Wise Health System

Price List for Shoppable Services. Effective 07-22-2022.

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.

Billing Description	Billing Code	CDM Code	Department	Gross Charge	Cash Price	PNR
CT Scan
CT HEAD/BRAIN W/O DYE	CPT 70450	12435144	Outpatient	$3,245	$2,109	Payer Rates
CT HEAD/BRAIN W/O DYE	CPT 70450	12435164	Outpatient	$3,245	$2,109	Payer Rates
CT HEAD/BRAIN W/O DYE	CPT 70450	40035144	Outpatient	$3,245	$2,109	Payer Rates
CT HEAD/BRAIN W/O DYE	CPT 70450	40035164	Outpatient	$3,245	$2,109	Payer Rates
CT THORAX DX C-	CPT 71250	12435256	Outpatient	$3,245	$2,109	Payer Rates
CT THORAX DX C+	CPT 71260	12435221	Outpatient	$3,675	$2,389	Payer Rates
CT ANGIOGRAPHY CHEST	CPT 71275	12435276	Outpatient	$4,725	$3,071	Payer Rates
CT NECK SPINE W/O DYE	CPT 72125	12435255	Outpatient	$3,245	$2,109	Payer Rates
CT PELVIS W/DYE	CPT 72193	12435251	Outpatient	$3,785	$2,460	Payer Rates
CT ABD & PELVIS W/O CONTRAST	CPT 74176	12435257	Outpatient	$3,245	$2,109	Payer Rates
CT ABD & PELV W/CONTRAST	CPT 74177	12435258	Outpatient	$3,785	$2,460	Payer Rates
CT ABD & PELV W/CONTRAST	CPT 74177	40035258	Outpatient	$3,785	$2,460	Payer Rates
CT HRT W/O DYE W/CA TEST	CPT 75571	1243528	Outpatient	$99	$64	Payer Rates
Cancer Services
CT SCAN FOR THERAPY GUIDE	CPT 77014	13533302	Outpatient	$589	$383	Payer Rates
RADIATION PHYSICS CONSULT	CPT 77336	13533318	Outpatient	$333	$216	Payer Rates
NTSTY MODUL RAD TX DLVR SMPL	CPT 77385	13533323	Outpatient	$1,424	$926	Payer Rates
RADIATION TREATMENT DELIVERY	CPT 77412	13533344	Outpatient	$693	$450	Payer Rates
CHEMO IV INFUSION 1 HR	CPT 96413	2043359	Outpatient	$688	$447	Payer Rates
Cardiology
TTE W/DOPPLER COMPLETE	CPT 93306	12548331	Outpatient	$2,657	$1,727	Payer Rates
LEFT HRT CATH W/VENTRCLGRPHY	CPT 93452	82481106	Outpatient	$13,087	$8,507	Payer Rates
MOD SED SAME PHYS/QHP EA	CPT 99153	82370353	Outpatient	$157	$102	Payer Rates
Clinic
HYPERBARIC OXYGEN THERAPY	CPT 99183	761510400	Outpatient	$902	$586	Payer Rates
OFFICE O/P EST LOW 20-29 MIN	CPT 99213	76151013	Outpatient	$356	$231	Payer Rates
Dialysis
DIALYSIS PROCEDURE	CPT 90999	8018512	Outpatient	$2,602	$1,691	Payer Rates
EEG
POLYSOM 6/> YRS 4/> PARAM	CPT 95810 (TC)	8707406	Outpatient	$5,411	$3,517	Payer Rates
EKG
ELECTROCARDIOGRAM TRACING	CPT 93005	1287301	Outpatient	$341	$222	Payer Rates
Emergency Room
INSERT TEMP BLADDER CATH	CPT 51702	9145052	Outpatient	$558	$363	Payer Rates
EMERGENCY DEPT VISIT	CPT 99282	9145023	Outpatient	$827	$538	Payer Rates
EMERGENCY DEPT VISIT	CPT 99283	9145022	Outpatient	$1,622	$1,054	Payer Rates
EMERGENCY DEPT VISIT	CPT 99283	40045022	Outpatient	$1,575	$1,024	Payer Rates
EMERGENCY DEPT VISIT	CPT 99284	9145021	Outpatient	$2,867	$1,864	Payer Rates
EMERGENCY DEPT VISIT	CPT 99284	40045021	Outpatient	$2,730	$1,775	Payer Rates
EMERGENCY DEPT VISIT	CPT 99285	9145018	Outpatient	$3,859	$2,508	Payer Rates
CRITICAL CARE FIRST HOUR	CPT 99291	9145026	Outpatient	$4,725	$3,071	Payer Rates
Hemodialysis
DIALYSIS PROCEDURE	CPT 90999 (G3)	80082125	Outpatient	$2,478	$1,611	Payer Rates
DIALYSIS PROCEDURE	CPT 90999 (G3)	80082127	Outpatient	$2,478	$1,611	Payer Rates
DIALYSIS PROCEDURE	CPT 90999 (G3)	80082128	Outpatient	$2,602	$1,691	Payer Rates
DIALYSIS PROCEDURE	CPT 90999 (G4)	80082134	Outpatient	$2,478	$1,611	Payer Rates
DIALYSIS PROCEDURE	CPT 90999 (G4)	80082135	Outpatient	$2,602	$1,691	Payer Rates
DIALYSIS PROCEDURE	CPT 90999 (G4)	80082136	Outpatient	$2,602	$1,691	Payer Rates
DIALYSIS PROCEDURE	CPT 90999 (G5)	80082142	Outpatient	$2,478	$1,611	Payer Rates
DIALYSIS PROCEDURE	CPT 90999 (G5)	80082143	Outpatient	$2,602	$1,691	Payer Rates
DIALYSIS PROCEDURE	CPT 90999 (G5)	80082144	Outpatient	$2,602	$1,691	Payer Rates
