Fee Schedule & Charge Master

Description

Dept

Code

Rate

*Items in RED=this service is not rendered at the facility at this time

ADULT DAY CARE -- DAILY RATE

NF

210.00

ADULT DAY CARE -- MEAL

NF

10.75

ADULT DAY CARE- SHOWER/BATH

NF

30.00

ALBUMIN UA MICRO

LAB

82042

17.50

ALBUTEROL 2.5MG/3ML INHALATION SOL

PHAR

J7613

4.80

AMBULANCE LOAD-BASIC LIFE SUPPORT

AMB

A0429

405.00

AMBULANCE PER MILEAGE

AMB

A0425

6.85

BASIC METABOLIC PANEL

LAB

80048

63.50

BILIRUBIN, TOTAL & DIRECT

LAB

82247

44.00

BIOPSY OF PROSTATE GLAND

N/A

55700

BNP EPTIDE I-STAT

LAB

83880

419.50

CARDIAC VALVE & OTHER PROCEDURES W/ CARDIAC CATHETERIZATION

N/A

DRG 216

CATARACT SURGERY

N/A

66984

CBC (AUTO) WITH 3 PT DIFF

LAB

85025

46.00

CEA

LAB

82378

158.25

CERVICAL SPINAL FUSION

N/A

DRG 473

CHEM 8

LAB

80047

63.50

CHOLESTEROL, TOTAL

LAB

82465

20.00

CLOSTRIDUM DIFF

LAB

87324

87.50

COAGULATION ASSESMENT BLOOD TEST

LAB

85730

69.40

COLONOSCOPY SCREENING

N/A

45378

COLONOSCOPY W/ BIOPSY

N/A

45380

COLONOSCOPY W/ POLYP REMOVAL

N/A

45385

COMPLETE BLOOD COUNT(CBC)

LAB

85027

27.50

COMPREHEN METABOLIC PANEL

LAB

80053

89.00

COVID, SARS COV-RNA

LAB

87635

153.00

CREATININE CLEARANCE

LAB

82575

39.00

CRP (C REACTIVE PROTEIN)

LAB

86140

47.50

CRYOSURGERY benign (1-14 LESIONS)

