP LEAD URINE 83655 $184.00 LABCORP LEAD WHOLE BLOOD 83655 $184.00 LABCORP LEGIONELLA ANTIBODY 86713 $246.00 LABCORP LEGIONELLA ANTIGEN IMMUNOFLUORESCENT 87278 $179.00 LABCORP LEVETIRACETAM (KEPRA) 80177 $233.00 LABCORP LIDOCAINE 80176 $180.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP LIPASE 83690 $152.00 LABCORP LIPOPROTEIN (A) 83695 $247.00 LABCORP LITHIUM 80178 $160.00 LABCORP LIVER KIDNEY MICROSOME AB 86376 $182.00 LABCORP LUTEINIZING HORMONE 83002 $306.00 LABCORP LYME DISEASE AB CONFIRM 86617 $201.00 LABCORP LYME DISEASE ANTIBODY 86618 $213.00 LABCORP LYSOZYME (MURAMIDASE) 85549 $181.00 LABCORP M MARINUM SUSC 87186 $188.00 LABCORP MAC SUSC 87186 $188.00 LABCORP MAGNESIUM URINE 83735 $111.00 LABCORP MATERNAL SCREEN QUAD 81511 $623.00 LABCORP METANEPHRINE FRACTIONATED 83835 $203.00 LABCORP METANEPHRINE FRACTIONATED, URINE 83835 $203.00 LABCORP MEXILETINE 80299 $182.00 LABCORP MIC PER PLATE 87186 $188.00 LABCORP MIC PER PLATE RAPID 87186 $188.00 LABCORP MIC PER PLATE SLOW 87186 $188.00 LABCORP MICROALBUMIN URINE QUANTITATIVE 82043 $99.00 LABCORP MITOCHONDRIAL M2 AB IGG 83516 $221.00 LABCORP MMA URINE 83921 $309.00 LABCORP MOLECULAR CYTO HER-2/NEU 88271 $315.00 LABCORP MTB AST CONFIRM 87190 $46.00 LABCORP MTB SUSC BROTH 87188 $170.00 LABCORP MTHFR (5,10-METHYLENETETRAHYDROFOLATE REDU 81291 $559.00 LABCORP MUMPS ANTIBODY IGG 86735 $187.00 LABCORP MUMPS ANTIBODY IGM 86735 $187.00 LABCORP MYCO TB PROBE 87556 $313.00 LABCORP MYCOBACTERIA TB NUCLEIC ACID PROBE AMPLIFI 87556 $462.00 LABCORP MYCOPLASMA PNEUMONIA, IGG 86738 $174.00 LABCORP MYCOPLASMA PNEUMONIA, IGM 86738 $286.00 LABCORP NORTRIPTYLINE 80335 $121.00 LABCORP ORGANISM ID 87153 $322.00 LABCORP OSMOLALITY 83930 $129.00 LABCORP OSMOLALITY STOOL 84999 $143.00 LABCORP OSMOLALITY, URINE 83935 $101.00 LABCORP OVA AND PARASITE FECAL 87177 $191.00 LABCORP OXALATE, URINE 24 HOUR 83945 $113.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP OXCARBAZEPINE (TRILEPTAL) 80183 $233.00 LABCORP PARIETAL CELL ANTIBODY IGG 83516 $221.00 LABCORP PARTIAL THROMBOPLASTIN SUBSTITUTION 85732 $289.00 LABCORP PARVOVIRUS B19 IGG 86747 $113.00 LABCORP PARVOVIRUS B19 IGM 86747 $113.00 LABCORP PH STOOL 83986 $57.00 LABCORP PHENOTYPE PREDICT 87900 $815.00 LABCORP PHOSPHOROUS URINE 84105 $67.00 LABCORP PINWORM EXAM 87172 $108.00 LABCORP PLASMINOGEN ASSAY 85420 $292.00 LABCORP PLT AB PROFILE 86022 $423.00 LABCORP PNEUMOCYSTIS CARINII ANTIGEN IMMUNOFLUORES 87281 $228.00 LABCORP PORPHOBILINOGEN URINE QUANTITATIVE 84110 $150.00 LABCORP PORPHYRIN 84311 $253.00 LABCORP PORPHYRINS URINE QUANTITATIVE FRACTIONATIO 84120 $249.00 LABCORP PRIMIDONE 80188 $151.00 LABCORP PROCALCITONIN 84145 $275.00 LABCORP PROGESTERONE 84144 $253.00 LABCORP PROLACTIN 84146 $398.00 LABCORP PROTEIN C ACTIVITY 85303 $426.00 LABCORP PROTEIN C ANTIGEN 85302 $405.00 LABCORP PROTEIN ELECTROPHORESIS 84165 $221.00 LABCORP PROTEIN ELECTROPHORESIS URINE 84166 $190.00 LABCORP PROTEIN S FREE 85306 $363.00 LABCORP PROTEIN S FUNCTIONAL 85306 $363.00 LABCORP PROTEIN S TOTAL 85305 $405.00 LABCORP PROTEIN TOTAL 84155 $104.00 LABCORP PROTEIN TOTAL URINE 84156 $100.00 LABCORP PSA SCREEN 84153 $249.00 LABCORP PSA TOTAL 84153 $249.00 LABCORP PTH INTACT 83970 $280.00 LABCORP PTT-LA MIX 85730 $122.00 LABCORP PYRUVATE 84210 $153.00 LABCORP PYRUVATE KINASE 84220 $189.00 LABCORP QUINIDINE 80194 $103.00 LABCORP RBC COUNT AUTOMATED ONLY 85041 $173.00 LABCORP RENIN 84244 $281.00 LABCORP RETIC COUNT AUTOMATED 85045 $70.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP RHEUMATOID FACTOR QUANT 86431 $154.00 LABCORP RMSF IGG 86757 $136.00 LABCORP RMSF IGM 86757 $136.00 LABCORP ROTAVIRUS ANTIGEN INFECTIOUS AGENT IMMUNOA 87425 $138.00 LABCORP RUBELLA ANTIBODY IGG 86762 $172.00 LABCORP RUBELLA ANTIBODY IGM 86762 $172.00 LABCORP RUBEOLA AB, IGG 86765 $169.00 LABCORP RUSSELL VIPER VENOM DILUTED 85613 $175.00 LABCORP SHIGA LIKE TOXIN 87427 $123.00 LABCORP SICKLE CELL RBC 85660 $86.00 LABCORP SIROLIMUS (RAPAMYCIN) 80195 $308.00 LABCORP SMEAR FLUORESCENT/ACID STAIN 87015 $95.00 LABCORP SMEAR FLUORESCENT/ACID STAIN 87206 $121.00 LABCORP SOMATOMEDIN - C 84305 $283.00 LABCORP SS-A IGG 86235 $101.00 LABCORP SS-B IGG 86235 $220.00 LABCORP SSDNA AB 84156 $100.00 LABCORP STOOL WBC STAIN 87205 $66.00 LABCORP STREP GROUP B W/DIRECT OPTICAL OBSERVATION 87802 $99.00 LABCORP STREP PNEUMO AG 87899 $197.00 LABCORP STREP PNEUMONIAE ANTIGEN 87899 $197.00 LABCORP T GONDII AB IGG 86777 $195.00 LABCORP T GONDII AB IGM 86778 $185.00 LABCORP T3 REVERSE 84482 $400.00 LABCORP T3 TOTAL 84480 $256.00 LABCORP T3 UPTAKE 84479 $117.00 LABCORP T3, FREE 84481 $335.00 LABCORP TACROLIMUS 80197 $400.00 LABCORP TESTOSTERONE 84403 $283.00 LABCORP TESTOSTERONE FREE 84402 $312.00 LABCORP TETANUS/DIPHTHERIA AB 86317 $241.00 LABCORP THROMBIN CLOTTING TIME 85670 $107.00 LABCORP THYROGLOBULIN 84432 $101.00 LABCORP THYROGLOBULIN ANTIBODY 86800 $141.00 LABCORP THYROID STIMULATING IMMUNOGLOBULINS 84445 $546.00 LABCORP THYROXINE BINDING GLOBULIN (TBG) 84442 $165.00 LABCORP TISSUE GRINDING 87176 $66.00 LABCORP TOBRAMYCIN PEAK 80200 $142.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LABCORP TOBRAMYCIN TROUGH 80200 $142.00 LABCORP TOXOPLASMA GONDII AB, IGG, CSF 86777 $195.00 LABCORP TRANSFERRIN 84466 $102.00 LABCORP TREPONEMA PALLIDUM ANTIBODY 86780 $145.00 LABCORP TREPONEMA PALLIDUM FTA ABS 86780 $145.00 LABCORP TROFILE CO-RECEPTOR 87906 $948.00 LABCORP TROFILE DNA PDF 87901 $1,275.00 LABCORP URINE 82570 $103.00 LABCORP VALPROIC ACID TOTAL 80164 $220.00 LABCORP VANILLYMANDELIC ACID (VMA) URINE 84585 $214.00 LABCORP VARICELLA ZOSTER ANTIBODY IGG 86787 $133.00 LABCORP VDRL CSF 86592 $101.00 LABCORP VITAMIN A 84590 $165.00 LABCORP VITAMIN B-1 (THIAMINE) 84425 $254.00 LABCORP VITAMIN B12 82607 $206.00 LABCORP VITAMIN B-2 (RIBOFLAVIN) 84252 $265.00 LABCORP VITAMIN B6 (PYRIDOXINE) 84207 $418.00 LABCORP VITAMIN C (ASCORBIC ACID) 82180 $182.00 LABCORP VITAMIN D (1 25 HYDROXY) 82652 $348.00 LABCORP VITAMIN D-3 25-OH 82306 $395.00 LABCORP VITAMIN E (ALPHA TOCOPHEROL) 84446 $203.00 LABCORP VON WILLEBRAND FACTOR AG 85246 $256.00 LABCORP VONWILLEBRAND FACTOR ACT 85245 $292.00 LABCORP WET PREP 87210 $74.00 LABCORP ZINC 84630 $182.00 LABCORP ZINC URINE 84630 $182.00 LABCORP ZONISAMIDE (ZONEGRAN) THERAPUTIC DRUG ANAL 80203 $159.00 LABCORPISLET CELL ANTIBODY 86341 $219.00 LABCORP-THYROID PEROXIDASE TPO AB 86376 $182.00 LABETALOL 100 MG TAB 1 EACH BLIST PACK $1.28 LABETALOL 100 MG TAB 100 EACH BLIST PACK $1.90 LABETALOL 100 MG TAB 100 EACH BOTTLE $1.80 LABETALOL 200 MG TAB 1 EACH BLIST PACK $1.03 LABETALOL 200 MG TAB 100 EACH BLIST PACK $1.87 LABETALOL 200 MG TAB 100 EACH BOTTLE $1.62 LABETALOL 300 MG TAB 1 EACH BLIST PACK $1.23 LABETALOL 300 MG TAB 100 EACH BLIST PACK $1.23 LABETALOL 5 MG/ML SOLN 20 ML VIAL $2.94 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LACOSAMIDE 100 MG TAB 60 EACH BLIST PACK $66.56 LACOSAMIDE 200 MG/20 ML SOLN 20 ML VIAL C9254 $79.42 LACOSAMIDE 50 MG TAB 60 EACH BLIST PACK $42.57 LACTATE DEHYDROGENASE (ENZYME) MEASUREMENT 83625 $168.00 LACTATE,CSF 83605 $187.00 LACTATED RINGERS SOLP 1,000 ML BAG J7120 $17.50 LACTATED RINGERS SOLP 500 ML BAG J7120 $17.50 LACTIC ACID 83605 $139.00 LACTIC ACID BODY FLUID 83605 $139.00 LACTIC ACID LEVEL 83605 $139.00 LACTOBACILLUS ACIDOPH-L.BULGAR 1 MILLION CELL CHEW $3.51 LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAP 100 $3.83 LACTOBACILLUS RHAMNOSUS GG 15 BILLION CELL CPSP 30 $2.28 LACTULOSE 20 GRAM/30 ML SOLN 30 ML CUP $1.42 LAMELLAR BODY DENSITY SENDOUT 83664 $139.00 LAMIVUDINE 10 MG/ML SOLN 240 ML BOTTLE $26.20 LAMIVUDINE 10 MG/ML SOLN 5 ML CUP $26.20 LAMIVUDINE 150 MG TAB 1 EACH BLIST PACK $16.04 LAMIVUDINE 150 MG TAB 30 EACH BLIST PACK $14.29 LAMIVUDINE 150 MG TAB 60 EACH BOTTLE $12.52 LAMIVUDINE-ZIDOVUDINE 150-300 MG TAB 60 EACH BOTTL $54.34 LAMOTRIGINE 100 MG TAB 100 EACH BLIST PACK $16.63 LAMOTRIGINE 25 MG TAB 1 EACH BLIST PACK $14.56 LAMOTRIGINE 25 MG TAB 100 EACH BLIST PACK $14.56 LAMOTRIGINE LEVEL 80175 $233.00 LANGUAGE EXPRESSION FUNCTIONAL LIMIT CURRENT STATU G9162 $0.01 LANGUAGE EXPRESSION FUNCTIONAL LIMIT DISCHARGE STA G9164 $0.01 LANGUAGE EXPRESSION FUNCTIONAL LIMIT GOAL STATUS G9163 $0.01 LANGUAGE FUNCTIONAL LIMIT CURRENT STATUS G9159 $0.01 LANGUAGE FUNCTIONAL LIMIT DISCHARGE STATUS G9161 $0.01 LANGUAGE FUNCTIONAL LIMIT GOAL STATUS G9160 $0.01 LANOLIN ALCOHOL-MO-W.PET-CERES CREA 113 G JAR $0.25 LANSOPRAZOLE 30 MG CPDR 1 EACH BLIST PACK $9.92 LANSOPRAZOLE 30 MG CPDR 100 EACH BLIST PACK $9.92 LANSOPRAZOLE 30 MG TBLD 100 EACH BLIST PACK $29.06 LANTHANUM 500 MG CHEW 45 EACH BOTTLE $50.43 LARYNGOSCOPY INDIRECT WITH REMOVAL OF FOREIGN BODY 31511 $561.00 LASER DESTRUCTION OF INCOMPETENT VEIN OF ARM OR LE 36478 $5,968.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LASER REPAIR TO IMPROVE EYE FLUID FLOW, 1 OR MORE 65855 $4,486.00 LASER VAPORIZATION OF PROSTATE INCLUDING CONTROL B 52648 $8,691.00 LATANOPROST 0.005 % DROP 2.5 ML DROP BTL $855.87 LDH-BLOOD 83615 $101.00 LDH-MISC 83615 $101.00 LDL CHOLESTEROL LEVEL 83721 $124.00 LEAD LEVEL 83655 $184.00 LEAD, BLOOD 83655 $184.00 LEGIONELLA PNEUMOPHILA,DFA 87278 $179.00 LETROZOLE 2.5 MG TAB 30 EACH BOTTLE $63.40 LEUCINE AMINOPEPTIDASE (ENZYME) LEVEL 83670 $76.00 LEUCOVORIN 100 MG SOLR 1 EACH VIAL J0640 $0.67 LEUCOVORIN 25 MG TAB 1 EACH BLIST PACK $8.99 LEUCOVORIN 350 MG SOLR 1 EACH VIAL J0640 $0.31 LEUCOVORIN 5 MG TAB 50 EACH BLIST PACK $11.38 LEUPROLIDE (1 MONTH) 7.5 MG SYKT 1 EACH KIT J9217 $6,128.36 LEUPROLIDE (3 MONTH) 22.5 MG SYKT 1 EACH KIT J9217 $18,384.59 LEUPROLIDE (3 MONTH) 22.5 MG SYRG 1 EACH SYRINGE J9217 $5,691.29 LEUPROLIDE (6 MONTH) 45 MG SYKT 1 EACH KIT J9217 $36,770.58 LEUPROLIDE (6 MONTH) 45 MG SYRG 1 EACH SYRINGE J9217 $11,382.55 LEUPROLIDE 3.75 MG SYKT 1 EACH KIT J1950 $5,142.69 LEVALBUTEROL 0.63 MG/3 ML NEBU 3 ML VIAL $43.68 LEVALBUTEROL 1.25 MG/3 ML NEBU 3 ML VIAL $5.60 LEVALBUTEROL 45 MCG/ACTUATION HFAA 15 G AER W/ADAP $257.93 LEVETIRACETAM 250 MG TAB 100 EACH BLIST PACK $0.82 LEVETIRACETAM 500 MG TAB 100 EACH BLIST PACK $11.07 LEVETIRACETAM 500 MG/5 ML (5 ML) SOLN 5 ML CUP $16.35 LEVETIRACETAM 500 MG/5 ML SOLN 5 ML VIAL J1953 $44.10 LEVETIRACETAM LEVEL 80177 $233.00 LEVOBUNOLOL 0.5 % DROP 5 ML DROP BTL $19.53 LEVOCARNITINE 100 MG/ML SOLN 118 ML BOTTLE $142.90 LEVOCARNITINE 200 MG/ML SOLN 5 ML VIAL J1955 $139.11 LEVOCARNITINE 330 MG TAB 90 EACH BLIST PACK $4.13 LEVOFLOXACIN 250 MG TAB 100 EACH BLIST PACK $51.54 LEVOFLOXACIN 500 MG TAB 100 EACH BLIST PACK $58.87 LEVOFLOXACIN 500 MG/100 ML PGBK 100 ML BAG J1956 $25.55 LEVOFLOXACIN 750 MG TAB 100 EACH BLIST PACK $28.72 LEVOFLOXACIN 750 MG TAB 20 EACH BOTTLE $42.09 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LEVOFLOXACIN IN D5W 250 MG/50 ML PGBK 50 ML BAG J1956 $17.68 LEVOFLOXACIN IN D5W 750 MG/150 ML PGBK 150 ML BAG J1956 $24.68 LEVOMEFOLATE CALCIUM 7.5 MG TAB 30 EACH BOTTLE $10.10 LEVONORGESTREL 14 MCG/24 HRS (3 YRS) 13.5 MG IUD 1 J7301 $3,178.84 LEVONORGESTREL 17.5 MCG/24 HRS (5 YRS) 19.5 MG IUD J7296 $3,817.66 LEVONORGESTREL 20 MCG/24 HOURS (5 YRS) 52 MG IUD 1 J7298 $4,004.74 LEVOTHYROXINE 100 MCG SOLR 1 EACH VIAL $443.45 LEVOTHYROXINE 100 MCG TAB 100 EACH BLIST PACK $5.09 LEVOTHYROXINE 100 MCG TAB 90 EACH BOTTLE $1.09 LEVOTHYROXINE 112 MCG TAB 1 EACH BLIST PACK $1.02 LEVOTHYROXINE 112 MCG TAB 100 EACH BLIST PACK $1.02 LEVOTHYROXINE 112 MCG TAB 100 EACH BOTTLE $2.28 LEVOTHYROXINE 112 MCG TAB 90 EACH BOTTLE $4.96 LEVOTHYROXINE 125 MCG TAB 100 EACH BLIST PACK $5.06 LEVOTHYROXINE 125 MCG TAB 90 EACH BOTTLE $0.92 LEVOTHYROXINE 150 MCG TAB 100 EACH BLIST PACK $5.04 LEVOTHYROXINE 150 MCG TAB 90 EACH BOTTLE $0.79 LEVOTHYROXINE 200 MCG SOLR 1 EACH VIAL $443.43 LEVOTHYROXINE 200 MCG TAB 100 EACH BLIST PACK $5.08 LEVOTHYROXINE 200 MCG TAB 90 EACH BOTTLE $0.71 LEVOTHYROXINE 25 MCG TAB 100 EACH BLIST PACK $3.33 LEVOTHYROXINE 25 MCG TAB 90 EACH BOTTLE $3.06 LEVOTHYROXINE 50 MCG TAB 1 EACH BLIST PACK $1.89 LEVOTHYROXINE 50 MCG TAB 1,000 EACH BOTTLE $4.96 LEVOTHYROXINE 50 MCG TAB 100 EACH BLIST PACK $5.04 LEVOTHYROXINE 500 MCG SOLR 1 EACH VIAL $104.74 LEVOTHYROXINE 75 MCG TAB 1 EACH BLIST PACK $2.09 LEVOTHYROXINE 75 MCG TAB 100 EACH BLIST PACK $5.20 LEVOTHYROXINE 75 MCG TAB 90 EACH BOTTLE $2.00 LEVOTHYROXINE 88 MCG TAB 1 EACH BLIST PACK $2.12 LEVOTHYROXINE 88 MCG TAB 90 EACH BOTTLE $1.95 LIDOCAINE (CARDIAC) 2 % 100 MG/5 ML (2 %) SYRG 5 M J2001 $2.71 LIDOCAINE (PF) 10 MG/ML (1 %) SOLN 10 ML AMPUL J2001 $21.70 LIDOCAINE (PF) 10 MG/ML (1 %) SOLN 30 ML VIAL J2001 $12.29 LIDOCAINE (PF) 10 MG/ML (1 %) SOLN 5 ML AMPUL J2001 $9.35 LIDOCAINE (PF) 10 MG/ML (1 %) SOLN 5 ML VIAL J2001 $10.33 LIDOCAINE (PF) 20 MG/ML (2 %) SOLN 10 ML AMPUL $2.53 LIDOCAINE (PF) 5 MG/ML (0.5 %) SOLN 50 ML VIAL $1.06 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LIDOCAINE 10 MG/ML (1 %) SOLN 20 ML VIAL $0.30 LIDOCAINE 10 MG/ML (1 %) SOLN 50 ML VIAL $0.23 LIDOCAINE 2 % JELL 30 ML TUBE $320.88 LIDOCAINE 2 % JELL 5 ML TUBE $29.40 LIDOCAINE 2 % JELP 20 ML SYRINGE $32.41 LIDOCAINE 2 % JELP 6 ML SYRINGE $24.99 LIDOCAINE 2 % SOLN 100 ML BOTTLE $46.20 LIDOCAINE 2 % SOLN 15 ML CUP $2.31 LIDOCAINE 20 MG/ML (2 %) SOLN 20 ML VIAL $0.44 LIDOCAINE 20 MG/ML (2 %) SOLN 50 ML VIAL $0.31 LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE $168.00 LIDOCAINE 40 MG/ML (4 %) SOLN 5 ML AMPUL $3.64 LIDOCAINE 5 % OINT 35.44 G TUBE $1,050.00 LIDOCAINE 5 % PTMD 1 EACH BOX $32.76 LIDOCAINE 5 % PTMD 30 EACH BOX $32.76 LIDOCAINE 5 MG/ML (0.5 %) SOLN 50 ML VIAL $17.50 LIDOCAINE IN 5 % DEXTROSE 8 MG/ML (0.8 %) SOLP 250 J2001 $31.50 LIDOCAINE LEVEL 80176 $180.00 LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 SOLN 50 ML V $0.29 LIDOCAINE-EPINEPHRINE 1 %-1:100,000 SOLN 20 ML VIA $0.45 LIDOCAINE-EPINEPHRINE 1 %-1:100,000 SOLN 50 ML VIA $0.30 LIDOCAINE-EPINEPHRINE 1 %-1:200,000 SOLN 30 ML VIA $1.44 LIDOCAINE-EPINEPHRINE 2 %-1:100,000 SOLN 20 ML VIA $0.80 LIDOCAINE-EPINEPHRINE 2 %-1:200,000 SOLN 10 ML VIA $3.75 LIDOCAINE-EPINEPHRINE 2 %-1:200,000 SOLN 20 ML VIA $3.30 LIDOCAINE-EPINEPHRINE-TETRACAINE (LET) TOPICAL SOL $108.54 LIDOCAINE-PRILOCAINE 2.5-2.5 % CREA 5 G TUBE $34.70 LINACLOTIDE 145 MCG CAP 30 EACH BOTTLE $59.34 LINACLOTIDE 72 MCG CAP 30 EACH BOTTLE $59.34 LINAGLIPTIN 5 MG TAB 100 EACH BLIST PACK $61.06 LINAGLIPTIN 5 MG TAB 30 EACH BOTTLE $57.61 LINEZOLID 600 MG TAB 1 EACH BLIST PACK $642.86 LINEZOLID 600 MG TAB 20 EACH BLIST PACK $642.86 LINEZOLID 600 MG TAB 20 EACH BOTTLE $503.99 LINEZOLID 600 MG TAB 30 EACH BLIST PACK $442.17 LINEZOLID 600 MG TAB 30 EACH BOTTLE $617.13 LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK 300 ML J2020 $273.00 LIOTHYRONINE 10 MCG/ML SOLN 1 ML VIAL $4,213.13 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LIOTHYRONINE 25 MCG TAB 100 EACH BOTTLE $0.73 LIOTHYRONINE 25 MCG TAB 90 EACH BOTTLE $0.77 LIOTHYRONINE 5 MCG TAB 100 EACH BOTTLE $2.77 LIOTHYRONINE 5 MCG TAB 90 EACH BOTTLE $2.98 LIPASE BODY FLUID 83690 $152.00 LIPASE, SERUM 83690 $152.00 LIPASE-PROTEASE-AMYLASE 10,000-34,000 -55,000 UNIT $12.85 LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT $7.12 LIPASE-PROTEASE-AMYLASE 5,000-17,000 -27,000 UNIT $6.50 LIPOPROTEIN (A) LEVEL 83695 $247.00 LIPOPROTEIN MEASUREMENT 83701 $193.00 LIPOPROTEIN NUMBER/SUBCLASS 83704 $397.00 LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2 (ENZYME) L 83698 $108.00 LIPOPRTN DIR MEAS SD LDL CHL 83722 $203.00 LIPOSOMAL AMPHOTERICIN B 50 MG SUSR 1 EACH VIAL J0289 $1,038.00 LISINOPRIL 10 MG TAB 1 EACH BLIST PACK $0.13 LISINOPRIL 10 MG TAB 100 EACH BLIST PACK $0.45 LISINOPRIL 10 MG TAB 100 EACH BOTTLE $0.87 LISINOPRIL 40 MG TAB 100 EACH BLIST PACK $0.17 LISINOPRIL 40 MG TAB 100 EACH BOTTLE $0.34 LISINOPRIL 5 MG TAB 100 EACH BLIST PACK $1.68 LISINOPRIL-HYDROCHLOROTHIAZIDE 10-12.5 MG TAB 100 $3.92 LISINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG TAB 100 $4.25 LISINOPRIL-HYDROCHLOROTHIAZIDE 20-25 MG TAB 1 EACH $3.92 LISINOPRIL-HYDROCHLOROTHIAZIDE 20-25 MG TAB 100 EA $4.30 LITHIUM 300 MG CAP 100 EACH BLIST PACK $0.74 LITHIUM 300 MG TAB 100 EACH BLIST PACK $0.90 LITHIUM 450 MG TBSR 100 EACH BLIST PACK $1.76 LITHIUM CITRATE 8 MEQ/5 ML (5 ML) SOLN 5 ML CUP $7.00 LITHIUM LEVEL 80178 $160.00 LIVER ENZYME (SGOT), LEVEL 84450 $121.00 LIVER ENZYME (SGPT), LEVEL 84460 $130.00 LIVER FUNCTION BLOOD TEST PANEL 80076 $337.00 LOPERAMIDE 1 MG/5 ML LIQD 5 ML CUP $6.27 LOPERAMIDE 1 MG/7.5 ML LIQD 240 ML BOTTLE $1.31 LOPERAMIDE 1 MG/7.5 ML LIQD 7.5 ML CUP $7.04 LOPERAMIDE 2 MG CAP 1 EACH BLIST PACK $3.07 LOPERAMIDE 2 MG CAP 100 EACH BLIST PACK $3.06 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge LOPINAVIR-RITONAVIR 400-100 MG/5 ML SOLN 160 ML BO $1,827.84 LORATADINE 10 MG TAB 100 EACH BLIST PACK $1.40 LORAZEPAM 0.5 MG TAB 1 EACH BLIST PACK $1.31 LORAZEPAM 0.5 MG TAB 1,000 EACH BOTTLE $2.24 LORAZEPAM 0.5 MG TAB 100 EACH BLIST PACK $0.32 LORAZEPAM 1 MG TAB 1 EACH BLIST PACK $3.17 LORAZEPAM 1 MG TAB 100 EACH BLIST PACK $3.17 LORAZEPAM 2 MG/ML CONC 30 ML BOTTLE $168.11 LORAZEPAM 2 MG/ML SOLN 1 ML VIAL J2060 $1.02 LORAZEPAM 2 MG/ML SOLN 10 ML VIAL J2060 $0.71 LORAZEPAM 4 MG/ML SOLN 1 ML VIAL J2060 $2.46 LOSARTAN 25 MG TAB 1 EACH BLIST PACK $5.64 LOSARTAN 25 MG TAB 100 EACH BLIST PACK $2.10 LOSARTAN 50 MG TAB 1 EACH BLIST PACK $3.37 LOSARTAN 50 MG TAB 100 EACH BLIST PACK $4.01 LOSARTAN 50 MG TAB 50 EACH BLIST PACK $3.37 LOSARTAN-HYDROCHLOROTHIAZIDE 50-12.5 MG TAB 90 EAC $8.76 LOVASTATIN 20 MG TAB 100 EACH BLIST PACK $5.08 LOW COST SKIN SUBSTITUTE FACE SCALP EYELID NECK GE C5275 $1,862.00 LOW COST SKIN SUBSTITUTE FACE SCALP EYELID NECK GE C5276 $1,246.00 LOW COST SKIN SUBSTITUTE FACE SCALP EYELID NECK GE C5277 $2,204.00 LOW COST SKIN SUBSTITUTE FACE SCALP EYELID NECK GE C5278 $1,246.00 LOW COST SKIN SUBSTITUTE TRUNK ARMS LEGS C5271 $1,624.00 LOW COST SKIN SUBSTITUTE TRUNK ARMS LEGS C5272 $1,246.00 LOW COST SKIN SUBSTITUTE TRUNK ARMS LEGS C5273 $5,437.00 LOW COST SKIN SUBSTITUTE TRUNK ARMS LEGS C5274 $2,379.00 LOW FREQUENCY NON-CONTACT NON-THERMAL ULTRASOUND W 97610 $374.00 LUBIPROSTONE 24 MCG CAP 60 EACH BOTTLE $8.66 LUBIPROSTONE 8 MCG CAP 60 EACH BOTTLE $25.98 LURASIDONE 20 MG TAB 30 EACH BOTTLE $171.28 LURASIDONE 40 MG TAB 100 EACH BLIST PACK $171.28 LURASIDONE 40 MG TAB 30 EACH BOTTLE $171.28 LYME AB 87476 $541.00 LYME AB IGM 87476 $541.00 M PNEUMONIAE IGM 86738 $174.00 M.I.C. SENS 87186 $188.00 MAALOX, LIDOCAINE 2% VISC, DIPHENHYDRAMINE, NYSTAT $12.78 MACROSCOPIC EXAMINATION (VISUAL INSPECTION) OF PAR 87169 $68.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MAFENIDE 85 MG/G CREA 113.4 G JAR $488.58 MAGNESIUM CHLORIDE 70 MG TBEC 60 EACH BOTTLE $0.43 MAGNESIUM CITRATE SOLN 296 ML BOTTLE $1.75 MAGNESIUM GLUCONATE (27 MG ELEMENTAL MG) 27 MG MAG $0.61 MAGNESIUM HYDROXIDE 400 MG/5 ML SUSP 30 ML BLIST P $1.37 MAGNESIUM HYDROXIDE 400 MG/5 ML SUSP 30 ML CUP $0.88 MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TAB 10 $0.16 MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TAB 12 $0.24 MAGNESIUM OXIDE 500 MG TAB 100 EACH BOTTLE $0.19 MAGNESIUM SULFATE 100 % CRYS 1,810 G BOX $12.67 MAGNESIUM SULFATE 4 MEQ/ML (50 %) SOLN 10 ML VIAL J3475 $1.85 MAGNESIUM SULFATE 4 MEQ/ML (50 %) SOLN 2 ML VIAL J3475 $6.64 MAGNESIUM SULFATE 4 MEQ/ML (50 %) SOLN 20 ML VIAL J3475 $1.82 MAGNESIUM SULFATE 4 MEQ/ML (50 %) SOLN 50 ML VIAL J3475 $3.11 MAGNESIUM SULFATE IN WATER 40 GRAM/1,000 ML (4 %) J3475 $35.00 MAGNESIUM SULFATE-GLYCERIN-NORMAL SALINE 1000 ML S $175.00 MAGNESIUM, SERUM 83735 $111.00 MAGNESIUM, URINE 83735 $111.00 MALARIA SMEAR 87207 $129.00 MALATE DEHYDROGENASE (ENZYME) LEVEL 83775 $61.00 MALATHION 0.5 % LOTN 59 ML BOTTLE $970.14 MAMMOGRAPHY OF BOTH BREASTS 77066 $547.00 MAMMOGRAPHY OF BOTH BREASTS 77067 $406.00 MAMMOGRAPHY OF ONE BREAST 77065 $397.00 MAMMOGRAPJY ? REVENUE CODE 401 G0378 $90.00 MANAGEMENT AND SUPERVISION OF OXYGEN CHAMBER THERA G0277 $1,190.00 MANAGEMENT OF MODULATION RADIOTHERAPY PLANNING 77301 $7,517.00 MANAGEMENT OF RADIATION THERAPY SIMULATION, SIMPLE 77280 $1,102.00 MANAGEMENT OF RADIATION THERAPY, 3D 77295 $7,626.00 MANAGEMENT OF RADIATION THERAPY, SIMULATION, COMPL 77290 $2,341.00 MANAGEMENT OF RADIATION THERAPY, SIMULATION, INTER 77285 $897.00 MANGANESE (HEAVY METAL) LEVEL 83785 $180.00 MANIPULATE SHLD JT GEN ANES 23700 $4,607.00 MANNITOL 20 % 20 % SOLP 250 ML BAG $492.63 MANNITOL 20 % 20 % SOLP 250 ML FLEX CONT $23.19 MANNITOL 25 % 25 % SOLN 50 ML VIAL J2150 $9.28 MANUAL (PHYSICAL) THERAPY TECHNIQUES TO 1 OR MORE 97140 $197.00 MANUAL MANEUVERS TO CHEST WALL TO ASSIST MOVEMENT 94668 $148.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MANUAL URINALYSIS TEST WITH EXAMINATION USING MICR 81000 $61.00 MANUAL URINALYSIS TEST WITH EXAMINATION USING MICR 81001 $136.00 MANUAL WHITE BLOOD CELL COUNT AND EVALUATION 85009 $28.00 MAPPING ELECTRCL BRAIN WAVE ACTIV PROV SEIZR ACTIV 95962 $680.00 MARIJUANA CONF MEC 80349 $232.00 MASS SPECTOMETRY QN 83789 $225.00 MASS SPECTROMETRY (LABORATORY TESTING METHOD) 83789 $255.00 MASSAGE OF HEART MUSCLE THROUGH CHEST CAVITY 32160 $3,790.00 MEASLES, MUMPS AND RUBELLA VACCINE 1,000-12,500 TC 90707 $33.04 MEASURE & GRAPHIC RECORDINGS SPEED OF BREATHED AIR 94070 $960.00 MEASURE & RECORD OF BRAIN WAVE (EEG) ACTIVITY CERE 95824 $1,593.00 MEASUREMENT & GRAPHIC REC AMOUNT&SPEED BREATHED AI 94060 $676.00 MEASUREMENT & REC NERVE CONDUCTION PATTERNS USING 95930 $1,131.00 MEASUREMENT & RECORDING ELECTRCL BRAIN WAVE ACTIV 95958 $2,459.00 MEASUREMENT AND GRAPHIC RECORDING OF TOTAL AND TIM 94010 $400.00 MEASUREMENT AND RECORDING OF BRAIN WAVE (EEG) ACTI 95816 $1,255.00 MEASUREMENT AND RECORDING OF BREATHING PATTERN OVE 94772 $1,711.00 MEASUREMENT BLOOD COAGULATION AND FIBRINOLYSIS (CL 85397 $176.00 MEASUREMENT C-REACTIVE PROTEIN FOR DETECTION OF IN 86140 $131.00 MEASUREMENT C-REACTIVE PROTEIN FOR DETECTION OF IN 86141 $131.00 MEASUREMENT FOR STREP ANTIBODY (STREP THROAT) 86060 $175.00 MEASUREMENT OF ANTIBODY (IGE) TO ALLERGIC SUBSTANC 86003 $67.00 MEASUREMENT OF ANTIBODY FOR ASSESSMENT OF AUTOIMMU 86039 $179.00 MEASUREMENT OF ANTIBODY FOR ASSESSMENT OF AUTOIMMU 86235 $220.00 MEASUREMENT OF ANTIBODY FOR RHEUMATOID ARTHRITIS A 86200 $190.00 MEASUREMENT OF ANTIBODY TO NONINFECTIOUS AGENT 86256 $203.00 MEASUREMENT OF ANTIBODY TO STREPTOKINASE (ENZYME) 86590 $46.00 MEASUREMENT OF BILIRUBIN 88720 $28.00 MEASUREMENT OF BRAIN WAVE (EEG) ACTIVITY GREATER T 95813 $2,301.00 MEASUREMENT OF COLD AGGLUTININ (PROTEIN) TO DETECT 86157 $151.00 MEASUREMENT OF COMPLEMENT (IMMUNE SYSTEM PROTEINS) 86160 $259.00 MEASUREMENT OF COMPLEMENT (IMMUNE SYSTEM PROTEINS) 86162 $281.00 MEASUREMENT OF COMPLEMENT FUNCTION (IMMUNE SYSTEM 86161 $253.00 MEASUREMENT OF DNA ANTIBODY 86225 $164.00 MEASUREMENT OF ELECTRICAL ACTIVITY (EEG) OUTSIDE T 95955 $1,746.00 MEASUREMENT OF ESOPHAGEAL SWALLOWING MOVEMENT 91010 $2,319.00 MEASUREMENT OF EXHALED CARBON DIOXIDE GAS 94770 $505.00 MEASUREMENT OF GROWTH HORMONE ANTIBODY 86277 $130.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MEASUREMENT OF HEART BLOOD FLOW AND RESPIRATION 93701 $411.00 MEASUREMENT OF HEPATITIS A ANTIBODY (IGM) 86709 $205.00 MEASUREMENT OF HYDROGEN IN BREATH TO TEST FOR GI S 91065 $412.00 MEASUREMENT OF IMMUNE SUBSTANCE (OLIGOCLONAL BANDS 83916 $294.00 MEASUREMENT OF IMMUNE SYSTEM PROTEIN 86280 $68.00 MEASUREMENT OF LARGEST AMOUNT OF AIR EXHALED FROM 94150 $139.00 MEASUREMENT OF LUNG DIFFUSING CAPACITY 94729 $420.00 MEASUREMENT OF OXYGEN SATURATION IN BLOOD USING EA 94760 $108.00 MEASUREMENT OF PROTEINS ASSOCIATED WITH PROSTATE C 81539 $2,388.00 MEASUREMENT OF SUBSTANCE USING IMMUNOASSAY TECHNIQ 83519 $353.00 MECHANICAL REMOVAL OF OBSTRUCTIVE MATERIAL FROM CE 36595 $4,461.00 MECHANICAL REMOVE OBSTRUCTIVE MATERIAL IN STOMACH 49460 $2,152.00 MECHANICAL SEPARATION OF PLASMA FROM OPENING BLOOD 36514 $3,340.00 MECHANICAL SEPARATION OF PLATELET CELLS FROM BLOOD 36513 $2,998.00 MECHANICAL SEPARATION OF WHITE BLOOD CELLS AND PLA 36522 $7,831.00 MECHANICAL SEPARATION OF WHITE BLOOD CELLS FROM TH 36511 $3,109.00 MECLIZINE 12.5 MG TAB 100 EACH BLIST PACK $2.48 MECLIZINE 25 MG TAB 100 EACH BLIST PACK $1.52 MECONIUM-PREP, DRUG SCREEN 80307 $180.00 MEDICAL NUTRITION THERAPY G0271 $82.00 MEDICAL NUTRITION THERAPY PERFORMED IN A GROUP SET 97804 $142.00 MEDICAL NUTRITION THERAPY RE-ASSESSMENT AND INTERV 97803 $193.00 MEDICAL NUTRITION THERAPY, ASSESSMENT AND INTERVEN 97802 $223.00 MEDICAL/SURGICAL SUPPLIES AND DEVICES GENERAL $0.01 MEDIUM CHAIN TRIGLYCERIDES 7.7 KCAL/ML OIL 946 ML $39.73 MEDROXYPROGESTERONE 10 MG TAB 1 EACH BLIST PACK $1.47 MEDROXYPROGESTERONE 10 MG TAB 30 EACH BLIST PACK $1.47 MEDROXYPROGESTERONE 150 MG/ML SUSP 1 ML VIAL J3490 $189.00 MEDROXYPROGESTERONE 150 MG/ML SYRG 1 ML SYRINGE J1050 $231.00 MEDROXYPROGESTERONE 2.5 MG TAB 100 EACH BOTTLE $1.10 MEGESTROL 20 MG TAB 1 EACH BLIST PACK S0179 $2.30 MEGESTROL 20 MG TAB 100 EACH BOTTLE S0179 $2.42 MEGESTROL 40 MG TAB 100 EACH BLIST PACK S0179 $4.79 MEGESTROL 400 MG/10 ML (10 ML) SUSP 10 ML CUP S0179 $7.51 MELATONIN 1 MG TAB 60 EACH BOTTLE $0.15 MELATONIN 3 MG TAB 1 EACH BLIST PACK $0.93 MELATONIN 3 MG TAB 100 EACH BLIST PACK $0.85 MELATONIN 3 MG TAB 60 EACH BOTTLE $0.44 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MELATONIN 5 MG TAB 1 EACH BLIST PACK $1.64 MELATONIN 5 MG TAB 50 EACH BLIST PACK $1.64 MELATONIN 5 MG TAB 90 EACH BOTTLE $0.20 MELOXICAM 15 MG TAB 1 EACH BLIST PACK $8.37 MELOXICAM 15 MG TAB 1,000 EACH BOTTLE $8.48 MELOXICAM 15 MG TAB 100 EACH BOTTLE $8.48 MELOXICAM 7.5 MG TAB 100 EACH BLIST PACK $0.61 MELOXICAM 7.5 MG TAB 50 EACH BLIST PACK $10.84 MEMANTINE 14 MG CSPX 30 EACH BOTTLE $53.42 MEMANTINE 14 MG CSPX 90 EACH BOTTLE $59.42 MEMANTINE 21 MG CSPX 30 EACH BOTTLE $53.42 MEMANTINE 28 MG CSPX 30 EACH BOTTLE $59.42 MEMANTINE 28 MG CSPX 90 EACH BOTTLE $59.42 MEMANTINE 5 MG TAB 100 EACH BLIST PACK $21.36 MEMANTINE 7 MG CSPX 30 EACH BOTTLE $59.42 MEMORY FUNCTIONAL LIMITED CURRENT STATUS G9168 $0.01 MEMORY FUNCTIONAL LIMITED DISCHARGE STATUS G9170 $0.01 MEMORY FUNCTIONAL LIMITED PROJECTED GOAL STATUS G9169 $0.01 MENINGOCOCCAL POLYSACCHARIDE 4 MCG/0.5 ML SOLN 0.5 90734 $535.60 MENTHOL-ZINC OXIDE 0.44-20.6 % OINT 113 G TUBE $17.40 MEPERIDINE 50 MG TAB 100 EACH BOTTLE $5.00 MEPERIDINE 50 MG/5 ML SOLN 500 ML BOTTLE $560.00 MEPERIDINE 50 MG/ML SOLN 1 ML VIAL J2175 $10.10 MEPIVACAINE 20 MG/ML (2 %) SOLN 20 ML VIAL J0670 $1.05 MEPOLIZUMAB 100 MG SOLR 1 EACH VIAL J2182 $11,697.49 MEPROBAMATE 400 MG TAB 100 EACH BOTTLE $13.86 MERCAPTOPURINE 50 MG TAB 25 EACH BOTTLE $14.32 MERCURY LEVEL 83825 $252.00 MEROPENEM 1 GRAM SOLR 1 EACH VIAL J2185 $61.19 MEROPENEM 500 MG SOLR 1 EACH VIAL J2185 $140.93 MESALAMINE 1.2 GRAM TBEC 120 EACH BOTTLE $39.32 MESALAMINE 1000 MG SUPP 30 EACH BOX $74.27 MESALAMINE 4 GRAM/60 ML ENEM 60 ML SQUEEZ BTL $85.05 MESALAMINE 400 MG CDTI 180 EACH BOTTLE $21.26 MESALAMINE 500 MG CPSR 120 EACH BOTTLE $25.50 MESNA 100 MG/ML SOLN 10 ML VIAL J9209 $278.46 METANEPHRINES FREE PLASMA 83835 $186.00 METANEPHRINES LEVEL 83835 $203.