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Mckenzie Health System McKenzie Health System Category Item Number Item Description Item Standard Charge Ambulance 3400140 ACLS INTERCEPT$ 1,111.00 Ambulance 3400018 ADV LIFE SUPPORT ALS2$ 1,748.00 Ambulance 3411888 AMB MILES BEYOND NEAREST FACILITY$ 20.00 Ambulance 3400300 AMBULANCE INTERCEPT$ 391.00 Ambulance 3400066 AMBULANCE MILEAGE PER MILE$ 20.00 Ambulance 3455555 AMBULANCE SANCTIONED STANDBY$ 50.00 Ambulance 3400420 AMBULANCE WAITING TIME, PER 1/2 HR$ 75.00 Ambulance 3400033 BASE BASIC EMERGENCY$ 1,016.00 Ambulance 3400034 BASE BASIC NON-EMERG$ 635.00 Ambulance 3400157 BASE PARAMEDIC EMERGENCY$ 1,208.00 Ambulance 3400159 BASE PARAMEDIC NON-EMERGENCY$ 763.00 Ambulance 3400019 SPECIAL CARE TRANSPPORT SCT$ 2,064.00 Diagnostic Imaging 2477062 3D MAMMOGRAPHY DIAGNOSTIC BILATERAL+$ 150.00 Diagnostic Imaging 2477061 3D MAMMOGRAPHY DIAGNOSTIC UNILATERAL+$ 117.00 Diagnostic Imaging 2477063 3D MAMMOGRAPHY SCREENING+$ 201.00 Diagnostic Imaging 2403564 4 VIEW KNEE LEFT$ 160.00 Diagnostic Imaging 2473564 4 VIEW KNEE RIGHT$ 160.00 Diagnostic Imaging 2473312 ABD ACUTE 3VIEWS$ 182.00 Diagnostic Imaging 2473304 ABDOMEN 1 VIEW$ 97.00 Diagnostic Imaging 2473305 ABDOMEN 1 VIEW FREQ$ 97.00 Diagnostic Imaging 2474010 ABDOMEN 2 VIEW$ 145.00 Diagnostic Imaging 2474011 ABDOMEN 2 VIEW FREQ$ 145.00 Diagnostic Imaging 2472652 ACROMICOCLAVICULAR JOINT$ 145.00 Diagnostic Imaging 2473190 ANKLE 2 VIEW RT$ 121.00 Diagnostic Imaging 2473189 ANKLE 2 VIEW LT$ 121.00 Diagnostic Imaging 2473197 ANKLE 3 VIEW LT$ 125.00 Diagnostic Imaging 2473198 ANKLE 3 VIEW RT$ 125.00 Diagnostic Imaging 2473615 ARTHROGRAM ANKLE+$ 428.00 Diagnostic Imaging 2473580 ARTHROGRAM KNEE+$ 471.00 Diagnostic Imaging 2473040 ARTHROGRAM SHOULDER+$ 409.00 Diagnostic Imaging 2407311 ARTHROGRAM WRIST+$ 436.00 Diagnostic Imaging 2473445 BARIUM ENEMA$ 555.00 Diagnostic Imaging 2473452 BARIUM ENEMA AND AIR$ 869.00 Diagnostic Imaging 2475549 BONE AGE STUDIES$ 97.00 Diagnostic Imaging 2477080 BONE DENSITY AXIAL SKELETON$ 169.00 Diagnostic Imaging 2477081 BONE DENSITY PERIPHERAL EXTREMITY$ 115.00 Diagnostic Imaging 2475556 BONE LENGTH STUDIES$ 148.00 Diagnostic Imaging 2475572 BONE SURVEY$ 265.00 Diagnostic Imaging 2475580 BONE SURVEY INFANT$ 396.00 Diagnostic Imaging 2441138 BREAST LT SURG SPECIMEN$ 69.00 Diagnostic Imaging 2441137 BREAST RT SURG SPECIMEN$ 69.00 Diagnostic Imaging 2472058 CERV SPINE AP & LATERAL$ 94.00 Diagnostic Imaging 2472074 CERV SPINE COMPLETE$ 184.00 Diagnostic Imaging 2471019 CHEST 1V XRAY$ 93.00 Diagnostic Imaging 2471020 CHEST 1V XRAY FREQ$ 93.00 Diagnostic Imaging 2471027 CHEST 2 VIEW XRAY$ 114.00 Diagnostic Imaging 2471028 CHEST 2 VIEW XRAY FREQ$ 114.00 Diagnostic Imaging 2471035 CHEST 4 VIEW FLORO+$ 341.00 Diagnostic Imaging 2471037 CHEST 4 VIEW XRAY$ 171.00 Diagnostic Imaging 2473502 CHOLANGIOGRAM OR$ 233.00 Diagnostic Imaging 2472504 CLAVICLE LEFT$ 112.00 Diagnostic Imaging 2472505 CLAVICLE RIGHT$ 112.00 Diagnostic Imaging 2206377 CT 3D VITREA$ 479.00 Diagnostic Imaging 2206376 CT 3D WITH INTERPRETATION$ 154.00 Diagnostic Imaging 2204177 CT ABD & PELVIS W ORAL & IV CONTRAST+$ 2,051.00 Diagnostic Imaging 2204176 CT ABD & PELVIS W/ ORAL CONTRAST+$ 1,333.00 Diagnostic Imaging 2274178 CT ABD & PELVIS WITH & W/O CONTRAST+$ 2,326.00 Diagnostic Imaging 2274177 CT ABD & PELVIS WITH IV CONTRAST ONLY+$ 2,051.00 Diagnostic Imaging 2274176 CT ABD & PELVIS WITHOUT CONTRAST$ 1,333.00 Diagnostic Imaging 2245039 CT ABDOMEN W & W/O CONTRAST+$ 1,727.00 Diagnostic Imaging 2274160 CT ABDOMEN W ORAL & IV CONTRAST+$ 1,519.00 Diagnostic Imaging 2245021 CT ABDOMEN W/ IV CONTRAST ONLY+$ 1,519.00 Diagnostic Imaging 2274150 CT ABDOMEN W/ ORAL CONTRAST+$ 994.00 Diagnostic Imaging 2245013 CT ABDOMEN W/O CONTRAST$ 994.00 Diagnostic Imaging 2243018 CT CERV SP W/O CONTRAST$ 1,097.00 Diagnostic Imaging 2242127 CT CERV SP W/WO CONT+$ 1,779.00 Diagnostic Imaging 2243026 CT CERVICAL SPINE W/CONTRAST+$ 1,507.00 Diagnostic Imaging 2275989 CT GUIDANCE$ 809.00 Diagnostic Imaging 2241038 CT HEAD WITH & W/O CONTRAST+$ 1,269.00 Diagnostic Imaging 2241020 CT HEAD WITH CONTRAST+$ 1,070.00 Diagnostic Imaging 2241012 CT HEAD WO CONTRAST$ 770.00 Diagnostic Imaging 2275571 CT HEART W/O CONTRAST W QUANT EVAL$ 283.00 Diagnostic Imaging 2245022 CT IAC W/CONTRAST+$ 1,816.00 Diagnostic Imaging 2245024 CT IAC W/WO CONTRAST+$ 1,816.00 Diagnostic Imaging 2245023 CT IAC WITH CONTRAST$ 1,816.00 Diagnostic Imaging 2274080 CT IAC WO CONTRAST$ 980.00 Diagnostic Imaging 2208032 CT LOW DOSE LUNG CANCER SCREENING$ 428.00 Diagnostic Imaging 2273701 CT LOW EXT LT W CONT+$ 1,488.00 Diagnostic Imaging 2244057 CT LOW EXT LT W&W/O CONTRAST+$ 1,802.00 Diagnostic Imaging 2244058 CT LOW EXT RT W CONT+$ 1,488.00 Diagnostic Imaging 2244065 CT LOW EXT RT W/WO CON+$ 1,802.00 Diagnostic Imaging 2244041 CT LOWER EXT RT W/O CONTRAST+$ 