RHC

17110

110.00

CT LOW EXT LT W&WO

RAD

73702

CT LOW EXT RT W&W/O

RAD

73702

CT L-SPINE WO

RAD

72131

CT UPPER EXT RT WO

RAD

73200

CT ABD W

RAD

74160

CT ABD W&WO

RAD

74170

CT ABD WO

RAD

74150

CT ABD/PELVIS NO CONTRAST

RAD

74176

CT ABD/PELVIS W/ AND WOUT

RAD

74178

CT ABD/PELVIS W/ CONTRAST

RAD

74177

CT BONE DENSITY

RAD

77078

CT BONE LGNTH SCANOGRAM

RAD

77073

CT CHEST W

RAD

71260

CT CHEST W&WO

RAD

71270

CT CHEST WO

CT

71250

CT C-SPINE W

RAD

72126

CT C-SPINE W&WO

RAD

72127

CT C-SPINE WO

RAD

72125

CT FACIAL/SINUS W

RAD

70487

CT FACIAL/SINUS W&WO

RAD

70488

CT FACIAL/SINUS WO

RAD

70486

CT HEAD W

RAD

70460

CT HEAD W&WO

RAD

70470

CT HEAD WO

RAD

70450

CT LIMITED ORBITS FOR MRI

RAD

70480

CT LIMITED-FOLLW UP

RAD

76380

CT LOW EXT LT W

RAD

73701

CT LOW EXT LT WO

RAD

73700

CT LOW EXT RT W

RAD

73701

CT LOW EXT RT WO

RAD

73700

CT L-SPINE W

RAD

72132

CT L-SPINE W&WO

RAD

72133

CT ORBITS/EAR NO CONTR

CT

70480

CT PELVIS W

RAD

72193

CT PELVIS W&WO

RAD

72194

CT PELVIS WO

RAD

72192

CT SOFT TISSUE NECK W

RAD

70491

CT SOFT TISSUE NECK W&WO

RAD

70492

CT SOFT TISSUE NECK WO

RAD

70490

CT T-SPINE W

RAD

72129

CT T-SPINE W&WO

RAD

72130

CT T-SPINE WO

RAD

72128

CT UPPER EXT LT W

RAD

73201

CT UPPER EXT LT W&WO

RAD

73202

CT UPPER EXT LT WO

RAD

73200

CT UPPER EXT R W

RAD

73201

CT UPPER EXT W&WO

RAD

73202

CTA ABD GENERAL

RAD

74175

CTA AORTA/ILIAC RUNOFF

CT

75635

CTA CAROTID ARTERIES

RAD

70498

CTA HEAD/CIRCLE OF WILLIS

RAD

70496

CTA PELVIS

RAD

72191

CTA RD AORTA/ILIAC

RAD

75635

CTA RD CAROTID ARTERIES

RAD

70498

CTA RD HEAD/CIRCLEOF WILL

RAD

70496

CTA RD THORAX/NON CORONAR

RAD

71275

CTA RD: ABD GENERAL

RAD

74175

CTA RD: PELVIS

RAD

72191

CTA THORAX/ NON CORONARY

RAD

71275

DOT PHYSICAL

RHC

99455

150.00

DRUGS OF ABUSE

LAB

80306

1045.00

EGD BIOPSY

N/A

43239

EKG

EKG

93005

130.00

ELECTROCARDIOGRAM, ROUTINE WITH INTERPRETATION AND REPORT

RAD

93000

ER CARE LEVEL 1

EDP

99281

84.00

ER CARE LEVEL 2

EDP

99282

124.00

ER CARE LEVEL 3

EDP

99283

130.00

ER CARE LEVEL 4

EDP

99284

215.00

ER CARE LEVEL 5

EDP

99285

280.00

ER ROOM CARE LEVEL 2

ED

99282

152.00

ER ROOM CARE LEVEL 3

ED

99283

221.00

ER ROOM CARE LEVEL 4

ED

99284

320.00

ER ROOM CARE LEVEL 5

ED

99285

362.00

ER ROOM LEVEL 1 - NURSE EVUALTION

ED

99281

74.00

ER ROOM LEVEL 5

ER

99285

362.00

ESR (SED RATE)

LAB

85651

28.00

ESTRADIOL

LAB

82670

189.09

FAMILY PSYCHOTHERAPY INCLUDING PATIENT, 50 MIN

N/A

90847

FAMILY PSYCHOTHERAPY NOT INCLUDING PATIENT, 50 MIN

N/A

90846

FERRITIN

LAB

82728

122.00

FERRITIN

LAB

82728

122.00

GI PATHOGEN PANEL, STOOL

LAB

87507

1871.60

GLUCOSE

LAB

82947

32.00

GLUCOSE TOLERANCE UP TO 3 SPECIMENS

LAB

82951

282.00

GROUP PSYCHOTHERAPY

N/A

90853

H PYLOR STOOL

LAB

87338

140.50

HEMATOCRIT

LAB

85014

19.00

HEMOGLOBIN A 1 C

LAB

83036

50.75

INJECTION OF ANESTHETIC/STEROID DRUG INTO SPINE

N/A

64483

INJECTION OF SUBSTANCE INTO SPINAL CANAL OF LOWER BACK

N/A

62322 - 62323

IRON

LAB

83540

56.50

KNEE ARTHROSCOPY

N/A

29881

LAPAROSCOPIC CHOLECYSTECTOMY

N/A

47562

LEFT HEART CATHETERIZATION

N/A

93452

LIPID PANEL

LAB

80061

50.00

LIVER FUNCTION PANEL

N/A

80076

65.60

MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY

N/A

DRG 470

MAMMOGRAM OF BOTH BREAST (BILATERAL)

N/A

77066

MAMMOGRAM OF ONE BREAST (UNILATERAL)