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge METFORMIN 500 MG TAB 1 EACH BLIST PACK $2.45 METFORMIN 500 MG TAB 100 EACH BLIST PACK $2.52 METFORMIN 500 MG TAB 100 EACH BOTTLE $2.46 METFORMIN 500 MG TB24 100 EACH BLIST PACK $2.38 METFORMIN 850 MG TAB 1 EACH BLIST PACK $2.48 METFORMIN 850 MG TAB 100 EACH BLIST PACK $2.48 METHACHOLINE 100 MG SOLR 1 EACH VIAL J7674 $95.27 METHADONE 10 MG TAB 1 EACH BLIST PACK $0.54 METHADONE 5 MG TAB 1 EACH BLIST PACK $0.81 METHADONE 5 MG TAB 100 EACH BLIST PACK $0.81 METHADONE 5 MG/5 ML SOLN 500 ML BOTTLE $0.70 METHADONE LEVEL 80358 $161.00 METHAZOLAMIDE 50 MG TAB 100 EACH BOTTLE $13.41 METHEMALBUMIN (PROTEIN) LEVEL 83857 $88.00 METHEMOGLOBIN (HEMOGLOBIN) ANALYSIS 83045 $41.00 METHENAMINE 0.5 GM TAB 100 EACH BOTTLE $3.10 METHEN-M.BLUE-S.PHOS-P.SAL-HYO 118-10-40.8-36-0.12 $12.19 METHEN-SOD PHOS-METH BLUE-HYOS 81.6-40.8-0.12 MG T $15.47 METHIMAZOLE 5 MG TAB 1 EACH BLIST PACK $1.54 METHIMAZOLE 5 MG TAB 100 EACH BOTTLE $1.55 METHOCARBAMOL 500 MG TAB 100 EACH BLIST PACK $1.49 METHOCARBAMOL 500 MG TAB 100 EACH BOTTLE $1.79 METHOCARBAMOL 750 MG TAB 1 EACH BLIST PACK $1.41 METHOCARBAMOL 750 MG TAB 100 EACH BLIST PACK $1.37 METHOCARBAMOL 750 MG TAB 100 EACH BOTTLE $1.70 METHOCARBAMOL 750 MG TAB 500 EACH BOTTLE $1.09 METHOHEXITAL 500 MG SOLR 1 EACH VIAL $278.32 METHOTREXATE 80299 $182.00 METHOTREXATE 2.5 MG TAB 100 EACH BLIST PACK J8610 $12.47 METHOTREXATE 2.5 MG TAB 100 EACH BOTTLE J8610 $12.47 METHOTREXATE SODIUM (PF) 25 MG/ML SOLN 2 ML VIAL J9250 $14.11 METHYL SALICYLATE LIQD 60 ML BOTTLE $17.64 METHYL SALICYLATE-MENTHOL 15-10 % CREA 85 G JAR $12.20 METHYLATION ANALYSIS (SM NUCLR RIBONCLEOPRT PLYPP 81331 $17.00 METHYLDOPA 250 MG TAB 1 EACH BLIST PACK $1.29 METHYLDOPA 250 MG TAB 100 EACH BOTTLE $1.46 METHYLENE BLUE 1 % (10 MG/ML) SOLN 10 ML VIAL Q9968 $704.76 METHYLERGONOVINE 0.2 MG TAB 12 EACH BOTTLE $261.45 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge METHYLERGONOVINE 0.2 MG TAB 28 EACH BOTTLE $235.17 METHYLERGONOVINE 0.2 MG/ML (1 ML) SOLN 1 ML AMPUL J2210 $30.02 METHYLERGONOVINE 0.2 MG/ML (1 ML) SOLN 1 ML VIAL J2210 $108.06 METHYLMALONIC ACID 83921 $309.00 METHYLNALTREXONE 12 MG/0.6 ML SOLN 0.6 ML VIAL J2212 $323.52 METHYLPHENIDATE HCL 5 MG TAB 100 EACH BOTTLE $2.56 METHYLPREDNISOLONE 4 MG DSPK 21 EACH BLIST PACK J7509 $5.78 METHYLPREDNISOLONE 4 MG TAB 100 EACH BLIST PACK J7509 $3.51 METHYLPREDNISOLONE 4 MG TAB 100 EACH BOTTLE J7509 $2.50 METHYLPREDNISOLONE ACETATE 40 MG/ML SUSP 1 ML VIAL J1030 $11.10 METHYLPREDNISOLONE ACETATE 80 MG/ML SUSP 1 ML VIAL J1040 $9.63 METHYLPREDNISOLONE ACETATE 80 MG/ML SUSP 5 ML VIAL J1040 $9.64 METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML SOLR 1 J2930 $40.69 METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML SOLR 1 EAC J2920 $25.27 METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG SOLR 1 J2930 $97.09 METHYLPREDNISOLONE SS 1,000 MG SOLR 1 EACH VIAL J2930 $175.95 METOCLOPRAMIDE HCL 10 MG TAB 1 EACH BLIST PACK $0.50 METOCLOPRAMIDE HCL 10 MG TAB 100 EACH BLIST PACK $0.23 METOCLOPRAMIDE HCL 5 MG/5 ML SOLN 10 ML BLIST PACK $3.94 METOCLOPRAMIDE HCL 5 MG/ML SOLN 2 ML VIAL J2765 $4.66 METOLAZONE 10 MG TAB 100 EACH BOTTLE $2.14 METOLAZONE 2.5 MG TAB 1 EACH BLIST PACK $11.50 METOLAZONE 2.5 MG TAB 100 EACH BOTTLE $6.26 METOLAZONE 5 MG TAB 1 EACH BLIST PACK $13.07 METOPROLOL 100 MG TAB 100 EACH BLIST PACK $0.80 METOPROLOL 100 MG TB24 1 EACH BLIST PACK $1.46 METOPROLOL 100 MG TB24 100 EACH BLIST PACK $1.47 METOPROLOL 25 MG TAB 1 EACH BLIST PACK $0.85 METOPROLOL 25 MG TAB 100 EACH BLIST PACK $1.03 METOPROLOL 25 MG TB24 1 EACH BLIST PACK $3.90 METOPROLOL 25 MG TB24 100 EACH BLIST PACK $4.34 METOPROLOL 5 MG/5 ML SOLN 5 ML VIAL $15.52 METOPROLOL 50 MG TAB 100 EACH BLIST PACK $1.11 METOPROLOL 50 MG TB24 1 EACH BLIST PACK $3.50 METOPROLOL 50 MG TB24 100 EACH BLIST PACK $1.95 METRONIDAZOLE 0.75 % GEL 45 G TUBE $1,117.78 METRONIDAZOLE 0.75 % GEL 70 G TUBE $269.50 METRONIDAZOLE 1 % GEL 60 G TUBE $724.50 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge METRONIDAZOLE 250 MG TAB 1 EACH BLIST PACK $2.35 METRONIDAZOLE 250 MG TAB 100 EACH BLIST PACK $2.02 METRONIDAZOLE 500 MG TAB 1 EACH BLIST PACK $1.61 METRONIDAZOLE 500 MG TAB 100 EACH BLIST PACK $1.45 METRONIDAZOLE 500 MG TAB 100 TABLET BOTTLE $0.93 METRONIDAZOLE 500 MG TAB 500 EACH BOTTLE $2.42 METRONIDAZOLE IN NACL 500 MG/100 ML PGBK 100 ML BA S0030 $9.45 METYRAPONE (HORMONE ANTIBODY) PANEL 80436 $752.00 MEXILETINE 150 MG CAP 100 EACH BOTTLE $8.88 MICONAZOLE 100 MG SUPP 7 EACH BOX $5.79 MICONAZOLE 2 % CREA 28 G TUBE $11.56 MICONAZOLE 2 % CREA 45 G TUBE/KIT $40.16 MICONAZOLE NITRATE 200 MG SUPP 3 EACH BOX $61.33 MICROALBUMIN, 24 HRS 82043 $99.00 MICROALBUMIN, URINE, RANDOM 82043 $99.00 MICROBIAL IDENTIFICATION 87158 $173.00 MICROFIBRILLAR COLLAGEN POWD 1 G PACKET $922.60 MICROSCOPIC EXAM OF ESOPHAGUS STOMACH/UPPER SMALL 43252 $5,250.00 MICROSCOPIC EXAMINATION FOR WHITE BLOOD CELLS WITH 85007 $27.00 MICROSCOPIC EXAMINATION OF ESOPHAGUS USING AN ENDO 43206 $5,249.00 MICROSCOPIC GENETIC ANALYSIS OF MUSCLE 88355 $551.00 MICROSCOPIC GENETIC ANALYSIS OF TISSUE 88368 $613.00 MICROSCOPIC GENETIC ANALYSIS OF TUMOR 88360 $361.00 MICROSCOPIC GENETIC ANALYSIS OF TUMOR 88361 $510.00 MICROSCOPIC GENETIC EXAMINATION MANUAL 88369 $1,130.00 MICROSCOPIC GENETIC EXAMINATION USING COMPUTER-ASS 88373 $404.00 MICROSCOPIC IMAGING USING ENDOSCOPE EACH SESSION 88375 $8,331.00 MICROSOMAL ANTIBODIES (AUTOANTIBODY) MEASUREMENT 86376 $182.00 MIDAZOLAM (PF) 1 MG/ML SOLN 2 ML VIAL J2250 $0.97 MIDAZOLAM 1 MG/ML SOLN 2 ML VIAL J2250 $0.68 MIDAZOLAM 10 MG/5 ML (2 MG/ML) SYRP 5 ML CUP $25.67 MIDAZOLAM 2 MG/ML SYRP 118 ML BOTTLE $890.02 MIDAZOLAM 5 MG/ML SOLN 1 ML VIAL J2250 $5.04 MIDAZOLAM 5 MG/ML SOLN 2 ML VIAL J2250 $5.25 MIDODRINE 5 MG TAB 1 EACH BLIST PACK $9.49 MIDODRINE 5 MG TAB 100 EACH BLIST PACK $15.71 MIDODRINE 5 MG TAB 100 EACH BOTTLE $14.55 MILRINONE 1 MG/ML SOLN 10 ML VIAL J2260 $28.49 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MILRINONE 100 ML BAG J2260 $91.00 MILRINONE IN 5 % DEXTROSE 20 MG/100 ML (200 MCG/ML J2260 $63.70 MINERAL OIL OIL 10 ML VIAL $58.45 MINERAL OIL OIL 472 ML BOTTLE $0.79 MINERAL OIL OIL 473 ML BOTTLE $0.74 MINERAL OIL-HYDROPHIL PETROLAT OINT 396 G JAR $45.74 MINOCYCLINE 50 MG CAP 1 EACH BLIST PACK $5.83 MINOCYCLINE 50 MG CAP 100 EACH BOTTLE $5.95 MINOXIDIL 10 MG TAB 100 EACH BLIST PACK $1.85 MINOXIDIL 10 MG TAB 100 EACH BOTTLE $1.13 MINOXIDIL 2.5 MG TAB 100 EACH BLIST PACK $5.93 MINOXIDIL 2.5 MG TAB 100 EACH BOTTLE $2.06 MIRABEGRON 25 MG TB24 30 EACH BOTTLE $53.80 MIRTAZAPINE 15 MG TAB 100 EACH BLIST PACK $0.35 MISOPROSTOL 100 MCG TAB 100 EACH BLIST PACK S0191 $5.72 MISOPROSTOL 100 MCG TAB 60 EACH BOTTLE S0191 $2.88 MISOPROSTOL 200 MCG TAB 1 EACH BLIST PACK S0191 $3.36 MISOPROSTOL 200 MCG TAB 100 EACH BLIST PACK S0191 $3.36 MITOMYCIN 40 MG SOLR 1 EACH VIAL J9280 $4,954.74 MITOMYCIN 5 MG SOLR 1 EACH VIAL J9280 $1,907.22 MOBILITY CURRENT STATUS G8978 $0.01 MOBILITY DISCHARGE STATUS G8980 $0.01 MOBILITY GOAL STATUS G8979 $0.01 MODAFINIL 100 MG TAB 1 EACH BLIST PACK $92.32 MODAFINIL 100 MG TAB 30 EACH BLIST PACK $92.32 MODERATE SEDATION SERVICES OTHER MD ADDITIONAL 15 99157 $142.00 MODERATE SEDATION SERVICES OTHER MD INITIAL 15 MIN 99155 $497.00 MODERATE SEDATION SERVICES OTHER MD INITIAL 15 MIN 99156 $257.00 MODERATE SEDATION SERVICES SAME MD ADDITIONAL 15 M 99153 $157.00 MODERATE SEDATION SERVICES SAME MD INITIAL 15 MIN 99151 $335.00 MODERATE SEDATION SERVICES SAME MD INITIAL 15 MIN 99152 $431.00 MOLECULAR PATHOLOGY PROCEDURE 81479 $425.00 MOLECULAR PATHOLOGY PROCEDURE LEVEL 1 81400 $740.00 MOLECULAR PATHOLOGY PROCEDURE LEVEL 2 81401 $896.00 MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 81402 $991.00 MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 81403 $518.00 MOLECULAR PATHOLOGY PROCEDURE LEVEL 5 81404 $1,592.00 MOLECULAR PATHOLOGY PROCEDURE LEVEL 6 81405 $2,988.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MOLECULAR PATHOLOGY PROCEDURE LEVEL 7 81406 $3,748.00 MOLECULAR PATHOLOGY PROCEDURE LEVEL 8 81407 $3,963.00 MOLECULAR PATHOLOGY PROCEDURE LEVEL 9 81408 $7,145.00 MONITOR & RECORD GASTROESOPHAGEAL REFLUX THROUGH N 91034 $1,327.00 MONITOR & RECORD GASTROESOPHAGEAL REFLUX WITH PH E 91035 $3,178.00 MONITORING OF GASTROESOPHAGEAL REFLUX PROLONGED 91038 $1,652.00 MONTELUKAST 10 MG TAB 100 EACH BLIST PACK $9.76 MONTELUKAST 5 MG CHEW 1 EACH BLIST PACK $11.50 MONTELUKAST 5 MG CHEW 50 EACH BLIST PACK $11.50 MORPHINE (PF) 0.5 MG/ML SOLN 10 ML AMPUL J2274 $105.49 MORPHINE (PF) 0.5 MG/ML SOLN 10 ML VIAL J2274 $25.69 MORPHINE (PF) 1 MG/ML SOLN 10 ML AMPUL J2274 $72.77 MORPHINE (PF) 1 MG/ML SOLN 10 ML VIAL J2274 $28.39 MORPHINE (PF) 10 MG/ML SOLN 20 ML AMPUL J2274 $873.60 MORPHINE 10 MG/5 ML SOLN 5 ML CUP $1.43 MORPHINE 10 MG/5 ML SOLN 500 ML BOTTLE $134.75 MORPHINE 10 MG/ML SOLN 1 ML VIAL J2270 $4.43 MORPHINE 100 MG TBSR 1 EACH BLIST PACK $4.01 MORPHINE 100 MG TBSR 100 EACH BLIST PACK $26.73 MORPHINE 100 MG TBSR 100 EACH BOTTLE $12.49 MORPHINE 15 MG TAB 100 EACH BLIST PACK $3.18 MORPHINE 15 MG TAB 100 EACH BOTTLE $1.54 MORPHINE 15 MG TBSR 1 EACH BLIST PACK $6.55 MORPHINE 15 MG TBSR 100 EACH BLIST PACK $6.55 MORPHINE 25 MG/ML SOLN 20 ML AMPUL J2274 $1,415.96 MORPHINE 30 MG TBSR 1 EACH BLIST PACK $2.59 MORPHINE 30 MG TBSR 100 EACH BLIST PACK $11.83 MORPHINE CONCENTRATE 10 MG/0.5 ML SYRG 1 EACH SYRI $2.20 MOTOR SPEECH FUNCTIONAL LIMIT CURRENT STATUS G8999 $0.01 MOTOR SPEECH FUNCTIONAL LIMIT DISCHARGE STATUS G9158 $0.01 MOTOR SPEECH FUNCTIONAL LIMIT GOAL STATUS G9186 $0.01 MR ANGIOGRAPHY ABDOMEN WITH & WITHOUT CONTRAST 74185 $4,941.00 MR ANGIOGRAPHY ABDOMEN WITH CONTRAST 74185 $4,941.00 MR ANGIOGRAPHY ABDOMEN WITHOUT CONTRAST 74185 $4,941.00 MR ANGIOGRAPHY CHEST WITH & WITHOUT CONTRAST 71555 $3,342.00 MR ANGIOGRAPHY CHEST WITH CONTRAST 71555 $3,342.00 MR ANGIOGRAPHY CHEST WITHOUT CONTRAST 71555 $3,342.00 MR ANGIOGRAPHY LOWER EXTREMITY WITH & WITHOUT CONT 73725 $3,798.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MR ANGIOGRAPHY LOWER EXTREMITY WITH CONTRAST 73725 $1,492.00 MR ANGIOGRAPHY LOWER EXTREMITY WITHOUT CONTRAST 73725 $1,492.00 MR ANGIOGRAPHY PELVIS WITH & WITHOUT CONTRAST 72198 $4,328.00 MR ANGIOGRAPHY PELVIS WITH CONTRAST 72198 $2,039.00 MR ANGIOGRAPHY PELVIS WITHOUT CONTRAST 72198 $2,063.00 MR ANGIOGRAPHY SPINE 72159 $2,039.00 MR ANGIOGRAPHY UPPER EXTREMITY 73225 $1,492.00 MRA SCAN OF HEAD BLOOD VESSELS 70544 $3,238.00 MRA SCAN OF HEAD BLOOD VESSELS BEFORE AND AFTER CO 70546 $4,874.00 MRA SCAN OF HEAD BLOOD VESSELS WITH CONTRAST 70545 $3,894.00 MRA SCAN OF NECK BLOOD VESSELS 70547 $3,039.00 MRA SCAN OF NECK BLOOD VESSELS BEFORE AND AFTER CO 70549 $3,756.00 MRA SCAN OF NECK BLOOD VESSELS WITH CONTRAST 70548 $3,902.00 MRI ? REVENUE CODE 61X G0378 $90.00 MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL 77048 $224.00 MRI OF HEART 75557 $3,236.00 MRI OF HEART BEFORE AND AFTER CONTRAST 75561 $3,438.00 MRI SCAN BONES OF THE EYE, FACE, AND/OR NECK 70540 $3,606.00 MRI SCAN BONES OF THE EYE, FACE, AND/OR NECK BEFOR 70543 $4,156.00 MRI SCAN BONES OF THE EYE, FACE, AND/OR NECK WITH 70542 $3,040.00 MRI SCAN BRAIN 70551 $3,235.00 MRI SCAN OF ABDOMEN 74181 $3,212.00 MRI SCAN OF ABDOMEN BEFORE AND AFTER CONTRAST 74183 $4,138.00 MRI SCAN OF ABDOMEN WITH CONTRAST 74182 $2,459.00 MRI SCAN OF ARM 73218 $3,513.00 MRI SCAN OF ARM BEFORE AND AFTER CONTRAST 73220 $4,404.00 MRI SCAN OF ARM JOINT 73221 $4,452.00 MRI SCAN OF ARM JOINT BEFORE AND AFTER CONTRAST 73223 $4,793.00 MRI SCAN OF ARM JOINT WITH CONTRAST 73222 $4,452.00 MRI SCAN OF ARM WITH CONTRAST 73219 $3,866.00 MRI SCAN OF BRAIN BEFORE AND AFTER CONTRAST 70553 $3,903.00 MRI SCAN OF BRAIN WITH CONTRAST 70552 $4,292.00 MRI SCAN OF CHEST 71550 $3,635.00 MRI SCAN OF CHEST BEFORE AND AFTER CONTRAST 71552 $4,140.00 MRI SCAN OF CHEST WITH CONTRAST 71551 $2,438.00 MRI SCAN OF JAW JOINTS 70336 $2,259.00 MRI SCAN OF LEG 73718 $3,665.00 MRI SCAN OF LEG BEFORE AND AFTER CONTRAST 73720 $4,260.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MRI SCAN OF LEG JOINT 73721 $4,224.00 MRI SCAN OF LEG JOINT BEFORE AND AFTER CONTRAST 73723 $4,968.00 MRI SCAN OF LEG JOINT WITH CONTRAST 73722 $3,494.00 MRI SCAN OF LEG WITH CONTRAST 73719 $4,140.00 MRI SCAN OF LOWER SPINAL CANAL 72148 $3,567.00 MRI SCAN OF LOWER SPINAL CANAL BEFORE AND AFTER CO 72158 $5,044.00 MRI SCAN OF LOWER SPINAL CANAL WITH CONTRAST 72149 $3,585.00 MRI SCAN OF MIDDLE SPINAL CANAL 72146 $3,163.00 MRI SCAN OF MIDDLE SPINAL CANAL BEFORE AND AFTER C 72157 $4,858.00 MRI SCAN OF MIDDLE SPINAL CANAL WITH CONTRAST 72147 $3,748.00 MRI SCAN OF PELVIS 72195 $3,608.00 MRI SCAN OF PELVIS BEFORE AND AFTER CONTRAST 72197 $4,240.00 MRI SCAN OF PELVIS WITH CONTRAST 72196 $2,481.00 MRI SCAN OF UPPER SPINAL CANAL 72141 $3,806.00 MRI SCAN OF UPPER SPINAL CANAL BEFORE AND AFTER CO 72156 $4,931.00 MRI SCAN OF UPPER SPINAL CANAL WITH CONTRAST 72142 $4,261.00 MRI STUDY 76390 $1,877.00 MTB COMPLEX BY AMPLIFIED PROBES 87149 $254.00 MUCOPOLYSACCHARIDES (PROTEIN) LEVEL 83864 $440.00 MULTIANALYTE ASSAY PROCEDURE WITH ALGORITHMIC ANAL 81599 $1,429.00 MULTIPLE INCISIONS FOR REMOVAL OF VARICOSE VEINS O 37765 $5,382.00 MULTIPLE INCISIONS FOR REMOVAL OF VARICOSE VEINS O 37766 $5,370.00 MULTIPLE MEASUREMENTS EYE FLUID PRESSURE EXTENDED 92100 $160.00 MULTIPLE MEASUREMENTS OXYGEN SATURATION IN BLOOD U 94761 $212.00 MULTIVITAMIN TAB 100 EACH BLIST PACK $0.21 MULTIVITAMIN WITH FOLIC ACID 400 MCG 400 MCG TAB 1 $0.39 MULTIVITAMIN WITH IRON TAB 100 EACH BOTTLE $0.18 MULTIVITAMIN WITH IRON TAB 250 EACH BOTTLE $0.09 MULTIVITAMINS WITH MINERALS ABD COENZYME Q10 400 M $91.56 MULTIVIT-IRON-FA-CALCIUM-MINS 9 MG IRON-400 MCG TA $0.37 MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/15 ML LIQ $1.79 MUMPS AB,IGM 86735 $212.00 MUPIROCIN 2 % CREA 15 G TUBE $858.06 MUPIROCIN 2 % OINT 1 G TUBE $71.70 MUPIROCIN 2 % OINT 22 G TUBE $39.35 MVI 12 ADULT 3,300 UNIT- 150 MCG/10 ML SOLN 10 ML $4.24 MVI 12 ADULT 3,300 UNIT- 150 MCG/10 ML SOLN 100 ML $72.10 MVI PED 80 MG-400 UNIT- 200 MCG/5 ML SOLN 5 ML VIA $6.63 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MVI PED 80 MG-400 UNIT- 200 MCG/5 ML SOLN 50 ML VI $679.00 MYCOPLASMA PNEUMONIA,IGG 86738 $174.00 MYCOPLASMA PNEUMONIA,IGM 86738 $174.00 MYELIN BASIC PROTEIN (NERVE PROTEIN) LEVEL, SPINAL 83873 $244.00 MYELOPEROXIDASE (WHITE BLOOD CELL ENZYME) MEASUREM 83876 $173.00 MYOGLOBIN (MUSCLE PROTEIN) LEVEL - LABCORP 83874 $137.00 MYOGLOBIN, SERUM 83874 $137.00 NABUMETONE 500 MG TAB 1 EACH BLIST PACK $4.54 NADOLOL 40 MG TAB 1 EACH BLIST PACK $25.29 NADOLOL 40 MG TAB 30 EACH BLIST PACK $6.95 NAFCILLIN 1 GRAM SOLR 1 EACH VIAL S0032 $46.20 NAFCILLIN 2 GRAM SOLR 1 EACH VIAL S0032 $92.40 NAFTIFINE 1 % GEL 60 G TUBE $1,658.37 NALBUPHINE 10 MG/ML SOLN 1 ML AMPUL J2300 $15.21 NALOXEGOL 12.5 MG TAB 30 EACH BOTTLE $48.30 NALOXEGOL 25 MG TAB 30 EACH BOTTLE $24.15 NALOXONE 0.4 MG/ML SOLN 1 ML VIAL J2310 $16.62 NALOXONE 0.4 MG/ML SOLN 10 ML VIAL J2310 $12.47 NALOXONE 1 MG/ML SYRG 2 ML SYRINGE J2310 $69.30 NALTREXONE 50 MG TAB 1 EACH BLIST PACK $7.55 NALTREXONE 50 MG TAB 30 EACH BLIST PACK $7.55 NALTREXONE 50 MG TAB 30 EACH BOTTLE $14.96 NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % DROP 5 ML DROP $12.13 NAPROXEN 125 MG/5 ML SUSP 500 ML BOTTLE $45.01 NAPROXEN 250 MG TAB 100 EACH BOTTLE $2.71 NAPROXEN 250 MG TAB 50 EACH BLIST PACK $2.72 NAPROXEN 375 MG TAB 1 EACH BLIST PACK $2.30 NAPROXEN 375 MG TAB 50 EACH BLIST PACK $2.30 NAPROXEN 500 MG TAB 1 EACH BOTTLE $234.50 NAPROXEN SODIUM 275 MG TAB 1 EACH BLIST PACK $10.56 NAPROXEN SODIUM 275 MG TAB 100 EACH BOTTLE $8.02 NAPROXEN SODIUM 275 MG TAB 50 EACH BLIST PACK $10.56 NASAL SMEAR FOR EOSINOPHILS (ALLERGY RELATED WHITE 89190 $92.00 NATEGLINIDE 60 MG TAB 30 EACH BLIST PACK $6.83 NATEGLINIDE 60 MG TAB 90 EACH BOTTLE $5.82 NATRIURETIC PEPTIDE (HEART AND BLOOD VESSEL PROTEI 83880 $279.00 NEBIVOLOL 10 MG TAB 30 EACH BOTTLE $5.01 NEBIVOLOL 10 MG TAB 90 EACH BOTTLE $4.58 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge NEBIVOLOL 5 MG TAB 1 EACH BLIST PACK $10.22 NEBIVOLOL 5 MG TAB 100 EACH BLIST PACK $10.22 NEEDLE BIOPSY OF ABDOMINAL CAVITY GROWTH, ACCESSED 49180 $2,469.00 NEEDLE BIOPSY OF KIDNEY, ACCESSED THROUGH THE SKIN 50200 $2,113.00 NEEDLE BIOPSY OF LIVER 47001 $1,986.00 NEEDLE BIOPSY OF LIVER, ACCESSED THROUGH THE SKIN 47000 $2,725.00 NEEDLE BIOPSY OF LUNG OR CHEST TISSUE, ACCESSED TH 32405 $1,713.00 NEEDLE BIOPSY OF LUNG USING AN ENDOSCOPE 31633 $1,646.00 NEEDLE BIOPSY OF MUSCLE, ACCESSED THROUGH THE SKIN 20206 $1,884.00 NEEDLE BIOPSY OF PANCREAS, ACCESSED THROUGH THE SK 48102 $2,941.00 NEEDLE BIOPSY OF SALIVARY GLAND 42400 $826.00 NEEDLE BIOPSY OF SPINAL CORD, ACCESSED BENEATH THE 62269 $3,083.00 NEEDLE BIOPSY OF THYROID, ACCESSED THROUGH THE SKI 60100 $918.00 NEEDLE BIOPSY OF WINDPIPE CARTILAGE, AIRWAY, AND/O 31629 $3,030.00 NEEDLE BIOPSY OR REMOVAL OF LYMPH NODES 38505 $1,850.00 NEEDLE MEASURE & RECORD ELECTRICL ACTIVITY OF MUSC 51785 $808.00 NEEDLE MEASURE & RECORD OF ELECTRICAL ACTIVITY OF 95861 $410.00 NEEDLE MEASUREMENT & REC ELECTRCL ACTIV CRANIAL NR 95867 $395.00 NEEDLE MEASUREMENT & REC ELECTRCL ACTIV CRANIAL NR 95868 $740.00 NEEDLE MEASUREMENT & REC MOVEMENT/FEELING ARM/LEG 95905 $372.00 NEEDLE MEASUREMENT & RECORD OF ELECTRICAL ACTIVITY 95865 $339.00 NEEDLE OR TROCAR BONE MARROW BIOPSY 38221 $1,984.00 NEFAZODONE 100 MG TAB 60 EACH BOTTLE $8.40 NEGATIVE PRESSURE WOUND THERAPY SURFACE AREA < OR 97605 $448.00 NEGATIVE PRESSURE WOUND THERAPY SURFACE AREA < OR 97607 $1,160.00 NEGATIVE PRESSURE WOUND THERAPY SURFACE AREA GREAT 97606 $369.00 NEGATIVE PRESSURE WOUND THERAPY SURFACE AREA GREAT 97608 $765.00 NEOMYCIN 500 MG TAB 100 EACH BOTTLE $4.77 NEOMYCIN-BACITRACIN-POLYMYXIN 3.5-400-10,000 MG-UN $199.32 NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 UNIT- 5,00 $12.45 NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5-400-5,000 MG-UN $0.37 NEOMYCIN-POLYMYXIN B 40 MG-200,000 UNIT/ML SOLN 1 $55,790.00 NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5 MG/G-10,000 U $69.51 NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5MG/ML-10,000 U $69.58 NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75 MG-10,000 UNIT- $216.79 NEOMYCIN-POLYMYXIN-HYDROCORTISONE 3.5-10,000-1 MG/ $352.38 NEOMYCIN-POLYMYXIN-HYDROCORTISONE 3.5-10,000-10 MG $572.04 NEOSTIGMINE METHYLSULFATE 1 MG/ML SOLN 10 ML VIAL J2710 $11.76 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge NEOTRACE 4 0.85 MCG-0.1 MG -25MCG-1.5MG/ML SOLN 2 $44.84 NESIRITIDE 1.5 MG SOLR 1 EACH VIAL J2325 $4,445.74 NEUROBEHAVIORAL STATUS EXAM INTERP & REP PSYCHOLOG 96116 $297.00 NEURONAL ANTIBODY IGG 83516 $221.00 NEURONAL VGKC AUTOANTIBODY 83519 $353.00 NEUROPSYCHOLOGICAL TESTING COMPUTER W/INTERP & REP 96120 $296.00 NEVIRAPINE 50 MG/5 ML SUSP 240 ML BOTTLE $777.84 NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT, TYPI 99201 $150.00 NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT, TYPI 99202 $150.00 NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT, TYPI 99203 $150.00 NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT, TYPI 99204 $150.00 NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT, TYPI 99205 $150.00 NFCT DS CHRNC HCV 6 ASSAYS 81596 $199.00 NGAL(NEUTROPHI GELATINASE ASSOC) 82397 $237.00 NIACIN 250 MG CPSR 100 EACH BOTTLE $0.29 NIACIN 500 MG TB24 90 EACH BOTTLE $21.19 NIACIN 500 MG TBSR 100 EACH BOTTLE $0.22 NIACINAMIDE 500 MG TAB 100 EACH BOTTLE $0.02 NICARDIPINE 20 MG CAP 90 EACH BOTTLE $7.80 NICARDIPINE 25 MG/10 ML SOLN 10 ML VIAL $84.60 NICARDIPINE 30 MG CAP 90 EACH BOTTLE $7.45 NICKEL LEVEL 83885 $159.00 NICOTINE (POLACRILEX) 2 MG GUM 50 EACH BLIST PACK $1.49 NICOTINE 14 MG/24 HR PT24 1 EACH PACKET $6.25 NICOTINE 14 MG/24 HR PT24 14 EACH BOX $7.50 NICOTINE 21 MG/24 HR PT24 1 EACH PACKET $6.25 NICOTINE 21 MG/24 HR PT24 14 EACH BOX $7.50 NICOTINE 7 MG/24 HR PT24 1 PATCH BOX $13.65 NICOTINE 7 MG/24 HR PT24 14 EACH BOX $7.50 NICOTINE 7 MG/24 HR PT24 14 EACH PACKET $14.07 NIFEDIPINE 10 MG CAP 100 EACH BLIST PACK $4.28 NIFEDIPINE 10 MG CAP 50 EACH BLIST PACK $6.87 NIFEDIPINE 30 MG (OSM) TR24 1 EACH BLIST PACK $4.64 NIFEDIPINE 30 MG (OSM) TR24 100 EACH BLIST PACK $4.64 NIMODIPINE 30 MG CAP 1 EACH BLIST PACK $54.50 NIMODIPINE 30 MG CAP 100 EACH BLIST PACK $32.40 NIMODIPINE 30 MG CAP 20 EACH BLIST PACK $64.24 NIMODIPINE 60 MG/20 ML SOLN 20 ML CUP $327.74 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge NITROFURANTOIN 100 MG CAP 100 EACH BLIST PACK $5.67 NITROFURANTOIN 25 MG/5 ML SUSP 230 ML BOTTLE $2,556.68 NITROFURANTOIN 25 MG/5 ML SUSP 5 ML CUP $255.66 NITROFURANTOIN 50 MG CAP 100 EACH BLIST PACK $7.73 NITROGLYCERIN 0.1 MG/HR PT24 30 EACH PACKET $8.94 NITROGLYCERIN 0.2 MG/HR PT24 1 EACH PACKET $6.66 NITROGLYCERIN 0.2 MG/HR PT24 30 EACH PACKET $2.97 NITROGLYCERIN 0.3 MG SUBL 100 EACH BOTTLE $1.65 NITROGLYCERIN 0.4 MG SUBL 100 EACH BOTTLE $1.65 NITROGLYCERIN 0.4 MG SUBL 25 EACH BOTTLE $5.24 NITROGLYCERIN 0.4 MG/HR PT24 1 EACH PACKET $7.61 NITROGLYCERIN 0.4 MG/HR PT24 30 EACH PACKET $7.61 NITROGLYCERIN 0.6 MG/HR PT24 30 EACH PACKET $7.22 NITROGLYCERIN 2 % OINT 1 G PACKET $6.89 NITROGLYCERIN 2 % OINT 30 G TUBE $149.10 NITROGLYCERIN 50 MG/10 ML (5 MG/ML) SOLN 10 ML VIA $56.88 NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) SOLN 250 M $81.38 NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL $336.00 NIVOLUMAB 100 MG/10 ML SOLN 10 ML VIAL J9299 $11,012.75 NIVOLUMAB 240 MG/24 ML SOLN 24 ML VIAL J9299 $26,040.00 NIVOLUMAB 40 MG/4 ML SOLN 4 ML VIAL J9299 $4,340.00 N-METH-D-ASP RECPT AB IGG 86255 $278.00 NON-CARDIAC VASCULAR FLOW IMAGING 78445 $836.00 NON-HORMONAL ANTI-NEOPLASTIC CHEMOTHERAPY BENEATH 96401 $427.00 NONINTEFACED LEAD URINE 83655 $184.00 NON-NEEDLE MEASURE & RECORD OF ELECTRICAL ACTIVITY 51784 $248.00 NOREPINEPHRINE 1 MG/ML SOLN 4 ML AMPUL $36.75 NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL $84.97 NORETHINDRONE 5 MG TAB 50 EACH BOTTLE $4.64 NORTRIPTYLINE 10 MG CAP 1 EACH BLIST PACK $1.97 NORTRIPTYLINE 10 MG CAP 100 EACH BLIST PACK $1.54 NORTRIPTYLINE 10 MG CAP 100 EACH BOTTLE $2.61 NORTRIPTYLINE 10 MG CAP 50 EACH BLIST PACK $1.97 NORTRIPTYLINE 25 MG CAP 1 EACH BLIST PACK $2.07 NORTRIPTYLINE 50 MG CAP 1 EACH BLIST PACK $0.44 NORTRIPTYLINE 75 MG CAP 100 EACH BOTTLE $1.97 NUCLEAR MEDICINE ? REVENUE CODE 34X G0378 $90.00 NUCLEAR MEDICINE BACKWASH OF URINE INTO KIDNEY 78740 $1,067.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge NUCLEAR MEDICINE IMAGING FOR THYROID UPTAKE MEASUR 78014 $1,536.00 NUCLEAR MEDICINE IMAGING OF THYROID 78013 $671.00 NUCLEAR MEDICINE KIDNEY FUNCTION STUDY 78725 $1,481.00 NUCLEAR MEDICINE MULTIPLE STUDIES VESSELS OF HEART 78454 $5,028.00 NUCLEAR MEDICINE STUDY BRAIN WITH METABOLIC EVALUA 78608 $8,907.00 NUCLEAR MEDICINE STUDY HEART FUNCTION REST/STRESS 78496 $1,520.00 NUCLEAR MEDICINE STUDY HEART MUSCLE WITH METABOLIC 78459 $6,566.00 NUCLEAR MEDICINE STUDY HEART WALL MOTION REST/STRE 78472 $2,020.00 NUCLEAR MEDICINE STUDY LIMITED AREA 78811 $6,253.00 NUCLEAR MEDICINE STUDY OF BLOOD CIRCULATION IN THE 78580 $1,855.00 NUCLEAR MEDICINE STUDY OF BONE AND/OR JOINT 78320 $3,008.00 NUCLEAR MEDICINE STUDY OF BRAIN 78607 $2,571.00 NUCLEAR MEDICINE STUDY OF BRAIN AND SPINAL CORD FL 78647 $2,520.00 NUCLEAR MEDICINE STUDY OF HEART MUSCLE 0399T $651.00 NUCLEAR MEDICINE STUDY OF KIDNEY 78710 $1,851.00 NUCLEAR MEDICINE STUDY OF KIDNEY WITH ASSESSMENT O 78701 $1,736.00 NUCLEAR MEDICINE STUDY OF KIDNEY WITH ASSESSMENT O 78707 $2,803.00 NUCLEAR MEDICINE STUDY OF KIDNEY WITH ASSESSMENT O 78708 $2,130.00 NUCLEAR MEDICINE STUDY OF KIDNEY WITH ASSESSMENT O 78709 $1,958.00 NUCLEAR MEDICINE STUDY OF LIVER 78205 $3,405.00 NUCLEAR MEDICINE STUDY OF LUNG VENTILATION 78579 $1,707.00 NUCLEAR MEDICINE STUDY OF LUNG VENTILATION & BLOOD 78582 $2,610.00 NUCLEAR MEDICINE STUDY OF RADIOACTIVE MATERIAL DIS 78803 $2,174.00 NUCLEAR MEDICINE STUDY OF RED BLOOD CELL 78120 $1,936.00 NUCLEAR MEDICINE STUDY OF RED BLOOD CELL 78130 $1,876.00 NUCLEAR MEDICINE STUDY OF TESTICLES AND BLOOD VESS 78761 $1,123.00 NUCLEAR MEDICINE STUDY RADIOACTIVE MATERIAL DISTRI 78800 $1,587.00 NUCLEAR MEDICINE STUDY RADIOACTIVE MATERIAL DISTRI 78801 $2,396.00 NUCLEAR MEDICINE STUDY RADIOACTIVE MATERIAL DISTRI 78802 $2,657.00 NUCLEAR MEDICINE STUDY RADIOACTIVE MATERIAL DISTRI 78804 $2,854.00 NUCLEAR MEDICINE STUDY RADIOACTIVE MATERIAL DISTRI 78805 $2,480.00 NUCLEAR MEDICINE STUDY RADIOACTIVE MATERIAL DISTRI 78806 $1,746.00 NUCLEAR MEDICINE STUDY RADIOACTIVE MATERIAL DISTRI 78807 $2,234.00 NUCLEAR MEDICINE STUDY VESSELS OF HEART USING DRUG 78451 $3,013.00 NUCLEAR MEDICINE STUDY VESSELS OF HEART USING DRUG 78452 $4,919.00 NUCLEAR MEDICINE STUDY W/MEASURE BLOOD CIRCULATION 78598 $1,254.00 NUCLEAR MEDICINE STUDY WITH CT IMAGING 78814 $6,984.00 NUCLEAR MEDICINE STUDY WITH CT IMAGING SKULL BASE 78815 $9,691.