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Cigna -

Sagamore

Aetna

Humana

Self Pay Traditional PPO HMO Exchange M/A PPO M/A HMO Commerical Commerical Honda NA Commerical Commerical

Shoppable Service

Ancillary Services

Code

Charge

Evaluation & Management Services

1 OFFICE/OUTPT VISIT, NEW, EXP PROB 99202 $ 188.91 $ 158.69 $ 141.89 $ 134.75 $ 134.75 $ 58.56 $ 58.56 $ 43.99 $ 170.02 $ 127.70 $ 151.13 168.70 $ 144.71 2 OFFICE/OUTPT VISIT, NEW, DETAILED 99203 $ 284.90 $ 239.32 $ 213.99 $ 203.22 $ 203.22 $ 88.32 $ 88.32 $ 66.34 $ 256.41 $ 192.59 $ 227.92 254.42 $ 218.24 3 OFFICE/OUTPT VISIT,NEW,MOD COMPLEX 99204 $ 436.69 $ 366.82 $ 328.00 $ 311.49 $ 311.49 $ 135.38 $ 135.38 $ 101.68 $ 393.02 $ 295.20 $ 349.36 389.97 $ 334.51 4 OFFICE/OUTPT VISIT,NEW,HIGH COMPLEX 99205 $ 543.75 $ 456.75 $ 408.41 $ 387.86 $ 387.86 $ 168.56 $ 168.56 $ 126.61 $ 489.38 $ 367.57 $ 435.00 485.57 $ 416.51 5 OFFICE/OUTPT VISIT, EST, PROB FOC 99212 $ 115.09 $ 96.68 $ 86.44 $ 82.09 $ 82.09 $ 35.68 $ 35.68 $ 26.80 $ 103.58 $ 77.80 $ 92.07 102.78 $ 88.16 6 OFFICE/OUTPT VISIT, EST, EXP PROB 99213 $ 191.75 $ 161.07 $ 144.02 $ 136.77 $ 136.77 $ 59.44 $ 59.44 $ 44.65 $ 172.57 $ 129.62 $ 153.40 171.23 $ 146.88 7 OFFICE/OUTPT VISIT, EST, DETAILED 99214 $ 284.04 $ 238.59 $ 213.34 $ 202.60 $ 202.60 $ 88.05 $ 88.05 $ 66.14 $ 255.63 $ 192.01 $ 227.23 253.64 $ 217.57 8 OFFICE/OUTPT VISIT, EST, COMPLEX 99215 $ 382.08 $ 320.95 $ 286.98 $ 272.54 $ 272.54 $ 118.44 $ 118.44 $ 88.96 $ 343.87 $ 258.28 $ 305.66 341.20 $ 292.67 9 Emergency Department Level 1 99281 $ 208.41 $ 175.07 $ 156.54 $ 148.66 $ 148.66 $ 64.61 $ 64.61 $ 48.53 $ 187.57 $ 140.88 $ 166.73 186.11 $ 159.64 10 Emergency Department Level 2 99282 $ 255.35 $ 214.49 $ 191.79 $ 182.14 $ 182.14 $ 79.16 $ 79.16 $ 59.46 $ 229.81 $ 172.61 $ 204.28 228.03 $ 195.60 11 Emergency Department Level 3 99283 $ 457.43 $ 384.24 $ 343.58 $ 326.29 $ 326.29 $ 141.80 $ 141.80 $ 106.51 $ 411.69 $ 309.22 $ 365.95 408.49 $ 350.39 12 Emergency Department Level 4 99284 $ 729.72 $ 612.97 $ 548.09 $ 520.51 $ 520.51 $ 226.21 $ 226.21 $ 169.91 $ 656.75 $ 493.28 $ 583.78 651.64 $ 558.97 13 Emergency Department Level 5 99285 $ 1,026.36 $ 862.14 $ 770.90 $ 732.10 $ 732.10 $ 318.17 $ 318.17 $ 238.98 $ 923.73 $ 693.81 $ 821.09 916.54 $ 786.19 14 Psychotherapy, 30 minutes 90832 $ 170.51 $ 143.23 $ 128.07 $ 121.62 $ 121.62 $ 52.86 $ 52.86 $ 39.70 $ 153.46 $ 115.26 $ 136.41 152.26 $ 130.61 15 Psychotherapy, 45 minutes 90834 $ 225.84 $ 189.70 $ 169.63 $ 161.09 $ 161.09 $ 70.01 $ 70.01 $ 52.58 $ 203.26 $ 152.66 $ 180.67 201.67 $ 172.99 16 Psychotherapy, 60 minutes 90837 $ 435.95 $ 366.19 $ 327.44 $ 310.96 $ 310.96 $ 135.14 $ 135.14 $ 101.51 $ 392.35 $ 294.69 $ 348.76 389.30 $ 333.93 17 Family Psychotherapy, not including patient, 50 min 90846 $ 273.27 $ 229.54 $ 205.25 $ 194.92 $ 194.92 $ 84.71 $ 84.71 $ 63.63 $ 245.94 $ 184.72 $ 218.61 244.03 $ 209.32 18 Family Psychotherapy, including patient, 50 min 90847 $ 365.08 $ 306.66 $ 274.21 $ 260.41 $ 260.41 $ 113.17 $ 113.17 $ 85.00 $ 328.57 $ 246.79 $ 292.06 326.01 $ 279.65 19 Group Therapy 90853 $ 87.44 $ 73.45 $ 65.67 $ 62.37 $ 62.37 $ 27.11 $ 27.11 $ 20.36 $ 78.69 $ 59.11 $ 69.95 78.08 $ 66.98 20 New patient, office or other outpatient visit, typically 30 min 99203 $ 161.47 $ 135.64 $ 121.28 $ 115.18 $ 115.18 $ 50.06 $ 50.06 $ 37.60 $ 145.33 $ 109.16 $ 129.18 144.20 $ 123.69 21 New patient, office or other outpatient visit, typically 45 min 99204 $ 246.16 $ 206.78 $ 184.89 $ 175.59 $ 175.59 $ 76.31 $ 76.31 $ 57.32 $ 221.55 $ 166.40 $ 196.93 219.82 $ 188.56 22 New patient, office or other outpatient visit, typically 60 min 99205 $ 306.01 $ 257.05 $ 229.85 $ 218.28 $ 218.28 $ 94.86 $ 94.86 $ 71.25 $ 275.41 $ 206.86 $ 244.81 273.27 $ 234.40 23 Patient office consultation, typicaly 40 min 99243 $ 623.46 $ 523.70 $ 468.28 $ 444.71 $ 444.71 $ 193.27 $ 193.27 $ 145.17 $ 561.11 $ 421.45 $ 498.77 556.75 $ 477.57 24 Patient office consultation, typicaly 60 min 99244 $ 927.23 $ 778.87 $ 696.44 $ 661.39 $ 661.39 $ 287.44 $ 287.44 $ 215.90 $ 834.51 $ 626.80 $ 741.79 828.02 $ 710.26 25 Initial new patient preventative medicine evaluation, (18-39

