Procedure Price 120MIN PED ESTRADIOL ESOTERIX/L/M/W/S1/L1 ... · Procedure Price AGAR DILUTION IMC $28.00 AGAR DILUTION L/M $27.50 Albumin (human) 25% 50ml $223.75 Albumin (human)

Procedure Price

120MIN PED ESTRADIOL ESOTERIX/L/M/W/S1/L1 $114.50

120MIN PED FSH ESOTERIX/L/M/W/L1 $112.00

120MIN PED LH ESOTERIX/L/M/W/S1/L1 $55.00

17-HYDROXYPROGEST MOHPG QC/Q/D/J/L/M/N/P/S/T/W/X/E/O/W1 $175.50

17-OH-CORTICOSTEROID ARUP ILH/IMC/E/S1/O/L1 $167.00

180 MIN PED FSH ESOTERIX L/M/W $112.00

180 MIN PED LH ESOTERIX L/M/W $55.00

24HOUR PED ESTRADIOL ESOTERIX/L/W/W/S1/H/L1 $114.50

24HOUR PED FSH ESOTERIX/L/M/W/H/L1 $112.00

24HOUR PED LH ESOTERIX/L/M/W/H/L1 $55.00

24HOUR PED TESTOSTER ESOTERIX/L/M/W/S1/L1 $85.50

25 OH VIT D2/D3 M25HDN Z/A/F/G/X/W1 $131.50

5' NUCLEOTIDASE ARUP L/M/P/T/C1/S1/L1 $87.50

5% dextrose and 0.45% saline $60.00

5% dextrose in lac ringers $60.00

5% dextrose/normal saline $60.00

5% dextrose/water $60.00

5-OH-INDOLEACETIC ACID E/L/M/O/P/R/T/C1/S1/L1/J $116.00

60MIN PED CAH6 PRO ESOTERIX/L/M/W/L1 $279.50

60MIN PED ESTRADIOL ESOTERIX/L/M/W/L1 $114.50

60MIN PED FSH ESOTERIX/L/M/W/L1 $112.00

60MIN PED LH ESOTERIX/L/M/W/S1/L1 $55.00

A GALACTOMANNAN AG MASPAG QC/Q/A/D/L/M/S/W/O/S1/N/L1/W1 $122.00

A PHAGOCYTOPHILUM AB MANAP QC/Q/Z/L/M/W/E/J/L1/O/S1/C1 $140.00

A-1 A PHENOTYPE MA1APP ALL EXCEPT A/B/F/G/H/J/K/N/V/Y/C2/P1/W1 $103.00

A-1-ANTITRYPFECAL MA1AF QC/Q/D/S/T/L/M/W/O/C1/S1/N/L1 $310.00

Abatacept injection $87.68

ABO RHD $54.00

ABO/RH D V/Z/Y/A/D/E/F/G/H/J/L/M/N/O/P/T/QC/S1/L1/C2/P1 $54.00

Acetaminophen injection $29.92

ACETAMINOPHEN QC/V/Z/Y/A/B/D/E/F/G/H/J/K/L/M/Q/T/S1/M1/L1/C2/P1/W1 $268.00

Acetazolamid sodium injectio $170.50

ACETYLCHOL RBC MACHS QC/Q/E/L/M/W/S1/L1 $47.50

Acetylcysteine injection $9.54

A'CHOLINE REC AB MARBI QC/Q/D/E/J/L/M/N/R/S/W/C1/S1/L1/O/W1 $315.50

ACHR BLOCKING AB MAYO M83379 /L/M/W $186.00

ACHR GANG NEURONAL AB MGANG Z/D/L/M/S/W/S1/N/L1/W1 $276.50

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Procedure Price

ACID FAST SMEAR L/M/C1/J/L1 $151.00

ACID PHOSPHATASE L/M ARUP/S1/L1 $99.00

ACT BLANK /M/ $97.00

ACT CATH LAB L/M/W $97.00

ACT L/M $97.00

ACT POC Y/L/M/T/V/W/S $97.00

ACT RADIOLOGY L/M $97.00

ACT SURGERY $97.00

ACUTE HEPATITIS BATTERY E/J/L/M/O/P/R/T/W/C1/S1/L1 $770.00

ACUTE LEUKEMIA PANEL /M/C1/S1/D/S/N/L1 $454.00

Acyclovir injection $11.30

ACYGLYCINESQNU MACYLG QC/Q/Z/M/L/W/D/S/S1/N/L1/W1 $293.00

ACYLCARNITINESQNTP MACRN QC/Q/Z/D/S/L/M/W/O/N/L1/C1/W1 $106.00

ADAMTS13 ACT INH PRO MADM13 QC/Q/Z/M/L/W/L1 $219.50

ADAMTS13 EVALUATION BCW M/PL/S1 $335.00

ADAMTS13 INHIB SCR MADMIS QC/Q/Z/M/L/W/L1 $366.00

ADAMTS13 INHIB TITER MADMBU QC/Q/Z/M/L/W/L1 $366.00

ADDITIONAL ANTIBODY $247.00

ADDITIONAL ID A/D/L/M/S/T/X/W/Q/QC $290.50

ADENO PCR PLASMA L/M/W/L1 $342.50

ADENO PCR SERUM/S1 $342.50

Adenosine inj 1mg $88.10

ADENOVIRUS PCR MLADV QC/Q/Z/X/L/M/W/L1/S1/E/P/O/J/R/C1/A/X/S/D/N $116.00

Adrenalin epinephrine inject $90.30

ADRENOCORTICOTROPIN MACTH QC/Q/Z/D/E/L/M/N/O/P/R/S/T/W/X/C1/S1/L1/W1 $186.00

AEROBIC ORGANISM ID X 2 L/M/W/E/C2 $99.50




AEROBIC ORGANISM IDENTIFICATION M/L/W/W/V/E/C2 $99.50

AEROMONAS PLATE $40.50

AFB IDENTIFY BILL $92.00

AFB IDENTIFY BILL X2 $92.00

AFP TUMOR MARKER QC/V/Z/Y/D/I/J/L/M/N/O/P/R/C1/S1/L1/C2/P1 $153.00

AFT BILL ONLY $43.00

AG/AB INFO ON UNITS $46.00

Agalsidase beta injection $338.05

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Procedure Price

AGAR DILUTION IMC $28.00

AGAR DILUTION L/M $27.50

Albumin (human) 25% 50ml $223.75

Albumin (human) 5% 50ml $123.50

ALBUMIN ALL $45.50

ALCOHOL BREATH F/N/M $172.50

ALCOHOL L/M/U/W $276.00

ALCOHOL URINE Z/O/Q/R/T/X/C1/L/M/W/O/R/S1 $120.00

Aldesleukin injection $7,767.45

ALDOLASE MALS QC/Q/A/D/F/G/L/M/P/R/S/W/X/C1/E/S1/N/L1 $99.00

ALDOS RENIN ACT RATIO ARUP L/M/W/R/S1/J/L1 $46.50

ALDOSTERONE MALDS QC/Q/Z/A/D/E/F/G/J/L/N/O/S/T/W/X/S1/P/L1/W1 $252.50

ALDOSTERONE URINE MALDU QC/Q/A/D/F/G/L/M/P/S/W/X/C1/S1/N/O/L1/W1 $199.00

ALIQUOTING CHARGE $60.00

ALK PHOS ALL $44.00

ALK PHOS FRACTION IMC/E/J/P/T/C1/S1 87078/L1 $66.00

ALK PHOS ISOENZYMES V/Y/E/L/M/O/S1/L1/C2/P1 $88.50

Alloderm $88.11

ALMOND ALLERGEN MALM QC/Q/Z/L/M/O/R/T/W/C1/S1/L1 $25.50

Alpha 1 proteinase inhibitor $10.24

ALPHA NAPH EST IMC $142.50

ALPHA-1-ANTITRYPSIN QC/Q/V/Y/E/J/L/M/O/P/R/W/C1/S1/L1/C2/P1 $182.00

ALPS PANEL SCREEN L/M/W/S1/L1 $549.00

ALT SGPT ALL $45.50

Alteplase recombinant $277.86

ALTERN TENIUS ALLRGN MALTN E/L/M/O/W/X/C1/L1 $25.50

ALUMINUM MAL QC/Q/L/M/P/W/C1/S1/L1 $130.00

ALUMINUM URINE ARUP ILH $258.00

AMIKACIN PEAK MPAMIK QC/Q/D/S/L/M/W/S1/N/L1 $50.50

AMIKACIN RANDOM MAMIKR QC/Q/L/M/P/W/C1/Z/L1 $50.50

Amikacin sulfate injection $33.27

AMIKACIN TROUGH MTAMIK QC/Q/D/S/T/L/M/W/N/Z/L1 $50.50

AMINO ACID QN MAAQP QC/Q/Z/D/T/S/X/L/M/W/J/C1/O/E/N/L1 $261.00

Aminophyllin 250 mg inj $63.62

Amiodarone hcl $89.75

AMIODARONE MAYO MAMIO QC/Q/Z/D/J/L/M/P/R/S/T/W/X/C1/N/L1 $69.50

AMITRIP/NORTRIP MAMTRP QC/Q/Z/D/E/S/T/X/L/M/P/R/W/N/C1/L1/W1 $43.50

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Procedure Price

AMMONIA QC/V/Z/Y/A/B/D/E/F/J/L/M/N/O/P/R/S/U/W/X/C1/S1/L1/P1/W1 $204.50

AMNIOTIC FLD SPECTRO IMC/ILH $86.00

AMNISURE L/M/S/W/X $172.00

AMNISURE QC/V/L/M/W/K/C2/P1/W1 $172.00

AMOXICILLIN ALLERGEN MAMOXY D/L/M/N/S/W//S1/L1 $25.50

AMPA-R Ab IFTITER MAMPIS Z/D/L/M/S/W/S1/N/L1 $226.00

AMPA-R AbCBA MAMPCS Z/D/L/M/S/W/S1/N/L1 $467.50

AMPHETAMINES URN D/L/M/S/T/X/O $63.00

AMPHIPHYSIN WEST BLT MABLOT Z/D/L/M/S/W/S1/N $340.50

Amphotericin b $117.90

Amphotericin b liposome inj $105.28

Ampicillin 500 mg inj $94.55

AMPICILLIN ALLERGEN MAMP QC/Q/D/L/M/S/W/S1/N/L1 $25.50

Ampicillin sodium per 1.5 gm $102.70

AMYLASE ALL $124.50

AMYLASE FLUID QC/V/Z/Y/A/D/E/F/G/L/M/Q/R/S/T/X/W/C1/N/C2/L1/H/O/P1 $124.50

AMYLASE TO REDPATH $19.00

AMYLASE URINE 12 HR QC/E/L/M/T/S1/L1 $144.00

AMYLASE URINE 2 HR QC/Y/L/M/P/T/W/S1/L1 $144.00

AMYLASE URINE 24HR QC/A/E/L/M/Q/T/X/W/S1/L1 $144.00

AMYLASE URINE 8 HOUR QC/E/M/W/S1/L1 $144.00

AMYLASE URINE QC/Z/A/L/M/Q/T/W/X/L1 $144.00

ANA 10 PANEL L/M/O/T/W/S1/R/P/J/E/L1 $43.00

ANA BY IFA C1/E/J/L/L1/M/O/P/R/W/S1 $43.00

ANA BY IFA W REFLEX C1/E/J/L/M/O/P/R/W/S1 $43.00

ANA TITER $117.00

ANAEROBIC ORGANISM ID /E/C2 $124.50

ANAEROBIC ORGANISM ID X 2 /E/C2 $124.50




Anastrozole 1 mg $26.25

ANCHOVY ALLERGEN MANCH D/S/L/M/W/S1/N/L1 $25.50

ANDROSTENEDIONE MANST QC/Q/D/L/M/P/S/W/X/E/C1/N/R/L1 $215.00

ANGELMAN SYNDROME L/M/W/L1 $1,667.50

ANGIO CONVERT ENZYME L/M/O/P/R/W/E/J/C1/S1/L1 $102.00

ANTENATAL RHIG Y/L/P1/W1 $130.50

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Procedure Price

ANTI GM1 ANTIBODY M/L/W/P ARUP/S1/L1 $94.50

ANTI SMOOTH MUSCLE AB E/J/L/M/O/P/R/W/C1/S1/L1 $272.50

ANTI THROMBIN 3 ACT L/M/P/R/W/E/O/J/C1/S1/L1 $76.00

ANTI THROMBIN III MATTF QC/Q/A/D/F/G/N/S/T/S1/W1 $129.50

ANTI-A TTR TRNS $131.00

ANTIBODY ELUTED $174.50

ANTIBODY ELUTION QC/V/Z/A/D/L/M/S/T/W/X/F/G/E/W1 $174.50

ANTIBODY ID V/Z/Y/A/D/L/M/P/S/T/W/X/F/G1/QC/P1/W1 $290.50

ANTIBODY IDENT FOR PATIENT SPECIMEN $290.50

ANTIBODY SCREEN $130.50

ANTIBODY SCREEN Z/Y/D/E/L/M/N/Q/S/T/W/X/C1/QC/L1/A/C2/P1 $130.50

ANTIBODY TITER Z/A/E/F/G/L/M/O/P/U/W/X/QC/P1/W1 $212.50

Antifibrinolytic ROTEM /M/ $143.00

ANTIGEN INFO $46.00

ANTIGEN PATIENT TEST Y/V/Z/A/N/S/T/W/QC/P1/W1 $46.00

ANTIGEN TEST PATIENT A/L/M/P/C1 $46.00

ANTI-Jo1 MJO1 D/S/T/X/L/P/W/M/C1/N $123.00

ANTIMULLERIAN HORMONE MAMH QC/Q/C1/E/J/L/M/N/W/X/O/S1/D/S/T/P/L1/W1 $238.00

ANTITHROMBIN 3 AG MATTI A/C1/D/J/L/L1/M/N/O/Q/QC/S/S1/W $170.00

Antithrombin iii injection $7.78

Antithymocyte globuln rabbit $1,625.77

ANTI-TPO/MICROSOM QC/V/Y/E/L/M/O/P/R/W/C1/F/S1/L1/P1 $100.50

ANTI-U1RNP MRNP D/S/T/X/L/M/W/E/C1/S1/N/Z/W1 $34.50

ANTI-XA BILL ONLY IMC/ILH/WDM $70.50

ANTI-XA QC/L/M/W/D/S/N/C1/O/X/S1/J/L1 $70.50

APOLIPOPROTEIN A1 AND B APABR Z/L/M/W/E/J/L1/O/S1/P/R/C1 $195.00

APOLIPOPROTEIN A-1 ARUP $67.00

APOLIPOPROTEIN A1 P APLA1 Z/L/M/W/E/J/L1/O/S1/P/R/C1 $173.00

APOLIPOPROTEIN B 50029 $28.50

APOLIPOPROTEIN B P APLB Z/L/M/W/E/J/L1/O/S1/P/R/C1 $64.00

APPLE ALLERGEN MAPPL QC/Q/L/M/O/R/T/W/S1/L1 $25.50

APRICOT ALLERGEN MAPR QC/Q/D/S/L/M/W/S1/N/L1 $25.50

Arbovirus Ab PanelCSF ABOPCM Z/L/M/W/E/J/L1/O/S1/P/R/C1 $41.00

Arbovirus Ab PanelS MARBOP Z/L/M/W/E/J/L1/O/S1/P/R/C1 $41.00

Arformoterol non-comp unit $20.45

ARGININE VASOPRESSIN MAVP QC/Q/A/D/F/G/L/M/N/S/W/X/C1/J/L1 $142.50

Aripiprazole lauroxil 1mg $5.46

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Procedure Price

ARSENIC 24HR URINE MASU24 QC/Q/D/S/L/M/R/W/C1/S1/N/L1/Z $156.00

ARSENIC FRACTION 24H MASFR D/S/N/Z/QC/Q/L/M/R/W/C1/S1/L1 $334.00

ARSENIC HAIR NAILS MASHA QC/Q/L/M/W/S1/L1 $195.50

ARSENIC MASB L/M/W/P $147.00

Arsenic trioxide injection $187.66

ARTHROPOD EXAM Z/M/X/L/W/L1 $242.00

ARYLSULFATASE URINE ARUP 95227 L/M/W/S1/L1 $382.00

ASO TITER E/L/M/O/P/R/T/W/X/C1/L1 $75.00

ASO/ADB J/L/M/O/P/R/W/E/C1/S1/L1 $75.00

ASPARAGUS ALLERGEN MASPAR QC/Q/D/S/T/L/M/W/S1/N/L1 $25.50

ASPER FUMIGATIS ALLR M82911M E/L/M/O/W/X/C1/S1//L1/W1 $25.50

ASPERGILLUS AGBAL MASPBA QC/Q/L/M/W/L1 $137.00

ASPERGILLUS IgG AB MSASP QC/C/D/L/M/S/W/C1/S1/N/L1 $81.50

ASPERGILLUS NIGER AL MASPG QC/Q/Z/D/S/L/M/W/X/S1/N/L1 $25.50

ASPIRIN Platelet Rct L/M/W/L1 $76.00

AST SGOT ALL $45.50

Atropine sulfate injection $14.78

AUTO AB TO SM MSM D/E/J/L/M/N/O/P/S/WC1/S1/X $44.50

AUTO AB TO SSARO MSSA D/E/J/L/M/P/R/S/W/C1/S1/N/X $51.00

AUTO AB TO SSBLB MSSB D/E/J/L/M/O/P/R/S/W/C1/S1/N/X $51.00

AUTO DO FEES QC $166.50

AUTO FP24 THAWED $184.50

AUTO PC LEUK $666.50

AUTO PRBCS $569.50

AUTO RETICULOCYTE A/D/G/J/K/L/M/N/O/P/QC/R/S/V/W/B1/S1/L1/C1/P1 $72.00

AVOCADO ALLERGEN MAVOC L/M/W/S1/L1 $25.50

Azacitidine injection $15.22

Azathioprine oral 50mg $13.00

Azithromycin $102.40

Azithromycin dihydrate oral $20.10

B. PERTUSSIS BY PCR E/J/L/M/O/W/S1/L1 $50.50

B-2 GLYCOPROT 1 IgGM L/M/O/W/S1/L1/T/P/I/C/D/N/S $46.00

B-2 GLYCOPROTN 1 IgA QC/Y/V/L/M/O/W/S1/L1/C2/P1/D/N/S $46.00

B-2 GLYCOPROTN 1 IgG QC/Y/V/L/M/W/S1/L1/C2/P1/D/N/S $46.00

B-2 GLYCOPROTN 1 IgM QC/Y/V/L/M/W/S1/L1/C2/P1/D/N/S $46.00

Baclofen 10 mg injection $115.00

BAKERS YEAST ALLERGN MBYST QC/D/L/M/S/W/C1/Q/N/L1 $25.50

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Procedure Price

BANANA ALLERGEN MBANA QC/Q/L/M/O/W/S1/L1 $25.50

BARB CONFIRM GC/MS ILH/IMC/WDM/O/C1/S1 $100.00

BARBITURATES URN /D/L/M/S/T/X/O $63.00

BARLEY ALLERGEN MBRLY QC/Q/Z/L/M/R/W/C1/S1/L1 $25.50

BARTONELLA AB IGG/IGM MBART QC/Q/A/D/F/G/L/M/N/O/P/S/W/C1/S1/L1/E/W1 $65.00

BASELINE PED ESTRADI ESOTERIX/L/M/W/S1/L1 $114.50

BASELINE PED FSH ESOTERIX/L/M/W/S1/L1 $112.00

BASELINE PED LH ESOTERIX/L/M/W/S1/L1 $55.00

BASELINE PED TESTOST ESOTERIX/L/M/W/S1/L1 $85.50

BASIC METABOLIC PNL Z/A/F/G/I/L/M/P/U/W/W1 $282.50

BASIL IGE MBASL QC/Q/Z/L/M/W/L1 $9.50

Basiliximab $7,256.20

BATTENS DISEASE NEUROGENETIC L/M/S1 $172.50

BB SPECIMEN TO HOLD V/Z/Y/A/F/G/L/M/Q/S/T/W/QC/S1/B1/P1 $28.00

B-CELL ALL FISH BALLF L/M/T/W/S1 $171.00

BCH G4 ISTAT ARTERIAL /M/ $69.00

BCH G4 ISTAT CAPILLARY /M/ $69.00

BCH ISTAT G4 VENOUS /M/ $69.00

BCR/ABL p210 pcr MBCRAB QC/Q/A/D/E/F/G/J/L/M/N/O/P/S/W/C1/S1/L1 $476.00

BEDSIDE GLUCOSE A/B/E/G/H/J/L/M/N/O/Q/QC/S/T/U/V/W/X/Y/Z/B1/C1/S1/C2/P1/W1 $40.50

BEEF ALLERGEN MBEEF QC/Q/L/M/O/T/W/C1/L1 $25.50

BEETS ALLERGEN MBEETS D/L/M/S/W/S1/N/L1 $25.50

Belatacept injection $7.92

Belimumab injection $84.59

BENZOS URN D/L/M/N/R/S/T/X/O $63.00

BERMUDA GRASS ALLERG MBERG E/L/M/O/W/X/C1/S1/L1 $25.50

BETA 2 GP1 AB IgA MAB2GP J/L/M $82.50

BETA 2 GP1 AB IgG MAYO MGB2GP L/M/W $82.50

BETA 2 GP1 AB IgM MAYO MMB2GP L/M/W $82.50

BETA 2 GP1 AB PNL MB2GMG Z/A/E/L/M/P/R/W/X/C1/S1 $47.00

BETA 2 MICROGLB CSF MB2MC QC/Q/D/L/M/W/S/N/L1 $124.50

BETA 2 MICROGLOB URN MB2MU QC/Q/Z $66.50

BETA HYDROXYBUTYRATE A/L/M/N/O/P/W/C1/Q/S1/C2/L1/W1 $58.50

BETA LACTAMASE $40.50

BETA LACTAMASE 2 $40.50

BETA LACTAMASE 3 $40.50

BETA-2-MICROGLOBULIN MB2M L/M/O/P/W/X/R/C1/S1/L1/J/W1 $124.50

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Procedure Price

BETA-LACTOGLOB ALGN MBLAC L/M/W/L1 $25.50

Betamethasone acetsod phosp $53.65

Bevacizumab injection $497.75

BICARBONATE URINE L/M/W $41.50

BILE ACD FRAC AND TL MBAFS QC/Q/L/M/W/X/S1/L1 $184.00

BILE ACIDS TOTAL S MBILEA QC/Q/J/D/E/L/M/R/S/W/C1/S1/N/Z/L1/W1 $93.00

BILI TOT AND DIRECT L/M/S/T/D/X/S1 $70.50

BILIRUBIN CORD /A/L/M/W/S1 $70.50

BILIRUBIN DIRECT ALL $70.50

BILIRUBIN FLUID QC/V/Y/A/D/L/M/S/X/L1/H/O/P1 $131.00

BILIRUBIN TOTAL ALL $70.50

BILIRUBIN TRANSCUTANEOUS L/M/W $45.50

BIOCHEM ID FUNGUS $90.00

BIOCHEM ID TYPE #2 $52.00

BIOCHEM ID TYPE #3 $52.00

BIOCHEM ID URINE $108.00

BIOCHEM ID URINE X 2 $108.00



BIOTINIDASE MBIOTS QC/Q/L/W/M/C1/S1/L1 $103.00

Bivalirudin $4.85

BK VIRUS DNA PLASMA MQBK QC/Q/D/L/M/P/S/W/C1/N/X/W1 $345.00

BK VIRUS DNA QN MQBKU QC/Q/D/L/M/S/W/C1/N/W1 $724.50

BKV PCR UR VIRACOR M/L/W/E/O/J/C1/S1/L1 $273.50

BKV PLAS VIRACOR M/L/W/E/O/J/C1/S1/L1 $273.50

BKV SERUM VIRACOR M/L/W/E/O/J/S1/L1 $273.50

BLACKBERRY ALLERGEN MBLACK D/S/L/M/W/S1/N/L1 $25.50

BLASTOMYCES AB EIA MAYO $214.00

BLASTOMYCES AB EIA MBLAST QC/Q/D/S/L/M/W/S1/N/O/L1/W1 $64.00

BLASTOMYCES AB MSBL QC/Q/L/M/P/W/C1/D/S/S1/N/L1/W1 $91.50

BLD ADMIN >6 UNITS $1,183.50

BLD ADMIN 2 UNITS $942.50

BLD ADMIN 3 UNITS $991.00

BLD ADMIN 4 UNITS $1,039.00



Bleomycin sulfate injection $258.33

8 of 172

Procedure Price

BLK/WHT PEPPER IGE MBLPEP L/M/W/Z/L1 $9.50

BLOOD ADMINISTRATION $894.50

BLOOD CULTURE ID 2ND ORG PCR $33.50

BLOOD GAS CAPILLARY L/M $128.00

BLOOD GAS ISTAT WDM $100.50

BLOOD GASES iSTAT $100.50

BLOOD GASES L/M $128.00

BLOOD URINE Y/A/I/K/L/M/T/X/O $58.00

BLUE MUSSEL ALELRGEN MMUSS QC/Q/L/M/W/C1/S1/L1 $25.50

BLUEBERRY ALLERGEN MBLUE D/S/L/M/W/S1/N/L1 $25.50

BNP A/D/F/G/H/K/L/M/P/R/S/T/U/W/B1/C1/M1/S1/W1 $262.50

BODY FLD CELL CNT E/J/L/M/O/P/R/S1/B1/L1 $141.50

BODY FLUID CRP $78.00

BODY FLUID CULTURE BY AUTOMATION E/J/L/M/W/L1/O $41.50

BODY FLUID HEMATOCRIT A/L/M/W/L1 $29.50

BORDETELLA PCR MBPRP QC/Q/X/P/R/S1 $206.00

Bortezomib injection $103.69

BOX ELDER/MAPLE TREE MBXMPL E/L/M/O/W/X/C1/S1/L1 $25.50

BRAZIL NUT ALLERGEN MBRAZ QC/Q/L/M/W/C1/L1 $25.50

Brentuximab vedotin inj $272.11

BROCCOLI ALLERGEN MBROC QC/Q/L/M/W/L1 $25.50

BROMIDE IMC/ILH/C1/E $91.00

BRUCELLA AB IgG/IgM M89476 QC/Q/A/D/L/M/O/S/W1/E/N/L1/R $33.50

BRUCELLA TL AB AGGL MBRUTA QC/Q/D/S/L/M/W/N/L1 $250.00

BUCKWHEAT ALLERGEN MBUCW D/S/L/M/W/N/L1 $25.50

Budesonide non-comp unit $20.00

BUDGERIGAR DROPPINGS MBDRP D/S/L/M/W/N/L1 $25.50

BUDGERIGAR FEATHERS MBFTH D/S/L/M/W/N/L1 $25.50

Bumetanide 0.5 mg $91.50

BUN ALL $44.00

BUN DIALYSATE 24 HR M/S1/L1 $39.50

Bupren/nal 3.1 to 6mg bupren $10.80

Bupren/nal 6.1 to 10mg bupre $11.05

Bupren/nal up to 3mg bupreno $6.60

BUPRENORPHINE MEDTOX L/M/W/S1/L1 $178.50

Buprenorphine oral 1mg $1.75

BUTALBITAL URINE ILH/IMC/WDM $61.00

9 of 172

Procedure Price

Butorphanol tartrate 1 mg $89.95

C DIFFICILE EIA L/M/W/H/J/T/O/P/R/S1/C1/L1 $104.00

C DIFFICILE MOLECULAR E/J/K/L/M/O/P/QC/R/T/V/W/Y/Z/C1/S1/C2/L1/P1 $102.50

C PEPTIDE MCPR D/E/J/L/M/N/O/P/R/S/T/W/X/C1/S1/L1/W1 $142.50

C-1 esterase berinert $113.31

C1 ESTERASE INHIBITR MC1ES QC/Q/Z/D/E/L/M/O/P/R/S/W/C1/S1/N/T/L1 $130.50

C1EST INHIBFUNCTIONAL MFC1EQ O/Q/Z/D/E/L/M/P/R/S/T/W/C/S1/N/L1/W1 $129.50

C1Q COMPLEMENT FUNC MC1QFX QC/Q/M/R/W/C1/S1/T/L1 $433.00

C5DC ACYLCARNITINE U MC5DCU L/M/W/L1 $257.00

CA 125 D/L/M/N/O/P/R/S/X/W/E/J/C1/S1/L1 $246.00

CA 15-3 ANTIGEN MCA153 A/D/E/F/G/J/L/M/N/O/P/Q/QC/S/T/W/X/C1/S1/L1/W1 $119.00

CA 27.29 MC2729 ALL EXCEPT B/K/U/V/Y/C2/P1 $48.00

CA19-9 MAYO M9288 A/F/G/T/X//W1 $137.00

CA19-9 QC/V/Y/D/S/E/J/L/M/N/O/P/R/W/C1/S1/L1/C2/P1 $137.00

CABBAGE ALLERGEN MCABB D/L/M/S/W/S1/N/L1 $25.50

CADMIUM MCDB L/M/W/C1/S1/L1 $124.50

CADMIUM URINE 24 HR MCDU QC/Q/D/S/L/M/W/S1/N/L1 $124.50

Caffeine citrate injection $91.95

CAFFEINE ILH/IMC/J $189.50

CAH PROFILE 6 ENDO SC IMC/S1/L1 $150.00

CAH PROFILE 7 ENDO SC IMC/S1/J/T/L1 $162.00

CALCITONIN MCATN QC/Q/D/L/M/N/O/S/W/X/C1/L1/W1 $178.50

Calcitonin salmon injection $3,441.50

CALCIUM ALL $45.50

Calcium gluconate injection $105.80

CALCIUM IONIZED E/J/L/M/O/P/R/C1/S1/L1 $92.50

CALCIUM UR 24 HR QC/V/Z/Y/U/A/D/E/F/G/J/L/M/N/O/P/Q/R/S/T/X1/S1/L1/P1/W1 $110.50

CALCIUM URINE QC/V/Y/Z/A/D/L/M/O/Q/R/S/T/X/W/C1/N/L1/E/P1 $110.50

CALCIUM/CREATININE QC/Z/M/P/E/S1/L1 $110.50

CALPROTECTIN FECAL Y/V/C2/C1/J/L/M/O/R/W/P/L1/P1 $218.50

CANARY FEATHER ALGRGN MCFTH D/S/L/M/W/N/L1 $25.50

CANDIDA ANTIBODY Y/V/L/M/PL/C1/S1/L1/C2/P1 $50.00

CANNABINOIDS URN /D/L/M/S/T/X/O $66.50

Capecitabine oral 500 mg $37.90

CARBA R ASSAY $58.00

CARBAM-1011 EPOXIDE MCARBG QC/Q/L/M/W/S1/Z/L1 $145.00

CARBAMAZEPINE QC/V/Z/Y/A/D/E/F/G/H/J/L/M/N/O/P/Q/R/S/T1/S1/B1/L1/C2/P1/W1 $214.50

10 of 172

Procedure Price

Carboplatin injection $184.55

CARBOXYHEMOGLOBIN D/L/M/N/P/R/S/S1/E/L1 $106.50

CARNITINE MCARN QC/Q/Z/D/S/X/L/M/W/E/R/S1/N/L1 $184.00

CAROTENE L/M/P $109.00

CARROT ALLERGEN MCROT QC/Q/L/M/W/C1/S1/L1 $25.50

CASEIN ALLERGEN MCASE QC/Q/L/M/W/L1 $25.50

CASHEW ALLERGEN MCASH QC/Q/L/M/W/C1/L1 $25.50

CASPR2 IGG CBA MCS2CS QC/D/S/N/Q $267.50

CAT EPITH ALLERGEN MCAT E/L/M/O/W/X/C1/L1 $25.50

CATECHOL FRAC FREE MCATP QC/Q/L/M/O/P/R/W/E/J/C1/S1/L1/W1 $224.00

CATECHOLAMINES 24HR UR E/J/L/M/O/P/R/C1/S1/L1 $145.00

CAULIFLOWER ALLERGEN MCALFL D/L/M/S/W/S1/N/L1 $25.50

CAYENNE PEPPER IGE MFPCYE D/L/M/S/W/N/L1 $75.00

CBC L/M/W/P1 $75.00

CBC W DIFF WAM L/M/W $97.00

CCP ANTIBODIES MAYO MCCP D/E/J/L/M/N/O/P/R/S/W/X/C1/S1/W1 $108.00

CCP IgG QC/Y/V/C1/E/J/L/M/N/O/P/R/T/W/S1/L1/C2/P1 $38.50

CD10 ANTIBODY $196.50



CD11b ANTIBODY $187.00

CD11c ANTIBODY $187.00









CD20 ON B CELLS L/M/W/L1 $202.00







11 of 172

Procedure Price



CD4 ABSOLUTE COUNT $329.00

CD4 ANTIBODY BILL ONLY $262.50










CD79A ANTIBODY $187.00

CD79B ANTIBODY $187.00


CEA BODY FLUID L/M/W/L1 $251.50

CEA QC/V/Y/J/A/B/D/E/F/G/J/L/M/O/P/Q/R/W/X/C1/S1/L1/C2/P1/W1 $251.50

CEA TO REDPATH $57.00

CEDAR TREE ALLERGEN MCEDR D/S/L/M/W/S1/N/L1 $25.50

Cefazolin sodium injection $92.70

Cefepime hcl for injection $94.65

Cefotaxime sodium injection $90.50

Cefoxitin sodium injection $101.60

Ceftaroline fosamil inj $13.15

Ceftriaxone sodium injection $92.00

CELERY ALLERGEN MCELY L/M/W/C1/S1/L1 $25.50

Centromere AbIgG QC/Y/V/C1/E/J/L/M/O/P/R/W/S1/L1/C2/P1 $43.00

CENTROMERE ANTIBODY M/R/W/C1 $95.00

CENTROMERE ANTIBODY MCMA O/Z/D/S/L/M/W/S1/N/L1/X $66.00

Certolizumab pegol inj 1mg $20.09

CERULOPLASMIN E/L/J/M/O/P/R/W/C1/S1/L1 $55.00

CERULOPLASMIN MCERS QC/Q/D/S/X/N/W1 $128.00

Cetuximab injection $123.01

CHEDDAR CHEESE ALLER MCCHZ D/S/L/M/W/N/L1 $25.50

CHEESE MOLD ALLERGEN MMCHZ QC/Q/D/S/L/M/W/N/L1 $25.50

CHERRY ALLERGEN MCHER L/M/W/S1/L1 $25.50

12 of 172

Procedure Price

CHESTNUT SWEET ALLER MCNUT L/M/W/L1 $25.50

CHICK PEA IGE MCHXP L/M/W/Z/S1/L1 $9.50

CHICKEN ALLERGEN MCHIC QC/Q/L/M/O/W/C1/L1 $25.50

CHICKEN DROPPING ALR MCDROP D/S/L/M/W/N/L1 $25.50

CHICKEN FEATHER ALRG MCHCK L/M/W/S1/L1 $25.50

CHICKEN SERUM PROT MCSPR D/S/L/M/W/S1/N/L1 $25.50

CHILD ALLERG PROFILE QC/Q/E/L/M/O/W/C1/L1 $25.00

CHLAMYDIA ABIGM 0065105 L/M/W/S1/L1 $28.00

CHLAMYDIA BY NAA E/J/L/M/S1/L1 $206.00

CHLAMYDIA BY NAA OTHER L/W/M/J/S1/L1 $217.00

CHLAMYDIA CULTURE MFCLCU QC/Q/C1/L/M/O/W/S1/L1 $100.50

CHLAMYDIA PNEUMONIAE CULTURE /M/PL/L1 $94.00

CHLAMYDIA SEROLOGY MSCLAM D/S/L/M/W/P/S1/N/L1 $61.50

CHLAMYDIA URINE L/M/O/P/W/J/S1/L1 $101.50

CHLORDIAZEPOXIDE ARUP ILH/IMC/S1/L1 $73.00

CHLORIDE ALL $42.00

CHLORIDE CSF V/Y/A/L/M/Q/T/X/W/L1/P1 $91.50

CHLORIDE FLUID A/L/M/X/W/L1 $80.00

CHLORIDE RAN URN MAYO 83747 L/M/W $38.50

CHLORIDE STOOL $48.00

CHLORIDE SWEAT A/M $50.50

CHLORIDE URINE 24 HR QC/Z/U/A/D/F/G/L/M/N/Q/S/T/W/X/C1/S1/L1 $103.50

CHLORIDE URINE QC/V/Y/Z/U/A/D/E/F/G/L/M/N/O/P/Q/R/S/T/W/X/C1/J/L1/P1/W1 $103.50

CHLORO ESTERASE IMC $138.00

Chloroprocaine hcl injection $132.30

Chlorothiazide sodium inj $682.90

CHLORPROMAZINE ARUP ILH/IMC/S1/L1 $116.00

Chlorpromazine hcl injection $144.95

CHOCOLATE/COCAL ALLG MCOCOA QC/Q/L/M/W/C1/S1/L1 $25.50

CHOLESTEROL ALL $45.50

CHOLESTEROL FLUID QC/V/Z/Y/D/H/M/Q/S/T/W/X/C1/L1/P1 $45.50

CHORIONIC GONAD BETA MBHCG QC/Q/X/L/M/P/R/W/O/J/S1/W1 $83.50

CHROM RAN UA MCR L/M/W/S1/L1 $47.50

CHROMAGRANIN A MCGAK QC/Q/Z/A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/C1/S1/L1/W1 $116.00

CHROMATIN AB QC/V/Y/C1/E/J/L/M/O/P/R/W/L1/C2/P1 $43.00

CHROMIUM 24 HR URINE CRU L/M/W/S1/L1 $214.00

CHROMIUMSERUM MCRS QC/Q/C1/J/Z/D/S/L/M/N/O/W/S1/L1/W1 $297.50

13 of 172

Procedure Price

CHROMO CONGEN AN BLD MCHRCB QC/Q/A/L/M/W/S1/S/D/N/L1/W1 $235.50

CHROMOSOMAL ANALYSIS NICU /M/S1 $1,072.00

CHROMOSOME ANAL -BM MAYO $1,147.50

CHROMOSOME ANALY AF MCHRAF J/L/M/W/L1 $428.00

CHROMOSOME ANALY BM MCHRBM L/M/W $321.00

CHROMOSOME MICRO ARRAYUIHC L/W/M/S1/L1 $2,382.00

CHRONIC URT INDEX MFCUIX QC/Q/Z/D/E/S/L/M/W/S1/N/T/P/L1 $198.00

Cidofovir injection $285.85

Cilastatin sodium injection $72.59

CINNAMON ALLERGEN MCINN D/S/L/M/W/N/L1 $25.50

Ciprofloxacin iv $92.30

Cisplatin 10 mg injection $77.05

CITRATE EXCRETION PEDS MRCITR L/M/O/W/S1/L1 $165.50

CITRATE URINE 24 HR MAYO M0320 QC/Q/D/E/S/T/L/M/N/O/W/C1/S1/L1 $245.50

CK ALL $99.50

CK ISO ELECTROPHRSIS $112.50

CK ISO ELECTROPHRSIS MCKELR QC/Q/L/M/W/S1/L1 $20.50

CKMB MASS ASSAY B/O/Y/C1 $194.50

CKMB V/Y/E/J/K/O/P/R/U/C1/X/S1/L1/P1 $194.50

CLADOSPORIUM ALLERGN MCLAD E/L/M/O/W/X/C1/L1 $25.50

CLAM ALLERGEN MCLAM E/L/M/O/W/C1/L1 $25.50

CLOBAZAM MFCLBZ Z/L/M/W/E/J/L1/O/S1/P/R/C1 $107.00

Clofarabine injection $305.73

CLOMIP/DESMETHCLOMIP MFCLM Z/D/L/M/S/W/X/S1/N/L1 $101.50

CLOMIPRAMINE MCLOM QC/Q/Z/D/S/X/L/M/W/N/L1/W1 $75.50

CLONAZEPAM 7 AMINOCL MCZPS QC/Q/C1/D/E/L/M/S/W/N/L1/X $56.00

Clonidine hydrochloride $150.20

CLOVE ALLERGEN IGE MCLOV L/M/W/L1 $9.50

Clozapine 25 mg $1.80

CLOZAPINE MAYO M500009 D/S/X/L/M/W $199.00

CLOZAPINE MCLZ Z/A/D/L/M/O/R/S/T/TM/W/X/C1/Q/S1/N/L1/E/W1 $99.50

CMV AB IGG AND IGM E/J/L/M/P/R/W/C1/S1/L1/D/N/S $55.50

CMV AB IGG L/M/P/R/W/C1/S1/L1/D/N/S $54.50

CMV AB IGM C/E/I/J/L/M/N/O/P/R/T/W/C1/L1/S1/D/N/S $55.50

CMV ANTIBODY IgG MCMG Z/L/M/W/J/X/W1 $146.00

CMV ANTIBODY IgM MAYO M87277 /L/M/W/J/W1 $95.50

CMV ANTIVIRAL RESIST L/M/W $609.00

14 of 172

Procedure Price

CMV BY PCR L/M/W/E/O/J/C1/L1 $356.00

CMV BY PCR PLASMA E/L/M/W/S1/C1/L1 $339.00

CMV DNA QNT PCR MQCMV QC/Q/A/D/F/G/J/N/S $264.50

CMV NEG BCCI IMBILHB1 $91.50

CMV NEG CHARGE $91.50

CMV PCR QUALITATIVE MLCMV QC/Q/A/D/S/X/S1/N/W1 $276.00

CMV PCR UR VIRACOR $202.50

CMV PLAS VIRACOR M/L/W/O/J/C1/S1/L1 $202.50

CMV SERUM VIRACOR M/L/W/S1/L1/P $202.50

CMV T CELL PANEL $176.50

CO2 ALL $42.00

CO2-ISTAT H/M $29.00

COAG FACTOR IX MF_9 QC/Q/Z/A/D/S/X/L/M/W/C1/S1/N/L1/W1 $118.50

COAG FACTOR VII MF_7 QC/Q/Z/A/D/L/S/M/W/X/T/E/J/C1/N/L1/W1 $136.50

COAG FACTOR VIII MF8A QC/Q/Z/A/S/L/M/W/N/S/D/C1/W1 $96.00

COAG FACTOR XI MF_11 QC/Q/Z/A/D/E/F/L/M/S/W/X/C1/S1/N/L1/W1 $259.00

COAG FACTOR XII MF_12 QC/Q/Z/A/X/L/M/W/J/D/S/N/C1/S1/L1/W1 $238.50

COBALT MCOS QC/Q/J/L/M/N/W/S1/D/S/L1/W1 $247.50

COCAINE CONFRM GC/MS L/M/R/W/C1 $100.00

COCAINE URN /D/L/M/S/T/X/O $63.00

COCCIDIODES ABCF/ID MRSCOC QC/D/S/L/W/M/N/L1 $257.00

COCCIDIOIDES AB EIA MCOXIS QC/Q/D/L/M/S/W/S1/N/L1/W1 $38.50

COCCIDIOIDES AB MSCOC QC/Q/Z/D/L/M/N/P/S/W/C1/S1/O/L1/W1 $44.50

COCCIDIOIDES AG SER MIRA L/M/W/L1 $181.50

COCCIDIOIDES AG URIN MIRA L/M/W/L1 $181.50

COCKLEBUR ALLERGEN MCBUR QC/Q/L/M/W/L1 $25.50

COCONUT ALLERGEN MCCNT QC/Q/L/M/W/C1/S1/L1 $25.50

CODFISH ALLERGEN MCOD E/L/M/O/W/C1/L1 $25.50

COL/ADP CHARGE $97.00

COL/EPI CHARGE $97.00

COLD AGGL TITER J/L/M/O/W/C1/L1 $179.00

COMP METABOLIC PROFILE Z/L/M/P/W $511.00

COMPLEMENT C1Q S C1Q Z/E/J/L/M/O/P/R/C1/S1/L1 $60.00

COMPLEMENT C2 MC2AG QC/Q/D/L/M/R/S/W/C1/S1/N/Z/L1 $162.00

COMPLEMENT C3 QC/V/Z/Y/A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/S1/L1/C2/P1/W1 $152.50

COMPLEMENT C4 QC/V/Z/Y/A/D/E/F/G/I/J/L/M/N/O/P/R/S/W1/S1/L1/C2/P1/W1 $181.00

COMPLEMENT C5 MAYO M9266 L/M/R/W/L1 $158.50

15 of 172

Procedure Price

COMPLEMENT TL CH50 MCOM QC/Q/D/E/J/L/M/N/P/R/S/T/W/X/S1/O/L1/W1 $174.50

CON TISS DIS CASCADE MCTDC O/Z/D/L/M/S/W/E/R/L1/X $67.50

CONV PAP CPT 88141 BILL ONLY $80.00




COOMBS CROSSMATCH $51.00

COPPER MCUS QC/Q/D/E/J/L/M/N/O/P/R/S/W/X/C1/S1/L1/W1 $52.00

COPPER URINE 24 HR MCUU QC/Q/D/S/X/L/M/R/W/C1/S1/N/L1/W1 $83.00

CORD BLOOD QC/Z/A/E/L/M/Q/T/W/X/S1/L1/P1 $66.00

CORDSTAT DRUG 12 L/M/W/J/X1/Q/S1/L1/V/P1 $267.50

CORDSTAT DRUG ANALYS 5 L/M/E/W/S1 $214.00

CORIANDER IGE CORI Z/L/M/W/L1 $9.50

CORN FOOD ALLERGEN MCORN Z/E/L/M/O/R/W/C1/S1/L1 $25.50

CORN POLLEN ALLERGEN MCRNP L/M/W/S1/L1 $25.50

CORTISOL 30 MINUTES Z/D/J/R/S/C2/N/L1/O $286.50

CORTISOL 60 MINUTES Z/D/J/R/S/C2/N/M/L/W/L1/O $286.50

CORTISOL AM QC/Z/A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/C1/S1/L1 $286.50

