Description,CPT,   Facility Price   ,   Professional Price   , Total Price ,  Self Pay Price ,
"Debridement-skin , sub q, muscle/fascia 20 Sq cm/<",11043," $1,586.00 "," $1,068.00 "," $2,654.00 "," $1,592.40 ",
SKIN SPLT GRFT TRNK/ARM/LEG 100 SQ CM/1% BA (15100,15100," $8,899.00 "," $2,254.00 "," $11,153.00 "," $6,691.80 ",
"Removal of 1 or more breast growth, open procedure 19120",19120,#N/A,#N/A,#N/A,#N/A,
"Injection Tendon Sheath, Ligament Charge (20550)",20550, $924.00 , $200.00 ," $1,124.00 ", $674.40 ,
Injection Trigger Point(s): 1 or 2 Muscle(s) Charg,20552," $1,066.00 ", $193.00 ," $1,259.00 ", $755.40 ,
Injection Trigger Point(s): 3 or more Muscle(s) Ch,20553," $1,090.00 ", $211.00 ," $1,301.00 ", $780.60 ,
DRAIN/INJ INTER JOINT/BURSA W/US (20606),20606," $1,045.00 ", $197.00 ," $1,242.00 ", $745.20 ,
Arthrocentesis Major Joint Charge (20610),20610," $1,061.00 ", $260.00 ," $1,321.00 ", $792.60 ,
DRAIN/INJ MAJOR JOINT/BURSA W/US (20611),20611," $1,088.00 ", $235.00 ," $1,323.00 ", $793.80 ,
Sacroiliac Joint Injection (27096),27096," $1,090.00 ", $306.00 ," $1,396.00 ", $837.60 ,
OT Long Arm Cast Units,29065, $221.00 ,, $221.00 , $132.60 ,
OT Short Arm Cast Units,29075, $221.00 ,, $221.00 , $132.60 ,
OT Hand and Lower Forearm Cast Units,29085, $221.00 ,, $221.00 , $132.60 ,
PT Long Leg Cast Application Units,29358, $221.00 ,, $221.00 , $132.60 ,
PT Cylindrical Cast Application Units,29365, $221.00 ,, $221.00 , $132.60 ,
PT Short Leg Cast Application Units,29405, $221.00 ,, $221.00 , $132.60 ,
Apply Multlay Comprs LWR Leg (29581),29581, $487.00 , $151.00 , $638.00 , $382.80 ,
Shaving of shoulder bone using an endoscope 29826,29826,#N/A,#N/A,#N/A,#N/A,
Removal of one knee cartilage using an endoscope 29881,29881,#N/A," $2,998.00 ",#N/A,#N/A,
Tracheostomy Tube Management Charge,31502, $674.00 , $166.00 , $840.00 , $504.00 ,
COLLECTION: Venous Draw,36415, $32.00 ,, $32.00 , $19.20 ,
Removal of tonsils and adenoid glands patient younger than age 12 42820,42820,#N/A,#N/A,#N/A,#N/A,
"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope 43235",43235," $3,803.00 ",," $3,803.00 "," $2,281.80 ",
"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope 43239",43239," $4,462.00 ",," $4,462.00 "," $2,677.20 ",
Diagnostic examination of large bowel using an endoscope 45378,45378," $3,150.00 ",," $3,150.00 "," $1,890.00 ",
Biopsy of large bowel using an endoscope 45380,45380," $5,108.00 ",," $5,108.00 "," $3,064.80 ",
Removal of polyps or growths of large bowel using an endoscope 45385,45385,#N/A,#N/A,#N/A,#N/A,
Ultrasound examination of lower large bowel using an endoscope 45391,45391,#N/A,#N/A,#N/A,#N/A,
Removal of gallbladder using an endoscope 47562,47562,#N/A,#N/A,#N/A,#N/A,
Repair of groin hernia patient age 5 years or older 49505,49505,#N/A,#N/A,#N/A,#N/A,
Biopsy of prostate gland 55700,55700,#N/A,#N/A,#N/A,#N/A,
Surgical removal of prostate and surrounding lymph nodes using an endoscope 55866,55866,#N/A,#N/A,#N/A,#N/A,
"Routine obstetric care for vaginal delivery, including pre-and post-delivery care 59400",59400,#N/A,#N/A,#N/A,#N/A,
