Description Amout Charged CPT CODE HCPCS ACIDOPHILUS 2 TABLET $11.00 RHYTHM STRIP ALONE $102.00 93041 DERMOPLAST PAIN SPRAY $29.36 FLU PED 0.25ML VAC $112.18 90685 FLU HD 0.5ML VAC(65YRS & UP) $257.50 90662 HEPARIN 5 UNIT/5ML FLUSH $34.90 FEMORAL NERVE BLOCK, SINGLE $560.00 64447 FEMORAL NERVE BLOCK, SINGLE $560.00 64447 VENTILATOR INIT/SUP $1,062.00 94002 PULSE OX OVERNIGHT STUDY $500.00 94762 ECHO, T.E.E. $1,210.00 93312 INTBAT ICU KIT SUP $78.00 CPT TX EVAL/DEMON $206.00 94667 UPDRFT 1ST TREATMENT $433.00 94640 O2 PER HOUR $24.00 SIMPLE SPIOMETRY (PFT) $135.00 94010 PRE/POST SPIRO EVAL (PFT) $478.00 94060 VENTILATOR SUBSEQ DA $754.00 94003 MED BRONCHO-DILATOR $19.00 HEATED MIST PER HR. $10.00 MDI INTIAL TREATMENT $433.00 94640 E.C.G. $154.00 93005 LIVER/SPLEEN SCAN $900.00 78216 SPLEEN SCAN W/WO VSF $811.00 78185 G.I. BLEEDING SCAN $1,152.00 78278 LUNG PERFUSION SCAN $840.00 78580 THYROID SCAN $551.00 78013 THYROID SCAN (123 I) $416.00 78012 THYROID SCN UPT MULT $697.00 78014 THYROID CA WHLE BODY $708.00 78018 BONE SCAN LIMIT AREA $918.00 78300 BONE SCAN WHOLE BODY $1,293.00 78306 BONE MARROW SCAN MLT $532.00 78103 RENAL SCAN W/VASFLOW $637.00 78701 MECKELS SCAN $465.00 78290 GALLIUM SCAN $2,337.00 78802 HEPATOBILIARY SCAN $792.00 78226 GASTRIC EMPTY SCAN $974.00 78264 THALLOUS CHLORI 4MCI $200.00 A9505 CISTERNOGRAPH $1,490.00 78630 MUGA SCAN $1,122.00 78472 MYO PERF TREADMILL $2,637.00 78452 RIBS UNIL INCLD CHST LT 3 V $281.83 71101 XRAY RIBS UNIL INCLD CHEST 3 V $281.83 71101 XRAY SPINE LUMBOSAC BND 2-3 V $149.65 72120 X-RAY HAND 2 VIEWS RT $281.83 73120 BONE SCAN, 3 PHASE $1,771.00 78315 X-RAY HAND 2 VIEWS LT $281.83 73120 GALLIUM SCAN 24HR $2,337.00 78802 GALLIUM SCAN 48HR $1,681.00 78804 GALLIUM SCAN 72HR $1,681.00 78804 MAA PER VIAL $82.00 A9540 BONE SPECT $1,164.00 78320 BRAIN SPECT $1,524.00 78607 MYOVIEW PER DOSE $761.00 A9502 CERETEC PER DOSE $1,887.00 A9521 LUNG/VENT/PERF QUANT $533.00 78598 RENOGRAM $921.00 78707 MDP UP TO 30 MCI $330.00 A9503 DTPA PER STUDY DOSE UP 25 MCI $227.00 A9539 SKELTL SRVY MORE 1YR $572.00 77075 SCAPULA, RIGHT $148.00 73010 XRAY CERVICAL SPINE 4 OR 5 V $376.00 72050 RAD EX STERNOCLAV (S) MIN 3 VI $160.00 71130 X-RAY CLAVICLE, RIGHT $175.00 73000 STERNUM MIN 2 VIEWS $189.00 71120 RIBS UNI 2 VIEWS RT $340.00 71100 X-RAY RIBS, BILAT 3 VIEWS $310.00 71110 SHOULDER 1 VIEW RIGHT $193.00 73020 SHOULDER 2 VIEWS, RT $244.00 73030 SHOULDER COMPLETE, RT MIN 2 V $305.00 73030 ELBOW RT 2 VIEWS $191.00 73070 FOREARM RT 2 VIEWS $282.00 73090 FINGER/FINGERS RT MIN 2 VIEWS $151.00 73140 HAND 3 VIEW RT $360.00 73130 HUMERUS 2 VIEW RT $233.00 73060 THORACIC SPINE 3VIEW $347.00 72072 LUMBOSAC SPINE >=4 $291.00 72110 X-RAY PELVIS 1-2 VIEWS $198.00 72170 PELVIS, 3 VIEWS $238.00 72190 LEG, RT 2 VIEWS $208.00 73590 TOE/TOES 2 VIEWS RT $150.00 73660 BONE AGE $172.00 77072 HEEL-OS CALCIS MIN 2 VIEWS RT $176.00 73650 WRIST COMPLETE RT MIN 3 V $257.00 73110 WRIST RT 2 VIEWS $170.00 73100 ANKLE COMPLETE RT MIN 3 V RT $307.00 73610 FEMUR, RT MIN 2 VIEWS $182.00 73552 FOOT COMPLETE MIN 3 VIEWS RT $329.00 73630 HIP 1 VIEW RT $131.00 73501 PROMETHAZINE HCL 50MG CREAM $16.00 HIP 2 - 3 VIEWS RT $182.00 73502 KNEE 1-2 VIEWS RT $140.00 73560 RAD EX KNEE, COM => 4 VIEWS RT $179.00 73564 X-RAY EYE/FOREIGN BODY RT $169.00 70030 RAD EX FACIAL BONES, MIN 3 VI $322.00 70150 MANDIBLE, PARTIAL < 4 VIEWS $126.00 70100 MANDIBLE COMPLETE MIN 4 VIEWS $145.00 70110 MASTOIDS 3 OR MORE $294.00 70130 RAD EX NASAL BONE, COM MIN 3 V $211.00 70160 SELLA TURCICA $193.00 70240 RAD EX SINUS, PARANASAL < 3 VI $195.00 70210 XRAY SINUSES PARANASAL MIN 3 V $247.00 70220 SKULL < 4 $231.00 70250 RAD EX SKULL, COM MIN 4 VIEWS $292.00 70260 T-M JOINT, BILATERAL $648.00 70330 RAD EXAM, FACIAL < 3 VIEWS $229.00 70140 PYELOGRAM (IVP) $1,279.00 74400 PYELOGRAM RETROGRADE $748.00 74420 ACUTE ABDOMEN SERIES $382.00 74022 ABDOMEN (KUB) 1 VIEW $191.00 74018 ABDOMEN 2 VIEWS $197.00 74019 ESOPHAGRAM $453.00 74220 CHOLANGIOGRAM OPERAT $438.00 74300 FLUOROSCOPY $398.00 76000 CHOLANGIOGRAM T-TUBE $5,871.00 47531 SMALL BOWEL SERIES $317.00 74250 BARIUM ENEMA $418.00 74270 BE COLON W AIR & BARIUM $586.00 74280 UPPER/GI SERIES $552.00 74240 X-RAY CHEST 1 VIEW $183.00 71045 CHEST PA & LAT 2 VIEWS $216.00 71046 INSERT LEADLESS C PM/RPL VENTR $42,895.00 33274 INS TRANSCATH PACEMAKER LEADLE $40,651.00 TOMOGRAMS $351.00 76100 METASTATIC SURVY LMT $196.00 77074 IVP/TOMOS $1,279.00 74400 X-RAY CERVICAL SPINE 2-3 VIEWS $348.00 72040 XRAY THORACIC SPINE AP&L 2 VIE $340.00 72070 LUMBAR SPINE AP&LAT 2 OR 3 V $259.00 72100 HIPS, BILATERAL $175.00 73521 FLUOROSCOPY OVER 60M $398.00 76000 SCANOGRAM $242.00 77073 ASPIRTION/INJCTION MAJOR JOINT $1,159.00 REM, NON-BIO DRUG DEL IMPLANT $767.00 ANOSCOPY W/POLYPECTOMY $5,385.00 X-RAY NECK, SOFT TISSUE $203.00 70360 CT SELLA/EAR/ORB WO $1,402.00 70480 CT CHEST WO CNTRST $930.00 71250 CT CHEST WI CNTRST $1,977.00 71260 CT CERV SPINE WO CNT $1,834.00 72125 CT CERV SPINE WI CNT $5,204.00 72126 CT THORACIC SPINE WI CONTRAST $3,301.00 72129 CT LUMBOSPINE WI CNT $5,204.00 72132 CT PELVIS WI CNTRST $1,784.00 72193 CT UP EXT RT WO/CONT $1,479.00 73200 CT UP EXT RT W/CONTR $1,479.00 73201 CT UP EXT RTW/WO CON $1,833.00 73202 CT LO EXT WO/CONTRAS $1,377.00 73700 CT LO EXT RT W/CONTR $1,734.00 73701 CT LO EXT RTW/WO CON $2,106.00 73702 CT ABDMN WI CNTRST $2,197.00 74160 EXECUTIVE CHEST 2 VIEWS $216.00 71046 CT NECK WI/WO CNTRST $2,431.00 70492 CT NECK WI CNTRST $2,294.00 70491 CT NECK WO CNTRST $1,882.00 70490 CT LIMITED STUDY $622.00 76380 INSRT/REP SGL CHAM PM VENTRICU $15,821.00 33207 CT HEAD WI CONTRAST $1,995.00 70460 CT HEAD WO/WI CNTRST $3,000.00 70470 CT SELL/EAR/ORB