Listado de servicios del Centro Comprensivo de Cáncer con sus precios.
| description | code|1 | code|1|type | modifiers | setting | drug_unit_of_measurement | drug_type_of_measurement | standard_charge|gross | standard_charge|discounted_cash | BCBS | FMV | IMC | MAPFRE | MCS | MCS CLASSICARE | MMM | MMMV | PSM | PSMV | TRIPLE S SALUD | TRIPLE S VITAL | TRICARE | TRIPLE S ADVANTAGE | VETERANOS | standard_charge|min | standard_charge|max | additional_generic_notes |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PER DIEM ONCOLOGY | 120 | REVCODE | BOTH | $1,200.00 | $979.00 | $983.98 | $950.00 | $900.00 | $918.00 | $1,050.00 | $1,020.00 | $1,070.53 | $1,005.00 | $992.00 | $979.00 | $992.00 | $1,200.00 | $1,030.00 | $1,200.00 | 900,00 | 1.200,00 | |||||
| FINE NEEDLE ASPRTN WITH IMG GU | 10005 | CPT | BOTH | $221.07 | $152.00 | $75.16 | $150.00 | $129.75 | $119.23 | $75.75 | $119.19 | $73.87 | $71.00 | $68.00 | $152.00 | $75.16 | $75.16 | $73.69 | $75.16 | 68,00 | 152,00 | |||||
| FNA BX W/US GDN EA ADDL | 10006 | CPT | BOTH | $154.05 | $116.50 | $68.25 | $75.00 | $61.65 | $51.58 | $51.58 | $56.68 | $43.22 | $71.00 | $27.20 | $116.50 | $51.27 | $51.27 | $51.35 | $51.27 | 272,00 | 1.165,00 | |||||
| Image-guided fluid collection | 10030 | CPT | BOTH | $589.61 | $338.00 | $600.25 | $338.00 | $570.00 | $338.00 | $144.29 | $146.25 | $134.87 | $686.00 | $600.25 | $338.00 | $136.49 | $129.11 | $129.11 | $129.11 | 12.911,00 | 686,00 | |||||
| BX BREAST 1ST LESION STRTCTC | 19081 | CPT | BOTH | $502.98 | $250.00 | $555.63 | $300.00 | $525.00 | $330.96 | $152.68 | $162.62 | $163.34 | $635.00 | $208.00 | $300.00 | $166.63 | $166.63 | $167.66 | $166.63 | 15.268,00 | 635,00 | |||||
| BX BREAST ADD LESION STRTCTC | 19082 | CPT | BOTH | $252.54 | $95.00 | $418.71 | $150.00 | $525.00 | $350.00 | $350.00 | $80.09 | $82.35 | $318.00 | $119.20 | $152.00 | $83.83 | $83.83 | $83.83 | $83.83 | 8.009,00 | 525,00 | |||||
| BX BREAST 1ST LESION US IMAG | 19083 | CPT | BOTH | $475.71 | $250.00 | $540.63 | $364.00 | $525.00 | $602.00 | $143.59 | $152.95 | $153.51 | $250.00 | $142.40 | $300.00 | $157.27 | $157.27 | $158.57 | $157.27 | 1.424,00 | 602,00 | |||||
| BX BREAST ADD LESION US IMAG | 19084 | CPT | BOTH | $236.82 | $125.00 | $414.22 | $182.00 | $525.00 | $350.00 | $350.00 | $75.35 | $393.09 | $125.00 | $72.80 | $150.00 | $77.95 | $77.95 | $77.95 | $77.95 | 728,00 | 525,00 | |||||
| BX BREAST 1ST LESION MR IMAG | 19085 | CPT | BOTH | $551.28 | $250.00 | $831.41 | $735.00 | $525.00 | $168.60 | $168.60 | $179.11 | $178.59 | $250.00 | $240.80 | $250.00 | $182.24 | $182.24 | $182.24 | $182.24 | 1.686,00 | 83.141,00 | |||||
| Under Breast Biopsy Procedures | 19100 | CPT | BOTH | $203.31 | $81.00 | $71.27 | $81.00 | $37.50 | $60.13 | $60.13 | $59.77 | $71.27 | $63.00 | $59.00 | $81.00 | $161.62 | $66.25 | $66.25 | $66.25 | 375,00 | 16.162,00 | |||||
| MASTECTOMY PARTIAL | 19301 | CPT | BOTH | $2,042.46 | $348.00 | $683.88 | $348.00 | $375.00 | $348.00 | $546.25 | $549.85 | $670.63 | $348.00 | $152.80 | $348.00 | $638.88 | $652.74 | $680.82 | $652.74 | 1.528,00 | 68.388,00 | |||||
| MASTECTOMY PARTIAL W/AXILLARY | 19302 | CPT | BOTH | $2,807.31 | $719.00 | $939.16 | $719.00 | $975.00 | $987.00 | $752.62 | $757.78 | $920.72 | $719.00 | $285.20 | $719.00 | $939.16 | $939.16 | $935.77 | $939.16 | 2.852,00 | 987,00 | |||||
| MASTECTOMY SIMPLE COMPLETE | 19303 | CPT | BOTH | $2,968.44 | $452.00 | $991.01 | $743.26 | $450.00 | $480.00 | $846.95 | $852.45 | $971.88 | $452.00 | $237.20 | $452.00 | $991.01 | $991.01 | $991.01 | $991.01 | 2.372,00 | 99.101,00 | |||||
| MAST MODF RAD W/AX LYMPH NOD W | 19307 | CPT | BOTH | $3,669.09 | $764.00 | $1,222.64 | $764.00 | $900.00 | $900.00 | $998.83 | $1,006.69 | $1,197.91 | $764.00 | $764.00 | $764.00 | $1,222.64 | $1,222.64 | $1,223.03 | $1,222.64 | 764,00 | 122.303,00 | |||||
| Repair and/or Recon Proc Breas | 19316 | CPT | BOTH | $2,439.15 | $568.00 | $812.58 | $609.44 | $660.00 | $644.93 | $644.93 | $649.16 | $804.14 | $568.00 | $478.00 | $568.00 | $812.58 | $779.45 | $779.45 | $779.45 | 478,00 | 81.258,00 | |||||
| REDUCTION MAMMAPLASTY | 19318 | CPT | BOTH | $3,371.22 | $1,000.00 | $1,625.32 | $1,000.00 | $1,500.00 | $927.30 | $927.30 | $937.79 | $1,700.00 | $750.00 | $608.40 | $1,000.00 | $1,121.05 | $1,073.74 | $1,073.74 | $1,073.74 | 6.084,00 | 1.700,00 | |||||
| Under Repair and/or Reconstruc | 19325 | CPT | BOTH | $1,891.26 | $750.00 | $731.25 | $731.25 | $1,125.00 | $750.00 | $533.35 | N/A | $624.88 | $750.00 | $273.60 | $750.00 | $750.00 | $607.62 | $607.62 | $607.62 | 2.736,00 | 1.125,00 | |||||
| REMOVAL INTACT MAMMARY IMPLANT | 19328 | CPT | BOTH | $1,707.39 | $314.00 | $568.96 | $314.00 | $240.00 | $409.92 | $409.92 | $415.66 | $563.21 | $175.00 | $84.00 | $314.00 | $568.96 | $568.96 | $569.13 | $568.96 | 84,00 | 56.913,00 | |||||
| REMOVAL MAMMARY IMPLANT MATERI | 19330 | CPT | BOTH | $796.14 | $394.00 | $663.54 | $265.42 | $240.00 | $105.00 | $527.08 | $533.01 | $657.07 | $354.00 | $84.00 | $394.00 | $663.54 | $636.65 | $636.65 | $636.65 | 84,00 | 66.354,00 | |||||
| IMMT INSJ BRST PROSTH FLWG MAS | 19340 | CPT | BOTH | $2,332.38 | $572.00 | $778.33 | $778.33 | $660.00 | $838.93 | $838.93 | $848.95 | $1,000.00 | $572.00 | $234.80 | $572.00 | $778.33 | $778.33 | $778.33 | $778.33 | 2.348,00 | 1.000,00 | |||||
| DLYD INSJ BRST PROSTH FLWG MAS | 19342 | CPT | BOTH | $2,346.24 | $697.00 | $781.19 | $781.19 | $675.00 | $769.63 | $769.63 | $779.47 | $1,200.00 | $278.80 | $604.00 | $697.00 | $781.19 | $750.14 | $750.14 | $750.14 | 2.788,00 | 1.200,00 | |||||
| NIPPLE/AREOLA RECONST | 19350 | CPT | BOTH | $828.19 | $676.00 | $690.37 | $676.00 | $539.00 | $557.47 | $560.09 | $649.86 | $1,600.00 | $550.00 | $246.80 | $676.00 | $690.37 | $664.31 | $664.31 | $664.31 | 2.468,00 | 1.600,00 | |||||
| BRST RCNSTJ IMMT/DLYD W/TISS E | 19357 | CPT | BOTH | $3,590.04 | $1,836.00 | $1,790.10 | $1,836.00 | $1,335.00 | $1,836.00 | $1,237.69 | $1,258.64 | $2,000.00 | $950.00 | $670.00 | $1,836.00 | $1,190.93 | $1,142.94 | $1,142.94 | $1,142.94 | 670,00 | 2.000,00 | |||||
| Under Repair and/or Reconstruc | 19361 | CPT | BOTH | $4,614.93 | $1,731.00 | $1,687.73 | $1,731.00 | $1,429.50 | $1,731.00 | $1,329.68 | $1,344.06 | $2,000.00 | $1,240.00 | $631.60 | $1,731.00 | $1,596.96 | $1,525.70 | $1,525.70 | $1,525.70 | 6.316,00 | 2.000,00 | |||||
| Breast reconstruction | 19364 | CPT | BOTH | $2,789.26 | $2,032.00 | $2,789.26 | $2,032.00 | $510.00 | $2,032.00 | $560.09 | $2,361.14 | $2,749.95 | $1,420.00 | $498.40 | $2,032.00 | $2,789.26 | $2,650.65 | $2,650.65 | $2,650.65 | 4.984,00 | 278.926,00 | |||||
| OPEN PERIPROSTHETIC CAPSULOTOM | 19370 | CPT | BOTH | $2,064.09 | $434.00 | $688.60 | $516.45 | $519.10 | $596.66 | $569.66 | $577.10 | $681.81 | $200.00 | $74.00 | $434.00 | $688.60 | $688.60 | $688.60 | $688.60 | 74,00 | 6.886,00 | |||||
| BREAST CAPSULECTOMY | 19371 | CPT | BOTH | $2,191.50 | $540.00 | $730.47 | $730.47 | $676.00 | $550.00 | $652.47 | $661.54 | $723.83 | $540.00 | $152.80 | $540.00 | $730.47 | $730.47 | $730.47 | $730.47 | 1.528,00 | 73.047,00 | |||||
| REVISION RECONSTRUCTED BREAST | 19380 | CPT | BOTH | $2,486.82 | $540.00 | $828.01 | $540.00 | $651.30 | $642.76 | $642.76 | $651.53 | $282.01 | $540.00 | $450.00 | $540.00 | $828.01 | $828.01 | $828.94 | $828.01 | 28.201,00 | 82.894,00 | |||||
| BIOPSY MUSCLE PERCUTANEOUS NEE | 20206 | CPT | BOTH | $174.12 | $121.00 | $57.91 | $57.91 | $75.00 | $70.00 | $52.15 | $58.04 | $57.27 | $50.00 | $49.00 | $121.00 | $57.91 | $57.91 | $57.91 | $57.91 | 49,00 | 121,00 | |||||
| BIOPSY BONE TROCAR/NEEDLE DEEP | 20225 | CPT | BOTH | $396.30 | $184.00 | $180.00 | $162.00 | $150.00 | $252.00 | $96.21 | $132.00 | $393.43 | $180.00 | $180.00 | $184.00 | $131.35 | $124.86 | $124.86 | $124.86 | 9.621,00 | 39.343,00 | |||||
| CORE NEEDLE BX LUNG /MED PERQ | 32408 | CPT | BOTH | $462.42 | $150.00 | $154.14 | $103.45 | N/A | $147.78 | $93.60 | $139.57 | $151.48 | $396.00 | $26.22 | $150.00 | $154.14 | $144.64 | $144.64 | $144.64 | 2.622,00 | 396,00 | |||||
| INSERTION INDWELLING TUNNELED | 32550 | CPT | BOTH | $251.02 | $715.00 | $627.41 | $627.41 | $885.00 | $197.06 | $197.06 | $188.48 | $203.32 | $715.00 | $137.95 | $715.00 | $207.45 | $194.78 | $194.78 | $194.78 | 13.795,00 | 885,00 | |||||
| RMVL NDWELLG TUN PLEURAL CATH | 32552 | CPT | BOTH | $194.23 | $145.00 | $160.19 | $160.19 | $151.65 | $137.34 | $137.34 | $134.02 | $157.24 | $150.00 | $117.00 | $145.00 | $160.19 | $64.08 | $151.25 | $64.08 | 6.408,00 | 16.019,00 | |||||
| INSERT CATH PLEURA W/ IMAGE | 32557 | CPT | BOTH | $182.74 | $117.00 | $155.00 | $117.00 | $870.00 | $117.00 | $141.00 | $151.02 | $148.43 | $117.00 | $56.69 | $117.00 | $151.02 | $141.73 | $141.73 | $141.73 | 5.669,00 | 870,00 | |||||
| NJX PX XTR VNGRPH W/INTRO NDL/ | 36005 | CPT | BOTH | $139.86 | $275.00 | $48.12 | $275.00 | $75.00 | $275.00 | $43.41 | $41.11 | $47.78 | $275.00 | $48.12 | $275.00 | $41.11 | $45.26 | $45.26 | $45.26 | 4.111,00 | 275,00 | |||||
| SLCTV CATHJ EA 1ST ORD ABDL PE | 36245 | CPT | BOTH | $672.03 | $242.00 | $237.41 | $242.00 | $225.00 | $242.00 | $225.50 | $204.23 | $232.81 | $242.00 | $362.45 | $242.00 | $237.41 | $1,150.36 | $1,150.36 | $1,150.36 | 20.423,00 | 115.036,00 | |||||
| SLCTV CATHJ 3RD+ ORD SLCTV ABD | 36247 | CPT | BOTH | $365.08 | $276.00 | $126.34 | $276.00 | $276.00 | $276.00 | $284.56 | $271.65 | $294.82 | $276.00 | $132.00 | $276.00 | $300.68 | $281.54 | $281.54 | $281.54 | 12.634,00 | 30.068,00 | |||||
| SLCTV CATHJ EA 2ND+ ORD ABDL P | 36248 | CPT | BOTH | $148.68 | $121.00 | $123.47 | $121.00 | $150.00 | $121.00 | $45.50 | $43.54 | $47.78 | $121.00 | $48.47 | $121.00 | $48.47 | $45.92 | $45.92 | $45.92 | 4.354,00 | 150,00 | |||||
| INSJ TUN CTR CVC W/O SUBQ PORT | 36558 | CPT | BOTH | $317.40 | $548.00 | $102.00 | $117.00 | $270.00 | $548.00 | $244.33 | $234.35 | $259.24 | $548.00 | $255.00 | $548.00 | $263.03 | $248.61 | $248.61 | $248.61 | 102,00 | 548,00 | |||||
| INSJ TUN CTR CTR VAD W/SUBQ PO | 36561 | CPT | BOTH | $1,023.90 | $1,039.00 | $300.00 | $339.88 | $1,200.00 | $307.90 | $307.90 | $295.90 | $332.43 | $1,039.00 | $120.00 | $1,039.00 | $339.88 | $318.46 | $318.46 | $318.46 | 120,00 | 1.200,00 | |||||
| RPLCMT COMPL TUN CVC W/O SUBQ | 36581 | CPT | BOTH | $223.94 | $502.00 | $124.51 | $502.00 | $579.00 | $502.00 | $764.67 | $167.27 | $182.31 | $502.00 | $122.82 | $502.00 | $185.77 | $175.47 | $175.47 | $175.47 | 12.282,00 | 76.467,00 | |||||
| RPLCMT COMPL TUN CTR VAD W/SUB | 36582 | CPT | BOTH | $352.97 | $940.00 | $293.42 | $940.00 | $1,084.50 | $940.00 | $266.58 | $255.75 | $287.02 | $940.00 | $275.00 | $940.00 | $293.42 | $275.73 | $275.73 | $275.73 | 25.575,00 | 10.845,00 | |||||
| RPLCMT COMPL PRPH CVC W/O SUBQ | 36584 | CPT | BOTH | $72.91 | $233.00 | $62.00 | $233.00 | $255.00 | $233.00 | $59.77 | $56.50 | $58.29 | $223.00 | $62.00 | $233.00 | $59.23 | $56.30 | $56.30 | $56.30 | 563,00 | 255,00 | |||||
| INSJ TRANSVNS INTRAHEPATC PORT | 37182 | CPT | BOTH | $6,000.00 | $720.00 | $3,858.75 | $720.00 | $829.50 | $720.00 | $769.53 | $731.29 | $804.82 | $720.00 | $233.20 | $720.00 | $816.67 | $770.00 | $770.00 | $770.00 | 2.332,00 | 385.875,00 | |||||
| VASC EMBOLIZE/OCCLUDE VENOUS | 37241 | CPT | BOTH | $525.56 | $1,331.00 | $1,164.63 | $1,331.00 | N/A | $1,331.00 | $407.60 | $404.33 | $432.93 | $1,880.00 | $1,164.63 | $1,331.00 | $432.98 | $403.51 | $403.51 | $403.51 | 40.351,00 | 1.880,00 | |||||
| VASC EMBOLIZE/OCCLUDE ARTERY | 37242 | CPT | BOTH | $577.45 | $1,331.00 | $1,164.63 | $1,331.00 | $5,490.00 | $1,331.00 | $452.35 | $451.36 | $470.02 | $1,331.00 | $1,165.00 | $1,331.00 | $477.23 | $449.01 | $449.01 | $449.01 | 44.901,00 | 5.490,00 | |||||
| VASC EMBOLIZE/OCCLUDE ORGAN | 37243 | CPT | BOTH | $3,000.00 | $1,746.00 | $1,800.00 | $1,746.00 | $6,930.00 | $1,746.00 | $539.06 | $538.17 | $552.70 | $1,746.00 | $371.37 | $1,746.00 | $559.63 | $530.54 | $530.54 | $530.54 | 37.137,00 | 6.930,00 | |||||
| VASC EMBOLIZE/OCCLUDE BLEED | 37244 | CPT | BOTH | $802.49 | $1,331.00 | $1,164.63 | $1,331.00 | $4,905.00 | $1,331.00 | $629.91 | $628.00 | $653.01 | $1,334.00 | $1,165.00 | $1,331.00 | $662.49 | $624.03 | $624.03 | $624.03 | 62.403,00 | 4.905,00 | |||||
| LAPS SURG SPLENC | 38120 | CPT | BOTH | $3,267.42 | $766.00 | N/A | $1,091.23 | $1,327.50 | $891.70 | $891.70 | $852.53 | $1,071.51 | $766.00 | $620.00 | $766.00 | $1,091.23 | $1,036.02 | $1,036.02 | $1,036.02 | 620,00 | 13.275,00 | |||||
| MARROW ASPIRATION ONLY | 38220 | CPT | BOTH | $212.79 | $30.00 | $161.46 | $30.00 | $157.50 | $30.00 | $54.02 | $117.25 | $67.77 | $30.00 | $88.39 | $30.00 | $69.02 | $65.12 | $65.12 | $65.12 | 30,00 | 16.146,00 | |||||
| MARROW BX NDL/TROCAR | 38221 | CPT | BOTH | $212.91 | $100.00 | $50.62 | $47.91 | $165.00 | $140.00 | $67.41 | $63.87 | $70.15 | $100.00 | $44.15 | $100.00 | $71.79 | $67.06 | $67.06 | $67.06 | 4.415,00 | 165,00 | |||||
| BX EXC LYMPH NODE BY NEEDLE | 38505 | CPT | BOTH | $356.37 | $126.00 | $90.12 | $126.00 | $75.00 | $126.00 | $642.42 | $59.62 | $86.07 | $126.00 | $57.80 | $126.00 | $86.66 | $82.57 | $82.57 | $82.57 | 578,00 | 64.242,00 | |||||
| BX/EXC LYMPH NODE OPN DP AX NO | 38525 | CPT | BOTH | $1,361.76 | $317.00 | $321.34 | $317.00 | $225.00 | $317.00 | $363.86 | $350.10 | $447.99 | $317.00 | $455.72 | $317.00 | $455.72 | $437.07 | $434.71 | $437.07 | 225,00 | 45.572,00 | |||||
| RESCJ PALATE/X10SV RESCJ LES | 42120 | CPT | BOTH | $1,255.25 | $444.00 | $781.96 | $186.48 | $600.00 | $341.72 | $854.30 | $847.38 | $1,022.38 | $444.00 | $400.00 | $444.00 | $1,042.61 | $977.97 | $977.97 | $977.97 | 18.648,00 | 104.261,00 | |||||
| PALATOPHARYNGOPLASTY | 42145 | CPT | BOTH | $850.18 | $675.00 | $289.41 | $283.50 | $945.00 | $240.08 | $600.21 | $612.16 | $701.13 | $675.00 | $185.20 | $675.00 | $708.55 | $673.83 | $673.83 | $673.83 | 1.852,00 | 945,00 | |||||
| RAD RESCJ TONSIL CLSR W/OTH FL | 42845 | CPT | BOTH | $2,747.47 | $1,260.00 | N/A | $908.92 | $1,800.00 | $775.33 | $1,938.32 | $1,836.10 | $2,236.22 | $1,200.00 | $468.00 | $1,260.00 | $1,931.50 | $2,132.13 | $2,132.13 | $2,132.13 | 468,00 | 223.622,00 | |||||
| RESCJ LAT PHRNGL WALL/PYRIFORM | 42892 | CPT | BOTH | $2,308.08 | $849.00 | $1,448.63 | $772.60 | $979.50 | $650.36 | $1,625.89 | $1,620.90 | $1,892.26 | $775.00 | $302.40 | $849.00 | $1,931.50 | $1,805.05 | $1,805.05 | $1,805.05 | 3.024,00 | 19.315,00 | |||||
| ESOPHAGOSCOPY RIGID TRNSO | 43180 | CPT | BOTH | $667.30 | $440.00 | $560.55 | $224.22 | $480.00 | $191.93 | $479.82 | N/A | $554.73 | $400.00 | $347.00 | $440.00 | $560.55 | $535.95 | $535.95 | $535.95 | 19.193,00 | 56.055,00 | |||||
| ESOPHAGOSCOPY RIGID TRNSO DX | 43191 | CPT | BOTH | $188.76 | $167.00 | $157.75 | $146.13 | $105.00 | $53.57 | $133.93 | $167.00 | $156.90 | $167.00 | $132.00 | $167.00 | $157.75 | $152.21 | $152.21 | $152.21 | 5.357,00 | 167,00 | |||||
| ESOPHAGOSCP RIG TRNSO INJECT | 43192 | CPT | BOTH | $206.77 | $195.00 | $172.64 | $69.06 | $135.00 | $59.41 | $148.50 | N/A | $171.47 | $195.00 | $154.00 | $195.00 | $172.64 | $165.49 | $165.49 | $165.49 | 5.941,00 | 195,00 | |||||
| ESOPHAGOSCP RIG TRNSO BIOPSY | 43193 | CPT | BOTH | $513.81 | $217.00 | $189.88 | $172.29 | $150.00 | $147.72 | $147.72 | $116.49 | $170.79 | $217.00 | $171.00 | $217.00 | $172.29 | $165.80 | $165.80 | $165.80 | 11.649,00 | 217,00 | |||||
| ESOPHAGOSCP RIG TRNSO REM FB | 43194 | CPT | BOTH | $234.28 | $250.00 | $218.75 | $78.69 | $150.00 | $68.09 | $170.23 | N/A | $193.83 | $217.00 | $197.00 | $250.00 | $196.73 | $187.06 | $187.06 | $187.06 | 6.809,00 | 250,00 | |||||
| ESOPHAGOSCOPY W BALLOON | 43195 | CPT | BOTH | $531.15 | $250.00 | $131.00 | $250.00 | $150.00 | $250.00 | $161.09 | N/A | $186.72 | $250.00 | $197.00 | $250.00 | $126.71 | $181.01 | $181.01 | $181.01 | 12.671,00 | 250,00 | |||||
| ESOPHAGOSCP GUIDE WIRE DILAT | 43196 | CPT | BOTH | $238.22 | $84.00 | $198.64 | $79.46 | $165.00 | $68.93 | $68.93 | N/A | $196.88 | $200.00 | $158.00 | $84.00 | $198.64 | $191.38 | $191.38 | $191.38 | 6.893,00 | 200,00 | |||||
| ESOPHAGOSCOPY FLEX DX BRUSH | 43197 | CPT | BOTH | $612.30 | $167.00 | $146.13 | $84.16 | $150.00 | $73.50 | $73.50 | $71.30 | $82.35 | $167.00 | $132.00 | $167.00 | $100.12 | $79.27 | $79.27 | $79.27 | 713,00 | 167,00 | |||||
| ESOPHAGOSC FLEX TRNSN BIOPSY | 43198 | CPT | BOTH | $299.67 | $217.00 | $189.88 | $217.00 | $165.00 | $350.00 | $88.04 | N/A | $98.95 | $217.00 | $132.00 | $217.00 | $89.10 | $94.82 | $94.82 | $94.82 | 8.804,00 | 350,00 | |||||
| ESPHGSC RGD/FLX DX +-COLLJ SPE | 43200 | CPT | BOTH | $267.39 | $167.00 | $150.00 | $167.00 | $225.00 | $81.57 | $81.57 | $95.10 | $87.77 | $150.00 | $60.00 | $167.00 | $105.03 | $85.00 | $85.00 | $85.00 | 60,00 | 225,00 | |||||
| ESPHGSC RGD/FLX DIRED SBMCSL N | 43201 | CPT | BOTH | $313.53 | $195.00 | $113.20 | $105.03 | $225.00 | $95.66 | $95.66 | $240.11 | $103.36 | $195.00 | $113.00 | $195.00 | $105.03 | $100.07 | $100.07 | $100.07 | 9.566,00 | 24.011,00 | |||||
| ESPHGSC RGD/FLX W/BX 1/MLT | 43202 | CPT | BOTH | $313.56 | $217.00 | $200.00 | $217.00 | $300.00 | $95.51 | $95.51 | $242.83 | $102.68 | $200.00 | $193.00 | $217.00 | $104.70 | $99.11 | $99.11 | $99.11 | 9.551,00 | 300,00 | |||||
| ESPHGSC RGD/FLX W/NJX SCLEROSI | 43204 | CPT | BOTH | $412.14 | $298.00 | $375.38 | $136.60 | $330.00 | $125.09 | $125.09 | $187.52 | $252.00 | $232.00 | $338.00 | $298.00 | $136.60 | $130.19 | $130.19 | $130.19 | 12.509,00 | 37.538,00 | |||||
| ESPHGSC RGD/FLX W/BAND LIG ESO | 43205 | CPT | BOTH | $429.99 | $300.00 | $263.25 | $142.15 | $345.00 | $130.25 | $130.25 | $187.25 | $270.00 | $300.00 | $237.00 | $300.00 | $142.15 | $135.05 | $135.05 | $142.15 | 13.025,00 | 345,00 | |||||
| ESPHGSC RGD/FLX W/RMVL FB | 43215 | CPT | BOTH | $430.86 | $250.00 | $243.75 | $143.81 | $375.00 | $129.83 | $129.83 | $141.67 | $132.50 | $250.00 | $225.00 | $250.00 | $143.81 | $136.59 | $136.59 | $136.59 | 12.983,00 | 375,00 | |||||
| ESPHGSC RGD/FLX RMVL TUM HOT B | 43216 | CPT | BOTH | $407.94 | $280.00 | $243.75 | $135.22 | $322.50 | $123.76 | $123.76 | $178.19 | $132.50 | $280.00 | $180.00 | $280.00 | $135.22 | $128.89 | $128.89 | $128.89 | 12.376,00 | 3.225,00 | |||||
| ESPHGSC RGD/FLX W/RMVL TUM SNA | 43217 | CPT | BOTH | $488.67 | $280.00 | $180.00 | $280.00 | $300.00 | $147.07 | $147.07 | $296.63 | $158.59 | $280.00 | $180.00 | $280.00 | $162.24 | $153.81 | $153.81 | $153.81 | 14.707,00 | 300,00 | |||||
| ESPHGSC RGD/FLX W/BALO DILAT < | 43220 | CPT | BOTH | $360.69 | $250.00 | $85.91 | $250.00 | $300.00 | $109.13 | $109.13 | $106.10 | $117.59 | $250.00 | $200.00 | $250.00 | $119.60 | $114.30 | $114.30 | $114.30 | 8.591,00 | 300,00 | |||||
| ESPHGSC RGD/FLX W/INSJ GD WIRE | 43226 | CPT | BOTH | $398.34 | $200.00 | $200.00 | $132.38 | $300.00 | $120.12 | $120.12 | $117.30 | $394.79 | $200.00 | $206.00 | $200.00 | $132.38 | $126.55 | $126.55 | $126.55 | 1.173,00 | 39.479,00 | |||||
| ESPHGSC RGD/FLX W/CTRL BLD | 43227 | CPT | BOTH | $503.31 | $350.00 | $320.00 | $167.08 | $300.00 | $152.00 | $180.88 | $177.63 | $164.01 | $350.00 | $320.00 | $350.00 | $167.08 | $158.34 | $158.34 | $158.34 | 152,00 | 350,00 | |||||
| ESPHGSC RGD/FLX W/NDSC US XM | 43231 | CPT | BOTH | $485.55 | $206.00 | $160.86 | N/A | $184.50 | $147.85 | $147.85 | $158.67 | $156.90 | $160.00 | N/A | $206.00 | N/A | N/A | N/A | N/A | 14.785,00 | 206,00 | |||||
| ESPHGSC RGD/FLX W/TNDSC US-GID | 43232 | CPT | BOTH | $607.08 | $285.00 | $202.08 | N/A | $240.00 | $183.18 | $183.18 | $217.81 | $196.21 | $210.00 | $243.00 | $285.00 | N/A | N/A | N/A | N/A | 18.318,00 | 285,00 | |||||
| Under Esophagogastroduodenosco | 43233 | CPT | BOTH | $233.18 | $200.00 | $233.18 | N/A | $540.00 | N/A | N/A | $223.40 | $227.38 | $170.00 | $158.00 | $200.00 | N/A | $233.18 | $233.18 | $233.18 | 158,00 | 540,00 | |||||
| UPPER STOMACH-INTESTINE SCOPE | 43235 | CPT | BOTH | $374.37 | $260.00 | $130.00 | $225.00 | $300.00 | $273.00 | $113.36 | $266.73 | $121.99 | $260.00 | $104.00 | $260.00 | $124.46 | $124.46 | $275.48 | $124.46 | 104,00 | 300,00 | |||||
| STOMACH-INTESTINE SCOPE INJEC | 43236 | CPT | BOTH | $421.59 | $290.00 | $92.68 | $290.00 | $334.50 | $128.21 | $128.21 | $326.21 | $136.90 | $290.00 | $57.60 | $290.00 | $139.38 | $139.38 | $362.48 | $139.38 | 576,00 | 36.248,00 | |||||
| UPR GI NDSC NDSC US XM LMTD ES | 43237 | CPT | BOTH | $596.64 | $261.00 | $261.00 | N/A | $195.00 | $179.85 | $179.85 | $195.55 | $194.51 | $170.00 | $138.00 | $261.00 | N/A | N/A | N/A | N/A | 138,00 | 261,00 | |||||
| UPR GI NDSC TNDSC US FINE NDL | 43238 | CPT | BOTH | $708.78 | $285.00 | $235.02 | N/A | $240.00 | $213.32 | $213.32 | $268.08 | $230.43 | $156.28 | $700.00 | $285.00 | N/A | N/A | N/A | N/A | 15.628,00 | 700,00 | |||||
| UPPER STOMACH-INTESTINE SCOPE | 43239 | CPT | BOTH | $421.59 | $290.00 | $290.00 | $350.00 | $330.00 | $406.00 | $128.06 | $157.96 | $384.28 | $290.00 | $40.39 | $290.00 | $140.06 | $132.77 | $132.77 | $132.77 | 4.039,00 | 406,00 | |||||
| UPR GI NDSC TRANSMURAL DRG PSE | 43240 | CPT | BOTH | $1,194.09 | $290.00 | $396.83 | N/A | $334.50 | $357.79 | $357.79 | $331.85 | $388.35 | $290.00 | $250.00 | $290.00 | $396.83 | N/A | N/A | N/A | 250,00 | 39.683,00 | |||||
| UPR GI NDSC TNDSC INTRAL TUBE/ | 43241 | CPT | BOTH | $433.05 | $275.00 | $248.00 | $144.54 | $375.00 | $131.60 | $131.60 | $143.15 | $248.00 | $275.00 | $223.00 | $275.00 | $144.54 | $144.54 | $144.54 | $144.54 | 1.316,00 | 375,00 | |||||
| STOMACH-INTESTINE SCOPE ULTRAS | 43242 | CPT | BOTH | $800.01 | $300.00 | $270.00 | N/A | $345.00 | $241.18 | $241.18 | $389.68 | $283.00 | $300.00 | $243.00 | $300.00 | N/A | N/A | N/A | N/A | 24.118,00 | 38.968,00 | |||||
| UPR GI NDSC NJX SCLEROSIS ESOP | 43243 | CPT | BOTH | $722.34 | $290.00 | $280.00 | $240.18 | $375.00 | $217.32 | $217.32 | $245.92 | $261.00 | $290.00 | $252.00 | $290.00 | $240.18 | $227.87 | $227.87 | $227.87 | 21.732,00 | 375,00 | |||||
| UPR GI NDSC BAND LIG ESOPHGL&/ | 43244 | CPT | BOTH | $746.55 | $300.00 | $270.00 | $248.19 | $375.00 | $225.16 | $225.16 | $271.43 | $270.00 | $300.00 | $97.20 | $300.00 | $248.19 | $234.09 | $234.09 | $234.09 | 972,00 | 375,00 | |||||