"Routine obstetric care for cesarean delivery, including pre-and post-delivery care 59510",59510,#N/A,#N/A,#N/A,#N/A,
Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care 59610,59610,#N/A,#N/A,#N/A,#N/A,
"NJX INTERLAMINAR CRV/THRC, with imaging guidance (",62321," $2,343.00 ", $391.00 ," $2,734.00 "," $1,640.40 ",
"NJX INTERLAMINAR LMBR/SAC, with imaging guidance (",62323," $2,343.00 ", $357.00 ," $2,700.00 "," $1,620.00 ",
Pump Analysis with Reprogramming Charge (62368),62368," $1,065.00 ", $168.00 ," $1,233.00 ", $739.80 ,
Anal SP inf pmp wt reprog/refill RN(62369),62369," $1,120.00 ",," $1,120.00 ", $672.00 ,
ANL SP infusion pmp wt/MD reprogram and refill (62,62370, $925.00 , $142.00 ," $1,067.00 ", $640.20 ,
Other Nerve Block Peripheral or Branch Charge (644,64450," $1,880.00 ", $467.00 ," $2,347.00 "," $1,408.20 ",
Lumbar Epidural (64483),64483," $3,242.00 ", $626.00 ," $3,868.00 "," $2,320.80 ",
Inj Paravert F Jnt C/T One Level (64490),64490," $3,330.00 ", $394.00 ," $3,724.00 "," $2,234.40 ",
Inj Paravert F Jnt L/S One Level (64493),64493," $3,333.00 ", $337.00 ," $3,670.00 "," $2,202.00 ",
Inj Paravert F Jnt L/S Two Levels (64494),64494," $1,309.00 ", $337.00 ," $1,646.00 ", $987.60 ,
CHEMODENERV MUSC NECK DYSTON (64616),64616," $1,027.00 ", $460.00 ," $1,487.00 ", $892.20 ,
CHEMODENERV 1 EXTREMITY 1-4 (64642),64642," $1,800.00 ", $443.00 ," $2,243.00 "," $1,345.80 ",
CHEMODENERV EACH ADD'L EXTRM 1-4 MUSCLES (64643),64643, $945.00 , $298.00 ," $1,243.00 ", $745.80 ,
CHEMODENERV 1 EXTREM 5/> MUS (64644),64644," $1,840.00 ", $485.00 ," $2,325.00 "," $1,395.00 ",
CHEMODENERV EACH ADD'L EXTREM 5/> MUSCLES (64645),64645," $1,127.00 ", $343.00 ," $1,470.00 ", $882.00 ,
CHEMODENERV TRUNK MUSC 1-5 (64646),64646," $1,800.00 ", $480.00 ," $2,280.00 "," $1,368.00 ",
Removal of recurring cataract in lens capsule using laser 66821,66821,#N/A,#N/A,#N/A,#N/A,
Removal of cataract with insertion of lens 66984,66984,#N/A,#N/A,#N/A,#N/A,
"CT scan, head or brain, without contrast 70450",70450," $3,088.00 ",," $3,088.00 "," $1,852.80 ",
MRI scan of brain before and after contrast 70553,70553," $6,720.00 ",," $6,720.00 "," $4,032.00 ",
XR Chest 1 View,71045, $510.00 ,, $510.00 , $306.00 ,
XR Chest 2 View,71046, $661.00 ,, $661.00 , $396.60 ,
XR Spine Cervical 2 or 3 Views,72040, $700.00 ,, $700.00 , $420.00 ,
XR Spine Thoracic 3 Views,72072, $810.00 ,, $810.00 , $486.00 ,
XR Spine Lumbosacral 2 or 3 Views,72100, $629.00 ,, $629.00 , $377.40 ,
"X-Ray, lower back, minimum four views 72110",72110, $962.00 ,, $962.00 , $577.20 ,
MRI Spine Cervical W/O Contrast,72141," $5,490.00 ",," $5,490.00 "," $3,294.00 ",
MRI scan of lower spinal canal 72148,72148," $4,788.00 ",," $4,788.00 "," $2,872.80 ",
XR Pelvis 1 or 2 Views,72170, $530.00 ,, $530.00 , $318.00 ,
"CT scan, pelvis, with contrast 72193",72193," $3,628.00 ",," $3,628.00 "," $2,176.80 ",
XR Shoulder + Grashey + Y + Axil RT,73030, $590.00 ,, $590.00 , $354.00 ,
XR Hip Complete Right,73502, $530.00 ,, $530.00 , $318.00 ,