CORTISOL BASELINE D/E/J/N/P/R/S/Z/C1/L1/O $286.50

CORTISOL DST Z/A/D/E/F/G/L/M/R/S/W/C1/L1 $286.50

CORTISOL PM QC/Z/A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/C1/S1/L1 $286.50

CORTISOL SALIVA MSALCT C1/D/E/J/L/L1/M/N/O/P/R/S/S1/W/Z/X $49.80

CORTISOL STIM 10 MIN $286.50






CORTISOL URINE 24 HR MCORTU QC/Q/A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/S1/L1/W1 $132.00

Cosyntropin cortrosyn inj $300.70

COTININE SERUM Y/A/B/F/G/J/L/M/O/P/T/W/C1/L1 $36.00

COTININE URINE Z/L/M/W/O/E/P/C1/L1 $36.00

COTTONWOOD TREE ALGR MCTWD E/L/M/O/W/X/C1/S1/L1 $25.50

COW EPITH ALLERGEN MCOW QC/Q/L/M/W/S1/L1 $25.50

COXSACKIE B ANTIBODIES MCOXB QC/Q/A/L/M/W/C1/S1/L1 $27.00

CR PLASMA TH $184.50

CRAB ALLERGEN MCRAB QC/Q/L/M/W/C1/S1/L1 $25.50

16 of 172

Procedure Price

CRANBERRY ALLERGEN MCRANB D/S/L/M/W/S1/N/L1 $25.50

CRAYFISH ALLERGEN MCRAY D/S/L/M/W/S1/N/L1 $25.50

C-REACTIVE PROTEIN V/Y/A/B/E/F/G/H/I/J/L/M/O/P/Q/R/T/W/S1/B1/L1/N/P1/W1 $78.00

CREAT RAN URN MAYO 83802 L/M/W/L1 $34.50

CREATINE DISOR BLD L/M/W/S1/L1 $139.00

CREATINE DISOR URN L/M/W/S1 $96.50

CREATININE CLEARANCE A/E/J/K/L/M/O/P/R/W/B1/L1/W1 $160.50

CREATININE DIALYSATE 24 HR M $60.50

CREATININE FLUID QC/V/Z/Y/A/D/L/M/S/X/W/C1/L1/P1 $99.50

CREATININE I $45.50

CREATININE URINE 24H QC/V/A/Y/B/D/E/F/G/J/K/L/M/N/O/P/Q/R/S1/B1/L1/C2/P1/W1 $127.50

CREATININE URINE ALL EXCEPT E/J $127.50

CREATININE Z/A/F/G/K/L/M/P/U/W/O/W1 $45.50

CRMP 5 IgG WEST BLOT MCRMWS Z/D/L/M/S/W/N/L1/W1 $316.50

Crossmatch Unit $114.00

CRYO $139.00

CRYO POOL 5 $694.00

CRYO POOL 5 THAWED $694.00

CRYO THAWED $170.50

CRYOGLOBULIN M/L/O/P/R/W/C1/S1/L1 $157.00

CRYOREDUCED FFP $184.50

CRYPTOC.TITER CSF D/L/M/S/T/W $172.50

CRYPTOC.TITER SERUM D/L/M/S/T $172.50

CRYPTOCOCCUS AG CSF Z/A/L/M/N/W/S1 $276.00

CRYPTOCOCCUS AG SERUM Z/D/I/L/M/N/S/T/C1/O $276.00

CRYSTALS BODY FLUID C1/E/H/J/L/M/O/P/W/S1/C1/L1/P1 $70.00

CSF ANGIO CONV ENZY MFACEC QC/Q/A/D/S/L/M/T/W/S1/N/L1/X/W1 $96.50

CSF CELL COUNT C1/L/M/O/W/L1 $159.00

CSF ENTEROVIRUS PCR L/M/W/C1/E/L1 $230.00

CSF FILM ARRAY PCR Q/QC/V/L/M/O/W/A/D/S/S1/N/J/L1/E/T/C2/Y/Z/C1/P1 $449.50

CSF IGG INDEX MSFIN QC/Q/A/D/S/T/X/L/M/W/S1/N/L1/W1 $38.50

CULT ACID FAST/SMEAR L/M/W/R/E/O/P/J/C1/S1/L1 $209.50

CULT ANAEROBE L/M/P/R/W/E/O/J/L1/S1 $180.00

CULT BLOOD ACID FAST ILH/IMC/WDM/C1/S1/L1 $242.00

CULT BLOOD FUNGUS L/M/R/W/S1/C1/L1 $153.50

CULT BLOOD PRODUCTS M $273.00

CULT BLOOD ROUTINE M/L/P/R/W/E/O/J/S1/L1 $273.00

17 of 172

Procedure Price

CULT BONE BANK IMC/S1 $117.50

CULT BRONCH QNT&GRAM ILH/IMC/WDM/L1 $215.00

CULT CATH TIP L/M/R/W/O/C1/L1 $349.50

CULT CIPRO RESIS SCR $47.00

CULT CSF AND GRAM E/J/L/M/O/P/R/W/L1 $389.00

CULT EAR L/M/R/W/E/O/J/S1/L1 $351.50

CULT EYE L/M/P/R/W/E/O/J/S1/L1 $351.50

CULT FLUID WITH GRAM E/J/L/M/O/P/R/W/S1/L1 $248.00

CULT FUNGUS L/M/P/R/W/E/O/J/C1/S1/L1/H $198.00

CULT GENITAL & GRAM L/M/O/P/R/W/E/J/S1/L1 $282.50

CULT GROUP A STREP E/L/M/R/W/S1/L1 $78.50

CULT HERPES SIMPLEX M/L/W ONLY MICRO ORDERS $215.00

CULT LEGIONELLA&DFA ILH/IMC/WDM/C1/R/L1 $224.00

CULT MRSA L/M/P/R/W/E/O/S1/L1 $68.50

CULT N. GON & GRAM ILH/IMC/WDM/L1 $149.00

CULT N. GONORRHOEAE ILH/IMC/WDM/L1 $149.00

CULT RESP C.FIBROSIS L/M/P/W/C1 $117.50

CULT RESPIR & GRAM L/M/P/R/W/E/O/J/S1/L1 $351.50

CULT SENSI REFERRAL ILH $151.50

CULT SONICATION & GRAM ILH/IMC/WDM/L1 $44.00

CULT THROAT L/M/O/P/R/W/E/J/S1/L1 $104.50

CULT TISSUE & GRAM E/J/L/M/O/P/R/W/C1/S1/L1 $229.50

CULT TISSUE QUANT ILH/IMC/WDM/L1 $356.00

CULT URINE L/M/P/R/W/E/O/J/S1/L1 $193.50

CULT VANCO RESIS SCR L/M/R/W/E/L1 $71.00

CULT WOUND & GRAM STAIN L/M/O/P/R/W/E/J/S1/L1 $349.50

CULT YEAST SCREEN L/M/P/W $173.50

CULTURE NASAL L/M/R/W/S1/L1 $104.50

CULTURE W/O SMEAR M/P/E/O/S1/L1 $242.00

CUMIN SEED ALLERGEN MFCUSE L/M/W/L1 $63.00

CURVULARIA LUNATAIgE MCURL L/W/M/S1/L1 $35.50

CYANIDE ARUP L/M/R/P/L1 $164.50

CYCLIC AMP URINE ARUP IMC/S1/L1 $155.50

Cyclophosphamide 100 mg inj $310.00

Cyclophosphamide oral 25 mg $10.88

CYCLOSPORA SPECIES MCYCL Z/L/M/W/J/S1 $55.50

CYCLOSPORIN J/L/M/O/P/R/W/C1/S1/E/L1 $228.00

18 of 172

Procedure Price

CYCLOSPORINE 2HR PD L/M/PL/S1/L1 $228.00

CYCLOSPORINE 6HR PD L/M/PL/S1/L1 $228.00

Cyclosporine oral 100 mg $20.35

Cyclosporine oral 25 mg $5.30

CYSTINE URINE 24 HR MCYSQN D/E/L/M/P/R/S/W/X/O/C1/S1/N/L1 $90.00

CYSTINURIA PROFILE MCYSR L/M/W/S1/L1 $155.50

Cytarabine hcl 100 mg inj $361.90

CYTOPLASMIC CD22 $187.00

CYTOPLASMIC CD3 $187.00

CYTOPLASMIC CD79a $187.00

CYTOPLASMIC NEUTRO AB MANCA QC/Q/E/J/L/M/N/O/P/R/T/W/X/C1/D/S/S1/L1/W1 $186.00

D DIMER MAYO MDDI L/M/W/S1/L1 $85.50

D5w infusion $60.00

Dacarbazine 100 mg inj $73.53

Dactinomycin injection $3,384.98

Daptomycin injection $2.13

Darbepoetin alfa non-esrd $17.67

DAT ANTI-IgG COOMBS SERUM $66.00

DAT/ANTIBODY SCREEN L/M/Q/W $130.50

Daunorubicin injection $210.13

DD FFP THAWED $289.50

DDFP24 THAW $289.50

D-DIMER SENS QUANT Z/L/M/O/P/W $117.00

Decitabine injection $82.36

DEER EPITH ALLERGEN MDEEP D/S/L/M/W/N/L1 $25.50

Deferoxamine mesylate inj $106.35

DEGLYCEROLIZED RBC IRRAD LEUK $773.50

DEGLYCEROLIZED RBC LEUKOFILTERED $672.50

DELTA-ALA URINE 24HR ARUP C1/L/M/R/S1/L1 $209.00

DENGUE VIRUS IGG/IGM MDENGM QC/Q/L/M/W/Z/S1/L1 $166.00

Denosumab injection $40.91

Dexamethasone sodium phos $88.60

Dexrazoxane hcl injection $871.10

Dextroamphetamine $2.88

DHEA-SULFATE QC/V/Y/D/E/I/J/L/M/N/O/P/R/S/W/X/C1/S1/T/L1/C2/P1 $197.00

DIABETES AUTOIMMUNE E/L/M/W/S1/L1 $209.50

DIABETES EVALUATION MDME L/M/W/S1/L1 $110.00

19 of 172

Procedure Price

DIALYSATE ANALYSIS IMC/S1 $40.50

Diazepam injection $114.85

DIAZEPAM/NORDIAZEPAM MDIA QC/Q/Z/D/S/X/L/M/W/T/S1/N/L1 $75.50

Dicyclomine injection $247.80

DIFFERENTIAL $97.00

DIGITOXIN ARUP ILH/IMC/S1/L1 $172.00

DIGOXIN /ALL EXCEPT MMH/B1 $179.50

Digoxin injection $144.15

DIHYDROTESTOSTERONE MDHTS QC/Q/Z/E/L/M/P/R/W/C1/S1/L1/W1 $90.00

Diphenhydramine hcl injectio $93.00

DIPHTHERIA AB IGG ARUP M/L/C1/S1/L1 $156.50

DIR PC LEUK $666.50

DIRECT ANTIGLOBULIN H/L/M/P/Q/T/W/X/C1/QC $66.00

DIRECT COMPLEMENT $66.00

DISOPYRAMIDE MDSP QC/Q/X/L/M/W/S1/L1 $70.00

D-LACTATE M8878 L/M/W/O/S1/C1/L1 $515.50

DNA DS AB TITER MADNA T/L1/X/Z/W1 $64.50

Docetaxel injection $14.41

DOG DANDER IGE MDOGDM E/L/M/O/W/X/C1/S1/L1 $25.50

DONOR SPECIFIC ANTIBODY J/L/M/O/W/C1/S1/L1 $688.00

Dopamine injection $90.10

Dornase alfa non-comp unit $55.37

DOUBLE STRANDED DNA M/L/PL/R/W/E/J/C1/S1/L1 $233.00

DOXEPIN MAYO MDXPIN QC/Z/D/S/T/X/L/M/W/N/L1/W1 $66.50

Doxorubicin hcl injection $354.30

Doxorubicin inj 10mg $1,158.89

DRG SCRN UR MONITOR J/L/M/W $841.00

DRG SCRN UR MONITOR L/M/W $338.00

DRUG SCN PRESCRP/OTC MDSS A/D/E/S/T/L/M/W/N/L1 $84.50

DRUG SCREEN HAIR USDTL M $112.50

DRUG SCREEN MECONIUM MEDTOX L/M/E/J/C1/S1/W $187.50

DRUG SCREEN URINE RAPID TEST L/W $541.50

DRUG SCRN UR LIMITED L/M/P/R/W/O/C1/S1/L1 $573.50

DRUGS OF ABUSE 10 URN L/M/W $9.00



DRUGS OF ABUSE 5B URN IMC $98.50

20 of 172

Procedure Price

DRUGS OF ABUSE 5E URN IMC $98.50

DRUGS OF ABUSE 7 URN /Y/P1 $98.50

DRUGS OF ABUSE 9 S1 $82.50

DRVVT CONFIRM BILL ONLY $38.50

DRVVT CONFIRM RATIO MDRVTC QC/Q/Z/D/S/N/W1 $134.00

DRVVT MIX MAYO MDRVTM QC/Q/Z/D/S/X/N/W1 $138.00

dsDNA Ab CRITH IFA MCRITH Z/D/L/M/S/W/S1/N/L1 $216.00

dsDNA AB REFLEXIGG MADNAR Z/D/L/M/S/W/S1/N/L1/X $23.50

Dtap vaccine < 7 yrs im $135.60

Dtap-hep b-ipv vaccine im $241.40

DUCK FEATHER ALELRGEN MDUCK QC/Q/L/M/W/L1 $25.50

E COLI 0157 PLATE $40.50

E HISTOLYTICA AB MSAM QC/Q/D/L/M/S/T/W/C1/S1/N/L1/W1 $73.00

EASTERN SYCAMORE ALG MESYC QC/Q/D/E/L/M/N/O/S/W/C1/S1/L1 $25.50

EBV Ab Profile C1/E/J/L/M/O/P/R/T/W/S1/L1 $37.50

EBV DNA DETECT/QUANT MEBVQU Z/QC/Q/N/D/S/L/M/W/L1/E/S1/O/C1/P/R/J/W1/X/W1 $131.00

EBV EARLY Ag IgG QC/Y/V/C1/E/J/L/M/O/P/R/T/W/S1/L1/P1 $37.50

EBV IGG AB/EARLY AG MEBVE D/L/M/N/S/W/X/J/C1/S1 $139.50

EBV Nuclear Ag IgG QC/Y/V/C1/E/J/L/M/O/P/R/T/W/S1/L1/P1 $37.50

EBV PCR PLASMA VIRACOR C/I/L/L1/O/S1/T/E/W//L1 $253.00

EBV PCR SERUM VIRACOR L/M/W/E/L1 $253.00

EBV VCA IgG QC/Y/V/C1/E/J/L/M/P/R/T/W/L1/P1 $37.50

EBV VCA IgM QC/Y/V/C1/E/J/L/M/O/P/R/T/W/L1/P1 $37.50

ECHINOCOCCUS ANTIBODY ARUP M/L/R/S1/L1 $102.00

ECHOVIRUS AB PANEL MECHO QC/Q/A/L/M/W/S1/L1 $27.00

ECOLI CULTURE POS PT L/M/W/L1 $30.00

Eculizumab injection $436.33

EGG WHITE ALLERGEN MEGG C1/E/L/M/O/W/X/L1 $32.00

EGG YOLK ALLERGEN MYOLK QC/Q/C1/E/L/M/R/W/S1/L1 $25.50

EHRL/ANAPL RPD PCR MEHRL QC/Q/Z/L/M/W/E/J/L1/O/S1/P/R/C1 $26.25

EHRLICHIA AB IGG MEHRC QC/D/S/N/M/L/W/A $200.50

ELECTROLYTES ALL $135.50

ELECTROLYTES STOOL IMC/ILH/WDM/C1/L1 $52.50

ELECTROLYTES URINE Z/A/F/G/O/P/Q/T/W/X/L1 $60.00

ELM ALLERGEN MELM E/L/M/O/W/X/C1/L1 $25.50

EMA Titer IgA/W1 $128.50

ENA ANTIBODIES C1/E/L/M/R/W/S1/L1/R $43.00

21 of 172

Procedure Price

ENA PROFILE MENAE Z/D/L/M/R/S/T/W/E/O/N/C1/S1/X/W1 $40.00

ENDOMYSIAL ANTIBODY MEMA ALL EXCEPT B/H/K/U/V/Y/C2/P1 $66.50

ENGLISH PLANTAINIGE MEGPL L/M/S/S1/L1 $25.50

ENTEROVIRUS PCRP MENTP QC/Q/Z/L/M/W/E/S1/L1/D/N/S/W1 $258.00

ENZYME AB PANEL A/L/SL/X/Q/QC $162.50

EOSINOPHIL COUNT A/D/L/M/S/T/W/C1 $73.00

EOSINOPHILS NASAL L/M/Q/T/W/C1/B1/L1 $83.50

EOSINOPHILS URINE QC/C1/J/L/M/O/Q/W/T/X/S1/L1 $73.00

EPICOCCUM ALLERGEN MEPUR L/M/W/S1/L1 $25.50

EPIDEMIOLOGY TYPING L/M/W $57.00

Epifix or epicord $1,048.60

Epoetin alfa 100 units esrd $62.33

Epoetin alfa non-esrd $78.22

EPSTEIN BARR PCR CSF MLEBV E/L/M/W/Z/L1 $203.50

Eptifibatide injection $110.53

ER ISTAT PANEL 8 L/M $100.50

Ertapenem injection $216.20

Erwinaze injection $770.48

ERYTHROPOIETIN MEPO ALL EXCEPT B/K/U/V/Y/C2/P1 $45.00

ESR ILH/IMC/PL/WDM $38.50

ESTRADIOL QC/V/Z/T/A/B/D/E/F/G/J/L/M/N/O/P/R/S/W/Z/C1/S1/L1/P1 $244.50

ESTRIOL MUE3 J/L/M/P/R/W/C1/S1/L1/W1 $57.00

ESTROGENS FRAC MESTF QC/Q/L/M/N/O/P/W/E/J/C1/S1/S/D/L1/X $45.00

ESTRONE ME1 QC/Q/D/S/X/L/M/N/P/W/E/O/J/C1/R/L1/W1 $169.50

Ethanolamine oleate 100 mg $884.20

ETHOSUXIMIDE C1/E/L/M/P/R/W/L1 $199.00

ETHOSUXIMIDE METHSX QC/Q/D/S/X/N/L/W/M/C1/E/J/L1/N/O/P/R/S1 $55.00

ETHYLENE GLYCOL METGL L/M/R/W/C1/S1/L1/W1 $82.00

Etoposide injection $118.57

EUCALYPTUS ALLERGEN MEUCL QC/D/S/L/M/W/Q/S1/N/L1 $25.50

EVEROLIMUS L/M/W/O/C1/L1 $168.50

EXCHANGE TRANSFUSION BLOOD ADMINISTRATION $1,861.50

EXCHANGE TRANSFUSION BLOOD ADMINISTRATION NEONATES $1,861.50

EXECUTIVE PROFILE IMMC $43.00

Expanded O&P UHL E/J/L/M/O/P/R/W/C1/L1/S1 $59.50

Extrinsic ROTEM /M//S1 $109.50

FABRY DISEASE MFABRZ L/M/W/L1 $896.50

22 of 172

Procedure Price

FACTOR II MF_2 ALL EXCEPT B/E/H/J/K/N/O/P/R/U/V/Y/B1/C2/P1 $145.50

FACTOR IX L/M/W/S1/L1 $95.00

Factor ix recombinant nos $2.64

FACTOR V LEIDEN PCR E/J/L/M/O/P/R/W/C1/S1/D/S/N/L1 $711.00

FACTOR V MFACTV QC/Q/Z/A/D/E/J/L/M/N/S/W/X/C1/S1/L1/W1 $219.00

Factor viia $3.67

FACTOR VIII D/L/M/N/P/R/S/W/S1/L1/C1 $95.00

Factor viii recombinant nos $3.07

FACTOR X MF_10 QC/Q/Z/A/D/S/X/L/M/N/W/E/C1/S1/L1/W1 $224.50

FALSE RAGWEED ALELRG MFRW QC/Q/D/S/L/M/W/N/L1 $25.50

FARMER'S LUNG ARUP 0050157 Y/V/L/M/W/T/C1/L1/P1 $13.00

FAT FECAL QUAL L/M/P/T/W/J $183.00

FAT URINE QUAL A/L/M/W $41.50

FATFECAL QUANT MFATF QC/Q/A/D/E/F/G/J/L/M/N/O/P/R/S/T/W/C1/L1/W1 $317.00

FATTY ACD PROFPEROX QC/Q/L/M/W/L1 $165.50

FATTY ACIDS FREE ARUP ILH/IMC/C1/L1 $220.00

FC CYTOPLASMIC KAPPA $61.50

FC CYTOPLASMIC LAMBDA $61.50

FECAL LACTOFERRIN QC/V/Z/Y/A/D/E/F/G/H/J/L/M/N/O/P/R/S/T/W/X/Q/L1/P1/W1 $100.00

FELBAMATE MFELBA D/S/X/L/M/W/O/P/E/C1/S1/N/L1/W1 $120.00

Fentanyl citrate injection $105.55

FERRET EPITH ALLERGN MFEEP D/S/L/M/W/N/L1 $25.50

FERRITIN ALL $240.00

Ferumoxytol non-esrd $3.66

FETAL BLOOD SCREEN ALL EXCEPT PATHLAB/P1 $70.00

FETAL FIBRONECTIN QC/Q/V/Z/Y/A/D/E/L/M/S/T/X/W/J/C1/L1/P1/W1 $748.00

FETAL HEMOGLOBIN FLOW CYTOMETRY J/L/M/W/C1 $268.00

FETAL SCREEN PATHLAB/B/L/X/V/C1/L1/P1/W1 $70.00

FFP BY APHERESIS $184.50

FFP THAWED $184.50

FFP THAWED 5 DAY PLASMA $184.50

FFP THAWED APHERESIS A $184.50

FFP THAWED APHERESIS B $184.50

FFP THAWED APHERESIS C $184.50

FFP2 THAWED 5 DAY PLASMA $184.50



23 of 172

Procedure Price

Fibrin Active ROTEM /M/ $143.00

FIBRINOGEN C2/QC/V/Z/Y/A/D/E/F/G/L/M/P/Q/S/T/X/N/L1/P1/W1 $105.00

FIBRINOGEN MFIBC QC/Q/Z/L/M/W/S/D/S1/N/L1/W1 $114.00

FIBRO/ACTI TEST MFIBRO QC/D/L/M/N/Q/S/W/X/J/L1/O/S1/C1/P/E/W1 $46.00

Finasteride 5 mg $2.55

FINCH FEATHER ALLERG MFINCH D/S/L/M/W/N/L1 $25.50

Flebogamma injection $113.23

FLECANIDE MAYO M9243 QC/Q/D/S/X/L/M/W/C1/S1/N/L1/W1 $137.50

FLM L/M/T/J $793.00

FLOW CYTO CD 138 $132.50



FLOW CYTOMETRY CD43 $187.00

FLOW CYTOMETRY CLL E/L/M/O/P/W/C1/D/S/N/L1 $272.50

FLOW CYTOMETRY DR ANTIBODY $187.00

FLOW CYTOMETRY FLKI $187.00

FLOW CYTOMETRY FLLI $187.00

FLOW CYTOMETRY LYMPHOMA L/M/O/D/S/N/L1 $281.50

FLOW CYTOMETRY XM ILH/IMC/L1 $647.50

Fluconazole $106.90

Fludarabine phosphate inj $546.30

FLUID ALBUMIN QC/V/Z/Y/D/E/H/J/L/M/Q/S/T/C1/O/N/L1/P1 $86.50

FLUID BUN V/L/M/W/L1/Z/P1 $95.50

FLUID RHEUMATOID FCT L/M/W/L1 $86.00

FLUORIDE MFL QC/Q/L/M/W/C1/S1/L1 $163.50

Fluorouracil injection $193.00

FLUOXETINE MFLUOX L/M/W/S1/L1 $145.00

FLUPHENAZINE ARUP ILH/PATHLAB $136.50

Fluphenazine decanoate 25 mg $149.50

FLURAZEPAM ARUP ILH $156.00

FMC7 $187.00

FOLATE ALL EXCEPT H/T/U/ $247.00

FOLATE RBC L/M/W/E/C1/S1/L1 $110.50

Fomepizole 15 mg $23.53

Fondaparinux sodium $35.97

FOOD ALLERGY PROFILE E/J/L/M/O/W/C1/S1/L1 $25.50

Fosaprepitant injection $6.02

24 of 172

Procedure Price

Fosphenytoin inj pe $99.33

FRAGILE XUIHC L/W/M/E/C1/S1/L1 $1,334.00

FRAN.TULARENSIS AB ARUP ILH $73.50

FRANCIS TULARENS AB MFRANC QC/Q/A/F/G/L/M/O/W/C1/L1/J $131.00

FREE LIGHT CHAINS UR L/M/W/O/P/R/C1/S1/L1 $75.00

FREE LT CHAINS SERUM V/Y/J/M/N/O/P/R/S/W/C1/S1/D/L1/P1 $75.00

FREE T3 QC/V/Z/Y/A/D/E/F/G/J/L/M/N/O/P/Q/R/S/W/1/S1/L1/P1/W1 $170.50

FRUCTOSAMINE MFRUCT QC/Q/D/E/J/L/M/P/S/W/X/S1/N/L1 $51.50

FSH QC/V/Z/Y/A/D/E/F/G/I/J/LM/N/O/P/Q/R/S/W/X/S1/C1/L1/P1/W1 $251.50

FUNGAL IMMUNODIF PNL C1/L/M/R/W/L1 $62.00

FUNGITELLVIRACOR $214.00

FUNGUS ID X1 IMC/L1/S1/M1 $90.00

FUNGUS ID X2 IMC $90.00




FUNGUS SMEAR L/M/W/C1/S1/L1 $164.50

Furosemide injection $99.90

FUSARIUM OXYSPORIgE MFFOVE L/M/N/W/S1/S/D/L1 $86.50

GABA-B-R Ab IFTITER MGABIS Z/D/L/M/S/W/S1/N/L1 $226.00

GABA-B-R AbCBA MGABCS Z/D/L/M/S/W/S1/N/L1 $467.50

GABAPENTIN MGABA QC/Q/D/J/L/M/P/S/T/W/X/C1/S1/N/L1 $210.00

GAD AB GAD65 MGD65S ALL EXCEPT B/H/K/U/V/Y/B1/C2/P1 $186.00

Gad-base mr contrast nos 1ml $20.13

Gadoxetate disodium inj $37.15

GALACTOSEMIA QUANT ARUP IMC/ILH/S1/L1 $347.50

GAMMA GT ALL $99.50

Gammagard liquid injection $141.99

Gamunex-c/gammaked $119.77

Ganciclovir sodium injection $262.60

Garamycin gentamicin inj $108.00

GARLIC IgE MGARL L/M/W/S1/L1 $35.50

GASTRIN E/L/M/O/P/W/C1/S1/L1 $100.50

GC BY NAA E/L/M/W/J/S1/L1 $206.00

GC BY NAA OTHER R/S1/L1 $217.00

GC/CHLAMYDIA BY NAA E/J/L/M/O/P/R/W/S1/L1 $206.00

GC/CHLAMYDIA BY NAA OTHER E/L/M/W/S1/J/L1 $206.00

25 of 172

Procedure Price

Gemcitabine hcl injection $138.38

GENTAMICIN ALL EXCEPT J/K/C2 $268.00

GENTAMICIN PEAK ALL BUT I $268.00

GENTAMICIN TROUGH ALL EXCEPT K $268.00

GERBIL EPITH ALLERGEN MGERB D/S/L/M/W/S1/N/L1 $25.50

GERMAN COCKROACH ALG MCOCR Z/E/L/M/O/W/X/C1 $25.50

GIANT RAGWEED ALLERG MGRW QC/Q/L/W/M/S1/L1 $25.50

GIARDIA AG STOOL E/L/M/R/O/C1 $169.50

GINGER IGE GING Z/L/M/W/L1 $9.50

GLIADIN AB IgA QC/Y/V/C1/E/J/L/M/O/P/R/T/W/L1/P1 $32.50

GLIADIN AB IgAIgG C1/E/J/L/M/O/P/R/T/W/S1/L1 $32.50

GLIADIN AB IgG QC/Y/V/C1/E/J/L/M/O/P/R/T/W/L1/P1 $32.50

GLIADIN ANTIBODIES MDGLDN Z/A/D/E/F/G/J/L/M/N/O/P/R/W1 $54.00

GLOM BASE MEM AB IGG MGBM A/D/S/X/L/M/P/R/W/C1/N/W1 $357.00

GLOM BMENT MEMB IgG QC/Y/V/L/M/W/L1/P1 $46.00

GLOMERULAR FILTRATION RATE L/M/T $45.50

GLU CHALLENGE 50 GM QC/V/Z/A/B/D/E/F/G/H/I/L/M/N/Q/R/S/T/R/W/S1/M1/C2/P1/W1 $93.50

GLU TOLERANCE GEST QC/I/L/M/Q/W/B/D/S/M1 $164.00

Glucagon hydrochloride/1 mg $630.45

GLUCAGON MAYO M0358 QC/Q/E/L/M/W/C1/S1/L1 $121.50

GLUCOSE 105 MINUTES $49.00




GLUCOSE 2 HR PP QC/Z/A/B/F/G/H/I/L/PL/Q/T/B1/L1 $93.50





GLUCOSE ALL $49.00

GLUCOSE BASELINE $49.00

GLUCOSE BEDSIDE IMC/ILH/WDM $40.50

GLUCOSE CSF QC/V/Z/Y/A/B/D/E/F/G/L/M/N/O/Q/S/T/B1/L1/C2/P1/W1 $58.50

GLUCOSE DIALYSATE 24 HR M/S1/L1 $38.50

GLUCOSE FLUID QC/V/Z/Y/A/D/E/F/G/H/J/L/M/N/Q/R/S/T/X//C1/S1/O/L1/C2/P1/W1 $58.50

GLUCOSE TOL 2HR QC/V/Y/D/L/M/Q/S/W/C2/P1 $93.50

GLUCOSE TOLERANCE 3 HR B/L/M/T/W/X/W1 $164.00

26 of 172

Procedure Price

GLUCOSE TOLERANCE 4 HR D/I/K/L/M/Q/S/T/W $164.00

GLUCOSE TOLERANCE 5 HR /D/I/L/M/S/T/X/W/C1 $164.00

GLUCOSE TOLERANCE 6H D/L/M/S/T/S1 $164.00

GLUCOSE URINE 24HR QC/Z/U/D/M/Q/S/W/S1/L1 $53.50

GLUCOSE URINE Z/U/A/D/F/G/L/M/S/W/C1/L1 $53.50

GLUCOSE-6-PD MG6PD QC/Q/D/S/X/L/M/P/R/W/T/E/J/C1/S1/N/L1 $100.50

GLUCOSEURINE V/Y/A/I/K/L/M/T/X/E $58.00

GLUTEN ALLERGEN MGLT J/L/M/W/S1/Z/L1 $25.50

GLYCATED ALBUMIN MAYO MFGLYA /L/M/W/S1/L1 $172.00

GLYCO A $187.00

GLYCOPROTEIN SYNDROME Z/L/W/M/S1/L1/J $95.50

GOAT EPITH ALLERGEN MGOAT D/S/L/M/W/S1/N/L1 $25.50

GOAT MILK ALLERGEN MGMILK QC/Q/D/S/L/M/W/N/L1 $25.50

Golimumab for iv use 1mg $66.69

GONORRHEA URINE L/M/P/E/J/O/W/S1/L1 $139.50

GONORRHEA/CHLAMYDIA URINE E/J/L/M/O/P/T/W/S1/L1 $101.50

GOOSE FEATHER ALLERG MGOOS L/M/W/S1/L1 $25.50

GP B STREP AG CSF L/M/T/X/W $229.50

GP B STREP AG SERUM L/M/X/W $211.00

GP B STREP AG URINE L/M/T/X/W $263.00

Graftjacket $309.16

GRAM STAIN J/L/M/P/W/S1/L1 $141.00

Granisetron hcl injection $11.64

GRANULOCYTE AB MLAGGT A/D/F/G/L/M/S/W/N/L1 $661.00

GRAPE ALLERGEN MGRAP QC/Q/Z/L/M/R/W/C1/S1/L1 $25.50

GRAPEFRUIT ALLERGEN MGRFR L/M/W/S1/L1 $25.50

GREEN BEAN ALLERGEN MGSTB QC/Q/L/M/O/S/W/C1/N/L1 $25.50

GREEN PEA ALLERGEN MGREA QC/Q/L/M/W/C1/L1 $25.50

GREEN PEPPER ALLERGN MGPEP D/L/M/S/W/S1/N/L1 $25.50

GROUP B STREP PCR L/M/W/E/L1 $127.50

GROWTH ASSESSMENT V ENDO SC L/M/W/H/C1/O/S1 $150.00

GROWTH HORMONE 105 MIN $102.00






27 of 172

Procedure Price





GROWTH HORMONE BASELINE $102.00

GROWTH HORMONE IMC/ILH/WDM/E/C1/S1/L1 $102.00

GUANIDINOACETATEU MFGCU M/L/W/S1 $390.00

GUINEA PIG EPITH ALR MGUIN QC/Q/L/M/W/S1/L1 $25.50

H INFLUENZAE AG CSF I/L/M/T/X/W $263.00

H INFLUENZAE AG SERUM L/M/T/X/W $229.50

H INFLUENZAE AG URN L/M/T/W $211.00

H PYLORI AB E/I/N/P/R/C1/S1/B1/W1 $180.50

H PYLORI BREATH MUBT T/L/M/W/X/L1 $134.00

H. FLU VACCINE RESP ARUP L/M/S1/L1 $237.00

H. PYLORI ANTIGEN W1/A/E/F/G/J/L/M/N/O/P/QC/R/T/V/Y/Z/C1/S1/L1/P1 $358.50

H. PYLORI SCRN QC/V/Y/A/F/G/H/L/M/P/R/W/O/R/E/C2/L1/P1 $61.50

HAKE ALLERGEN MHAKE D/S/L/M/W/S1/N/L1 $25.50

HALIBUT ALLERGEN MHALI QC/Q/D/S/L/M/W/S1/N/L1 $25.50

Haloperidol decanoate inj $131.50

Haloperidol injection $99.50

HALOPERIDOL MHALO QC/Q/A/D/S/L/M/S1/N/Z/L1 $150.50

HAMSTER EPITH ALLERG MHEPI QC/Q/D/S/L/M/W/S1/N/L1 $25.50

HAPTOGLOBIN QC/V/Z/Y/A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/C1/S1/L1/P1/W1 $158.00

