Clay County Memorial Hospital

Price List for Shoppable Services. Effective 05-17-2022.

Hospital Website Machine-Readable Chargemaster

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Disclaimer: The Hospital determines its standard charges for patient items and services through the use of a chargemaster system, which is a list of charges for the components of patient care that go into every patient’s bill. These are the baseline rates for items and services provided at the Hospital. The chargemaster is similar in concept to the manufacturer’s suggested retail price (“MSRP”) on a particular product or good. The charges listed provide only a general starting point in determining the potential costs of an individual patient’s care at the Hospital. This list does not reflect the actual out-of-pocket costs that may be paid by a patient for any particular service, it is not binding, and the actual charges for items and services may vary. Individuals with questions about their out-of-pocket costs of service and other financial information should contact the hospital or consider contacting their insurers for further information. The cost of treatment also may be impacted by variables involved in a patient’s actual care, such as specific equipment or supplies required, the length of time spent in surgery or recovery, additional tests, or any changes in care or unexpected conditions or complications that arise.

Service Description	Service Code	Department	Charge Code	Cash Price	Rates
CT Scan
CT HEAD/BRAIN W/O DYE	CPT 70450	Outpatient	7319339	$1,423
CT MAXILLOFACIAL W/O DYE	CPT 70486	Outpatient	7319343	$1,559
CT THORAX DX C-	CPT 71250	Outpatient	7319349	$1,429
CT THORAX DX C+	CPT 71260	Outpatient	7319348	$2,117
CT THORAX DX C-/C+	CPT 71270	Outpatient	7319342	$2,578
CT NECK SPINE W/O DYE	CPT 72125	Outpatient	7319365	$1,816
CT CHEST SPINE W/O DYE	CPT 72128	Outpatient	7319372	$1,764
CT LUMBAR SPINE W/O DYE	CPT 72131	Outpatient	7319373	$2,129
CT PELVIS W/O DYE	CPT 72192	Outpatient	7319354	$1,787
CT PELVIS W/DYE	CPT 72193	Outpatient	7319341	$2,031
CT ABD & PELVIS W/O CONTRAST	CPT 74176	Outpatient	7319357	$3,787
CT ABD & PELV W/CONTRAST	CPT 74177 (TC)	Outpatient	7319350	$4,536
CT ABD & PELV 1/> REGNS	CPT 74178	Outpatient	7319359	$4,627
Cardiology
TTE W/O DOPPLER COMPLETE	CPT 93307	Outpatient	7610070	$1,828
Clinic
OFFICE O/P NEW LOW 30-44 MIN	CPT 99203	Outpatient	9200003	$239
OFFICE O/P NEW MOD 45-59 MIN	CPT 99204	Outpatient	9200004	$299
OFFICE O/P NEW HI 60-74 MIN	CPT 99205	Outpatient	9200005	$358
OFFICE O/P EST LOW 20-29 MIN	CPT 99213	Outpatient	9200008	$358
OFFICE O/P EST MOD 30-39 MIN	CPT 99214	Outpatient	9200009	$358
(N/O) PATIENT OFFICE CONSULTATION, 40 MIN	CPT 99243	-	-	-	-
(N/O) PATIENT OFFICE CONSULTATION, 60 MIN	CPT 99244	-	-	-	-
(N/O) INITIAL NEW PATIENT PREVENTATIVE MEDICINE EVALUATION ...	CPT 99385	-	-	-	-
(N/O) INITIAL NEW PATIENT PREVENTATIVE MEDICINE EVALUATION ...	CPT 99386	-	-	-	-
EEG