IV Therapy
HYDRATION IV INFUSION INIT	CPT 96360	9126014	Outpatient	$482	$313	Payer Rates
HYDRATE IV INFUSION ADD-ON	CPT 96361	4126021	Outpatient	$88	$57	Payer Rates
HYDRATE IV INFUSION ADD-ON	CPT 96361	9126015	Outpatient	$210	$137	Payer Rates
THER/PROPH/DIAG IV INF INIT	CPT 96365	9126011	Outpatient	$526	$342	Payer Rates
THER/PROPH/DIAG IV INF INIT	CPT 96365	1322604	Outpatient	$526	$342	Payer Rates
THER/PROPH/DIAG IV INF ADDON	CPT 96366	4126012	Outpatient	$175	$114	Payer Rates
THER/PROPH/DIAG IV INF ADDON	CPT 96366	9126038	Outpatient	$210	$137	Payer Rates
TX/PROPH/DG ADDL SEQ IV INF	CPT 96367	9126050	Outpatient	$256	$166	Payer Rates
TX/PROPH/DG ADDL SEQ IV INF	CPT 96367	20426010	Outpatient	$107	$70	Payer Rates
THER/PROPH/DIAG INJ SC/IM	CPT 96372	412609	Outpatient	$337	$219	Payer Rates
THER/PROPH/DIAG INJ SC/IM	CPT 96372	482604	Outpatient	$337	$219	Payer Rates
THER/PROPH/DIAG INJ SC/IM	CPT 96372	9126033	Outpatient	$312	$203	Payer Rates
THER/PROPH/DIAG INJ SC/IM	CPT 96372	2042607	Outpatient	$318	$207	Payer Rates
THER/PROPH/DIAG INJ IV PUSH	CPT 96374	9126012	Outpatient	$303	$197	Payer Rates
THER/PROPH/DIAG INJ IV PUSH	CPT 96374	40026032	Outpatient	$297	$193	Payer Rates
TX/PRO/DX INJ NEW DRUG ADDON	CPT 96375	4126019	Outpatient	$596	$387	Payer Rates
TX/PRO/DX INJ NEW DRUG ADDON	CPT 96375	9126016	Outpatient	$318	$207	Payer Rates
TX/PRO/DX INJ NEW DRUG ADDON	CPT 96375	40026016	Outpatient	$303	$197	Payer Rates
TX/PRO/DX INJ SAME DRUG ADON	CPT 96376	4126020	Outpatient	$306	$199	Payer Rates
TX/PRO/DX INJ SAME DRUG ADON	CPT 96376	9126047	Outpatient	$312	$203	Payer Rates
Imaging
US EXAM ABDOM COMPLETE	CPT 76700	12540215	Outpatient	$1,073	$697	Payer Rates
ECHO EXAM OF ABDOMEN	CPT 76705	12540234	Outpatient	$825	$536	Payer Rates
US EXAM ABDO BACK WALL COMP	CPT 76770	12540255	Outpatient	$1,074	$698	Payer Rates
OB US >= 14 WKS SNGL FETUS	CPT 76805	12540277	Outpatient	$1,476	$959	Payer Rates
OB US >= 14 WKS SNGL FETUS	CPT 76805	12540278	Outpatient	$1,391	$904	Payer Rates
TRANSVAGINAL US NON-OB	CPT 76830	12540241	Outpatient	$833	$541	Payer Rates
TRANSVAGINAL US NON-OB	CPT 76830	EX12540241	Outpatient	$809	$526	Payer Rates
TRANSVAGINAL US NON-OB	CPT 76830	EX40040241	Outpatient	$809	$526	Payer Rates
ECHO GUIDE FOR BIOPSY	CPT 76942	1940213	Outpatient	$1,383	$899	Payer Rates
BREAST TOMOSYNTHESIS BI	CPT 77063	1264038	Outpatient	$150	$98	Payer Rates
DX MAMMO INCL CAD UNI	CPT 77065 (LT)	1264015	Outpatient	$324	$211	Payer Rates
DX MAMMO INCL CAD UNI	CPT 77065 (RT)	1264016	Outpatient	$324	$211	Payer Rates
DX MAMMO INCL CAD BI	CPT 77066	1264014	Outpatient	$420	$273	Payer Rates
SCR MAMMO BI INCL CAD	CPT 77067	1264033	Outpatient	$301	$196	Payer Rates
EXTREMITY STUDY	CPT 93970	12592111	Outpatient	$1,706	$1,109	Payer Rates
Inpatient Procedures
(Not Offered) CARDIAC VALVE OR CARDIOTHORACIC PROCEDURE WI ...	DRG 216	-	-	-	-	-
(Not Offered) SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC	DRG 460	-	-	-	-	-
(Not Offered) MAJOR JOINT REPLACEMENT OR REATTACHMENT OF L ...	DRG 470	-	-	-	-	-
(Not Offered) CERVICAL SPINAL FUSION WITHOUT CC OR MCC	DRG 473	-	-	-	-	-
(Not Offered) UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGN ...	DRG 743	-	-	-	-	-
Laboratory
COVID FLU COMBO VIR RESP RNA 3 TRGT	CPT 0240U	1003001339	Outpatient	$232	$151	Payer Rates
ROUTINE VENIPUNCTURE	CPT 36415	100300304	Outpatient	$31	$20	Payer Rates
ROUTINE VENIPUNCTURE	CPT 36415	100300480	Outpatient	$3	$2	Payer Rates
ROUTINE VENIPUNCTURE	CPT 36415	100300485	Outpatient	$12	$8	Payer Rates
ROUTINE VENIPUNCTURE	CPT 36415	1023001304	Outpatient	$13	$8	Payer Rates
ROUTINE VENIPUNCTURE	CPT 36415	1023001310	Outpatient	$11	$7	Payer Rates
