DEIDENTIFIED CHARGES Negotiated Price for Third-Party Payors

Procedure/

Charge

Number

Procedure NameCode

Type Charges

CPT/DRG

Code

Rev

Code HCPCS Range Name/DRG Billing Category Case Volume

Minimum

Insurance

Amount

Maximum

Insurance

Amount

Self -

Pay/Cash

Price

Dean

Health Plan Quartz

BlueCross

BlueShield Alliance WPS Health

Medicare

Replacement

833291 COLONOSCOPY,DIAGNOSTIC CPT 935 45378 960 Surgery Digestive System CMS Required - 96 355.3 691.9 701.25 542.3 626.45 626.45 561 691.9 355.3

8102679 DX MAMMO INCL CAD BILAT CPT 370 77066 401 Radiology Breast, Mammography CMS Required - 94 140.6 273.8 277.5 214.6 247.9 247.9 222 273.8 140.6

800249 CT SCAN,HEAD/BRAIN,W/O CONTRAST MATL CPT 2,216.00 70450 351 Radiology Diagnostic Radiology CMS Required - 865 842.08 1,639.84 1,662.00 1,285.28 1,484.72 1,484.72 1,329.60 1,639.84 842.08

800803 CT ABD & PELVIS W/CONTRAST CPT 6,172.00 74177 352 Radiology Diagnostic Radiology CMS Required - 831 2,345.36 4,567.28 4,629.00 3,579.76 4,135.24 4,135.24 3,703.20 4,567.28 2,345.36

8102673 NJX INTERLAMINAR LMBR/SAC W IMAGING CPT 2,302.00 62323 361 Surgery Nervous System CMS Required - 8 874.76 1,703.48 1,726.50 1,335.16 1,542.34 1,542.34 1,381.20 1,703.48 874.76

800569 US,PREG UTER,FETAL & MAT, 2-3 TRIMEST CPT 1,132.00 76805 402 Radiology Diagnostic Ultrasound CMS Required - 79 430.16 837.68 849 656.56 758.44 758.44 679.2 837.68 430.16

60075320 CHG URINALYSIS, AUTO, W/O SCOPE CPT 36 81003 307 Pathology and Lab Urinalysis Procedures CMS Required - 761 13.68 26.64 27 20.88 24.12 24.12 21.6 26.64 13.68

832363 ED EGD FLEX TRANSORAL DX CPT 576 43235 960 Surgery Digestive System CMS Required - 63 218.88 426.24 432 334.08 385.92 385.92 345.6 426.24 218.88

833941 SHLDR ARTHROSCOP,PART ACROMIOPLAS CPT 767 29826 975 Surgery Musculoskeletal System CMS Required - 6 291.46 567.58 575.25 444.86 513.89 513.89 460.2 567.58 291.46

832536 PR EXC BREAST CYST OPEN 1 OR MORE LESIONS CPT 1,765.00 19120 960 Surgery Integumentary System CMS Required - 6 670.7 1,306.10 1,323.75 1,023.70 1,182.55 1,182.55 1,059.00 1,306.10 670.7

60016690 COMPREHEN METABOLIC PANEL CPT 379 80053 301 Pathology and Lab Organ or Disease Oriented Panels CMS Required - 5476 144.02 280.46 284.25 219.82 253.93 253.93 227.4 280.46 144.02

60016670 RENAL FUNCTION PANEL CPT 116 80069 301 Pathology and Lab Organ or Disease Oriented Panels CMS Required - 43 44.08 85.84 87 67.28 77.72 77.72 69.6 85.84 44.08

812837 OFFICE/OUTPT VISIT,NEW,LEVL IV CPT 222 99204 761 Medicine Service/ProceduresHome Health Procedures and Services CMS Required - 421 84.36 164.28 166.5 128.76 148.74 148.74 133.2 164.28 84.36

60020290 CHG COMPLETE CBC & AUTO DIFF WBC CPT 210 85025 305 Pathology and Lab Hematology and Coagulation Procedures CMS Required - 4111 79.8 155.4 157.5 121.8 140.7 140.7 126 155.4 79.8

832436 PREVENTIVE VISIT, NEW, AGE 18-39 CPT 193 99385 960 Medicine Service/ProceduresHome Health Procedures and Services CMS Required - 41 73.34 142.82 144.75 111.94 129.31 129.31 115.8 142.82 73.34

60083290 CHG PROSTATE SPECIFIC ANTIGEN,FREE CPT 189 84154 301 Pathology and Lab Chemistry Procedures CMS Required - 4 71.82 139.86 141.75 109.62 126.63 126.63 113.4 139.86 71.82

833837 FULL ROUT OBSTE CARE,CESAREAN DELIV CPT 8,639.00 59510 975 Surgery Maternity Care and Delivery CMS Required - 4 3,282.82 6,392.86 6,479.25 5,010.62 5,788.13 5,788.13 5,183.40 6,392.86 3,282.82

833133 KNEE SCOPE,MED/LAT MENISECTOMY CPT 2,337.00 29881 981 Surgery Musculoskeletal System CMS Required - 39 888.06 1,729.38 1,752.75 1,355.46 1,565.79 1,565.79 1,402.20 1,729.38 888.06

60017350 METABOLIC PANEL TOTAL CA CPT 239 80048 301 Pathology and Lab Organ or Disease Oriented Panels CMS Required - 3247 90.82 176.86 179.25 138.62 160.13 160.13 143.4 176.86 90.82

832437 PREVENTIVE VISIT, NEW, AGE 40-64 CPT 234 99386 960 Medicine Service/ProceduresHome Health Procedures and Services CMS Required - 32 88.92 173.16 175.5 135.72 156.78 156.78 140.4 173.16 88.92

800698 X-RAY EXAM OF LOWER SPINE 4 VW CPT 1,133.00 72110 320 Radiology Diagnostic Radiology CMS Required - 31 430.54 838.42 849.75 657.14 759.11 759.11 679.8 838.42 430.54