years) 99385 $ 196.48 $ 165.04 $ 147.58 $ 140.15 $ 140.15 $ 60.91 $ 60.91 $ 45.75 $ 176.83 $ 132.82 $ 157.18 175.46 $ 150.50 26 Initial new patient preventative medicine evaluation, (40-64

years) 99386 $ 228.10 $ 191.60 $ 171.32 $ 162.70 $ 162.70 $ 70.71 $ 70.71 $ 53.11 $ 205.29 $ 154.19 $ 182.48 203.69 $ 174.72

Laboratory & Pathology Services

27 Basic metabolic panel 80048 $ 197.48 $ 165.88 $ 148.33 $ 140.86 $ 140.86 $ 61.22 $ 61.22 $ 45.98 $ 177.73 $ 133.49 $ 157.98 176.35 $ 151.27 28 Comprehensive metabolic panel 80053 $ 220.48 $ 185.20 $ 165.60 $ 157.26 $ 157.26 $ 68.35 $ 68.35 $ 51.34 $ 198.43 $ 149.04 $ 176.38 196.88 $ 168.88 29 Lipid panel (cholesterol and triglycerides) 80061 $ 186.72 $ 156.84 $ 140.24 $ 133.19 $ 133.19 $ 57.88 $ 57.88 $ 43.48 $ 168.05 $ 126.22 $ 149.38 166.74 $ 143.03 30 Renal function panel 80069 $ 174.36 $ 146.46 $ 130.96 $ 124.37 $ 124.37 $ 54.05 $ 54.05 $ 40.60 $ 156.93 $ 117.87 $ 139.49 155.71 $ 133.56 31 Liver function panel 80076 $ 164.56 $ 138.23 $ 123.60 $ 117.38 $ 117.38 $ 51.01 $ 51.01 $ 38.32 $ 148.10 $ 111.24 $ 131.65 146.95 $ 126.05 32 Urinalysis test, automated with microscopy 81001 $ 79.88 $ 67.10 $ 60.00 $ 56.98 $ 56.98 $ 24.76 $ 24.76 $ 18.60 $ 71.89 $ 54.00 $ 63.90 71.33 $ 61.19 33 Urinalysis test, non-automated without microscopy 81002 $ 18.07 $ 15.18 $ 13.57 $ 12.89 $ 12.89 $ 5.60 $ 5.60 $ 4.21 $ 16.26 $ 12.21 $ 14.45 16.13 $ 13.84 34 Urinalysis test, automated, without microscopy 81003 $ 55.93 $ 46.98 $ 42.01 $ 39.89 $ 39.89 $ 17.34 $ 17.34 $ 13.02 $ 50.33 $ 37.81 $ 44.74 49.94 $ 42.84 35 PSA (prostate specific antigen), total 84153 $ 213.67 $ 179.48 $ 160.49 $ 152.41 $ 152.41 $ 66.24 $ 66.24 $ 49.75 $ 192.30 $ 144.44 $ 170.93 190.81 $ 163.67 36 PSA (prostate specific antigen), free 84154 $ 101.64 $ 85.38 $ 76.34 $ 72.50 $ 72.50 $ 31.51 $ 31.51 $ 23.67 $ 91.47 $ 68.71 $ 81.31 90.76 $ 77.85 37 Thyroid stimulating hormone (TSH) 84443 $ 267.47 $ 224.67 $ 200.89 $ 190.78 $ 190.78 $ 82.91 $ 82.91 $ 62.28 $ 240.72 $ 180.81 $ 213.97 238.85 $ 204.88 38 Complete blood count, with diffeential white blood cells, 85025 $ 108.34 $ 91.00 $ 81.37 $ 77.28 $ 77.28 $ 33.58 $ 33.58 $ 25.23 $ 97.50 $ 73.24 $ 86.67 96.75 $ 82.99 39 Complete blood count 