XR Knee 1 or 2 Views Right,73560, $530.00 ,, $530.00 , $318.00 ,
XR Knee Standing AP Bilateral,73565, $548.00 ,, $548.00 , $328.80 ,
MRI scan of leg joint 73721,73721," $4,786.00 ",," $4,786.00 "," $2,871.60 ",
XR Abdomen 1 View,74018, $670.00 ,, $670.00 , $402.00 ,
CT scan of abdomen and pelvis with contrast 74177,74177," $7,549.00 ",," $7,549.00 "," $4,529.40 ",
XR Fluoroscopic Swallow Study,74230, $748.00 ,, $748.00 , $448.80 ,
Ultrasound of abdomen 76700,76700," $2,211.00 ",," $2,211.00 "," $1,326.60 ",
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 76805,76805,#N/A,#N/A,#N/A,#N/A,
Ultrasound pelvis through vagina 76830,76830,#N/A,#N/A,#N/A,#N/A,
Ultrasonic Guidance for Injection Charge (76942),76942, $897.00 , $285.00 ," $1,182.00 ", $709.20 ,
Fluoroscopic Guidance- Needle Localization (77002),77002," $1,470.00 ", $508.00 ," $1,978.00 "," $1,186.80 ",
Mammography of one breast 77065,77065,#N/A,#N/A,#N/A,#N/A,
Mammography of both breasts 77066,77066,#N/A,#N/A,#N/A,#N/A,
"Mammography, screening, bilateral 77067",77067,#N/A,#N/A,#N/A,#N/A,
Basic metabolic panel 80048,80048, $374.00 ,, $374.00 , $224.40 ,
"Blood test, comprehensive group of blood chemicals 80053",80053, $466.00 ,, $466.00 , $279.60 ,
Obstetric blood test panel 80055,80055,#N/A,#N/A,#N/A,#N/A,
"Blood test, lipids (cholesterol and triglycerides) 80061",80061, $290.00 ,, $290.00 , $174.00 ,
Kidney function panel test 80069,80069, $380.00 ,, $380.00 , $228.00 ,
Liver function blood test panel 80076,80076, $343.00 ,, $343.00 , $205.80 ,
Cyclosporine Level,80158, $333.00 ,, $333.00 , $199.80 ,
Valproic Acid Level,80164, $214.00 ,, $214.00 , $128.40 ,
Tacrolimus Level,80197, $386.00 ,, $386.00 , $231.60 ,
Manual urinalysis test with examination using microscope 81000 or 81001,81001, $118.00 ,, $118.00 , $70.80 ,
Automated urinalysis test 81002 or 81003,81003, $78.00 ,, $78.00 , $46.80 ,
Adrenocorticotropic Hormone (ACTH),82024, $507.00 ,, $507.00 , $304.20 ,
Ammonia,82140, $149.00 ,, $149.00 , $89.40 ,
"Vitamin D, 25-Hydroxy",82306, $380.00 ,, $380.00 , $228.00 ,
Cortisol-Total,82533, $319.00 ,, $319.00 , $191.40 ,
Vitamin B12 and Folate,82607, $263.00 ,, $263.00 , $157.80 ,
DHEA Sulfate,82626, $362.00 ,, $362.00 , $217.20 ,
Ferritin,82728, $243.00 ,, $243.00 , $145.80 ,
Folate-Folic Acid Level,82746, $177.00 ,, $177.00 , $106.20 ,
"Bld Glucose, Capillary",82962, $73.00 ,, $73.00 , $43.80 ,
Follicle Stimulating Hormone,83001, $321.00 ,, $321.00 , $192.60 ,
Luteinizing Hormone,83002, $363.00 ,, $363.00 , $217.80 ,
Hemoglobin Glycosated,83036, $164.00 ,, $164.00 , $98.40 ,
Iron and Iron Binding Capacity,83540, $158.00 ,, $158.00 , $94.80 ,
Iron Binding Capacity,83550, $200.00 ,, $200.00 , $120.00 ,
Lactate Dehydrogenase/LDH,83615, $99.00 ,, $99.00 , $59.40 ,
Magnesium Level,83735, $153.00 ,, $153.00 , $91.80 ,
B-Natiuretic Peptide,83880, $396.00 ,, $396.00 , $237.60 ,
Phosphorous Level,84100, $90.00 ,, $90.00 , $54.00 ,
Prealbumin,84134, $262.00 ,, $262.00 , $157.20 ,
Prolactin,84146, $370.00 ,, $370.00 , $222.00 ,
PSA (prostate specific antigen) 84153-84154,84153, $100.00 ,, $100.00 , $60.00 ,
