charge cpt(r)/hcpcs effective description billing code 01 ......perq dev breast 1st mri imag 19287...
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Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
ANESTHESIA FOR PACEMAKER 00530 $3,442.00
ANESTHESIA FOR AICD 00534 $3,442.00
ANESTHESIA FOR EP PROCEDURES 00537 $3,496.00
ANESTH HEART SURGERY GREAT VESSELS 00560 $3,600.00
ANESTHESIA CARDIAC CATH 01920 $3,184.00
MRI ANESTHESIA, GENERAL 01922 $1,612.00
ANESTHESIA-IR ART INTRACRANIAL 01926 $1,193.00
FNA BIOPSY WO IMAGING EA ADD LESION 10004 $311.00
FNA BIOPSY WO IMAGING EA ADD LESION 10004 $311.00
FNA BIOPSY W US GUIDE 1ST LESION 10005 $1,469.00
FNA BIOPSY W US GUIDE EA ADD LESION 10006 $735.00
FNA BIOPSY W FLUORO 1ST LESION 10007 $1,469.00
FNA BIOPSY W FLUORO EA ADD LESION 10008 $735.00
FNA BIOPSY W CT GUIDE 1ST LESION 10009 $1,469.00
FNA BIOPSY W CT GUIDE EA ADD LESION 10010 $735.00
FNA BIOPSY W MRI 1ST LESION 10011 $1,469.00
FNA BIOPSY W MRI EA ADD LESION 10012 $735.00
FNA WO GUIDE 1ST LESION PAT 10021 $622.00
IMAGE-GUIDED CATH FLUID DRAINAGE 10030 $2,939.00
I&D ABSCESS, SIMPLE OR SINGLE 10060 $656.00
DRAIN SKIN ABSCESS SIMPLE 10060 $656.00
INCISION/REM FB SUBQ SIMPLE 10120 $622.00
DRAINAGE OF HEMATOMA/FLUID 10140 $3,018.00
ASPIRATION PUNCTURE 10160 $622.00
PUNCTURE DRAINAGE OF LESION 10160 $622.00
DEBRIDE SUBQ TISSUE 20SQCM< 11042 $1,029.00
DEBRIDE MUSC/FASCIA FIRST 20 SQ CM 11043 $1,780.00
DEBRIDE SUBQ TISSUE ADD 20 SQ CM 11045 $470.00
DEBRIDE MUSC/FASCIA ADD 20 SQ CM 11046 $890.00
BENIGN HYPERKERATOTIC 1 LESION 11055 $338.00
BENIGN HYPERKERATOTIC 2-4 LESIONS 11056 $338.00
BENIGN HYPERKERATOTIC 5+ LESIONS 11057 $548.00
TANGENTIAL SKIN BX SINGLE LESION 11102 $622.00
TANGENTIAL SKIN BX EACH ADD LESION 11103 $311.00
PUNCH BIOPSY OF SKIN SINGLE LESION 11104 $622.00
PUNCH BIOPSY OF SKIN EACH ADD LESION 11105 $311.00
INCISIONAL BX OF SKIN SINGLE LESION 11106 $622.00
INCISIONAL BX OF SKIN EACH ADD LESION 11107 $311.00
Page 1 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
EXCISION,BENIGN LESION,>4.0 CM 11426 $4,650.00
TRIM NONDYSTROPHIC NAILS,ANY NUM 11719 $247.00
DEBRIDE NAIL,ANY METHOD 1 TO 5 11720 $275.00
DEBRIDE NAIL,ANY METHOD 6/MORE 11721 $320.00
AVULSION NAIL PLATE SINGLE 11730 $539.00
SUBUNGUAL HEMATOMA EVAC 11740 $211.00
EXCISION-NAIL & MATRIX 11750 $1,192.00
EPIDERM AUTOGRFT TAL 1ST 100 SQCM 15110 $3,137.00
APP SKN GRAFT TAL<100CM 1ST25 15271 $3,137.00
APP SKN GRAFT TAL<100CM ADD25 15272 $981.00
APP SKN GRAFT TAL>100 1ST100 15273 $5,421.00
APP SKN GRAFT FNHFG<100 1ST25 15275 $3,137.00
APP SKN GRAFT FNHFG<100ADD25 15276 $347.00
TX BURN 1ST DEGREE INITIAL 16000 $338.00
DRESS/DEBRIDE-SMALL 16020 $338.00
DRESS/DEBRIDE-MEDIUM 16025 $548.00
DRESS/DEBRIDE-LARGE 16030 $622.00
DEST BENIGN LESION 1ST LESION 17000 $338.00
DEST BENIGN LESIONS (2-14)EACH 17003 $79.00
DEST FLAT WARTS <15 LESIONS 17110 $338.00
CAUTERIZATION CHEM TISSUE GRAN 17250 $338.00
PUNC/ASPIR BREAST CYST 19000 $1,399.00
BX BREAST 1ST LESION STRTCTC 19081 $2,697.00
BX BREAST ADD LESION STRTCTC 19082 $1,195.00
BX BREAST 1ST LESION US IMAG 19083 $2,697.00
BX BREAST ADD LESION US IMAG 19084 $1,007.00
BX BREAST 1ST LESION MRI IMAG 19085 $2,697.00
BX BREAST ADD LESION MRI IMAG 19086 $1,007.00
PERQ DEVICE BREAST 1ST IMAG 19281 $1,559.00
PERQ DEVICE BREAST EA IMAG 19282 $661.00
PERQ DEV BREAST 1ST STRTCTC 19283 $1,485.00
PERQ DEV BREAST 1ST US IMAG 19285 $1,146.00
PERQ DEV BREAST ADD US IMAG 19286 $661.00
PERQ DEV BREAST 1ST MRI IMAG 19287 $1,559.00
NEEDLE BIOPSY,MUSCLE 20206 $2,697.00
BONE BIOPSY,TROCAR/NEEDLE SUPERF 20220 $2,697.00
BONE BIOPSY,TROCAR/NEEDLE DEEP 20225 $4,493.00
INJECT SINUS TRACT FOR DX W XRAY 20501 $842.00
Page 2 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
INJECTION,THERAPEUTIC CARPAL T 20526 $544.00
INJ-SNGL TENDON SHEATH/LIGAMNT 20550 $831.00
INJ TRIGGER PT(S)-1/2MUSCLE 20552 $912.00
INJ TRIGGER PT(S)-3/MORE MS 20553 $908.00
INJ/ASPIR-SMALL JT/BURSA W/O US GUIDE 20600 $760.00
INJ/ASPIR-SMALL JT/BURSA WITH US GUIDE 20604 $723.00
INJ/ASPIR-INTERMED JT/BURSA W/O US GUIDE 20605 $760.00
INJ/ASPIR-INT JT/BURSA WITH US GUIDE 20606 $1,087.00
INJ/ASPIR-LARGE JT/BURSA W/O US GUIDE 20610 $993.00
INJ/ASPIR-LARGE JT/BURSA WITH US GUIDE 20611 $915.00
ABLATE, BONE TUMOR(S) PERQ 20982 $14,144.00
RESET DISLOCATED JAW CLOSED TX INITIAL OR SUBSEQUENT 21480 $430.00
I&D DEEP ABSC/HEMATOMA NECK/CHEST 21501 $5,871.00
BIOPSY SOFT TISSUE NECK/CHEST 21550 $2,697.00
PERQ CERIVICOTHORACIC INJECT 22510 $9,245.00
PERQ LUMBOSACRAL INJECTION 22511 $9,245.00
VERTEBROPLASTY ADDL INJECT 22512 $4,624.00
PERQ VERTEBRAL AUGMENT THORACIC 22513 $22,463.00
PERQ VERTEBRAL AUGMENT LUMBAR 22514 $22,463.00
PERQ VERTEBRAL AUG EACH ADDL 22515 $11,233.00
INJ PROC SHOULDER ARTHROGRAPHY/CT/MRI 23350 $948.00
DISLOC SHOULDER W/MANIP CLSD 23650 $1,437.00
INJECTION FOR ELBOW ARTHROGRAM 24220 $920.00
DISLOC TX ELBOW W/O ANES CLSD 24600 $1,300.00
TX ELBOW CHILD W/MANIP CLSD 24640 $1,018.00
INJECTION FOR WRIST ARTHROGRAM 25246 $597.00
DISLOC TX RADIUS/ULNA CLSD 25605 $2,700.00
DISLOC TX CARPAL W/MANIP CLSD 25660 $1,156.00
TREAT METACARPAL FX W/MANIPULATION 26605 $523.00
TX FINGER FX-W MANIPULATION 26725 $722.00
DISLOC TX FINGER W/O ANES CLSD 26770 $1,156.00
INJECTION HIP ARTHROGRAM 27093 $1,474.00
INJECT FOR SACROILIAC JOINT 27096 $1,552.00
TREAT HIP DISL W/O ANES CLOSED 27250 $722.00
TREAT HIP DISL W/O ANES POST ARTH 27265 $722.00
INJECTION KNEE CONTRAST 27369 $781.00
DISLOC TX KNEE W/O ANES CLSD 27550 $1,188.00
INJECTION FOR ANKLE ARTHROGRAM 27648 $881.00
Page 3 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
DISLOC TX ANKLE WO ANESTH CLSD 27840 $1,706.00
CAST APPL LONG ARM 29065 $700.00
CAST APPL SHORT ARM 29075 $792.00
SPLINT APPLICATION LONG ARM 29105 $505.00
SPLINT APPLICATION SHORT ARM 29125 $418.00
SPLINT APPL SHORT ARM DYNAMIC 29126 $211.00
SPLINT APPLICATION FINGER 29130 $327.00
SPLINT APPL FINGER DYNAMIC 29131 $171.00
APPL OF HIP SPICA CAST 1LEG 29305 $723.00
CAST APPL LONG LEG 29345 $577.00
APPL OF LONG LEG CAST BRACE 29358 $723.00
CAST APPL SHORT LEG 29405 $475.00
CAST APPL SHORT LEG-WALKING 29425 $877.00
APPLY RIGID LEG CAST 29445 $871.00
APPLY RIGID LEG CAST RN 29445 $871.00
SPLINT APPLICATION LONG LEG 29505 $592.00
SPLINT APPLICATION SHORT LEG 29515 $488.00
APPLY UNNA BOOT 29580 $519.00
APPLY MULTLAY COMPRS LOWER LEG 29581 $486.00
APPLY MULTLAY COMPRS UPPER ARM,FOREARM, HAND & FINGERS 29584 $496.00
CAST REMOVAL GNTLT/BOOT/BODY 29700 $525.00
CAST REMOVAL FULL ARM/LEG 29705 $601.00
CAST WINDOWING 29730 $271.00
REMOVE NASAL FOREIGN BODY 30300 $279.00
ENDOTRACHEAL INTUBATION 31500 $1,342.00
TRACHEOTOMY TUBE CHANGE 31502 $832.00
LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC 31575 $662.00
LARYNGOSCOPY,DIAGNOSTIC 31575 $662.00
LARYNGOSCOPY,FLEXIBLE FIBEROPTIC; W/REMOVAL OF FOREIGN BODY 31577 $1,311.00
CATH ASPIRATION, NASAL TRACHEAL 31720 $471.00
THORACOTOMY 32110 $6,643.00
NEEDLE BIOPSY PLEURA 32400 $2,697.00
PERCUT BX, LUNG/MEDIASTINUM 32405 $2,697.00
INSERTION INDWELLING TUNNELED PLEURAL CATHETER 32550 $8,875.00
TUBE THORACOSTOMY INCLUDES WATER SEAL 32551 $1,966.00
REMOVAL PLEURAL W CUFF 32552 $1,734.00
THORACENTESIS WITHOUT IMAGING GUIDANCE 32554 $1,816.00
THORACENTESIS WITH IMAGING GUIDANCE 32555 $1,738.00
Page 4 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
INSERT CATH PLEURA W/IG 32557 $1,966.00
CHEST SURGERY PROCEDURE UNLISTED 32999 $1,499.00
PERICARDIOCENTESIS,INITIAL 33010 $1,966.00
PPM INSERT-SNGL-VENT W/LEAD(S) 33207 $22,510.00
PPM INSERT DUAL CH W/LEADS (S) 33208 $19,561.00
TRANSVENOUS TEMP PACER SNGL CH 33210 $18,611.00
TRANSVENOUS TEMP PACER DUAL CH 33211 $18,611.00
PPM/AICD LEAD REVISION 33215 $6,340.00
INSERTION,PPM/AICD ONE LEAD 33216 $16,255.00
REVISION OF POCKET FOR PPM 33222 $4,777.00
REVISION OF POCKET FOR AICD 33223 $4,561.00
BI-VENT UPGRADE 33224 $28,595.00
BI-VENT NEW 33225 $18,589.00
REPOS. LT. VENTRICULAR LEAD 33226 $4,986.00
PPM REMVL W/PPM INSERT SNGL LD 33227 $14,742.00
PPM REMVL W/PPM INSERT DUAL LD 33228 $22,510.00
PPM REMVL W/PPM INSERT MULT LD 33229 $41,057.00
ICD INSERT ONLY(DUAL LD EXIST) 33230 $67,563.00
PPM GENERATOR REMOVAL 33233 $16,255.00
PPM LEAD REMOVAL-SNGL LEAD SYS 33234 $6,886.00
PPM LEAD REMOVAL-DUAL LEAD SYS 33235 $6,260.00
AICD GENERATOR REMOVAL 33241 $6,260.00
AICD LEAD(S) EXTRACTION (S) 33244 $6,260.00
ICD INSERT W/LD(S)1/2 CHAMBER 33249 $74,010.00
ICD REMVL W/ICD INSERT SNGL LD 33262 $53,232.00
ICD REMVL W/ICD INSERT DUAL LD 33263 $53,232.00
ICD REMVL W/ICD INSERT MULT LD 33264 $74,010.00
ICD SUBQ INSERT OR REPLACEMT W LEAD 33270 $74,010.00
PPM INSERT SINGLE VENT LEADLESS 33274 $30,709.00
PPM REMOVAL LEADLESS 33275 $5,283.04
INSERT SUBQ CRM W PROGRAMMING 33285 $16,805.00
REMOVAL SUBQ CRM W PROGRAMMING 33286 $3,375.00
IMPLANT TRANSCATH PULM ARTERY RHC 33289 $84,452.00
LT ATRIAL APPENDAGE CLOSURE 33340 $24,485.00
IAB INSERTION 33967 $5,302.00
INSERT VAD ARTERY ACCESS 33990 $13,417.00
INSERT VAD ARTERY & VEIN ACCESS 33991 $13,417.00
IV START 36000 $674.00
Page 5 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
INJECTION RX EXTREMITY PSEUDOANEURYSM 36002 $1,465.00
INJECTION,EXTREMITY VENOGRAM 36005 $1,938.00
INJECTION PROC,EXTREMITY,VENOGRAPHY 36005 $1,938.00
PLACE CATH IN VEIN,SVC,IVC 36010 $2,213.00
PLACE CATH IN VEIN,SELECT 36011 $2,181.00
PLACE CATH IN VEIN,SUBSELECT 36012 $2,207.00
PLACE CATH IN LT/RT PULM ART 36014 $2,480.00
PLACE CATH IN SUBSEGMT PULM ART 36015 $1,401.00
INTRO NEEDLE CATH UE/LE ARTERY 36140 $3,183.00
PLACE CATH AORTA 36200 $2,685.00
INTRODUCTION OF CATHETER,AORTA 36200 $2,685.00
PLACE CATH SELECTIVE ART,NECK 36215 $2,711.00
UPPER EXTREMITY ANGIO 36215 $2,711.00
PLACE CATH SUBSELECT ART,NECK 36216 $2,609.00
PLACE CATH SUBSUBSELECT ART,NECK 36217 $3,983.00
PLACE CATH ADDN SUBSELEC ART,NECK 36218 $1,214.00
PLACE CATH THORACIC AORTA ANGIO 36221 $8,794.00
PLACE CATH CAROTID/INOM ARTS-IPS EXT ANGIO 36222 $8,794.00
PLACE CATH CAROTID/INOM ART-IPS INT ANGIO 36223 $8,530.00
PLACE CATH CAROTD ART ANGIO 36224 $15,352.00
PLACE CATH SUBCLAVIAN ART ANGIO 36225 $8,794.00
PLACE CATH VERTEBRAL ART ANGIO 36226 $15,352.00
PLACE CATH XTRNL CAROTID ANGIO 36227 $4,630.00
PLACE CATH INTRACRANIAL ART ANGIO 36228 $4,630.00
ABD/LOW EXT A, 1ST ORDER 36245 $2,734.00
PLACE CATH SELECT ART,ABD/PEL 36245 $2,734.00
PLACE CATH SUBSELECT ART,ABD/PEL 36246 $4,814.00
PLACE CATH SUBSUBSELECT ART,ABD/PEL 36247 $3,756.00
PLACE CATH ADDN SUBSEL ART,ABD/PEL 36248 $1,828.00
CATH PLACE REN ART 1ST UNILAT 36251 $8,365.00
CATH PLACE REN ART 1ST BILAT 36252 $8,763.00
CATH PLACE REN ART 2ND+ UNILAT 36253 $8,530.00
CATH PLACE REN ART 2ND+ BIL 36254 $8,208.00
VENIPUNCTURE,<AGE3,SCALP VEIN 36405 $67.00
ROUTINE VENIPUNCTURE 36415 $48.00
TRANSFUSION-BLD/BLD PRODUCTS 36430 $1,120.00
PERCUT PORTAL VEIN CATH 36481 $4,426.00
VENOUS SELECT SAMPLING W CATH 36500 $1,679.00
Page 6 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
INSERTION OF CATHETER UMB VEIN 36510 $1,082.00
APHERESIS,THERAPEUTIC WBC 36511 $4,332.00
APHERESIS,THERAPEUTIC RBC 36512 $3,610.00
APHERESIS,THERAPEUTIC PLASMA 36514 $3,971.00
CVC, NON TUNNELED < AGE 5 36555 $3,610.00
INSERT NON-TUNNEL CV CATH < 5 Y/O 36555 $3,610.00
CVC, NON TUNNELED >AGE 5 36556 $3,446.00
INSERT NON-TUNNEL CV CATH 36556 $3,446.00
INSERT TUNNELED CV CATH W/O PORT OR PUMP 36558 $6,247.00
CVC,PORT PLACEMENT > AGE 5 36561 $8,610.00
INSERT TUNNELED CV CATH SUB Q 36561 $8,610.00
INSERT TUNNELED CV CATH 36563 $10,547.00
INSERT PICC W/O SUB-Q PORT <5 Y/O 36568 $2,891.00
PICC LINE PLACE WO GUIDANCE < AGE 5 36568 $2,891.00
INSERT TUNNELED CV CATH W/O SUB Q 36569 $3,561.00