(N/O) SLEEP STUDY	CPT 95810	-	-	-	-
EKG
(N/O) ELECTROCARDIOGRAM, ROUTINE, WITH INTERPRETATION AND ...	CPT 93000	-	-	-	-
ELECTROCARDIOGRAM TRACING	CPT 93005	Outpatient	7010049	$170
RHYTHM ECG TRACING	CPT 93041	Outpatient	2000003	$93
Emergency Room
RPR S/N/AX/GEN/TRNK 2.5CM/<	CPT 12001	Outpatient	500043	$381
RPR S/N/AX/GEN/TRNK2.6-7.5CM	CPT 12002	Outpatient	500031	$192
RPR F/E/E/N/L/M 2.5 CM/<	CPT 12011	Outpatient	500047	$394
THER/PROPH/DIAG INJ SC/IM	CPT 96372	Outpatient	8614051	$242
THER/PROPH/DIAG INJ SC/IM	CPT 96372	Outpatient	8690782	$196
NEW PATIENT LEVEL I	CPT 99201	Outpatient	9200001	$119
OFFICE O/P NEW SF 15-29 MIN	CPT 99202	Outpatient	9200002	$179
EMERGENCY DEPT VISIT	CPT 99281	Outpatient	500058	$229
EMERGENCY DEPT VISIT	CPT 99282	Outpatient	500066	$376
EMERGENCY DEPT VISIT	CPT 99283	Outpatient	500068	$630
EMERGENCY DEPT VISIT	CPT 99284	Outpatient	500070	$970
EMERGENCY DEPT VISIT	CPT 99285	Outpatient	500077	$1,106
IV Therapy
HYDRATION IV INFUSION INIT	CPT 96360	Outpatient	8600083	$248
HYDRATE IV INFUSION ADD-ON	CPT 96361	Outpatient	8600084	$80
THER/PROPH/DIAG IV INF INIT	CPT 96365	Outpatient	8600081	$584
THER/PROPH/DIAG INJ IV PUSH	CPT 96374	Outpatient	8610095	$242
TX/PRO/DX INJ NEW DRUG ADDON	CPT 96375	Outpatient	8610075	$90
TX/PRO/DX INJ SAME DRUG ADON	CPT 96376	Outpatient	96376	$90
Imaging
US EXAM OF HEAD AND NECK	CPT 76536	Outpatient	7419155	$413
US EXAM ABDOM COMPLETE	CPT 76700	Outpatient	7419138	$533
US EXAM ABDOM COMPLETE	CPT 76700	Outpatient	7419140	$772
ECHO EXAM OF ABDOMEN	CPT 76705	Outpatient	7419143	$502
US EXAM ABDO BACK WALL COMP	CPT 76770	Outpatient	7410088	$518
US EXAM ABDO BACK WALL COMP	CPT 76770	Outpatient	7419139	$546
US EXAM ABDO BACK WALL COMP	CPT 76770	Outpatient	7419151	$502
OB US >= 14 WKS SNGL FETUS	CPT 76805	Outpatient	7419148	$869
TRANSVAGINAL US NON-OB	CPT 76830	Outpatient	7419823	$452
US EXAM PELVIC COMPLETE	CPT 76856	Outpatient	7419146	$502
(N/O) MAMMOGRAPHY OF ONE BREAST	CPT 77065	-	-	-	-
(N/O) MAMMOGRAPHY OF BOTH BREASTS	CPT 77066	-	-	-	-
(N/O) MAMMOGRAPHY, SCREENING, BILATERAL	CPT 77067	-	-	-	-
Inpatient Procedures
(N/O) CARDIAC VALVE OR CARDIOTHORACIC PROCEDURE WITH CARDI ...	DRG 216	-	-	-	-
(N/O) SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC	DRG 460	-	-	-	-
(N/O) MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXT ...	DRG 470	-	-	-	-
(N/O) CERVICAL SPINAL FUSION WITHOUT CC OR MCC	DRG 473	-	-	-	-
(N/O) UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WIT ...	DRG 743	-	-	-	-
Laboratory
4 PLEX COMBO PCR CCMH	CPT 0241U	Outpatient	60180010	$309
ROUTINE VENIPUNCTURE	CPT 36415	Outpatient	6016113	$16
METABOLIC PANEL TOTAL CA	CPT 80048	Outpatient	6000912	$124
METABOLIC PANEL TOTAL CA	CPT 80048	Outpatient	6000917	$124
METABOLIC PANEL TOTAL CA	CPT 80048	Outpatient	6016270	$124
GENERAL HEALTH PANEL	CPT 80050	Outpatient	6016707	$425
COMPREHEN METABOLIC PANEL	CPT 80053	Outpatient	6000907	$226
COMPREHEN METABOLIC PANEL	CPT 80053	Outpatient	6000914	$226