Vitamin B6 Level,84207, $350.00 ,, $350.00 , $210.00 ,
Somatomedin C,84305, $279.00 ,, $279.00 , $167.40 ,
"Testosterone, Total",84403, $298.00 ,, $298.00 , $178.80 ,
Thyroxine Free,84439, $100.00 ,, $100.00 , $60.00 ,
"TSH, 3rd Generation",84443, $248.00 ,, $248.00 , $148.80 ,
TSH w/Reflex to FT4,84443, $231.00 ,, $231.00 , $138.60 ,
Uric Acid,84550, $74.00 ,, $74.00 , $44.40 ,
CBC-Hemoglobin and Hematocrit Only,85014, $57.00 ,, $57.00 , $34.20 ,
Hemoglobin,85018, $45.00 ,, $45.00 , $27.00 ,
"Complete blood cell count, with differential white blood cells, automated 85025",85025, $195.00 ,, $195.00 , $117.00 ,
"Complete blood count, automated 85027",85027, $224.00 ,, $224.00 , $134.40 ,
"Blood test, clotting time 85610",85610, $116.00 ,, $116.00 , $69.60 ,
Sedimentation Rate Non-automated,85651, $82.00 ,, $82.00 , $49.20 ,
Coagulation assessment blood test 85730,85730, $140.00 ,, $140.00 , $84.00 ,
C Reactive Protein,86140, $140.00 ,, $140.00 , $84.00 ,
Culture-Blood,87040, $307.00 ,, $307.00 , $184.20 ,
Culture-Sputum Respiratory w/ Gm Stain,87070, $264.00 ,, $264.00 , $158.40 ,
Culture-Wound Aerobic/Anaerobic w/Gm Stain,87070, $364.00 ,, $364.00 , $218.40 ,
VRE Screen,87081, $83.00 ,, $83.00 , $49.80 ,
Culture-Urine,87086, $221.00 ,, $221.00 , $132.60 ,
"Smear, primary source, with interpretation",87205, $67.00 ,, $67.00 , $40.20 ,
C Difficile by PCR,87324, $181.00 ,, $181.00 , $108.60 ,
"MRSA Screen, PCR",87641, $333.00 ,, $333.00 , $199.80 ,
Coronavirus nCOV-19 by PCR (2019),87798, $111.00 ,, $111.00 , $66.60 ,
"INTERMEDIATE NEW PATIENT, EYE EXAM PT (92002)",92002, $274.00 , $125.00 , $399.00 , $239.40 ,
SLP Auditory Processing Treatment Units,92507, $150.00 ,, $150.00 , $90.00 ,
SLP Group Therapy Units,92508, $127.00 ,, $127.00 , $76.20 ,
Evaluation of Speech Sound Production Units,92522, $272.00 ,, $272.00 , $163.20 ,
Evaluation of Speech Sound Production w/ Evaluatio,92523, $272.00 ,, $272.00 , $163.20 ,
SLP Swallow Dysfnction Oral Feed Tx Unit,92526, $213.00 ,, $213.00 , $127.80 ,
SLP Non-Speech AAC Device Tx Units,92606, $171.00 ,, $171.00 , $102.60 ,
SLP Speech AAC Eval First Hour Units,92607, $736.00 ,, $736.00 , $441.60 ,
SLP Treatment-Speech Gen Device Units,92609, $157.00 ,, $157.00 , $94.20 ,
SLP Pharyngeal Swallow Fnctn Eval Units,92610, $267.00 ,, $267.00 , $160.20 ,
SLP Fluoroscopic Evaluation Units,92611, $917.00 ,, $917.00 , $550.20 ,
SLP Fiber Optic Endo Swallow Eval Units,92612, $894.00 ,, $894.00 , $536.40 ,
"Electrocardiogram, routine, with interpretation and report 93000",93000," $2,057.00 ",," $2,057.00 "," $1,234.20 ",
"12 Lead Ekg, Tracing Only",93005, $316.00 ,, $316.00 , $189.60 ,
Insertion of catheter into left heart for diagnosis 93452,93452,#N/A,#N/A,#N/A,#N/A,
US Venous B/L Lwr Extrem Duplex Scan,93970," $1,626.00 ",," $1,626.00 ", $975.60 ,
Mechanical Ventilation Subsequent Days Charge,94003," $1,672.00 ",," $1,672.00 "," $1,003.20 ",
Small Volume Nebulizer Charge,94640, $258.00 ,, $258.00 , $154.80 ,