PICC LINE PLACE WO GUIDANCE > AGE 5 36569 $3,561.00
INSERT PICC CV CATH W/SUBQ PORT 36571 $6,545.00
PICC LINE PLACE W GUIDANCE < AGE 5 36572 $2,891.00
PICC LINE PLACE W GUIDANCE > AGE 5 36573 $3,561.00
REPAIR TUNNELED CV CATH W/O PORT 36575 $1,610.00
REPLACE NONTUNNELED CVC WO SUBQ PORT 36580 $3,310.00
REPLACE TUNNELED CVC WO SUBQ PORT 36581 $6,247.00
REPLACE TUNNELED CVC W SUBQ PORT 36582 $7,705.00
REPLACE PICC WO SUBQ PORT W IMAGING 36584 $3,703.00
RMVL TNLD CV CATH W/O PORT,PUMP 36589 $1,884.00
RMVL TNLD CV CATH W/ PORT,PUMP 36590 $2,891.00
COLLECT BLOOD-VENOUS PORT 36591 $290.00
COLLECT BLOOD-VENOUS DVCE 36591 $290.00
COLLECT BLOOD FROM CATHETER VENOUS NOS 36592 $285.00
COLLECT BLOOD-VENOUS CATH 36592 $285.00
DECLOTTING OF VASCULAR DEVICE 36593 $1,003.00
MECH RMV TUNNELED CV CATH SEP ACC 36595 $5,949.00
REPOSITION VENOUS CATHETER 36597 $2,891.00
CONTRAST INJ CENT VEN CATH, INC FLOURO 36598 $793.00
ARTERIAL PUNCTURE-BLOOD DX 36600 $280.00
ARTERIAL LINE FOR MONITORING 36620 $1,082.00
ARTERIAL CATH INSERTION-PERCT 36620 $1,082.00
ARTERIAL CATH INSERTION-CUTDN 36625 $2,943.00
Page 7 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
INSERT CATH UMB ART 36660 $2,012.00
INTRO ANGIO DIALYSIS CIRCUIT S&I 36901 $1,958.00
INTRO PTA DIALYSIS CIRCUIT IMG S&I 36902 $13,806.00
INTRO STENT DIALYSIS CIRCUIT S&I 36903 $27,902.00
THROMB INF ANGIO DIALYSIS CIRCUIT 36904 $13,806.00
THROMB INF PTA DIALYSIS CIRCUIT 36905 $27,902.00
CENTRAL PTA DIALYSIS CIRCUIT S&I 36907 $21,146.00
CENTRAL STENT DIALYSIS CIRCUIT S&I 36908 $21,146.00
EMBO OCCLUSION DIALYSIS CIRCUIT S&I 36909 $21,146.00
INSERT TRANSVEN INTRAHEP PORTOSYS SHUNT 37182 $27,152.00
TIPS REVISION W IMAGING 37183 $29,609.00
PRIM PERC MECH THROMB, ARTER INIT 37184 $14,157.00
PRIM PERC MECH THROMB, ARTER SUB 37185 $8,408.00
SEC PERC MECH THROMBECT, ARTERIAL,W OTHER PROC 37186 $8,025.00
PERCUT MECH THROMB, VENOUS 37187 $10,170.00
INSERT IVC FILTER WITH IG & SI 37191 $10,252.00
REPOSITIONING,VENA CAVA FILTER 37192 $8,431.00
RETRIEVAL/REMVL VENA CAVA FLTR 37193 $8,853.00
TRANSCATH RETRVL,PERCUT W/IMAGING 37197 $10,075.00
TRANSCATHETER BIOPSY 37200 $10,547.00
TRANS THPY ART CORO/INTRAC DAY 1 37211 $10,547.00
TRANSCATH THERAPY,VEN, INIT DAY 37212 $4,986.00
TRANSCATH THERAPY,ART-VEN, SUBQ DY 37213 $7,274.00
TRANSCATH THERAPY CESSATION 37214 $7,274.00
TRANSCATH STENT, CCA W/EPS 37215 $25,413.00
TRANSCATH STENT, CCA W/O EPS 37216 $14,755.00
REVSC ILIAC ART INIT VESSEL 37220 $14,320.00
REVSC ILIAC ART W/STENT 37221 $29,609.00
REVSC ILIAC ART EA ADDL VSL 37222 $14,320.00
REVSC ILIAC W/STENT EA ADDL 37223 $15,001.00
REVASC FEM/POP ARTERY,ANGIO 37224 $14,320.00
REVASC FEM/POP ART,ANGIO/ATHER 37225 $30,453.00
REVASC FEM/POP ART,ANGIO/STENT 37226 $30,453.00
REVASC FEM/POP ART,ANGIO/STENT/ATH 37227 $51,792.00
REVASC TIBIAL/PERON ART,ANGIO INIT 37228 $26,519.00
REVASC TIB/PERON ART,ANG/ATH INIT 37229 $40,610.00
REVASC TIB/PERON ART,ANG/STENT INIT 37230 $40,610.00
REVASC TIBIAL/PERON ART,ANGIO ADD 37232 $14,320.00
Page 8 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
ARTERIAL STENT OPEN PERQ INITIAL 37236 $31,018.00
OPEN PERQ PLACE STENT EA ADDL 37237 $15,001.00
VENOUS STENT OPEN PERQ INITIAL 37238 $31,018.00
VENOUS STENT OPEN PERQ EA ADDL 37239 $13,637.00
VASC EMBOLIZE/OCCLUDE VENOUS 37241 $30,076.00
VASC EMBOLIZE/OCCLUDE ARTERY 37242 $30,076.00
VASC EMBOLIZE/OCCLUDE ORGAN 37243 $30,076.00
VASC EMBOLIZE/OCCLUDE BLEED 37244 $30,076.00
PTA 1ST ART IMG S&I 37246 $13,806.00
PTA EA ADDL ART IMG S&I 37247 $6,904.00
PTA 1ST VEIN IMG S&I 37248 $13,806.00
PTA EA ADDL VEIN IMG S&I 37249 $6,904.00
US IV FIRST VESSEL ADD-ON 37252 $2,577.00
US IV EACH ADD VESSEL ADD-ON 37253 $1,203.00
LIGATION OF A-V FISTULA 37607 $6,659.00
COLLECT BLOOD-ARTERIAL CATH 37799 $2,398.00
BONE MARROW ASPIRATION 38220 $2,697.00
DX BONE MARROW BIOPSIES 38221 $3,371.00
DX BONE MARROW BX & ASPIR 38222 $2,697.00
NEEDLE BIOPSY, LYMPH NODE(S) 38505 $2,697.00
LYMPHATICS INJ-SUBQUE/MUSCLE 38792 $1,104.00
BIOPSY SALIVARY GLAND,NEEDLE 42400 $2,511.00
INJECTION FOR SALIVARY X-RAY 42550 $413.00
NASO GASTRIC TUBE PLACEMENT 43752 $661.00
PLACEMENT NG/OG TUBE BY PHYSICIAN 43752 $661.00
GASTRIC INTUBATION TREATMENT 43753 $577.00
REPLACE GTUBE WO IMAGE ENDO OR TRACT REV 43762 $1,038.00
REPLACE GTUBE REV TRACT WO IMAGE ENDO 43763 $1,038.00
DRAIN APPENDICEAL ABSCESS, OPEN 44900 $4,239.00
I&D PERIRECTAL ABSCESS 46040 $5,319.00
I&D PERIANAL ABSCESS,SUPERFICIAL 46050 $1,610.00
INCISION HEMORRHOID EXTERNAL 46083 $981.00
ANASCOPY;DIAGNOSTIC 46600 $417.00
NEEDLE BIOPSY LIVER 47000 $3,207.00
ABLAT,OPEN,1+ LIVER TUMOR(S),PERCUT RF 47382 $14,681.00
CHOLECYSTOSTOMY,PERCUT 47490 $7,569.00
INJ PERQ CHOLANGIO EXIST W RAD/GDE 47531 $5,823.00
INJ PERQ CHOLANGIO NEW W RAD/GDE 47532 $7,569.00
Page 9 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
PERQ BIL CATH PLACE EXT W RAD/GDE 47533 $7,569.00
PERQ BIL CATH PLACE INT-EXT W R/GDE 47534 $7,569.00
BIL CATH EX/ CV TO EXT W RAD/GDE 47536 $7,569.00
BIL CATH REMOVAL REQ FLUORO GDE 47537 $1,640.00
PERQ BIL STENT PLACE EXIST W R/GDE 47538 $14,681.00
ENDOLUML BX(S) BIL TREE W RAD/GDE 47543 $4,413.00
NEEDLE BIOPSY OF PANCREAS 48102 $2,697.00
PARACENTESIS, ABD W/O IMAGING 49082 $1,772.00
PARACENTESIS,ABD W/IMAGING 49083 $1,857.00
PERCUT BIOPSY, ABDOMINAL MASS 49180 $2,697.00
SCLEROTX FLUID COLLECTION 49185 $2,807.00
AIR/CONTRAST INJECT INTO ABDOMEN 49400 $822.00
IMAGE CATH FLUID COLXN VISC 49405 $4,581.00
IMAGE CATH FLUID PERI/RETRO 49406 $4,581.00
INTERSTITIAL PLACEMENT PERQ 49411 $3,903.00
INSERT TUN IP CATH PERC W/IMAGING 49418 $9,112.00
REMOVE PERM CANNULA/CATHETER 49422 $6,831.00
DRAINAGE CATHETER EXCHANGE 49423 $4,894.00
CONTRAST INJ,ABSCESS/CYST VIA CATH TUBE 49424 $933.00
INSERT GASTROSTOMY TUBE PERCUTANEOUS 49440 $3,622.00
INSERT DUODENOSTOMY/JEJUNOSTOMY TUBE PERCUTANEOUS 49441 $4,140.00
CONVERT GASTROSTOMY-GASTRO-JEJUNOSTOMY TUBE PERCUTANEOUS 49446 $3,622.00
REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS 49450 $1,759.00
REPLACE DUODENOSTOMY/JEJUNOSTOMY TUBE PERCUTANEOUS 49451 $1,748.00
REPLACEMENT GASTRO-JEJUNOSTOMY TUBE PERCUTANEOUS 49452 $1,748.00
CONTRAST INJECTION PERCUTANEOUOS RADIOLOGIC EVAL GI TUBE 49465 $1,064.00
BIOPSY OF KIDNEY,PERCUTANEOUS 50200 $3,371.00
CHANGE URETER STENT, PERCUT 50382 $6,834.00
REMOVE URETER STENT, PERCUT 50384 $4,938.00
REMOVE RENAL TUBE W/FLUORO 50389 $3,668.00
PERCUT DRAIN/INJECT RENAL CYST 50390 $2,712.00
INJ THRU KIDNEY TUBE NEW W RGDE 50430 $2,496.00
INJ THRU KIDNEY TUBE EXIST W RGDE 50431 $2,496.00
PERQ NEPH CATH NEW ACCESS W RAD/GDE 50432 $7,166.00
PERQ URET CATH NEW ACCESS W RAD/GDE 50433 $6,791.00
CONV PERQ NEPH-URET CATH W RAD/GDE 50434 $3,392.00
EXCHANGE PERQ NEPH CATH W RAD/GDE 50435 $3,392.00
DILAT EXISTING URINARY TRACT RS&I 50436 $3,480.00
Page 10 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
DILAT URINARY TRACT NEW ACCESS RS&I 50437 $5,854.00
PERC RADIOFREQ ABLATE RENAL TUMOR 50592 $9,815.00
CRYOABLATION RENAL TUMOR UNILATERAL 50593 $15,191.00
ENDOLUMINAL BX PELVIS W RAD/GDE 50606 $2,496.00
INJECT RETROGRADE/CONDUIT X-RAY 50690 $1,230.00
PERQ URTRL STENT EXIST W RAD/GDE 50693 $10,671.00
PERQ URTRL STENT NEW WO CATH W RGDE 50694 $10,671.00
PERQ URTRL STENT NEW W CATH W RGDE 50695 $10,671.00
ASPIRATION BLADDER TROCAR/INTRACATHETER 51101 $2,042.00
ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER 51102 $5,316.00
INJECTION FOR BLADDER X-RAY 51600 $1,130.00
INJECT FOR RETROGRADE URETHOCYSTO 51610 $534.00
BLADDER IRRIGATION 51700 $460.00
INSERTION CATH MINI 51701 $371.00
INSERTION CATHETER FOLEY 51702 $413.00
BLADDER TUBE CHANGE 51705 $792.00
BLADDER TUBE CHANGE, COMPLICATED 51710 $1,679.00
ANAL URINARY MUSCLE STUDY 51785 $460.00
BLADDER SCAN PROCEDURE 51798 $234.00
CIRCUMCISION 54150 $3,392.00
INJECT CORPORA CAVERN,PHARM AGNT 54235 $758.00
INSERT UTERINE TNDM/VAG OVOID 57155 $7,544.00
INSERT VAG RAD AFTLOAD DEVICE 57156 $1,617.00
CATH/INJECT HYSTEROSALPINGOGRAM 58340 $1,067.00
AMNIOCENTESIS-DIAGNOSTIC 59000 $1,518.00
FETAL CONTRACTION STRESS TEST 59020 $1,370.00
FETAL NON-STRESS TEST 59025 $782.00
D/C OR D/E 59160 $5,151.00
INSERTION-CERVICAL DIALATOR 59200 $1,359.00
EPISIOTOMY OR VAGINAL REPAIR,BY OTHER THAN ATTENDING PHY 59300 $4,546.00
CERVICAL CERCLAGE 59320 $5,430.00
DELIVERY SERVICES-VAGINAL 59409 $5,233.00
EXTERNAL CEPHALIC VERSION 59412 $5,430.00
DELIVERY PLACENTA (SEP PROC) 59414 $5,151.00
C-SECTION DELIVERY SER 59514 $4,171.00
TREATMENT,MISSED AB,ANY TRI. 59812 $5,430.00
CERCLAGE REMOVAL 59899 $321.00
ASPIRATION AND/OR INJECTION THYROID CYST 60300 $1,402.00
Page 11 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
BRAIN CANAL SHUNT PROCEDURE 61070 $1,983.00
ICP MONITOR INSERTION 61107 $3,831.00
ENDOVASC TEMP BALLOON OCCLUS,HEAD/NECK 61623 $33,120.00
PERM OCCLUSION/EMBOLIZATION,PERCUT, CNS 61624 $11,916.00
PERCUT CATH OCCLUSN NON CNS LESN 61626 $30,109.00
INTRACRANIAL BALLOON ANGIOPLASTY 61630 $14,423.00
INTRACRANIAL BALLOON ANGIOPLSTY W/STENT 61635 $17,436.00
BALLOON DILATION INTRACRANIAL VASOSPASM INIT 61640 $24,663.00
PERQ ART M-THROMBECT NFS 61645 $14,570.00
ENDOVAS INTRACRANIAL RX ADMIN INIT 61650 $9,157.00
ENDOVAS INTRACRANIAL RX ADMIN ADDL 61651 $4,579.00
CSF SHUNT REPROGRAM 62252 $825.00
PERCUT ASPIR VERTEBRAL DISC 62267 $2,245.00
LUMBAR PUNCTURE DX 62270 $1,519.00
LUMBAR PUNCTURE-DIAGNOSTIC 62270 $1,519.00
SPINAL PUNCTURE,LUMBAR,DIAG. 62270 $1,519.00
SPINAL PUNCTURE,LUMBAR,DIAGNOSTIC 62270 $1,519.00
SPINAL PUNCTURE,DIAGNOSTIC 62270 $1,519.00
LUMBAR PUNCTURE-THERAPEUTIC 62272 $1,265.00
INJ,LUMB EPIDUR,BLOOD/CLOT PATCH 62273 $2,533.00
SPINAL BLOOD PATCH INJECTION 62273 $2,533.00
INJECT,MYELOGRAPHY &/OR CT SCAN,SPINAL 62284 $1,818.00
DISKO INJ,EA LEVEL-LUMBAR 62290 $2,376.00
MYELOGRAPHY VIA LUMBAR IN LUMBOSACRAL 62304 $3,499.00
MYELOGRAPHY VIA LUMBAR IN 2+ REGIONS 62305 $3,499.00
INJ,EPI CERV/THOR SINGLE W/O IG 62320 $2,554.00
INJ,EPI CERV/THOR SINGLE W IG 62321 $2,510.00
INJ,EPI LUMB/SAC SINGLE W IG 62323 $2,510.00
IMPLANT NEUROSTIM EPI ARRAY 63650 $16,542.00
INJ-ANES-TRIGEMINAL NERVE 64400 $1,043.00
INJ ANES GREATER OCCIPITAL NERVE 64405 $1,265.00
INJ-ANES AGENT-CERVICAL PLEXUS 64413 $1,395.00
INJ-ANES-BRACHIAL PLEXUS,SNGLE 64415 $2,022.00
INJ ANES SUPRASCAPULAR NERVE 64418 $1,395.00
INJ-INTERCOSTAL MULTIPLE 64421 $2,739.00
INJ-ANES-ILIOINGUINAL NERVES 64425 $1,395.00
INJ ANES AGENT OTHER PHER NRV 64450 $1,308.00
INJ-FORAMEN EPI CERV/THOR SNGL 64479 $2,654.00
Page 12 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
INJ-FORAMEN EPI CER/THOR ADDL 64480 $1,346.00
INJ-FORAMEN EPI LUM/SAC SNGL 64483 $3,114.00
INJ,FORAMEN,L/S,1 LEVEL 64483 $3,114.00
INJ-FORAMEN EPI LUM/SAC ADDL 64484 $1,633.00
INJ,FORAMEN,L/S,ADDL LEVELS 64484 $1,633.00
INJ PARA FACET C/T 1 LVL W/IG 64490 $4,308.00
INJ PARA FACET C/T 2D LVL W/IG 64491 $3,746.00
INJ PARA FACET C/T 3D LVL W/IG 64492 $3,568.00
INJ PARA FACET L/S 1 LVL W/IG 64493 $4,689.00
INJ PARA FACET L/S 2D LVL W/IG 64494 $3,310.00
INJ PARA FACET L/S 3D LVL W/IG 64495 $3,310.00
STELLATE GANGLION INJECTION 64510 $2,510.00
LUMBAR SYMP BLOCK 64520 $3,020.00
INJ ANES CELIAC PLEXUS 64530 $2,420.00
INJECT NERV BLOCK CELIAC PLEXUS 64530 $2,420.00
PRQ POST TIBIAL NV STIM SINGLE 64566 $667.00
BILAT CHEMODENERV MUSC INNERVATED 64615 $760.00
NEURO DEST FACET C/T W/IG SNGL 64633 $5,992.00
NEURO DEST FACET C/T W/IG ADDL 64634 $4,217.00
NEURO DEST FACET L/S W/IG SNGL 64635 $6,080.00
NEURO DEST FACET L/S W/IG ADDL 64636 $4,383.00
NEUROLYTIC DEST-OTHER NERVE 64640 $2,282.00
CHEMODENERVE- 1ST EXTREMITY 5+ MUSCLE(S) 64644 $1,395.00
CHEMODENERVE- ADDL EXTREMITY 5+ MUSCLE(S) 64645 $912.00
