CPT4 Code Descripon Charge Amount NICARDIPINE HCL 20MG/200ML PRE-MIXED IV $ 419.00 A9270GY TRAVATAN $ 354.00 BAYHEP B PFS $ 653.00 J1645 FRAGMIN 18000U $ 423.00 AMMONIA AROMATIC INH $ 4.00 A4340 CATH FOLEY COUDE LTX 5CC 22 FR $ 31.00 CLIP RESOLUTION $ 844.00 A4351 CATHETER URETHRAL BARDIA 14 FR $ 27.00 64832 REPAIR NERVE ADD ON $ 417.00 C1726 BALLOON HERCULES 15-16.5-18MM $ 663.00 C1726 DILATOR BAL CRE SGL USE FIXED $ 855.00 C1726 DILATOR BAL CRE SGL USE FIXED $ 855.00 C1726 DILATOR BAL CRE SGL USE FIXED $ 855.00 C1726 DILATOR CRE FIXED WIRE BALLOON $ 855.00 C1726 DILATOR COLONIC BAL CRE WIRE GU $ 986.00 27705 INCISION OF TIBIA $ 17,350.00 28270 RELEASE OF FOOT CONTRACTURE $ 8,186.00 28296 CORRECTION OF BUNION $ 8,186.00 28315 REMOVAL OF SESAMOID BONE $ 8,186.00 28405 TREATMENT OF HEEL FRACTURE $ 665.00 28725 FUSION OF FOOT BONES $ 31,327.00 29820 ARTHROSCOPY SHLDRR SYNOVEC PAR $ 17,350.00 29824 SHOULDER ARTHROSCOPY MUMFORD $ 8,186.00 29826 SHOULDER ARTHROSCOPY/SURGERY $ 1,440.00 29827 ARTHROSCOP ROTATOR CUFF REPR $ 17,350.00 29894 ANKLE ARTHROSCOPY/SURGERY $ 8,186.00 31254 REVISION OF ETHMOID SINUS $ 15,053.00 31295 SINUS ENDO W/BALLON DIL MAX $ 15,053.00 31297 SINUS ENDO W/BALLON DIL SPHENOID $ 15,053.00 36907 TRANSLUMINAL BALLOON ANGIOPLAST $ 235.00 38220 BONE MARROW ASPIRATION $ 4,172.00 46260 REMOVE IN/EX HEM GROUPS 2+ $ 7,166.00 47379 LAPAROSCOPE PROCEDURE LIVER $ 13,891.00 47600 REMOVAL OF GALLBLADDER $ 1,944.00 52235 CYSTOSCOPY AND TREATMENT $ 8,346.00 56501 DESTROY VULVA LESIONS SIM $ 4,854.00 58140 MYOMECTOMY ABDOM METHOD $ 2,156.00 58301 REMOVE INTRAUTERINE DEVICE $ 497.00 58350 REOPEN FALLOPIAN TUBE $ 12,725.00 59409 OBSTETRICAL CARE $ 7,034.00 64491 INJ PARAVERT F JNT C/T 2 LEV $ 107.00 64494 INJ PARAVERT F JNT L/S 2 LEV $ 91.00 77001 FLUOROGUIDE FOR VEIN DEVICE $ 114.00 G0460 AUTOLOGOUS PRP FOR ULCERS $ 4,854.00 64718 REVISE ULNAR NERVE AT ELBOW $ 4,984.00 64787 IMPLANT NERVE END $ 374.00 42900 REPAIR THROAT WOUND $ 3,522.00 27825 TREAT LOWER LEG FRACTURE $ 4,178.00 12053 INTMD WND RPR FACE MM 5.1-7.5 CM $ 962.00 !1 12041 INTMD WND RPR N-HF-GEN=<2.5 CM $ 962.00 CLIP HEMO-LOK LARGE $ 158.00 27618 EXC LEG/ANKLE TUM < 3 CM $ 4,172.00 25248 REMOVE FOREARM FOREIGN BODY $ 4,178.00 46258 REMOVE IN/EX HEM GRP W/FISTU $ 7,166.00 27752 CLOSD TX TIBIAL SHAFT W/MANIP $ 4,178.00 36558 INSERT TUNNELED CVC W/O PORT/PUMP AGE>5 $ 7,714.00 36569 INS PICC AGE 5 