COMPREHEN METABOLIC PANEL	CPT 80053	Outpatient	6016706	$270
(N/O) OBSTETRIC BLOOD TEST PANEL	CPT 80055	-	-	-	-
LIPID PANEL	CPT 80061	Outpatient	6016703	$84
LIPID PANEL	CPT 80061	Outpatient	6017962	$84
LIPID PANEL	CPT 80061	Outpatient	6017963	$84
RENAL FUNCTION PANEL	CPT 80069	Outpatient	6016171	$190
ACUTE HEPATITIS PANEL	CPT 80074	Outpatient	6017112	$391
HEPATIC FUNCTION PANEL	CPT 80076	Outpatient	6016272	$109
CONTRACT URINE DRUG SCREEN	CPT 80100	Outpatient	60180000	$45
ASSAY OF DIGOXIN TOTAL	CPT 80162	Outpatient	6016643	$109
ASSAY DIPROPYLACETIC ACD TOT	CPT 80164	Outpatient	6017021	$78
DRUG SCRN QUAN LEVETIRACETAM	CPT 80177	Outpatient	6017299	$117
ASSAY OF TACROLIMUS	CPT 80197	Outpatient	6016197	$77
ASSAY OF VANCOMYCIN	CPT 80202	Outpatient	6016646	$83
DRUG TEST PRSMV INSTRMNT	CPT 80306	Outpatient	6016135	$109
DRUG TEST PRSMV INSTRMNT	CPT 80306	Outpatient	6016136	$109
(N/O) URINALYSIS TEST USING MICROSCOPE	CPT 81000	-	-	-	-
URINALYSIS AUTO W/SCOPE	CPT 81001	Outpatient	6016101	$59
(N/O) URINALYSIS TEST	CPT 81002	-	-	-	-
URINALYSIS AUTO W/O SCOPE	CPT 81003	Outpatient	6016109	$44
MICROSCOPIC EXAM OF URINE	CPT 81015	Outpatient	6016103	$59
MICROSCOPIC EXAM OF URINE	CPT 81015	Outpatient	6016105	$59
MICROSCOPIC EXAM OF URINE	CPT 81015	Outpatient	6016110	$59
URINE PREGNANCY TEST	CPT 81025	Outpatient	6016067	$50
URINALYSIS VOLUME MEASURE	CPT 81050	Outpatient	6016500	$13
UR ALBUMIN QUANTITATIVE	CPT 82043	Outpatient	6016357	$54
ASSAY OF BREATH ETHANOL	CPT 82075	Outpatient	6016023	$90
ASSAY OF AMYLASE	CPT 82150	Outpatient	6016009	$80
ASSAY TEST FOR BLOOD FECAL	CPT 82274	Outpatient	6016070	$67
VITAMIN D 25 HYDROXY	CPT 82306	Outpatient	6016542	$114
TOTAL CORTISOL	CPT 82533	Outpatient	6017534	$68
ASSAY OF CK (CPK)	CPT 82550	Outpatient	6016030	$89
CREATINE MB FRACTION	CPT 82553	Outpatient	6016047	$45
ASSAY OF CREATININE	CPT 82565	Outpatient	6016038	$64
ASSAY OF URINE CREATININE	CPT 82570	Outpatient	6017011	$63
VITAMIN B-12	CPT 82607	Outpatient	6016501	$67
VITAMIN B-12	CPT 82607	Outpatient	6017227	$67
DEHYDROEPIANDROSTERONE	CPT 82626	Outpatient	6016626	$138
DEHYDROEPIANDROSTERONE	CPT 82627	Outpatient	6017333	$150
ASSAY OF ERYTHROPOIETIN	CPT 82668	Outpatient	6017668	$106
ASSAY OF TOTAL ESTRADIOL	CPT 82670	Outpatient	6017192	$126
ASSAY OF ESTRONE	CPT 82679	Outpatient	6017178	$134
ASSAY OF FERRITIN	CPT 82728	Outpatient	6016505	$119
ASSAY OF FERRITIN	CPT 82728	Outpatient	6017222	$119
ASSAY OF FOLIC ACID SERUM	CPT 82746	Outpatient	6016502	$161
ASSAY OF FOLIC ACID SERUM	CPT 82746	Outpatient	6017228	$161
ASSAY IGA/IGD/IGG/IGM EACH	CPT 82784	Outpatient	6016784	$64
GLUCOSE TOLERANCE TEST (GTT)	CPT 82951	Outpatient	6016052	$183
GTT-ADDED SAMPLES	CPT 82952	Outpatient	6016051	$62
ASSAY OF GDH ENZYME	CPT 82965	Outpatient	6016669	$19
ASSAY OF GGT	CPT 82977	Outpatient	6017060	$30
ASSAY OF GONADOTROPIN (FSH)	CPT 83001	Outpatient	6017455	$180
ASSAY OF GONADOTROPIN (LH)	CPT 83002	Outpatient	6016779	$104