HAZELNUT FOOD ALLERG MNUTH L/M/W/C1/S1/L1 $25.50

HAZELNUT TREE ALLERG MHAZ L/M/W/L1 $25.50

HC 1' PROFUNDUS TENDON REPAIR $5,126.56

HC 12 LEAD EKG; TRACING ONLY $207.80

HC 1-3 LEAD EKG TRACING ONLY $195.72

HC 2-D ECHO LIMITED OR FOLLOWUP $665.01

HC 2D TEE W OR W/O FOL W/CON IN $2,577.10

HC 3D RENDER W POSTPROCESS $886.03

HC 3D RENDER WO POSTPROCESS $737.77

HC ABD AORTOGRAM W BILATERAL RUNOFF $4,757.99

HC ABD PARACENTESIS $1,251.13

HC ABD PARACENTESIS W/IMAGING $1,948.56

HC ABDOMINAL AORTOGRAM $4,556.42

HC ABLATE ARRHYTHMIA ADD ON $16,038.65

28 of 172

Procedure Price

HC ABLATE BONE TUMOR(S) PERQ CRYO $9,500.00

HC ABLATE LIVER RADIOFREQ PERC $8,443.83

HC ABLATE LIVER TUMOR(S) PERQ CRYO $8,761.78

HC ABLATE RENAL TUMOR CRYO PERC $12,088.40

HC ABLATE RENAL TUMOR RF PERC $10,389.72

HC ABLATE, BONE TUMOR(S) PERQ $8,714.47

HC ABP MONITORING 24+ HRS; RECORDING $463.32

HC ABP MONITORING 24+ HRS; SCANNING ANALYSIS $430.84

HC ABSCESS FISTULA SINUS TRACT STUDY $578.60

HC ACCESS CENTER PSYCH EVALUATION $707.81

HC ACJ BILATERAL W WO WEIGHTS $377.27

HC ACOUSTIC IMMITTANCE TESTING $164.99

HC ACOUSTIC REFL THRESHOLD TST $53.31

HC ADHESION BARRIER LVL 2 $1,519.56





HC ADJ GASTRIC BAND DIAM VIA INJ/ASP SALINE $1,518.99

HC ADL/SELF CARE TRN EA 15M $143.83

HC ADMIN HEPATITIS B VACCINE $118.33

HC ADMIN INFLUENZA VIRUS VACCINE $112.68

HC ADMIN PNEUMONIA VACCINE $62.58

HC ADRENAL ANGIOGRAM BILAT $4,087.21

HC ADRENAL ANGIOGRAM UNIL $3,489.42

HC ADRENAL VENOGRAM SELECTIVE BILAT $4,062.78

HC ADRENAL VENOGRAM UNIL SELCTV $3,101.75

HC AEROSOL PENTAMIDEN FOR P CARINII $313.27

HC AEROSOL SPUTUM COLLECT $174.05

HC AICD, DUAL CHAMBER LVL 1 $2,707.43





HC AICD, OTHER THAN SING/DUAL LVL 1 $2,516.06



29 of 172

Procedure Price



HC AICD, SINGLE CHAMBER LVL 1 $2,707.43






HC AIR AMBULANCE ROTARY WING $9,604.69

HC AIRWAY INHALATION TREATMENT INITIAL $349.17

HC AIRWAY INHALATION TREATMENT SUBQ $244.42

HC ALCOHOL/DRUG INTENSIVE OP $858.51

HC ALGINATE/FG DRESS 16 SQIN/ $44.77

HC ALLERGY TEST PERQ & ICUT DRUGS/BIOL $84.96

HC ALLODERM PER SQ CM LVL 1 $88.11

HC ALLOSKIN PER SQ CM LVL 1 $350.68

HC AMBULATORY CARE CLASS I $543.26

HC AMBULATORY CARE CLASS II $583.88

HC AMBULATORY CARE CLASS III $624.69

HC AMBULATORY CARE CLASS IV $651.68

HC AMBULATORY CARE CLASS V $678.62

HC AMNIOCENTESIS, DIAGNOSTIC $709.61

HC AMPUTATE FING/TH SGL W DIR CLOSE $3,261.29

HC AMPUTATE FING/TH SGL W LOC ADV FLAP $2,663.52

HC AMPUTATE TOE; IP JOINT $3,626.78

HC AMPUTATE TOE; MTP JOINT $3,626.78

HC ANALYZE NEUROSTIM COMPLX W PROG $515.69

HC ANALYZE NEUROSTIM SIMPLE $372.55

HC ANCHOR/SCREW BN/BN,TIS/BN LVL 1 $395.83

HC ANCHOR/SCREW BN/BN,TIS/BN LVL 10 $11,311.62








30 of 172

Procedure Price



HC ANCHOR/SCREW BN/BN,TIS/BN LVL 2 $969.01














HC ANESTHESIA BASE $661.26

HC ANESTHESIA BASE INCIDENT TO RADIOLOGY $571.66

HC ANESTHESIA LOCAL BASE $351.76

HC ANESTHESIA LOCAL MIN $3.52

HC ANESTHESIA MAC BASE $661.26

HC ANESTHESIA MAC MIN $7.04

HC ANESTHESIA MIN $7.04

HC ANESTHESIA MINUTE INCIDENT TO RADIOLOGY $7.04

HC ANESTHESIA SUPPLIES GENERAL LVL 1 $418.16

HC ANESTHESIA SUPPLIES GENERAL LVL 2 $1,529.14

HC ANGIOGR EA ADDTL VESSEL $2,633.75

HC ANGIOGRAM EXISTING CATHETER FOLLOW-UP $1,446.36

HC ANKLE 2 VIEWS $349.09

HC ANKLE MIN 3 VIEWS $427.55

HC ANO RECTAL MANOMETRY $1,875.44

HC ANOSCOPY DX $290.46

HC ANOSCOPY ENDO $168.25

HC ANS PARASYMP & SYMP W/TILT $207.54

HC ANTEGRADE PYEL NEPHR LOOPOGRAM $734.93

HC APHASIA ASSESSMENT PER HR $563.91

HC APHERESIS PLATELETS $3,891.48

31 of 172

Procedure Price

HC APHERESIS SELECTIVE $3,524.70

HC APLIGRAF PER SQ CM LVL 1 $111.85



HC APPLICATION OF HIP CAST 1 LEG $464.48

HC APPLICATON ON-BODY INJECTOR $157.33

HC APPLY FINGER SPLINT DYNAMIC $124.11

HC APPLY FINGER SPLINT STATIC $388.06

HC APPLY GAUNTLET CAST $131.73

HC APPLY HALO CRANIAL $7,962.59

HC APPLY LONG ARM CAST $322.87

HC APPLY LONG ARM SPLINT $502.78

HC APPLY LONG LEG CAST $375.66

HC APPLY LONG LEG SPLINT $502.78

HC APPLY MULTLAY COMPRS LWR LEG $235.30

HC APPLY MULTLAY COMPRS LWR LEG BILAT $470.60

HC APPLY RIGID TOTAL CONTACT LEG CAST $449.89

HC APPLY SH LEG CAST $549.63

HC APPLY SH LEG CAST BILAT $506.14

HC APPLY SHORT ARM CAST $322.87

HC APPLY SHORT ARM SPLINT STATIC $407.32

HC APPLY SHORT LEG SPLINT $399.05

HC APPLY TENS UNIT $214.44

HC APPLY WLKR SH LEG CAST $342.97

HC AQUATIC THERAPY W EX EA 15 MIN $207.69

HC ARRHYTHMIA INDUCTION $5,389.95

HC ART OCCLUSIVE DEVICE PLCMT $219.85

HC ARTERIAL CATH SAMPLE/MONITOR/TRANSF $419.28

HC ARTERIAL PUNCTURE BLOOD FOR DX $124.18

HC ARTERY EXPOS/GRAFT ARTERY FOR ECMO/ECLS $6,540.24

HC ARTHRODESIS SACROILIAC JOINT PERQ $15,498.42

HC ARTHROFLEX PER 1 SQ CM LVL 1 $107.00






32 of 172

Procedure Price





HC ARTISS FIBRIN SEALANT 2 ML LVL 1 $202.67



HC ASP INJ RENAL CYST/PELVIS PERC $1,833.26

HC ASP INJ SHUNT/RESERVOIR $795.13

HC ASP INJ THYROID CYST $697.69

HC ASP INTERDISCAL DX PERC $1,022.65

HC ASPIRATE PLEURA W/ IMAGING $2,393.48

HC ASPIRATE PLEURA W/O IMAGING $1,331.86

HC ASPIRATE/INJ GANGLION CYST $507.20

HC ASSMT & CARE PLN PT COG IMP $137.06

HC ASSTV TECHN ASSMNT EA 15M $103.85

HC ASTIGMATISM-CORRECT FUNCTION LVL 2 $235.00

HC ASTIGMATISM-CORRECT FUNCTION LVL 3 $300.00

HC ATHERECTOMY ABD AORTA TRLUML PERHP $21,286.58

HC ATHERECTOMY ILIAC TRLUML PERIP EA VES $21,286.58

HC ATT E/N/E/L; D 10 SQ CM $2,949.81

HC ATT F/C/M/N/A/G/H/F 10 SQ CM $3,084.00

HC ATTEN CURRENT STATUS $0.01

HC ATTEN D/C STATUS $0.01

HC ATTEN GOAL STATUS $0.01

HC AUD OSSEO DEV, INT/EXT COMP LVL 1 $2,707.43









HC AUDIENT DISP FEE 1 $350.00

HC AUDIENT DISP FEE 2 $500.00

HC AUDITORY EP COMPREHENSIVE $1,461.13

33 of 172

Procedure Price

HC AUDITORY EP LIMITED $190.37

HC AUTOLOG BLOOD OP SALVAGE $925.97

HC AUTOM URINALYSIS WO MICRO $39.86

HC BALLOON DILATE URTRL STRIX $4,734.07

HC BASIC DOSIMETRY CALC $535.65

HC BASIC VESTIBULAR EVALUATION $1,858.33

HC BEHAVIORAL QUAL ANALYSIS VOICE $252.79

HC BF PERINEAL MUSCLES OR SPINCTER $213.53

HC BILIARY ENDO PERQ DX W/SPECI $3,214.76

HC BILIARY ERCP $1,037.09

HC BILIARY PANCREATIC ERCP $1,147.45

HC BILIARY STENT, COAT/COV W/DEL SYS LVL 1 $2,516.06










HC BILIARY STENT, NO-COAT/NO-COV W/DL LVL 1 $2,516.06







HC BILIRUBIN TOTAL TRANSCUT $45.60

HC BIOFEEDBACK ANY MODALITY $166.86

HC BIOPSY ANORECTAL WALL ANAL APPROACH $2,288.11

HC BIRTH REGISTRATION $40.00

HC BL DRAW $41.93

HC BL DRAW < 3 YRS FEM/JUGULAR $66.34

HC BLEPHAROTOMY DRAIN ABSC EYELID $619.49

HC BLOOD CELL SAVER LVL 1 $606.88

HC BLOOD CELL SAVER LVL 2 $1,139.67

34 of 172

Procedure Price





HC BLOOD PRESSURE SCREENING $2.25

HC BLOOD PROFILE CWELL $31.00

HC BLUE CROSS OBSERVATION $1.00

HC BODY POS CURRENT STATUS $0.01

HC BODY POS D/C STATUS $0.01

HC BODY POS GOAL STATUS $0.01

HC BONE AGE STUDIES $302.48

HC BONE LENGTH STUDIES $574.92

HC BONE MARROW ASPIRATION $1,284.13

HC BONE MARROW BIOPSY $1,653.98

HC BONE MARROW BIOPSY AMB $730.70

HC BONE SURVEY COMPLETE $980.12

HC BONE SURVEY INFANT $324.86

HC BONE SURVEY LIMITED $597.84

HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 1 $464.88

HC BONE/ALLOGRAFT PRODUCTS/CEMENT LVL 10 $5,428.53


















35 of 172

Procedure Price





HC BRACHYTH SEED ADMIN CATH LVL 1 $779.62

HC BRACHYTH SEED ADMIN CATH LVL 2 $1,771.88






HC BRACHYTHERAPY NEEDLE LVL 1 $1,519.56





HC BRACHYTX ISODOSE PLAN COMPLEX $1,990.95

HC BRACHYTX ISODOSE PLAN INTERMED $1,783.24

HC BRACHYTX ISODOSE PLAN SIMPLE $1,273.19

HC BRACHYTX NON-STRAND YTTRIUM-90 $36,401.13

HC BRACHYTX, NON-STR,HDR IR-192 LVL 1 $506.71

HC BRACHYTX, NON-STR,HDR IR-192 LVL 2 $748.04

HC BRACHYTX, STRANDED, I-125 $246.87

HC BRACHYTX, STRANDED, P-103 $283.29

HC BREAST TOMOSYNTHESIS DIG DX BILAT $48.15

HC BREAST TOMOSYNTHESIS DIG DX UNIL $48.15

HC BREAST TOMOSYNTHESIS DIG SCREEN BILAT $48.15

HC BREATH RECORDING INFANT $622.45

HC BRIDGE APPT DAY OF DISCHARGE $118.07

HC BRONCH THERMOPLSTY 1 LOBE $4,633.58

HC BRONCH THERMOPLSTY 2/> LOBES $4,633.58

HC BRONCHOSCOPY LEVEL I $3,472.98

HC BRONCHOSCOPY LEVEL II $3,802.43

HC BRONCHOSCOPY LEVEL III $5,228.07

HC BRONCHOSCOPY LEVEL IV $9,043.40

HC BRONCHOSCOPY W/EBUS LEVEL I $3,842.33

HC BRONCHOSCOPY W/EBUS LEVEL II $4,171.77

36 of 172

Procedure Price

HC BRONCHOSCOPY W/EBUS LEVEL III $5,597.43

HC BRONCHOSCOPY W/FB REMOVAL $1,637.76

HC BRONCHOSPASM PRE & POST BD $770.45

HC BRONCHOSPASM PROVOCATION EVAL $1,497.00

HC BUNDLE OF HIS RECORDING $5,892.53

HC BURS, BLADES, BITS, LVL 1 $396.68

HC BURS, BLADES, BITS, LVL 10 $5,414.85









HC BX ABD RETROPERITO MASS PERC NDL $2,132.99

HC BX BONE TROCAR NDL DEEP $3,863.41

HC BX BONE TROCAR NDL SUPERFICIAL $1,705.53

HC BX BREAST 1ST LESION MR IMAG $3,998.22

HC BX BREAST 1ST LESION STEREOTACTIC $4,797.86

HC BX BREAST 1ST LESION US IMAG $4,797.86

HC BX BREAST ADD LESION MR IMAG $1,999.11

HC BX BREAST ADD LESION STEREOTACTIC $2,398.94

HC BX BREAST ADD LESION US IMAG $2,398.94

HC BX BREAST PERC NDL WO GUIDE $1,653.98

HC BX ENDO BILIARY VIA T-TUBE PERC $7,386.68

HC BX LIVER W OTHER PROCEDURE $496.83

HC BX LUNG/MEDIASTINUM PERC NDL $2,226.18

HC BX LYMPH NODES PERC SUPERFICIAL $1,717.98

HC BX MUSCLE PERC NDL $2,181.10

HC BX NEEDLE LIVER PERC $2,132.99

HC BX PANCREAS PERC $1,833.26

HC BX PLEURA PERC NDL $2,409.67

HC BX PROSTATE NDLE PUNCH $2,393.02

HC BX RENAL PERC $2,132.99

HC BX SALIVARY GLAND $1,494.40

HC BX SKIN SQ/MM EA ADDTL $296.09

37 of 172

Procedure Price

HC BX SKIN SQ/MM SGL $592.18

HC BX SOFT TISSUE BACK/FLANK SUPERFICIAL $1,790.78

HC BX SOFT TISSUE HIP/PELVIS SUPERFICIAL $1,622.56

HC BX SOFT TISSUE NECK/THORAX $3,320.52

HC BX THYROID PERC CORE NDL $988.65

HC BX TRANSCATHETER $6,804.35

HC BX TRANSCATHETER RAD $3,246.42

HC C REP S/A/L 1.1-2.5 CM $755.84

HC C REP TRUNK EA ADDTL 5 CM/< $426.32

HC C0/MEMBRANE DIFFUSE CAPACITY $545.51

HC C1-C2 PUNCTURE WO INJECTION $1,685.25

HC CABLES/CRIMP/CLAMP/FORCEPS LVL 1 $389.09

HC CABLES/CRIMP/CLAMP/FORCEPS LVL 2 $1,311.19





HC CALCANEUS MIN 2 VIEWS $332.27

HC CALORIC VSTBLR TEST W/REC BIL BITHERM $347.28

HC CALORIC VSTBLR TEST W/REC BIL MTHERM $347.28

HC CANALITH REPOSITIONING PROCEDURE $150.00

HC CANTHOTOMY $2,998.48

HC CAPILLARY BLOOD DRAW $8.72

HC CAR SEAT/BED TEST 60 MIN $172.03

HC CAR SEAT/BED TEST ADDTL 30 MIN $86.02

HC CARDIAC ASSIST OR IMPL DEVICE NO HCPCS LVL 8 $49,648.00

HC CARDIAC REHAB PHASE III PER VISIT $118.89

HC CARDIAC REHAB W CONT ECG PHASE I $292.48

HC CARDIAC REHAB W CONT ECG PHASE II $292.48

HC CARDIAC REHAB WO CONT ECG $292.48

HC CARDIAC STENT, COAT/COV W/DEL SYS LVL 1 $2,516.06







38 of 172

Procedure Price






HC CARDIAC STENT, COAT/COV W/O DL SY LVL 10 $16,159.55

HC CARDIAC STENT, COAT/COV W/O DL SYS LVL 1 $2,516.06





HC CARDIAC STENT, COATCOV W/DEL SYS LVL 10 $16,159.55

HC CARDIAC STENT, NO-COA/NO-COV W/DL LVL 1 $2,516.06







HC CARDIAC STENT, NO-COAT/COV W/O DL LVL 1 $2,516.06







HC CARDIOVASC/HEART SUPPLIES GENERAL LVL 1 $382.73

HC CARDIOVASC/HEART SUPPLIES GENERAL LVL 2 $1,842.76





HC CARDIOVASCULAR CATHS, NO HCPCS LVL 1 $354.37

HC CARDIOVASCULAR CATHS, NO HCPCS LVL 10 $6,463.82




39 of 172

Procedure Price





HC CARDIOVERSION $1,536.41

HC CARDIOVERSION ELECTIVE INT $1,275.33

HC CAROTID DUPLEX SCAN; BILAT $1,054.19

HC CAROTID DUPLEX SCAN; UNIL/LIMIT $598.54

HC CARRY CURRENT STATUS $0.01

HC CARRY D/C STATUS $0.01

HC CARRY GOAL STATUS $0.01

HC CARTRIDGE EXCHANGE CAPD $742.13

HC CARTRIDGE EXCHANGE CRRT $1,009.28

HC CAST ORTHO SOFT GOODS LVL 1 $259.69

HC CAST ORTHO SOFT GOODS LVL 10 $1,671.52










HC CATH CAROTID VERTEBRAL $1,573.14

HC CATH CHANGE UNDER FLUORO $1,085.04

HC CATH LAB RECOVERY PER HOUR $1,118.71

HC CATH PLC SEGMENTAL ARTERY $1,427.65

HC CATH PLC SVC/IVC NONSELECTIVE $1,216.25

HC CATH PLC VEIN 1ST ORDER SELECTIVE $1,248.18

HC CATH PLC VEIN 2ND ORDER SELECTIVE $1,321.60

HC CATH PORTAL VEIN PERC $2,491.52

HC CATH SUPRAPUBIC/CYSTOSCOPIC LVL 1 $438.84

HC CATH SUPRAPUBIC/CYSTOSCOPIC LVL 2 $566.97

HC CATH VENOUS ORGAN BLOOD SAMPLE SELECTIVE $2,059.65

HC CATH, EP, 19 OR FEW ELECT LVL 1 $907.19

HC CATH, EP, 19 OR FEW ELECT LVL 10 $9,695.71

40 of 172

Procedure Price










HC CATH, EP, 20 OR MORE ELEC LVL 1 $2,516.06










HC CATH, EP, COOL-TIP LVL 1 $2,516.06









HC CATH, EP, DIAG/ABL, 3D/VECT LVL 1 $2,516.06







HC CATH, EP, OTHR THAN COOL-TIP LVL 1 $2,516.06


41 of 172

Procedure Price








HC CATH, HEMODIALYSIS,LONG-TERM LVL 1 $477.37

HC CATH, HEMODIALYSIS,LONG-TERM LVL 10 $9,695.71










HC CATH, INTRA ECHOCARDIOGRAPHY LVL 1 $779.62

HC CATH, INTRA ECHOCARDIOGRAPHY LVL 10 $9,695.71








HC CATH, INTRAVAS ULTRASOUND LVL 1 $779.62

HC CATH, INTRAVAS ULTRASOUND LVL 10 $9,695.71








HC CATH,HEMODIALYSIS,SHORT-TERM LVL 1 $1,063.13

42 of 172

Procedure Price





HC CATHETER ASPIRATION NASOTRACHEAL $177.54

HC CATHETER OCCLUSION LVL 1 $779.62

HC CATHETER OCCLUSION LVL 2 $1,519.56






HC CATHETER, ABLATION LVL 1 $2,953.14



HC CATHETER, GUIDING LVL 1 $574.10

HC CATHETER, GUIDING LVL 10 $5,506.99














HC CATHETER, INTRASPINAL LVL 1 $2,516.06



HC CATHETER, URETERAL LVL 1 $407.98

HC CATHETER, URETERAL LVL 2 $1,519.56



43 of 172

Procedure Price





HC CD CONSULT $168.54

HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 1 $780.18

HC CENTRAL PERIPHERAL CATHS, NO HCPCS LVL 2 $3,039.13






HC CEREBR SEIZURE 16/> CH; EA 24 HRS $4,384.76

HC CEREBR SEIZURE 8-CH; EA 24 HRS $3,288.96

HC CEREBR SEIZURE EEG EA 24 HRS $1,897.82

HC CEREBR SEIZURE PORT 16 CH; EA 24 HRS $3,387.53

HC CERVICAL FOAM COLLAR LVL 1 $108.54

HC CERVICAL SPINE 2 OR 3 VIEWS $463.63

HC CERVICAL SPINE MIN 4 VIEWS $656.32

HC CHANGE GASTROSTOMY TUBE $896.14

HC CHANGE G-TUBE TO G-J PERC $2,039.92

HC CHANGE OF CYSTOSTOMY TUBE COMPLICATED $1,254.45

HC CHANGE OF CYSTOSTOMY TUBE SIMPLE $707.87

HC CHANGE OF URETER TUBE/STENT $3,598.98

HC CHANGE STENT VIA TRANSURETH $5,804.08

HC CHANGE URETER STENT PERCUT $4,865.23

HC CHEM CAUT GRANULATION TISS $579.33

HC CHEMO ANTI-NEOPL SQ/IM $288.79

HC CHEMO CNS INTRATHECAL W LP $844.51

HC CHEMO HORMON ANTINEOPL SQ/IM $279.87

HC CHEMO IA PUSH TECHNIQUE $583.55

HC CHEMO INJ VIA SQ RESERVOIR $358.52

HC CHEMO IV INFUS EACH ADDL SEQ $345.36

HC CHEMO PROLONG INFUSE W/PUMP $797.31

HC CHEMO, IV INFUSION, 1 HR $801.48

HC CHEMO, IV INFUSION, ADDL HR $321.40

HC CHEMO, IV PUSH, ADDL DRUG $369.50

44 of 172

Procedure Price

HC CHEMO, IV PUSH, SNGL DRUG $456.12

HC CHEMODENER MUSCLE LARYNX EMG $843.14

HC CHEMODENERV 1 EXTREM 1-4 MUSC $843.14

HC CHEMODENERV 1 EXTREM 1-4 MUSC ADDTL $421.57

HC CHEMODENERV 1 EXTREM 5/> MUSC $843.14

HC CHEMODENERV 1 EXTREM 5/> MUSC ADDTL $421.57

HC CHEMODENERV MUSC MIGRAINE $420.22

HC CHEMODENERV MUSC NECK DYSTON $481.63

HC CHEMODENERV TRUNK MUSC 1-5 $843.14

HC CHEMODENERV TRUNK MUSC 6/> $843.14

HC CHEMODENERVATION ANAL MUSC $1,853.78

HC CHEMOTX ADMN PRTL CAVITY $882.46

HC CHEST PT INIT OR EVAL $174.12

HC CHEST PT SUBSEQUENT $163.34

HC CHEST TUBE PLACEMENT $2,288.11

HC CHEST/NG TUBE; SUCTION/DRAIN SUPPLY LVL1 $460.69

HC CHEST/NG TUBE; SUCTION/DRAIN SUPPLY LVL2 $1,410.41



HC CHOLANGIOGRAM INTRAOP $790.76

HC CHOLANGIOGRAM INTRAOP ADDTL $404.44

HC CHOLECYSTOSTOMY PERC $6,760.53

HC CHORIONIC VILLUS SAMPLING $805.51

HC CIRCUMCISION $837.55

HC CIRCUMCISION NEONATE $2,599.49

HC CISTERNOGRAM S&I $657.25

HC CL LACERATION MOUTH VESTIB >2.5 CM $731.15

HC CL LACERATION MOUTH VESTIB 2.5 CM/< $821.65

HC CL TX ACLAV DISLOC W MANIP $505.55

HC CL TX ACLAV DISLOC WO MANIP $366.99

HC CL TX ANKLE DISLOCATION WO ANESTH $621.43

HC CL TX ART FX MCP/IP JNT W MANIP $1,285.94

HC CL TX BIMALLEOLAR ANKLE FX W MANIP $1,285.94

HC CL TX BIMALLEOLAR ANKLE FX WO MANIP $676.79

HC CL TX C HUMERUS FX W MANIP $1,285.94

HC CL TX C HUMERUS FX WO MANIP $397.77

HC CL TX CALCANEAL FX WO MANIP $513.79

45 of 172

Procedure Price

HC CL TX CARP B FX (NOT NAV) WO MANIP $418.35

HC CL TX CARPAL SCAPHOID FX WO MANIP $408.92

HC CL TX CARPL SCAPHOID FX W MANIP $1,285.94

HC CL TX CLAVICULAR FX WO MANIP $326.05

HC CL TX CMC DISL W MANIP EA $304.43

HC CL TX CMC DISLOC THUMB W MANIP $549.42

HC CL TX CMC FX DISLOC THUMB W MANIP $1,285.94

HC CL TX COCCYGEAL FRACTURE $267.36

HC CL TX D FEM FX WO MANIP $355.39

HC CL TX D PHAL FX FGR/THMB W MANIP $463.96

HC CL TX D PHAL FX FGR/THMB WO MANIP $287.25

HC CL TX DISTL FIB FX W MANIP $717.23

HC CL TX DSTL FIB FX WO MANIP $485.51

HC CL TX DSTL RADIOULNAR DISLOC W MANIP $364.59

HC CL TX EC HUMERUS FX W MANIP $1,285.94

HC CL TX EC HUMERUS FX WO MANIP $439.33

HC CL TX FEMORAL SHAFT FX W MANIP $1,922.47

HC CL TX FEMORAL SHAFT FX WO MANIP $920.14

HC CL TX FEMUR FX OR EPIPHYS SEP $1,285.94

HC CL TX FX GT PHALANX W MANIP $233.82

HC CL TX FX GT PHALANX WO MANIP $218.10

HC CL TX FX PHALANX/PHALANG W MANIP $1,137.75

HC CL TX FX PHALNX/PHALNG WO MANIP $226.84

HC CL TX GR TUBEROSITY FX WO MANIP $408.85

HC CL TX GTR TROCHNTRC FX WO MANIP $410.00

HC CL TX HUMERUS FX W MANIP $1,285.94

HC CL TX HUMERUS FX WO MANIP $535.02

HC CL TX IC SPINE/TUBEROSITY FX KNEE $429.78

HC CL TX INTR/PERI/SBTRCHNTC FEM FX W MANIP $3,745.00

HC CL TX IP JNT D W MANIP WO ANESTH $868.69

HC CL TX IP JOINT DISL WO ANESTH $329.85

HC CL TX IP JT DISLOC W MANIP W ANESTH $444.86

HC CL TX KNEE DISL WO ANESTH $652.23

HC CL TX LUNATE DISLOC W MANIP $1,913.46

HC CL TX MAND/MAXILL ALVEOLAR RIDGE FX $4,335.99

HC CL TX MANDIBULAR FX WO MANIP $542.66

HC CL TX MC FX SGL W MANIP $757.87

46 of 172

Procedure Price

HC CL TX MC FX SGL WO MANIP EA BONE $361.75

HC CL TX MCP DISLOC SGL W MANIP $747.67

HC CL TX MED ANKLE FX W/ MANIP $4,236.50

HC CL TX METATARSAL FX W MANIP $464.52

HC CL TX METATARSAL FX WO MANIP $634.27

HC CL TX MONTEGGIA ELB FX W MANIP $4,543.73

HC CL TX MTP JNT DISLOC WO ANESTH $267.28

HC CL TX NASAL SEPTAL FX $4,447.17

HC CL TX NURSEMAID ELBOW W MANIP $350.11

HC CL TX OF ACETABULUM FX WO MANIP $695.22

HC CL TX OF NASAL BONE FX WO STABILIZ $1,592.32

HC CL TX OF RADIAL SHAFT FX WO MANIP $395.29

HC CL TX ORBIT FX NOT BLOW OUT WO MANIP $919.68

HC CL TX PATELLAR DISLOCATION WO ANESTH $583.17

HC CL TX PELVIC RING FX W MANIP $998.75

HC CL TX PELVIC RING FX WO MANIP $624.22

HC CL TX PHAL SHAFT FX WO MANIP $252.71

HC CL TX PHALANG SHFT FX W MANIP $422.55

HC CL TX POST HIP DISLOC WO ANESTH $1,296.12

HC CL TX POSTOP HIP DISLOC W ANESTH $2,693.22

HC CL TX PROX FEM FX WO MANIP $368.79

HC CL TX PROX FIB/SHAFT FX WO MANIP $467.64

HC CL TX PROX FIB/SHAFT W MANIP $1,483.67

HC CL TX PROX HUMERAL FX W MANIP $2,226.31

HC CL TX PROX HUMERAL FX WO MANIP $591.68

HC CL TX PROX TIBIAL FX W SK TRACTION $4,990.76

HC CL TX PROX TIBIAL FX WO MANIP $571.62

HC CL TX RADIAL & ULNA FX W MANIP $1,285.94

HC CL TX RADIAL & ULNAR FX WO MANIP $394.21

HC CL TX RADIAL HD/NECK FX W MANIP $1,285.94

HC CL TX RADIAL HD/NECK FX WO MANIP $414.19

HC CL TX RADIAL SHFT FX W MANIP $1,285.94

HC CL TX SC/TC FEMUR FX W MANIP $2,571.88

HC CL TX SC/TC FEMUR FX WO MANIP $430.00

HC CL TX SC/TC HUMERUS FX WO MANIP $551.56

HC CL TX SC/TX HUMERUS SHFT FX W MANIP $1,285.94

HC CL TX SCAPULAR FX W MANIP $1,285.94

47 of 172

Procedure Price

HC CL TX SCAPULAR FX WO MANIP $327.12

HC CL TX SCLAV DISLOC W MANIP $505.55

HC CL TX SHDR DISLOC W NK FX W MANIP $1,285.94

HC CL TX SHLDR DISL W MANI WO ANESTH $1,012.24

HC CL TX SHLDR DISL W MANIP W ANESTH $3,542.47

HC CL TX SHLDR DISLOC & FX GT W MANIP $1,285.94

HC CL TX TALOTARSAL JOINT DIS WO ANESTH $460.05

HC CL TX TALUS FX W MANIP $1,629.08

HC CL TX TALUS FX WO MANIP $478.17

HC CL TX TIB SHFT FX W MANIP $2,296.16

HC CL TX TIB SHFT FX WO MANIP $531.63

HC CL TX TMJ DISLOCATION INITIAL $490.98

HC CL TX TRANS-SPL FX DISL W MANIP $403.97

HC CL TX TRAUMA HIP DISLOC W ANESTH $2,530.34

HC CL TX TRAUMA HIP DISLOC WO ANESTH $838.18

HC CL TX TRIMALL ANKLE FX W MANIP $1,628.30

HC CL TX TRIMALL ANKLE FX WO MANIP $434.17

HC CL TX ULNAR FX PROXIMAL END W MANIP $2,234.48

HC CL TX ULNAR SHAFT FX WO MANIP $391.07

HC CL TX ULNAR SHFT FX W MANIP $691.05

HC CL TX VERTEBRAL BODY FX WO MANIP $408.85

HC CL TX WB DSTL TIB FX W MANIP $1,913.46

HC CL TX WB DSTL TIB WO MANIP $590.42

HC CL TXT OF NASAL BONE FX WO MANIP $221.23

HC CLAVICLE COMPLETE $372.16

HC CLEAR LENSECTOMY RESTOR LENS IMPLANT $2,300.00

HC CLEAR LENSECTOMY SN60WF LENS IMPLANT $1,555.00

HC CLEAR LENSECTOMY TORIC LENS IMPLANT $1,800.00

HC CLOSED TX OF ULNAR STYLOID FX $439.33

HC CLOSED TX PATELLAR FX WO MANIP $507.53

HC CLTX FEMORAL HEAD FX WO MANIP $1,348.20

HC CLTX MEDIAL ANKLE FX WO MANIP $489.71

HC CLTX POST ANKLE FX W MNPJ $1,285.94

HC CLTX POST ANKLE FX WO MANIP $364.59

HC CLTX RAD/INTERCARPL DISL 1+ BONE W MANIP $508.25

HC CNTRL POST EPISTAX INIT $565.24

HC CO2 EXPIRED GAS BY IR $348.60

48 of 172

Procedure Price

HC COAG TIME ACTIVATED $93.82

HC COCHLEAR IMPLANT SYSTEM LVL 12 $48,900.00

HC COCHLEAR IMPLANT SYSTEM LVL 13 $59,954.24

HC COGNITIVE SKILLS DEVELOPMENT EA 15M $152.00

HC COGNITIVE TEST BY HC PRO $291.08

HC COLLAG DRESS 16 SQIN/ $105.12

HC COLLAGEN IMPLANT URINARY TRACT 2.5 ML LVL 1 $1,519.56





HC COLLECT BLOOD FROM PICC $143.77

HC COLLECT SWEAT FOR TEST $231.15

HC COLON W AIR AND BARIUM $949.49

HC COLON W CONTRAST $756.94

HC COLONOSCOPY LEVEL I $3,540.29

HC COLONOSCOPY LEVEL II $3,976.01

HC COLONOSCOPY LEVEL III $4,747.90

HC COLONOSCOPY LEVEL IV $5,778.45

HC COLONOSCOPY W ENDOSCOPE US $7,927.29

HC COLONOSCOPY W ENDOSCOPIC FN BX $8,410.05

HC COLONOSCOPY W/DECOMPRESSION $1,795.50

HC COLPORRHAPHY $3,852.00

HC COLPOSCOPY OF CERVIX $175.27

HC COMMUNITY/WORK TRAINING EA 15M $152.00

HC COMP EP EVAL W INDUCTION $17,087.51

HC COMP EP EVAL W LA RECORDING $8,175.71

HC COMP EP EVAL W LV RECORDING $7,327.98

HC COMP EP EVAL WO A INDUCTION $7,903.70

HC COMPL ACUTE ABDOMEN W PA CHEST $488.92

HC COMPL CBC W PLT W AUTOM DIFF $15.20

HC COMPL FETAL DOPPER ECHOCARGIOGRAM $708.40

HC COMPLETE CERVICAL SPINE $727.09

HC COMPLEX CYSTOMETROGRAM $1,906.76

HC COMPLEX PROCEDURE $818.30

HC COMPLEX UROFLOWMETRY $953.38

HC COMPREHENSIVE AUDIOMETRY EVAL W SR $171.34

49 of 172

Procedure Price

HC COMPRESSION STOCKING BK18-30 LVL 1 TAKE HOME $390.11








HC CONN TISS, HUMAN (INC FASCIA) LVL 1 $2,232.56












HC CONN TISS, NON-HUMAN LVL 1 $2,516.06











HC CONT BRONCHODILATOR TX 1ST HOUR $310.54

HC CONT BRONCHODILATOR TX EA ADDL HOUR $268.48

HC CONTINUING RADIATION PHYSICS CONSULT $681.20

HC CONTINUOUS GLUCOSE MONITOR $594.16

HC CONTINUOUS PULSE OX $642.64

HC CONTRAST GADOLINIUM NOS PER ML $13.98

50 of 172

Procedure Price

HC CONTROL NASAL HEMORRH ANT COMPL $384.25

HC CONTROL NASAL HEMORRH ANT SMPL $560.85

HC CONTROL OROPHARYNGEAL HEMORRH SMPL $438.07

HC CONVERSION EXT BIL DRG CATH $7,500.00

HC CONVERT NEPHROSTOMY CATH EXIST TRACT $4,800.00

HC CONVERT PERC GT TO JT $3,002.78

HC CORDOCENTESIS (INTRAUTERINE) $373.84

HC CORONARY ART/GRFT ANGIO S&I $12,698.95

HC CORONARY ARTERY ANGIO S&I $9,984.33

HC CORPACK PLACEMENT WO FLUORO $479.32

HC CORPORA CAVERNOSA-GLANS PENIS FISTULIZ $3,391.14

HC CPR $1,456.85

HC C-REACTIVE PROTEIN, HS $33.00

HC CREP E/N/E/L 1.1-2.5 CM $974.15

HC CREP E/N/E/L 2.6-7.5 CM $1,422.54

HC CREP E/N/E/L EA ADDTL 5 CM/< $366.56

HC CREP F/G/H/F 1.1-2.5 CM $867.02

HC CREP F/G/H/F 2.6-7.5 CM $985.68

HC CREP F/G/H/F EA ADD 5 CM/< $888.87

HC CREP S/A/L 2.6-7.5 CM $879.41

HC CREP S/A/L EA ADD 5 CM/< $377.98

HC CREP TRUNK 2.6-7.5 CM $606.03

HC CRITICAL CARE 30-74 MIN $3,863.74

HC CRITICAL CARE EACH ADDTL 30 MIN $1,174.92

HC CRRT DAILY MONITORING FEE $1,721.73

HC CRYOABLATION PROBE LVL 1 $779.62

HC CRYOABLATION PROBE LVL 10 $5,414.85











51 of 172

Procedure Price










HC CT ABD & PELVIS W WO CONTR 1+ REG/SEC $6,472.60

HC CT ABD & PELVIS WO CONTRAST $4,829.63

HC CT ABDOMEN & PELVIS W CONTRAST $5,327.70

HC CT ABDOMEN W CONTRAST $2,761.72

HC CT ABDOMEN W WO CONTRAST $3,494.55

HC CT ABDOMEN WO CONTRAST $2,378.25

HC CT ANGIO ABD AND PELV WO W CONTRAST $6,100.00

HC CT ANGIOGRAPHY ABDOMEN W WO CONTRAST $3,250.26

HC CT ANGIOGRAPHY AORTA ILIOFEMORAL RUNOFF $3,109.88

HC CT ANGIOGRAPHY CHEST W WO CONTRAST $3,738.63

HC CT ANGIOGRAPHY HEAD W WO CONTRAST $3,457.96

HC CT ANGIOGRAPHY HEART $2,645.55

HC CT ANGIOGRAPHY LOWER EXTR W WO CONTRAST $3,560.37

HC CT ANGIOGRAPHY NECK W WO CONTRAST $3,047.86

HC CT ANGIOGRAPHY PELVIS W WO CONTRAST $2,991.84

HC CT ANGIOGRAPHY UPPER EXTR W WO CONTRAST $2,686.70

HC CT BONE DENSITY AXIAL $560.33

HC CT CERVICAL SPINE W CONTRAST $3,096.37

HC CT CERVICAL SPINE W WO CONTRAST $3,122.91

HC CT CERVICAL SPINE WO CONTRAST $2,845.61

HC CT CHEST W CONTRAST $2,809.99

HC CT CHEST W WO CONTRAST $3,215.46

HC CT CHEST WO CONTRAST $2,222.24

HC CT COLONOGRAPHY SCREEN $1,678.00

HC CT COLONOGRAPHY W CONTRAST DX $2,012.88

HC CT COLONOGRAPHY WO CONTRAST DX $1,702.35

HC CT GUIDANCE FOR RADIATION THERAPY $1,361.14

HC CT GUIDANCE NEEDLE PLACEMENT $1,906.40

52 of 172

Procedure Price

HC CT GUIDANCE TISSUE ABLATION $2,181.73

HC CT HEAD OR BRAIN W CONTRAST $2,381.82

HC CT HEAD OR BRAIN W WO CONTRAST $2,786.73

HC CT HEAD OR BRAIN WO CONTRAST $2,194.15

HC CT HEART EVAL CARDIAC STRUCTURE $2,645.55

HC CT HEART EVAL CONGENITAL DISEASE $2,645.55

HC CT HEART WO CONTRAST W CALCIUM SCORE $136.23

HC CT LIMITED OR FOLLOWUP STUDY $326.18

HC CT LOWER EXTR W CONTRAST $2,374.67

HC CT LOWER EXTR W WO CONTRAST $3,049.28

HC CT LOWER EXTR WO CONTRAST $2,129.34

HC CT LUMBAR SPINE W CONTRAST $2,807.57

HC CT LUMBAR SPINE W WO CONTRAST $3,283.64

HC CT LUMBAR SPINE WO CONTRAST $2,595.26

HC CT LUNG CANCER SCREEN $196.61

HC CT MAXILLOFACIAL W CONTRAST $2,493.68

HC CT MAXILLOFACIAL W WO CONTRAST $2,858.18

HC CT MAXILLOFACIAL WO CONTRAST $2,143.64

HC CT ORBIT SELLA MID INNER EAR W CONTR $2,302.03

HC CT ORBIT SELLA MID INNER EAR W WO CONTR $2,978.46

HC CT ORBIT SELLA MID INNER EAR WO CONTR $2,199.61

HC CT PELVIS W CONTRAST $2,766.41

HC CT PELVIS W WO CONTRAST $3,325.61

HC CT PELVIS WO CONTRAST $2,335.23

HC CT PERFUSION W/CONTRAST CBF $3,195.69

HC CT SCAN FOR STEREOTACTIC LOCALIZATION $2,381.82

HC CT SOFT TISSUE NECK W CONTRAST $2,500.91

HC CT SOFT TISSUE NECK W WO CONTRAST $2,984.42

HC CT SOFT TISSUE NECK WO CONTRAST $2,262.73

HC CT THORACIC SPINE W CONTRAST $2,812.14

HC CT THORACIC SPINE W WO CONTRAST $3,339.76

HC CT THORACIC SPINE WO CONTRAST $2,400.88

HC CT UPPER EXTR W CONTRAST $2,327.64

HC CT UPPER EXTR W WO CONTRAST $2,771.69

HC CT UPPER EXTR WO CONTRAST $2,111.48

HC CTRL POST EPISTAX SQ $180.96

HC CURETTAGE POSTPARTUM $2,789.32

53 of 172

Procedure Price

HC CUSTOM STANDARD PACKS, KITS LVL 1 $354.37

HC CUSTOM STANDARD PACKS, KITS LVL 2 $1,410.41






HC CVSLR STRESS TEST; TRACING $903.66

HC CYSTO F/URTL STRIX/STENOSIS $8,761.78

HC CYSTO W DIL OF URETHRAL STRICTURE $2,954.53

HC CYSTO W MEATOTOMY; UNIL OR BILAT $3,364.83

HC CYSTO W REM FB/CALC/STNT URETH OR BLDR SMPL $1,982.31

HC CYSTOGRAM MIN 3 VIEWS $649.29

HC CYSTOURETHROSCOPY $985.41

HC CYSTOURETHROSCOPY W URETERAL CATH $3,368.38

HC DAILY CARE CORONARY $4,935.00

HC DAILY CARE INTENSIVE $4,935.00

HC DAILY CARE INTENSIVE PEDIATRIC $6,585.00

HC DAILY CARE INTENSIVE PEDIATRIC STEP DOWN $4,225.00

HC DAILY CARE INTENSIVE STEP DOWN $2,865.00

HC DAILY CARE NURSERY LEVEL I $1,490.00

HC DAILY CARE NURSERY LEVEL II $5,450.00

HC DAILY CARE NURSERY LEVEL III $5,450.00

HC DAILY CARE NURSERY LEVEL IV NICU $5,450.00

HC DAILY CARE PACU $1.00

HC DAILY CARE PRIVATE REHAB $1,400.00

HC DAILY CARE SEMIPRIVATE DETOX $1,870.00

HC DAILY CARE SEMIPRIVATE EMU/HIGH ACUITY $1,845.00

HC DAILY CARE SEMIPRIVATE HOSPICE $220.00

HC DAILY CARE SEMIPRIVATE OBSTETRICS $1,490.00

HC DAILY CARE SEMIPRIVATE OBSTETRICS INTERMEDIATE $3,780.00

HC DAILY CARE SEMIPRIVATE ONCOLOGY $1,490.00

HC DAILY CARE SEMIPRIVATE PEDIATRICS $2,080.00

HC DAILY CARE SEMIPRIVATE PSYCH $2,015.00

HC DAILY CARE SEMIPRIVATE REHAB $2,190.00

HC DAILY CARE SEMIPRIVATE ROUTINE $1,490.00

HC DAILY CARE SEMIPRIVATE TELE $1,910.00

54 of 172

Procedure Price

HC DAILY CARE SP PEDS ONCOLOGY/HEMATOLOGY $3,570.00

HC DAILY TREATMENT HOSPITAL CDC $650.00

HC DEB BONE ADD-ON $1,559.80

HC DEB MUSC/FASCIA ADD-ON $501.77

HC DEB SUBQ TISSUE ADD-ON $583.80

HC DEBR EXZ/INF SKIN 10% BS $501.77

HC DEBR O FX SKIN TO BONE $2,214.65

HC DEBR W OPEN FX SKIN & SQ $1,132.61

HC DEBRIDE NAILS 1-5 $116.67

HC DEBRIDE NAILS 6/> $168.65

HC DEBRIDE SKIN & BONE $3,736.71

HC DEBRIDE SKIN & MUSCLE $2,481.05

HC DEBRIDE SKIN TO SQ TISSUE $1,240.50

HC DECLOT VASCULAR DEVICE $595.53

HC DECOMPR FINGERS/HAND INJ INJURY $3,114.26

HC DEEP FB REM - FOREARM/WRIST $4,988.64

HC DEEP REM FB FROM UA/ELBOW $3,320.53

HC DELIVERY OF PLACENTA $3,982.93

HC DERMACELL PER 1 SQ CM LVL 3 $240.14

HC DERMACELL PER 1 SQ CM LVL 4 $451.17

HC DERMAGRAFT PER SQ CM LVL 1 $126.58

HC DESIGN MLC DEVICE FOR IMRT $12,377.16

HC DESTROY C/TH FACET JNT ADDL UNIL $226.96

HC DESTROY CERV/THOR FACET JNT UNIL $1,685.25

HC DESTROY L/S FACET JNT ADDL UNIL $649.25

HC DESTROY LUMB/SAC FACET JNT UNIL $1,685.25

HC DESTRUCT B9 LESION 1-14 $258.87

HC DEVLOPMENT TEST W/ I&R $68.53

HC DEXTRANOMER/HYALURONIC ACID 1 ML LVL 5 $6,746.51

HC DIABETES MGMT PROG, GROUP $335.00

HC DIABETES MGMT PROG, INDIV $700.00

HC DIABETES OP SELF-MGMT, GROUP 30 MIN $48.00

HC DIABETES OP SELF-MGMT, INDIV 30 MIN $75.00

HC DIALYSIS CIRCUIT EMBOLJZ/OCCL $14,500.00

HC DIETARY CONSULT $27.55

HC DIL URETH STRICT SOUND MALE INITIAL $566.69

HC DIL URETHR STRICT FILIF/FOLLOW; MALE INIT $3,323.97

55 of 172

Procedure Price

HC DILATE & CATH SALIVARY DUCT $490.97

HC DILATE BILIARY DUCT/AMPULLA $5,159.52

HC DILATE BILIARY STRICTURE W/O STENT PERC $4,507.02

HC DILATE BILIARY STRICTURE W/STENT PERC $4,507.02

HC DILATE CYSTO W URETER/PYELOSCOPY $3,892.18

HC DILATE ESOPH UNGUIDED SND/BOUG $1,431.70

HC DILATE FOR STRICTURE OR OBSTR $572.86

HC DILATE NEPHROSTOMY TRACT PERC $3,523.45

HC DILATE URETERS/URETHRA/NEPHROSTOMY $2,199.74

HC DIRECT REFER HOSPITAL OBSERV $130.14

HC DISABILITY DETERMINATION $322.66

HC DISPOSABLE INSTRUMENTS LVL 1 $512.49

HC DISPOSABLE INSTRUMENTS LVL 10 $4,608.28



HC DISPOSABLE INSTRUMENTS LVL 2 $606.82








HC DISPOSABLE RADIOLOGY SUPPLIES LVL 1 $383.06

HC DIVIDE PLANTAR FASCIA AND MUSCLE $4,156.95

HC DLYD PLMT XTN PROSTH 1ST VSL $7,000.00

HC DLYD PLMT XTN PROSTH EA ADDL $7,000.00

HC DOPPLER COLOR FLOW $381.09

HC DOPPLER ECHO; COMPLETE $487.81

HC DOPPLER ECHO; LIMITED/ F-UP $301.88

HC DR ABSC CYST HEMAT MOUTH SIMPLE $545.69

HC DR ABSC CYST HEMAT-MOUTH; COMPLICATED $905.56

HC DR ABSC CYST HEMATOM DENTOALVEOLAR $167.70