| UPR GI NDSC DILAT GSTR OUTLET | 43245 | CPT | BOTH | $538.80 | $300.00 | $290.00 | $300.00 | $375.00 | $160.79 | $160.79 | $172.57 | $607.94 | $300.00 | $116.00 | $300.00 | $178.13 | $169.60 | $169.60 | $169.60 | 116,00 | 60.794,00 | |||||
| UPR GI NDSC DIRED PLMT PRQ GAS | 43246 | CPT | BOTH | $611.04 | $344.00 | $330.00 | $344.00 | $375.00 | $403.20 | $182.61 | $231.19 | $256.70 | $268.00 | $132.00 | $344.00 | $203.38 | $192.23 | $192.23 | $192.23 | 132,00 | 4.032,00 | |||||
| STOMACH-INTESTINE SCOPE FOR FO | 43247 | CPT | BOTH | $539.94 | $270.00 | $270.00 | $179.54 | $375.00 | $162.56 | $162.56 | $184.04 | $390.72 | $270.00 | $97.20 | $270.00 | $179.54 | $169.33 | $169.33 | $169.33 | 972,00 | 39.072,00 | |||||
| UPR GI NDSC INSJ GD WIRE DILAT | 43248 | CPT | BOTH | $506.46 | $200.00 | $120.98 | $200.00 | $300.00 | $200.00 | $153.26 | $173.01 | $165.03 | $200.00 | $112.46 | $200.00 | $155.64 | $159.31 | $159.31 | $159.31 | 11.246,00 | 300,00 | |||||
| UPR GI NDSC BALO DILAT ESOPH < | 43249 | CPT | BOTH | $468.72 | $250.00 | $290.00 | $250.00 | $375.00 | $141.43 | $141.43 | $159.58 | $152.83 | $250.00 | $44.74 | $250.00 | $155.64 | $147.33 | $147.33 | $147.33 | 4.474,00 | 375,00 | |||||
| UPR GI NDSC RMVL LES HOT BX/BI | 43250 | CPT | BOTH | $522.00 | $280.00 | $313.67 | $280.00 | $390.00 | $155.49 | $155.49 | $173.50 | $169.44 | $280.00 | $125.47 | $280.00 | $172.58 | $163.79 | $163.79 | $163.79 | 12.547,00 | 390,00 | |||||
| UPR GI NDSC RMVL TUM POLYP/OTH | 43251 | CPT | BOTH | $597.63 | $299.00 | $143.23 | $299.00 | $450.00 | $98.00 | $180.06 | $210.16 | $194.85 | $299.00 | $137.96 | $299.00 | $198.61 | $187.79 | $187.79 | $187.79 | 98,00 | 450,00 | |||||
| EGD US TRANSMURAL INJXN/MARK | 43253 | CPT | BOTH | $800.01 | $299.00 | N/A | N/A | $240.00 | $240.82 | $240.82 | $235.45 | $260.93 | $299.00 | $235.00 | N/A | N/A | N/A | N/A | N/A | 235,00 | 299,00 | |||||
| Under Esophagogastroduodenosco | 43254 | CPT | BOTH | $299.00 | $299.00 | N/A | $299.00 | $240.00 | N/A | $247.62 | $268.76 | $268.05 | $299.00 | $235.00 | $299.00 | $274.50 | $258.36 | $258.36 | $258.36 | 235,00 | 299,00 | |||||
| UPR GI NDSC CTRL BLD ANY METH | 43255 | CPT | BOTH | $611.28 | $330.00 | N/A | $330.00 | $450.00 | $184.44 | $184.44 | $259.61 | $198.92 | $330.00 | $58.61 | $330.00 | $203.47 | $192.01 | $192.01 | $192.01 | 5.861,00 | 450,00 | |||||
| STOMACH-INTESTINE SCOPE WITH U | 43259 | CPT | BOTH | $688.86 | $270.00 | $243.00 | N/A | $450.00 | $207.70 | $207.70 | $279.52 | $289.00 | $270.00 | $219.00 | N/A | N/A | N/A | N/A | N/A | 2.077,00 | 450,00 | |||||
| ERCP DX COLLJ SPEC BR/WA SPX | 43260 | CPT | BOTH | $983.40 | $265.00 | $400.00 | $265.00 | $450.00 | $700.00 | $294.86 | $318.71 | $375.00 | $265.00 | $94.23 | $265.00 | $326.83 | $307.89 | $307.89 | $307.89 | 9.423,00 | 700,00 | |||||
| ERCP W/BX 1/MLT | 43261 | CPT | BOTH | $1,031.64 | $625.00 | $274.22 | $342.78 | $525.00 | $309.41 | $309.41 | $362.48 | $562.00 | $625.00 | $197.60 | $625.00 | $342.78 | $322.78 | $322.78 | $322.78 | 1.976,00 | 625,00 | |||||
| ERCP W/SPHNCTROTOMY/PAPILLOTOM | 43262 | CPT | BOTH | $1,089.27 | $600.00 | $260.64 | $362.52 | $450.00 | $326.40 | $326.40 | $393.52 | $408.00 | $600.00 | $104.26 | $600.00 | $362.52 | $340.58 | $340.58 | $340.58 | 10.426,00 | 600,00 | |||||
| ERCP W/PRESS MEAS SPHNCTR ODDI | 43263 | CPT | BOTH | $1,089.18 | $600.00 | $362.52 | $362.52 | $450.00 | N/A | $326.50 | $353.58 | $354.46 | $600.00 | $311.00 | $600.00 | $362.52 | $341.22 | $341.22 | $341.22 | 311,00 | 600,00 | |||||
| ERCP W/RMVL ST1/CALCULI BILIAR | 43264 | CPT | BOTH | $1,110.24 | $650.00 | $265.44 | $368.76 | $675.00 | $332.67 | $332.67 | $472.11 | $497.25 | $650.00 | $410.00 | $650.00 | $368.76 | $347.69 | $347.69 | $347.69 | 26.544,00 | 675,00 | |||||
| ERCP W/DSTRJ LITHOTRP ST1/CALC | 43265 | CPT | BOTH | $1,321.98 | $650.00 | $439.79 | $439.79 | $675.00 | $395.14 | $395.14 | $529.93 | $585.00 | $650.00 | $340.00 | $650.00 | $439.79 | $412.12 | $412.12 | $412.12 | 340,00 | 675,00 | |||||
| ERCP DUCT STENT PLACEMENT | 43274 | CPT | BOTH | $1,412.10 | $652.00 | $570.50 | $570.50 | $420.00 | $421.88 | $421.88 | $472.29 | $458.49 | $652.00 | $513.00 | $652.00 | $468.90 | $440.91 | $440.91 | $440.91 | 420,00 | 652,00 | |||||
| ERCP REMOVE FORGN BODY DUCT | 43275 | CPT | BOTH | $1,147.95 | $650.00 | $568.75 | $650.00 | $345.00 | $343.85 | $343.85 | $363.36 | $585.00 | $650.00 | $512.00 | $650.00 | $381.24 | $359.03 | $359.03 | $359.03 | 34.385,00 | 650,00 | |||||
| ERCP STENT EXCHANGE W/DILATE | 43276 | CPT | BOTH | $587.92 | $273.00 | $321.10 | $321.10 | $435.00 | $175.73 | $439.33 | $459.23 | $585.00 | $650.00 | $512.00 | $273.00 | $488.31 | $458.72 | $458.72 | $458.72 | 17.573,00 | 650,00 | |||||
| ERCP EA DUCT/AMPULLA DILATE | 43277 | CPT | BOTH | $1,154.25 | $583.00 | $510.13 | $383.67 | $345.00 | $346.79 | $345.79 | $365.64 | $414.00 | $583.00 | $512.00 | $583.00 | $383.57 | $360.97 | $360.97 | $360.97 | 345,00 | 583,00 | |||||
| ERCP LESION ABLATE W/DILATE | 43278 | CPT | BOTH | $856.54 | $460.00 | $439.10 | $175.64 | $390.00 | $157.91 | $394.78 | $396.19 | $428.67 | $460.00 | $362.00 | $460.00 | $439.10 | $412.75 | $412.75 | $412.75 | 15.791,00 | 460,00 | |||||
| EXC LOCAL MAL TUM STOMACH | 43611 | CPT | BOTH | $3,786.36 | $787.00 | $1,260.72 | $900.80 | $907.50 | $1,039.74 | $1,039.74 | $1,041.78 | $1,241.29 | $650.00 | $360.32 | $787.00 | N/A | $1,198.53 | $1,198.53 | $1,198.53 | 36.032,00 | 126.072,00 | |||||
| LAPS ENTEROLSS FRING INTSTINAL | 44180 | CPT | BOTH | $2,845.92 | $300.00 | $677.34 | $712.36 | $795.00 | $782.40 | $782.40 | $785.33 | $930.54 | $300.00 | $289.00 | $300.00 | $949.81 | $899.07 | $899.07 | $899.07 | 289,00 | 94.981,00 | |||||
| LAPS JEJUNOSTOMY | 44186 | CPT | BOTH | $2,019.99 | $740.00 | $674.36 | $674.36 | $855.00 | $550.78 | $550.78 | $527.69 | $660.12 | $740.00 | $438.00 | $740.00 | $674.36 | $637.59 | $637.59 | $637.59 | 438,00 | 855,00 | |||||
| LAPS ILEOST/JEJUNOSTOMY NON-TU | 44187 | CPT | BOTH | $3,381.87 | $758.00 | $804.88 | $1,123.17 | $939.90 | $940.57 | $940.57 | $951.24 | $1,101.00 | $758.00 | $658.00 | $758.00 | $1,123.17 | $1,057.85 | $1,057.85 | $1,057.85 | 658,00 | 112.317,00 | |||||
| ENTEROSCOPY > 2ND PRTN X ILE R | 44364 | CPT | BOTH | $622.83 | $280.00 | $224.25 | $224.25 | $420.00 | $187.70 | $187.70 | $184.23 | $252.00 | $280.00 | $202.00 | $280.00 | $206.94 | $195.57 | $195.57 | $195.57 | 18.423,00 | 420,00 | |||||
| SCOPE OF COLON THRU OSTOMY FOR | 44388 | CPT | BOTH | $237.96 | $209.00 | $114.35 | $209.00 | $255.00 | $142.79 | $142.79 | $153.06 | $155.88 | $209.00 | $64.00 | $209.00 | $158.71 | $150.51 | $150.51 | $150.51 | 64,00 | 255,00 | |||||
| SCOPE OF COLON WITH BIOPSY THR | 44389 | CPT | BOTH | $525.24 | $230.00 | $190.00 | $230.00 | $345.00 | $157.57 | $157.57 | $170.35 | $420.20 | $230.00 | $190.00 | $230.00 | $174.33 | $165.10 | $165.10 | $165.10 | 15.757,00 | 4.202,00 | |||||
| COLSC THRU STOMA W/RMVL FB | 44390 | CPT | BOTH | $641.70 | $250.00 | $212.49 | $212.49 | $300.00 | $193.22 | $193.22 | $190.00 | $209.08 | $250.00 | $200.00 | $250.00 | $212.49 | $202.03 | $202.03 | $202.03 | 190,00 | 300,00 | |||||
| COLSC THRU STOMA CTRL BLD | 44391 | CPT | BOTH | $702.45 | $300.00 | $260.00 | $233.94 | $450.00 | $211.09 | $211.09 | $211.12 | $229.42 | $300.00 | $260.00 | $300.00 | $233.94 | $220.15 | $220.15 | $220.15 | 21.109,00 | 450,00 | |||||
| COLSC THRU STOMA RMVL LES CAUT | 44392 | CPT | BOTH | $605.79 | $310.00 | $280.00 | $310.00 | $357.00 | $181.18 | $181.18 | $184.71 | $198.92 | $310.00 | $252.00 | $310.00 | $202.33 | $192.20 | $192.20 | $192.20 | 18.118,00 | 357,00 | |||||
| COLSC THRU STOMA W/RMVL TUM PO | 44394 | CPT | BOTH | $686.64 | $366.00 | $261.00 | $366.00 | $435.00 | $233.00 | $206.16 | $236.20 | $224.33 | $366.00 | $252.00 | $366.00 | $229.40 | $215.91 | $215.91 | $215.91 | 20.616,00 | 435,00 | |||||
| COLO VIA STOMA MUCOSAL RESECT | 44403 | CPT | BOTH | $858.69 | $240.00 | $451.29 | N/A | N/A | N/A | N/A | N/A | $302.27 | $240.00 | $193.00 | $240.00 | $307.78 | $290.09 | $290.09 | $290.09 | 193,00 | 45.129,00 | |||||
| COLONOSCOPY W/ULTRASOUND | 44406 | CPT | BOTH | $279.74 | $94.50 | $279.36 | $92.76 | N/A | $83.64 | $209.09 | N/A | $227.72 | $225.00 | $177.00 | $94.50 | N/A | $219.84 | $219.84 | $219.84 | 8.364,00 | 27.936,00 | |||||
| COLONOSCOPY W/NDL ASPIR/BX | 44407 | CPT | BOTH | $335.51 | $116.76 | $279.36 | $111.74 | N/A | $84.45 | $250.44 | N/A | $273.47 | $278.00 | $219.00 | $116.76 | N/A | $263.22 | $263.22 | $263.22 | 8.445,00 | 27.936,00 | |||||
| PROCTOSGMDSC RGD W/DILAT | 45303 | CPT | BOTH | $257.91 | $70.00 | $86.30 | $54.00 | $97.50 | $98.00 | $79.11 | $780.91 | $85.73 | $70.00 | $55.00 | $70.00 | $86.30 | $82.89 | $82.89 | $82.89 | 54,00 | 78.091,00 | |||||
| PROCTOSGMDSC RGD W/BX 1/MLT | 45305 | CPT | BOTH | $223.32 | $77.00 | $74.10 | $70.00 | $90.00 | $78.40 | $67.36 | $166.34 | $73.20 | $77.00 | $50.00 | $77.00 | $74.18 | $71.24 | $71.24 | $71.24 | 50,00 | 16.634,00 | |||||
| PROCTOSGMDSC RGD W/RMVL FB | 45307 | CPT | BOTH | $292.56 | $150.00 | $103.20 | $117.00 | $112.50 | $89.65 | $89.65 | $179.13 | $100.98 | $150.00 | $50.00 | $150.00 | $103.20 | $99.34 | $99.34 | $99.34 | 50,00 | 17.913,00 | |||||
| PROCTOSGMDSC RGD RMVL 1 LES CA | 45308 | CPT | BOTH | $258.81 | $152.00 | $86.60 | $63.00 | $105.00 | $75.19 | $75.19 | $162.80 | $85.40 | $152.00 | $86.00 | $152.00 | $86.60 | $82.82 | $82.82 | $82.82 | 63,00 | 1.628,00 | |||||
| PROCTOSGMDSC RGD RMVL 1 LES SN | 45309 | CPT | BOTH | $275.55 | $152.00 | $91.44 | $63.00 | $105.00 | $80.10 | $80.10 | $76.82 | $90.48 | $152.00 | $86.00 | $152.00 | $108.74 | $87.99 | $87.99 | $87.99 | 63,00 | 152,00 | |||||
| PROCTOSGMDSC RGD RMVL MLT TUM | 45315 | CPT | BOTH | $327.84 | $152.00 | $108.74 | $63.00 | $135.00 | $83.28 | $93.28 | $178.38 | $233.48 | $152.00 | $90.00 | $152.00 | $112.29 | $103.82 | $103.82 | $103.82 | 63,00 | 23.348,00 | |||||
| PROCTOSGMDSC RGD CTRL BLD | 45317 | CPT | BOTH | $336.51 | $200.00 | $130.00 | $117.00 | $180.00 | $102.08 | $102.08 | $210.04 | $225.69 | $200.00 | $60.00 | $200.00 | $107.70 | $107.48 | $107.48 | $107.48 | 60,00 | 22.569,00 | |||||
| PROCTOSGMDSC RGD ABLTJ LES | 45320 | CPT | BOTH | $323.67 | $150.00 | $150.00 | $135.00 | $180.00 | $93.38 | $93.38 | $188.14 | $105.39 | $150.00 | $131.00 | $150.00 | $107.70 | $107.48 | $107.48 | $107.48 | 9.338,00 | 18.814,00 | |||||
| PROCTOSGMDSC RGD DCMPRN VOLVUL | 45321 | CPT | BOTH | $319.47 | $150.00 | $150.00 | $135.00 | $172.50 | $91.82 | $91.82 | $97.96 | $135.00 | $150.00 | $135.00 | $150.00 | $105.97 | $103.17 | $103.17 | $103.17 | 9.182,00 | 1.725,00 | |||||
| PROCTOSGMDSC RGD TNDSC STENT P | 45327 | CPT | BOTH | $359.28 | $150.00 | $119.81 | $63.00 | $172.50 | $103.70 | $103.70 | $104.55 | $117.59 | $150.00 | $72.00 | $150.00 | $119.81 | $114.80 | $114.80 | $114.80 | 63,00 | 1.725,00 | |||||
| SCOPE OF SIGMOID COLON ONLY FO | 45330 | CPT | BOTH | $169.98 | $110.00 | $126.59 | $75.00 | $285.00 | $154.00 | $48.25 | $175.73 | $189.77 | $88.00 | $50.64 | $110.00 | $56.89 | $55.40 | $55.40 | $55.40 | 4.825,00 | 285,00 | |||||
| SCOPE OF SIGMOID COLON ONLY WI | 45331 | CPT | BOTH | $219.24 | $140.00 | $110.00 | $110.00 | $330.00 | $196.00 | $62.84 | $268.96 | $71.84 | $112.00 | $110.00 | $140.00 | $307.96 | $70.30 | $70.30 | $70.30 | 6.284,00 | 330,00 | |||||
| SGMDSC FLX RMVL FB | 45332 | CPT | BOTH | $319.86 | $150.00 | $120.00 | $108.00 | $345.00 | $210.00 | $97.30 | $101.62 | $104.37 | $150.00 | $120.00 | $150.00 | $106.78 | $101.37 | $101.37 | $101.37 | 973,00 | 345,00 | |||||
| SGMDSC FLX RMVL LES CAUT | 45333 | CPT | BOTH | $286.29 | $140.00 | $140.00 | $126.00 | $660.00 | $86.94 | $86.94 | $253.81 | $336.50 | $112.00 | $140.00 | $140.00 | $95.33 | $90.99 | $90.99 | $90.99 | 8.694,00 | 660,00 | |||||
| SGMDSC FLX CTRL BLD | 45334 | CPT | BOTH | $357.63 | $200.00 | $120.00 | $180.00 | $390.00 | $109.17 | $109.17 | $125.48 | $117.25 | $200.00 | $120.00 | $200.00 | $119.27 | $119.27 | $114.09 | $119.27 | 10.917,00 | 390,00 | |||||
| SGMDSC FLX DIRED SBMCSL NJX AN | 45335 | CPT | BOTH | $207.27 | $113.00 | $99.16 | $101.70 | $130.50 | $62.69 | $62.69 | $84.41 | $298.21 | $113.00 | $99.00 | $113.00 | $66.95 | $65.43 | $65.43 | $65.43 | 6.269,00 | 29.821,00 | |||||
| SGMDSC FLX DCMPRN VOLVULUS ANY | 45337 | CPT | BOTH | $351.12 | $180.00 | $143.33 | $162.00 | $207.00 | $107.62 | $107.62 | $118.99 | $162.00 | $180.00 | $129.00 | $180.00 | $116.44 | $116.44 | $116.44 | $116.44 | 10.762,00 | 207,00 | |||||
| SGMDSC FLX RMVL TUM POLYP/OTH | 45338 | CPT | BOTH | $367.02 | $140.00 | $122.85 | $180.00 | $330.00 | $111.17 | $111.17 | $276.22 | $119.62 | $140.00 | $123.00 | $140.00 | $122.03 | $258.64 | $258.64 | $258.64 | 11.117,00 | 330,00 | |||||
| SGMDSC FLX DILAT BALO 1/MORE S | 45340 | CPT | BOTH | $237.06 | $258.00 | $226.40 | $180.00 | $297.00 | $72.65 | $72.65 | $106.47 | $78.00 | $258.00 | $226.00 | $258.00 | $79.40 | $79.40 | $79.40 | $79.40 | 7.265,00 | 297,00 | |||||
| SGMDSC FLX NDSC US XM | 45341 | CPT | BOTH | $377.55 | $130.00 | $125.86 | $99.00 | $154.50 | $114.84 | $114.84 | $131.07 | $123.01 | $130.00 | $103.00 | $130.00 | N/A | $125.86 | $130.31 | $125.86 | 99,00 | 1.545,00 | |||||
| SGMDSC FLX TNDSC US GID NDL AS | 45342 | CPT | BOTH | $518.01 | $300.00 | $191.64 | $153.00 | $160.50 | $156.52 | $156.52 | $200.00 | $171.94 | $140.00 | $172.00 | $300.00 | N/A | $171.94 | $171.94 | $171.94 | 140,00 | 300,00 | |||||
| SCOPE OF COLON FOR DIAGNOSIS | 45378 | CPT | BOTH | $282.00 | $160.00 | $280.00 | $300.00 | $450.00 | $448.00 | $169.26 | $98.89 | $187.16 | $160.00 | $112.00 | $160.00 | $187.16 | $187.16 | $332.05 | $187.16 | 9.889,00 | 450,00 | |||||
| COLSC FLX PROX SPLENIC FLXR RM | 45379 | CPT | BOTH | $727.56 | $350.00 | $250.00 | $315.00 | $495.00 | $218.50 | $218.50 | $250.52 | $237.21 | $350.00 | $266.00 | $350.00 | $242.60 | $242.60 | $428.97 | $242.60 | 2.185,00 | 495,00 | |||||
| SCOPE OF COLON WITH BIOPSY | 45380 | CPT | BOTH | $613.32 | $392.00 | $300.00 | $462.65 | $495.00 | $270.00 | $184.14 | $238.68 | $199.60 | $280.00 | $108.00 | $392.00 | $203.12 | $203.12 | $192.95 | $203.12 | 108,00 | 495,00 | |||||
| COLSC FLX PROX SPLENIC FLXR SB | 45381 | CPT | BOTH | $613.32 | $380.00 | $275.00 | $270.00 | $352.50 | $233.00 | $184.29 | $226.53 | $199.26 | $220.00 | $122.27 | $380.00 | $203.12 | $203.12 | $416.89 | $203.12 | 12.227,00 | 41.689,00 | |||||
| COLSC FLX PROX SPLENIC FLXR CT | 45382 | CPT | BOTH | $789.45 | $355.00 | $282.75 | $263.06 | $502.50 | $237.51 | $237.51 | $304.28 | $257.20 | $355.00 | $283.00 | $355.00 | $263.06 | $263.06 | $732.63 | $263.06 | 23.751,00 | 73.263,00 | |||||
| COLSC FLX PROX SPLENIC FLXR RM | 45384 | CPT | BOTH | $695.94 | $384.00 | $333.45 | $375.00 | $510.00 | $207.91 | $207.91 | $249.46 | $226.71 | $300.00 | $129.84 | $384.00 | $232.13 | $232.13 | $475.10 | $232.13 | 12.984,00 | 510,00 | |||||
| COLSC FLX PROX SPLENIC FLXR RM | 45385 | CPT | BOTH | $774.78 | $590.00 | $590.00 | $522.00 | $750.00 | $220.00 | $232.88 | $283.60 | $252.46 | $590.00 | $531.00 | $590.00 | $258.20 | $258.20 | $447.76 | $258.20 | 220,00 | 750,00 | |||||
| COLSC FLX PROX SPLENIC FLXR DI | 45386 | CPT | BOTH | $645.78 | $582.00 | $523.80 | $523.80 | $670.50 | $193.81 | $193.81 | $245.14 | $210.44 | $582.00 | $471.00 | $582.00 | $214.20 | $214.20 | $214.20 | $214.20 | 19.381,00 | 6.705,00 | |||||
| COLONOSCOPY W ABLATION | 45388 | CPT | BOTH | $765.21 | $467.00 | $375.00 | $262.83 | $467.00 | $285.78 | $246.84 | $255.07 | $2,515.79 | $467.00 | $73.59 | $467.00 | $274.12 | $258.64 | $258.64 | $258.64 | 7.359,00 | 251.579,00 | |||||
| COLONOSCOPY W/STENT PLCMT | 45389 | CPT | BOTH | $353.51 | $380.00 | $293.90 | $86.40 | N/A | $105.84 | $264.59 | $264.49 | $239.90 | $380.00 | $300.00 | $380.00 | $293.90 | $276.39 | $276.39 | $276.39 | 864,00 | 380,00 | |||||
| COLONOSCOPY W/RESECTION | 45390 | CPT | BOTH | $1,012.77 | $590.00 | $336.54 | $247.04 | N/A | $301.72 | $301.72 | $337.59 | $330.06 | $590.00 | $464.00 | $590.00 | $336.54 | $317.27 | $317.27 | $317.27 | 24.704,00 | 590,00 | |||||
| COLSC FLX PROX SPLENIC FLXR ND | 45391 | CPT | BOTH | $784.26 | $250.00 | $261.35 | $225.00 | $312.00 | $300.02 | $236.19 | $261.42 | $256.19 | $250.00 | $203.00 | $250.00 | N/A | N/A | N/A | N/A | 203,00 | 312,00 | |||||
| COLSC FLX PROX SPLENIC FLXR US | 45392 | CPT | BOTH | $929.88 | $318.00 | $307.77 | $286.20 | $445.50 | $2,000.00 | $277.94 | $317.29 | $307.77 | $318.00 | $258.00 | $318.00 | N/A | N/A | N/A | N/A | 258,00 | 2.000,00 | |||||
| COLONOSCOPY W/DECOMPRESSION | 45393 | CPT | BOTH | $308.95 | $96.60 | $256.38 | $74.98 | N/A | $111.18 | $111.18 | N/A | $250.09 | $230.00 | $181.00 | $96.60 | $256.38 | $240.15 | $240.15 | $240.15 | 7.498,00 | 25.638,00 | |||||
| COLONOSCOPY W/BAND LIGATION | 45398 | CPT | BOTH | $287.16 | $350.00 | $238.72 | $350.00 | N/A | $350.00 | $213.89 | N/A | $234.84 | $350.00 | $122.40 | $350.00 | $238.72 | $225.57 | $225.57 | $225.57 | 1.224,00 | 350,00 | |||||
| LAPS SURG CHOLECSTC | 47562 | CPT | BOTH | $2,047.20 | $750.00 | $702.00 | $750.00 | $1,425.00 | $555.12 | $555.12 | $558.41 | $669.61 | $750.00 | $632.00 | $750.00 | $684.40 | $648.92 | $648.92 | $648.92 | 55.512,00 | 1.425,00 | |||||
| BX PNCRS PRQ NDL | 48102 | CPT | BOTH | $720.00 | $397.00 | $237.34 | $397.00 | $457.50 | $397.00 | $220.90 | $237.34 | $218.72 | $397.00 | $178.90 | $397.00 | $237.34 | $225.57 | $225.57 | $225.57 | 1.789,00 | 4.575,00 | |||||
| ABD PARACENTESIS W/IMAGING | 49083 | CPT | BOTH | $322.92 | $263.00 | $107.44 | $263.00 | $252.00 | $263.00 | $97.98 | $312.20 | $99.90 | $263.00 | $71.39 | $263.00 | $107.44 | $107.44 | $101.99 | $107.44 | 7.139,00 | 3.122,00 | |||||
| IMAGE CATH FLUID COLXN VISC | 49405 | CPT | BOTH | $237.24 | $483.00 | $422.63 | $78.42 | $660.00 | $77.77 | $194.42 | $203.37 | $192.48 | $483.00 | $468.00 | $483.00 | $196.06 | $185.09 | $185.09 | $185.09 | 7.777,00 | 660,00 | |||||
| INSERT TUN IP CATH PERC | 49418 | CPT | BOTH | $245.22 | $319.00 | $287.10 | $319.00 | $1,422.00 | $198.01 | $198.01 | $199.28 | $199.60 | $319.00 | $114.84 | $319.00 | $202.66 | $191.58 | $191.58 | $191.58 | 11.484,00 | 1.422,00 | |||||
| Under Drainage Catheter Proced | 49423 | CPT | BOTH | $1,645.20 | $78.00 | $70.49 | $78.00 | $564.00 | $78.00 | $66.26 | $66.28 | $70.49 | $78.00 | $46.88 | $78.00 | $70.32 | $66.97 | $66.97 | $66.97 | 4.688,00 | 564,00 | |||||
| RNL BX PRQ TROCAR/NDL | 50200 | CPT | BOTH | $386.88 | $174.00 | $164.00 | $174.00 | $199.50 | $174.00 | $127.69 | $121.58 | $125.72 | $174.00 | $84.77 | $174.00 | $128.24 | $128.24 | $121.10 | $128.24 | 8.477,00 | 1.995,00 | |||||
| PLMT NEPHROSTOMY CATHETER | 50432 | CPT | BOTH | $920.00 | $555.00 | $204.78 | $555.00 | $645.00 | $555.00 | $200.98 | $200.90 | $202.65 | $555.00 | $824.47 | $555.00 | $204.78 | $194.53 | $194.53 | $194.53 | 19.453,00 | 82.447,00 | |||||
| LAP ABLATION OF RENAL MASS | 50542 | CPT | BOTH | $3,542.73 | $1,575.00 | $851.60 | $1,575.00 | $1,099.50 | $1,200.00 | $1,036.93 | $979.87 | $1,164.03 | $1,575.00 | $1,418.00 | $1,575.00 | $1,180.91 | $1,129.20 | $1,129.20 | $1,129.20 | 8.516,00 | 1.575,00 | |||||
| LAPS PRTL NFRCT | 50543 | CPT | BOTH | $4,294.83 | $2,012.00 | $1,708.00 | $602.78 | $1,248.00 | $529.49 | $1,323.72 | $1,251.99 | $1,483.58 | $2,012.00 | $1,811.00 | $2,012.00 | $1,506.96 | $1,441.26 | $1,441.26 | $1,441.26 | 52.949,00 | 2.012,00 | |||||
| LAPS PLEOPLASTY | 50544 | CPT | BOTH | $3,789.66 | $1,708.00 | $800.00 | $1,708.00 | $1,189.50 | $1,708.00 | $1,112.30 | $1,051.40 | $1,235.87 | $1,708.00 | $1,537.00 | $1,708.00 | $1,255.54 | $1,198.60 | $1,198.60 | $1,198.60 | 800,00 | 1.708,00 | |||||
| LAPS NFRCT W/PRTL URTREC | 50546 | CPT | BOTH | $1,471.15 | $1,621.00 | $1,621.00 | $487.58 | $1,290.00 | $426.15 | $1,065.38 | $1,007.22 | $1,200.96 | $1,621.00 | $1,459.00 | $1,621.00 | $1,218.96 | $1,166.64 | $1,166.64 | $1,166.64 | 42.615,00 | 1.621,00 | |||||
| LAPS NFRCT W/TOT URTREC | 50548 | CPT | BOTH | $1,641.12 | $3,000.00 | $3,000.00 | $542.67 | $1,177.50 | $481.56 | $1,203.90 | $1,136.82 | $1,335.16 | $3,000.00 | $2,700.00 | $3,000.00 | $1,356.67 | $1,592.66 | $1,592.66 | $1,592.66 | 48.156,00 | 3.000,00 | |||||
| ABLATION 1 OR MORE RENAL TUMOR | 50592 | CPT | BOTH | $995.79 | $2,086.00 | $2,086.00 | $2,086.00 | $1,737.00 | $2,086.00 | $326.86 | $308.86 | $340.23 | $2,086.00 | $1,877.00 | $2,086.00 | $344.92 | $327.30 | $327.30 | $327.30 | 30.886,00 | 2.086,00 | |||||
| LAP PROSTATECTOMY RETROPUBIC R | 55866 | CPT | BOTH | $4,155.54 | $1,545.00 | $1,054.65 | $1,545.00 | $1,545.00 | $1,207.90 | $1,207.90 | $1,460.37 | $1,240.00 | $1,545.00 | $1,391.00 | $1,545.00 | $1,456.61 | $1,157.51 | $1,157.51 | $1,157.51 | 105.465,00 | 1.545,00 | |||||
| HYSTSC RMVL LEIOMYOMATA | 58561 | CPT | BOTH | $440.86 | $450.00 | $395.93 | $146.15 | $645.00 | $191.42 | $478.56 | $461.81 | $451.00 | $450.00 | $355.00 | $450.00 | $365.37 | $346.14 | $346.14 | $346.14 | 14.615,00 | 645,00 | |||||
| Laparoscopic/Hysteroscopic Pr | 58578 | CPT | BOTH | $5,953.92 | BR | $1,391.12 | N/A | N/A | N/A | N/A | N/A | $1,100.00 | $1,320.00 | $1,389.13 | BR | $1,391.12 | N/A | N/A | N/A | 1.100,00 | 139.112,00 | |||||
| RESECTION OF OVARIAN | 58952 | CPT | BOTH | $4,755.99 | $1,285.00 | $1,692.69 | $1,285.00 | $1,285.00 | N/A | $1,394.62 | $1,317.82 | $1,668.94 | $1,285.00 | $1,041.00 | $1,285.00 | $1,692.69 | $1,606.02 | $1,606.02 | $1,606.02 | 1.041,00 | 169.269,00 | |||||
| ADRNLECTOMY EXPL ADRNL TABDL L | 60540 | CPT | BOTH | $3,314.10 | $888.00 | $1,102.56 | $1,102.56 | $1,200.00 | $913.00 | $913.00 | $869.41 | $1,086.76 | $888.00 | $720.00 | $888.00 | $1,102.56 | $1,052.46 | $1,052.46 | $1,052.46 | 720,00 | 1.200,00 | |||||
| LAPS ADRNLECTOMY PRTL/COMPL TA | 60650 | CPT | BOTH | $3,669.27 | $1,080.00 | $1,219.57 | $1,219.57 | $1,245.00 | $1,028.95 | $1,028.95 | $978.80 | $1,199.27 | $1,080.00 | $1,080.00 | $1,080.00 | $1,219.57 | $1,163.01 | $1,163.01 | $1,163.01 | 9.788,00 | 1.245,00 | |||||
| ITPRL PRE-AUR MCF&MSB | 61590 | CPT | BOTH | $9,382.89 | $2,200.00 | $3,137.62 | $3,137.62 | $2,538.00 | $2,593.12 | $2,593.12 | $2,493.39 | $3,075.60 | $2,200.00 | $1,815.00 | $2,200.00 | $3,137.62 | $2,928.38 | $2,928.38 | $2,928.38 | 1.815,00 | 313.762,00 | |||||