H PYLORI DRUG ADMIN	CPT 83014	Outpatient	6016013	$71
GLYCOSYLATED HEMOGLOBIN TEST	CPT 83036	Outpatient	6016073	$121
GLYCOSYLATED HEMOGLOBIN TEST	CPT 83036	Outpatient	6017410	$121
ASSAY OF INSULIN	CPT 83525	Outpatient	6016525	$64
ASSAY OF IRON	CPT 83540	Outpatient	6016503	$39
ASSAY OF IRON	CPT 83540	Outpatient	6017453	$39
ASSAY OF LACTIC ACID	CPT 83605	Outpatient	6016648	$83
ASSAY OF LIPASE	CPT 83690	Outpatient	6017359	$96
ASSAY OF MAGNESIUM	CPT 83735	Outpatient	6016925	$115
ASSAY OF MYOGLOBIN	CPT 83874	Outpatient	6016664	$70
ASSAY OF NATRIURETIC PEPTIDE	CPT 83880	Outpatient	6000909	$209
ASSAY OF NATRIURETIC PEPTIDE	CPT 83880	Outpatient	6016068	$209
ASSAY OF PARATHORMONE	CPT 83970	Outpatient	6017009	$280
ASSAY ALKALINE PHOSPHATASE	CPT 84075	Outpatient	6084080	$21
ASSAY ALKALINE PHOSPHATASES	CPT 84080	Outpatient	6017087	$21
ASSAY OF PHOSPHORUS	CPT 84100	Outpatient	6017074	$58
ASSAY OF SERUM POTASSIUM	CPT 84132	Outpatient	6016074	$66
ASSAY OF PREALBUMIN	CPT 84134	Outpatient	6016134	$47
ASSAY OF PROLACTIN	CPT 84146	Outpatient	6017644	$180
ASSAY OF PSA TOTAL	CPT 84153	Outpatient	6016254	$99
ASSAY OF PSA TOTAL	CPT 84153	Outpatient	6017033	$99
ASSAY OF PSA TOTAL	CPT 84153	Outpatient	6017037	$99
ASSAY OF PSA TOTAL	CPT 84153	Outpatient	6017842	$99
ASSAY OF PSA FREE	CPT 84154	Outpatient	6017841	$98
ASSAY OF PROTEIN SERUM	CPT 84155	Outpatient	6017989	$58
ASSAY OF PROTEIN URINE	CPT 84156	Outpatient	6017124	$33
PROTEIN E-PHORESIS SERUM	CPT 84165	Outpatient	6017165	$62
ASSAY OF SEX HORMONE GLOBUL	CPT 84270	Outpatient	6017269	$92
ASSAY OF SERUM SODIUM	CPT 84295	Outpatient	6016095	$66
ASSAY OF FREE TESTOSTERONE	CPT 84402	Outpatient	6017440	$135
ASSAY OF TOTAL TESTOSTERONE	CPT 84403	Outpatient	6017270	$109
ASSAY OF VITAMIN B-1	CPT 84425	Outpatient	6016425	$51
ASSAY OF FREE THYROXINE	CPT 84439	Outpatient	6016543	$41
ASSAY THYROID STIM HORMONE	CPT 84443	Outpatient	6016443	$90
ASSAY THYROID STIM HORMONE	CPT 84443	Outpatient	6016444	$90
ASSAY OF TRANSFERRIN	CPT 84466	Outpatient	6017188	$144
ASSAY TRIIODOTHYRONINE (T3)	CPT 84480	Outpatient	6016480	$80
FREE ASSAY (FT-3)	CPT 84481	Outpatient	6017481	$95
ASSAY OF TROPONIN QUANT	CPT 84484	Outpatient	6016645	$83
ASSAY OF TROPONIN QUANT	CPT 84484	Outpatient	6016649	$83
ASSAY OF BLOOD/URIC ACID	CPT 84550	Outpatient	6016108	$41
ASSAY OF ZINC	CPT 84630	Outpatient	6017765	$96
ASSAY OF C-PEPTIDE	CPT 84681	Outpatient	6017681	$124
CHORIONIC GONADOTROPIN TEST	CPT 84702	Outpatient	6017805	$52
BL SMEAR W/DIFF WBC COUNT	CPT 85007	Outpatient	6016042	$26
BL SMEAR W/DIFF WBC COUNT	CPT 85007	Outpatient	6016043	$15
HEMATOCRIT	CPT 85014	Outpatient	6016054	$32
HEMOGLOBIN	CPT 85018	Outpatient	6016055	$32
COMPLETE CBC W/AUTO DIFF WBC	CPT 85025	Outpatient	6016031	$64
COMPLETE CBC W/AUTO DIFF WBC	CPT 85025	Outpatient	6017919	$88
COMPLETE CBC AUTOMATED	CPT 85027	Outpatient	6016999	$63
AUTOMATED RETICULOCYTE COUNT	CPT 85045	Outpatient	6017097	$58
BLOOD SMEAR INTERPRETATION	CPT 85060	Outpatient	6017104	$82