HC DR ABSC/HEMATOMA NASAL INT $741.44

HC DR ABSC/HEMATOMA NASAL SEPTUM $793.26

HC DR EXT EAR ABSCESS/HEMATOMA COMPL $2,530.03

HC DR EXT EAR ABSCESS/HEMATOMA SIMPLE $545.69

56 of 172

Procedure Price

HC DRAIN ABSCESS RETROPERITONEAL OPEN $4,468.87

HC DRAIN BL W/CATH INSERTION SUPRAPUBIC $4,200.34

HC DRAIN BLADDER BY NEEDLE $538.79

HC DRAIN BLADDER BY TROCAR/CATH $860.17

HC DRAIN EXTERNAL AUDITORY CANAL ABSCESS $545.69

HC DRAIN FINGER ABSC COMPLICATED $1,702.48

HC DRAIN FINGER ABSC SIMPLE $461.15

HC DRAIN PERIRENAL/RENAL ABSCESS OPEN $4,865.23

HC DRAIN PERITONEAL ABSCESS OR CYST; OPEN $3,781.31

HC DRAIN/INJ INTERM JNT/BURSA $454.54

HC DRAIN/INJ INTERM JOINT/BURSA W US $517.62

HC DRAIN/INJ MAJOR JNT/BURSA $762.35

HC DRAIN/INJ MAJOR JOINT/BURSA W US $361.46

HC DRAIN/INJ SMALL JOINT/BURSA W US $451.82

HC DRAIN/INJECT SM JNT/BURSA $553.33

HC DRAINAGE CATH LVL 1 $136.62

HC DRAINAGE CATH LVL 12 $12,927.63


HC DRAINAGE CATH LVL 2 $812.18







HC DRAINAGE CATH PLACEMENT W IMG GUIDANCE $1,344.73

HC DRAINAGE CATHS LVL 1 $805.51

HC DRAINAGE CATHS LVL 2 $3,969.00

HC DRAINAGE OF ABSCESS OF PALATE UVULA $507.16

HC DRAINAGE OF SCROTAL WALL ABCESS $1,284.13

HC DRAW BLOOD OFF VENOUS DEVICE $143.77

HC DRESS/DEBRID P-THICK BURN L >10% $571.17

HC DRESS/DEBRID P-THICK BURN M 5-10% $522.44

HC DRESS/DEBRID P-THICK BURN S <5% $535.24

HC DRESSING/SKIN SEALANTS LVL 1 $367.34

HC DRESSING/SKIN SEALANTS LVL 10 $4,493.49


57 of 172

Procedure Price













HC DRIVER EVAL/TRAINING VOC REHAB $140.00

HC DRIVING EVAL $325.00

HC DRIVING TRAINING $90.00

HC DRUG ADMIN & HEMODYNMIC MEAS $827.04

HC DUPLEX A IVC IL/BPG; COMPL $1,101.80

HC DUPLEX A IVC IL/BPG; UNIL/LIMIT $790.00

HC DUPLEX ARTERIAL FLOW LIMITED $1,007.50

HC DUPLEX EXT VEINS UNIL/LIMIT $1,090.51

HC DUPLEX EXT VEINS; BILAT $1,583.96

HC DUPLEX HEMODIALYSIS ACCESS $728.02

HC DUPLEX LE ART/BPG; BILAT $1,306.78

HC DUPLEX LE ART/BPG; UNIL/LIMIT $933.46

HC DUPLEX UE ART/BPG; BILAT $1,246.88

HC DUPLEX UE ART/BPG; UNIL/LIMIT $832.18

HC DX BONE MARROW BX & ASPIR $2,568.26

HC DX BRONCHOSCOPE/WASH $1,260.95

HC DX LARYNGOSCOPY EXCL NB $2,806.93

HC DX MAMMO INCL CAD BILAT $441.85

HC DX MAMMO INCL CAD UNIL $357.10

HC DXA BONE DENSITY AXIAL $596.23

HC EAR PROTECTOR EVAL $30.29

HC EARS, NOSE, THROAT SUP NON-AIRWAY LVL 12 $4,656.50

HC EARS, NOSE, THROAT SUP NON-AIRWAY LVL 20 $6,463.82

HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 1 $461.06

HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 2 $753.04

58 of 172

Procedure Price

HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL 3 $1,936.95







HC EARS, NOSE, THROAT SUP, NON-AIRWAY LVL10 $4,493.49








HC ECG 0-24 HRS SCANNING ANALYSIS REPORT $614.51

HC ECG 0-48 HRS SCANNING ANALYSIS REPORT $709.78

HC ECG MONITOR 0-24 HRS RECORDING $464.74

HC ECG MONITOR 0-48 HRS RECORDING $485.89

HC ECHO TRANSESOPHAGEAL (TEE) $2,617.02

HC ECHO TRANSESOPHAGEAL COMPLETE $1,877.10

HC ECMO/ECLS DAILY MGMT ARTERY $6,540.24

HC ECMO/ECLS DAILY MGMT VENOUS $6,540.24

HC ECMO/ECLS INITIATION ARTERY $6,540.24

HC ECMO/ECLS INITIATION VENOUS $6,540.24

HC ECMO/ECLS INS CTR CANNULA 6+YRS $6,540.24

HC ECMO/ECLS INS PERIPH CANNULA OPEN 6+YRS $6,540.24

HC ECMO/ECLS INS PERIPH CANNULA PERQ 6+YRS $6,540.24

HC ECMO/ECLS REMOV CTR CANNULA 6+YRS $6,540.24

HC ECMO/ECLS REMOV PERIPH CANNULA OPEN 6+YRS $6,540.24

HC ECMO/ECLS REMOV PERIPH CANNULA PERQ 6+YRS $6,540.24

HC ECMO/ECLS REPOS CTR CANNULA 6+YRS $6,540.24

HC ECMO/ECLS REPOS PERIPH CANNULA PERQ 6+YRS $6,540.24

HC ED LEVEL 1 INIT ASSESS $65.41

HC ED LEVEL 1 VISIT $414.13


HC ED LEVEL 2 VISIT $686.99

59 of 172

Procedure Price


HC ED LEVEL 3 VISIT $1,076.56





HC EDUCATION PROGRAM $150.00

HC EEG 41-60 MINUTES $1,274.00

HC EEG AWAKE & ASLEEP $1,142.78

HC EEG AWAKE & DROWSY $1,200.24

HC EEG CEREBRAL SILENCE $1,454.44

HC EEG DURING NONCRANIAL SURG $2,889.89

HC EEG OVER 1 HOUR $1,861.89

HC EGD CONTROL BLEEDING ANY $2,615.23

HC EKG SIGNAL-AVERAGED $383.00

HC ELBOW 2 VIEWS $362.99

HC ELBOW ARTHROGRAM $913.14

HC ELBOW MIN 3 VIEWS $432.91

HC ELECTRO HEARING AID TEST BOTH $71.98

HC ELECTRO HEARING AID TEST ONE $50.39

HC ELECTROCONVULSIVE THERAPY $1,429.96

HC ELECTROPHYS MAP 3D ADD ON $10,884.13

HC EMBOLIZ PROTECT SYS LVL 1 $779.62

HC EMBOLIZ PROTECT SYS LVL 10 $9,695.71










HC EMERG DIALYSIS ESRD PT $1,489.59

HC EMG ANAL/URETHR SPHINCT NOT NEEDLE $158.91

HC ENDO OR 121-200 MINUTES $5,844.95

HC ENDO PROBE, BALLOON, SNARE, OTHER LVL 1 $366.41

60 of 172

Procedure Price

HC ENDO PROBE, BALLOON, SNARE, OTHER LVL 2 $1,049.07





HC ENDO PROBES, BALLOONS, SNARES LVL 16 $7,000.00



HC ENDOLUMINAL BX BILIARY TREE $5,100.00

HC ENDOLUMINAL BX URETER/RENAL PLVS $870.71

HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 1 $382.85

HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL 2 $1,101.83








HC ENDOMEC- SUPPLIES STAPLERS/RELOADS LVL10 $4,493.49






HC ENDOMYOCARDIAL BIOPSY $2,518.69

HC ENDOSCOPY RECOVERY PER HOUR $175.45

HC ENDOVASC VISC AORTA 1 GRAFT $6,308.71




HC ENDOVEN THER CHEM ADHES 1ST $8,125.56

HC ENDOVEN THER CHEM ADHES SBSQ $4,062.78

HC ENDOVENOUS MCHNCHEM 1ST VEIN $4,985.00

HC ENDOVENOUS MCHNCHEM ADD-ON $1,500.00

HC EO - PREFAB RIGID WO JNTS LVL 1 $319.61

HC EO PREFAB W ADJ POSIT LOCKING JNTS LVL 1 $891.80

61 of 172

Procedure Price

HC EO W/O JOINTS CF LVL 1 $514.96

HC EP & ABLATE SUPRAVENT ARRHYT $33,822.41

HC EP & ABLATE VENTRIC TACHY $41,605.47

HC EP EVAL CD LEADS INIT/REPLACEMENT $4,875.57

HC EP EVAL CD W GENERATOR TEST $4,875.57

HC EP EVAL CD W PACING $2,276.71

HC EP STEERABLE GUIDING INTRO/SHEATH LVL 1 $779.62

HC EP STEERABLE GUIDING INTRO/SHEATH LVL 2 $1,519.56




HC EP STEERABLE GUIDING INTROSHEATH LVL 4 $3,039.13

HC EP STEERABLE GUIDING INTROSHEATH LVL 5 $3,798.91

HC EP/ABLATION CATHS, NO HCPCS LVL 1 $2,516.06





HC EPIC DISP FEE BASIC 1 $250.00

HC EPIC DISP FEE BASIC 2 $500.00

HC EPIC DISP FEE PREMIUM 1 $750.00

HC EPIC DISP FEE PREMIUM 2 $1,500.00

HC EPIC DISP FEE STANDARD 1 $500.00

HC EPIC DISP FEE STANDARD 2 $1,000.00

HC EPIDRM AUTOGRFT F/NK/HF/G 100 SQ CM/1% BA $2,875.95

HC EPIDRM AUTOGRFT F/NK/HF/G ADD 100 SQ CM/1% BA $2,982.95

HC EPIDRM AUTOGRFT T/A/L 100 SQ CM/1% BA $2,875.95

HC EPIDRM AUTOGRFT T/A/L ADD 100 SQ CM/1% BA $2,875.95

HC EPIFIX PER 1 SQ CM LVL 2 $844.12

HC EPIFIX PER 1 SQ CM LVL 3 $1,048.60

HC ERCP CLASS I $6,007.30

HC ERCP CLASS II $9,712.04

HC ERCP CLASS III $11,651.10

HC ERCP CLASS IV $13,381.14

HC ERCP CLASS V $16,703.80

HC ESCHAROTOMY INIT INC $522.44

HC ESOPHAGEAL DIL W/O EGD W WIRE $1,296.90

62 of 172

Procedure Price

HC ESOPHAGEAL MAL/HURST DIL $1,244.00

HC ESOPHAGRAM $524.95

HC ESOPHAGUS MOTILITY STUDY $2,004.70

HC EVAC SU HEMATOMA $502.78

HC EVAL FOR SPEECH DEVICE RX 1HR $464.45

HC EVAL IMPL PUMP W PROGR $444.87

HC EVAL SPEECH SOUND LANG COMPREHEN $252.79

HC EVAL TO USE/FIT VOICE PROSTH $464.45

HC EVALUATE PT USE OF INHALER $177.54

HC EVALUATE SPEECH FLUENCY $252.79

HC EVALUATE SPEECH PRODUCTION $252.79

HC EVALUATE SWALLOWING FUNCTION $414.71

HC EVASC RPR A-AO NDGFT $11,500.00

HC EVASC RPR A-AO NDGFT RUPTR $11,500.00

HC EVASC RPR A-BIILIAC NDGFT $12,000.00

HC EVASC RPR A-BIILIAC RUPTR $12,000.00

HC EVASC RPR A-UNILAC NDGFT $12,000.00

HC EVASC RPR ILIO-ILIAC NDGFT $14,000.00

HC EVASC RPR ILIO-ILIAC RUPTR $14,000.00

HC EVENT RECORDER, CARDIAC LVL 1 $2,516.06









HC EVOKED AUDITORY TEST COMPLETE $237.03

HC EVOKED AUDITORY TEST LIMITED $237.03

HC EVOKED AUDITORY TEST QUAL $178.40

HC EWHO RIGID W/O JNTS CF LVL 1 $1,713.41

HC EWHO W/JOINT(S) CF LVL 1 $1,801.53

HC EX FOR SPEECH DEVICE RX ADDL 30M $285.56

HC EXC ABD LES SC < 3 CM $3,357.97

HC EXC ABD LES SC 3 CM/> $4,488.39

HC EXC ARM/ELBOW LES SC < 3 CM $1,660.27

63 of 172

Procedure Price

HC EXC ARM/ELBOW LES SC 3 CM/> $2,214.65

HC EXC BACK LES SC < 3 CM $3,357.97

HC EXC BACK LES SC 3 CM/> $4,488.39

HC EXC BEN LES S/N/HF/G; 0.5 CM/< $1,378.80

HC EXC BEN LES T/A/L 0.6-1.0 CM $592.18

HC EXC BEN LES T/A/L 1.1-2.0 CM $845.17

HC EXC BEN LES T/A/L; 3.1-4.0 CM $2,466.09

HC EXC BENIGN LES S/N/EX/G 1.1-2.0 CM $1,919.69

HC EXC CYST/GANGLION TOES $4,248.80

HC EXC EXT THROMBOSED HEMORRHOIDS $2,235.77

HC EXC FACE LES SC < 2 CM $1,574.22

HC EXC FACE LES SC 2 CM/> $1,574.22

HC EXC FACE-MM B9+MARG 0.5 < CM $887.44

HC EXC FOREARM LES SC < 3 CM $1,660.27

HC EXC FOREARM LES SC 3 CM/> $2,194.77

HC EXC HAND LES SC < 1.5 CM $1,660.27

HC EXC HAND LES SC 1.5 CM/> $2,194.77

HC EXC HIP PELVIS LES SC 3 CM/> $2,214.65

HC EXC HIP/PELVIS LES SC < 3 CM $2,214.65

HC EXC LEG/ANKLE LES SC 3 CM/> $2,214.65

HC EXC M LES T/A/L 3.1-4.0 CM $1,790.78

HC EXC NECK LES SC < 3 CM $3,357.97

HC EXC NECK LES SC 3 CM/> $4,488.39

HC EXC SHOULDER LES SC < 3 CM $1,660.27

HC EXC SHOULDER LES SC 3 CM/> $2,194.77

HC EXC THIGH/KNEE LES SC < 3 CM $2,194.77

HC EXC THIGH/KNEE LES SC 3 CM/> $2,214.65

HC EXCHANGE BILIARY DRG CATH $6,574.72

HC EXCHANGE NEPHROSTOMY CATH $6,182.12

HC EXCHANGE PREVIOUS DRAINAGE CATH $3,618.32

HC EXCISE VAGINAL CYST OR TUMOR $4,266.70

HC EXERCISE TST BRNCSPSM $210.06

HC EXHALED NITRIC OXIDE MEAS $151.02

HC EXPL P WND ABD/FLANK $3,144.16

HC EXPL P WND EXTREM $1,650.94

HC EXPL/REM FB IPH JOINT EA $2,727.95

HC EXPLORATION OF CHEST $6,612.92

64 of 172

Procedure Price

HC EXT CEPHALIC VERSION $2,458.14

HC EXT ECG 48 HRS TO 21 DAYS SCAN W/REPORT $130.30

HC EXT ECG RECORDING 48 HRS TO 21 DAYS $130.30

HC EXTENDED OUTPATIENT TREATMENT $858.51

HC EXTENDED RECOVERY EA ADDTL HR $141.45

HC EXTENDED RECOVERY INITIAL HR $704.10

HC EXTENSOR TENDON REPAIR FINGER EACH $2,430.80

HC EXTERNAL FIXATOR LEVEL 1 $396.90

HC EXTERNAL FIXATOR LEVEL 10 $12,927.63





HC EXTERNAL FIXATOR LEVEL 2 $815.07







HC EXTREM VENOGRAM INJ $715.70

HC EXTREMITY ANGIO BILAT $5,775.00

HC EXTREMITY ANGIO UNIL $5,750.00

HC EXTREMITY VENOGRAM BILAT $1,966.79

HC EXTREMITY VENOGRAM UNIL $1,561.42

HC EYE DISPOSABLE SUPPLIES LVL 1 $686.27

HC EYE DISPOSABLE SUPPLIES LVL 10 $5,414.85









HC EYE MEDICATIONS LEVEL 1 $48.48


65 of 172

Procedure Price

HC EYE MEDICATIONS LEVEL 11 $2,943.22









HC EYE SUPPLIES MISC LVL 1 $643.66

HC EYE SUPPLIES MISC LVL 2 $692.43

HC F18 FDG TO 45 MCI $1,829.92

HC FACIAL BONES LESS THAN 3 VIEWS $382.59

HC FACIAL BONES MIN 3 VIEWS $454.93

HC FAMILY THERAPY W PT 50 MIN $250.00

HC FAMILY THERAPY WITH PATIENT IP $402.68

HC FECAL MICROBIOTA PREP INSTIL $129.04

HC FECAL MICROBIOTA PREPARATION $2,877.94

HC FEM/POPL REVAS W/ATHER $27,053.51

HC FEM/POPL REVAS W/TLA $14,686.14

HC FEM/POPL REVASC STNT & ATHER $40,876.58

HC FEM/POPL REVASC W/STENT $26,689.65

HC FEMALE STERILIZATION IMPLANT LVL 1 $462.88

HC FEMALE STERILIZATION IMPLANT LVL 10 $5,700.00


HC FEMALE STERILIZATION IMPLANT LVL 2 $850.00








HC FEMORAL N BLOCK SGL $844.67

HC FETAL CARDIOVASC 2-D US $1,298.23

HC FETAL CONTRACTION STRESS TEST $288.71

HC FETAL FLUID DRAINAGE W US $373.88

66 of 172

Procedure Price

HC FETAL NON-STRESS TEST $681.50

HC FETAL NON-STRESS TEST MULTIPLE $681.50

HC FETAL SHUNT PLCMNT W US $373.88

HC FINGER OR FINGERS MIN 2 VIEWS $308.45

HC FIT OR INSERT PESSARY $272.51

HC FLORBETAPIR F18 TO 10 MCI $8,917.50

HC FLUCICLOVINE F-18 PER 1 MCI $1,078.00

HC FLUORO EXAM MORE THAN 1HR NON RAD $969.36

HC FLUOROGUIDANCE FOR NEEDLE PLC $706.21

HC FLUOROGUIDANCE FOR SPINE INJECT $693.70

HC FLUOROGUIDE FOR VENOUS DEVICE $767.97

HC FLUOROSCOPE EXAMINATION $676.22

HC FLUTTER VALVE/ACAPELLA CHEST PT INIT $174.12

HC FLUTTER VALVE/ACAPELLA CHEST PT SUBQ $163.30

HC FNA W GUIDANCE $849.72

HC FNA WO IMAGING $296.07

HC FO NONTORSION JOINT CF LVL 1 $656.63

HC FO PIP/DIP W/O JOINT/SPRING LVL 1 $134.00

HC FO PIP/DIP WITH JOINT/SPRING LVL 1 $140.84

HC FO W/O JOINTS CF LVL 1 $380.49

HC FOAM DRESSING PAD >16&<=48SQIN TAKE HOME $56.01

HC FOOT 2 VIEWS $341.93

HC FOOT INSERT FORM TO PATIENT LVL 1 $363.86

HC FOOT MIN 3 VIEWS $416.49

HC FOREARM 2 VIEWS $393.31

HC FOREIGN BODY IN EYE $289.14

HC FORESKIN MANIPULATION $454.13

HC FSH $26.40

HC FUNCTIONAL CAPACITY EVAL 15 MIN PT $45.81

HC GA67 GALLIUM PER MCI $211.06

HC GADOXETATE DISODIUM INJ 1 ML $121.93

HC GAIT TRAINING THERAPY EA 15 MIN $141.70

HC GASTRIC BAND LEVEL 1 $1,771.88





67 of 172

Procedure Price




HC GASTROSCOPY LEVEL I $2,817.17

HC GASTROSCOPY LEVEL II $3,470.78

HC GASTROSCOPY LEVEL III $5,084.05

HC GASTROSCOPY LEVEL IV $5,819.53

HC GASTROSCOPY W/EUS LEVEL I $8,123.56

HC GASTROSCOPY W/EUS LEVEL II $8,280.83

HC GASTROSCOPY W/EUS LEVEL III $8,839.11

HC GASTROSCOPY W/EUS LEVEL IV $9,932.96

HC GC STOCKING FULL LNGTH 30-40 LVL 1 TAKE HOME $390.11


HC GC STOCKING FULL LNGTH 30-40 LVL 3 TAKE HOME $2,214.42






HC GC STOCKING THIGHLNGTH 18-30 LVL 1 TAKE HOME $390.11












HC GC STOCKING WAISTLNGTH 30-40 LVL 1 TAKE HOME $390.11






68 of 172

Procedure Price



HC GENERATOR NEURO RECHG BAT SYS NON-HF LVL 1 $2,516.06








HC GENERATOR, NEURO NON-RECHARGE LVL 1 $2,516.06








HC G-ESOPH REFLUX W MUCOSAL PH $1,670.92

HC G-ESOPH REFLUX W NASAL PH $1,586.02

HC GI TRACT CAPSULE ENDOSCOPY $2,629.49

HC GI TRACT IMG CAPSULE ENDOSCOPY $1,458.77

HC GLUCOSE BLD BY MONITOR DEVICE $11.26

HC GLUCOSE QUAN BLOOD $39.34

HC GRAFT COMPOSITE $2,921.09

HC GRAFT, VASCULAR LVL 1 $1,172.46












69 of 172

Procedure Price


HC GRAFTJACKET EXPRESS 1 CC LVL 17 $5,096.97

HC GRAFTJACKET SKIN SUB PER SQ CM LVL 1 $256.13





HC GRAFTS, NON VASCULAR LVL 1 $1,736.45









HC GROUP PSYCH PARTIAL HOSP 45-50M $365.97

HC GROUP THERAPY NOT MULTI-FAMILY $395.25

HC GRP NUTRITION THERAPY; EA 30M $26.75

HC GUEST TRAY - BREAKFAST $8.55

HC GUEST TRAY - DINNER OR SUPPER $12.81

HC GUIDANCE FOR RADIATION TX DLVR $1,088.91

HC GUIDE CATH FLUID DRAINAGE $1,165.23

HC GUIDE WIRE LVL 1 $159.79

HC GUIDE WIRE LVL 10 $5,414.85





HC GUIDE WIRE LVL 2 $575.68








70 of 172

Procedure Price

HC GYNE SUPPLIES GENERAL LVL 1 $582.05

HC GYNE SUPPLIES GENERAL LVL 2 $1,873.66




HC HAND 2 VIEWS $342.39

HC HAND MIN 3 VIEWS $416.82

HC HAST W OXYGEN TITRATE $487.81

HC HAST W REPORT $487.81

HC HBOT FULL BODY CHAMBER 30M $517.66

HC HCG QUAL $47.06

HC HDR RDNCL NTRSTL/ICAV BRCHTX >12 CHAN $7,490.00

HC HDR RDNCL NTRSTL/ICAV BRCHTX 1 CHAN $6,697.79

HC HDR RDNCL NTRSTL/ICAV BRCHTX 2-12 CHAN $7,227.23

HC HDR RDNCL SKN SURF BRACHYTX LES > 2CM/2+ CHAN $810.72

HC HDR RDNCL SKN SURF BRACHYTX LES TO 2CM/1 CHAN $492.20

HC HEALTH RISK ASSESS CWELL $62.00

HC HEAR IN AMERICA DISPENSING FEE 1 $550.00

HC HEAR IN AMERICA DISPENSING FEE 2 $1,100.00

HC HEAR IN AMERICA HEARING AID EVAL 1 $52.50

HC HEAR IN AMERICA HEARING AID EVAL 2 $100.00

HC HEARING AID ANNUAL CHECK BOTH $114.22

HC HEARING AID ANNUAL CHECK ONE EAR $88.84

HC HEARING AID CHECK BOTH EARS $114.22

HC HEARING AID CHECK ONE EAR $88.84

HC HEARING AID EXAM BOTH EARS $272.87

HC HEARING AID EXAM ONE EAR $272.87

HC HEARING SCREEN $26.25

HC HEARING SCREENING $88.72

HC HEART SYMP IMAGE PLNR $2,239.34

HC HEART SYMP IMAGE PLNR SPECT $2,747.71

HC HEMODIALYSIS 1 EVAL $869.90

HC HEMOGLOBIN GLYCOSYLATED TEST (A1C) $18.40

HC HEMORRHOID BANDING $2,288.11

HC HEMOSTASIS SUPPLIES GENERAL LVL 1 $236.73

HC HEMOSTASIS SUPPLIES GENERAL LVL 2 $2,251.40


71 of 172

Procedure Price


HC HEP B VACC ADULT 3 DOSE IM $58.00

HC HFO NONTORSION JOINT, PREFAB LVL 1 $223.37





HC HFO NONTORSION JOINT, PREFAB LVL 6 $1,063.69




HC HFO W/JOINT(S) CF LVL 1 $390.11





HC HFO W/JOINT(S) CF LVL 6 $1,063.69




HC HFO W/O JOINTS CF LVL 1 $483.02





HC HFO W/O JOINTS CF LVL 6 $1,063.69




HC HFO W/O JOINTS PF LVL 1 $115.68





HC HFO W/O JOINTS PF LVL 6 $1,063.69



72 of 172

Procedure Price


HC HIGH COMPRES BAND >=3" $76.95

HC HIGH RISK ANTE/INTRA/POST OB MGMT ADD-ON $1,942.71

HC HIP ARTHROGRAM $1,051.20

HC HO W/O JOINTS CF LVL 1 $390.11





HC HO W/O JOINTS CF LVL 6 $1,063.69




HC HOCM 350-399 MG/ML IODINE PER ML $0.56

HC HOCM UP TO 149 MG/ML IODINE PER ML $0.71

HC HOME SLEEP TEST/TYPE 2 PORTA $509.79



HC HOSPICE CARE IP NON RESPITE $743.00

HC HOSPITALITY LEVEL I $1,000.00

HC HUMERUS MIN 2 VIEWS $397.39

HC HYDRATE IV INFUSION EA ADDTL HR $218.24

HC HYDRATION IV INFUSION INIT 31-60 MIN $541.09

HC HYDROCOLLD DRG <=16 W/O BDR LVL 1 TAKE HOME $73.01




HC HYMENOTOMY $3,840.37

HC HYPERTHERMIA EXT DEEP 4+ CM $982.30

HC HYPERTHERMIA EXT SUPERFICIAL = $1,848.89

HC HYPERTHERMIA INTERST; > 5 APPL $982.30

HC HYPERTHERMIA INTERST; 5 OR < APPL $982.30

HC HYPERTHERMIA INTRACAVITARY PROBE(S) $982.30

HC HYSTEROSALPINGOGRAM $632.67

HC I & D OF BARTHOLINS GLAND ABSCESS $279.64

HC I & D OF VULVA OR PERINEAL ABSCESS $362.46

HC I&D ABSC COMPL OR MULTI $583.76

73 of 172

Procedure Price

HC I&D ABSC SMPL OR SGL $573.27

HC I&D ABSC THIGH/KNEE DEEP $3,026.56

HC I&D ABSCESS PERITONSILLAR $955.99

HC I&D ABSCESS RETROPHARYNGEAL INTERNAL $2,094.80

HC I&D BURSA UA/ELBOW $1,575.20

HC I&D CPLX POSTOP WND INF $3,713.31

HC I&D HEMATOMA $3,134.89

HC I&D LEG/ANKLE DEEP ABSC/HEMATOMA $3,710.14

HC I&D PERIANAL ABSCESS $1,870.14

HC I&D PERIRECTAL OR ISCHIAL ABSCESS $2,235.77

HC I&D PILONID CYS SMPL $545.69

HC I&D PILONID CYST CPLX $2,773.15

HC I&D VAGINAL HEMATOMA PP $2,390.13

HC I131 IODIDE CAP DX PER MCI $234.35

HC I131 IODIDE CAP RX MCI $481.50

HC I131 IODIDE SOL DX PER 1 MCI $180.08

HC IC THROMBOLYSIS $2,571.00

HC ICC ABLATION AV NODE CREATE CHB $10,136.29

HC IIV3 VACCINE SPLT 0.5 ML IM $25.00

HC ILEOSCOPY THRU STOMA ENDO $3,540.29

HC ILIAC REVASC $13,729.69

HC ILIAC REVASC ADD-ON $11,208.23

HC ILIAC REVASC W/STENT $27,552.76

HC ILIAC REVASC W/STENT ADD-ON $19,500.00

HC IMAGE CATH FLUID COLL PERI/RETRO $4,984.27

HC IMAGE CATH FLUID COLL TRANSVAG/RECTAL $4,153.56

HC IMAGE CATH FLUID COLL VISCERAL $4,153.56

HC IMMUNIZATION ADM 1 VACCINE $124.25

HC IMMUNIZATION ADM EA ADDTL VACCINE $84.32

HC IMPL BREAST PROSTH SILICONE/EQUAL LVL 1 $1,519.56








74 of 172

Procedure Price



HC IMPL DUAL CHAMB RR PACEMAKER LVL 1 $3,798.91















HC IMPL EXTENS PACING LEAD/NEUROSTIM LVL 1 $1,382.07












HC IMPL INDWELLING PORT LVL 1 $1,459.13








75 of 172

Procedure Price


HC IMPL NEUROSTIM LEAD TEST KIT LVL 1 $779.62

HC IMPL NEUROSTIM LEAD TEST KIT LVL 19 $29,087.18







HC IMPL PACEMAKER NOT SGL/DUAL CHAMB LVL 1 $16,159.55



HC IMPL PRESSURE SENSOR W ANGIO $31,081.78

HC IMPL PT ACTIVATED CARD EVENT RECORDER $11,660.30

HC IMPL PULMON LIQUID SEALANT LVL 1 $779.62

HC IMPL PULMON LIQUID SEALANT LVL 2 $1,519.56





HC IMPL SGL CHAMBR RR PACEMAKER LVL 1 $3,798.91













HC IMPL SYNTH VOCAL CORD LVL 1 $779.62

HC IMPL SYNTH VOCAL CORD LVL 2 $2,707.43



76 of 172

Procedure Price






HC IMPL URINARY SPHINCTER PROSTH LVL 1 $779.62

HC IMPL URINARY SPHINCTER PROSTH LVL 10 $14,543.54








HC IMPL/REPL PR PUMP FOR INFUSION $16,196.47

HC IMPLANT/INSERT DEVICE NOC LVL 1 $435.06

HC IMPLANT/INSERT DEVICE NOC LVL 10 $7,393.51










HC IMPLANT/INSERT DEVICE NOC LVL 2 $814.66











77 of 172

Procedure Price















HC IMPLANTABLE TISS MARKER LVL 1 $331.37

HC IMPREG GAUZE NO H20/SAL/YARD LVL 1 TAKE HOME $390.11




HC IMRT/CONFORMAL RTH PLAN $6,894.99

HC IN111 INOXINE WBC PER 0.5 MCI $3,324.70

HC IN111 PENTETATE PER 0.5 MCI $2,931.35

HC IN111 PROSTASCINT TO 10 MCI $8,794.02

HC IN111 SATUMOMAB TO 6 MCI $2,345.08

HC INC & REM FB SQ COMPL $2,371.27

HC INC & REM FB SQ SMPL $705.49

HC INCISE FOOT/TOE FASCIA $4,156.95

HC INCISE THROMBOSED HEMORRHOID EXT $425.77

HC INDEPENDENT THERAPY PROGRAM $70.00

HC INDEPENDENT THERAPY PROGRAM OT $85.00

HC INDIUM IN111 AUTO WBC DX $4,735.93

HC INDIUM IN111 PENTETREO TO 6MCI $8,536.27

HC INDIVIDUAL PSYCHOTHERAPY IP $402.68

HC INFLATABLE PENILE PROSTHESIS LVL 1 $779.62

HC INFLATABLE PENILE PROSTHESIS LVL 10 $14,543.54



78 of 172

Procedure Price
















HC INFLUENZA VACCINE LIVE INTRANASAL $32.00

HC INFUSE RADIOACTIVE MATERIALS $793.13

HC INFUSION PUMP, PROGRAMMABLE LVL 1 $2,516.06





HC INFUSION PUMP,NON-PROG, PERM LVL 1 $779.62

HC INFUSION PUMP,NON-PROG, PERM LVL 10 $5,817.42












HC INGEST CHALLENGE ADDL 60 MIN $356.85

HC INGEST CHALLENGE INIT 120 MIN $885.36

79 of 172

Procedure Price

HC INIT NUTRITION THERAPY; EACH 15M $26.75

HC INIT TX 1ST DEGR BURN $245.29

HC INJ & ASP FOR TX BONE CYST $882.63

HC INJ ABSCESS CYST CONTRAST $676.80

HC INJ AIR/CONTRAST INTO PERITONEAL CAVITY $305.07

HC INJ ANESTH CELIAC PLEXUS $1,385.37

HC INJ ANESTH FACIAL NERVE $558.02

HC INJ ANESTH GREATER OCCIPITAL NERVE $675.14

HC INJ ANESTH OTHR PERIPHERAL NRV/BRANCH $935.98

HC INJ ANESTH PUDENDAL NERVE $1,290.55

HC INJ ANESTH STELLATE GANGLION $1,290.55

HC INJ ANESTH SUPRASCAPULAR NERVE $713.07

HC INJ ANESTH TRIGEMINAL NERVE $713.36

HC INJ ARTHROGRAM ELBOW $288.41

HC INJ ARTHROGRAM HIP W/ANESTH $655.25

HC INJ ARTHROGRAM HIP W/O ANESTH $512.18

HC INJ ARTHROGRAM SHOULDER $408.99

HC INJ ARTHROGRAM WRIST $339.55

HC INJ CONTRAST KNEE ARTHROGRAPHY $478.34

HC INJ EPIDURAL BLOOD OR CLOT PATCH $810.82

HC INJ EXT ANEURYSM PERC $583.53

HC INJ FOR CHOLANGIOGRAM EXIST ACCESS $3,828.92

HC INJ FOR CHOLANGIOGRAM NEW ACCESS $2,773.16

HC INJ FOR CYSTOGRAM VCU $1,057.18

HC INJ FOR EVAL PERITONEAL-VENOUS SHUNT $454.75

HC INJ FOR MYELOGRAM LUMBAR $1,285.40

HC INJ FOR NEPHR/URETEROGRAM EXIST ACCESS $1,610.03

HC INJ FOR NEPHR/URETEROGRAM NEW ACCESS $2,568.19

HC INJ FOR SIALOGRAPHY $223.14

HC INJ FOR URETEROGRAM THRU INDWELLING CATH $183.54

HC INJ GADOTERATE MEGLUMI 0.1ML $3.00

HC INJ INTERLAM C/T W CATH PLC W IMG $2,598.93

HC INJ INTERLAM C/T W IMG $2,598.93

HC INJ INTERLAM L/S W CATH PLC W IMG $2,892.57

HC INJ INTERLAM L/S W IMG $2,892.57

HC INJ LYMPHANGIOGRAPHY $1,285.33

HC INJ MAMMARY DUCT $342.97

80 of 172

Procedure Price

HC INJ MYELOGRAM C1- C2 $1,674.36

HC INJ PARAVERT F JNT C/T 1 LEV $1,381.81

HC INJ PARAVERT F JNT C/T 2 LEV $490.49

HC INJ PARAVERT F JNT C/T 3 LEV $490.49

HC INJ PARAVERT F JNT L/S 1 LEV $1,381.81

HC INJ PARAVERT F JNT L/S 2 LEV $490.49

HC INJ PARAVERT F JNT L/S 3 LEV $490.49

HC INJ RA TRACER ID SENTINEL NODE $445.49

HC INJ SACRAL AUGMT BILAT PERC $6,112.95

HC INJ SACRAL AUGMT UNIL PERC $5,340.64

HC INJ SALINE HYSTEROGRAM $436.14

HC INJ SCLEROSING SOLN - SGL VEIN $296.07

HC INJ SCLEROSING SOLUTION; MULTI, SAME LEG $296.07

HC INJ SGL TENDON SHTH OR LIGAMENT $432.13

HC INJ SINUS TRACT DIAGNOSTIC $513.21

HC INJ SINUS TRACT THERAPEUTIC $1,084.22

HC INJ SULF HEXA LIPID MICROSPH PER ML $125.19

HC INJ TO SEE ILEAL CONDUIT /URETEROPYELOGR $1,565.44

HC INJ TRIGGER POINT 1/2 MUSCL $431.42

HC INJ URETHRA RETRO $1,685.96

HC INJ W/FLUOR, EVAL CV DEVICE $689.54

HC INJ(S) FORAMEN EPID C/T ADDTL LEV $660.24

HC INJ(S) FORAMEN EPID L/S ADDTL LEV $735.99

HC INJ(S) FORAMEN EPIDURAL C/T SGL LEV $1,393.81

HC INJ(S) FORAMEN EPIDURAL L/S SGL LEV $1,393.80

HC INJECT FOR SPINE DISK X-RAY LUMBAR $1,150.06

HC INJECT L VENTR/ATRIAL ANGIO $1,737.94

HC INJECT PULM ART HRT CATH $5,421.20

HC INJECT R VENTR/ATRIAL ANGIO $1,737.94

HC INJECT SUPRVLV AORTOGRAPHY $2,524.35

HC INJECT TRIGGER POINTS=/>3 $426.54

HC INJECTION(S) SPIDER VEINS $295.15

HC INS 1 TV ELECTRODE PM-DEFIB $8,085.13

HC INS 2 TV ELECTRODE PM-DEFIB $8,085.13

HC INS BLADDER CATH COMPLEX $352.51

HC INS BONE DEVICE FOR RSA $225.45

HC INS CATH REN ART 1ST BILAT $4,738.30

81 of 172

Procedure Price

HC INS CATH REN ART 1ST UNILAT $4,404.45

HC INS CATH REN ART 2ND+ BILAT $4,404.45

HC INS CATH REN ART 2ND+ UNILAT $4,738.30

HC INS ENDOVAS VENA CAVA FILTR $10,369.92

HC INS IA PERC BALLOON $6,500.00

HC INS MARK ABD/PEL FOR RT PERQ $2,640.24

HC INS NONTUN CENTRAL VENOUS CATH <5YRS $2,429.65

HC INS NON-TUNNEL CV CATH 5 YRS/> $2,493.25

HC INS PACK FOR NON-OB VAG HEMORRHAGE $311.41

HC INS PICC AGE 5 YRS/> $2,493.25

HC INS PICC DEVICE W PORT 5 YRS/> $4,734.05

HC INS SWAN GANZ BEDSIDE $2,660.28

HC INS TISS EXP NOT BREAST $4,592.77

HC INS TUNNELED CV CATH W SQ PORT $6,576.95

HC INS TUNNELED CV CATH WO SQ PORT $4,715.22

HC INS WIRE/PIN W SK TRACT $4,385.57

HC INS/REPL SUBQ DEFIBRILLATOR $36,625.33

HC INS/REPL TEMP TRANSV SC CARD ELECTR/CATH $8,085.13

HC INSERT BLADDER CATHETER $164.44

HC INSERT CATH PLEURA W/ IMAGE $2,791.83

HC INSERT CATH PLEURA W/O IMAGE $1,359.72

HC INSERT CERVICAL DILATOR $513.45

HC INSERT CV ACCESS DEVICE TUNNELED > 5 YRS $5,013.57

HC INSERT CV CATH 2 CATH/SITES TUN NO PORT $4,763.04

HC INSERT CV CATH TUNNELED >5 YRS $5,508.05

HC INSERT HEART PM ATRIAL $18,857.61

HC INSERT HEART PM ATRIAL & VENT $23,061.95

HC INSERT HEART PM VENTRICULAR $18,857.61

HC INSERT HEPATIC SHUNT (TIPS) $18,150.00

HC INSERT IP CATH FOR DR/DIALYSIS PERM $6,332.22

HC INSERT MARK THOR FOR RT PERQ $2,640.24

HC INSERT PACE-DEFIB W/LEAD DUAL $43,025.79

HC INSERT PACE-DEFIB W/LEAD SGL $34,246.25

HC INSERT PACING LEAD & CONNECT $22,169.65

HC INSERT PALATE IMPLANTS $2,620.68

HC INSERT PERITONEAL VENOUS SHUNT $6,800.00

HC INSERT PERM CATH W SQ RESERV $8,536.97

82 of 172

Procedure Price

HC INSERT PICC < 5 YRS $2,493.25

HC INSERT PLEURAL CATH $7,759.52

HC INSERT PULSE GEN DUAL LEADS $17,455.27

HC INSERT PULSE GEN MULT LEADS $17,455.27

HC INSERT PULSE GEN SGL LEAD $15,422.80

HC INSERT PULSE GEN W/DUAL LEADS $25,626.39

HC INSERT TEMP BLADDER CATH $201.47

HC INSERT TUN IP CATH PERC $8,100.00

HC INSERT UTERI TANDEMS/OVOIDS $2,789.32

HC INSERT VAD ARTERY ACCESS $18,857.61

HC INSERT VAG BRACHYTX DEVICE $664.97

HC INSERTION OF CHEST TUBE $1,314.51

HC INT REP F/E/N/L/MM 12.6-20.0 CM $643.85

HC INT REP F/E/N/L/MM 2.5 CM/< $840.09




HC INT REP N/H/F/G >30.0 CM $1,494.08

HC INT REP N/H/F/G 12.6-20.0 CM $465.06

HC INT REP N/H/F/G 2.5 CM/< $619.93

HC INT REP N/H/F/G 2.6-7.5 CM $581.53

HC INT REP N/H/F/G 20.1-30.0 CM $492.82

HC INT REP N/H/F/G 7.6-12.5 CM $629.46

HC INT REP S/A/T/EX >30.0 CM $1,494.08

HC INT REP S/A/T/EX 12.6-20.0 CM $1,303.29

HC INT REP S/A/T/EX 2.5 CM/< $678.56

HC INT REP S/A/T/EX 2.6-7.5 CM $735.23



HC INTEGRA BMWD PER SQ CM LVL 1 $264.72




HC INTENSITY MODUL RAD TX DLVR (IMRT) CPLX $3,208.04

HC INTENSITY MODUL RAD TX DLVR (IMRT) SMPL $3,208.04

HC INTENSIVE OP PSYCH PER DAY $858.51

HC INTERACTIVE GROUP THERAPY IP $342.27

83 of 172

Procedure Price

HC INTERCAVITARY APPL COMPLEX $3,278.46

HC INTERCAVITARY APPL INTERMEDIATE $1,854.85

HC INTERGT EVAL INPER LEADLS PM $251.45

HC INTERMEDIATE PROCEDURE $716.00

HC INTERNAL AUDITORY MEATI COMPL $324.86

HC INTERPRETOR SERVICES PER 15 MIN $15.00

HC INTERSPINOUS IMPLANT LVL 1 $2,516.06
















HC INTERST RS APPL; COMPLEX $4,879.15

HC INTMD WND REPAIR FACE/MM 20.1-30.0 CM $578.72

HC INTRA ATRIAL PACING $5,389.95

HC INTRA ATRIAL RECORDING $5,389.95

HC INTRA VENTRICULAR PACING $5,389.95

HC INTRA-ARTERIAL RPHARM RX $1,135.98

HC INTRACARDIAC ECHO AT OP $4,756.49

HC INTRACAV RS APPL; SIMPLE $941.01

HC INTRACRANIAL ARTERY DOPPLER LIMITED $1,082.97

HC INTRACRANIAL ARTERY DOPPLER; COMPL $1,398.65

HC INTRA-OP NEURO MONITOR IN OR EA 15 MIN $145.34

HC INTRATUBAL OCCLUSION DEVICE $752.19

HC INTRO CATH DIALYSIS CIRCUIT $4,100.00

HC INTRO CATH DIALYSIS CIRCUIT W STENT $22,443.87

HC INTRO CATH DIALYSIS CIRCUIT W TBA $14,500.00

84 of 172

Procedure Price

HC INTRO/SHEATH, LASER LVL 1 $606.97

HC INTRO/SHEATH, LASER LVL 10 $14,543.54





HC INTRO/SHEATH, NON-LASER LVL 1 $418.16

HC INTRO/SHEATH, NON-LASER LVL 11 $6,463.82








HC INTRODUCE LONG GI TUBE $1,352.69

HC INTRODUCERS/SHEATHS LVL 1 $409.68

HC INTRODUCERS/SHEATHS LVL 2 $1,934.88






HC INTRVASC US NONCORONARY 1ST $6,200.00

HC INTRVASC US NONCORONARY ADDTL $5,800.00

HC INTUBATION ET EMERGENT $1,119.34

HC IODINE I-123 IOBENGUANE TO 15 MCI $5,101.10

HC IODINE I-123 SOD IODIDE PER 100 UCI TO 999 UCI $269.67

HC IONM REMOTE/>1 PT OR PER HR $581.27

HC IOWA KIDNEY ACQUISITION $80,991.51

HC IP ACUTE DIALYSIS $1,374.59

HC IP CHRONIC HEMODIALYSIS $1,339.86

HC IP RENAL DIALYSIS CAPD $1,237.88

HC IP UTILIZATION MGMT $51.00

HC IRRADIATE BLD PRODUCT, EA UNIT $355.58

HC IRRIG DRUG DELIVERY DEVICE $161.37

HC IRRIGATE CORPORA CAVERNOSA PRIAPISM $394.28

85 of 172

Procedure Price

HC IRRIGATION SUPPLIES GENERAL LVL 1 $224.28

HC IRRIGATION SUPPLIES GENERAL LVL 2 $616.61

HC IV DOPPLER EA ADDTL VESSEL $2,991.05

HC IV DOPPLER INITIAL VESSEL $5,585.07

HC IV HUMAN RHO D IG INJ 100 IU $346.15

HC IV SOLUTIONS $87.18

HC IV US CORONARY V EA ADDTL $2,352.76

HC IV US CORONARY V INITIAL $3,574.63

HC IVP INFUSION $879.13

HC IVP INFUSION W TOMOGRAPHY $945.11

HC IVP W WO TOMOGRAPHY OR KUB $882.94

HC JOINT DEVICE (IMPLANTABLE) LVL 1 $435.06

HC JOINT DEVICE (IMPLANTABLE) LVL 10 $7,393.51










HC JOINT DEVICE (IMPLANTABLE) LVL 2 $814.66















86 of 172

Procedure Price









HC JOINT SURVEY 1 VIEW $479.94

HC KERATOMILEUSIS (LASIK/ASA LASER) LVL 1 $378.00




HC KNEE 1 OR 2 VIEWS $360.85

HC KNEE 3 VIEWS $456.84

HC KNEE ARTHROGRAM $977.99

HC KNEE MIN 4 VIEWS $525.25

HC KNEE STRAPPING $331.49

HC KNEES STANDING AP $327.48

HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 1 $390.11





HC KO W/ ADJ FLEX/EXT ROTAT CUS LVL 6 $1,063.69




HC KYLEENA, 19.5 MG $4,331.88

HC L HRT ART/GRFT ANGIO $17,236.36

HC L HRT ARTERY/VENTRICLE ANGIO $14,521.74

HC L HRT CATH TRNSPTL PUNCTURE $7,783.06

HC L201 THALLIUM PER MCI $146.57

HC LANG COMP CURRENT STATUS $0.01

HC LANG COMP D/C STATUS $0.01

HC LANG COMP GOAL STATUS $0.01

HC LANG EXPRESS CURRENT STATUS $0.01

87 of 172

Procedure Price

HC LANG EXPRESS D/C STATUS $0.01

HC LANG EXPRESS GOAL STATUS $0.01

HC LAPOROSCOPY SUPPLIES GENERAL LVL 1 $280.67

HC LAPOROSCOPY SUPPLIES GENERAL LVL 2 $809.19

HC LAPOROSCOPY SUPPLIES GENERAL LVL 3 $1,895.98

HC LAPOROSCOPY SUPPLIES GENERAL LVL 4 $3,244.69

HC LAPS PELVIC LYMPHADEC $14,470.70

HC LARYNGEAL FUNCTION STUDIES $685.86

HC LARYNGOSCOPY FLEX DIAGNOSTIC $971.76

HC LARYNGOSCOPY FLEX W FB REM $2,100.00

HC LARYNGOSCOPY FLEXIBLE $2,288.11

HC LARYNGOSCOPY IND DIAGNOSTIC $545.08

HC LASER/ROBOTIC SUPPLIES GENERAL LVL 1 $1,671.78



HC LEAD CORONARY VENOUS LVL 1 $1.00

HC LEAD CORONARY VENOUS LVL 2 $2,707.43









HC LEAD, AICD, ENDO DUAL COIL LVL 1 $1.00

HC LEAD, AICD, ENDO DUAL COIL LVL 10 $16,159.55





HC LEAD, AICD, ENDO SINGLE COIL LVL 1 $2,516.06



HC LEAD, AICD, NON SING/DUAL LVL 1 $2,516.06



88 of 172

Procedure Price

HC LEAD, NEUROSTIMULATOR LVL 1 $2,516.06





HC LEAD, PMKR, TRANSVENOUS VDD LVL 1 $1.00

HC LEAD, PMKR, TRANSVENOUS VDD LVL 2 $2,707.43




HC LEADLESS C PM INS/RPL VENTR $22,681.86

HC LEFT HRT CATH W/VENTRCLGRPHY $10,826.14

HC LENS, INTRAOCULAR (NEW TECH) LVL 1 $1,196.38







HC LENS, INTRAOCULAR ANTERIOR LVL 1 $1,139.67