| MRI TMPRMAND JT | 70336 | CPT | BOTH | $913.41 | $650.00 | $223.53 | $650.00 | $700.00 | $650.00 | $241.84 | $263.23 | $281.60 | $650.00 | $216.41 | $650.00 | $293.23 | $259.19 | $259.19 | $259.19 | 21.641,00 | 700,00 | |||||
| CT HEAD/BRN C-MATRL | 70450 | CPT | BOTH | $350.55 | $275.00 | $87.41 | $275.00 | $300.00 | $225.00 | $116.85 | $122.02 | $111.49 | $300.00 | $83.06 | $275.00 | $113.79 | $105.63 | $105.63 | $105.63 | 8.306,00 | 300,00 | |||||
| CT HEAD/BRN C+ MATRL | 70460 | CPT | BOTH | $492.72 | $275.00 | $122.83 | $275.00 | $325.00 | $280.00 | $164.24 | $160.22 | $155.54 | $300.00 | $117.01 | $275.00 | $113.79 | $164.24 | $166.97 | $164.24 | 11.379,00 | 325,00 | |||||
| CT HEAD/BRN C-/C+ | 70470 | CPT | BOTH | $579.15 | $275.00 | $144.34 | $275.00 | $325.00 | $280.00 | $193.05 | $163.09 | $182.99 | $300.00 | $137.28 | $275.00 | $188.30 | $171.63 | $171.63 | $171.63 | 13.728,00 | 325,00 | |||||
| CT ORBIT SELLA/POST FOSSA/EAR | 70480 | CPT | BOTH | $516.87 | $275.00 | $166.73 | $275.00 | $300.00 | $275.00 | $137.79 | $172.41 | $166.73 | $300.00 | $126.62 | $275.00 | $171.21 | $157.30 | $157.30 | $157.30 | 12.662,00 | 300,00 | |||||
| CT ORBIT SELLA/POST FOSSA/EAR | 70481 | CPT | BOTH | $605.64 | $275.00 | $190.45 | $275.00 | $325.00 | $275.00 | $209.38 | $234.69 | $197.65 | $300.00 | $197.65 | $275.00 | $195.68 | $178.51 | $178.51 | $178.51 | 17.851,00 | 325,00 | |||||
| CT ORBIT SELLA/POST FOSSA/EAR | 70482 | CPT | BOTH | $712.08 | $275.00 | $222.30 | $275.00 | $300.00 | $275.00 | $227.89 | $259.21 | $222.30 | $300.00 | $215.40 | $275.00 | $230.16 | $207.79 | $207.79 | $207.79 | 20.779,00 | 300,00 | |||||
| CT MAXLFCL AREA C-MATRL | 70486 | CPT | BOTH | $424.41 | $275.00 | $134.87 | $275.00 | $300.00 | $275.00 | $107.55 | $166.57 | $134.87 | $300.00 | $99.81 | $275.00 | $137.86 | $126.80 | $126.80 | $126.80 | 9.981,00 | 300,00 | |||||
| CT MAXLFCL AREA C+ MATRL | 70487 | CPT | BOTH | $506.46 | $275.00 | $194.85 | $275.00 | $325.00 | $275.00 | $130.55 | $201.92 | $159.95 | $300.00 | $120.05 | $275.00 | $164.29 | $150.50 | $150.50 | $150.50 | 12.005,00 | 325,00 | |||||
| CT MAXLFCL AREA C-/C+ | 70488 | CPT | BOTH | $620.28 | $275.00 | $61.00 | $275.00 | $325.00 | $275.00 | $137.79 | $241.60 | $194.85 | $300.00 | $146.42 | $275.00 | $200.86 | $182.06 | $182.06 | $182.06 | 61,00 | 325,00 | |||||
| CT SOFT TISS NCK C-MATRL | 70490 | CPT | BOTH | $496.83 | $275.00 | $157.91 | $275.00 | $300.00 | $275.00 | $137.79 | $165.72 | $157.91 | $300.00 | $120.53 | $275.00 | $162.14 | $148.51 | $148.51 | $148.51 | 12.053,00 | 300,00 | |||||
| CT SOFT TISS NCK C+ MATRL | 70491 | CPT | BOTH | $615.99 | $275.00 | $194.51 | $275.00 | $325.00 | $280.00 | $205.33 | $198.18 | $194.51 | $300.00 | $145.63 | $275.00 | $200.13 | $182.03 | $182.03 | $182.03 | 14.563,00 | 325,00 | |||||
| CT SOFT TISS NCK C-/C+ | 70492 | CPT | BOTH | $746.52 | $275.00 | $233.82 | $275.00 | $325.00 | $275.00 | $211.38 | $234.55 | $233.82 | $300.00 | $175.53 | $275.00 | $240.86 | $218.45 | $218.45 | $218.45 | 17.553,00 | 325,00 | |||||
| CT ANGIOGRAPHY HEAD W/CONTRAST | 70496 | CPT | BOTH | $798.09 | $275.00 | $264.32 | $275.00 | $325.00 | $275.00 | $225.72 | $304.63 | $264.32 | $300.00 | $210.01 | $275.00 | $85.26 | $259.12 | $259.12 | $259.12 | 8.526,00 | 325,00 | |||||
| CT ANGIOGRAPHY NECK W/CONTRAST | 70498 | CPT | BOTH | $798.09 | $275.00 | $264.32 | $275.00 | $325.00 | $275.00 | $224.26 | $304.63 | $264.32 | $300.00 | $209.50 | $275.00 | $269.07 | $259.12 | $259.12 | $259.12 | 2.095,00 | 325,00 | |||||
| MRI ORBIT FACE &/NECK W/O CONT | 70540 | CPT | BOTH | $783.75 | $650.00 | $239.92 | $650.00 | $650.00 | $455.00 | $261.25 | $286.95 | $239.22 | $575.00 | $194.61 | $650.00 | $248.62 | $223.41 | $223.41 | $223.41 | 19.461,00 | 650,00 | |||||
| MRI ORBIT FACE&NCK C+ MATRL | 70542 | CPT | BOTH | $934.32 | $650.00 | $359.88 | $650.00 | $650.00 | $650.00 | $300.72 | $332.27 | $284.99 | $575.00 | $230.85 | $650.00 | $295.28 | $264.37 | $264.37 | $264.37 | 23.085,00 | 650,00 | |||||
| MRI ORBIT FACE&NCK C-/C+ | 70543 | CPT | BOTH | $1,174.44 | $650.00 | $359.88 | $650.00 | $650.00 | $620.00 | $391.48 | $409.71 | $359.88 | $575.00 | $289.86 | $650.00 | $372.55 | $335.22 | $335.22 | $335.22 | 28.986,00 | 650,00 | |||||
| MRI- Brain STEM C-MATRL | 70551 | CPT | BOTH | $665.43 | $650.00 | $207.05 | $650.00 | $650.00 | $520.00 | $221.81 | $292.74 | $207.05 | $575.00 | $165.91 | $650.00 | $213.35 | $194.38 | $194.38 | $194.38 | 16.591,00 | 650,00 | |||||
| MRI- Brain STEM C+ MATRL | 70552 | CPT | BOTH | $926.79 | $650.00 | $286.69 | $650.00 | $650.00 | $387.50 | $308.93 | $348.63 | $286.69 | $647.00 | $230.05 | $650.00 | $295.23 | $267.91 | $267.91 | $267.91 | 23.005,00 | 650,00 | |||||
| MRI- Brain STEM C-/C+ | 70553 | CPT | BOTH | $1,094.10 | $650.00 | $337.52 | $625.00 | $650.00 | $658.75 | $364.70 | $411.26 | $337.52 | $657.00 | $271.31 | $650.00 | $348.43 | $315.64 | $315.64 | $315.64 | 27.131,00 | 65.875,00 | |||||
| MRI BRAIN FUNCTIONAL W/O PHYSI | 70554 | CPT | BOTH | $1,305.24 | N/A | $401.90 | N/A | N/A | N/A | $340.00 | $358.33 | $401.90 | N/A | $322.85 | N/A | $416.50 | $375.60 | $375.60 | $375.60 | 32.285,00 | 4.165,00 | |||||
| CT THORAX C-MATRL | 71250 | CPT | BOTH | $440.01 | $300.00 | $139.95 | $300.00 | $300.00 | $225.00 | $146.67 | $154.64 | $139.95 | $300.00 | $133.42 | $300.00 | $143.02 | $131.63 | $131.63 | $131.63 | 13.163,00 | 300,00 | |||||
| CT THORAX C+ MATRL | 71260 | CPT | BOTH | $557.07 | $300.00 | $175.54 | $300.00 | $325.00 | $140.00 | $185.69 | $192.96 | $175.54 | $300.00 | $160.96 | $300.00 | $214.12 | $165.15 | $165.15 | $165.15 | 140,00 | 325,00 | |||||
| CT THORAX C-/C+ | 71270 | CPT | BOTH | $660.39 | $300.00 | $207.05 | $300.00 | $325.00 | $292.00 | $220.13 | $232.76 | $207.05 | $300.00 | $192.82 | $300.00 | $165.97 | $194.11 | $194.11 | $194.11 | 16.597,00 | 325,00 | |||||
| CT ANGIOGRAPHY CHEST W/CONTRAS | 71275 | CPT | BOTH | $808.59 | $300.00 | $267.37 | $300.00 | $325.00 | $296.00 | $269.53 | $249.26 | $267.37 | $300.00 | $215.07 | $300.00 | $275.54 | $262.67 | $262.67 | $262.67 | 21.507,00 | 325,00 | |||||
| MRI CH C-MATRL | 71550 | CPT | BOTH | $910.29 | $650.00 | $303.63 | $650.00 | $650.00 | $650.00 | $258.79 | $291.61 | $303.63 | $575.00 | $216.16 | $650.00 | $308.23 | $310.33 | $310.33 | $310.33 | 21.616,00 | 650,00 | |||||
| MRI CH C+ MATRL | 71551 | CPT | BOTH | $1,317.21 | $650.00 | $303.63 | $650.00 | $650.00 | $650.00 | $341.62 | $377.05 | $398.17 | $575.00 | $328.27 | $650.00 | $415.23 | $369.22 | $369.22 | $369.22 | 30.363,00 | 650,00 | |||||
| MRI CH C-/C+ | 71552 | CPT | BOTH | $1,445.49 | $650.00 | $477.13 | $650.00 | $650.00 | $496.00 | $481.83 | $468.80 | $477.13 | $575.00 | $402.76 | $650.00 | $402.65 | $463.19 | $463.19 | $463.19 | 40.265,00 | 650,00 | |||||
| CT CRV SPI C+ MATRL | 72126 | CPT | BOTH | $562.29 | $275.00 | $177.57 | $275.00 | $325.00 | $275.00 | $174.26 | $129.51 | $177.57 | $300.00 | $163.43 | $275.00 | $182.74 | $166.77 | $166.77 | $166.77 | 12.951,00 | 325,00 | |||||
| CT CRV SPI C-/C+ | 72127 | CPT | BOTH | $660.39 | $275.00 | $208.07 | $275.00 | $325.00 | $275.00 | $204.58 | $228.57 | $208.07 | $300.00 | $193.61 | $275.00 | $215.15 | $194.43 | $194.43 | $194.43 | 19.361,00 | 325,00 | |||||
| CT THRC SPI C-MATRL | 72128 | CPT | BOTH | $430.59 | $300.00 | $136.23 | $300.00 | $300.00 | $300.00 | $124.89 | $154.65 | $136.23 | $300.00 | $116.78 | $300.00 | $139.91 | $128.40 | $128.40 | $128.40 | 11.678,00 | 300,00 | |||||
| CT THRC SPI C+ MATRL | 72129 | CPT | BOTH | $565.47 | $300.00 | $178.92 | $300.00 | $325.00 | $300.00 | $174.52 | $193.20 | $178.92 | $300.00 | $164.19 | $300.00 | $184.13 | $168.39 | $168.39 | $168.39 | 16.419,00 | 325,00 | |||||
| CT THRC SPI C-/C+ | 72130 | CPT | BOTH | $663.54 | $300.00 | $210.10 | $300.00 | $325.00 | $300.00 | $124.89 | $229.71 | $210.10 | $300.00 | $194.89 | $300.00 | $215.85 | $196.71 | $196.71 | $196.71 | 12.489,00 | 325,00 | |||||
| CT LMBR SPI C-MATRL | 72131 | CPT | BOTH | $429.54 | $275.00 | $135.55 | $275.00 | $300.00 | $225.00 | $143.18 | $154.19 | $135.55 | $300.00 | $116.78 | $275.00 | $139.56 | $128.07 | $128.07 | $128.07 | 11.678,00 | 300,00 | |||||
| CT LMBR SPI C+ MATRL | 72132 | CPT | BOTH | $562.29 | $300.00 | $177.91 | $300.00 | $325.00 | $300.00 | $204.18 | $192.74 | $177.91 | $3.00 | $163.43 | $300.00 | $182.74 | $167.42 | $167.42 | $167.42 | 3,00 | 325,00 | |||||
| CT LMBR SPI C-/C+ | 72133 | CPT | BOTH | $660.39 | $300.00 | $208.75 | $300.00 | $325.00 | $300.00 | $204.18 | $228.57 | $208.75 | N/A | $193.10 | $300.00 | $214.80 | $194.76 | $194.76 | $194.76 | 1.931,00 | 325,00 | |||||
| MRI SPI CANAL&CNTS CRV C-MATRL | 72141 | CPT | BOTH | $650.70 | $600.00 | $201.29 | $650.00 | $650.00 | $325.00 | $216.90 | $278.32 | $201.29 | $635.00 | $161.34 | $600.00 | $208.46 | $188.52 | $188.52 | $188.52 | 16.134,00 | 650,00 | |||||
| MRI SPI CANAL&CNTS CRV C+ MATR | 72142 | CPT | BOTH | $948.96 | $650.00 | $291.77 | $650.00 | $650.00 | $465.00 | $316.32 | $356.85 | $291.77 | $700.00 | $234.37 | $650.00 | $302.21 | $272.45 | $272.45 | $272.45 | 23.437,00 | 700,00 | |||||
| MRI SPI CANAL&CNTS THRC C-MATR | 72146 | CPT | BOTH | $650.70 | $650.00 | $201.29 | $650.00 | $650.00 | $650.00 | $173.17 | $278.78 | $201.29 | $635.00 | $232.59 | $650.00 | $208.11 | $188.84 | $188.84 | $188.84 | 17.317,00 | 650,00 | |||||
| MRI SPI CANAL&CNTS THRC C+ MAT | 72147 | CPT | BOTH | $942.63 | $650.00 | $289.40 | $650.00 | $650.00 | $465.00 | $314.21 | $314.21 | $289.40 | $700.00 | $232.59 | $650.00 | $232.50 | $269.54 | $269.54 | $269.54 | 2.325,00 | 700,00 | |||||
| MRI SPI CANAL&CNTS LMBR C-MATR | 72148 | CPT | BOTH | $651.75 | $650.00 | $201.97 | $650.00 | $650.00 | $520.00 | $217.25 | $217.25 | $201.97 | $575.00 | $161.34 | $650.00 | $299.07 | $189.17 | $189.17 | $189.17 | 16.134,00 | 650,00 | |||||
| MRI SPI CANAL&CNTS LMBR C+ MAT | 72149 | CPT | BOTH | $934.20 | $650.00 | $286.69 | $650.00 | $650.00 | $542.50 | $311.40 | $344.03 | $286.69 | $700.00 | $231.32 | $650.00 | $296.63 | $267.57 | $267.57 | $267.57 | 23.132,00 | 700,00 | |||||
| MRI CERVICAL SPI CANAL&CNTS C- | 72156 | CPT | BOTH | $1,104.66 | $650.00 | $339.21 | $650.00 | $650.00 | $465.00 | $368.22 | $413.51 | $339.21 | $647.00 | $272.83 | $650.00 | $350.54 | $211.37 | $211.37 | $211.37 | 21.137,00 | 650,00 | |||||
| MRI THORACIC SPI CANAL&CNTS C- | 72157 | CPT | BOTH | $1,106.76 | $650.00 | $339.89 | $650.00 | $650.00 | $465.00 | $368.92 | $386.07 | $339.89 | $647.00 | $273.34 | $650.00 | $350.89 | $317.26 | $317.26 | $317.26 | 27.334,00 | 650,00 | |||||
| MRI SPI CANAL&CNTS C-/C+ LMBR | 72158 | CPT | BOTH | $1,102.53 | $650.00 | $338.53 | $650.00 | $650.00 | $465.00 | $367.51 | $402.91 | $338.53 | $647.00 | $272.33 | $650.00 | $349.49 | $315.96 | $315.96 | $315.96 | 27.233,00 | 650,00 | |||||
| CT ANGIOGRAPHY PELVIS W/CONTRA | 72191 | CPT | BOTH | $804.39 | $300.00 | $266.01 | $300.00 | $325.00 | $304.00 | $268.13 | $293.70 | $266.01 | $300.00 | $219.13 | $300.00 | $271.50 | $261.05 | $295.60 | $268.13 | 21.913,00 | 325,00 | |||||
| CT PELVIS C-MATRL | 72192 | CPT | BOTH | $441.06 | $300.00 | $139.95 | $300.00 | $300.00 | $300.00 | $114.23 | $130.51 | $139.95 | $300.00 | $104.58 | $300.00 | $143.37 | $131.63 | $131.63 | $131.63 | 10.458,00 | 300,00 | |||||
| CT PELVIS C+ MATRL | 72193 | CPT | BOTH | $711.12 | $300.00 | $235.85 | $300.00 | $300.00 | $300.00 | $171.61 | $199.92 | $235.85 | $300.00 | $161.00 | $300.00 | $240.33 | $224.43 | $224.43 | $224.43 | 161,00 | 300,00 | |||||
| CT PELVIS C-/C+ | 72194 | CPT | BOTH | $719.49 | $300.00 | $238.90 | $300.00 | $325.00 | $300.00 | $196.73 | $223.41 | $238.90 | $300.00 | $92.00 | $300.00 | $243.43 | $234.52 | $234.52 | $234.52 | 92,00 | 325,00 | |||||
| MRI PELVIS C-MATRL | 72195 | CPT | BOTH | $796.29 | $650.00 | $242.97 | $650.00 | $650.00 | $455.00 | $265.43 | $292.01 | $242.97 | $575.00 | $216.16 | $650.00 | $252.77 | $225.65 | $225.65 | $225.65 | 21.616,00 | 650,00 | |||||
| MRI PELVIS C+ MATRL | 72196 | CPT | BOTH | $935.28 | $650.00 | $285.33 | $650.00 | $650.00 | $542.50 | $311.76 | $342.69 | $285.33 | $575.00 | $249.60 | $650.00 | $295.94 | $265.54 | $265.54 | $265.54 | 2.496,00 | 650,00 | |||||
| MRI PELVIS C-/C+ | 72197 | CPT | BOTH | $1,174.38 | $650.00 | $358.19 | $625.00 | $650.00 | $697.50 | $391.46 | $419.92 | $358.19 | $575.00 | $305.84 | $650.00 | $371.84 | $332.93 | $332.93 | $332.93 | 30.584,00 | 6.975,00 | |||||
| CT UXTR C-MATRL | 73200 | CPT | BOTH | $477.03 | $300.00 | $154.53 | $300.00 | $300.00 | $300.00 | $124.89 | $153.44 | $154.53 | $300.00 | $116.78 | $300.00 | $160.84 | $152.49 | $152.49 | $152.49 | 11.678,00 | 300,00 | |||||
| CT UXTR C+ MATRL | 73201 | CPT | BOTH | $681.57 | $300.00 | $212.81 | $300.00 | $325.00 | $300.00 | $169.34 | $187.94 | $212.81 | $300.00 | $159.63 | $300.00 | $219.05 | $197.72 | $197.72 | $197.72 | 15.963,00 | 325,00 | |||||
| CT UXTR C-/C+ | 73202 | CPT | BOTH | $719.49 | $300.00 | $238.17 | $300.00 | $325.00 | $300.00 | $208.85 | $236.78 | $238.57 | $300.00 | $199.21 | $300.00 | $243.43 | $234.51 | $234.51 | $234.51 | 19.921,00 | 325,00 | |||||
| CT ANGIOGRAPHY UPPER EXTREMITY | 73206 | CPT | BOTH | $804.36 | $300.00 | $266.01 | $300.00 | $400.00 | $300.00 | $248.56 | $270.30 | $266.01 | $300.00 | $235.12 | $300.00 | $271.15 | $261.05 | $261.05 | $261.05 | 23.512,00 | 400,00 | |||||
| MRI UXTR OTH/THN JT C-MATRL | 73218 | CPT | BOTH | $895.59 | $650.00 | $298.89 | $650.00 | $650.00 | $650.00 | $253.85 | $287.31 | $65.06 | $300.00 | $212.63 | $650.00 | $303.39 | $298.53 | $298.53 | $298.53 | 6.506,00 | 650,00 | |||||
| MRI UXTR OTH/THN JT C+ MATRL | 73219 | CPT | BOTH | $1,167.51 | $650.00 | $353.44 | $650.00 | $650.00 | $650.00 | $302.49 | $335.72 | $353.44 | $300.00 | $289.46 | $650.00 | $366.44 | $326.26 | $326.26 | $326.26 | 28.946,00 | 650,00 | |||||
| MRI UXTR OTH/THN JT C-/C+ | 73220 | CPT | BOTH | $1,430.79 | $650.00 | $436.81 | $650.00 | $650.00 | $650.00 | $375.29 | $415.71 | $436.81 | $300.00 | $358.89 | $650.00 | $454.87 | $404.27 | $404.27 | $404.27 | 300,00 | 650,00 | |||||
| MRI ANY JT UXTR C-MATRL | 73221 | CPT | BOTH | $690.87 | $650.00 | $214.17 | $650.00 | $650.00 | $650.00 | $180.39 | $204.33 | $214.17 | $300.00 | $170.50 | $650.00 | $220.71 | $201.57 | $201.57 | $201.57 | 1.705,00 | 650,00 | |||||
| MRI ANY JT UXTR C+ MATRL | 73222 | CPT | BOTH | $1,105.26 | $650.00 | $333.11 | $650.00 | $650.00 | $650.00 | $283.81 | $316.13 | $412.41 | $300.00 | $272.46 | $650.00 | $347.25 | $307.37 | $307.37 | $307.37 | 27.246,00 | 650,00 | |||||
| MRI ANY JT UXTR C-/C+ | 73223 | CPT | BOTH | $1,363.32 | $650.00 | $412.41 | $650.00 | $650.00 | $650.00 | $353.33 | $393.12 | $412.41 | $300.00 | $77.22 | $650.00 | $429.76 | $380.50 | $380.50 | $380.50 | 7.722,00 | 650,00 | |||||
| CT LXTR C-MATRL | 73700 | CPT | BOTH | $429.54 | $300.00 | $135.89 | $300.00 | $300.00 | $300.00 | $124.89 | $153.90 | $135.89 | $300.00 | $116.78 | $300.00 | $139.56 | $128.40 | $128.40 | $128.40 | 11.678,00 | 300,00 | |||||
| CT LXTR C+ MATRL | 73701 | CPT | BOTH | $556.02 | $300.00 | $175.54 | $300.00 | $325.00 | $300.00 | $171.61 | $190.47 | $175.54 | $300.00 | $161.92 | $300.00 | $180.33 | $164.83 | $164.83 | $164.83 | 16.192,00 | 325,00 | |||||
| CT LXTR C-/C+ | 73702 | CPT | BOTH | $648.81 | $300.00 | $205.70 | $300.00 | $325.00 | $300.00 | $206.57 | $236.31 | $205.70 | $300.00 | $196.67 | $300.00 | $211.68 | $193.15 | $193.15 | $193.15 | 19.315,00 | 325,00 | |||||
| CT ANGIOGRAPHY LOWER EXTREMITY | 73706 | CPT | BOTH | $816.93 | $300.00 | $270.42 | $300.00 | $300.00 | $300.00 | $252.75 | $297.83 | $270.42 | $300.00 | $246.01 | $300.00 | $275.31 | $265.26 | $265.26 | $265.26 | 24.601,00 | 300,00 | |||||
| MRI LXTR OTH/THN JT C-MATRL | 73718 | CPT | BOTH | $774.27 | $650.00 | $237.21 | $650.00 | $650.00 | $650.00 | $253.85 | $287.17 | $237.21 | $575.00 | $212.37 | $650.00 | $245.48 | $220.15 | $220.15 | $220.15 | 21.237,00 | 650,00 | |||||
| MRI IMG LXTR OTH/THN JT C+ MAT | 73719 | CPT | BOTH | $913.23 | $650.00 | $278.55 | $650.00 | $650.00 | $650.00 | $302.24 | $341.03 | $278.55 | $575.00 | $236.43 | $650.00 | $371.85 | $259.81 | $259.81 | $259.81 | 23.643,00 | 650,00 | |||||
| MRI LXTR OTH/THN JT C-/C+ | 73720 | CPT | BOTH | $1,174.44 | $650.00 | $358.53 | $650.00 | $650.00 | $650.00 | $377.31 | $418.25 | $358.53 | $575.00 | $305.34 | $650.00 | $371.85 | $33.26 | $33.26 | $33.26 | 3.326,00 | 650,00 | |||||
| MRI ANY JT LXTR C-MATRL | 73721 | CPT | BOTH | $688.77 | $650.00 | $213.83 | $650.00 | $650.00 | $650.00 | $180.64 | $204.33 | $213.83 | $575.00 | $170.50 | $650.00 | $220.36 | $201.25 | $201.25 | $201.25 | 1.705,00 | 650,00 | |||||
| MRI ANY JT LXTR C+ MATRL | 73722 | CPT | BOTH | $1,107.36 | $650.00 | $333.45 | $650.00 | $650.00 | $650.00 | $286.34 | $320.36 | $333.45 | $575.00 | $274.24 | $650.00 | $347.95 | $309.00 | $309.00 | $309.00 | 27.424,00 | 650,00 | |||||
| MRI ANY JT LXTR C-/C+ | 73723 | CPT | BOTH | $1,359.09 | $650.00 | $411.05 | $650.00 | $650.00 | $650.00 | $354.60 | $392.88 | $411.05 | $575.00 | $337.32 | $650.00 | $428.36 | $379.52 | $379.52 | $379.52 | 33.732,00 | 650,00 | |||||
| CT ABD C-MATRL | 74150 | CPT | BOTH | $452.58 | $300.00 | $143.68 | $300.00 | $300.00 | $300.00 | $117.66 | $133.84 | $143.68 | $300.00 | $107.35 | $300.00 | $147.86 | $134.86 | $134.86 | $134.86 | 10.735,00 | 300,00 | |||||
| CT ABD C-/C+ | 74170 | CPT | BOTH | $745.71 | $300.00 | $247.38 | $300.00 | $325.00 | $300.00 | $199.75 | $234.68 | $247.28 | $300.00 | $188.26 | $300.00 | $252.44 | $262.03 | $262.03 | $262.03 | 18.826,00 | 325,00 | |||||
| CT ANGIO ABD&PELV W/O&W/DYE | 74174 | CPT | BOTH | $1,262.97 | $300.00 | $401.90 | $450.00 | $325.00 | $287.06 | $420.99 | $365.48 | $401.90 | $382.50 | $256.35 | $300.00 | $415.43 | $376.23 | $376.23 | $376.23 | 25.635,00 | 450,00 | |||||
| CT ANGIOGRAPHY ABDOMEN W/CONTR | 74175 | CPT | BOTH | $806.49 | $300.00 | $267.03 | $300.00 | $325.00 | $300.00 | $235.29 | $298.15 | $267.03 | $300.00 | $220.14 | $300.00 | $272.20 | $262.03 | $262.03 | $262.03 | 22.014,00 | 325,00 | |||||
| CT ABD & PELVIS W/O CONTRAST | 74176 | CPT | BOTH | $605.04 | $450.00 | $192.48 | $450.00 | $400.00 | $285.00 | $201.68 | $174.94 | $192.48 | $300.00 | $143.78 | $450.00 | $196.88 | $181.61 | $181.61 | $181.61 | 14.378,00 | 450,00 | |||||
| CT ABD & PELV W/CONTRAST | 74177 | CPT | BOTH | $1,023.84 | $450.00 | $322.61 | $450.00 | $400.00 | $381.00 | $341.28 | $255.37 | $322.61 | $382.50 | $255.37 | $450.00 | $335.34 | $298.84 | $298.84 | $298.84 | 25.537,00 | 450,00 | |||||
| CT ABD & PELV 1/> REGNS | 74178 | CPT | BOTH | $1,148.19 | $450.00 | $361.24 | $450.00 | $400.00 | $378.40 | $382.73 | $297.74 | $361.24 | $300.00 | $250.05 | $450.00 | $375.40 | $334.62 | $334.62 | $334.62 | 25.005,00 | 450,00 | |||||
| MRI- Abdominal | 74181 | CPT | BOTH | $672.87 | $650.00 | $207.73 | $650.00 | $650.00 | $387.50 | $224.29 | $297.74 | $207.73 | $575.00 | $202.71 | $650.00 | $214.06 | $193.41 | $193.41 | $193.41 | 19.341,00 | 650,00 | |||||
| MRI ABD C+ MATRL | 74182 | CPT | BOTH | $1,056.63 | $650.00 | $321.93 | $650.00 | $650.00 | $620.00 | $352.21 | $375.21 | $321.93 | $575.00 | $274.97 | $650.00 | $333.27 | $298.86 | $298.86 | $298.86 | 27.497,00 | 650,00 | |||||
| MRI ABD C-/C+ | 74183 | CPT | BOTH | $1,176.51 | $650.00 | $359.54 | $650.00 | $650.00 | $650.00 | $381.10 | $421.30 | $359.54 | $575.00 | $306.60 | $650.00 | $372.53 | $334.23 | $334.23 | $334.23 | 3.066,00 | 650,00 | |||||
| CT COLONOGRPHY DX IMAGE POSTPR | 74261 | CPT | BOTH | $684.63 | $300.00 | $351.40 | $300.00 | $329.40 | $300.00 | $228.21 | $220.53 | $341.70 | $320.00 | $166.99 | $300.00 | $229.12 | $217.26 | $237.01 | $228.21 | 16.699,00 | 3.514,00 | |||||
| CT COLONOGRPHY DX IMAGE POSTPR | 74262 | CPT | BOTH | $908.25 | $311.00 | $396.86 | $311.00 | $369.00 | $307.52 | $302.75 | $308.12 | $384.20 | $300.00 | $267.97 | $311.00 | $305.48 | $294.10 | $294.10 | $294.10 | 26.797,00 | 39.686,00 | |||||
| MRI FETAL SNGL/1ST GESTATION | 74712 | CPT | BOTH | $1,139.85 | $650.00 | $377.84 | $650.00 | $60.00 | $650.00 | $329.52 | $329.39 | $377.84 | $552.50 | $271.68 | $650.00 | $382.77 | $381.57 | $381.57 | $381.57 | 60,00 | 650,00 | |||||
| MRI FETAL EA ADDL GESTATION | 74713 | CPT | BOTH | $685.14 | $325.00 | $210.78 | $325.00 | N/A | $325.00 | $181.76 | $181.68 | $210.78 | $276.25 | $170.91 | $325.00 | $218.13 | $196.56 | $196.56 | $196.56 | 17.091,00 | 325,00 | |||||
| CARDIAC MRI MORPHOLOGY & FUNCT | 75557 | CPT | BOTH | $966.45 | $650.00 | $294.48 | $650.00 | $358.00 | $390.00 | $322.15 | $272.70 | $294.48 | $575.00 | $236.29 | $650.00 | $307.29 | $273.63 | $273.63 | $273.63 | 23.629,00 | 650,00 | |||||
| CARDIAC MRI W/O CONTRAST W STR | 75559 | CPT | BOTH | $1,339.44 | N/A | $394.79 | N/A | $522.00 | $520.00 | $446.48 | $355.30 | $394.79 | N/A | $163.67 | N/A | $414.55 | $365.59 | $365.59 | $365.59 | 16.367,00 | 522,00 | |||||
| CARDIAC MRI W/W/O CONTRAST & F | 75561 | CPT | BOTH | $1,276.38 | $650.00 | $385.64 | $650.00 | $544.00 | $619.20 | $425.46 | $358.54 | $385.64 | $575.00 | $219.75 | $650.00 | $403.48 | $356.61 | $356.61 | $356.61 | 21.975,00 | 650,00 | |||||
| CARDIAC MRI W/W/O CONTRAST W S | 75563 | CPT | BOTH | $1,502.91 | N/A | $448.33 | N/A | N/A | $619.20 | $500.97 | $423.09 | $448.33 | N/A | $370.41 | N/A | $472.78 | $415.16 | $415.16 | $415.16 | 37.041,00 | 6.192,00 | |||||
| CARDIAC MRI FOR VELOCITY FLOW | 75565 | CPT | BOTH | $161.22 | $78.00 | $48.12 | $78.00 | $72.00 | $65.18 | $53.74 | $45.79 | $48.12 | $78.00 | $39.28 | $78.00 | $50.85 | $44.23 | $44.23 | $44.23 | 3.928,00 | 78,00 | |||||
| CT HEART NO CONTRAST QUANT EVA | 75571 | CPT | BOTH | $325.44 | N/A | $104.71 | N/A | $72.80 | $54.75 | $108.48 | $58.17 | $104.71 | N/A | $64.59 | N/A | $106.54 | $99.50 | $99.50 | $99.50 | 5.475,00 | 10.848,00 | |||||
| CT HEART CONTRAST EVAL CARDIAC | 75572 | CPT | BOTH | $795.00 | $117.00 | $238.23 | $117.00 | $214.60 | $195.11 | $265.00 | $230.89 | $238.23 | $117.00 | $204.68 | $117.00 | $245.00 | $225.58 | $225.58 | $225.58 | 117,00 | 265,00 | |||||