CPAP/BiPAP Subsequent Charge,94660, $846.00 ,, $846.00 , $507.60 ,
CPAP/BiPAP Initial Charge,94660, $846.00 ,, $846.00 , $507.60 ,
Chest Physical Therapy Subsequent Charge,94668, $218.00 ,, $218.00 , $130.80 ,
Yes - Metaneb Charge,94669, $266.00 ,, $266.00 , $159.60 ,
Pulse Oximetry-Spot Check Charge,94760, $146.00 ,, $146.00 , $87.60 ,
Pulse Oximetry-Multiple Determinations Charge,94761, $306.00 ,, $306.00 , $183.60 ,
Pulse Oximetry Overnight Monitoring Charge,94762, $587.00 ,, $587.00 , $352.20 ,
Sleep study 95810,95810," $5,294.00 ", $814.00 ," $6,108.00 "," $3,664.80 ",
EEG SRALab,95819, $843.00 , $180.00 ," $1,023.00 ", $613.80 ,
EMG Guidance with Chemodenervation Charge (95874),95874, $252.00 , $117.00 , $369.00 , $221.40 ,
"Needle electromyography, each extremity; limited (",95885, $310.00 , $75.00 , $385.00 , $231.00 ,
"Needle electromyography, each extremity, with rela",95886, $346.00 , $141.00 , $487.00 , $292.20 ,
MOTOR&/SENS 3-4 NRV CNDJ TST (95908),95908, $573.00 , $187.00 , $760.00 , $456.00 ,
MOTOR&/SENS 5-6 NRV CNDJ TST (95909),95909, $800.00 , $222.00 ," $1,022.00 ", $613.20 ,
MOTOR&SENS 7-8 NRV CNDJ TEST (95910),95910, $882.00 , $299.00 ," $1,181.00 ", $708.60 ,
MOTOR&SEN 9-10 NRV CNDJ TEST (95911),95911," $1,173.00 ", $373.00 ," $1,546.00 ", $927.60 ,
Canalith Repositioning Units,95992, $205.00 ,, $205.00 , $123.00 ,
"Neurobehavioral Status Exam, per hour",96116, $516.00 ,, $516.00 , $309.60 ,
Neurobehavioral Status Exam Add On (96121),96121, $295.00 ,, $295.00 , $177.00 ,
Neuropsych testing by physician or other qualified,96132, $767.00 ,, $767.00 , $460.20 ,
Neuropsych testing by physician or other qualified,96133, $689.00 ,, $689.00 , $413.40 ,
Psych or Neuropsych test admin or scoring by physi,96136, $384.00 ,, $384.00 , $230.40 ,
"Psych or neuropsych test admin and scoring, each a",96137, $346.00 ,, $346.00 , $207.60 ,
Psych or neuropsych test admin and scoring by tech,96138, $390.00 ,, $390.00 , $234.00 ,
"Psych or neuropsych test admin by technician, each",96139, $275.00 ,, $275.00 , $165.00 ,
Health and Behavior Assessment/Re-Assessment (9615,96156, $320.00 ,, $320.00 , $192.00 ,
"Health and Behavior Intervention, Indiv, initial 30 min (96158)",96158, $320.00 ,, $320.00 , $192.00 ,
"Health and Behavior Intervention, Indiv, Ea Addtl 15 min (96159)",96159, $161.00 ,, $161.00 , $96.60 ,
"Health and Behavior Intervention Family, Initial 30 min (96167)",96167, $268.00 ,, $268.00 , $160.80 ,
"Health and Behavior Intervention Family, Ea Addtl 15 min (96168)",96168, $134.00 ,, $134.00 , $80.40 ,
PT Attended E-Stim Units,97032, $213.00 ,, $213.00 , $127.80 ,
OT Attended E-Stim Units,97032, $213.00 ,, $213.00 , $127.80 ,
PT Ultrasound Units,97035, $183.00 ,, $183.00 , $109.80 ,
OT Ultrasound Units,97035, $183.00 ,, $183.00 , $109.80 ,
PT Therapeutic Exercise Units,97110, $223.00 ,, $223.00 , $133.80 ,
OT Therapeutic Exercise Units,97110, $223.00 ,, $223.00 , $133.80 ,
PT Neuromuscular Reeducation Units,97112, $221.00 ,, $221.00 , $132.60 ,
OT Neuromuscular Reeducation Units,97112, $221.00 ,, $221.00 , $132.60 ,
