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 0.45 % NACL WITH KCL 20 MEQ 20 MEQ/L SOLP 1,000 ML J3480 $26.60 3D REPORT WITH WORKSTATION 76377 $1,765.00 3D REPORT WITHOUT WORKSTATION 76376 $1,518.00 40 MEQ POTASSIUM CHLORIDE IN 0.9% SODIUM CHLORIDE J3480 $20.90 AB TITER FLOUR NON INFECT EA 86256 $23.00 ABACAVIR 300 MG TAB 30 EACH BLIST PACK $76.30 ABACAVIR 300 MG TAB 50 EACH BLIST PACK $76.33 ABATACEPT (WITH MALTOSE) 250 MG SOLR 1 EACH VIAL J0129 $9,541.80 ABCIXIMAB 10 MG/5 ML SOLN 5 ML VIAL J0130 $11,290.56 ABDOMINAL ASPIRATION OF FLUID SURROUNDING FETUS FO 59000 $911.00 ABDOMINAL ASPIRATION TO REDUCE AMOUNT OF FLUID SUR 59001 $1,451.00 ABDOMINAL INFUSION OF NORMAL SALINE INTO FETAL AMN 59070 $815.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS 76812 $242.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS (LESS THAN 76802 $526.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS SINGLE OR 76801 $792.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS SINGLE OR 76805 $840.00 ABDOMINAL ULTRASOUND OF PREGNANT UTERUS SINGLE OR 76811 $825.00 ABDOMINAL ULTRASOUND PREGNANT UTERUS (GREATER OR E 76810 $714.00 ACAMPROSATE 333 MG TBEC 50 EACH BLIST PACK $7.87 ACARBOSE 25 MG TAB 100 EACH BOTTLE $6.84 ACE - ANGIO CONVERTING ENZYME 82164 $211.00 ACEBUTOLOL 200 MG CAP 50 EACH BLIST PACK $8.22 ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) SOLN 100 J0131 $396.72 ACETAMINOPHEN 120 MG SUPP 1 EACH BOX $2.95 ACETAMINOPHEN 32 MG/ML SYRG 2.5 ML SYRINGE $47.55 ACETAMINOPHEN 325 MG SUPP 1 EACH BOX $1.50 ACETAMINOPHEN 325 MG SUPP 12 EACH BOX $4.98 ACETAMINOPHEN 325 MG TAB 100 EACH BLIST PACK $0.49 ACETAMINOPHEN 325 MG TAB 100 EACH BOTTLE $0.49 ACETAMINOPHEN 325 MG TAB 100 EACH BOX $0.49 ACETAMINOPHEN 325 MG TAB 750 EACH BLIST PACK $0.48 ACETAMINOPHEN 500 MG TAB 1,000 EACH BOTTLE $0.15 ACETAMINOPHEN 500 MG TAB 100 EACH BLIST PACK $0.40 ACETAMINOPHEN 500 MG TAB 100 EACH PACKAGE $0.40 ACETAMINOPHEN 650 MG SUPP 50 EACH BOX $4.51 ACETAMINOPHEN 650 MG/20.3 ML SOLN 20.3 ML CUP $9.26 ACETAMINOPHEN-CODEINE 120-12 MG/5 ML SOLN 473 ML B $0.72 ACETAMINOPHEN-CODEINE 300-15 MG TAB 100 EACH BOTTL $2.31 ACETAMINOPHEN-CODEINE 300-30 MG TAB 1 EACH BLIST P $2.74 ACETAMINOPHEN-CODEINE 300-30 MG TAB 100 EACH BLIST $2.74 ACETAMINOPHEN-CODEINE 300-60 MG TAB 100 EACH BLIST $5.36 ACETAMINOPHEN-TYLENOL) 80307 $369.00 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 ACETAZOLAMIDE 250 MG TAB 100 EACH BLIST PACK $15.91 ACETAZOLAMIDE 500 MG CPSR 100 EACH BOTTLE $32.63 ACETAZOLAMIDE 500 MG CPSR 30 EACH BLIST PACK $37.20 ACETAZOLAMIDE 500 MG SOLR 1 EACH VIAL J1120 $200.45 ACETIC ACID (BULK) 3 % LIQD 500 ML BOTTLE $193.80 ACETIC ACID (BULK) 5 % LIQD 500 ML BOTTLE $193.80 ACETIC ACID 0.25 % SOLN 1,000 ML BOTTLE $53.20 ACETIC ACID 2 % SOLN 15 ML BOTTLE $900.14 ACETIC ACID 2 % SOLN 15 ML DROP BTL $304.04 ACETIC ACID-HYDROCORTISONE 1-2 % DROP 10 ML DROP B $1,546.07 ACETYLCHOLINE BINDING AB 83519 $1,153.00 ACETYLCHOLINE BLOCK AB 83516 $130.00 ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) KIT 1 EACH K $859.03 ACETYLCHOLINE MODULATING AB 83516 $130.00 ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 10 ML VIAL $110.81 ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL J0132 $1,714.56 ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 4 ML $29.16 ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 