ROUTINE VENIPUNCTURE	CPT 36415	110300304	Outpatient	$32	$21	Payer Rates
ROUTINE VENIPUNCTURE	CPT 36415	12330018	Outpatient	$28	$18	Payer Rates
ROUTINE VENIPUNCTURE	CPT 36415	1323001	Outpatient	$31	$20	Payer Rates
METABOLIC PANEL IONIZED CA	CPT 80047	100301900	Outpatient	$365	$237	Payer Rates
METABOLIC PANEL TOTAL CA	CPT 80048	1003011235	Outpatient	$11	$7	Payer Rates
METABOLIC PANEL TOTAL CA	CPT 80048	1003011306	Outpatient	$11	$7	Payer Rates
METABOLIC PANEL TOTAL CA	CPT 80048	10030120	Outpatient	$349	$227	Payer Rates
METABOLIC PANEL TOTAL CA	CPT 80048	100301642	Outpatient	$202	$131	Payer Rates
COMPREHEN METABOLIC PANEL	CPT 80053	1003011301	Outpatient	$20	$13	Payer Rates
COMPREHEN METABOLIC PANEL	CPT 80053	100301582	Outpatient	$520	$338	Payer Rates
(Not Offered) OBSTETRIC BLOOD TEST PANEL	CPT 80055	-	-	-	-	-
LIPID PANEL	CPT 80061	10030191	Outpatient	$324	$211	Payer Rates
RENAL FUNCTION PANEL	CPT 80069 (QW)	100301585	Outpatient	$115	$75	Payer Rates
HEPATIC FUNCTION PANEL	CPT 80076	1003011297	Outpatient	$11	$7	Payer Rates
HEPATIC FUNCTION PANEL	CPT 80076	100301790	Outpatient	$323	$210	Payer Rates
HEPATIC FUNCTION PANEL	CPT 80076	100301976	Outpatient	$219	$142	Payer Rates
DRUG ASSAY SALICYLATE	CPT 80179	100301557	Outpatient	$274	$178	Payer Rates
ASSAY OF VANCOMYCIN	CPT 80202	100301758	Outpatient	$131	$85	Payer Rates
(Not Offered) URINALYSIS TEST USING MICROSCOPE	CPT 81000	-	-	-	-	-
URINALYSIS AUTO W/SCOPE	CPT 81001	1003071262	Outpatient	$5	$3	Payer Rates
URINALYSIS AUTO W/SCOPE	CPT 81001	100307722	Outpatient	$166	$108	Payer Rates
URINALYSIS AUTO W/SCOPE	CPT 81001	EX100307722	Outpatient	$174	$113	Payer Rates
URINALYSIS AUTO W/O SCOPE	CPT 81003 (QW)	10030720	Outpatient	$49	$32	Payer Rates
URINE PREGNANCY TEST	CPT 81025	1003071208	Outpatient	$23	$15	Payer Rates
URINE PREGNANCY TEST	CPT 81025	100307514	Outpatient	$166	$108	Payer Rates
ASSAY OF AMMONIA	CPT 82140	100301116	Outpatient	$98	$64	Payer Rates
ASSAY OF AMYLASE	CPT 82150 (QW)	100301113	Outpatient	$225	$146	Payer Rates
ASSAY TEST FOR BLOOD FECAL	CPT 82274 (QW)	100301472	Outpatient	$68	$44	Payer Rates
ASSAY CARBOXYHB QUANT	CPT 82375	20230189	Outpatient	$131	$85	Payer Rates
ASSAY OF CK (CPK)	CPT 82550	100301318	Outpatient	$238	$155	Payer Rates
ASSAY OF CREATININE	CPT 82565 (QW)	100301329	Outpatient	$166	$108	Payer Rates
ASSAY OF CREATININE	CPT 82565 (QW)	100301883	Outpatient	$164	$107	Payer Rates
ASSAY OF URINE CREATININE	CPT 82570 (QW)	100301163	Outpatient	$57	$37	Payer Rates
VITAMIN B-12	CPT 82607	100301749	Outpatient	$83	$54	Payer Rates
ASSAY OF FERRITIN	CPT 82728	100301801	Outpatient	$195	$127	Payer Rates
ASSAY OF FOLIC ACID SERUM	CPT 82746	100301377	Outpatient	$105	$68	Payer Rates
BLOOD GASES W/O2 SATURATION	CPT 82805	20230162	Outpatient	$233	$151	Payer Rates
ASSAY GLUCOSE BLOOD QUANT	CPT 82947 (QW)	100301395	Outpatient	$29	$19	Payer Rates
GLUCOSE BLOOD TEST	CPT 82962	100301397	Outpatient	$33	$21	Payer Rates
GLYCOSYLATED HEMOGLOBIN TEST	CPT 83036 (QW)	100301100	Outpatient	$253	$164	Payer Rates
BLOOD METHEMOGLOBIN ASSAY	CPT 83050	20230190	Outpatient	$71	$46	Payer Rates
ASSAY OF IRON	CPT 83540	EX100301457	Outpatient	$32	$21	Payer Rates
IRON BINDING TEST	CPT 83550	EX100301456	Outpatient	$78	$51	Payer Rates
ASSAY OF LACTIC ACID	CPT 83605 (QW)	100301724	Outpatient	$242	$157	Payer Rates
LACTATE (LD) (LDH) ENZYME	CPT 83615	100301446	Outpatient	$226	$147	Payer Rates
ASSAY OF LIPASE	CPT 83690	100301454	Outpatient	$210	$137	Payer Rates
ASSAY OF MAGNESIUM	CPT 83735	100301461	Outpatient	$197	$128	Payer Rates
ASSAY OF MYOGLOBIN	CPT 83874	EX10030124	Outpatient	$351	$228	Payer Rates
ASSAY OF NATRIURETIC PEPTIDE	CPT 83880 (QW)	100301715	Outpatient	$195	$127	Payer Rates