812835 OFFICE/OUTPT VISIT,NEW,LEVL V CPT 320 99205 761 Medicine Service/ProceduresHome Health Procedures and Services CMS Required - 30 121.6 236.8 240 185.6 214.4 214.4 192 236.8 121.6

REMOVE TONSILS/ADENOIDS,

Uterine & adnexa proc for non-malignancy DRG 31,645.00 MS743 Diagnosis Related Group Diagnosis Related Group CMS Required - 1 12,025.10 23,417.30 23,733.75 18,354.10 21,202.15 21,202.15 18,987.00 23,417.30 12,025.10

60075080 CHG URINALYSIS NONAUTO W/O SCOPE CPT 30 81002 307 Pathology and Lab Urinalysis Procedures CMS Required - 0 11.4 22.2 22.5 17.4 20.1 20.1 18 22.2 11.4

811302 POLYSOMNOGRAPHY, 4 OR MORE CPT 5,214.00 95810 740 Medicine Service/ProceduresNeurology and Neuromuscular Procedures CMS Required - 0 1,981.32 3,858.36 3,910.50 3,024.12 3,493.38 3,493.38 3,128.40 3,858.36 1,981.32

833838 ROUT OB CARE,VAG DELIV,PREV C-SEC CPT 8,192.00 59610 975 Surgery Maternity Care and Delivery CMS Required - 0 3,112.96 6,062.08 6,144.00 4,751.36 5,488.64 5,488.64 4,915.20 6,062.08 3,112.96

Cardiac valve & oth maj cardiothoracic proc w card cathDRG MS216 Diagnosis Related Group Diagnosis Related Group CMS Required - 0 Not offered

Spinal fusion except cervical DRG MS460 Diagnosis Related Group Diagnosis Related Group CMS Required - 0 Not offered

Cervical spinal fusion DRG MS473 Diagnosis Related Group Diagnosis Related Group CMS Required - 0 Not offered

COLONOSCOPY W/ENDOSCOPE US CPT 45391 Surgery Digestive System CMS Required - 0 Not offered

BIOPSY OF PROSTATE,NEEDLE/PUNCH CPT 55700 Surgery Male Genital System CMS Required - 0 Not offered

LAP,PROSTATECTOMY,RADICAL,W/NERVE SPARE CPT 55866 Surgery Male Genital System CMS Required - 0 Not offered

NJX INTERLAMINAR LMBR/SAC WO IMAGING CPT 62322 Surgery Nervous System CMS Required - 0 Not offered

OBSTETRIC PANEL CPT 80055 Pathology and Lab Organ or Disease Oriented Panels CMS Required - 0 Not offered

CHG URINALYSIS, NONAUTO, W/SCOPE CPT 81000 Pathology and Lab Urinalysis Procedures CMS Required - 0 Not offered

PSYTX PT AND OR FAMILY 30 MINUTES CPT 90832 Medicine Service/ProceduresPsychiatry Services and Procedures CMS Required - 0 Not offered

PSYTX PT AND OR FAMILY 45 MINUTES CPT 90834 Medicine Service/ProceduresPsychiatry Services and Procedures CMS Required - 0 Not offered

PSYTX PT AND OR FAMILY 60 MINUTES CPT 90837 Medicine Service/ProceduresPsychiatry Services and Procedures CMS Required - 0 Not offered

FAMILY PSYCHOTHERAPY,NO PT CPT 90846 Medicine Service/ProceduresPsychiatry Services and Procedures CMS Required - 0 Not offered

FAMILY PSYCHOTHERAPY W PHYS CPT 90847 Medicine Service/ProceduresPsychiatry Services and Procedures CMS Required - 0 Not offered

GROUP PSYCHOTHERAPY CPT 90853 Medicine Service/ProceduresPsychiatry Services and Procedures CMS Required - 0 Not offered

L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I CPT 93452 Medicine Service/ProceduresCardiovascular Procedures CMS Required - 0 Not offered

815755 MANUAL THER TECH,1+REGIONS,EA 15 MIN CPT 175 97140 430 Medicine Service/ProceduresAdaptive Behavior Services 1494 66.5 129.5 131.25 101.5 117.25 117.25 105 129.5 66.5

8103259 XRAY EXAM CHEST 1 VIEW CPT 404 71045 324 Radiology Diagnostic Radiology 1176 153.52 298.96 303 234.32 270.68 270.68 242.4 298.96 153.52

8102704 PT EVAL MOD COMPLEXITY CPT 445 97162 424 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 840 169.1 329.3 333.75 258.1 298.15 298.15 267 329.3 169.1

812806 INHAL RX, AIRWAY OBST/DX SPUTUM INDUCT CPT 196 94640 410 Medicine Service/ProceduresPulmonary Procedures 648 74.48 145.04 147 113.68 131.32 131.32 117.6 145.04 74.48

8102703 PT EVAL LOW COMPLEXITY CPT 445 97161 424 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 510 169.1 329.3 333.75 258.1 298.15 298.15 267 329.3 169.1

815752 GAIT TRAINING THERAPY CPT 154 97116 420 Medicine Service/ProceduresAdaptive Behavior Services 460 58.52 113.96 115.5 89.32 103.18 103.18 92.4 113.96 58.52

815749 NEUROMUSC REEDUCAT,1 OR MORE AREAS, EA 15 MINCPT 156 97112 430 Medicine Service/ProceduresAdaptive Behavior Services 433 59.28 115.44 117 90.48 104.52 104.52 93.6 115.44 59.28

815759 THERAPEUTIC ACTIVITIES CPT 159 97530 430 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 376 60.42 117.66 119.25 92.22 106.53 106.53 95.4 117.66 60.42

815745 ULTRASOUND THERAPY CPT 155 97035 430 Medicine Service/ProceduresAdaptive Behavior Services 324 58.9 114.7 116.25 89.9 103.85 103.85 93 114.7 58.9