85027 $ 111.81 $ 93.92 $ 83.98 $ 79.76 $ 79.76 $ 34.66 $ 34.66 $ 26.03 $ 100.63 $ 75.58 $ 89.45 99.85 $ 85.65 40 Prothrombin time 85610 $ 79.88 $ 67.10 $ 60.00 $ 56.98 $ 56.98 $ 24.76 $ 24.76 $ 18.60 $ 71.89 $ 54.00 $ 63.90 71.33 $ 61.19 41 Thromboplastin time, partial (PTT), plasma or whole blood 85730 $ 111.81 $ 93.92 $ 83.98 $ 79.76 $ 79.76 $ 34.66 $ 34.66 $ 26.03 $ 100.63 $ 75.58 $ 89.45 99.85 $ 85.65 42 Venous Blood Gas Standard 82803 $ 300.28 $ 252.23 $ 225.54 $ 214.19 $ 214.19 $ 93.09 $ 93.09 $ 69.92 $ 270.25 $ 202.99 $ 240.22 268.15 $ 230.01 43 DRUG SCREEN MULTIPLE CLASS 80307 $ 244.49 $ 205.37 $ 183.64 $ 174.40 $ 174.40 $ 75.79 $ 75.79 $ 56.93 $ 220.04 $ 165.27 $ 195.59 218.33 $ 187.28 44 Microalbumin/Creatinine Urine 82043 $ 77.01 $ 64.69 $ 57.84 $ 54.93 $ 54.93 $ 23.87 $ 23.87 $ 17.93 $ 69.31 $ 52.06 $ 61.61 68.77 $ 58.99 45 VITAMIN D, 25-HYDROXY 82306 $ 333.38 $ 280.04 $ 250.40 $ 237.80 $ 237.80 $ 103.35 $ 103.35 $ 77.63 $ 300.05 $ 225.36 $ 266.71 297.71 $ 255.37 46 VITAMIN B12 82607 $ 205.66 $ 172.76 $ 154.47 $ 146.70 $ 146.70 $ 63.76 $ 63.76 $ 47.89 $ 185.10 $ 139.03 $ 164.53 183.66 $ 157.54 47 Hemoglobin A1c DC 83036 $ 125.06 $ 105.05 $ 93.93 $ 89.21 $ 89.21 $ 38.77 $ 38.77 $ 29.12 $ 112.56 $ 84.54 $ 100.05 111.68 $ 95.80 48 MAGNESIUM 83735 $ 140.47 $ 118.00 $ 105.51 $ 100.20 $ 100.20 $ 43.55 $ 43.55 $ 32.71 $ 126.42 $ 94.96 $ 112.38 125.44 $ 107.60 49 Pro-BNP 83880 $ 335.47 $ 281.80 $ 251.97 $ 239.29 $ 239.29 $ 104.00 $ 104.00 $ 78.11 $ 301.92 $ 226.78 $ 268.38 299.58 $ 256.97 50 Testosterone; total 84403 $ 198.56 $ 166.79 $ 149.14 $ 141.63 $ 141.63 $ 61.55 $ 61.55 $ 46.23 $ 178.70 $ 134.22 $ 158.85 177.31 $ 152.10 51 OBSTETRICS PANEL W/87389 80081 $ 386.60 $ 324.74 $ 290.37 $ 275.76 $ 275.76 $ 119.85 $ 119.85 $ 90.02 $ 347.94 $ 261.34 $ 309.28 345.23 $ 296.13 52 Arterial Blood Gas RT Standard 82803 $ 300.28 $ 252.23 $ 225.54 $ 214.19 $ 214.19 $ 93.09 $ 93.09 $ 69.92 $ 270.25 $ 202.99 $ 240.22 268.15 $ 230.01 53 Gastrin SB 82941 $ 245.87 $ 206.53 $ 184.67 $ 175.38 $ 175.38 $ 76.22 $ 76.22 $ 57.25 $ 221.28 $ 166.21 $ 196.70 219.56 $ 188.34 54 BODY FLUID GLUCOSE 82945 $ 79.88 $ 67.10 $ 60.00 $ 56.98 $ 56.98 $ 24.76 $ 24.76 $ 18.60 $ 71.89 $ 54.00 $ 63.90 71.33 $ 61.19 55 