YRS/> $ 3,042.00 STAPLE ENDO GIA RR 60MM MED THICK $ 1,262.00 BAG BILE $ 30.00 SUTURE TI CRON 5-0 $ 13.00 ELECTRODE LOOP 2 X 1 $ 68.00 WIRE FIBER $ 66.00 SUTURE MAXON 4-0 $ 8.00 BAG BILE 9 1/2" $ 30.00 58150 TOTAL HYSTERECTOMY $ 15,304.00 15271 SKIN SUB GRAFT TRNK/ARM/LEG $ 4,854.00 82009 ACETONE-BLOOD $ 46.00 82150 AMYLASE-FLUID $ 59.00 82570 CREATININE-FLUID $ 36.00 80051 ELECTROLYTES-ST $ 68.00 82438 CHLORIDE-FLUID $ 36.00 80299 MEXILETINE-SERUM $ 245.00 83615 LDH-FLUID $ 36.00 82945 GLUCOSE-FLUID $ 36.00 83935 OSMOLALITY-FECES $ 107.00 84302 SODIUM-FLUID $ 36.00 84110 PORPHOBIL/QUANT $ 41.00 80320 ALCOHOL-BLOOD $ 125.00 84157 PROTEIN-CSF $ 52.00 82085 ALDOLASE $ 52.00 80192 PROCAIN/NAPA $ 132.00 80299 DISOPYRAMIDE SE $ 83.00 80150 AMIK-TROUGH $ 118.00 84075 ALKALINE PHOSPTSE $ 36.00 80299 DIGITOXIN-SERUM $ 83.00 82805 GASES-BLD BASE EX $ 227.00 82985 GLYCOSYLATED ALBUMIN $ 85.00 82128 AMINO ACID SC-BL $ 67.00 80061 LIPID PANEL $ 93.00 82330 CA IONIZED MEAS $ 81.00 82128 AMINO ACID SC-UR $ 67.00 82108 ALUMINUM-PLASMA $ 121.00 82150 AMYLASE-2HR URINE $ 59.00 82150 AMYLASE-RANDOM UR $ 59.00 82438 CHLORIDE-CSF $ 36.00 82436 CHLORIDE-RAND UR $ 36.00 82465 CHOLESTEROL-FLUID $ 36.00 82139 AMINO ACID QNT-UR $ 929.00 82570 CREATININE-RAN UR $ 36.00 82575 CREATININE CL-2HR $ 114.00 80299 DYPHYLLINE-SERUM $ 83.00 82140 AMMONIA-BLOOD $ 114.00 80051 ELECTROLYTES-RA U $ 68.00 80176 LIDOCAINE-SERUM $ 83.00 85549 LYSOZYME-URINE $ 87.00 !2 83785 MANGANESE-BLOOD $ 290.00 83661 L/S-PG AMN FLD $ 134.00 80299 MEPHENYTOIN-SERUM $ 83.00 80299 METHOTREXATE-SER $ 125.00 83935 OSMOLALITY-RAN UR $ 107.00 83986 PH-FLUID $ 35.00 84133 POTASSIUM-RAND UR $ 36.00 82150 AMYLASE-BLOOD $ 59.00 84300 SODIUM-RANDOM UR $ 36.00 84430 THIOCYANATE-SERUM $ 56.00 84478 TRIGLYCERIDES-FL $ 36.00 84540 UUN-12HR URINE $ 36.00 84540 UUN-RANDOM URINE $ 36.00 83880 BNP $ 160.00 80164 VALPROIC ACID TOTAL-SER $ 126.00 80202 VANCO-TROUGH $ 132.00 82652 VIT D 1,25-DI-OH $ 176.00 86235 ANTIEXTRACTABLE NUCLEAR AG $ 295.00 80299 ANTIBIOTIC LEVEL $ 83.00 87529 HSV I/II DNA BY PCR $ 556.00 80188 PRIMIDONE-SERUM $ 132.00 80184 PHENOBARBITAL-SER $ 132.00 80185 PHENYTOIN-SERUM $ 132.00 80156 CARBAMAZEP.SER. $ 132.00 81050 VOLUME MEAS. $ 15.00 82040 ALBUMIN-SERUM $ 36.00 82175 ARSENIC - URINE $ 332.00 80299 TOCAINIDE-SERUM $ 317.00 82951 GLUCOSE TOL 3SP $ 108.00 80299 FLECAINIDE-SERUM $ 83.00 80299 AMOXAPINE-SERUM $ 