8102709 OT EVAL LOW COMPLEXITY CPT 439 97165 434 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 311 166.82 324.86 329.25 254.62 294.13 294.13 263.4 324.86 166.82

813961 CARDIAC REHAB/MONITOR CPT 297 93798 943 Medicine Service/ProceduresCardiovascular Procedures 306 112.86 219.78 222.75 172.26 198.99 198.99 178.2 219.78 112.86

815763 SELF CARE/HOME MGMT TRAIN,EA 15 MIN CPT 152 97535 430 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 282 57.76 112.48 114 88.16 101.84 101.84 91.2 112.48 57.76

835576 ANES LOWER INTEST NDSC NOS CPT 19.13 811 964 Anesthesia Anesthesia 255 7.27 14.16 14.35 11.1 12.82 12.82 11.48 14.16 7.27

835577 ANES LOWER INTEST SCRN COLONOSCOPY CPT 19.13 812 964 Anesthesia Anesthesia 183 7.27 14.16 14.35 11.1 12.82 12.82 11.48 14.16 7.27

801065 MEAS,POST-VOID RES,US,NON-IMAGING CPT 240 51798 761 Surgery Urinary System 162 91.2 177.6 180 139.2 160.8 160.8 144 177.6 91.2

815025 ELECTRICAL STIMULATION THERAPY (UNATTENDED) CPT 155 97014 420 Medicine Service/ProceduresAdaptive Behavior Services 157 58.9 114.7 116.25 89.9 103.85 103.85 93 114.7 58.9

830515 INJ,ANES AGENT,FEMORAL NERVE,SINGLE CPT 1,858.00 64447 960 Surgery Nervous System 155 706.04 1,374.92 1,393.50 1,077.64 1,244.86 1,244.86 1,114.80 1,374.92 706.04

833929 TOTAL KNEE ARTHROPLASTY CPT 5,878.00 27447 975 Surgery Musculoskeletal System 148 2,233.64 4,349.72 4,408.50 3,409.24 3,938.26 3,938.26 3,526.80 4,349.72 2,233.64

8102710 OT EVAL MOD COMPLEXITY CPT 439 97166 434 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 147 166.82 324.86 329.25 254.62 294.13 294.13 263.4 324.86 166.82

8102705 PT EVAL HIGH COMPLEXITY CPT 445 97163 424 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 147 169.1 329.3 333.75 258.1 298.15 298.15 267 329.3 169.1

816161 PR NONINVASV OXYGEN SATUR SINGLE CPT 26 94760 450 Medicine Service/ProceduresPulmonary Procedures 143 9.88 19.24 19.5 15.08 17.42 17.42 15.6 19.24 9.88

811646 GROUP THERAPEUTIC PROCEDURES CPT 66 97150 420 Medicine Service/ProceduresAdaptive Behavior Services 127 25.08 48.84 49.5 38.28 44.22 44.22 39.6 48.84 25.08

835574 ANES UPPER GI NDSC PX NOS CPT 19.13 731 964 Anesthesia Anesthesia 126 7.27 14.16 14.35 11.1 12.82 12.82 11.48 14.16 7.27

810505 INSERT,NON-INDWELLING BLADDER CATHETER CPT 195 51701 761 Surgery Urinary System 120 74.1 144.3 146.25 113.1 130.65 130.65 117 144.3 74.1

830582 INJECT NERV BLCK,OTHR PERIPH NERV CPT 375 64450 964 Surgery Nervous System 109 142.5 277.5 281.25 217.5 251.25 251.25 225 277.5 142.5

811505 EXHALED CARBON DIOXIDE TEST CPT 176 94770 460 Medicine Service/ProceduresPulmonary Procedures 106 66.88 130.24 132 102.08 117.92 117.92 105.6 130.24 66.88

834461 TAP BLOCK BILATERAL BY INJ W GUIDE CPT 3,184.00 64488 960 Surgery Nervous System 102 1,209.92 2,356.16 2,388.00 1,846.72 2,133.28 2,133.28 1,910.40 2,356.16 1,209.92

810507 INSERT,TEMP INDWELLING BLAD CATH,SIMPLE CPT 253 51702 761 Surgery Urinary System 89 96.14 187.22 189.75 146.74 169.51 169.51 151.8 187.22 96.14

835578 ANES UPPER AND LOWER GI NDSC PX CPT 19.13 813 964 Anesthesia Anesthesia 81 7.27 14.16 14.35 11.1 12.82 12.82 11.48 14.16 7.27

812675 SPEECH/HEARING THERAPY CPT 350 92507 440 Medicine Service/ProceduresSpecial Otorhinolaryngologic Services and Procedures78 133 259 262.5 203 234.5 234.5 210 259 133

8103513 POS AIRWAY PRESSURE, CPAP CPT 690 94660 410 Medicine Service/ProceduresPulmonary Procedures 78 262.2 510.6 517.5 400.2 462.3 462.3 414 510.6 262.2

831213 FLUOROSCOPE EXAMINATION CPT 217 76000 972 Radiology Diagnostic Radiology 67 82.46 160.58 162.75 125.86 145.39 145.39 130.2 160.58 82.46

833072 REVISE MEDIAN N/CARPAL TUNNEL SURG CPT 1,825.00 64721 960 Surgery Nervous System 62 693.5 1,350.50 1,368.75 1,058.50 1,222.75 1,222.75 1,095.00 1,350.50 693.5

810112 ECG MONITOR/REC, 24 HRS RECORDNG CPT 1,024.00 93225 731 Medicine Service/ProceduresCardiovascular Procedures 61 389.12 757.76 768 593.92 686.08 686.08 614.4 757.76 389.12

811338 EVAL,ORAL & PHARYNGEAL SWALLOW FUNCTION CPT 630 92610 440 Medicine Service/ProceduresSpecial Otorhinolaryngologic Services and Procedures58 239.4 466.2 472.5 365.4 422.1 422.1 378 466.2 239.4

8102715 ATHLETIC TRN EVAL LOW CMPLX CPT 465 97169 951 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 57 176.7 344.1 348.75 269.7 311.55 311.55 279 344.1 176.7