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge NUCLEAR MEDICINE STUDY WITH CT IMAGING WHOLE BODY 78816 $8,884.00 NUCLEAR MEDICINE STUDY WITH MEASUREMENT OF BLOOD C 78597 $2,207.00 NUCLEAR MEDICINE WHOLE BODY STUDY FOR THYROID CANC 78018 $2,667.00 NYSTATIN 100,000 UNIT/GRAM CREA 15 G TUBE $61.27 NYSTATIN 100,000 UNIT/GRAM OINT 15 G TUBE $61.27 NYSTATIN 100,000 UNIT/GRAM POWD 15 G SQUEEZ BTL $96.13 NYSTATIN 100,000 UNIT/ML SUSP 473 ML BOTTLE $405.60 NYSTATIN 100,000 UNIT/ML SUSP 5 ML CUP $3.89 NYSTATIN 500,000 UNIT TAB 100 EACH BOTTLE $4.97 NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% CREA 1 $391.81 OBINUTUZUMAB 1,000 MG/40 ML SOLN 40 ML VIAL J9301 $67.78 OBS CARVEOUT RC 48X G0378 $90.00 OBS CARVEOUT RC 921 G0378 $90.00 OBSTETRIC BLOOD TEST PANEL 80055 $514.00 OCCLUSION OF ABNORMAL ARTERY, ACCESSED THROUGH THE 61624 $5,478.00 OCCLUSION OF ARTERIAL OR VENOUS HEMORRHAGE 37244 $23,901.00 OCCLUSION OF ARTERY 37242 $22,232.00 OCCLUSION OF HEAD OR NECK ARTERY, ACCESSED THROUGH 61626 $15,158.00 OCCLUSION OF TUMORS OR OBSTRUCTED BLOOD VESSEL 37243 $29,034.00 OCCLUSION OF VENOUS MALFORMATIONS 37241 $22,052.00 OCCUPATIONAL THERAPY ? REVENUE CODE 43X G0378 $90.00 OCRELIZUMAB 30 MG/ML SOLN 10 ML VIAL J2350 $68,250.00 OCTREOTIDE 100 MCG/ML SOLN 1 ML VIAL J2354 $13.65 OCTREOTIDE 50 MCG/ML SOLN 1 ML VIAL J2354 $18.90 OCTREOTIDE 500 MCG/ML SOLN 1 ML AMPUL J2354 $54.38 OCTREOTIDE 500 MCG/ML SOLN 1 ML VIAL J2354 $14.70 OCTREOTIDE ACETATE 100 MCG/ML (1 ML) SYRG 1 ML SYR $34.55 OCTREOTIDE ACETATE 50 MCG/ML (1 ML) SYRG 1 ML SYRI $17.50 OCTREOTIDE,MICROSPHERES 20 MG SSRR 1 EACH VIAL J2353 $17,140.59 OCTREOTIDE,MICROSPHERES 30 MG SSRR 1 EACH VIAL J2353 $25,666.80 OFLOXACIN 0.3 % DROP 5 ML DROP BTL $73.29 OLANZAPINE 10 MG SOLR 1 EACH VIAL $36.03 OLANZAPINE 5 MG TAB 1 EACH BLIST PACK $46.26 OLANZAPINE 5 MG TAB 100 EACH BLIST PACK $46.26 OLANZAPINE ZYDIS 10 MG TBDL 1 EACH BLIST PACK $24.67 OLANZAPINE ZYDIS 10 MG TBDL 30 EACH BLIST PACK $36.70 OLANZAPINE ZYDIS 10 MG TBDL 30 EACH BOTTLE $36.66 OLANZAPINE ZYDIS 20 MG TBDL 1 EACH BLIST PACK $35.78 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge OLANZAPINE ZYDIS 20 MG TBDL 30 EACH BOTTLE $35.74 OLANZAPINE ZYDIS 5 MG TBDL 100 EACH BLIST PACK $49.96 OLANZAPINE ZYDIS 5 MG TBDL 30 EACH BOTTLE $49.90 OLMESARTAN 20 MG TAB 1 EACH BLIST PACK $5.49 OLMESARTAN 20 MG TAB 30 EACH BOTTLE $7.70 OLMESARTAN 20 MG TAB 90 EACH BOTTLE $5.49 OLMESARTAN 5 MG TAB 30 EACH BOTTLE $17.97 OLOPATADINE 0.1 % DROP 5 ML DROP BTL $942.66 OMALIZUMAB 150 MG SOLR 1 EACH VIAL J2357 $4,466.25 OMALIZUMAB 150 MG/ML SYRG 1 ML SYRINGE j2357 $4,555.57 OMALIZUMAB 75 MG/0.5 ML SYRG 0.5 ML SYRINGE J2357 $2,277.79 OMEGA ACUTE HEPATITIS PANEL 80074 $789.00 OMEGA COMPLEX SPEC STAIN O/P TRIC 87209 $154.00 OMEGA HEPATITIS A VIRUS AB IGM 86709 $269.00 OMEGA HEPATITIS B SURFACE ANTIGEN 87340 $210.00 OMEGA HEPATITIS C AB 86803 $293.00 OMEGA T VAGINALIS PCR 87661 $380.00 OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAP 120 EACH BOTT $3.39 OMEGA-ALPHA FETOPROTEIN TUM MRKR 82105 $221.00 OMEGA-CANCER AG CA 19-9 86301 $318.00 OMEGA-CANCER ANTIGEN 125 86304 $376.00 OMEGA-CTRACH DNA PROBE 87491 $171.00 OMEGA-ESTRADIOL,ADULT PREM FEMALE 82670 $412.00 OMEGA-HEPATITIS B CORE AB IGM 86705 $244.00 OMEGA-NUC ACID AM NEISSERIA 87591 $206.00 OMEGA-RPR 86592 $101.00 OMEGA-RUBELLA ANTIBODY IGG 86317 $283.00 OMEGA-TRIIODOTHYRONINE FREE T3 84481 $335.00 OMEPRAZOLE 20 MG CPDR 100 EACH BOTTLE $7.26 OMEPRAZOLE 20 MG CPDR 30 EACH BOTTLE $7.27 ONABOTULINUMTOXINA 100 UNIT SOLR 1 EACH VIAL J0585 $31.55 ONCOPROTEIN (CANCER RELATED GENE) MEASUREMENT 83951 $373.00 ONDANSETRON 2 MG/ML SOLN 20 ML VIAL J2405 $2.84 ONDANSETRON 4 MG TAB 1 EACH BLIST PACK Q0162 $83.80 ONDANSETRON 4 MG TAB 100 EACH BLIST PACK Q0162 $83.80 ONDANSETRON 4 MG TBDL 30 EACH BLIST PACK Q0162 $39.00 ONDANSETRON HCL (PF) 4 MG/2 ML SOLN 2 ML VIAL J2405 $4.83 OPEN FEMORAL ARTERY EXPOSURE 34812 $7,900.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge OPEN TREATMENT OF BROKEN FINGER 26615 $10,083.00 OPEN TREATMENT OF BROKEN FINGER OR THUMB 26765 $7,791.00 OPEN TREATMENT OF BROKEN FOREARM BONE AT ELBOW 24655 $2,003.00 OPEN TREATMENT OF BROKEN GREAT TOE 28505 $4,026.00 OPEN TREATMENT OF BROKEN HAND OR FINGER 26746 $10,013.00 OPENING OF WINDPIPE THROUGH NECK FOR INSERTION OF 31600 $2,723.00 OPHTHALMIC IRRIGATION SOLUTION IRSL 118 ML BOTTLE $13.22 OPIATES LEVELS 80361 $214.00 OPIOIDS LEVELS 80363 $259.00 OPIOIDS LEVELS 80364 $225.00 OPIUM-BELLADONNA 16.2-60 MG SUPP 1 EACH BOX $117.09 OPIUM-BELLADONNA 16.2-60 MG SUPP 12 EACH BOX $117.09 OR LEVEL 1 1ST 15 MINUTES $2,153.00 OR LEVEL 1 EACH ADDITIONAL 15 MINUTES $1,417.00 OR LEVEL 2 1ST 15 MINUTES $4,278.00 OR LEVEL 2 EACH ADDITIONAL 15 MINUTES $1,737.00 OR LEVEL 3 1ST 15 MINUTES $6,430.00 OR LEVEL 3 EACH ADDITIONAL 15 MINUTES $2,833.00 OR LEVEL 4 1ST 15 MINUTES $8,555.00 OR LEVEL 4 EACH ADDITIONAL 15 MINUTES $5,722.00 OR LEVEL 5 1ST 15 MINUTES $10,707.00 OR LEVEL 5 EACH ADDITIONAL 15 MINUTES $7,138.00 OR LEVEL 6 1ST 15 MINUTES $12,860.00 OR LEVEL 6 EACH ADDITIONAL 15 MINUTES $8,555.00 OR LEVEL 7 1ST 15 MINUTES $14,984.00 OR LEVEL 7 EACH ADDITIONAL 15 MINUTES $9,999.00 OR LEVEL 8 1ST 15 MINUTES $17,137.00 OR LEVEL 8 EACH ADDITIONAL 15 MINUTES $11,415.00 OR ROBOTICS/HIGH TECH $5,271.00 ORAL ADMINISTRATION OF RADIOACTIVE MATERIAL THERAP 79005 $1,780.00 ORAL INTRODUCTION OF LONG DRAINAGE TUBE INTO SMALL 44500 $1,081.00 ORGANIC ACID LEVEL 83921 $309.00 ORGANIC ACIDS LEVEL 83918 $603.00 ORPHENADRINE 100 MG TBSR 100 EACH BOTTLE $7.61 ORPHENADRINE 30 MG/ML SOLN 2 ML VIAL J2360 $77.71 OSELTAMIVIR 30 MG CAP 10 EACH BLIST PACK $49.63 OSELTAMIVIR 75 MG CAP 10 EACH BLIST PACK G9019 $63.79 OSMOLALITY, SERUM 83930 $129.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge OSTEOCALCIN (BONE PROTEIN) LEVEL 83937 $230.00 OTHER PRIMARY FUNCTION LIMIT CURRENT STATUS G8990 $0.01 OTHER PRIMARY FUNCTION LIMIT DISCHARGE STATUS G8992 $0.01 OTHER PRIMARY FUNCTION LIMIT GOAL STATUS G8991 $0.01 OTHER SPEECH/LANGUAGE FUNCTIONAL LIMIT CURRENT STA G9174 $0.01 OTHER SPEECH/LANGUAGE FUNCTIONAL LIMIT DISCHARGE S G9176 $0.01 OTHER SPEECH/LANGUAGE FUNCTIONAL LIMIT GOAL STATUS G9175 $0.01 OTHER SUBSEQUENT FUNCTION LIMIT CURRENT STATUS G8993 $0.01 OTHER SUBSEQUENT FUNCTION LIMIT DISCHARGE STATUS G8995 $0.01 OTHER SUBSEQUENT FUNCTION LIMIT GOAL STATUS G8994 $0.01 OTHER THERAPEUTIC ? REVENUE CODE 940 G0378 $90.00 OVERNIGHT MEASUREMENT OXYGEN SATURATION IN BLOOD U 94762 $385.00 OVULATION TESTS 84830 $83.00 OXACILLIN 1 GRAM SOLR 1 EACH VIAL J2700 $47.25 OXACILLIN 10 GRAM SOLR 1 EACH VIAL J2700 $462.00 OXACILLIN 2 GRAM SOLR 1 EACH VIAL J2700 $46.73 OXALATE LEVEL 83945 $113.00 OXALIPLATIN 100 MG/20 ML SOLN 20 ML VIAL J9263 $840.00 OXALIPLATIN 50 MG/10 ML (5 MG/ML) SOLN 10 ML VIAL J9263 $420.00 OXANDROLONE 10 MG TAB 60 EACH BOTTLE $83.35 OXANDROLONE 2.5 MG TAB 1 EACH BLIST PACK $24.26 OXANDROLONE 2.5 MG TAB 30 EACH BLIST PACK $24.26 OXCARBAZEPINE 300 MG TAB 100 EACH BLIST PACK $4.82 OXCARBAZEPINE LEVEL 80183 $233.00 OXYBUTYNIN 5 MG TAB 1 EACH BLIST PACK $1.16 OXYBUTYNIN 5 MG TAB 100 EACH BLIST PACK $1.16 OXYBUTYNIN 5 MG TR24 100 EACH BLIST PACK $10.53 OXYBUTYNIN 5 MG TR24 50 EACH BLIST PACK $11.15 OXYBUTYNIN 5 MG/5 ML SYRP 473 ML BOTTLE $182.11 OXYBUTYNIN 5 MG/5 ML SYRP 5 ML CUP $2.10 OXYCHLOROSENE SODIUM SOLR 2 G JAR $19.28 OXYCODONE 10 MG TAB 1 EACH BLIST PACK $2.42 OXYCODONE 10 MG TR12 20 EACH BLIST PACK $17.36 OXYCODONE 20 MG TR12 20 EACH BLIST PACK $32.33 OXYCODONE 5 MG TAB 1 EACH BLIST PACK $1.89 OXYCODONE 5 MG TAB 100 EACH BLIST PACK $1.89 OXYCODONE 5 MG/5 ML SOLN 5 ML CUP $25.83 OXYCODONE-ACETAMINOPHEN 10-325 MG TAB 1 EACH BLIST $12.43 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge OXYCODONE-ACETAMINOPHEN 10-325 MG TAB 100 EACH BLI $12.43 OXYCODONE-ACETAMINOPHEN 10-325 MG TAB 100 EACH BOT $12.43 OXYCODONE-ACETAMINOPHEN 5-325 MG TAB 100 EACH BLIS $4.79 OXYCODONE-ACETAMINOPHEN 5-325 MG TAB 100 EACH BOTT $4.79 OXYCODONE-ACETAMINOPHEN 7.5-325 MG TAB 1 EACH BLIS $9.50 OXYCODONE-ACETAMINOPHEN 7.5-325 MG TAB 100 EACH BL $9.50 OXYCODONE-ASPIRIN 4.8355-325 MG TAB 100 EACH BOTTL $4.14 OXYMETAZOLINE 0.05 % SPRY 15 ML SQUEEZ BTL $7.19 OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL $6.30 OXYTOCIN 10 UNIT/ML SOLN 1 ML VIAL J2590 $4.54 PACLITAXEL 6 MG/ML CONC 50 ML VIAL J9267 $270.90 PACLITAXEL-PROTEIN BOUND 100 MG SUSR 1 EACH VIAL J9264 $5,280.38 PALIPERIDONE 3 MG TR24 1 EACH BLIST PACK $89.04 PALIPERIDONE 3 MG TR24 100 EACH BLIST PACK $89.04 PALIPERIDONE 3 MG TR24 30 EACH BOTTLE $106.85 PALIPERIDONE 6 MG TR24 1 EACH BLIST PACK $44.52 PALIPERIDONE 6 MG TR24 100 EACH BLIST PACK $53.42 PALIPERIDONE 6 MG TR24 30 EACH BOTTLE $53.42 PALIPERIDONE PALMITATE 156 MG/ML SYRG 1 ML SYRINGE J2426 $1,751.23 PALIVIZUMAB 100 MG/ML SOLN 1 ML VIAL 90378 $11,882.71 PALIVIZUMAB 50 MG/0.5 ML SOLN 0.5 ML VIAL 90378 $6,292.86 PALONOSETRON 0.25 MG/5 ML SOLN 5 ML VIAL J2469 $126.00 PAMIDRONATE 30 MG/10 ML (3 MG/ML) SOLN 10 ML VIAL J2430 $58.00 PAMIDRONATE 60 MG/10 ML (6 MG/ML) SOLN 10 ML VIAL J2430 $117.78 PAMIDRONATE 90 MG/10 ML (9 MG/ML) SOLN 10 ML VIAL J2430 $150.57 PANCREATIC ELASTASE (ENZYME) MEASUREMENT 82656 $77.00 PANCREATIC ELASTASE STOOL 83520 $287.00 PANITUMUMAB 400 MG/20 ML (20 MG/ML) SOLN 20 ML VIA J9303 $19,948.95 PANTOPRAZOLE 40 MG GRPS 30 EACH PACKET $31.64 PANTOPRAZOLE 40 MG SOLR 1 EACH VIAL C9113 $21.00 PANTOPRAZOLE 40 MG TBEC 100 EACH BLIST PACK $14.30 PANTOPRAZOLE 40 MG TBEC 90 EACH BOTTLE $13.75 PAP TEST 88174 $120.00 PAP TEST 88175 $160.00 PAP TEST 88177 $44.00 PAP TEST (PAP SMEAR) 88165 $87.00 PAP TEST (PAP SMEAR) 88141 $57.00 PAP TEST (PAP SMEAR) 88142 $128.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PAP TEST (PAP SMEAR) 88164 $87.00 PAPAVERINE 30 MG/ML SOLN 2 ML VIAL J2440 $75.13 PARAB-CETYL,STEA ALC-P.GLY-SLS CLSR 118 ML BOTTLE $16.11 PARANEOPLASTIC AB BY IFA 86255 $200.00 PARATHY HORMONE 83970 $280.00 PAREGORIC 2 MG/5 ML LIQD 473 ML BOTTLE $1,205.20 PAREGORIC 2 MG/5 ML LIQD 5 ML CUP $12.78 PARICALCITOL 1 MCG CAP 30 EACH BOTTLE $38.82 PARICALCITOL 5 MCG/ML SOLN 1 ML VIAL J2501 $12.73 PARIETAL CELL AB,IGG 83516 $226.00 PAROXETINE 12.5 MG TB24 30 EACH BOTTLE $19.52 PAROXETINE 20 MG TAB 100 EACH BLIST PACK $0.47 PARTIAL PROTHROMBIN TIME LA 85730 $122.00 PARTIAL REMOVAL OF BONE WITH RELEASE OF SPINAL COR 63035 $6,386.00 PARTIAL REMOVAL OF TOE BONE 28124 $3,737.00 PARTIAL REMOVE BONE W/RELEASE OF SPINAL CORD OR SP 63030 $12,023.00 PARTIAL THROMBIN TIME LA 85611 $135.00 PATHOLOGY EXAM OF TISSUE USING A MICROSCOPE MODERA 88304 $316.00 PATHOLOGY EXAM OF TISSUE USING A MICROSCOPE MODERA 88307 $673.00 PATHOLOGY EXAMINATION OF SPECIMEN DURING SURGERY 88329 $286.00 PATHOLOGY EXAMINATION OF SPECIMEN DURING SURGERY 88332 $127.00 PATHOLOGY EXAMINATION OF SPECIMEN DURING SURGERY 88334 $157.00 PATHOLOGY EXAMINATION OF TISSUE DURING SURGERY 88331 $201.00 PATHOLOGY EXAMINATION OF TISSUE SPECIMEN DURING SU 88333 $349.00 PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE 88300 $145.00 PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE 88302 $233.00 PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE 88305 $413.00 PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE 88309 $925.00 PATIROMER CALCIUM SORBITEX 8.4 GRAM PWPK 4 EACH PA $153.98 PED MULTIVIT-IRON 10 MG/ML 750 UNIT-400 UNIT-10 MG $29.93 PEDI MULTIVIT NO.45-FLUORIDE 0.25MG-IRON 10MG/ML 0 $121.80 PEDI MULTIVIT NO.82 W-FLUORIDE 0.25 MG/ML DROP 50 $121.80 PEDIATRIC MULTIVITAMIN NO.81 750-35-400 UNIT-MG-UN $29.93 PEGFILGRASTIM 6 MG/0.6 ML SYIN 0.6 ML SYRINGE J2505 $27,115.45 PEGFILGRASTIM 6 MG/0.6ML SYRG 0.6 ML SYRINGE J2505 $26,170.45 PEGFILGRASTIM-CBQV 6 MG/0.6 ML SYRG 0.6 ML SYRINGE Q5111 $17,535.00 PEGFILGRASTIM-JMDB 6 MG/0.6 ML SYRG 0.6 ML SYRINGE Q5108 $17,535.00 PEMBROLIZUMAB 25 MG/ML SOLN 4 ML VIAL J9271 $19,239.85 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PEMETREXED 100 MG SOLR 1 EACH VIAL J9305 $2,799.37 PEMETREXED 500 MG SOLR 1 EACH VIAL J9305 $13,996.92 PENICILLIN G BENZATHIN,PROCAIN 1,200,000 UNIT/ 2 M J0558 $526.86 PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML SYRG 2 J0561 $330.47 PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML SYRG 4 J0561 $338.59 PENICILLIN G BENZATHINE 600,000 UNIT/ML SYRG 1 ML J0561 $381.61 PENICILLIN G POTASSIUM 20 MILLION UNIT SOLR 1 EACH J2540 $21.27 PENICILLIN G POTASSIUM 5 MILLION UNIT SOLR 1 EACH J2540 $21.27 PENICILLIN G PROCAINE-PENICILLIN G BENZATHINE 1,20 J0558 $526.86 PENICILLIN G SODIUM 5 MILLION UNIT SOLR 1 EACH VIA $24.19 PENICILLIN V POTASSIUM 250 MG TAB 100 EACH BOTTLE $2.40 PENICILLIN V POTASSIUM 500 MG TAB 100 EACH BOTTLE $4.08 PENTAMIDINE 300 MG SOLR 1 EACH VIAL S0080 $700.94 PENTAZOCINE-NALOXONE 50-0.5 MG TAB 100 EACH BOTTLE $11.55 PENTOXIFYLLINE 400 MG TBSR 100 EACH BLIST PACK $5.24 PENTOXIFYLLINE 400 MG TBSR 100 EACH BOTTLE $0.78 PEPPERMINT OIL OIL 30 ML BOTTLE $84.21 PERCUTANEOUS ACCESS & CLOSURE FEMORAL ART FOR DELI 34713 $382.00 PERCUTANEOUS BREAST BIOPSY W/DEVICE ADDL LESION 19082 $2,657.00 PERCUTANEOUS INSERT SMALL BOWEL TUBE 49441 $3,740.00 PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML SUSP 2 ML Q9957 $826.00 PERIPHERAL VEIN RENIN (KIDNEY ENZYME) STIMULATION 80417 $363.00 PERITONEAL DIALYSIS NON-CAPD 90945 $1,936.00 PERITONEAL-VENOUS SHUNT PATENCY TEST 78291 $1,783.00 PERMANENT BLOCKAGE OF DIALYSIS CIRCUIT WITH IMAGIN 36909 $2,833.00 PERMETHRIN 1 % LIQD 59 ML BOTTLE $36.76 PERMETHRIN 5 % CREA 60 G TUBE $433.23 PERPHENAZINE 2 MG TAB 100 EACH BLIST PACK $6.88 PERPHENAZINE 2 MG TAB 100 EACH BOTTLE $6.11 PERPHENAZINE-AMITRIPTYLINE 2-25 MG TAB 100 EACH BO $6.84 PERQ ART TRLUML M-THROMBEC &/NFS INTRACRANIAL 61645 $14,191.00 PERQ BALO DILA IC VSPSM EA VSL DIFF VASC TER 61642 $3,842.00 PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC 43762 $4,521.00 PERTUZUMAB 420 MG/14 ML (30 MG/ML) SOLN 14 ML VIAL J9306 $20,439.57 PET ? REVENUE CODE 404 G0378 $90.00 PH STOOL 83986 $57.00 PH URINE 83986 $57.00 PH, BODY FLUID, EXCEPT BLOOD 83986 $57.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PHENAZOPYRIDINE 100 MG TAB 100 EACH BOTTLE $9.45 PHENAZOPYRIDINE 200 MG TAB 100 EACH BOTTLE $7.00 PHENCYCLIDINE (PCP), URINE 83992 $182.00 PHENOBARBITAL 100 MG TAB 500 EACH BOTTLE $0.63 PHENOBARBITAL 130 MG/ML SOLN 1 ML VIAL J2560 $182.96 PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ELIX 473 ML BOT $321.17 PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ELIX 5 ML CUP $11.08 PHENOBARBITAL 30 MG TAB 500 EACH BOTTLE $0.37 PHENOBARBITAL 97.2 MG TAB 100 EACH BOTTLE $0.69 PHENOBARBITAL LEVEL 80184 $193.00 PHENOL 1.4 % SPRA 20 ML BOTTLE $7.70 PHENTOLAMINE 5 MG SOLR 1 EACH VIAL J2760 $1,872.50 PHENYLALANINE, PKU (AMINO ACID) LEVEL 84030 $135.00 PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % OINT 2 $24.50 PHENYLEPHRINE 0.125 % DROP 15 ML DROP BTL $14.02 PHENYLEPHRINE 0.25 % SPRY 15 ML SQUEEZ BTL $13.97 PHENYLEPHRINE 0.5 % SPRY 15 ML SQUEEZ BTL $13.97 PHENYLEPHRINE 10 % DROP 5 ML DROP BTL $175.00 PHENYLEPHRINE 10 MG/ML SOLN 1 ML VIAL J2370 $0.25 PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL J2370 $0.18 PHENYLEPHRINE 2.5 % DROP 15 ML DROP BTL $393.75 PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % SUPP 24 EA $2.04 PHENYTOIN 100 MG CAP 100 EACH BLIST PACK $2.38 PHENYTOIN 100 MG CAP 100 EACH BOTTLE $2.24 PHENYTOIN 100 MG/4 ML SUSP 4 ML CUP $56.28 PHENYTOIN 125 MG/5 ML SUSP 237 ML BOTTLE $101.20 PHENYTOIN 125 MG/5 ML SUSP 4 ML CUP $1.71 PHENYTOIN 50 MG CHEW 1 EACH BLIST PACK $2.74 PHENYTOIN 50 MG CHEW 100 EACH BLIST PACK $6.90 PHENYTOIN 50 MG/ML SOLN 2 ML VIAL J1165 $5.31 PHENYTOIN 50 MG/ML SOLN 5 ML VIAL J1165 $6.93 PHENYTOIN LEVEL 80185 $154.00 PHENYTOIN LEVEL 80186 $205.00 PHOSPHATASE (ENZYME) LEVEL 84075 $101.00 PHOSPHATASE (ENZYME) MEASUREMENT 84080 $222.00 PHOSPHATE LEVEL 84100 $93.00 PHOSPHOHEXOSE ISOMERASE (ENZYME) LEVEL 84087 $556.00 PHOSPHOLIPID ANTIBODY (AUTOIMMUNE ANTIBODY) MEASUR 86148 $167.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PHOSPHOLIPID TEST 85598 $238.00 PHOSPHORUS URINE 84105 $67.00 PHYSICAL PERFORMANCE TEST OR MEASUREMENT WITH REPO 97750 $169.00 PHYSICAL THERAPY ? REVENUE CODE 42X G0378 $90.00 PHYSOSTIGMINE SALICYLATE 1 MG/ML SOLN 2 ML AMPUL $155.83 PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML SYRG 0.5 ML J3430 $28.35 PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN 1 ML AMPUL J3430 $50.65 PHYTONADIONE (VITAMIN K1) 5 MG TAB 100 EACH BOTTLE $123.40 PILOCARPINE 1 % DROP 15 ML DROP BTL $331.85 PILOCARPINE 2 % DROP 15 ML DROP BTL $399.68 PILOCARPINE 4 % DROP 15 ML DROP BTL $418.79 PILOCARPINE HCL 0.4% PREPARTION 100 ML BOTTLE $420.00 PINWORM TEST 87172 $108.00 PIOGLITAZONE 15 MG TAB 1 EACH BLIST PACK $3.92 PIOGLITAZONE 15 MG TAB 100 EACH BLIST PACK $19.89 PIOGLITAZONE 15 MG TAB 30 EACH BOTTLE $24.52 PIOGLITAZONE 30 MG TAB 1 EACH BLIST PACK $15.20 PIOGLITAZONE 30 MG TAB 100 EACH BLIST PACK $15.20 PIOGLITAZONE 30 MG TAB 30 EACH BOTTLE $18.74 PIOGLITAZONE 30 MG TAB 90 EACH BOTTLE $0.35 PIPERACILLIN-TAZOBACTAM 2.25 GRAM SOLR 1 EACH VIAL J2543 $28.84 PIPERACILLIN-TAZOBACTAM 3.375 GRAM SOLR 1 EACH VIA J2543 $42.00 PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML PGBK 50 M J2543 $96.08 PIPERACILLIN-TAZOBACTAM 4.5 GRAM SOLR 1 EACH VIAL J2543 $81.85 PLACE BREAST LOCALIZATION DEVICE ACCESSED THROUGH 19281 $893.00 PLACE BREAST LOCALIZATION DEVICE ACCESSED THROUGH 19282 $2,306.00 PLACE BREAST LOCALIZATION DEVICE ACCESSED THROUGH 19283 $2,647.00 PLACE BREAST LOCALIZATION DEVICE ACCESSED THROUGH 19285 $1,146.00 PLACE BREAST LOCALIZATION DEVICE ACCESSED THROUGH 19286 $1,168.00 PLACE EAR PROBE COMPUTERIZED MEASURE SOUND W/INTER 92587 $355.00 PLACE INTERSTITIAL DEVICE C9728 $5,268.00 PLACE SCALP ELECTRODES ASSESS&REC RESPONSE SEVRL A 92585 $1,240.00 PLACEMENT CATHETER OF GALLBLADDER & PANCREAS UNDER 74330 $1,391.00 PLACEMENT EAR PROBE FOR COMPUTERIZED MEASUREMENT 92558 $194.00 PLACEMENT EXTENSION PROSTH FOR ENDOVASCULAR REPAIR 34709 $965.00 PLACEMENT OCCLUSIVE DEVICE G0269 $617.00 PLACEMENT OF CATHETER OF KIDNEY ACCESSED THROUGH T 50432 $3,072.00 PLACEMENT OF DRAINAGE CATHETER OF BILIARY DUCT ACC 47533 $6,531.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PLACEMENT OF INTRA-UTERINE DEVICE (IUD) FOR PREGNA 58300 $678.00 PLACEMENT OF STENT AND DRAINAGE CATHETER OF BILIAR 47540 $16,652.00 PLACEMENT OF STENT IN ESOPHAGUS STOMACH AND/OR UPP 43266 $6,132.00 PLACEMENT OF STENT OF BILIARY DUCT ACCESSED THROUG 47538 $11,682.00 PLACEMENT OF STENT OF URINARY DUCT 50693 $7,341.00 PLACEMENT OF STENT OF URINARY DUCT 50694 $6,894.00 PLACEMENT OF STENT OF URINARY DUCT ACCESSED THROUG 50695 $8,925.00 PLACEMENT OF STENT ON ESOPHAGUS USING AN ENDOSCOPE 43212 $6,778.00 PLACEMENT OF STENT PANCREATIC OR BILE DUCT USING A 43274 $4,454.00 PLACEMENT OF TEMPORARY PACEMAKER LEADS 33210 $9,526.00 PLACEMENT OF TEMPORARY PACEMAKER LEADS 33211 $10,998.00 PLASTIC REPAIR OF TEAR DUCTS 68700 $6,702.00 PLATELET AGGEGATION 85576 $341.00 PLATELET ANTIBODY 86022 $375.00 PLATELET ASSOC ANTIBODY ID 86023 $335.00 PLATELET COUNT, AUTOMATED TEST 85049 $185.00 PLATELET FUNCTION ANALYSIS/ADP 85576 $341.00 PLATELET FUNCTION TEST 85597 $150.00 PLATELET RECEP INHIB-ASPIRIN 85576 $341.00 PLATELET RECEP INHIB-P2Y12 85576 $341.00 PLATELETS PHERESIS PATHOGEN REDUCED OR RAPID BACT P9073 $2,545.00 PNEUMOC 13-VALENT CONJUGATE 0.5 ML SYRG 0.5 ML SYR 90670 $790.71 PNEUMOCOCCAL VACCINE 25 MCG/0.5 ML SOLN 0.5 ML VIA 90732 $441.82 PNEUMOCOCCAL VACCINE 25 MCG/0.5 ML SYRG 0.5 ML SYR 90732 $396.96 POCT BLOOD CREATININE LEVEL 82565 $104.00 POCT BLOOD GAS PH PCO2 PO2 82803 $286.00 POCT BLOOD GLUCOSE (SUGAR) TEST PERFORMED BY HAND- 82962 $19.00 POCT CHLORIDE 82435 $50.00 POCT COAGULATION TIME ACTIVATED 85347 $175.00 POCT CREATINE KINASE (CK) MB 82553 $212.00 POCT GLUCOSE 82947 $82.00 POCT HEMATOCRIT 85014 $53.00 POCT HEMOGLOBIN 85018 $17.00 POCT HEMOGLOBIN A1C 83036 $193.00 POCT IONIZED CALCIUM 82330 $152.00 POCT POTASSIUM 84132 $62.00 POCT PREGNANCY TEST URINE 81025 $164.00 POCT SODIUM 84295 $65.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge POCT TCO2 82374 $111.00 POCT TROPONIN, QUAN 84484 $228.00 POLIOVIRUS VACCINE (IPV) 40-8-32 UNIT/0.5 ML SUSP 90713 $146.96 POLYCARBOPHIL 625 MG TAB 1 EACH BLIST PACK $0.78 POLYETHYLENE GLYCOL 17 GRAM PWPK 1 EACH PACKET $6.54 POLYETHYLENE GLYCOL 17 GRAM PWPK 100 EACH PACKET $5.34 POLYETHYLENE GLYCOL 17 GRAM PWPK 14 EACH PACKET $10.52 POLYETHYLENE GLYCOL 236-22.74-6.74 -5.86 GRAM SOLR $35.00 POLYMYXIN B SULF-TRIMETHOPRIM 10,000 UNIT- 1 MG/ML $47.04 POOLING OF PLATELETS OR OTHER BLOOD PRODUCTS 86965 $162.00 PORACTANT ALFA 120 MG/1.5 ML SUSP 1.5 ML VIAL $1,795.04 PORACTANT ALFA 240 MG/3 ML SUSP 3 ML VIAL $3,539.55 PORPHOBLGN UR QUANT 84110 $150.00 POST COITAL MUCOUS EXAM Q0115 $112.00 POTASSIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL $22.68 POTASSIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL $44.10 POTASSIUM BICARBONATE 25 MEQ TBEF 1 EACH PACKET $1.05 POTASSIUM BICARBONATE 25 MEQ TBEF 30 EACH BOTTLE $1.16 POTASSIUM BICARBONATE 25 MEQ TBEF 30 EACH PACKET $1.37 POTASSIUM CHLORIDE 10 MEQ CPSR 1 EACH BLIST PACK $14.00 POTASSIUM CHLORIDE 10 MEQ CPSR 100 EACH BOTTLE $3.48 POTASSIUM CHLORIDE 10 MEQ TBSR 1 EACH BLIST PACK $1.71 POTASSIUM CHLORIDE 10 MEQ TBSR 100 EACH BLIST PACK $1.71 POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL J3480 $4.20 POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL J3480 $17.36 POTASSIUM CHLORIDE 2 MEQ/ML SOLN 250 ML VIAL J3480 $62.13 POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL J3480 $16.26 POTASSIUM CHLORIDE 20 MEQ/15 ML LIQD 15 ML CUP $42.63 POTASSIUM CHLORIDE 20 MEQ/15 ML LIQD 473 ML BOTTLE $42.63 POTASSIUM CHLORIDE 40 MEQ/15 ML LIQD 15 ML CUP $42.63 POTASSIUM CHLORIDE 40 MEQ/15 ML LIQD 473 ML BOTTLE $42.63 POTASSIUM CHLORIDE 8 MEQ CPSR 100 EACH BOTTLE $3.29 POTASSIUM CHLORIDE 8 MEQ TBSR 1 EACH BLIST PACK $2.04 POTASSIUM CHLORIDE IN 0.9% SODIUM CHLORIDE 20 MEQ/ J3480 $8.75 POTASSIUM CHLORIDE IN WATER 0.4 MEQ/ML PGBK 100 ML J3480 $13.65 POTASSIUM CHLORIDE IN WATER 10 MEQ/100 ML PGBK 100 J3480 $14.35 POTASSIUM CHLORIDE IN WATER 10 MEQ/50 ML PGBK 50 M J3480 $14.00 POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML PGBK 100 J3480 $11.20 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML PGBK 50 M J3480 $50.00 POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML PGBK 100 J3480 $14.70 POTASSIUM CHLORIDE SA 10 MEQ TBTQ 1 EACH BLIST PAC $5.26 POTASSIUM CHLORIDE SA 10 MEQ TBTQ 100 EACH BLIST P $5.26 POTASSIUM CHLORIDE SA 20 MEQ TBTQ 1 EACH BLIST PAC $2.80 POTASSIUM CHLORIDE SA 20 MEQ TBTQ 100 EACH BLIST P $2.29 POTASSIUM IODIDE 1 GRAM/ML SOLN 237 ML BOTTLE $2.61 POTASSIUM IODIDE 1 GRAM/ML SOLN 30 ML BOTTLE $1,360.80 POTASSIUM IODIDE 1 GRAM/ML SOLN 8 ML CUP $20.86 POTASSIUM PHOSPHATE (MONOBASIC) 500 MG TBSO 100 EA $2.12 POTASSIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL $61.22 POTASSIUM PHOSPHATE 3 MMOL/ML SOLN 50 ML VIAL $282.45 POTASSIUM, BODY FLUID 84133 $84.00 POTASSIUM, SODIUM PHOSPHATES 280-160-250 MG PWPK 1 $1.87 POTASSIUM, URINE 84133 $84.00 POVIDONE-IODINE 10 % OINT 28.35 G TUBE $10.91 POVIDONE-IODINE 10 % SOLN 118 ML BOTTLE $5.78 POVIDONE-IODINE 5 % SOLN 30 ML BOTTLE $2.42 POVIDONE-IODINE 7.5 % SOLN 118 ML BOTTLE $16.11 POVIDONE-IODINE 7.5 % SOLN 118 ML BOX $9.50 PRALIDOXIME 1 GRAM SOLR 1 EACH VIAL J2730 $91.88 PRALIDOXIME 1 GRAM SOLR 6 EACH VIAL J2730 $91.04 PRAMIPEXOLE 0.125 MG TAB 1 EACH BLIST PACK $2.61 PRAMIPEXOLE 0.125 MG TAB 90 EACH BOTTLE $10.33 PRAMIPEXOLE 0.25 MG TAB 100 EACH BLIST PACK $10.21 PRAMIPEXOLE 0.5 MG TAB 1 EACH BLIST PACK $0.78 PRAMIPEXOLE 0.5 MG TAB 30 EACH BLIST PACK $0.78 PRAMIPEXOLE 0.5 MG TAB 90 EACH BOTTLE $10.33 PRAMOXINE 1 % FOAM 15 G CANISTER $183.49 PRAMOXINE-CALAMINE 1-8 % LOTN 177 ML BOTTLE $16.73 PRAMOXINE-HYDROCORTISONE 1-1 % CREA 28.4 G TUBE $869.05 PRAMOXINE-HYDROCORTISONE 1-1 % CREA 30 G TUBE $509.57 PRAMOXINE-HYDROCORTISONE 1-1 % FOAM 10 G CAN $339.82 PRASUGREL 10 MG TAB 30 EACH BOTTLE $28.89 PRAVASTATIN 10 MG TAB 1 EACH BLIST PACK $11.20 PRAVASTATIN 10 MG TAB 100 EACH BLIST PACK $11.20 PRAVASTATIN 10 MG TAB 90 EACH BOTTLE $11.25 PRAVASTATIN 40 MG TAB 1 EACH BLIST PACK $16.70 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PRAVASTATIN 40 MG TAB 100 EACH BLIST PACK $16.70 PRAVASTATIN 40 MG TAB 90 EACH BOTTLE $16.78 PRAZOSIN 1 MG CAP 100 EACH BLIST PACK $6.34 PRAZOSIN 1 MG CAP 100 EACH BOTTLE $3.13 PRAZOSIN 2 MG CAP 1 EACH BLIST PACK $4.42 PRAZOSIN 2 MG CAP 100 EACH BLIST PACK $4.42 PRAZOSIN 5 MG CAP 1 EACH BLIST PACK $3.02 PRAZOSIN 5 MG CAP 100 EACH BLIST PACK $3.02 PRAZOSIN 5 MG CAP 100 EACH BOTTLE $1.15 PREALBUMIN (PROTEIN) LEVEL 84134 $135.00 PREDNISOLONE 15 MG/5 ML (3 MG/ML) SOLN 237 ML BOTT J7510 $5.34 PREDNISOLONE 15 MG/5 ML (3 MG/ML) SOLN 5 ML CUP J7510 $1.83 PREDNISOLONE ACETATE 0.12 % DRPS 10 ML DROP BTL $1,165.05 PREDNISOLONE ACETATE 0.12 % DRPS 5 ML DROP BTL $582.51 PREDNISOLONE ACETATE 1 % DRPS 10 ML DROP BTL $386.89 PREDNISOLONE ACETATE 1 % DRPS 5 ML DROP BTL $582.51 PREDNISOLONE SODIUM PHOSPHATE 1 % DROP 10 ML DROP $209.86 PREDNISONE 1 MG TAB 1,000 EACH BOTTLE J7512 $0.84 PREDNISONE 1 MG TAB 100 EACH BLIST PACK J7512 $0.97 PREDNISONE 10 MG TAB 1 EACH BLIST PACK J7512 $0.38 PREDNISONE 10 MG TAB 100 EACH BLIST PACK J7512 $0.93 PREDNISONE 20 MG TAB 1 EACH BLIST PACK J7512 $0.21 PREDNISONE 20 MG TAB 100 EACH BLIST PACK J7512 $1.00 PREDNISONE 5 MG TAB 1 EACH BLIST PACK J7512 $0.70 PREDNISONE 5 MG TAB 100 EACH BLIST PACK J7512 $0.87 PREDNISONE 50 MG TAB 100 EACH BLIST PACK J7512 $1.47 PREGABALIN 25 MG CAP 1 EACH BLIST PACK $5.64 PREGABALIN 25 MG CAP 90 EACH BOTTLE $32.77 PREGABALIN 50 MG CAP 1 EACH BLIST PACK $5.64 PREGABALIN 50 MG CAP 100 EACH BLIST PACK $36.05 PREGABALIN 50 MG CAP 90 EACH BOTTLE $29.49 PREGNANEDIOL (REPRODUCTIVE HORMONE) LEVEL 84135 $157.00 PREGNENOLONE (REPRODUCTIVE HORMONE) LEVEL 84140 $195.00 PREMASOL 6 % 6 % SOLP 500 ML BAG $83.13 PRENATAL VITAMIN 27 MG IRON- 0.8 MG TAB 1 EACH BLI $0.73 PRENATAL VITAMIN 27 MG IRON- 0.8 MG TAB 100 EACH B $0.26 PREPARATION GRAFT SITE TRUNK ARM OR LEG 1ST 100CM 15002 $4,260.00 PREPARATION OF GRAFT SITE AT TRUNK, ARMS, OR LEGS 15003 $1,652.