FIBRIN DEGRADATION QUANT	CPT 85379	Outpatient	6017380	$215
PROTHROMBIN TIME	CPT 85610	Outpatient	6000908	$61
PROTHROMBIN TIME	CPT 85610	Outpatient	6000915	$61
PROTHROMBIN TIME	CPT 85610	Outpatient	6016079	$61
RBC SED RATE NONAUTOMATED	CPT 85651	Outpatient	6016090	$47
THROMBOPLASTIN TIME PARTIAL	CPT 85730	Outpatient	6016115	$74
THROMBOPLASTIN TIME PARTIAL	CPT 85730	Outpatient	6017311	$37
ALLG SPEC IGE CRUDE XTRC EA	CPT 86003	Outpatient	6017113	$27
ANTINUCLEAR ANTIBODIES	CPT 86038	Outpatient	6017255	$50
ANTINUCLEAR ANTIBODIES (ANA)	CPT 86039	Outpatient	6017256	$46
C-REACTIVE PROTEIN	CPT 86140	Outpatient	6016140	$83
NUCLEAR ANTIGEN ANTIBODY	CPT 86235	Outpatient	6016235	$101
HETEROPHILE ANTIBODY SCREEN	CPT 86308	Outpatient	6016750	$60
IMMUNOFIX E-PHORESIS SERUM	CPT 86334	Outpatient	6017334	$91
MICROSOMAL ANTIBODY EACH	CPT 86376	Outpatient	6017047	$70
RHEUMATOID FACTOR QUANT	CPT 86431	Outpatient	6017099	$44
TB INTRADERMAL TEST	CPT 86580	Outpatient	8600099	$75
SYPHILIS TEST NON-TREP QUAL	CPT 86592	Outpatient	6017592	$30
EPSTEIN-BARR NUCLEAR ANTIGEN	CPT 86664	Outpatient	6017675	$70
EPSTEIN-BARR CAPSID VCA	CPT 86665	Outpatient	6017677	$77
HEP B SURFACE ANTIBODY	CPT 86706	Outpatient	6017706	$45
MUMPS ANTIBODY	CPT 86735	Outpatient	6017197	$55
RUBELLA ANTIBODY	CPT 86762	Outpatient	6017202	$61
RUBEOLA ANTIBODY	CPT 86765	Outpatient	6017266	$54
HEPATITIS C AB TEST	CPT 86803	Outpatient	6017243	$60
BLOOD TYPING SEROLOGIC ABO	CPT 86900	Outpatient	6017108	$26
BLOOD TYPING SEROLOGIC RH(D)	CPT 86901	Outpatient	6017086	$26
COMPATIBILITY TEST SPIN	CPT 86920	Outpatient	6016116	$287
BLOOD CULTURE FOR BACTERIA	CPT 87040	Outpatient	6017038	$104
BLOOD CULTURE FOR BACTERIA	CPT 87040	Outpatient	6017039	$104
FECES CULTURE AEROBIC BACT	CPT 87045	Outpatient	6017101	$40
FECES CULTURE AEROBIC BACT	CPT 87045	Outpatient	6017115	$40
STOOL CULTR AEROBIC BACT EA	CPT 87046	Outpatient	6017103	$40
CULTURE OTHR SPECIMN AEROBIC	CPT 87070	Outpatient	6017712	$52
CULTURE OTHR SPECIMN AEROBIC	CPT 87070	Outpatient	6017905	$36
CULTURE OTHR SPECIMN AEROBIC	CPT 87070	Outpatient	6017711	$126
CULTR BACTERIA EXCEPT BLOOD	CPT 87075	Outpatient	6017076	$97
CULTURE ANAEROBE IDENT EACH	CPT 87076	Outpatient	6017358	$55
CULTURE AEROBIC IDENTIFY	CPT 87077	Outpatient	6017357	$55
URINE CULTURE/COLONY COUNT	CPT 87086	Outpatient	6017054	$97
URINE CULTURE/COLONY COUNT	CPT 87086	Outpatient	6017482	$97
URINE BACTERIA CULTURE	CPT 87088	Outpatient	60161063	$70
CULTURE TYPE IMMUNOLOGIC	CPT 87147	Outpatient	6017772	$55
OVA AND PARASITES SMEARS	CPT 87177	Outpatient	6017116	$79
OVA AND PARASITES SMEARS	CPT 87177	Outpatient	6016128	$79
MICROBE SUSCEPTIBLE MIC	CPT 87186	Outpatient	6017774	$63
SMEAR GRAM STAIN	CPT 87205	Outpatient	6017061	$26
SMEAR COMPLEX STAIN	CPT 87209	Outpatient	6017131	$37
CLOSTRIDIUM AG IA	CPT 87324	Outpatient	6017180	$50
HIV-1 AG W/HIV-1&2 AB AG IA	CPT 87389	Outpatient	6017026	$182
SARSCOV CORONAVIRUS AG IA	CPT 87426 (QW)	Outpatient	60180006	$309