NEUROLYTIC DEST-CELIAC PLEXUS 64680 $5,261.00
REMOVAL FB EYE 65205 $592.00
CLEAR OUTER EAR CANAL 69200 $211.00
REM IMPACTED CERUMEN IRR/LVG UNILAT 69209 $362.00
REMOVAL IMPACTED CERUMEN INSTR UNILAT 69210 $362.00
X-RAY JAW <4 VW 70100 $413.00
X-RAY JAW 4+ VW 70110 $741.00
X-RAY FACIAL BONES <3 VW 70140 $476.00
X-RAY FACIAL BONES 3+ VW 70150 $803.00
X-RAY NASAL BONES 70160 $479.00
X-RAY ORBITS 70200 $672.00
X-RAY SINUSES <3 VW 70210 $396.00
X-RAY SINUSES 3+ VW 70220 $643.00
X-RAY SKULL <4 VW 70250 $537.00
Page 13 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
X-RAY SKULL 4+ VW 70260 $965.00
X-RAY TMJ BILAT 70330 $610.00
MRI, TMJ 70336 $3,187.00
PANORAMIC X-RAY OF JAWS 70355 $563.00
X-RAY NECK SOFT TISSUE 70360 $490.00
X-RAY SIALOGRAM 70390 $998.00
CT HEAD W/O CONT 70450 $2,540.00
CT HEAD W/ CONT 70460 $2,653.00
CT HEAD W/ AND W/OUT 70470 $2,919.00
POSTFOSSA/EAR W/O CONTRAST CT 70480 $2,597.00
POST-FOSSA/EAR W/CONTRAST CT 70481 $2,666.00
POSTFOSSA-EAR W,W/O CONTRST CT 70482 $3,042.00
CT MAXILLOFACIAL W/O 70486 $2,651.00
CT MAXILLOFACIAL W/ 70487 $2,814.00
CT MAXILLOFAC W/,W/O 70488 $2,991.00
SOFT TISSUE NECK W/O 70490 $2,581.00
CT SOFT TISSUE NECK W/ 70491 $3,102.00
CT NECK W/,W/O 70492 $2,990.00
CTA HEAD W/O,W,POST PROCESS 70496 $3,248.00
CTA NECK W/O,W,POST PROCESS 70498 $3,392.00
MRI, FACE, NECK 70540 $3,546.00
MRI, FACE, NECK W/CONTRAST 70542 $4,347.00
MRI, FACE, NECK, COMBO 70543 $5,060.00
MR ANGIO, HEAD 70544 $3,227.00
MR ANGIO, NECK 70547 $3,129.00
MR ANGIO, NECK W/CONTRAST 70548 $3,550.00
MR ANGIO, NECK, W&WO CONTRAST 70549 $3,971.00
MRI BRAIN 70551 $3,435.00
MRI BRAIN CONTRAST 70552 $3,621.00
MRI BRAIN COMBO 70553 $4,935.00
CHEST XRAY SINGLE VIEW 71045 $379.00
CHEST XRAY 2 VIEWS 71046 $531.00
CHEST XRAY 3 VIEWS 71047 $501.00
CHEST XRAY 4/MORE VIEWS 71048 $521.00
X-RAY RIBS 2 VW UNILAT 71100 $470.00
X-RAY RIBS, CHEST 3+ VW 71101 $601.00
X-RAY RIBS, CHEST 4+ VW 71111 $1,061.00
X-RAY STERNUM 2+ VW 71120 $471.00
Page 14 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
X-RAY STERNO-CLAVICLUAR JT 71130 $337.00
CT SCAN,THORAX,W/O CONTRAST 71250 $2,745.00
CAT SCAN OF CHEST CONTRAST 71260 $3,156.00
CAT SCAN OF CHEST COMBO 71270 $3,327.00
CT ANGIO, CHEST (NON-CORON), COMBO, INCL IMG PROC 71275 $3,812.00
MRI, CHEST 71550 $3,919.00
MRI, CHEST, COMBO 71552 $5,742.00
X-RAY SPINE ONE VIEW 72020 $416.00
X-RAY CERV SPINE 2 VW 72040 $593.00
X-RAY CERV SPINE 4 VW 72050 $769.00
X-RAY CERV SPINE 7 VW 72052 $828.00
X-RAY THORACIC SPINE 2 VW 72070 $560.00
X-RAY THORACIC SPINE+SWIM 3 VW 72072 $667.00
X-RAY THORACIC SPINE 4 VW 72074 $764.00
X-RAY THOR-LUMB SP 2 VW 72080 $525.00
XR SPINE ENTIRE L/T ONE VW 72081 $207.00
X-RAY LUMBAR SPINE 2/3 VW 72100 $582.00
X-RAY LUMBAR SPINE 4 VW 72110 $873.00
SPINE L/S COMPLETE W BEND 6+ 72114 $1,101.00
DX SPINE L/S BENDING ONLY 2-3 VIEWS 72120 $758.00
CT SCAN,CERVICAL SPINE,W/O CONTRAST 72125 $3,200.00
CT SCAN CERV SPINE CONTRAST 72126 $3,418.00
CT SCAN CERV SP COMBO 72127 $3,675.00
CT SCAN,THORACIC SPINE,W/O CONTRAST 72128 $2,935.00
CT SCAN DORSAL SP CONTRAST 72129 $2,758.00
CT SCAN,LUMBAR SPINE,W/O CONTRAST 72131 $3,133.00
CT SCAN LUMBAR SP CONTRAST 72132 $3,549.00
MRI, CERV SPINE 72141 $4,022.00
MRI, CERV SPINE CONTRAST 72142 $4,302.00
MRI, DORSAL SPINE 72146 $3,935.00
MRI, DORSAL SPINE CONTRAST 72147 $3,825.00
MRI, LUMBAR SPINE 72148 $4,096.00
MRI, LUMBAR SPINE CONTRAST 72149 $3,972.00
MRI, CERV SPINE COMBO 72156 $5,400.00
MRI, DORSAL SPINE COMBO 72157 $5,181.00
MRI, LUMBAR SPINE COMBO 72158 $5,250.00
X-RAY PELVIS 1/2 VW 72170 $416.00
X-RAY PELVIS 3+ VW 72190 $569.00
Page 15 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
CT ANGIO, PELVIS, COMBO, INCL IMAGE PROC 72191 $3,336.00
CT SCAN,PELVIS,W/O CONTRAST 72192 $2,774.00
CT SCAN OF PELVIS CONTRAST 72193 $3,460.00
CT SCAN OF PELVIS COMBO 72194 $3,799.00
MRI, PELVIS, W/O CONTRAST 72195 $3,638.00
MRI, PELVIS W/CONTRAST 72196 $3,261.00
MRI, PELVIS, COMBO 72197 $5,149.00
X-RAY SACROILIAC JTS <3 VW 72200 $431.00
X-RAY SACROILIAC JTS 3+ VW 72202 $571.00
X-RAY SACRUM/COCCYX 2+ VW 72220 $480.00
MYELOGRAPHY LUMBAR SPINE 72265 $1,691.00
EPIDUROGRAPHY,SUPERV/INTERPRET 72275 $1,427.00
DISCO,EA LEVEL,S&I-LUMBAR 72295 $5,651.00
X-RAY CLAVICLE 73000 $421.00
X-RAY SCAPULA 73010 $475.00
X-RAY SHOULDER 1 VW 73020 $415.00
X-RAY SHOULDER 2+ VW 73030 $515.00
ARTHROGRAM OF SHOULDER 73040 $1,253.00
X-RAY AC JTS 73050 $479.00
X-RAY HUMERUS 73060 $457.00
X-RAY ELBOW 2 VW 73070 $405.00
X-RAY ELBOW 3+ VW 73080 $521.00
X-RAY FOREARM 2 VW 73090 $444.00
X-RAY ARM, INFANT 73092 $406.00
X-RAY WRIST 2 VW 73100 $413.00
X-RAY WRIST 3+ VW 73110 $550.00
ARTHROGRAM OF WRIST 73115 $1,149.00
X-RAY HAND 2 VW 73120 $345.00
X-RAY HAND 3+ VW 73130 $536.00
X-RAY EXAM OF FINGER(S) 73140 $353.00
CT SCAN,UPPER EXTREMITY,W/O CONTRAST 73200 $2,546.00
CT SCAN OF ARM CONTRAST 73201 $2,752.00
CT SCAN OF ARM COMBO 73202 $3,305.00
CT ANGIO,UPPER EXTREM,COMBO 73206 $2,970.00
MRI, UPPER EXTREM 73218 $3,174.00
MRI UPPER EXTR, W/CONTRAST 73220 $5,294.00
MRI, JOINT UPPER EXTREM 73221 $3,577.00
MRI, JOINT UPPER EXTREM W/CONTRAST 73222 $3,586.00
Page 16 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
MRI, JOINT UPPER EXTREM COMBO 73223 $4,232.00
MR ANGIO UPPER EXTREMITY W/CONT 73225 $5,513.00
MR ANGIO UPPER EXTREMITY W/ W/O CONT 73225 $5,513.00
XRAY HIP UNI W/WO PELVIS 1 VW 73501 $207.00
XRAY HIP UNI W/WO PELVIS 2-3 VW 73502 $311.00
XRAY HIP BIL W/WO PELVIS 2 VW 73521 $427.00
XRAY HIP BIL W/WO PELVIS 3-4 VW 73522 $599.00
XRAY HIP BIL W/WO PELVIS 5+ VW 73523 $1,304.00
ARTHROGRAM OF HIP 73525 $913.00
XRAY FEMUR 1 VW 73551 $207.00
XRAY FEMUR 2+ VW 73552 $258.00
X-RAY KNEE 1 OR 2 VIEW 73560 $422.00
X-RAY KNEE 3 VIEW 73562 $538.00
X-RAY KNEE 4+ VIEW 73564 $645.00
X-RAY KNEE BILAT STANDING 73565 $360.00
X-RAY TIB + FIB, 2VW 73590 $457.00
X-RAY LEG, INFANT 73592 $458.00
X-RAY ANKLE 2 VW 73600 $410.00
X-RAY ANKLE 3+ VW 73610 $547.00
ARTHROGRAM OF ANKLE 73615 $974.00
X-RAY FOOT 2 VW 73620 $428.00
X-RAY FOOT 3+ VW 73630 $478.00
X-RAY HEEL 73650 $416.00
X-RAY TOE(S) 73660 $334.00
CT SCAN,LOWER EXTREMITY,W/O CONTRAST 73700 $2,619.00
CT SCAN OF LEG CONTRAST 73701 $2,731.00
CT SCAN OF LEG COMBO 73702 $2,633.00
CT ANGIO,LOWER EXTREM,COMBO,IMAGE PRC 73706 $3,714.00
MRI, LOWER EXTREM 73718 $3,561.00
MRI, LOWER EXTREM W/CONTRAST 73719 $3,941.00
MRI, LOWER EXTR, W/O CONTRAST F/U BY CONTRAST 73720 $4,575.00
MRI LOWER EXTREM JT, W/O CONTRAST 73721 $4,024.00
MRI, JOINT OF LEG W/CONTRAST 73722 $3,751.00
MRI, JOINT OF LEG. COMBO 73723 $4,999.00
XRAY ABDOMEN 1 VIEW 74018 $404.00
XRAY ABDOMEN 2 VIEWS 74019 $688.00
XRAY ABDOMEN 3/MORE VIEWS 74021 $688.00
X-RAY ABDOMEN,COMP ACUTE SERIES 74022 $847.00
Page 17 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
CT SCAN,ABDOMEN,W/O CONTRAST 74150 $2,907.00
CT SCAN OF ABDOMEN CONTRAST 74160 $3,651.00
CT SCAN OF ABDOMEN COMBO 74170 $4,104.00
CTA ABD/PEL W & W/O 74174 $7,453.00
CT ANGIO, ABD, COMBO,INCL IMAGE PROCESS 74175 $3,393.00
CT SCAN,ABD & PELVIS,W/O CONTRAST 74176 $7,909.00
CT SCAN,ABD & PELVIS,W CONTRAST 74177 $7,588.00
CT SCAN,ABD & PELVIS,COMBO 74178 $8,609.00
MRI, ABDOMEN (MRI) 74181 $3,410.00
MRI, ABDOMEN, COMBO 74183 $5,255.00
X-RAY PERITONEUM 74190 $1,028.00
CONTRAST XRAY THROAT/CERV ESOPHA 74210 $625.00
ESOPHAGRAM 74220 $848.00
SWALLOWING FCN,W/CINE &/OR VIDEO 74230 $786.00
XRAY UPPER GI TRACT 74240 $823.00
XRAY UPPER GI TRACT + KUB 74241 $1,251.00
XRAY UPPER GI TRACT,W/SMALL INTEST,F/T 74245 $1,553.00
XRAY UPPER GI AIR CONTRAST+KUB 74247 $1,156.00
X-RAY,UPPER GI TRACT W/CONT,SMALL INTEST 74249 $1,825.00
X-RAY,SMALL BOWEL,W/MULT SERIAL FILMS 74250 $1,034.00
X-RAY COLON CONTRAST 74270 $1,183.00
X-RAY COLON AIR CONTRAST 74280 $1,266.00
X-RAY B.E. REDUCTN INTUSS 74283 $1,290.00
X-RAY OPER CHOLANGIOGRAM 74300 $1,155.00
X-RAY OPER CHOLANGIO ADDNL SET 74301 $693.00
X-RAY FOR BILE DUCT ENDOSCOPY 74328 $1,611.00
X-RAY FOR PANCREAS ENDOSCOPY 74329 $1,344.00
X-RAY BILE/PANCREAS ENDOSCOPY 74330 $1,622.00
X-RAY IV PYELOGRAM (IVP) 74400 $1,267.00
X-RAY RETROGRADE PYELOGRAM 74420 $982.00
X-RAY ANTEGRADE PYELOGRAM TUBE 74425 $939.00
X-RAY CYSTOGRAM, MIN 3 VIEW 74430 $994.00
X-RAY URETHROCYSTOGRAM 74450 $1,056.00
X-RAY URETHROCYSTOGRAM+VOIDING S&I 74455 $969.00
DILATION URETER(S) URETHRA RS&I 74485 $3,392.00
X-RAY HYSTEROSALPINGOGRAM 74740 $603.00
CARDIAC MRI MORPHOLOGY & FUNCTION WO CONTRAST 75557 $3,246.00
CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ 75561 $3,470.00
Page 18 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
CT HEART W/O CONTRAST QUANT EVAL CALCIUM 75571 $964.00
CT CONT EVAL CARD CONGEN HEART DISEASE 75573 $3,922.00
CT ANGIO HRT CORNRY ART/BYPASS GRFTS CONTRAST 3D POST 75574 $3,394.00
CONTRAST EXAM THORACIC AORTA 75600 $7,003.00
ANGIO AORTOGRAM THOR SERIAL 75605 $8,530.00
ABDOMINAL AORTOGRAM S&I 75625 $6,600.00
ANGIO AORTOGRAM ABD SERIAL 75625 $6,600.00
ANGIO AORTOBIFEMORAL W CATH 75630 $6,600.00
CT ANGIO AORTOBIFEMORAL, COMBO 75635 $3,024.00
ANGIO SPINAL SELECTV 75705 $8,530.00
ANGIO EXTREMITY UNILAT 75710 $6,600.00
S & I EXTREMITY BILATERAL 75716 $6,600.00
ANGIO EXTERMITY BILAT 75716 $6,600.00
ANGIO VISCERAL SELECTV/SUBSELEC 75726 $8,530.00
ANGIO PELVIS 75736 $8,530.00
ANGIO PULMON UNILAT SELECT 75741 $6,600.00
ANGIO PULMON BILAT SELECT 75743 $6,600.00
ANGIO EA ADDNL SELECTV VESSEL 75774 $3,410.00
VENOGRAM EXTREM UNILAT 75820 $1,621.00
VENOGRAPHY,EXTREMITY UNI S&I 75820 $1,621.00
VENOGRAM EXTREM BILAT 75822 $1,966.00
VENOGRAM INFER VENA CAVA 75825 $4,986.00
VENOGRAM SUPER VENA CAVA 75827 $2,548.00
VENOGRAM RENAL UNILAT 75831 $4,986.00
VENOGRAM SINUS/JUGULAR 75860 $4,986.00
PERCUT XHEPATIC PORTO+DYNAMIC 75885 $4,986.00
PERCUT XHEPATIC PORTOGRAM 75887 $4,227.00
VENOGRAM HEPATIC W HEMODYNAMICS 75889 $4,986.00
VENOUS SAMPLING BY CATHETER 75893 $8,530.00
TRANSCATHETER RX EMBOLIZATN 75894 $5,929.00
ANGIOGRAM,F/U STUDY,CATH THER/EMBOL/INF 75898 $1,966.00
REMOVE,OBST MATL,CVA DEV VIA SEP VIA SEP VEN ACC 75901 $469.00
VASCULAR BIOPSY 75970 $3,482.00
CHANGE PERCUT TUBE/DRAIN CATH W CONTRAST 75984 $1,647.00
RAD GUIDED,PERCUT DRAINAGE,W/CATH PLACE 75989 $1,919.00
CARDIAC FLUORO/FILM 76000 $833.00
FLUOROSCOPE EXAMINATION 76000 $833.00
X-RAY NOSE-RECTUM CHILD F.B. 76010 $402.00
Page 19 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
X-RAY FISTULA,ABSCESS,SINUS TRACT 76080 $936.00
X-RAY EXAM, BREAST SPECIMEN 76098 $974.00
3D RENDER W/O IMAGE POSTPROCESS 76376 $822.00
3D RENDERING W/ IMAGE POSTPROCESS 76377 $1,213.00
CT SCAN,LIMITED/LOCALIZED F/U STUDY 76380 $1,274.00
MRI SPECTROSCOPY 76390 $2,949.00
UNLISTED DX RADIOGRAPHIC PROCEDURE 76499 $1,434.00
HEAD, REAL TIME 76506 $904.00
HEAD/NECK TISSUES,REAL TIME 76536 $989.00
CHEST,REAL TIME 76604 $742.00
ULTRASOUND BREAST COMPLETE 76641 $315.00
ULTRASOUND BREAST LIMITED 76642 $263.00
ABDOM,B-SCAN &/OR REAL TIME,COMPLETE 76700 $1,420.00
ABDOMEN LIMITED 76705 $1,006.00
US RETROPERITONEAL COMPLETE 76770 $1,298.00
US,RETROPERIT,REAL TIME,COMPLETE 76770 $1,298.00
RETROPERITNL ABD, LTD 76775 $884.00
US,TRANSPLANTED KIDNEY, REAL TIME/DOPPLER 76776 $919.00
SPINAL CANAL & CONTENTS 76800 $895.00
OB < 14 WKS, SINGLE FETUS 76801 $877.00
OB < 14 WKS, ADD'L FETUS 76802 $462.00
OB >/= 14 WKS, SNGL FETUS 76805 $1,235.00
OB >/= 14 WKS, ADDL FETUS 76810 $1,051.00
US,PREG UT,FET & MAT,DETL FET EXM 76811 $786.00
ULTRASOUND OF PREG UTERUS LMTD 76815 $649.00
US,PREGNANT UTERUS,LIMITED, 1/> FETUSES 76815 $649.00
US,PREGNANT UTERUS,F/U,TRANSABD APP 76816 $541.00
US,PREGNANT UTERUS,TRANSVAGINAL 76817 $646.00
FETAL BIOPHYSICAL PROFILE WO NST 76819 $735.00
US DOPPLER FETAL UMBILICAL ARTERY 76820 $636.00