N/A

77065

MAMMOGRAM SCREENING, BILATERAL

N/A

77067

MRI BRAIN W AND WO CONTRAST

N/A

70553

MRI LOWER EXTREMITY JOINT WO CONTRAST

N/A

73721

MRI LUMBAR SPINE WO CONTRAST

N/A

72148

MRSA PRE OP SCREENING

LAB

87641

217.50

NURSE VISIT

RHC

99211

33.50

NURSE VISIT-HOME

NUR

G0490

75.00

OBSTETRIC BLOOD PANEL

LAB

80055

255.00

OFFICE VISIT ESTABLISHED LEVEL 2

RHC

99212

92.50

OFFICE VISIT ESTABLISHED LEVEL 3

RHC

99213

125.00

OFFICE VISIT ESTABLISHED LEVEL 4

RHC

99214

183.50

OFFICE VISIT ESTABLISHED LEVEL 5

RHC

99215

262.50

OFFICE VISIT NEW LEVEL 1

RHC

99201

105.00

OFFICE VISIT NEW LEVEL 2

RHC

99202

131.00

OFFICE VISIT NEW LEVEL 3

RHC

99203

197.50

OFFICE VISIT NEW LEVEL 4

RHC

99204

291.00

OFFICE VISIT NEW LEVEL 5

RHC

99205

347.50

PATIENT OFFICE CONSULTATION, TYPICALLY 40 MIN

RHC

99243

281.00

PATIENT OFFICE CONSULTATION, TYPICALLY 60 MIN

RHC

99244

390.00

PHYSICAL THERAPY, THERAPUTIC EXERCISE

N/A

97110

PREGNANCY TEST-URINE

LAB

81025

26.50

PREVENTIVE VISIT EST PT 12-17 YRS

RHC

99394

150.00

PREVENTIVE VISIT EST PT 1-4 YRS

RHC

99392

125.00

PREVENTIVE VISIT EST PT 18-39 YRS

RHC

99395

150.00

PREVENTIVE VISIT EST PT 40-64 YRS

RHC

99396

187.50

PREVENTIVE VISIT EST PT 5-11 YRS

RHC

99393

125.00

PREVENTIVE VISIT EST PT 65+ YRS

RHC

99397

195.00

PREVENTIVE VISIT EST UNDER 1 YR

RHC

99391

125.00

PREVENTIVE VISIT NEW PT 12-17 YRS

RHC

99384

172.50

PREVENTIVE VISIT NEW PT 1-4 YRS

RHC

99382

126.00

PREVENTIVE VISIT NEW PT 18-39 YRS

RHC

99385

172.50

PREVENTIVE VISIT NEW PT 40-64 YRS

RHC

99386

195.00

PREVENTIVE VISIT NEW PT 5-11 YRS

RHC

99383

126.00

PREVENTIVE VISIT NEW PT 65+ YRS

RHC

99387

201.00

PREVENTIVE VISIT NEW PT UNDER 1 YR

RHC

99381

45.00

PSA (Prostate Specific Antigens)