SARSCOV CORONAVIRUS AG IA	CPT 87426 (QW)	Outpatient	60180007	$309
SHIGA-LIKE TOXIN AG IA	CPT 87427	Outpatient	6017107	$90
SARSCOV & INF VIR A&B AG IA	CPT 87428	Outpatient	6017961	$232
NOS EACH ORGANISM AG IA	CPT 87449	Outpatient	6017179	$67
NOS EACH ORGANISM AG IA	CPT 87449	Outpatient	6017211	$253
CHYLMD TRACH DNA AMP PROBE	CPT 87491	Outpatient	6017187	$120
HEPATITIS C REVRS TRNSCRPJ	CPT 87522	Outpatient	6017768	$240
N.GONORRHOEAE DNA AMP PROB	CPT 87591	Outpatient	6017189	$108
SARS-COV-2 COVID-19 AMP PRB	CPT 87635	Outpatient	60180009	$300
INFLUENZA ASSAY W/OPTIC	CPT 87804	Outpatient	6074000	$72
INFLUENZA ASSAY W/OPTIC	CPT 87804	Outpatient	6074001	$72
RSV ASSAY W/OPTIC	CPT 87807	Outpatient	6016191	$66
STREP A ASSAY W/OPTIC	CPT 87880	Outpatient	6016751	$65
TISSUE EXAM BY PATHOLOGIST	CPT 88305	Outpatient	6017999	$221
SPECIMEN HANDLING PT-LAB	CPT 99001	Outpatient	6016333	$41
PSA SCREENING	HCPCS G0103	Outpatient	6017031	$99
DRUG TEST DEF 1-7 CLASSES	HCPCS G0480	Outpatient	6017326	$515
DRUG TEST DEF 1-7 CLASSES	HCPCS G0480	Outpatient	6017401	$515
DRUG TEST DEF 1-7 CLASSES	HCPCS G0480	Outpatient	6017414	$515
DRUG TEST DEF 1-7 CLASSES	HCPCS G0480	Outpatient	6017416	$515
COV-19 AMP PRB HGH THRUPUT	HCPCS U0003	Outpatient	60180003	$300
COV-19 AMP PRB HGH THRUPUT	HCPCS U0003	Outpatient	60180005	$300
Language Pathology
SPEECH/HEARING THERAPY	CPT 92507 (GN)	Outpatient	2800082	$193
ORAL FUNCTION THERAPY	CPT 92526 (GN)	Outpatient	2800083	$210
MRI
MRI BRAIN STEM W/O DYE	CPT 70551	Outpatient	7519711	$2,005
MRI BRAIN STEM W/O & W/DYE	CPT 70553	Outpatient	7519713	$3,127
MRI NECK SPINE W/O DYE	CPT 72141	Outpatient	7519730	$2,005
MRI LUMBAR SPINE W/O DYE	CPT 72148	Outpatient	7519715	$2,005
MRI JNT OF LWR EXTRE W/O DYE	CPT 73721	Outpatient	7519707	$2,005
MRI JNT OF LWR EXTRE W/O DYE	CPT 73721	Outpatient	7519729	$2,005
INJ PROHANCE MULTIPACK	HCPCS A9576	Outpatient	7519731	$379
Medical and Surgical Supplies
WOUND CLOSURE BY ADHESIVE	HCPCS G0168	Outpatient	5000034	$101
Other Diagnostic
EXTRACRANIAL BILAT STUDY	CPT 93880	Outpatient	7410078	$1,787
LOWER EXTREMITY STUDY	CPT 93925	Outpatient	7410080	$1,072
EXTREMITY STUDY	CPT 93970	Outpatient	7410082	$1,787
EXTREMITY STUDY	CPT 93971	Outpatient	7410084	$1,215
Other Procedures and Observation
DEB SUBQ TISSUE 20 SQ CM/<	CPT 11042	Outpatient	500051	$496
DEB SUBQ TISSUE ADD-ON	CPT 11045	Outpatient	500700	$496
US URINE CAPACITY MEASURE	CPT 51798	Outpatient	3000003	$69
RMVL DEVITAL TIS 20 CM/<	CPT 97597	Outpatient	1500005	$251
RMVL DEVITAL TIS ADDL 20CM/<	CPT 97598	Outpatient	1502000	$42
CASIRIVI AND IMDEVI INFUSION	HCPCS M0243	Outpatient	8610201	$929
Other Therapeutic
BLOOD TRANSFUSION SERVICE	CPT 36430	Outpatient	6036430	$1,344
CARDIAC REHAB/MONITOR	CPT 93798	Outpatient	2000007	$246
NEG PRESS WOUND TX <=50 CM	CPT 97605	Outpatient	1500004	$1,411
RBC LEUKOCYTES REDUCED	HCPCS P9016	Outpatient	6016118	$715
Psychiatric
(N/O) PSYCHOTHERAPY, 30 MIN	CPT 90832	-	-	-	-