1,072.00 Diagnostic Imaging 2244040 CT LOWER EXT LEFT W/O CONTRAST+$ 1,072.00 Diagnostic Imaging 2242143 CT LUMBAR SP W/WO CONT+$ 1,777.00 Diagnostic Imaging 2243067 CT LUMBAR SPINE W/CONTRAST+$ 1,505.00 Diagnostic Imaging 2243059 CT LUMBAR SPINE W/O CONTRAST$ 1,072.00 Diagnostic Imaging 2270482 CT MASTOIDS W & W/O CONTRAST+$ 1,982.00 Diagnostic Imaging 2270481 CT MASTOIDS W/CONTRAST+$ 1,816.00 Diagnostic Imaging 2270480 CT MASTOIDS W/O CONTRAST$ 1,170.00 Diagnostic Imaging 2241095 CT MAXILLOFACIAL W/WO+$ 1,354.00 Diagnostic Imaging 2241087 CT MAXILLOFACIAL W+$ 1,114.00 Diagnostic Imaging 2241079 CT MAXILLOFACIAL/SINUS W/O$ 924.00 Diagnostic Imaging 2277012 CT NEEDLE GUIDANCE$ 835.00 Diagnostic Imaging 2241061 CT ORBIT SELLA W& W/O CONTRAST+$ 1,982.00 Diagnostic Imaging 2241053 CT ORBIT W CONTRAST+$ 1,816.00 Diagnostic Imaging 2241046 CT ORBIT W/O CONTRAST$ 1,170.00 Diagnostic Imaging 2243091 CT PELVIS W & W/O CONTRAST+$ 1,713.00 Diagnostic Imaging 2243083 CT PELVIS W/ IV CONTRAST ONLY+$ 1,488.00 Diagnostic Imaging 2272193 CT PELVIS W/ ORAL & IV CONTRAST+$ 1,488.00 Diagnostic Imaging 2272192 CT PELVIS W/ ORAL CONTRAST+$ 967.00 Diagnostic Imaging 2243075 CT PELVIS W/O CONTRAST+$ 967.00 Diagnostic Imaging 2246094 CT SCOUT VIEW W/O$ 734.00 Diagnostic Imaging 2241111 CT SOFT TISSUE NECK W/CONTRAST+$ 1,554.00 Diagnostic Imaging 2241103 CT SOFT TISSUE NECK W/O CONTRAST$ 1,170.00 Diagnostic Imaging 2241129 CT SOFT TISSUE NECK W/WO+$ 1,830.00 Diagnostic Imaging 2242135 CT T SPINE W/WO CONT+$ 1,792.00 Diagnostic Imaging 2243042 CT THORACIC SPINE W/CONTRAST+$ 1,509.00 Diagnostic Imaging 2243034 CT THORACIC SPINE W/O CONTRAST$ 1,072.00 Diagnostic Imaging 2242028 CT THORAX W/CONTRAST+$ 1,510.00 Diagnostic Imaging 2242010 CT THORAX W/O CONTRAST$ 1,079.00 Diagnostic Imaging 2242036 CT THORAX W/WO CONTRAST+$ 1,810.00 Diagnostic Imaging 2244024 CT UPPER EXT LEFT W/CONTRAST+$ 1,466.00 Diagnostic Imaging 2244016 CT UPPER EXT LEFT W/O CONTRAST+$ 1,072.00 Diagnostic Imaging 2244032 CT UPPER EXT LEFT W/WO CONTRAST+$ 1,823.00 Diagnostic Imaging 2244025 CT UPPER EXT RIGHT W/CONTRAST+$ 1,466.00 Diagnostic Imaging 2244017 CT UPPER EXT RIGHT W/O CONTRAST+$ 1,072.00 Diagnostic Imaging 2244033 CT UPPER EXT RIGHT W/WO CONTRAST+$ 1,823.00 Diagnostic Imaging 2274175 CTA ABDOMEN W & W/O CONTRAST+$ 2,024.00 Diagnostic Imaging 2274174 CTA ABDOMEN/PELVIS W & W/O CONTRAST+$ 2,561.00 Diagnostic Imaging 2275635 CTA AORTO-ILIOFEMORAL