Bill Item Long Desc Explanation Notes Price Stool for Occult Blood POC 44.00 Blood Glucose Monitoring POC 15.00 Urine Dipstick POC 51.00 URINE PREGNANCY TEST POC 47.00 Amylase Level 85.00 Home Visit Level 1 Established - 125.00 Home Visit Level 2 Established 170.00 Home Visit Level 3 Established 200.00 Hospital Discharge Management 30 min or Less - 160.00 Initial Hospital Care Level 1 - 200.00 Initial Hospital Care Level 2 - 300.00 Initial Hospital Care Level 3 - 400.00 Initial Observation Care Level 1 200.00 Initial Observation Care Level 2 - 300.00 Initial Observation Care Level 3 400.00 Nursing Facility Discharge Management 30 min or Less 150.00 Obs/ Same Day Inpatient Care Level 1 300.00 Observation/ Same Day Inpatient Care Level 2 400.00 Observation/ Same Day Inpatient Care Level 3 500.00 Observation Care Discharge - 160.00 Office/Outpatient Visit Level 1 Established 40.00 Office/Outpatient Visit Level 3 Established Specialty 160-190 Preventive Medicine 1-4 years New 235.00 Preventive Medicine 12-17 years Established 235.00 Preventive Medicine 12-17 years New 275.00 Preventive Medicine 18-39 years Established 240.00 Preventive Medicine 18-39 years New 275.00 Preventive Medicine 40-64 years Established 280.00 Preventive Medicine 40-64 years New 345.00 Preventive Medicine 5-11 years New 245.00 Preventive Medicine 65+ years Established 285.00 Preventive Medicine 65+ years New 270.00 Preventive Medicine < 1 year Established 200.00 Preventive Medicine < 1 year New 225.00 Subsequent Hospital Care Level 1 - 100.00 Subsequent Hospital Care Level 2 - 175.00 Subsequent Hospital Care Level 3 - 230.00 .Glucose Fasting 70-210 Glucose Level 70.00 Blood Urea Nitrogen 70.00 Creatinine Level 70.00 Sodium Level 70.00 Potassium Level 70.00 Chloride Level 70.00 Carbon Dioxide Level 90.00 Alanine Aminotransferase 70.00 Aspartate Aminotransferase 70.00 Albumin Level 66.00 Alkaline Phosphatase 70.00 Ammonia Level 88.00 Bilirubin Direct 70.00 Bilirubin Total 70.00 Arterial Blood Gas 1 182.00 Calcium Level 70.00 Cholesterol High Density Lipid 85.00 Cholesterol Low Density Lipids 85.00 Cholesterol Total 70.00 Creatine Kinase 77.00 C-Reactive Protein 110.00 D-Dimer 110.00 Digoxin Level 124.00 Gamma Glutamyl Transferase 61.00 HEMOGLOBIN 105.00 Hematocrit 105.00 Hemoglobin A1c 85.00 Lactic Acid 85.00 Lactate Dehydrogenase 30.00 Lipase Level 70.00 Lithium Level 105.00 Magnesium Level 35.00 Prothrombin Time 55.00 Partial Thromboplastin Time 55.00 Phosphorus Level 70.00 Platelet Count 105.00 Protein Level 24 Hour Urine 70.00 Protein, total, refractometry; serum, plasma or whole blood 70.00 Protein Level Urine 70.00 Sedimentation Rate 105.00 Thyroid Stimulating Hormone 110.00 Triglycerides 70.00 Uric Acid 70.00 Vitamin B12 Level 110.00 White Blood Count 105.00 Bladder Scan 260.00 Hepatitis A Adult Vaccine 64.00 Hepatitis A Peds/Adol Vaccine 2 Dose Sched Charge 42.00 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose), IM POC 26.00 Flu Vaccine Split 6-35 Months IM POC 15.00 Flu Vaccine Split 3 yrs and above IM 15.00 Flu Vaccine Live Intranasal POC 15.00 Pneumococcal Conjugate Polyvalent Vaccine < 5yrs POC 140.00 Rabies