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PREPARATION OF SPECIMEN USING LASER 88380 $370.00 PREPARATION OF SPECIMEN, MANUAL 88381 $521.00 PREPARATION OF TISSUE FOR EXAMINATION BY REMOVING 88311 $87.00 PREPARE GRAFT SITE FACE SCALP EYELID MOUTH NECK EA 15004 $1,091.00 PREPARE GRAFT SITE OF FACE SCALP EYELID MOUTH NECK 15005 $1,088.00 PRETREATMENT RED BLOOD CELLS FOR USE IN ANTIBODY A 86970 $163.00 PRETREATMENT RED BLOOD CELLS FOR USE IN ANTIBODY A 86971 $166.00 PRETREATMENT SERUM FOR USE IN RED BLOOD CELL ANTIB 86977 $216.00 PRETREATMENT SERUM FOR USE IN RED BLOOD CELL ANTIB 86978 $252.00 PREVENTIVE MEDICINE COUNSELING APPROXIMATELY 15 MI 99401 $31.00 PREVENTIVE MEDICINE COUNSELING APPROXIMATELY 30 MI 99402 $83.00 PREVENTIVE MEDICINE COUNSELING APPROXIMATELY 60 MI 99404 $135.00 PREVENTIVE MEDICINE COUNSELING, APPROXIMATELY 45 M 99403 $105.00 PRIMAQUINE 26.3 MG TAB 100 EACH BOTTLE $7.07 PRIMIDONE 250 MG TAB 100 EACH BLIST PACK $3.32 PRIMIDONE 50 MG TAB 100 EACH BLIST PACK $2.78 PRIMIDONE LEVEL 80188 $151.00 PROBENECID 500 MG TAB 1 EACH BLIST PACK $5.72 PROBENECID 500 MG TAB 100 EACH BOTTLE $3.44 PROBING OF NASAL-TEAR DUCT 68840 $1,296.00 PROBRAIN NAT PEPTIDE NT 83880 $279.00 PROCAINAMIDE 100 MG/ML SOLN 10 ML VIAL J2690 $362.81 PROCALAMINE 3 % SOLP 1,000 ML BAG $108.50 PROCALCITONIN (HORMONE) LEVEL 84145 $275.00 PROCESSING AND STORAGE OF BLOOD UNIT OR COMPONENT 86890 $278.00 PROCHLORPERAZINE 10 MG TAB 1 EACH BLIST PACK S0183 $3.40 PROCHLORPERAZINE 10 MG TAB 100 EACH BLIST PACK S0183 $3.40 PROCHLORPERAZINE 25 MG SUPP 12 EACH BOX $44.04 PROCHLORPERAZINE 5 MG TAB 100 EACH BLIST PACK S0183 $2.15 PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SO J0780 $38.85 PROGESTERONE (REPRODUCTIVE HORMONE) LEVEL 84144 $253.00 PROGESTERONE 100 MG CAP 100 EACH BOTTLE $7.35 PROGESTERONE 100 MG INST 1 EACH BLIST PACK $49.94 PROGESTERONE 100 MG INST 21 EACH BLIST PACK $49.94 PROGESTERONE 50 MG/ML OIL 10 ML VIAL J2675 $1.11 PROGRAMMED HEART RHYTHM STIMULATION AFTER DRUG INF 93623 $9,437.00 PROGRAMMING DEVICE EVALUATION OF HEART MONITORING 93260 $144.00 PROINSULIN (PANCREATIC HORMONE) LEVEL 84206 $318.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PROLACTIN (MILK PRODUCING HORMONE) LEVEL 84146 $398.00 PROLACTIN-PROLACTIN 84146 $398.00 PROLONGED CHEMOTHERAPY INFUSION INTO ARTERY PORT/I 96425 $1,414.00 PROLONGED CHEMOTHERAPY INFUSION INTO VEIN PORT/IMP 96416 $1,139.00 PROMETHAZINE 12.5 MG SUPP 1 EACH BOX $63.00 PROMETHAZINE 12.5 MG SUPP 12 EACH BOX $61.97 PROMETHAZINE 25 MG SUPP 1 EACH BOX $30.98 PROMETHAZINE 25 MG SUPP 12 EACH BOX $30.98 PROMETHAZINE 25 MG TAB 100 EACH BLIST PACK $1.67 PROMETHAZINE 25 MG TAB 100 EACH BOTTLE $1.77 PROMETHAZINE 25 MG/ML SOLN 1 ML AMPUL J2550 $1.94 PROMETHAZINE 50 MG SUPP 1 EACH BOX $31.29 PROMETHAZINE 50 MG SUPP 12 EACH BOX $31.29 PROMETHAZINE 50 MG TAB 100 EACH BOTTLE $0.68 PROMETHAZINE 50 MG/ML SOLN 1 ML AMPUL J2550 $0.97 PROMETHAZINE 50 MG/ML SOLN 1 ML VIAL J2550 $1.44 PROMETHAZINE 6.25 MG/5 ML SYRP 473 ML BOTTLE Q0169 $1.65 PROMETHAZINE 6.25 MG/5 ML SYRP 5 ML CUP Q0169 $1.65 PROMETHAZINE GEL 25 MG/ 0.5 ML SYRG 0.5 ML SYRINGE $15.00 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML SYRP 118 ML B $0.34 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML SYRP 473 ML B $0.30 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML SYRP 5 ML CUP $0.30 PROMETHAZINE-DEXTROMETHORPHAN 6.25-15 MG/5 ML SYRP $76.15 PROPAFENONE 150 MG TAB 100 EACH BLIST PACK $3.28 PROPAFENONE 150 MG TAB 100 EACH BOTTLE $5.73 PROPARACAINE 0.5 % DROP 15 ML DROP BTL $147.37 PROPOFOL INFUSION EMUL 10 ML VIAL J2704 $12.60 PROPOFOL INFUSION EMUL 100 ML VIAL J2704 $131.25 PROPOFOL INFUSION EMUL 20 ML VIAL J2704 $25.20 PROPRANOLOL 1 MG/ML SOLN 1 ML VIAL J1800 $35.00 PROPRANOLOL 10 MG TAB 100 EACH BLIST PACK $1.23 PROPRANOLOL 10 MG TAB 100 EACH BOTTLE $1.43 PROPRANOLOL 20 MG TAB 1 EACH BLIST PACK $2.03 PROPRANOLOL 20 MG TAB 100 EACH BOTTLE $1.79 PROPRANOLOL 40 MG TAB 1 EACH BLIST PACK $1.14 PROPRANOLOL 40 MG TAB 100 EACH BOTTLE $2.51 PROPRANOLOL 60 MG CS24 100 EACH BOTTLE $7.20 PROPRANOLOL 80 MG CS24 100 EACH BOTTLE $6.32 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PROPRANOLOL 80 MG TAB 100 EACH BOTTLE $0.42 PROPYLTHIOURACIL 50 MG TAB 1 EACH BLIST PACK $9.10 PROPYLTHIOURACIL 50 MG TAB 100 EACH BOTTLE $3.15 PROSTATE SPEC ANTIGEN (PSA),TOTAL 84153 $249.00 PROSTATE SPECIFIC, PSA TOTAL SCREENING 84153 $249.00 PROT TOTAL SERUM PLASMA WHOLE BLOOD 84155 $104.00 PROTAMINE 10 MG/ML SOLN 25 ML VIAL J2720 $154.79 PROTAMINE 10 MG/ML SOLN 5 ML VIAL J2720 $49.14 PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH I 88372 $188.00 PROTEIN ANALYSIS OF TISSUE WITH INTERPRETATION AND 88371 $184.00 PROTEIN C ANTIGEN (CLOTTING INHIBITOR) MEASUREMENT 85303 $426.00 PROTEIN C, (CLOTTING INHIBITOR) ACTIVITY 85302 $405.00 PROTEIN ELECT CSF 84166 $190.00 PROTEIN ELECT URINE 84166 $190.00 PROTEIN ELECT, SERUM 84165 $221.00 PROTEIN MEASUREMENT 84182 $441.00 PROTEIN MEASUREMENT, BODY FLUID 84166 $190.00 PROTEIN MEASUREMENT, SERUM 84165 $221.00 PROTEIN S (CLOTTING INHIBITOR) LEVEL 85305 $405.00 PROTEIN S FREE 85306 $363.00 PROTEIN S FUNCTIONAL 85306 $363.00 PROTEIN TEST FOR DIAGNOSIS AND MONITORING OF BLADD 86386 $131.00 PROTEIN TOTAL URINE 84156 $100.00 PROTEIN, TOTAL BODY FLUID 84157 $105.00 PROTEIN, TOTAL, CSF 84157 $104.00 PROTEINASE-3 ANTIBODY 83520 $286.00 PROTHROMBIN TIME 85610 $86.00 PROTOPORPHYRIN (METABOLISM SUBSTANCE) SCREENING TE 84203 $71.00 PSA (PROSTATE SPECIFIC ANTIGEN) MEASUREMENT 84153 $249.00 PSA (PROSTATE SPECIFIC ANTIGEN) MEASUREMENT 84154 $211.00 PSA (PROSTATE SPECIFIC ANTIGEN) MEASUREMENT 84152 $152.00 PSA ULTRA SENSITIVE 84153 $216.00 PSEUDOEPHEDRINE 30 MG TAB 100 EACH BOTTLE $0.11 PSEUDOEPHEDRINE 60 MG TAB 100 EACH BOTTLE $0.09 PSYCHIATRIC DIAGNOSTIC EVALUATION 90791 $567.00 PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SER 90792 $567.00 PSYCHOTHERAPY, 45 MINUTES 90836 $878.00 PSYCHOTHERAPY, 60 MINUTES 90838 $495.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge PSYLLIUM HUSK (WITH SUGAR) PWPK 1 EACH PACKET $0.37 PSYLLIUM HUSK (WITH SUGAR) PWPK 30 EACH PACKET $0.51 PTCA FOR CTO ADDITIONAL BRANCH C9608 $23,777.00 PTH RELATED PEPTIDE 82542 $371.00 PTT 85730 $122.00 PULMONARY EXERCISE TESTING 94618 $578.00 PULMONARY EXERCISE TESTING 94621 $1,749.00 PULMONARY PHASE III $143.00 PULMONARY REHABILITATION G0424 $622.00 PULMONARY SERVICE OR OPERATION 94799 $51.00 PULPOTOMY D3220 $241.00 PUNCTURE ASPIRATION OF BREAST CYST 19001 $454.00 PUNCTURE OF SKIN FOR COLLECTION OF BLOOD SAMPLE 36416 $20.00 PYRAZINAMIDE 80299 $182.00 PYRAZINAMIDE 500 MG TAB 1 EACH BLIST PACK $17.85 PYRAZINAMIDE 500 MG TAB 100 EACH BLIST PACK $17.85 PYRIDOSTIGMINE 5 MG/ML SOLN 2 ML AMPUL $26.88 PYRIDOSTIGMINE 60 MG TAB 100 EACH BLIST PACK $2.59 PYRIDOXINE (VITAMIN B6) 100 MG TAB 50 EACH BLIST P $0.25 PYRIDOXINE (VITAMIN B6) 100 MG/ML SOLN 1 ML VIAL J3415 $31.92 PYRIDOXINE (VITAMIN B6) 50 MG TAB 1 EACH BLIST PAC $0.49 PYRIDOXINE (VITAMIN B6) 50 MG TAB 100 EACH BOTTLE $0.10 PYRIDOXINE (VITAMIN B6) 50 MG TAB 50 EACH BLIST PA $0.49 PYRUVATE KINASE (ENZYME) LEVEL 84220 $189.00 QUANTITATION OF THERAPEUTIC DRUG 80299 $182.00 QUETIAPINE 100 MG TAB 1 EACH BLIST PACK $5.67 QUETIAPINE 100 MG TAB 100 EACH BLIST PACK $6.00 QUETIAPINE 200 MG TAB 100 EACH BLIST PACK $5.35 QUETIAPINE 200 MG TB24 60 EACH BOTTLE $61.34 QUETIAPINE 25 MG TAB 1 EACH BLIST PACK $13.22 QUETIAPINE 25 MG TAB 100 EACH BLIST PACK $13.99 QUETIAPINE 25 MG TAB 100 EACH BOTTLE $14.00 QUETIAPINE 300 MG TB24 100 EACH BLIST PACK $89.38 QUETIAPINE 300 MG TB24 60 EACH BOTTLE $53.62 QUETIAPINE 50 MG TB24 100 EACH BLIST PACK $34.49 QUETIAPINE 50 MG TB24 60 EACH BOTTLE $31.04 QUETIAPINE ER 150 MG TB24 60 EACH BOTTLE $61.93 QUINAPRIL 20 MG TAB 1 EACH BLIST PACK $1.12 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge QUINAPRIL 20 MG TAB 30 EACH BLIST PACK $1.12 QUINAPRIL 20 MG TAB 90 EACH BOTTLE $1.07 QUINAPRIL 5 MG TAB 90 EACH BOTTLE $4.28 QUINIDINE GLUCONATE 324 MG TBSR 100 EACH BOTTLE $31.72 QUINIDINE GLUCONATE 80 MG/ML SOLN 10 ML VIAL $75.46 QUINIDINE LEVEL 80194 $103.00 QUINIDINE SULFATE 300 MG TAB 100 EACH BOTTLE $1.33 QUININE (DRUG) LEVEL 84228 $96.00 QUININE SULFATE 324 MG CAP 1 EACH BLIST PACK $18.53 RABIES IMMUNE GLOBULIN 150 UNIT/ML SOLN 2 ML VIAL 90375 $3,278.90 RABIES VACCINE, PCEC 2.5 UNIT SUSR 1 EACH VIAL 90675 $1,415.40 RACEPINEPHRINE 2.25 % NEBU 1 EACH VIAL $6.30 RADIATION THERAPY CONSULTATION 77370 $1,687.00 RADIATION THERAPY CONSULTATION PER WEEK 77336 $765.00 RADIATION THERAPY DELIVERY 77385 $3,280.00 RADIATION THERAPY DELIVERY 77386 $3,280.00 RADIATION THERAPY PLAN 77306 $1,800.00 RADIATION THERAPY PLAN 77307 $1,752.00 RADIATION THERAPY PLAN 77316 $787.00 RADIATION THERAPY PLAN 77318 $1,250.00 RADIATION THERAPY TOTAL BODY PORT PLAN 77321 $1,008.00 RADIATION TREATMENT DELIVERY 77402 $518.00 RADIATION TREATMENT DELIVERY 77407 $804.00 RADIATION TREATMENT DELIVERY 77412 $1,144.00 RADIATION TREATMENT DEVICES, DESIGN AND CONSTRUCTI 77332 $599.00 RADIATION TREATMENT DEVICES, DESIGN AND CONSTRUCTI 77333 $758.00 RADIATION TREATMENT DEVICES, DESIGN AND CONSTRUCTI 77334 $2,166.00 RADIATION TREATMENT MANAGEMENT, 1 OR 2 TREATMENTS 77431 $761.00 RADIOACTIVE MATERIAL THERAPY INTO ARTERY 79445 $2,231.00 RADIOACTIVE MATERIAL THERAPY INTO BONE JOINT 79440 $1,356.00 RADIOACTIVE MATERIAL THERAPY INTO TISSUE 79300 $913.00 RADIOACTIVE MATERIAL THERAPY INTO VEIN 79101 $2,278.00 RADIOLOGICAL S & I IMAGING OF LUNG ARTERY CONTRAST 75746 $1,986.00 RADIOLOGICAL SUPERVISION & INTERP DILATION BILIARY 74363 $944.00 RADIOLOGICAL SUPERVISION & INTERP DILATION OF KIDN 74485 $3,035.00 RADIOLOGICAL SUPERVISION & INTERP IMAGING LIVER VE 75885 $3,644.00 RADIOLOGICAL SUPERVISION & INTERP IMAGING LIVER VE 75889 $3,256.00 RADIOLOGICAL SUPERVISION & INTERP IMAGING OF ARTER 75716 $2,727.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge RADIOLOGICAL SUPERVISION & INTERP OF DRAWING BLOOD 75893 $5,316.00 RADIOLOGICAL SUPERVISION & INTERP OF IMAGING OF AR 75710 $6,085.00 RADIOLOGICAL SUPERVISION & INTERP OF IMAGING OF AR 75743 $6,440.00 RADIOLOGICAL SUPERVISION & INTERP OF IMAGING OF VE 75820 $1,071.00 RADIOLOGICAL SUPERVISION & INTERP OF IMAGING OF VE 75822 $1,863.00 RADIOLOGICAL SUPERVISION & INTERP OF IMAGING OF VE 75860 $3,217.00 RADIOLOGICAL SUPERVISION & INTERP OF INSERT CATHET 74328 $830.00 RADIOLOGICAL SUPERVISION & INTERP OF INSERT CATHET 74329 $1,280.00 RADIOLOGICAL SUPERVISION & INTERP OF OBSTRUCT OF B 75894 $3,219.00 RADIOLOGICAL SUPERVISION & INTERP OF PLACE BLOOD V 75958 $1,275.00 RADIOLOGICAL SUPERVISION & INTERP OF PLACEMENT CAT 75989 $1,464.00 RADIOLOGICAL SUPERVISION & INTERP PLACE BLOOD VESS 75959 $1,275.00 RADIOLOGICAL SUPERVISION & INTERP PLACEMENT LONG S 74340 $624.00 RADIOLOGICAL SUPERVISION & INTERP REMOVAL OBSTRUCT 75901 $562.00 RADIOLOGICAL SUPERVISION & INTERP X-RAY ABDOMINAL 75630 $2,607.00 RADIOLOGICAL SUPERVISION & INTERP X-RAY OF BILE AN 74300 $1,379.00 RADIOLOGICAL SUPERVISION & INTERP X-RAY OF DISC OF 72295 $2,471.00 RADIOLOGICAL SUPERVISION & INTERP X-RAY OF SPINAL 72270 $1,747.00 RADIOLOGICAL SUPERVISION & INTERP X-RAY OF TEAR DR 70170 $775.00 RADIOLOGICAL SUPERVISION & INTERP X-RAY OF URINARY 74430 $729.00 RADIOLOGICAL SUPERVISION & INTERP X-RAY OF URINARY 74450 $850.00 RADIOLOGICAL SUPERVISION & INTERP X-RAY OF URINARY 74455 $945.00 RADIOLOGICAL SUPERVISION & INTERPRETATION CHANGE O 75984 $1,473.00 RADIOLOGICAL SUPERVISION & INTERPRETATION IMAGING 75809 $906.00 RADIOLOGICAL SUPERVISION & INTERPRETATION IMAGING 75825 $5,727.00 RADIOLOGICAL SUPERVISION & INTERPRETATION IMAGING 75833 $5,835.00 RADIOLOGICAL SUPERVISION & INTERPRETATION OF CT GU 77012 $3,051.00 RADIOLOGICAL SUPERVISION & INTERPRETATION REPAIR O 75956 $1,275.00 RADIOLOGICAL SUPERVISION & INTERPRETATION REPAIR O 75957 $1,275.00 RADIOLOGICAL SUPERVISION & INTERPRETATION X-RAY OF 74740 $1,075.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION IMAGIN 75831 $5,105.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION IMAGIN 75741 $4,818.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION OF BIO 75970 $2,410.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION OF IMA 75827 $2,017.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION OF IMA 77053 $661.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION OF IMA 77054 $630.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION OF IMA 75705 $7,516.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION OF IMA 75726 $7,523.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge RADIOLOGICAL SUPERVISION AND INTERPRETATION OF IMA 75736 $5,936.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION OF IMA 75756 $3,268.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION OF IMA 75774 $1,813.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 70390 $542.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 72240 $1,353.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 72255 $1,227.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 72265 $1,261.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 72275 $1,587.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 74425 $998.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 74445 $557.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 73040 $803.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 73085 $922.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 73115 $803.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 73525 $789.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 73580 $809.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 75605 $6,023.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION X-RAY 75625 $2,442.00 RADIOLOGICAL SUPERVISN & INTERP REMOVE OBSTRUCTIVE 75902 $406.00 RADIOLOGY DIAGNOSTIC RADIOLOGY ? REVENUE CODE 32X G0378 $90.00 RALOXIFENE 60 MG TAB 1 EACH BLIST PACK $23.95 RALOXIFENE 60 MG TAB 100 EACH BOTTLE $24.92 RALTEGRAVIR 400 MG TAB 60 EACH BOTTLE $110.21 RAMIPRIL 1.25 MG CAP 1 EACH BLIST PACK $6.64 RAMIPRIL 1.25 MG CAP 100 EACH BOTTLE $5.36 RAMIPRIL 1.25 MG CAP 30 EACH BLIST PACK $6.64 RAMIPRIL 2.5 MG CAP 1 EACH BLIST PACK $0.31 RAMIPRIL 2.5 MG CAP 100 EACH BLIST PACK $0.31 RAMIPRIL 5 MG CAP 1 EACH BLIST PACK $0.17 RAMIPRIL 5 MG CAP 100 EACH BLIST PACK $0.17 RAMIPRIL 5 MG CAP 100 EACH BOTTLE $1.66 RAMUCIRUMAB 10 MG/ML SOLN 10 ML VIAL J9308 $3,942.23 RAMUCIRUMAB 10 MG/ML SOLN 50 ML VIAL J9308 $19,711.13 RANGE OF MOTION TESTING OF ARM, LEG OR EACH SPINE 95851 $160.00 RANITIDINE 15 MG/ML SYRP 10 ML CUP $12.11 RANITIDINE 150 MG TAB 1 EACH BLIST PACK $0.63 RANITIDINE 150 MG TAB 100 EACH BLIST PACK $0.63 RANITIDINE 25 MG/ML SOLN 6 ML VIAL J2780 $187.11 RANITIDINE 50 MG/2 ML (25 MG/ML) SOLN 2 ML VIAL J2780 $51.98 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge RANOLAZINE 500 MG TB12 60 EACH BOTTLE $23.58 RASBURICASE 1.5 MG SOLR 1 EACH VIAL J2783 $3,641.94 RECORDING EVALUATE HEIGHT & DURATION HEART BEATS T 93278 $604.00 RECOVERY PHASE 1 1ST 15 MINUTES $712.00 RECOVERY PHASE 1 EACH ADDITIONAL 15 MINUTES $144.00 RECOVERY PHASE 2 1ST 15 MINUTES $356.00 RECOVERY PHASE 2 EACH ADDITIONAL 15 MINUTES $69.00 RED BLOOD CELL ANTIBODY DETECTION TEST 86880 $92.00 RED BLOOD CELL ANTIBODY LEVEL 86886 $198.00 RED BLOOD CELL CONCENTRATION MEASUREMENT 85014 $53.00 RED BLOOD CELL FRAGILITY MEASUREMENT 85557 $228.00 RED BLOOD CELL FRAGILITY MEASUREMENT 85547 $66.00 RED BLOOD CELL FRAGILITY MEASUREMENT 85555 $220.00 RED BLOOD CELL HEMOGLOBIN CONCENTRATION 85013 $43.00 RED BLOOD CELL SEDIMENTATION RATE, TO DETECT INFLA 85652 $111.00 RED BLOOD COUNT AUTOMATED, WITH ADDITIONAL CALCULA 85046 $104.00 RED BLOOD COUNT, MANUAL TEST 85044 $90.00 RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED 97168 $250.00 RE-EVALUATION OF PHYSICAL THERAPY TYPICALLY 20 MIN 97164 $189.00 REFERENCE CHLORIDE, OTHER SOURCE 82438 $121.00 REFILLING & MAINTENANCE MD IMPLANT SPINAL/BRAIN DR 95991 $632.00 REFILLING & MAINTENANCE OF IMPLANTABLE PUMP OR RES 96522 $414.00 REFILLING AND MAINTENANCE OF PORTABLE PUMP 96521 $653.00 REGADENOSON 0.4 MG/5 ML SYRG 5 ML SYRINGE J2785 $1,020.43 RELEASE OF SMALL BOWEL SCAR TISSUE USING AN ENDOSC 44180 $11,763.00 RELEASE OF TWISTED LARGE BOWEL USING AN ENDOSCOPE 45337 $1,059.00 RELOCATE PATIENT SKIN TO FOREHEAD CHEEK CHIN MOUTH 15241 $1,220.00 RELOCATION OF DEFIBRILLATOR DEVICE SKIN POCKET 33223 $2,503.00 RELOCATION OF PACEMAKER GENERATOR SKIN POCKET 33222 $5,171.00 RELOCATION OF PATIENT SKIN (20 SQ CM OR LESS) TO S 15220 $2,748.00 RELOCATION OF PATIENT SKIN TO TRUNK 15201 $1,338.00 RELOCATION PATIENT SKIN TO NOSE EARS EYELID AND/OR 15260 $3,529.00 REMIFENTANIL 1 MG SOLR 1 EACH VIAL $247.80 REMOTE EVALUATIONS DEFIB TRANSM TECHN REV SUPP & D 93296 $146.00 REMOTE EVALUATIONS IMPLANT HEART REC SYST TECHN RE 93299 $174.00 REMOTE EVALUATIONS OF DEFIBRILLATOR UP TO 90 DAYS 93295 $155.00 REMOVAL (2 CM OR GREATER) TISSUE GROWTH BENEATH TH 21012 $2,857.00 REMOVAL (2 CM OR GREATER) TISSUE GROWTH BENEATH TH 21013 $5,050.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REMOVAL (5 CENTIMETERS OR GREATER) MUSCLE GROWTH O 21554 $7,725.00 REMOVAL (LESS THAN 1.5 CM) TISSUE GROWTH BENEATH T 28043 $4,182.00 REMOVAL (LESS THAN 2 CM) TISSUE GROWTH BENEATH THE 21011 $2,868.00 REMOVAL (LESS THAN 3 CM) TISSUE GROWTH BENEATH SKI 24075 $3,417.00 REMOVAL (LESS THAN 3 CM) TISSUE GROWTH BENEATH THE 21930 $4,342.00 REMOVAL (LESS THAN 3 CM) TISSUE GROWTH BENEATH THE 23075 $2,999.00 REMOVAL (LESS THAN 3 CM) TISSUE GROWTH BENEATH THE 27327 $4,358.00 REMOVAL (LESS THAN 3 CM) TISSUE GROWTH BENEATH THE 27618 $4,721.00 REMOVAL (LESS THAN 5 CENTIMETERS) MUSCLE GROWTH IN 22900 $10,290.00 REMOVAL (LESS THAN 5 CENTIMETERS) MUSCLE GROWTH OF 27048 $7,766.00 REMOVAL AND REPLACEMENT MULTIPLE LEAD PERMANENT PA 33229 $38,145.00 REMOVAL AND REPLACEMENT OF DEFIBRILLATOR PULSE GEN 33262 $67,272.00 REMOVAL AND REPLACEMENT OF DEFIBRILLATOR PULSE GEN 33263 $68,797.00 REMOVAL AND REPLACEMENT OF DEFIBRILLATOR PULSE GEN 33264 $66,717.00 REMOVAL AND REPLACEMENT OF DUAL LEAD PERMANENT PAC 33228 $33,908.00 REMOVAL AND REPLACEMENT OF INDWELLING STENT IN URI 50382 $4,407.00 REMOVAL AND REPLACEMENT OF INDWELLING STENT IN URI 50385 $4,435.00 REMOVAL AND REPLACEMENT OF SINGLE LEAD PERMANENT P 33227 $33,084.00 REMOVAL AND REPLACEMENT OF SKIN LEVEL PORT OF STOM 43888 $6,381.00 REMOVAL AND TYING 2 OR MORE HEMORRHOID GROUP 46946 $2,742.00 REMOVAL AND TYING HEMORRHOID GROUP 46945 $6,055.00 REMOVAL AND/OR SCRAPING OF LOWER JAW BONE GROWTH O 21040 $6,903.00 REMOVAL FOREIGN BODY OR STENT FROM PANCREATIC OR B 43275 $4,293.00 REMOVAL FOREIGN BODY STONE OR STENT FROM BLADDER C 52310 $1,990.00 REMOVAL FOREIGN MATERIAL FROM SKIN & TISSUE AT OPE 11010 $2,481.00 REMOVAL GROWTH (0.5 CM OR LESS) OF THE FACE EAR EY 11440 $639.00 REMOVAL GROWTH (0.5 CM OR LESS) OF THE SCALP NECK 11420 $4,157.00 REMOVAL GROWTH (0.6 TO 1.0 CM) OF THE FACE EARS EY 11441 $620.00 REMOVAL GROWTH (0.6 TO 1.0 M) OF THE SCALP NECK HA 11421 $1,037.00 REMOVAL GROWTH (1.1 TO 2.0 CM) OF THE FACE EARS EY 11442 $1,011.00 REMOVAL GROWTH (1.1 TO 2.0 CM) OF THE SCALP NECK H 11422 $4,179.00 REMOVAL MALIGNANT GROWTH (0.5 CM OR LESS) OF FACE 11640 $981.00 REMOVAL MALIGNANT GROWTH (0.6 TO 1.0 CENTIMETERS) 11601 $657.00 REMOVAL MALIGNANT GROWTH (0.6 TO 1.0 CM) OF FACE E 11641 $1,053.00 REMOVAL MALIGNANT GROWTH (0.6 TO 1.0 CM) OF SCALP 11621 $1,190.00 REMOVAL MALIGNANT GROWTH (1.1 TO 2.0 CENTIMETERS) 11602 $777.00 REMOVAL MALIGNANT GROWTH (1.1 TO 2.0 CM) OF FACE E 11642 $1,162.00 REMOVAL MALIGNANT GROWTH (1.1 TO 2.0 CM) OF SCALP 11622 $1,646.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REMOVAL MALIGNANT GROWTH (2.1 TO 3.0 CENTIMETERS) 11603 $1,039.00 REMOVAL MALIGNANT GROWTH (2.1 TO 3.0 CM) OF FACE E 11643 $1,437.00 REMOVAL MALIGNANT GROWTH (2.1 TO 3.0 CM) OF SCALP 11623 $1,618.00 REMOVAL MALIGNANT GROWTH (3.1 TO 4 CENTIMETERS) OF 11604 $1,537.00 REMOVAL MALIGNANT GROWTH (3.1 TO 4 CM) OF SCALP NE 11624 $3,332.00 REMOVAL MALIGNANT GROWTH (3.1 TO 4.0 CM) OF FACE E 11644 $2,331.00 REMOVAL MALIGNANT GROWTH (OVER 4.0 CENTIMETERS) OF 11606 $3,212.00 REMOVAL OF 1 OR MORE BREAST GROWTH, OPEN PROCEDURE 19120 $4,219.00 REMOVAL OF 2 TO 4 THICKENED SKIN GROWTHS 11056 $322.00 REMOVAL OF ABDOMINAL CAVITY CATHETER 49422 $5,545.00 REMOVAL OF ANAL GROWTH 46220 $3,634.00 REMOVAL OF ANAL POLYPS OR GROWTHS USING AN ENDOSCO 46610 $3,159.00 REMOVAL OF ANTIBODIES FROM SURFACE OF RED BLOOD CE 86860 $276.00 REMOVAL OF APPENDIX USING AN ENDOSCOPE 44970 $8,045.00 REMOVAL OF BILIARY DUCT OR GALLBLADDER STONE ACCES 47544 $3,530.00 REMOVAL OF BLOOD ACCUMULATION BETWEEN NAIL AND NAI 11740 $204.00 REMOVAL OF BLOOD CLOT FROM DIALYSIS GRAFT, OPEN PR 36831 $14,097.00 REMOVAL OF BLOOD CLOT IN HEART ARTERY, ACCESSED TH 92973 $6,271.00 REMOVAL OF BLOOD FLOW ASSIST DEVICE IN AORTA, ACCE 33968 $2,298.00 REMOVAL OF BONE IMPLANT 20670 $1,946.00 REMOVAL OF BREAST GROWTH, OPEN PROCEDURE 19125 $4,943.00 REMOVAL OF CATHETER IN ARTERY OR VEINCM 37214 $9,089.00 REMOVAL OF CENTRAL VENOUS CATHETER FOR INFUSION 36589 $1,515.00 REMOVAL OF CONGENITAL DEFECT OF LYMPH NODES AT UND 38550 $6,465.00 REMOVAL OF DEEP BONE IMPLANT 20680 $3,172.00 REMOVAL OF DEEP FOREIGN BODY IN MUSCLE OR TENDON 20525 $6,934.00 REMOVAL OF DEFIBRILLATOR ELECTRODE 33272 $10,539.00 REMOVAL OF DEFIBRILLATOR ELECTRODES 33244 $6,458.00 REMOVAL OF DEFIBRILLATOR PULSE GENERATOR 33241 $3,692.00 REMOVAL OF DRUG DELIVERY IMPLANT FROM TISSUE 11982 $3,521.00 REMOVAL OF ELECTRODE FROM RIGHT HEART 33234 $3,291.00 REMOVAL OF ELECTRODES FROM RIGHT HEART 33235 $4,404.00 REMOVAL OF EMBEDDED FOREIGN BODY OF MOUTH 40804 $912.00 REMOVAL OF EMBEDDED FOREIGN BODY OF MOUTH 40805 $2,221.00 REMOVAL OF ENGORGED HEMORRHOID 46320 $3,560.00 REMOVAL OF EXCESSIVE SKIN AND FAT OF UPPER EYELID 15823 $3,522.00 REMOVAL OF EXCESSIVE SKIN OF LOWER EYELID 15820 $3,695.00 REMOVAL OF EXCESSIVE SKIN OF LOWER EYELID AND FAT 15821 $4,310.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REMOVAL OF EXCESSIVE SKIN OF UPPER EYELID 15822 $2,816.00 REMOVAL OF EXTERNAL FEMALE GENITAL SCAR TISSUE 56441 $2,511.00 REMOVAL OF EYE CONTENTS 65091 $10,841.00 REMOVAL OF EYELID GROWTH 67840 $2,905.00 REMOVAL OF FACIAL BONES 21026 $9,592.00 REMOVAL OF FLUID FROM BETWEEN LUNG AND CHEST CAVIT 32551 $1,400.00 REMOVAL OF FLUID FROM CHEST CAVITY 32554 $1,863.00 REMOVAL OF FLUID FROM CHEST CAVITY WITH IMAGING GU 32555 $1,039.00 REMOVAL OF FLUID FROM CHEST CAVITY WITH INSERT IND 32556 $1,635.00 REMOVAL OF FLUID FROM CHEST CAVITY WITH INSERT IND 32557 $3,600.00 REMOVAL OF FOREIGN BODIES IN ESOPHAGUS USING AN EN 43215 $3,231.00 REMOVAL OF FOREIGN BODIES IN LARGE BOWEL USING AN 45332 $988.00 REMOVAL OF FOREIGN BODIES IN LARGE BOWEL USING AN 45379 $2,209.00 REMOVAL OF FOREIGN BODIES IN SMALL BOWEL USING AN 44363 $3,021.00 REMOVAL OF FOREIGN BODIES OF ESOPHAGUS STOMACH AND 43247 $3,986.00 REMOVAL OF FOREIGN BODIES OF ESOPHAGUS USING AN EN 43194 $4,019.00 REMOVAL OF FOREIGN BODY FROM EAR CANAL 69200 $281.00 REMOVAL OF FOREIGN BODY FROM EAR CANAL UNDER ANEST 69205 $5,117.00 REMOVAL OF FOREIGN BODY FROM THROAT 42809 $372.00 REMOVAL OF FOREIGN BODY FROM TISSUE, ACCESSED BENE 10120 $334.00 REMOVAL OF FOREIGN BODY FROM TISSUE, ACCESSED BENE 10121 $2,627.00 REMOVAL OF FOREIGN BODY FROM VOICE BOX USING AN EN 31530 $4,490.00 REMOVAL OF FOREIGN BODY IN EXTERNAL EYE, CONJUNCTI 65205 $286.00 REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON 20520 $4,440.00 REMOVAL OF FOREIGN BODY IN NOSE 30300 $299.00 REMOVAL OF FOREIGN BODY IN UTERUS USING AN ENDOSCO 58562 $4,486.00 REMOVAL OF FOREIGN BODY, EXTERNAL EYE, CORNEA 65220 $524.00 REMOVAL OF FOREIGN BODY, EXTERNAL EYE, CORNEA WITH 65222 $215.00 REMOVAL OF FORESKIN OF USING CLAMP OR DEVICE 54150 $441.00 REMOVAL OF FORESKIN, NEONATE (28 DAYS OF AGE OR LE 54160 $1,386.00 REMOVAL OF GALLBLADDER 46700 $4,952.00 REMOVAL OF GALLBLADDER USING AN ENDOSCOPE 47562 $9,770.00 REMOVAL OF GALLBLADDER WITH X-RAY STUDY OF BILE DU 47563 $8,846.00 REMOVAL OF GROWTH (0.5 CENTIMETERS OR LESS) OF THE 11400 $713.00 REMOVAL OF GROWTH (0.6 TO 1.0 CENTIMETERS) OF THE 11401 $849.00 REMOVAL OF GROWTH (1.1 TO 2.0 CENTIMETERS) OF THE 11402 $1,169.00 REMOVAL OF GROWTH (2.1 TO 3.0 CENTIMETERS) OF THE 11403 $1,313.00 REMOVAL OF GROWTH (2.1 TO 3.0 CM) OF FACE EARS EYE 11443 $1,460.