RUNOFF+$ 2,351.00 Diagnostic Imaging 2270496 CTA HEAD W & W/O IV CONTRAST+$ 1,941.00 Diagnostic Imaging 2275574 CTA HEART ANGIOGRAPHY W 3D IMAGING+$ 1,573.00 Diagnostic Imaging 2275572 CTA HEART W CONTRAST W 3D TO EVAL+$ 1,258.00 Diagnostic Imaging 2275573 CTA HEART W CONTRAST W 3D W CONGENITAL+$ 1,610.00 Diagnostic Imaging 2273706 CTA LOWER EXTREMITY W/WO CONTRAST+$ 2,145.00 Diagnostic Imaging 2270498 CTA NECK W & W/O CONTRAST+$ 1,935.00 Diagnostic Imaging 2272191 CTA PELVIS W & W/O CONTRAST+$ 2,014.00 Diagnostic Imaging 2271275 CTA THORAX+$ 1,978.00 Diagnostic Imaging 2273206 CTA UPPER EXTREMITY+$ 2,145.00 Diagnostic Imaging 2473684 CYSTOGRAM+$ 156.00 Diagnostic Imaging 2400206 DIGITAL MAMM DIAGNOSTIC UNILATERAL$ 551.00 Diagnostic Imaging 2400204 DIGITAL MAMM DIAGNOSTIC BILATERAL$ 694.00 Diagnostic Imaging 2400202 DIGITAL MAMM SCREENING BILATERAL$ 344.00 Diagnostic Imaging 2103350 DOBUTAMINE STRESS ECHO+$ 1,181.00 Diagnostic Imaging 2593325 DOPPLER ECHO COLOR FLOW$ 135.00 Diagnostic Imaging 2593320 DOPPLER ECHO PULSED WAVE$ 289.00 Diagnostic Imaging 2193306 ECHOCARDIOGRAPHY$ 1,459.00 Diagnostic Imaging 2108929 ECHOCARDIOGRAPHY W/CONTRAST+$ 1,811.00 Diagnostic Imaging 2472751 ELBOW 2 VIEW LT$ 111.00 Diagnostic Imaging 2472752 ELBOW 2 VIEW RT$ 111.00 Diagnostic Imaging 2472769 ELBOW 3 VIEW LEFT$ 126.00 Diagnostic Imaging 2472770 ELBOW 3 VIEW RIGHT$ 126.00 Diagnostic Imaging 2473353 ESOPHAGUS+$ 363.00 Diagnostic Imaging 2470268 FACIAL BONES COMPLET$ 169.00 Diagnostic Imaging 2473552 FEMUR LEFT$ 133.00 Diagnostic Imaging 2403552 FEMUR RIGHT$ 133.00 Diagnostic Imaging 2475739 FINGERS XRAY LT$ 126.00 Diagnostic Imaging 2475740 FINGERS XRAY RT$ 126.00 Diagnostic Imaging 2475630 FISTULA STUDY+$ 229.00 Diagnostic Imaging 2477001 FLUORO GUIDANCE FOR CENTR VEN ACC$ 119.00 Diagnostic Imaging 2441194 FLUORO UP TO 1 HOUR$ 193.00 Diagnostic Imaging 2473222 FOOT 2 VIEW RIGHT$ 107.00 Diagnostic Imaging 2473221 FOOT 2V LEFT$ 107.00 Diagnostic Imaging 2473239 FOOT 3 VIEW LT$ 117.00 Diagnostic Imaging 2473240 FOOT 3 VIEW RT$ 117.00 Diagnostic Imaging 2472801 FOREARM XR DIAG LT$ 105.00 Diagnostic Imaging 2472802 FOREARM XR DIAG RT$ 105.00 Diagnostic Imaging 2476010 FOREIGN BODY, CHILD, NOSE TO RECTUM XRAY$ 107.00 Diagnostic Imaging 2473120 HAND 2 VIEW LEFT$ 107.00 Diagnostic Imaging 2473121 HAND 2 VIEW RIGHT$ 107.00 Diagnostic Imaging 2472918 HAND 3 VIEW
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