PT Aquatic Units,97113, $227.00 ,, $227.00 , $136.20 ,
PT Gait Training Units,97116, $189.00 ,, $189.00 , $113.40 ,
OT Therapeutic Cognitive Function Units,97129, $118.00 ,, $118.00 , $70.80 ,
OT Ther Cognitive Func Addl 15min Units,97130, $110.00 ,, $110.00 , $66.00 ,
PT Manual Therapy Units,97140, $227.00 ,, $227.00 , $136.20 ,
OT Manual Therapy Units,97140, $227.00 ,, $227.00 , $136.20 ,
PT Group Therapy Units,97150, $109.00 ,, $109.00 , $65.40 ,
OT Group Therapy Units,97150, $109.00 ,, $109.00 , $65.40 ,
PT Evaluation Low Complexity Charge,97161, $240.00 ,, $240.00 , $144.00 ,
PT Evaluation Moderate Complexity Charge,97162, $240.00 ,, $240.00 , $144.00 ,
PT Evaluation High Complexity,97163, $240.00 ,, $240.00 , $144.00 ,
PT Re-Evaluation,97164, $185.00 ,, $185.00 , $111.00 ,
OT Evaluation Low Complexity,97165, $240.00 ,, $240.00 , $144.00 ,
OT Evaluation Moderate Complexity,97166, $240.00 ,, $240.00 , $144.00 ,
OT Evaluation High Complexity Charge,97167, $240.00 ,, $240.00 , $144.00 ,
OT Re-Evaluation,97168, $199.00 ,, $199.00 , $119.40 ,
PT Therapeutic Activity Units,97530, $207.00 ,, $207.00 , $124.20 ,
OT Therapeutic Activities Units,97530, $207.00 ,, $207.00 , $124.20 ,
PT Self Care/Home Management Units,97535, $187.00 ,, $187.00 , $112.20 ,
Voc Rehab Group Units,97537, $164.00 ,, $164.00 , $98.40 ,
OT Wheelchair Management Units,97542, $187.00 ,, $187.00 , $112.20 ,
PT Wheelchair Management Units,97542, $187.00 ,, $187.00 , $112.20 ,
PT Work Hardening-Initial 2 Hours Units,97545, $679.00 ,, $679.00 , $407.40 ,
Selective Debridement Less than or Equal to 20 cm ,97597, $670.00 ,, $670.00 , $402.00 ,
PT Physical Performance Test,97750, $241.00 ,, $241.00 , $144.60 ,
OT Physical Performance Test,97750, $241.00 ,, $241.00 , $144.60 ,
OT Orthotic Management/Train Units,97760, $189.00 ,, $189.00 , $113.40 ,
OT Prosthetic Management/Train Units,97761, $206.00 ,, $206.00 , $123.60 ,
OT Orthotic/Prosthetic Use Subsequent Unit(s),97763, $197.00 ,, $197.00 , $118.20 ,
Acupuncture without E-Stim. Initial 15 minutes Cha,97810,#N/A, $104.00 ,#N/A,#N/A,
Office Visit Level 2 New Charge- 99202,99202, $282.00 , $168.00 , $450.00 , $270.00 ,
Telehealth Visit Level 2 New Charge- 99202,99202,#N/A, $135.00 ,#N/A,#N/A,
Office Visit Level 3 New Charge- 99203,99203, $372.00 , $260.00 , $632.00 , $379.20 ,
Telehealth Visit Level 3 New Charge- 99203,99203,#N/A, $208.00 ,#N/A,#N/A,
Office Visit Level 4 New Charge- 99204,99204, $474.00 , $422.00 , $896.00 , $537.60 ,
Telehealth Visit Level 4 New Charge- 99204,99204,#N/A, $339.00 ,#N/A,#N/A,
Office Visit Level 5 New Charge- 99205,99205, $616.00 , $551.00 ," $1,167.00 ", $700.20 ,
Telehealth Visit Level 5 New Charge- 99205,99205,#N/A, $440.00 ,#N/A,#N/A,
Office Visit Level 2 Est Charge- 99212,99212, $282.00 , $85.00 , $367.00 , $220.20 ,
Telehealth Visit Level 2 Est Charge- 99212,99212,#N/A, $69.00 ,#N/A,#N/A,
Office Visit Level 3 Est Charge- 99213,99213, $296.00 , $161.00 , $457.00 , $274.20 ,
Telehealth Visit Level 3 Est Charge- 99213,99213,#N/A, $129.00 ,#N/A,#N/A,