ECHOGRAPHY,TRANSVAGINAL 76830 $893.00
US,PELVIC (NONOB),REAL TIME,COMP 76856 $1,140.00
US,PELVIC (NONOB),REAL TIME LIMIT 76857 $749.00
ECHO,SCROTUM & CONTENTS 76870 $985.00
US COMPL JOINT RT W/IMAGE DOC 76881 $885.00
US LTD JOINT RT W/IMAGE DOC 76882 $571.00
US,INFANT HIPS,DYNAMIC 76885 $558.00
US,INFANT HIPS,LIMITED/STATIC 76886 $427.00
Page 20 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
US GUIDANCE FOR PERICARDIOCENTESIS 76930 $712.00
PSEUDO-ANEURYSM COMPRESSION 76936 $889.00
US GUID,COMP REPAIR,PSEUDO-ANEUR/ANEUR/AV FIST 76936 $889.00
US GUIDANCE FOR VASCULAR ACCESS 76937 $604.00
US GUIDANCE FOR NEEDLE PLACEMENT 76942 $1,145.00
US GUIDE AMNIOCENTESIS 76946 $475.00
US GUIDANCE FOR RADIOELEMENT APPL 76965 $1,838.00
ULTRASOUND EXAM FOLLOW-UP 76970 $339.00
ULTRASOUND ELASTOGRAPHY PARENCHYMA 76981 $560.00
FLUORO GUIDE VENOUS ACCESS DEVICE 77001 $692.00
FLUORO GUIDE NEEDLE PLACEMENT 77002 $819.00
FLUORO GUIDE SPINE INJECTION 77003 $908.00
CT GUIDANCE NEEDLE PLACEMENT 77012 $2,751.00
CT GUIDANCE TISSUE ABLATION 77013 $2,531.00
MRI BREAST WO CONTRAST UNILATERAL 77046 $3,272.00
MRI BREAST WO CONTRAST BILATERAL 77047 $4,110.00
MAMMARY DUCTOGRAM, SINGLE 77053 $563.00
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS, UNILAT OR BILAT 77063 $70.00
DX MAMMO UNILATERAL W/WO CAD 77065 $356.00
DX MAMMO BILAT W/WO CAD 77066 $474.00
SCREENING MAMMO BILAT W/WO CAD 77067 $318.00
X-RAYS FOR BONE AGE 77072 $372.00
X-RAYS, BONE LENGTH STUDIES 77073 $528.00
X-RAYS, BONE SURVEY, LIMITED 77074 $809.00
X-RAYS, BONE SURVEY COMPLETE 77075 $1,094.00
X-RAYS, BONE SURVEY, INFANT 77076 $803.00
JOINT SURVEY, SINGLE VIEW 77077 $400.00
DEXA,BONE DENSITY,AXIAL SKELETON 77080 $269.00
SIMPLE SIMULATION 77280 $2,999.00
INTERMED SIMULATION 77285 $2,644.00
COMPLEX SIMULATION 77290 $4,536.00
RESPIRATORY MOTION MGMT SIMULATION 77293 $5,164.00
SIM-AIDED FIELD SETTING;3-D 77295 $8,689.00
BASIC DOSIMETRY 77300 $1,009.00
IMRT PLAN 77301 $14,756.00
TELETHERAPY ISODOSE PLAN SIMPLE 77306 $647.00
TELETHERAPY ISODOSE PLAN COMPLEX 77307 $8,530.00
SPECIAL DOSIMETRY 77331 $1,004.00
Page 21 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
BEAM SHAP. DEVICE SIMP 77332 $1,058.00
BEAM SHAPING DEV INTER 77333 $1,291.00
BEAM SHAPING DEV COMP 77334 $2,175.00
CONT PHYSICS SUPPORT 77336 $1,172.00
MLC DEVICE DESIGN FOR IMRT 77338 $16,036.00
SPEC MED PHYS CONSULT 77370 $1,486.00
SRS TX 1 SESSION CRANIAL LINEAR 77372 $16,907.00
LINAC SRS FRACT PER SESSION M5 FRACT 77373 $6,593.00
IMRT DELIVERY SIMPLE 77385 $3,667.00
IMRT DELIVERY COMPLEX 77386 $3,667.00
GUIDANCE FOR RT DELIVERY 77387 $1,763.00
RT DELIVERY >=1 MEV SIMPLE 77402 $340.00
RT DELIVERY >=1 MEV COMPLEX 77412 $1,634.00
R.T.PORT FILM 77417 $537.00
SPECIAL TREATMENT PROCEDURE 77470 $3,326.00
AFTERLOAD BRACHY WWO DOSI 1CH 77770 $8,576.00
AFTERLOAD BRACHY WWO DOSI 2-12CH 77771 $16,636.00
AFTERLOAD BRACHY WWO DOSI >12CH 77772 $25,850.00
INTERSTI.RADIO.AP:10+ 77778 $7,932.00
THYROID UPTAKE MEASUREMENT 78012 $699.00
THYROID IMAGING W/BLOOD FLOW 78013 $1,246.00
THYROID IMAGING W/BLOOD FLOW W/UPTAKE 78014 $1,625.00
THYROID MET IMAGING BODY 78018 $2,668.00
PARATHYROID NUCLEAR IMAGING 78070 $1,762.00
LYMPHATICS & LYMPH GLANDS IMAGING 78195 $2,464.00
LIVER IMAGING (SPECT) 78205 $2,479.00
LIVER IMAGE (3-D) W/FLOW 78206 $1,930.00
LIVER AND SPLEEN IMAGING 78215 $1,598.00
HEPATOBILIARY IMAGING 78226 $2,615.00
HEPATOBILIARY WITH CCK 78227 $2,490.00
GASTRIC EMPTYING STUDY 78264 $2,180.00
ACUTE GI BLOOD LOSS IMAGING 78278 $1,841.00
BOWEL IMAGING 78290 $1,736.00
BONE IMAGING, LIMITED AREA 78300 $1,465.00
BONE IMAGING, WHOLE BODY 78306 $2,249.00
BONE IMAGING, 3 PHASE 78315 $2,479.00
BONE IMAGING (SPECT) 78320 $2,291.00
MYOCARDIAL SPECT MULTIPLE STUDIES 78452 $5,091.00
Page 22 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
GATED HEART, PLANAR SINGLE 78472 $2,320.00
PET MYOCARDIAL PERF MULTIPLE 78492 $5,872.00
CARDIOVASC NUCL EXAM UNLISTED 78499 $1,221.00
LUNG PERFUSION IMAGING 78580 $2,081.00
LUNG VENT/PERF IMAGING 78582 $3,149.00
QUANT DIFF LUNG PERF/VENT 78598 $3,149.00
BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR 78606 $2,034.00
BRAIN IMAGING TOMOGRAPHIC SPECT 78607 $2,406.00
BRAIN IMAGING PET METABOLIC 78608 $5,404.00
BRAIN FLOW IMAGING ONLY 78610 $1,393.00
CSF FLUID SCAN CISTERNOGRAPHY 78630 $3,637.00
CSF LEAKAGE DETECTION & LOCALIZATION 78650 $2,406.00
RENAL IMAGING, MORPH W/ FLOW/FUNC 78707 $2,185.00
RENAL IMAG, MORPH W/ FLO/FUNC, RX SGL 78708 $2,115.00
URETERAL REFLUX STUDY 78740 $1,661.00
TUMOR IMAGING, LIMITED AREA 78800 $1,674.00
TUMOR IMAGING, WHOLE BODY 78802 $2,418.00
TUMOR IMAGING, WHOLE BODY, 2 OR MORE DAYS 78804 $3,303.00
ABSCESS IMAGING, LTD AREA 78805 $2,406.00
ABSCESS IMAGING, WHOLE BODY 78806 $3,170.00
PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 78815 $6,316.00
PET IMAGING FOR CT ATTENUATION WHOLE BODY 78816 $6,571.00
NUC THERAPY INTRACAVITARY RADIOCOLLOID 79005 $2,085.00
RADIOACTIVE THERAPY INTRA ART ADMIN 79445 $1,043.00
BASIC METABOLIC PAN-ION CALC 80047 $240.00
BASIC METABOLIC PANEL 80048 $371.00
ELECTROLYTES, SERUM 80051 $169.00
COMP METABOLIC PANEL 80053 $482.00
OBSTETRIC PANEL 80055 $347.00
LIPID PANEL 80061 $371.00
RENAL PANEL 80069 $200.00
ACUTE HEPATITIS PANEL 80074 $468.00
HEPATIC FUNCTION PANEL 80076 $405.00
AMIKACIN 80150 $165.00
DRUG SCREEN CAFFEINE QUANT 80155 $78.00
CARBAMAZEPINE TOTAL 80156 $210.00
CYCLOSPORIN (CYCLO) 80158 $445.00
DIGOXIN 80162 $162.00
Page 23 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
VALPROIC ACID (DEPAKANE) 80164 $205.00
ETHOSUXIMIDE 80168 $129.00
DRUG ASSAY EVEROLIMUS REF 80169 $233.00
GENTAMICIN 80170 $226.00
DRUG SCREEN GABAPENTIN QUANT 80171 $63.00
DRUG SCREEN LAMOTRIGINE QUANT 80175 $63.00
LIDOCAINE (XYLOCAINE) 80176 $165.00
DRUG SCREEN LEVETIRACETAM QUANT 80177 $63.00
LITHIUM 80178 $191.00
DRUG SCREEN MYCOPHENOLATE QUANT 80180 $85.00
DRUG SCREEN OXCARBAZEPINE QUANT 80183 $63.00
PHENOBARB 80184 $201.00
PHENOBARBITAL 80184 $201.00
DILANTIN (PHENYTOIN) 80185 $198.00
PHENYTOIN FREE 80186 $121.00
PRIMIDONE 80188 $130.00
TACROLIMUS 80197 $433.00
THEOPHYLLINE (AMINOPHYLLINE) 80198 $185.00
TOBRAMYCIN 80200 $357.00
TOPIRAMATE 80201 $154.00
VANCOMYCIN LEVEL 80202 $216.00
ZONISAMIDE QUANT 80203 $63.00
METHOTREXATE 80299 $401.00
DRUG QUANTITATION-NOT SPECIFED 80299 $401.00
DRUG TEST PRSMV DIR OPT OBS LAB 80305 $167.00
DRUG TEST PRSMV CHEM ANLYZR LAB 80307 $167.00
DRUG TEST PRSMV CHEM ANLYZR REF 80307 $167.00
DRUG TEST PAIN MANAGEMENT REF 80307 $167.00
DRUG TEST PAIN MANAGEMENT RFLX REF 80307 $167.00
CLINICAL PATH CONSULT-LIMITED 80500 $192.00
URINALYSIS COMPLETE (UA) 81001 $158.00
URINALYSIS (DIPSTICK) W/O MIC 81002 $90.00
URINALYSIS,NON-AUTO,W/O MICRO 81002 $90.00
URINALYSIS,AUTO W/O MICRO 81003 $92.00
URINALYSIS MICRO 81015 $80.00
URINE PREGNANCY TEST COLOR COMP 81025 $190.00
URINE PREGNANCY TEST-COLORCOMP 81025 $190.00
URINE VOL.MEASURE,TIMED COLL. 81050 $46.00
Page 24 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
BRCA1&2 SEQ FULL DUP DEL REF 81162 $6,215.00
BCR ABL1 TRANSLOCATION REF 81206 $741.00
BCR/ABL1 GENE MINOR BRK-REF 81207 $654.00
BRCA1 GENE KNOWN FAM VARIANT REF 81215 $751.00
CALR GEN EXON 9 MUTATION PCR REF 81219 $520.00
CFTR GENE COMMON VAR REF 81220 $1,114.00
CFTR GENE DUP DELET VARIANT REF 81222 $1,338.00
CFTR GENE FULL SEQUENCE-REF 81223 $2,646.00
CYTOGEN M ARRAY COPY NO&SNP-REF 81229 $4,064.00
F2 GENE ANALYSIS A VARIANT REF 81240 $233.00
F5 GENE LEIDEN VAR 81241 $290.00
FMR1 GENE DETECTION (FRAGILE X) - REF 81243 $276.00
FMR1 GENE ALLELE CHARACTERIZATION REF 81244 $789.00
HFE GENE ANALYSIS REF 81256 $310.00
HBA1/HBA2 GENE-REF 81257 $872.00
IKBKAP GENE 81260 $189.00
IGH VARI REGIONAL MUTATION REF 81263 $1,563.00
JAK2 V617F MUTATION DETECT 81270 $394.00
MTHFR GENE COMMON VARIANT REF 81291 $208.00
PCA3/KLK3 ANTIGEN - REF 81313 $801.00
PMS2 GENE KNOWN FAM VARIANT REF 81318 $750.00
SNRPN/UBE3A GENE-REF 81331 $537.00
TPMT GENE ANAL COMMON VARIANTS REF 81335 $710.00
TRG GENE REARRANGEMENT ANALYSIS REF 81342 $953.00
HLA I TYPING 1 ANTIGEN LR-REF 81374 $313.00
HLA II TYPING 1 LOCUS LR - REF 81376 $437.00
HLA I TYPING COMPLETE HR REF 81379 $1,951.00
HLA I TYPING 1 LOCUS HR-REF 81380 $762.00
HLA I TYPING 1 ALLELE HR REF 81381 $340.00
HLA II TYPING 1 LOC HR-REF 81382 $746.00
HLA II TYPING 1 ALLELE HR - REF 81383 $391.00
MOPATH PROCEDURE LEVEL 1 81400 $208.00
MOPATH LEVEL 2 APOE 2 Mutat-REF 81401 $938.00
MOPATH PROCEDURE LEVEL 3 81402 $988.00
MOPATH PROCEDURE LEVEL 4-REF 81403 $551.00
MOPATH PROCEDURE LEVEL 5-REF 81404 $2,646.00
MOPATH PROCEDURE LEVEL 6-REF 81405 $1,323.00
FETAL CHROMOSOMAL ANEUPLOIDY REF 81420 $1,900.00
Page 25 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
FETAL CHRMOML MICRODELTJ REF 81422 $2,006.00
UNLISTED MOLECULAR PATH-500-REF 81479 $1,213.00
FETAL CONGEN ABNOR ASSAY 2 ANAL REF 81508 $125.00
FETAL CONGENITAL ABNOR ASSAY 4 ANAL 81511 $307.00
ONCOLOGY PROSTATE PROB SCORE REF 81539 $1,520.00
ACETONE OR KETONES-SERUM-QUANT 82010 $110.00
ACYLCARNITINE QUANT 82017 $243.00
ACTH 82024 $489.00
CYCLIC AMP 82030 $242.00
ALBUMIN,SERUM 82040 $76.00
ALBUMIN OTHER SOURCE QUAN EA LAB 82042 $76.00
ALBUMIN OTHER SOURCE QUAN EA REF 82042 $76.00
MICROALBUMIN URINE QT 82043 $116.00
ALDOLASE 82085 $158.00
ALDOSTERONE 82088 $279.00
ALPHA I ANTITRYPSIN 82103 $235.00
ALPHA-1-ANTITRYPSIN,PHENOTYPE 82104 $252.00
ALPHA FETO PROTEIN 82105 $159.00
ALPHA FETOPROTEIN AM 82106 $186.00
AFP L3 FRACTION & TOTAL AFP REF 82107 $204.00
ALUMINUM 82108 $151.00
AMINO ACID SINGL QUANT EA SPEC 82131 $372.00
AMINOLEVULINIC ACID 82135 $131.00
AMINO ACIDS QUANT 82139 $894.00
AMMONIA 82140 $172.00
AMYLASE URINE TIMED 82150 $263.00
AMYLASE 82150 $263.00
ANDROSTENEDIONE 82157 $167.00
ANGIOTENSIN II 82163 $342.00
ANGIOTENSIN I CONV ENZYME 82164 $258.00
APOLIPOPROTEIN A1 REF 82172 $191.00
APOLIPOPROTEIN B 82172 $191.00
ARSENIC 82175 $135.00
ASCORBIC ACID-VITC 82180 $92.00
BETA 2 MICROGLOBULIN 82232 $137.00
BILE ACIDS TOTAL 82239 $144.00
BILIRUBIN,TOTAL 82247 $91.00
BILIRUBIN DIRECT LAB 82248 $88.00
Page 26 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
OCCULT BLOOD STOOL 3 SPECIMENS 82270 $74.00
OCCULT BLOOD,OTHER SOURCES 82271 $55.00
BLOOD OCCULT-FECES 1 SPECIMEN 82272 $50.00
BLOOD OCCULT PEROXIDASE SINGLE 82272 $50.00
OCCULT BLOOD FECES IMMUNOASSAY 82274 $119.00
CADMIUM 82300 $110.00
VITAMIN D,25 HYDROXY 82306 $231.00
CALCITONIN BY RIA 82308 $193.00
CALCIUM 82310 $83.00
CALCIUM IONIZED 82330 $145.00
CALCIUM URINE RANDOM 82340 $99.00
CALCIUM,URINE QUANT,TIMED SPEC 82340 $99.00
CALCULUS SPECTROSCOPY 82365 $50.00
CDT (CARB DEF TRANSFERRIN) 82373 $470.00
CARBON DIOXIDE 82374 $71.00
CARBOXYHEMOGLOBIN,QUANT 82375 $139.00
CARCINOEMBRYONIC ANTIGEN 82378 $299.00
CARNITINE(T&F),QUANT,EA SPEC. 82379 $206.00
CAROTENE 82380 $166.00
CATECHOLAMINES FRACT 82384 $221.00
CERULOPLASMIN 82390 $133.00
CHEMILUMINESCENT ASSAY 82397 $540.00
CHLORIDE SERUM (CL) 82435 $65.00
CHLORIDE URINE 82436 $82.00
CHLORIDE-OTHER SOURCE 82438 $87.00
CHOLESTEROL 82465 $83.00
CHOLINESTERASE,SERUM 82480 $89.00
CHOLINESTERASE RBC 82482 $102.00
ASSAY OF CHROMIUM 82495 $71.00
CITRATE 82507 $191.00
COLLAGEN CROSSLINKS,ANY METH. 82523 $151.00
COPPER SERUM 82525 $108.00
CORTICOSTERONE 82528 $331.00
CORTISOL,FREE 82530 $162.00
CORTISOL 82533 $192.00
CREATINE 82540 $108.00
COL CHROMO/MASS SPECT,QUAL,SNG 82542 $364.00
CREATINE KINASE(CK)(CPK)-TOTAL 82550 $211.00
Page 27 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
CPK ISOENZYMES 82552 $248.00
CK-MB 82553 $326.00
CREATININE BLOOD 82565 $80.00
CREATININE BODY FLUID 82570 $100.00
CREATININE-OTHER SOURCE 82570 $100.00
CREATININE CLEARANCE 82575 $176.00