GLUCOSE SERUM PP 82947 $ 79.88 $ 67.10 $ 60.00 $ 56.98 $ 56.98 $ 24.76 $ 24.76 $ 18.60 $ 71.89 $ 54.00 $ 63.90 71.33 $ 61.19 56 .Fasting GTT 82950 $ 79.88 $ 67.10 $ 60.00 $ 56.98 $ 56.98 $ 24.76 $ 24.76 $ 18.60 $ 71.89 $ 54.00 $ 63.90 71.33 $ 61.19 57 .GTT 1 HR 100 gm Gest. 82951 $ 179.44 $ 150.73 $ 134.78 $ 128.00 $ 128.00 $ 55.63 $ 55.63 $ 41.78 $ 161.50 $ 121.30 $ 143.56 160.24 $ 137.45 58 Glucose-6-Phosphate Dehydrogenase, Blood SB 82955 $ 135.16 $ 113.53 $ 101.52 $ 96.41 $ 96.41 $ 41.90 $ 41.90 $ 31.47 $ 121.64 $ 91.36 $ 108.12 120.69 $ 103.53 59 WHITE BLOOD COUNT 85048 $ 79.88 $ 67.10 $ 60.00 $ 56.98 $ 56.98 $ 24.76 $ 24.76 $ 18.60 $ 71.89 $ 54.00 $ 63.90 71.33 $ 61.19 60 PLATELET COUNT AUTO 85049 $ 79.88 $ 67.10 $ 60.00 $ 56.98 $ 56.98 $ 24.76 $ 24.76 $ 18.60 $ 71.89 $ 54.00 $ 63.90 71.33 $ 61.19 61 Bone Marrow Interpretation 85097 $ 291.41 $ 244.78 $ 218.88 $ 207.86 $ 207.86 $ 90.34 $ 90.34 $ 67.85 $ 262.27 $ 196.99 $ 233.13 260.23 $ 223.22 62 Coagulation Factor II Activity SB 85210 $ 161.85 $ 135.96 $ 121.57 $ 115.45 $ 115.45 $ 50.18 $ 50.18 $ 37.69 $ 145.67 $ 109.41 $ 129.48 144.54 $ 123.98 63 Coagulation Factor V Activity SB 85220 $ 209.26 $ 175.78 $ 157.17 $ 149.26 $ 149.26 $ 64.87 $ 64.87 $ 48.72 $ 188.33 $ 141.46 $ 167.41 186.87 $ 160.29 64 Coagulation Factor VII Activity SB 85230 $ 240.97 $ 202.42 $ 181.00 $ 171.89 $ 171.89 $ 74.70 $ 74.70 $ 56.11 $ 216.88 $ 162.90 $ 192.78 215.19 $ 184.59 65 Coagulation Factor VIII Activity SB 85240 $ 208.01 $ 174.73 $ 156.24 $ 148.37 $ 148.37 $ 64.48 $ 64.48 $ 48.43 $ 187.21 $ 140.61 $ 166.41 185.75 $ 159.34 66 Insulin Antibody SB 86337 $ 248.65 $ 208.87 $ 186.76 $ 177.36 $ 177.36 $ 77.08 $ 77.08 $ 57.90 $ 223.79 $ 168.09 $ 198.92 222.05 $ 190.47 67 Infliximab Activity and Neutralizing Antibody SB 86352 $ 297.89 $ 250.23 $ 223.75 $ 212.49 $ 212.49 $ 92.35 $ 92.35 $ 69.36 $ 268.10 $ 201.37 $ 238.31 266.02 $ 228.18 68 T-Cells, CD4/CD8 by Flow Cytometry, Blood SB 86359 $ 71.20 $ 59.81 $ 53.48 $ 50.79 $ 50.79 $ 22.07 $ 22.07 $ 16.58 $ 64.08 $ 48.13 $ 56.96 63.59 $ 54.54 69 T cells; absolute CD4 and CD8 count, including ratio 86360 $ 264.05 $ 221.80 $ 198.33 $ 188.34 $ 188.34 $ 81.85 $ 81.85 $ 61.48 $ 237.64 $ 178.49 $ 211.24 235.79 $ 202.26