816823 ABD PARACENTESIS W/IMAGING CPT 2,213.00 49083 361 Surgery Digestive System 39 840.94 1,637.62 1,659.75 1,283.54 1,482.71 1,482.71 1,327.80 1,637.62 840.94

811125 MECHANICAL TRACTION THERAPY CPT 142 97012 420 Medicine Service/ProceduresAdaptive Behavior Services 37 53.96 105.08 106.5 82.36 95.14 95.14 85.2 105.08 53.96

830520 INJ,ANES AGENT,BRACHIAL PLEXUS,SINGLE CPT 2,122.00 64415 964 Surgery Nervous System 32 806.36 1,570.28 1,591.50 1,230.76 1,421.74 1,421.74 1,273.20 1,570.28 806.36

8104282 NDL INSJ W/O NJX 3+ MUSC CPT 0.01 20561 420 Surgery Musculoskeletal System 31 0 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0

814443 CANALITH REPOSITIONING PROC CPT 184 95992 420 Medicine Service/ProceduresNeurology and Neuromuscular Procedures 27 69.92 136.16 138 106.72 123.28 123.28 110.4 136.16 69.92

8102706 PT RE-EVAL EST PLAN CARE CPT 205 97164 424 Medicine Service/ProceduresPhysical Medicine and Rehab Evaluations 27 77.9 151.7 153.75 118.9 137.35 137.35 123 151.7 77.9

833025 COLONOSCOPY,REMV LESN,FORCEP/CAUTERY CPT 1,168.00 45384 960 Surgery Digestive System 24 443.84 864.32 876 677.44 782.56 782.56 700.8 864.32 443.84

832678 LAP,CHOLECYSTECTOMY/GRAPH CPT 3,068.00 47563 960 Surgery Digestive System 24 1,165.84 2,270.32 2,301.00 1,779.44 2,055.56 2,055.56 1,840.80 2,270.32 1,165.84

8104281 NDL INSJ W/O NJX 1 OR 2 MUSC CPT 0.01 20560 420 Surgery Musculoskeletal System 22 0 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0

800229 X-RAY OPER CHOLANGIOGRAM CPT 974 74300 320 Radiology Diagnostic Radiology 21 370.12 720.76 730.5 564.92 652.58 652.58 584.4 720.76 370.12

833720 INCISE FINGER TENDON SHEATH CPT 1,322.00 26055 960 Surgery Musculoskeletal System 21 502.36 978.28 991.5 766.76 885.74 885.74 793.2 978.28 502.36

832365 EGD FLEX TRANSORAL W BALLN DIL

813724 HIB VACCINE, PRP-OMP, IM CPT 114.53 90647 636 Medicine Service/ProceduresVaccines/Toxoids 63 43.52 84.75 85.9 66.43 76.74 76.74 68.72 84.75 43.52

813731 ROTAVIRUS VACCINE, ORAL CPT 213.86 90680 636 Medicine Service/ProceduresVaccines/Toxoids 62 81.27 158.26 160.4 124.04 143.29 143.29 128.32 158.26 81.27

813740 DTAP/HEPB/IPV VACCINE,IM CPT 245.75 90723 636 Medicine Service/ProceduresVaccines/Toxoids 60 93.39 181.86 184.31 142.54 164.65 164.65 147.45 181.86 93.39

810874 IMMUNIZ ADMIN EACH ADDL CPT 51 90472 771 Medicine Service/ProceduresImmunization Administration for Vaccines/Toxoids140 19.38 37.74 38.25 29.58 34.17 34.17 30.6 37.74 19.38

800475 HT MUSCLE IMAGE SPECT, MULT CPT 8,657.00 78452 341 Radiology Nuclear Medicine Procedures 91 3,289.66 6,406.18 6,492.75 5,021.06 5,800.19 5,800.19 5,194.20 6,406.18 3,289.66

814574 IMADM THROUGH 18YR ANY ROUTE 1ST VAC/TOXOIDCPT 51 90460 771 Medicine Service/ProceduresImmunization Administration for Vaccines/Toxoids49 19.38 37.74 38.25 29.58 34.17 34.17 30.6 37.74 19.38

812443 PR DESTRUC PREMALG,FIRST LESION CPT 224 17000 361 Surgery Integumentary System 10 85.12 165.76 168 129.92 150.08 150.08 134.4 165.76 85.12

832522 EXC SKIN BENIG >4CM TRUNK,ARM,LEG CPT 1,051.00 11406 960 Surgery Integumentary System 10 399.38 777.74 788.25 609.58 704.17 704.17 630.6 777.74 399.38

813750 PNEUMOCOCCAL VACC, 13 VAL IM CPT 513.25 90670 636 Medicine Service/ProceduresVaccines/Toxoids 130 195.04 379.81 384.94 297.69 343.88 343.88 307.95 379.81 195.04

813741 PNEUMOCOCCAL VACCINE,23-VALENT,ADULT CPT 433.39 90732 636 Medicine Service/ProceduresVaccines/Toxoids 79 164.69 320.71 325.04 251.37 290.37 290.37 260.03 320.71 164.69

816830 PR PULM FUNCT TST PLETHYSMOGRAP CPT 362 94726 460 Medicine Service/ProceduresPulmonary Procedures 60 137.56 267.88 271.5 209.96 242.54 242.54 217.2 267.88 137.56

816833 PR C02/MEMBANE DIFFUSE CAPACITY CPT 343 94729 460 Medicine Service/ProceduresPulmonary Procedures 58 130.34 253.82 257.25 198.94 229.81 229.81 205.8 253.82 130.34

813723 HEPA VACCINE PED/ADOL-2 DOSE CPT 120.25 90633 636 Medicine Service/ProceduresVaccines/Toxoids 31 45.7 88.99 90.19 69.75 80.57 80.57 72.15 88.99 45.7