ASSAY OF PARATHORMONE	CPT 83970	100301653	Outpatient	$228	$148	Payer Rates
ASSAY OF BLOOD PKU	CPT 84030	100301559	Outpatient	$168	$109	Payer Rates
ASSAY OF PHOSPHORUS	CPT 84100	100301498	Outpatient	$53	$34	Payer Rates
ASSAY OF SERUM POTASSIUM	CPT 84132	100301518	Outpatient	$63	$41	Payer Rates
PROCALCITONIN (PCT)	CPT 84145	100301895	Outpatient	$412	$268	Payer Rates
ASSAY OF PSA TOTAL	CPT 84153	100301522	Outpatient	$413	$268	Payer Rates
ASSAY OF PSA FREE	CPT 84154	100301713	Outpatient	$104	$68	Payer Rates
ASSAY OF PROTEIN URINE	CPT 84156	1003011206	Outpatient	$32	$21	Payer Rates
ASSAY OF FREE THYROXINE	CPT 84439	100301649	Outpatient	$306	$199	Payer Rates
ASSAY THYROID STIM HORMONE	CPT 84443 (QW)	100301697	Outpatient	$364	$237	Payer Rates
ASSAY THYROID STIM HORMONE	CPT 84443 (QW)	EX100301697	Outpatient	$347	$226	Payer Rates
ASSAY OF TROPONIN QUANT	CPT 84484	100301640	Outpatient	$347	$226	Payer Rates
ASSAY OF TROPONIN QUANT	CPT 84484	100301893	Outpatient	$364	$237	Payer Rates
ASSAY OF TROPONIN QUANT	CPT 84484	EX10030125	Outpatient	$253	$164	Payer Rates
ASSAY OF TROPONIN QUANT	CPT 84484	EX10030126	Outpatient	$375	$244	Payer Rates
CHORIONIC GONADOTROPIN TEST	CPT 84702	100301437	Outpatient	$320	$208	Payer Rates
CHORIONIC GONADOTROPIN ASSAY	CPT 84703 (QW)	100301510	Outpatient	$197	$128	Payer Rates
BL SMEAR W/DIFF WBC COUNT	CPT 85007	100305400	Outpatient	$53	$34	Payer Rates
BL SMEAR W/O DIFF WBC COUNT	CPT 85008	100300311	Outpatient	$67	$44	Payer Rates
HEMATOCRIT	CPT 85014 (QW)	EX100305426	Outpatient	$28	$18	Payer Rates
HEMOGLOBIN	CPT 85018 (QW)	100305431	Outpatient	$27	$18	Payer Rates
HEMOGLOBIN	CPT 85018 (QW)	EX100305431	Outpatient	$28	$18	Payer Rates
COMPLETE CBC W/AUTO DIFF WBC	CPT 85025 (QW)	1003051230	Outpatient	$8	$5	Payer Rates
COMPLETE CBC W/AUTO DIFF WBC	CPT 85025 (QW)	1003051337	Outpatient	$11	$7	Payer Rates
COMPLETE CBC W/AUTO DIFF WBC	CPT 85025 (QW)	10030520	Outpatient	$154	$100	Payer Rates
COMPLETE CBC W/AUTO DIFF WBC	CPT 85025 (QW)	100305305	Outpatient	$151	$98	Payer Rates
COMPLETE CBC AUTOMATED	CPT 85027	100305379	Outpatient	$151	$98	Payer Rates
COAGULATION TIME ACTIVATED	CPT 85347	100305404	Outpatient	$157	$102	Payer Rates
FIBRIN DEGRADATION QUANT	CPT 85379	100305337	Outpatient	$333	$216	Payer Rates
PROTHROMBIN TIME	CPT 85610 (QW)	100305187	Outpatient	$123	$80	Payer Rates
PROTHROMBIN TIME	CPT 85610 (QW)	10030522	Outpatient	$126	$82	Payer Rates
PROTHROMBIN TIME	CPT 85610 (QW)	100305538	Outpatient	$114	$74	Payer Rates
RBC SED RATE AUTOMATED	CPT 85652	100305561	Outpatient	$127	$83	Payer Rates
THROMBOPLASTIN TIME PARTIAL	CPT 85730	100305539	Outpatient	$125	$81	Payer Rates
C-REACTIVE PROTEIN	CPT 86140	100302536	Outpatient	$125	$81	Payer Rates
MYCOPLASMA ANTIBODY	CPT 86738	10030264	Outpatient	$90	$59	Payer Rates
RBC ANTIBODY SCREEN	CPT 86850	1003021346	Outpatient	$197	$128	Payer Rates
BLOOD TYPING SEROLOGIC ABO	CPT 86900	EX1003021370	Outpatient	$165	$107	Payer Rates
BLOOD TYPING SEROLOGIC RH(D)	CPT 86901	EX1003021360	Outpatient	$112	$73	Payer Rates
COMPATIBILITY TEST ELECTRIC	CPT 86923	1003021382	Outpatient	$382	$248	Payer Rates
BLOOD CULTURE FOR BACTERIA	CPT 87040	100306323	Outpatient	$90	$59	Payer Rates
CULTURE OTHR SPECIMN AEROBIC	CPT 87070	100306333	Outpatient	$428	$278	Payer Rates
CULTURE OTHR SPECIMN AEROBIC	CPT 87070	100306633	Outpatient	$408	$265	Payer Rates
CULTR BACTERIA EXCEPT BLOOD	CPT 87075	100306118	Outpatient	$405	$263	Payer Rates
URINE BACTERIA CULTURE	CPT 87088	100306735	Outpatient	$84	$55	Payer Rates
MICROBE SUSCEPTIBLE MIC	CPT 87186	100306146	Outpatient	$83	$54	Payer Rates
SMEAR GRAM STAIN	CPT 87205	1003061354	Outpatient	$160	$104	Payer Rates