HC LENS, INTRAOCULAR POSTERIOR LVL 1 $1,139.67








HC LEV 1 HOSP TYPE B ED VISIT $182.00



89 of 172

Procedure Price



HC LEVEL 0 25% CHARGE AMBULATORY SURGERY $164.65


HC LEVEL 0 AMBULATORY SURGERY $698.29



HC LEVEL 1 AMBULATORY SURGERY $1,888.30



HC LEVEL 2 50% CHARGE AMBULATORY SURGERY $1,218.56

















HC LEVEL A 25% CHARGE AMBULATORY SURGERY $253.15

HC LEVEL A 50% CHARGE AMBULATORY SURGERY $506.02

HC LEVEL A AMBULATORY SURGERY $1,026.71

HC LEVONORGESTREL IU 52MG LILETTA $4,331.88

HC LEVONORGESTREL IU 52MG MIRENA $4,331.88

HC LHI ACOUSTIC REFL THRESHOLD TST $29.65

HC LHI AIR COND W/HAS $32.96

HC LHI AIR ONLY TESTING $32.96

HC LHI AUDIOLOGY CONSULT $112.35

HC LHI PURE TONE AIR&BONE $66.99

90 of 172

Procedure Price

HC LHI QUICK SIN TST $41.74

HC LHI SPEECH AUDIOM THRESHOLD W SR $53.82

HC LHI SPEECH AUDIOM THRESHOLD W SR - MARYL CNC $53.82

HC LHI SPRINT $41.74

HC LHI STENGER TST - PURE TONE AIR $21.97

HC LHI STENGER TST - SPEECH $21.97

HC LHI TYMPANOMETRY $29.65

HC LHI TYMPANOMETRY W/ REFLEX AND REFLEX DECAY $40.64

HC LHI TYMPANOMETRY W/ REFLEX MEASUREMENTS $40.64

HC LIGATE FALLOP TUBE ABD/VAG POSTPARTUM $4,500.00

HC LIGATION MAJOR ARTERY EXTREMITY $8,121.90

HC LIPIODOL EMBOLETIC PER EA 10 ML $3,294.42

HC LITHOTRIPSY ESWL BILATERAL $24,536.17

HC LITHOTRIPSY ESWL UNILATERAL $21,312.26

HC LIVER BX ENDO $2,288.11

HC LIVER ELASTOGRAPHY $347.75

HC LO FLEXIBL L1-BELOW L5 PRE LVL 1 $390.11




HC LOCM 100-199 MG/ML IODINE 1ML $1.96



HC LOCM>=400 MG/ML IODINE 1ML $22.72

HC LOW COST SKIN SUB APP F/NK/HF/G +25 SQCM $1,752.14

HC LOW COST SKIN SUB APP F/NK/HF/G 25 SQCM $2,134.41

HC LOW COST SKIN SUB APP F/NK/HF/G CH +100 SQCM $1,879.56

HC LOW COST SKIN SUB APP F/NK/HF/G CH 100 SQCM $2,134.41

HC LOW COST SKIN SUB APP T/A/L +25 SQCM $1,752.14

HC LOW COST SKIN SUB APP T/A/L 25 SQCM $2,006.99

HC LOW COST SKIN SUB APP T/A/L CH +100 SQCM $1,879.56

HC LOW COST SKIN SUB APP T/A/L CH 100 SQCM $2,134.41

HC LOW DOSE CT LUNG SCREENING $212.93

HC LOW FREQUENCY NON-THERMAL US $225.29

HC LOWR EXTR INFANT MIN 2 VIEWS $121.53

HC LTD FETAL DOPPLER ECHOCARDIOGRAM OB $486.89

HC LUMBAR SPINE DISK $3,145.79

91 of 172

Procedure Price

HC LUMBOSACR SPINE 2 OR 3 VIEWS $488.27

HC LUMBOSACR SPINE BEND 2 OR 3 VIEWS $612.93

HC LUMBOSACR SPINE COMPL W BENDING MIN 6 VW $753.71

HC LUMBOSACR SPINE MIN 4 VIEWS $731.75

HC LUNG BIOPSY W NEEDLE $2,954.91

HC LUNG CATHETER INSERTION $2,019.67

HC LV PACING LEAD ADD ON $22,169.65

HC LWR XTR VASC STUDY BILAT $910.76

HC LYMPHANGIO EXTREM ONLY UNIL $1,199.75

HC LYMPHANGIOGRAM EXTREMITY; BILAT $1,890.00

HC LYMPHANGIOGRAM PELVIC/ABD; BILAT $4,749.46

HC LYMPHANGIOGRAM PELVIC/ABD; UNILAT $1,872.88

HC LYSE CHEST FIBRIN INIT DAY $852.39

HC LYSE CHEST FIBRIN SUBQ DAY $852.39

HC MAJOR PROCEDURE $4,001.28

HC MAMMARY INTERNAL ANGIOGRAM $2,374.57

HC MANDIBLE LESS THAN 4 VIEWS $333.45

HC MANDIBLE MIN 4 VIEWS $548.26

HC MANIPULATE KNEE JNT UNDER ANESTH $2,393.59

HC MANOMETRY THRU INDWELLING CATH (WHITAKER) $1,615.30

HC MANUAL THERAPY EA 15M $167.17

HC MAP TACHYCARDIA ADD ON $9,754.61

HC MASSAGE THERAPY EA 15M $151.67

HC MASTOIDS LESS THAN 3 VIEWS EACH $493.54

HC MASTOIDS MIN 3 VIEWS EACH SIDE $409.08

HC MASTOTOMY W EXPL DEEP $3,710.14

HC MATRISTEM MICROMATRIX 1 MG LVL 1 $17.36

HC MAXIMAL VOLUNTARY VENTILATION $150.38

HC MD HBO THERAPY PER SESSION LEVEL 1 $1,334.74



HC MDFC FLAP W/PRSRV VASC PEDCL $5,163.98

HC MDI AIRWAY INHALATION TX INITIAL $244.42

HC MDI AIRWAY INHALATION TX SUBQ $244.42

HC MEASURE LUNG VOL THRU INF-2 YRS $568.59

HC MEATOTOMY; EXCEPT IN NEWBORN $3,419.57

HC MECH REM OBSTRUCTION CVAD $4,734.05

92 of 172

Procedure Price

HC MEMORY CURRENT STATUS $0.01

HC MEMORY D/C STATUS $0.01

HC MEMORY GOAL STATUS $0.01

HC MES VA COMP AND BENEFIT EVALUATION $105.00

HC MESH (IMPLANTABLE) LVL 1 $779.62

HC MESH (IMPLANTABLE) LVL 10 $9,695.71




















HC MH PH $1,250.00

HC MIDLINE INFUSION CATH LVL 1 $885.95

HC MIDLINE INFUSION CATH LVL 10 $9,695.71










93 of 172

Procedure Price


HC MINOR PROCEDURE $1,915.60

HC MINOR PROCEDURE LEVEL 1 $381.27

HC MINOR PROCEDURE LEVEL 2 $762.57

HC MINOR PROCEDURE LEVEL 3 $1,143.83



HC MISC IMPLANT CHARGE LVL1 $2,877.94













HC MISC SUPPLY CHARGE LVL 1 $122.66

HC MISC SUPPLY CHARGE LVL 10 $9,049.33










HC MM X-RAY OF MAMMARY DUCT $522.30

HC MM X-RAY OF MAMMARY DUCTS $1,004.17

HC MOBILITY CURRENT STATUS $0.01

HC MOBILITY D/C STATUS $0.01

HC MOBILITY GOAL STATUS $0.01

HC MOD SED ENDO 5/> YRS INIT 15 MIN $474.95

94 of 172

Procedure Price

HC MOD SED OTHER PHYS/QHP $610.56

HC MOD SED OTHER PHYS/QHP 5/>YRS 15M $448.07

HC MOD SED OTHER PHYS/QHP EA 15 MIN $128.40

HC MOD SED SAME PHYS/QHP $474.95

HC MOD SED SAME PHYS/QHP 5/>YRS 15M $474.95

HC MOD SED SAME PHYS/QHP EA ADD 15M $175.48

HC MODALITY CONTRAST BATHS EA 15M $101.29

HC MODALITY HUBBARD TANK EA 15M $275.80

HC MODALITY INFRARED $11.36

HC MODALITY IONTOPHORESIS EA 15M $192.48

HC MODALITY M ELECTR STIM EA 15M $167.14

HC MODALITY MECHANICAL TRACTION $123.35

HC MODALITY PARAFFIN BATH $100.26

HC MODALITY ULTRASOUND EA 15M $134.99

HC MODALITY ULTRAVIOLET $127.84

HC MODALITY VASOPNEUMATIC DEVICES $175.68

HC MODALITY WHIRLPOOL $200.00

HC MORCELLATOR LVL 1 $1,098.57







HC MOTION ANALYSIS VIDEO/3D $738.85

HC MOTION FLUORO SWALLOW FCN $714.52

HC MOTOR SPEECH CURRENT STATUS $0.01

HC MOTOR SPEECH D/C STATUS $0.01

HC MOTOR SPEECH GOAL STATUS $0.01

HC MR CHOLANGIOPANCREATOGRAPHY (MRCP) $3,799.00

HC MR GUIDANCE FOR NEEDLE PLACE $2,759.88

HC MR SPECTROSCOPY $2,619.56

HC MRA ABDOMEN W CONTRAST $2,542.60

HC MRA ABDOMEN W WO CONTRAST $2,542.60

HC MRA ABDOMEN WO CONTRAST $2,542.60

HC MRA CHEST W WO CONTRAST $3,215.46

HC MRA CHEST WO CONTRAST $2,977.28

95 of 172

Procedure Price

HC MRA HEAD W CONTRAST $3,501.28

HC MRA HEAD W WO CONTRAST $4,094.28

HC MRA HEAD WO CONTRAST $3,394.09

HC MRA LOW EXTR W CONTRAST $3,221.87

HC MRA LOW EXTR W WO CONTRAST $5,408.74

HC MRA LOW EXTR WO CONTRAST $2,864.98

HC MRA NECK W CONTRAST $3,752.55

HC MRA NECK W WO CONTRAST $4,055.05

HC MRA NECK WO CONTRAST $2,831.98

HC MRA PELVIS W CONTRAST $2,612.11

HC MRA W/DYE SPINAL CANAL $2,964.25

HC MRA W/DYE UPPER EXTREMITY $3,399.75

HC MRA W/O DYE SPINAL CANAL $2,964.25

HC MRA W/O DYE UPPER EXTR $3,399.75

HC MRA W/O&W/DYE SPINAL CANAL $2,964.25

HC MRA W/O&W/DYE UPPER EXTR $3,399.75

HC MRI ABDOMEN W CONTRAST $3,986.57

HC MRI ABDOMEN W WO CONTRAST $5,527.01

HC MRI ABDOMEN WO CONTRAST $3,799.00

HC MRI BRAIN W CONTRAST $4,453.84

HC MRI BRAIN W WO CONTRAST $7,145.46

HC MRI BRAIN WO CONTRAST $4,122.57

HC MRI BREAST BILAT W CONTRAST $3,321.73

HC MRI BREAST BILAT W WO CONTRAST $3,321.73

HC MRI BREAST BILAT WO CONTRAST $2,900.00

HC MRI BREAST UNIL W CONTRAST $3,321.73

HC MRI BREAST UNIL W WO CONTRAST $3,321.73

HC MRI BREAST UNIL WO CONTRAST $2,900.00

HC MRI CAD BREAST $100.00

HC MRI CARDIAC FOR MORPH W WO CONTR $3,266.67

HC MRI CARDIAC FOR MORPH WO CONTRAST $2,786.13

HC MRI CHEST W CONTRAST $2,977.28

HC MRI CHEST W WO CONTRAST $4,681.46

HC MRI CHEST WO CONTRAST $2,381.82

HC MRI FETAL EA ADDL GESTATION $4,122.57

HC MRI FETAL SNGL/1ST GESTATION $4,122.57

HC MRI LOW EXTR ANY JOINT W CONTRAST $3,676.94

96 of 172

Procedure Price

HC MRI LOW EXTR ANY JOINT W WO CONTR $4,949.42

HC MRI LOW EXTR ANY JOINT WO CONTRAST $3,637.97

HC MRI LOW EXTR NOT JOINT W CONTRAST $3,796.06

HC MRI LOW EXTR NOT JOINT W WO CONTR $4,551.66

HC MRI LOW EXTR NOT JOINT WO CONTRAST $3,220.45

HC MRI OF TMJ $3,215.49

HC MRI ORBIT FACE NECK W CONTRAST $4,406.37

HC MRI ORBIT FACE NECK W WO CONTRAST $5,311.46

HC MRI ORBIT FACE NECK WO CONTRAST $3,255.95

HC MRI PELVIS W CONTRAST $4,189.62

HC MRI PELVIS W WO CONTRAST $4,982.18

HC MRI PELVIS WO CONTRAST $3,046.79

HC MRI SPINE CERVICAL W CONTRAST $4,088.25

HC MRI SPINE CERVICAL W WO CONTRAST $5,416.25

HC MRI SPINE CERVICAL WO CONTRAST $3,822.08

HC MRI SPINE LUMBAR W CONTRAST $4,458.90

HC MRI SPINE LUMBAR W WO CONTRAST $5,709.22

HC MRI SPINE LUMBAR WO CONTRAST $4,173.66

HC MRI SPINE THORACIC W CONTRAST $4,333.43

HC MRI SPINE THORACIC W WO CONTRAST $5,437.65

HC MRI SPINE THORACIC WO CONTRAST $3,304.13

HC MRI UP EXTR ANY JOINT W CONTRAST $3,810.91

HC MRI UP EXTR ANY JOINT W WO CONTR $4,226.84

HC MRI UP EXTR ANY JOINT WO CONTRAST $3,539.39

HC MRI UP EXTR NOT JOINT W CONTRAST $3,292.87

HC MRI UP EXTR NOT JOINT W WO CONTR $4,061.13

HC MRI UP EXTR NOT JOINT WO CONTRAST $2,723.14

HC MSLT/MWT; GLOBAL $3,543.21

HC MULTIHANCE INJ PER ML $7.65

HC MUSC MYOQ/FSCQ FLP H&N PEDCL $5,163.98

HC MUSC TEST DONE W/NERV TEST COMP $361.70

HC MUSC TST DONE W/NERV TEST LTD $272.87

HC MUSCLE TEST 1 LIMB $621.86

HC MUSCLE TEST 2 LIMBS $690.67



HC MUSCLE TEST MANUAL EXTREM OR TRUNK $90.00

97 of 172

Procedure Price

HC MYELOGRAM CERVICAL $1,691.69

HC MYELOGRAM LUMBOSACRAL $1,624.81

HC MYELOGRAM SPINE 2 OR MORE REGIONS $2,012.64

HC MYELOGRAM THORACIC $1,785.33

HC MYELOGRAPHY LUMBAR INJ 2+ REGIONS $1,605.00

HC MYELOGRAPHY LUMBAR INJ CERV $1,926.00

HC MYELOGRAPHY LUMBAR INJ LS $1,605.00

HC MYELOGRAPHY LUMBAR INJ THOR $1,605.00

HC MYOCARDIAL STRAIN IMAGING $882.75

HC MYRINGOTOMY $515.52

HC N BLOCK SGL SCIATIC NRV $1,086.68

HC N EMG; THORACIC MUSCLES NOT T1/T12 $420.95

HC NASAL BONES MIN 3 VIEWS $416.82

HC NASAL ENDO W BLD CNTRL $1,662.50

HC NASOPHARYNGOSCOPY W ENDOSCOPE $485.72

HC N-AUTOM URINALYS WO MICRO $24.76

HC NAVIGATIONAL BRONCHOSCOPY $7,621.82

HC NB RESUSCITATION OB $656.74

HC NEG PRESS WND TX <=50 SQ CM (NON-DME) $482.45

HC NEG PRESS WND TX >50 CM (NON-DME) $482.45

HC NEG PRESS WOUND TX <=50 CM (DME) $227.73

HC NEG PRESS WOUND TX >50 CM (DME) $296.07

HC NEURAGEN NERVE GUIDE, PER CM LVL 1 $779.62

HC NEURAGEN NERVE GUIDE, PER CM LVL 2 $2,707.43








HC NEUROMUSCLE RE-EDUC EA 15M $155.69

HC NG TUBE PLC W FLUORO $318.50

HC NITRIC OXIDE HOURLY $450.56

HC NJX NONCMPND SCLRSNT 1 VEIN $2,988.16

HC NJX NONCMPND SCLRSNT MLT VN $2,988.16

HC NM BONE IMAGING 3 PHASE $1,686.10

98 of 172

Procedure Price

HC NM BONE IMAGING LTD $935.19

HC NM BONE IMAGING MULT AREAS $1,145.65

HC NM BONE IMAGING WHOLE BODY $1,592.48

HC NM BONE MARROW IMAGING MULT AREAS $941.77

HC NM BONE SPECT $1,727.09

HC NM BRAIN IMAGE W FLOW MIN 4 VIEWS $1,400.00

HC NM BRAIN SPECT $1,868.97

HC NM BRAIN W FLOW LESS THAN 4 VIEWS $836.16

HC NM CARDIAC BLOOD POOL MULT $2,035.50

HC NM CARDIAC BLOOD POOL SGL $1,521.88

HC NM CSF FLOW CISTERNOGRAPHY $1,568.32

HC NM GASTRIC EMPTY IMAG STUDY $1,928.96

HC NM GASTRIC EMPTY IMAG STUDY MULTI DAY $2,469.31

HC NM GASTRIC EMPTYING STUDY $1,542.66

HC NM GASTRIC REFLUX STUDY $1,473.05

HC NM GI BLEED STUDY $1,428.39

HC NM HEART MUSC IMAGING PLANAR MULT $2,814.08

HC NM HEART MUSC IMAGING PLANAR SGL $2,124.68

HC NM HEART MUSCLE SPECT MULT $4,215.81

HC NM HEART MUSCLE SPECT SGL $2,387.78

HC NM HEPATOBIL SYST IMAGE W/DRUG $1,664.94

HC NM HEPATOBILIARY SYSTEM IMAGING $1,664.94

HC NM INFLAMM LOCALIZ LTD AREA $1,423.01

HC NM INFLAMM LOCALIZ SPECT $2,027.17

HC NM INFLAMM LOCALIZ WHOLE BODY $2,115.03

HC NM IV INJ RA DRUG DX STUDY $479.06

HC NM KIDNEY FLOW FUNCT W DRUG $1,841.33

HC NM KIDNEY FLOW FUNCT WO DRUG $1,664.90

HC NM KIDNEY IMAGING MORPHOLOGY $1,183.40

HC NM KIDNEY IMAGING SPECT $1,739.33

HC NM LIVER IMAGE STATIC ONLY $1,523.34

HC NM LIVER SPECT $1,818.98

HC NM LIVER SPECT W VASC FLOW $2,035.97

HC NM LIVER SPLEEN STATIC $1,322.86

HC NM LUNG PERF&VENTILAT DIFERENTL $2,029.32

HC NM LUNG PERFUSION DIFFERENTIAL $2,029.32

HC NM LUNG PERFUSION IMAGING $1,392.36

99 of 172

Procedure Price

HC NM LUNG VENTILAT&PERFUS IMAGING $2,029.32

HC NM LUNG VENTILATION IMAGING $2,029.32

HC NM LYMPH OR LYMPH NODE IMAGING $1,552.94

HC NM MECKELS DIVERT EXAM $1,343.34

HC NM MI PLANAR QUAL QUAN $1,727.25

HC NM MI PLANAR SPECT $1,881.64

HC NM PARATHYROID IMAGING $1,207.97

HC NM PERITONEAL VENOUS SHUNT PATENCY $680.10

HC NM PET BRAIN METABOLIC EVAL $5,540.78

HC NM PET CARDIAC METABOL EVAL $4,445.20

HC NM PET IMAGE W CT LTD $6,009.33

HC NM PET IMAGE W CT SKULL THIGH $6,961.43

HC NM PET IMAGE W CT WHOLE BODY $7,163.33

HC NM RADIOPHARM THERAPY IV ADMIN $1,440.07

HC NM RADIOPHARM THERAPY ORAL $1,558.95

HC NM SPLEEN IMAGING ONLY $593.24

HC NM THYROID METASTASES WHOLE BODY $1,777.54

HC NM TUMOR LOCALIZ LTD RA DISTRIB $1,382.89

HC NM TUMOR LOCALIZ MULT $1,320.01

HC NM TUMOR LOCALIZ SPECT $1,967.15

HC NM TUMOR LOCALIZ WHOLE BODY 1 DAY $2,029.91

HC NM TUMOR LOCALIZ WHOLE BODY 2 DAY $2,536.41

HC NM UREA BREATH TEST C14 ACQ $241.04

HC NM UREA BREATH TEST C14 ANALYSIS $372.42

HC NM URETER REFLUX STUDY $1,054.44

HC NM URINARY BLADDER RETENTION $735.91

HC NO SHOW/CANCELLATION $22.47

HC NON WND ELECT STIM $133.74

HC NON-CARDIAC ENDOVASC CATH LVL 1 $779.62

HC NON-CARDIAC ENDOVASC CATH LVL 10 $5,817.42








100 of 172

Procedure Price





HC NONCOVERED OBSERVATION PER HOUR $87.94

HC NON-EMERG TRANSP/MILE $22.83

HC NON-HEU TC-99M ADD-ON/DOSE $10.00

HC NON-PNEUM WALK BOOT PRE OTS LVL 1 $162.44

HC NONSELECT CATH TRANSLUMBAR AORTA $1,689.16

HC NONSELECTIVE CATH AORTA $1,852.88

HC NONSELECTIVE CATH PLACEMENT IN VEIN $216.63

HC NONVASC BALLN TISS DISECTR CATH LVL 1 $779.62

HC NONVASC BALLN TISS DISECTR CATH LVL 2 $1,519.56






HC NON-VASC BALLOON DILATN CATH LVL 1 $496.14

HC NON-VASC BALLOON DILATN CATH LVL 10 $9,695.71










HC NOSE TO RECTUM FOREIGN BODY CHILD $291.80

HC NOT INFLATE PENILE PROSTH LVL 1 $779.62

HC NOT INFLATE PENILE PROSTH LVL 18 $29,087.18






101 of 172

Procedure Price



HC NRV CONDUCT TST 11-12 STUDIES $423.32

HC NRV CONDUCT TST 13/> STUDIES $423.32





HC NRV RPR W/NRV ALGRFT 1ST $8,816.44

HC NS CATH EXTREMITY ARTERY $3,500.00

HC NSW DEBRIDEM WO A/SESSION $286.59

HC NVR CONDUCT TST 1-2 STUDIES $477.44

HC O/P VISIT EST LEVEL 1 $312.83





HC O/P VISIT NEW LEVEL 1 $312.83





HC OASIS TRI-LAYER WND MATRX PER SQ CM LVL1 $46.23

HC OASIS WOUND MATRIX PER SQ CM LVL 1 $40.18

HC OASIS WOUND MATRIX PER SQ CM LVL 2 $50.02

HC OB ADD-ON $3,253.45

HC OB BASE LEVEL 2 $2,177.45





HC OB LEVEL O $2,047.98

HC OB PER MIN LEVEL 2 $6.47





102 of 172

Procedure Price

HC OBSERVATION PER HOUR $614.70

HC OBSERVATION PER HOUR EMU/HIGH ACUITY $307.78

HC OBSERVATION PER HOUR NO HCPCS $87.94

HC OCCULT BLOOD FECES $20.46

HC OCTAFLUOROPROPANE MIC INJ 1ML $330.50

HC OCULAR IMP AQUEOUS DRAIN LVL 1 $1,098.57










HC OP ACUTE DIALYSIS $1,186.45

HC OPEN CHEST HEART MASSAGE $3,334.55

HC OPEN TX D PHAL FX FGR/THMB EACH $6,800.00

HC OPEN/PERQ PLACE STENT 1ST ART $15,213.58

HC OPEN/PERQ PLACE STENT EA ADD ART $15,213.58

HC OPEN/PERQ PLACE STENT EA ADD VEIN $15,213.58

HC OPEN/PERQ PLACE STENT SAME VEIN $15,213.58

HC OPPS/PHP TRAIN & EDUC SERV $267.60

HC OPTIC FORAMINA $396.77

HC OPTOKINETIC NYSTAGMUS W RECORD $359.35

HC OR NEURO SUPPLIES, NO HCPCS LVL 1 $433.89

HC OR NEURO SUPPLIES, NO HCPCS LVL 10 $4,493.49











103 of 172

Procedure Price











HC ORAL GALLBLADDER STUDY $363.95

HC ORAL MR CONTRAST PER 100 ML $31.57

HC ORBITS COMPL MIN 4 VIEWS $524.00

HC ORGAN PROCUREMENT LIVING DONOR $94,223.91

HC ORTH/PROSTH MGMT SUBQ ENC 15M $152.00

HC ORTHO SUPPLIES GENERAL LVL 1 $308.81

HC ORTHO SUPPLIES GENERAL LVL 2 $2,119.14





HC ORTHOPANTOGRAM PANORAMIC X-RAY JAWS $315.60

HC ORTHOTIC MGMT AND TRAINING EA 15M $152.00

HC OSCILLATING TRACKING W RECORD $335.47

HC OSSICULAR IMPLANT LVL 1 $865.30

HC OSSICULAR IMPLANT LVL 2 $2,659.78

HC OSSICULAR IMPLANT LVL 3 $3,419.73

HC OSTEOPATHIC MANIPULATION $123.05

HC OSTOMY SUPPLY LVL 1 $390.11




HC OSTOMY SUPPLY LVL 5 $1,640.63

HC OT EVAL HIGH COMPLEX $374.50

HC OT EVAL LOW COMPLEX $321.00

HC OT EVAL MOD COMPLEX $353.10

HC OT RE-EVAL EST PLAN CARE $268.35

104 of 172

Procedure Price

HC OTHER NERVE BLOCK $921.51

HC OTHER PACEMAKER LEAD LVL 1 $694.57

HC OTHER PACEMAKER LEAD LVL 2 $2,707.43




HC OTHER PT/OT CURRENT STATUS $0.01

HC OTHER PT/OT D/C STATUS $0.01

HC OTHER PT/OT GOAL STATUS $0.01

HC OTHER SPEECH LANG CURRENT STATUS $0.01

HC OTHER SPEECH LANG D/C STATUS $0.01

HC OTHER SPEECH LANG GOAL STATUS $0.01

HC OXYGEN INITIAL DAY $643.99

HC OXYGEN SUBQ DAY $367.99

HC OXYGEN UPTAKE REST INDIRECT $1,082.93

HC P32 NA PHOSPHATE PER MCI $703.53

HC PACER POCKET REVISION $2,558.50

HC PACU CLASS 1 PER MIN $14.94



HC PAD REHAB PER SESSION $187.25

HC PANCREATIC ERCP $1,746.78

HC PARACENTESIS ENDO $3,002.78

HC PARATHYRD PLANAR W/SPECT & CT $1,393.29

HC PARATHYRD PLANAR W/WO SUBTR $1,298.02

HC PARE BENIGN LES SGL $168.65

HC PATIENT POSITIONING DEVICE LVL 2 $82.64

HC PB VALVULOPLASTY AORTOC VALVE $7,744.97

HC PB VALVULOPLASTY MITRAL VALVE $10,012.19

HC PB VALVULOPLASTY PULMON VALVE $10,012.19

HC PEG TUBE PLACEMENT ENDO $3,976.01

HC PELVIC ANGIOGRAM $4,370.04

HC PELVIC EXAMINATION UNDER ANESTH $2,550.06

HC PELVIS 1 OR 2 VIEWS $379.03

HC PELVIS MIN 3 VIEWS $464.23

HC PERC ASPIRATION SPINAL CORD CYST $2,639.25

HC PERC BIL ENDO W REM CALC $4,275.89

105 of 172

Procedure Price

HC PERC CORON THROMBECTOMY $6,456.21

HC PERC DILATION BILE DUCT STRICTURE $1,531.34

HC PERC DRUG-EL COR REVASC CABG EA ADDL BR $20,967.67

HC PERC DRUG-EL COR REVASC CABG SGL $20,967.67

HC PERC DRUG-EL COR REVASC CHRON OCCL ADDL $20,967.67

HC PERC DRUG-EL COR REVASC CHRON OCCL SGL $20,967.67

HC PERC DRUG-EL COR REVASC W AMI SGL $20,967.67

HC PERC DRUG-EL COR STENT ATHER EA ADDL BR $20,967.67

HC PERC DRUG-EL COR STENT ATHER SGL ART/BR $20,967.67

HC PERC DRUG-EL COR STENT EA ADDL BRANCH $13,669.49

HC PERC DRUG-EL COR STENT SGL ART/BRANCH $13,669.49

HC PERC INC ACHILLES TENDON W LOC ANESTH $4,156.95

HC PERC INC ADDUCTOR/HAMSTRING TENDON $4,156.95

HC PERC INC HIP ADDUCTOR $3,700.00

HC PERC PLACEMENT ENTEROCLYSIS TUBE $786.18

HC PERC PLACEMENT OF ENTEROCLYSIS TUBE $2,370.77

HC PERC SK FIX FEMORAL FX DISTAL END $5,340.64

HC PERFLUTREN LIPID MICROS INJ PER ML $318.85

HC PERFUSION BASE $4,397.02

HC PERFUSION PER MINUTE $26.40

HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 1 $331.26

HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL 2 $1,073.54








HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL10 $5,414.85

HC PERFUSION SUPPLIES SHUNTS, FILTERS LVL11 $7,112.18

HC PERICARDIOCENTESIS INITIAL $1,085.44

HC PERIPROC EVAL INPER LEDLS PM $188.32

HC PERITONEAL LAVAGE $872.22

HC PERITONEOGRAM AFTER INJECTION $725.57

HC PERQ ACCESS & CLSR FEM ART $2,500.00

HC PERQ ART M-THROMBECT &/OR INFS $8,528.27

106 of 172

Procedure Price

HC PERQ CERVICOTHORACIC INJECT $5,871.26

HC PERQ DEV BREAST 1ST LES MAMMO $4,236.35

HC PERQ DEV BREAST 1ST LES MR GUIDE $3,530.29

HC PERQ DEV BREAST 1ST LES STEREOTACT $3,530.29

HC PERQ DEV BREAST 1ST LES US IMAG $3,530.29

HC PERQ DEV BREAST ADD LES MAMMO $1,765.16

HC PERQ DEV BREAST ADD LES MR GUIDE $1,765.16

HC PERQ DEV BREAST ADD LES STEREOTACT $1,765.16

HC PERQ DEV BREAST ADD LES US IMAG $1,765.16

HC PERQ DEV SOFT TISS 1ST IMAG $1,028.57

HC PERQ DEV SOFT TISS ADD IMAG $1,028.57

HC PERQ G/COLON TUBE IMG EXAM W CONTRAST $440.53

HC PERQ LUMBOSACRAL INJECT $5,871.26

HC PERQ RF ABLATE TX PULM TUMOR(S) $8,271.90

HC PERQ STENT/CHEST VERT ART $12,865.25

HC PERQ VERTEBRAL AUGMENTATION EA ADDTL $18,716.62

HC PERQ VERTEBRAL AUGMENTATION LUMBAR $13,134.46

HC PERQ VERTEBRAL AUGMENTATION THORACIC $13,134.46

HC PET RADIOPHARM DX NON-TUMOR ID NOC $6,961.42

HC PET RADIOPHARM DX TUMOR ID NOC $6,961.42

HC PHARMACOLOGIC MGMT W/PSYTX $84.99

HC PHARYNX CERVICAL ESOPHAGUS $427.78

HC PHLEBOTOMY, THERAPEUTIC $136.47

HC PHOTOCHEMO TAR AND UV B $200.58

HC PHOTOTHERAPY NEWBORN $729.69

HC PHYSICAL PERFORM EA 15M $152.00

HC PIN ULNAR STYLOID FX $4,252.70

HC PINCH GRFT SM DEFECT TO 2 CM $851.83

HC PLACE CATH CAROTID ART $8,143.38

HC PLACE CATH EXTERNAL CAROTID $8,597.55

HC PLACE CATH INTRACRANIAL ART $4,741.24

HC PLACE CATH SUBCLAVIAN ART $8,518.84

HC PLACE CATH THORACIC AORTA $7,355.85

HC PLACE CATH VERTEBRAL ART $8,518.84

HC PLACE GASTROSTOMY TUBE PERC $1,898.02

HC PLACE NDL MUSC/TIS FOR RT $5,732.27

HC PLACE NDLES H&N FOR RT $4,708.45

107 of 172

Procedure Price

HC PLACE NEEDLE INTRAOSSEOUS INFUSION $314.37

HC PLACE NEEDLES PELVIC FOR RT $5,296.65

HC PLACE PO BREAST CATH FOR RAD $9,598.09

HC PLACE RT DEVICE/MARKER, PROS $1,320.11

HC PLACEMENT LONG GI TUBE $652.51

HC PLACENTA ALPHA MICRO IG C/V $137.62

HC PLASTIC REP UTERINE CERVIX VAGINAL $4,545.22

HC PLC CATH CAROTD/INOM ART W ANG IPSIL EXT $7,243.49

HC PLC CATH CAROTD/INOM ART W ANG IPSIL INT $7,243.49

HC PLC DUOD/JEJ TUBE PERC $2,039.92

HC PLC INTERSTITIAL DVC NON PROSTATE SGL/ML $2,656.26

HC PLC STENT CCA W/EMBOL PROTECT $15,365.16

HC PLC STENT CHOLEDOCHAL $4,474.37

HC PLC TRANSPERINEAL NDL PROSTATE $7,407.32

HC PLEURAL BIOPSY W NEEDLE $2,571.14

HC PLMT ACCESS BIL TREE SM BWL $2,773.16

HC PLMT BILIARY DRAINAGE CATH EXT $7,500.00

HC PLMT BILIARY DRAINAGE CATH INT-EXT $7,500.00

HC PLMT NEPHROSTOMY CATH $7,409.70

HC PLMT NEPHROURETERAL CATH NEW ACCESS $6,100.00

HC PLMT PRQ BIL DUCT STNT EXIST ACCESS $9,300.00

HC PLMT URETERAL STNT PRQ NEW ACCESS W CATH $10,058.67

HC PLMT URETERAL STNT PRQ NEW ACCESS WO CATH $7,800.00

HC PLMT URETERAL STNT PRQ PRE-EXIST TRACT $6,294.05

HC PLMT XTN PROSTH EVASC RPR $15,000.00

HC POLYSOM $4,574.01

HC PORCINE IMPLANT PERMACOL PER SQ CM LVL 1 $64.57

HC PORT IMG $262.41

HC POS AIRWAY PRESSURE CPAP/BIPAP INITIAL $2,633.44

HC POS AIRWAY PRESSURE CPAP/BIPAP SUBQ $1,299.75

HC POSITIONAL NYSTAGMUS MIN 4 POS $759.60

HC PRE OP PM DEVICE EVAL $381.46

HC PREFAB AFO ANKLE GAUNTLET LVL 1 $390.11





108 of 172

Procedure Price

HC PREFAB AFO ANKLE GAUNTLET LVL 6 $1,063.69




HC PREFAB ELASTIC KO W JNTS LVL 1 $390.11




HC PREFAB ELASTIC KO W JNTS LVL 5 $1,063.69




HC PREFAB METACARPL FX ORTHOSIS LVL 1 $313.90





HC PREFAB METACARPL FX ORTHOSIS LVL 6 $1,063.69




HC PREFAB TLSO TO SCAPULAR SPINE LVL 1 $1,382.07





HC PREFAB WHFO WO JNTS LVL 1 $743.17

HC PREFAB WHFO WO JNTS LVL 2 $3,039.13




HC PRE-OP SERVICE LVRS COMPLETE $6,702.53

HC PRESBYOPIA-CORRECT FUNCTION LVL 4 $650.00

HC PRESBYOPIA-CORRECT FUNCTION LVL 5 $4,444.46

HC PRIMATRIX SKIN SUB PER SQ CM LVL 1 $194.68



109 of 172

Procedure Price


HC PROCTOSCOPY $2,288.11

HC PROCTOSCOPY W BX ENDO $2,288.11

HC PROCTOSIG RIGID; W REM FB $4,411.71

HC PROCTOSIGMOIDOSCOPY RIGID DX $1,026.94

HC PROG EVAL INPER LEADLS PM $251.45

HC PROLONGED IV INF, REQ PUMP $1,348.25

HC PROLONGED SERVICE OFFICE EA ADDTL 30 MIN $175.00

HC PROLONGED SERVICE OFFICE INITIAL 60 MIN $250.00

HC PROSTATIC RF WATER VAPOR TX $3,391.14

HC PROSTHESIS, BREAST, IMP LVL 1 $779.62

HC PROSTHESIS, BREAST, IMP LVL 2 $2,707.43








HC PROSTHETIC IMPLANT NOS LVL 8 $4,747.59

HC PROSTHETIC TRAINING EA 15M $152.00

HC PRQ CARD ANGIO/ATHRECT 1 ART $17,206.58

HC PRQ CARD ANGIO/ATHRECT ADDL $17,206.58

HC PRQ CARD REVASC CHRONIC 1VSL $20,967.67

HC PRQ CARD REVASC CHRONIC ADDL $20,967.67

HC PRQ CARD REVASC MI 1 VSL $20,967.67

HC PRQ CARD STENT ATHREC/ANGIO 1 ART $20,967.67

HC PRQ CARD STENT ATHREC/ANGIO ADDL $20,967.67

HC PRQ CARD STENT W/ANGIO 1 VSL $13,669.49

HC PRQ CARD STENT W/ANGIO ADDL $13,669.49

HC PRQ CARDIAC ANGIOPLAST 1 ART $9,908.41

HC PRQ CARDIAC ANGIOPLAST ADDL ART $9,908.41

HC PRQ REVASC BYP GRAFT 1 VSL $20,967.67

HC PRQ REVASC BYP GRAFT ADDL $20,967.67

HC PSA; TOTAL $26.40

HC PSS W 4/> PARAM W CPAP/BIPAP 6+ YRS $5,499.62

HC PSS W 4/> PARAM W TECH 6+ YRS $5,108.69

110 of 172

Procedure Price

HC PSYCH DIAG EVAL W/MED SRVC $500.16

HC PSYCH DIAGNOSTIC EVAL NON-COVERED $500.16

HC PSYCH DIAGNOSTIC EVAL SUBSTANCE ABUSE $500.16

HC PSYCH DIAGNOSTIC EVALUATION $500.16

HC PSYTX COMPLEX INTERACTIVE $17.87

HC PSYTX CRISIS EA ADDL 30 MIN $191.09

HC PSYTX CRISIS INITIAL 60 MIN $382.17

HC PSYTX W PT 30 MIN (16-37 MIN) $254.99

HC PSYTX W PT 45 MIN (38-52 MIN) $335.57

HC PSYTX W PT 60 MIN (>53 MIN) $382.17

HC PSYTX W PT W E&M 30 MIN (16-37 MIN) $254.99

HC PSYTX W PT W E&M 45 MIN (38-52 MIN) $335.57

HC PSYTX W PT W E&M 60 MIN (>53 MIN) $382.17

HC PT EVAL HIGH COMPLEX $401.25

HC PT EVAL LOW COMPLEX $353.10

HC PT EVAL MOD COMPLEX $374.50

HC PT PROGR NEUROSTIM LVL 1 $779.62

HC PT PROGR NEUROSTIM LVL 10 $9,695.71











HC PT RE-EVAL EST PLAN CARE $268.35

HC PT/OT EVAL SPECIAL $85.00

HC PT/OT THERAPY SPECIAL $85.00

HC PTA AIR AND BONE $129.86

HC PTA AIR ONLY $100.06

HC PULM FCN STRENGTH 2/> INDIV $340.30

HC PULM FCN THERAPY 15 MIN $153.18

HC PULM FUNCT TEST OSCILLOMETRY $364.61

HC PULM FUNCT TST PLETHYSMOGRAP $770.45

111 of 172

Procedure Price

HC PULM FUNCTION TEST BY GAS $755.70

HC PULM MS THERAPY 15 MIN $141.63

HC PULM REHAB PHASE I $295.41

HC PULMONARY ANGIOGRAM SELECT BILAT $4,633.39

HC PULMONARY ANGIOGRAM SELECT UNIL $3,824.17

HC PULMONARY REHAB W EXER $481.50

HC PULMONARY STRESS COMPLEX $2,098.16

HC PULMONARY STRESS TESTING $791.70

HC PULSE OX MULTIPLE $233.20

HC PULSE OX SGL $61.24

HC PUNCT ASP ABSC HEMAT CYST $321.36

HC PUNCT ASP BREAST CYST EA ADDTL $217.92

HC PUNCT ASP BREAST CYST INITIAL $849.72

HC PUNCTURE SPINAL THERAPEUTIC $713.07

HC PURAPLY/PURAPLY AM PER SQ CM LVL 1 $149.80









HC PVB THORACIC 2ND+ INJ SITE $1,252.26

HC PVB THORACIC CONT INFUSION $1,252.26

HC PVB THORACIC SINGLE INJ SITE $1,252.26

HC R HRT ART/GRFT ANGIO $18,987.71

HC R HRT CORONARY ARTERY ANGIO $16,273.07

HC R&L HRT ART/VENTRICLE ANGIO $14,521.74

HC R&L HRT ART/VENTRICLE ANGIO W BYPASS $17,236.36

HC R&L HRT CATH W/VENTRICLGRPHY $10,826.14

HC RAD TX DELIVER SUPERFICIAL/ORTHO VOLTAGE $396.34

HC RAD TX DLVR COMPLEX >= 1 MEV $888.90

HC RAD TX DLVR INTERMED >= 1 MEV $760.41

HC RAD TX DLVR SIMPLE >= 1 MEV $514.39

HC RADIOLOGY RECOVERY PER HOUR $439.71

HC RADIOPHARM DX AGENT NOC $573.36

112 of 172

Procedure Price

HC RADIUM RA223 DICHLORIDE THER PER UCI $206.55

HC RE-ASSESS NUTRITION THER; EA 15M $26.75

HC REDO ENDOVAS VENA CAVA FILTER $2,374.57

HC REDUCTION OF PROCIDENTIA UNDER ANESTH $1,129.59

HC REFILL/MAINT, PORTABLE PUMP $576.40

HC REM CORNEAL EPITHELIUM W/WO CHEMOCAUT $770.05

HC REM DEEP FB OF FOOT $1,678.98

HC REM DEEP FB THIGH OR KNEE $4,108.86

HC REM EMBEDDED FB MOUTH VESTIB SIMPLE $708.25

HC REM ENDOVAS VENA CAVA FILTER $7,150.00

HC REM FB CONJUNCTIVA EMBEDDED $426.77

HC REM FB CONJUNCTIVA SUPERFICIAL $608.67

HC REM FB CORNEAL W SLIT LAMP $495.35

HC REM FB EXT AUDITORY CANAL WO ANESTH $364.96

HC REM FB EXT EYE CORNEAL WO SLIT LAMP $592.06

HC REM FB FOOT SQ $787.12

HC REM FB INTRANASAL $395.71

HC REM FB MUSCLE SMPL $1,284.13

HC REM FB SHOULDER; SQ $1,343.01

HC REM FB UP ARM OR ELBOW SQ $1,653.98

HC REM GAUNTLET BOOT OR BODY CAST $226.03

HC REM IMPL CONTRACEP CAPS $865.44

HC REM IMPL DEEP $4,352.76

HC REM OBSTRUCT G/COLON TUBE W FLUORO $801.26

HC REM SC/DC ICD LEAD TV EXTRACT $3,543.83

HC REM SKIN TAGS TO 15 $231.56

HC REM SUBQ DEFIB ELECTRODE $4,092.13

HC REM TE WO INS PERM PROSTH $4,488.39

HC REM TUNNELED CVAD W PORT/PUMP $2,493.25

HC REMOTE PT 30 DAY ECG REV/REPORT $321.55

HC REMOVAL BIL DUCT/GALLBLDR CALCULI $3,866.91

HC REMOVAL BILIARY DRG CATH $4,200.00

HC REMOVAL IMPACTED CERUMEN (EARWAX) $399.05

HC REMOVAL OF NAIL BED $1,505.97

HC REMOVAL OF PM GENERATOR $7,021.56

HC REMOVE & REPLACE CVD GEN DUAL LEADS $29,170.21

HC REMOVE & REPLACE CVD GEN MULT LEADS $40,830.14

113 of 172

Procedure Price

HC REMOVE & REPLACE CVD GEN SGL LEAD $29,170.21

HC REMOVE & REPLACE PM GEN DUAL LEADS $20,999.11

HC REMOVE & REPLACE PM GEN MULT LEADS $20,999.11

HC REMOVE & REPLACE PM GEN SGL LEAD $18,966.62

HC REMOVE 1 PACER LEAD ONLY $3,543.83

HC REMOVE 2 PACER LEAD ONLY $3,543.83

HC REMOVE DRUG IMPLANT $539.30

HC REMOVE EMBEDDED FB EYELID $449.33

HC REMOVE FOREIGN BODY PHARYNX $314.37

HC REMOVE FULL ARM OR LEG CAST $226.03

HC REMOVE IMPACTED EAR WAX UNI $399.05

HC REMOVE IMPLANTABLE LOOP RECORDER $1,322.36

HC REMOVE INTRVAS FOREIGN BODY $7,150.00

HC REMOVE IUD $207.85

HC REMOVE LUNG CATHETER $583.53

HC REMOVE PERITONEAL-VENOUS SHUNT $4,985.14

HC REMOVE PULSE GENERATOR $3,543.83

HC REMOVE RENAL W/NEPHROSTOMY W/FLUORO $1,366.63

HC REMOVE STENT VIA TRANSURETH $1,615.30

HC REMOVE SUPPORT IMPLANT SUPERFICIAL $3,003.43

HC REMOVE TNL CV CATH $2,959.01

HC REMOVE TUNNELED IP CATH $4,980.82

HC REMOVE URETER STENT PERC $4,289.28

HC REMOVE VAD DIFFERENT SESSION $6,634.00

HC REMOVE/REPLC EXT/INT NEPHROURETER CATH $3,015.27

HC RENAL CYST STUDY $771.71

HC RENAL VENOGRAM SELECTIVE BILAT $4,426.61

HC RENAL VENOGRAM SELECTIVE UNIL $3,306.87

HC REP BLOOD VESSEL DIRECT HAND FINGER $4,579.88

HC REP DEV, URINARY, W/SLING LVL 1 $779.62

HC REP DEV, URINARY, W/SLING LVL 10 $9,695.71







114 of 172

Procedure Price







HC REP ET HAND WO FG EA TENDON $2,468.58

HC REP LAC 2.5CM/< FLR MOUTH/ANT 2/3 $251.63

HC REP LAC TONGUE FLR MOUTH > 2.6 CPLX $1,535.63

HC REP LACERAT 2.5CM/<; POST 1/3 TONGUE $490.97

HC REP MCP/IP JNT COLLAT LIGAMENT $3,103.19

HC REP T/M EXTENSOR FA/W 1' EA $3,048.67

HC REP TENDN/MSCL FARM/WRIST $3,048.67

HC REPAIR BLOOD VESSEL DIRECT UPR EXTREM $4,650.07

HC REPAIR CV ACCESS CATH W/OPORT TUN/NONTUN $1,293.54

HC REPAIR CVA DEVICE W PORT/PUMP $2,088.25

HC REPAIR LEAD PACE-DEFIB DUAL $4,196.37

HC REPAIR LEAD PACE-DEFIB SGL $3,543.83

HC REPAIR LIP FT VERMILION ONLY $731.15

HC REPAIR LIP FT; > 1/2 V HGT OR COMPLEX $1,300.79

HC REPAIR LIP FT; UP TO HALF VERTICAL HEIGHT $1,299.87

HC REPAIR NAIL BED $505.02

HC REPL DIGIT TIP TO ST $5,028.14

HC REPLACE AORTIC VALVE OPEN AXILLARY ART $44,940.00

HC REPLACE AORTIC VALVE OPEN FEMORAL ART $44,940.00

HC REPLACE AORTIC VALVE OPEN TRANSAORTIC $44,940.00

HC REPLACE AORTIC VALVE PERQ $37,500.00

HC REPLACE CATH ONLY OF VAD $4,832.12

HC REPLACE CV ACCESS DEVICE TUNNELED W/PORT $6,797.34

HC REPLACE CV CATH NONTUNNEL $2,142.31

HC REPLACE CV CATH TUNNEL W/O PORT $5,508.05

HC REPLACE DUOD/JEJ TUBE PERC $1,352.69

HC REPLACE G/C TUBE PERC $1,352.69

HC REPLACE GASTROSTOMY TUBE $2,288.11

HC REPLACE G-J TUBE PERC $1,352.69

HC REPLACE PICC CATH $2,142.31

HC REPLACEMENT DEVICE NO CHARGE $1.00

115 of 172

Procedure Price

HC REPOS PREV IMPL SUBQ DEFIB $4,092.13

HC REPOSITION GASTROSTOMY TUBE $1,898.02

HC REPOSITION L VENTRIC LEAD $3,543.83

HC REPOSITION PACING DEFIB LEAD $3,543.83

HC REPOSITION PICC/CVC W/FLOURO $2,492.57

HC REPOSITIONING OF GASTRO TUBE $2,288.11

HC RESEARCH TESTING $967.34

HC RESIDENTIAL CARE ALCOHOL REHABILITATION $1,225.00

HC RESIDENTIAL CARE CHEMICAL DEPENDENCY $1,225.00

HC RESIDENTIAL CARE DRUG REHABILITATION $1,225.00

HC RESIDENTIAL GUEST LCDC $135.00

HC RESPIRATOR MOTION MGMT SIMUL $1,269.15

HC RESPIRATORY- NON AIRWAY LVL 1 $390.11




HC RESPIRATORY- NON AIRWAY LVL 7 $1,535.47