LAB

84153 or 84154

102.00

PSYCHOTHERAPY, 30 MIN

N/A

90832

PSYCHOTHERAPY, 45 MIN

N/A

90834

PSYCHOTHERAPY, 60 MIN

N/A

90837

PT/INR

LAB

85610

36.50

REMOVAL OF 1 OR MORE BREAST GROWTH, OPEN PROCEDURE

N/A

19120

REMOVAL OF RECURRING CATARACT IN LENS CAPSULE USING LASER

N/A

66821

RENAL PANEL

LAB

80069

65.50

REPAIR INGUINAL HERNIA, AGE 5 OR OLDER

N/A

49505

ROUTINE OB CARE FOR CESAREAN DELIVERY, INCLUDING PRE AND POST DELIVERY CARE

N/A

59510

ROUTINE OB CARE FOR VAGINAL DELIVERY, AFTER PRIOR CESAREAN SECTION, INCLUDING PRE & POST DELIVERY CARE

N/A

59610

ROUTINE OB CARE FOR VAGINAL DELIVERY, INCLUDING PRE AND POST DELIVERY CARE

N/A

59400

SHOULDER ARTHROSCOPY

N/A

29826

SKIN TAG REMOVAL UP TO 15 LESIONS

RHC

11200

142.00

SLEEP STUDY

N/A

95810

SPINAL FUSION EXCEPT CERVICAL

N/A

DRG 460

SURGICAL REMOVAL OF PROSTATE GLAND AND LYMPH NODES

N/A

55866

T3 FREE

LAB

84481

97.80

T3 TOTAL

LAB

84480

80.00

TECHNICAL COMPONENT (TC MODIFER) ADD ON'S TO XRAY'S

RAD

61.00

TELEMED

TELE

Q3014

25.76

TESTOSTERONE FREE AND TOTAL

LAB

84403

118.20

THERAPUTIC PHLEBOTOMY

LAB

99195

150.00

TONSILLECTOMY AND ADENOIDECTOMY, UNDER 12

N/A

42820

TREATMENT ROOM

ROOM

120.00

TSH

LAB

84443

64.00

ULTRASOUND FETAL, 14+ WEEKS

N/A

76805

ULTRASOUND OF ABDOMEN

N/A

76700

ULTRASOUND OF LARGE BOWEL

N/A

45391

ULTRASOUND PELVIS

N/A

76830

UPPER GASTROINTESTINAL ENDOSCOPY

N/A

43235

URINALYSIS

LAB

81002

32.00

URINALYSIS USING MICROSCOPE

N/A

81000 or 81001

40.50

UTERINE AND ANDEXA PROCEDURES

N/A

DRG 743

VEIN PUNCTURE

LAB

36415

30.00

VIT B 12

LAB

82607

89.00

VITAMIN D 25-OH

LAB

82306

189.10

WELL WOMAN EXAM

RHC

G0101

165.00

WELL WOMAN EXAM

RHC

G0101

165.00

XRAY ABDOMEN - 1 VIEW

RAD

74018

155.00

XRAY ABDOMEN - ACUTE w 1v chest

RAD

74022

271.50

XRAY ABDOMEN 2V

RAD

74019

231.50

XRAY AC JOINTS W/W/O WGTS

RAD

73050

187.50

XRAY ANKLE LT 1VIEW

RAD

73600

160.50

XRAY ANKLE LT - 2 VIEWS

RAD

73600

160.50

XRAY ANKLE LT - 3 VIEWS

RAD

73610

193.00

XRAY ANKLE RT - 2 VIEWS

RAD

73600

160.50

XRAY ANKLE RT - 3 VIEWS

RAD

73610

193.00

XRAY ANKLE RT 1 VIEW

RAD

73600

160.50

XRAY BILATERAL HIP / PELVIS 2 VIEW

RAD

73521

312.00

XRAY BILATERAL HIP W/WO PELVIS 3-4 VIEW

RAD

73522

360.00

XRAY CHEST - 1 VIEW

RAD

71045

135.50

XRAY CHEST - 2 VIEWS

RAD

71046

182.00

XRAY CHEST 3 VIEWS

RAD

71047

229.00

XRAY CHEST 4 VIEWS OR MORE

RAD

71048

276.00

XRAY CHEST LATERAL VIEW

RAD

71035

135.50

XRAY CLAVICLE LT COMPLETE

RAD

73000

155.00

XRAY CLAVICLE RT COMPLETE

RAD

73000

155.00

XRAY CSPINE 2-3 VIEWS

RAD

72040

194.00

XRAY CSPINE COMPLETE

RAD

72050

292.00

XRAY CSPINE CPLT/FLX EXT

RAD

72052

287.00

XRAY ELBOW LT - 2 VIEWS

RAD

73080

176.50

XRAY ELBOW LT - 3 VIEWS

RAD

73080

195.00

XRAY ELBOW RT - 2 VIEWS

RAD

73080

176.00

XRAY ELBOW RT - 3 VIEWS

RAD

73080

195.00

XRAY FACIAL COMPLETE 3V

RAD

70150

253.00