| CT HRT CONTRST CARDIAC STRUCT& | 75573 | CPT | BOTH | $914.49 | $157.00 | $301.60 | $157.00 | $305.50 | $277.74 | $304.83 | $289.48 | $301.60 | $157.00 | $268.48 | $157.00 | $307.89 | $303.19 | $303.19 | $303.19 | 157,00 | 30.789,00 | |||||
| 3D RNDR I&R CT MRI US/OTH X RE | 76376 | CPT | BOTH | $69.42 | $117.00 | $24.40 | $117.00 | $111.00 | $42.40 | $23.14 | $42.72 | $24.40 | N/A | N/A | $117.00 | $23.65 | $25.02 | $25.02 | $25.02 | 2.314,00 | 117,00 | |||||
| 3D RNDR I&R CT MRI US/OTH REQ | 76377 | CPT | BOTH | $218.70 | $134.00 | $76.92 | $134.00 | $134.00 | $109.60 | $72.90 | $63.95 | $76.92 | N/A | N/A | $134.00 | $74.39 | $77.30 | $77.30 | $77.30 | 6.395,00 | 134,00 | |||||
| CT LMTD/LOCLZD F-UP STD | 76380 | CPT | BOTH | $386.28 | $152.00 | $132.50 | $152.00 | $146.00 | $152.00 | $87.57 | $108.93 | $132.50 | N/A | $78.97 | $152.00 | $130.15 | $129.37 | $129.37 | $129.37 | 7.897,00 | 152,00 | |||||
| MRI SPECTROSCOPY | 76390 | CPT | BOTH | $850.00 | $850.00 | N/A | $850.00 | $650.00 | $850.00 | $850.00 | $850.00 | $974.77 | N/A | N/A | $850.00 | $850.00 | $850.00 | $850.00 | $850.00 | 650,00 | 97.477,00 | |||||
| CT GUIDANCE STEREOTACTIC LOCAL | 77011 | CPT | BOTH | $726.81 | $225.00 | $227.72 | $225.00 | $295.00 | $225.00 | $170.12 | $166.10 | $227.72 | $225.00 | $162.41 | $225.00 | $235.41 | $212.69 | $212.69 | $212.69 | 16.241,00 | 295,00 | |||||
| CT GUIDANCE NEEDLE PLACEMENT | 77012 | CPT | BOTH | $455.40 | $450.00 | $143.68 | $225.00 | $293.00 | $99.92 | $99.92 | $99.13 | $143.68 | $700.00 | $89.34 | $450.00 | $147.76 | $122.71 | $122.71 | $122.71 | 8.934,00 | 700,00 | |||||
| CT GUIDANCE &MONITORING VISC T | 77013 | CPT | BOTH | $562.80 | $230.00 | $420.11 | $460.00 | $433.00 | $180.00 | $179.10 | $370.48 | $420.11 | $460.00 | $138.26 | $230.00 | $185.36 | $175.44 | $175.44 | $175.44 | 13.826,00 | 460,00 | |||||
| CT GUIDANCE RADIATION THERAPY | 77014 | CPT | BOTH | $381.15 | $180.00 | $122.33 | $180.00 | $124.00 | $180.00 | N/A | $92.97 | $122.23 | $180.00 | $86.11 | $180.00 | $124.61 | $116.38 | $116.38 | $116.38 | 8.611,00 | 180,00 | |||||
| MRI BREAST BILATERAL | 77049 | CPT | BOTH | $1,194.33 | $684.00 | $364.63 | $650.00 | $650.00 | $684.00 | $398.11 | $378.85 | $364.63 | $552.50 | N/A | $684.00 | $377.40 | $338.43 | $338.43 | $338.43 | 33.843,00 | 684,00 | |||||
| CT BONE MINERAL DENSITY STUDY | 77078 | CPT | BOTH | $281.46 | $684.00 | $98.61 | $684.00 | $130.00 | $684.00 | $54.09 | $60.78 | $98.61 | $85.00 | $52.73 | $684.00 | $95.50 | $97.65 | $97.65 | $97.65 | 5.273,00 | 684,00 | |||||
| PET IMAGING CT FOR ATTENUATION | 78814 | CPT | BOTH | $2,472.86 | $1,890.00 | $1,101.54 | $1,400.00 | $1,000.00 | $1,002.62 | $1,002.62 | $1,628.00 | $809.17 | $1,606.50 | $1,000.00 | $1,890.00 | $1,270.00 | $1,386.98 | $1,386.98 | $1,386.98 | 80.917,00 | 1.890,00 | |||||
| PET IMAGING CT ATTENUATION SKU | 78815 | CPT | BOTH | $2,494.40 | $1,900.00 | $1,110.69 | $1,400.00 | $1,000.00 | $1,013.09 | $1,013.09 | $1,639.44 | $819.11 | $1,615.00 | $1,000.00 | $1,900.00 | $1,270.00 | $1,386.98 | $1,386.98 | $1,386.98 | 81.911,00 | 1.900,00 | |||||
| PET IMAGING FOR CT ATTENUATION | 78816 | CPT | BOTH | $2,615.40 | $2,050.00 | $1,111.52 | $1,400.00 | $1,000.00 | $1,014.48 | $1,014.48 | $820.46 | $820.46 | $1,742.50 | $1,000.00 | $2,050.00 | $1,270.00 | $1,386.98 | $1,386.98 | $1,386.98 | 82.046,00 | 2.050,00 | |||||
| BASIC METABOLIC PANEL CALCIUM | 80047 | CPT | BOTH | $41.19 | $12.00 | $13.73 | $12.00 | $13.60 | N/A | $13.73 | $13.73 | $13.73 | N/A | $8.06 | $12.00 | $9.61 | N/A | N/A | N/A | 806,00 | 1.373,00 | |||||
| BMP BASIC METABOLIC PANEL CALC | 80048 | CPT | BOTH | $25.38 | $12.00 | $8.46 | $16.00 | $40.00 | $11.52 | $11.52 | $8.46 | $8.46 | $12.00 | $11.12 | $12.00 | $11.98 | $8.46 | $8.90 | $8.46 | 846,00 | 40,00 | |||||
| GENERAL HLTH PANEL | 80050 | CPT | BOTH | $139.23 | $45.24 | N/A | N/A | $90.00 | $43.00 | $43.00 | N/A | $10.07 | N/A | N/A | $45.24 | N/A | N/A | N/A | N/A | 1.007,00 | 90,00 | |||||
| ELECTROLYTE PANEL | 80051 | CPT | BOTH | $21.03 | $10.00 | $6.69 | $15.00 | $18.00 | $12.00 | $12.00 | $7.01 | $7.01 | $10.00 | $6.69 | $10.00 | $7.64 | $7.01 | $7.01 | $7.01 | 669,00 | 18,00 | |||||
| CMP COMPRE METAB PANEL | 80053 | CPT | BOTH | $17.50 | $17.50 | $10.07 | $24.00 | $55.00 | $19.20 | $19.20 | $10.56 | $10.56 | $25.00 | $15.86 | $17.50 | $14.97 | $10.56 | $14.39 | $10.56 | 1.007,00 | 55,00 | |||||
| OB PANEL | 80055 | CPT | BOTH | $143.43 | $54.00 | $47.81 | $54.00 | $75.00 | $65.12 | $65.12 | $47.81 | $47.81 | $51.00 | $45.58 | $54.00 | $52.10 | $47.81 | $47.81 | $47.81 | 4.558,00 | 75,00 | |||||
| LIPID PANEL | 80061 | CPT | BOTH | $40.17 | $28.00 | $13.39 | $30.00 | $25.00 | $22.40 | $22.40 | $13.39 | $13.39 | $40.00 | $18.24 | $28.00 | $14.59 | $13.39 | $14.09 | $13.39 | 1.339,00 | 40,00 | |||||
| RENAL FUNC PANEL RNL FUNCJ PAN | 80069 | CPT | BOTH | $26.04 | $12.21 | $8.68 | $20.00 | $53.00 | $16.00 | $16.00 | $8.68 | $8.68 | $12.00 | $8.28 | $12.21 | $9.46 | $8.68 | $8.68 | $8.68 | 828,00 | 53,00 | |||||
| AC HEPATITIS PANEL AQT HEP PAN | 80074 | CPT | BOTH | $142.89 | $70.00 | $47.63 | $70.00 | $80.00 | $64.89 | $64.89 | $47.63 | $47.63 | $70.00 | $45.42 | $70.00 | $81,020.00 | $47.63 | $47.63 | $47.63 | 4.542,00 | 81.020,00 | |||||
| HEPATC FUNCT PANEL | 80076 | CPT | BOTH | $24.51 | $13.60 | $8.17 | $16.00 | $35.00 | $11.20 | $11.20 | $8.17 | $8.17 | $13.00 | $7.79 | $13.60 | $8.90 | $8.17 | $8.17 | $8.17 | 779,00 | 35,00 | |||||
| OBSTETRIC PANEL | 80081 | CPT | BOTH | $224.58 | $103.97 | $71.38 | $103.97 | $102.00 | N/A | N/A | $74.86 | $74.69 | $75.12 | $71.38 | $103.97 | $81.58 | $74.86 | $74.86 | $74.86 | 7.138,00 | 10.397,00 | |||||
| URNLS DIP STICK/TABLET RGNT NO | 81000 | CPT | BOTH | $12.06 | $7.75 | $3.02 | $7.00 | $8.00 | $5.34 | $5.34 | $4.02 | $4.02 | $7.00 | N/A | $7.75 | $3.46 | $4.02 | $4.02 | $4.02 | 302,00 | 8,00 | |||||
| U/A URNLS DIP STICK/TABLET RG | 81001 | CPT | BOTH | $9.51 | $7.75 | $3.46 | $7.00 | $8.00 | $6.40 | $6.40 | $3.17 | $3.17 | $7.00 | $3.26 | $7.75 | $4.48 | $3.17 | $3.92 | $3.17 | 317,00 | 8,00 | |||||
| URNLS DIP STICK/TABLET RGNT NO | 81002 | CPT | BOTH | $10.44 | $3.30 | $2.61 | $4.00 | $7.00 | $3.30 | $3.30 | $3.48 | $3.48 | $5.00 | N/A | $3.30 | $2.78 | $3.48 | $3.48 | $3.48 | 261,00 | 7,00 | |||||
| URNLS DIP STICK/TABLET RGNT AU | 81003 | CPT | BOTH | $6.75 | $2.00 | $2.25 | $3.00 | $8.00 | $6.40 | $6.40 | $2.25 | $2.25 | $2.00 | $2.14 | $2.00 | $2.45 | $2.25 | $2.25 | $2.25 | 2,00 | 8,00 | |||||
| URNLS QUAL/SEMIQUAN XCPT IAS | 81005 | CPT | BOTH | $6.51 | $10.00 | $2.36 | $5.00 | $5.00 | $2.95 | $2.95 | $2.17 | $2.17 | $7.00 | N/A | $10.00 | $2.36 | $2.17 | $2.17 | $2.17 | 217,00 | 10,00 | |||||
| URNLS BACTERIURIA SCR XCPT CUL | 81007 | CPT | BOTH | $89.94 | $3.59 | $22.49 | $3.00 | $4.00 | $3.49 | $3.49 | $29.98 | $29.98 | $3.00 | N/A | $3.59 | N/A | $29.98 | $29.98 | $29.98 | 3,00 | 2.998,00 | |||||
| URNLS MCRSCP ONLY | 81015 | CPT | BOTH | $9.15 | $4.24 | $2.91 | $3.00 | $6.00 | $3.00 | $3.00 | $3.05 | $3.05 | $5.00 | N/A | $4.24 | $3.32 | $3.05 | $3.05 | $3.05 | 291,00 | 6,00 | |||||
| URNLS 2/3 GLASS TST | 81020 | CPT | BOTH | $14.10 | $3.76 | $3.53 | $4.00 | $8.00 | $5.02 | $5.02 | $4.70 | $4.70 | N/A | N/A | $3.76 | N/A | $4.70 | $4.70 | $4.70 | 353,00 | 8,00 | |||||
| URINE PREGNANCY TST VIS COLOR | 81025 | CPT | BOTH | $25.83 | $7.00 | $8.61 | $7.00 | $10.00 | $8.00 | $8.00 | $8.61 | $8.61 | $7.00 | $6.03 | $7.00 | $6.89 | $8.61 | $8.61 | $8.61 | 603,00 | 10,00 | |||||
| HPA-1 GENOTYPING | 81105 | CPT | BOTH | $366.66 | $120.71 | $105.62 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $120.71 | $81,105.00 | $122.22 | $122.22 | $122.22 | 10.562,00 | 81.105,00 | |||||
| HPA-2 GENOTYPING | 81106 | CPT | BOTH | $366.66 | $120.71 | $105.62 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $120.71 | N/A | $122.22 | $122.22 | $122.22 | 10.562,00 | 12.222,00 | |||||
| HPA-3 GENOTYPING | 81107 | CPT | BOTH | $366.66 | $120.71 | $105.62 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $120.71 | N/A | $122.22 | $122.22 | $122.22 | 10.562,00 | 12.222,00 | |||||
| HPA-4 GENOTYPING | 81108 | CPT | BOTH | $366.66 | $120.71 | $105.62 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $120.71 | N/A | $122.22 | $122.22 | $122.22 | 10.562,00 | 12.222,00 | |||||
| HPA-5 GENOTYPING | 81109 | CPT | BOTH | $366.66 | $120.71 | $105.62 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $120.71 | N/A | $122.22 | $122.22 | $122.22 | 10.562,00 | 12.222,00 | |||||
| HPA-6 GENOTYPING | 81110 | CPT | BOTH | $366.66 | $120.71 | $105.62 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $120.71 | N/A | $122.22 | $122.22 | $122.22 | 10.562,00 | 12.222,00 | |||||
| HPA-9 GENOTYPING | 81111 | CPT | BOTH | $366.66 | $120.71 | $105.62 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $120.71 | N/A | $122.22 | $122.22 | $122.22 | 10.562,00 | 12.222,00 | |||||
| HPA-15 GENOTYPING | 81112 | CPT | BOTH | $366.66 | $120.71 | $105.62 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $120.71 | N/A | $122.22 | $122.22 | $122.22 | 10.562,00 | 12.222,00 | |||||
| BRCA1&2 SEQ & FULL DUP/DEL | 81162 | CPT | BOTH | $5,474.64 | $1,802.34 | $1,824.88 | $1,802.34 | $1,900.00 | N/A | $468.00 | $1,838.81 | $1,824.88 | N/A | N/A | $1,802.34 | $1,824.88 | $1,824.88 | $1,824.88 | $1,824.88 | 468,00 | 1.900,00 | |||||
| BRCA 1 GENE FOR DUPLICATION | 81166 | CPT | BOTH | $904.05 | N/A | $301.35 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $301.35 | $301.35 | $301.35 | $301.35 | 30.135,00 | 30.135,00 | |||||
| BRCA 2 FOR DUPLICATION OR DELE | 81167 | CPT | BOTH | $848.64 | N/A | $282.88 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $282.88 | $282.88 | $282.88 | 28.288,00 | 28.288,00 | |||||
| HRDTRY BRST CA-RLATD DSORDRS | 81432 | CPT | BOTH | $2,037.15 | $670.66 | $509.29 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $670.66 | N/A | $679.05 | $679.05 | $679.05 | 50.929,00 | 67.905,00 | |||||
| HRDTRY BRST CA-RLATD DSORDRS | 81433 | CPT | BOTH | $1,316.79 | $433.51 | $329.20 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $433.51 | N/A | $438.93 | $438.93 | $438.93 | 3.292,00 | 43.893,00 | |||||
| HEREDITARY RETINAL DISORDERS | 81434 | CPT | BOTH | $1,793.73 | $478.33 | $448.43 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $478.33 | N/A | $597.91 | $597.91 | $597.91 | 44.843,00 | 59.791,00 | |||||
| HEREDITARY COLON CANCER | 81435 | CPT | BOTH | $1,754.70 | $550.00 | $438.68 | N/A | N/A | N/A | $584.90 | $584.90 | $584.90 | $397.38 | $557.73 | $550.00 | $584.90 | $584.90 | $584.90 | $584.90 | 39.738,00 | 5.849,00 | |||||
| HEREDITARY COLON CA SYND | 81436 | CPT | BOTH | $1,754.70 | $550.00 | $438.68 | N/A | N/A | N/A | $584.90 | $584.90 | $584.90 | $397.38 | $557.73 | $550.00 | N/A | $584.90 | $584.90 | $584.90 | 39.738,00 | 5.849,00 | |||||
| HEREDTRY NURONDCRN TUM DSRDR | 81437 | CPT | BOTH | $1,316.79 | $433.51 | $329.20 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $433.51 | N/A | $438.93 | $438.93 | $438.93 | 3.292,00 | 43.893,00 | |||||
| HEREDTRY NURONDCRN TUM DSRDR | 81438 | CPT | BOTH | $1,316.79 | $433.51 | $329.20 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $433.51 | N/A | $438.93 | $438.93 | $438.93 | 3.292,00 | 43.893,00 | |||||
| HRDTRY CARDMYPY GENE PANEL | 81439 | CPT | BOTH | $1,754.70 | $577.68 | $438.68 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $577.68 | N/A | $584.90 | $584.90 | $584.90 | 43.868,00 | 5.849,00 | |||||
| ALBUMIN SERUM PLASMA/WHOLE BLO | 82040 | CPT | BOTH | $14.85 | $1.50 | $4.00 | $7.00 | $7.00 | $6.74 | $6.74 | $4.95 | $4.95 | $7.00 | $4.72 | $1.50 | $5.39 | $4.95 | $4.95 | $4.95 | 15,00 | 7,00 | |||||
| ALBUMIN URINE/OTH SRC QUAN EA | 82042 | CPT | BOTH | $23.34 | $4.00 | $4.95 | $4.00 | $30.00 | $4.00 | $4.00 | $7.78 | $7.78 | $4.00 | $4.94 | $4.00 | $5.64 | $7.78 | $7.78 | $7.78 | 4,00 | 30,00 | |||||
| ALBUMIN URINE MICROALBUMIN QUA | 82043 | CPT | BOTH | $17.34 | $70.00 | $6.30 | $35.00 | $50.00 | $28.00 | $28.00 | $5.78 | $5.78 | $35.00 | $5.51 | $70.00 | $6.30 | $5.78 | $7.14 | $5.78 | 551,00 | 70,00 | |||||
| ALBUMIN URINE MICROALBUMIN SEM | 82044 | CPT | BOTH | $18.69 | $2.50 | $4.67 | $2.50 | $25.00 | $2.50 | $2.50 | $6.23 | $6.23 | $2.00 | $32.37 | $2.50 | $4.36 | $6.23 | $6.23 | $6.23 | 2,00 | 3.237,00 | |||||
| ALBUMIN ISCHEMIA MODF | 82045 | CPT | BOTH | $101.82 | $64.09 | $33.94 | $64.09 | $7.00 | $46.24 | $46.24 | $33.94 | $33.94 | N/A | $32.37 | $64.09 | $36.99 | $33.94 | $33.94 | $33.94 | 7,00 | 6.409,00 | |||||
| ALCOHOL BRTH | 82075 | CPT | BOTH | $90.00 | $24.00 | $22.50 | $22.50 | $36.00 | $24.00 | $30.00 | $30.00 | $30.00 | N/A | $11.49 | $24.00 | $30.00 | $30.00 | $30.00 | $30.00 | 1.149,00 | 36,00 | |||||
| GASES BLD PH ONLY | 82800 | CPT | BOTH | $33.00 | $8.80 | $8.25 | $8.25 | $27.00 | $40.00 | $20.00 | $11.00 | $11.00 | $32.00 | $8.07 | $8.80 | $11.00 | $11.00 | $11.00 | $11.00 | 807,00 | 40,00 | |||||
| THIAMINE | 84425 | CPT | BOTH | $63.69 | $80.00 | $23.14 | $60.00 | $70.00 | $80.00 | $48.00 | $21.23 | $21.23 | $32.00 | $20.24 | $80.00 | $23.14 | $21.23 | $21.23 | $21.23 | 2.024,00 | 80,00 | |||||
| THIOCYANATE | 84430 | CPT | BOTH | $34.89 | $68.49 | $11.63 | $57.00 | $65.00 | $48.00 | $56.00 | $11.63 | $11.63 | $6.00 | $11.10 | $68.49 | $12.68 | $11.63 | $11.63 | $11.63 | 6,00 | 6.849,00 | |||||
| THROMBOXANE METABOLITE W/WO TH | 84431 | CPT | BOTH | $105.33 | $28.09 | $35.11 | $35.11 | $20.30 | $48.00 | $22.89 | $35.11 | $35.11 | N/A | $16.02 | $28.09 | $35.11 | $35.11 | $35.11 | $35.11 | 1.602,00 | 48,00 | |||||
| THYROGLOBULIN | 84432 | CPT | BOTH | $48.18 | $25.00 | $16.06 | $40.00 | $82.00 | $56.00 | $140.00 | $16.06 | $16.06 | $25.00 | $15.32 | $25.00 | $17.50 | $16.06 | $16.06 | $16.06 | 1.532,00 | 140,00 | |||||
| T4 TOTAL THYROXINE TOT | 84436 | CPT | BOTH | $20.61 | $10.00 | $6.87 | $9.00 | $15.00 | $18.54 | $9.35 | $6.87 | $6.87 | $15.00 | $6.55 | $10.00 | $7.48 | $6.87 | $6.87 | $6.87 | 655,00 | 1.854,00 | |||||
| THYROXINE REQ ELUTION | 84437 | CPT | BOTH | $19.41 | $15.49 | $6.47 | $15.49 | $20.00 | $140.00 | $12.00 | $6.47 | $6.47 | $10.00 | $6.17 | $15.49 | $7.05 | $6.47 | $6.47 | $6.47 | 617,00 | 140,00 | |||||
| T4 FREE THYROXINE FR | 84439 | CPT | BOTH | $27.06 | $19.49 | $9.82 | $20.00 | $30.00 | $9.35 | $24.00 | $9.02 | $9.02 | $10.00 | $8.60 | $19.49 | $12.77 | $9.02 | $9.02 | $9.02 | 86,00 | 30,00 | |||||
| THYROXINE BNDNG GLOBULIN | 84442 | CPT | BOTH | $44.34 | $59.79 | $14.10 | $55.00 | $75.00 | $12.00 | $44.00 | $14.78 | $14.78 | $32.00 | $14.10 | $59.79 | $16.11 | $14.78 | $14.78 | $14.78 | 12,00 | 75,00 | |||||
| TSH THYR STIMULATING HORM | 84443 | CPT | BOTH | $50.40 | $30.00 | $16.80 | $30.00 | $40.00 | $24.00 | $24.00 | $16.80 | $16.80 | $20.00 | $22.08 | $30.00 | $23.80 | $16.80 | $20.75 | $16.80 | 168,00 | 40,00 | |||||
| THYR STIMULATING IGS | 84445 | CPT | BOTH | $152.58 | $70.00 | $50.86 | $80.00 | $154.00 | $44.00 | $160.00 | $50.86 | $50.86 | $35.00 | $48.49 | $70.00 | $55.42 | $50.86 | $50.86 | $50.86 | 35,00 | 160,00 | |||||
| TOCOPHEROL ALPHA | 84446 | CPT | BOTH | $42.54 | $62.74 | $13.52 | $59.00 | $60.00 | $24.00 | $52.00 | $14.18 | $14.18 | $32.00 | $13.52 | $62.74 | $15.45 | $14.18 | $14.18 | $14.18 | 1.352,00 | 6.274,00 | |||||
| TRANSCORTIN | 84449 | CPT | BOTH | $54.00 | $17.78 | $17.16 | $25.00 | $40.00 | $160.00 | $24.52 | $18.00 | $18.00 | N/A | $17.16 | $17.78 | $18.00 | $18.00 | $18.00 | $18.00 | 1.716,00 | 160,00 | |||||
| AST TRANSFERASE ASPARTATE AMIN | 84450 | CPT | BOTH | $15.54 | $8.00 | $14.18 | $8.00 | $10.00 | $52.00 | $8.00 | $5.18 | $5.18 | $7.00 | $4.94 | $8.00 | $5.64 | $5.18 | $5.18 | $5.18 | 494,00 | 52,00 | |||||
| ALT TRANSFERASE ALANINE AMINO | 84460 | CPT | BOTH | $15.90 | $8.00 | $5.30 | $8.00 | $10.00 | $24.52 | $7.22 | $5.30 | $5.30 | $7.00 | $5.05 | $8.00 | $5.78 | $5.30 | $5.30 | $5.30 | 505,00 | 2.452,00 | |||||
| TRANSFERRIN | 84466 | CPT | BOTH | $38.28 | $30.00 | $12.76 | $30.00 | $35.00 | $8.00 | $32.00 | $12.76 | $12.76 | $15.00 | $12.17 | $30.00 | $13.91 | $12.76 | $12.76 | $12.76 | 8,00 | 35,00 | |||||
| TRIGLYCERIDES | 84478 | CPT | BOTH | $17.22 | $15.00 | $5.74 | $14.00 | $13.00 | $8.00 | $12.00 | $5.74 | $5.74 | $15.00 | $5.48 | $15.00 | $6.26 | $5.74 | $5.74 | $5.74 | 548,00 | 15,00 | |||||
| T3 UP THYR HORM UPTK/THYR HORM | 84479 | CPT | BOTH | $19.41 | $10.00 | $6.47 | $10.00 | $15.00 | $32.00 | $8.81 | $6.47 | $6.47 | $13.00 | $6.17 | $10.00 | $7.05 | $6.47 | $6.47 | $6.47 | 617,00 | 32,00 | |||||
| TRIIODOTHYRO9 T3 TOT | 84480 | CPT | BOTH | $42.54 | $25.40 | $14.18 | $24.00 | $35.00 | $12.00 | $36.00 | $14.18 | $14.18 | $22.00 | $13.52 | $25.40 | $15.45 | $14.18 | $14.18 | $14.18 | 12,00 | 36,00 | |||||
| TRIIODOTHYRO9 T3 FR | 84481 | CPT | BOTH | $50.82 | $48.49 | $16.94 | $48.00 | $115.00 | $8.81 | $56.00 | $16.94 | $16.94 | $25.00 | $16.15 | $48.49 | $18.46 | $16.94 | $16.94 | $16.94 | 881,00 | 115,00 | |||||
| TRIIODOTHYRO9 T3 REVERSE | 84482 | CPT | BOTH | $47.28 | $40.00 | $15.03 | $43.00 | $100.00 | $36.00 | $64.00 | $15.76 | $15.76 | $25.00 | $9.38 | $40.00 | $17.18 | $15.76 | $15.76 | $15.76 | 938,00 | 100,00 | |||||
| TROPONIN QUAN | 84484 | CPT | BOTH | $37.41 | $25.00 | $12.47 | $30.00 | $65.00 | $56.00 | $24.00 | $12.47 | $12.47 | $25.00 | $9.38 | $25.00 | $10.72 | $12.47 | $12.47 | $12.47 | 938,00 | 65,00 | |||||
| TRYPSIN DUOL FLU | 84485 | CPT | BOTH | $21.60 | $5.00 | $5.40 | $5.40 | $12.00 | $64.00 | $5.00 | $7.20 | $7.20 | $7.00 | $7.16 | $5.00 | $8.18 | $7.20 | $7.20 | $7.20 | 5,00 | 64,00 | |||||
| TRYPSIN FECES QUAL | 84488 | CPT | BOTH | $21.90 | $7.21 | $6.97 | $11.00 | $12.00 | $24.00 | $9.95 | $7.30 | $7.30 | N/A | $6.97 | $7.21 | $7.30 | $7.30 | $7.30 | $7.30 | 697,00 | 24,00 | |||||
| TRYPSIN FECES QUAN 24-HR COLLJ | 84490 | CPT | BOTH | $29.79 | $7.94 | $7.45 | $8.00 | $12.00 | $5.00 | $10.35 | $9.93 | $9.93 | $13.00 | $7.25 | $7.94 | $9.93 | $9.93 | $9.93 | $9.93 | 5,00 | 13,00 | |||||
| CBC+DIFF BLD# COMPL AUTO HHRWP | 85025 | CPT | BOTH | $16.00 | $9.00 | $7.77 | $9.00 | $11.00 | $5.24 | $9.00 | $7.77 | $7.77 | $8.00 | $8.09 | $9.00 | $11.02 | $7.77 | $9.59 | $7.77 | 524,00 | 1.102,00 | |||||
| CBC W/O DIFF BLD# COMPL AUTO H | 85027 | CPT | BOTH | $15.00 | $6.00 | $6.47 | $7.00 | $6.00 | $4.00 | $8.81 | $6.47 | $6.47 | $10.00 | $6.17 | $6.00 | $9.17 | $6.47 | $7.98 | $6.47 | 4,00 | 10,00 | |||||
| BLD# MNL C-CNT RBC WBC/PLTLT E | 85032 | CPT | BOTH | $12.93 | $5.00 | $4.10 | $5.00 | $8.00 | $9.00 | $5.86 | $4.31 | $4.31 | $2.00 | $4.10 | $5.00 | $4.69 | $4.31 | $4.31 | $4.31 | 2,00 | 9,00 | |||||
| BLD# RED BLD CELL AUTO | 85041 | CPT | BOTH | $9.06 | $7.20 | $3.02 | $7.00 | $5.00 | $8.81 | $5.60 | $3.02 | $3.02 | $2.00 | $2.88 | $7.20 | $3.29 | $3.02 | $3.02 | $3.02 | 2,00 | 881,00 | |||||
| BLD# RETICULOCYTE MNL | 85044 | CPT | BOTH | $12.93 | $5.00 | $4.31 | $5.00 | $10.00 | $5.86 | $8.00 | $4.31 | $4.31 | $3.00 | $4.10 | $5.00 | $4.69 | $4.31 | $4.31 | $4.31 | 3,00 | 10,00 | |||||
| BLD# RETICULOCYTE AUTO | 85045 | CPT | BOTH | $11.97 | $3.94 | $3.99 | $5.00 | $8.00 | $5.60 | $5.45 | $3.99 | $3.99 | N/A | $3.82 | $3.94 | $3.99 | $3.99 | $3.99 | $3.99 | 382,00 | 8,00 | |||||
| BLD# RETICULOCYTES AUTO 1+ CEL | 85046 | CPT | BOTH | $16.71 | $5.50 | $5.31 | $8.00 | $14.00 | $8.00 | $7.59 | $5.57 | $5.57 | N/A | $5.31 | $5.50 | $5.57 | $5.57 | $5.57 | $5.57 | 531,00 | 14,00 | |||||
| BLD# WBC AUTO | 85048 | CPT | BOTH | $7.62 | $3.00 | $2.54 | $3.00 | $4.00 | $5.45 | $3.46 | $2.54 | $2.54 | $2.00 | $2.42 | $3.00 | $2.77 | $2.54 | $2.54 | $2.54 | 2,00 | 545,00 | |||||
| BLD# PLTLT AUTO | 85049 | CPT | BOTH | $13.44 | $5.00 | $4.48 | $5.00 | $8.00 | $7.59 | $6.00 | $4.48 | $4.48 | $5.00 | $4.27 | $5.00 | $4.88 | $4.48 | $4.48 | $4.48 | 427,00 | 8,00 | |||||
| RETICULATED PLTLT ASSAY | 85055 | CPT | BOTH | $107.22 | $28.59 | $26.81 | N/A | $45.00 | N/A | N/A | N/A | N/A | N/A | $25.53 | $28.59 | $35.74 | $35.74 | $35.74 | $35.74 | 2.553,00 | 45,00 | |||||
| BLD SMR PRPH INTERPJ PHYS WRTT | 85060 | CPT | BOTH | $74.46 | $30.00 | $29.25 | N/A | $30.00 | N/A | N/A | N/A | N/A | N/A | N/A | $30.00 | $24.61 | $24.61 | $24.61 | $24.61 | 2.461,00 | 30,00 | |||||
| B1 MARROW SMR INTERPJ | 85097 | CPT | BOTH | $147.87 | $40.00 | $36.41 | N/A | $117.00 | N/A | N/A | N/A | N/A | N/A | N/A | $40.00 | $48.54 | $48.54 | $48.54 | $48.54 | 3.641,00 | 117,00 | |||||
| SICKLING RBC RDCTJ | 85660 | CPT | BOTH | $16.53 | $5.76 | $5.51 | $5.00 | $10.00 | $11.50 | $11.50 | $5.51 | $5.51 | $5.00 | $6.29 | $5.76 | $5.76 | $5.51 | $5.78 | $5.51 | 5,00 | 115,00 | |||||
| ANTB ID PLTLT ANTIBODIES | 86022 | CPT | BOTH | $55.11 | $50.00 | $20.02 | $48.00 | $124.00 | Adquisition cost | $56.00 | $18.37 | $18.37 | $47.50 | $17.51 | $50.00 | $53.77 | $18.37 | $18.37 | $18.37 | 1.751,00 | 124,00 | |||||
| BLD BANK PHYS SVCS DIFFC CROSS | 86077 | CPT | BOTH | $152.10 | $46.14 | $53.20 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $46.14 | N/A | $49.93 | $56.71 | $49.93 | 4.614,00 | 5.671,00 | |||||
| BLD BANK PHYS SVCS INVSTGJ TFU | 86078 | CPT | BOTH | $152.10 | $46.14 | $39.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $46.14 | N/A | $49.93 | $49.93 | $49.93 | 39,00 | 4.993,00 | |||||
| BLD BANK PHYS SVCS AUTHJ DEVIJ | 86079 | CPT | BOTH | $151.05 | $45.84 | $38.40 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $45.84 | N/A | $49.93 | $49.93 | $49.93 | 384,00 | 4.993,00 | |||||
| COLD AGGLUTININ SCR | 86156 | CPT | BOTH | $24.21 | $11.00 | $8.07 | $10.00 | $12.00 | $59.00 | $59.00 | $8.07 | $8.07 | $11.00 | $6.38 | $11.00 | $7.30 | $8.07 | $8.07 | $8.07 | 638,00 | 59,00 | |||||
| COLD AGGLUTININ TITER | 86157 | CPT | BOTH | $24.18 | $13.00 | $8.06 | $13.00 | $15.00 | $95.00 | $95.00 | $8.06 | $8.06 | $10.00 | $7.69 | $13.00 | $8.78 | $8.06 | $8.06 | $8.06 | 769,00 | 95,00 | |||||
| CA 15-3 IA TUM AG QUAN CA 15-3 | 86300 | CPT | BOTH | $62.43 | $39.83 | $20.81 | $27.00 | $57.00 | $27.42 | $27.42 | $20.81 | $20.81 | $17.00 | $21.11 | $39.83 | $28.51 | $20.81 | $20.81 | $20.81 | 17,00 | 57,00 | |||||