Contracted Payers

Anthem

UHC

(2)

Shoppable Service

Ancillary Services

Code

Charge

70 Hepatitis B Virus Core Abs (Total), Reflex to HBc Ab, IgM SB 86704 $ 168.03 $ 141.15 $ 126.21 $ 119.86 $ 119.86 $ 52.09 $ 52.09 $ 39.12 $ 151.23 $ 113.59 $ 134.43 150.05 $ 128.71 71 Hepatitis B Virus Core Antibody, IgM SB 86705 $ 172.82 $ 145.17 $ 129.81 $ 123.27 $ 123.27 $ 53.57 $ 53.57 $ 40.24 $ 155.54 $ 116.83 $ 138.26 154.33 $ 132.38 72 Hepatitis B Virus Surface Antibody, Quantitative SB 86706 $ 149.74 $ 125.78 $ 112.47 $ 106.81 $ 106.81 $ 46.42 $ 46.42 $ 34.87 $ 134.76 $ 101.22 $ 119.79 133.72 $ 114.70 73 Hepatitis A Virus Antibodies (Total) SB 86708 $ 172.66 $ 145.03 $ 129.68 $ 123.16 $ 123.16 $ 53.52 $ 53.52 $ 40.20 $ 155.39 $ 116.72 $ 138.13 154.18 $ 132.26 74 Hepatitis A Virus Antibody, IgM SB 86709 $ 145.80 $ 122.47 $ 109.51 $ 104.00 $ 104.00 $ 45.20 $ 45.20 $ 33.95 $ 131.22 $ 98.56 $ 116.64 130.20 $ 111.68 75 Antibody; West Nile virus 86789 $ 241.30 $ 202.69 $ 181.24 $ 172.12 $ 172.12 $ 74.80 $ 74.80 $ 56.18 $ 217.17 $ 163.12 $ 193.04 215.48 $ 184.84 76 Thyroglobulin Ab and Thyroglobulin, Tumor Marker, Reflex SB 86800 $ 146.90 $ 123.40 $ 110.34 $ 104.79 $ 104.79 $ 45.54 $ 45.54 $ 34.21 $ 132.21 $ 99.31 $ 117.52 131.19 $ 112.53 77 Hepatitis C Virus Antibody SB 86803 $ 198.92 $ 167.10 $ 149.41 $ 141.89 $ 141.89 $ 61.67 $ 61.67 $ 46.32 $ 179.03 $ 134.47 $ 159.14 177.64 $ 152.37 78 LAB CULTURE-BLOOD 87040 $ 233.78 $ 196.37 $ 175.59 $ 166.75 $ 166.75 $ 72.47 $ 72.47 $ 54.43 $ 210.40 $ 158.03 $ 187.02 208.76 $ 179.07 79 Culture, Feces, Routine, with Campylobacter and Shiga Toxin

Antigens, EIA SB 87045 $ 129.80 $ 109.03 $ 97.50 $ 92.59 $ 92.59 $ 40.24 $ 40.24 $ 30.22 $ 116.82 $ 87.75 $ 103.84 115.91 $ 99.43 80 Culture, bacterial; stool, aerobic, additional pathogens, is 87046 $ 101.81 $ 85.52 $ 76.47 $ 72.62 $ 72.62 $ 31.56 $ 31.56 $ 23.71 $ 91.63 $ 68.82 $ 81.45 90.92 $ 77.99 81 Culture, Herpes Simplex Virus SB 87252 $ 326.16 $ 273.98 $ 244.98 $ 232.65 $ 232.65 $ 101.11 $ 101.11 $ 75.94 $ 293.55 $ 220.48 $ 260.93 291.26 $ 249.84 82 Virus isolation; tissue culture, additional studies or defin 87253 $ 158.12 $ 132.82 $ 118.76 $ 112.79 $ 112.79 $ 49.02 $ 49.02 $ 36.82 $ 142.31 $ 106.89 $ 126.50 141.20 $ 121.12 83 Herpes Simplex Virus (HSV) Culture and Typing SB 87255 $ 221.50 $ 186.06 $ 166.37 $ 157.99 $ 157.99 $ 68.66 $ 68.66 $ 51.57 $ 199.35 $ 149.73 $ 177.20 197.80 $ 169.67 84 Mycoplasma pneumoniae, Qualitative PCR SB 87581 $ 254.56 $ 213.83 $ 191.20 $ 181.58 $ 181.58 $ 78.91 $ 78.91 $ 59.27 $ 229.10 $ 172.08 $ 203.65 227.32 $ 194.99 85 CG DNA ASSAY 87591 $ 188.81 $ 158.60 $ 141.82 $ 134.68 $ 134.68 $ 58.53 $ 58.53 $ 43.96 $ 169.93 $ 127.64 $ 151.05 168.61 $ 144.63 86 HPV DNA, High Risk with 16 and 18 Genotyping, ThinPrep SB 87624 $ 327.43 $ 275.04 $ 245.94 $ 233.56 $ 233.56 $ 101.50 $ 101.50 $ 76.24 $ 294.69 $ 221.34 $ 261.95 292.40 $ 250.81 87 Respiratory Pathogen Panel, PCR SB 87633 $ 549.17 $ 461.30 $ 412.48 $ 391.72 $ 391.72 $ 170.24 $ 170.24 $ 127.87 $ 494.25 $ 371.23 $ 439.33 490.41 $ 420.66 88 2019 Novel Coronavirus (COVID-19), NAA SB 87635 $ 325.73 $ 273.61 $ 244.66 $ 232.34 $ 232.34 $ 100.98 $ 100.98 $ 75.84 $ 293.16 $ 220.19 $ 260.58 290.88 $ 249.51 89 STAPH A DNA AMP PROBE 801756 87640 $ 218.80 $ 183.79 $ 164.34 $ 156.07 $ 156.07 $ 67.83 $ 67.83 $ 50.95 $ 196.92 $ 147.91 $ 175.04 195.39 $ 167.60 90 87641 MR STAPH DNA AMP PROBE 801756 87641 $ 218.80 $ 183.79 $ 164.34 $ 156.07 $ 156.07 $ 67.83 $ 67.83 $ 50.95 $ 196.92 $ 147.91 $ 175.04 195.39 $ 167.60 91 87660 TRICHOMONAS VAGDIRPROBE 801619 87660 $ 66.95 $ 56.24 $ 50.28 $ 47.75 $ 47.75 $ 20.75 $ 20.75 $ 15.59 $ 60.25 $ 45.26 $ 53.56 59.78 $ 51.28 92 Trichomonas vaginalis by Transcription-Mediated