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REMOVAL OF GROWTH (2.1 TO 3.0 CM) OF THE SCALP NEC 11423 $1,460.00 REMOVAL OF GROWTH (3.1 TO 4.0 CENTIMETERS) OF THE 11404 $1,455.00 REMOVAL OF GROWTH (3.1 TO 4.0 CM) OF THE SCALP NEC 11424 $1,673.00 REMOVAL OF GROWTH (4.0 CENTIMETERS) OF THE TRUNK, 11406 $4,957.00 REMOVAL OF GROWTH (OVER 4.0 CM) OF THE SCALP NECK 11426 $2,979.00 REMOVAL OF GROWTH OF CORNEA 65400 $3,411.00 REMOVAL OF GROWTH OF MOUTH 40812 $3,842.00 REMOVAL OF GROWTH OF ROOF OF MOUTH 42106 $6,188.00 REMOVAL OF GROWTH OF SCLERA 66130 $7,402.00 REMOVAL OF GROWTH OF SCLERA 68130 $4,402.00 REMOVAL OF GROWTH OF SKIN AND TISSUE ON NOSE 30124 $4,344.00 REMOVAL OF GROWTH OF TENDON COVERING OR JOINT CAPS 28090 $4,095.00 REMOVAL OF GROWTH OF TENDON FINGER OR HAND 26160 $4,192.00 REMOVAL OF HEMORRHOID BY RUBBER BANDING 46221 $1,314.00 REMOVAL OF IMPACT EAR WAX, ONE EAR 69210 $271.00 REMOVAL OF IMPACTED EAR WAX BY WASHING 69209 $382.00 REMOVAL OF IMPLANTABLE CONTRACEPTIVE CAPSULES 11976 $1,145.00 REMOVAL OF IMPLANTED LENS IN EYE 65920 $9,549.00 REMOVAL OF INDWELLING STENT IN URINARY DUCT (URETE 50386 $1,903.00 REMOVAL OF INFLAMED OR INFECTED SKIN 11001 $120.00 REMOVAL OF INFLAMED OR INFECTED SKIN, UP TO 10% OF 11000 $3,432.00 REMOVAL OF INTRA-UTERINE DEVICE (IUD) FOR PREGNANC 58301 $469.00 REMOVAL OF KIDNEY DRAINAGE TUBE (URETER) USING FLU 50389 $1,571.00 REMOVAL OF LARGE BOWEL POLYPS OR GROWTHS USING AN 44394 $2,857.00 REMOVAL OF LOWER HEART CHAMBER BLOOD FLOW ASSIST D 33992 $6,575.00 REMOVAL OF MALIGNANT GROWTH (0.5 CM OR LESS) OF TH 11600 $639.00 REMOVAL OF MORE THAN 4 THICKENED SKIN GROWTHS 11057 $381.00 REMOVAL OF MULTIPLE EXTERNAL ANAL GROWTHS 46230 $4,966.00 REMOVAL OF NAIL 11750 $914.00 REMOVAL OF OUTER LAYER OF CORNEA 65435 $1,826.00 REMOVAL OF PERIPHERAL VENOUS CATHETER FOR INFUSION 36590 $4,658.00 REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR 33233 $9,360.00 REMOVAL OF PLAQUE & INSERTION OF STENTS INTO ARTER 37231 $42,928.00 REMOVAL OF PLAQUE AND INSERT STENT IN MAJOR CORONA 92933 $24,230.00 REMOVAL OF PLAQUE AND INSERT STENT IN MAJOR CORONA 92934 $24,230.00 REMOVAL OF PLAQUE IN ARTERY IN ONE LEG ENDOVASCULA 37229 $28,057.00 REMOVAL OF PLAQUE IN ARTERY IN ONE LEG ENDOVASCULA 37233 $4,802.00 REMOVAL OF PLAQUE MAJOR CORONARY ARTERY OR BRANCH 92924 $30,420.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REMOVAL OF PLAQUE MAJOR CORONARY ARTERY OR BRANCH 92925 $30,420.00 REMOVAL OF POLYP OR GROWTH OF RECTUM AND LARGE BOW 45308 $8,125.00 REMOVAL OF POLYPS IN NOSE 30110 $3,621.00 REMOVAL OF POLYPS OR GROWTHS IN LARGE BOWEL USING 45384 $3,060.00 REMOVAL OF POLYPS OR GROWTHS OF ESOPHAGUS STOMACH 43250 $2,283.00 REMOVAL OF POLYPS OR GROWTHS OF ESOPHAGUS STOMACH 43251 $3,868.00 REMOVAL OF POLYPS OR GROWTHS OF LARGE BOWEL USING 45338 $2,340.00 REMOVAL OF POLYPS OR GROWTHS OF LARGE BOWEL USING 45385 $4,292.00 REMOVAL OF PORTION OF EXTERNAL EAR 69110 $2,468.00 REMOVAL OF RECTAL GROWTH 45171 $5,197.00 REMOVAL OF RECTAL MUSCLE GROWTH 45172 $5,846.00 REMOVAL OF RECURRING CATARACT IN LENS CAPSULE USIN 66821 $2,396.00 REMOVAL OF REMAINING OR REGROWN PROSTATE TISSUE WI 52630 $12,602.00 REMOVAL OF ROD WITH TENDON GRAFT AT HAND OR FINGER 26418 $4,084.00 REMOVAL OF SALIVARY CYST UNDER TONGUE 42408 $7,868.00 REMOVAL OF SALIVARY GLAND STONE 42330 $7,465.00 REMOVAL OF SCAR TISSUE FOLLOWING PENILE FORESKIN R 54162 $3,969.00 REMOVAL OF SINGLE ANAL POLYP OR GROWTH USING AN EN 46611 $1,935.00 REMOVAL OF SINGLE THICKENED SKIN GROWTH 11055 $297.00 REMOVAL OF SKIN AND BONE FIRST 20 SQ CM OR LESS 11044 $1,603.00 REMOVAL OF SKIN AND TISSUE 11045 $747.00 REMOVAL OF SKIN AND TISSUE FIRST 20 SQ CM OR LESS 11042 $795.00 REMOVAL OF SKIN AND/OR MUSCLE 11046 $1,357.00 REMOVAL OF SKIN AND/OR MUSCLE FIRST 20 SQ CM OR LE 11043 $989.00 REMOVAL OF SKIN DEBRIS AND DRAINAGE OF MASTOID CAV 69220 $365.00 REMOVAL OF SKIN OF FINGER OR TOE NAIL 11765 $344.00 REMOVAL OF SKIN SUTURE WITH CHANGE OF BLADDER TUBE 51705 $544.00 REMOVAL OF SKIN TAGS 11201 $266.00 REMOVAL OF SOFT TISSUE GROWTH OF EAR CANAL 69145 $4,989.00 REMOVAL OF SPERM DUCT 55250 $4,608.00 REMOVAL OF STONE FROM BILE OR PANCREATIC DUCT USIN 43264 $4,312.00 REMOVAL OF SUTURE AROUND SKIN SURFACE TUBE WITH CH 51710 $2,044.00 REMOVAL OF SUTURES BETWEEN UPPER AND LOWER EYELIDS 67710 $3,236.00 REMOVAL OF SUTURES UNDER ANESTHESIA BY OTHER SURGE 15851 $3,787.00 REMOVAL OF SUTURES UNDER ANESTHESIA BY SAME SURGEO 15850 $906.00 REMOVAL OF TAILBONE CYST 11770 $4,742.00 REMOVAL OF TISSUE CONNECTING TONGUE AND FLOOR OF M 41115 $1,928.00 REMOVAL OF TISSUE FROM 1 TO 5 FINGER OR TOE NAILS 11720 $188.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REMOVAL OF TISSUE FROM 6 OR MORE FINGER OR TOE NAI 11721 $211.00 REMOVAL OF TISSUE FROM PLACENTA FOR DIAGNOSIS 59015 $1,335.00 REMOVAL OF TISSUE FROM WOUNDS PER SESSION 97597 $350.00 REMOVAL OF TISSUE FROM WOUNDS PER SESSION 97598 $340.00 REMOVAL OF TISSUE FROM WOUNDS PER SESSION 97602 $204.00 REMOVAL OF TISSUE LINING OF ESOPHAGUS STOMACH AND/ 43254 $3,868.00 REMOVAL OF TISSUE LINING OF ESOPHAGUS USING AN END 43211 $2,917.00 REMOVAL OF UP TO AND INCLUDING 15 SKIN TAGS 11200 $441.00 REMOVAL OF VENA CAVA FILTER BY ENDOVASCULAR APPROA 37193 $11,003.00 REMOVAL OR BIVALVING OF FULL ARM OR LEG CAST 29705 $273.00 REMOVAL OR BIVALVING OF GAUNTLET, BOOT, OR BODY CA 29700 $357.00 REMOVAL OR BIVALVING OF SHOULDER, HIP SPICA, OR JA 29710 $372.00 REMOVAL OR CRUSHING KIDNEY STONE (OVER 2 CM) OR IN 50081 $13,282.00 REMOVAL OR DESTRUCTION OF CERVIX 57522 $3,546.00 REMOVAL OR DESTRUCTION OF GROWTH IN NOSE 30117 $5,809.00 REMOVAL OR RELOCATION OF CORNEAL CONJUNCTIVA 65420 $4,346.00 REMOVAL OR RELOCATION OF CORNEAL CONJUNCTIVA 65426 $8,407.00 REMOVAL OR REVISION OF NEUROSTIMULATOR PULSE GENER 63688 $8,488.00 REMOVAL OR REVISION OF SPINAL NEUROSTIMULATOR ELEC 63661 $5,430.00 REMOVAL SKIN & TISSUE BENEATH THE SKIN OF ANUS/NAV 11471 $6,281.00 REMOVAL SKIN & TISSUE BENEATH THE SKIN OF UNDERARM 11451 $4,742.00 REMOVAL SPINAL CANAL DRUG INFUSION PUMP OR DEVICE 62365 $11,995.00 REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR 33286 $1,594.00 REMOVAL TISSUE GROWTH BENEATH THE SKIN AT FOREARM 25071 $5,563.00 REMOVAL TISSUE GROWTH BENEATH THE SKIN OF NECK OR 21555 $4,885.00 REMOVAL/CRUSHING KIDNEY STONE OR INSERT KIDNEY STE 50080 $12,430.00 REMOVE BLOOD CLOT & INJECTIONS TO DISSOLVE BLOOD C 37184 $7,153.00 REMOVE BLOOD CLOT & INJECTIONS TO DISSOLVE BLOOD C 37185 $2,232.00 REMOVE BLOOD CLOT & INJECTIONS TO DISSOLVE BLOOD C 37186 $2,389.00 REMOVE BLOOD CLOT & INJECTIONS TO DISSOLVE BLOOD C 37187 $6,698.00 REMOVE BLOOD CLOT & INJECTIONS TO DISSOLVE BLOOD C 37188 $5,783.00 REMOVE MULTIPLE HEMORRHOIDS W/EXCISION ABNORMAL AN 46261 $6,218.00 REMOVE MULTIPLE HEMORRHOIDS WITH REPAIR OF ABNORMA 46262 $5,987.00 REMOVE PLAQUE & INSERTION OF STENTS INTO ARTERIES 37227 $42,773.00 REMOVE PLAQUE IN ARTERIES IN ONE LEG ENDOVASCULAR 37225 $36,576.00 RENAL VEIN RENIN (KIDNEY ENZYME) STIMULATION PANEL 80416 $1,089.00 RENIN (KIDNEY ENZYME) LEVEL 84244 $281.00 REPAGLINIDE 0.5 MG TAB 100 EACH BOTTLE $12.81 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REPAGLINIDE 1 MG TAB 1 EACH BLIST PACK $6.54 REPAGLINIDE 1 MG TAB 100 EACH BOTTLE $6.41 REPAGLINIDE 1 MG TAB 30 EACH BLIST PACK $6.22 REPAIR OF 2 ELECTRODES FOR PERMANENT PACEMAKER OR 33220 $7,178.00 REPAIR OF ABNORMAL ANAL DRAINAGE TRACT 46270 $4,791.00 REPAIR OF ABNORMAL ANAL DRAINAGE TRACT 46707 $4,952.00 REPAIR OF ANAL MUSCLE AND ABNORMAL ANAL DRAINAGE T 46275 $5,300.00 REPAIR OF BLOOD VESSEL OF ARM 35206 $8,185.00 REPAIR OF BLOOD VESSEL OF LEG 35226 $1,931.00 REPAIR OF CENTRAL VENOUS CATHETER FOR INFUSION 36575 $1,010.00 REPAIR OF CENTRAL VENOUS CATHETER FOR INFUSION 36576 $3,124.00 REPAIR OF DEFECT OR PERFORATION OF EARDRUM 69620 $9,345.00 REPAIR OF EARDRUM 69610 $6,832.00 REPAIR OF ELECTRODE FOR PERMANENT PACEMAKER OR DEF 33218 $10,521.00 REPAIR OF FINGER OR TOE NAIL BED 11760 $512.00 REPAIR OF FINGER TENDON 26350 $5,611.00 REPAIR OF FINGER TENDON 26433 $5,931.00 REPAIR OF FOREARM AND/OR WRIST TENDON OR MUSCLE 25270 $6,210.00 REPAIR OF HAND TENDON 26410 $3,728.00 REPAIR OF HERNIA OF MUSCLE AT ESOPHAGUS AND STOMAC 43281 $19,185.00 REPAIR OF LACERATION TO FLOOR OF MOUTH AND/OR TONG 41250 $607.00 REPAIR OF LACERATION TO FLOOR OF MOUTH AND/OR TONG 41252 $1,598.00 REPAIR OF LIGAMENT OF HAND OR FINGER JOINT 26540 $6,667.00 REPAIR OF LIP AND BORDER 40650 $2,133.00 REPAIR OF MUSCLE AT ESOPHAGUS AND STOMACH USING AN 43280 $19,185.00 REPAIR OF SEPARATION OF WOUND CLOSURE 12020 $544.00 REPAIR OF SEPARATION OF WOUND CLOSURE WITH INSERTI 12021 $536.00 REPAIR OF TENDON OR MUSCLE OF UPPER ARM OR ELBOW 24341 $12,073.00 REPAIR OF TOE TENDON, ACCESSED THROUGH THE SKIN 28010 $4,248.00 REPAIR OF TRAUMATIC TEAR IN LUNG AND/OR CONTROL OF 32110 $3,527.00 REPAIR OF TURNING-OUTWARD EYELID DEFECT 67916 $5,087.00 REPAIR OF VERTICAL LIP WOUND EXTENDING TO HALF OF 40652 $1,533.00 REPAIR OF VERTICAL LIP WOUND EXTENDING TO OVER HAL 40654 $1,369.00 REPAIR OF WOUND SCALP HAND FOOT OVER 30CM 12007 $580.00 REPAIR OF WOUND (1.1 TO 2.5 CENTIMETERS) EYELIDS, 13151 $1,209.00 REPAIR OF WOUND (1.1 TO 2.5 CENTIMETERS) OF SCALP, 13120 $2,003.00 REPAIR OF WOUND (2.5 CM OR LESS) OF FACE EARS EYEL 12051 $414.00 REPAIR OF WOUND (2.6 TO 5.0 CM) OF FACE EARS EYELI 12052 $505.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REPAIR OF WOUND (2.6 TO 7.5 CENTIMETERS) EYELIDS, 13152 $1,511.00 REPAIR OF WOUND (2.6 TO 7.5 CENTIMETERS) OF NECK H 12042 $436.00 REPAIR OF WOUND (2.6 TO 7.5 CENTIMETERS) OF SCALP, 13121 $768.00 REPAIR OF WOUND (2.6 TO 7.5 CENTIMETERS) OF TRUNK 13101 $972.00 REPAIR OF WOUND (5.1 TO 7.5 CM) OF FACE EARS EYELI 12053 $576.00 REPAIR OF WOUND (7.6 TO 12.5 CM) OF FACE EARS EYEL 12054 $721.00 REPAIR OF WOUND FACE EAR EYE NOSE LIP 12.6CM TO 2 12016 $548.00 REPAIR OF WOUND FACE EAR EYE NOSE LIP 7.6CM TO 12 12015 $518.00 REPAIR OF WOUND FACE EAR EYE NOSE LIP 5.1CM TO 7.5 12014 $474.00 REPAIR OF WOUND FACE EAR EYE NOSE LIP OVER 30CM 12018 $816.00 REPAIR OF WOUND FACE EAR EYE NOSE LIP OVER 30CM 12057 $1,345.00 REPAIR OF WOUND OF EYELID MARGIN 67935 $5,603.00 REPAIR OF WOUND OF EYELIDS, NOSE, EARS, AND/OR LIP 13153 $519.00 REPAIR OF WOUND OF SCALP, ARMS, AND/OR LEGS 13122 $443.00 REPAIR OF WOUND OF TRUNK 13102 $742.00 REPAIR ROOT D3333 $1,076.00 REPAIR WOUND (1.1 TO 2.5 CM) FACE MOUTH NECK UNDER 13131 $806.00 REPAIR WOUND (12.6 TO 20.0 CENTIMETERS) OF NECK HA 12045 $1,031.00 REPAIR WOUND (12.6 TO 20.0 CM) OF FACE EARS EYELID 12055 $753.00 REPAIR WOUND (12.6 TO 20.0 CM) OF SCALP NECK UNDER 12005 $725.00 REPAIR WOUND (12.6 TO 20.0 CM) OF THE SCALP UNDERA 12035 $935.00 REPAIR WOUND (2.5 CENTIMETERS OR LESS) OF NECK HAN 12041 $368.00 REPAIR WOUND (2.5 CM OR LESS) OF FACE EAR EYELID N 12011 $674.00 REPAIR WOUND (2.5 CM OR LESS) OF SCALP NECK UNDERA 12001 $323.00 REPAIR WOUND (2.5 CM OR LESS) OF THE SCALP UNDERAR 12031 $376.00 REPAIR WOUND (2.6 TO 5.0 CM) OF FACE EAR EYELID NO 12013 $453.00 REPAIR WOUND (2.6 TO 7.5 CM) FACE MOUTH NECK UNDER 13132 $993.00 REPAIR WOUND (2.6 TO 7.5 CM) OF SCALP NECK UNDERAR 12002 $390.00 REPAIR WOUND (2.6 TO 7.5 CM) OF THE SCALP UNDERARM 12032 $462.00 REPAIR WOUND (20.1 TO 30.0 CM) OF FACE EARS EYELID 12056 $781.00 REPAIR WOUND (20.1 TO 30.0 CM) OF SCALP NECK UNDER 12006 $1,141.00 REPAIR WOUND (20.1 TO 30.0 CM) OF THE SCALP UNDERA 12036 $676.00 REPAIR WOUND (7.6 TO 12.5 CENTIMETERS) OF NECK HAN 12044 $1,550.00 REPAIR WOUND (7.6 TO 12.5 CM) OF SCALP NECK UNDERA 12004 $531.00 REPAIR WOUND (7.6 TO 12.5 CM) OF THE SCALP UNDERAR 12034 $537.00 REPAIR WOUND OF FOREHEAD CHEEK CHIN MOUTH NECK UND 13133 $499.00 REPLACEMENT OF CENTRAL VENOUS CATHETER 36580 $2,007.00 REPLACEMENT OF CENTRAL VENOUS CATHETER 36581 $5,739.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REPLACEMENT OF CENTRAL VENOUS CATHETER 36582 $5,134.00 REPLACEMENT OF KIDNEY DRAINAGE CATHETER ACCESSED T 50435 $4,179.00 REPLACEMENT OF LIVER DUCT DRAINAGE CATHETER ACCESS 47536 $3,623.00 REPLACEMENT OF PERIPHERAL VENOUS CATHETER 36584 $2,557.00 REPLACEMENT OF SMALL BOWEL TUBE 49451 $2,981.00 REPLACEMENT OF STENT PANCREATIC OR BILE DUCT USING 43276 $7,524.00 REPLACEMENT OF STOMACH OR LARGE BOWEL TUBE 49450 $2,468.00 REPLANTATION OF AMPUTATED FINGER 20822 $8,193.00 REPOSITIONING MANEUVERS FOR TREATMENT OF VERTIGO, 95992 $191.00 REPOSITIONING OF FORESKIN INCLUDING SCAR TISSUE RE 54450 $859.00 REPOSITIONING OF IMPLANTED PACEMAKER OR DEFIBRILLA 33215 $7,160.00 REPOSITIONING OF PREVIOUSLY IMPLANTED DEFIBRILLATO 33273 $6,565.00 REPOSITIONING OF STOMACH FEEDING TUBE 43761 $2,230.00 REPRODUCTIVE HORMONE PANEL (ESTRADIOL) 80415 $461.00 REPRODUCTIVE HORMONE PANEL (TESTOSTERONE) 80414 $426.00 REPROGRAMMING OF PROGRAMMABLE BRAIN AND SPINAL FLU 62252 $699.00 RESHAPING OF TIP OF NOSE 30400 $8,738.00 RESIN TWO SURFACES D2331 $190.00 RESP BLOOD GAS 02 SAT ONLY 82810 $160.00 RESP BLOOD GAS PH 82800 $282.00 RESP CARBOXYHEMOGLOBIN QUANT 82375 $131.00 RESP CHLORIDE 82435 $50.00 RESP METHEMOGLOBIN QUANT 83050 $159.00 RESP POTASSIUM 84132 $62.00 RESP SODIUM 84295 $65.00 RESP VIRUS RAPID CULT 87254 $269.00 RESPIRATORY CULT 87070 $211.00 RESPIRATORY INHALED AEROSOL TREATMENT TO RELIEVE A 94644 $221.00 RESPIRATORY INHALED AEROSOL TREATMENT TO RELIEVE A 94645 $186.00 RESPIRATORY INHALED PRESSURE/NONPRESSURE TREATM RE 94640 $121.00 RESPIRATORY MOTION MANAGEMENT SIMULATION 77293 $1,849.00 RESPIRATORY SYNCYTIAL VIRUS ANTIBODY INJECTION INT 90378 $3,314.00 RESTORATION OF EYELID BLINKING FUNCTION 67912 $6,445.00 RETIC COUNT AUTOMATED 85045 $70.00 RETIC COUNT, MANUAL 85044 $68.00 RETICULATED (YOUNG) PLATELET MEASUREMENT 85055 $153.00 REVISION OF DIALYSIS GRAFT, OPEN PROCEDURE 36832 $14,765.00 REVISION OF LARGE BOWEL OPENING AND SCAR TISSUE RE 44340 $8,806.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge REVISION OF PREVIOUS MASTOID SURGERY 69602 $11,183.00 REVISION OF PREVIOUS MASTOID SURGERY AND EAR DRUM 69604 $12,947.00 REVISION OF SHUNTS TO BYPASS BLOOD FLOW TO LIVER U 37183 $18,704.00 REVISION OF SKIN LEVEL PORT OF STOMACH BANDING DEV 43886 $7,054.00 REVISION OR REPAIR OF OPERATIVE WOUND OF EYE 66250 $4,242.00 REVIVING NEWBORN AT DELIVERY 99465 $1,448.00 RHAMNOSUS 10 BILLION CELL -200 MG CPSP 30 EACH BLI $2.17 RHEUMATOID FACTOR ANALYSIS 86430 $137.00 RHEUMATOID FACTOR LEVEL 86431 $154.00 RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) SYRG 1 J2790 $67.20 RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML S J2791 $364.10 RIBOSOMAL P IGG 86235 $220.00 RIFABUTIN 150 MG CAP 100 EACH BOTTLE $61.23 RIFAMPIN 150 MG CAP 30 EACH BLIST PACK $6.69 RIFAMPIN 300 MG CAP 100 EACH BLIST PACK $4.77 RIFAMPIN 300 MG CAP 100 EACH BOTTLE $16.07 RIFAMPIN 300 MG CAP 60 EACH BOTTLE $7.04 RIFAMPIN 600 MG SOLR 1 EACH VIAL $749.95 RIFAXIMIN 200 MG TAB 30 EACH BOTTLE $86.98 RIFAXIMIN 550 MG TAB 60 EACH BLIST PACK $165.80 RILPIVIRINE 25 MG TAB 30 EACH BOTTLE $146.04 RINGER'S SOLP 1,000 ML BAG j7120 $38.50 RISPERIDONE 0.25 MG TAB 100 EACH BLIST PACK $13.79 RISPERIDONE 0.25 MG TAB 60 EACH BOTTLE $13.65 RISPERIDONE 1 MG TAB 100 EACH BLIST PACK $8.79 RISPERIDONE 2 MG TAB 100 EACH BLIST PACK $6.79 RISPERIDONE MICROSPHERES 25 MG/2 ML SYRG 1 EACH BO J2794 $20.36 RISPERIDONE MICROSPHERES 37.5 MG/2 ML SYRG 1 EACH J2794 $20.36 RITONAVIR 100 MG TAB 30 EACH BOTTLE $32.40 RITUXIMAB 10 MG/ML CONC 10 ML VIAL J9312 $3,945.97 RITUXIMAB 10 MG/ML CONC 50 ML VIAL J9312 $19,729.85 RITUXIMAB-HYALURONIDASE,HUMAN 1400 MG/11.7 ML (120 J9312 $27,621.96 RITUXIMAB-HYALURONIDASE,HUMAN 1600 MG/13.4 ML (120 J9312 $31,566.47 RIVAROXABAN 10 MG TAB 100 EACH BLIST PACK $62.72 RIVAROXABAN 15 MG TAB 100 EACH BLIST PACK $41.81 RIVAROXABAN 20 MG TAB 100 EACH BLIST PACK $31.36 RIVASTIGMINE 13.3 MG/24 HOUR PT24 1 EACH BOX $47.73 RIVASTIGMINE 13.3 MG/24 HOUR PT24 30 EACH BOX $47.73 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge RIVASTIGMINE 4.6 MG/24 HR PT24 1 EACH BOX $96.04 RIVASTIGMINE 4.6 MG/24 HR PT24 30 EACH BOX $96.04 RIVASTIGMINE 9.5 MG/24 HR PT24 1 EACH PACKET $47.73 RIVASTIGMINE 9.5 MG/24 HR PT24 30 EACH BOX $47.73 RIVASTIGMINE TARTRATE 1.5 MG CAP 100 EACH BLIST PA $14.85 RIVASTIGMINE TARTRATE 1.5 MG CAP 60 EACH BOTTLE $14.85 RMSF AB IGG 86757 $104.00 RNP (ENA) AB EACH 86235 $221.00 ROCURONIUM 10 MG/ML SOLN 5 ML VIAL $21.58 ROFLUMILAST 500 MCG TAB 20 EACH BLIST PACK $48.98 ROMIDEPSIN 10 MG/2 ML SOLR 1 EACH VIAL J9315 $13,434.33 ROMIPLOSTIM 250 MCG SOLR 1 EACH VIAL J2796 $7,578.69 ROMIPLOSTIM 500 MCG SOLR 1 EACH VIAL J2796 $15,157.38 ROOM & BOARD CORONARY CARE UNIT PRIVATE $4,106.00 ROOM & BOARD INTENSIVE CARE UNIT $4,106.00 ROOM & BOARD ISOLATION $3,390.00 ROOM & BOARD MED/SURG GENERAL PRIVATE $2,176.00 ROOM & BOARD MED/SURG GENERAL SEMI PRIVATE $2,176.00 ROOM & BOARD MED/SURG OB/GYN PRIVATE $2,176.00 ROOM & BOARD MED/SURG ONCOLOGY DELUXE $2,331.00 ROOM & BOARD MED/SURG ONCOLOGY PRIVATE $2,176.00 ROOM & BOARD MED/SURG ONCOLOGY SEMI PRIVATE $2,176.00 ROOM & BOARD MED/SURG REHABILITATION PRIVATE $2,176.00 ROOM & BOARD MED/SURG REHABILITATION SEMI PRIVATE $2,176.00 ROOM & BOARD NEONATAL INTENSIVE CARE UNIT $4,106.00 ROOM & BOARD NURSERY GENERAL $639.00 ROOM & BOARD OBSTETRICS SEMI PRIVATE $2,176.00 ROOM & BOARD TELEMETRY $3,390.00 ROPINIROLE 0.25 MG TAB 100 EACH BOTTLE $2.11 ROPINIROLE 1 MG TAB 100 EACH BLIST PACK $0.74 ROPIVACAINE (PF) 2 MG/ML (0.2 %) SOLN 100 ML FLEX J2795 $162.40 ROPIVACAINE (PF) 2 MG/ML (0.2 %) SOLN 20 ML VIAL J2795 $40.67 ROPIVACAINE (PF) 2 MG/ML (0.2 %) SOLN 200 ML FLEX J2795 $324.80 ROPIVACAINE (PF) 5 MG/ML (0.5 %) SOLN 100 ML BOTTL J2795 $3.20 ROPIVACAINE (PF) 5 MG/ML (0.5 %) SOLN 200 ML BOTTL J2795 $38.33 ROPIVACAINE (PF) 5 MG/ML (0.5 %) SOLN 30 ML VIAL J2795 $12.60 ROSUVASTATIN 10 MG TAB 1 EACH BLIST PACK $2.94 ROSUVASTATIN 10 MG TAB 100 EACH BLIST PACK $14.07 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ROSUVASTATIN 10 MG TAB 90 EACH BOTTLE $15.65 ROTAVIRUS VACCINE LIVE 2 ML SOLN 2 ML TUBE 90680 $348.14 ROUTINE ELECTROCARDIOGRAM (EKG) WITH TRACING USING 93005 $400.00 RPR W/RFLX 86592 $101.00 RPR, BLOOD QUANT 86593 $136.00 RT ASSESSMENT $105.00 RT CALCIUM IONIZED 82330 $152.00 RUBBER BANDING OF LARGE BOWEL USING AN ENDOSCOPE 45350 $2,886.00 RUBELLA AB 86762 $176.00 RUBELLA ANTIBODY, IGG 86762 $172.00 RUBELOA AB,IGG 86765 $161.00 RUBEOLA ANTIBODY, IGG 86765 $169.00 SACUBITRIL-VALSARTAN 24-26 MG TAB 60 EACH BOTTLE $35.64 SACUBITRIL-VALSARTAN 49-51 MG TAB 60 EACH BOTTLE $32.43 SACUBITRIL-VALSARTAN 97-103 MG TAB 60 EACH BOTTLE $32.43 SALICYLATE-SERUM 80307 $178.00 SALMETEROL 50 MCG/DOSE DSDV 28 EACH BLIST PACK $31.14 SCLERODERMA (SCL70) (ENA) AB 86235 $194.00 SCOPOLAMINE 1 MG OVER 3 DAYS PT3D 1 EACH BOX $80.41 SCOPOLAMINE 1 MG OVER 3 DAYS PT3D 10 EACH BOX $89.44 SCOPOLAMINE 1 MG OVER 3 DAYS PT3D 24 EACH BOX $89.44 SCOPOLAMINE 1 MG OVER 3 DAYS PT3D 4 EACH BOX $235.94 SCRAPING OF LINING OF UTERUS POST-DELIVERY 59160 $2,553.00 SCRAPING OF SKIN 15783 $1,234.00 SCRAPING OF SKIN OF FACE 15780 $5,653.00 SCRAPING OF THE CERVIX USING AN ENDOSCOPE 57456 $887.00 SCRAPING OF TISSUE OF CERVIX 57505 $733.00 SCREEN QUAD 81511 $623.00 SCREENING ABDOMINAL AORTA WITH IMAGE DOCUMENTATION 76706 $448.00 SCREENING CT SCAN OF LARGE BOWEL 74263 $2,837.00 SCREENING DIGITAL TOMOGRAPHY OF BOTH BREASTS 77063 $124.00 SCREENING EXAMINATION OF SPECIMEN CELLS 88160 $62.00 SCREENING PAPANICOLAOU SMEAR CERVICAL OR VAGINAL U P3000 $90.00 SCREENING TEST FOR COMPATIBLE BLOOD UNIT 86902 $314.00 SCREENING TEST FOR MONONUCLEOSIS (MONO) 86308 $176.00 SCREENING TEST FOR PATHOGENIC ORGANISMS 87081 $186.00 SCREENING TEST FOR PATHOGENIC ORGANISMS WITH COLON 87084 $71.00 SCREENING TEST FOR RED BLOOD CELL ANTIBODIES 86850 $118.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SECOND REPAIR OF SURGICAL WOUND 13160 $3,489.00 SELENIUM (VITAMIN) LEVEL 84255 $184.00 SELENIUM SULFIDE 2.5 % LOTN 120 ML BOTTLE $69.30 SELF CARE CURRENT STATUS G8987 $0.01 SELF CARE DISCHARGE STATUS G8989 $0.01 SELF CARE GOAL STATUS G8988 $0.01 SELF-CARE OR HOME MANAGEMENT TRAINING, EACH 15 MIN 97535 $147.00 SEMEN ANALYSIS FOR SPERM PRESENCE 89321 $92.00 SEMEN ANALYSIS PRESENCE AND/OR MOTILITY OF SPERM 89300 $68.00 SEMEN FRUCTOSE (CARBOHYDRATE) LEVEL 82757 $143.00 SENNA 8.6 MG TAB 1,000 EACH BOTTLE $0.07 SENNA 8.6 MG TAB 100 EACH BLIST PACK $0.27 SENNA 8.6 MG TAB 100 EACH BOTTLE $0.09 SENNA-DOCUSATE 8.6-50 MG TAB 100 EACH BLIST PACK $0.45 SENNA-DOCUSATE 8.6-50 MG TAB 100 EACH BOTTLE $0.07 SENNOSIDES 8.8 MG/5 ML SYRP 236 ML BOTTLE $0.45 SENNOSIDES 8.8 MG/5 ML SYRP 5 ML CUP $0.45 SENSORY TECHNIQUE ENHANCE PROCESS & ADAPT ENVIRONM 97533 $112.00 SEPARATION OF NAIL PLATE FROM NAIL BED 11730 $291.00 SEPARATION OF NAIL PLATE FROM NAIL BED 11732 $195.00 SEPT9 (SEPTIN9) METHYLATION ANALYSIS 81327 $427.00 SEROTONIN (HORMONE) LEVEL 84260 $267.00 SERTRALINE 25 MG TAB 100 EACH BLIST PACK $1.41 SERTRALINE 50 MG TAB 1 EACH BLIST PACK $0.70 SERTRALINE 50 MG TAB 100 EACH BLIST PACK $0.70 SERTRALINE 50 MG TAB 90 EACH BOTTLE $9.98 SEVELAMER 400 MG TAB 360 EACH BOTTLE $14.82 SEVELAMER 800 MG TAB 180 EACH BOTTLE $14.82 SEVELAMER 800 MG TAB 270 EACH BOTTLE $21.33 SEVELAMER CARBONATE 0.8 GRAM PWPK 1 EACH PACKET $39.71 SEVELAMER CARBONATE 0.8 GRAM PWPK 90 EACH BOX $71.12 SEVELAMER CARBONATE 0.8 GRAM PWPK 90 EACH PACKET $39.71 SEVELAMER CARBONATE 2.4 GRAM PWPK 90 EACH PACKET $71.12 SEVOFLURANE LIQD 250 ML BOTTLE $499.63 SEX HORMONE BINDING GLOBULIN (PROTEIN) LEVEL 84270 $255.00 SEX IDENTIFICATION 88130 $125.00 SEX IDENTIFICATION 88140 $66.00 SGPT ALT 84460 $130.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SHAVING 0.5 CM OR LESS SKIN GROWTH OF FACE EAR EYE 11310 $275.00 SHAVING 0.5 CM OR LESS SKIN GROWTH OF SCALP NECK H 11305 $284.00 SHAVING 0.6 TO 1.0 CM SKIN GROWTH OF SCALP NECK HA 11306 $427.00 SHAVING 1.1 TO 2.0 CM SKIN GROWTH OF FACE EAR EYEL 11312 $741.00 SHAVING 1.1 TO 2.0 CM SKIN GROWTH OF SCALP NECK HA 11307 $427.00 SHOCK WAVE CRUSHING OF KIDNEY STONES $18,384.00 SIALIC ACID (ORGANIC ACID) LEVEL 84275 $170.00 SIGMOIDOSCOPY CANCER SCREENING G0104 $1,582.00 SIGMOIDOSCOPY W/RESECTION 45349 $3,824.00 SILDENAFIL (ANTIHYPERTENSIVE) 20 MG TAB 1 EACH BLI S0090 $70.79 SILDENAFIL (ANTIHYPERTENSIVE) 20 MG TAB 90 EACH BO S0090 $73.75 SILICA (SILICON) LEVEL 84285 $194.00 SILVER NITRATE APPLICATOR 75-25 % STCK 100 EACH PA $6.45 SILVER NITRATE APPLICATOR 75-25 % STCK 100 EACH TU $0.38 SILVER SULFADIAZINE 1 % CREA 25 G TUBE $31.33 SILVER SULFADIAZINE 1 % CREA 400 G JAR $247.80 SILVER SULFADIAZINE 1 % CREA 50 G TUBE $51.80 SIMETHICONE 125 MG CAP 72 EACH BLIST PACK $0.11 SIMETHICONE 40 MG/0.6 ML DRPS 30 ML DROP BTL $12.29 SIMETHICONE 80 MG CHEW 100 EACH BLIST PACK $0.31 SIMPLE CONTROL OF NOSE BLEED 30901 $288.00 SIMVASTATIN 10 MG TAB 1 EACH BLIST PACK $4.88 SIMVASTATIN 10 MG TAB 100 EACH BLIST PACK $4.88 SIMVASTATIN 40 MG TAB 1 EACH BLIST PACK $2.15 SIMVASTATIN 40 MG TAB 100 EACH BLIST PACK $2.15 SIMVASTATIN 40 MG TAB 100 EACH BOX $0.09 SIMVASTATIN 40 MG TAB 90 EACH BOTTLE $2.14 SINGLE PLANE IMAGING PROCEDURE 76100 $611.00 SIROLIMUS LEVEL 80195 $308.00 SITAGLIPTIN 25 MG TAB 1 EACH BLIST PACK $63.17 SITAGLIPTIN 25 MG TAB 100 EACH BLIST PACK $63.17 SITAGLIPTIN 25 MG TAB 30 EACH BOTTLE $60.14 SITAGLIPTIN 25 MG TAB 90 EACH BOTTLE $60.14 SITAGLIPTIN 50 MG TAB 100 EACH BLIST PACK $63.17 SITAGLIPTIN 50 MG TAB 90 EACH BOTTLE $60.14 SKELETAL MUSCLE RELAXANTS LEVELS 80369 $84.00 SKELETAL MUSCLE RELAXANTS LEVELS 80370 $259.00 SKIN APPLICATION OF TAR AND ULTRAVIOLET B OR PETRO 96910 $191.