| CA 19-9 IA TUM AG QUAN CA 19-9 | 86301 | CPT | BOTH | $62.43 | $39.83 | $21.94 | $30.00 | $55.00 | $27.42 | $27.42 | $20.81 | $20.81 | $17.00 | $19.19 | $39.83 | $21.94 | $20.81 | $20.81 | $20.81 | 17,00 | 55,00 | |||||
| CA 125 IA TUM AG QUAN CA 125 | 86304 | CPT | BOTH | $62.43 | $39.83 | $20.81 | $39.00 | $65.00 | $27.42 | $27.42 | $20.81 | $20.81 | $17.00 | $19.19 | $39.83 | $28.51 | $20.81 | $20.81 | $20.81 | 17,00 | 65,00 | |||||
| ANTB CMV CMV IGM | 86645 | CPT | BOTH | $50.55 | $30.45 | $16.85 | $29.00 | $50.00 | $12.00 | $12.00 | $16.85 | $16.85 | $14.00 | $18.52 | $30.45 | $30.45 | $16.85 | $30.45 | $16.85 | 12,00 | 50,00 | |||||
| THYROGLOBULIN ANTB | 86800 | CPT | BOTH | $47.73 | $33.66 | $15.91 | $40.00 | $30.00 | $16.00 | $40.00 | $15.91 | $13.75 | $17.00 | $15.17 | $33.66 | $17.34 | $15.91 | $15.91 | $15.91 | 1.375,00 | 40,00 | |||||
| ANTB SCR RBC EA SERUM TQ | 86850 | CPT | BOTH | $29.31 | $57.60 | $9.77 | $10.00 | $21.00 | $30.00 | $30.00 | $9.77 | $6.84 | N/A | $4.19 | $57.60 | $57.60 | $9.77 | $57.60 | $9.77 | 419,00 | 576,00 | |||||
| ANTIBODY ELUTION RBC EACH | 86860 | CPT | BOTH | $210.00 | $76.67 | N/A | N/A | $60.00 | N/A | N/A | N/A | N/A | N/A | N/A | $76.67 | $76.67 | $76.67 | $76.67 | $76.67 | 60,00 | 7.667,00 | |||||
| ANTB ID RBC ANTIBODIES EA PANE | 86870 | CPT | BOTH | $50.00 | $103.33 | $53.49 | $53.49 | $45.00 | $140.00 | $140.00 | N/A | $41.76 | N/A | $16.32 | $103.33 | $103.33 | $103.33 | $103.33 | $103.33 | 1.632,00 | 140,00 | |||||
| ANTIHUMAN GLOBULIN DIR EA ANTI | 86880 | CPT | BOTH | $16.17 | $5.32 | $5.39 | $6.00 | $12.00 | $30.00 | $30.00 | $5.39 | $4.66 | $5.86 | $6.29 | $5.32 | $5.86 | $5.39 | $5.39 | $5.39 | 466,00 | 30,00 | |||||
| IADNA MLT ORGANISMS DIR PRB | 87800 | CPT | BOTH | $131.01 | $39.62 | $38.25 | N/A | $45.00 | $9.75 | $28.00 | $43.67 | $34.67 | N/A | $38.25 | $39.62 | $43.67 | $43.67 | $43.67 | $43.67 | 975,00 | 45,00 | |||||
| ECG ROUTINE ECG W/LEAST 12 LDS | 93005 | CPT | BOTH | $20.04 | N/A | $6.80 | $17.00 | $15.00 | $9.60 | $9.60 | $6.20 | $11.00 | $6.00 | $6.62 | N/A | $6.27 | $6.27 | $8.69 | $6.27 | 6,00 | 17,00 | |||||
| ECG ROUTINE ECG W/LEAST 12 LDS | 93010 | CPT | BOTH | $25.17 | $20.00 | $10.20 | $10.20 | $15.00 | $16.00 | $7.71 | $7.78 | $10.20 | $15.00 | $15.00 | $20.00 | $8.32 | $8.32 | $8.39 | $8.32 | 771,00 | 20,00 | |||||
| ECHO TTHRC R-T 2D -+M-MODE COM | 93306 | CPT | BOTH | $627.51 | N/A | $268.00 | $397.80 | $400.00 | $194.15 | $209.17 | $207.06 | $218.50 | $397.80 | $249.00 | $397.80 | $206.05 | $209.17 | $211.52 | $209.17 | 19.415,00 | 400,00 | |||||
| INTRAVENOUS INFUSION INITIAL | 96360 | CPT | BOTH | $95.82 | N/A | $35.17 | N/A | $49.00 | N/A | $31.97 | $31.97 | $46.42 | $30.00 | N/A | N/A | $35.17 | $30.25 | $30.25 | $30.25 | 30,00 | 49,00 | |||||
| IV INFUSION HYDRATION EACH ADD | 96361 | CPT | BOTH | $36.51 | $13.00 | $25.00 | $25.00 | $13.00 | $49.00 | $11.66 | $14.04 | $14.92 | $11.00 | $25.00 | N/A | $13.22 | $13.22 | $13.22 | $13.22 | 11,00 | 49,00 | |||||
| IV INFUSION THERAPY/PROPHYLAXI | 96365 | CPT | BOTH | $222.36 | $50.00 | $69.68 | $40.00 | $53.90 | $50.00 | $50.85 | $53.05 | $64.72 | $50.00 | $45.00 | $50.00 | $69.68 | $62.94 | $74.12 | $69.68 | 40,00 | 7.412,00 | |||||
| IV INFUSION THERAPY PROPHYLAXI | 96366 | CPT | BOTH | $67.35 | $16.00 | $21.57 | $12.00 | $19.00 | $16.00 | $15.13 | $22.45 | $20.67 | $16.00 | $14.00 | $16.00 | $21.57 | $21.57 | $21.57 | $21.57 | 12,00 | 2.245,00 | |||||
| IV NFS THER PROPH/DX ADDL SEQU | 96367 | CPT | BOTH | $83.94 | $27.00 | $30.98 | $27.00 | $28.00 | $27.00 | $27.98 | $27.98 | $29.14 | $27.00 | $24.00 | $27.00 | $30.98 | $19.49 | $19.49 | $19.49 | 1.949,00 | 3.098,00 | |||||
| IV NFS THERAPY PROPHYLAXIS/DX | 96368 | CPT | BOTH | $64.20 | $16.00 | $20.88 | $16.00 | N/A | $16.00 | $16.29 | $21.40 | $19.99 | $14.00 | $14.00 | $16.00 | $20.88 | $20.88 | $20.88 | $20.88 | 14,00 | 214,00 | |||||
| SUBCUTANEOUS INFUSION INITIAL | 96369 | CPT | BOTH | $479.88 | $129.00 | $148.88 | $129.00 | $115.70 | $129.00 | $138.59 | $159.96 | $141.65 | N/A | $116.00 | $129.00 | $148.88 | $135.11 | $135.11 | $135.11 | 1.157,00 | 15.996,00 | |||||
| SUBCUTANEOUS INFUSION EACH ADD | 96370 | CPT | BOTH | $46.26 | $14.00 | $15.64 | $14.00 | $13.60 | $14.00 | $12.36 | $15.42 | $15.59 | N/A | $13.00 | $14.00 | $15.64 | $15.91 | $15.91 | $15.91 | 1.236,00 | 1.591,00 | |||||
| SUBQ INFUSION ADDITIONAL PUMP | 96371 | CPT | BOTH | $199.44 | $58.00 | $60.35 | $58.00 | $55.00 | $58.00 | $51.75 | $66.48 | $56.93 | N/A | $52.00 | $58.00 | $60.35 | $56.02 | $56.02 | $56.02 | 5.175,00 | 6.648,00 | |||||
| THERAPEUTIC PROPHYLACTIC/DX IN | 96372 | CPT | BOTH | $43.11 | $12.50 | $14.60 | $12.50 | N/A | $14.07 | $19.57 | $14.37 | $15.26 | $15.00 | $11.00 | $12.50 | $14.60 | $14.60 | $17.01 | $14.60 | 11,00 | 1.957,00 | |||||
| THERAPEUTIC PROPHYLACTIC/DX NJ | 96373 | CPT | BOTH | $55.77 | N/A | $18.43 | N/A | $15.00 | N/A | $15.53 | $18.59 | $18.30 | N/A | N/A | N/A | $18.43 | $13.96 | $13.96 | $13.96 | 1.396,00 | 1.859,00 | |||||
| THER PROPH/DX NJX IV PUSH SING | 96374 | CPT | BOTH | $126.42 | N/A | $40.40 | $40.00 | $43.00 | N/A | $41.70 | $42.14 | $42.93 | N/A | $26.65 | N/A | $40.40 | $34.14 | $34.14 | $34.14 | 2.665,00 | 43,00 | |||||
| THER PROPH/DX NJX EA SEQL IV P | 96375 | CPT | BOTH | $51.60 | $14.76 | $15.00 | $15.00 | $19.00 | $16.17 | $16.81 | $17.20 | $19.99 | N/A | N/A | N/A | $16.36 | $14.30 | $14.30 | $14.30 | 143,00 | 1.999,00 | |||||
| APPLICATON ON-BODY INJECTOR | 96377 | CPT | BOTH | $61.02 | N/A | $19.48 | N/A | N/A | N/A | $19.57 | $20.34 | $18.64 | N/A | N/A | N/A | $19.48 | $17.54 | $17.54 | $17.54 | 1.754,00 | 2.034,00 | |||||
| CHEMOTX ADMN SUBQ/IM NON-HORMO | 96401 | CPT | BOTH | $248.73 | $35.00 | $78.39 | $24.00 | N/A | $35.00 | $54.49 | $82.91 | $73.54 | $35.00 | $31.00 | $35.00 | $78.39 | $66.69 | $66.69 | $66.69 | 24,00 | 8.291,00 | |||||
| CHEMOTX ADMN SUBQ/IM HORMONAL | 96402 | CPT | BOTH | $100.05 | $35.00 | $34.23 | $24.00 | N/A | $35.00 | $24.68 | $33.35 | $34.23 | $35.00 | $23.00 | $35.00 | $34.12 | $35.12 | $35.12 | $35.12 | 23,00 | 3.512,00 | |||||
| CHEMOTX ADMN ILESN UP&W/7 < | 96405 | CPT | BOTH | $88.11 | $40.00 | $29.14 | $40.00 | N/A | $40.00 | $26.51 | $29.37 | $29.14 | $40.00 | $25.00 | $40.00 | $87.38 | $27.87 | $27.87 | $27.87 | 25,00 | 8.738,00 | |||||
| CHEMOTX ADMN ILESN > 7 | 96406 | CPT | BOTH | $136.38 | $80.00 | $45.42 | $80.00 | N/A | $80.00 | $41.03 | $45.46 | $132.84 | $80.00 | $37.00 | $80.00 | $138.21 | $42.78 | $42.78 | $42.78 | 37,00 | 13.821,00 | |||||
| CHEMOTX ADMN IV PUSH TQ 1/1ST | 96409 | CPT | BOTH | $342.60 | $35.00 | $108.71 | $46.00 | N/A | $35.00 | $80.26 | $114.20 | $102.00 | $35.00 | $31.00 | $35.00 | $108.71 | $93.06 | $93.06 | $93.06 | 31,00 | 1.142,00 | |||||
| CHEMOTX ADMN IV PUSH TQ EA SBS | 96411 | CPT | BOTH | $187.56 | $35.00 | $59.22 | $24.00 | $25.00 | $35.00 | $45.70 | $62.52 | $55.91 | $35.00 | $32.00 | $35.00 | $59.22 | $51.07 | $51.07 | $51.07 | 24,00 | 6.252,00 | |||||
| CHEMOTX ADMN IV NFS TQ UP 1 HR | 96413 | CPT | BOTH | $383.46 | $60.00 | $55.00 | $40.00 | $120.00 | $56.00 | $97.95 | $149.33 | $132.16 | $60.00 | $55.00 | $60.00 | $141.13 | $120.08 | $120.08 | $120.08 | 40,00 | 14.933,00 | |||||
| CHEMOTHERAPY ADMN IV INFUSION | 96415 | CPT | BOTH | $94.77 | $37.00 | $36.08 | $30.00 | $27.00 | $37.00 | $21.91 | $31.59 | $28.47 | $25.46 | $32.00 | $37.00 | $29.93 | $25.68 | $25.68 | $25.68 | 2.191,00 | 37,00 | |||||
| CHEMOTX ADMN TQ INIT PROLNG CH | 96416 | CPT | BOTH | $444.90 | $50.00 | $88.63 | $45.00 | $127.50 | $50.00 | $101.00 | $148.30 | $129.79 | $50.00 | $44.00 | $50.00 | $138.37 | $118.15 | $118.15 | $118.15 | 44,00 | 1.483,00 | |||||
| CHEMOTX ADMN IV NFS TQ EA SEQL | 96417 | CPT | BOTH | $217.11 | $37.00 | $68.63 | $35.00 | $60.00 | $37.00 | $46.05 | $72.37 | $65.06 | $37.00 | $32.00 | $37.00 | $68.63 | $59.21 | $59.21 | $59.21 | 32,00 | 7.237,00 | |||||
| CHEMOTX ADMN IA PUSH TQ | 96420 | CPT | BOTH | $348.99 | $65.00 | $111.52 | $64.00 | N/A | $65.00 | $75.73 | $75.73 | $104.03 | $65.00 | $53.00 | $65.00 | $111.52 | $95.03 | $95.03 | $95.03 | 53,00 | 11.152,00 | |||||
| CHEMOTX ADMN IA NFS TQ UP 1 HR | 96422 | CPT | BOTH | $544.08 | $75.00 | $169.76 | $72.00 | N/A | $75.00 | $120.98 | $181.36 | $159.95 | $75.00 | $63.00 | $75.00 | $169.76 | $145.17 | $145.17 | $145.17 | 63,00 | 18.136,00 | |||||
| CHEMOTHERAPY ADMN INTRAARTERIA | 96423 | CPT | BOTH | $249.81 | $45.00 | $78.40 | $40.00 | N/A | $45.00 | $56.84 | $83.27 | $73.87 | $45.00 | $35.00 | $45.00 | $78.40 | $67.36 | $67.36 | $67.36 | 35,00 | 8.327,00 | |||||
| CHEMOTX ADMN IA NFS > 8 HR PRT | 96425 | CPT | BOTH | $583.08 | $58.00 | $182.66 | $56.00 | N/A | $58.00 | $129.01 | $194.36 | $171.47 | $58.00 | $49.00 | $58.00 | $182.66 | $156.23 | $156.23 | $156.23 | 49,00 | 19.436,00 | |||||
| CHEMOTX ADMN PLEURAL CAVITY RE | 96440 | CPT | BOTH | $376.98 | $104.00 | $135.02 | $96.00 | N/A | $104.00 | $117.99 | $125.66 | $133.52 | $104.00 | $84.00 | $104.00 | $135.02 | $131.32 | $131.32 | $131.32 | 84,00 | 13.502,00 | |||||
| CHEMOTX ADMN PRTL CAVITY | 96446 | CPT | BOTH | $77.40 | $100.00 | $87.75 | $100.00 | N/A | $100.00 | $20.62 | $25.80 | $25.42 | $100.00 | $88.00 | $100.00 | $27.30 | $19.07 | $19.07 | $19.07 | 1.907,00 | 100,00 | |||||
| CHEMOTX ADMN CNS REQ&W/SPI PNX | 96450 | CPT | BOTH | $236.88 | $115.00 | $77.62 | $112.00 | N/A | $115.00 | $72.45 | $78.96 | $76.92 | $115.00 | $174.70 | $115.00 | $77.62 | $74.12 | $74.12 | $74.12 | 7.245,00 | 1.747,00 | |||||
| OFFICE OUTPT NEW 20 MIN | 99202 | CPT | BOTH | $149.91 | $32.00 | $74.32 | $30.00 | $37.00 | $30.00 | $48.12 | $42.36 | $72.86 | $32.00 | $36.18 | $32.00 | $45.33 | $48.12 | $48.12 | $48.12 | 30,00 | 7.432,00 | |||||
| OFFICE OUTPT NEW 30 MIN | 99203 | CPT | BOTH | $253.68 | $38.00 | $84.54 | $30.00 | $37.00 | $30.00 | $83.02 | $81.36 | $83.02 | $31.28 | $91.35 | $38.00 | $84.54 | $83.02 | $83.02 | $83.02 | 30,00 | 9.135,00 | |||||
| OFFICE OUTPT NEW 45 MIN | 99204 | CPT | BOTH | $413.04 | $38.00 | $136.89 | $102.67 | $37.00 | $40.00 | $133.52 | $133.52 | $133.52 | $32.00 | $92.60 | $38.00 | $136.89 | $133.52 | $133.52 | $136.89 | 32,00 | 13.689,00 | |||||
| OFFICE OUTPT NEW 60 MIN | 99205 | CPT | BOTH | $560.88 | $38.00 | $185.76 | $30.00 | $37.00 | $30.00 | $181.30 | $181.30 | $181.30 | $38.00 | $46.20 | $38.00 | $185.76 | $181.30 | $181.30 | $185.76 | 30,00 | 18.576,00 | |||||
| OFFICE OUTPT EST 5 MIN | 99211 | CPT | BOTH | $27.27 | $30.00 | $9.01 | $25.00 | $30.00 | $25.00 | $8.81 | $8.81 | $8.81 | $30.00 | $6.58 | $30.00 | $9.01 | $8.81 | $8.81 | $9.01 | 658,00 | 30,00 | |||||
| OFFICE OUTPT EST 10 MIN | 99212 | CPT | BOTH | $109.05 | $30.00 | $36.73 | $25.00 | $30.00 | $25.00 | $22.40 | $68.59 | $35.58 | $30.00 | $46.20 | $30.00 | $36.73 | $35.58 | $35.58 | $36.73 | 224,00 | 6.859,00 | |||||
| OFFICE OUTPT EST 15 MIN | 99213 | CPT | BOTH | $204.45 | $30.00 | $67.59 | $25.00 | $30.00 | $25.00 | $66.08 | $68.59 | $66.08 | $35.00 | $73.88 | $30.00 | $67.59 | $89.20 | $89.20 | $89.20 | 25,00 | 892,00 | |||||
| OFFICE OUTPT EST 25 MIN | 99214 | CPT | BOTH | $125.50 | $30.00 | $99.14 | $25.00 | $30.00 | $25.00 | $97.60 | $68.59 | $97.60 | $56.43 | $56.43 | $30.00 | $99.14 | $125.50 | $125.50 | $125.50 | 25,00 | 1.255,00 | |||||
| OFFICE OUTPT EST 40 MIN | 99215 | CPT | BOTH | $444.57 | $30.00 | $147.32 | $25.00 | $30.00 | $25.00 | $143.24 | $68.59 | $143.34 | $104.16 | $104.16 | $30.00 | $147.32 | $176.07 | $176.07 | $176.07 | 25,00 | 17.607,00 | |||||
| OFFICE CONSLTJ 15 MIN | 99241 | CPT | BOTH | $85.00 | $48.00 | $50.00 | $32.00 | $48.00 | $45.00 | $85.00 | $40.05 | $20.00 | $48.00 | $85.00 | $48.00 | $85.00 | $85.00 | $85.00 | $85.00 | 20,00 | 85,00 | |||||
| OFFICE CONSLTJ 30 MIN | 99242 | CPT | BOTH | $85.00 | $85.00 | $50.00 | $25.00 | $32.00 | $32.00 | $85.00 | $76.26 | $34.13 | $85.00 | $40.00 | $85.00 | $25.00 | $76.26 | $76.26 | $76.26 | 25,00 | 85,00 | |||||
| OFFICE CONSLTJ 40 MIN | 99243 | CPT | BOTH | $85.00 | $85.00 | $75.00 | $30.00 | $43.00 | $85.00 | $88.00 | $105.27 | $35.00 | $85.00 | $50.00 | $85.00 | $50.00 | $105.27 | $105.27 | $105.27 | 30,00 | 10.527,00 | |||||
| OFFICE CONSLTJ 60 MIN | 99244 | CPT | BOTH | $85.00 | $85.00 | $50.00 | $30.00 | $85.00 | $45.00 | N/A | $167.97 | $35.00 | $45.00 | $117.00 | $85.00 | $45.00 | $152.70 | $152.70 | $152.70 | 30,00 | 16.797,00 | |||||
| OFFICE CONSLTJ 80 MIN | 99245 | CPT | BOTH | $85.00 | $50.00 | $50.00 | $50.00 | $50.00 | $30.00 | $30.00 | $195.43 | $40.00 | $35.00 | $40.00 | $85.00 | N/A | $85.00 | $195.43 | $85.00 | 30,00 | 19.543,00 | |||||
| Oncology Emergency Room Per Di | 99281 | CPT | BOTH | $200.00 | $213.00 | $167.85 | $145.00 | $200.00 | $160.00 | $190.00 | $208.00 | $17.72 | $210.00 | $170.00 | $213.00 | $160.00 | $67.02 | $213.00 | $67.02 | 1.772,00 | 213,00 | |||||
| Oncology Emergency Room Per Di | 99282 | CPT | BOTH | $200.00 | $213.00 | $167.85 | $165.00 | $200.00 | $160.00 | $190.00 | $208.00 | $42.02 | $210.00 | $171.00 | $213.00 | $160.00 | $129.84 | $213.00 | $129.84 | 4.202,00 | 213,00 | |||||
| Oncology Emergency Room Per Di | 99283 | CPT | BOTH | $200.00 | $213.00 | $167.85 | $145.00 | $200.00 | $160.00 | $190.00 | $208.00 | $72.18 | $210.00 | $170.00 | $213.00 | $160.00 | $218.82 | $213.00 | $218.82 | 7.218,00 | 21.882,00 | |||||
| Oncology Emergency Room Per Di | 99284 | CPT | BOTH | $200.00 | $213.00 | $167.85 | $145.00 | $200.00 | $160.00 | $190.00 | $208.00 | $121.32 | $210.00 | $170.00 | $213.00 | $160.00 | $371.67 | $213.00 | $371.67 | 12.132,00 | 37.167,00 | |||||
| Oncology Emergency Room Per Di | 99285 | CPT | BOTH | $200.00 | $213.00 | $167.85 | $145.00 | $200.00 | $160.00 | $190.00 | $208.00 | $176.55 | $210.00 | $170.00 | $213.00 | $160.00 | $542.25 | $213.00 | $542.25 | 145,00 | 54.225,00 | |||||
| MRI LXTR OTH/THN JT C-MATRL | 7371826 | CPT | 26 | BOTH | $198.18 | $325.00 | $52.68 | $325.00 | $325.00 | $260.00 | $61.80 | $57.89 | $64.72 | $287.50 | $250.00 | $325.00 | $65.85 | $65.85 | $66.06 | $65.85 | 5.268,00 | 325,00 | ||||
| ELEC ALYS ANTITACHYCARDIA PM S | 372426 | CPT | BOTH | $733.11 | $228.00 | $350.48 | $228.00 | N/A | N/A | N/A | $244.37 | N/A | $190.40 | $176.00 | $228.00 | $350.48 | $329.58 | $329.58 | $329.58 | 176,00 | 35.048,00 | |||||
| GUIDANCE STEREOTACTIC ANESTHES | 19081A | CPT | BOTH | $201.19 | $120.00 | $225.00 | $120.00 | $475.00 | $132.38 | $61.07 | $65.05 | $65.34 | $254.00 | $83.20 | $120.00 | $66.65 | $66.65 | $66.65 | $66.65 | 6.107,00 | 475,00 | |||||
| BIOPSY BREAST WITH PLACEMEN | 19081FF | CPT | BOTH | $524.31 | $300.00 | $347.29 | $121.00 | $525.00 | $536.00 | $536.00 | $1,350.00 | $1,125.00 | $900.00 | $992.00 | $300.00 | $331.00 | $300.00 | $300.00 | $300.00 | 121,00 | 1.350,00 | |||||
| BX BREAST 1ST LESION STRTCTC | 19081FF50 | CPT | 50 | BOTH | $1,504.59 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $1,350.00 | $1,488.00 | N/A | N/A | N/A | N/A | N/A | 1.350,00 | 1.488,00 | ||||
| BX BREAST 1ST LESION STRTCTC | 19081SG | CPT | SG | BOTH | $502.98 | $250.00 | $347.29 | $300.00 | $525.00 | $536.00 | $536.00 | $167.66 | $1,125.00 | N/A | $208.00 | $250.00 | N/A | $166.63 | $167.66 | $166.63 | 16.663,00 | 1.125,00 | ||||
| BX BREAST ADD LESION STRTCTC | 19082FF | CPT | BOTH | $264.84 | $150.00 | $173.64 | $121.00 | $525.00 | $350.00 | $71.92 | $1,350.00 | N/A | $525.00 | $496.00 | $150.00 | $166.00 | $264.84 | $150.00 | $264.84 | 7.192,00 | 1.350,00 | |||||
| BX BREAST 1ST LESION US IMAGIN | 19083A | CPT | BOTH | $300.00 | $250.00 | $216.25 | $145.60 | N/A | $240.80 | $57.44 | $61.18 | $61.40 | $100.00 | $56.96 | $120.00 | $62.90 | $62.91 | $62.91 | $62.91 | 5.696,00 | 250,00 | |||||
| BIOPSY BREAST WITH PLACEMEN | 19083FF | CPT | BOTH | $492.96 | $300.00 | $347.29 | $121.00 | $525.00 | $536.00 | $450.00 | $1,350.00 | $1,125.00 | $525.00 | $882.00 | $300.00 | $331.00 | $300.00 | $300.00 | $300.00 | 121,00 | 1.350,00 | |||||
| BX BREAST 1ST LESION US IMAG | 19083FF50 | CPT | 50 | BOTH | $1,504.59 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $1,200.00 | $1,323.00 | N/A | N/A | N/A | N/A | N/A | 1.200,00 | 1.323,00 | ||||
| BX BREAST 1ST LESION US IMAG | 19083IR | CPT | BOTH | $475.71 | N/A | N/A | $250.00 | N/A | $450.00 | $450.00 | N/A | $436.19 | N/A | N/A | N/A | N/A | $157.27 | $158.57 | $157.27 | 15.727,00 | 450,00 | |||||
| BX BREAST 1ST LESION US IMAG | 19083SG | CPT | SG | BOTH | $1,427.00 | N/A | N/A | N/A | N/A | $536.00 | $536.00 | $1,350.00 | $1,125.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 536,00 | 1.350,00 | ||||
| BX BREAST ADD LESION US IMAG | 19084FF | CPT | BOTH | $236.82 | $150.00 | $173.64 | $150.00 | $525.00 | $350.00 | $71.92 | $1,019.00 | $345.94 | $525.00 | $441.00 | $150.00 | $166.00 | $150.00 | $150.00 | $150.00 | 7.192,00 | 1.019,00 | |||||
| BX BREAST ADD LESION US IMAG | 19084IR | CPT | BOTH | $236.82 | N/A | $327.32 | $150.00 | $525.00 | $450.00 | $450.00 | $78.94 | $345.94 | N/A | N/A | N/A | N/A | $150.00 | $150.00 | $150.00 | 7.894,00 | 525,00 | |||||
| BX BREAST 1ST LESION MR IMAG | 19085FF | CPT | BOTH | $665.78 | $300.00 | $173.64 | $121.00 | N/A | $536.00 | $536.00 | $1,350.00 | $1,125.00 | $1,000.00 | $1,103.00 | $300.00 | $331.00 | $300.00 | $300.00 | $300.00 | 121,00 | 1.350,00 | |||||
| BX BREAST BILAT LESION MR IMAG | 19085FF50 | CPT | 50 | BOTH | $510.00 | N/A | N/A | N/A | N/A | $536.00 | $536.00 | $950.00 | N/A | $1,500.00 | $1,654.00 | N/A | N/A | N/A | N/A | N/A | 536,00 | 1.654,00 | ||||
| BX BREAST 1ST LESION MR IMAG | 19085SG | CPT | SG | BOTH | $551.28 | $300.00 | $616.90 | $735.00 | $525.00 | $536.00 | $536.00 | $183.76 | $665.78 | N/A | $240.80 | $300.00 | N/A | $182.24 | $183.76 | $182.24 | 18.224,00 | 735,00 | ||||
| Under Breast Biopsy Procedures | 19100A | CPT | BOTH | $203.31 | $32.40 | $28.51 | $32.40 | N/A | $24.05 | $24.05 | $23.91 | $28.51 | $25.20 | $23.60 | $32.40 | $65.65 | $26.50 | $26.50 | $26.50 | 236,00 | 6.565,00 | |||||
| Under Breast Biopsy Procedures | 19100FF | CPT | BOTH | $203.31 | $1,000.00 | $810.34 | $850.00 | N/A | $875.00 | N/A | N/A | N/A | $1,005.00 | $1,047.00 | $1,000.00 | N/A | $1,081.00 | $1,081.00 | $1,081.00 | 81.034,00 | 1.081,00 | |||||
| Under Breast Biopsy Procedures | 19100SG | CPT | SG | BOTH | $203.31 | N/A | N/A | N/A | N/A | $254.00 | $254.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 254,00 | 254,00 | ||||
| MASTECTOMY PARTIAL | 19301A | CPT | BOTH | $816.98 | $146.16 | $273.55 | $139.20 | $150.00 | $139.20 | $301.05 | $219.94 | $268.25 | $139.20 | $61.12 | $139.20 | $255.55 | $261.10 | $261.10 | $261.10 | 6.112,00 | 30.105,00 | |||||
| MASTECTOMY PARTIAL | 19301FF | CPT | BOTH | $2,968.47 | $1,500.00 | $810.34 | $1,966.00 | $850.00 | $1,500.00 | $1,500.00 | N/A | $2,090.00 | $2,200.00 | $950.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.200,00 | |||||
| MASTECTOMY PARTIAL W/AXILLARY | 19302A | CPT | BOTH | $1,122.92 | $320.04 | $375.66 | 287..60 | N/A | $394.80 | $301.05 | $303.11 | $368.29 | $287.60 | $114.08 | $287.60 | $375.66 | $375.66 | $375.66 | $375.66 | 11.408,00 | 3.948,00 | |||||
| MASTECTOMY PARTIAL W/AXILLARY | 19302FF | CPT | BOTH | $2,967.00 | $1,500.00 | $810.34 | $1,966.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $2,200.00 | $700.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 700,00 | 2.200,00 | |||||
| MASTECTOMY SIMPLE COMPLETE | 19303A | CPT | BOTH | $1,187.38 | $256.62 | $396.44 | $297.30 | N/A | $192.00 | $338.78 | $340.98 | $388.75 | $180.80 | $94.88 | $180.80 | $396.40 | $396.40 | $396.40 | $396.40 | 9.488,00 | 39.644,00 | |||||
| MASTECTOMY SIMPLE COMPLETE | 19303FF | CPT | BOTH | $2,363.81 | $1,500.00 | $810.34 | $1,966.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $750.00 | $2,200.00 | N/A | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 750,00 | 2.200,00 | |||||
| MAST MODF RAD W/AX LYMPH NOD W | 19307A | CPT | BOTH | $1,467.64 | $343.14 | $489.06 | $305.60 | N/A | $360.00 | $399.53 | $402.68 | $479.16 | $305.60 | $305.60 | $305.60 | $489.06 | $489.06 | $489.06 | $489.06 | 3.056,00 | 48.906,00 | |||||
| MAST MODF RAD W/AX LYMPH NOD W | 19307FF | CPT | BOTH | $3,602.70 | $1,500.00 | $810.34 | $1,966.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $2,200.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.200,00 | |||||
| MAST MODF RAD W/AX LYMPH NOD W | 19307FF-PK | CPT | BOTH | $3,602.70 | $1,500.00 | N/A | $1,966.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $1,500.00 | $997.00 | N/A | $1,500.00 | $1,500.00 | 997,00 | 1.966,00 | |||||
| Repair and/or Recon Pro Breast | 19316A | CPT | BOTH | $2,439.15 | $227.60 | $325.02 | $243.78 | N/A | $257.97 | $257.97 | $259.66 | $321.66 | $227.20 | $191.20 | $227.60 | $325.06 | $779.45 | $779.45 | $779.45 | 1.912,00 | 77.945,00 | |||||
| Repair and/or Recon Proc Breas | 19316FF | CPT | BOTH | $2,439.15 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $4,000.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 4.000,00 | |||||
| Repair and/or Recon Proc Breas | 19316FF-PK | CPT | BOTH | $2,439.15 | $568.00 | $809.09 | $3,700.00 | N/A | $644.93 | $644.93 | N/A | $809.09 | $568.00 | $809.09 | $568.00 | $809.09 | $1,500.00 | $1,500.00 | $1,500.00 | 568,00 | 3.700,00 | |||||
| REDUCTION MAMMAPLASTY | 19318A | CPT | BOTH | $1,348.49 | $420.00 | $650.13 | $400.00 | $600.00 | $370.92 | $370.92 | $375.12 | $680.00 | $300.00 | $109.44 | $400.00 | $448.52 | $429.50 | $429.50 | $429.50 | 10.944,00 | 680,00 | |||||
| REDUCTION MAMMAPLASTY | 19318FF | CPT | BOTH | $1,575.00 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $2,500.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| Under Repair and/or Reconstruc | 19325A | CPT | BOTH | $1,891.26 | $300.00 | $292.50 | $292.50 | N/A | $300.00 | $213.34 | N/A | $249.95 | $300.00 | $109.44 | $300.00 | $300.00 | $243.05 | $243.05 | $243.05 | 10.944,00 | 300,00 | |||||
| Under Repair and/or Reconstruc | 19325FF | CPT | BOTH | $1,891.26 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| REMOVAL INTACT MAMMARY IMPLANT | 19328A | CPT | BOTH | $682.96 | $131.88 | $227.58 | $125.60 | N/A | $163.97 | $163.97 | $166.26 | $225.28 | $70.00 | $33.60 | $125.60 | $227.58 | $227.58 | $227.58 | $227.58 | 336,00 | 22.758,00 | |||||