CRYOFIBRINOGEN 82585 $123.00
CRYOGLOBULINS 82595 $80.00
CYANIDE LEVEL QUANT REF 82600 $149.00
CYANOCOBALAMIN 82607 $161.00
VIT B-12 BINDING CAP 82608 $84.00
DEHYDROEPIANDROSTERONE 82626 $206.00
DHEA-S 82627 $208.00
DESOXYCORTICOSTERONE 11- 82633 $200.00
DEOXYCORTISOL,11 82634 $175.00
VITAMIN D 1,25 DIHYDROXY 82652 $258.00
ENZYME CELL ACTIVITY 82657 $279.00
ELECTROPHORETIC TECHNIQUE 82664 $302.00
ERYTHROPOIETIN 82668 $193.00
ESTRADIOL (E2) 82670 $402.00
ESTRADIOL (E2) 82670 $402.00
ESTROGENS FRACTIONATED 82671 $419.00
ESTRIOL SERUM 82677 $161.00
ESTRONE 82679 $144.00
ETHYLENE GLYCOL 82693 $328.00
FAT OR LIPIDS,FECES,QUAL. 82705 $72.00
LIPIDS FECES QUANT 82710 $207.00
FATTY ACIDS,NONESTERIFIED 82725 $116.00
VERY LONG CHAIN FATTY ACIDS 82726 $324.00
FERRITIN 82728 $165.00
FERRITIN 82728 $165.00
FETAL FIBRONECTIN 82731 $847.00
FOLIC ACID,SERUM 82746 $158.00
FOLIC ACID,RBC 82747 $139.00
IMMUNOGLOBULIN A 82784 $233.00
IMMUNOGLOBULIN M (IGM) 82784 $233.00
IMMUNOGLOBULIN G (IGG) 82784 $233.00
IMMUNOGLOBULIN IGE 82785 $315.00
Page 28 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
IGG SUBCLASSES 1,2,3 OR 4,EACH 82787 $207.00
PH BLOOD 82800 $110.00
BLOOD GASES 82803 $310.00
GASES,BLOOD,O2,SATURATION ONLY 82810 $110.00
GASTRIN SERUM 82941 $159.00
GLUCAGON 82943 $150.00
GLUCOSE,BODY FLUID,NOT BLOOD 82945 $93.00
GLUCOSE,QUANT,BLOOD 82947 $71.00
BLOOD GLUCOSE 82947 $71.00
BLOOD GLUCOSE BY REAGENT STRIP 82948 $65.00
GLUCOSE 1HR GESTATIONAL LOAD 82950 $86.00
GLUCOSE TOLERANCE 3 SPECIMENS 82951 $193.00
GLUCOSE TOLERANCE TEST (3 SP) 82951 $193.00
GLUCOSE TOLERANCE EA ADDL SPEC 82952 $59.00
GLUCOSE TOLERANCE TEST(EA ADD) 82952 $59.00
GLUCOSE-6-PHOSPHATE DEHYDROG 82955 $110.00
POC GLUCOSE BLOOD TEST BY DEVICE 82962 $7.00
GLUCOSE BLOOD TEST 82962 $7.00
GAMMA GT REF 82977 $119.00
GAMMA GT 82977 $119.00
FRUCTOSAMINE 82985 $96.00
FSH SERUM 83001 $330.00
LUTEINIZING HORMONE 83002 $339.00
HUMAN GROWTH HORMONE 83003 $128.00
HAPTOGLOBIN 83010 $143.00
H.PYLORI,UREA BREATH TEST 83013 $643.00
HEAVY METALS-QUANT,EACH 83018 $206.00
HEMOGLOBIN ELECTROPHORESIS-REF 83020 $56.00
HEMOGLOBIN FRACT/QUANT,CHROMO-REF 83021 $85.00
FETAL HEMOGLOBIN ASSAY QUAL REF 83033 $21.00
GLYCOHEMOGLOBIN A1C 83036 $174.00
METHEMOGLOBIN 83050 $190.00
PLASMA HEMOGLOBIN 83051 $97.00
HEMOSIDERIN 83070 $63.00
HISTAMINE 83088 $256.00
HOMOCYSTEINE, SERUM 83090 $217.00
HOMOVANILLIC ACID 83150 $181.00
HYDROXYCORTICOSTEROIDS, 17- 83491 $149.00
Page 29 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
HYDROXYCORTICOSTEROIDS 17 REF 83491 $149.00
HYDROXYINDOLACETIC ACID URINE 83497 $135.00
HYDROXYPROGESTERONE, 17-D 83498 $235.00
IMMUNOASSAY,QUAL/SEMIQUAN-MULT 83516 $189.00
IMMUNOSSAY ANAL RIA NONANTIBODY REF 83519 $363.00
IMMUNOASSAY,ANALYTE-NONSP.TECH 83520 $291.00
IMMUNOASSAY FOR ANALYTE-NSMETH 83520 $291.00
INSULIN 83525 $204.00
IRON 83540 $107.00
IRON BINDING CAPACITY 83550 $106.00
KETOSTEROIDS, 17- TOTAL 83586 $120.00
LACTIC ACID 83605 $156.00
LDH 83615 $100.00
LDH ISOENZYMES-SEP. & QUANT. 83625 $114.00
LACTOFERRIN FECAL QUAL REF 83630 $107.00
LACTOFERRIN FECAL QUAL LAB 83630 $107.00
LEAD BLOOD REF 83655 $107.00
LIPASE 83690 $238.00
LIPOPROTEINS A*R 83695 $61.00
LIPO-ASSOC PHOS A2 (LP-PLA2) 83698 $488.00
LIPOPROTEIN QT BLOOD BY NMR 83704 $339.00
HIGH DENSITY LIPOPROTEIN (HDL) 83718 $108.00
CHOLESTEROL DIRECT LDL 83721 $85.00
MAGNESIUM 83735 $104.00
MANGANESE 83785 $135.00
MASS SPECTOMETRY-QN CARNITINE 83789 $400.00
MERCURY LEVEL QUANT REF 83825 $122.00
METANEPHRINES TOTAL 83835 $311.00
MYELIN BASIC PROTEIN 83873 $311.00
MYOGLOBIN 83874 $158.00
NATRIURETIC PEPTIDE 83880 $261.00
NATRIURETIC PEPTIDE (BNP) 83880 $261.00
NEPHELOMETRY EA NOT SPEC REF 83883 $107.00
NUCLEOTIDASE, 5- 83915 $92.00
OBIGOCLONAL IMMUNE (BANDS) 83916 $374.00
ORGANIC ACIDS TOTAL QT EA SPEC 83918 $511.00
ORGANIC ACID SINGLE QUANT REF 83921 $186.00
OSMOLALITY BLOOD 83930 $110.00
Page 30 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
OSMOLALITY URINE 83935 $116.00
OSTEOCALCIN 83937 $139.00
OXYLATES URINE QUANT 83945 $213.00
DES-GAMMA-CARBOXY PROTHROMBIN 83951 $234.00
INTEROPERATIVE PTH INTACT 83970 $257.00
PARATHORMONE 83970 $257.00
PH,BODY FLUID,NOT SPECIFIED 83986 $61.00
CALPROTECTIN, FECAL 83993 $226.00
ALKALINE PHOSPHATASE 84075 $91.00
ALKALINE PHOSPHATASE 84075 $91.00
PHOSPHATES,ALK-ISOENZYMES 84080 $131.00
PHOSPHORUS 84100 $85.00
PHOSPHORUS URINE 84105 $77.00
PORPHOBILINOGEN URINE QUANT 84110 $97.00
PAMG-1 RAPID ASSAY,ROM AMNISUR 84112 $249.00
PORPHYRINS QUANT 84120 $329.00
POTASSIUM,SERUM-PLASMA OR WB 84132 $65.00
POTASSIUM RANDOM URINE 84133 $85.00
PREALBUMIN 84134 $139.00
PREGNENOLONE 84140 $184.00
17-HYDROXYPREGNENOLONE 84143 $145.00
PROGESTERONE 84144 $392.00
PROCALCITONIN (PCT) REF 84145 $473.00
PROCALCITONIN (PCT) LAB 84145 $473.00
PROLACTIN 84146 $360.00
PROSTAGLANDIN REF 84150 $130.00
PSA SCREENING TOTAL LAB 84153 $274.00
PSA DIAGNOSTIC TOTAL LAB 84153 $274.00
PSA DIAGNOSTIC TOTAL REF 84153 $274.00
PROSTATE SPECIFIC ANTIGEN-FREE 84154 $197.00
PROTEIN,TOTAL EXCEPT REFRACT. 84155 $87.00
PROTEIN,TOTAL,URINE 84156 $96.00
PROTEIN,TOTAL,OTHER SOURCE 84157 $96.00
ASSAY OF PROTEIN ANY SOURCE 84160 $20.00
PAPP-A (PREG ASSC PLASMA PROT) 84163 $150.00
PROTEIN ELECTROPHORESIS 84165 $145.00
PROTEIN ELP (URINE,CSF) 84166 $160.00
WESTERN BLOT FOR BAND ID 84182 $291.00
Page 31 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
ZINC PROTOPORPHYRINS 84202 $109.00
PROINSULIN 84206 $235.00
VITAMIN B6 84207 $217.00
PYRUVIC ACID 84210 $110.00
ASSAY OF PYRUVATE KINASE 84220 $169.00
RECEPTOR ASSAY,NON-ENDOCRINE 84238 $297.00
RENIN 84244 $182.00
RIBOFLAVIN ASSAY VITAMIN B-2 REF 84252 $440.00
SELENIUM 84255 $128.00
SEROTONIN BLOOD 84260 $511.00
SEX HORMONE BINDING GLOBULIN 84270 $223.00
SODIUM,SERUM-PLASMA OR WB 84295 $65.00
SODIUM RANDOM URINE 84300 $84.00
SODIUM,URINE 84300 $84.00
SODIUM,OTHER SOURCE 84302 $106.00
SOMATOMEDIN-C (245) 84305 $433.00
SOMATOSTATIN 84307 $239.00
BODY FLUID CHOLESTEROL 84311 $248.00
SPECTROPHOTOMETRY,ANALYTE NS 84311 $248.00
SPECIFIC GRAVITY NON-URINE 84315 $75.00
SUGARS SINGLE QUAL REF 84376 $24.00
SUGARS,MONO,DI,OLIGO,QUANT 84378 $265.00
SULFATE URINE 84392 $100.00
TESTOSTERONE,FREE 84402 $293.00
TESTOSTERONE BLOOD 84403 $374.00
VITAMIN B1 THIAMINE REF 84425 $183.00
THYROGLOBULIN 84432 $252.00
T4 (THYROXINE) 84436 $195.00
THYROXINE,TOTAL 84436 $195.00
THYROXINE FREE REF 84439 $251.00
THYROXINE FREE 84439 $251.00
THYROID BINDING GLOBULIN 84442 $254.00
TSH 84443 $321.00
THYROID STIM IMMUNE GLOBULINS 84445 $521.00
VITAMIN E 84446 $117.00
TRANSFERASE ASPART AMINO SGOT 84450 $161.00
TRANSFERASE ALANINE AMINO SGPT 84460 $181.00
TRANSFERASE ALANINE AMINO SGPT REF 84460 $181.00
Page 32 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
TRANSFERRIN 84466 $134.00
TRIGLYCERIDES 84478 $102.00
THYROID HORMONE UPTAKE 84479 $193.00
T3 (TRIIODOTHYRONINE) 84480 $280.00
TRIIODOTHYRONINE T3,FREE 84481 $315.00
FREE T3 TRIIODOTHYRONINE 84481 $315.00
TRIIODOTHYRONINE T3,REVERSE 84482 $301.00
TROPONIN,QUANTITIVE 84484 $312.00
UREA NITROGEN,QUANTITIVE 84520 $71.00
UREA NITROGEN,URINE 84540 $85.00
URIC ACID 84550 $93.00
URIC ACID-OTHER SOURCE 84560 $88.00
VANILLYLMANDELIC ACID URINE 84585 $280.00
VASOACTIVE INTESTINAL PEPTIDE 84586 $440.00
VASOPRESSIN (ADH) 84588 $253.00
VITAMIN A 84590 $122.00
VITAMIN B3 NIACIN 84591 $257.00
ASSAY OF VITAMIN K 84597 $303.00
VOLATILES 84600 $255.00
ZINC SERUM 84630 $100.00
C-PEPTIDE LEVEL 84681 $164.00
GONADOTROPIN,CHORIONIC-QUANT. 84702 $360.00
GONADOTROPIN,CHORIONIC-QUAL. 84703 $269.00
UNLISTED CHEMISTRY PROCEDURE 84999 $125.00
POTASSIUM-FLUID 84999 $125.00
AUTOMATED DIFF WBC COUNT 85004 $88.00
MANUAL DIFF WBC COUNT 85007 $61.00
BLOOD COUNT-HEMATOCRIT 85014 $54.00
HEMOGLOBIN 85018 $53.00
CBC, AUTO W/AUTOMATED DIFF 85025 $245.00
HEMOGRAM + PLTS 85027 $170.00
BLOOD COUNT,RBC,AUTOMATED 85041 $68.00
BLOOD COUNT RETICULOCYTES AUTO 1 85046 $22.00
BLOOD COUNT,WBC,AUTOMATED 85048 $92.00
BLOOD COUNT-PLATELET-AUTOMATED 85049 $141.00
RETICULATED PLATELET ASSAY 85055 $72.00
CLOTTING,FACTOR II(FIBRINOGEN) 85210 $276.00
CLOTTING,FACTOR V 85220 $404.00
Page 33 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
CLOTTING FACTOR VII 85230 $512.00
CLOTTING,FACTOR VIII,ONE STAGE 85240 $471.00
FACTOR VIII RELATED ANTIGEN 85244 $605.00
CLOTTING,FACTOR VIII,VW,RISTOC 85245 $475.00
CLOTTING,FACTOR VIII,VW ANTIGN 85246 $405.00
FACTOR VIII VW MULTIMERIC 85247 $539.00
FACTOR IX 85250 $512.00
FACTOR IX 85250 $512.00
CLOTTING,FACTOR X 85260 $456.00
CLOTTING FACTOR XI (PTA) LAB 85270 $447.00
CLOTTING FACTOR XI (PTA) REF 85270 $447.00
CLOTTING,FACTOR XII (HAGEMAN) 85280 $485.00
CLOTTING,FACTOR XIII,SCRN SOL 85291 $238.00
ANTITHROMBIN III,ACTIVITY 85300 $218.00
ANTITHROMBIN 3,ANTIGEN ASSAY 85301 $179.00
CLOT INHIB PROTEIN C ANTIGEN 85302 $246.00
PROTEIN C ACTIVITY 85303 $268.00
CLOT INHIB-PROTEIN S,TOTAL 85305 $252.00
CLOT INHIB-PROTEIN S,FREE 85306 $235.00
ACT.PROTEIN C RESISTANCE ASSAY 85307 $181.00
FACTOR INHIBITOR TEST 85335 $462.00
ACTIVATED CLOTTING TIME (ACT) 85347 $201.00
ACTIVATED CLOTTING TIME (ACT) - BLD 85347 $201.00
EUGLOBULIN LYSIS 85360 $134.00
FIBRIN DEGRAD PRODUCT 85362 $268.00
D-DIMER QUANTITATIVE 85379 $298.00
FIBRINOGEN QUANT 85384 $156.00
FIBRINOGEN QUANT - BLD 85384 $156.00
COAG AND FIB FNC (ADAMTS-13) 85397 $408.00
PLASMINOGEN ACTIVATOR 85415 $429.00
FIBRINOLYTIC F/I,PLASMINOGEN 85420 $191.00
KLEIHAUER BETKE STAIN FETAL RBC BLD 85460 $186.00
RBC-FETOMATERNAL HEMOR-ROSETTE 85461 $106.00
HEPARIN ASSAY 85520 $479.00
LEUKOCYTE ALK P 85540 $237.00
MURAMIDASE 85549 $251.00
RBC OSMOTIC FRAGILITY REF 85555 $117.00
RAPID PLATLET FUNC ASSAY 85576 $206.00
Page 34 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
RAPID PLATELET FUNC ASSAY - BLD 85576 $206.00
HEXAGONAL PHOSPHOLIPID REF 85598 $99.00
PROTHROMBIN TIME (PT) 85610 $84.00
PROTHROMBIN TIME 85610 $84.00
PROTHROMBIN TIME-SUB PLASMA FR 85611 $90.00
DILUTED RUSSELL VIP VEN TIME 85613 $107.00
SED RATE,ERYTHROCYTE,AUTOMATED 85652 $159.00
SICKLING OF RBC,REDUCTION-REF 85660 $89.00
SICKLE CELL PREP 85660 $89.00
THROMBIN TIME (TT) REF 85670 $99.00
THROMBIN TIME (TT) LAB 85670 $99.00
PARTIAL THROMBO TIME 85730 $191.00
THROMBOPLASTIN TIME PARTIAL 85730 $191.00
THROMBOPLASTIN TIME-SUB PLASMA 85732 $183.00
VISCOSITY 85810 $96.00
AGGLUTININS,FEBRILE,E.ANTIGEN 86000 $86.00
ALLERGEN SPECIFIC IGG 86001 $144.00
ALLERGEN SPEC IGE QUAN SEMIQUAN REF 86003 $100.00
ALLERGEN SPEC IGE QUAN SEMIQUAN LAB 86003 $100.00
ALLERGEN SPEC IGE QUAL MULTIAL LAB 86005 $191.00
ALLERGEN SPEC IGE RECOMB EA REF 86008 $210.00
ANTIBODY ID PLATELET ANTIBODIES REF 86022 $306.00
ANTIBODY ID PLATELET ANTIBODIES LAB 86022 $306.00
AB ID,PLATELET IMMUNOG.ASSAY 86023 $170.00
ANA (ANTI NUCLEAR ANTIBODY) 86038 $162.00
ANTINUCLEAR ANTIBODIES,TITER 86039 $143.00
ASO TITER STREPTO. 86060 $214.00
C REACTIVE PROTEIN 86140 $124.00
C-REACTIVE PROTEIN-HIGH SENS. 86141 $129.00
BETA 2 GLYCOPROTEIN I AB,EACH 86146 $137.00
CARDIOLIPIN ANTIBODY-EA IG CLS 86147 $307.00
PHOSPHOLIPID ANTIBODY 86148 $134.00
COLD AGGLUTININS TITER 86157 $153.00
COMPLEMENT ANTIGEN EA COMPONENT REF 86160 $152.00
COMPLEMENT ANTIGEN EA COMPONENT LAB 86160 $152.00
COMPLEMENT,FUNCTIONAL ACTIVITY 86161 $145.00
COMPLEMENT, TOTAL (CH50) 86162 $203.00
CCP ANTIBODY 86200 $174.00
Page 35 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
ANTI-DNASE-B 86215 $112.00
DNA ANTIBODY 86225 $151.00
DNA AB SINGLE STRAND 86226 $175.00
EXTRACTABLE NUCLEAR ANTIGEN,AB 86235 $259.00
SCLERODERMA (SCL 70) AB 86235 $259.00
FLUORESCENT N.INF AGENT-SCREEN 86255 $159.00
FLOURESCENT ANTIBODY TITER 86256 $151.00