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SKIN GRAFT AT TRUNK ARMS OR LEGS 1ST 100CM OR LESS 15100 $3,215.00 SKIN GRAFT AT TRUNK ARMS OR LEGS 1ST 100CM OR LESS 15110 $6,133.00 SKIN GRAFT AT TRUNK ARMS OR LEGS 1ST 100CM OR LESS 15130 $4,334.00 SKIN GRAFT AT TRUNK, ARMS, OR LEGS 15101 $6,758.00 SKIN GRAFT AT TRUNK, ARMS, OR LEGS 15111 $449.00 SKIN GRAFT FACE SCALP EYELID MOUTH NECK EAR EYE HA 15121 $2,258.00 SKIN GRAFT FACE SCALP EYELID MOUTH NECK EARS EYE H 15116 $596.00 SKIN GRAFT FACE SCALP EYELID MOUTH NECK EARS EYE R 15115 $3,873.00 SKIN TEST FOR CANDIDA (YEAST) 86485 $110.00 SKIN TEST FOR TUBERCULOSIS 86580 $74.00 SLEEP MONITORING OF PATIENT (6 YEARS OR OLDER) IN 95810 $4,469.00 SLEEP MONITORING OF PATIENT (6 YEARS OR OLDER) IN 95811 $5,783.00 SLEEP MONITORING OF PATIENT IN SLEEP LAB 95808 $3,830.00 SLEEP STUDY ATTENDED BY A TECHNICIAN 95807 $2,908.00 SMALL BOWEL ENDOSCOPY 44369 $4,265.00 SMEAR FOR INFECTIOUS AGENTS 87210 $74.00 SMEAR FOR PARASITES 87177 $191.00 SMITH (ENA) AB 86235 $221.00 SMOKING & TOBACCO USE INTERMEDIATE COUNSEL > THAN 99406 $68.00 SMOKING AND TOBACCO USE INTENSIVE COUNSELING, GREA 99407 $71.00 SMRNP IGG AB 86235 $220.00 SNIP INCISION OF TEAR DUCT OPENING 68420 $5,788.00 SOD HYALURONATE-SOD CHONDROITIN-SOD HYALURONATE 3 $880.95 SOD PHOS DI, MONO-K PHOS MONO 250 MG TAB 1 EACH BL $5.60 SOD PHOS DI, MONO-K PHOS MONO 250 MG TAB 100 EACH $1.78 SOD PICOSULF-MAG OX-CITRIC AC 10 MG-3.5 GRAM-12 GR $270.62 SODIUM ACETATE 4 MEQ/ML SOLN 100 ML VIAL $37.10 SODIUM BICARBONATE 1 MEQ/ML (8.4 %) SOLN 50 ML VIA $20.39 SODIUM BICARBONATE 10 MEQ/10 ML (8.4 %) SYRG 10 ML $59.01 SODIUM BICARBONATE 4 % SOLN 5 ML VIAL $32.04 SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) SYRG 10 ML S $4.54 SODIUM BICARBONATE 650 MG TAB 100 EACH BOTTLE $0.24 SODIUM BICARBONATE 650 MG TAB 500 EACH DOSE-PACK $0.29 SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SYRG 50 ML SYR $22.14 SODIUM BODY FLUID 84302 $113.00 SODIUM CHLORIDE 0.45 % SOLP 1,000 ML BAG $5.25 SODIUM CHLORIDE 0.45 % SOLP 1,000 ML FLEX CONT $5.25 SODIUM CHLORIDE 0.45 % SOLP 500 ML BAG $8.75 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SODIUM CHLORIDE 0.65 % SPRA 44 ML SQUEEZ BTL $7.39 SODIUM CHLORIDE 0.9 % NEBU 3 ML VIAL $0.77 SODIUM CHLORIDE 0.9 % SOLN 1,000 ML BOTTLE $14.00 SODIUM CHLORIDE 0.9 % SOLN 3,000 ML BOTTLE $63.00 SODIUM CHLORIDE 0.9 % SOLN 5,000 ML BOTTLE $105.00 SODIUM CHLORIDE 0.9 % SOLN 500 ML BOTTLE $14.00 SODIUM CHLORIDE 0.9 % SOLP 1,000 ML FLEX CONT J7030 $4.38 SODIUM CHLORIDE 0.9 % SOLP 100 ML BAG ABCDE $21.88 SODIUM CHLORIDE 0.9 % SOLP 100 ML FLEX CONT ABCDE $24.50 SODIUM CHLORIDE 0.9 % SOLP 250 ML BAG J7050 $7.88 SODIUM CHLORIDE 0.9 % SOLP 250 ML FLEX CONT J7050 $14.00 SODIUM CHLORIDE 0.9 % SOLP 50 ML BAG ABCDE $42.00 SODIUM CHLORIDE 0.9 % SOLP 500 ML FLEX CONT J7040 $7.88 SODIUM CHLORIDE 0.9% SOLN 10 ML VIAL $3.82 SODIUM CHLORIDE 0.9% SOLP 1,000 ML FLEX CONT J7030 $1.05 SODIUM CHLORIDE 0.9% SOLP 250 ML FLEX CONT J7050 $4.38 SODIUM CHLORIDE 0.9% SOLP 50 ML BAG ABCDE $8.75 SODIUM CHLORIDE 0.9% SOLP 50 ML FLEX CONT ABCDE $10.33 SODIUM CHLORIDE 0.9% SOLP 500 ML BAG J7040 $1.75 SODIUM CHLORIDE 0.9% SOLP 500 ML FLEX CONT J7040 $2.28 SODIUM CHLORIDE 1 GRAM TAB 100 EACH BOTTLE $0.37 SODIUM CHLORIDE 2 % DROP 15 ML DROP BTL $63.79 SODIUM CHLORIDE 2.5 MEQ/ML SOLP 40 ML VIAL $5.74 SODIUM CHLORIDE 3 % SOLP 500 ML BAG $11.38 SODIUM CHLORIDE 4 MEQ/ML SOLP 100 ML VIAL $45.15 SODIUM CHLORIDE 4 MEQ/ML SOLP 200 ML VIAL $106.40 SODIUM CHLORIDE 4 MEQ/ML SOLP 30 ML VIAL $18.90 SODIUM CHLORIDE 5 % OINT 3.5 G TUBE $42.39 SODIUM CHLORIDE BACTERIOSTATIC 0.9 % SOLN 30 ML VI $4.62 SODIUM CHLORIDE PGBK 100 ML BAG ABCDE $21.00 SODIUM CHLORIDE PGBK 50 ML BAG ABCDE $20.83 SODIUM CHLORIDE SYRG 10 ML SYRINGE $0.74 SODIUM CHLORIDE SYRG 3 ML SYRINGE $1.99 SODIUM HYALURONATE 14 MG/ML SYRG 0.55 ML SYRINGE $852.71 SODIUM HYALURONATE 14 MG/ML SYRG 1 EACH SYRINGE $916.15 SODIUM HYPOCHLORITE 0.25 % SOLN 473 ML BOTTLE $41.39 SODIUM HYPOCHLORITE 0.5 % SOLN 473 ML BOTTLE $41.39 SODIUM NITRITE-SOD THIOSULFATE 300 MG/10 ML- 12.5 $714.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SODIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL $127.16 SODIUM PHOSPHATES 19-7 GRAM/118 ML ENEM 133 ML SQU $4.19 SODIUM POLYSTYRENE SULFON-SORB 15-19.3 GRAM/60 ML $39.48 SODIUM POLYSTYRENE SULFON-SORB 15-20 GRAM/60 ML SU $39.48 SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) SOL $374.50 SODIUM URINE 84300 $84.00 SODIUM, URINE 84300 $84.00 SODIUM,URINE 24HR 84300 $74.00 SOL TRANSFERRIN RECEP ASSAY 84238 $365.00 SOLIFENACIN 10 MG TAB 30 EACH BOTTLE $24.02 SOLIFENACIN 5 MG TAB 90 EACH BOTTLE $48.03 SOMATOSTATIN (GROWTH HORMONE INHIBITOR) LEVEL 84307 $667.00 SORBITOL 3 % SOLN 3,000 ML BOTTLE $94.50 SORBITOL 70 % SOLN 473 ML BOTTLE $0.68 SOTALOL 120 MG TAB 100 EACH BOTTLE $7.31 SOTALOL 80 MG TAB 100 EACH BLIST PACK $8.12 SOTALOL 80 MG TAB 100 EACH BOTTLE $8.97 SP GRAVITY-URINE 81003 $18.00 SPECIAL RADIATION THERAPY PLANNING 77331 $497.00 SPECIAL RADIATION TREATMENT PROCEDURE 77470 $2,471.00 SPECIAL STAIN FOR MICROORGANISM 87205 $66.00 SPECIAL STAIN FOR MICROORGANISM 87206 $121.00 SPECIAL STAIN FOR PARASITES 87209 $154.00 SPECIAL STAINED SPECIMEN SLIDES TO EXAMINE TISSUE 88313 $213.00 SPECIAL STAINED SPECIMEN SLIDES TO EXAMINE TISSUE 88314 $370.00 SPECIAL STAINED SPECIMEN SLIDES TO EXAMINE TISSUE 88341 $428.00 SPECIAL STAINED SPECIMEN SLIDES TO IDENTIFY ORGANI 88312 $170.00 SPECIFIC GRAVITY (LIQUID WEIGHT) MEASUREMENT 84315 $39.00 SPECIMEN ANALYSIS FOR BLOOD 82271 $29.00 SPEECH THERAPY ? REVENUE CODE 44X G0378 $90.00 SPERM ISOLATION WITH SEMEN ANALYSIS FOR FERTILIZAT 89260 $229.00 SPINAL TAP FOR DIAGNOSIS 62270 $547.00 SPINAL TAP WITH DRAINAGE OF SPINAL FLUID 62272 $570.00 SPIRONOLACTONE 25 MG TAB 1 EACH BLIST PACK $1.50 SPIRONOLACTONE 25 MG TAB 100 EACH BLIST PACK $1.50 SPIRONOLACTONE 25 MG TAB 500 EACH BOTTLE $1.57 SPIRONOLACTONE 5 MG/ML SUSP 1 ML SYRINGE A9270 $5.95 SPIRONOLACTONE 50 MG TAB 1 EACH BLIST PACK $1.54 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SPIRONOLACTONE 50 MG TAB 100 EACH BLIST PACK $1.69 SPIRONOLACTONE-HYDROCHLOROTHIAZIDE 25-25 MG TAB 1 $7.56 SPLITTING OF BLOOD OR BLOOD PRODUCTS 86985 $189.00 SPUTUM SPECIMEN COLLECTION 89220 $145.00 SSA (ENA) AB EACH 86235 $220.00 SSB (ENA) AB EACH 86235 $221.00 STEM CELLS COUNT, TOTAL 86367 $312.00 STEREOISOMER (ENANTIOMER) DRUG ANALYSIS 80374 $259.00 STEREOTACTIC BODY RADIATION THERAPY 1 OR MORE LESI 77372 $34,142.00 STEREOTACTIC BODY RADIATION THERAPY 1 OR MORE LESI 77373 $21,393.00 STEREOTACTIC TREATMENT OF BRAIN GROWTH COMPLEX FIR 61798 $5,570.00 STERILE TALC 4 GRAM SUSR 1 EACH VIAL $350.00 STERILE WATER (BOTTLE) SOLN 1,000 ML FLEX CONT $28.00 STERILE WATER (BOTTLE) SOLN 3,000 ML FLEX CONT $5.25 STERILE WATER (BOTTLE) SOLN 500 ML FLEX CONT $7.00 STERILE WATER SOLP 1,000 ML BAG A4217 $10.50 STERILE WATER SOLP 2,000 ML BAG A4217 $21.00 STOMACH AND ESOPHAGUS REGURGITATION STUDY 78262 $2,136.00 STOMACH EMPTYING STUDY 78264 $1,677.00 STOOL ANALYSIS FOR BILIRUBIN 82252 $37.00 STOOL ANALYSIS FOR BLOOD 82272 $63.00 STOOL ANALYSIS FOR BLOOD TO SCREEN FOR COLON TUMOR 82270 $65.00 STOOL CALPROTECTIN (PROTEIN) LEVEL 83993 $519.00 STOOL CULTURE 87045 $202.00 STOOL FAT ANALYSIS 82705 $121.00 STOOL FAT MEASUREMENT 82715 $142.00 STOOL LACTOFERRIN (IMMUNE SYSTEM PROTEIN) ANALYSIS 83630 $156.00 STOOL LACTOFERRIN (IMMUNE SYSTEM PROTEIN) LEVEL 83631 $162.00 STOOL PORPHYRINS (METABOLISM SUBSTANCE) LEVEL 84126 $333.00 STOOL WBC STAIN 87205 $86.00 STRAPPING OF ANKLE AND/OR FOOT 29540 $162.00 STRAPPING OF CHEST 29200 $227.00 STRAPPING OF ELBOW OR WRIST 29260 $345.00 STRAPPING OF HAND OR FINGER 29280 $215.00 STRAPPING OF HIP 29520 $219.00 STRAPPING OF KNEE 29530 $318.00 STRAPPING OF SHOULDER 29240 $381.00 STRAPPING OF TOES 29550 $282.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge STRAPPING, UNNA BOOT 29580 $357.00 STRENGTH/ENDURANCE RESPIRATORY MUSCLES PROCEDURE G0237 $129.00 STREP TEST (STREPTOCOCCUS, GROUP A) 87880 $79.00 STUDIES OF THE SPONTANEOUS STOMACH MOVEMENT FUNCTI 91020 $3,223.00 STUDY OF ANORECTAL PRESSURE GENERATED BY MUSCLES S 91122 $1,613.00 SUCCINYLCHOLINE 20 MG/ML SOLN 10 ML VIAL J0330 $40.29 SUCRALFATE 1 GRAM TAB 100 EACH BLIST PACK $2.70 SUCRALFATE 1 GRAM TAB 100 EACH BOTTLE $2.81 SUCRALFATE 100 MG/ML SUSP 10 ML CUP $42.63 SUCROSE ORAL SOLUTION LIQD 473 ML BOTTLE $0.08 SUCTION ASSISTED REMOVAL OF FAT FROM ARM 15878 $3,363.00 SUCTION ASSISTED REMOVAL OF FAT FROM HEAD AND NECK 15876 $5,505.00 SUCTION ASSISTED REMOVAL OF FAT FROM LEG 15879 $6,273.00 SUFENTANIL 50 MCG/ML SOLN 2 ML AMPUL J3490 $3.18 SUFENTANIL 50 MCG/ML SOLN 5 ML AMPUL $2.69 SUGAMMADEX 100 MG/ML SOLN 2 ML VIAL $418.91 SULFACETAMIDE 10 % DROP 15 ML DROP BTL $213.52 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML 200-4 $7.67 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG TAB 1 EACH $2.32 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG TAB 30 EAC $2.96 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML SOLN $21.00 SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TAB 100 E $1.30 SULFASALAZINE 500 MG TAB 1 EACH BLIST PACK $1.95 SULFASALAZINE 500 MG TAB 100 EACH BOTTLE $0.89 SUMATRIPTAN 25 MG TAB 9 EACH BLIST PACK $94.68 SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SOLN 0.5 ML VIAL J3030 $297.50 SUPERVISION, HANDLING, LOADING OF RADIATION 77790 $846.00 SURG PATH COMPLEX 88305 $413.00 SURG PATH LEVEL 4 88305 $413.00 SURGICAL PATHOLOGY CONSULTATION AND REPORT 88321 $95.00 SURGICAL PATHOLOGY CONSULTATION AND REPORT 88323 $440.00 SURGICAL, UNCOMPLICATED 88304 $316.00 SUTURE OF MOUTH LACERATION 2.5 CM OR LESS 40830 $502.00 SUTURE OF MOUTH LACERATION OVER 2.5 CM 40831 $1,436.00 SUTURE OF RECENT WOUND OF THE EYELID INVOLVING LID 67930 $5,942.00 SUTURE REPAIR OF A TURNING-OUTWARD DEFECT OF UPPER 67914 $5,195.00 SWALLOWING FUNCTION LIMIT CURRENT STATUS G8996 $0.01 SWALLOWING FUNCTION LIMIT DISCHARGE STATUS G8998 $0.01 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SWALLOWING FUNCTION LIMIT GOAL STATUS G8997 $0.01 T CELL COUNT AND RATIO 86360 $416.00 T CELLS COUNT, TOTAL 86359 $263.00 T PALLIDUM AB IGG BY ELISA 86780 $145.00 T WHIPPLEI DNA 87798 $315.00 TACROLIMUS 1 MG CAP 100 EACH BLIST PACK J7507 $15.61 TACROLIMUS 1 MG CAP 100 EACH BOTTLE J7507 $7.81 TACROLIMUS 5 MG CAP 100 EACH BLIST PACK J7507 $7.80 TACROLIMUS LEVEL 80197 $400.00 TAMOXIFEN 10 MG TAB 100 EACH BLIST PACK S0187 $8.29 TAMSULOSIN 0.4 MG CAP 1 EACH BLIST PACK $14.75 TAMSULOSIN 0.4 MG CAP 100 EACH BLIST PACK $14.75 TAPENTADOL 50 MG TAB 100 EACH BLIST PACK $24.31 TAPENTADOL 75 MG TAB 100 EACH BLIST PACK $28.41 TAPENTADOL LEVEL 80372 $259.00 TBO-FILGRASTIM 300 MCG/0.5 ML SYRG 0.5 ML SYRINGE J1447 $629.16 TBO-FILGRASTIM 300 MCG/0.5 ML SYRG 1 EACH $1,049.41 TBO-FILGRASTIM 300 MCG/ML SOLN 1 ML VIAL $1,049.43 TBO-FILGRASTIM 480 MCG/0.8 ML SYRG 0.8 ML SYRINGE J1447 $1,679.52 TCAT INSERTIONJ/RPL PERM LEADLESS PACEMAKER RV W/I 33274 $42,225.00 TDAP 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML SUSP 0.5 ML V 90715 $199.49 TELEPHONIC EVALUATION SNGL/DUAL/MULT LD PACEMKR HE 93293 $174.00 TELMISARTAN 20 MG TAB 1 EACH BLIST PACK $15.19 TELMISARTAN 20 MG TAB 30 EACH BLIST PACK $27.97 TELMISARTAN 80 MG TAB 1 EACH BLIST PACK $0.68 TELMISARTAN 80 MG TAB 30 EACH BLIST PACK $6.99 TEMAZEPAM 15 MG CAP 1 EACH BLIST PACK $2.50 TEMAZEPAM 15 MG CAP 100 EACH BLIST PACK $2.50 TEMOZOLOMIDE 140 MG CAP 14 EACH BOTTLE J8700 $1,188.12 TEMPORARY CLOSURE OF EYELIDS BY SUTURE 67875 $2,667.00 TENOFOVIR 300 MG TAB 30 EACH BOTTLE $159.63 TERAZOSIN 1 MG CAP 1 EACH BLIST PACK $5.62 TERAZOSIN 1 MG CAP 100 EACH BLIST PACK $4.01 TERAZOSIN 2 MG CAP 1 EACH BLIST PACK $2.81 TERAZOSIN 2 MG CAP 100 EACH BLIST PACK $2.81 TERAZOSIN 5 MG CAP 1 EACH BLIST PACK $1.12 TERAZOSIN 5 MG CAP 100 EACH BLIST PACK $1.12 TERBINAFINE HCL 250 MG TAB 30 EACH BOTTLE $22.37 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge TERBUTALINE 1 MG/ML SOLN 1 ML VIAL J3105 $4.20 TEST FOR DETECTING GENES ASSOCIATED WITH CANCER 81455 $2,592.00 TEST FOR DETECTING GENES ASSOCIATED WITH FETAL DIS 81420 $2,728.00 TEST FOR DETECTING GENES ASSOCIATED WITH FETAL DIS 81422 $3,182.00 TESTING FOR PRESENCE OF DRUG 80306 $102.00 TESTOSTERONE (HORMONE) LEVEL 84403 $283.00 TESTOSTERONE 1 % (50 MG/5 GRAM) GLPK 5 G PACKET $89.65 TESTOSTERONE CYPIONATE 200 MG/ML OIL 1 ML VIAL J1071 $21.00 TESTOSTERONE FREE 84402 $312.00 TETANUS & DIPHTHERIA TOXOIDS (ADULT) 5-2 LF UNIT/0 90714 $144.24 TETANUS IMMUNE GLOBULIN 250 UNIT SYRG 1 EACH SYRIN J1670 $2,225.58 TETANUS TOXOID-DIPHTHERIA 2-2 LF UNIT/0.5 ML SUSP 90714 $105.51 TETRACAINE 0.5 % DROP 15 ML DROP BTL $36.91 TETRACAINE HCL (BULK) POWD 25 G JAR $85.75 TETRACAINE HCL (PF) 0.5 % DROP 4 ML DROP BTL $42.97 TETRACYCLINE 250 MG CAP 100 EACH BOTTLE $6.99 TETRAHYDROZOLINE 0.05 % DROP 15 ML DROP BTL $7.51 THAWING OF FRESH FROZEN PLASMA UNIT 86927 $202.00 THC METABOLITE URINE QUANT 80349 $232.00 THEOPHYLLINE 200 MG CP24 100 EACH BOTTLE $12.47 THEOPHYLLINE 300 MG CP24 100 EACH BOTTLE $5.11 THEOPHYLLINE 300 MG TB12 100 EACH BOTTLE $5.01 THEOPHYLLINE 80 MG/15 ML ELIX 473 ML BOTTLE $15.49 THEOPHYLLINE- LEV 80198 $244.00 THEOPHYLLINE LEVEL 80198 $244.00 THERAPEUTIC ACTIVITIES TO IMPROVE FUNCTION EACH 15 97530 $151.00 THERAPEUTIC EXERCISE DEV STRENGTH ENDUR RNG OF MTN 97110 $170.00 THERAPEUTIC HOT AND COLD BATHS TO 1 OR MORE AREAS, 97034 $91.00 THERAPEUTIC INTERVENTION WITH FOCUS ON COGNITIVE F 97127 $148.00 THERAPEUTIC MASSAGE TO 1 OR MORE AREAS, EACH 15 MI 97124 $111.00 THERAPEUTIC PROCEDURE RE-EDUCATE BRAIN-TO-NERVE-TO 97112 $191.00 THERAPEUTIC PROCEDURES IN A GROUP SETTING 97150 $142.00 THERAPEUTIC RADIOLOGY PORT FILMS 77417 $279.00 THERAPEUTIC REMOVAL OF WHOLE BLOOD TO CORRECT BLOO 99195 $322.00 THERAPEUTIC SERVICES FOR USE OF SPEECH-GENERATING 92609 $332.00 THERMOLABILE (HEAT SENSITIVE) HEMOGLOBIN LEVEL 83065 $57.00 THIAMINE 100 MG/ML SOLN 2 ML VIAL J3411 $2.18 THIAMINE MONONITRATE (VIT B1) 100 MG TAB 100 EACH $0.06 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge THIORIDAZINE 100 MG TAB 1 EACH BLIST PACK $3.80 THIORIDAZINE 25 MG TAB 1 EACH BLIST PACK $2.67 THIORIDAZINE 50 MG TAB 1 EACH BLIST PACK $1.67 THIORIDAZINE 50 MG TAB 100 EACH BOTTLE $1.83 THIOTHIXENE 10 MG CAP 100 EACH BOTTLE $11.75 THROMB,HM-FIBRIN-APROTIN,S-CA 10 ML SYRG 10 ML SYR $2,557.03 THROMBIN (BOVINE) 20,000 UNIT SOLR 1 EACH VIAL $1,188.78 THROMBIN (BOVINE) 20,000 UNIT SPRY 1 EACH KIT $1,248.24 THROMBIN (BOVINE) 20,000 UNIT SPSY 1 EACH KIT $1,248.24 THROMBIN (BOVINE) 5,000 UNIT SPSY 1 EACH KIT $307.48 THROMBIN (RECOMBINANT) 20,000 UNIT SOLR 1 EACH KIT $1,444.80 THROMBIN (RECOMBINANT) 5,000 UNIT SOLR 1 EACH KIT $361.20 THROMBIN TIME, FIBRINOGEN SCREENING TEST 85670 $107.00 THROMBIN TIME, FIBRINOGEN SCREENING TEST 85675 $52.00 THROMBOENDARTERECTMY W/PATCH GRAFT CAROTID VERTEB 35301 $19,866.00 THROMBOMODULIN (COAGULATION PROTEIN) MEASUREMENT 85337 $79.00 THROMBOPLASTIN INHIBITION (CIRCULATING ANTICOAGULA 85705 $52.00 THYROGLOBULIN 84432 $101.00 THYROID 30 MG TAB 100 EACH BOTTLE $2.12 THYROID 60 MG TAB 100 EACH BOTTLE $2.36 THYROID HORMONE EVALUATION 84479 $117.00 THYROID HORMONE, T3 MEASUREMENT 84480 $256.00 THYROID HORMONE, T3 MEASUREMENT 84481 $335.00 THYROID HORMONE, T3 MEASUREMENT 84482 $344.00 THYROID PEROXIDASE AB 86376 $182.00 THYROID STIMULATING IMMUNE GLOBULINS (THYROID RELA 84445 $546.00 THYROTROPIN ALFA 1.1 MG SOLR 1 EACH VIAL J3240 $6,758.33 THYROTROPIN RELEASING HORMONE STIMULATION PANEL 2 80439 $554.00 THYROXINE (THYROID CHEMICAL) LEVEL 84437 $53.00 THYROXINE (THYROID CHEMICAL) MEASUREMENT 84436 $146.00 THYROXINE (THYROID CHEMICAL) MEASUREMENT 84439 $176.00 THYROXINE BINDING GLOBULIN (THYROID RELATED PROTEI 84442 $165.00 TIAGABINE THERAPUTIC DRUG ANALYSIS 80199 $179.00 TICAGRELOR 60 MG TAB 60 EACH BOTTLE $24.71 TICAGRELOR 90 MG TAB 100 EACH BLIST PACK $26.19 TIMED ASSESSMENT OF BLADDER EMPTYING 51736 $271.00 TIMOLOL 0.25 % DROP 5 ML DROP BTL $11.48 TIMOLOL 0.5 % DROP 15 ML DROP BTL $39.22 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge TIMOLOL 0.5 % DROP 5 ML DROP BTL $21.11 TIOTROPIUM 18 MCG CPDV 5 EACH BLIST PACK $71.45 TIROFIBAN 12.5 MG/250 ML (50 MCG/ML) SOLN 250 ML B J3246 $2,174.38 TISSUE CULTURE FOR DISORDERS OF AMNIOTIC FLUID OR 88235 $1,224.00 TISSUE CULTURE FOR TUMOR DISORDERS OF BONE MARROW 88237 $952.00 TISSUE CULTURE FOR VIRUS ISOLATION 87253 $313.00 TISSUE CULTURE INOCULATION FOR VIRUS ISOLATION 87252 $313.00 TISSUE CULTURE TO IDENTIFY SKIN DISORDERS 88233 $1,047.00 TISSUE CULTURE TO IDENTIFY WHITE BLOOD CELL DISORD 88230 $661.00 TISSUE FUNGI OR PARASITES 87220 $74.00 TISSUE OR CELL ANALYSIS BY IMMUNOLOGIC TECHNIQUE 88342 $230.00 TISSUE PREPARATION FOR CULTURE 87176 $66.00 TISSUE TRANSFER REPAIR OF WOUND (10 SQ CENTIMETERS 14000 $3,104.00 TISSUE TRANSFER REPAIR OF WOUND (10 SQ CM OR LESS) 14020 $3,333.00 TISSUE TRANSFER REPAIR OF WOUND (10.1 TO 30.0 SQ C 14001 $8,481.00 TISSUE TRANSFER REPAIR OF WOUND (30.1 TO 60.0 SQ C 14301 $7,176.00 TISSUE TRANSFER REPAIR WND (10 SQ CM OR <) FACE UN 14040 $2,700.00 TISSUE TRANSFER REPAIR WND (10.1 TO 30.0CM) FACE U 14041 $4,453.00 TISSUE TRANSFER REPAIR WOUND (10 SQ CM OR LESS) OF 14060 $4,531.00 TIZANIDINE 4 MG TAB 1 EACH BLIST PACK $2.65 TIZANIDINE 4 MG TAB 100 EACH BLIST PACK $2.58 TIZANIDINE 4 MG TAB 150 EACH BOTTLE $2.56 TOBRAMYCIN (ANTIBIOTIC) LEVEL 80200 $142.00 TOBRAMYCIN (PF) 300 MG/5 ML NEBU 5 ML AMPUL $450.70 TOBRAMYCIN 0.3 % DROP 5 ML DROP BTL $50.96 TOBRAMYCIN 0.3 % OINT 3.5 G TUBE $900.30 TOBRAMYCIN 1.2 GRAM SOLR 1 EACH VIAL J3260 $735.00 TOBRAMYCIN 40 MG/ML SOLN 2 ML VIAL $8.32 TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % DRPS 5 ML DROP $457.94 TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OINT 3.5 G TUBE $958.48 TOBRAMYCIN-PEAK 80200 $142.00 TOBRAMYCIN-RANDOM 80200 $142.00 TOBRAMYCIN-TROUGH 80200 $142.00 TOCILIZUMAB 400 MG/20 ML (20 MG/ML) SOLN 20 ML VIA J3262 $9,402.33 TOCILIZUMAB 80 MG/4 ML (20 MG/ML) SOLN 4 ML VIAL J3262 $1,880.48 TOLNAFTATE 1 % CREA 15 G TUBE $17.85 TOLTERODINE 2 MG CP24 30 EACH BOTTLE $33.41 TOLTERODINE 2 MG CP24 90 EACH BOTTLE $33.41 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge TOLTERODINE 2 MG TAB 60 EACH BOTTLE $5.94 TOLTERODINE 4 MG CP24 1 EACH BLIST PACK $21.97 TOLTERODINE 4 MG CP24 30 EACH BLIST PACK $21.97 TOLTERODINE 4 MG CP24 30 EACH BOTTLE $16.71 TOPIRAMATE 100 MG TAB 100 EACH BLIST PACK $21.70 TOPIRAMATE 25 MG TAB 100 EACH BLIST PACK $7.35 TOPIRAMATE LEVEL 80201 $221.00 TOPOTECAN 4 MG SOLR 1 EACH VIAL J9351 $588.00 TOPOTECAN 4 MG/4 ML (1 MG/ML) SOLN 4 ML VIAL J9351 $630.00 TORSEMIDE 100 MG TAB 1 EACH BLIST PACK $1.01 TORSEMIDE 20 MG TAB 100 EACH BLIST PACK $1.46 TORSEMIDE 5 MG TAB 100 EACH BOTTLE $4.44 TOTAL CELL COUNT FOR NATURAL KILLER CELLS (WHITE B 86357 $314.00 TOTAL PROTEIN LEVEL 84160 $59.00 TOTAL PROTEIN LEVEL, BODY FLUID 84157 $105.00 TOXOPLASMA ANTIBODY IGG 86777 $195.00 TRABECTEDIN 1 MG SOLR 1 EACH VIAL J9352 $11,798.15 TRACE ELEMENTS CR-CU-MN-ZN CONCENTRATE 10 MCG-1 MG $62.00 TRACING OF ELECTRICAL ACTIVITY OF THE HEART USING 93041 $359.00 TRAINING IN USE OF ORTHOTICS FOR ARMS LEGS AND/OR 97760 $136.00 TRAINING IN USE OF PROSTHESIS FOR ARMS AND/OR LEGS 97761 $145.00 TRAMADOL 50 MG TAB 100 EACH BLIST PACK $2.79 TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) SOLN 10 $87.43 TRANEXAMIC ACID 650 MG TAB 30 EACH BOTTLE $18.25 TRANSCORTIN (CORTISOL BINDING PROTEIN) LEVEL 84449 $162.00 TRANSFER OF SKIN FLAP TO EYELIDS, NOSE, EARS, OR L 15630 $3,268.00 TRANSFERRIN (IRON BINDING PROTEIN) LEVEL 84466 $102.00 TRANSFUSION OF BLOOD OR BLOOD PRODUCTS 36430 $1,235.00 TRANSLOCATION ANALYSIS (BCR/ABL1) MAJOR BREAKPOINT 81207 $634.00 TRANSLOCATION ANALYSIS (BCR/ABL1) MINOR BREAKPOINT 81206 $808.00 TRANSPLANT ANTIBODY MEASUREMENT 86808 $245.00 TRANSPLANT OF TENDON TO PALM 26490 $9,754.00 TRANSPLANTATION OF FETAL SAC TISSUE TO CORNEA 65780 $13,965.00 TRASTUZUMAB 150 MG SOLR 1 EACH VIAL J9355 $6,354.74 TRASTUZUMAB-ANNS 420 MG SOLR 1 EACH VIAL Q5117 $15,528.49 TRAUMA RESPONSE TEAM G0390 $1,158.00 TRAVASOL 10 % SOLP 2,000 ML BAG $210.00 TRAVEL FEE PER TRIP P9604 $28.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge TRAVOPROST 0.004 % DROP 2.5 ML DROP BTL $772.24 TRAZODONE 100 MG TAB 1 EACH BLIST PACK $0.23 TRAZODONE 100 MG TAB 100 EACH BLIST PACK $1.37 TRAZODONE 50 MG TAB 1 EACH BLIST PACK $0.55 TRAZODONE 50 MG TAB 100 EACH BLIST PACK $1.52 TRAZODONE 50 MG TAB 100 EACH BOTTLE $3.76 TREAT CLAVICLE FRACTURE 23500 $1,168.00 TREAT DISLOCATED ELBOW 24640 $480.00 TREAT FINGER FRACTURE 26720 $682.00 TREAT FINGER FRACTURE 26750 $1,023.00 TREATMENT OF BROKEN FOOT BONE 28450 $535.00 TREATMENT OF DISLOCATED ELBOW UNDER ANESTHESIA 24605 $3,159.00 TREATMENT OF ELBOW DISLOCATION 24600 $704.00 TREATMENT OF HIP DISLOCATION 27250 $807.00 TREATMENT OF INCOMPLETE ABORTION 59812 $2,616.00 TREATMENT OF SWALLOWING AND/OR ORAL FEEDING FUNCTI 92526 $306.00 TREATMENT SPEECH LANGUAGE VOICE COMM/HEARING PROCE 92507 $292.00 TRIAMCINOLONE 0.025 % CREA 15 G TUBE $15.59 TRIAMCINOLONE 0.1 % CREA 15 G TUBE $20.42 TRIAMCINOLONE 0.1 % CREA 454 G JAR $81.04 TRIAMCINOLONE 0.1 % LOTN 60 ML BOTTLE $315.00 TRIAMCINOLONE 0.1 % OINT 15 G TUBE $19.53 TRIAMCINOLONE 0.1 % OINT 454 G JAR $144.60 TRIAMCINOLONE 0.1 % PSTE 5 G TUBE $282.07 TRIAMCINOLONE 0.5 % CREA 15 G TUBE $35.39 TRIAMCINOLONE 0.5 % OINT 15 G TUBE $35.33 TRIAMCINOLONE ACETONIDE 40 MG/ML SUSP 1 ML VIAL J3301 $2.46 TRIAMCINOLONE ACETONIDE 40 MG/ML SUSP 10 ML VIAL J3301 $1.70 TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MG CAP 1,0 $1.26 TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MG CAP 100 $1.31 TRIAMTERENE-HYDROCHLOROTHIAZIDE 75-50 MG TAB 1 EAC $3.20 TRIAMTERENE-HYDROCHLOROTHIAZIDE 75-50 MG TAB 100 E $3.20 TRIAZOLAM 0.25 MG TAB 10 EACH BOTTLE $6.42 TRICHOMONAS VAGINALIS DIRECT 87660 $130.00 TRICYCLICS, DRUG SCREEN 80307 $180.00 TRIFLUOPERAZINE 2 MG TAB 1 EACH BLIST PACK $7.00 TRIFLUOPERAZINE 2 MG TAB 100 EACH BLIST PACK $7.00 TRIFLUOPERAZINE 2 MG TAB 100 EACH BOTTLE $4.51 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge TRIFLUOPERAZINE 5 MG TAB 100 EACH BOTTLE $5.68 TRIFLURIDINE 1 % DROP 7.5 ML DROP BTL $780.28 TRIGLYCERIDES LEVEL 84478 $124.00 TRIGLYCERIDES, FLUID 84478 $124.00 TRIHEXYPHENIDYL 2 MG TAB 100 EACH BOTTLE $0.64 TRIIODOTHYRONINE, TOTAL 84480 $256.00 TRIMETHOBENZAMIDE 100 MG/ML SOLN 2 ML VIAL J3250 $147.31 TRIMETHOPRIM 100 MG TAB 50 EACH BLIST PACK $1.18 TRIMMING NAILS G0127 $163.00 TRIMMING OF FINGERNAILS OR TOENAILS 11719 $143.00 TRIPTORELIN PAMOATE 11.25 MG SUSR 1 EACH BOX J3315 $10,246.82 TRIPTORELIN PAMOATE 22.5 MG SUSR 1 EACH BOX J3315 $20,493.65 TROPHAMINE INFUSION 10 % SOLP 500 ML BAG $106.75 TROPHAMINE INFUSION 6 % SOLP 500 ML BAG $94.50 TROPICAMIDE 0.5 % DROP 15 ML DROP BTL $35.02 TROPICAMIDE 1 % DROP 15 ML DROP BTL $128.52 TROPICAMIDE 1 % DROP 3 ML DROP BTL $42.84 TROPONIN (PROTEIN) ANALYSIS 84484 $228.00 TRYPAN BLUE 0.06 % SYRG 0.5 ML SYRINGE $208.95 TRYPSIN (PANCREATIC ENZYME) MEASUREMENT, INTESTINA 84485 $62.00 TUBERCULIN 5 TUB. UNIT /0.1 ML SOLN 0.1 ML SYRINGE 86580 $37.45 TUBERCULIN 5 TUB. UNIT /0.1 ML SOLN 1 ML VIAL 86580 $37.31 TUBERCULOSIS TEST 86480 $416.00 TUBERCULOSIS TEST 86481 $554.00 TURNING OF FETUS FROM BREECH TO PRESENTING POSITIO 59412 $2,590.00 TYING OF DILATED VEINS OF STOMACH AND/OR ESOPHAGUS 43244 $3,057.00 TYING OR BANDING OF A PASSAGE BETWEEN AN ARTERY AN 37607 $7,895.00 TYING OR BIOPSY OF TEMPORAL ARTERY (SIDE OF SKULL) 37609 $4,726.00 TYING OR INCISION FALLOPIAN TUBES 58600 $9,504.00 ULTRASONIC GUIDANCE DURING SURGERY 76998 $1,011.00 ULTRASONIC GUIDANCE FOR ADMINISTRATION OF RADIATIO 76965 $852.00 ULTRASONIC GUIDANCE FOR DRAINAGE OF SAC THAT COVER 76930 $242.00 ULTRASONIC GUIDANCE IMAGE SUPERVISION & INTERP FOR 76945 $744.00 ULTRASONIC GUIDANCE IMAGING SUPERVISION & INTERP F 76942 $1,178.00 ULTRASONIC GUIDANCE IMAGING SUPERVISION & INTERP T 76941 $585.00 ULTRASONIC GUIDANCE IMAGING SUPERVISION & INTERPRE 76946 $580.00 ULTRASONIC GUIDANCE IMAGING SUPERVISION & INTERPRE 76948 $740.00 ULTRASOUND ? REVENUE CODE 402 G0378 $90.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ULTRASOUND AND MONITORING OF HEART OF FETUS 76818 $707.00 ULTRASOUND BEHIND ABDOMINAL CAVITY 76770 $758.00 ULTRASOUND BEHIND ABDOMINAL CAVITY, LIMITED 76775 $996.00 ULTRASOUND EVALUATION OF BLOOD VESSEL DURING DIAGN 37252 $2,754.00 ULTRASOUND EVALUATION OF BLOOD VESSEL DURING DIAGN 37253 $2,997.00 ULTRASOUND EVALUATION OF HEART BLOOD VESSEL 93662 $6,141.00 ULTRASOUND EVALUATION OF HEART BLOOD VESSEL DURING 93571 $4,544.00 ULTRASOUND EVALUATION OF HEART BLOOD VESSEL DURING 93572 $2,701.00 ULTRASOUND EVALUATION OF HEART BLOOD VESSEL OR GRA 92978 $3,371.00 ULTRASOUND EVALUATION OF HEART BLOOD VESSEL OR GRA 92979 $1,283.00 ULTRASOUND EXAM HEART INCLUDING COLOR BLOOD FLOW R 93306 $2,879.00 ULTRASOUND EXAM HEART PERFORMED DURING REST EXERCI 93350 $2,808.00 ULTRASOUND EXAM OF ESOPHAGUS STOMACH/UPPER SMALL B 43237 $4,412.00 ULTRASOUND EXAM OF ESOPHAGUS STOMACH/UPPER SMALL B 43259 $2,860.00 ULTRASOUND EXAMINATION OF CONGENITAL HEART DEFECT 93303 $962.00 ULTRASOUND EXAMINATION OF ESOPHAGUS USING AN ENDOS 43231 $3,145.00 ULTRASOUND EXAMINATION OF LARGE BOWEL USING AN END 45341 $1,672.00 ULTRASOUND EXAMINATION OF LOWER LARGE BOWEL USING 45391 $3,639.00 ULTRASOUND FOLLOW-UP STUDY 76970 $398.00 ULTRASOUND GUIDANCE FOR ACCESSING INTO BLOOD VESSE 76937 $580.00 ULTRASOUND GUIDANCE FOR REPAIR OF BLOOD VESSEL 76936 $1,543.00 ULTRASOUND GUIDANCE FOR TISSUE DESTRUCTION 76940 $1,217.00 ULTRASOUND GUIDED FINE NEEDLE ASPIRATION/BIOPSIES 44407 $2,985.00 ULTRASOUND GUIDED FINE NEEDLE ASPIRATION/BIOPSY ES 43232 $3,509.00 ULTRASOUND GUIDED NEEDLE ASPIRATION OR BIOPSY LARG 45342 $2,524.00 ULTRASOUND GUIDED NEEDLE ASPIRATION OR BIOPSY OF E 43238 $3,868.00 ULTRASOUND GUIDED NEEDLE ASPIRATION/BIOPSY ESOPHAG 43242 $3,160.00 ULTRASOUND GUIDED NEEDLE ASPIRATION/BIOPSY OF LOWE 45392 $2,745.00 ULTRASOUND LIMITED SCAN ABDOMINAL PELVIC/SCROTAL A 93976 $1,069.00 ULTRASOUND LIMITED SCAN OF PENILE ARTERIAL INFLOW 93981 $764.00 ULTRASOUND MEASUREMENT OF BLADDER CAPACITY AFTER V 51798 $184.00 ULTRASOUND OF ABDOMEN 76700 $1,313.00 ULTRASOUND OF ABDOMEN 76705 $828.00 ULTRASOUND OF ARM OR LEG 76882 $1,068.00 ULTRASOUND OF BONE DENSITY MEASUREMENT 76977 $620.00 ULTRASOUND OF BRAIN 76506 $679.00 ULTRASOUND OF CHEST 76604 $547.00 ULTRASOUND OF CORNEAL STRUCTURE AND MEASUREMENT 76514 $145.