HC RESPIRATORY- NON AIRWAY LVL 9 $1,665.00

HC RET DEV, INSERTABLE LVL 1 $637.87

HC RET DEV, INSERTABLE LVL 10 $5,414.85














HC RETROGRADE PYELOGRAM W WO KUB $791.97

HC RETROGRADE URETHROGRAM $703.47

HC REVISE COLOSTOMY SIMPLE $3,377.64

HC REVISE HEPATIC SHUNT (TIPS) $17,500.00

116 of 172

Procedure Price

HC REVISE PERITONEAL-VENOUS SHUNT $4,937.78

HC REVISE POCKET SC/DC ICD $3,138.67

HC REVSC OPN/PRQ TIB/PERO STENT $23,531.01

HC RIBS BILAT 3 VIEWS $577.52

HC RIBS CHEST BILAT MIN 4 VIEWS $676.43

HC RIBS CHEST UNIL MIN 3 VIEWS $525.19

HC RIBS UNILATERAL 2 VIEWS $442.42

HC RIGHT HEART CATH $7,506.98

HC RIGHT VENTRICULAR RECORDING $5,389.95

HC ROUTINE VENIPUNCTURE $33.54

HC RPHARM MONOCLONAL AB THERAPY $1,708.73

HC RW AIR MILEAGE/MILE $167.92

HC SACRUM COCCYX MIN 2 VIEWS $426.89

HC SBRT DELIVERY PER FRACTION $15,474.68

HC SC INF THER ADDL HR $173.28

HC SC INF THER RESET PUMP $255.92

HC SC INF THER UP TO 1 HR $246.97

HC SCAPULA COMPL $396.57

HC SCLEROTX FLUID COLLECTION $2,106.09

HC SCR MAMMO INCL CAD BILAT $349.65

HC SCR MAMMO INCL CAD UNIL $349.65

HC SELECT CATH ART BRACH CEPH 1ST ORDER $1,839.15

HC SELECT CATH ART BRACH CEPH 2ND ORDER $2,538.25

HC SELECT CATH ART BRACH CEPH 3RD ORDER $2,232.27

HC SELECT CATH ART BRACH CEPH EA ADDTL $1,555.98

HC SELECT CATH ART L EXTR ABD/P 1ST ORDER $2,345.25

HC SELECT CATH ART L EXTR ABD/P 2ND ORDER $1,995.85

HC SELECT CATH ART L EXTR ABD/P 3RD ORDER $2,230.70

HC SELECT CATH ART L EXTR ABD/P EA ADDTL $437.15

HC SELECT PICTURE AUDIOMETRY $79.96

HC SELECTIVE CATH LT/RT PULMONARY ARTERY $1,321.60

HC SELF CARE CURRENT STATUS $0.01

HC SELF CARE D/C STATUS $0.01

HC SELF CARE GOAL STATUS $0.01

HC SELLA TURCICA $219.13

HC SENSORY INTEGRATION EA 15M $103.85

HC SEPTAL DEFECT IMPL SYSTEM LVL 1 $779.62

117 of 172

Procedure Price

HC SEPTAL DEFECT IMPL SYSTEM LVL 10 $9,695.71
















HC SEWHO, AIRPLANE DESIGNE LVL 1 $1,519.56





HC SHAVE LES T/A/L 0.6-1.0 CM $313.26

HC SHOULDER 1 VIEW $330.48

HC SHOULDER ARTHROGRAM $1,028.89

HC SHOULDER MIN 2 VIEWS $439.45

HC SHUNTOGRAM FOR NV SHUNT $550.44

HC SI JOINTS LESS THAN 3 VIEWS $302.49

HC SI JOINTS MIN 3 VIEWS $397.40

HC SIALOGRAM $571.32

HC SIALOLITHOTOMY SM UNCOMPLICATED $4,447.16

HC SIGMOIDOSCOPY LEVEL I $1,439.28

HC SIGMOIDOSCOPY LEVEL II $1,936.22

HC SIGMOIDOSCOPY LEVEL III $2,241.01

HC SIGMOIDOSCOPY LEVEL IV $2,956.09

HC SIGMOIDOSCOPY W/EUS LEVEL I $4,114.28

HC SIGMOIDOSCOPY W/EUS LEVEL II $4,611.22

HC SIGMOIDOSCOPY W/EUS LEVEL III $4,916.01

118 of 172

Procedure Price

HC SIGMOIDOSCOPY W/EUS LEVEL IV $5,631.09

HC SIJ ANESTH/STERIOD INJ PAIN $1,115.05

HC SIMPLE PROCEDURE $613.74

HC SIMULATION; COMPLEX $1,924.51

HC SIMULATION; INTERMEDIATE $1,043.27

HC SIMULATION; SIMPLE $815.06

HC SINUS OR JUGL CATH VENOGRAM $2,374.57

HC SINUSES LESS THAN 3 VIEWS $345.36

HC SINUSES MIN 3 VIEWS $468.44

HC SKIN SUB GRAFT T/A/L 25 SQ CM $2,006.99

HC SKIN SUB GRAFT T/A/L ADD 25 SQ CM $1,752.14

HC SKIN SUB GRFT F/NK/HF/G 25 SQ CM $2,134.41

HC SKIN SUB GRFT F/NK/HF/G ADD 25 SQ CM $1,752.14

HC SKIN SUB GRFT T/A/L CH ADD 100 SQ CM $1,879.56

HC SKIN SUB GRFT T/A/L CHILD 100 SQ CM $2,581.99

HC SKIN SUBSTITUTE AS DEVICE NO HCPCS LVL 1 $1,184.51








HC SKIN SUBSTITUTE NOS LVL 6 $12,927.63

HC SKN SUB GRFT F/NK/HF/G CH ADD 100 SQ CM $1,879.56

HC SKN SUB GRFT F/NK/HF/G CHILD 100 SQ CM $2,134.41

HC SKULL LESS THAN 4 VIEWS $428.89

HC SKULL MIN 4 VIEWS $595.46

HC SLCTV WND DEBRIDEM 20 CM OR < $406.33

HC SLCTV WND DEBRIDEM ADDTL 20 CM/< $406.33

HC SLEEP STUDY UNATT & RESP EFFT $1,451.27

HC SLEEP STUDY UNATT W/ANALYSIS $1,451.27

HC SLS-EPS PERIPH NRV; LWR LIMBS $1,158.97

HC SLS-EPS; PERIPH NRV; UP LIMBS $927.14

HC SM 153 LEXIDRONAM UP TO 150 MCI $27,461.43

HC SMALL BOWEL ENDO LEVEL I $3,366.52

HC SMALL BOWEL ENDO LEVEL II $3,787.02

119 of 172

Procedure Price

HC SMALL BOWEL ENDO LEVEL III $5,319.55

HC SMALL BOWEL ENDO LEVEL IV $7,185.02

HC SMALL BOWEL VIA ENTEROCLYSIS TUBE $681.68

HC SMALL BOWEL W SERIAL IMG $632.13

HC SMOKE/TOBACCO COUNSELING > 10 MIN $53.86

HC SMOKE/TOBACCO COUNSELING 3-10 MIN $53.86

HC SMPL BLADDER IRRIGATE LAVAGE/INSTILL $582.99

HC SO - ACROMIOCLAVICULAR PREFAB LVL 1 $390.11




HC SO - PREFAB FIG OF 8 RESTRAINER LVL 1 $390.11




HC SO CAP DESIGN W/O JNTS CF LVL 1 $1,519.56





HC SOFT TISSUE NECK $289.63

HC SOLUTION DIALYSIS LEVEL 1 $169.27



HC SP HEPATIC VENOGRAM WO HDM $4,513.09

HC SP MECH REMOV INTRALUMINAL OBST MATERIAL $1,330.97

HC SP MECH REMOV PERICATHETER OBST MATERIAL $15,969.36

HC SPECIAL DOSIMETRY $524.00

HC SPECIAL PHYSICS CONSULT $896.99

HC SPECIAL RADIATION TREATMENT $2,442.79

HC SPECIALITY NEEDLE LVL 1 $360.86

HC SPECIALITY NEEDLE LVL 2 $1,240.62





HC SPEECH AUDIOM THRESHOLD $47.09

120 of 172

Procedure Price

HC SPEECH AUDIOM THRESHOLD W SR $84.75

HC SPEECH SWALLOW/VFSS EVAL SPECIAL $85.00

HC SPEECH THERAPY SPECIAL $85.00

HC SPEECH/HEARING THERAPY $330.93

HC SPEECH/HEARING THERAPY GROUP $155.32

HC SPEECH/LANGUAGE EVAL SPECIAL $85.00

HC SPIN/BRAIN PUMP REFIL & MAIN $342.52

HC SPIN/BRAIN PUMP REFIL & MAIN BY DOC $342.52

HC SPINAL ANCHOR/SCREW BN/BN,TIS/BN LVL 1 $2,516.06





























121 of 172

Procedure Price



HC SPINAL ANGIOGRAM SELECTIVE $4,914.29

HC SPINAL IMPLANT LVL 1 $2,516.06


























HC SPINAL PUNCTURE LUMBAR DIAG $1,289.57

HC SPINE 1 VIEW ANY LOCATION $340.85

HC SPIROMETRY $364.61

HC SPIROMETRY W/BRONCHDIL INF-2 YRS $237.03

HC SPL AVULSE NP EA ADDTL $168.65

HC SPL AVULSE NP SGL $337.02

HC SPONTANEOUS NYSTAGMUS GAZE & FIX $403.93

HC SR89 STRONTIUM PER MCI $3,490.88

122 of 172

Procedure Price

HC SREP F/E/N/L/MM 12.6-20.0 CM $683.51

HC SREP F/E/N/L/MM 2.5 CM/< $650.97

HC SREP F/E/N/L/MM 2.6-5.0 CM $676.66

HC SREP F/E/N/L/MM 20.1-30.0 CM $767.54

HC SREP F/E/N/L/MM 5.1-7.5 CM $694.88

HC SREP F/E/N/L/MM 7.6-12.5 CM $767.64

HC SREP S/N/A/G/TR/E >30 CM $774.63

HC SREP S/N/A/G/TR/E 12.6-20.0 CM $744.24

HC SREP S/N/A/G/TR/E 2.5 CM/< $619.93




HC SRS LINEAR BASED 1 SESSION $21,877.97

HC ST BX SHOULDER SUPERFICIAL $1,574.22

HC STENT PLACEMT ANTE CAROTID $11,903.24

HC STENT PLACEMT RETRO CAROTID $11,903.24

HC STENT PLMT CTR DIALYSIS SEG $15,213.58

HC STENT, NON-COR, TEM W/DEL SYSTEM LVL 1 $1,382.07






HC STENT, NON-COR, TEM W/DEL SYSTEM LVL10 $6,463.82





HC STENT, NON-COR, TEM W/O DEL LVL 1 $1,204.88









123 of 172

Procedure Price


HC STENTS, NON VASCULAR LVL 1 $1,736.45









HC STERNOCLAVICULAR MIN 3 VIEWS $327.51

HC STERNUM MIN 2 VIEWS $416.82

HC STIM & PACING S/P IV DRUGS $5,605.56

HC STRAP ANKLE OR FOOT $264.10

HC STRAPPING ELBOW OR WRIST $297.36

HC STRAPPING HAND OR FINGER $228.32

HC STRAPPING OF TOES $214.64

HC STRAPPING SHOULDER $322.01

HC STRATTICE TM PER 1 SQ CM LVL 1 $83.20

HC STRESS TTE ONLY $1,290.33

HC SUB PT/OT CURRENT STATUS $0.01

HC SUB PT/OT D/C STATUS $0.01

HC SUB PT/OT GOAL STATUS $0.01

HC SUPERV, HNDL, LOAD - RAD SOURCE $473.99

HC SUPERVISED FITNESS $30.00

HC SURG TX INCOMPL ABORTION $2,165.02

HC SURG TX MISSED ABORT 1ST TRIMESTER $3,921.92

HC SURG TX MISSED ABORT 2ND TRIMESTER $3,921.92

HC SURGERY LEVEL 1 - EA ADDTL 15 MIN $380.00

HC SURGERY LEVEL 1 - INIT 30 MIN $2,535.00





HC SURGERY LEVEL 4 - EA ADDTL 15 MIN $1,235.00



124 of 172

Procedure Price




HC SURGERY PER MIN LEVEL 1 $48.10

HC SURGICAL SPECIMEN $601.45

HC SUTURE/STAPLES/CLOSURE DEVICES LVL 1 $120.65

HC SUTURE/STAPLES/CLOSURE DEVICES LVL 2 $414.56

HC SUTURE/STAPLES/CLOSURE DEVICES LVL 3 $2,279.34







HC SVC VENOGRAM W/SERIALOGRAPHY $2,880.11

HC SWALLOW CURRENT STATUS $0.01

HC SWALLOW D/C STATUS $0.01

HC SWALLOW GOAL STATUS $0.01

HC SWALLOWING FUNCTION W CINE VIDEO $546.40

HC SYNTHETIC IMPLNT URINARY 1ML LVL 1 $1,519.56






HC TBA CENTRAL DIALYSIS SEG $9,500.00

HC TC99 TILMANOCEPT DIAG TO 0.5 MCI $1,670.42

HC TC99M BICISATE TO 25 MCI $1,524.30

HC TC99M DISOFENIN TO 15 MCI $287.27

HC TC99M DMSA TO 10 MCI $909.90

HC TC99M GLUCEPTATE TO 25 MCI $84.79

HC TC99M HMPAO TO 25 MCI $3,704.66

HC TC99M LABELED RBC TO 30 MCI $372.04

HC TC99M MAA TO 10 MCI $228.65

HC TC99M MAG3 TO 15 MCI $593.37

HC TC99M MEBROFENIN TO 15 MCI $158.30

HC TC99M MEDRONATE TO 30 MCI $146.57

125 of 172

Procedure Price

HC TC99M OXIDRONATE TO 30 MCI $187.60

HC TC99M PENTETATE TO 25 MCI $211.06

HC TC99M PERTECHNETATE PER MCI $27.52

HC TC99M PYROPHOSPHATE TO 25 MCI $157.08

HC TC99M SESTAMIBI $370.88

HC TC99M SULFUR COLLOID TO 20 MCI $293.14

HC TC99M TETROFOSMIN $674.22

HC TCAT DLVR ENHNCD FIXJ DEV $13,000.00

HC TCD EMBOLI DETECT W INJ $462.70

HC TCM HOURLY $17.87

HC TCM INITIATION $105.50

HC TEAM CONFERENCE FOR SRS $554.68

HC TECHNETIUM TC99M AEROSOL =< 75 MCI $294.25

HC TECHNETIUM TC99M AUTO WBC DX $4,735.93

HC TEE FOR MONITORING $2,416.77

HC TEE W OR W/O FOL W/CONT MON $2,113.25

HC TEETH COMPLETE FULL MOUTH $233.61

HC TEETH PARTIAL EXAM < FULL MOUTH $233.61

HC TELEPHONIC INTERPRETIVE SERVICES PER MIN $1.70

HC TELETHERAPY ISODOSE PLAN COMPLEX $4,708.00

HC TELETHERAPY ISODOSE PLAN SIMPLE $2,568.00

HC TELETHERAPY PLAN SPECIAL, TOTAL BODY $3,423.59

HC TEMP TRANSCUTAN PACING $1,523.03

HC TENOMYOT SHOULDER; MULTI $4,156.95

HC TENOTOMY ADDUCTOR/HAMSTRING PERC MULTI $4,156.95

HC TENOTOMY ELBOW PERC $4,988.34

HC TENOTOMY OP FLEXOR FT SGL/MULTI $3,849.39

HC TENOTOMY SHOULDER SINGLE $5,340.64

HC TENOTOMY SQ TOE SINGLE $2,492.03

HC THER/DX CONCURRENT INF $138.14

HC THER/PRO/DX INJ IV PUSH $387.97

HC THER/PROPH/DIAG INJ SC/IM $157.33

HC THER/PROPH/DX IV INF EA ADDTL HR $241.39

HC THER/PROPH/DX IV INF INIT UP TO 1HR $585.09

HC THERAP BE OR AIR FOR OBSTRUCT $571.22

HC THERAP EXERCISE ROM EA 15M $152.61

HC THERAPEUTIC ACTIVITY DIR EA 15M $143.83

126 of 172

Procedure Price

HC THERAPEUTIC RAD SIMUL 3 DIMENSIONAL $8,916.00

HC THERAPEUTIC REHAB GROUP $107.65

HC THERAPEUTIC SP DEVICE SERVICE $207.74

HC THERASKIN PER SQ CM LVL 1 $142.02



HC THORACENTESIS ENDO $2,288.11

HC THORACENTESIS W/TUBE INSERT ENDO $2,288.11

HC THORACIC AORTOGRAM W SERIALOGRAPHY $4,131.27

HC THORACIC AORTOGRAM WO SERIALOGRAPHY $3,665.62

HC THORACIC SPINE 2 VIEWS $452.55

HC THORACIC SPINE 3 VIEWS $524.41

HC THORACIC SPINE MIN 4 VIEWS $595.46

HC THORACOLUMBAR SPINE 2 VIEWS MIN $442.19

HC THORACOSCOPY W BX $7,486.24

HC THORACOSCOPY W PLEURODESIS $7,611.10

HC THRMBC/INFS DIALYSIS CIRCUIT $15,721.93

HC THRMBC/INFS DIALYSIS CIRCUIT W STENT $30,935.51

HC THRMBC/INFS DIALYSIS CIRCUIT W TBA $27,500.61

HC THROMBECT/EMBOLECTOMY CATH LVL 1 $911.50

HC THROMBECT/EMBOLECTOMY CATH LVL 10 $9,695.71












HC THROMBECTOMY OF ARTERIAL/VENOUS GRAFT $6,204.47

HC THROMBECTOMY PERC TRANSLUM MCH VEIN ADDL $8,528.27

HC THROMBECTOMY PERC TRANSLUM MECH ART ADDL $7,613.01

HC THROMBECTOMY PERC TRANSLUM MECH ART INIT $8,528.27

HC THROMBECTOMY PERC TRANSLUM MECH VEIN $10,233.93

127 of 172

Procedure Price

HC THROMBECTOMY TRANSLUM MECH VEIN SEC PERC $6,500.00

HC THROMBOLYSIS CEREBRAL BY IV INFUSION $406.04

HC THROMBOLYTIC ART THERAPY $13,960.79

HC THROMBOLYTIC ART/VEN THER CESS&CATH REM $7,750.00

HC THROMBOLYTIC ART/VEN THERAPY $8,200.00

HC THROMBOLYTIC VENOUS THERAPY $6,500.00

HC THYROID IMAG W/BLOOD FLOW $1,055.29

HC THYROID IMAG W/BLOOD FLOW SGL/MULT QUAN $1,758.80

HC THYROID STIMULATING HORMONE $26.40

HC THYROID UPTAKE MEASUREMENT $559.89

HC THYROTROPIN ALFA 0.9 MG IN 1.1 MG VIAL $12,396.78

HC TIB/PER REVASC ADD-ON $9,707.94

HC TIB/PER REVASC STENT & ATHER $39,820.64

HC TIB/PER REVASC STNT & ATHER $32,275.28

HC TIB/PER REVASC W/ATHER $25,997.57

HC TIB/PER REVASC W/STENT $27,846.02

HC TIB/PER REVASC W/TLA $14,022.95

HC TIBIA FIBULA 2 VIEWS $406.77

HC TIBPER REVASC W/ATHER ADD-ON $18,452.20

HC TILT TABLE TESTING $1,989.00

HC TLSO TRIPLANE CNTRL W HYPEREXT LVL 3 $2,518.40

HC TMJ BILATERAL $487.72

HC TMJ UNILATERAL $409.67

HC TOE OR TOES MIN 2 VIEWS $304.88

HC TOMOGRAM $337.26

HC TOTAL VITAL CAPACITY $175.76

HC TPRNL PLMT BIODEGRDABL MATRL $5,204.07

HC TRACH SUPPLIES LVL 1 $359.95

HC TRACH SUPPLIES LVL 2 $1,519.56




HC TRACH TUBE CHG BEFORE FISTULA TRACT $612.77

HC TRACHEOSTOMY EMERG CRICOTHYROID $731.15

HC TRACH-ESOPH VOICE PROS MD IN LVL 1 $1,519.56



128 of 172

Procedure Price



HC TRANSABD AMNIOINFUSION W US $805.51

HC TRANSCATH CLOSURE OF ASD $15,260.94

HC TRANSCATH EMBOL HEAD/NECK NOT CNS $17,185.81

HC TRANSCATH EMBOLIZATION TX $5,123.77

HC TRANSCATH RENAL SYMP DENERV BILAT $6,136.61

HC TRANSCATH RENAL SYMP DENERV UNI $6,136.61

HC TRANSFUSION BLOOD > 6 UNITS $1,377.06

HC TRANSFUSION BLOOD 1 UNIT $1,040.80

HC TRANSFUSION BLOOD 2 UNITS $1,096.85





HC TRANSFUSION INTRAUTERINE FETAL $491.48

HC TRANSHEP PORTOGRAM W/HEMO PERC $3,969.05

HC TRANSHEP PORTOGRAM W/O HEMO PERC $3,810.91

HC TRANSL ATHERECT ROTATN CATH LVL 1 $779.62

HC TRANSL ATHERECT ROTATN CATH LVL 10 $9,695.71











HC TRANSLUM ANGIOPL NON-LASER CATH LVL 1 $779.62

HC TRANSLUM ANGIOPL NON-LASER CATH LVL 10 $9,695.71






129 of 172

Procedure Price





HC TRANSLUM ANGIOPL NON-LASER DRUG COATED CATH LVL 3 $9,951.00

HC TRAUMA RESPONS LEV1 FAC LEV 1 $6,204.12






HC TREAT BIG TOE FRACTURE $4,550.40

HC TREAT FINGER DISLOCATION $5,137.06

HC TREAT FX RAD INTRA-ARTICUL; 2 FRAGS $11,090.87

HC TREAT PLEURODESIS W/AGENT $1,362.78

HC TREAT SWALLOWING DYSFUNCTION $267.80

HC TREAT ULNAR FRACTURE WO MANIP $400.54

HC TREATMENT OF BLADDER LESION $457.29

HC TRIM ND NAILS $105.77

HC TRIM SKIN LESIONS 2 TO 4 $168.65

HC TRIM SKIN LESIONS OVER 4 $196.23

HC TRLUML BALLOON ANGIOP EA ADDTL ART $3,729.95

HC TRLUML BALLOON ANGIOP EA ADDTL VEIN $11,778.68

HC TRLUML BALLOON ANGIOP INIT ART $12,177.11

HC TRLUML BALLOON ANGIOP INIT VEIN $11,778.68

HC TRNSLUM ATHERECT DIRECTNL CATH LVL 1 $779.62

HC TRNSLUM ATHERECT DIRECTNL CATH LVL 10 $9,695.71











130 of 172

Procedure Price


HC TTE 2D W OR W/O CONTR FOLLOW W CONTR F-UP $1,365.01

HC TTE W OR W/O CONTR FOLLOW W CONTR DOPPLER $2,799.71

HC TTE W OR W/O CONTR FOLLOW W CONTR ECG $2,777.72

HC TTE W OR W/O CONTR FOLLOW W CONTR STRESS $1,990.33

HC TTE W/ DOPPLER COMPLETE $2,099.71

HC TTE W/O DOPPLER COMPLETE $1,137.82

HC TX ATRIAL FIB PULM VEIN ISOL $39,500.00

HC TX CL ELBOW DISLOC W ANESTH $2,693.22

HC TX CL ELBOW DISLOC WO ANESTH $710.82

HC TX DEVICES; COMPLEX $1,237.71

HC TX DEVICES; INTERMED $756.94

HC TX DEVICES; SIMPLE $550.68

HC TX FRACTURE D RADIUS/ULNA W MANIP $1,712.98

HC TX FRACTURE D RADIUS/ULNA WO MANIP $538.62

HC TX FX DISTAL RADIAL/EPIPHYS SEPARATION $4,252.70

HC TX GASTRO INTUB W/ASP $1,481.13

HC TX L/R ATRIAL FIB ADDL $16,038.65

HC TX S WND DEHIS W PACK $888.87

HC TX S WND DEHISC SMPL $775.66

HC TX TARSAL BONE FX WO MANIP $450.90

HC TX/PRO/DX INJ NEW DRG ADD-ON $251.59

HC TX/PRO/DX INJ SAME DRG ADD-ON $225.34

HC TX/PROPH/DX ADDL SEQ IV INF UP TO 1HR $257.73

HC TYMPANOMETRY & REFLEX THRESH $129.86

HC TYMPANOMETRY SLP $82.50

HC UE FX ORTHOSIS, HUMERAL LVL 1 $1,519.56





HC UGI BALLOON DIL ESOPH < 30 MM DIA $2,328.32

HC UGI DIAGNOSTIC $1,721.63

HC UGI W AIR BARIUM W SMALL BOWEL $1,023.23

HC UGI W AIR W KUB $818.59

HC UGI W AIR WO KUB $755.52

HC UGI W BX SGL/MULTIPLE $4,272.66

131 of 172

Procedure Price

HC UGI W KUB $857.94

HC UGI W REMOVAL OF FB $1,431.70

HC UGI W SMALL BOWEL $1,028.46

HC UGI WO KUB $684.31

HC ULTRASOUND ELASTOGRAPHY $298.36

HC UMBIL CORD OCCLUSION W US $373.88

HC UNLISTED DX RADIOLOGY $59.17

HC UNLISTED MRI PROCEDURE $4,176.70

HC UNLISTED PROC DENTOALVEOLAR STRUCT $221.15

HC UNLISTED PROC FEMALE GENITAL SYSTEM $291.04

HC UNLISTED PROCEDURE ABD PERITONEUM $4,740.71

HC UNLISTED PROCEDURE ANUS $1,029.49

HC UNLISTED PROCEDURE BILIARY TRACT $3,847.26

HC UNLISTED PROCEDURE BREAST $2,941.89

HC UNLISTED PROCEDURE CASTING OR STRAPPING $183.23

HC UNLISTED PROCEDURE COLON $1,689.64

HC UNLISTED PROCEDURE ENDOCRINE SYSTEM $12,087.79

HC UNLISTED PROCEDURE HUMERUS/ELBOW $408.85

HC UNLISTED PROCEDURE INTESTINE ENDO $6,260.66

HC UNLISTED PROCEDURE LEG OR ANKLE $347.20

HC UNLISTED PROCEDURE LUNGS/PLEURA $4,500.00

HC UNLISTED PROCEDURE MALE GENITAL SYSTEM $846.42

HC UNLISTED PROCEDURE MUSCULOSKELETAL $3,792.40

HC UNLISTED PROCEDURE NERVOUS SYSTEM $489.36

HC UNLISTED PROCEDURE NOSE $179.66

HC UNLISTED PROCEDURE PHARYNX ADENOIDS $186.57

HC UNLISTED PROCEDURE RECTUM $953.81

HC UNLISTED PROCEDURE SALIVARY GLAND $341.00

HC UNLISTED PROCEDURE STOMACH $1,442.36

HC UNLISTED PROCEDURE TONGUE FLR-MOUTH $218.32

HC UNLISTED PROCEDURE URINARY SYSTEM $870.71

HC UNLISTED VASC PROCEDURE $805.22

HC UNNA BOOT STRAPPING $235.30

HC UNNA BOOT STRAPPING BILATERAL $470.60

HC UP TO 2 YRS OLD, SPIROMETRY $184.17

HC UPPR EXTR INFANT MIN 2 VIEWS $475.18

HC UPR/L XTREMITY ART 2 LEVELS $687.73

132 of 172

Procedure Price

HC UPR/L XTREMITY ART 2 LEVELS UNILAT $650.58

HC UPR/L XTREMITY ART STDY 3+ LEVELS $1,167.53

HC UPR/LXTR ART STDY 3+ LVLS UNILAT $998.21

HC URETERAL EMBOLIZATION/OCCL $7,707.80

HC URINARY INCONT REP DEV WO SLG GRFT LVL 1 $779.62

HC URINARY INCONT REP DEV WO SLG GRFT LVL 2 $2,707.43








HC URINE PREGNANCY, VISUAL COLOR $141.50

HC UROLOGY SUPPLIES GENERAL LVL 1 $632.20

HC UROLOGY SUPPLIES GENERAL LVL 2 $1,666.35

HC UROLOGY SUPPLIES GENERAL LVL 3 $4,939.02

HC US ABD W CONTRAST $483.64

HC US ABDL AORTA SCREEN AAA $582.95

HC US BREAST COMPLETE $705.16

HC US BREAST LIMITED $537.04

HC US DUPLEX ARTERIAL FLOW COMPL $1,173.47

HC US EXAM ABDOMEN COMPLETE $1,271.55

HC US EXAM ABDOMEN LIMITED $949.72

HC US EXAM CHEST $711.80

HC US EXAM KIDNEY TRANSPL W DOPPLER $986.91

HC US EXAM OF HEAD AND NECK $901.49

HC US EXAM OF HEAD ECHOENCEPHALOGRAM $597.72

HC US EXAM PELVIC COMP TRANSABDOMINAL $1,076.57

HC US EXAM PELVIC LTD TRANSABDOMINAL $665.27

HC US EXAM RETROPERITONEAL COMPL $1,017.46

HC US EXAM RETROPERITONEAL LTD $881.98

HC US FBP W NON-STRESS TEST $901.24

HC US FBP WO NONSTRESS TEST $773.40

HC US FETAL CARDIOVASC 2-D FOLLOWUP OB $765.34

HC US FETAL MIDL CEREBRAL ARTERY ECHO $730.55

HC US FOR FETAL TRANSF/CORDOCENTESIS $245.75

133 of 172

Procedure Price

HC US GUIDANCE AMNIOCENTESIS $701.36

HC US GUIDANCE COMPRESSION REPAIR $1,177.96

HC US GUIDANCE INTRAOPERATIVE $1,030.74

HC US GUIDANCE TISSUE ABLATION $700.00

HC US GUIDANCE VASCULAR ACCESS $702.23

HC US GUIDED NEEDLE PLACEMENT $809.05

HC US GUIDED PERICARDIOCENTESIS $499.41

HC US INFANT HIPS W MANIPULATION $1,124.73

HC US INFANT HIPS WO MANIPULATION $541.12

HC US INTERSTITIAL RE APPLIC $1,259.87

HC US NON OB TRANSVAG $875.33

HC US NUCHAL MEAS 1 GEST OB $222.93

HC US NUCHAL MEAS ADD-ON OB $111.46

HC US OB COMPLETE ADDL FETUS $830.18

HC US OB COMPLETE SNGL FETUS $996.21

HC US OB DETAILED ADDL FETUS $661.04

HC US OB DETAILED SNGL FETUS $1,120.68

HC US OB FOLLOW UP PER FETUS $618.31

HC US OB LESS THAN 14 WKS ADDL FETUS $566.35

HC US OB LESS THAN 14 WKS SNGL FETUS $855.75

HC US OB LIMITED FETUS(S) $634.77

HC US OB TRANSVAGINAL $382.53

HC US PROSTATE VOLUME FOR BT $971.20

HC US PV RESIDUAL URINE $79.99

HC US SALINE INFUSED SONOHYSTEROGRAM $893.27

HC US SCROTUM AND CONTENTS $935.11

HC US SPINE $685.07

HC US TRANSRECTAL $832.97

HC US UMBILICAL ARTERY ECHO $730.55

HC US XTR NON-VASC COMPLETE $838.14

HC US XTR NON-VASC LTD $630.94

HC VACUUM DRAIN BOTTLE/TUBE KIT LVL 2 $482.74

HC VAGINAL DELIVERY LEVEL 1 $5,206.58




HC VAGINAL DELIVERY ONLY $4,482.19

134 of 172

Procedure Price

HC VALVES, HEART LVL 1 $2,707.43


















HC VASC EMBOLIZE/OCCLUDE ARTERY $18,210.99

HC VASC EMBOLIZE/OCCLUDE BLEED $18,210.99

HC VASC EMBOLIZE/OCCLUDE ORGAN $18,210.99

HC VASC EMBOLIZE/OCCLUDE VENOUS $18,210.99

HC VASCULAR CLOSURE DEVICE LVL 1 $1,346.63










HC VASCULAR GRAFT, SYNTHETIC, IMPLANT LVL 1 $2,707.43





135 of 172

Procedure Price





HC VASCULAR GRAFT, SYNTHTIC, IMPLANT LVL 10 $16,159.55

HC VASCULAR STENT, COAT/COV W/DEL SYS LVL 1 $2,516.06









HC VASCULAR STENT, COAT/COV W/DL SYS LVL 10 $14,543.54







HC VASCULAR STENT, COAT/COV W/O DL SY LVL 1 $2,516.06






HC VASCULAR STENT, COAT/COV W/O DL SY LVL10 $16,159.55

HC VASCULAR STENT, COATCOV W/O DL SY LVL 4 $6,463.82

HC VASCULAR STENT, NO-COA/NO-COV W/DL LVL 1 $2,516.06






HC VASCULAR STENT, NO-COAT/COV W/O DL LVL 1 $2,516.06


136 of 172

Procedure Price







HC VASCULAR STENT, NO-COAT/COV W/O DL LVL17 $27,471.17

HC VASCULAR SUPPLIES GENERAL LVL 1 $478.28

HC VASCULAR SUPPLIES GENERAL LVL 19 $41,971.83



HC VENA CAVA FILTER LVL 1 $2,516.06








HC VENIPUNCTURE AGE 3 YRS/> $120.00

HC VENIPUNCTURE CUTDOWN > AGE 1 $314.37

HC VENOGRAM HEPATIC W/HEMO $4,873.43

HC VENOGRAM IVC W SERIALOGRAPHY $5,813.98

HC VENOUS SAMPLING - RENIN VEIN $4,062.78

HC VENT MGMT INPAT INIT DAY $3,639.82

HC VENT MGMT INPAT SUBQ DAY $1,887.54

HC VEP TEST CNS; CHECKERBD/FLASH $1,135.87

HC VERTEBROPLASTY INJECT EA ADDTL $5,871.26

HC VESSEL MAP FOR HEMODIALYSIS ACCESS $738.36

HC VISC & INFRAREN ABD 1 PROSTH $6,308.71



HC VISC & INFRAREN ABD 4+ PROST $6,891.06

HC VISCERAL ANGIOGRAM SELECTIVE $4,861.89

HC VISUAL REINFORCEMENT AUDIOMETRY $129.86

HC VOICE CURRENT STATUS $0.01

HC VOICE D/C STATUS $0.01

137 of 172

Procedure Price

HC VOICE GOAL STATUS $0.01

HC VOIDING URETHROCYSTOGRAM $702.64

HC WEDGE EXC NAIL FOLD $300.93

HC WELLNESS IMMUNIZATION FLU INTRANASAL $30.00

HC WELLNESS IMMUNIZATION INFLUENZA $24.00

HC WHEELCHAIR MNGMENT TRAINING EA 15M $125.00

HC WHFO - PREFAB WRIST COCK-UP LVL 1 $339.54





HC WHFO - PREFAB WRIST COCK-UP LVL 6 $1,063.69




HC WHFO NONTORSION JOINT PREFAB LVL 1 $496.81

HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 1 $352.30





HC WHFO PREFAB FLEX GLV W ELAST CNTRL LVL 6 $1,063.69




HC WHFO W/JOINT(S) CUSTOM FAB LVL 1 $1,519.56





HC WHFO, RIGID W/O JOINTS LVL 1 $750.24

HC WHFO, RIGID W/O JOINTS LVL 2 $3,039.13




HC WHO W/NONTORSION JNT(S) CF LVL 1 $2,947.54


138 of 172

Procedure Price




HC WHO W/O JOINTS CF LVL 1 $720.21

HC WHO W/O JOINTS CF LVL 2 $3,039.13




HC WIRELESS PRESSURE SENSOR LVL 7 $90,000.00

HC WOC THERAPY/EDU IP 15 MIN $110.81

HC WORK HARDENING EA ADDTL HR $304.00

HC WORK HARDENING INIT 2 HRS $608.00

HC WOUND POUCH EACH LVL 1 $405.03

HC WOUND PREP F/N/HF/G 100 SQ CM/1% BA $563.63

HC WOUND VAC SUPPLIES LVL 1 $72.64

HC WOUND VAC SUPPLIES LVL 2 $1,519.56




HC WRIST 2 VIEWS $337.63

HC WRIST ARTHROGRAM $887.59

HC WRIST COMPL MIN 3 VIEWS $413.48

HC XE133 XENON PER 10 MCI $698.76

HC X-RAY C/T SPINE DISK $3,383.76

HC X-RAY EXAM ABDOMEN 1 VIEW $298.72

HC X-RAY EXAM ABDOMEN 2 VIEWS $362.00

HC X-RAY EXAM ABDOMEN 3+ VIEWS $382.25

HC X-RAY EXAM CHEST 1 VIEW $298.72

HC X-RAY EXAM CHEST 2 VIEWS $362.00

HC X-RAY EXAM CHEST 3 VIEWS $374.50

HC X-RAY EXAM CHEST 4+ VIEWS $390.00

HC X-RAY EXAM ENTIRE SPINE 1 VW $384.07

HC X-RAY EXAM ENTIRE SPINE 2/3 VW $615.25

HC X-RAY EXAM ENTIRE SPINE 4/5 VW $642.00

HC X-RAY EXAM ENTIRE SPINE 6/> VW $652.70

HC X-RAY EXAM HIP UNI 1 VIEW $290.26

HC X-RAY EXAM HIP UNI 2-3 VIEWS $423.19

139 of 172

Procedure Price

HC X-RAY EXAM HIP UNI 4/> VIEWS $508.25

HC X-RAY EXAM HIPS BI 2 VIEWS $589.48

HC X-RAY EXAM HIPS BI 3-4 VIEWS $647.89

HC X-RAY EXAM HIPS BI 5/> VIEWS $706.88

HC X-RAY EXAM OF FEMUR 1 VW $412.65

HC X-RAY EXAM OF FEMUR 2/> VW $451.01

HCG QUANTITATIVE ALL $357.00

HCG SCREEN SERUM ALL EXCEPT B/F/H/J/V/L1/P1 $153.00

HCG TUMOR MARKER L/M/W/S1/O/P/L1 $158.00

HDL CHOLESTEROL ALL $58.00

HEALTH RISK A PROFILE L/M/W/S1 $52.50

HEAVY METAL SCR 24HR W/RFLX MHMU24 QC/Q/D/S/L/M/P/R/W/X/C1/N/L/Z $20.00

HEAVY MTL SCRN DEMOG MHMDB QC/Q/D/E/L/M/P/R/S/T/W/X/C1/S1/N/L1 $43.00

HEINZ BODIES ARUP L/M/S1 $261.00

HELM SATIVUM IgE FHSSE L/M/W/L1 $86.50

HELMIN HALODESIGE MHELM L/W/M/S1/L1 $35.50

HEMATOCRIT L/M/W $48.00

Hemin 1 mg $42.92

HEMOGLOBIN L/M/W $48.00

HEMOGLOBIN PHORESIS MHBELC Z/E/M/P/R/T/W/X/C1/J/L1/W1 $134.50

HEMOGLOBIN PLASMA V/Y/J/L/M/P/C1/P1 $68.00

HEMOGLOBIN S SCREEN MSDEX Z/D/S/X/L/M/W/J/N/W1 $45.00

HEMOLYTIC DISEASE OF NEWBORN ILHIMC $290.50

HEMOQUANTFECES MAYO M9220 L/M/W/J/S1/L1 $47.50

HEMOSIDERINURINE Z/A/E/F/G/L/M/R/W/C1/J/L1/W1 $92.00

HEMOSURE FECAL OCC BLD /A/W1 $182.50

HEP A TOTAL AB E/J/L/M/O/P/QC/R/T/W/C1/L1/S1 $83.50

HEP B CORE IGM J/O/P/R/C1/S1/L1 $345.50

HEP B CORE TOT AB Z/E/J/L/M/R/W/C1/S1/L1 $83.50

Hep b ig im $264.40

HEP B SUR AB L/M/N/P/W/C1 $345.50

Hep B Sur AB Monitor Post Transplant M87893 L/M/W/S1/J/L1 $221.50

HEP B SURF AG CONF MHBGNT QC/Q/D/L/M/S/W/S1/N/L1/W1 $220.50

HEP B SURF AG CONF Y/C2/M/V/L1/P1 $66.00

HEP B SURFACE AB QC/V/Y/E/J/L/M/O/P/R/W/S1/L1/C2/P1 $345.50

HEP C GENO RESOLUTN MHCVGR QC/Q/Z/C1/A/D/E/J/L/M/O/R/S/S1/W/X/N/L1/W1 $146.00

HEP C VIRUS GENOTYPE MHCVG QC/Q/Z/C1/D/E/J/L/M/O/P/R/S/W/X/A/S1/N/L1/W1 $241.00

140 of 172

Procedure Price

HEP INDUCED THROMBO QC/C1/L/M/W//L1 $270.00

HEP PANEL CHRONIC B MCHSBP QC/Q/E/J/L/M/T/W/S1/L1/W1 $58.50

Hepa vacc ped/adol 2 dose im $151.40

Hepa vaccine adult im $222.60

Heparin Effect ROTEM /M//S1 $133.50

HEPARIN PF4 Ab MHITIG QC/A/D/S/X/C1/S1/N/W1 $671.00

HEPATIC FUNCTION PANEL L/M/W $346.00

HEPATIC FUNCTION PANEL QC/V/Y/B/L/M/P/Q/T/C1/S1/B1/L1/P1 $277.00

HEPATITIS A AB IGM Z/J/L/M/O/P/W/C1/S1/R/L1 $174.50

HEPATITIS B CORE MHBC A/D/F/G/S/T/Q/L/M/P/W/X/C1/S1/N/W1 $64.50

HEPATITIS B DNA QNT MHBVQN QC/Q/E/J/L/M/N/O/P/R/S/W/C1/X/S1/L1/W1 $404.00

HEPATITIS B SURF AG E/J/L/M/O/P/R/W/C1/S1/L1 $301.00

HEPATITIS BE AB MHEAB QC/Q/D/E/J/L/M/O/R/S/W/C1/S1/L1/W1 $114.00

HEPATITIS Be AG MAYO MEAG QC/Q/D/E/S/L/M/R/W/J/C1/S1/N/T/L1/W1 $114.00

HEPATITIS C AB E/J/L/M/O/P/T/W/C1/S1/L1 $140.50

HEPATITIS C RT PCR E/J/L/M/O/P/R/W/C1/S1/L1/D/N/S $196.00

HEPATITIS C RT PCR MHCVQN QC/Q/Z/A/F/G/X/S1/W1 $698.50

HEPATITIS D AB MFHEPD QC/Q/L/M/W/S1/L1 $293.00

HEPATITIS E IGG S MHEVG Z/L/M/W/L1 $124.00

HEPATITIS E IGM CONF MEVMLM Z/L/M/W/L1 $257.00

HEPATITIS E IGM S MHEVM Z/L/M/W/L1 $124.00

Hepb vacc 3 dose ped/adol im $133.60

Hepb vaccine 3 dose adult im $202.00

HEREDIT HEMOCHROMAT MHFE QC/Q/C1/Z/A/D/M/N/O/L/S/W/S1/R/L1/X/W1 $291.50

HEROIN URN L/M/W/L1 $7.50

HERRING ALLERGEN MHERR D/S/L/M/W/S1/N/L1 $25.50

HETEROPHILE AB TITER $107.50

HETEROPHILE AB TITER ARUP M/L/E/L1 $114.00

Hexosaminidase A MMUGS L/M/W/C1/S1/L1 $369.00

HGB A1C CONFIRMATION MHBA1C L/M/W/L1 $25.50

HGB A1C W eAG $167.00

HGB A1C W/eAG QC/V/Z/Y/B/D/F/J/K/N/Q/S/U/S1/L1/P1 $167.00

HGB/HCT L/M/W/P1 $34.00

HHV 6 PCR PLASMA L/M/W/L1 $342.50

HHV 6 PCR SERUM L/M/W/S1/L1 $342.50

Hib prp-omp vacc 3 dose im $140.00

HIGH SENSITIVITY CRP A/D/E/F/G/J/L/M/N/O/P/QC/R/S/W/V/Z/Y/C1/L1/S1/P1 $105.50

141 of 172

Procedure Price

HISTAMINE ARUP IMC/S1/L1 $187.00

HISTONE AUTO AB MHIS QC/Q/L/M/W/C1/S1/Z/L1/X $117.00

HISTOPLASMA AB MSHSTO QC/Q/Z/A/D/E/J/L/M/N/O/P/R/S/W/X/C1/S1/L1/W1 $33.00

HISTOPLASMA AG MFHIST QC/Q/A/D/N/S/X/T $440.00

HISTOPLASMA AG S 310 C1/L/M/T/W/L1 $178.00

HISTOPLASMA AG U 310 C1/L/M/R/T/P/W/O/E/L1 $178.00

HIV 1/2 AB RAPID SCRN QC/V/F/J/N/Q/P1 $91.50

HIV 4TH GEN Z/QC/E/J/L/M/N/O/P/R/W/C1/D/S/L1/S1 $35.50

HIV AB /J/L/M/O/P/R/W $152.50

HIV Ag/Ab CONFIRM E/J/L/M/O/P/R/W/L1 $70.50

HIV RAPID K/L/M/W/X/S1/L1 $69.50

HIV1 DRUG RESISTANCE $281.00

HIV1 GENOTYPE SEQ V/Y/L/M/W/S1/P1 $656.00

HIV1 INTEGRASE GENO $508.50

HIV1 ULTRASENSITIVE VIRAL LOAD L/M/W/E/J/C1/L1 $611.00

HIV-1/2 AB DIFF MHVDIP D/L/M/S/W/Z/Q/N/X $211.00

HLA ABC PHENOTYPE ILH/IMC/P/C1/L1 $785.50

HLA B27 MLY27B QC/Q/D/E/J/L/M/P/R/S/W/X/O/C1/S1/N/L1/W1 $124.00

HLA CAD DONOR BAT $1,876.00

HLA DR PHENOTYPE L/M/L1 $804.50

HLA LIVING DONOR XM L/M/L1 $647.50

HLA PHENOTYPE 1 L/M/W/L1 $804.50

HNK1 CD57 PROFILE 505026 L/M/W $111.50

Hocm <=149 mg/ml iodine 1ml $0.13

HOMOCYSTEINE QC/V/Y/D/E/J/L/M/N/O/P/R/S/W/C1/S1/L1/P1 $161.50

HONEY ALLERGEN MHUNY QC/Q/D/L/M/S/W/S1/N/L1 $25.50

HONEY BEE VENOMIgE MHBV L/M/W/S1/L1/C1 $30.00

HORSE EPITH ALLERGEN MHORS QC/Q/L/M/W/S1/L1 $25.50

HORSE MEAT ALLERGEN MHORM L/M/W/S1/L1/Z $25.50

HORSE SERUM PROTEIN MHSPR D/S/L/M/W/S1/N/L1 $25.50

HOUSE DUST GREER LAB MHDG QC/Q/D/S/L/M/W/N/L1 $25.50

HOUSE DUST MITES/DF M82905 E/L/M/O/W/X/C1/L1 $25.50

HOUSE DUST MITES/DP M82904 E/L/M/O/W/X $25.50

HOUSE DUST PNL ALLER MHD1 D/S/X/S1/N/L1 $59.50

HPV HIGH RISK SCR PCR L/M/W/E/C1/S1/L1 $190.50

HSV 1/2 AB MHSV QC/Q/Z/A/D/E/F/G/J/L/M/N/O/P/R/S/T/S1/L1/W1 $33.00

HSV AB IgM by IFA MHSMR QC/Q/A/E/L/M/P/S/D/W/X/C/N/Z/J/L1/S1/W1 $277.00

142 of 172

Procedure Price

HSV BY PCR BLOOD MHERPB Z/L/M/W/L1 $83.50

HSV BY PCR E/J/L/M/O/P/R/W/C1/S1/L1 $177.00

HSV CULT- NEONATE MAYO MVHSV L/M/W/S1/D/S/N/X $180.00

HTLV I/II AB W/RFLX ARUP V/L/M/W/Y/S1/L1/P1 $37.50

Humate-p inj $2.55

HVA URINE 24 HR E/L/M/W/S1/L1 $163.50

Hyaluronidase recombinant $3.66

Hydralazine hcl injection $172.45

Hydrocortisone sodium succ i $116.90

HYDROGEN BR D-XYLOSE IMC/C1 $204.00

HYDROGEN BR FRUCTOSE IMC $204.00

HYDROGEN BR GLUSIBO IMC/S1 $255.00

HYDROGEN BR LACTOSE IMC $204.00

HYDROGEN BR SUCROSE IMC $204.00

Hydromorphone injection $113.90

HYDROXYLASE AB MOH21 D/L/M/S/W/N/Z/L1 $213.50

Hydroxyurea 500 mg $6.20

Hydroxyzine hcl injection $108.90

Hydroxyzine pamoate 25mg $1.30

Ibandronate sodium injection $380.77

IBD sgi DIAGNOSTIC H/L/M/W/C1/S1/L1 $75.00

Ibuprofen injection $323.00

Idarubicin hcl injection $255.70

IDENT SEROL.TYPING $52.00

Ifosfamide injection $419.85

IGF BINDING PROTEIN-3 V/Y/S1/P1 $152.00

IGFBP-3 MIGFB3 QC/Q/Z/D/L/M/N/S/W/X/C1/L1/W1 $152.00

IgG SUBCLASSES MAYO M9259 QC/Q/A/D/E/J/L/M/N/P/R/S/W/X/J/C1/L1/W1 $98.00

IGM NEWBORN IMC/S1 $132.50

IHD POC CR/GFR NOVA L/M/W $38.00

IHDBC8 BCH /M/ $92.50

Iiv no prsv increased ag im $181.40

Iiv4 vacc no prsv 0.5 ml im $123.45

ILH CAPILLARY COLL LCAP $28.00

ILH VENIPUNCTURE LVEN $28.00

ILH/IMMC HSV BILLING TEST $116.00

IMC AFB MIC $85.50

143 of 172

Procedure Price

IMC ARIS $149.50

IMC CAPILLARY COLLMCAP $28.00

IMC KB $98.00

IMC MIC $149.50

IMC SPEC HANDLING $53.50

IMC VENIPUNCTURE $28.00

IMC YEAST MIC $206.50

IMGLB FREE LIGHT CHAIN MFLCP QC/A/L/M/P/W/T/E/O/X/W1 $151.00

IMIPRA/DESIPRA MIMIPR QC/Q/Z/D/E/L/M/P/N/S/T/W/X/C1/S1/L1 $43.50

IMMATURE PLT FRACTION L/M/W/S1/L1 $48.00

IMMUKNOW VIRACOR L/M/O/W/L1 $321.00

Immune globulin powder $177.45

IMMUNO OCCULT BLOOD M $47.00

IMMUNOFIXATION SERUM QC/V/Y/A/D/F/G/J/L/M/N/O/P/R/S/W/X/C1/S1/L1/P1/W1 $267.50

IMMUNOFIXATION URINE QC/Y/V/A/F/G/L/M/P/R/X/W/O/C1/S1/L1/J/P1 $267.50

IMMUNOGLOB D MIGD L/M/W/C1/S1/L1/X $181.50

IMMUNOGLOBULIN A QC/V/Y/A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/C1/S1/L1/C2/P1 $106.50

IMMUNOGLOBULIN E E/J/L/M/O/P/R/W/C1/L1 $110.50

IMMUNOGLOBULIN G QC/V/Y/A/D/E/F/G/J/L/M/N/O/Q/R/S/W/X/C1/S1/L1/C2/P1 $104.50

IMMUNOGLOBULIN M QC/V/Y/A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/C1/S1/L1/C2/P1 $104.50