(N/O) PSYCHOTHERAPY, 45 MIN	CPT 90834	-	-	-	-
(N/O) PSYCHOTHERAPY, 60 MIN	CPT 90837	-	-	-	-
(N/O) FAMILY PSYCHOTHERAPY, NOT INCLUDING PATIENT, 50 MIN	CPT 90846	-	-	-	-
(N/O) FAMILY PSYCHOTHERAPY, INCLUDING PATIENT, 50 MIN	CPT 90847	-	-	-	-
(N/O) GROUP PSYCHOTHERAPY	CPT 90853	-	-	-	-
Pulmonary Function
MEASURE BLOOD OXYGEN LEVEL	CPT 94760	Outpatient	2600025	$43
MEASURE BLOOD OXYGEN LEVEL	CPT 94760	Outpatient	2600031	$23
Radiology
X-RAY EXAM CHEST 1 VIEW	CPT 71045	Outpatient	7119013	$184
X-RAY EXAM CHEST 2 VIEWS	CPT 71046	Outpatient	7119014	$187
X-RAY EXAM RIBS UNI 2 VIEWS	CPT 71100	Outpatient	7119066	$214
X-RAY EXAM NECK SPINE 2-3 VW	CPT 72040	Outpatient	7119305	$298
X-RAY EXAM NECK SPINE 6/>VWS	CPT 72052	Outpatient	7119097	$361
X-RAY EXAM THORAC SPINE 2VWS	CPT 72070	Outpatient	7119081	$214
X-RAY EXAM L-S SPINE 2/3 VWS	CPT 72100	Outpatient	7119082	$242
X-RAY EXAM L-S SPINE 2/3 VWS	CPT 72100	Outpatient	7119555	$286
X-RAY EXAM L-2 SPINE 4/>VWS	CPT 72110	Outpatient	7119098	$370
X-RAY EXAM OF PELVIS	CPT 72170	Outpatient	7119060	$170
X-RAY EXAM OF SHOULDER	CPT 73030 (RT)	Outpatient	7119073	$206
X-RAY EXAM OF SHOULDER	CPT 73030 (LT)	Outpatient	7119076	$206
X-RAY EXAM OF SHOULDER	CPT 73030 (LT)	Outpatient	7119080	$206
X-RAY EXAM OF SHOULDER	CPT 73030	Outpatient	7119325	$194
X-RAY EXAM OF ELBOW	CPT 73070 (RT)	Outpatient	7119025	$176
X-RAY EXAM OF ELBOW	CPT 73070 (LT)	Outpatient	7119026	$176
X-RAY EXAM OF FOREARM	CPT 73090 (RT)	Outpatient	7119036	$185
X-RAY EXAM OF FOREARM	CPT 73090 (LT)	Outpatient	7119037	$185
X-RAY EXAM OF WRIST	CPT 73110 (LT)	Outpatient	7119092	$214
X-RAY EXAM OF WRIST	CPT 73110 (RT)	Outpatient	7119093	$214
X-RAY EXAM OF HAND	CPT 73130 (RT)	Outpatient	7119039	$204
X-RAY EXAM OF HAND	CPT 73130 (LT)	Outpatient	7119040	$204
X-RAY EXAM HIP UNI 2-3 VIEWS	CPT 73502 (RT)	Outpatient	7119042	$214
X-RAY EXAM HIP UNI 2-3 VIEWS	CPT 73502 (LT)	Outpatient	7119045	$214
X-RAY EXAM HIPS BI 2 VIEWS	CPT 73521	Outpatient	7119313	$307
X-RAY EXAM OF KNEE 3	CPT 73562 (LT)	Outpatient	7119046	$215
X-RAY EXAM OF KNEE 3	CPT 73562 (RT)	Outpatient	7119047	$215
X-RAY EXAM OF ANKLE	CPT 73610 (RT)	Outpatient	7119006	$204
X-RAY EXAM OF ANKLE	CPT 73610 (LT)	Outpatient	7119019	$204
X-RAY EXAM OF FOOT	CPT 73630 (RT)	Outpatient	7119035	$201
X-RAY EXAM OF FOOT	CPT 73630 (LT)	Outpatient	7119038	$201
X-RAY EXAM ABDOMEN 1 VIEW	CPT 74018	Outpatient	7119001	$181
X-RAY EXAM ABDOMEN 2 VIEWS	CPT 74019	Outpatient	7119002	$224
CT BONE DENSITY AXIAL	CPT 77078	Outpatient	7276075	$603
Respiratory
BREATHING CAPACITY TEST	CPT 94010	Outpatient	2600020	$59
AIRWAY INHALATION TREATMENT	CPT 94640	Outpatient	2600015	$78
POS AIRWAY PRESSURE CPAP	CPT 94660	Outpatient	2600004	$27
EVALUATE PT USE OF INHALER	CPT 94664	Outpatient	2600016	$79
Surgical Procedures
REMOVAL OF BREAST LESION	CPT 19120	Outpatient	1100050	$2,966
(N/O) SHAVING OF SHOULDER BONE USING ENDOSCOPE	CPT 29826	-	-	-	-
(N/O) REMOVAL OF ONE KNEE CARTILAGE USING AN ENDOSCOPE	CPT 29881	-	-	-	-