293.00 82150 AMYLASE-24HR UR $ 59.00 80162 DIGOXIN TOTAL $ 126.00 80200 TOBRA-TROUGH $ 126.00 80170 GENTA-TROUGH $ 132.00 83088 HISTAMINE-BLOOD $ 134.00 83670 LAP-LEUC AMIN PEP $ 125.00 83050 METHEMOGLOBIN $ 125.00 84132 POTASSIUM-SERUM $ 36.00 83550 IRON-TIBC $ 93.00 82962 GLUCOSE-BLOOD-BEDSIDE $ 35.00 84520 BUN-UREA N $ 36.00 82175 ARSENIC-BLOOD $ 87.00 82495 CHROMIUM $ 239.00 82952 GLU TOL. 6TH HR $ 36.00 82340 CALCIUM - URINE $ 36.00 82131 CYSTINE QUANT $ 185.00 82310 CALCIUM-TOTAL-BLOOD $ 36.00 82382 CATECHOLAMINES-UR $ 79.00 82435 CHLORIDE-SERUM $ 36.00 82465 CHOLESTEROL $ 36.00 82480 CHOLINESTERASE $ 52.00 82375 CO/ CARBON MONOXIDE $ 29.00 82525 COPPER - URINE $ 58.00 82525 COPPER-SERUM $ 58.00 82374 CO2 CONTENT $ 36.00 !3 82550 CPK TOTAL $ 36.00 82570 CREAT-24HR URINE $ 36.00 82575 CREAT CLEAR-24HR $ 114.00 82565 CREATININE-BLOOD $ 36.00 82507 CITRIC ACID-URINE $ 344.00 82553 CKMB $ 111.00 80150 AMIKACIN-PEAK $ 118.00 80170 GENTAMICIN-PEAK $ 132.00 80200 TOBRAMYCIN-PEAK $ 126.00 82952 GLU TOL 5TH HR $ 36.00 84156 RAND UR PROTEIN $ 52.00 80051 ELECTROLYTE PL $ 68.00 80051 LYTES,24HR URINE $ 68.00 82668 ERYTHROPOIETIN $ 135.00 82710 FECAL FATS QUANT $ 239.00 82977 GGTP $ 36.00 84080 ALK PHOS ISOENZ $ 71.00 84134 PREALBUMIN-SERUM $ 71.00 82805 GASES-BLOOD $ 227.00 83491 GLUCORTICOID 170H $ 83.00 83655 LEAD-BLOOD/OCH $ 94.00 82947 GLUCOSE-FBS $ 36.00 83036 GLYCOHEMOGLOBIN $ 85.00 87899 HIV AG RAPID $ 90.00 82533 CORTISOL POST DEXAMETHASONE $ 185.00 83718 HDL CHOLESTEROL $ 108.00 83015 HEAVY METALS-UR $ 465.00 83090 HOMOCYSTEINE-SE $ 185.00 83540 IRON-SERUM $ 59.00 83605 LACTIC ACID $ 114.00 83615 LDH TOTAL-SERUM $ 36.00 83655 LEAD - URINE $ 94.00 83655 LEAD-BLOOD $ 94.00 83690 LIPASE $ 93.00 80178 LITHIUM $ 114.00 83735 MAGNESIUM-SERUM $ 59.00 83735 MAGNESIUM-URINE $ 59.00 83825 MERCURY BLOOD $ 73.00 83825 MERCURY-URINE $ 73.00 82131 METH. MALON SER $ 185.00 82131 METH. MALOMIC-UR $ 185.00 83874 MYOGLOBIN - SERUM $ 59.00 83874 MYOGLOBIN QNT-UR $ 59.00 83930 OSMOLALITY-SERUM $ 107.00 83935 OSMOLAL-24HR UR $ 107.00 83945 OXALATE URINE $ 60.00 82810 OXYGEN SAT-BLOOD $ 87.00 82800 PH-BLOOD $ 35.00 84105 PHOSPHORUS -URINE $ 36.00 84100 PHOSPHORUS-BLOOD $ 36.00 84106 PORPHOBIL-QUAL $ 37.00 84119 PORPHYRINS QU-UR $ 41.00 84133 POTASSIUM-24HR UR $ 36.00 84138 PREGNANETRIOL $ 290.00 84155 PROT TOTAL-W-CA $ 52.00 84220 PYRUVATE KINASE $ 129.00 !4 80194 QUINIDINE $ 