87661 $ 242.64 $ 203.81 $ 182.24 $ 173.07 $ 173.07 $ 75.22 $ 75.22 $ 56.50 $ 218.37 $ 164.02 $ 194.11 216.67 $ 185.86 93 BK Virus, Quantitative PCR, Blood SB 87799 $ 502.45 $ 422.06 $ 377.39 $ 358.40 $ 358.40 $ 155.76 $ 155.76 $ 116.99 $ 452.20 $ 339.65 $ 401.96 448.69 $ 384.88 94 Legionella pneumophila 1 Antigen, Urine SB 87899 $ 167.15 $ 140.41 $ 125.55 $ 119.23 $ 119.23 $ 51.82 $ 51.82 $ 38.92 $ 150.44 $ 112.99 $ 133.72 149.27 $ 128.04 95 Cytology Brushing / Washing Fl 88104 $ 119.79 $ 100.63 $ 89.98 $ 85.45 $ 85.45 $ 37.14 $ 37.14 $ 27.89 $ 107.81 $ 80.98 $ 95.83 106.97 $ 91.76 96 Cytopathology 88108 $ 160.41 $ 134.75 $ 120.48 $ 114.42 $ 114.42 $ 49.73 $ 49.73 $ 37.35 $ 144.37 $ 108.44 $ 128.33 143.25 $ 122.87 97 MD Interpretation Cytopath 88141 $ 78.64 $ 66.06 $ 59.07 $ 56.10 $ 56.10 $ 24.38 $ 24.38 $ 18.31 $ 70.78 $ 53.16 $ 62.91 70.23 $ 60.24 98 Non Gyn Pap 88160 $ 160.41 $ 134.75 $ 120.48 $ 114.42 $ 114.42 $ 49.73 $ 49.73 $ 37.35 $ 144.37 $ 108.44 $ 128.33 143.25 $ 122.87 99 Cyto Prep Screening Interpretation 88161 $ 160.41 $ 134.75 $ 120.48 $ 114.42 $ 114.42 $ 49.73 $ 49.73 $ 37.35 $ 144.37 $ 108.44 $ 128.33 143.25 $ 122.87 100 Breast Aspiration 88170 $ 121.54 $ 102.09 $ 91.29 $ 86.69 $ 86.69 $ 37.68 $ 37.68 $ 28.30 $ 109.39 $ 82.16 $ 97.23 108.54 $ 93.10 101 Eval of Fine Needle Aspirate 88172 $ 160.41 $ 134.75 $ 120.48 $ 114.42 $ 114.42 $ 49.73 $ 49.73 $ 37.35 $ 144.37 $ 108.44 $ 128.33 143.25 $ 122.87 102 Pap Diagnostic, ThinPrep (Imaged) SB 88175 $ 186.27 $ 156.47 $ 139.91 $ 132.87 $ 132.87 $ 57.74 $ 57.74 $ 43.37 $ 167.65 $ 125.92 $ 149.02 166.34 $ 142.69 103 Cyto Prep Consult 88333 $ 252.74 $ 212.31 $ 189.84 $ 180.28 $ 180.28 $ 78.35 $ 78.35 $ 58.85 $ 227.47 $ 170.85 $ 202.20 225.70 $ 193.60 104 88720 Bilirubin Total Transcutaneous POC 88720 $ 45.69 $ 38.38 $ 34.32 $ 32.59 $ 32.59 $ 14.16 $ 14.16 $ 10.64 $ 41.12 $ 30.89 $ 36.55 40.80 $ 35.00