CA 15-3 86300 $289.00
CA 27.29 86300 $289.00
IMMUNOASSAY TUMOR ANT-CA 19-9 86301 $300.00
CA 19-9 86301 $300.00
CA 125 86304 $369.00
HETEROPHILE SCREEN 86308 $197.00
CHROMOGRANIN A 86316 $361.00
IMMUNOASSAY-TUMOR,OTHER,QUANT. 86316 $361.00
IMMUNOASSAY,INF AGENT,QUANT 86317 $231.00
IMMUNODIFFUSION,GEL,QUAL,EACH 86331 $149.00
CIQ IMMUNE COMPLEX 86332 $402.00
IMMUNOFIXATION ELECTROPHORESIS 86334 $191.00
IMMUNOFIX ELP URINE/CSF 86335 $200.00
INHIBIN A 86336 $113.00
INSULIN ANTIBODIES 86337 $378.00
INTRINSIC FACTOR ANTIBODIES 86340 $140.00
ISLET CELL ANTIBODY 86341 $278.00
CELLULAR FUNCTION ASSAY 86352 $708.00
LYMPHOCYTE TRANSFORMATION 86353 $234.00
MONONUCLEAR CELL AG NOS 86356 $319.00
T CELLS,TOTAL COUNT 86359 $184.00
T CELLS,ABSOLUTE CD4/CD8 COUNT 86360 $269.00
T CELL ABSOLUTE COUNT CD4 86361 $151.00
MICROSOMAL ANTIBODIES-EACH 86376 $232.00
ANTI THY MICROSOMAL 86376 $232.00
PARTICLE AGGLUTINATION TEST 86403 $239.00
STREP, PYOGENES, AB SCREEN 86403 $239.00
CRYPTOCOCCUS ANTIGEN TITER 86406 $39.00
RHEUMATOID FACTOR QUANTITATIVE LAB 86431 $98.00
RA QUANT TITER 86431 $98.00
TB TEST CELL IMM MEAS AG - BLD 86480 $586.00
Page 36 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
PPD-TB SKIN TEST 86580 $35.00
SYPHILIS TEST,NON-TREP,QUAL 86592 $135.00
SYPHILIS TEST,NON-TREP,QUANT 86593 $162.00
ANTIBODY, ASPERGILLUS 86606 $186.00
ANTIBODY,BACTERIUM,NOT SPEC. 86609 $89.00
BARTONELLA ANTIBODY 86611 $147.00
BLASTOMYCES AB LATE 86612 $184.00
BORDETELLA ANTIBODY 86615 $118.00
AB,BORRELIA BURGDORFERI CONFRM 86617 $243.00
LYME DISEASE ANTIBODY 86618 $314.00
ANTIBODY, BRUCELLA 86622 $92.00
ANTIBODY,CAMPYLOBACTER 86625 $238.00
ANTIBODY,CANDIDA 86628 $229.00
CHLAMYDIA GROUP AB 86631 $173.00
ANTIBODY,CHLAMYDIA,IGM 86632 $160.00
ANTIBODY,COCCIDIOIDES 86635 $103.00
ANTIBODY,COXIELLA BRUNETII 86638 $86.00
ANTIBODY,CYTOMEGALOVIRUS (CMV) 86644 $174.00
CMV SCREEN UBS 86644 $174.00
ANTIBODY,CYTOMEGALOVIRUS,IGM 86645 $145.00
ANTIBODY,ENCEPHALITIS,CA. 86651 $162.00
ANTIBODY,ENCEPHALITIS,EAST EQ. 86652 $158.00
ANTIBODY,ENCEPHALITIS,ST.LOUIS 86653 $145.00
ANTIBODY,ENCEPHALITIS,WEST. EQ 86654 $134.00
ANTIBODY,ENTEROVIRUS 86658 $232.00
EPSTEIN BARR VIRUS-EARLY ANT 86663 $257.00
EPSTEIN BARR VIRUS-NUC ANTIGEN 86664 $197.00
EPSTEIN BARR VIRUS-CAPSID AG 86665 $251.00
ANTIBODY,EHRLICHIA 86666 $274.00
ANTIBODY,FUNGUS,NOT ELSEWHERE 86671 $170.00
HELICOBACTER AB SERUM 86677 $278.00
ANTIBODY,HELMINTH,NOT ELSEWHRE 86682 $330.00
HIV-WESTERN BLOT CONFIRM 86689 $363.00
ANTIBODY,HEPATITIS,DELTA AGENT 86692 $172.00
ANTIBODY,HERPES SIMPLEX,NSTYPE 86694 $119.00
ANTIBODY,HERPES SIMPLEX TYPE 1 86695 $160.00
ANTIBODY,HERPES SIMPLEX TYPE 2 86696 $122.00
HISTOPLASMOSIS AB 86698 $101.00
Page 37 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
HTLV III (HIV) 86701 $240.00
HIV-2 ANTIBODY 86702 $313.00
HEPATITIS B CORE AB 86704 $125.00
HEP B CORE IGM (HBCAB) 86705 $141.00
HEP B S ANTIBODY (HBSAB) 86706 $130.00
HEP B E ANTIBODY (HBEAB) 86707 $105.00
HEPATITIS A ANTIBODY,TOTAL 86708 $125.00
HEPATITIS A IGM AB 86709 $145.00
ANTIBODY INFLUENZA VIRUS 86710 $114.00
ANTIBODY,LEGIONELLA 86713 $257.00
LEPTOSPIRA ANTIBODY 86720 $125.00
MUMPS CF SINGLE 86735 $119.00
ANTIBODY MUMPS 86735 $119.00
MYCOPLASMA ANTIBODY 86738 $232.00
ANTIBODY,PARVOVIRUS 86747 $124.00
ANTIBODY,PROTOZOA,NOT SPECIFED 86753 $218.00
ANTIBODY,RICKETTSIA 86757 $135.00
RUBELLA IGM 86762 $119.00
RUBELLA IMMUNITY SC 86762 $119.00
RUBEOLA IMMUNITY SC 86765 $116.00
ANTIBODY TOXOPLASMA REF 86777 $118.00
ANTIBODY TOXOPLASMA IGM REF 86778 $126.00
ANTIBODY,TREPONEMA PALLIDUM 86780 $109.00
ANTIBODY, VARICELLA-ZOSTER 86787 $233.00
WEST NILE VIRUS ANTIBODY IGM 86788 $203.00
WEST NILE VIRUS ANTIBODY 86789 $203.00
ANTIBODY,VIRUS,NOS 86790 $133.00
ZIKA VIRUS IGM ANTIBODY REF 86794 $170.00
ANTI THYROGLOBULIN 86800 $231.00
HEPATITIS C AB 86803 $161.00
HLA-B27 86812 $320.00
SERUM RBC ANTIBODY SCREEN 86850 $219.00
ELUTION RBC AB EACH ELUTION BLD 86860 $625.00
SERUM RBC AB EACH PANEL BLD 86870 $1,000.00
COOMBS TEST DIRECT BLD 86880 $375.00
COOMBS TEST-INDIRECT 86886 $259.00
ABO BLOOD GROUP BLD 86900 $211.00
ABO (BLOOD GROUP) 86900 $211.00
Page 38 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
BLOOD TYPING RH (D) BLD 86901 $134.00
BLOOD TYPING AG REAGENT BLD 86902 $1,750.00
BLOOD TYPING RBC ANTIGENS BLD 86905 $1,000.00
BLOOD TYPING RH PHENOTYPE COMP BLD 86906 $1,000.00
COMPATIBILITY TEST-IMMED.SPIN 86920 $259.00
COMPATIBILITY TEST-ANTIGLOBULN 86922 $280.00
COMPATIBILITY TEST-ELECTRONIC 86923 $259.00
PRETREATMENT RBC AB ID BLD 86970 $750.00
AUTO ABSORPTION EA ABSORPTION BLD 86978 $1,250.00
UNLISTED TRANSFUSION PROCEDURE BLD 86999 $1,250.00
SPECIMEN CONCENTRATION 87015 $70.00
BLOOD CULTURE FOR BACTERIA 87040 $229.00
CULTURE-FECES,BACTERIA 87045 $379.00
CULTURE-STOOL,BACTERIA,EACH 87046 $152.00
CULTURE ROUTINE 87070 $338.00
CULTURE BACTERI AEROBIC,OTHER 87071 $343.00
CULTURE,BACTERIA,ANAEROBIC 87075 $228.00
CULTURE,ANAEROB IDENT EACH 87076 $107.00
CULTURE,AEROBIC IDENTIFY 87077 $90.00
CULTURE-PRESUMPTIVE-SCREEN 87081 $139.00
CULTURE,OTHER/COLONY COUNT 87084 $55.00
URINE CULTURE/COLONY COUNT 87086 $254.00
CULTURE,FUNGI,PRSM ID,SK,HR,NL 87101 $128.00
CULTURE,FUNGI,PRSM ID,OTHR SRC 87102 $181.00
CULTURE,FUNGI,PRSM ID, BLOOD 87103 $195.00
CULTURE,FUNGI,DEF ID, YEAST 87106 $102.00
CULTURE,FUNGI,DEF ID, MOLD 87107 $83.00
CULTURE MYCOPLASMA 87109 $161.00
MYCOBACTERIA CULTURE 87116 $182.00
DNA RNA AMPLIFIED PROBE MIC 87150 $121.00
MACROSCOPIC EXAM PARASITE MIC 87169 $42.00
OVA & PARASITES SMEARS MIC 87177 $231.00
OVA & PARASITES SMEARS REF 87177 $231.00
MICROBE SUSCEPTIBLE,DIFFUSE 87181 $59.00
MICROBE SUSCEPTIBLE,DISK 87184 $93.00
SUSCEPTIBILITY (MIC) 87186 $139.00
SMEAR,GRAM STAIN 87205 $150.00
AFB STAIN 87206 $161.00
Page 39 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
SMEAR,ACID FAST STAIN 87206 $161.00
SMEAR,SPECIAL STAIN 87207 $221.00
SMEAR COMPLEX STAIN MIC 87209 $45.00
SMEAR COMPLEX STAIN REF 87209 $45.00
C DIFFICELE(C DIFF)TOXIN ASSAY 87230 $172.00
VIRUS ISOL CULT/ADDL DEFIN ID 87253 $292.00
VIRUS INOCULATION,SHELL VIA 87254 $228.00
ADENOVIRUS BY DFA 87260 $202.00
CYTOMEGALOVIRUS DFA 87271 $44.00
INFLUENZA B,AG,IF 87275 $190.00
INFLUENZA A,AG,IF 87276 $191.00
PARAINFLUENZA,AG,IF 87279 $193.00
RESPIRATORY SYNCYTIAL VIRUS 87280 $179.00
PNEUMOCYSTIS CARNII,AG,IF 87281 $298.00
VARICELLA ZOSTER BY DFA 87290 $156.00
ASPERGILLUS AG EIA 87305 $210.00
CLOSTRIDIUM AG IA MIC 87324 $42.00
CRYPTOSPORIDIUM AG MIC 87328 $193.00
GIARDIA ANTIGEN 87329 $193.00
ENTAMOEBA HIST AG 87337 $134.00
INF AGENT HPYLORI STOOL EIA MIC 87338 $281.00
HEP B ANTIGEN 87340 $135.00
HBSAG NEUTRALIZATION 87341 $117.00
HEP B E ANTIGEN (HBEAG) 87350 $105.00
INF.AGENT-IMMUNO-HEPATITIS-DLT 87380 $311.00
HISTOPLASMA ANTIGEN EIA 87385 $181.00
HIV1 AG W HIV1-2 AB DIAGNOSTIC LAB 87389 $86.00
RAPID INFLUENZA A AND B (EIA) 87400 $223.00
RESP SYNCYTIAL AG,EIA 87420 $308.00
ROTAVIRUS 87425 $174.00
INF AG DETECT NOS IA MULT REF 87449 $217.00
BARTONELLA DNA AMP PROBE 87471 $610.00
B.BURGDORFERI AMP DNA 87476 $353.00
CANDIDA SPECIES DIR PROBE 87480 $79.00
CNS DNA AMP PROBE TYPE 12-25 REF 87483 $1,430.00
CHLAMYDIA PNEUMONIA AMP PROBE REF 87486 $87.00
CHLAMYDIA PNEUM DNA AMP PROBE MIC 87486 $87.00
CHLAMYDIA AMP 87491 $314.00
Page 40 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
CLOSTRIDIUM,AMP PROBE 87493 $300.00
INF.AGENT BY NUC-CYTOMEGA-APT 87496 $438.00
CMV QUANTIFICATION DNA 87497 $692.00
ENTEROVIRUS AMP PROBE REF 87498 $357.00
VANCOMYCIN DNA AMP PROBE 87500 $139.00
INFLUENZA DNA AMP PROBE 87502 $335.00
INFLUENZA DNA AMP PROBE ADDL 87503 $83.00
GARDNERELLA VAG DIRECT PROBE 87510 $79.00
INF.AGENT-BY NUC-HEP B-QUANT. 87517 $622.00
INF.AGENT-BY NUC-HEP C-AMP PRB 87521 $622.00
HEPATITIS C DETECT-PROBE TECH. 87522 $676.00
HSV,AMPLIFIED PROBE TECHNIQUE 87529 $549.00
HSV,AMPLIFIED PROBE TECHNIQUE 87529 $549.00
HIV-1 AMPLIFIED PROBE 87535 $595.00
HIV VIRAL LOAD RNA QT 87536 $753.00
HIV-2 AMPLIFIED PROBE 87538 $523.00
MYCOBACTERIA TB AMP PROBE DNA 87556 $561.00
MYCOPLASMA PNEUM DNA AMP PROBE MIC 87581 $87.00
GC NUCLEIC AMP 87591 $279.00
HPV HIGH-RISK TYPES REF 87624 $152.00
HPV HIGH-RISK TYPES MIC 87624 $152.00
RESP VIRUS 3-5 TARGETS MIC 87631 $317.00
RESP VIRUS 12-25 TARGETS MIC 87633 $1,050.00
RESP VIRUS 12-25 TARGETS REF 87633 $1,050.00
STAPH AUREUS DNA AMP PROBE 87640 $139.00
MRSA BY PCR (AMP) 87641 $302.00
STREP GROUP B AMPLIFIED PROBE 87653 $125.00
TRICHAMONAS VAG DIRECT PROBE 87660 $79.00
TRICHOMONAS VAGINALIS AMPLIF REF 87661 $120.00
ZIKA VIRUS DNA RNA AMP PROBE REF 87662 $300.00
INF AGENT NUC NOT SPECFD PRBE 87798 $521.00
INFECTIOUS AGENT DNA QUANT NOS 87799 $532.00
DETECT AGNT MULT DNA AMP PROBE 87801 $643.00
POC INFLUENZA ASSAY W/ OPTIC 87804 $33.00
POC RSV 87807 $30.00
RAPID STREP SCREEN 87880 $185.00
EHEC (SHIGA TOXIN) DETECTION 87899 $204.00
INF.AGENT-IMMUNOASSAY-NOT SPFD 87899 $204.00
Page 41 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
INF.AGENT GENOTYPE ANAL-HIV-1 87901 $1,460.00
INF.AGENT-GENOTYPE ANAL-HEP C 87902 $1,359.00
PHENOTYPE ANAL-HIV-1- 1-10 DRG 87903 $2,100.00
GENOTYPE DNA HEPATITIS B-REF 87912 $1,217.00
CYTOLOGY I 88104 $291.00
CYTOPATHOLOGY-CONCENTRATION 88108 $177.00
CYTOLOGY CELLULAR ENHANCEMENT 88112 $170.00
CYTOPATH-SMEARS-OTHER SOURCE 88160 $224.00
CYTOPATH-PREPARATION 88161 $218.00
CYTOPATH TBS C/V MANUAL 88164 $46.00
CYTOPATH-EVALUATION OF FNA-IMM 88172 $369.00
CYTOPATH-FNA EVAL INTERPRET. 88173 $426.00
CYTOPATH C/V AUTO FLUID REDO 88175 $127.00
CYTOPATH FNA EVAL-ADDL 88177 $170.00
FLOW CYTO CELL CYCLE OR DNA-REF 88182 $232.00
FLOW CYTOMETRY FIRST MARKER 88184 $436.00
FLOW CYTOMETRY EA ADDL MARKER 88185 $110.00
FLOW CYTOMETRY READ 2-8 MARKERS REF 88187 $100.00
FLOW CYTO 16+ MARKERS REF 88189 $170.00
TISSUE CULT-NON-NEOPL-LYMPHCYT-REF 88230 $526.00
NON-NEOPLASTIC-CULTURE-SKIN/TS 88233 $789.00
NEOPLASTIC-CULTURE-B.MARROW 88237 $852.00
CHROMO ANYL- 15-20CELLS 2KARY-REF 88262 $590.00
CHROMO ANALYSIS- 20-25 CELLS 88264 $772.00
MOLECULAR CYTOGENETICS-DNA PRB 88271 $74.00
MOLE CYTO-CHROMO SITU 10-30CLS 88273 $313.00
MOLE CYTO-INTER SITU-100-300 C 88275 $369.00
CHROMO ANAL-ADD KARYOTYPES 88280 $210.00
CYTO/MOLECULAR REPORT-REF 88291 $174.00
LEVEL I SURG PATH GROSS ONLY 88300 $193.00
LEVEL II S.PATH GROSS&MICRO 88302 $320.00
LEVEL III S.PATH GROSS&MICRO 88304 $425.00
LEVEL IV S.PATH GROSS&MICRO 88305 $572.00
LEVEL V S.PATH GROSS&MICRO 88307 $882.00
LEVEL VI S.PATH GROSS&MICRO 88309 $1,099.00
DECALCIFICATION PROCEDURE 88311 $154.00
SPECIAL STAINS,GROUP 1,EACH 88312 $254.00
SPECIAL STAINS,GROUP 2,EACH 88313 $255.00
Page 42 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
SLIDE CONSULT REQUIRE PREP 88323 $291.00
TISSUE BIOPSY CONS 88325 $746.00
PATH CONSULT-1ST TISSUE BLOCK 88331 $520.00
PATH CONSULT-EA ADD TISSUE BLK 88332 $298.00
INTRAOP CYTO PATH CONSULT 1 88333 $1,082.00
INTRAOP CYTO PATH CONSULT 2 88334 $273.00
IMMUNOHISTO ANTIBODY ADD SLIDE PAT 88341 $478.00
IMMUNOHISTO ANTIBODY ADD SLIDE REF 88341 $478.00
IMMUNOHISTO ANTIBODY 1ST SLIDE 88342 $502.00
IMMUNOCYTOCHEMISTRY,EACH AB 88342 $502.00
IMMUNOFLUOR AB PER SPEC INIT 88346 $458.00
ELECTRON MICROSCOPY DIAG - PAT 88348 $1,082.00
TUMOR IMMUNOHISTOCHEM-MANUAL 88360 $436.00
MORPH ANAL TUMOR IMMUNO 88360 $436.00
BILIRUBIN TOT.TRANSCUTANEOUS 88720 $41.00
CELL CT W/DIFF,MISC BODY FLUID 89051 $243.00
LEUKOCYTES STOOL 89055 $169.00
CRYSTAL ID BY MICROSCOPY 89060 $189.00
FAT QUAL STOOL URINE RESP SEC 89125 $78.00
SMEAR FOR EOSINOPHILS 89190 $125.00
SWEAT COLLECTION 89230 $377.00
SEMEN ANALYSIS,POSTVASECTOMY 89321 $113.00
IMMUNIZATION ADMINISTRATION 90471 $77.00