812370 CTRL NOSEBLEED,ANTER,SIMPLE CPT 350 30901 361 Surgery Respiratory System 30 133 259 262.5 203 234.5 234.5 210 259 133

800594 US GUIDE, VASCULAR ACCESS CPT 1,171.00 76937 402 Radiology Diagnostic Ultrasound 15 444.98 866.54 878.25 679.18 784.57 784.57 702.6 866.54 444.98

812575 HEP B VACC ADULT 3 DOSE IM CPT 147.25 90746 636 Medicine Service/ProceduresVaccines/Toxoids 14 55.96 108.97 110.44 85.41 98.66 98.66 88.35 108.97 55.96

810073 INTMD WND REPAIR TRUNK,ARM,LEG 2.6-7.5 CPT 669 12032 361 Surgery Integumentary System 13 254.22 495.06 501.75 388.02 448.23 448.23 401.4 495.06 254.22

813738 CHICKEN POX VACCINE,LIVE,SUBCUT CPT 295.9 90716 636 Medicine Service/ProceduresVaccines/Toxoids 11 112.44 218.97 221.93 171.62 198.25 198.25 177.54 218.97 112.44

810136 ELECTROCARDIOGRAM, TRACING CPT 277 93005 730 Medicine Service/ProceduresCardiovascular Procedures 2796 105.26 204.98 207.75 160.66 185.59 185.59 166.2 204.98 105.26

813737 PR TDAP VACCINE 7 YO AND OLDER IM CPT 78 90715 636 Medicine Service/ProceduresVaccines/Toxoids 361 29.64 57.72 58.5 45.24 52.26 52.26 46.8 57.72 29.64

812425 REPR SUPERF WND BODY

810060 OFFICE/OUTPT VISIT,EST,LEVL V CPT 193 99215 761 Medicine Service/ProceduresHome Health Procedures and Services 111 73.34 142.82 144.75 111.94 129.31 129.31 115.8 142.82 73.34

8102397 X-RAY EXAM HIPS BI 3-4 VIEWS CPT 907 73522 320 Radiology Diagnostic Radiology 111 344.66 671.18 680.25 526.06 607.69 607.69 544.2 671.18 344.66

830183 FETAL NON-STRESS TEST CPT 175 59025 960 Surgery Maternity Care and Delivery 99 66.5 129.5 131.25 101.5 117.25 117.25 105 129.5 66.5

8101792 DIG BREAST TOMOSYNTHESIS BILATERAL CPT 44 77062 401 Radiology Breast, Mammography 92 16.72 32.56 33 25.52 29.48 29.48 26.4 32.56 16.72

835443 OFFICE/OUTPT VISIT,NEW,LEVL I CPT 47 99201 983 Medicine Service/ProceduresHome Health Procedures and Services 85 17.86 34.78 35.25 27.26 31.49 31.49 28.2 34.78 17.86

800263 CT ANGIO,NECK COMBO,INCL IMAGE PROCESS CPT 3,633.00 70498 350 Radiology Diagnostic Radiology 84 1,380.54 2,688.42 2,724.75 2,107.14 2,434.11 2,434.11 2,179.80 2,688.42 1,380.54

800010 FLUOROSCOPIC GUIDANCE NEEDLE PLACE CPT 743 77002 320 Radiology Radiologic Guidance 79 282.34 549.82 557.25 430.94 497.81 497.81 445.8 549.82 282.34

800575 US,PREGNANT UTERUS,TRANSVAGINAL CPT 749 76817 402 Radiology Diagnostic Ultrasound 71 284.62 554.26 561.75 434.42 501.83 501.83 449.4 554.26 284.62

803961 DUPLEX ABD/PEL VASC STUDY,COMPLETE CPT 1,238.00 93975 921 Medicine Service/ProceduresNon-Invasive Vascular Diagnostic Studies 61 470.44 916.12 928.5 718.04 829.46 829.46 742.8 916.12 470.44

8102400 X-RAY EXAM OF FEMUR MIN 2 VIEWS CPT 496 73552 320 Radiology Diagnostic Radiology 58 188.48 367.04 372 287.68 332.32 332.32 297.6 367.04 188.48

815109 PR PREVENTIVE VISIT,EST,18 - 39 CPT 161 99395 510 Medicine Service/ProceduresHome Health Procedures and Services 52 61.18 119.14 120.75 93.38 107.87 107.87 96.6 119.14 61.18

810437 APPLY FOREARM SPLINT,STATIC CPT 310 29125 361 Surgery Musculoskeletal System 47 117.8 229.4 232.5 179.8 207.7 207.7 186 229.4 117.8

800881 X-RAY EXAM OF HUMERUS CPT 401 73060 320 Radiology Diagnostic Radiology 47 152.38 296.74 300.75 232.58 268.67 268.67 240.6 296.74 152.38

830526 DRAIN/INJECT INTERMEDIATE JOINT/BURSA CPT 110 20605 960 Surgery Musculoskeletal System 45 41.8 81.4 82.5 63.8 73.7 73.7 66 81.4 41.8

815106 PREVENTIVE VISIT,EST,AGE 1-4 CPT 144 99392 510 Medicine Service/ProceduresHome Health Procedures and Services 41 54.72 106.56 108 83.52 96.48 96.48 86.4 106.56 54.72

800900 X-RAY EXAM OF ELBOW 2 VW CPT 395 73070 320 Radiology Diagnostic Radiology 38 150.1 292.3 296.25 229.1 264.65 264.65 237 292.3 150.1

800779 X-RAY CLAVICLE CPT 375 73000 320 Radiology Diagnostic Radiology 37 142.5 277.5 281.25 217.5 251.25 251.25 225 277.5 142.5

800755 SWALLOWING FCN,W/CINE &/OR VIDEO CPT 916 74230 320 Radiology Diagnostic Radiology 32 348.08 677.84 687 531.28 613.72 613.72 549.6 677.84 348.08