Radiology Services

105 Ultrasound Breast Biopsy 19083 $ 245.06 $ 205.85 $ 184.06 $ 174.80 $ 174.80 $ 75.97 $ 75.97 $ 57.06 $ 220.55 $ 165.66 $ 196.05 218.84 $ 187.72 106 Ultrasound Liver Biopsy 47000 $ 883.96 $ 742.53 $ 663.94 $ 630.53 $ 630.53 $ 274.03 $ 274.03 $ 205.82 $ 795.57 $ 597.55 $ 707.17 789.38 $ 677.12 107 US Paracentesis 49083 $ 2,051.81 $ 1,723.52 $ 1,541.12 $ 1,463.56 $ 1,463.56 $ 636.06 $ 636.06 $ 477.75 $ 1,846.63 $ 1,387.00 $ 1,641.45 1,832.27 $ 1,571.69 108 CT, head or brain, without contrast material 70450 $ 1,694.91 $ 1,423.72 $ 1,273.05 $ 1,208.98 $ 1,208.98 $ 525.42 $ 525.42 $ 394.64 $ 1,525.42 $ 1,145.74 $ 1,355.93 1,513.55 $ 1,298.30 109 MRI scan of brain wihtout contrast material, followed by

contrast material 70553 $ 4,573.42 $ 3,841.67 $ 3,435.10 $ 3,262.22 $ 3,262.22 $ 1,417.76 $ 1,417.76 $ 1,064.88 $ 4,116.08 $ 3,091.59 $ 3,658.74 4,084.07 $ 3,503.24 110 X-ray, Chest 2 Views 71046 $ 236.41 $ 198.59 $ 177.57 $ 168.63 $ 168.63 $ 73.29 $ 73.29 $ 55.05 $ 212.77 $ 159.81 $ 189.13 211.12 $ 181.09 111 X-ray, lower back, Minimum four views 72110 $ 268.31 $ 225.38 $ 201.53 $ 191.39 $ 191.39 $ 83.18 $ 83.18 $ 62.47 $ 241.48 $ 181.38 $ 214.65 239.60 $ 205.53 112 CT Angio Chest 72125 $ 3,417.27 $ 2,870.51 $ 2,566.71 $ 2,437.54 $ 2,437.54 $ 1,059.35 $ 1,059.35 $ 795.68 $ 3,075.54 $ 2,310.04 $ 2,733.81 3,051.62 $ 2,617.63 113 MRI scan of lower sinal canal 72148 $ 2,906.91 $ 2,441.80 $ 2,183.38 $ 2,073.50 $ 2,073.50 $ 901.14 $ 901.14 $ 676.85 $ 2,616.21 $ 1,965.04 $ 2,325.52 2,595.87 $ 2,226.69 114 CT scan, pelvis, with contrast 72193 $ 1,795.77 $ 1,508.44 $ 1,348.80 $ 1,280.92 $ 1,280.92 $ 556.69 $ 556.69 $ 418.13 $ 1,616.19 $ 1,213.92 $ 1,436.61 1,603.62 $ 1,375.56 115 MRI Pelvis w/ + w/o Contrast 72197 $ 3,362.68 $ 2,824.65 $ 2,525.71 $ 2,398.60 $ 2,398.60 $ 1,042.43 $ 1,042.43 $ 782.97 $ 3,026.41 $ 2,273.14 $ 2,690.14 3,002.87 $ 2,575.81 116 MRI UE Non Joint w/ + w/o Contrast Right 73220 $ 3,889.23 $ 3,266.95 $ 2,921.20 $ 2,774.19 $ 2,774.19 $ 1,205.66 $ 1,205.66 $ 905.57 $ 3,500.31 $ 2,629.08 $ 3,111.38 3,473.08 $ 2,979.15 117 MRI UE Joint w/o Contrast 73221 $ 2,906.91 $ 2,441.80 $ 2,183.38 $ 2,073.50 $ 2,073.50 $ 901.14 $ 901.14 $ 676.85 $ 2,616.21 $ 1,965.04 $ 2,325.52 2,595.87 $ 2,226.69 118 MRI, any joint of lower extremity, without contrast material 73721 $ 2,906.91 $ 2,441.80 $ 2,183.38 $ 2,073.50 $ 2,073.50 $ 901.14 $ 901.14 $ 676.85 $ 2,616.21 $ 1,965.04 $ 2,325.52 2,595.87 $ 2,226.69 119 CT scan of abdomen and pelvis with contrast 74177 $ 3,012.75 $ 2,530.71 $ 2,262.87 $ 2,148.99 $ 2,148.99 $ 933.95 $ 933.95 $ 701.49 $ 2,711.47 $ 2,036.59 $ 2,410.20 2,690.38 $ 2,307.76 120 MRI Abdomen w/ + w/o Contrast 74183 $ 4,344.23 $ 3,649.15 $ 3,262.95 $ 3,098.74 $ 3,098.74 $ 1,346.71 $ 1,346.71 $ 1,011.51 $ 3,909.81 $ 2,936.66 $ 3,475.38 3,879.40 $ 3,327.68 121 Ultrasound of abdomen 76700 $ 1,053.53 $ 884.96 $ 791.30 $ 751.48 $ 751.48 $ 326.59 $ 326.59 $ 245.30 $ 948.17 $ 712.17 $ 842.82 940.80 $ 807.00 122 Abdominal ultrasound of pregnant uterus (greater or equal to