LEGION PNEUMOPHILIA AG IF	CPT 87278	100306218	Outpatient	$50	$33	Payer Rates
HEPATITIS B SURFACE AG IA	CPT 87340	100306429	Outpatient	$296	$192	Payer Rates
INFLUENZA A/B EACH AG IA	CPT 87400	100306740	Outpatient	$261	$170	Payer Rates
RESP SYNCYTIAL VIRUS AG IA	CPT 87420	100306549	Outpatient	$112	$73	Payer Rates
SARSCOV CORONAVIRUS AG IA	CPT 87426 (QW)	1003021381	Outpatient	$58	$38	Payer Rates
STAPH A DNA AMP PROBE	CPT 87640	EX100306944	Outpatient	$329	$214	Payer Rates
MR-STAPH DNA AMP PROBE	CPT 87641	EX100306943	Outpatient	$329	$214	Payer Rates
STREP A DNA AMP PROBE	CPT 87651 (QW)	1003061357	Outpatient	$147	$96	Payer Rates
AGENT NOS ASSAY W/OPTIC	CPT 87899 (QW)	100306214	Outpatient	$85	$55	Payer Rates
TISSUE EXAM BY PATHOLOGIST	CPT 88304	100310657	Outpatient	$107	$70	Payer Rates
TISSUE EXAM BY PATHOLOGIST	CPT 88305	100310658	Outpatient	$147	$96	Payer Rates
Language Pathology
SPEECH/HEARING THERAPY	CPT 92507 (GN)	752440206	Outpatient	$336	$218	Payer Rates
ORAL FUNCTION THERAPY	CPT 92526 (GN)	742440212	Outpatient	$411	$267	Payer Rates
EVALUATE SWALLOWING FUNCTION	CPT 92610 (GN)	742440200	Outpatient	$281	$183	Payer Rates
MRI
MRI BRAIN STEM W/O DYE	CPT 70551	12761133	Outpatient	$3,245	$2,109	Payer Rates
MRI BRAIN STEM W/O & W/DYE	CPT 70553	12761135	Outpatient	$4,326	$2,812	Payer Rates
MRI NECK SPINE W/O DYE	CPT 72141	1276123	Outpatient	$3,245	$2,109	Payer Rates
MRI LUMBAR SPINE W/O DYE	CPT 72148	1276129	Outpatient	$3,245	$2,109	Payer Rates
MRI JNT OF LWR EXTRE W/O DYE	CPT 73721 (RT)	12761461	Outpatient	$3,245	$2,109	Payer Rates
MRI JNT OF LWR EXTRE W/O DYE	CPT 73721 (LT)	12761462	Outpatient	$3,245	$2,109	Payer Rates
MRI JNT OF LWR EXTRE W/O DYE	CPT 73721 (50)	12761467	Outpatient	$4,326	$2,812	Payer Rates
Other Procedures and Observation
DEB SUBQ TISSUE 20 SQ CM/<	CPT 11042	761761137	Outpatient	$339	$220	Payer Rates
APPLY MULTLAY COMPRS LWR LEG	CPT 29581	761761292	Outpatient	$361	$235	Payer Rates
COLLECT BLOOD FROM PICC	CPT 36592	4176113	Outpatient	$234	$152	Payer Rates
OFFICE O/P NEW LOW 30-44 MIN	CPT 99203	761761119	Outpatient	$345	$224	Payer Rates
OFFICE O/P NEW MOD 45-59 MIN	CPT 99204	761761120	Outpatient	$571	$371	Payer Rates
OFFICE O/P NEW HI 60-74 MIN	CPT 99205	761761121	Outpatient	$820	$533	Payer Rates
OFFICE O/P NEW HI 60-74 MIN	CPT 99205 (25)	761761126	Outpatient	$820	$533	Payer Rates
OFFICE O/P EST MOD 30-39 MIN	CPT 99214	761761130	Outpatient	$1,751	$1,138	Payer Rates
OFFICE O/P EST HI 40-54 MIN	CPT 99215	761761131	Outpatient	$2,513	$1,633	Payer Rates
Other Therapeutic
CARDIAC REHAB/MONITOR	CPT 93798	7639432	Outpatient	$297	$193	Payer Rates
MEDICAL NUTRITION INDIV IN	CPT 97802	39423	Outpatient	$126	$82	Payer Rates
MED NUTRITION INDIV SUBSEQ	CPT 97803	39424	Outpatient	$202	$131	Payer Rates
RBC LEUKOCYTES REDUCED	HCPCS P9016	10038114	Outpatient	$1,054	$685	Payer Rates
Psychiatric
PSYTX W PT 45 MINUTES	CPT 90834	8129143	Outpatient	$209	$136	Payer Rates
PSYTX W PT 60 MINUTES	CPT 90837	8129419	Outpatient	$525	$341	Payer Rates
FAMILY PSYTX W/PT 50 MIN	CPT 90847	8129167	Outpatient	$749	$487	Payer Rates
GROUP PSYCHOTHERAPY	CPT 90853	8129154	Outpatient	$386	$251	Payer Rates
GROUP PSYCHOTHERAPY	CPT 90853	8129155	Outpatient	$386	$251	Payer Rates
Pulmonary Function
MEASURE BLOOD OXYGEN LEVEL	CPT 94760	20246038	Outpatient	$94	$61	Payer Rates
MEASURE BLOOD OXYGEN LEVEL	CPT 94761	20246039	Outpatient	$204	$133	Payer Rates
MEASURE BLOOD OXYGEN LEVEL	CPT 94762	20246037	Outpatient	$1,002	$651	Payer Rates
Radiology
X-RAY EXAM CHEST 1 VIEW	CPT 71045	12032433	Outpatient	$410	$267	Payer Rates
X-RAY EXAM CHEST 1 VIEW	CPT 71045	12032434	Outpatient	$422	$274	Payer Rates