Office Visit Level 4 Est Charge- 99214,99214, $372.00 , $252.00 , $624.00 , $374.40 ,
Telehealth Visit Level 4 Est Charge- 99214,99214,#N/A, $202.00 ,#N/A,#N/A,
Office Visit Level 5 Est Charge- 99215,99215, $474.00 , $363.00 , $837.00 , $502.20 ,
Telehealth Visit Level 5 Est Charge- 99215,99215,#N/A, $290.00 ,#N/A,#N/A,
"Patient office consultation, typically 40 min 99243",99243, $163.00 , $366.00 , $529.00 , $317.40 ,
Office Consult Level 4 Charge- 99244,99244, $221.00 , $568.00 , $789.00 , $473.40 ,
Initial new patient preventive medicine evaluation (18-39 years) 99385,99385,#N/A, $390.00 ,#N/A,#N/A,
Initial new patient preventive medicine evaluation (40-64 years) 99386,99386,#N/A, $426.00 ,#N/A,#N/A,
Prolong Outpt/Office Vis 99417 EA 15 min,99417,#N/A, $76.00 ,#N/A,#N/A,
Audio Telephone E/M Services 5-10 min - 99441,99441,#N/A, $65.00 ,#N/A,#N/A,
Audio Telephone E/M Services 11-20 min - 99442,99442,#N/A, $105.00 ,#N/A,#N/A,
Audio Telephone E/M Services 21-30 min – 99443,99443,#N/A, $148.00 ,#N/A,#N/A,
"DRAIN/INJ MAJOR JOINT/BURSA W/US, Bilateral (20611-50)",2061150," $1,725.00 ", $351.00 ," $2,076.00 "," $1,245.60 ",
Respiratory Pathogen Panel by Muliplex PCR,0202U," $2,015.00 ",," $2,015.00 "," $1,209.00 ",
"HYDROFERA BLUE FOAM DRESSING 4 X 5""""",A6209, $6.00 ,, $6.00 , $3.60 ,
"Knee Orthosis, Elastic w/ Condylar Pads and Joints",L1820, $744.00 ,, $744.00 , $446.40 ,
"Knee Orthosis, Immobilizer, Canvas",L1830, $435.00 ,, $435.00 , $261.00 ,
"Ankle-Foot Orthosis, Supramalleolar w/ Straps",L1907," $2,939.00 ",," $2,939.00 "," $1,763.40 ",
"Ankle-Foot Orthosis, Rigid Anterior Tibial Section, Total Carbon Material, Prefabricated",L1932," $4,660.00 ",," $4,660.00 "," $2,796.00 ",
"Ankle-Foot Orthosis, Plastic, Molded to Patient",L1940," $2,543.00 ",," $2,543.00 "," $1,525.80 ",
"Ankle-Foot Orthosis, Spiral, Plastic or Other Material, Prefabricated",L1951," $4,386.00 ",," $4,386.00 "," $2,631.60 ",
"Ankle-Foot Orthosis, Plastic, Posterior Solid Ankle, Molded to Patient",L1960," $3,237.00 ",," $3,237.00 "," $1,942.20 ",
"Ankle-Foot Orthosis, Plastic, w/ Ankle Joint, Molded to Patient",L1970," $3,617.00 ",," $3,617.00 "," $2,170.20 ",
"Knee-Ankle-Foot Orthosis, Double Upright, Free Knee, Molded to Patient",L2036," $9,681.00 ",," $9,681.00 "," $5,808.60 ",
"Lower Extremity Addition, Limited Ankle Motion Joint",L2200, $264.00 ,, $264.00 , $158.40 ,
"Lower Extremity Addition, Dorsiflexion/Plantarflexion/Resistance Assist Ankle Joint",L2220, $421.00 ,, $421.00 , $252.60 ,
"Lower Extremity Addition, Foot Plate, Stirrup Attachment, Molded to Patient",L2250," $2,145.00 ",," $2,145.00 "," $1,287.00 ",
"Lower Extremity Addition, Valgus/Varus Correction Plastic Modification",L2275, $682.00 ,, $682.00 , $409.20 ,
"Lower Extremity Addition, Molded Inner Boot",L2280," $2,949.00 ",," $2,949.00 "," $1,769.40 ",
"Addition, Knee Joint, Drop Lock, Stance or Swing",L2405, $455.00 ,, $455.00 , $273.00 ,
"Lower Extremity Orthosis Addition, Drop Lock Retainer",L2785, $156.00 ,, $156.00 , $93.60 ,