811340 EVAL,SWALLOW FUNCTION,CINE/VIDEO RECORD CPT 630 92611 440 Medicine Service/ProceduresSpecial Otorhinolaryngologic Services and Procedures29 239.4 466.2 472.5 365.4 422.1 422.1 378 466.2 239.4

811287 NONINVASV OXYGEN SATUR,MULTIPLE CPT 49 94761 410 Medicine Service/ProceduresPulmonary Procedures 26 18.62 36.26 36.75 28.42 32.83 32.83 29.4 36.26 18.62

816030 PREVENTIVE VISIT, NEW, AGE 5-11 CPT 163 99383 510 Medicine Service/ProceduresHome Health Procedures and Services 22 61.94 120.62 122.25 94.54 109.21 109.21 97.8 120.62 61.94

812247 HEARING AID, DIGIT, BIN, BTE CPT 3,900.00 V5261 271 HCPCS HCPCS 22 1,482.00 2,886.00 2,925.00 2,262.00 2,613.00 2,613.00 2,340.00 2,886.00 1,482.00

815107 PREVENTIVE VISIT,EST,AGE5-11 CPT 149 99393 510 Medicine Service/ProceduresHome Health Procedures and Services 21 56.62 110.26 111.75 86.42 99.83 99.83 89.4 110.26 56.62

800461 BONE IMAGING, WHOLE BODY CPT 2,491.00 78306 341 Radiology Nuclear Medicine Procedures 19 946.58 1,843.34 1,868.25 1,444.78 1,668.97 1,668.97 1,494.60 1,843.34 946.58

802889 DUPLEX ABD/PEL VASC STUDY,LIMITD CPT 462 93976 921 Medicine Service/ProceduresNon-Invasive Vascular Diagnostic Studies 18 175.56 341.88 346.5 267.96 309.54 309.54 277.2 341.88 175.56

815781 PREVENTIVE VISIT,EST,65 & OVER CPT 183 99397 510 Medicine Service/ProceduresHome Health Procedures and Services 15 69.54 135.42 137.25 106.14 122.61 122.61 109.8 135.42 69.54

815108 PREVENTIVE VISIT,EST,12-17 CPT 157 99394 510 Medicine Service/ProceduresHome Health Procedures and Services 14 59.66 116.18 117.75 91.06 105.19 105.19 94.2 116.18 59.66

813732 DTAP IMMUNIZATION, IM CPT 112.65 90700 636 Medicine Service/ProceduresVaccines/Toxoids 12 42.81 83.36 84.49 65.34 75.48 75.48 67.59 83.36 42.81

816028 PR PREVENTIVE VISIT NEW INFANT CPT 247 99381 510 Medicine Service/ProceduresHome Health Procedures and Services 12 93.86 182.78 185.25 143.26 165.49 165.49 148.2 182.78 93.86

813190 EVOKED AUDITORY TEST,LIMITED CPT 296 92587 471 Medicine Service/ProceduresSpecial Otorhinolaryngologic Services and Procedures12 112.48 219.04 222 171.68 198.32 198.32 177.6 219.04 112.48

8103640 FNA BX W US GDN 1ST LES CPT 1,171.00 10005 361 Surgery Fine Needle Aspiration 12 444.98 866.54 878.25 679.18 784.57 784.57 702.6 866.54 444.98

803795 US EXTREMITY NON-VASC REAL-TIME IMG COMPL CPT 100 76881 972 Radiology Diagnostic Ultrasound 11 38 74 75 58 67 67 60 74 38

816029 PREVENTIVE VISIT,NEW,AGE 1-4 CPT 162 99382 510 Medicine Service/ProceduresHome Health Procedures and Services 11 61.56 119.88 121.5 93.96 108.54 108.54 97.2 119.88 61.56

8102398 X-RAY EXAM HIPS BI MIN 5 VIEWS CPT 1,032.00 73523 320 Radiology Diagnostic Radiology 11 392.16 763.68 774 598.56 691.44 691.44 619.2 763.68 392.16

800347 MRI, CERV SPINE COMBO CPT 6,591.00 72156 612 Radiology Diagnostic Radiology 11 2,504.58 4,877.34 4,943.25 3,822.78 4,415.97 4,415.97 3,954.60 4,877.34 2,504.58

812213 VISUAL AUDIOMETRY (VRA) CPT 229 92579 471 Medicine Service/ProceduresSpecial Otorhinolaryngologic Services and Procedures10 87.02 169.46 171.75 132.82 153.43 153.43 137.4 169.46 87.02

832823 PREVENTIVE VISIT, NEW, AGE 12-17 CPT 202 99384 960 Medicine Service/ProceduresHome Health Procedures and Services 9 76.76 149.48 151.5 117.16 135.34 135.34 121.2 149.48 76.76

816849 HEPATOBIL SYST IMAGE W/DRUG CPT 2,522.00 78227 341 Radiology Nuclear Medicine Procedures 9 958.36 1,866.28 1,891.50 1,462.76 1,689.74 1,689.74 1,513.20 1,866.28 958.36

830630 OFFICE/OUTPT VISIT,EST,LEVL II CPT 226 99212 960 Medicine Service/ProceduresHome Health Procedures and Services 3164 85.88 167.24 169.5 131.08 151.42 151.42 135.6 167.24 85.88

830529 ELECTROCARDIOGRAM REPORT CPT 9 93010 985 Medicine Service/ProceduresCardiovascular Procedures 2699 3.42 6.66 6.75 5.22 6.03 6.03 5.4 6.66 3.42

8103260 XRAY EXAM CHEST 2 VIEWS CPT 565 71046 324 Radiology Diagnostic Radiology 1735 214.7 418.1 423.75 327.7 378.55 378.55 339 418.1 214.7

830629 OFFICE/OUTPT VISIT,EST,LEVL I CPT 170 99211 960 Medicine Service/ProceduresHome Health Procedures and Services 1653 64.6 125.8 127.5 98.6 113.9 113.9 102 125.8 64.6