4 ML VIAL $28.43 ACIDOPHILUS 100 MILLION CELL GRPK 1 EACH PACKET $15.44 ACIDOPHILUS 100 MILLION CELL GRPK 12 EACH PACKET $7.39 ACIDOPHILUS-SPOROGENES 35 MILLION- 25 MILLION CELL $1.60 ACNE SURGERY 10040 $266.00 ACTH LEVEL 82024 $324.00 ACTIVATED CHARCOAL 25 GRAM/120 ML SUSP 120 ML BOTT $9.12 ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSP 12 $9.12 ACTIVITY THERAPY G0176 $1,090.00 ACUTE DIGESTIVE TRACT BLOOD LOSS IMAGING 78278 $873.00 ACYCLOVIR 200 MG CAP 100 EACH BLIST PACK $11.62 ACYCLOVIR 200 MG/5 ML SUSP 473 ML BOTTLE $17.88 ACYCLOVIR 400 MG TAB 100 EACH BLIST PACK $4.90 ACYCLOVIR 50 MG/ML SOLN 10 ML VIAL J0133 $102.60 ACYCLOVIR 50 MG/ML SOLN 20 ML VIAL J0133 $191.52 ADEFOVIR 10 MG TAB 30 EACH BOTTLE $430.16 ADENOSINE (DIAGNOSTIC) 3 MG/ML SOLN 30 ML VIAL J0153 $2,587.34 ADENOSINE 3 MG/ML SOLN 2 ML VIAL J0153 $28.26 ADENOSINE 3 MG/ML SYRG 2 ML SYRINGE J0153 $164.31 ADENOVIRUS ANTIGEN IMMUNOFLUORESCENT 87260 $522.00 ADMIN AND INTERPRETATION OF PATIENT FOCUSED HEALTH 96160 $92.00 ADMINISTRATION FLU VIRUS VACCINATION 90471 $124.00 ADMINISTRATION HEPATITIS B VACCINATION 90471 $154.00 ADMINISTRATION OF 1 VACCINE 90471 $106.00 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 ADMINISTRATION OF DRUG FOR HELICOBACTER PYLORI 83014 $61.00 ADMINISTRATION OF INFLUENZA VIRUS VACCINE SUBSEQUE 90472 $106.00 ADMINISTRATION OF MEDICATION TO INDUCE VOMITING 99175 $320.00 ADMINISTRATION OF VACCINE 90472 $106.00 ADMINISTRATION PNEUMOCOCCAL VACCINATION 90471 $153.00 ADO-TRASTUZUMAB EMTANSINE 100 MG SOLR 1 EACH VIAL J9354 $26,847.00 ADO-TRASTUZUMAB EMTANSINE 160 MG SOLR 1 EACH VIAL J9354 $42,955.20 ADRENAL GLAND STIMULATION PANEL 80412 $2,577.00 AG DETECT LEGIONELLA EIA QL MULTI 87449 $461.00 AIR AND BONE CONDUCTION ASSESSMENT OF HEARING LOSS 92557 $330.00 AL HYD-MG TR-ALG AC-SOD BICARB 80-14.2 MG CHEW 100 $0.55 ALBUMIN, FLUID 82042 $58.00 ALBUMIN, HUMAN 25 % 25 % SOLP 100 ML FLEX CONT P9047 $1,064.00 ALBUMIN, HUMAN 25 % 25 % SOLP 50 ML FLEX CONT P9047 $532.00 ALBUMIN, HUMAN 5 % SOLP 250 ML FLEX CONT P9045 $338.20 ALBUTEROL 1.25 MG/3 ML NEBU 3 ML VIAL $12.61 ALBUTEROL 2 MG/5 ML SYRP 473 ML BOTTLE $2.39 ALBUTEROL 2.5 MG /3 ML (0.083 %) NEBU 3 ML VIAL $11.92 ALBUTEROL 90 MCG/ACTUATION HFAA 18 G CANISTER $504.93 ALBUTEROL 90 MCG/ACTUATION HFAA 6.7 G CANISTER $727.19 ALBUTEROL 90 MCG/ACTUATION HFAA 8 G CANISTER $189.70 ALBUTEROL 90 MCG/ACTUATION HFAA 8.5 G CANISTER $543.22 ALCOHOL 98 % SOLN 5 ML AMPUL $1,082.05 ALCOHOL 98 % SOLN 5 ML VIAL $768.06 ALCOHOL-ETHYL, URINE 80320 $342.00 ALCOHOLS LEVELS 80322 $246.00 ALDOSTERONE SUPPRESSION EVALUATION PANEL 80408 $982.00 ALENDRONATE 10 MG TAB 100 EACH BOTTLE $11.12 ALENDRONATE 10 MG TAB 20 EACH BLIST PACK $22.21 ALENDRONATE 70 MG TAB 12 EACH BLIST PACK $11.06 ALENDRONATE 70 MG TAB 20 EACH BLIST PACK $16.25 ALFENTANIL 500 MCG/ML SOLN 2 ML AMPUL $31.92 ALFENTANIL 500 MCG/ML SOLN 5 ML AMPUL $28.67 ALFUZOSIN 10 MG TB24 100 EACH BOTTLE $26.87 ALIGNMENT OF KNEE JOINT UNDER ANESTHESIA 27570 $5,063.00 ALISKIREN 150 MG TAB 30 EACH BOTTLE $54.69 ALLERGENS, EA (RAST) 86003 $49.00 ALLOPURINOL 100 MG TAB 100 EACH BLIST PACK $2.87 ALLOPURINOL 300 MG TAB 100 EACH BLIST PACK $5.76 ALLOPURINOL 500 MG SOLR 1 EACH VIAL $43,634.37 ALPRAZOLAM 0.25 MG TAB 1 EACH BLIST PACK $4.96 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.