REMOVE TONSILS AND ADENOIDS	CPT 42820	Outpatient	1100126	$4,054
EGD DIAGNOSTIC BRUSH WASH	CPT 43235	Outpatient	1100049	$3,429
(N/O) BIOPSY EXAM OF ESOPHAGUS, STOMACH OR SMALL BOWEL USI ...	CPT 43239	-	-	-	-
DIAGNOSTIC COLONOSCOPY	CPT 45378	Outpatient	1100046	$3,429
(N/O) BIOPSY EXAM OF LARGE BOWEL USING AN ENDOSCOPE	CPT 45380	-	-	-	-
COLONOSCOPY W/LESION REMOVAL	CPT 45385	Outpatient	1100153	$4,236
(N/O) ULTRASOUND EXAMINATION OF LOWER LARGE BOWEL USING AN ...	CPT 45391	-	-	-	-
LAPAROSCOPIC CHOLECYSTECTOMY	CPT 47562	Outpatient	1100031	$7,355
PRP I/HERN INIT REDUC >5 YR	CPT 49505	Outpatient	1100048	$3,688
(N/O) BIOPSY OF PROSTATE GLAND	CPT 55700	-	-	-	-
(N/O) SURGICAL REMOVAL OF PROSTATE AND SURROUNDING LYMPH N ...	CPT 55866	-	-	-	-
(N/O) OBSTETRIC CARE, PLANNED VAGINAL DELIVERY	CPT 59400	-	-	-	-
(N/O) OBSTETRIC CARE, PLANNED CESAREAN DELIVERY	CPT 59510	-	-	-	-
(N/O) OBSTETRIC CARE, PLANNED VAGINAL DELIVERY (POST DELIV ...	CPT 59610	-	-	-	-
(N/O) INJECTION(S) OF THERAPEUTIC SUBSTANCE	CPT 62322	-	-	-	-
(N/O) INJECTION(S) OF THERAPEUTIC SUBSTANCE	CPT 62323	-	-	-	-
(N/O) INJECTION(S) OF ANESTHETIC INTO LOWER SPINE USING IM ...	CPT 64483	-	-	-	-
AFTER CATARACT LASER SURGERY	CPT 66821	Outpatient	1100308	$1,277
XCAPSL CTRC RMVL W/O ECP	CPT 66984	Outpatient	1100300	$5,562
(N/O) INSERTION OF CATHETER INTO LEFT HEART FOR DIAGNOSIS	CPT 93452	-	-	-	-
Therapy
HOT OR COLD PACKS THERAPY	CPT 97010 (GO)	Outpatient	2800018	$34
HOT OR COLD PACKS THERAPY	CPT 97010 (GP)	Outpatient	2800056	$34
MECHANICAL TRACTION THERAPY	CPT 97012 (GP)	Outpatient	2800057	$62
ULTRASOUND THERAPY	CPT 97035 (GO)	Outpatient	2800025	$46
ULTRASOUND THERAPY	CPT 97035 (GP)	Outpatient	2800063	$46
THERAPEUTIC EXERCISES	CPT 97110 (GO)	Outpatient	2800026	$80
THERAPEUTIC EXERCISES	CPT 97110 (GP)	Outpatient	2800064	$80
NEUROMUSCULAR REEDUCATION	CPT 97112 (GO)	Outpatient	2800027	$88
NEUROMUSCULAR REEDUCATION	CPT 97112 (GP)	Outpatient	2800065	$88
GAIT TRAINING THERAPY	CPT 97116 (GP)	Outpatient	2800067	$82
MANUAL THERAPY 1/> REGIONS	CPT 97140 (GO)	Outpatient	2800030	$91
MANUAL THERAPY 1/> REGIONS	CPT 97140 (GP)	Outpatient	2800069	$91
PT EVAL LOW COMPLEX 20 MIN	CPT 97161 (GP)	Outpatient	2800100	$215
PT EVAL MOD COMPLEX 30 MIN	CPT 97162 (GP)	Outpatient	2800101	$215
OT EVAL LOW COMPLEX 30 MIN	CPT 97165 (GO)	Outpatient	2800104	$224
OT EVAL MOD COMPLEX 45 MIN	CPT 97166 (GO)	Outpatient	2800105	$224
THERAPEUTIC ACTIVITIES	CPT 97530 (GO)	Outpatient	2800032	$78
THERAPEUTIC ACTIVITIES	CPT 97530 (GP)	Outpatient	2800071	$78
SELF CARE MNGMENT TRAINING	CPT 97535 (GO)	Outpatient	2800034	$89
PT ELEC STIMULATION	HCPCS G0283GP (GP)	Outpatient	2800038	$51
Uncategorized
IMMUNIZATION ADMIN	CPT 90471	Outpatient	8610054	$93
GROUND MILEAGE	HCPCS A0425	Outpatient	900021	$25
ALS1-EMERGENCY	HCPCS A0427	Outpatient	900016	$1,350
BLS	HCPCS A0428	Outpatient	900300	$710
BLS-EMERGENCY	HCPCS A0429	Outpatient	900004	$1,137
AMBULANCE RESPONSE/TREATMENT	HCPCS A0998	Outpatient	900034	$109