| REMOVAL INTACT MAMMARY IMPLANT | 19328FF | CPT | BOTH | $2,000.00 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| REMOVAL MAMMARY IMPLANT MATERI | 19330A | CPT | BOTH | $796.14 | $165.48 | $265.42 | $106.17 | N/A | $42.00 | $210.83 | $213.20 | $262.83 | $141.60 | $33.60 | $157.60 | $265.42 | $254.66 | $254.66 | $254.66 | 336,00 | 26.542,00 | |||||
| REMOVAL MAMMARY IMPLANT MATERI | 19330FF | CPT | BOTH | $950.00 | $1,500.00 | $810.34 | $850.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.200,00 | |||||
| IMMT INSJ BRST PROSTH FLWG MAS | 19340A | CPT | BOTH | $932.95 | $240.24 | $311.33 | $311.83 | N/A | $335.57 | $335.57 | $339.58 | $400.00 | $228.80 | $93.92 | $228.80 | $311.33 | $311.33 | $311.33 | $311.33 | 9.392,00 | 400,00 | |||||
| IMMT INSJ BRST PROSTH FLWG MAS | 19340FF | CPT | BOTH | $3,098.73 | $1,500.00 | $810.34 | $850.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.200,00 | |||||
| DLYD INSJ BRST PROSTH FLWG MAS | 19342A | CPT | BOTH | $938.50 | $316.68 | $312.48 | $312.48 | N/A | $307.85 | $307.85 | $311.78 | $480.00 | $111.52 | $241.60 | $278.00 | $312.48 | $300.06 | $300.06 | $300.06 | 11.152,00 | 480,00 | |||||
| DLYD INSJ BRST PROSTH FLWG MAS | 19342FF | CPT | BOTH | $2,910.10 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| NIPPLE/AREOLA RECONST ANESTH | 19350A | CPT | BOTH | $828.19 | $300.30 | $312.48 | $270.40 | $207.60 | $222.99 | $224.04 | $259.94 | $640.00 | $220.00 | $98.72 | $270.40 | $276.15 | $265.72 | $265.72 | $265.72 | 9.872,00 | 640,00 | |||||
| NIPPLE/AREOLA RECONST OR SERV | 19350FF | CPT | BOTH | $2,000.00 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $4,000.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 4.000,00 | |||||
| NIPPLE/AREOLA RECONST OR SERV | 19350FF-PK | CPT | BOTH | $2,000.00 | $1,500.00 | $810.34 | $3,700.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $4,000.00 | N/A | $1,500.00 | $997.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 4.000,00 | |||||
| BRST RCNSTJ IMMT/DLYD W/TISS E | 19357A | CPT | BOTH | $1,436.02 | $734.40 | $716.04 | $734.40 | N/A | $734.40 | $495.08 | $503.46 | $800.00 | $380.00 | $268.00 | $734.40 | $476.37 | $457.18 | $457.18 | $457.18 | 268,00 | 800,00 | |||||
| BRST RCNSTJ IMMT/DLYD W/TISS E | 19357FF | CPT | BOTH | $2,000.00 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | N/A | $971.00 | $4,000.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 4.000,00 | |||||
| BRST RCNSTJ IMMT/DLYD W/TISS E | 19357FF-PK | CPT | BOTH | $2,000.00 | $1,500.00 | $810.34 | $3,700.00 | $850.00 | $1,500.00 | $1,500.00 | N/A | $971.00 | $4,000.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 4.000,00 | |||||
| Under Repair and/or Reconstruc | 19361A | CPT | BOTH | $4,614.93 | $692.40 | $675.09 | $692.40 | N/A | $692.40 | $531.87 | $537.62 | $800.00 | $496.00 | $252.64 | $692.40 | $638.78 | $610.28 | $610.28 | $610.28 | 25.264,00 | 800,00 | |||||
| Under Repair and/or Reconstruc | 19361FF | CPT | BOTH | $4,614.93 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| Breast reconstruction | 19364A | CPT | BOTH | $2,789.26 | $1,115.70 | $1,115.70 | $812.80 | N/A | $812.80 | $224.04 | $944.46 | $1,099.98 | $568.00 | $199.35 | $812.80 | $1,115.70 | $1,060.26 | $1,060.26 | $1,060.26 | 19.935,00 | 11.157,00 | |||||
| Breast reconstruction | 19364FF | CPT | BOTH | $2,789.26 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| OPEN PERIPROSTHETIC CAPSULOTOM | 19370A | CPT | BOTH | $825.64 | $182.28 | $275.44 | $812.80 | $207.64 | $238.66 | $275.44 | $230.84 | $272.72 | $80.00 | $74.00 | $173.60 | $275.44 | $275.44 | $275.44 | $275.44 | 74,00 | 8.128,00 | |||||
| CAPSULOTOMY BREAST | 19370FF | CPT | BOTH | $1,155.85 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| BREAST CAPSULECTOMY | 19371A | CPT | BOTH | $876.57 | $226.80 | $292.19 | $292.19 | $270.40 | $220.00 | $260.99 | $264.62 | $289.53 | $216.00 | $61.12 | $216.00 | $292.19 | $292.19 | $292.19 | $292.19 | 6.112,00 | 29.219,00 | |||||
| BREAST CAPSULECTOMY | 19371FF | CPT | BOTH | $1,850.00 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| REVISION RECONSTRUCTED BREAST | 19380A | CPT | BOTH | $994.73 | $226.80 | $331.20 | $216.00 | N/A | $257.10 | $257.10 | $260.61 | $112.80 | $216.00 | $180.00 | $216.00 | $331.20 | $331.20 | $331.20 | $331.20 | 1.128,00 | 3.312,00 | |||||
| REVISION RECONSTRUCTED BREAST | 19380FF | CPT | BOTH | $950.00 | $1,500.00 | $810.34 | $2,500.00 | $850.00 | $1,500.00 | $1,500.00 | $2,200.00 | $2,090.00 | $1,205.00 | $1,047.00 | $1,500.00 | $1,047.00 | $1,500.00 | $1,500.00 | $1,500.00 | 81.034,00 | 2.500,00 | |||||
| BIOPSY MUSCLE PERCUTANEOUS NEE | 20206A | CPT | BOTH | $181.20 | $48.40 | $23.16 | $23.16 | N/A | $28.00 | $20.84 | $23.22 | $22.91 | $20.00 | $19.60 | $48.40 | $23.16 | $23.16 | $23.16 | $23.16 | 196,00 | 484,00 | |||||
| BIOPSY MUSCLE PERCUTANEOUS NEE | 20206FF | CPT | BOTH | $174.12 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| BIOPSY MUSCLE PERCUTANEOUS NEE | 20206IR | CPT | BOTH | $750.24 | $500.00 | $496.13 | $450.00 | $475.00 | $450.00 | $450.00 | $512.00 | $472.00 | $500.00 | $551.00 | $500.00 | $496.00 | $500.00 | $500.00 | $500.00 | 450,00 | 551,00 | |||||
| BIOPSY BONE TROCAR/NEEDLE DEEP | 20225A | CPT | BOTH | $396.30 | $73.60 | $72.00 | $64.80 | $150.00 | $100.80 | $38.48 | $52.80 | $157.37 | $72.00 | $72.00 | $73.60 | $52.54 | $49.94 | $49.94 | $49.94 | 3.848,00 | 15.737,00 | |||||
| BIOPSY BONE TROCAR/NEEDLE DEEP | 20225FF | CPT | BOTH | $1,187.13 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| BIOPSY BONE TROCAR/NEEDLE DEEP | 20225IR | CPT | BOTH | $750.00 | $500.00 | $520.93 | $450.00 | $475.00 | $450.00 | $450.00 | $512.00 | $495.00 | $500.00 | $551.00 | $500.00 | $496.00 | $500.00 | $500.00 | $500.00 | 450,00 | 551,00 | |||||
| CORE NEEDLE BX LUNG /MED PERQ | 32408A | CPT | BOTH | $462.42 | $60.00 | $61.65 | $41.38 | N/A | $59.11 | $37.44 | $55.83 | $60.59 | $158.40 | $10.49 | $60.00 | $61.66 | $57.86 | $57.86 | $57.86 | 1.049,00 | 1.584,00 | |||||
| CORE NEEDLE BX LUNG/MED PERQ | 32408FF | CPT | BOTH | $462.42 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| CORE NEEDLE BX LUNG/MED PERQ | 32408IR | CPT | BOTH | $693.63 | $500.00 | $520.93 | $496.13 | $475.00 | $450.00 | $450.00 | $512.00 | $500.00 | $500.00 | $500.00 | $500.00 | $496.00 | $500.00 | $500.00 | $500.00 | 450,00 | 52.093,00 | |||||
| INSERTION INDWELLING TUNNELED | 32550A | CPT | BOTH | $251.02 | $286.00 | $250.96 | $250.96 | $885.00 | $78.82 | $78.82 | $75.39 | $81.33 | $286.00 | $55.19 | $286.00 | $82.98 | $77.91 | $77.91 | $77.91 | 5.519,00 | 885,00 | |||||
| INSERTION INDWELLING TUNNELED | 32550IR | CPT | BOTH | $2,594.37 | $700.00 | $450.00 | N/A | N/A | $630.00 | $630.00 | $712.00 | N/A | N/A | $772.00 | $700.00 | $694.00 | $700.00 | $700.00 | $700.00 | 450,00 | 772,00 | |||||
| RMVL NDWELLG TUN PLEURAL CATH | 32552A | CPT | BOTH | $194.23 | $58.00 | $64.08 | $64.08 | N/A | $54.94 | $54.94 | $53.61 | $62.90 | $60.00 | $46.80 | $58.00 | $64.08 | $25.63 | $25.63 | $25.63 | 2.563,00 | 6.408,00 | |||||
| RMVL NDWELLG TUN PLEURAL CATH | 32552FF | CPT | BOTH | $597.60 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| RMVL NDWELLG TUN PLEURAL CATH | 32552IR | CPT | BOTH | $597.60 | $700.00 | N/A | N/A | N/A | $630.00 | $630.00 | $712.00 | $512.00 | N/A | $772.00 | $700.00 | $694.00 | $700.00 | $700.00 | $700.00 | 512,00 | 772,00 | |||||
| INSERT CATH PLEURA W/ IMAGE | 32557A | CPT | BOTH | $182.74 | $74.34 | $62.00 | $46.80 | N/A | $46.80 | $56.40 | $60.41 | $59.37 | $46.80 | $22.68 | $46.80 | $60.40 | $56.69 | $56.69 | $56.69 | 2.268,00 | 7.434,00 | |||||
| INSERT CATH PLEURA W/ IMAGE | 32557FF | CPT | BOTH | $182.74 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| INSERT CATH PLEURA W/ IMAGE | 32557IR | CPT | BOTH | $1,912.02 | $700.00 | $729.30 | $630.00 | N/A | $630.00 | $630.00 | $712.00 | $495.00 | $700.00 | $772.00 | $700.00 | $694.00 | $700.00 | $700.00 | $700.00 | 495,00 | 772,00 | |||||
| NJX PX XTR VNGRPH W/INTRO NDL/ | 36005A | CPT | BOTH | $139.86 | $110.00 | $19.25 | $46.80 | $110.00 | $110.00 | $17.36 | $16.44 | $19.11 | $110.00 | $19.25 | $110.00 | $16.44 | $18.10 | $18.10 | $18.10 | 1.644,00 | 110,00 | |||||
| NJX PX XTR VNGRPH W/INTRO NDL/ | 36005FF | CPT | BOTH | $1,400.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,800.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,200.00 | $1,200.00 | $1,200.00 | 750,00 | 1.800,00 | |||||
| NJX PX XTR VNGRPH W/INTRO NDL/ | 36005IR | CPT | BOTH | $1,400.00 | $1,200.00 | N/A | $1,080.00 | $1,140.00 | $1,080.00 | $1,080.00 | $1,000.00 | $1,080.00 | N/A | $1,323.00 | $1,200.00 | $1,191.00 | $1,200.00 | $1,200.00 | $1,200.00 | 1.000,00 | 1.323,00 | |||||
| SLCTV CATHJ EA 1ST ORD ABDL PE | 36245A | CPT | BOTH | $286.44 | $101.64 | $94.96 | $96.80 | $225.00 | $96.80 | $90.20 | $81.69 | $93.12 | $96.80 | $144.98 | $96.80 | $94.96 | $460.15 | $460.15 | $460.15 | 8.169,00 | 46.015,00 | |||||
| SLCTV CATHJ EA 1ST ORD ABDL PE | 36245FF | CPT | BOTH | $672.03 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| SLCTV CATHJ EA 1ST ORD ABDL PE | 36245IR | CPT | BOTH | $1,050.00 | $700.00 | $729.30 | $630.00 | $665.00 | $1,080.00 | $1,080.00 | N/A | $650.00 | N/A | $1,323.00 | $700.00 | $694.00 | $1,050.00 | $700.00 | $1,050.00 | 630,00 | 1.323,00 | |||||
| SLCTV CATHJ 3RD+ ORD SLCTV ABD | 36247A | CPT | BOTH | $365.08 | $115.92 | $50.54 | $110.40 | $110.40 | $110.40 | $113.82 | $108.66 | $117.93 | $110.40 | $52.80 | $110.40 | $120.27 | $112.62 | $112.62 | $112.62 | 5.054,00 | 12.027,00 | |||||
| SLCTV CATHJ 3RD+ ORD SLCTV ABD | 36247FF | CPT | BOTH | $365.08 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $300.86 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 30.086,00 | 1.081,00 | |||||
| SLCTV CATHJ 3RD+ ORD SLCTV ABD | 36247IR | CPT | BOTH | $1,800.00 | $1,200.00 | $1,250.24 | $1,080.00 | $1,200.00 | $1,080.00 | $1,080.00 | N/A | $1,080.00 | N/A | $1,323.00 | $1,200.00 | $1,191.00 | $1,200.00 | $1,200.00 | $1,200.00 | 1.080,00 | 1.323,00 | |||||
| SLCTV CATHJ EA 2ND+ ORD ABDL P | 36248A | CPT | BOTH | $59.47 | $48.40 | $49.39 | $48.40 | $60.00 | $48.40 | $18.20 | $17.41 | $19.11 | $48.50 | $19.39 | $48.40 | $19.39 | $18.37 | $18.37 | $18.37 | 1.741,00 | 60,00 | |||||
| SLCTV CATHJ EA 2ND+ ORD ABDL P | 36248FF | CPT | BOTH | $148.68 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| SLCTV CATHJ EA 2ND+ ORD ABDL P | 36248IR | CPT | BOTH | $148.68 | $1,200.00 | $1,190.70 | $40.50 | $150.00 | $1,080.00 | $1,080.00 | $49.56 | $99.56 | N/A | $1,323.00 | $1,200.00 | $1,191.00 | $1,200.00 | $1,200.00 | $1,200.00 | 405,00 | 1.323,00 | |||||
| INSJ TUN CTR CVC W/O SUBQ PORT | 36558A | CPT | BOTH | $317.40 | $291.20 | $40.80 | $46.80 | $108.00 | $219.20 | $97.73 | $93.74 | $103.72 | $200.80 | $102.00 | $219.20 | $105.21 | $99.44 | $99.44 | $99.44 | 408,00 | 2.912,00 | |||||
| INSJ TUN CTR CVC W/O SUBQ PORT | 36558FF | CPT | BOTH | $317.40 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| INSJ TUN CTR CVC W/O SUBQ PORT | 36558IR | CPT | BOTH | $1,800.00 | $1,200.00 | $1,250.24 | $1,080.00 | $1,200.00 | $1,200.00 | $1,200.00 | $1,100.00 | $1,080.00 | N/A | $1,323.00 | $1,200.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 1.080,00 | 1.323,00 | |||||
| INSJ TUN CTR CTR VAD W/SUBQ PO | 36561A | CPT | BOTH | $409.56 | $415.60 | $120.00 | $135.95 | $123.00 | $123.16 | $123.16 | $118.36 | $132.97 | $415.60 | $48.00 | $415.60 | $135.95 | $127.38 | $127.38 | $127.38 | 48,00 | 4.156,00 | |||||
| INSJ TUN CTR CTR VAD W/SUBQ PO | 36561FF | CPT | BOTH | $900.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| INSJ TUN CTR CTR VAD W/SUBQ PO | 36561IR | CPT | BOTH | $1,800.00 | $1,200.00 | $1,250.24 | $1,080.00 | $1,200.00 | $1,200.00 | $1,200.00 | $1,200.00 | $1,080.00 | $1,200.00 | $1,323.00 | $1,200.00 | $1,191.00 | $1,200.00 | $1,200.00 | $1,200.00 | 1.080,00 | 1.323,00 | |||||
| RPLCMT COMPL TUN CVC W/O SUBQ | 36581A | CPT | BOTH | $223.94 | $200.80 | $49.80 | $200.80 | $579.00 | $200.80 | $305.87 | $66.91 | $72.92 | $200.80 | $49.13 | $376.00 | $74.31 | $70.19 | $70.19 | $70.19 | 4.913,00 | 579,00 | |||||
| RPLCMT COMPL TUN CVC W/O SUBQ | 36581FF | CPT | BOTH | $223.94 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| RPLCMT COMPL TUN CVC W/O SUBQ | 36581IR | CPT | BOTH | $1,800.00 | $1,200.00 | $1,250.24 | $1,080.00 | $1,200.00 | $1,200.00 | $1,200.00 | N/A | $1,080.00 | N/A | N/A | $1,200.00 | $1,191.00 | $1,800.00 | $1,200.00 | $1,800.00 | 1.080,00 | 1.800,00 | |||||
| RPLCMT COMPL TUN CTR VAD W/SUB | 36582A | CPT | BOTH | $352.97 | $376.00 | $117.37 | $376.00 | $1,084.50 | $376.00 | $106.63 | $102.30 | $114.81 | $376.00 | $110.00 | $93.20 | $117.37 | $110.29 | $110.29 | $110.29 | 932,00 | 10.845,00 | |||||
| RPLCMT COMPL TUN CTR VAD W/SUB | 36582FF | CPT | BOTH | $1,800.00 | $1,030.00 | $3,810.34 | $850.00 | $850.00 | $1,200.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 381.034,00 | |||||
| RPLCMT COMPL TUN CTR VAD W/SUB | 36582IR | CPT | BOTH | $1,800.00 | $1,200.00 | N/A | $1,080.00 | $1,200.00 | $1,200.00 | $1,200.00 | N/A | $1,080.00 | N/A | N/A | $1,200.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 1.080,00 | 1.323,00 | |||||
| RPLCMT COMPL PRPH CVC W/O SUBQ | 36584A | CPT | BOTH | $72.91 | $93.20 | $24.80 | $93.20 | $102.00 | $93.20 | $23.91 | $22.60 | $23.32 | $89.20 | $24.80 | $288.00 | $23.69 | $22.52 | $22.52 | $22.52 | 2.252,00 | 288,00 | |||||
| RPLCMT COMPL PRPH CVC W/O SUBQ | 36584FF | CPT | BOTH | $72.91 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| RPLCMT COMPL PRPH CVC W/O SUBQ | 36584IR | CPT | BOTH | $1,800.00 | $1,200.00 | N/A | $1,080.00 | $1,200.00 | $1,200.00 | $1,200.00 | N/A | $1,080.00 | N/A | N/A | $1,200.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 1.080,00 | 1.323,00 | |||||
| INSJ TRANSVNS INTRAHEPATC PORT | 37182A | CPT | BOTH | $987.76 | $288.00 | $1,543.50 | $288.00 | $288.00 | $288.00 | $307.81 | $292.52 | $321.93 | $288.00 | $93.28 | $288.00 | $326.67 | $308.25 | $308.25 | $308.25 | 9.328,00 | 15.435,00 | |||||
| INSJ TRANSVNS INTRAHEPATC PORT | 37182FF | CPT | BOTH | $6,000.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $3,600.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $6,000.00 | $4,000.00 | $6,000.00 | 750,00 | 6.000,00 | |||||
| INSJ TRANSVNS INTRAHEPATC PORT | 37182IR | CPT | BOTH | $6,000.00 | $4,000.00 | N/A | $3,500.00 | $1,900.00 | $3,600.00 | $3,600.00 | $2,000.00 | $3,850.00 | N/A | $4,410.00 | $4,000.00 | $3,969.00 | $4,000.00 | $4,000.00 | $4,000.00 | 1.900,00 | 4.410,00 | |||||
| VASC EMBOLIZE/OCCLUDE VENOUS | 37241A | CPT | BOTH | $525.56 | $532.40 | $465.85 | $532.40 | N/A | $532.40 | $163.04 | $161.73 | $173.17 | $752.00 | $465.85 | $532.40 | $173.19 | $161.40 | $161.40 | $161.40 | 1.614,00 | 752,00 | |||||
| VASC EMBOLIZE/OCCLUDE VENOUS | 37241FF | CPT | BOTH | $3,000.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,200.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $3,000.00 | $2,000.00 | $3,000.00 | 750,00 | 3.000,00 | |||||
| VASC EMBOLIZE/OCCLUDE VENOUS | 37241IR | CPT | BOTH | $3,000.00 | $2,000.00 | $3,858.75 | $1,080.00 | $1,900.00 | $1,200.00 | $1,200.00 | N/A | $1,080.00 | N/A | $5,292.00 | $2,000.00 | $1,323.00 | $3,000.00 | $2,000.00 | $3,000.00 | 1.080,00 | 5.292,00 | |||||
| VASC EMBOLIZE/OCCLUDE ARTERY | 37242A | CPT | BOTH | $577.45 | $532.40 | $465.85 | $532.40 | N/A | $532.40 | $180.94 | $180.54 | $188.01 | $532.40 | $466.00 | $532.40 | $190.89 | $179.60 | $179.60 | $179.60 | 1.796,00 | 5.324,00 | |||||
| VASC EMBOLIZE/OCCLUDE ARTERY | 37242FF | CPT | BOTH | $3,000.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,200.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $3,000.00 | $2,000.00 | $3,000.00 | 750,00 | 3.000,00 | |||||
| VASC EMBOLIZE/OCCLUDE ARTERY | 37242IR | CPT | BOTH | $3,000.00 | $2,000.00 | $1,250.24 | $1,080.00 | $1,900.00 | $1,200.00 | $1,200.00 | N/A | $1,080.00 | N/A | $5,292.00 | $2,000.00 | $1,323.00 | $3,000.00 | $2,000.00 | $3,000.00 | 1.080,00 | 5.292,00 | |||||
| VASC EMBOLIZE/OCCLUDE ORGAN | 37243A | CPT | BOTH | $676.32 | $698.40 | $720.00 | $698.40 | N/A | $698.40 | $215.62 | $215.26 | $221.08 | $698.40 | $148.55 | $532.40 | $223.85 | $212.22 | $212.22 | $212.22 | 14.855,00 | 720,00 | |||||
| VASC EMBOLIZE/OCCLUDE ORGAN | 37243FF | CPT | BOTH | $3,000.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,200.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $3,000.00 | $2,000.00 | $3,000.00 | 750,00 | 3.000,00 | |||||
| VASC EMBOLIZE/OCCLUDE ORGAN | 37243IR | CPT | BOTH | $3,000.00 | $2,000.00 | $1,250.24 | $1,080.00 | $1,900.00 | $1,200.00 | $1,200.00 | $1,500.00 | $1,080.00 | N/A | $5,292.00 | $2,000.00 | $1,323.00 | $2,000.00 | $2,000.00 | $2,000.00 | 1.080,00 | 5.292,00 | |||||
| VASC EMBOLIZE/OCCLUDE BLEED | 37244A | CPT | BOTH | $802.49 | $532.40 | $465.85 | $532.40 | N/A | $532.40 | $251.96 | $251.20 | $261.20 | $533.60 | $466.00 | $420.00 | $265.00 | $249.61 | $249.61 | $249.61 | 24.961,00 | 5.336,00 | |||||
| VASC EMBOLIZE/OCCLUDE BLEED | 37244FF | CPT | BOTH | $3,000.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,200.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $3,000.00 | $2,000.00 | $3,000.00 | 750,00 | 3.000,00 | |||||
| VASC EMBOLIZE/OCCLUDE BLEED | 37244IR | CPT | BOTH | $3,000.00 | $2,000.00 | $1,190.70 | $1,080.00 | $1,900.00 | $1,200.00 | $1,200.00 | N/A | $1,080.00 | N/A | $5,292.00 | $2,000.00 | $1,323.00 | $2,000.00 | $2,000.00 | $2,000.00 | 1.080,00 | 5.292,00 | |||||
| LAPS SURG SPLENC | 38120A | CPT | BOTH | $1,306.97 | $306.40 | N/A | $436.49 | $531.00 | $356.68 | $356.68 | $341.01 | $428.60 | $306.40 | $248.00 | $306.40 | $436.49 | $414.41 | $414.41 | $414.41 | 248,00 | 531,00 | |||||
| LAPS SURG SPLENC | 38120FF | CPT | BOTH | $3,267.42 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | N/A | N/A | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| LAPS SURG SPLENC | 38120R | CPT | BOTH | $7,000.00 | $1,000.00 | N/A | $700.00 | $850.00 | $5,000.00 | $5,000.00 | $4,500.00 | $4,000.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 700,00 | 5.000,00 | |||||
| MARROW ASPIRATION ONLY | 38220A | CPT | BOTH | $212.79 | $12.00 | $64.58 | $12.00 | $63.00 | $12.00 | $21.61 | $46.90 | $27.11 | $12.00 | $35.36 | $12.00 | $27.61 | $26.05 | $26.05 | $26.05 | 12,00 | 6.458,00 | |||||
| DX BONE MARROW ASPIRATION | 38220FF | CPT | BOTH | $1,500.00 | $1,030.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 1.005,00 | 1.081,00 | |||||
| DX BONE MARROW ASPIRATION | 38220IR | CPT | BOTH | $1,500.00 | $500.00 | N/A | N/A | $475.00 | N/A | N/A | N/A | N/A | N/A | N/A | $500.00 | $496.00 | N/A | N/A | N/A | 475,00 | 500,00 | |||||
| MARROW BX NDL/TROCAR | 38221A | CPT | BOTH | $85.16 | $40.00 | $20.25 | $19.16 | $66.00 | $56.00 | $26.96 | $25.55 | $28.06 | $40.00 | $17.66 | $40.00 | $28.72 | $26.82 | $26.82 | $26.82 | 1.766,00 | 66,00 | |||||
| MARROW BX NDL/TROCAR | 38221FF | CPT | BOTH | $212.91 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| MARROW BX NDL/TROCAR | 38221IR | CPT | BOTH | $750.00 | $500.00 | N/A | $450.00 | $475.00 | $450.00 | $450.00 | $512.00 | $495.00 | N/A | N/A | $500.00 | $496.00 | $500.00 | $500.00 | $500.00 | 450,00 | 512,00 | |||||
| BX/EXC LYMPH NODE NDL SUPFC | 38505A | CPT | BOTH | $84.78 | $50.40 | $36.04 | $50.40 | $50.40 | $50.40 | $256.97 | $39.25 | $34.43 | $50.40 | $23.12 | $50.40 | $34.66 | $33.03 | $33.03 | $33.03 | 2.312,00 | 25.697,00 | |||||
| BX/EXC LYMPH NODE NDL SUPFC | 38505FF | CPT | BOTH | $800.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $1,200.00 | $1,000.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 81.034,00 | 1.200,00 | |||||
| BX EXC LYMPH NODE BY NEEDLE | 38505IR | CPT | BOTH | $750.00 | $500.00 | $450.00 | $450.00 | $475.00 | $450.00 | $450.00 | $512.00 | $495.00 | $500.00 | $551.00 | $500.00 | $496.00 | $500.00 | $500.00 | $500.00 | 450,00 | 551,00 | |||||
| BX/EXC LYMPH NODE OPN DP AX NO | 38525A | CPT | BOTH | $544.70 | $126.80 | $128.54 | $126.80 | $150.00 | $126.80 | $145.54 | $140.04 | $179.20 | $126.80 | $182.29 | $126.80 | $182.29 | $173.88 | $173.88 | $173.88 | 1.268,00 | 18.229,00 | |||||
| BX/EXC LYMPH NODE OPN DP AX NO | 38525FF | CPT | BOTH | $910.00 | $1,030.00 | N/A | $850.00 | $850.00 | $875.00 | $1,050.00 | $1,200.00 | $1,000.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 850,00 | 1.200,00 | |||||
| RESCJ PALATE/X10SV RESCJ LES | 42120A | CPT | BOTH | $1,255.25 | $177.60 | $417.04 | $74.59 | N/A | $136.69 | $341.72 | $338.95 | $408.95 | $177.60 | $160.00 | $177.60 | $417.04 | $391.19 | $391.19 | $391.19 | 7.459,00 | 41.704,00 | |||||
| RESCJ PALATE/X10SV RESCJ LES | 42120FF | CPT | BOTH | $1,255.25 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| RESCJ PALATE/X10SV RESCJ LES | 42120R | CPT | BOTH | $1,255.25 | N/A | N/A | $5,246.00 | N/A | $3,400.00 | $3,400.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 3.400,00 | 5.246,00 | |||||
| UVULECTOMY EXC UVULA | 42140A | CPT | BOTH | $193.79 | $68.46 | $66.00 | $66.02 | N/A | $68.46 | $51.44 | N/A | $81.71 | N/A | N/A | $68.46 | N/A | $66.02 | $66.02 | $66.02 | 5.144,00 | 8.171,00 | |||||
| UVULECTOMY EXC UVULA | 42140R | CPT | BOTH | $193.79 | N/A | N/A | $5,246.00 | N/A | $2,000.00 | $2,000.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 2.000,00 | 5.246,00 | |||||
| PALATOPHARYNGOPLASTY | 42145A | CPT | BOTH | $850.18 | $270.00 | $283.42 | $113.40 | N/A | $96.03 | $240.08 | $244.86 | $280.45 | $270.00 | $74.08 | $270.00 | $283.42 | $269.53 | $269.53 | $269.53 | 7.408,00 | 28.342,00 | |||||
| PALATOPHARYNGOPLASTY | 42145FF | CPT | BOTH | $800.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | N/A | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| PALATOPHARYNGOPLASTY | 42145R | CPT | BOTH | $850.18 | N/A | N/A | $5,246.00 | N/A | $3,400.00 | $3,400.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 3.400,00 | 5.246,00 | |||||
| RAD RESCJ TONSIL CLSR W/OTH FL | 42845A | CPT | BOTH | $2,747.47 | $504.00 | $115.76 | $363.57 | N/A | $310.13 | $775.33 | $734.11 | $894.49 | $480.00 | $187.20 | $504.00 | $772.60 | $852.85 | $852.85 | $852.85 | 11.576,00 | 89.449,00 | |||||