Vaccine IM Charge 695.00 DTaP Diphtheria/Pertussis, acellular/Tetanus Vaccine DTaP Under 7 yrs POC 34.00 MMR Measles/Mumps/Rubella Virus Vaccine POC 121.00 IPV Inactivated Poliovirus Vaccine POC 43.00 Varicella Virus Vaccine POC 214.00 Diphth/Haemophilus/Pertusis,Acel/Tetanus Vaccine POC 59.00 Diphth/HepB/Pertussis,Acel/Polio/Tetanus Vaccine POC 129.00 Pneumococcal 23-Valent Adult Vaccine POC 150.00 Meningococcal Vaccine POC 144.00 Hepatitis B Vaccine, Pediatric 3 Dose Sched POC 32.00 Hepatitis B Vaccine, Adult 78.00 EKG 12 Lead, Interp/Report Only Charge 251.00 Wet Mount POC 37.00 KOH POC 49.00 HEMOGLOBIN POC 34.00 Rapid Strep POC 44.00 Arthrocentesis Intermed Joint, Wrist, Elbow, Ankle Charge 140.00 Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 0.6 to 1.0 cm Charge 330.00 Inj(s); Single Tendon Sheath, or Ligament, Aponeurosis (eg, Planterar ""Fascia"") Charge 116.00 Inj(s); Single or Mult Trigger Point(S), One or Two Muscle(s) Charge 106.00 Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for IM Use POC 55.00 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use POC 145.00 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use POC 354.00 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals 7 yrs POC 56.00 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for IM Use POC 203.00 Pressurized or nonpressurized inhalation treatment for acute airway obstruction Charge 32.00 Monospot POC 62.00 Tetanus, diphtheria toxoids & acellular pertussis vaccine (TdaP), 7 years or older, IM use POC 64.00 Zoster (shingles) vaccine, live, subcutaneous injection POC 228.00 Influenza virus vaccine, splie virus, preservative free, for children 6-35 months of age, IM POC (in 10.00 Lead Level POC 105.00 Human Papilloma virus (HPV) Vaccine POC 186.00 Creatine Kinase-MB 156.00 Human Papilloma virus (HPV) Vaccine POC 167.00 Telemetry 208.00 Administration of Blood 860.00 Rapid Respiratory Syntycial Virus (RSV) 185.00 Screening Pap Smear w/Prep & Transfer To Lab (Task/Charge) 34.00 COLLECTION: Arterial Draw 40.00 COLLECTION: Venous Draw 40.00 COLLECTION: 24 Hour Urine 40.00 Therapeutic Phlebotomy 193.00 BD DEXA Axial Skeleton 370.00 CT Abdomen w/ + w/o Cont Other charges may apply 3,730.00 CT Abdomen w/ Cont Other charges may apply 2,015.00 CT Abdomen w/o Cont Other charges may apply 1,590.00 CT Head or Brain w/ + w/o Cont Other charges may apply 1,820.00 CT Head or Brain w/ Cont Other charges may apply 1,575.00 CT Head or Brain w/o Cont Other charges may apply 1,370.00 CT LE w/ Cont Lt Other charges may apply 1,740.00 CT LE w/ Cont Rt Other charges may apply 1,740.00 CT LE w/o Cont Lt Other charges may apply 1,465.00 CT LE w/o Cont Rt Other charges may apply 1,465.00 CT Orbit Sella etc. w/ Cont Other charges may apply 1,945.00 CT Orbit Sella etc. w/o Cont Other charges may apply 1,495.00 CT Pelvis w/ + w/o Cont Other charges may apply 1,965.00 CT Pelvis w/ Cont Other charges may apply 1,750.00 CT Pelvis w/o Cont Other charges may apply 1,390.00 CT Spine Cervical w/o Cont Other charges may apply 1,580.00 CT Spine Lumbar w/o Cont Other charges may apply 1,550.00 CT Spine Thoracic w/o Cont Other charges may apply 