X-RAY EXAM CHEST 2 VIEWS	CPT 71046	12032435	Outpatient	$548	$356	Payer Rates
X-RAY EXAM L-S SPINE 2/3 VWS	CPT 72100	120320133	Outpatient	$615	$400	Payer Rates
X-RAY EXAM L-2 SPINE 4/>VWS	CPT 72110	120320136	Outpatient	$829	$539	Payer Rates
X-RAY EXAM ABDOMEN 1 VIEW	CPT 74018	1203208	Outpatient	$390	$254	Payer Rates
DXA BONE DENSITY AXIAL	CPT 77080	1263201	Outpatient	$686	$446	Payer Rates
Respiratory
WITHDRAWAL OF ARTERIAL BLOOD	CPT 36600	20241012	Outpatient	$88	$57	Payer Rates
VENT MGMT INPAT SUBQ DAY	CPT 94003	202410102	Outpatient	$1,338	$870	Payer Rates
VENT MGMT INPAT SUBQ DAY	CPT 94003	20241052	Outpatient	$1,338	$870	Payer Rates
AIRWAY INHALATION TREATMENT	CPT 94640 (76)	202410109	Outpatient	$192	$125	Payer Rates
AIRWAY INHALATION TREATMENT	CPT 94640	20241059	Outpatient	$192	$125	Payer Rates
AIRWAY INHALATION TREATMENT	CPT 94640	20241092	Outpatient	$192	$125	Payer Rates
OFFICE O/P NEW LOW 30-44 MIN	CPT 99203	7634105	Outpatient	$345	$224	Payer Rates
BEHAV CHNG SMOKING 3-10 MIN	CPT 99406	20241055	Outpatient	$42	$27	Payer Rates
HBOT, FULL BODY CHAMBER, 30M	HCPCS G0277	761413162	Outpatient	$994	$646	Payer Rates
Surgical Procedures
NJX INTERLAMINAR LMBR/SAC	CPT 62322	1937022	Outpatient	$1,287	$837	Payer Rates
Therapy
HOT OR COLD PACKS THERAPY	CPT 97010 (GP)	7504203	Outpatient	$99	$64	Payer Rates
HOT OR COLD PACKS THERAPY	CPT 97010 (GP)	75042035	Outpatient	$99	$64	Payer Rates
HOT OR COLD PACKS THERAPY	CPT 97010 (GO)	751430158	Outpatient	$104	$68	Payer Rates
HOT OR COLD PACKS THERAPY	CPT 97010 (GO)	751430159	Outpatient	$104	$68	Payer Rates
MECHANICAL TRACTION THERAPY	CPT 97012 (GP)	75042036	Outpatient	$138	$90	Payer Rates
ELECTRIC STIMULATION THERAPY	CPT 97014 (GP)	75042068	Outpatient	$115	$75	Payer Rates
VASOPNEUMATIC DEVICE THERAPY	CPT 97016 (GP)	75042037	Outpatient	$253	$164	Payer Rates
VASOPNEUMATIC DEVICE THERAPY	CPT 97016 (GO)	751430197	Outpatient	$265	$172	Payer Rates
PARAFFIN BATH THERAPY	CPT 97018 (GO)	751430157	Outpatient	$102	$66	Payer Rates
ULTRASOUND THERAPY	CPT 97035 (GP)	75042027	Outpatient	$138	$90	Payer Rates
ULTRASOUND THERAPY	CPT 97035 (GO)	751430164	Outpatient	$142	$92	Payer Rates
THERAPEUTIC EXERCISES	CPT 97110 (GP)	74042029	Outpatient	$203	$132	Payer Rates
THERAPEUTIC EXERCISES	CPT 97110 (GO)	741430154	Outpatient	$199	$129	Payer Rates
THERAPEUTIC EXERCISES	CPT 97110 (GO)	741430182	Outpatient	$209	$136	Payer Rates
THERAPEUTIC EXERCISES	CPT 97110 (GP)	75042029	Outpatient	$203	$132	Payer Rates
THERAPEUTIC EXERCISES	CPT 97110 (GO)	751430154	Outpatient	$199	$129	Payer Rates
THERAPEUTIC EXERCISES	CPT 97110 (GO)	751430182	Outpatient	$199	$129	Payer Rates
NEUROMUSCULAR REEDUCATION	CPT 97112 (GP)	75042032	Outpatient	$192	$125	Payer Rates
NEUROMUSCULAR REEDUCATION	CPT 97112 (GO)	751430174	Outpatient	$196	$127	Payer Rates
AQUATIC THERAPY/EXERCISES	CPT 97113 (GP)	75042046	Outpatient	$232	$151	Payer Rates
GAIT TRAINING THERAPY	CPT 97116 (GP)	74042033	Outpatient	$111	$72	Payer Rates
MANUAL THERAPY 1/> REGIONS	CPT 97140 (GP)	75042022	Outpatient	$153	$99	Payer Rates
MANUAL THERAPY 1/> REGIONS	CPT 97140 (GO)	751430167	Outpatient	$149	$97	Payer Rates
MANUAL THERAPY 1/> REGIONS	CPT 97140 (GO)	751430169	Outpatient	$158	$103	Payer Rates
GROUP THERAPEUTIC PROCEDURES	CPT 97150 (GP)	75042323	Outpatient	$276	$179	Payer Rates
PT EVAL LOW COMPLEX 20 MIN	CPT 97161 (GP)	7504241	Outpatient	$411	$267	Payer Rates
PT EVAL MOD COMPLEX 30 MIN	CPT 97162 (GP)	7404242	Outpatient	$493	$320	Payer Rates
PT EVAL MOD COMPLEX 30 MIN	CPT 97162 (GP)	7504242	Outpatient	$493	$320	Payer Rates
PT RE-EVAL EST PLAN CARE	CPT 97164 (GP)	75042434	Outpatient	$218	$142	Payer Rates
OT EVAL LOW COMPLEX 30 MIN	CPT 97165 (GO)	74143486	Outpatient	$391	$254	Payer Rates
