CMH PHYSICIAN PRACTICE PRICING EFFECTIVE FEBRUARY 1, 2018 SERVICE DESCRIPTION PRICE 1 lung with ventilation; PRO $1,600.00 12 LEAD EKG $0.01 1ST HOSP CARE PR D 30 MIN $201.13 1ST HOSP CARE PR D 50 MIN $271.90 1ST HOSP CARE PR D 70 MIN $402.72 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB $258.16 1ST HOSP/BIRTHING CENTER NB ADMIT&DSCHG SM DATE $294.25 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/< $2,592.55 1ST INPT CONSLTJ 110 MIN $475.01 1ST INPT CONSLTJ 20 MIN $114.73 1ST INPT CONSLTJ 40 MIN $176.70 1ST INPT CONSLTJ 55 MIN $269.62 1ST INPT CONSLTJ 80 MIN $388.96 1ST NF CARE PR D E/M HI SEVERITY $320.35 1ST NF CARE PR D E/M LW SEVERITY $237.44 1ST NF CARE PR D E/M MOD SEVERITY $251.01 1ST OBS CARE PR D HIGH SEVERITY $369.28 1ST OBS CARE PR D LOW SEVERITY $198.80 1ST OBS CARE PR D MODERATE SEVERITY $269.53 1ST PREVENTIVE MEDICINE NEW PATIENT < 1YR $274.17 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 12-17 YR $294.88 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 1-4 YRS $271.93 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 18-39YRS $338.17 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 40-64YRS $379.14 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 5-11 YRS $290.27 1ST PREVENTIVE MEDICINE NEW PATIENT AGE 65YRS&> $76.69 2 OR MORE FALLS WITH INJURY $0.01 7 FIELD PHOTO INTERP DOC REV $0.01 76856 U/S PELVIC COMPL/OFC; PRO $319.25 ABD PARACENTESIS WO IMAGING $219.25 ABDL LMPHADEC REG CELIAC GSTR PORTAL PRIPNCRTC $740.82 ABDOM PARACENTESE WO/IMAGING GUIDANCE $465.49 ABDOMEN ULTRASOUND LTD $215.32 Abdominoperineal resection; PRO $800.00 ABLATION & RCNSTJ ATRIA LMTD $3,868.03 ABLTJ SOF TISS INF TURBS UNI/BI SUPFC $539.42 ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL $800.04 Access to CVC; PRO $500.00 ACETABULOPLASTY $3,708.81 ACETABULOPLASTY RESECTION FEMORAL HEAD $3,130.04 ACNE SURGERY $270.19 ACUP 1/> NDLS W/ELEC STIMJ 1ST 15 MIN $40.10 ACUP 1/> NDLS W/ELEC STIMJ EA 15 MIN W/RE-INSJ $37.88 ACUP 1/> NDLS W/O ELEC STIMJ 1ST 15 MIN $40.10 ACUP 1/> NDLS W/O ELEC STIMJ EA 15 MIN $27.85 ADENOIDECTOMY PRIM AGE 12/> $663.20 ADENOIDECTOMY PRIM UNDER AGE 12 $613.63 ADJACENT TISSUE TRANSFER/REARGMT TRUNK 10 CM/< $1,464.90 ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES $1,305.01 ADMN&INTERPJ HLTH RISK ASSMT INSTRUMENT $35.65 Adrenalectomy; PRO $1,100.00 ADRENALIN 1 ML $8.00 ADRENALIN, EPINEPHRINE $5.00 ADVNC CARE PLAN IN RCRD $0.01 ADVNC CARE PLAN TLK DOCD $0.01 ADVNCD CARE PLAN 30 MINS $206.10 ADVNCD CARE PLAN ADDTL 30 MINS $204.65 AFO; PREFAB W/FITTING+AD $133.02 AIR CAST $315.59 ALBUTEROL UNIT 1MG $5.00 ALGINATE OR OTHER FIBER GELLING DRESSING $22.32 All procedures nerve, muscle, tendon, knee; PRO $500.00 All procedures nerve, muscle, tendon, upper leg; PRO $500.00 All procedures veins includes exploration; PRO $400.00 ALLERGEN IMMUN OTHER SERUM $23.97 ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED $535.60 ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL $306.95 ALUMINUM CRUTCHES $74.28 Amniocentesis Anes; PRO $500.00 AMNIOCNTS DX $362.67 AMNISURE/ROM POINT OF CARETEST $40.00 AMNT PAIN NOTED NONE PRSNT $0.01 AMNT PAIN NOTED PAIN PRSNT $0.01 AMP ANKLE-MALLI TIBFIB W/PLSTC CLSR&RESCJ NRV $1,955.09 AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT LOCAL FLAP $1,864.29 AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT W/DIR CLSR $1,860.26 AMP LEG THRU TIBFIB W/IMMT FITG TQ W/1ST CST $2,496.84 AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION $1,946.49 AMP LEG THRU TIBIA&FIBULA SEC CLOSURE/SCAR REVJ $1,653.98 AMP MTCRPL W/FNGR/THMB 1 +-INTEROSS TR $2,018.04 AMP THIGH THRU FEMUR SEC CLOSURE/SCAR REVISION $1,408.07 AMPUTATION ARM THRU HUMERUS W/PRIMARY CLOSURE $1,997.76 AMPUTATION FOOT MIDTARSAL $1,560.01 AMPUTATION FOOT TRANSMETARSAL $2,172.56 AMPUTATION FOREARM THROUGH RADIUS & ULNA $2,015.45 AMPUTATION LEG THROUGH TIBIA&FIBULA $2,714.26 AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR $1,778.00 AMPUTATION METATARSAL W/TOE SINGLE $1,277.87 AMPUTATION THIGH THROUGH FEMUR ANY LEVEL $2,372.98 AMPUTATION THIGH THROUGH FEMUR RE-AMPUTATION $2,132.81 AMPUTATION TOE INTERPHALANGEAL JOINT $1,124.55 AMPUTATION TOE METATARSOPHALANGEAL JOINT $1,199.88 Amputation; PRO $600.00 ANALYZE PACEMAKER SYSTEM; PRO $645.02 ANES Gastrocnemius recession $600.00 ANGIOGRAPHY EXT BIL $191.36 ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I $52.53 ANGRPH XTR UNI RS&I $167.32 ANKLE DISARTICULATION $1,868.31 ANKLE FOOT ORTHOSIS AFO $689.67 ANKLE FOOT ORTHOTIC $146.32 ANNUAL DEPRESSION SCR 15 MIN; PRO $52.18 ANNUAL WELLNESS VISIT INITIAL $499.65 ANNUAL WELLNESS VISIT SUBSEQ $335.27 Anorectal procedure; PRO $600.00 ANOSC DX +-COLLJ SPEC BR/WA SPX $243.29 ANRCT XM SURG REQ ANES GENERAL SPI/EDRL DX $318.00 ANT COLPORRHAPHY RPR CSTOCELE +-RPR URETHROCELE $1,953.82 ANTB HIV-1 $20.00 ANTEPARTUM C DLVR&POSTPARTUM FA V AP C DLVER $5,558.86 ANTEPARTUM CARE ONLY 4-6 VSTS $1,274.26 ANTEPARTUM CARE ONLY 7+ VSTS $2,288.04 ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS $2,119.82 ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS $3,605.00 ANTERIOR TIBIAL TUBERCLEPLASTY $2,240.63 ANTI RHEUM DRUGTHXPYRXD GVN $0.01 ANTIGEN,RAPID GROUP A STREP $39.00 AORTOGRAPY ABDL SRLOGRAPY RS&I $165.83 APLIGRAF,PER SQUARE CM $81.69 APPENDEC INDICATED PURPOSE OTH MAJOR PX X SPX $246.51 APPENDEC RPTD APPENDIX ABSC/PRITONITIS $2,493.56 APPENDECTOMY INCIDENTAL TO PROCEDURE $1,885.51 APPL CLUBFOOT CAST MOLDING/MNPJ LONG/SHORT LEG $352.65 APPL HIP SPICA CAST ONE&ONE-HALF SPICA/BOTH LEGS $768.36 APPL SURF TC NSTIM $46.80 APPLICATION CAST ELBOW FINGER SHORT ARM $251.32 APPLICATION CAST HAND&LOWER FOREARM GAUNTLET $227.23 APPLICATION CAST SHOULDER HAND LONG ARM $279.72 APPLICATION CYLINDER CAST THIGH ANKLE $290.15 APPLICATION FINGER SPLINT STATIC $97.72 APPLICATION FINGER SPLINT STATIC ER PHY $65.05 APPLICATION INTERVERTEBRAL BIOMECHANICAL DEVICE $1,116.68 APPLICATION LONG ARM SPLINT SHOULDER HAND $248.17 APPLICATION LONG LEG CAST THIGH-TOE $386.18 APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE $373.11 APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES $226.92 APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM $2,656.14 Application of lower leg cast removal or repair; PRO $400.00 APPLICATION SHORT ARM SPLINT DYNAMIC $223.51 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC $182.53 APPLICATION SHORT LEG CAST BELOW KNEE-TOE $231.41 APPLICATION SHORT LEG SPLINT CALF FOOT $203.27 APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM $1,417.63 APPLY FEET, DIG, TO 100 SQCM; 1ST 25 SQ CM $419.99 APPLY SHORT LEG CAST $222.02 APPROPRIATE EMPIRIC ANTIBIOTIC PRESCRIBED $0.01 ARANESP/MCG NON ESRD $14.40 Arteries of knee and popliteal area; PRO $900.00 ARTERIOVENOUS ANASTOMOSIS OPEN DIRECT $1,985.00 Arteriovenous fistula; PRO $700.00 ARTHO KNEE OSTEOCHOND ALLOGRAFT $3,695.30 Arthoscopic ankle and/or foot; PRO $400.00 Arthoscopic elbow procedures; PRO $400.00 ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 $4,998.89 ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC $1,545.00 ARTHRD ANT MIN DISCECT INTERBODY CERV BELW C2 $3,672.98 ARTHRD CARP/MTCRPL JT DGT OTH/THN THMB W/AGRFT $2,269.18 ARTHRD CARP/MTCRPL JT DGT OTHER THAN THUMB EACH $2,036.13 ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ $2,067.08 ARTHRD IPHAL JT +-INT FIXJ $1,626.63 ARTHRD IPHAL JT +-INT FIXJ EA IPHAL JT $297.27 ARTHRD IPHAL JT +-INT FIXJ W/AGRFT $2,010.24 ARTHRD IPHAL JT +-INT FIXJ W/AGRFT EA JT $624.59 ARTHRD MIDTARSL/TARS MLT/TRANSVRS $2,157.08 ARTHRD MIDTARSL/TARS MLT/TRANSVRS W/OSTEOT $2,303.44 ARTHRD MTCARPHLNGL JT +-INT FIXJ $1,938.96 ARTHRD MTCARPHLNGL JT +-INT FIXJ W/AGRFT $2,202.09 ARTHRD W/TDN LNGTH&ADVMNT TARSL NVCLR-CUNEIFORM $1,957.99 ARTHRD W/XTNSR HALLUCIS LONGUS TR 1ST METAR NCK $1,892.39 ARTHRD WRST COMPL W/O B1 GRF $2,084.54 ARTHRD WRST W/ILIAC/OTH AGRFT $2,427.61 ARTHRD WRST W/SLIDING GRF $2,274.97 ARTHRO ANKLE EXCISION OF OSTEOCHON DEFECT $1,960.29 ARTHRO KNEE MEN REPAIR MED AND LATERAL $2,436.13 ARTHROCENTESIS ASPIR&/INJECTION INTERM JT/BURSA $141.78 ARTHROCENTESIS ASPIR&/INJECTION MAJOR JT/BURSA $174.07 ARTHROCENTESIS ASPIR&/INJECTION SMALL JT/BURSA $135.01 ARTHRODESIS ANKLE OPEN $2,937.80 ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC $968.43 ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT $1,389.54 ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT $2,395.75 ARTHRODESIS KNEE ANY TECHNIQUE $4,087.53 ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR $1,029.11 ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR $4,774.51 ARTHRODESIS MIDTARSOMETATARSAL SINGLE JOINT $2,076.24 ARTHRODESIS PANTALAR $3,469.18 ARTHRODESIS POSTERIOR/POSTEROLATERAL EA ADDL $1,142.02 ARTHRODESIS POSTERIOR/POSTEROLATERAL LUMBAR $4,498.47 ARTHRODESIS SACROILIAC JOINT $1,821.22 ARTHRODESIS SACROILIAC JOINT W/OBTAINING GRAFT $3,253.88 ARTHRODESIS SUBTALAR $2,283.15 ARTHRODESIS TRIPLE $2,236.78 ARTHRODESIS WRIST LIMITED W/AUTOGRAFT $2,122.42 ARTHRODESIS WRIST LIMITED W/O BONE GRAFT $1,665.58 ARTHROPLASTY ANKLE $1,725.24 ARTHROPLASTY ELBOW W/MEMBRANE $2,507.62 ARTHROPLASTY FEM CONDYLES/TIBIAL PLATEAU KNEE $2,362.69 ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER $4,269.22 ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY $3,525.83 ARTHROPLASTY INTERPHALANGEAL JOINT EACH $1,201.36 ARTHROPLASTY INTERPHALANGEAL JT W/PROSTHETIC EA $2,056.58 ARTHROPLASTY KNEE HINGE PROSTHESIS $3,428.25 ARTHROPLASTY PATELLA W/O PROSTHESIS $1,835.17 ARTHROPLASTY PATELLA W/PROSTHESIS $2,340.35 ARTHROPLASTY RADIAL HEAD $1,781.57 ARTHROPLASTY RADIAL HEAD W/IMPLANT $1,897.69 Arthroscopic procedure hip joint; PRO $500.00 Arthroscopic shoulder procedure; PRO $500.00 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE $1,661.51 ARTHROSCOPY ANKLE SURGICAL SYNOVECTOMY PARTIAL $1,417.28 ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOOSE/FB $1,160.10 ARTHROSCOPY HIP SURGICAL W/SYNOVECTOMY $1,927.08 ARTHROSCOPY KNEE DIAGNOSTIC +-SYNOVIAL BX