| RAD RESCJ TONSIL CLSR W/OTH FL | 42845R | CPT | BOTH | $2,747.47 | N/A | N/A | $5,246.00 | N/A | $3,400.00 | $3,400.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 3.400,00 | 5.246,00 | |||||
| RESCJ LAT PHRNGL WALL/PYRIFORM | 42892A | CPT | BOTH | $2,308.08 | $339.60 | $379.45 | $309.40 | N/A | $260.14 | $650.36 | $648.36 | $756.90 | $310.00 | $120.96 | $339.60 | $772.60 | $772.60 | $772.60 | $772.60 | 12.096,00 | 7.726,00 | |||||
| RESCJ LAT PHRNGL WALL/PYRIFORM | 42892R | CPT | BOTH | $2,308.08 | N/A | N/A | $5,246.00 | N/A | $3,400.00 | $3,400.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 3.400,00 | 5.246,00 | |||||
| ESPHGSC RGD/FLX W/NDSC US XM | 43231A | CPT | BOTH | $194.22 | N/A | $64.34 | $82.40 | $184.50 | $59.14 | $59.14 | $63.47 | $62.76 | $64.00 | N/A | N/A | N/A | N/A | N/A | N/A | 5.914,00 | 1.845,00 | |||||
| Digital Endosonogrphy Facility | 43231FF | CPT | BOTH | $3,000.00 | $3,000.00 | $810.34 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,250.00 | $3,250.00 | $3,250.00 | 81.034,00 | 4.000,00 | |||||
| ESPHGSC RGD/FLX W/TNDSC US-GID | 43232A | CPT | BOTH | $242.83 | N/A | $80.33 | $82.40 | $240.00 | $73.27 | $73.27 | $87.12 | $78.48 | $84.00 | $97.20 | N/A | N/A | N/A | N/A | N/A | 7.327,00 | 240,00 | |||||
| Digital Endosonography Facilit | 43232FF | CPT | BOTH | $3,000.00 | $3,000.00 | $810.34 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,250.00 | $3,250.00 | $3,250.00 | 81.034,00 | 4.000,00 | |||||
| UPR GI NDSC NDSC US XM LMTD ES | 43237A | CPT | BOTH | $596.64 | N/A | $104.40 | $104.40 | $195.00 | $179.85 | $71.94 | $78.22 | $77.80 | $68.00 | $55.20 | N/A | N/A | N/A | N/A | N/A | 552,00 | 195,00 | |||||
| Digital Endosonography Facilit | 43237FF | CPT | BOTH | $3,000.00 | $3,000.00 | $810.34 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,250.00 | $3,250.00 | $3,250.00 | 81.034,00 | 4.000,00 | |||||
| COLSC FLX PROX SPLENIC FLXR SB | 43238A | CPT | BOTH | $708.78 | N/A | $94.01 | $175.64 | $240.00 | $85.32 | $85.33 | $107.23 | $92.17 | $62.51 | $280.00 | N/A | N/A | N/A | N/A | N/A | 6.251,00 | 280,00 | |||||
| Digital Endosonography Facilit | 43238FF | CPT | BOTH | $3,000.00 | $3,000.00 | $810.34 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,250.00 | $3,250.00 | $3,250.00 | 81.034,00 | 4.000,00 | |||||
| UPR GI NDSC TRANSMURAL DRG PSE | 43240A | CPT | BOTH | $477.64 | N/A | $158.73 | $158.73 | $334.50 | $143.12 | $143.12 | $132.74 | $155.34 | $116.00 | $100.00 | N/A | N/A | N/A | N/A | N/A | 100,00 | 3.345,00 | |||||
| Esophagogastroduodenoscopy Pro | 43240FF | CPT | BOTH | $3,000.00 | $3,000.00 | $810.34 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,250.00 | $3,250.00 | $3,250.00 | 81.034,00 | 4.000,00 | |||||
| STOMACH-INTESTINE SCOPE ULTRAS | 43242A | CPT | BOTH | $320.00 | N/A | $108.00 | $120.00 | $345.00 | $96.47 | $96.47 | $155.87 | $113.20 | $120.00 | $97.20 | N/A | N/A | N/A | N/A | N/A | 9.647,00 | 345,00 | |||||
| Digital Endosonography Facilit | 43242FF | CPT | BOTH | $3,000.00 | $3,000.00 | $810.34 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,250.00 | $3,250.00 | $3,250.00 | 81.034,00 | 4.000,00 | |||||
| EGD US TRANSMURAL INJXN/MARK | 43253A | CPT | BOTH | $320.00 | N/A | N/A | $106.48 | $75.00 | $96.33 | $96.33 | $94.18 | $104.37 | $119.60 | $94.00 | N/A | N/A | N/A | N/A | N/A | 75,00 | 1.196,00 | |||||
| Esophagogastroduodenoscopy | 43253FF | CPT | BOTH | $3,000.00 | $3,000.00 | $810.34 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,250.00 | $3,250.00 | $3,250.00 | 81.034,00 | 4.000,00 | |||||
| STOMACH-INTESTINE SCOPE WITH U | 43259A | CPT | BOTH | $275.54 | N/A | N/A | $108.00 | $450.00 | $83.08 | $83.08 | $111.81 | $115.60 | $108.00 | $87.60 | N/A | N/A | N/A | N/A | N/A | 8.308,00 | 450,00 | |||||
| STOMACH-INTESTINE SCOPE WITH U | 43259FF | CPT | BOTH | $4,304.00 | $3,000.00 | $810.34 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,250.00 | $3,250.00 | $3,250.00 | 81.034,00 | 4.000,00 | |||||
| ERCP DX COLLJ SPEC BR/WA SPX | 43260A | CPT | BOTH | $393.36 | $106.00 | $140.00 | $106.00 | $180.00 | $280.00 | $117.94 | $127.48 | $150.00 | $106.00 | $37.69 | $106.00 | $130.73 | $123.16 | $123.16 | $123.16 | 3.769,00 | 280,00 | |||||
| ERCP | 43260FF | CPT | BOTH | $1,260.00 | $1,000.00 | $810.34 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | $750.00 | $1,000.00 | $992.00 | N/A | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP DX COLLJ SPEC BR/WA SPX M | 43260M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | $1,653.75 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 165.375,00 | |||||
| ERCP W/BX 1/MLT | 43261A | CPT | BOTH | $412.66 | $250.00 | $109.69 | $137.11 | $525.00 | $123.76 | $123.76 | $144.99 | $224.80 | $250.00 | $79.04 | $250.00 | $137.11 | $129.11 | $129.11 | $129.11 | 7.904,00 | 525,00 | |||||
| ERCP | 43261FF | CPT | BOTH | $1,089.27 | $1,000.00 | $810.34 | $800.00 | $1,000.00 | N/A | $700.00 | $800.00 | $750.00 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP Materials | 43261M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP W/SPHNCTROTOMY/PAPILLOTOM | 43262A | CPT | BOTH | $435.71 | $240.00 | $104.26 | $145.01 | $450.00 | $130.56 | $130.56 | $157.41 | $163.20 | $240.00 | $41.70 | $240.00 | $145.01 | $136.23 | $136.23 | $136.23 | 417,00 | 450,00 | |||||
| ERCP W/SPHNCTROTOMY/PAPILLOTOM | 43262FF | CPT | BOTH | $1,089.27 | $1,000.00 | $810.34 | $800.00 | $1,000.00 | $700.00 | $700.00 | $800.00 | $750.00 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP Materials | 43262M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP W/PRESS MEAS SPHNCTR ODDI | 43263A | CPT | BOTH | $435.67 | $240.00 | $145.01 | $145.01 | $450.00 | $130.60 | $130.60 | $141.43 | $141.78 | $240.00 | $124.40 | $240.00 | $145.01 | $136.49 | $136.49 | $136.49 | 1.244,00 | 450,00 | |||||
| ERCP | 43263FF | CPT | BOTH | $1,260.00 | $1,000.00 | $810.34 | $800.00 | $1,000.00 | $700.00 | $700.00 | $800.00 | $750.00 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP W/PRESS MEAS SPHNCTR ODDI | 43263M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP W/RMVL ST1/CALCULI BILIAR | 43264A | CPT | BOTH | $444.10 | $260.00 | $106.18 | $147.50 | $675.00 | $133.07 | $133.07 | $188.84 | $198.90 | $260.00 | $164.00 | $260.00 | $147.50 | $139.08 | $139.08 | $139.08 | 10.618,00 | 675,00 | |||||
| ERCP | 43264FF | CPT | BOTH | $1,260.00 | $1,000.00 | $810.34 | $800.00 | $1,000.00 | N/A | $700.00 | $800.00 | $750.00 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP Materials | 43264M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP W/DSTRJ LITHOTRP ST1/CALC | 43265A | CPT | BOTH | $528.79 | $260.00 | $175.92 | $175.92 | $675.00 | $158.06 | $158.06 | $211.97 | $234.00 | $260.00 | $136.00 | $260.00 | $175.92 | $164.85 | $164.85 | $164.85 | 136,00 | 675,00 | |||||
| ERCP | 43265FF | CPT | BOTH | $1,089.27 | $1,000.00 | $810.34 | $850.00 | $1,000.00 | N/A | $700.00 | $800.00 | $750.00 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP Materials | 43265M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP DUCT STENT PLACEMENT | 43274A | CPT | BOTH | $564.84 | $260.80 | $228.20 | $228.20 | $75.00 | $168.75 | $168.75 | $188.92 | $183.40 | $260.80 | $205.20 | $260.80 | $187.56 | $176.36 | $176.36 | $176.36 | 75,00 | 2.608,00 | |||||
| ERCP | 43274FF | CPT | BOTH | $2,000.00 | $1,000.00 | $810.34 | $850.00 | $1,000.00 | $700.00 | $700.00 | $800.00 | $750.00 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP DUCT STENT PLACEMENT | 43274M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP REMOVE FORGN BODY DUCT | 43275A | CPT | BOTH | $459.18 | $260.00 | $277.50 | $260.00 | $138.00 | $137.54 | $137.54 | $145.34 | $234.00 | $260.00 | $204.80 | $260.00 | $238.88 | $143.61 | $143.61 | $143.61 | 13.754,00 | 2.775,00 | |||||
| ERCP | 43275FF | CPT | BOTH | $2,000.00 | $1,000.00 | $810.34 | N/A | N/A | N/A | $700.00 | $800.00 | $750.00 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP W REMOVAL OF FOREIGN BODY | 43275M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP STENT EXCHANGE W/DILATE | 43276A | CPT | BOTH | $587.92 | $260.00 | $128.44 | $128.44 | $75.00 | $70.29 | $175.73 | $183.69 | $234.00 | $260.00 | $204.80 | $109.20 | $195.32 | $183.49 | $183.49 | $183.49 | 7.029,00 | 260,00 | |||||
| ERCP | 43276FF | CPT | BOTH | $2,000.00 | $1,000.00 | $810.34 | N/A | N/A | N/A | $700.00 | $800.00 | $750.00 | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP STENT EXCHANGE W/DILATE | 43276M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP EA DUCT/AMPULLA DILATE | 43277A | CPT | BOTH | $461.70 | $184.00 | $204.05 | $153.47 | $75.00 | $138.72 | $138.72 | $146.26 | $165.60 | $233.20 | $204.80 | $233.20 | $153.43 | $144.39 | $144.39 | $144.39 | 75,00 | 2.332,00 | |||||
| ERCP | 43277FF | CPT | BOTH | $2,000.00 | N/A | $810.34 | N/A | $1,000.00 | N/A | N/A | $800.00 | $750.00 | $1,000.00 | $1,323.00 | $1,323.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 750,00 | 1.323,00 | |||||
| ERCP EA DUCT/AMPULLA DILATE | 43277M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| ERCP LESION ABLATE W/DILATE | 43278A | CPT | BOTH | $856.54 | $314.80 | $175.64 | $70.26 | $75.00 | $63.16 | $157.91 | $158.48 | $171.47 | $184.00 | $144.80 | $184.00 | $175.64 | $165.10 | $165.10 | $165.10 | 6.316,00 | 3.148,00 | |||||
| ERCP | 43278FF | CPT | BOTH | $1,089.27 | $1,000.00 | $810.34 | $850.00 | $1,000.00 | $700.00 | $700.00 | $800.00 | $750.00 | $1,000.00 | $1,000.00 | $1,000.00 | $1,000.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.200,00 | |||||
| ERCP LESION ABLATE W DILATE | 43278M | CPT | BOTH | $2,000.00 | $1,000.00 | $926.10 | $800.00 | $1,000.00 | $700.00 | $700.00 | N/A | N/A | $1,000.00 | $992.00 | $1,000.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 700,00 | 1.323,00 | |||||
| EXC LOCAL MAL TUM STOMACH | 43611A | CPT | BOTH | $1,514.54 | $330.54 | $504.29 | $360.32 | $363.00 | $415.90 | $415.90 | $416.71 | $496.52 | $160.00 | $144.13 | $314.80 | N/A | $479.41 | $479.41 | $479.41 | 14.413,00 | 50.429,00 | |||||
| EXC LOCAL MAL TUM STOMACH | 43611FF | CPT | BOTH | $3,786.36 | $787.00 | $810.34 | $850.00 | $850.00 | $1,039.74 | $1,039.74 | $800.00 | $1,241.29 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 787,00 | 124.129,00 | |||||
| EXC LOCAL MAL TUM STOMACH | 43611LAP | CPT | BOTH | $3,786.36 | N/A | N/A | N/A | N/A | $1,250.00 | $1,250.00 | N/A | N/A | $1,500.00 | N/A | N/A | N/A | N/A | N/A | N/A | 1.250,00 | 1.500,00 | |||||
| EXC LOCAL MAL TUM STOMACH | 43611R | CPT | BOTH | $3,786.36 | N/A | N/A | $5,246.00 | N/A | $5,000.00 | $5,000.00 | N/A | N/A | $5,000.00 | N/A | N/A | N/A | N/A | N/A | N/A | 5.000,00 | 5.246,00 | |||||
| LAPS ENTEROLSS FRING INTSTINAL | 44180A | CPT | BOTH | $1,138.37 | $120.00 | $271.00 | $284.94 | N/A | $312.96 | $312.96 | $314.13 | $372.22 | $120.00 | $115.60 | $120.00 | $379.92 | $359.63 | $359.63 | $359.63 | 1.156,00 | 37.992,00 | |||||
| LAPS ENTEROLSS FRING INTSTINAL | 44180FF | CPT | BOTH | $2,845.92 | $1,030.00 | $810.34 | $4,700.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $5,000.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 5.000,00 | |||||
| LAPS ENTEROLSS FRING INTSTINAL | 44180LAP | CPT | BOTH | $2,845.92 | $500.00 | $677.34 | $4,700.00 | $795.00 | $1,250.00 | $1,250.00 | $2,500.00 | $1,235.00 | $1,200.00 | $1,488.00 | $500.00 | $551.00 | $500.00 | $500.00 | $500.00 | 500,00 | 4.700,00 | |||||
| LAPS ENTEROLSS FRING INTSTINAL | 44180R | CPT | BOTH | $2,845.92 | $3,000.00 | N/A | $5,246.00 | N/A | $3,400.00 | $3,400.00 | N/A | N/A | $5,000.00 | $5,000.00 | $3,000.00 | N/A | $3,000.00 | $3,000.00 | $3,000.00 | 3.000,00 | 5.246,00 | |||||
| LAPS JEJUNOSTOMY | 44186A | CPT | BOTH | $808.00 | $296.00 | $194.66 | $269.74 | N/A | $220.31 | $220.31 | $211.08 | $264.05 | $296.00 | $175.20 | $296.00 | $269.74 | $255.04 | $255.04 | $255.04 | 1.752,00 | 296,00 | |||||
| LAPS JEJUNOSTOMY | 44186FF | CPT | BOTH | $3,000.00 | $1,030.00 | $810.34 | $4,700.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | N/A | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 4.700,00 | |||||
| LAPAROSCOPE EQUIPMENT AND MATE | 44186LAP | CPT | BOTH | $1,400.00 | $350.00 | N/A | $350.00 | $1,200.00 | $1,250.00 | $1,250.00 | $2,500.00 | $1,235.00 | $1,500.00 | $1,488.00 | $350.00 | N/A | N/A | N/A | N/A | 350,00 | 2.500,00 | |||||
| LAPS JEJUNOSTOMY | 44186R | CPT | BOTH | $2,019.99 | $3,000.00 | N/A | $5,246.00 | N/A | $3,400.00 | $3,400.00 | N/A | N/A | $5,000.00 | $5,000.00 | $3,000.00 | N/A | $3,000.00 | $3,000.00 | $3,000.00 | 3.000,00 | 5.246,00 | |||||
| LAPS ILEOST/JEJUNOSTOMY NON-TU | 44187A | CPT | BOTH | $1,352.75 | $303.20 | $321.96 | $449.27 | N/A | $376.23 | $376.23 | $380.50 | $440.40 | $303.20 | $263.20 | $303.20 | $449.27 | $423.14 | $423.14 | $423.14 | 2.632,00 | 44.927,00 | |||||
| LAPS ILEOST/JEJUNOSTOMY NON-TU | 44187FF | CPT | BOTH | $3,381.87 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,250.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.250,00 | |||||
| LAPS ILEOSTO/JEJUNOSTOMY | 44187LAP | CPT | BOTH | $1,400.00 | $3,000.00 | N/A | N/A | N/A | N/A | $1,250.00 | $1,300.00 | $1,235.00 | N/A | $1,488.00 | $3,000.00 | N/A | $3,000.00 | $3,000.00 | $3,000.00 | 1.235,00 | 3.000,00 | |||||
| LAPS ILEOST/JEJUNOSTOMY NON-TU | 44187R | CPT | BOTH | $4,000.00 | $3,000.00 | N/A | $5,246.00 | N/A | $3,400.00 | $3,400.00 | N/A | N/A | $5,000.00 | $5,000.00 | $3,000.00 | N/A | $3,000.00 | $3,000.00 | $3,000.00 | 3.000,00 | 5.246,00 | |||||
| SGMDSC FLX NDSC US XM | 45341A | CPT | BOTH | $151.02 | $54.60 | $50.34 | $39.60 | $154.50 | $45.94 | $45.94 | $52.43 | $49.20 | $52.00 | $41.20 | N/A | N/A | N/A | N/A | N/A | 396,00 | 1.545,00 | |||||
| Digital Endosonography (EUS) F | 45341FF | CPT | BOTH | $3,000.00 | $3,000.00 | $1,157.63 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,000.00 | $3,250.00 | $3,000.00 | 115.763,00 | 4.000,00 | |||||
| Colonoscopy with Endoscopy US | 45391A | CPT | BOTH | $313.52 | $100.00 | $104.54 | $90.00 | N/A | $120.01 | $94.48 | $104.57 | $102.48 | $100.00 | $81.20 | N/A | N/A | N/A | N/A | N/A | 812,00 | 12.001,00 | |||||
| Digital Endosonography (EUS) F | 45391FF | CPT | BOTH | $3,000.00 | $3,000.00 | $1,157.63 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,000.00 | $3,250.00 | $3,000.00 | 115.763,00 | 4.000,00 | |||||
| COLSC FLX PROX SPLENIC FLXR US | 45392A | CPT | BOTH | $929.88 | $127.20 | $123.11 | $114.48 | $445.50 | $800.00 | $111.18 | $126.92 | $123.11 | $127.20 | $103.20 | N/A | N/A | N/A | N/A | N/A | 1.032,00 | 800,00 | |||||
| Digital Endosonography (EUS) F | 45392FF | CPT | BOTH | $3,000.00 | $3,000.00 | $1,157.63 | $4,000.00 | $3,500.00 | $2,000.00 | $2,000.00 | $3,500.00 | $3,000.00 | $3,500.00 | $3,859.00 | $3,000.00 | $3,583.00 | $3,000.00 | $3,250.00 | $3,000.00 | 115.763,00 | 4.000,00 | |||||
| LAPS SURG CHOLECSTC | 47562A | CPT | BOTH | $818.88 | $315.00 | $280.80 | $140.00 | $1,425.00 | $222.05 | $222.05 | $223.36 | $267.84 | $300.00 | $252.80 | $300.00 | $273.76 | $259.57 | $259.57 | $259.57 | 140,00 | 1.425,00 | |||||
| LAPS SURG CHOLECSTC | 47562FF | CPT | BOTH | $1,908.93 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| LAPAROSCOPE EQUIPMENT AND MATE | 47562LAP | CPT | BOTH | $1,400.00 | $350.00 | $405.17 | $1,350.00 | $1,200.00 | $1,250.00 | $1,250.00 | $1,300.00 | $1,235.00 | $600.00 | $1,488.00 | $350.00 | $386.00 | $350.00 | $350.00 | $350.00 | 350,00 | 1.488,00 | |||||
| LAPAROSCOPE EQUIPMENT AND MATE | 47562LAPO | CPT | BOTH | $1,400.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $1,500.00 | $1,488.00 | N/A | N/A | N/A | N/A | N/A | 1.488,00 | 1.500,00 | |||||
| LAPS SURG CHOLECSTC | 47562R | CPT | BOTH | $2,047.20 | N/A | N/A | N/A | N/A | $5,000.00 | $5,000.00 | $4,500.00 | $4,000.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 4.000,00 | 5.000,00 | |||||
| BX PNCRS PRQ NDL | 48102A | CPT | BOTH | $720.00 | $158.80 | $94.94 | $158.80 | $457.50 | $158.80 | $220.90 | $94.94 | $87.49 | $158.80 | $71.56 | $158.80 | $94.94 | $90.23 | $90.23 | $90.23 | 7.156,00 | 4.575,00 | |||||
| BX PNCRS PRQ NDL | 48102FF | CPT | BOTH | $720.00 | $397.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 397,00 | 1.081,00 | |||||
| BX PNCRS PRQ NDL | 48102IR | CPT | BOTH | $750.00 | $500.00 | $520.93 | $450.00 | $475.00 | $450.00 | $450.00 | $512.00 | $495.00 | N/A | $551.00 | $500.00 | $496.00 | $500.00 | $500.00 | $500.00 | 450,00 | 551,00 | |||||
| ABD PARACENTESIS W/IMAGING | 49083A | CPT | BOTH | $129.17 | $105.20 | $42.98 | $105.20 | N/A | $105.20 | $39.19 | $124.88 | $39.96 | $105.20 | $28.56 | $105.20 | $42.98 | $42.98 | $42.98 | $42.98 | 2.856,00 | 12.488,00 | |||||
| ABD PARACENTESIS W/IMAGING | 49083FF | CPT | BOTH | $322.92 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $263.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 263,00 | 1.081,00 | |||||
| ABD PARACENTESIS W/IMAGING | 49083IR | CPT | BOTH | $900.00 | $700.00 | $520.93 | $450.00 | $475.00 | $630.00 | $630.00 | $512.00 | $682.50 | $500.00 | $772.00 | $700.00 | $694.00 | $700.00 | $700.00 | $700.00 | 450,00 | 772,00 | |||||
| IMAGE CATH FLUID COLXN VISC | 49405A | CPT | BOTH | $237.24 | $193.20 | $169.05 | $31.37 | N/A | $31.11 | $77.77 | $81.35 | $76.99 | $193.20 | $187.20 | $193.20 | $78.42 | $74.04 | $74.04 | $74.04 | 3.111,00 | 1.932,00 | |||||
| IMAGE CATH FLUID COLXN VISC | 49405FF | CPT | BOTH | $237.24 | $483.00 | $422.63 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 42.263,00 | 1.081,00 | |||||
| IMAGE CATH FLUID COLXN VISC | 49405IR | CPT | BOTH | $900.00 | $700.00 | $729.30 | $630.00 | $665.00 | $630.00 | $630.00 | $712.00 | $650.00 | N/A | $772.00 | $700.00 | $694.00 | $700.00 | $700.00 | $700.00 | 630,00 | 772,00 | |||||
| INSERT TUN IP CATH PERC | 49418A | CPT | BOTH | $245.22 | $127.60 | $114.84 | $127.60 | $1,422.00 | $79.20 | $79.20 | $79.71 | $79.84 | $127.60 | $45.94 | $127.60 | $81.06 | $76.63 | $76.63 | $76.63 | 4.594,00 | 1.422,00 | |||||
| INSERT TUN IP CATH PERC | 49418FF | CPT | BOTH | $245.22 | $1,030.00 | $1,323.00 | $850.00 | $850.00 | $1,200.00 | $1,200.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.323,00 | |||||
| INSERT TUN IP CATH PERC | 49418IR | CPT | BOTH | $245.22 | N/A | $1,323.00 | $1,080.00 | $1,422.00 | $1,200.00 | $1,200.00 | $1,100.00 | $1,100.00 | N/A | $1,323.00 | $500.00 | $496.00 | N/A | N/A | N/A | 496,00 | 1.422,00 | |||||
| Under Drainage Catheter Proced | 49423A | CPT | BOTH | $1,645.20 | $31.20 | $28.28 | $31.20 | N/A | $31.20 | $26.50 | $26.51 | $28.20 | $31.20 | $18.75 | $31.20 | $28.13 | $26.79 | $26.79 | $26.79 | 1.875,00 | 312,00 | |||||
| Under Drainage Catheter Proced | 49423FF | CPT | BOTH | $1,645.20 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| Under Drainage Catheter Proced | 49423IR | CPT | BOTH | $1,645.20 | $2,000.00 | $630.00 | N/A | $665.00 | $1,200.00 | $1,200.00 | $1,100.00 | N/A | $500.00 | $2,205.00 | $2,000.00 | $1,323.00 | $2,000.00 | $2,000.00 | $2,000.00 | 500,00 | 2.205,00 | |||||
| RNL BX PRQ TROCAR/NDL | 50200A | CPT | BOTH | $154.75 | $69.60 | $65.60 | $69.60 | $199.50 | $69.60 | $51.08 | $48.63 | $50.29 | $69.60 | $33.91 | $69.60 | $51.30 | $51.30 | $51.30 | $51.30 | 3.391,00 | 1.995,00 | |||||
| RNL BX PRQ TROCAR/NDL | 50200FF | CPT | BOTH | $750.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| RNL BX PRQ TROCAR/NDL | 50200IR | CPT | BOTH | $750.00 | $500.00 | $520.93 | $1,437.00 | $475.00 | $450.00 | $450.00 | $512.00 | $1,125.00 | $500.00 | $551.00 | $500.00 | $496.00 | $500.00 | $500.00 | $500.00 | 450,00 | 1.437,00 | |||||
| PLMT NEPHROSTOMY CATHETER | 50432A | CPT | BOTH | $247.79 | $222.00 | $81.91 | $222.00 | N/A | $222.00 | $80.39 | $80.36 | $81.06 | $222.00 | $329.79 | $222.00 | $81.91 | $77.81 | $77.81 | $77.81 | 7.781,00 | 32.979,00 | |||||
| PLMT NEPHROSTOMY CATHETER | 50432FF | CPT | BOTH | $920.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $555.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 555,00 | 1.081,00 | |||||
| PLMT NEPHROSTOMY CATHETER | 50432IR | CPT | BOTH | $1,600.00 | $2,000.00 | N/A | $1,080.00 | $665.00 | $1,200.00 | $1,200.00 | $1,100.00 | $650.00 | $700.00 | $2,205.00 | $2,000.00 | $1,323.00 | $2,000.00 | $2,000.00 | $2,000.00 | 650,00 | 2.205,00 | |||||
| LAPS ABLTJ RNL MASS LES | 50542A | CPT | BOTH | $1,425.96 | $630.00 | $340.64 | $630.00 | N/A | $480.00 | $414.77 | $391.95 | $465.61 | $630.00 | $567.20 | $630.00 | $472.36 | $451.86 | $451.86 | $451.86 | 34.064,00 | 630,00 | |||||
| LAP ABLATION OF RENAL MASS | 50542FF | CPT | BOTH | $3,542.73 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,800.00 | $1,800.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.800,00 | |||||
| LAP ABLATION OF RENAL MASS | 50542IR | CPT | BOTH | $3,542.73 | N/A | $851.60 | $1,907.00 | N/A | $1,200.00 | $1,180.91 | $8,178.00 | $6,815.00 | $3,500.00 | $851.60 | N/A | N/A | N/A | N/A | N/A | 8.516,00 | 8.178,00 | |||||
| LAP ABLATION OF RENAL MASS | 50542LAP | CPT | BOTH | $2,800.00 | N/A | N/A | N/A | N/A | $1,250.00 | $1,250.00 | N/A | $850.00 | N/A | $1,488.00 | N/A | N/A | N/A | N/A | N/A | 850,00 | 1.488,00 | |||||
| LAP ABLATION OF RENAL MASS | 50542R | CPT | BOTH | $3,542.73 | N/A | N/A | $5,246.00 | N/A | $5,000.00 | $5,000.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 5.000,00 | 5.246,00 | |||||
| LAPS PRTL NFRCT | 50543A | CPT | BOTH | $1,817.95 | $804.80 | $683.20 | $241.11 | N/A | $211.80 | $529.49 | $500.80 | $593.43 | $804.80 | $724.40 | $804.80 | $602.78 | $576.50 | $576.50 | $576.50 | 2.118,00 | 8.048,00 | |||||
| LAPS PRTL NFRCT | 50543FF | CPT | BOTH | $4,294.83 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,800.00 | $1,800.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.800,00 | |||||
| LAPS PRTL NFRCT | 50543LAP | CPT | BOTH | $4,294.83 | $2,012.00 | N/A | $2,550.00 | N/A | $1,250.00 | $1,250.00 | N/A | $435.14 | N/A | $1,488.00 | $2,012.00 | $938.00 | N/A | N/A | N/A | 43.514,00 | 2.550,00 | |||||
| LAPS PRTL NFRCT | 50543R | CPT | BOTH | $1,817.95 | N/A | N/A | $5,246.00 | N/A | $5,000.00 | $5,000.00 | $4,500.00 | $4,000.00 | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 4.000,00 | 5.246,00 | |||||