OT EVAL LOW COMPLEX 30 MIN	CPT 97165 (GO)	75143486	Outpatient	$391	$254	Payer Rates
OT EVAL MOD COMPLEX 45 MIN	CPT 97166 (GO)	74143487	Outpatient	$484	$315	Payer Rates
OT EVAL MOD COMPLEX 45 MIN	CPT 97166 (GO)	75143487	Outpatient	$484	$315	Payer Rates
THERAPEUTIC ACTIVITIES	CPT 97530 (GP)	74042024	Outpatient	$146	$95	Payer Rates
THERAPEUTIC ACTIVITIES	CPT 97530 (GO)	741430168	Outpatient	$154	$100	Payer Rates
THERAPEUTIC ACTIVITIES	CPT 97530 (GP)	75042024	Outpatient	$146	$95	Payer Rates
THERAPEUTIC ACTIVITIES	CPT 97530 (GO)	751430168	Outpatient	$154	$100	Payer Rates
SELF CARE MNGMENT TRAINING	CPT 97535 (GO)	741430171	Outpatient	$198	$129	Payer Rates
SELF CARE MNGMENT TRAINING	CPT 97535 (GO)	751430172	Outpatient	$198	$129	Payer Rates
Uncategorized
REMOVAL OF BREAST LESION	CPT 19120	WSXINT19120	Outpatient	$1,252	$814	Payer Rates
SHO ARTHRS SRG DECOMPRESSION	CPT 29826	WSXMSC29826	Outpatient	$444	$289	Payer Rates
KNEE ARTHROSCOPY/SURGERY	CPT 29881	WSXMSC29881	Outpatient	$1,367	$889	Payer Rates
REMOVE TONSILS AND ADENOIDS	CPT 42820	WSXDIG42820	Outpatient	$732	$476	Payer Rates
EGD DIAGNOSTIC BRUSH WASH	CPT 43235	WSXDIG43235	Outpatient	$674	$438	Payer Rates
EGD BIOPSY SINGLE/MULTIPLE	CPT 43239	WSXDIG43239	Outpatient	$903	$587	Payer Rates
DIAGNOSTIC COLONOSCOPY	CPT 45378	WSXDIG45378	Outpatient	$812	$528	Payer Rates
COLONOSCOPY AND BIOPSY	CPT 45380	WSXDIG45380	Outpatient	$1,044	$679	Payer Rates
COLONOSCOPY W/LESION REMOVAL	CPT 45385	WSXDIG45385	Outpatient	$1,095	$712	Payer Rates
COLONOSCOPY W/ENDOSCOPE US	CPT 45391	WSXDIG45391	Outpatient	$667	$434	Payer Rates
LAPAROSCOPIC CHOLECYSTECTOMY	CPT 47562	WSXDIG47562	Outpatient	$1,661	$1,080	Payer Rates
PRP I/HERN INIT REDUC >5 YR	CPT 49505	WSXDIG49505	Outpatient	$1,314	$854	Payer Rates
BIOPSY OF PROSTATE	CPT 55700	WSXMGN55700	Outpatient	$631	$410	Payer Rates
LAPARO RADICAL PROSTATECTOMY	CPT 55866	WSXMGN55866	Outpatient	$3,699	$2,404	Payer Rates
OBSTETRICAL CARE	CPT 59400	WSXFGN59400	Outpatient	$5,264	$3,422	Payer Rates
CESAREAN DELIVERY	CPT 59510	WSXFGN59510	Outpatient	$5,824	$3,786	Payer Rates
VBAC DELIVERY	CPT 59610	WSXFGN59610	Outpatient	$5,515	$3,585	Payer Rates
NJX INTERLAMINAR LMBR/SAC	CPT 62323	WSXNRV62323	Outpatient	$241	$157	Payer Rates
NJX AA&/STRD TFRM EPI L/S 1	CPT 64483	WSXNRV64483	Outpatient	$572	$372	Payer Rates
AFTER CATARACT LASER SURGERY	CPT 66821	WSXEYE66821	Outpatient	$854	$555	Payer Rates
XCAPSL CTRC RMVL W/O ECP	CPT 66984	WSXEYE66984	Outpatient	$1,616	$1,050	Payer Rates
METABOLIC PANEL TOTAL CA	CPT 80048 (QW)	WLAB80048	Outpatient	$21	$14	Payer Rates
COMPREHEN METABOLIC PANEL	CPT 80053 (QW)	WLAB80053	Outpatient	$20	$13	Payer Rates
LIPID PANEL	CPT 80061 (QW)	WLAB80061	Outpatient	$20	$13	Payer Rates
URINALYSIS AUTO W/SCOPE	CPT 81001	WLAB81001	Outpatient	$8	$5	Payer Rates
URINALYSIS NONAUTO W/O SCOPE	CPT 81002 (QW)	WLAB81002	Outpatient	$9	$6	Payer Rates
URINALYSIS AUTO W/O SCOPE	CPT 81003 (QW)	WLAB81003	Outpatient	$20	$13	Payer Rates
URINE PREGNANCY TEST	CPT 81025 (QW)	WLAB81025	Outpatient	$22	$14	Payer Rates
GLYCOSYLATED HEMOGLOBIN TEST	CPT 83036 (QW)	WLAB83036	Outpatient	$25	$16	Payer Rates
ASSAY OF PSA TOTAL	CPT 84153	WLAB84153	Outpatient	$46	$30	Payer Rates
ASSAY THYROID STIM HORMONE	CPT 84443 (QW)	WLAB84443	Outpatient	$42	$27	Payer Rates
COMPLETE CBC W/AUTO DIFF WBC	CPT 85025 (QW)	WLAB85025	Outpatient	$22	$14	Payer Rates
COMPLETE CBC AUTOMATED	CPT 85027	WLAB85027	Outpatient	$16	$10	Payer Rates
PROTHROMBIN TIME	CPT 85610	WLAB85610	Outpatient	$11	$7	Payer Rates
THROMBOPLASTIN TIME PARTIAL	CPT 85730	WLAB85730	Outpatient	$15	$10	Payer Rates
SARSCOV CORONAVIRUS AG IA	CPT 87426 (QW)	WLAB87426	Outpatient	$75	$49	Payer Rates