PNEUMOCOCCAL ADMINISTRATION 90471 $77.00
INFLUENZA ADMINISTRATION 90471 $77.00
VFC VACCINE ADMINISTRATION 90471 $22.00
OP DIAGNOSTIC INTERVIEW 90791 $429.00
OP DIAG INTERVIEW ER/C&L 90791 $429.00
OP DIAG INTERVIEW-ER 90791 $429.00
IOP DIAGNOSTIC INTERVIEW 90791 $429.00
IOP DIAGNOSTIC INTERVIEW CD 90791 $429.00
PHP DIAG INTERVIEW 90791 $429.00
PSYCHOTHERAPY PT &/ FAMILY 30 MIN 90832 $248.00
PSYCHOTHERAPY PT &/ FAMILY 45 MIN IOP 90834 $325.00
PSYCHOTHERAPY PT &/ FAMILY 45 MIN IOP CD 90834 $325.00
PSYCHOTHERAPY PT &/ FAMILY 45 MIN 90834 $325.00
PSYCHOTHERAPY PT &/ FAMILY 60 MIN IOP 90837 $325.00
PSYCHOTHERAPY PT &/ FAMILY 60 MIN CD 90837 $325.00
Page 43 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
PSYCHOTHERAPY FOR CRISIS 60 MIN 90839 $295.00
IOP FAMILY THERAPY W/O PT 90846 $333.00
IOP FAMILY THERAPY W/ PT 90847 $365.00
PHP FAMILY THERAPY W/ PATIENT 90847 $365.00
IOP GROUP THERAPY-PSYCH 90853 $234.00
IOP GROUP THERAPY-CD 90853 $234.00
HEMODIALYSIS 90935 $1,643.00
CAPD 90945 $1,173.00
CCPD 90945 $1,173.00
CRRT 90945 $1,173.00
ESOPH MOTILITY/MANOMETRY 91010 $1,944.00
AMBULATORY PH/24 HR 91034 $1,536.00
SPEECH LANG TX-INDIVIDUAL 92507 $183.00
SPEECH LANGUAGE TX-GROUP 92508 $59.00
EVALUATION OF SPEECH FLUENCY 92521 $293.00
EVALUATE SPEECH PRODUCTION 92522 $293.00
SPEECH SOUND LANG COMPREHEN 92523 $406.00
BEHAVRAL QUALIT ANALYS VOICE 92524 $293.00
SWALLOWING DYSFUNCTION TREATMT 92526 $188.00
EVOKED AUDITORY SCREEN 92558 $30.00
BER 92585 $1,254.00
ORAL PHARYNGEAL EVALUATION 92610 $222.00
VIDEOFLUOROSCOPIC EVALUATION 92611 $753.00
VIDEO FLEX FIBERENDO EVAL 92612 $322.00
PRQ CARDIAC ANGIOPLAST 1 ART 92920 $15,001.00
PRQ CARDIAC ANGIOPLAST ADDL 92921 $15,001.00
PRQ CARD ANGIO/ATHRECT 1 ART 92924 $33,060.00
PRQ CARD ANGIO/ATHRECT ADDL 92925 $27,342.00
PRQ CARD STENT W/ANGIO 1 VSL 92928 $32,621.00
PRQ CARD STENT W/ANGIO ADDL 92929 $22,757.00
PRQ REVASC BYP GRAFT 1 VSL 92937 $24,267.00
PRQ REVASC BYP GRAFT 1 VSL 92937 $24,267.00
PRQ CARD REVASC MI 1 VSL 92941 $24,267.00
PRQ CARD REVASC CHRONIC 1VSL 92943 $26,519.00
PRQ CARD REVASC CHRONIC ADDL 92944 $19,677.00
CARDIOPULMONARY RESUSCITATION 92950 $1,668.00
CARDIOVERSION EXTERNAL ELECTVE 92960 $2,432.00
PERCUTANEOUS CORO THROMBECTOMY 92973 $9,379.00
Page 44 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
THROMBOLYTIC THERAPY(CORONARY) 92977 $1,608.00
INTRAVAS US PROCEDURE INIT VSL 92978 $6,709.00
ELECTROCARDIOGRAM 93005 $459.00
CARDIOVASCULAR STRESS TEST 93017 $1,504.00
CARDIAC STRESS TEST-EKG TRACING 93017 $1,504.00
RHYTHM STRIP 93041 $215.00
INTERROGATION DEVICE EVAL ICD 93289 $269.00
ECHO-CONGENITAL COMP W/O CONT 93303 $1,687.00
ECHO-CONGENITAL LTD W/O CONT 93304 $1,212.00
ECHO-CNGNTL LTD W/ CONT 93304 $1,212.00
ECHO COMP W/O CONTRAST 93306 $3,495.00
ECHO COMP W/ CONTRAST 93306 $3,495.00
ECHOCARDIOGRAM LTD W/O CONT 93308 $1,302.00
ECHOCRDGRM LTD W/ CONT 93308 $1,302.00
TRANSESOPHAGEAL ECHO W/O CONT 93312 $3,207.00
TRANSESPHGL ECHO W/ CONT 93312 $3,207.00
TEE-CONGENITAL W/O CONTRAST 93315 $2,314.00
CARDIAC DOPPLER EXAM(2ND) 93320 $1,138.00
CARDIAC DOPPLER EXAM 93320 $1,138.00
CARDIAC DOPPLER LIMITED 93321 $554.00
COLOR FLOW MAPPING 93325 $853.00
ECHO REST/STRESS W/O CONTRAST 93350 $2,065.00
ECHO REST/STRESS W/ CONT 93350 $2,065.00
CATH RIGHT HEART 93451 $12,490.00
CATH LEFT HEART W/VENTRCL GRAPH 93452 $11,355.00
CATH RT/LT HEART W/ VENTGRAPH 93453 $20,591.00
CORONARY ARTERY ANGIO S&I 93454 $12,490.00
CORONARY ARTERY/GRAFT ANGIO 93455 $14,941.00
RT HRT CORONARY ARTERY ANGIO 93456 $17,168.00
RT HRT ARTERY/GRAFT ANGIO 93457 $17,168.00
LT HRT ART/VENTRICLE ANGIO 93458 $17,168.00
LT HRT ARTERY/GRAFT ANGIO 93459 $18,491.00
RT/LT HRT ART/VENTRICLE ANGIO 93460 $20,094.00
RT/LT HRT ART/VENT ANGIO BYP 93461 $26,344.00
L HRT CATH TRNSPTL PUNCTURE 93462 $5,601.00
SWAN LINE INSERTION 93503 $5,184.00
SWAN GANZ INSERTION 93503 $5,184.00
INJ SUPRAVALVULAR AORTOGRAPHY 93567 $3,178.00
Page 45 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
DOPPLER PRESSURE-INIT. VESSEL 93571 $5,152.00
DOPPLER PRESSURE-ADDL. VESSEL 93572 $3,256.00
PTC W/IMPLANT ATRIAL 93580 $40,610.00
INTRACARDIAC EP 3D MAPPING 93613 $7,889.00
EP STUDY-RT A/V PACE W/INDUCT 93620 $15,741.00
EP STUDY-LT ATR PACE W/INDUCT 93621 $7,889.00
ELECTROPHYSIOLOGY EVALUATION 93622 $7,350.00
POST DRUG INFUSION EPS 93623 $7,889.00
EP EVAL CARDIO/DEFIB LEADS 93640 $10,043.00
EP EVAL CARDIO/DIFIB GENERATOR 93641 $5,945.00
EP EVAL CARDIO/DEFIB SNG/DUAL 93642 $3,150.00
AV NODE ABLATION 93650 $14,127.00
EP & ABLATE SUPRAVENT ARRHYT 93653 $37,189.00
EP & ABLATE VENTRIC TACHY 93654 $37,189.00
ABLATE ARRHYTHMIA ADD ON 93655 $19,525.00
TX ATRIAL FIB PULM VEIN ISOL 93656 $37,189.00
TX ATRIAL FIB ADD ON 93657 $11,025.00
CAR. TILT TABLE TEST 93660 $2,779.00
INTRACARDIAC ECHOCARDIOGRAPHY 93662 $7,889.00
AMBULATORY 24HR BP RECORDING 93786 $211.00
AMBULATORY 24HR BP ANALYSIS 93788 $211.00
CARDIOVERSION INTERNAL ICD ELECTIVE 93799 $2,124.00
CAROTID DUPLEX SCAN BILAT 93880 $1,620.00
DUPLEX SCAN EXTRACRANIAL,BILAT 93880 $1,620.00
TEMPORAL ARTERY SCAN BILAT 93880 $1,620.00
CAROTID DUPLEX SCAN LIMITED 93882 $649.00
CAROTID DUPLEX SCAN UNILAT 93882 $649.00
DUPLEX SCAN EXTRACRANIAL,LIMITED 93882 $649.00
TEMPORAL ARTERY SCAN UNILAT 93882 $649.00
TRANSCRANIAL DOPPLER COMPLETE 93886 $1,121.00
TRANSCRAN DOPPLER INTRACRAN ART 93886 $1,121.00
TRANSCRANIAL DOPPLER LIMITED 93888 $574.00
TRANSCRAN DOPPLER INTRACRAN,LIMITED 93888 $574.00
TCD STUDY FOR PFO EVALU 93893 $1,221.00
NONINVASV EXTREM EXAM,1LEVEL,BILAT 93922 $726.00
LE ARTERIAL EXAM SINGLE LEVEL 93922 $726.00
UE ARTERIAL EXAM SINGLE LEVEL 93922 $726.00
NONINVASV EXTREM EXAM,MULT,BILAT 93923 $1,077.00
Page 46 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
LE ARTERIAL EXAM MULTI LEVEL 93923 $1,077.00
DUPLEX LO EXTREM ART BILAT 93925 $1,518.00
LE ARTERIAL DUPLEX SCAN BILAT 93925 $1,518.00
DUPLEX LO EXTREM ART UNILAT/LTD 93926 $1,028.00
LE ARTERIAL DUPLEX SCAN LMTD 93926 $1,028.00
LE ARTERIAL DUPLEX SCAN UNILAT 93926 $1,028.00
DUPLEX UP EXTREM ART BILAT 93930 $1,292.00
UE ARTERIAL DUPLEX SCAN BILAT 93930 $1,292.00
ALLENS TEST BILATERAL 93930 $1,292.00
DUPLEX UP EXTREM ART UNILAT/LTD 93931 $964.00
UE ARTERIAL DUPLEX SCAN LMTD 93931 $964.00
UE ARTERIAL DUPLEX SCAN UNILAT 93931 $964.00
ALLENS TEST UNILATERAL 93931 $964.00
VEIN MAPPING SAPHENOUS BILAT 93970 $1,465.00
DUPLEX EXTREM VENOUS,BILAT 93970 $1,465.00
LE VENOUS DUPLEX SCAN BILAT 93970 $1,465.00
UE VENOUS DUPLEX SCAN BILAT 93970 $1,465.00
VEIN MAP CEPHALIC BILATERAL 93970 $1,465.00
VEIN MAP BASILIC BILATERAL 93970 $1,465.00
DUPLEX EXTREM VENOUS,UNI OR LTD 93971 $1,227.00
LE VENOUS DUPLEX SCAN UNILAT 93971 $1,227.00
UE VENOUS DUPLEX SCAN UNILAT 93971 $1,227.00
VEIN MAP CEPHALIC UNILATERAL 93971 $1,227.00
VEIN MAP BASILIC UNILATERAL 93971 $1,227.00
VEIN MAP SAPHANOUS UNILAT 93971 $1,227.00
VENOUS DUPLEX SCAN LIMITED 93971 $1,227.00
DUPLEX ABD/PEL VASC STUDY,COMPLETE 93975 $1,445.00
US VISCERAL VASCULAR COMPLETE 93975 $1,445.00
US VISCERAL VASCULAR LIMITED 93976 $1,066.00
DUPLEX ABD/PEL VASC STUDY,LIMITD 93976 $1,066.00
DUPLEX LARGE VESSEL(S),COMPLETE 93978 $1,265.00
AORTA & ILIAC COMPLETE 93978 $1,265.00
INFER VENA CAVA & ILIAC COMPLT 93978 $1,265.00
DUPLEX LARGE VESSEL(S),LIMITED 93979 $830.00
AORTA & ILIAC LIMITED 93979 $830.00
INFERIOR VENA CAVA & ILIAC LTD 93979 $830.00
DUPLEX HEMODIALYSIS ACCESS 93990 $719.00
HEMODIALYSIS ACCESS DUPLEX 93990 $719.00
Page 47 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
VENTILATION(BIPAP)-FIRST DAY 94002 $3,170.00
CONT VENTILATION-FIRST DAY 94002 $3,170.00
CONT VENTILATION-SUBSQ DAY 94003 $2,282.00
VENTILATION(BIPAP)-SUBSQ DAY 94003 $2,282.00
SPIROMETRY W/ GRAPHIC RCD (NO PROFEE) 94010 $482.00
SPIROMETRY W/ BRONCHODILATION 94060 $791.00
PRE&POST SPIROMETRY 94060 $791.00
BRONCHOSPASM PROVOCATION EVAL 94070 $690.00
VITAL CAPACITY 94150 $273.00
SURFACTANT ADMIN THRU TUBE 94610 $373.00
EXERCISE TEST BRONCOSPASM 94617 $252.00
PULMONARY STRESS TEST 94618 $252.00
CARDIOPULM EXERCISE TEST 94621 $1,686.00
NPPB TREATMENT 94640 $373.00
NPPB OP TREATMENT 94640 $373.00
AEROSOL/VAPOR INHALATIONS 94640 $373.00
VENT. INLINE MEDS 94640 $373.00
AIRWAY INHALATION TREATMENT 94640 $373.00
AEROSOL PENTAMINDINE TREATMENT 94642 $373.00
CPAP INITIATION/MANAGEMENT 94660 $925.00
RESP CARE ASSESSMENT 94664 $373.00
CHEST PHYSIOTHERAPY-INITIAL 94667 $231.00
CHEST PHYSIOTHERAPY-SUBSQ 94668 $211.00
MECH CHEST WALL OSCIL PER/SESSION 94669 $373.00
02 UPTAKE,REST INDIRECT 94690 $536.00
PLETHYSMOGRAPHY LUNG VOLUMES 94726 $498.00
CO2/MEMBRANE DIFFUSE CAPACITY 94729 $166.00
EAR/PULSE OXIMETRY-SINGLE DETM 94760 $190.00
EAR/PULSE OXIMETRY-OVERNIGHT MONITOR 94762 $369.00
CO2 EXPIRED GAS DETERMINATION 94770 $498.00
EEG EXTENDED MONITORING <1 HR 95812 $1,962.00
EEG AWAKE 95816 $1,488.00
EEG 95819 $1,207.00
EEG SLEEP 95822 $1,618.00
EEG CEREBRAL DEATH EVAL 95824 $1,461.00
TENSILON TEST 95857 $498.00
EMG ONE EXTR 95860 $614.00
EMG TWO EXTR 95861 $909.00
Page 48 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
EMG THREE EXTR 95863 $981.00
EMG FOUR EXTR 95864 $1,284.00
MUSCLE TEST LARYNX 95865 $211.00
CRANIAL NERVE EMG UNI 95867 $273.00
CRANIAL NERVE EMG BILAT 95868 $273.00
EMG PARASPINAL MUSCLES 95869 $273.00
EMG SINGLE MUSCLE 95870 $261.00
EMG EXTREMITY W/NCD LIMITED 95885 $679.00
EMG EXTREMITY W/NCD COMPLETE 95886 $679.00
EMG NON-EXTREMITY W/NCD 95887 $382.00
NRV CONDUCT STUDIES 1-2 95907 $273.00
NRV CONDUCT STUDIES 3-4 95908 $498.00
NRV CONDUCT STUDIES 5-6 95909 $498.00
NRV CONDUCT STUDIES 7-8 95910 $498.00
NRV CONDUCT STUDIES 9-10 95911 $889.00
NRV CONDUCT STUDIES 11-12 95912 $889.00
NRV CONDUCT STUDIES 13+ 95913 $889.00
SSEP UPPER EXTREMITIES 95925 $1,371.00
SSEP LOWER EXTREMITY 95926 $1,626.00
SEP TRUNK AND SCALP 95927 $273.00
MEP UPPER LIMBS 95928 $1,806.00
MEP LOWER LIMBS 95929 $1,806.00
VEP TEST EXCEPT GLAUCOMA 95930 $1,414.00
REP NERVE CONDUCTION 95937 $273.00
SSEP UPPER & LOWER EXTREMITY 95938 $889.00
MEP UPPER AND LOWER 95939 $1,806.00
INTRAOP NEURO IN OR 1:1 PER 15 MIN 95940 $139.00
EEG-VIDEO-24HR 95951 $5,296.00
EEG DURING CAROTID SURGERY 95955 $1,207.00
24 HR EEG MONITORING 95956 $4,230.00
ELECTRODE STIM BRAIN 1ST HR 95961 $1,806.00
ANALYSIS,NEUROSTIM W/O PROG 95970 $303.00
ANALYZE CRANIAL NEUROSTIM SIMPLE PRGM 95976 $74.00
ANALYZE CRANIAL NEUROSTIM COMPLEX PRGM 95977 $235.00
ANALYSIS IMP NEUROSTIM FIRST 15 MIN 95983 $153.00
ANALYSIS IMP NEUROSTIM ADDL 15 MIN 95984 $153.00
CANALITH REPOSITIONING PROC 95992 $231.00
ASSESSMENT OF APHASIA PER HR 96105 $435.00
Page 49 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
DEVELOPMENTAL TEST ADMIN FIRST HOUR 96112 $272.00
DEVELOPMENTAL TEST ADMIN ADD 30MIN 96113 $136.00
NEUROBEHAVIOR STATUS EXAM EA ADD HR 96121 $249.00
PSYCH TEST EVAL FIRST HOUR 96130 $272.00
PSYCH TEST EVAL ADD HOUR 96131 $136.00
NEUROPSYCH TEST EVAL FIRST HOUR 96132 $272.00
NEUROPSYCH TEST EVAL ADD HOUR 96133 $136.00
PSYCH NEUR TEST PHYS 1ST 30M 96136 $34.50
PSYCH NEUR TEST PHYS ADD 30 MIN 96137 $17.25
PSYCH NEURTEST TECH 1ST 30M 96138 $34.50
PSYCH NEUR TEST TECH ADD 30 MIN 96139 $17.25
PSYCH NEUR TEST AUTOMATED 96146 $34.50
INF THERAPY-HYDRATION 31-60MIN 96360 $697.00
INF THERAPY-HYDRATION EA ADDHR 96361 $366.00
INF THERAPY-TH/DIAG-INIT < 1HR 96365 $732.00
INF THERAPY-TH/DIAG-INIT ADDHR 96366 $400.00
INF THERAPY-TH/DIAG-SEQ < 1HR 96367 $522.00
INF THERAPY-TH/DIAG-CONC < 1HR 96368 $470.00
SUBCUTANEOUS INFUSION EACH ADDL HR 96370 $108.00
INJECTION-DIAG/THERAP-SQ/IM 96372 $226.00
THERA PROPH DX INJ INTRA ARTERIAL 96373 $382.00
TX-PRO-DX IV PUSH SNGL/INITIAL 96374 $385.00
TX-PRO-DX IV PUSH NEW DRG 96375 $317.00