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ULTRASOUND OF DIALYSIS ACCESS 93990 $568.00 ULTRASOUND OF FETAL BRAIN ARTERY 76821 $789.00 ULTRASOUND OF FETAL HEART 76827 $969.00 ULTRASOUND OF FETAL HEART BLOOD FLOW 76825 $1,394.00 ULTRASOUND OF FETAL UMBILICAL ARTERY FLOW RATE 76820 $702.00 ULTRASOUND OF FETUS 76819 $836.00 ULTRASOUND OF HEAD AND NECK 76536 $874.00 ULTRASOUND OF HIPS WITH MANIPULATION, INFANT 76885 $339.00 ULTRASOUND OF HIPS, INFANT 76886 $339.00 ULTRASOUND OF LEG OR ARM 76881 $835.00 ULTRASOUND OF ONE BREAST 76641 $691.00 ULTRASOUND OF ONE BREAST 76642 $680.00 ULTRASOUND OF PELVIS 76856 $999.00 ULTRASOUND OF PELVIS 76857 $904.00 ULTRASOUND OF PREGNANT UTERUS (FIRST TRIMESTER) SI 76813 $835.00 ULTRASOUND OF PREGNANT UTERUS, 1 OR MORE FETUS(ES) 76815 $462.00 ULTRASOUND OF PROSTATE 76873 $612.00 ULTRASOUND OF RECTUM 76872 $1,031.00 ULTRASOUND OF SCROTUM 76870 $878.00 ULTRASOUND OF UTERUS 76831 $1,192.00 ULTRASOUND PELVIS THROUGH VAGINA 76830 $767.00 ULTRASOUND RE-EVALUATION OF PREGNANT UTERUS, PER F 76816 $786.00 ULTRASOUND SCAN ABDOMINAL PELVIC/SCROTAL ARTERIAL 93975 $1,128.00 ULTRASOUND SCAN OF PENILE ARTERIAL INFLOW AND VENO 93980 $777.00 ULTRASOUND SCAN OF VENA CAVA OR GROIN GRAFT OR VES 93978 $1,063.00 ULTRASOUND SCAN VEINS 1 ARM/LEG/LTD W/ASSESS COMPR 93971 $1,168.00 ULTRASOUND SCAN VEINS BOTH ARMS/LEGS W/ASSESS COMP 93970 $1,208.00 ULTRASOUND SCANNING OF BLOOD FLOW ON BOTH SIDES OF 93880 $1,711.00 ULTRASOUND SCANNING OF HEAD AND NECK VESSEL BLOOD 93886 $1,491.00 ULTRASOUND STUDY OF ARTERIES AND ARTERIAL GRAFTS O 93925 $1,315.00 ULTRASOUND STUDY OF ARTERIES AND ARTERIAL GRAFTS O 93926 $682.00 ULTRASOUND STUDY OF ARTERIES AND ARTERIAL GRAFTS O 93930 $1,249.00 ULTRASOUND STUDY OF ARTERIES AND ARTERIAL GRAFTS O 93931 $646.00 ULTRASOUND STUDY OF ARTERIES OF BOTH ARMS AND LEGS 93922 $827.00 ULTRASOUND STUDY OF ARTERIES OF BOTH ARMS AND LEGS 93923 $981.00 UNATTENDED SLEEP STUDY W/RECORDING HEART RATE OXYG 95806 $820.00 UNLISTED MOLECULAR PATH PROC 81479 $425.00 UREA 20 % CREA 85 G TUBE $41.95 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge UREA NITROGEN LEVEL TO ASSESS KIDNEY FUNCTION 84520 $100.00 UREA NITROGEN LEVEL TO ASSESS KIDNEY FUNCTION 84540 $77.00 UREA NITROGEN LEVEL TO ASSESS KIDNEY FUNCTION 84525 $31.00 URIC ACID LEVEL, BLOOD 84550 $86.00 URINALYSIS, 2 OR 3 GLASS TEST 81020 $31.00 URINALYSIS, AUTO 81003 $76.00 URINALYSIS, AUTO POCT 81003 $76.00 URINALYSIS, MANUAL TEST 81002 $80.00 URINE ALBUMIN (PROTEIN) LEVEL 82042 $95.00 URINE CALCIUM LEVEL 82340 $150.00 URINE CULTURE QT 87088 $119.00 URINE LACTOSE (CARBOHYDRATE) ANALYSIS 83633 $45.00 URINE MICROALBUMIN (PROTEIN) ANALYSIS 82044 $25.00 URINE OSMOLALITY (CONCENTRATION) MEASUREMENT 83935 $101.00 URINE POTASSIUM LEVEL 84133 $84.00 URINE PREGNANCY TEST 81025 $164.00 URINE SULFATE (ACID) LEVEL 84392 $84.00 URINE VOLUME MEASUREMENT 81050 $24.00 UROBILINOGEN (METABOLISM SUBSTANCE) ANALYSIS, URIN 84578 $27.00 UROBILINOGEN (METABOLISM SUBSTANCE) LEVEL, STOOL 84577 $103.00 UROBILINOGEN (METABOLISM SUBSTANCE) MEASUREMENT, U 84583 $42.00 URSODIOL 20 MG/ML SUSP 1 EACH BLIST PACK $26.75 URSODIOL 300 MG CAP 100 EACH BLIST PACK $26.75 URSODIOL 300 MG CAP 100 EACH BOTTLE $26.74 USTEKINUMAB 130 MG/26 ML SOLN 26 ML VIAL Q9989 $6,719.99 VACCINE FOR HEPATITIS A INJECTION INTO MUSCLE ADUL 90632 $201.00 VACCINE FOR HEPATITIS B (3 DOSE) FOR INJECTION INT 90744 $154.00 VACCINE FOR INFLUENZA ADMINISTERED INTO MUSCLE PRE 90673 $90.00 VACCINE FOR INFLUENZA FOR ADMINISTRATION INTO MUSC 90658 $54.00 VACCINE FOR INFLUENZA FOR INJECTION INTO MUSCLE 90662 $110.00 VACCINE FOR INFLUENZA FOR INJECTION INTO MUSCLE 90682 $148.00 VACCINE FOR PNEUMOCOCCAL POLYSACCHARIDE? >2YRS 90732 $284.00 VACCINE FOR TETANUS AND DIPHTHERIA TOXOIDS INJECTI 90714 $104.00 VAGINAL DELIVERY 59409 $5,421.00 VAGINAL DRAINAGE OF OVARIAN CYSTS 58800 $3,012.00 VAGINAL FLUID CHEMICAL ANALYSIS FOR BACTERIA 82120 $31.00 VAGINAL REMOVAL OF UTERUS TUBES AND/OR OVARIES USI 58552 $20,168.00 VAGINAL SUTURE OF CERVIX DURING PREGNANCY 59320 $3,048.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge VAGINAL ULTRASOUND OF PREGNANT UTERUS 76817 $970.00 VALACYCLOVIR 500 MG TAB 100 EACH BLIST PACK $13.91 VALGANCICLOVIR 450 MG TAB 1 EACH BLIST PACK $288.24 VALGANCICLOVIR 450 MG TAB 30 EACH BLIST PACK $288.24 VALIUM LEVEL 80346 $202.00 VALPROATE 250 MG/5 ML SOLN 473 ML BOTTLE $253.29 VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL $72.61 VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) $1.94 VALPROIC ACID 250 MG CAP 100 EACH BLIST PACK $3.52 VALPROIC ACID LEVEL 80164 $220.00 VALPROIC ACID LEVEL 80165 $109.00 VALSARTAN 40 MG TAB 1 EACH BLIST PACK $13.60 VALSARTAN 80 MG TAB 1 EACH BLIST PACK $8.11 VALSARTAN 80 MG TAB 100 EACH BLIST PACK $8.13 VALSARTAN 80 MG TAB 90 EACH BOTTLE $8.48 VALSARTAN-HYDROCHLOROTHIAZIDE 160-12.5 MG TAB 1 EA $4.84 VALSARTAN-HYDROCHLOROTHIAZIDE 160-12.5 MG TAB 50 E $4.84 VALSARTAN-HYDROCHLOROTHIAZIDE 160-12.5 MG TAB 90 E $14.96 VALSARTAN-HYDROCHLOROTHIAZIDE 80-12.5 MG TAB 1 EAC $4.24 VALSARTAN-HYDROCHLOROTHIAZIDE 80-12.5 MG TAB 50 EA $4.24 VALSARTAN-HYDROCHLOROTHIAZIDE 80-12.5 MG TAB 90 EA $13.75 VANCOMYCIN (ANTIBIOTIC) LEVEL 80202 $163.00 VANCOMYCIN 1,000 MG SOLR 1 EACH VIAL J3370 $12.58 VANCOMYCIN 1.25 GRAM SOLR 1 EACH VIAL J3370 $84.42 VANCOMYCIN 1.5 GRAM SOLR 1 EACH VIAL J3370 $101.30 VANCOMYCIN 10 GRAM SOLR 1 EACH BOTTLE J3370 $892.50 VANCOMYCIN 10 GRAM SOLR 1 EACH VIAL J3370 $898.84 VANCOMYCIN 125 MG CAP 20 EACH BLIST PACK $156.53 VANCOMYCIN 5 GRAM SOLR 1 EACH VIAL J3370 $373.52 VANCOMYCIN 50 MG/ML SOLR 150 ML BOTTLE $19.08 VANCOMYCIN 50 MG/ML SOLR 5 ML CUP $19.08 VANCOMYCIN 500 MG SOLR 1 EACH VIAL J3370 $33.77 VANCOMYCIN 750 MG SOLR 1 EACH VIAL J3370 $40.70 VANCOMYCIN-PEAK 80202 $163.00 VANCOMYCIN-RANDOM 80202 $167.00 VANCOMYCIN-TROUGH 80202 $161.00 VARICELLA VIRUS VACCINE (LIVE) 1,350 UNIT/0.5 ML S 90716 $543.05 VARICELLA ZOSTER ANTIBODY IGM 86787 $133.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge VASOPRESSIN 20 UNIT/ML SOLN 1 ML VIAL $755.12 VASOPRESSIN 20 UNIT/ML SOLN 10 ML VIAL $6,391.56 VDRL CSF 86592 $101.00 VECURONIUM 10 MG SOLR 1 EACH VIAL $26.46 VEDOLIZUMAB 300 MG SOLR 1 EACH VIAL J3380 $25,609.79 VENLAFAXINE 25 MG TAB 1 EACH BLIST PACK $7.22 VENLAFAXINE 25 MG TAB 30 EACH BLIST PACK $7.23 VENLAFAXINE 25 MG TAB 50 EACH BLIST PACK $7.22 VENLAFAXINE 37.5 MG CP24 100 EACH BLIST PACK $13.10 VENLAFAXINE 37.5 MG TAB 1 EACH BLIST PACK $7.00 VENLAFAXINE 37.5 MG TAB 100 EACH BLIST PACK $7.00 VENLAFAXINE 37.5 MG TAB 100 EACH BOTTLE $7.00 VENLAFAXINE 75 MG CP24 100 EACH BLIST PACK $1.10 VENOGRAPHY FOR BLOOD CLOT IN VEINS, BOTH LEGS OR A 78458 $1,068.00 VENTILATION ASSISTANCE AND MANAGEMENT, HOSPITAL IN 94002 $808.00 VENTILATION ASSISTANCE AND MANAGEMENT, HOSPITAL IN 94003 $795.00 VERAPAMIL 120 MG C24P 1 EACH BLIST PACK $18.78 VERAPAMIL 120 MG C24P 100 EACH BOTTLE $6.11 VERAPAMIL 120 MG TAB 100 EACH BLIST PACK $2.63 VERAPAMIL 120 MG TBSR 1 EACH BLIST PACK $8.11 VERAPAMIL 120 MG TBSR 100 EACH BLIST PACK $8.11 VERAPAMIL 120 MG TBSR 100 EACH BOTTLE $3.76 VERAPAMIL 180 MG TBSR 1 EACH BLIST PACK $5.81 VERAPAMIL 180 MG TBSR 100 EACH BLIST PACK $5.81 VERAPAMIL 180 MG TBSR 100 EACH BOTTLE $3.36 VERAPAMIL 2.5 MG/ML SOLN 2 ML AMPUL $34.61 VERAPAMIL 2.5 MG/ML SOLN 2 ML VIAL $60.77 VERAPAMIL 2.5 MG/ML SOLN 4 ML VIAL $30.57 VERAPAMIL 240 MG TBSR 100 EACH BLIST PACK $4.44 VERAPAMIL 80 MG TAB 100 EACH BLIST PACK $2.00 VILAZODONE 20 MG TAB 30 EACH BOTTLE $17.40 VINBLASTINE 1 MG/ML SOLN 10 ML VIAL J9360 $180.88 VINCRISTINE 2 MG/2 ML SOLN 2 ML VIAL J9370 $44.87 VINORELBINE 10 MG/ML SOLN 1 ML VIAL J9390 $126.00 VIRACOR ADENOVIRUS 87799 $568.00 VIRACOR ASPERGILLUS PCR 87798 $315.00 VIRACOR BK VIRUS QUANT 87799 $568.00 VIRACOR CMV QUANT PCR 87799 $568.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge VIRACOR EBV QUANT 87799 $568.00 VIRAL CULTURE RESPIRATORY 87252 $324.00 VIRUS ISOLATE SHELL ID 87254 $239.00 VISCER/INFRARENAL ABDOM AORTA 4+ PROSTHESIS 34848 $3,673.00 VIT E-GLYCERIN-DIMETHICONE LOTN 473 ML BOTTLE $41.39 VITAMIN A 10000 UNIT CAP 100 EACH BOTTLE $0.09 VITAMIN A AND D OINT 113 G JAR $13.84 VITAMIN A AND D OINT 56.7 G TUBE $11.31 VITAMIN A LEVEL 84590 $165.00 VITAMIN B-1 (THIAMINE) LEVEL 84425 $254.00 VITAMIN B-2 (RIBOFLAVIN) LEVEL 84252 $265.00 VITAMIN B-6 LEVEL 84207 $418.00 VITAMIN D (1 25 DIHYDROXY) 82652 $348.00 VITAMIN D,25-HYDROXY (CALCIFEDIOL 82306 $395.00 VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML DROP $141.75 VITAMIN E (DL, ACETATE) 400 UNIT CAP 100 EACH BOTT $0.22 VITAMIN E 100 UNIT CAP 100 EACH BOTTLE $0.38 VITAMIN K 100 MCG TAB 100 EACH BOTTLE $0.15 VITAMIN K LEVEL 84597 $330.00 VITAMIN MEASUREMENT 84591 $321.00 VOICE FUNCTIONAL LIMIT CURRENT STATUS G9171 $0.01 VOICE FUNCTIONAL LIMIT DISCHARGE STATUS G9173 $0.01 VOICE FUNCTIONAL LIMIT GOAL STATUS G9172 $0.01 VOLATILE CHEMICAL MEASUREMENT 80320 $232.00 VOLUME REDUCTION OF BLOOD UNIT OR BLOOD PRODUCT 86960 $261.00 VORICONAZOLE 200 MG SOLR 1 EACH VIAL J3465 $626.60 VORICONAZOLE 200 MG TAB 1 EACH BLIST PACK $82.08 VORICONAZOLE 200 MG TAB 30 EACH BLIST PACK $82.08 VORICONAZOLE 200 MG TAB 30 EACH BOTTLE $35.12 VORTIOXETINE 5 MG TAB 30 EACH BOTTLE $52.92 WALKING TRAINING TO 1 OR MORE AREAS, EACH 15 MINUT 97116 $155.00 WARFARIN 1 MG TAB 100 EACH BLIST PACK $25.98 WARFARIN 10 MG TAB 100 EACH BLIST PACK $3.36 WARFARIN 2 MG TAB 100 EACH BLIST PACK $18.07 WARFARIN 2.5 MG TAB 100 EACH BLIST PACK $9.32 WARFARIN 5 MG TAB 100 EACH BLIST PACK $9.72 WARFARIN 7.5 MG TAB 100 EACH BLIST PACK $12.95 WARFARIN 7.5 MG TAB 100 EACH BOTTLE $3.43 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge WATER FOR INJECTION, STERILE SOLN 10 ML VIAL A4217 $3.64 WATER FOR INJECTION, STERILE SOLN 100 ML VIAL A4217 $17.15 WATER FOR INJECTION, STERILE SOLN 20 ML VIAL A4217 $5.18 WATER POOL THERAPY TO 1 OR MORE AREAS EACH 15 MINU 97113 $146.00 WBC AUTOMATED 85048 $118.00 WEDGING OF CAST 29740 $613.00 WESTERN BLOT 84182 $441.00 WESTERN BLOT HIV CONFIRM 86689 $355.00 WHEELCHAIR MANAGEMENT, EACH 15 MINUTES 97542 $103.00 WHITE BLOOD CELL ANTIGEN MEASUREMENT 86356 $286.00 WHITE BLOOD CELL ENZYME ACTIVITY MEASUREMENT 85549 $181.00 WHITE BLOOD CELL FUNCTION MEASUREMENT 86344 $66.00 WHITE BLOOD CELL FUNCTION MEASUREMENT 86353 $589.00 WHITE BLOOD CELL TRANSFUSION 86950 $288.00 WHITE PETROLATUM GEL 30 G TUBE $2.94 WHITE PETROLATUM GEL 71 G TUBE $9.94 WHITE PETROLATUM OINT 28.35 G TUBE $9.03 WHITE PETROLATUM-MINERAL OIL 57.7-31.9 % OINT 3.5 $22.90 WHITE PETROLATUM-MINERAL OIL 83-15 % OINT 3.5 G TU $22.71 WITCH HAZEL 50 % PADM 100 EACH BOX $0.12 WORK HARDENING OR CONDITIONING 97546 $216.00 WORK HARDENING OR CONDITIONING, FIRST 2 HOURS 97545 $527.00 XR CHEST 3 VIEWS 71047 $440.00 XR MASTOIDS MINIMUM 3 VIEWS UNILATERAL 70130 $597.00 XR OPTIC FORAMINA UNILATERAL 70190 $304.00 XR RIBS W CHEST MINIMUM 4 VIEWS BILATERAL 71111 $1,080.00 XR RIBS W/O CHEST 3+ VIEWS BILATERAL 71110 $758.00 XR TMJ (TEMPOROMANDIBULAR JOINT) OPEN/CLOSED BILAT 70330 $408.00 X-RAY ANALYSIS OF STONE 82370 $103.00 X-RAY LOWER AND SACRAL SPINE INCLUDING BENDING VIE 72114 $627.00 X-RAY LOWER AND SACRAL SPINE INCLUDING BENDING VIE 72120 $360.00 X-RAY LOWER SPINAL CANAL WITH RADIOLOGICAL SUPERVI 62304 $1,647.00 X-RAY LOWER SPINAL CANAL WITH RADIOLOGICAL SUPERVI 62305 $1,874.00 X-RAY OF ABDOMEN 2 VIEWS 74019 $698.00 X-RAY OF ABDOMEN, SINGLE VIEW 74018 $349.00 X-RAY OF ANKLE, 2 VIEWS 73600 $455.00 X-RAY OF ANKLE, MINIMUM OF 3 VIEWS 73610 $317.00 X-RAY OF ARM IN INFANT MINIMUM OF 2 VIEWS 73092 $337.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge X-RAY OF BONE AT BASE OF SKULL 70240 $204.00 X-RAY OF BONES 77074 $872.00 X-RAY OF BONES OF FACE, LESS THAN 3 VIEWS 70140 $278.00 X-RAY OF BONES OF FACE, MINIMUM OF 3 VIEWS 70150 $485.00 X-RAY OF BONES OF NOSE, MINIMUM OF 3 VIEWS 70160 $341.00 X-RAY OF BOTH COLLAR BONES 73050 $245.00 X-RAY OF BOTH KNEES, STANDING, FRONT TO BACK VIEW 73565 $406.00 X-RAY OF BREAST BONE, MINIMUM OF 2 VIEWS 71120 $386.00 X-RAY OF CHEST, 1 VIEW, FRONT 71045 $378.00 X-RAY OF CHEST, 2 VIEWS, FRONT AND SIDE 71046 $424.00 X-RAY OF CHEST, MINIMUM OF 4 VIEWS 71048 $408.00 X-RAY OF COLLAR BONE 73000 $365.00 X-RAY OF ELBOW, 2 VIEWS 73070 $395.00 X-RAY OF ELBOW, MINIMUM OF 3 VIEWS 73080 $399.00 X-RAY OF ESOPHAGUS 74220 $733.00 X-RAY OF EYE BONES, MINIMUM OF 4 VIEWS 70200 $596.00 X-RAY OF FEMUR, MINIMUM 2 VIEWS 73552 $382.00 X-RAY OF FINGERS, MINIMUM OF 2 VIEWS 73140 $281.00 X-RAY OF FOOT, 2 VIEWS 73620 $436.00 X-RAY OF FOOT, MINIMUM OF 3 VIEWS 73630 $438.00 X-RAY OF FOREARM, 2 VIEWS 73090 $429.00 X-RAY OF HAND, 2 VIEWS 73120 $321.00 X-RAY OF HAND, MINIMUM OF 3 VIEWS 73130 $341.00 X-RAY OF HEEL, MINIMUM OF 2 VIEWS 73650 $314.00 X-RAY OF HIP WITH PELVIS, 1 VIEW 73501 $567.00 X-RAY OF HIP WITH PELVIS, 2-3 VIEWS 73502 $429.00 X-RAY OF JUNCTION OF BREAST AND COLLAR BONES, MINI 71130 $225.00 X-RAY OF KNEE, 1 OR 2 VIEWS 73560 $334.00 X-RAY OF KNEE, 3 VIEWS 73562 $386.00 X-RAY OF KNEE, 4 OR MORE VIEWS 73564 $443.00 X-RAY OF LARGE BOWEL WITH CONTRAST 74270 $730.00 X-RAY OF LARGE BOWEL WITH CONTRAST 74280 $936.00 X-RAY OF LEG IN INFANT MINIMUM OF 2 VIEWS 73592 $258.00 X-RAY OF LOWER AND SACRAL SPINE, 2 OR 3 VIEWS 72100 $426.00 X-RAY OF LOWER AND SACRAL SPINE, MINIMUM OF 4 VIEW 72110 $683.00 X-RAY OF LOWER LEG, 2 VIEWS 73590 $383.00 X-RAY OF MANDIBLE, MINIMUM OF 4 VIEWS 70110 $522.00 X-RAY OF MIDDLE AND LOWER SPINE, 2 VIEWS 72080 $471.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge X-RAY OF MIDDLE SPINE, 3 VIEWS 72070 $471.00 X-RAY OF MIDDLE SPINE, MINIMUM OF 4 VIEWS 72074 $717.00 X-RAY OF PARANASAL SINUS, COMPLETE, MINIMUM OF 3 V 70220 $656.00 X-RAY OF PELVIS, 1 OR 2 VIEWS 72170 $437.00 X-RAY OF PELVIS, MINIMUM OF 2 VIEWS 72220 $370.00 X-RAY OF RIBS OF ONE SIDE OF BODY, 2 VIEWS 71100 $546.00 X-RAY OF RIBS ON ONE SIDE OF BODY INCLUDING THE CH 71101 $719.00 X-RAY OF SACROILIAC JOINTS, 3 OR MORE VIEWS 72202 $522.00 X-RAY OF SALIVARY GLAND 70380 $279.00 X-RAY OF SHOULDER BLADE 73010 $299.00 X-RAY OF SHOULDER, 1 VIEW 73020 $495.00 X-RAY OF SHOULDER, MINIMUM OF 2 VIEWS 73030 $497.00 X-RAY OF SKULL, COMPLETE, MINIMUM OF 4 VIEWS 70260 $554.00 X-RAY OF SKULL, LESS THAN 4 VIEWS 70250 $451.00 X-RAY OF SMALL INTESTINE 74250 $1,017.00 X-RAY OF SMALL INTESTINE BY SMALL BOWEL TUBE 74251 $1,839.00 X-RAY OF SOFT TISSUE OF NECK 70360 $269.00 X-RAY OF SPINE OF NECK, 2 OR 3 VIEWS 72040 $415.00 X-RAY OF SPINE, 1 VIEW 72020 $295.00 X-RAY OF SPINE, 2 OR 3 VIEWS 72082 $434.00 X-RAY OF SPINE, MINIMUM OF 6 VIEWS 72084 $580.00 X-RAY OF TOES, MINIMUM OF 2 VIEWS 73660 $372.00 X-RAY OF UPPER ARM, MINIMUM OF 2 VIEWS 73060 $370.00 X-RAY OF UPPER DIGESTIVE TRACT WITH CONTRAST 74246 $976.00 X-RAY OF UPPER SPINE, 6 OR MORE VIEWS 72052 $815.00 X-RAY OF VOICE BOX OR THROAT 70370 $426.00 X-RAY OF WRIST, 2 VIEWS 73100 $324.00 X-RAY OF WRIST, MINIMUM OF 3 VIEWS 73110 $350.00 X-RAY SURVEY OF FOREARM OR WRIST BONE DENSITY 77075 $1,151.00 X-RAY UPPER DIGESTIVE TRACT W/CONTRAST FOLLOW X-RA 74249 $1,329.00 X-RAY UPPER DIGESTIVE TRACT, KIDNEYS, URINARY DUCT 74241 $811.00 X-RAY UPPER SPINAL CANAL WITH RADIOLOGICAL SUPERVI 62302 $1,767.00 YERSINIA CULTURE 87046 $60.00 ZAFIRLUKAST 20 MG TAB 1 EACH BLIST PACK $5.23 ZIDOVUDINE 10 MG/ML SOLN 20 ML VIAL J3485 $122.57 ZIDOVUDINE 10 MG/ML SYRP 240 ML BOTTLE $197.40 ZIDOVUDINE 100 MG CAP 100 EACH BOTTLE $7.07 ZINC LEVEL 84630 $182.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge ZINC OXIDE 10 % OINT 56.7 G JAR $13.69 ZINC OXIDE 20% 20 % OINT 28.35 G TUBE $10.82 ZINC OXIDE 20% 20 % OINT 453.6 G JAR $168.29 ZINC OXIDE 20% 20 % OINT 454 G JAR $23.84 ZINC OXIDE 25% 25 % PSTE 500 G JAR $150.50 ZINC OXIDE-COD LIVER OIL 40 % PSTE 113 G TUBE $565.57 ZINC OXIDE-COD LIVER OIL 40 % PSTE 57 G TUBE $388.03 ZINC SULFATE 220 (50) MG CAP 1 EACH BLIST PACK $0.83 ZINC SULFATE 220 (50) MG CAP 100 EACH BLIST PACK $0.83 ZINC SULFATE 220 (50) MG CAP 100 EACH BOTTLE $0.15 ZINC SULFATE 5 MG/ML SOLN 5 ML VIAL $205.10 ZIPRASIDONE 20 MG CAP 40 EACH BLIST PACK $11.68 ZIPRASIDONE 20 MG CAP 60 EACH BOTTLE $31.37 ZIPRASIDONE 20 MG CAP 80 EACH BLIST PACK $29.63 ZIPRASIDONE 20 MG/ML (FINAL CONC.) SOLR 1 EACH VIA J3486 $104.33 ZIPRASIDONE 40 MG CAP 40 EACH BLIST PACK $5.84 ZIPRASIDONE 80 MG CAP 1 EACH BLIST PACK $2.91 ZIPRASIDONE 80 MG CAP 80 EACH BLIST PACK $2.91 ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) SOLN 4 ML V J9400 $6,720.00 ZOLEDRONIC ACID 4 MG/5 ML SOLN 5 ML VIAL J3489 $756.00 ZOLEDRONIC ACID-MANNITOL-WATER 5 MG/100 ML PGBK 10 J3489 $3,515.40 ZOLPIDEM 5 MG TAB 1 EACH BLIST PACK $3.07 ZOLPIDEM 5 MG TAB 100 EACH BLIST PACK $16.19 ZONISAMIDE 100 MG CAP 1 EACH BLIST PACK $6.02 ZONISAMIDE 100 MG CAP 100 EACH BLIST PACK $6.91 ZONISAMIDE 100 MG CAP 100 EACH BOTTLE $7.67 ZONISAMIDE 100 MG CAP 50 EACH BLIST PACK $6.02 ZONISAMIDE LEVEL 80203 $159.00 ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUSR 90736 $937.09

DRG Description DRG Average Charges ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R. 3 $371,666.00 TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R. 4 $311,010.00 TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W MCC 11 $106,159.00 TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W CC 12 $179,681.00 TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W/O CC/MCC13 $31,956.00 INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC 20 $255,122.00 INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC 21 $283,882.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC 22 $178,593.00 CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY23 $212,763.00 IMPLANT OR EPILEPSY W NEUROSTIMULATOR CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC 24 $162,160.00 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC 25 $163,097.00 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC 26 $97,177.00 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC 27 $87,776.00 SPINAL PROCEDURES W MCC 28 $357,273.00 SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS 29 $119,765.00 SPINAL PROCEDURES W/O CC/MCC 30 $46,630.00 VENTRICULAR SHUNT PROCEDURES W MCC 31 $130,342.00 VENTRICULAR SHUNT PROCEDURES W CC 32 $71,265.00 VENTRICULAR SHUNT PROCEDURES W/O CC/MCC 33 $85,598.00 CAROTID ARTERY STENT PROCEDURE W CC 35 $52,874.00 CAROTID ARTERY STENT PROCEDURE W/O CC/MCC 36 $51,636.00 EXTRACRANIAL PROCEDURES W MCC 37 $85,677.00 EXTRACRANIAL PROCEDURES W CC 38 $74,850.00 EXTRACRANIAL PROCEDURES W/O CC/MCC 39 $48,704.00 PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC 40 $180,183.00 PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM 41 $113,648.00 PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC 42 $104,529.00 SPINAL DISORDERS & INJURIES W/O CC/MCC 53 $189.00 NERVOUS SYSTEM NEOPLASMS W MCC 54 $25,522.00 NERVOUS SYSTEM NEOPLASMS W/O MCC 55 $30,345.00 DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC 56 $74,542.00 DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC 57 $59,014.00 MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W MCC 58 $46,561.00 MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W CC 59 $52,205.00 MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W/O CC/MCC 60 $31,861.00 ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC61 AGENT$160,113.00 W MCC ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC62 AGENT$100,669.00 W CC ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC63 AGENT$76,383.00 W/O CC/MCC INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC 64 $48,384.00 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS 65 $41,514.00 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC 66 $30,233.00 NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC 68 $41,364.00 TRANSIENT ISCHEMIA W/O THROMBOLYTIC 69 $34,360.00 NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC 70 $40,315.00 NONSPECIFIC CEREBROVASCULAR DISORDERS W CC 71 $31,143.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC 72 $50,873.00 CRANIAL & PERIPHERAL NERVE DISORDERS W MCC 73 $33,317.00 CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC 74 $27,761.00 VIRAL MENINGITIS W CC/MCC 75 $41,026.00 HYPERTENSIVE ENCEPHALOPATHY W MCC 77 $61,382.00 HYPERTENSIVE ENCEPHALOPATHY W CC 78 $38,610.00 HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC 79 $33,488.00 TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC 82 $3,565.00 TRAUMATIC STUPOR & COMA, COMA >1 HR W CC 83 $35,559.00 TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC 84 $17,365.00 TRAUMATIC STUPOR & COMA, COMA <1 HR W CC 86 $51,108.00 TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC 87 $21,774.00 CONCUSSION W CC 89 $53,746.00 OTHER DISORDERS OF NERVOUS SYSTEM W MCC 91 $51,362.00 OTHER DISORDERS OF NERVOUS SYSTEM W CC 92 $36,182.00 OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC 93 $20,928.00 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W MCC 94 $342,137.00 BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC 95 $62,920.00 NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC 97 $55,127.00 NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W CC 98 $67,480.00 SEIZURES W MCC 100 $45,899.00 SEIZURES W/O MCC 101 $29,132.00 HEADACHES W/O MCC 103 $16,577.00 NEUROLOGICAL EYE DISORDERS 123 $49,777.00 OTHER DISORDERS OF THE EYE W/O MCC 125 $37,519.00 MAJOR HEAD & NECK PROCEDURES W/O CC/MCC 130 $24,588.00 CRANIAL/FACIAL PROCEDURES W CC/MCC 131 $58,211.00 OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC 133 $114,475.00 OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC 134 $67,089.00 SINUS & MASTOID PROCEDURES W CC/MCC 135 $138,150.00 EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC 147 $99,784.00 DYSEQUILIBRIUM 149 $22,690.00 OTITIS MEDIA & URI W/O MCC 153 $27,744.00 OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC 155 $34,485.00 OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC 156 $33,836.00 DENTAL & ORAL DISEASES W MCC 157 $32,681.00 DENTAL & ORAL DISEASES W CC 158 $22,540.00 MAJOR CHEST PROCEDURES W MCC 163 $127,114.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MAJOR CHEST PROCEDURES W CC 164 $83,398.00 MAJOR CHEST PROCEDURES W/O CC/MCC 165 $110,638.00 OTHER RESP SYSTEM O.R. PROCEDURES W MCC 166 $93,455.00 OTHER RESP SYSTEM O.R. PROCEDURES W CC 167 $51,269.00 PULMONARY EMBOLISM W MCC 175 $39,795.00 PULMONARY EMBOLISM W/O MCC 176 $22,487.00 RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC 177 $49,617.00 RESPIRATORY INFECTIONS & INFLAMMATIONS W CC 178 $48,828.00 RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC 179 $28,846.00 RESPIRATORY NEOPLASMS W MCC 180 $39,589.00 RESPIRATORY NEOPLASMS W CC 181 $37,887.00 RESPIRATORY NEOPLASMS W/O CC/MCC 182 $39,012.00 MAJOR CHEST TRAUMA W MCC 183 $47,585.00 PLEURAL EFFUSION W MCC 186 $32,595.00 PLEURAL EFFUSION W CC 187 $35,740.00 PLEURAL EFFUSION W/O CC/MCC 188 $13,828.00 PULMONARY EDEMA & RESPIRATORY FAILURE 189 $27,283.00 CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC 190 $27,549.00 CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC 191 $25,306.00 CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC 192 $19,985.00 SIMPLE PNEUMONIA & PLEURISY W MCC 193 $30,493.00 SIMPLE PNEUMONIA & PLEURISY W CC 194 $27,406.00 SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC 195 $18,607.00 INTERSTITIAL LUNG DISEASE W MCC 196 $29,207.00 INTERSTITIAL LUNG DISEASE W CC 197 $23,431.00 PNEUMOTHORAX W MCC 199 $24,976.00 PNEUMOTHORAX W CC 200 $32,344.00 PNEUMOTHORAX W/O CC/MCC 201 $21,351.00 BRONCHITIS & ASTHMA W CC/MCC 202 $27,867.00 BRONCHITIS & ASTHMA W/O CC/MCC 203 $13,614.00 RESPIRATORY SIGNS & SYMPTOMS 204 $8,868.00 OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC 205 $30,257.00 OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC 206 $11,948.00 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS OR PERIPHERAL207 EXTRACORPOREAL$99,754.00 MEMBRANE OXYGENATION (ECMO) RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS 208 $51,401.00 OTHER HEART ASSIST SYSTEM IMPLANT 215 $325,459.00 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC 216 $288,499.00 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W CC 217 $176,671.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC 219 $315,285.00 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC 220 $193,401.00 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC 221 $170,823.00 CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC 224 $227,419.00 CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC 226 $377,773.00 CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC 227 $168,165.00 OTHER CARDIOTHORACIC PROCEDURES W MCC 228 $103,206.00 OTHER CARDIOTHORACIC PROCEDURES W/O MCC 229 $135,963.00 CORONARY BYPASS W PTCA W/O MCC 232 $148,841.00 CORONARY BYPASS W CARDIAC CATH W MCC 233 $219,792.00 CORONARY BYPASS W CARDIAC CATH W/O MCC 234 $191,738.00 CORONARY BYPASS W/O CARDIAC CATH W MCC 235 $212,738.00 CORONARY BYPASS W/O CARDIAC CATH W/O MCC 236 $143,595.00 AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC 239 $127,669.00 AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC 240 $106,361.00 AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W/O CC/MCC 241 $49,312.00 PERMANENT CARDIAC PACEMAKER IMPLANT W MCC 242 $151,073.00 PERMANENT CARDIAC PACEMAKER IMPLANT W CC 243 $85,991.00 PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC 244 $88,103.00 AICD GENERATOR PROCEDURES 245 $173,979.00 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR246 4+ ARTERIES$112,010.00 OR STENTS PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC 247 $82,551.00 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W NON-DRUG-ELUTING STENT W MCC248 OR 4+$86,775.00 ARTERIES OR STENTS PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC 249 $84,695.00 PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC 250 $68,620.00 PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC 251 $93,700.00 OTHER VASCULAR PROCEDURES W MCC 252 $88,520.00 OTHER VASCULAR PROCEDURES W CC 253 $109,677.00 OTHER VASCULAR PROCEDURES W/O CC/MCC 254 $75,476.00 UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W MCC 255 $134,117.00 UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC 256 $50,085.00 UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W/O CC/MCC 257 $48,001.00 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC 260 $94,407.00 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC 261 $114,237.00 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W/O CC/MCC 262 $90,761.00 VEIN LIGATION & STRIPPING 263 $174,018.00 OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 $68,888.00 AICD LEAD PROCEDURES 265 $205,262.