IMMUNOGLOBULINS AGM Q/QC/V/D/E/F/G/J/L/M/N/O/P/R/S/W/X/Y/C1/S1/L1/C2/P1 $106.50

INFECTIOUS MONO SCRN ALL $107.50

Infliximab not biosimil 10mg $239.81

INFLU A/B AG QC/Z/A/D/E/F/G/K/L/M/N/P/Q/R/T/SA/W/B1/M1/L1/C1/P1/W1 $128.50

INFLUENZA A ANTIGEN Y/D/T/O/S1/C2 $236.00

INFLUENZA A B PCR L/M/W $198.50

INFLUENZA ABS IGG IGM V/Y/L/M/S1/L1/P1 $28.00

INHIBIN-A V/Y/L/M/PL/S1/L1/P1 $268.50

Inj aripiprazole ext rel 1mg $11.12

Inj benztropine mesylate $147.50

Inj beta interferon sq 1 mcg $29.56

Inj calcitriol per 0.1 mcg $19.01

Inj ceftazidime per 500 mg $100.70

Inj cladribine per 1 mg $129.11

Inj cuvitru 100 mg $35.79

Inj desmopressin acetate $125.00

Inj dihydroergotamine mesylt $2,441.05

144 of 172

Procedure Price

Inj dobutamine hcl/250 mg $96.95

Inj enoxaparin sodium $94.40

Inj estrogen conjugate 25 mg $681.10

Inj ferric carboxymaltos 1mg $3.30

Inj filgrastim excl biosimil $3.56

Inj heparin sodium per 10 u $87.80

Inj heparin sodium per 1000u $105.50

Inj ivig privigen 500 mg $144.75

Inj levocarnitine per 1 gm $100.75

Inj magnesium sulfate $94.90

Inj mepivacaine hcl/10 ml $90.00

Inj midazolam hydrochloride $88.65

Inj milrinone lactate / 5 mg $127.00

Inj morphine pf epid ithc $119.05

Inj nalbuphine hydrochloride $94.75

Inj naloxone hydrochloride $166.65

Inj octafluoropropane mic ml $330.50

Inj pembrolizumab $90.09

Inj perflutren lip micros ml $318.85

Inj potassium chloride $88.10

Inj prohance multipack $29.36

Inj propofol 10 mg $88.10

Inj protamine sulfate/10 mg $92.20

Inj sulf hexa lipid microsph $125.19

Inj tbo filgrastim 1 microg $5.97

Inj testosterone cypionate $1.66

Inj. bendeka 1 mg $49.29

Injection alemtuzumab $147.33

Injection aminocaproic acid $100.65

Injection aztreonam 500 mg $76.70

Injection benralizumab $319.73

Injection blinatumomab $271.27

Injection cerliponase alfa $360.29

Injection clindamycin phosp $111.20

Injection dalbavancin $31.57

Injection daratumumab 10 mg $101.25

Injection doxercalciferol $93.75

145 of 172

Procedure Price

Injection edaravone $39.12

Injection elotuzumab 1mg $12.53

Injection famotidine 20 mg $89.30

Injection fosphenytoin sodi $242.80

Injection fulvestrant $216.49

Injection isavuconazonium $0.57

Injection lacosamide $4.21

Injection mepolizumab 1mg $58.25

Injection metronidazole $97.50

Injection nafcillin sodium $132.90

Injection nivolumab $57.83

Injection ocrelizumab 1 mg $108.63

Injection onabotulinumtoxina $13.48

Injection oritavancin $49.06

Injection pegfilgrastim 6mg $12,549.65

Injection pentamidine iseth $421.30

Injection peramivir $3.60

Injection sulfamethoxazole $100.05

Injection vedolizumab $39.78

Injection voriconazole $17.94

Injection zarxio $2.13

INSECT ID TO UHL L/W/M/E/S1/L1 $24.00

INSUL LIKE GR FCT1 MIGFMS QC/Q/Z/A/D/E/F/G/L/M/N/P/R/S/W/X/C1/O/S1/L1/J/W1 $59.00

INSULIN ANTIBODIES MINAB QC/Q/D/L/M/O/R/S/W/X/C1/S1/N/L1/E $155.00

Insulin dispos pen 3 ml $661.70

Insulin injection $6.00

Insulin intermed 5 u $228.90

Insulin long acting 5 u $249.25

Insulin most rapid 5 u $638.70

INSULIN QC/V/Y/D/E/J/L/M/N/O/P/R/S/W/C1/S1/L1/P1 $61.50

Insulin rapid 5 u $6.00

Integra bmwd $378.44

INTERLEUKIN 6 ARUP L/M/S1/L1 $196.50

INTIPARIETAL CELL AB L/M/W/S1/J/L1 $130.50

INTRIN FACTOR BLK AB MIFBA QC/Q/A/D/E/F/G/L/M/N/P/S/T/W/X/C1/S1/J/L1 $57.00

Intrinsic ROTEM /M/ $109.50

ION CALCIUM-ISTAT M $29.00

146 of 172

Procedure Price

Ipilimumab injection $273.87

Ipratropium bromide non-comp $1.30

Irinotecan injection $190.20

IRON & IRON BINDING I/J/L/M/P/W $65.00

IRON ALL EXCEPT H/T/U $65.00

IRON STAIN /M $66.50

Iron sucrose injection $5.34

IRRADIATED AT BCCI L/M $125.00

ISLET CELL AB E/J/V/Y/L/M/O/P/R/C1/S1/L1/P1 $127.50

ISOAGLTN TITR ANTI-A MATITH J/L/M/R/W/P/S1/L1 $151.00

ISOAGLTN TITR ANTI-B MBTITH J/L/M/R/W/P/S1/L1 $151.00

ISTAT HCT/HGB /M/ $23.00

ITRACONAZOLE MITCON QC/Q/Z/L/M/W/R/C1/S1/T/L1 $433.50

JAK2 V617F MUTATBLD MJAK2B QC/Q/A/D/E/F/G/J/L/M/N/O/P/R/S/W/S1/L1/W1 $872.00

JC VIRUS PCR L/M/P/PL/R/V/Y/L1/P1 $695.50

Jo 1 AbIgG QC/V/Y/C1/E/J/L/M/O/P/R/W/L1/P1 $43.00

JOHNSON GRASS ALLERG MJOHN QC/Q/L/M/W/S1/L1 $25.50

JUNE GRASS ALLERGEN MJUNE L/M/W/C1/L1 $25.50

KAPPA $61.50

Kcentra per i.u. $4.00

KETONESURINE QC/V/Y/A/D/K/L/M/S/T/U/O/E/S1/B1/L1/P1/W1 $53.00

Ketorolac tromethamine inj $95.00

KIDNEY BEAN ALLERGEN MKIDBN D/L/M/S/W/S1/N/L1 $25.50

KIWI ALLERGEN MKIWI QC/Q/L/M/W/S1/L1 $25.50

Kyleena 19.5 mg $4,331.88

LACOSAMIDE MLACO /D/J/S/L/M/N/O/Q/QC/W/Z/C1/L1/S1 $180.00

LACTIC ACDWHOLE BLD S/L/M/W $18.50

LACTIC ACID ALL EXCEPT J/QC/Z $114.00

LACTIC ACID CSF A/D/L/M/S/T/X/W/L1/W1 $98.50

LACTIC ACID-ISTAT /M/ $29.00

LACTOSE TOLERANCE D/E/L/M/P/S/L1 $124.00

LAMB ALLERGEN MLAMB D/S/L/M/N/O/Q/QC/W/S1/L1 $25.50

LAMBDA $61.50

LAMBS QUARTER IGE MLAMQ QC/Q/L/M/W/L1 $25.50

LAMELLAR BODY CT J/L/M $45.00

LAMOTRIGINE MLAMO QC/Q/D/E/J/L/M/N/O/P/R/S/T/W/X/C1/S1/L1/W1 $191.50

Lanreotide injection $121.55

147 of 172

Procedure Price

LATEX ALLERGEN MLATX L/M/W/C1/L1 $25.50

LAVAGEFLUID $141.50

LDH ALL $99.50

LDH CSF Z/A/L/M/X/W/L1 $74.00

LDH FLUID QC/V/Z/Y/A/E/F/G/H/J/L/M/Q/R/T/X/C1/C2/L1/P1 $74.00

LDH ISOENZYMES ARUP L/M/P/C1/S1/L1 $34.50

LDL CHOL DIRECT QC/Y/V/Z/A/B/D/E/F/G/H/I/L/M/N/O/P/Q/S/T/W/C1/S1 B1 L1/P1/W1 $79.50

LEAD L/M/R/W/X/C1/S1/L1 $107.50

LEAD URINE 24 HR MPBU QC/Q/D/S/T/X/L/M/X/N/L1 $83.00

LEAD VENOUS W/DEMO MPBDV C/C1/J/L/L1/M/O/P/Q/QC/R/S1/T/W/X/Z $14.00

LEGIONELLA AG UR QC/V/Z/Y/A/D/E/F/G/I/J/L/M/N/O/S/W/C1/S1/L1/P1 $262.00

LEGIONELLA ANTIBODY MSLEG QC/Q/D/L/M/S/T/X/W/C1/S1/N/L1/O $110.50

LEMON ALLERGEN MLEM L/M/W/S1/L1 $25.50

LENTIL ALLERGEN MLEN QC/Q/D/S/L/M/W/N/L1 $25.50

LEPTOSPIRA AB ARUP ILH $106.50

LEPTOSPIRA ANTIBODY MLEPDT Z/QC/Q/A/D/F/G/L/M/O/S/W/C1/N/L1 $191.00

LETTUCE ALLERGEN MLETT QC/Q/D/L/M/S/W/S1/N/L1 $25.50

LEUCINE AMINO PEPTIDASE ARUP IMCINT/C1/L1 $164.50

Leucovorin calcium injection $363.30

LEUK ACID PHOS IMC $178.00

Leuprolide acetate /3.75 mg $2,676.50

Leuprolide acetate injeciton $593.80

Leuprolide acetate suspnsion $3,122.35

Levalbuterol non-comp unit $5.23

Levetiracetam injection $29.85

LEVETIRACETAM J/L/M/O/P/R/W/E/C1/L1 $71.50

LEVETIRACETAM MLEVE QC/Q/Z/A/D/S/X/L/M/W/T/N/W1 $261.50

Levofloxacin injection $101.90

LEWIS ANTIGEN TYPE L/M $46.00

LGI1 IGG CBA MLG1CS QC/D/S/N/Q $294.50

Lidocaine injection $93.50

LIME ALLERGEN MLIME D/L/M/S/W/S1/N/L1 $25.50

LIMITED UR DRUG SCRN L/M/P/W/O/C1/S1 $254.50

Linezolid injection $97.15

LINSEED IGE MLINS L/M/W/Z/S1/L1 $9.50

LIPASE ALL $214.50

LIPASE FLUID V/I/J/L/M/Q/D/L1/O/P1 $214.50

148 of 172

Procedure Price

LIPID PANEL PATH LAB WELLNESS IMC $168.50

LIPID PANEL QC/V/K/M/L/W/C1/B1/C2/P1 $119.50

LIPOPROTEIN A MLIPA D/S/X/L/M/O/R/W/C1/J/S1/N/L1 $100.50

LITHIUM QC/V/Z/Y/A/D/E/F/G/I/J/K/L/M/N/O/P/Q/R/S/T1/S1/B1/L1/P1 $109.00

LIVER FIBROSIS MFLFFT QC/Q/C1/J/O/L/M/W/S1/T/L1/P $95.00

LKM ANTIBODIES MLKM QC/Q/D/E/L/M/N/O/S/W/C1/S1/L1/W1 $342.50

LOBSTER ALLERGEN MLOB QC/Q/L/M/W/C1/S1/L1 $25.50

Locm 100-199mg/ml iodine 1ml $1.96



LORAZEPAM ARUP L/M/R/S1/L1 $133.00

Lorazepam injection $92.85

LSD URINE MEDTOX L/M/S1/L1 $511.00

LUPUS ANTI BAT1 P $27.50

LUPUS ANTI BAT2 L/M/W/S1 $38.50

LUPUS ANTI BAT3 L/M/W $39.50

LUPUS ANTI BAT4 P $228.00

LUPUS ANTICOAGULANT E/J/L/M/O/P/W/C1/S1/L1 $32.00

LUPUS ANTICOAGULANT MLUPPR QC/Q/T/W/X/S/D/S1/N/W1 $107.00

LUPUS PTT MIX 1:1 MAPTTM QC/Q/Z/D/S/N/W1 $125.00

LUTEINIZING HORMONE QC/V/Z/Y/A/B/D/E/F/G/I/J/L/M/N/O/P/Q/R/S/W1/S1/L1/C1/C2/P1/W1 $231.50

LYME AB IGG J/L/M/P/W/L1 $69.00

LYME AB IGM J/L/M/P/W/L1 $69.00

LYME BY PCR MPBORR Z/C1/L/M/W/L1/W1 $323.50

LYME CNS IgG RFLX MLNBAB QC/Q/Z/L/M/W $70.00

LYME CNS INF IgG AB INDEX MLNBAI QC/Q/Z/L/M/W $170.00

LYME CONFIRMATION MLYWB QC/Q/D/E/F/G/J/L/M/N/O/P/R/S/T/W/X/C1/L1/S1/W1 $118.00

LYME DIS AB SERO A/C1/C2/E/J/L/L1/M/O/P/QC/R/S1/V/W/Y/P1 $69.00

LYMPHOCYTE SUBSETS 2901300 L/M/W/C1 $117.50

LYSOZYME MMUR QC/Q/D/S/L/M/W/C1/S1/N/L1/O $123.50

LYTES AND OSMOL PANEL F EFPO Z/W1/R/T/L/M/W/E/J/L1/O/P/W1 $114.00

M G EVALUATION ADULT MMGA1 QC/Z/A/D/L/M/O/R/S/W/J//X/C1/S1/N/L1/W1 $70.50

M PNEUMONIAE IgMIFA MYCPN QC/Q/A/D/L/M/N/S/W/X/L1 $273.00

MACADAMIA NUT ALLERG MFMCNE QC/Q/D/L/M/S/W/S1/N/L1 $25.50

MACHINE IONIZED CALCIUM $92.50

MAGNESIUM ALL $104.50

MAGNESIUM URINE $109.00

149 of 172

Procedure Price

MAGNESIUM URINE 24HR U/A/E/F/G/L/M/P/Q/S/W/X/S1/O/C1/L1 $109.00

MALARIA PARASITEMIA MPARCT QC/L/M/W $81.50

MALARIA PCR W REFLEX MLMALP QC/L/M/W/L1 $219.50

MALARIA RAPID SCREEN J/L/M/W/C1/S1/L1 $58.50

MALARIA/BABESIA MMAL QC/A/C1/W1 $81.50

MANGANESE MMNS QC/Q/D/J/L/M/N/O/S/W/C1/S1/L1 $60.00

MANGO ALLERGEN MMANGO L/M/W/S1/L1 $25.50

Mannitol injection $93.00

MAPROTILINE ARUP ILH $235.00

MARJORAM IGE MARJ Z/L/M/W/L1 $9.50

MATERNAL ABO INCOMP ILHIMC $174.50

Mcv4 menacwy vaccine im $334.20

MEASURED O2 SAT QC/S/L/M/T $117.00

Medroxyprogesterone acetate $3.37

MELANIN URINE ARUP IMC/S1/L1 $56.50

MELON ALLERGEN MMELN L/M/W/S1/L1 $25.50

Menb-4c vacc 2 dose im $419.00

MEPERIDINE ARUP L/M/PL/S1/L1 $229.00

Meperidine hydrochl /100 mg $135.10

MEPROBAMATE ARUP 2011521 L/M/W/T/S1/L1 $203.50

MERCURY MHG QC/Q/D/J/L/M/S/W/C1/S1/N/L1 $155.00

MERCURY URINE 24 HR MHGU QC/Q/D/S/L/M/W/S1/N/L1 $130.00

Meropenem $98.55

Mesna injection $360.05

MESQUITE ALLERGEN MMESQ D/L/M/S/W/N/L1 $25.50

METANEPHRINE FREE MPMET QC/Q/D/E/J/L/M/O/P/R/S/W/X/C1/T/S1/N/L1/W1 $516.50

METANEPHRINES URN 24HR E/J/L/M/O/P/R/C1/S1/L1 $208.00

Methadone injection $126.40

Methadone oral 5mg $10.79

METHADONE URINE L/M/T $61.00

METHADONE/METABOL MMDNS Z/QC/Q/D/L/M/S/W/S1/C1/N/L1/W1 $220.50

METHEMOGLOBIN QC/Y/Z/V/A/J/L/M/O/P/R/S/T/X/C1/S1/L1/P1 $96.50

METHOTREXATE ILH/IMC/WDM/C1/L1 $135.50

Methotrexate oral 2.5 mg $8.60

Methotrexate sodium inj $366.25

Methylergonovin maleate inj $136.90

METHYLMALONIC ACD QN MMAS QC/Q/Z/A/D/E/F/G/J/L/M/N/P/S/T/S1/O/L1/W1 $233.00

150 of 172

Procedure Price

Methylnaltrexone injection $4.01

METHYLPHENIDATE MRIT D/S/N/L/M/W/E/J/L1/O/S1/P/R/C1 $95.00

Methylprednisolone 40 mg inj $104.90

Methylprednisolone 80 mg inj $127.65

Methylprednisolone injection $110.80

Methylprednisolone oral $2.40

Metoclopramide hcl injection $94.25

MEXILETINE MAYO M9245 QC/Q/A/D/S/X/L/M/W/S1/N/L1 $146.00

MG EVAL PEDIATRIC MMGP1 QC/Q/L/W/M/N/D/S/L1 $120.50

Micafungin sodium injection $6.66

MICROSPORIDIA BY PCR MAYO QC/Q/Z/L/M/W/L1 $374.50

MILK ALLERGEN IGE MMILK C1/E/J/L/M/O/W/L1/X/W1 $25.50

MINIMUM ALB EXCRET L/M/P/R/W/O/J/L1 $127.50

MINK EPITH ALLERGEN M82136 D/S/L/M/W/S1 $25.50

Minoxidil 10 mg $0.81

Mirena 52 mg $4,331.88

Misoprostol oral 200 mcg $9.74

MITOCHON ANTIBODY MAMA QC/Q/Z/E/L/M/P/T/W/X/C1/D/S/O/S1/N/L1/W1 $81.00

MITOCHONDRIAL AB E/J/L/M/O/P/W/C1/S1/L1 $257.00

Mitomycin injection $387.70

Mitoxantrone hydrochl / 5 mg $289.67

MMR PANEL E/L/M/W/S1/L1 $31.50

Mmr vaccine sc $229.35

MMRV PANEL L/M/W/E/S1/L1 $31.50

MOLD PANEL ALLERGEN MMOLD1 D/L/M/S/W/S1/N/L1 $55.50

MONOCLONAL PROTEIN STUDY MMPSS Z/T/C1/W1 $193.50

Morphine sulfate injection $113.80

MOUNTAIN CEDAR ALLER MCED E/L/M/O/W/X/C1/S1/L1 $25.50

MOUSE EPITH ALLERGEN MMOUS QC/Q/D/S/L/M/W/S1/N/L1 $25.50

MOUSE URINE PROTEIN MMOUP D/S/L/M/W/S1/N/L1 $25.50

MPO $187.00

MPOA REFLEX BILL ONLY $66.00

MS First Trimester UHL U5555-5 A/Q/S1 $102.50

MS Integrated Samp 2 UHL U5557-7 A/D/M/Q/S/T/S1/N/L1 $102.50

MS NTD AMNIOTIC UHL15019-3 D/M/L/W/P/Q/S/T $140.00

MS NTD SERUM UHL19177-5 A/D/L/M/O/Q/S/T/X/C1/S1 $84.50

MS Quad UHL U14000-0 A/D/E/L/M/P/Q/R/S/W/C1/S1/N/L1/W1 $59.00

151 of 172

Procedure Price

MUCOPOLYSAC SCRN MMPSSC L/M/W/L1 $275.00

MUCORIgE MMUC L/M/N/W/S1/D/S/L1 $18.00

MUGWORTIGE MMUG QC/Q/L/W/N/M/S1/D/S/L1 $35.50

MULBERRY ALLERGEN MMULB E/D/L/M/O/S/W/X/C1/S1/N/L1 $25.50

MULT SCLEROSIS PROF MMSP2 QC/Q/Z/L/M/W/D/S/S1/N/L1 $99.00

MUMPS AB IgG QC/Y/V/C1/E/J/L/M/O/P/W/S1/L1/P1 $31.50

MUMPS AB IGG/IGM MMMPGM QC/Z/D/E/L/M/N/O/R/S/W/X/C1/S1/T/L1/W1 $88.50

MUMPS IgG SCREEN MMPPG Z/E/J/L/M/O/W/X/C1/W1 $103.50

MUSHROOM ALLERGEN MMUSH QC/Q/D/L/M/S/W/N/L1 $25.50

MUSK ANTIBODY MFMUSK M/L/R/W/E/C1 $988.00

MUSK AUTOANTIBODY MMUSK D/L/M/R/S/W/N/L1/P $722.50

MVISTA Histo AG MFHST QC/Q/L/M/T/W/L1 $155.00

MVISTA SERUM BLASTOMYCES Ag L/M/W/L1 $181.50

MVISTA URINE BLASTOMYCES Ag L/M/W/L1 $181.50

MYCO HOMINIS PCR MMHRP D/L/M/S/W/S1/N/L1 $481.50

Mycophenolate mofetil oral $19.05

Mycophenolic acid $7.25

MYCOPHENOLIC ACID MMPA QC/Q/D/L/J/M/R/S/X/W/C1/E/S1/N/L1 $153.00

MYCOPL PNEUMO AB V/Y/P1 $78.00

MYCOPLASMA IGG/IGM MMYCO QC/Q/A/D/F/G/L/M/N/O/P/R/S/W/X/E/S1/Z/L1 $78.00

MYCOPLASMA PNEUMO DNA QUAL PCR MMPRP QC/Q/Z/D/L/M/S/W/S1/N/L1 $411.00

MYELOPEROXIDASE AB MMPO Z/L/M/W/C1/D/S/S1/N $157.00

MYELOPEROXIDASE IgG Y/Y/QC/L/M/P/W/C1/L1/C2/P1/Q/S1/O $46.00

MYOCARDIAL ANTIBODY ARUP ILH/PATHLAB/S1/L1 $145.50

MYOGLOBIN SERUM E/J/K/L/M/O/P/W/X $114.50

MYOGLOBIN URINE C1/E/L/M/O/P/W/S1/L1 $149.00

Na ferric gluconate complex $21.47

Naltrexone depot form $1.37

NASAL MRSA PCR Z/E/H/J/L/O/T/W/L1 $146.00

NASH FIBROSURE 550140 J/L/M/O/T/W/C1/S1/L1/P $48.00

Natalizumab injection $41.49

NATURAL KILLER FUNCT 2900800 L/M/W/L1 $312.50

Nelarabine injection $293.44

NEONATAL SCREEN UHL QC/A/D/L/M/Q/S/T/U/X/W/S1/N/L1/W1 $69.50

Neostigmine methylslfte inj $54.68

NEURONAL VG K CHAN AB MVGKC Z/D/L/M/S/W/S1/N/W1 $276.50

NICOTINE METAB SERUM MNICOS QC/Q/Z/A/D/N/P/R/S/X/E/S1/L1/W1 $90.00

152 of 172

Procedure Price

NICOTINE METAB URINE MNICOU QC/Q/Z/A/D/F/G/J/S/X/N/R/L1/W1 $68.50

Nicotine patch nonlegend $3.55

NICOTINE URINE L1 $106.50

NICU TYPE AND SCREEN ILHIMCWDM $130.50

NMDA-R Ab IFTITER MNMDIS Z/D/L/M/S/W/S1/N/L1 $226.00

NMDA-RECEPTOR ABCBA MNMDCS Z/D/L/M/S/W/S1/N/L1 $467.50

NMO AUTOANTIBODY IGG M83185 D/S/X/L/M/W/S1/L1 $293.00

NMO/AGP4 IGG MNMOFS QC/Q/Z/D/S/X/N/W1/L1/S1/O $280.00

NMO/AQP4-IGG CBACSF NMOCC Q/Z/L/M/W/C1/L1 $301.50

Non-covered item or service $5,493.65

Non-heu tc-99m add-on/dose $18.40

Normal saline solution infus $89.60

NORTRIPTYLINES MNOTRP QC/Q/Z/J/L/M/W/X/C1/S1/L1 $182.00

NTX-TELOPEPTIDE MNTXPR A/D/L/L1/M/N/S/S1/W/X/W1 $54.50

OAK ALLERGEN MOAK E/L/M/O/W/X/C1/L1 $25.50

Oasis tri-layer wound matrix $46.23

OAT ALLERGEN MOATS L/M/Q/QC/S/W/Z/C1/S1/L1 $25.50

Obinutuzumab inj $125.09

OCC BLD DIAGNOSTIC X3 Z/H/R/E/B1/L1/C1/N/U/M1/B/L/M/W/J $78.00

OCC BLD IMMUNO DIAG Z/H/K/O/P/S1/C1/L/M/W/T/C2 $47.00

OCCULT BLD GASTRIC QC/L/M/O/Q/S/T/W/B1/L1 $80.00

OCCULT BLD SCREEN X3 Z/H/K/O/C1/L/M/W/C2 $47.00

OCCULT BLOOD SCREEN 3SPEC Z/D/E/G/N/Q/S/U/B1/C1/P/R/P1/L/M/W/X $78.00

OCCULT BLOOD STOOL QC/A/F/G/Q/SA/T/J $78.00

Octreotide inj non-depot $90.10

Octreotide injection depot $410.33

Ofatumumab injection $116.58

OH-PROLINE T/F URINE ARUP ILH/IMC/S1/L1 $312.50

OKT3 ANTIBODY IMC/S1/L1 $510.50

OLIGOCLONAL BANDS SF MOLIG QC/Q/Z/A/D/S/T/X/L/M/W/S1/N/L1/W1 $45.00

OLIVE ALLERGEN MOLIVF D/S/L/M/W/S1/N/L1 $25.50

Omalizumab injection $76.73

Ondansetron hcl injection $88.10

ONION ALLERGEN MONIO QC/Q/L/M/W/S1/L1 $25.50

OPIATE CONFIRM GC/MS ILH/IMC/WDM/C1/S1 $114.50

OPIATE QUANT BY GCMS MEDTOX C1/L/M/O/R/W/L1 $63.50

OPIATES URINE D/E/L/M/S/T/X/O $63.00

153 of 172

Procedure Price

OR ISTAT PANEL 6 $100.50

OR ISTAT PANEL 8 $100.50

OR STAT PANEL 7 $100.50

Oral aprepitant $17.83

Oral dexamethasone $1.25

Oral everolimus $11.20

ORANGE ALLERGEN MORNG QC/Q/L/M/W/C1/S1/L1 $25.50

ORCHARD GRASS ALLERGEN MORCH QC/Q/M/L/W/C1/S1/L1 $25.50

OREGANO IGE OREG Z/L/M/W/L1 $9.50

ORGANISM CONCENTRATION $40.50

ORGN ACD SCRN URINE MAY MOAU QC/Q/D/J/L/M/P/R/S/T/C1/O/N/L1/W1 $180.50

Orphenadrine injection $120.30

OSMOLALITY QC/V/Z/Y/A/D/E/F/G/H/L/M/N/O/P/R/S/T/W/X/1/S1/L1/P1/W1 $159.00

OSMOLALITY STOOL IMC/ILH/WDM/L1/C1/S1 $58.50

OSMOLALITY URINE QC/V/Z/Y/A/D/E/F/G/H/J/L/M/N/O/P/R/S/T/W/1/S1/L1/P1/W1 $110.50

OSMOTIC FRAGILITY MFRAG QC/Q/A/D/L/M/S/T/X/W/C1/N/L1/W1 $332.50

Ovine up to 999 usp units $1.12

Oxacillin sodium injeciton $27.73

OXALATE URINE /M/O/P/C1/L1 $78.00

OXALATE URINE 24 HR E/L/M/O/P/R/W/C1/S1/L1 $78.00

Oxaliplatin $2.80

OXCARBAZEPINE MOMHC QC/Q/D/J/L/M/O/P/R/S/T/W/X/C1/S1/E/N/L1/W1 $206.00

OXYCODONE URINE L/M/W/S1/L1 $63.00

OXYCODONE URN QNT MEDTOX J/M/O/L1 $63.50

Oxytocin injection $99.20

OYSTER ALLERGEN MOYST QC/Q/L/M/W/C1/L1 $25.50

P2Y12 Platelet Rctvt L/M/W/L1 $109.50

PACKED CELLS $267.50

Paclitaxel injection $5.63

Paclitaxel protein bound $25.64

Paliperidone palmitate inj $21.94

Pamidronate disodium /30 mg $115.15

PANCREATIC ELASTSTL MFPAN1 QC/C1/Q/S1/O/R/L1/P/L/M/W/S/D/N/X/E/J/W1 $114.00

Papaverin hcl injection $156.20

PAPRIKA IGE MPAPR L/M/W/Z/L1 $9.50

PAR B19 PCR SERUM VIRACOR $297.50

PARANEO AUTOANTIAB MPAVAL QC/Q/Z/L/M/O/R/W/D/S/N/C1/S1/L1 $51.50

154 of 172

Procedure Price

PARANEOPLASTICWB MWBN Z/D/L/M/S/W/S1/N $168.50

PARASITE EXAMINATION M/L/W/X $242.00

PAROXETINE MEDTOX ILH/IMC/S1 $251.50

PARSLEY ALLERGEN MPSLY D/L/M/S/W/S1/N/L1 $25.50

PARVO B19 AG IgG/IgM MAYO MPARVS QC/Q/X/L/M/P/R/S/D/W/N/S1/L1/O/W1 $140.00

PARVO B19 BY PCR MPARVO QC/Q/L/M/W/S1/L1 $465.50

PARVO B19 PCR PLASMA VIRACOR $297.50

PBP2A BILL $59.00

PC CIL VOL RED $797.00

PC CN I L A $722.00

PC CN I L B $722.00

PC CN L A $597.00

PC IRRAD LEUKO $624.50

PC LEUKO $500.00

PCAS3IRRAD LEUKO $624.50

PCAS3IRRAD LEUKO SPLIT A $327.00

PCAS3IRRAD LEUKO SPLIT B $327.00

PCAS3LEUK $500.00

PCAS5IL $624.50

PCAS5LEUKO $500.00

PCP CONFIRM GC/MS ILH/IMC/WDM/O/C1/S1 $114.50

Pcv13 vaccine im $447.60

PCWASHEDIL $782.50

PCWASHL $619.00

PEACH ALLERGEN MPECH QC/Q/L/M/W/S1/L1 $25.50

PEANUT ALLERGEN MPEAN C1/E/L/M/O/W/X/L1 $25.50

PEAR ALLERGEN M82807 L/M/W/C1/L1 $25.50

PECAN ALLERGEN MPEC QC/Q/L/M/W/C1/L1 $25.50

PEDIATRIC BLOOD ADMINISTRATION $926.00

PEDIATRIC TESTOSTERONE ESOTERIX /M/H/S1/L1 $85.50

PEDS ESTRADIOL ESOTERIX /L/M/W/O/S1/J/L1 $114.50

PEDS FSH ESOTERIX /M/H/O/J/L1/P $112.00

PEDS LH ESOTERIX /M/H/J/L1/P $55.00

Pegaspargase injection $25,961.80

Pegloticase injection $5,116.68

Pemetrexed injection $130.14

Peng benzathine/procaine inj $28.20

155 of 172

Procedure Price

PENICILLIN G ALLERGN MPBPO QC/Q/D/L/M/S/W/S1/N/L1 $25.50

Penicillin g benzathine inj $70.28

Penicillin g potassium inj $90.35

PENICILLIN V ALLERGN MPENIV QC/Q/D/L/M/S/W/S1/N/L1 $25.50

PENICILLIUM IgE MPENL E/L/M/O/W/X/C1/S1/L1/Z $25.50

Pentamidine non-comp unit $201.30

PENTOBARBITAL IMC/C1 $100.00

Pentobarbital sodium inj $208.55

PERIOD/VOLUME ALL $68.50

Perphenazine 4mg oral $3.60

PH ARTERIAL Z/K/L/M/P/S/D/X/T/O/L1/W1 $44.50

PH FECAL MFPHFL C1/L/M/W/Z/L1 $79.00

pH FLUID QC/V/Z/Y/A/D/H/L/M/R/S/T/X/C1/L1//O/C2 $135.00

PH PLT SPLIT BAG 1 $1,244.50

PH PLT SPLIT BAG 2 $1,244.50

PH STOOL A/F/G/T $107.50

PH URINE CHEMISTRY ILH/IMC/WDM/L1 $56.00

PH VENOUS L/M/N $44.50

PHENCYCLIDINE URINE E/L/M/T/O $68.00

PHENOBARBITAL ALL EXCEPT I/S1 $214.50

Phenobarbital sodium inj $151.55

Phentolaine mesylate inj $937.50

Phenylephrine hcl injection $179.30

PHENYTOIN ALL $214.50

PHENYTOIN FR AND TL MPNTFT QC/Q/D/J/L/M/O/R/S/W/C1/S1/N/L1 $45.00

Phenytoin sodium injection $15.85

PHOSPHATIDYL ABS GMA ARUP L/M/C1/S1/L1 $80.00

PHOSPHATIDYL GLYCEROL IMC/ILH/J $343.00

PHOSPHOLIPID AB IGA MAYO MACLIP E/L/M/W/C1/S1 $78.00

PHOSPHOLIPID AB IGA QC/J/L/M/O/V/W/Y/S1/L1/P1 $48.00

PHOSPHOLIPID AB IGG QC/Y/V/L/M/W/S1/L1/P1 $48.00

PHOSPHOLIPID AB IGM QC/Y/V/L/M/W/S1/L1/P1 $48.00

PHOSPHOLIPID AB MCLPMG D/E/J/L/M/N/O/P/R/S/T/W/X/C1/S1/W1 $125.00

PHOSPHOLIPID IGG/IGM E/L/M/O/W/S1/C1/L1 $48.00

PHOSPHOLIPIDS MPPL P/Z/L/M/R/W/S1/L1 $142.00

PHOSPHORUS ALL $45.50

PHOSPHORUS URINE 24HR QC/V/Y/Z/U/A/D/E/F/G/L/M/N/P/Q/R/S/T/W/C1/S1/O/L1/P1 $127.50

156 of 172

Procedure Price

PHOSPHORUS URINE QC/Y/V/Z/A/F/G/L/M/Q/T/W/C1/L1/P1 $127.50

pHURINE V/Z/A/D/K/L/S/T/X/O/C2/P1 $32.50

PIG EPITH ALLERGEN MPIGE D/S/L/M/W/N/L1 $25.50

PIGEON FEATHER ALLER MPIGF D/S/L/M/W/N/L1 $25.50

PINE NUT ALLERGEN MPINE D/S/L/M/W/S1/N/L1 $25.50

PINEAPPLE ALLERGEN MPNAP QC/Q/L/M/W/C1/S1/L1 $25.50

PINWORM PREP /A/D/E/F/G/J/K/L/M/O/QC/P/S/W/X/V/Y/Z/L1/S1/P1 $114.00

Piperacillin/tazobactam $92.55

PISTACHIO ALLERGEN MPISTA L/M/W/C1/S1/L1 $25.50

PLACENTAL ART GASES A/L/M/W/S1/W1 $128.00

PLACENTAL VENOUS GAS A/L/M/S1/W1 $128.00

PLASMA FROZEN W/IN 24 HR THAWED PART A $184.50

PLASMA FROZEN W/IN 24 HRS THAWED $184.50

PLASMA FROZEN W/IN 24HR THAWED PART B $184.50

PLASMA FROZEN W/IN 24HR THAWED PART C $184.50

PLASMA FROZEN W/IN 24HR THAWED PART D $184.50

PLATE AB DIR AB V/Y/L/M/S1/L1/P1 $56.00

PLATELET AB SCREEN MPLABN D/S/Z/L/M/W/C1/S1/QC/N/L1/W1 $93.50

PLATELET COUNT L/M/W/P1 $48.00

PLATELET LEUKOREDUCED $386.50

PLT $196.00

PLT >9 LEUK BCCI M $233.00

PLT IRRADIATED $207.50

PLT PHERESIS IR LEUK BAG 2 $824.50

PLT PHERESIS IRLEUKVOL RED $1,458.00

PLT PHERESIS IRR HLA MATCHED $3,612.50

PLT PHERESIS IRR LEUKO HLA MATCHED $3,612.50

PLT PHERESIS IRR LEUKO HLA MATCHED BAG 2 $3,612.50

PLT PHERESIS LEUKOREDUCED SHORT $809.50

PLT PHERESISCMV NEGIRLEUKO $1,334.00

PLT PHERESISIRLEUKO $1,369.00

PLT PHERESISIRLEUKOBAG 2 $1,369.00

PLT PHERESISIRLEUKOBAG 3 $1,369.00

PLT PHERESISIRLEUKOSPLIT $824.50

PLT PHERESISIRRHLA MATCHED $3,612.50

PLT PHERESISLEUKO $1,244.50

PLT PHERESISLEUKOBAG 2 $1,244.50

157 of 172

Procedure Price

PLT PHERESISLEUKOBAG 3 $1,244.50

PLT PHERESISLEUKOSPLIT B $603.50

PLT POOL IRRAD LEUKO $251.00

PLT POOL5 IRR LE $235.50

PLT POOL5 LEUKO $211.00

PLT POOLLEUKO $203.50

PLTIRRADLEUKO $511.50

PLTPH CMVLR $1,208.50

PLTPH CN IR L B $1,334.00

PLTPH I LEUK WASHED PART A IMMC $1,728.00

PLTPH I LEUK WASHED PART B IMMC $1,728.00

PLTPH I LEUK WASHED PART C IMMC $1,728.00

PLTPH IR LEUKO BAG 3 $1,728.00

PLTPH IR LEUKO WASHED $1,728.00

PLTPH IR LEUKO WASHED BAG 2 $1,728.00

PLTPHIRRLEUKODIVIDEDPART A $835.00

PLTPHIRRLEUKODIVIDEDPART B $835.00

PLUM ALLERGEN MPLUM QC/Q/L/M/W/S1/L1 $25.50

PM-1 ANTIBODY MFPMSA D/S/L/M/W/C1/S1/N/L1 $168.00

PNEUMOCYSTIS BY PCR MPNRP A/L/M/W/X/S1/L1 $262.00

POC TROPONIN $63.00

POOLED CRYO $139.00

POOLED PLTS ACRODOSE IRRAD LEUKO $1,369.00

POOLED PLTS ACRODOSE LEUKOREDUCED $1,244.50

POPPY SEED IgE MPOPSD D/L/M/S/W/N/L1 $25.50

Porfimer sodium injection $38,727.58

PORK ALLERGEN MPORK QC/Q/L/M/O/W/C1/S1/L1 $25.50

PORPHOBILIQN RND U MPBGU QC/Q/Z/L/M/W/C1/J/L1/O/P/S1/R $128.00

PORPHYR QNRANDU MPQNRU QC/Q/Z/L/M/W/L1/W1 $44.00

PORPHYRINS RBC ARUP L/M/C1/S1/L1 $223.50

PORPHYRINS UR 24 HR MPQNU QC/Q/Z/A/D/L/M/N/P/R/S/W/X/C1/S1/L1 $178.00

POS BLD CULT ID PCR BILL ONLY L/M/W $33.50

POTASSIUM ALL $44.00

POTASSIUM FLUID A/L/M/L1 $80.00

POTASSIUM STOOL L/M/W/L1 $48.00

POTASSIUM URINE 24HR QC/V/Z/Y/U/A/D/F/G/L/M/N/Q/S/T/W/X/C1/S1/L1/O/P1 $60.00

POTASSIUM URINE QC/V/Z/Y/U/A/D/E/F/G/H/L/M/N/O/P/Q/R/S/T/W/1/L1/P1/W1 $60.00

158 of 172

Procedure Price

POTASSIUM-ISTAT H/M $29.00

POTASSIUMUR MRKUR L/M/W/L1 $30.00

POTATO ALLERGEN MPOTA QC/Q/L/M/W/C1/S1/L1 $32.00

Ppsv23 vacc 2 yrs+ subq/im $276.55