60136230 INFECT DETECT DNA RNA SARS COVID19 CPT 42 U0003 306 HCPCS HCPCS 763 15.96 31.08 31.5 24.36 28.14 28.14 25.2 31.08 15.96

802715 DRAIN/INJECT LARGE JOINT/BURSA CPT 170 20610 361 Surgery Musculoskeletal System 595 64.6 125.8 127.5 98.6 113.9 113.9 102 125.8 64.6

812930 PCHG TTE W/DOPPLER, COMPLETE CPT 2,530.00 93306 483 Medicine Service/ProceduresCardiovascular Procedures 429 961.4 1,872.20 1,897.50 1,467.40 1,695.10 1,695.10 1,518.00 1,872.20 961.4

800219 PR XRAY EXAM OF FOOT 3PLUS VW CPT 581 73630 320 Radiology Diagnostic Radiology 376 220.78 429.94 435.75 336.98 389.27 389.27 348.6 429.94 220.78

800795 CT ABD & PELVIS W/O CONTRAST CPT 5,355.00 74176 352 Radiology Diagnostic Radiology 291 2,034.90 3,962.70 4,016.25 3,105.90 3,587.85 3,587.85 3,213.00 3,962.70 2,034.90

800671 X-RAY EXAM OF LOWER SPINE 2/3 VW CPT 621 72100 320 Radiology Diagnostic Radiology 289 235.98 459.54 465.75 360.18 416.07 416.07 372.6 459.54 235.98

811358 DUPLEX EXTREM VENOUS,UNI OR LTD CPT 1,303.00 93971 921 Medicine Service/ProceduresNon-Invasive Vascular Diagnostic Studies 243 495.14 964.22 977.25 755.74 873.01 873.01 781.8 964.22 495.14

801402 CT ANGIO, CHEST, COMBO, INCL IMAGE PROC CPT 3,633.00 71275 350 Radiology Diagnostic Radiology 235 1,380.54 2,688.42 2,724.75 2,107.14 2,434.11 2,434.11 2,179.80 2,688.42 1,380.54

800267 CAT SCAN OF CHEST CONTRAST CPT 2,918.00 71260 352 Radiology Diagnostic Radiology 213 1,108.84 2,159.32 2,188.50 1,692.44 1,955.06 1,955.06 1,750.80 2,159.32 1,108.84

873564 X-RAY EXAM, KNEE, 4 OR MORE VW CPT 612 73564 320 Radiology Diagnostic Radiology 197 232.56 452.88 459 354.96 410.04 410.04 367.2 452.88 232.56

831243 ECHO,PELVIC (NONOBSTETRIC) CPT 70 76856 972 Radiology Diagnostic Ultrasound 194 26.6 51.8 52.5 40.6 46.9 46.9 42 51.8 26.6

803556 US ABDOMINAL R T W IMAGE DOC LIMITED CPT 38 76705 972 Radiology Diagnostic Ultrasound 189 14.44 28.12 28.5 22.04 25.46 25.46 22.8 28.12 14.44

817898 FLU VACC PRSV FREE INC ANTIG CPT 121.3 90662 636 Medicine Service/ProceduresVaccines/Toxoids 176 46.09 89.76 90.98 70.35 81.27 81.27 72.78 89.76 46.09

810098 CARDIAC STRESS TST,TRACING ONLY CPT 1,378.00 93017 482 Medicine Service/ProceduresCardiovascular Procedures 163 523.64 1,019.72 1,033.50 799.24 923.26 923.26 826.8 1,019.72 523.64

800606 PR DXA BONE DENSITY STUDY 1PLUS SI CPT 858 77080 320 Radiology Bone/Joint Studies 149 326.04 634.92 643.5 497.64 574.86 574.86 514.8 634.92 326.04

8101794 US BREAST UNILATERAL LIMITED CPT 855 76642 402 Radiology Diagnostic Ultrasound 122 324.9 632.7 641.25 495.9 572.85 572.85 513 632.7 324.9

800293 CT SCAN,LOWER EXTREMITY,W/O CONTRAST CPT 2,359.00 73700 352 Radiology Diagnostic Radiology 122 896.42 1,745.66 1,769.25 1,368.22 1,580.53 1,580.53 1,415.40 1,745.66 896.42

800537 PR X-RAY EXAM OF RIBS/CHEST 3PLUS CPT 980 71101 320 Radiology Diagnostic Radiology 113 372.4 725.2 735 568.4 656.6 656.6 588 725.2 372.4

8103263 XRAY EXAM ABDOMEN 1 VIEW CPT 377 74018 320 Radiology Diagnostic Radiology 111 143.26 278.98 282.75 218.66 252.59 252.59 226.2 278.98 143.26

800266 CT SCAN,THORAX,W/O CONTRAST CPT 2,368.00 71250 352 Radiology Diagnostic Radiology 104 899.84 1,752.32 1,776.00 1,373.44 1,586.56 1,586.56 1,420.80 1,752.32 899.84

810233 DUPLEX SCAN EXTRACRANIAL,BILAT CPT 3,461.00 93880 921 Medicine Service/ProceduresNon-Invasive Vascular Diagnostic Studies 101 1,315.18 2,561.14 2,595.75 2,007.38 2,318.87 2,318.87 2,076.60 2,561.14 1,315.18

831224 US,HEAD/NECK TISSUES,B-SCAN/REAL TIME CPT 66 76536 972 Radiology Diagnostic Ultrasound 100 25.08 48.84 49.5 38.28 44.22 44.22 39.6 48.84 25.08

814727 BREATHING CAPACITY TEST CPT 47 94010 460 Medicine Service/ProceduresPulmonary Procedures 99 17.86 34.78 35.25 27.26 31.49 31.49 28.2 34.78 17.86

800567 US, PREG UTER,FETAL & MAT,1ST TRIMEST CPT 985 76801 402 Radiology Diagnostic Ultrasound 99 374.3 728.9 738.75 571.3 659.95 659.95 591 728.9 374.3