| LAPS PLEOPLASTY | 50544A | CPT | BOTH | $1,515.86 | $683.20 | $320.00 | $683.20 | N/A | $683.20 | $444.92 | $420.56 | $494.35 | $683.20 | $614.80 | $683.20 | $502.22 | $479.44 | $479.44 | $479.44 | 320,00 | 6.832,00 | |||||
| LAPS PLEOPLASTY | 50544FF | CPT | BOTH | $3,789.66 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,800.00 | $1,800.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.800,00 | |||||
| LAPS PLEOPLASTY | 50544LAP | CPT | BOTH | $3,789.66 | $1,708.00 | N/A | $2,550.00 | N/A | N/A | N/A | $1,300.00 | $1,235.00 | N/A | $1,488.00 | $1,708.00 | N/A | N/A | N/A | N/A | 1.235,00 | 2.550,00 | |||||
| LAPS PLEOPLASTY | 50544R | CPT | BOTH | $3,789.66 | N/A | N/A | $5,246.00 | N/A | $5,000.00 | $5,000.00 | $4,500.00 | $4,000.00 | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 4.000,00 | 5.246,00 | |||||
| LAPS NFRCT W/PRTL URTREC | 50546A | CPT | BOTH | $1,471.15 | $648.40 | $648.40 | $683.20 | N/A | $170.46 | $426.15 | $402.89 | $480.38 | $648.40 | $583.60 | $648.40 | $487.58 | $466.66 | $466.66 | $466.66 | 17.046,00 | 6.832,00 | |||||
| LAPS NFRCT W/PRTL URTREC | 50546FF | CPT | BOTH | $1,471.15 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,800.00 | $1,800.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.800,00 | |||||
| LAPS NFRCT W/PRTL URTREC | 50546LAP | CPT | BOTH | $1,471.15 | $680.82 | N/A | $2,550.00 | N/A | $1,250.00 | $1,250.00 | N/A | $356.40 | N/A | $1,488.00 | $680.82 | N/A | N/A | N/A | N/A | 3.564,00 | 2.550,00 | |||||
| LAPS NFRCT W/PRTL URTREC | 50546R | CPT | BOTH | $1,471.15 | N/A | N/A | $487.58 | N/A | $5,000.00 | $5,000.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 48.758,00 | 5.000,00 | |||||
| LAP DONOR NEPHRECTOMY | 50547FF | CPT | BOTH | $4,863.72 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,800.00 | $1,800.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.800,00 | |||||
| LAP DONOR NEPHRECTOMY | 50547LAP | CPT | BOTH | $4,863.72 | N/A | N/A | $2,550.00 | N/A | $1,250.00 | $1,250.00 | N/A | N/A | N/A | $1,488.00 | N/A | N/A | N/A | N/A | N/A | 1.250,00 | 2.550,00 | |||||
| 50547FF - LAP DONOR NEPHRECTOM | 50547R | CPT | BOTH | $4,863.72 | N/A | N/A | $5,246.00 | N/A | $1,800.00 | $1,800.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 1.800,00 | 5.246,00 | |||||
| LAPS NFRCT W/TOT URTREC | 50548A | CPT | BOTH | $1,641.12 | $1,200.00 | $1,200.00 | $217.07 | N/A | $192.62 | $481.56 | $454.72 | $534.06 | $1,200.00 | $1,080.00 | $1,200.00 | $542.67 | $637.06 | $637.06 | $637.06 | 19.262,00 | 1.200,00 | |||||
| LAPS NFRCT W/TOT URTREC | 50548FF | CPT | BOTH | $1,641.12 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,800.00 | $1,800.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.800,00 | |||||
| LAPS NFRCT W/TOT URTREC | 50548LAP | CPT | BOTH | $1,641.12 | $1,260.00 | N/A | $2,550.00 | N/A | $1,250.00 | $1,250.00 | N/A | $419.60 | N/A | $1,488.00 | $1,260.00 | N/A | N/A | N/A | N/A | 4.196,00 | 2.550,00 | |||||
| LAPS NFRCT W/TOT URTREC | 50548R | CPT | BOTH | $1,641.12 | N/A | N/A | $5,246.00 | N/A | $5,000.00 | $5,000.00 | $4,500.00 | $4,000.00 | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 4.000,00 | 5.246,00 | |||||
| ABLATION 1 OR MORE RENAL TUMOR | 50592A | CPT | BOTH | $398.32 | $834.40 | $834.40 | $834.40 | N/A | $834.40 | $130.74 | $123.54 | $136.09 | $834.40 | $750.80 | $834.40 | $137.97 | $130.92 | $130.92 | $130.92 | 12.354,00 | 8.344,00 | |||||
| ABLATION 1 OR MORE RENAL TUMOR | 50592FF | CPT | BOTH | $3,200.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $1,200.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.200,00 | |||||
| ABLATION 1 OR MORE RENAL TUMO | 50592IR | CPT | BOTH | $3,200.00 | $2,400.00 | $2,500.00 | $4,800.00 | N/A | $1,200.00 | $1,200.00 | $4,691.00 | $3,909.00 | $2,500.00 | $2,205.00 | $2,400.00 | $1,323.00 | $1,200.00 | $1,200.00 | $1,200.00 | 1.200,00 | 4.800,00 | |||||
| LAPS PRST8ECT RETROPUBIC RAD W | 55866A | CPT | BOTH | $1,758.73 | $618.00 | $421.83 | $618.00 | $618.00 | $483.16 | $2,200.00 | $584.15 | $496.00 | $618.00 | $556.40 | $582.64 | $421.86 | $463.00 | $463.00 | $463.00 | 42.183,00 | 2.200,00 | |||||
| LAPS PROSTATECTOMY RETROPUBIC | 55866FF | CPT | BOTH | $1,400.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| LAPS PROSTATECTOMY RETROPUBIC | 55866LAP | CPT | BOTH | $4,155.54 | $850.00 | N/A | N/A | $1,200.00 | N/A | $1,250.00 | $1,300.00 | $1,235.00 | N/A | $1,488.00 | $850.00 | N/A | N/A | N/A | N/A | 850,00 | 1.488,00 | |||||
| LAP PROSTATECTOMY RETROPUBIC R | 55866R | CPT | BOTH | $4,155.54 | $4,000.00 | N/A | $5,246.00 | N/A | $5,000.00 | $5,000.00 | $4,500.00 | $4,000.00 | $5,000.00 | $5,000.00 | $4,000.00 | $4,000.00 | $4,000.00 | $4,000.00 | $4,000.00 | 4.000,00 | 5.246,00 | |||||
| HYSTSC LSS INTRAUTERINE ADS | 58559A | CPT | BOTH | $350.36 | $105.00 | N/A | $116.37 | N/A | $119.34 | $119.34 | N/A | $108.00 | N/A | N/A | $105.00 | N/A | $116.37 | $116.37 | $116.37 | 105,00 | 11.934,00 | |||||
| HYSTSC LSS INTRAUTERINE ADS | 58559R | CPT | BOTH | $350.36 | N/A | N/A | $5,246.00 | N/A | $2,500.00 | $2,500.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 2.500,00 | 5.246,00 | |||||
| HYSTSC DIV/RESCJ INTRAUTERINE | 58560A | CPT | BOTH | $386.38 | $147.00 | N/A | $127.86 | N/A | $134.95 | $134.95 | N/A | $136.00 | N/A | N/A | $147.00 | N/A | $127.86 | $127.86 | $127.86 | 12.786,00 | 147,00 | |||||
| HYSTSC DIV/RESCJ INTRAUTERINE | 58560R | CPT | BOTH | $386.38 | N/A | N/A | $5,246.00 | N/A | $2,700.00 | $2,700.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 2.700,00 | 5.246,00 | |||||
| HYSTSC RMVL LEIOMYOMATA | 58561A | CPT | BOTH | $440.86 | $180.00 | $158.37 | $58.46 | N/A | $76.57 | $191.42 | $184.72 | $180.40 | $180.00 | $142.00 | $180.00 | $146.15 | $138.46 | $138.46 | $138.46 | 5.846,00 | 19.142,00 | |||||
| HYSTSC RMVL LEIOMYOMATA | 58561FF | CPT | BOTH | $440.86 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| HYSTSC RMVL LEIOMYOMATA | 58561LAP | CPT | BOTH | $440.86 | $202.44 | N/A | N/A | N/A | $1,250.00 | $1,250.00 | N/A | $180.40 | N/A | $1,488.00 | $202.44 | $386.00 | N/A | N/A | N/A | 1.804,00 | 1.488,00 | |||||
| HYSTSC RMVL LEIOMYOMATA | 58561R | CPT | BOTH | $440.86 | N/A | N/A | $5,246.00 | N/A | $2,700.00 | $2,700.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 2.700,00 | 5.246,00 | |||||
| HYSTSC ENDOMETRIAL ABLTJ | 58563A | CPT | BOTH | $303.42 | $122.22 | N/A | $100.44 | N/A | $119.36 | $119.36 | N/A | $565.94 | N/A | N/A | $122.22 | N/A | $100.44 | $100.44 | $100.44 | 10.044,00 | 56.594,00 | |||||
| HYSTSC ENDOMETRIAL ABLTJ | 58563R | CPT | BOTH | $303.42 | N/A | N/A | $5,246.00 | N/A | $2,700.00 | $2,700.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 2.700,00 | 5.246,00 | |||||
| HYSTEROSCOPY /STERILIZATION | 58565R | CPT | BOTH | $1,335.00 | N/A | N/A | $5,246.00 | N/A | $2,700.00 | $2,700.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 2.700,00 | 5.246,00 | |||||
| LAP UTERUS | 58578A | CPT | BOTH | $2,385.78 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $440.00 | $528.00 | $555.65 | BR | $556.45 | N/A | N/A | N/A | 440,00 | 55.645,00 | |||||
| Laparoscopic/Hysteroscopic Pr | 58578FF | CPT | BOTH | $5,953.92 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| Laparoscopic/Hysteroscopic Pr | 58578LAP | CPT | BOTH | $1,400.00 | N/A | N/A | N/A | N/A | N/A | N/A | $1,300.00 | $1,235.00 | $600.00 | $551.00 | N/A | N/A | N/A | N/A | N/A | 551,00 | 1.300,00 | |||||
| Laparoscopic/Hysteroscopic Pr | 58578LAPO | CPT | BOTH | $1,400.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | $1,500.00 | $1,488.00 | N/A | N/A | N/A | N/A | N/A | 1.488,00 | 1.500,00 | |||||
| Laparoscopic/Hysteroscopic Pr | 58578R | CPT | BOTH | $5,953.92 | N/A | N/A | $5,246.00 | N/A | $3,400.00 | $3,400.00 | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | 3.400,00 | 5.246,00 | |||||
| RESCJ PRIM PRTL MAL W/BSO&OMNT | 58952A | CPT | BOTH | $2,020.34 | $514.00 | $677.08 | $514.00 | $514.00 | $557.85 | $557.85 | $527.13 | $667.58 | $514.00 | $416.40 | $514.00 | $677.08 | $642.41 | $642.41 | $642.41 | 4.164,00 | 67.708,00 | |||||
| RESECTION OF OVARIAN | 58952R | CPT | BOTH | $2,020.34 | $3,300.00 | N/A | $5,246.00 | N/A | $3,400.00 | $557.85 | N/A | N/A | N/A | $5,000.00 | $3,300.00 | $3,300.00 | $3,300.00 | $3,300.00 | $3,300.00 | 55.785,00 | 5.246,00 | |||||
| ADRNLECTOMY EXPL ADRNL TABDL L | 60540A | CPT | BOTH | $1,325.64 | $355.20 | $441.02 | $441.02 | N/A | $365.20 | $365.20 | $347.76 | $434.70 | $355.20 | $288.00 | $355.20 | $441.02 | $420.98 | $420.98 | $420.98 | 288,00 | 44.102,00 | |||||
| ADRNLECTOMY EXPL ADRNL TABDL L | 60540FF | CPT | BOTH | $750.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| ADRNLECTOMY EXPL ADRNL TABDL L | 60540IR | CPT | BOTH | $750.00 | $500.00 | N/A | $450.00 | $475.00 | $450.00 | $450.00 | $512.00 | N/A | N/A | N/A | $500.00 | $496.00 | $500.00 | $500.00 | $500.00 | 450,00 | 512,00 | |||||
| ADRNLECTOMY EXPL ADRNL TABDL L | 60540R | CPT | BOTH | $3,232.98 | N/A | N/A | $5,246.00 | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 5.000,00 | 5.246,00 | |||||
| LAPS ADRNLECTOMY PRTL/COMPL TA | 60650A | CPT | BOTH | $1,467.71 | $432.00 | $487.83 | $487.53 | N/A | $411.58 | $411.58 | $391.52 | $479.71 | $432.00 | $432.00 | $432.00 | $487.83 | $465.20 | $465.20 | $465.20 | 39.152,00 | 48.783,00 | |||||
| LAPS ADRNLECTOMY PRTL/COMPL TA | 60650FF | CPT | BOTH | $3,000.00 | $1,030.00 | $810.34 | $850.00 | $850.00 | $875.00 | $1,050.00 | $800.00 | $750.00 | $1,005.00 | $1,047.00 | $1,030.00 | $1,047.00 | $1,081.00 | $1,081.00 | $1,081.00 | 750,00 | 1.081,00 | |||||
| LAPS ADRNLECTOMY PRTL/COMPL TA | 60650LAP | CPT | BOTH | $3,669.27 | $800.00 | N/A | $1,219.57 | $1,245.00 | $1,250.00 | $1,250.00 | $1,223.09 | $875.31 | $600.00 | $1,488.00 | $800.00 | $551.00 | N/A | N/A | N/A | 551,00 | 1.488,00 | |||||
| LAPS ADRNLECTOMY PRTL/COMPL TA | 60650R | CPT | BOTH | $3,669.27 | N/A | N/A | N/A | N/A | $3,400.00 | $3,400.00 | $4,000.00 | $4,000.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 3.400,00 | 4.000,00 | |||||
| ITPRL PRE-AUR MCF&MSB | 61590A | CPT | BOTH | $3,753.16 | $924.00 | $1,255.05 | $1,255.05 | N/A | $1,037.25 | $1,037.25 | $997.36 | $1,230.24 | $880.00 | $726.00 | $880.00 | $1,255.05 | $171.35 | $171.35 | $171.35 | 17.135,00 | 125.505,00 | |||||
| ITPLL PRE AUR MCF& MSB | 61590FF | CPT | BOTH | $9,225.00 | $1,030.00 | N/A | $850.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 850,00 | 1.030,00 | |||||
| ITPRL PRE-AUR MCF&MSB | 61590R | CPT | BOTH | $9,382.89 | N/A | N/A | N/A | N/A | $5,000.00 | $5,000.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 5.000,00 | 5.000,00 | |||||
| Screeningmammographydigital | G0202 | HCPCS | BOTH | $117.90 | N/A | N/A | $70.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 70,00 | 70,00 | |||||
| Screeningmammographydigital | G020226 | HCPCS | BOTH | $36.40 | N/A | N/A | $35.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 35,00 | 35,00 | |||||
| Screeningmammographydigital | G0202TC | HCPCS | TC | BOTH | $81.50 | N/A | N/A | $35.00 | $50.50 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 35,00 | 505,00 | ||||
| DIAGNOSTIC MAMMOGRAPHY UNILATE | G0206 | HCPCS | BOTH | $154.20 | N/A | N/A | $50.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 50,00 | 50,00 | |||||
| DIAGNOSTIC MAMMOGRAPHY UNILATE | G020626 | HCPCS | 26 | BOTH | $110.85 | N/A | N/A | $35.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 35,00 | 35,00 | ||||
| DIAGNOSTIC MAMMOGRAM UNILATERA | G0206TC | HCPCS | TC | BOTH | $257.73 | N/A | N/A | $35.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 35,00 | 35,00 | ||||
| DX DIGITALBREAST TOMO UNI/LAT | G0279 | HCPCS | BOTH | $45.93 | N/A | $42.16 | $42.16 | $40.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 40,00 | 4.216,00 | |||||
| DX DIGITALBREAST TOMO UNI/LAT | G027926 | HCPCS | BOTH | $45.93 | N/A | $42.16 | $42.16 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 4.216,00 | 4.216,00 | |||||
| DX DIGITALBREAST TOMO UNI/LAT | G0279TC | HCPCS | TC | BOTH | $45.93 | N/A | $42.16 | $42.16 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 4.216,00 | 4.216,00 | ||||
| Whole Blood for Transfusion | P9010 | HCPCS | BOTH | $447.00 | $252.00 | $219.00 | $219.00 | $447.00 | $180.00 | $180.00 | $180.00 | $180.00 | $219.00 | $253.47 | $252.00 | $252.00 | $153.17 | $252.00 | $153.17 | 15.317,00 | 447,00 | |||||
| Blood, split unit | P9011 | HCPCS | BOTH | $315.00 | $216.67 | $105.00 | $105.00 | $220.00 | $220.00 | $220.00 | $220.00 | $220.00 | BR | $253.47 | $216.67 | $216.67 | N/A | $216.67 | NULL | 105,00 | 25.347,00 | |||||
| CRYOPRECIPITATE, EACH UNIT | P9012 | HCPCS | BOTH | $165.00 | $53.33 | $46.85 | $46.85 | N/A | $60.00 | $60.00 | $60.00 | $60.00 | $46.85 | $57.89 | $53.33 | $53.33 | $81.53 | $53.33 | $81.53 | 4.685,00 | 8.153,00 | |||||
| RED BLOOD CELLS LEULOCYTES | P9016 | HCPCS | BOTH | $540.00 | $294.00 | $249.00 | $249.00 | $190.00 | $198.00 | $198.00 | $198.00 | $198.00 | $249.45 | $276.62 | $294.00 | $294.00 | $192.39 | $294.00 | $192.39 | 190,00 | 294,00 | |||||
| FRESH FROZEN PLASMA (SINGLE DO | P9017 | HCPCS | BOTH | $180.00 | $110.25 | $105.00 | $105.00 | $70.00 | $57.50 | $57.50 | $75.00 | $75.00 | $105.00 | $121.50 | $110.25 | $110.25 | $84.40 | $110.25 | $84.40 | 575,00 | 1.215,00 | |||||
| PLATELETS EACH UNIT | P9019 | HCPCS | BOTH | $540.00 | $105.47 | $100.45 | $100.45 | $75.00 | $89.70 | $89.70 | $75.00 | $75.00 | $100.45 | $116.20 | $105.47 | $105.47 | $72.79 | $105.47 | $72.79 | 7.279,00 | 1.162,00 | |||||
| PLATELET RICH PLASMA EA | P9020 | HCPCS | BOTH | $180.00 | $61.67 | N/A | N/A | N/A | $60.00 | $60.00 | $60.00 | $60.00 | N/A | N/A | $61.67 | $61.67 | $61.67 | $61.67 | $61.67 | 60,00 | 6.167,00 | |||||
| RED BLOOD CELLS, EACH UNIT | P9021 | HCPCS | BOTH | $510.00 | $252.00 | $219.00 | $219.00 | $175.00 | $190.00 | $190.00 | $190.00 | $190.00 | $219.00 | $253.47 | $252.00 | $252.00 | $252.00 | $252.00 | $252.00 | 175,00 | 25.347,00 | |||||
| RED BLOOD CELLS WASHED EACH UN | P9022 | HCPCS | BOTH | $645.00 | $218.00 | $203.73 | $203.73 | $645.00 | $215.00 | $215.00 | $215.00 | $215.00 | $203.73 | $265.04 | $218.00 | $218.00 | $387.85 | $218.00 | $387.85 | 20.373,00 | 645,00 | |||||
| PLASMA, POOLDE MULTIPLE DONO | P9023 | HCPCS | BOTH | $1,350.00 | $470.00 | $100.00 | $100.00 | $450.00 | $105.00 | $550.00 | $550.00 | $550.00 | BR | $532.51 | $470.00 | $470.00 | $91.01 | $470.00 | $91.01 | 9.101,00 | 550,00 | |||||
| PLATELETS, LEUKOCYTES REDUCED | P9031 | HCPCS | BOTH | $1,500.00 | $108.33 | N/A | N/A | N/A | $115.00 | $115.00 | $115.00 | $590.00 | $138.90 | $108.33 | $108.33 | $108.33 | $108.33 | $108.33 | $108.33 | 10.833,00 | 590,00 | |||||
| PLATELETS IRRADIATED EA | P9032 | HCPCS | BOTH | $285.00 | $118.33 | N/A | N/A | N/A | $115.00 | $115.00 | $115.00 | $115.00 | N/A | N/A | $118.33 | $118.33 | $118.33 | $118.33 | $118.33 | 115,00 | 11.833,00 | |||||
| PLATELETS LEUKOCYTES REDUCED I | P9033 | HCPCS | BOTH | $345.00 | $136.67 | N/A | N/A | N/A | $135.00 | $135.00 | $135.00 | $135.00 | N/A | N/A | $136.67 | $136.67 | $136.67 | $136.67 | $136.67 | 135,00 | 13.667,00 | |||||
| PLATELET, PHERESIS, EACH UNIT | P9034 | HCPCS | BOTH | $1,350.00 | $474.60 | $480.00 | $452.00 | $415.00 | $483.00 | $483.00 | $500.00 | $500.00 | N/A | $474.60 | $474.60 | $474.60 | $474.60 | $474.60 | $474.60 | 415,00 | 500,00 | |||||
| PLATELETS PHERESIS LEUKOCYTES | P9035 | HCPCS | BOTH | $1,500.00 | $533.33 | $480.00 | $480.00 | $500.00 | $575.00 | $575.00 | $575.00 | $575.00 | BR | $607.70 | $533.33 | $533.33 | $533.33 | $533.33 | $533.33 | 480,00 | 6.077,00 | |||||
| PLATELETS ,PHERESIS LEUKOCYTE | P9037 | HCPCS | BOTH | $1,725.00 | $610.72 | $600.00 | $600.00 | $530.00 | $600.00 | $600.00 | $600.00 | $600.00 | BR | $636.70 | $610.72 | $610.72 | $610.72 | $610.72 | $610.72 | 530,00 | 6.367,00 | |||||
| BILL BLOOD IRRADIATED, EACH | P9038 | HCPCS | BOTH | $630.00 | $213.00 | N/A | N/A | $630.00 | $215.00 | $215.00 | $215.00 | $215.00 | N/A | $288.19 | $213.00 | $213.00 | $213.00 | $213.00 | $213.00 | 213,00 | 630,00 | |||||
| RBC DEGLYCEROLIZED | P9039 | HCPCS | BOTH | $750.00 | $306.00 | N/A | N/A | N/A | Adquisition cost | Adquisition cost | N/A | N/A | N/A | N/A | $306.00 | $306.00 | $306.00 | $306.00 | $306.00 | 306,00 | 306,00 | |||||
| RED BLOOD CELLS LEUKOCYTES RED | P9040 | HCPCS | BOTH | $220.00 | $229.95 | $30.00 | $30.00 | $210.00 | $235.00 | $235.00 | $235.00 | $235.00 | BR | $311.90 | $229.95 | $229.95 | $229.95 | $229.95 | $229.95 | 30,00 | 3.119,00 | |||||
| PLASMA CRYOPRECIPITATE REDUCED | P9044 | HCPCS | BOTH | $270.00 | $90.00 | N/A | N/A | N/A | $90.00 | $90.00 | $90.00 | $90.00 | N/A | $104.19 | $90.00 | $90.00 | $90.00 | $90.00 | $90.00 | 90,00 | 10.419,00 | |||||
| RBC LEUCOCYTES REDUCED | P9051 | HCPCS | BOTH | $230.00 | $233.67 | N/A | N/A | N/A | $130.50 | $130.50 | $230.00 | $230.00 | N/A | $266.26 | $233.67 | $233.67 | $233.67 | $233.67 | $233.67 | 1.305,00 | 26.626,00 | |||||
| PLATELETS HLA REDUCED | P9052 | HCPCS | BOTH | $1,800.00 | $531.67 | N/A | N/A | N/A | Adquisition cost | Adquisition cost | $600.00 | $600.00 | N/A | $636.70 | $531.67 | $531.67 | $531.67 | $531.67 | $531.67 | 53.167,00 | 6.367,00 | |||||
| PLATELETS PHERESIS LEUCOCYTES | P9053 | HCPCS | BOTH | $1,770.00 | $546.67 | N/A | N/A | N/A | $600.00 | $600.00 | $590.00 | $590.00 | N/A | $648.27 | $546.67 | $546.67 | $546.67 | $546.67 | $546.67 | 54.667,00 | 64.827,00 | |||||
| RBC LEUKOCYTES REDUCED | P9054 | HCPCS | BOTH | $650.00 | $218.00 | N/A | N/A | N/A | $600.00 | Adquisition cost | COST | COST | N/A | N/A | $218.00 | $218.00 | $218.00 | $218.00 | $218.00 | 218,00 | 600,00 | |||||
| PLT LEUKOCYTES REDUCED CMV NE | P9055 | HCPCS | BOTH | $1,590.00 | $521.67 | N/A | N/A | N/A | $550.00 | $550.00 | $5,550.00 | $5,550.00 | N/A | $607.70 | $521.67 | $521.67 | $521.67 | $521.67 | $521.67 | 52.167,00 | 5.550,00 | |||||
| WHOLE BLOOD LEUKOCYTES REDUCE | P9056 | HCPCS | BOTH | $705.00 | N/A | N/A | N/A | N/A | $235.00 | $235.00 | $235.00 | $235.00 | N/A | $271.99 | $235.00 | $235.00 | $235.00 | $235.00 | $235.00 | 235,00 | 27.199,00 | |||||
| Red blood cells, frozen/ | P9057 | HCPCS | BOTH | $735.00 | N/A | N/A | N/A | N/A | $631.37 | $631.37 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 63.137,00 | 63.137,00 | |||||
| RBC CMV NEGATIVE IRRADIATE | P9058 | HCPCS | BOTH | $735.00 | $245.00 | N/A | N/A | N/A | $245.00 | $245.00 | $245.00 | $245.00 | N/A | $283.56 | $245.00 | $245.00 | $245.00 | $245.00 | $245.00 | 245,00 | 28.356,00 | |||||
| FRESH FROZEN PLASMA | P9059 | HCPCS | BOTH | $195.00 | $65.00 | N/A | N/A | N/A | $70.00 | $70.00 | $70.00 | $70.00 | N/A | N/A | $65.00 | $65.00 | $65.00 | $65.00 | $65.00 | 65,00 | 70,00 | |||||
| Plasma, pooled multiple donor, | P9070 | HCPCS | BOTH | $233.07 | $77.69 | N/A | N/A | N/A | $75.00 | $75.00 | $75.00 | $75.00 | N/A | N/A | $77.69 | $77.69 | $77.69 | $77.69 | $77.69 | 75,00 | 7.769,00 | |||||
| Plasma (single donor), pathoge | P9071 | HCPCS | BOTH | $255.00 | $85.00 | N/A | N/A | N/A | $115.00 | $115.00 | $500.00 | $500.00 | N/A | N/A | $85.00 | $85.00 | $85.00 | $85.00 | $85.00 | 85,00 | 500,00 | |||||
| PLATELET,PHERESIS, PATHOGEN RE | P9072 | HCPCS | BOTH | $1,925.55 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 0,00 | 0,00 | |||||
| Platelets, pheresis, pathogen- | P9073 | HCPCS | BOTH | $2,120.00 | $706.67 | $706.67 | $706.67 | N/A | $720.00 | $720.00 | $720.00 | $720.00 | $555.66 | $737.95 | $706.67 | $706.67 | $706.67 | $706.67 | $706.67 | 55.566,00 | 73.795,00 | |||||
| PATHOGEN TEST FOR PLATELET | P9100 | HCPCS | BOTH | $120.00 | N/A | N/A | N/A | N/A | $11.50 | $11.50 | $40.00 | $40.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 115,00 | 40,00 | |||||
| CHEMOTHERAPY ROOM | Q0081 | HCPCS | BOTH | $250.00 | $125.00 | $159.75 | $105.00 | $150.00 | $150.00 | $150.00 | $165.00 | $165.00 | $300.00 | $110.00 | $125.00 | $125.00 | $250.00 | $125.00 | $250.00 | 105,00 | 300,00 | |||||
| INFUSUIN THER, OTHER CHEMOTHER | Q0081SG | HCPCS | SG | BOTH | $250.00 | $100.00 | $152.15 | $100.00 | $150.00 | $150.00 | $150.00 | $165.00 | $165.00 | $125.00 | $110.00 | $100.00 | $110.00 | $250.00 | $105.00 | $250.00 | 100,00 | 250,00 | ||||
| Chemotherapy administration by | Q0083 | HCPCS | BOTH | $600.00 | N/A | N/A | N/A | N/A | N/A | N/A | $250.00 | $200.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 200,00 | 250,00 | |||||
| Chemotherapy adm IV PUSH | Q0083SG | HCPCS | SG | BOTH | $600.00 | N/A | N/A | $30.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 30,00 | 30,00 | ||||
| Chemotherapy Facility Fee | Q0084 | HCPCS | BOTH | $450.00 | N/A | N/A | N/A | N/A | N/A | N/A | $250.00 | $250.00 | $350.00 | N/A | N/A | N/A | N/A | N/A | N/A | 250,00 | 350,00 | |||||
| Chemotherapy ADM INF TECH PER | Q0084SG | HCPCS | SG | BOTH | $450.00 | N/A | N/A | $100.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 100,00 | 100,00 | ||||
| CHEMOTHERAPY ROOM | Q0085 | HCPCS | BOTH | $250.00 | $100.00 | $159.75 | $138.00 | N/A | $150.00 | $150.00 | $250.00 | $250.00 | $350.00 | N/A | $100.00 | N/A | $250.00 | $100.00 | $250.00 | 100,00 | 350,00 |
Actualizado: 11/09/2026
| Descargo de responsabilidad |
|---|
| A su leal saber y entender, este hospital ha incluido toda la información aplicable sobre cargos estándar de conformidad con los requisitos de la norma 45 CFR 180.50, y la información codificada es veraz, exacta y completa a la fecha indicada en el archivo. Este hospital ha incluido todos los cargos negociados específicos para cada pagador que pueden expresarse en dólares. En el caso de cargos negociados específicos para pagadores que no pueden expresarse como una cifra en dólares en el archivo legible por máquina o que no se conocen de antemano, el hospital certifica que dicho cargo se basa en un algoritmo, porcentaje o fórmula contractual que impide indicar una cifra en dólares; asimismo, el hospital ha facilitado toda la información de la que dispone para que el público pueda calcular dicha cifra, incluida, entre otros elementos, la lista de tarifas específica o los componentes a los que hace referencia el porcentaje, algoritmo o fórmula en cuestión. |