"Lower Extremity Orthosis Addition, Soft Interface for Molded Plastic, Below Knee",L2820, $423.00 ,, $423.00 , $253.80 ,
"Foot Insert, Removable, UCB Type, Molded to Patient",L3000," $1,642.00 ",," $1,642.00 ", $985.20 ,
"Foot Insert, Removable, Longitudinal Arch Support, Molded to Patient",L3010, $916.00 ,, $916.00 , $549.60 ,
"Orthopedic Shoe, Custom Plastizote",L3253, $193.00 ,, $193.00 , $115.80 ,
"Lift, Heel, Tapered to Metatarsal, Per Inch",L3300, $273.00 ,, $273.00 , $163.80 ,
"Lift, Heel and Sole, Neoprene, Per Inch",L3310, $426.00 ,, $426.00 , $255.60 ,
"Lift, Heel, Per Inch",L3334, $200.00 ,, $200.00 , $120.00 ,
"Wedge, Heel",L3350, $118.00 ,, $118.00 , $70.80 ,
"Shoulder Orthosis, Acro/Clavicular Canvas",L3670, $539.00 ,, $539.00 , $323.40 ,
"EO with Joint, Prefabricated Custom Fit",L3760," $2,375.00 ",," $2,375.00 "," $1,425.00 ",
"Elbow Orthosis, Rigid w/o Joints, Prefabricated",L3762, $512.00 ,, $512.00 , $307.20 ,
"Wrist-Hand-Finger Orthosis, w/o joints, Prefabricated, Includes Fitting and Adjustment",L3807," $1,191.00 ",," $1,191.00 ", $714.60 ,
"Wrist-Hand Orthosis, Wrist Extension Control Cock-up, Non-Molded",L3908, $349.00 ,, $349.00 , $209.40 ,
L4205 Repair Labor 15 minutes,L4205, $147.00 ,, $147.00 , $88.20 ,
Repair/Replace Minor Part,L4210, $-   ,, $-   , $-   ,
Ankle Contracture Splint,L4396, $880.00 ,, $880.00 , $528.00 ,
"Addition to LE, test socket, BK",L5620," $1,383.00 ",," $1,383.00 ", $829.80 ,
"Addition to LE, BK, acrylic socket",L5629," $1,471.00 ",," $1,471.00 ", $882.60 ,
"Addition to LE, BK, total contact",L5637," $1,779.00 ",," $1,779.00 "," $1,067.40 ",
"Addition to LE, BK/AK, custom fab or prefab, socket insert, silicone gel, elasto or equal, for use w",L5673," $2,885.00 ",," $2,885.00 "," $1,731.00 ",
"Addit to LE, BK/AK, custom fab or prefab, socket insert, silicone gel, elasto or equal, not for use",L5679," $2,402.00 ",," $2,402.00 "," $1,441.20 ",
"Addition to LE, BK, suspension/sealing sleeve, w/ or w/out valve, any material, each",L5685, $448.00 ,, $448.00 , $268.80 ,
"Prosthetic sock, multiple ply, below knee, each",L8420, $75.00 ,, $75.00 , $45.00 ,
"Prosthetic sock, multiple ply, above knee, each",L8430, $85.00 ,, $85.00 , $51.00 ,
"Prosthetic shrinker, below knee, each",L8440, $164.00 ,, $164.00 , $98.40 ,
"Prosthetic shrinker, above knee, each",L8460, $234.00 ,, $234.00 , $140.40 ,
"Prosthetic sock, single ply fitting, below knee, each",L8470, $27.00 ,, $27.00 , $16.20 ,
"Prosthetic sock, single ply fitting, above knee, each",L8480, $38.00 ,, $38.00 , $22.80 ,
Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities 216,,#N/A,#N/A,#N/A,#N/A,
Spinal fusion except cervical without major comorbid conditions or complications (MCC) 460,,#N/A,#N/A,#N/A,#N/A,
Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC). 470,,#N/A,#N/A,#N/A,#N/A,
Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC). 473,,#N/A,#N/A,#N/A,#N/A,
Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 743,,#N/A,#N/A,#N/A,#N/A,
ROOM/BED: General,," $2,780.00 ",," $2,780.00 "," $1,668.00 ",
ROOM/BED: Neuro,," $3,110.00 ",," $3,110.00 "," $1,866.00 ",