PRA CLASS I DTT L/M $792.50

PRA CLASS I L/M/C1/L1 $467.50

PRA CLASS II ABS $792.50

PRA CLASS II L/M/C1/L1 $467.50

PRADER-WILLI SYN L/M/W/S1/L1 $1,667.50

PREALBUMIN QC/V/Z/Y/A/D/E/F/G/J/L/M/N/O/P/Q/R/S/T/W/X1/S1/L1/P1/W1 $122.00

Prednisolone oral per 5 mg $1.95

Prednisone ir or dr oral 1mg $1.25

PREGNENOLONE SERUM MPREGN QC/C1/L/M/W/S1/L1 $208.00

PREWARM XM X $51.00

PRIMIDONE IMC/ILH/P/C1/S1/L1/E $214.50

Prion CJD Analysis $75.00

PRO BNP MAYO M84291 R/S1/W1 $312.00

PRO-BNP E/J/M/N/O/P/Q/QC/SA/X/Y/Z/C1/C2/L1/P1 $262.50

Procainamide hcl injection $34.80

PROCALCITONIN A/B/C1/C2/D/E/F/G/J/L/L1/M/M1/N/O/P/QC/S/S1/V/X/Y/Z/P1/R/W1 $172.50

PROCALCITONIN MPCT /L/M/W $368.00

Prochlorperazine injection $124.50

PROGESTERONE QC/V/Z/Y/A/B/E/F/G/J/L/M/O/P/R/W/X/S1/L1/P1/W1 $102.00

PROINSULIN MPINS QC/Q/A/L/M/N/W/C1/D/S/J/L1/R $173.00

PROLACTIN QC/V/Z/Y/A/D/E/F/G/J/L/M/N/O/P/Q/R/S/W/X/C1/S1/L1/P1/W1 $251.50

PROME THIOPURINE MET 3200 Y/L/M/V/W/S1/O/C1/L1/P1 $364.00

PROMET FIBROSPECT II 4000 O/V/Y/L/M/W/S1/L1/P1 $171.00

PROMETH CELIA SERO 1155 V/Y/L/M/W/S1/O/L1/C1/P1 $262.00

PROMETH CELIAC GENETICS V/Y/L/M/W/E/S1/L1/P1 $271.00

PROMETH CELIAC PLUS 6360 V/Y/M/W/S1/L1/P1 $350.00

PROMETH TPMT ENZYME 3320 V/Y/L/M/O/R/W/C1/S1/L1/P1 $225.50

PROMETH TPMT GENETICS 3300/S1/V/Y/L1/P1 $330.00

Promethazine hcl injection $95.50

PROMETHEUS IBS DIAG 8000 V/Y/M/S/S1/P1 $92.50

PROPAFENONE MPFN QC/Q/L/M/W/S1/L1 $144.50

PROPOXYPHENE URINE L/M/W/K $76.50

Propranolol injection $99.90

159 of 172

Procedure Price

PROSTATIC ACID PHOS MPACP D/S/T/X/L/M/P/W/S1/N/L1 $71.00

PROT S ACTIVITY MS_FX QC/Q/A/D/F/G/S/T/X/S1/N/W1 $236.50

PROT/CREAT RATIO UA /Z/Y/A/B/D/E/F/G/J/K/L/M/N/O/P/Q/R/S/X/S1/B1/L1/C2/P1/W1 $147.00

PROTEIN C ACTIVITY A/E/L/M/P/R/W/X/O/C1/S1/L1 $76.00

PROTEIN C ACTIVITY MCFX QC/Q/A/D/F/G/S/T/C1/S1/W1 $260.00

PROTEIN C AG MAYO M9127 ALL EXCEPT B/H/K/R/U/V/Y/C2/P1 $44.50

PROTEIN CSF QC/V/Z/Y/A/B/D/E/F/G/J/L/M/N/Q/S/T/U/W/X/C1/O/L1/C2/P1/W1 $99.50

PROTEIN DIALYSATE 24 HR M $51.50

PROTEIN FLUID QC/V/Z/Y/A/D/E/F/G/H/J/L/M/N/Q/R/S/T/X/C1/L1/C2/P1 $99.50

PROTEIN PHORESIS E/J/L/M/O/P/R/C1/S1/L1/X $186.50

PROTEIN PHORESIS URN E/J/L/M/O/P/R/C1/S1/L1/X $186.50

PROTEIN S ACTIVITY E/J/L/M/O/P/R/W/C1/S1/L1 $107.00

PROTEIN S AG FREE MPSTF QC/Q/A/D/E/F/G/L/M/N/P/S/T/X/W/C1/S1/O/L1/W1 $45.00

PROTEIN S TOTAL MPST QC/Q/A/D/F/G/L/M/S/T/W/X/S1/N/O/L1/W1 $45.00

PROTEIN URINE 12 HR QC/D/E/L/M/P/Q/S/W/X/S1/L1 $147.00

PROTEIN URINE 24HR QC/V/Z/Y/A/B/D/E/F/G/J/K/L/M/N/O/P/Q/R/S/1/S1/L1/C2/P1/W1 $147.00

PROTEIN URINE QC/Z/Y/A/B/D/E/F/G/J/K/L/M/N/O/P/Q/R/S/U1/S1/B1/L1/C2/P1/W1 $147.00

PROTEINASE 3 Ab IgG QC/Y/V/L/M/W/C1/L1/P1/O/S1/T $46.00

PROTEINASE 3 AB MPR3 Z/E/L/M/W/X/C1/D/S/S1/N $66.00

PROTEINTOTAL ALL $45.50

PROTEINURINE V/Y/I/K/L/M/PL/O $46.00

PROTIME ALL $50.00

PROTIME M/W/L/MCFARLAND $50.00

PSA SCREEN Z/Y/V/E/K/L/M/N/W/C1/B1/C2/P1 $219.50

PSA TOTALFREE MPSAFT L/M/P/R/W/X/O/J/D/S/C1/E/S1/N/L1/W1 $138.50

PSA V/Z/E/K/L/M/N/P/W/C1/B1/C2/M1/P1 $219.50

PSEUDOCHOLINESTERASE MPCHES D/J/S/X/L/M/W/C1/N/E/L1 $51.00

PT G20210A MUTATION E/J/L/M/O/P/R/W/C1/S1/D/S/N/L1 $187.00

PTH INTACT ALL EXCEPT H/U $131.00

PTH INTACT W CALCIUM QC/V/Z/Y/L/M/R/PATHLAB/S1/L1/P1 $131.00

PTH RELATED PEPTIDE MPTHRP QC/Q/A/D/E/F/G/J/L/M/N/O/S/W/X/C1/Z/L1/W1 $190.00

PTT ALL $50.00

PYRIDINIUM CROSSLINKSTOTAL ARUPIMCINT/L1 $249.00

PYRIDOXAL 5-PHOSPHATE MPLP ALL EXCEPT B/K/U/T/V/Y/C2/P1 $212.00

Pyridoxine hcl 100 mg $117.90

PYRUVATE KINASERBC MPK QC/Q/D/S/L/M/W/S1/N/L1/W1 $158.00

PYRUVIC ACID MPRY QC/Q/Z/L/M/W/X/C1/S1/L1 $104.50

160 of 172

Procedure Price

Q FEVER AB IgG/IgM MQFP QC/Q/C1/A/D/S/L/M/O/W/S1/N/L1/W1 $101.00

QUANTIFERON TB GOLD E/J/L/M/O/P/R/W/T/S1/C1/L1 $98.00

QuantiFERON TB GOLD H/U $190.50

QUETIAPINE MEDTOX L/M/C1/S1/L1 $223.50

RA TITER M9060 M/L/W//S1 $34.50

RABBIT ALLERGEN MRAMB D/S/L/M/W/N/L1 $25.50

RABBIT EPITH ALLERGN MREPII L/M/W/L1 $25.50

RABBIT SERUM PROTEIN MRSER D/S/L/M/W/N/L1 $25.50

RABBIT URINE PROTEIN MRUPR D/S/L/M/W/N/L1 $25.50

Rabies ig heat treated $753.88

Rabies ig im/sc $1,507.75

Rabies vaccine im $766.30

RABIES VIRUS AB E/M/S1/L1 $146.50

Ranitidine hydrochloride inj $99.90

Rasburicase $640.95

RASPBERRY ALLERGEN MRASP D/S/L/M/W/N/L1 $25.50

RASURI URIC ACID QC/A/L/M/S/W/L1 $99.50

RAT EPITH ALLERGEN MRAT D/S/L/M/W/N/L1 $25.50

RAT SERUM PROTEIN MRTSP D/S/L/M/W/S1/N/L1 $25.50

RAT URINE PROTEIN MRTUP D/S/L/M/W/S1/N/L1 $25.50

RBC ADSORPTION A/D/M/S/T/X/Q/QC $399.00

RC CMV LEUKO $597.00

RC CMVIRLR $722.00

RCL VOL RED $575.00

RED BLOOD CELL EXCH ILHIMCWDM $3,344.50

RED CELLS A $500.00

RED CELLS AUTOLOGOUS BAG 1 $688.00

RED CELLS AUTOLOGOUS BAG 2 $688.00

RED CELLS B $569.50

RED CELLS DEGLYCEROLIZED BAG 1 $574.50

RED CELLS DEGLYCEROLIZED BAG 2 $574.50

RED CELLS DEGLYCEROLIZED IRRADIATED BAG 1 $825.00

RED CELLS DEGLYCEROLIZED IRRADIATED BAG 2 $825.00

RED CELLS IRR LR A 05771 $624.50

RED CELLS IRR LR B 05781 $624.50

RED CELLS IRRAD LR A $624.50

RED CELLS IRRAD LR B $624.50

161 of 172

Procedure Price

RED CELLS IRRADIATED LEUKOREDUCED WASHED BAG 1 $849.50

RED CELLS IRRADIATED LEUKOREDUCED WASHED BAG 2 $849.50

RED CELLS IRRADIATED WASHED BAG 1 $849.50

RED CELLS IRRADIATED WASHED BAG 2 $849.50

RED CELLS LEUKO WASHED $694.00

RED CELLS LEUKOREDUCED WASHED BAG 1 $694.00

RED CELLS LEUKOREDUCED WASHED BAG 2 $694.00

RED CELLS LR A $500.00

RED CELLS LR A 04771 $500.00

RED CELLS LR B $500.00

RED CELLS LR B 04791 $500.00

RED ROUGH PIGWEED MRRRP E/L/M/O/W/C1/S1/L1 $25.50

REDUCING SUBST STOOL A/F/G/T $81.50

REDUCING SUBST STOOL C/E/J/L/M/P/V/W/Y/L1/P1 $23.50

REDUCING SUBSTURINE Y/L/M/Q/T $58.00

Regadenoson injection $143.36

RENAL FUNCTION PNL Z/A/I/L/M/P/U/W/F/G/O/W1 $355.50

RENIN MPRA QC/Q/Z/D/E/F/G/L/M/O/P/R/S/X/Y/W/S1/N/L1/W1 $128.00

REPEAT AB SCREEN $130.50

REPTILASE TIME ARUP L/M/P/S1/L1 $171.00

REPTILASE TIME REFLEX BILL ARUP L $123.50

RESP ALLERG PROFILE E/L/M/O/W/C1/S1/L1 $25.00

RESP FILMARRAY PCR A/B1/C1/D/E/H/J/L/M/N/O/P/QC/R/S/S1/W/L1/B/W1 $112.50

RETICULIN AB RTA QC/Q/A/D/S/X/L/M/P/R/W/C1/S1/N/L1/J $148.00

RH IMMUNE GLOBULIN L/M/W/P1 $70.00

RHEUMATOID FACTOR QC/V/Z/Y/A/D/E/F/G/I/J/L/M/N/O/P/S/W/X/C1/S1/L1/P1 $86.00

Rho d immune globulin inj $323.50

RIBOSOME P ABIGG MRIB O/Z/D/L/M/P/S/W/C1/N/X $125.50

Ribosome P AbIgG QC/Y/V/C1/L/M/P/W/L1/P1 $43.00

RICE ALLERGEN MRICE QC/Q/L/M/W/C1/S1/L1 $25.50

Ringers lactate infusion $60.00

Risperidone long acting $21.64

RISTOCETIN COFACTOR MRIST D/S/X/L/M/W/E/O/C1/S1/N/L1/W1 $240.50

Rituximab injection $2,135.10

Riv4 vacc recombinant dna im $181.40

RNP AbIgG QC/Y/V/C1/E/J/L/M/O/P/R/W/L1/P1 $43.00

Romiplostim injection $150.45

162 of 172

Procedure Price

Ropivacaine hcl injection $44.25

ROSEMARY ALLERGEN MFROSE L/M/W/L1 $63.00

ROUGH MARSH ELDER AL MMARS E/L/M/N/O/W/C1/D/S/L1 $25.50

RPR CONFIRM L/M/W/L1 $91.50

RPR QUALITATIVE QC/V/Y/D/E/F/N/O/P/R/S/T/X/C1/S1/W1 $91.50

RPR RESP TO THERAPY L/M/W/L1 $91.50

RSV AG BY IFA L/M/W/L1 $62.00

RSV ANTIGEN ALL $248.50

Rsv mab im 50mg $2,964.25

RUBELLA AB IGG QC/Y/V/J/L/M/O/P/R/W/S1/L1/P1 $18.00

RUBELLA IGM L/M/P/S1/L1 $139.50

RUBELLA SCREEN Z/D/E/L/M/N/O/P/Q/R/S/W/X/C1 $107.50

RUBEOLA AB IgG MROPG QC/Q/Z/E/J/L/M/O/P/W/X/C1/S1/W1 $115.50

RUBEOLA AB IgG QC/Y/V/C1/E/J/L/M/P/W/S1/L1/P1 $31.50

RUBEOLA AB IGG/IGM MROGM QC/Q/D/S/X/L/M/P/W/S1/N/L1/W1 $115.50

RUSSIAN THISTLE ALRG MRUSS E/L/M/O/W/X/C1/S1/L1 $25.50

RWB IR LEUK IMMC $624.50

RYE ALLERGEN MRYE QC/Q/L/M/W/C1/L1 $25.50

RYE GRASS ALLERGEN MRYEG L/M/W/L1 $25.50

S PNEUMO AG CSF L/M/T/X/W $263.00

S PNEUMO AG SERUM L/M/T/X/W $263.00

S PNEUMO AG URINE A/C1/D/E/J/L/M/N/QC/S/T/V/W/Y/Z/L1/P1 $229.50

S PNEUMO IgG AB 23 MPN23 QC/Q/Z/D/J/L/M/N/P/R/S/W/C1/X/S1/O/L1/W1 $11.50

SACCHAROMYCES IGA MAASCA E/D/S/N/L/M/W/Q/L1 $294.50

SAGE ALLERGEN IGE MFSAG L/M/W/L1 $86.50

SALICYLATE QC/Z/A/B/D/F/G/H/K/L/M/O/P/Q/S/T/X/C1/S1/L1/W1 $99.50

SALMON ALLERGEN MSALM QC/Q/L/M/O/W/C1/S1/L1 $25.50

SALMONELLA ABS 2010798 L/M/W/L1 $33.00

SALMONELLA TYPHI ABS ARUP L/M/W $24.00

SARDINE ALLERGEN MSARD D/S/L/M/W/S1/N/L1 $25.50

Sargramostim injection $118.41

SCABIES EXAMINATION L/M/W/C1/L1 $114.00

SCALLOPS ALLERGEN MSCALS E/L/M/O/W $25.50

Scl 70 AbIGG QC/V/Y/C1/E/J/L/M/O/P/R/W/S1/L1/P1 $43.00

SCL70 AUTOANTIBODIES MSCL70 D/S/N/T/R/X/L/M/P/W/E/C1 $74.00

SCREENOVA & PARASITES E/J/L/M/P/R/W/C1/S1/L1 $55.50

SELENIUM MSES QC/Q/A/D/E/J/L/M/O/P/S/W/C1/S1/N/L1/W1 $141.50

163 of 172

Procedure Price

SELENIUM URINE 24 HR ARUP IMC/L1 $151.50

SEMEN ANALYSIS M/P/R/S1/L1 $228.50

SENS 1 DRUG $25.50

SENS 11 DRUGS $25.50

SENS 2 DRUGS $25.50


SENS 3 DRUGS $25.50


SENS 4 DRUGS $25.50


SENS 5 DRUGS $25.50

SENS 6 DRUGS $25.50

SENS 7 DRUGS $25.00

SENS 8 DRUGS $25.00

SENS 9 DRUGS $25.00

SEROLOGIC TYPING $124.50

Serotonin RelUnfra Hep MFPORC QC/Q/L/M/W/C1/S1/L1 $419.50

SEROTONIN WHOLE BLD MSERWB QC/Q/L/M/W/C1/L1 $198.00

SERTRALINE MFSERT L/M/W/L1 $192.00

SERUM BACTERIC.LEVEL /L/X//S1 $317.50

SERUM REDOX TO ST LOUIS L/M/W/S1/L1 $89.00

SESAME SEED IGE ALG MSESA E/L/M/O/W $25.50

SEX HORMONE BIND GLOB MSHBG A/D/L/M/O/P/R/S/W/X/E/C1/S1/N/L1/W1 $109.00

SEX HORMONE BIND GLOB V/Y/L/M/X/W/P1 $109.00

SHEEP WOOL ALLERGEN MSHWL D/S/L/M/W/S1/N/L1 $25.50

SHIGELLA CULT POS PT 10019 L/M/W $123.00

SHORT RAGWEED ALLERG MSRW E/L/M/O/W/X/C1/L1 $25.50

SHRIMP ALLERGEN MSHRI E/L/M/O/W/C1/L1 $25.50

SICKLE CELL SCREEN QC/V/Z/Y/A/L/M/P/W/C1/J/E/S1/L1/P1 $111.00

SILVER BIRCH TREE AL MBIR QC/Q/L/M/W/C1/S1/L1 $25.50

Sincalide injection $289.85

SIROLIMUS E/J/L/M/O/P/R/C1/S1/L1 $124.00

Sirolimus oral $36.10

SLAM ASSOC PROTEIN 2901900 L/M/W $135.50

Sm AmIgG QC/Y/V/C1/E/J/L/M/O/P/W/R/S1/C1/L1/P1 $43.00

SMA CONFIRM GC/MS ILH/IMC/P/WDM/S1 $114.50

SMA CONFIRM GCMS C1/J/L/M/O/W/S1/P/L1 $114.50

164 of 172

Procedure Price

SODIUM ALL $41.00

SODIUM FLUID QC/A/L/M/L1 $40.50

SODIUM RAN URN MAYO 84522 /L1 $34.50

SODIUM STOOL ILH/IMC/WDM/L1 $52.50

SODIUM URINE 24HR QC/V/Z/Y/U/A/B/D/E/F/G/L/M/N/O/P/Q/S/T/W/X/S1/L1/W1 $59.00

SODIUM URINE QC/V/Z/Y/U/A/B/D/E/F/G/H/J/L/M/N/O/P/Q/R/S/T1/L1/W1 $59.00

SODIUM-ISTAT H/M $29.00

SOLE FISH ALLERGEN MSOLEF D/S/L/M/W/S1/N/L1 $25.50

SOLUBLE INTERLEUKIN 2-R SIL2R L/M/W/S1/L1 $372.50

SOLUBLE TRANS RECEPT MASTFR QC/Q/A/D/E/F/G/J/L/M/S/T/W/X/S1/N/L1/W1 $206.50

SOYBEAN ALLERGEN MSOY C1/E/L/M/O/W/L1/W1 $25.50

SPEC GRAVITY URINE Z/Y/A/D/E/I/K/L/M/O/S/T/X $41.00

SPECIFIC GRAVITY FLD V/Z/Y/A/D/L/M/Q/S/X/W/C1/S1/L1/O $57.50

SPERM COUNT L/M/P/S1/L1 $84.50

SPINACH ALLERGEN MSPIN QC/Q/D/L/M/S/W/S1/N/L1 $25.50

SPOTTED FEVER GR AB MSFGP QC/Q/Z/L/M/W/E/J/L1/O/S1/P/R/C1/W1 $36.00

SQUASH ALLERGEN MSQUA D/L/M/O/S/W/S1/N/L1 $25.50

SQUID ALLERGEN MSQUID QC/Q/D/S/L/M/W/S1/N/L1 $25.50

SS-A/RO AbIgG QC/Y/V/C1/E/J/L/M/P/R/W/O/L1/P1 $43.00

SS-B/LA AbIgG QC/Y/V/C1/E/J/L/M/P/R/W/O/L1/P1 $43.00

STACLOT LA P MSTLA QC/Q/Z/D/L/M/S/W/X/C1/S1/N/L1/W1 $355.00

STAPH KB IMC $98.00

STAT C DIFFICILE MOLEC L/W/M $158.50

Sterile cefuroxime injection $91.40

STERILITY CULTURE /O $185.50

STL CRYPTOSPORIDIUM V/Y/L/M/R/W/J/C1/S1 $144.00

STONE ANALYSIS MCASA QC/Q/A/D/E/F/G/J/L/M/N/P/R/S/T/Q/C1/S1/L1/W1 $48.00

STONE ANALYSIS UROLITH ILH $101.00

STOOL FILMARRAY PCR B1/C1/D/E/H/J/L/M/N/O/P/Q/QC/R/S/S1/T/V/W/Y/L1/B/P1 $608.00

STOOL FOR SHIGA TOXIN V/Y/H/L/M/W/C1/S1 $173.50

STOOL ROTAVIRUS T/A/D/E/F/G/J/L/M/N/O/P/R/S/T/W/X1/S1/L1/W1 $249.50

STOOL WBC A/E/F/G/J/K/L/M/N/O/P/Q/R/W/C1/B1/L1 $73.00

Strattice tm $83.20

STRAWBERRY ALLERGEN MSTRBY QC/Q/L/M/W/C1/S1/L1 $25.50

STREP A SCR POC L/M/W $71.00

STREP GP A ANTIGEN $71.50

STREP GP A ANTIGEN ALL $71.00

165 of 172

Procedure Price

STRIATED MUS IGG TITER BILL ONLY $105.00

STRIATED MUSCLE AB MSTR QC/Q/L/M/W/E/C1/S1/N/D/S/L1 $120.50

Succinycholine chloride inj $91.35

SUDAN BLACK IMC $142.00

SULFOCYSTEINE L/M/W/S1/L1 $428.50

SULFONAMIDES ARUP L/M/S1/L1 $101.00

Sumatriptan succinate / 6 mg $223.80

SUNFLOWER SEED ALLER MAYO??/L1 $25.50

SUPERSATURATION U MSAT24 L/M/O/R/W/Z/L1/W1 $89.00

Supprelin la implant $61,909.95

SWEAT CHLORIDE $101.00

SWEET POTATO ALLERGN MSPOT QC/Q/L/M/W/S1/L1 $25.50

SWORDFISH ALLERGEN MSWORD D/S/L/M/W/S1/N/L1 $25.50

SYPHILIS AB IGG QC/Y/V/J/L/M/W/Q/O/C1/P/J/L1/P1 $50.50

T VAGINALIS BY EIA L/M/P/W/J/S1/L1 $58.50

T&B BASIC PANEL E/J/L/M/P/R/W/C1/S1/O/L1 $202.00

T&B HELPER/SUPPRESSOR E/J/L/M/P/C1/S1/L1 $349.00

T3 REVERSE V/Y/L/M/P/R/E/J/C1/O/S1/L1/P1 $117.50

T3 UPTAKE Y/V/L/M/W/E/J/O/P/R/C1/S1/L1/P1 $15.00

Tacrol astagraf ex rel oral $0.77

Tacrol envarsus ex rel oral $1.71

Tacrolimus imme rel oral 1mg $8.20

TACROLIMUS L/M/R/E/O/J/C1/S1/L1 $306.50

Tamoxifen 10 mg $3.20

TARRAGON IGE /L1 $76.00

TB Gold Plus E/J/L/M/O/P/R/W/T/S1/C1/L1 $90.00

TB PCR BILL $382.00

T-CELL GENE REARRANGEMENT MAYO L/M/S1/L1 $766.00

Td vacc no presv 7 yrs+ im $153.30

Tdap vaccine 7 yrs/> im $167.60

TdT $187.00

TEA ALLERGEN MTEA QC/Q/M/L/W/L1 $25.50

TELOMERIC REGIONS BY FISH U OF I L/M/S1 $1,747.50

Temozolomide $27.37

Temsirolimus injection $105.60

Terbutaline sulfate inj $123.50

TEST FRFEMALE/CHILD V/C1/E/J/L/M/O/P/R/T/W/S1/L1 $134.00

166 of 172

Procedure Price

TESTOSTERONE FRMALE C1/E/J/L/M/O/P/R/W/S1/L1 $59.00

TESTOSTERONE GROUP MTGRP A/D/E/F/G/J/O/P/R/S/T/X/S1/N/W1 $49.50

TESTOSTERONE T/B/F MTTFB QC/L/M/W/E/P/S1/T/C1/L1 $28.50

TESTOSTERONE TOT/BIOAVAIL MTTBS QC/Q/E/J/L/M/O/W/C1/S1/T/L1 $45.00

TESTOSTERONEFREE V/Y/P1 $121.50

TESTOSTERONETOTAL /X $160.50

TESTOSTERONETOTAL V/Y/A/E/F/G/J/L/M/O/P/R/W/C1/S1/L1/P1 $160.50

Tetanus immune globulin inj $1,083.60

TETANUS TOX IgG AB MTTIGS QC/Q/D/J/L/M/N/P/S/R/W/C1/O/L1 $66.50

TETNUS/DIPHTH AB PNL MDTABS QC/Q/Z/D/S/L/M/W/C1/N/O/L1 $63.00

THAL AND HEMOGL EVAL MTHEVP L/M/W/Z/Q/S1/L1/W1 $125.00

THAWING CHARGE QC $31.50

THC CONFIRM GC/MS L/M/O/P/R/W/C1/J/S1/L1 $114.50

THEOPHYLLINE ALL $186.50

THERAP PHLEB BAG $12.00

THERAP PLASMA EXCH COLUMN $3,344.50

THERAP PLASMA EXCH ILHIMCWDM $3,344.50

Theraskin $341.43

THIAMIN WHOLE BLOOD MTDP QC/Q/Z/A/D/E/F/G/J/L/M/N/O/P/R/S/S1/X/L1/W1 $92.50

Thiamine hcl 100 mg $97.45

THIN PREP PAP 88141 L/M $107.50




THINPREP PAP 88174 ARUP L/M $145.00

THIORADAZINE ARUP ILH/PATHLAB $139.50

THIOTHIXENE MFFTHIS QC/Q/L/M/W/S1/L1 $142.50

THROMBIN TIME BILL ONLY L/M/W $35.00

THROMBIN TIME I/L/M/O/X/E/C1/L1 $35.00

THROMBIN TIME MTT QC/Q/Z/D/S/T/L/M/P/W/X/W1 $64.50

THYME IGE THYM Z/L/M/W/L1 $9.50

THYROGLOBULIN AB QC/E/J/L/M/O/P/R/V/Y/W/C1/S1/L1/P1 $88.00

THYROGLOBULIN PANEL MHTG2 QC/Q/D/E/J/L/M/N/P/R/S/T/W/X/Z/C1/O/S1/L1 $52.50

THYROID AB GROUP J/L/M/O/P/R/W/C1/S1/L1 $100.50

THYROID STIM IM'GLOB MTSI QC/Q/A/D/E/J/L/M/N/O/P/R/S/W/X/C1/Z/S1/T/L1/W1 $502.50

Thyrotropin injection $12,396.78

THYROXINE BIND GLOB MTBGI QC/Q/D/S/L/M/P/R/W/X/S1/N/T/J/L1 $116.00

167 of 172

Procedure Price

THYROXINE FREE QC/A/B/D/F/G/I/J/K/L/M/P/Q/R/S/T/W/X/S1/B1/L1/W1 $170.50

THYROXINE TOTAL T4 QC/V/Z/Y/A/B/D/E/F/G/J/L/M/N/O/P/Q/R/S/T/W1/S1/L1/P1/W1 $194.50

TIAGABINE MFGTIA QC/Q/D/S/L/M/R/W/S1/N/L1 $147.50

TILAPIA ALLERGEN IgE MFFTIL D/L/M/O/S/W/N/L1 $86.50

TIMOTHY GRASS ALLERG MTIMG E/L/M/O/W/X/C1/L1 $25.50

TIS TRANSGLU AB PROF MTSTGP D/E/J/L/M/N/O/P/R/S/W/X/C1/S1 $93.00

TIS TRANSGLUTN IGA AB MTTGA A/D/E/F/G/J/L/M/N/O/P/R/S/W/X/S1/W1 $62.50

Tobramycin non-comp unit $158.25

TOBRAMYCIN PEAK QC/V/Z/Y/A/F/G/L/M/P/R/T/X/W/C1/L1/P1/W1 $186.50

TOBRAMYCIN QC/V/Y/A/E/F/G/L/M/X/W/R/L1/P1 $186.50

Tobramycin sulfate injection $92.60

TOBRAMYCIN TROUGH QC/V/Z/Y/A/F/G/L/M/R/T/X/W/C1/O/L1/P1/W1 $186.50

TOCAINIDE ARUP IMC/ILH/S1/L1 $268.00

Tocilizumab injection $12.01

TOMATO ALLERGEN MTOMA QC/Q/L/M/R/W/C1/L1 $25.50

TOPIRAMATE MTOPI QC/Q/Z/A/D/E/F/G/J/L/M/N/O/P/S/T/W/X/S1/L1/W1 $219.50

Topotecan injection $32.13

TORCH PROFILE IgG MTRCHG D/S/M/L/W/C1/S1/N/L1/J $74.50

TORCH PROFILE IgM MTCHM QC/Q/D/L/M/S/W/C1/S1/N/L1/J $38.50

TOTAL PROTEINU MRPTU L/M/W/S1/L1 $113.00

TOXOPLASMA AB IGM MTXM J/L/M/O/R/W/C1/L1/W1 $29.00

TOXOPLASMA ANTIBODY UHL /S1 $255.00

TOXOPLASMA IgG AB J/L/M/O/R/W/C1/S1/T/L1 $122.00

TPEX ADD CHG $112.00

TRANSFERRIN QC/V/Y/A/E/F/G/I/J/L/M/O/P/W/C1/S1/R/L1/P1 $158.00

TRANSFUSION REACTION /A/E/L/M/Q/T/W/X/QC $66.00

Trastuzumab injection $204.26

Trauma ROTEM Battery $143.00

TRAZODONE MFFTRZ Z/A/D/F/G/L/M/S/T/W/C1/S1/N/L1 $102.00

TREPONEMA PALLIDUM A U24312-1 A/D/M/P/O/S/X/W/C1/S1/L1 $48.50

Triamcinolone acet inj nos $126.30

TRICHINELLA AB MAYO MSTRIC Z/L/M/W/S1/L1/W1 $138.50

TRICHOSPOR PULLANS IGE MTRPU L/M/W/S1/L1 $35.50

TRICYCLIC ANTIDEPRESSANTS ARUP L/M/S1/L1 $40.00

TRIGLYCERIDE FLUID QC/V/Z/Y/A/D/L/M/N/R/S/T/X/C1/L1/O/P1/W1 $57.00

TRIGLYCERIDES ALL $45.50

TRIIODOTHYRONINE A/E/F/G/J/L/M/O/P/W/R/C1/L1/W1 $202.50

168 of 172

Procedure Price

TROPONIN T K/X/L/M/W $155.50

TROUT ALLERGEN MTROT QC/Q/D/S/L/M/W/S1/N/L1 $25.50

TRYPTASE MTRYPT QC/Q/A/D/E/F/G/L/M/S/W/P/C1/J/Z/S1/N/O/L1/W1 $306.50

TSH 3RD GENERATION I/K/L/M/P/U/W/C1/B1/P1 $268.00

TSH RECEPTOR AB Y/V/L/M/W/S1/C1/L1/E/P1 $108.00

tTG AB IgA QC/Y/V/C1/E/J/L/M/O/P/R/T/W/S1/L1/P1 $32.50

tTG AB IgAIgG C1/E/J/L/M/O/P/R/T/W/S1/L1 $32.50

tTG AB IgG QC/Y/V/C1/E/J/L/M/O/P/R/T/W/S1/L1/P1 $32.50

TUMERIC ALLERGEN IGE MFCTUR L/M/W/L1 $86.50

TUNA ALLERGEN MTUNA QC/Q/L/M/W/C1/S1/L1 $25.50

TURKEY ALLERGEN MTURK QC/Q/L/M/W/L1 $25.50

TURKEY FEATHER ALLER MTURKF L/M/W/L1 $25.50

TYPE AND SCREEN Z/Y/D/E/L/M/N/Q/S/T/W/X/C1/Q/L1/A/P1/W1 $130.50

UA HISTOPLASMA AG MFMVHU QC/Q/Z/Q/S1/D/S/N/L1/X/W1 $381.00

UA HISTOPLASMA AG UHIST QC/Q/A/D/N/R/S/T/Z/X/W1 $182.00

UMACRO BILL $56.00

Unclassified biologics $1,591.85

UPC PT CLINIC ONLY /M $50.00

UPC PTT CLINIC ONLY M/S1 $50.00

UR HEAVY METAL SCRN MHMSU QC $60.00

UREA CLEARANCE ILH $160.50

UREA CLEARANCE IMC/S1/L1 $50.50

UREA NITRO URN 24HR V/Z/U/A/D/E/F/G/L/M/P/Q/R/S/T/W/X/S1/L1/P1 $110.50

UREA NITROGEN URINE A/D/L/M/O/Q/S/V/W/X/Y/Z/C1/L1/P1/W1 $127.50

UREAPLASMA PCR MURRP Z/D/S/L/W/M/C1/S1/N/L1 $667.00

URIC ACID ALL $99.50

URIC ACID FLUID A/F/G/J/L/M/R/X/C1/L1 $86.50

URIC ACID URINE 24HR QC/V/Y/Z/A/D/E/F/G/L/M/N/O/P/Q/S/T/W/X/C1/S1/L1/P1 $127.50

URIC ACID URINE QC/Y/Z/A/L/M/N/Q/T/Q/X/D/S/C1/L1/P1 $57.50

URINALYSIS L/M/W/PL $65.00

URINALYSIS POC L/M/W $56.00

URINE CREA 12 HR E/L/M/W/S1/L1 $127.50

URINE CREA CLEAR 12 HR L/M/W/S1/L1 $160.50

URINE HCG SCREEN L/M/Q/W $107.50

URINE MACROSCOPIC ALL EXCEPT NS1Z $56.00

URINE MICRO POC $65.00

URINE MICROSCOPIC B/C1/E/H/X/P1 $28.50

169 of 172

Procedure Price

URINE MICROSCOPIC QC/Y/A/D/F/G/I/K/L/N/O/Q/R/S/T/U/W/X/C1/S1/C2/L1/P1/W1 $65.00

URINE PROTEIN OB 24 L/M/W/S1/O/L1 $147.00

Ustekinumab iv inject 1 mg $24.73

VAGINITIS SCREEN A/D/H/L1/N/QC/S/T/V/Y/P1/W1/P $48.50

VALPROIC ACID QC/V/Z/Y/A/B/D/E/F/G/H/L/M/N/O/P/R/S/T/U/W1/S1/B1/L1/P1/W1 $200.50

Vancomycin hcl injection $105.30

VANCOMYCIN PEAK ALL EXCEPT J/K/Q/U $192.50

VANCOMYCIN QC/V/Y/A/F/G/L/M/Q/R/W/X/S/D/B1/L1/C2/P1/W1 $192.50

VANCOMYCIN TROUGH ALL $192.50

Var vaccine live subq $331.55

VARICELLA IgG AB E/J/L/M/N/O/P/R/W/C1 $55.00

VARICELLA ZOSTER IGG MVZPG Z/X/L/M/W/W1 $129.00

VARICELLA ZOSTERPCR MLVZV QC/Q/E/L/M/N/P/W/X/C1/D/S/W1 $114.50

Varicella-zoster ig im $1,343.60

VDRL CSF L/M/W/C1 $91.50

VENOUS BLOOD GAS L/M/S1 $128.00

VIABILITY DYE 7AAD $61.50

VIBRIO PLATE $40.50

Vinblastine sulfate inj $47.07

Vincristine sulfate 1 mg inj $378.60

Vinorelbine tartrate inj $121.70

VIP MVIP /ALL $422.50

VIRAL NONRESP CULT MVIRNR QC/Q/D/S/T/M/L/W/X/N/W1 $89.50

VISCOSITY MVISCS QC/Q/D/S/L/M/W/C1/S1/N/L1/W1 $76.50

Visualization adjunct $50.93

VIT B12 BIND CAP MFVITB QC/Q/L/M/W/S1/L1 $111.50

VIT D 125 DIHYDROXY MDHVD QC/Q/A/D/E/F/G/J/L/M/N/O/P/R/S/T/W/X/C1/S1/L1/W1 $131.50

VIT D125-DIHYDROXY V/Y/P1 $131.50

VITAMIN A MVITA D/E/J/L/L1/M/N/O/P/Q/QC/R/S/S1/T/W/X/Z/W1 $107.00

VITAMIN B12 & FOLATE QC/Z/A/F/G/I/L/M/W/S1/L1/C2/W1 $247.00

Vitamin b12 injection $101.50

VITAMIN B12 QC/V/Z/Y/A/B/D/E/F/G/I/J/K/L/M/N/O/P/Q/R/S1/S1/L1/C2/P1/W1 $230.50

VITAMIN C MVITC QC/Q/A/D/F/G/L/M/N/S/X/W/C1/S1/T/L1/J/W1 $71.00

VITAMIN D25 HYDROXY Q/QC/V/Z/Y/A/B/D/E/F/G/J/K/L1/N/C2/P1/W1 $141.50

VITAMIN E E/J/L/M/O/P/R/C1/S1/L1 $116.50

VITAMIN K 1 MVITK1 QC/Q/D/S/L/M/N/W/E/J/C1/S1/L1/X/W1 $197.50

Vitamin k phytonadione inj $132.50

170 of 172

Procedure Price

VMA URINE 24HR C1/E/J/L/M/P/R/W/S1/L1 $98.00

VOLATILE SCRNS MVLTS L/M/W/C1/S1/L1 $284.50

VOLATILE SCRNU MVLTU M/L/W/S1/L1 $151.00

VON WILL FACTR MULTI MVWFM L/M/W/S1/D/S/N/L1/Z/W1 $99.50

VON WILLEBRAND PROF MVWPR E/L/O/M/N/R/W/C1/S1/D/S/L1/J/W1 $172.00

VONWILLEBRAND FC ACT MVWFX J/Z/D/E/L/M/N/S/T/W/X/W1 $355.00

VONWILLEBRAND FC AG MAYO M9051 QC/Q/A/D/S/X/L/M/W/N/L1 $340.00

VORICONAZOLE MVORI A/D/E/F/G/J/L/M/N/O/S/W/Z/L1/S1/W1 $274.00

VZV AB IGG IGM VZGM QC/A/E/F/G/L/M/O/P/R/W/X/C1/S1/J/L1/W1 $149.50

VZV AB IgM MVZM QC/Q/D/E/J/L/M/N/P/R/S/W/X/C1/S1/L1 $169.50

VZV ANTIBODY IgG Q/QC/Y/V/C1/E/J/L/M/O/P/R/W/S1/L1/P1 $18.00

VZV BY PCR C1/E/J/L/M/O/P/T/W/S1/L1 $165.00

W NILE IgG/IgM CSF MWNC QC/Q/Z/D/L/M/S/W/X/C1/S1/N/L1 $46.00

WALNUT FOOD ALLERGEN MBLW E/L/M/O/W/C1/L1 $25.50

WALNUT TREE ALLERGEN MWALN E/L/M/O/W/C1/L1 $25.50

WARFARIN MWRF L/M/W/S1/L1 $263.00

WASHED PC $574.50

WASP VENOM ALLERGEN MWSPV D/L/M/S/W/C1/N/L1/O $25.50

WATERMELON ALLERGEN MWMEL QC/Q/D/S/L/M/W/Z/N/L1 $25.50

WBC AND DIFFERENTIAL L/M/W $57.50

WBC COUNT L/M/W $57.50

WDM CAPILLARY COLLWCAP $28.00

WDM VENIPUNCTURE $28.00

WELLNESS CELL PROFILE IMC $23.50

WEST NILE AB IGG IGM MWNS A/C1/D/E/F/G/J/L/L1/M/N/O/P/Q/QC/R/S/S1/W/X/Z/W1 $37.50

WEST NILE VIRUS PCR MLCWNV QC/Q/A/D/F/G/L/M/S/W/T/N/L1/C1 $194.00

WEST NILE VIRUS PCR P WNVP Z/L/M/W/E/J/L1/O/S1/P/R/C1 $97.00

WESTERN RAGWEED ALRG MWRW QC/Q/L/W/M/S1/L1 $25.50

WET MOUNT EXAM L/M/W/L1 $149.00

WHEAT ALLERGEN MWHT C1/E/L/M/O/W/L1 $25.50

WHEY ALLERGEN MWHEY D/S/L/M/W/S1/N/L1 $25.50

WHITE ASH TREE ALLER MASHW E/L/M/O/W/X/C1/S1/L1 $25.50

WHITE BEAN ALELRGEN MBENW QC/Q/L/M/W/L1 $25.50

WHITE FAC HORNET VEN MWFHV L/W/M/S1/L1/C1/O $30.00

WHITE HICKORY TREE MWHIC D/E/L/M/N/O/S/W/C1/L1 $25.50

WHITE PINE ALLERGEN MWPIN QC/Q/D/S/L/M/W/S1/N/L1 $25.50

WHOLE BLOOD $402.50

171 of 172

Procedure Price

WILLOW ALLERGEN MWILL L/M/W/L1 $25.50

WORM IDENTIFICATION UHL D/M/O/S/P/S1/L1 $59.50

XANAX MFALPX QC/Q/A/F/G/L/M/R/W/C1/L1 $167.00

YEAST ID $90.00

YEAST ID X2 $90.00

YEAST ID X3 $90.00

YEL FACE HORNET VEN MYFHV L/M/W/L1/C1/O $30.00

YELLOW JACKET ALLERG MYJV D/L/M/S/W/C1/S1/N/L1/O $25.50

YERSINIA PLATE $40.50

Zidovudine $4.84

ZINC MZNS QC/Q/D/E/J/L/M/N/O/P/R/S/T/W/X/C1/S1/L1/W1 $41.50

ZINC PROTOPORPH Y/V/L/M/C1/S1/R/E/P/P1 $43.00

Ziprasidone mesylate $137.20

Zoledronic acid 1mg $548.75

ZONISAMIDE MZONI QC/Q/D/E/L/M/P/R/S/T/W/X/O/C1/N/L1/S1/W1 $343.00

172 of 172

Documents

Procedure Price 120MIN PED ESTRADIOL ESOTERIX/L/M/W/S1/L1 ... · Procedure Price AGAR DILUTION IMC $28.00 AGAR DILUTION L/M $27.50 Albumin (human) 25% 50ml $223.75 Albumin (human)