TX-PRO-DX IV PUSH SAME DRUG 96376 $189.00
APPLICATION ON-BODY INJECTOR 96377 $74.00
CHEMO ADMIN-SQ/IM NON HORMONAL 96401 $489.00
CHEMO ADMIN-SQ/IM HORMONAL 96402 $489.00
CHEMO ADMIN-IV-PUSH 1ST DRUG 96409 $629.00
CHEMO ADMIN-IV-PUSH ADDL DRUG 96411 $584.00
CHEMO ADMIN-IV-1ST DRUG < 1 HR 96413 $1,071.00
CHEMO ADMIN-IV INF-EA ADD HR 96415 $510.00
CHEMO ADMIN-IV-DIFF DRUG < 1HR 96417 $596.00
CHEMO ADMIN INTRA ART PUSH 96420 $649.00
CHEMO ADMIN INTO CNS 96450 $1,071.00
IRRIGATE IMPLANTED VNS PRT 96523 $290.00
HOT OR COLD PACKS THERAPY 97010 $118.00
MECHANICAL TRACTION 97012 $153.00
E STIM-UNATTENDED-NON WND CARE 97014 $204.00
Page 50 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
ELECTRIC STIMULATION THERAPY 97014 $204.00
PARAFFIN BATH 97018 $127.00
PARAFFIN BATH-M59 97018 $127.00
PARAFFIN TREATMENT 97018 $127.00
PARAFFIN TREATMENT-M59 97018 $127.00
E STIM ATTENDED 15 MIN 97032 $146.00
ELEC STIM ATTENDED 15 MIN 97032 $146.00
IONTOPHORESIS EA 15 MIN 97033 $173.00
CONTRAST BATHS EA 15 MIN 97034 $126.00
ULTRASOUND PER 15 MIN 97035 $152.00
THERAPEUTIC EXERCISE EA 15 MIN 97110 $177.00
THERAPEUTIC EXERCISE EA 15 MIN-M59 97110 $177.00
NEUROMS REED,BALANCE,COOR,POST 97112 $124.00
NEUROMS REED,BALANCE,COOR,POST-M59 97112 $124.00
NEUROMUSCULAR REED. EA 15 MIN 97112 $124.00
NEUROMUSCULAR RE-EDUCATION 97112 $124.00
NEUROMUSCULAR RE-EDUCATION-M59 97112 $124.00
AQUATIC THERAPY W/THERAPEUT EX 97113 $183.00
GAIT TRAINING 97116 $150.00
GAIT TRAINING-M59 97116 $150.00
PT GAIT TRAINING-15 MIN 97116 $150.00
MASSAGE 97124 $141.00
MANUAL THERAPY TECHNIQUE 15MIN 97140 $196.00
MANUAL THERAPY TECHNIQUE 15MIN-M59 97140 $196.00
MANUAL THERAPY JOINT MOBILIZAT-M59 97140 $196.00
MANUAL THERAPY JOINT MOBILIZAT 97140 $196.00
MANUAL THER TECHNIQUE 15MIN 97140 $196.00
GROUP ACTIVITIES 97150 $160.00
BEHAVIOR ID ASSESSMENT EA 15 MIN 97151 $67.00
BEHAVIOR ID SUPPORT ASSMT EA 15 MIN 97152 $67.00
PT EVAL LOW COMPLEX 20 MIN 97161 $318.00
PT EVAL MOD COMPLEX 30 MIN 97162 $318.00
PT EVAL HIGH COMPLEX 45 MIN 97163 $318.00
PT RE-EVAL EST PLAN CARE 97164 $199.00
OT EVAL LOW COMPLX 30 MIN 97165 $332.00
OT EVAL MOD COMPLX 45 MIN 97166 $332.00
OT EVAL HIGH COMPLX 60 MIN 97167 $332.00
OT RE-EVAL EST PLAN CARE 97168 $230.00
Page 51 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
THERAPEUTIC ACTIVITIES 15 MIN-M59 97530 $145.00
THERAPEUTIC ACTIVITIES 15 MIN 97530 $145.00
SENSORY INT TECHNIQUES 15 MIN-M59 97533 $105.00
SENSORY INT TCHNQS 15 MIN 97533 $105.00
FUNCTIONAL TRNG SELF CARE 15M 97535 $139.00
FUNCTIONAL TRNG SELF CARE 15M-M59 97535 $139.00
SELF CARE/ADLS 15 MIN 97535 $139.00
SELF CARE ADL TRAINING 15 MIN 97535 $139.00
SELF CARE ADL TRAINING 15 MIN-M59 97535 $139.00
COMMUNITY WORK REINTEGRATE15MN 97537 $127.00
WHEELCHAIR MAN/PROP TRNG 15MIN 97542 $160.00
DEBRIDE-SELECTIVE FIRST 20 CM 97597 $439.00
DEBRIDE-SELECTIVE FIRST 20 CM RN 97597 $439.00
DEBRIDE-SELECTIVE ADDL 20 CM 97598 $220.00
DEBRIDE-SELECTIVE ADDL 20 CM RN 97598 $231.00
DEBRIDEMENT NON-SELECTIVE 97602 $338.00
DEBRIDEMENT NON-SELECTIVE RN 97602 $338.00
NEG PRESS WND THERAPY <50CM DME 97605 $338.00
NEG PRESS WND THERAPY <50CM RN DME 97605 $338.00
NEG PRESS WND THERAPY >50CM DME 97606 $622.00
NEG PRESS WND THERAPY >50CM RN DME 97606 $622.00
EVAL PHYS PERFORMANCE 15 MIN 97750 $114.00
EVAL PHYS PERFORMANCE 15 MIN-M59 97750 $114.00
INITIAL ORTHOTIC TRAINING EA 15 MIN 97760 $173.00
INIT PROSTHETIC TRAINING EA 15 MIN 97761 $158.00
SUBSQ PROS/ORTHO TRAINING EA 15 MIN 97763 $158.00
LAB SPECIMEN HANDLING REF 99001 $87.00
CON SEDATION< 5 YR 1ST 15 MIN 99151 $497.00
CON SEDATION/>5 YR 1ST 15 MIN 99152 $419.00
CON SEDATION EA ADDL 15 MIN 99153 $357.00
PHLEBOTOMY,THERAPEUTIC 99195 $399.00
LEVEL I NEW PATIENT 99201 $180.00
LEVEL I NEW PATIENT-ET 99201 $180.00
OFFICE VISIT-NEW-LEVEL 1 99201 $180.00
LEVEL II NEW PATIENT 99202 $242.00
OFFICE VISIT-NEW-LEVEL 2 99202 $242.00
LEVEL III NEW PATIENT 99203 $292.00
LEVEL III NEW PATIENT-ET 99203 $292.00
Page 52 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
OFFICE VISIT-NEW-LEVEL 3 99203 $292.00
LEVEL IV NEW PATIENT 99204 $406.00
OFFICE VISIT-NEW-LEVEL 4 99204 $406.00
OFFICE VISIT-NEW-LEVEL 5 99205 $477.00
LEVEL I VISIT ESTABLISHED PT 99211 $171.00
LEVEL I VISIT ESTABLISHED-ET 99211 $171.00
OFFICE VISIT-EST-LEVEL 1 99211 $171.00
LEVEL II VISIT ESTABLISHED PT 99212 $209.00
LEVEL II VISIT ESTABLISHED-ET 99212 $209.00
OFFICE VISIT-EST-LEVEL 2 99212 $209.00
LEVEL III VISIT ESTABLISHED 99213 $259.00
LEVEL III VISIT ESTABLISHED-ET 99213 $259.00
OFFICE VISIT-EST-LEVEL 3 99213 $259.00
LEVEL IV VISIT ESTABLISHED PT 99214 $320.00
OFFICE VISIT-EST-LEVEL 4 99214 $320.00
OFFICE VISIT-EST-LEVEL 5 99215 $406.00
LEVEL I BRIEF 99281 $513.00
SUTURE REMOVAL 99281 $190.00
LEVEL II LIMITED 99282 $1,011.00
LEVEL III INTERMEDIATE 99283 $1,516.00
LEVEL IV EXTENDED 99284 $2,601.00
LEVEL V COMPREHENSIVE 99285 $3,755.00
CRITICAL CARE-30 TO 74 MINUTES 99291 $5,110.00
CRITICAL CARE-EA ADDL 30 MIN 99292 $2,556.00
SMOKING COUNSELING VISIT 3-10 MIN 99406 $66.00
SMOKING COUNSELING VISIT > 10 MIN 99407 $99.00
ATTENDANCE AT DELIVERY 99464 $303.00
NEWBORN RESUSCITATION 99465 $1,026.00
CEREBRAL PERFUSION ANALYSIS 0042T $2,561.00
PERQ STENT CHEST/VERT ART, 1ST VESSEL 0075T $12,789.00
CIMT STUDY 0126T $209.00
EXPOSURE BEHAVIOR TX EA 15 MIN 0373T $33.50
LC APP SKN GRAFT TAL<100CM 1ST25 C5271 $1,340.00
LC APP SKN GRAFT TAL<100CM ADD25 C5272 $610.00
LC APP SKN GRAFT FNHFG<100 1ST25 C5275 $1,340.00
MRA W/O CONT, ABD C8901 $3,451.00
MRA W/O FOL W/CONT, ABD C8902 $4,628.00
MRI BREAST W CONTRAST UNILATERAL C8903 $4,069.00
Page 53 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
MRI W/O FOL W/CONT, BREAST, C8908 $4,618.00
MRA W/O CONT, CHEST C8910 $3,481.00
MRA W/O FOL W/CONT, CHEST C8911 $4,185.00
MRA W/O CONT, LWR EXT C8913 $3,169.00
MRA W/O FOL W/CONT, LWR EXT C8914 $4,540.00
MRA W/O CONT, PELVIS C8919 $3,415.00
MRA W/O FOL W/CONT, PELVIS C8920 $4,023.00
CATH PCDR,DE,SINGLE VSL LAD C9600 $30,036.00
CATH PCDR,DE,SINGLE VSL,CIRC C9600 $30,036.00
CATH PCDR,DE SINGLE VSL,RCA C9600 $30,036.00
CATH PCDR,DE,ADDL VSL,LAD C9601 $26,237.00
CATH PCDR,DE,ADDL VSL,CIRC C9601 $26,237.00
CATH PCDR,DE,ADDL VSL,RCA C9601 $26,237.00
PERC ATHERECTOMY DES SINGLE LC C9602 $37,953.00
PERC ATHERECTOMY DES SINGLE LD C9602 $37,953.00
PERC ATHERECTOMY DES SINGLE RC C9602 $37,953.00
PERC REVAS CABG DES SINGLE LC C9604 $26,407.00
PERC REVAS CABG DES SINGLE LD C9604 $26,407.00
PERC REVAS CABG DES SINGLE RC C9604 $26,407.00
PERC REVAS TOT AMI DES SINGLE LC C9606 $40,610.00
PERC REVAS TOT AMI DES SINGLE LD C9606 $40,610.00
PERC REVAS TOT AMI DES SINGLE RC C9606 $40,610.00
PERC REVAS CHRO DES SINGLE LC C9607 $40,610.00
PERC REVAS CHRO DES SINGLE LD C9607 $40,610.00
PERC REVAS CHRO DES SINGLE RC C9607 $40,610.00
PERC REVAS CHRO DES ADDL RC C9608 $27,223.00
CREATION AVF W SECONDARY PROCEDURE C9754 $19,338.00
CREATION AVF W RADIOFREQUENCY RS&I C9755 $19,338.00
PHP ACTIVITY THERAPY PER DAY G0176 $482.00
PHP EDUCATION TRAINING/DAY G0177 $484.00
RT MUSCLE STRENGTH/END-IND-15M G0237 $184.00
RT IMPROVE FUNCTION-IND-15 MIN G0238 $124.00
RT IMPROVE MUSCLE/FUNCTION-GRP G0239 $127.00
INJECTION-SACROILIAC-ANES/STER G0260 $2,464.00
INJ FOR SACROILIAC JT ANESTH G0260 $2,464.00
OCCLUSIVE DEVICE PLACEMENT G0269 $2,170.00
HYPERBARIC 02 CHAMBER EA 30MIN G0277 $797.00
ILIAC CONTRALATERAL WITH CATH G0278 $15,667.00
Page 54 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS, UNILAT OR BILAT G0279 $70.00
LOW DOSE CT LUNG CA SCREEN G0297 $290.00
ROOM/CARE - OBSERVATION HOUR CHARGE G0378 $180.00
GREEN TRAUMA ACTIVATE PRE-NOTIFY G0390 $10,908.00
YELLOW TRAUMA ACTIVATE PRE-NOTIFY G0390 $19,293.00
RED TRAUMA ACTIVATE PRE-NOTIFY G0390 $27,495.00
PHP GROUP PSYCHOTHERAPY 45-50 MIN G0410 $285.00
PHP INTERACTIVE GRP THRPY 45-50 MIN G0411 $546.00
PROSTATE BIOPSY ANY METHOD PAT G0416 $989.00
PULM REHAB,ONE HOUR SESSION G0424 $406.00
ANNUAL WELLNESS VISIT INITIAL G0438 $549.00
ANNUAL WELLNESS VISIT SUBSEQ G0439 $336.00
HIV AG AB COMB ASSAY SCREENING LAB G0475 $90.00
ASSAY UNSPECIFIED DRUG CLASS REF G0480 $248.00
ALCOHOL BIOMARKERS REF G0480 $248.00
ASSAY OF BENZODIAZEPINES 1 REF G0480 $248.00
ASSAY ANTIDEPRESSANT TRICYCLIC REF G0480 $248.00
ASSAY OF ALCOHOL REF G0480 $248.00
ASSAY OF AMPHETAMINES REF G0480 $248.00
ASSAY OF BARBITURATES REF G0480 $248.00
ASSAY OF COCAINE REF G0480 $248.00
ASSAY OF METHADONE REF G0480 $248.00
ASSAY OF OPIATES REF G0480 $248.00
CHEMO EXTENDED IV W/PUMP HOME G0498 $920.00
COGNITIVE SKILL DEV 15 MIN G0515 $119.00
PAP SMEAR OBTAIN/PREP Q0091 $68.00
SMEAR,WET MOUNT,SALINE/INK Q0111 $155.00
KOH WET MOUNT-HAIR,SKIN,NAILS Q0112 $109.00
PINWORM STUDY Q0113 $138.00
TELEHEALTH ORIGINATING SITE FACILITY FEE Q3014 $69.00
NB SCREEN STATE S3620 $89.00
WELLNESS ASSESSMENT-NON PHYS S5190 $280.00
SMOKING CESSATION GROUP S9453 $116.00
ROOM/CARE - MED/SURG/GYN PRIVATE $2,701.00
ROOM/CARE - ISOLATION $2,970.00
ROOM/CARE - NEGATIVE PRESSURE ISOLATION $4,249.00
ROOM/CARE - OB PRIVATE $2,701.00
ROOM/CARE - PEDIATRIC PRIVATE $2,701.00
Page 55 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
ROOM/CARE - ONCOLOGY PRIVATE $2,875.00
ROOM/CARE - REHAB PRIVATE $2,701.00
ROOM/CARE - MED/SURG/GYN SEMI PRIV $2,701.00
ROOM/CARE - PEDIATRIC SEMI PRIVATE $2,701.00
ROOM/CARE - PICU SEMI PRIVATE $2,701.00
ROOM/CARE - ONCOLOGY SEMI PRIVATE $2,875.00
ROOM/CARE - REHAB SEMI PRIVATE $2,701.00
ROOM/CARE - NEWBORN LEVEL 1 $1,532.00
ROOM/CARE - NEWBORN LEVEL 2 $2,875.00
ROOM/CARE - NEWBORN LEVEL 3 $4,737.00
ROOM/CARE - NEWBORN LEVEL 4 $5,229.00
ROOM/CARE - ICU $4,926.00
ROOM/CARE - PEDIATRIC ICU $5,229.00
ROOM/CARE - INTERMEDIATE ICU $4,249.00
ROOM/CARE - TELEMETRY $4,249.00
ROOM/CARE - PACU ICU OVERFLOW $4,926.00
HYSTERECTOMY SERVICES $9,516.00
PERFUSION $16,354.00
ROBOTIC SURGERY SERVICES $36.00
SURGERY MINUTES - 1ST 30 MINS LEVEL 1 $2,958.00
SURGERY MINUTES - 1ST 30 MINS LEVEL 2 $3,517.00
SURGERY MINUTES - 1ST 30 MINS LEVEL 3 $4,024.00
SURGERY MINUTES - 1ST 30 MINS LEVEL 4 $4,573.00
SURGERY MINUTES - 1ST 30 MINS LEVEL 5 $5,009.00
SURGERY MINUTES - EA ADDL 1 MIN LEVEL 1 $53.00
SURGERY MINUTES - EA ADDL 1 MIN LEVEL 2 $56.00
SURGERY MINUTES - EA ADDL 1 MIN LEVEL 3 $60.00
SURGERY MINUTES - EA ADDL 1 MIN LEVEL 4 $63.00
SURGERY MINUTES - EA ADDL 1 MIN LEVEL 5 $69.00
ANES TIME/MIN $43.00
ANES-TIME GENERAL $43.00
ANESTHESIA $43.00
LOCAL $793.00
BLOCK $1,259.00
SPINAL $1,196.00
EPIDURAL ANESTHESIA FOR LABOR $934.00
EPISTAXIS CONTROL $673.00
REPAIR-SIMPLE/INTERMED LEVEL 1 $905.00
Page 56 of 57
Description
CPT(R)/HCPCS
Billing Code
Charge
Effective
01/01/2019
REPAIR-SIMPLE/INTERMED LEVEL 2 $1,721.00
REPAIR-COMPLEX-LVL 1,1.1-7.5CM $3,014.00
REPAIR-COMPLEX-LVL 1, ADD 5 CM $556.00
REPAIR-COMPLEX-NEEL 1.0-2.5 CM $351.00
REPAIR-COMPLEX-NEEL 2.6-7.5 CM $703.00
REPAIR-COMPLEX-NEEL ADDL 5 CM $351.00
I & D $2,618.00
RECOVERY ROOM TIME 1HR $2,724.00
RECOVERY SVSC TIME ADDL 1/2 HR $559.00
RECOVERY SERVICES $2,724.00
PACU - 1ST 60 MINS PHASE I $1,893.00
PACU - EA ADDL 30 MINS PHASE I $896.00
PACU - 1ST 60 MINS PHASE II $1,893.00
PACU - EA ADDL 30 MINS PHASE II $896.00
SURGICAL SERVICES 1/4 HOUR $1,316.00
ENDO MIN 1ST 30 MIN LVL 1 $2,958.00
ENDO MIN 1ST 30 MIN LVL 2 $3,517.00
ENDO MIN 1ST 30 MIN LVL 3 $4,024.00
ENDO MIN 1ST 30 MIN LVL 4 $4,573.00
ENDO MIN 1ST 30 MIN LVL 5 $5,009.00
ENDO ADDL MIN LVL 2 $56.00
ENDO ADDL MIN LVL 3 $60.00
ENDO ADDL MIN LVL 4 $63.00
ENDO ADDL MIN LVL 5 $69.00
BRONCHOSCOPY PROC-THERAPEUTIC $7,033.00
BRONCHOSCOPY-DIAGNOSTIC $4,015.00
BRONCHOSCOPY - PEDIATRIC $4,015.00
CVP/DEEP LINE INSERT $1,960.00
TRACH PLANNED $5,236.00
CRANIAL HALO $9,047.00
Page 57 of 57