132.00 84300 SODIUM-24HR URINE $ 36.00 84295 SODIUM-SERUM $ 36.00 80198 THEOPHYLLINE $ 132.00 84450 TRNSMNSE SGOT AST $ 36.00 84460 TRANSAMINASE SGPT $ 36.00 84478 TRIGLYCERIDES $ 36.00 84560 URIC ACID - URINE $ 36.00 84550 URIC ACID-BLOOD $ 36.00 84540 UUN-24HR URINE $ 36.00 84425 VITAMIN B1 $ 104.00 82180 VITAMIN C $ 41.00 82306 VITAMIN D (25-OH) $ 136.00 84620 XYLOSE TOLERANCE $ 66.00 83915 5'-NUCLEOTIDASE $ 180.00 82950 GLUCOSE PP W DOSE $ 50.00 80173 HALOPERIDOL-SER $ 83.00 84081 PG AMNIOTIC FL QUAL $ 77.00 80299 FLUPHENAZINE-SE $ 144.00 82247 BILIR-CORD BLD $ 36.00 86255 ACETYLCHOLINE RECEPTOR AB $ 176.00 84600 ALCOHOL METHYL, BLOOD $ 77.00 82105 ALPHA FETOPROTEIN, MATERN $ 140.00 80299 AMIODARONE, SERUM $ 83.00 82248 BILIRUBIN DIRECT, SERUM $ 36.00 82247 BILIRUBIN TOTAL, SERUM $ 36.00 82340 CALCIUM, RANDOM URINE $ 36.00 80048 BASIC MET PNL $ 79.00 80158 CYCLOSPORINE FPIA, SERUM $ 126.00 82955 G6PD QUANT. BLOOD $ 160.00 82947 GLUCOSE 1HR POST PRANDIAL $ 50.00 82947 GLUCOSE-SPINAL FLUID $ 36.00 87522 HCV RNA, QUANTITATIVE $ 211.00 86692 HEP B DELTA AB $ 180.00 87515 HEPATITIS B VIRUS DNA $ 374.00 86804 HEPATITIS C BY RIBA, SERU $ 316.00 83835 METANEPHRINES FRAC, URINE $ 140.00 82043 MICROALBUMIN, 24HR URINE $ 63.00 84311 PHOSPHOLIPIDS, SERUM $ 41.00 82951 3 HR GLUCOSE TOLERANCE, S $ 176.00 84066 ACID PHOSPHATASE PROSTATI $ 167.00 82024 ADRENOCORTICOTROPHIC HORM $ 254.00 82088 ALDOSTERONE, SERUM $ 254.00 82088 ALDOSTERONE, URINE $ 254.00 82164 ANGIOTENSIN CONV ENZYME,S $ 126.00 84703 BHCG QUALITATIVE, SERUM $ 47.00 84681 C-PEPTIDE, SERUM $ 98.00 86301 CARBOHYDRATE ANTIGEN 19-9 $ 100.00 88262 CHROMOSOME ANALYSIS,BLOOD $ 604.00 82533 CORTISOL, SERUM $ 185.00 82670 ESTRADIOL, SERUM $ 52.00 82677 ESTRIOL TOTAL, SERUM $ 71.00 82672 ESTROGENS TOTAL, SERUM $ 200.00 82728 FERRITIN, SERUM $ 125.00 82746 FOLATE, SERUM $ 125.00 83001 FOLLICLE STIMULATING HORM $ 125.00 !5 84439 FREE T4, SERUM $ 83.00 82941 GASTRIN, SERUM $ 83.00 84702 HCG MICRO DILUTION, SERUM $ 227.00 86709 HEPATITIS A AB IGM $ 136.00 86704 HEPATITIS B CORE ANTIBODY $ 136.00 86705 HEPATITIS B CORE IGM ANTI $ 136.00 86706 HEPATITIS B SURFACE ANTIB $ 93.00 87340 HEPATITIS B SURFACE ANTIG $ 93.00 86707 HEPATITIS BE ANTIBODY $ 125.00 87350 HEPATITIS BE ANTIGEN $ 176.00 83498 HYDROXYPROGESTERONE 17-AL $ 125.00 83525 INSULIN, SERUM $ 41.00 86337 INSULINE ANTIBODIES, SERU $ 373.00 86340 INTRINSIC FACTOR BLK