803770 US,PREGNANT UTERUS,F/U,TRANSABD APP CPT 683 76816 402 Radiology Diagnostic Ultrasound 95 259.54 505.42 512.25 396.14 457.61 457.61 409.8 505.42 259.54

813348 COMPREHENSIVE HEARING TEST CPT 433 92557 471 Medicine Service/ProceduresSpecial Otorhinolaryngologic Services and Procedures93 164.54 320.42 324.75 251.14 290.11 290.11 259.8 320.42 164.54

800255 CT SCAN,MAXILLOFACIAL AREA,W/O CONTRAST CPT 2,255.00 70486 351 Radiology Diagnostic Radiology 91 856.9 1,668.70 1,691.25 1,307.90 1,510.85 1,510.85 1,353.00 1,668.70 856.9

800243 JOINT SURVEY SINGLE VIEW 2 OR MORE CPT 651 77077 320 Radiology Bone/Joint Studies 76 247.38 481.74 488.25 377.58 436.17 436.17 390.6 481.74 247.38

800562 US,RETROPERIT, B-SCAN/REAL TIME,COMPLETE CPT 1,159.00 76770 402 Radiology Diagnostic Ultrasound 76 440.42 857.66 869.25 672.22 776.53 776.53 695.4 857.66 440.42

800332 MRI BRAIN CPT 5,418.00 70551 611 Radiology Diagnostic Radiology 76 2,058.84 4,009.32 4,063.50 3,142.44 3,630.06 3,630.06 3,250.80 4,009.32 2,058.84

812426 REPR SUP NPTERF WND BODY 2.6-7.5 CPT 454 12002 361 Surgery Integumentary System 71 172.52 335.96 340.5 263.32 304.18 304.18 272.4 335.96 172.52

811357 DUPLEX EXTREM VENOUS,BILAT CPT 1,806.00 93970 921 Medicine Service/ProceduresNon-Invasive Vascular Diagnostic Studies 63 686.28 1,336.44 1,354.50 1,047.48 1,210.02 1,210.02 1,083.60 1,336.44 686.28

800224 X-RAY EXAM OF TOE(S) CPT 325 73660 320 Radiology Diagnostic Radiology 60 123.5 240.5 243.75 188.5 217.75 217.75 195 240.5 123.5

831246 ECHO,SCROTUM & CONTENTS CPT 100 76870 972 Radiology Diagnostic Ultrasound 58 38 74 75 58 67 67 60 74 38

800953 X-RAY EXAM OF FOREARM 2 VW CPT 409 73090 320 Radiology Diagnostic Radiology 58 155.42 302.66 306.75 237.22 274.03 274.03 245.4 302.66 155.42

810113 ECG MONITOR/REP, 24 HRS ANALY/RPT CPT 969 93226 731 Medicine Service/ProceduresCardiovascular Procedures 58 368.22 717.06 726.75 562.02 649.23 649.23 581.4 717.06 368.22

833923 TOTAL HIP ARTHROPLASTY CPT 5,880.00 27130 975 Surgery Musculoskeletal System 57 2,234.40 4,351.20 4,410.00 3,410.40 3,939.60 3,939.60 3,528.00 4,351.20 2,234.40

810493 DRAIN SKIN ABSCESS SIMPLE CPT 328 10060 361 Surgery Integumentary System 55 124.64 242.72 246 190.24 219.76 219.76 196.8 242.72 124.64

800613 X-RAY EXAM NECK SPINE 4/5VWS CPT 902 72050 320 Radiology Diagnostic Radiology 55 342.76 667.48 676.5 523.16 604.34 604.34 541.2 667.48 342.76

800361 MRI, JOINT UPPER EXTREM CPT 3,679.00 73221 610 Radiology Diagnostic Radiology 54 1,398.02 2,722.46 2,759.25 2,133.82 2,464.93 2,464.93 2,207.40 2,722.46 1,398.02

800596 CERVICAL SPINE 2 OR 3 VW CPT 590 72040 320 Radiology Diagnostic Radiology 52 224.2 436.6 442.5 342.2 395.3 395.3 354 436.6 224.2

800625 X-RAY EXAM OF THORACIC SPINE 2 VW CPT 621 72070 320 Radiology Diagnostic Radiology 52 235.98 459.54 465.75 360.18 416.07 416.07 372.6 459.54 235.98

800001 X-RAY EXAM OF WRIST 2 VW CPT 535 73100 320 Radiology Diagnostic Radiology 45 203.3 395.9 401.25 310.3 358.45 358.45 321 395.9 203.3

813267 GLUCOSE CONTINUOUS MONITORING CPT 537 95250 920 Medicine Service/ProceduresEndocrinology Services 45 204.06 397.38 402.75 311.46 359.79 359.79 322.2 397.38 204.06

8103264 XRAY EXAM ABDOMEN 2 VIEWS CPT 651 74019 320 Radiology Diagnostic Radiology 45 247.38 481.74 488.25 377.58 436.17 436.17 390.6 481.74 247.38

800277 CT SCAN,LUMBAR SPINE,W/O CONTRAST CPT 2,482.00 72131 352 Radiology Diagnostic Radiology 42 943.16 1,836.68 1,861.50 1,439.56 1,662.94 1,662.94 1,489.20 1,836.68 943.16

800340 MRI, CERV SPINE CPT 5,053.00 72141 612 Radiology Diagnostic Radiology 42 1,920.14 3,739.22 3,789.75 2,930.74 3,385.51 3,385.51 3,031.80 3,739.22 1,920.14

800805 X-RAY ABDOMEN,COMP ACUTE SERIES CPT 842 74022 320 Radiology Diagnostic Radiology 40 319.96 623.08 631.5 488.36 564.14 564.14 505.2 623.08 319.96

803948 CT ANGIO ABD&PELV W/O&W/DYE CPT 6,791.00 74174 352 Radiology Diagnostic Radiology 39 2,580.58 5,025.34 5,093.25 3,938.78 4,549.97 4,549.97 4,074.60 5,025.34 2,580.58