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W MCC 268 $292,085.00 AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC 269 $190,324.00 OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC 270 $133,203.00 OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC 271 $127,654.00 OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC 272 $136,080.00 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC 280 $46,744.00 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC 281 $39,243.00 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC 282 $41,669.00 ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC 283 $48,579.00 ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC 284 $30,183.00 ACUTE MYOCARDIAL INFARCTION, EXPIRED W/O CC/MCC 285 $47,786.00 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC 286 $57,183.00 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC 287 $48,785.00 ACUTE & SUBACUTE ENDOCARDITIS W MCC 288 $39,664.00 HEART FAILURE & SHOCK W MCC OR PERIPHERAL EXTRACORPOREAL MEMBRANE OXYGENATION291 $30,769.00 (ECMO) HEART FAILURE & SHOCK W CC 292 $27,859.00 HEART FAILURE & SHOCK W/O CC/MCC 293 $21,856.00 DEEP VEIN THROMBOPHLEBITIS W CC/MCC 294 $30,050.00 CARDIAC ARREST, UNEXPLAINED W MCC OR PERIPHERAL EXTRACORPOREAL MEMBRANE296 OXYGENATION$46,878.00 (ECMO) CARDIAC ARREST, UNEXPLAINED W CC 297 $44,463.00 PERIPHERAL VASCULAR DISORDERS W MCC 299 $62,062.00 PERIPHERAL VASCULAR DISORDERS W CC 300 $39,154.00 PERIPHERAL VASCULAR DISORDERS W/O CC/MCC 301 $24,755.00 ATHEROSCLEROSIS W MCC 302 $18,023.00 ATHEROSCLEROSIS W/O MCC 303 $14,488.00 HYPERTENSION W MCC 304 $28,311.00 HYPERTENSION W/O MCC 305 $27,374.00 CARDIAC CONGENITAL & VALVULAR DISORDERS W MCC 306 $49,657.00 CARDIAC CONGENITAL & VALVULAR DISORDERS W/O MCC 307 $32,259.00 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC 308 $37,909.00 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC 309 $24,539.00 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC 310 $19,831.00 ANGINA PECTORIS 311 $28,060.00 SYNCOPE & COLLAPSE 312 $27,510.00 CHEST PAIN 313 $16,928.00 OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC 314 $48,591.00 OTHER CIRCULATORY SYSTEM DIAGNOSES W CC 315 $23,084.00 OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC 316 $28,743.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC 326 $134,942.00 STOMACH, ESOPHAGEAL & DUODENAL PROC W CC 327 $62,466.00 STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC 328 $60,646.00 MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC 329 $139,201.00 MAJOR SMALL & LARGE BOWEL PROCEDURES W CC 330 $81,450.00 MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC 331 $68,821.00 RECTAL RESECTION W/O CC/MCC 334 $116,440.00 PERITONEAL ADHESIOLYSIS W MCC 335 $138,802.00 PERITONEAL ADHESIOLYSIS W CC 336 $80,274.00 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W MCC 338 $226,340.00 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC 339 $78,336.00 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC 340 $46,820.00 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC 341 $193,893.00 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC 342 $56,744.00 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC 343 $34,683.00 MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC 346 $34,751.00 ANAL & STOMAL PROCEDURES W CC 348 $32,832.00 INGUINAL & FEMORAL HERNIA PROCEDURES W CC 351 $47,746.00 INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC 352 $50,947.00 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC 354 $51,791.00 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC 355 $47,308.00 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC 356 $229,048.00 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC 357 $40,135.00 MAJOR ESOPHAGEAL DISORDERS W CC 369 $32,098.00 MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC 370 $28,285.00 MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC 371 $52,664.00 MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC 372 $35,545.00 MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC 373 $8,506.00 DIGESTIVE MALIGNANCY W MCC 374 $73,684.00 DIGESTIVE MALIGNANCY W CC 375 $42,808.00 DIGESTIVE MALIGNANCY W/O CC/MCC 376 $51,435.00 G.I. HEMORRHAGE W MCC 377 $39,623.00 G.I. HEMORRHAGE W CC 378 $29,556.00 G.I. HEMORRHAGE W/O CC/MCC 379 $16,426.00 COMPLICATED PEPTIC ULCER W MCC 380 $30,031.00 COMPLICATED PEPTIC ULCER W CC 381 $37,213.00 COMPLICATED PEPTIC ULCER W/O CC/MCC 382 $23,259.00 UNCOMPLICATED PEPTIC ULCER W MCC 383 $19,924.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge UNCOMPLICATED PEPTIC ULCER W/O MCC 384 $26,609.00 INFLAMMATORY BOWEL DISEASE W MCC 385 $37,872.00 INFLAMMATORY BOWEL DISEASE W CC 386 $20,038.00 INFLAMMATORY BOWEL DISEASE W/O CC/MCC 387 $24,795.00 G.I. OBSTRUCTION W MCC 388 $35,267.00 G.I. OBSTRUCTION W CC 389 $24,797.00 G.I. OBSTRUCTION W/O CC/MCC 390 $16,850.00 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC 391 $33,457.00 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC 392 $19,285.00 OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC 393 $38,422.00 OTHER DIGESTIVE SYSTEM DIAGNOSES W CC 394 $26,749.00 OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC 395 $11,614.00 CHOLECYSTECTOMY W C.D.E. W CC 412 $69,376.00 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC 414 $93,233.00 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC 415 $102,371.00 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC 416 $74,900.00 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC 417 $77,360.00 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC 418 $61,714.00 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC 419 $42,037.00 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W MCC 423 $109,215.00 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W CC 424 $52,437.00 CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC 432 $39,722.00 CIRRHOSIS & ALCOHOLIC HEPATITIS W CC 433 $22,473.00 CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC 434 $19,010.00 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC 435 $67,887.00 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC 436 $42,374.00 DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC 438 $33,518.00 DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC 439 $21,431.00 DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC 440 $16,752.00 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W MCC 441 $56,352.00 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC 442 $29,807.00 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC/MCC 443 $20,967.00 DISORDERS OF THE BILIARY TRACT W MCC 444 $47,107.00 DISORDERS OF THE BILIARY TRACT W CC 445 $47,835.00 DISORDERS OF THE BILIARY TRACT W/O CC/MCC 446 $33,434.00 COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC 453 $447,796.00 COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC 454 $222,479.00 COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC 455 $163,645.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC 456 $362,366.00 SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W CC 457 $401,635.00 SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W/O CC/MCC 458 $367,285.00 SPINAL FUSION EXCEPT CERVICAL W MCC 459 $208,732.00 SPINAL FUSION EXCEPT CERVICAL W/O MCC 460 $136,887.00 WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC 463 $108,209.00 WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC 464 $138,908.00 WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC 465 $55,264.00 REVISION OF HIP OR KNEE REPLACEMENT W MCC 466 $582,779.00 REVISION OF HIP OR KNEE REPLACEMENT W CC 467 $121,139.00 REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC 468 $76,854.00 MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY469 W MCC$102,605.00 OR TOTAL ANKLE REPLACEMENT MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY470 W/O MCC$68,500.00 CERVICAL SPINAL FUSION W MCC 471 $132,380.00 CERVICAL SPINAL FUSION W CC 472 $106,563.00 CERVICAL SPINAL FUSION W/O CC/MCC 473 $83,067.00 AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC 474 $72,759.00 AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC 475 $51,183.00 BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC 478 $58,725.00 BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC 479 $66,621.00 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC 480 $90,917.00 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC 481 $72,473.00 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC 482 $51,198.00 MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES 483 $79,183.00 KNEE PROCEDURES W PDX OF INFECTION W CC 486 $109,142.00 KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC 488 $152,273.00 KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC 489 $35,283.00 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W MCC 492 $83,973.00 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W CC 493 $83,184.00 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W/O CC/MCC 494 $59,535.00 LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W/O CC/MCC 497 $27,347.00 SOFT TISSUE PROCEDURES W CC 501 $83,821.00 SOFT TISSUE PROCEDURES W/O CC/MCC 502 $118,135.00 FOOT PROCEDURES W MCC 503 $80,640.00 FOOT PROCEDURES W CC 504 $46,695.00 FOOT PROCEDURES W/O CC/MCC 505 $48,978.00 ARTHROSCOPY 509 $51,490.00 SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W MCC 510 $111,619.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W/O CC/MCC 512 $45,851.00 HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC 513 $34,646.00 HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC 514 $32,385.00 OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC 515 $91,313.00 OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC 516 $59,307.00 OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC 517 $69,461.00 BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM 518 $88,474.00 BACK & NECK PROC EXC SPINAL FUSION W CC 519 $78,056.00 BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC 520 $106,516.00 FRACTURES OF FEMUR W MCC 533 $86,779.00 FRACTURES OF FEMUR W/O MCC 534 $30,390.00 FRACTURES OF HIP & PELVIS W MCC 535 $32,476.00 FRACTURES OF HIP & PELVIS W/O MCC 536 $25,078.00 OSTEOMYELITIS W MCC 539 $102,922.00 OSTEOMYELITIS W CC 540 $16,619.00 PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC 542 $51,422.00 PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC 543 $17,845.00 PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC 544 $41,873.00 CONNECTIVE TISSUE DISORDERS W MCC 545 $35,768.00 SEPTIC ARTHRITIS W CC 549 $38,490.00 MEDICAL BACK PROBLEMS W MCC 551 $40,285.00 MEDICAL BACK PROBLEMS W/O MCC 552 $25,878.00 BONE DISEASES & ARTHROPATHIES W/O MCC 554 $26,294.00 SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W MCC 555 $12,382.00 SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC 556 $20,995.00 TENDONITIS, MYOSITIS & BURSITIS W/O MCC 558 $27,438.00 AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC 559 $72,541.00 AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC 560 $49,543.00 AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC 561 $42,315.00 FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W MCC 562 $24,824.00 FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC 563 $26,256.00 OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC 564 $29,053.00 OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC 565 $28,501.00 OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC 566 $94,069.00 SKIN DEBRIDEMENT W MCC 570 $119,351.00 SKIN DEBRIDEMENT W CC 571 $67,112.00 SKIN DEBRIDEMENT W/O CC/MCC 572 $45,829.00 SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC 574 $106,044.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W CC 577 $25,301.00 SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC 578 $29,881.00 OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC 579 $50,410.00 OTHER SKIN, SUBCUT TISS & BREAST PROC W CC 580 $39,097.00 OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC 581 $94,482.00 MASTECTOMY FOR MALIGNANCY W CC/MCC 582 $113,377.00 MASTECTOMY FOR MALIGNANCY W/O CC/MCC 583 $185,266.00 BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC 584 $89,994.00 BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC 585 $80,618.00 SKIN ULCERS W MCC 592 $37,432.00 SKIN ULCERS W CC 593 $23,830.00 SKIN ULCERS W/O CC/MCC 594 $14,976.00 MALIGNANT BREAST DISORDERS W MCC 597 $56,303.00 MALIGNANT BREAST DISORDERS W CC 598 $124,014.00 MALIGNANT BREAST DISORDERS W/O CC/MCC 599 $1,615.00 NON-MALIGNANT BREAST DISORDERS W CC/MCC 600 $28,976.00 NON-MALIGNANT BREAST DISORDERS W/O CC/MCC 601 $22,275.00 CELLULITIS W MCC 602 $32,861.00 CELLULITIS W/O MCC 603 $19,856.00 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC 605 $23,911.00 MINOR SKIN DISORDERS W/O MCC 607 $26,030.00 ADRENAL & PITUITARY PROCEDURES W CC/MCC 614 $93,899.00 ADRENAL & PITUITARY PROCEDURES W/O CC/MCC 615 $63,575.00 AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W MCC 616 $115,995.00 AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W CC 617 $58,104.00 O.R. PROCEDURES FOR OBESITY W MCC 619 $52,456.00 O.R. PROCEDURES FOR OBESITY W CC 620 $65,614.00 O.R. PROCEDURES FOR OBESITY W/O CC/MCC 621 $45,544.00 SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC 622 $124,970.00 SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC 623 $60,637.00 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W MCC 625 $76,670.00 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W CC 626 $31,926.00 THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC 627 $36,410.00 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC 628 $150,655.00 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC 629 $64,883.00 DIABETES W MCC 637 $34,975.00 DIABETES W CC 638 $25,215.00 DIABETES W/O CC/MCC 639 $19,515.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 640 $36,716.00 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC 641 $24,968.00 ENDOCRINE DISORDERS W MCC 643 $33,927.00 ENDOCRINE DISORDERS W CC 644 $37,839.00 ENDOCRINE DISORDERS W/O CC/MCC 645 $19,665.00 MAJOR BLADDER PROCEDURES W CC 654 $79,837.00 KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC 656 $91,973.00 KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC 657 $58,035.00 KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC 658 $50,881.00 KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC 659 $111,151.00 KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC 660 $51,395.00 KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC 661 $46,776.00 MINOR BLADDER PROCEDURES W CC 663 $181,617.00 PROSTATECTOMY W CC 666 $88,225.00 PROSTATECTOMY W/O CC/MCC 667 $35,590.00 TRANSURETHRAL PROCEDURES W MCC 668 $122,130.00 TRANSURETHRAL PROCEDURES W CC 669 $50,971.00 TRANSURETHRAL PROCEDURES W/O CC/MCC 670 $55,526.00 OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC 673 $67,754.00 OTHER KIDNEY & URINARY TRACT PROCEDURES W CC 674 $43,257.00 OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC 675 $34,756.00 RENAL FAILURE W MCC 682 $40,352.00 RENAL FAILURE W CC 683 $26,144.00 RENAL FAILURE W/O CC/MCC 684 $15,868.00 KIDNEY & URINARY TRACT NEOPLASMS W MCC 686 $40,117.00 KIDNEY & URINARY TRACT INFECTIONS W MCC 689 $35,215.00 KIDNEY & URINARY TRACT INFECTIONS W/O MCC 690 $24,630.00 URINARY STONES W/O ESW LITHOTRIPSY W/O MCC 694 $18,434.00 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W MCC 695 $13,068.00 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC 696 $42,635.00 OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC 698 $40,246.00 OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC 699 $24,315.00 OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC 700 $1,385.00 MAJOR MALE PELVIC PROCEDURES W CC/MCC 707 $64,098.00 MAJOR MALE PELVIC PROCEDURES W/O CC/MCC 708 $51,026.00 PENIS PROCEDURES W CC/MCC 709 $49,553.00 TRANSURETHRAL PROSTATECTOMY W CC/MCC 713 $62,599.00 TRANSURETHRAL PROSTATECTOMY W/O CC/MCC 714 $30,031.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC 717 $56,959.00 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W/O CC/MCC 718 $30,291.00 MALIGNANCY, MALE REPRODUCTIVE SYSTEM W MCC 722 $31,463.00 BENIGN PROSTATIC HYPERTROPHY W/O MCC 726 $25,927.00 INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC 727 $11,106.00 INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC 728 $19,155.00 OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W/O CC/MCC 730 $16,571.00 UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC 738 $68,973.00 UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC/MCC 741 $39,026.00 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC 742 $45,558.00 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC 743 $37,639.00 D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC 744 $20,105.00 VAGINA, CERVIX & VULVA PROCEDURES W CC/MCC 746 $189,406.00 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 748 $85,345.00 OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W CC/MCC 749 $86,514.00 MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W MCC 754 $61,554.00 INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W CC 758 $19,872.00 INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC 759 $52,966.00 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W CC/MCC 760 $27,089.00 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W/O CC/MCC 761 $29,209.00 VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C 768 $17,152.00 POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE 769 $12,216.00 POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE 776 $16,745.00 ABORTION W/O D&C 779 $34,096.00 CESAREAN SECTION W STERILIZATION W MCC 783 $43,332.00 CESAREAN SECTION W STERILIZATION W CC 784 $36,104.00 CESAREAN SECTION W STERILIZATION W/O CC/MCC 785 $33,512.00 CESAREAN SECTION W/O STERILIZATION W MCC 786 $40,377.00 CESAREAN SECTION W/O STERILIZATION W CC 787 $36,841.00 CESAREAN SECTION W/O STERILIZATION W/O CC/MCC 788 $34,326.00 NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY 789 $23,088.00 EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE 790 $46,811.00 PREMATURITY W MAJOR PROBLEMS 791 $66,768.00 PREMATURITY W/O MAJOR PROBLEMS 792 $4,043.00 FULL TERM NEONATE W MAJOR PROBLEMS 793 $12,229.00 NEONATE W OTHER SIGNIFICANT PROBLEMS 794 $2,750.00 NORMAL NEWBORN 795 $2,099.00 VAGINAL DELIVERY W STERILIZATION/D&C W CC 797 $10,445.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge VAGINAL DELIVERY W STERILIZATION/D&C WO CC/MCC 798 $23,964.00 SPLENECTOMY W/O CC/MCC 801 $42,225.00 OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W CC 803 $46,492.00 VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC 805 $15,821.00 VAGINAL DELIVERY W/O STERILIZATION/D&C W CC 806 $14,778.00 VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC 807 $13,324.00 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC 808 $48,104.00 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC 809 $25,595.00 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC 810 $29,482.00 RED BLOOD CELL DISORDERS W MCC 811 $32,298.00 RED BLOOD CELL DISORDERS W/O MCC 812 $23,811.00 COAGULATION DISORDERS 813 $19,294.00 RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC 815 $25,825.00 RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC 816 $13,195.00 OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W CC 818 $37,511.00 OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W/O CC/MCC 819 $18,249.00 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC 827 $81,127.00 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC/MCC 828 $52,841.00 MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER829 PROCEDURE$72,829.00 W CC/MCC OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC 831 $29,811.00 OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC 832 $15,770.00 OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC 833 $13,760.00 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC 834 $83,427.00 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC 835 $22,437.00 LYMPHOMA & NON-ACUTE LEUKEMIA W MCC 840 $83,977.00 LYMPHOMA & NON-ACUTE LEUKEMIA W CC 841 $60,160.00 LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC 842 $98,831.00 OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W MCC 843 $60,621.00 OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC 844 $35,584.00 CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC 847 $66,585.00 RADIOTHERAPY 849 $1,470.00 INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC 853 $138,117.00 INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC 854 $59,419.00 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC 856 $63,843.00 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC 857 $74,913.00 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC 858 $56,895.00 POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC 862 $43,950.00 POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC 863 $42,804.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge FEVER AND INFLAMMATORY CONDITIONS 864 $17,347.00 VIRAL ILLNESS W/O MCC 866 $55,238.00 OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC 867 $36,674.00 OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W/O CC/MCC 869 $1,515.00 SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS OR PERIPHERAL EXTRACORPOREAL870 MEMBRANE$158,448.00 OXYGENATION (ECMO) SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC 871 $49,147.00 SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC 872 $28,373.00 ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION 880 $34,439.00 DEPRESSIVE NEUROSES 881 $72,901.00 ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY 884 $26,280.00 PSYCHOSES 885 $27,207.00 ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC 896 $33,294.00 ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC 897 $22,275.00 WOUND DEBRIDEMENTS FOR INJURIES W CC 902 $76,083.00 WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC 903 $43,051.00 SKIN GRAFTS FOR INJURIES W CC/MCC 904 $166,097.00 SKIN GRAFTS FOR INJURIES W/O CC/MCC 905 $31,258.00 HAND PROCEDURES FOR INJURIES 906 $43,565.00 OTHER O.R. PROCEDURES FOR INJURIES W MCC 907 $61,968.00 OTHER O.R. PROCEDURES FOR INJURIES W CC 908 $45,337.00 OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC 909 $40,213.00 TRAUMATIC INJURY W MCC 913 $24,587.00 TRAUMATIC INJURY W/O MCC 914 $14,697.00 ALLERGIC REACTIONS W MCC 915 $29,045.00 ALLERGIC REACTIONS W/O MCC 916 $17,787.00 POISONING & TOXIC EFFECTS OF DRUGS W MCC 917 $27,633.00 POISONING & TOXIC EFFECTS OF DRUGS W/O MCC 918 $18,642.00 COMPLICATIONS OF TREATMENT W MCC 919 $51,823.00 COMPLICATIONS OF TREATMENT W CC 920 $40,754.00 COMPLICATIONS OF TREATMENT W/O CC/MCC 921 $27,197.00 OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC 922 $33,957.00 OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC 923 $44,742.00 O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC 940 $76,544.00 O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC 941 $33,602.00 SIGNS & SYMPTOMS W MCC 947 $26,813.00 SIGNS & SYMPTOMS W/O MCC 948 $24,995.00 AFTERCARE W CC/MCC 949 $63,453.00 AFTERCARE W/O CC/MCC 950 $59,159.00 LCMC Health is committed to helping patients understand and prepare for the cost of their care. LCMC Health provides a list of charges for services provided at our facilities; however, a patient’s out-of-pocket responsibility for these charges will vary, depending on their insurance coverage and benefit plan. We understand that it is confusing for a patient to navigate through the many factors involved in their final cost. Please contact our Financial Assistance staff at 504.702.3500 with any questions about a future service or a bill you have received. Service Description CPT/HCPCS Code Charge OTHER FACTORS INFLUENCING HEALTH STATUS 951 $1,687.00 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 955 $160,577.00 LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA 956 $95,617.00 OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC 963 $26,584.00 OTHER MULTIPLE SIGNIFICANT TRAUMA W CC 964 $89,312.00 HIV W EXTENSIVE O.R. PROCEDURE W MCC 969 $114,940.00 HIV W MAJOR RELATED CONDITION W MCC 974 $94,639.00 HIV W MAJOR RELATED CONDITION W CC 975 $72,913.00 HIV W MAJOR RELATED CONDITION W/O CC/MCC 976 $47,400.00 HIV W OR W/O OTHER RELATED CONDITION 977 $25,418.00 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC 981 $102,204.00 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC 982 $72,685.00 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC 983 $47,121.00 NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC 987 $85,093.00 NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC 988 $51,949.00 NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC 989 $41,255.00 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 998 $19,451.00