INFLUENZA ASSAY W/OPTIC	CPT 87804 (QW)	WLAB87804	Outpatient	$52	$34	Payer Rates
STREP A ASSAY W/OPTIC	CPT 87880 (QW)	WLAB87880	Outpatient	$41	$27	Payer Rates
IM ADMIN 1ST/ONLY COMPONENT	CPT 90460	WVACA90460	Outpatient	$42	$27	Payer Rates
IM ADMIN 1ST/ONLY COMPONENT	CPT 90460	WVACA904601	Outpatient	$42	$27	Payer Rates
IM ADMIN EACH ADDL COMPONENT	CPT 90461	WVACA90461	Outpatient	$32	$21	Payer Rates
IMMUNIZATION ADMIN	CPT 90471	9177134	Outpatient	$112	$73	Payer Rates
PSYCH DIAGNOSTIC EVALUATION	CPT 90791	WMED90791	Outpatient	$150	$98	Payer Rates
PSYTX W PT 30 MINUTES	CPT 90832	WTRT90832	Outpatient	$75	$49	Payer Rates
PSYTX W PT 30 MINUTES	CPT 90832 (95)	WTRTTH90832	Outpatient	$75	$49	Payer Rates
PSYTX W PT 45 MINUTES	CPT 90834	WTRT90834	Outpatient	$100	$65	Payer Rates
PSYTX W PT 45 MINUTES	CPT 90834 (95)	WTRTTH90834	Outpatient	$100	$65	Payer Rates
PSYTX W PT 60 MINUTES	CPT 90837	WTRT90837	Outpatient	$120	$78	Payer Rates
PSYTX W PT 60 MINUTES	CPT 90837 (95)	WTRTTH90837	Outpatient	$120	$78	Payer Rates
FAMILY PSYTX W/O PT 50 MIN	CPT 90846 (95)	WMEDTH90846	Outpatient	$100	$65	Payer Rates
FAMILY PSYTX W/PT 50 MIN	CPT 90847	WMED90847	Outpatient	$100	$65	Payer Rates
FAMILY PSYTX W/PT 50 MIN	CPT 90847 (95)	WMEDTH90847	Outpatient	$100	$65	Payer Rates
GROUP PSYCHOTHERAPY	CPT 90853	WMED90853	Outpatient	$68	$44	Payer Rates
ELECTROCARDIOGRAM COMPLETE	CPT 93000	WMED93000	Outpatient	$43	$28	Payer Rates
DEVELOPMENTAL SCREEN W/SCORE	CPT 96110	WMED96110	Outpatient	$158	$103	Payer Rates
BRIEF EMOTIONAL/BEHAV ASSMT	CPT 96127	WTRT96127	Outpatient	$12	$8	Payer Rates
PT-FOCUSED HLTH RISK ASSMT	CPT 96160	WMED96160	Outpatient	$8	$5	Payer Rates
THER/PROPH/DIAG INJ SC/IM	CPT 96372	WMED96372	Outpatient	$42	$27	Payer Rates
OFFICE O/P NEW LOW 30-44 MIN	CPT 99203 (95)	WEM992031	Outpatient	$271	$176	Payer Rates
OFFICE O/P NEW LOW 30-44 MIN	CPT 99203	WEMFP99203	Outpatient	$271	$176	Payer Rates
OFFICE O/P NEW LOW 30-44 MIN	CPT 99203	WEMSP99203	Outpatient	$271	$176	Payer Rates
OFFICE O/P NEW MOD 45-59 MIN	CPT 99204	7635103	Outpatient	$411	$267	Payer Rates
OFFICE O/P NEW MOD 45-59 MIN	CPT 99204 (95)	WEM992041	Outpatient	$411	$267	Payer Rates
OFFICE O/P NEW MOD 45-59 MIN	CPT 99204	WEMFP99204	Outpatient	$411	$267	Payer Rates
OFFICE O/P NEW MOD 45-59 MIN	CPT 99204	WEMSP99204	Outpatient	$411	$267	Payer Rates
OFFICE O/P NEW HI 60-74 MIN	CPT 99205	7635104	Outpatient	$517	$336	Payer Rates
OFFICE O/P NEW HI 60-74 MIN	CPT 99205	WEMFP99205	Outpatient	$517	$336	Payer Rates
OFFICE O/P NEW HI 60-74 MIN	CPT 99205	WEMSP99205	Outpatient	$517	$336	Payer Rates
OFFICE O/P EST SF 10-19 MIN	CPT 99212	WEMSP99212	Outpatient	$113	$73	Payer Rates
OFFICE O/P EST LOW 20-29 MIN	CPT 99213	WEMSP99213	Outpatient	$186	$121	Payer Rates
OFFICE O/P EST MOD 30-39 MIN	CPT 99214	WEMFP99214	Outpatient	$273	$177	Payer Rates
OFFICE O/P EST MOD 30-39 MIN	CPT 99214	WEMSP99214	Outpatient	$273	$177	Payer Rates
OFFICE O/P EST HI 40-54 MIN	CPT 99215	WEMSP99215	Outpatient	$365	$237	Payer Rates
SUBSEQUENT HOSPITAL CARE	CPT 99232	WEM99232	Outpatient	$183	$119	Payer Rates
OFFICE CONSULTATION	CPT 99243	WEM99243	Outpatient	$247	$161	Payer Rates
OFFICE CONSULTATION	CPT 99244	WEM99244	Outpatient	$272	$177	Payer Rates
PREV VISIT NEW AGE 18-39	CPT 99385	WEM99385	Outpatient	$698	$454	Payer Rates
PREV VISIT NEW AGE 40-64	CPT 99386	WEM99386	Outpatient	$725	$471	Payer Rates
PER PM REEVAL EST PAT INFANT	CPT 99391	WEM99391	Outpatient	$407	$265	Payer Rates
PREV VISIT EST AGE 1-4	CPT 99392	WEM99392	Outpatient	$446	$290	Payer Rates
PREV VISIT EST AGE 40-64	CPT 99396	WEM99396	Outpatient	$603	$392	Payer Rates
TELEHEALTH FACILITY FEE	HCPCS Q3014	4778025	Outpatient	$211	$137	Payer Rates