1,520.00 CT UE w/ Cont Lt Other charges may apply 1,765.00 CT UE w/ Cont Rt Other charges may apply 1,765.00 CT UE w/o Cont Lt Other charges may apply 1,470.00 CT UE w/o Cont Rt Other charges may apply 1,470.00 MRA Head w/ Cont Other charges may apply 2,710.00 MRA Neck w/o Cont Other charges may apply 1,935.00 MRI Brain w/ + w/o Cont Other charges may apply 3,600.00 MRI Brain w/ Cont Other charges may apply 2,735.00 MRI Brain w/o Cont Other charges may apply 2,650.00 MRI Chest w/ + w/o Cont Other charges may apply 3,595.00 MRI Face Neck Orbit w/ + w/o Cont Other charges may apply 3,720.00 MRI Face Neck Orbit w/ Cont Other charges may apply 3,005.00 MRI LE Joint w/ + w/o Cont Lt Other charges may apply 3,625.00 MRI LE Joint w/ + w/o Cont Rt Other charges may apply 3,625.00 MRI LE Joint w/o Cont Lt Other charges may apply 2,445.00 MRI LE Joint w/o Cont Rt Other charges may apply 2,445.00 MRI Pelvis w/ Cont Other charges may apply 2,790.00 MRI Pelvis w/o Cont Other charges may apply 2,495.00 MRI Spine Cervical w/ Cont Other charges may apply 2,830.00 MRI Spine Cervical w/o Cont Other charges may apply 2,510.00 MRI Spine Lumbar w/ Cont Other charges may apply 2,800.00 MRI Spine Lumbar w/o Cont Other charges may apply 2,550.00 MRI Spine Thoracic w/ Cont Other charges may apply 2,655.00 MRI Spine Thoracic w/o Cont Other charges may apply 2,535.00 MRI UE Joint w/o Cont Lt Other charges may apply 2,380.00 MRI UE Joint w/o Cont Rt Other charges may apply 2,380.00 NM Bone Ltd Other charges may apply 1,000.00 NM Bone Whole Body Other charges may apply 1,440.00 NM Bone 3 Phase Study Other charges may apply 1,665.00 NM Cardiac Blood Pool Gated Single Other charges may apply 1,635.00 NM GI Blood Loss Other charges may apply 1,645.00 NM Kidney w/ Flow w/ Pharm Other charges may apply 2,015.00 NM Pulm Perf Other charges may apply 1,055.00 NM Thyroid Only Other charges may apply 875.00 US Abdomen Comp 695.00 US Abdomen Ltd 635.00 US Carotid Duplex Bil 1,145.00 US Chest 505.00 US Head +Neck Soft Tissue 835.00 US Pregnant < 14 Weeks Ea Addl Gest 610.00 US Pregnant Transvaginal 490.00 US Retroperitoneal Comp 695.00 US Scrotum +Contents 555.00 US UE Veins Duplex Bil 909.00 US UE Veins Duplex Lt 659.00 XR Abdomen 1 View 190.00 XR Abdomen 2 Views 260.00 XR Ankle Comp Min 3 Views Lt 205.00 XR Ankle Comp Min 3 Views Rt 205.00 XR Heel Min 2 Views Lt 180.00 XR Heel Min 2 Views Rt 180.00 XR Chest 1 View 170.00 XR Chest 2 Views 220.00 XR Clavicle Comp Lt 185.00 XR Clavicle Comp Rt 185.00 XR Elbow 2 Views Lt 200.00 XR Elbow 2 Views Rt 200.00 XR Facial Bones < 3 Views 190.00 XR Facial Bones Comp Min 3 Views 270.00 FLUOROSCOPY, Up to 1 Hour 290.00 XR Foot 2 Views Lt 180.00 XR Foot 2 Views Rt 180.00 XR Foot Comp Min 3 Views Lt 205.00 XR Foot Comp Min 3 Views Rt 205.00 XR Forearm 2 Views Lt 190.00 XR Forearm 2 Views Rt 190.00 XR Eye FB Bil 175.00 XR Hand 2 Views Lt 175.00 XR Hand 2 Views Rt 175.00 XR Hand Min 3 Views Lt 220.00 XR Hand Min 3 Views Rt 220.00 XR Humerus Min 2 Views Lt 200.00 XR Humerus Min 2 Views Rt 200.00 XR Knee 3 Views Lt 230.00 XR Knee 3 Views Rt 230.00 XR Knee 1 or 2 Views Lt 190.00 XR Knee 1 or 2 Views Rt 190.00