WO/W $1,887.00 70482 CT CHEST WO/WI CNTRS $2,886.00 71270 CT PELVIS WO/WI CNTR $1,971.00 72194 CT ABD WO/WI CNTRST $2,494.00 74170 CT HEAD WO CONTRAST $2,000.00 70450 CT PELVIS WO CNTRST $1,778.00 72192 CT THOR SPINE WO CNT $1,957.00 72128 CT LUMBOSPINE WO CNT $1,685.00 72131 CT MAXILLOFACIAL WI $1,730.00 70487 CT MAXILLOFACIAL W/O $1,441.00 70486 CT ABDMN WO CNTRST $1,426.00 74150 VIDEO FLUOR. SWA.STY $362.00 74230 US HEPATIC $472.00 76705 US EXTREMITY RT $193.00 76882 US SCROTUM $618.00 76870 US PELVIS COMPLETE $473.00 76856 US OB COMPLETE $271.00 76805 MAMMO SURG SPECIMEN $564.00 76098 US ABDOMEN $637.00 76700 US GALLBLADDER $472.00 76705 MAMMOGRAM BILATERAL $187.00 77066 CT 3D RENDER W/O WS $268.00 76376 PULSE OX SINGLE DETERMINE $70.00 94760 MAMMO SCRN/INDUSTRY $155.00 77067 MRI BRAIN W/O CONT $2,429.00 70551 MRI ORB/FAC/NECK WO $1,568.00 70540 MRI CERV SPINE WO $2,051.00 72141 MRI THROAC SP WO $2,644.00 72146 MRI LUMB SPINE WO $2,105.00 72148 MRI ABDOMEN WO CONT $1,490.00 74181 MRI CHEST WO CONT $2,200.00 71550 DLCO TEST (PFT) $266.00 94729 VENOUS PH $48.00 83986 O2 PER 24 HRS. $442.00 CPAP INITIAL $318.00 94660 INFER VENCAV GRM S&I $5,838.00 75825 IVC FILTER PLACEMENT $5,548.00 37191 INSRT PM PULSE GEN SNGL LEAD $7,960.00 33212 PERCSTNT REN PLVS RT $5,404.00 50695 PERCCATH REN PLVS RT $4,540.00 50433 MRI UP EXT JNT RT W/O CONTRAST $2,838.00 73221 MRI LO EXT JNT RT WO $2,904.00 73721 OXYGEN SATURATIN SDY $92.00 82810 AMNISURE $245.00 84112 PLSEOX MULTI/CONT DY $102.00 94761 INSRT/REP DUAL CHAM PM ATRL VE $17,012.00 33208 ART. DUPLEX BILAT $1,164.00 93925 ART. UNILAT STUDY RT $674.00 93926 ECHO, 2D/M MODE $1,200.00 93306 US PELVIS TRANS.VAG. $675.00 76830 US RENAL, UNI RT $377.00 76775 US AORTA $377.00 76775 US OB LIMITED 1 + FETUS $233.00 76815 US FTL AGE FLUP Q FS $494.00 76816 US THYROID $530.00 76536 US BABY HEAD $241.00 76506 ULTRASOUND BREAST LIMITED,UNIL $484.00 76642 US CHEST $316.00 76604 MYOCARDIAL BIOPSY $3,024.00 93505 STRESS W/RHYTHM STRP $678.00 93017 GLUCOSE $44.00 82947 GLUCOSE - 2 HR $44.00 82947 GLUCOSE PC /GLUCOLA $51.00 82950 BUN $46.00 84520 SODIUM $47.00 84295 POTASSIUM $40.00 84132 CHLORIDES $61.00 82435 CO 2 $31.00 82374 CALCIUM $47.00 82310 PHOSPHORUS $54.00 84100 URIC ACID $40.00 84550 AMYLASE $60.00 82150 BILIRUBIN (TOTAL) $52.00 82247 BILIRUBIN (DIRECT) $55.00 82248 ALKALINE PHOSPHATASE $75.00 84075 PROTEIN/SERUM $41.00 84155 ALBUMIN / SERUM $39.00 82040 ALPHA-1-ANTITRYPSIN MUT ANA SO $174.00 81332 SGOT $45.00 84450 SGPT $28.00 84460 LDH $43.00 83615 CPK $66.00 82550 CHOLESTEROL $54.00 82465 CREATININE (SERUM) $50.00 82565 EXC TR-EXT B9+MAR 3.1-4 CM LES $374.00 11404 T4 FREE $78.00 84439 IRON $48.00 83540 IRON BINDING (TOTAL) $63.00 83550 TRIGLYCERIDES $38.00 84478 ANTI QGIB AB SO $463.00 83520 MTB COMPLEX PCR SO $818.00 87801 URINE CREAT.