XRAY FEMUR LT - 2 VIEWS

RAD

73552

210.00

XRAY FEMUR RT 2 VIEWS

RAD

73552

210.00

XRAY FINGERS LT

RAD

73140

116.50

XRAY FINGERS RT

RAD

73140

116.50

XRAY FOOT LT - 2 VIEWS

RAD

73620

200.00

XRAY FOOT LT 3 V

RAD

73630

218.00

XRAY FOOT RT - 2 VIEWS

RAD

73620

200.00

XRAY FOOT RT - 3 > VIEWS

RAD

73630

218.00

XRAY FOREARM LT - 2 VIEWS

RAD

73090

155.00

XRAY FOREARM RT - 2 VIEWS

RAD

73090

155.00

XRAY HAND LT - 2 VIEWS

RAD

73120

155.00

XRAY HAND LT - 3 VIEWS

RAD

73130

177.50

XRAY HAND RT - 2 VIEWS

RAD

73120

155.00

XRAY HAND RT - 3 VIEWS

RAD

73130

177.50

XRAY HEEL LT - 2 < VW

RAD

73650

140.00

XRAY HEEL RT - 2 < VIEWS

RAD

73650

140.00

XRAY HIP LT - 2 < VW

RAD

73502

284.50

XRAY HIP LT 1 VIEW

RAD

73500

157.50

XRAY HIP RT - 1 VIEW

RAD

73501

157.50

XRAY HIP RT 2 - 3 VIEWS w/wo pelvis

RAD

73502

284.50

XRAY HUMERUS LT - 2 VIEWS

RAD

73060

155.00

XRAY HUMERUS RT - 2 VIEWS

RAD

73060

155.00

XRAY KNEE LT - 2 VIEWS

RAD

73560

155.00

XRAY KNEE LT - 3 VIEWS

RAD

73562

193.00

XRAY KNEE LT - COMPLETE

RAD

73564

415.50

XRAY KNEE RT - 2 VIEWS

RAD

73560

155.00

XRAY KNEE RT - 3 VIEWS

RAD

73562

193.00

XRAY KNEE RT - COMPLETE

RAD

73564

415.50

XRAY LUMBAR SPINE 2-3VIEW

RAD

72100

231.50

XRAY LUMBAR SPINE 4-5 VIEWS

RAD

72110

466.00

XRAY MANDIBLE LT 1-2 VIEW

RAD

70100

182.00

XRAY MANDIBLE RT 1-2 VIEW

RAD

70100

182.00

XRAY NASAL BONES 3 VIEWS

RAD

70160

190.50

XRAY NECK - SOFT TISSUE

RAD

70360

116.50

XRAY ORBITS COMP MIN 4 VW

RAD

70200

253.00

XRAY PELVIS 1 OR 2 VIEWS

RAD

72170

169.00

XRAY PELVIS COMPLETE

RAD

72190

238.00

XRAY PELVIS/HIP INFANT

RAD

73540

190.50

XRAY RIBS BILATERAL 3 VIEW

RAD

71110

290.00

XRAY RIBS BILATERAL W/ PA CHEST

RAD

71111

375.00

XRAY RIBS LT UNI-2 VIEW

RAD

71100

227.00

XRAY RIBS RT UNI - 2 VIEWS

RAD

71100

227.00

XRAY RIBS UNILATERAL +PA CHEST

RAD

71101

350.00

XRAY SACRUM/COCCYX

RAD

72220

231.50

XRAY SCAPULA LT

RAD

73010

177.50

XRAY SCAPULA RT

RAD

73010

177.50

XRAY SHOULDER LT - 1 VIEW

RAD

73020

155.00

XRAY SHOULDER LT - MIN 2 VIEW

RAD

73030

177.50

XRAY SHOULDER RT - MIN 2 VIEW

RAD

73030

177.50

XRAY SHOULDER RT 1 VIEW

RAD

73020

155.00

XRAY SI JOINTS 1 OR 2 VIEWS

RAD

72200

155.00

XRAY SINUS 1-2 VIEWS

RAD

70210

182.00

XRAY SINUS-COMPLETE

RAD

70220

246.50

XRAY SKULL 1-3 VIEWS

RAD

70250

231.50

XRAY SKULL COMPLETE

RAD

70260

350.00

XRAY SPINE 1 VIEW

RAD

72020

96.00

XRAY STERNUM

RAD

71120

231.50

XRAY TB/FB LT

RAD

73590

155.00

XRAY TB/FB RT

RAD

73590

155.00

XRAY THORACOL REPEAT

RAD

72080

245.50

XRAY THORACOLUMBAR

RAD

72080

245.50

XRAY TOES

RAD

73660

113.06

XRAY TSPINE 2 VIEWS

RAD

72070

231.50

XRAY TSPINE 4 VIEWS

RAD

72074

380.00

XRAY WRIST LT - 2 VIEWS

RAD

73100

155.00

XRAY WRIST LT - COMPLETE

RAD

73110

230.00

XRAY WRIST RT - 2 VIEWS

RAD

73100

155.00

XRAY WRIST RT COMP

RAD

73110

230.00