14 weeks 0 days) single or first fetus 76805 $ 123 Ultransound, transvaginal 76830 $ 124 MRI Breast w/ + w/o Contrast Bilateral 77049 $ 125 Mammography of one breast 77065 $ 126 Mammography of both breasts 77066 $ 127 Mammography, screening, bilateral 77067 $ 128 XR Orbits Complete Bilateral 70200 $ 129 XR Sinuses Paranasal < 3 Views 70210 $ 130 XR Sinuses Complete 70220 $ 131 CT Maxillofacial w/o Contrast 70486 $ 132 CT Soft Tissue Neck w/ + w/o Contrast 70492 $ 133 CT Chest w/o Contrast 71250 $ 134 XR Hip 2-3 Views Lt 73502 $ 135 XR Femur 2 Views Rt 73552 $ 136 XR Knee 1 or 2 Views Right 73560 $ 137 XR Knees AP Standing 73565 $ 138 XR Ankle 2 Views Left 73600 $ 139 XR Foot 2 Views Right 73620 $ 140 Magnetic resonance angiography, 141 XR Abdomen AP 74018 $ 157.89 $ 142 XR Abdomen Acute Series 74022 $ 143 CT Abdomen and Pelvis w/ 144 MRI Abdomen w/ + w/o Contrast 74183 $ 145 XR Esophagus 74220 $ 536.51 $ 146 XR Upper GI w/ Small Bowel 74240 $ 147 XR Barium Enema Regular w/ or w/o KUB 74270 $ 148 US Breast Comp Left 76641 $ 149 US Abdomen Complete 76700 $ 631.96 $ 530.84 $ 474.66 $ 450.78 $ 450.78 $ 195.91 $ 195.91 $ 147.15 $ 568.76 $ 427.20 $ 505.57 564.34 $ 484.08 631.96 $ 530.84 $ 474.66 $ 450.78 $ 450.78 $ 195.91 $ 195.91 $ 147.15 $ 568.76 $ 427.20 $ 505.57 564.34 $ 484.08 3,699.59 $ 3,107.65 $ 2,778.76 $ 2,638.92 $ 2,638.92 $ 1,146.87 $ 1,146.87 $ 861.42 $ 3,329.63 $ 2,500.89 $ 2,959.67 3,303.73 $ 2,833.89 490.06 $ 411.65 $ 368.08 $ 349.56 $ 349.56 $ 151.92 $ 151.92 $ 114.11 $ 441.05 $ 331.28 $ 392.05 437.62 $ 375.39 612.63 $ 514.61 $ 460.15 $ 436.99 $ 436.99 $ 189.92 $ 189.92 $ 142.65 $ 551.37 $ 414.13 $ 490.11 547.08 $ 469.28 351.46 $ 295.23 $ 263.98 $ 250.70 $ 250.70 $ 108.95 $ 108.95 $ 81.83 $ 316.32 $ 237.58 $ 281.17 313.86 $ 269.22 234.64 $ 197.10 $ 176.24 $ 167.37 $ 167.37 $ 72.74 $ 72.74 $ 54.63 $ 211.18 $ 158.62 $ 187.72 209.54 $ 179.74 329.78 $ 277.01 $ 247.70 $ 235.23 $ 235.23 $ 102.23 $ 102.23 $ 76.79 $ 296.80 $ 222.93 $ 263.82 294.49 $ 252.61 232.56 $ 195.35 $ 174.68 $ 165.88 $ 165.88 $ 72.09 $ 72.09 $ 54.15 $ 209.30 $ 157.21 $ 186.05 207.68 $ 178.14 2,079.19 $ 1,746.52 $ 1,561.68 $ 1,483.09 $ 1,483.09 $ 644.55 $ 644.55 $ 484.12 $ 1,871.28 $ 1,405.51 $ 1,663.36 1,856.72 $ 1,592.66 3,986.80 $ 3,348.91 $ 2,994.48 $ 2,843.78 $ 2,843.78 $ 1,235.91 $ 1,235.91 $ 928.29 $ 3,588.12 $ 2,695.03 $ 3,189.44 3,560.21 $ 3,053.89 1,795.77 $ 1,508.44 $ 1,348.80 $ 1,280.92 $ 1,280.92 $ 556.69 $ 556.69 $ 418.13 $ 1,616.19 $ 1,213.92 $ 1,436.61 1,603.62 $ 1,375.56 223.93 $ 188.10 $ 168.19 $ 159.73 $ 159.73 $ 69.42 $ 69.42 $ 52.14 $ 201.54 $ 151.37 $ 179.14 199.97 $ 171.53 178.68 $ 150.09 $ 134.21 $ 127.46 $ 127.46 $ 55.39 $ 55.39 $ 41.61 $ 160.82 $ 120.79 $ 142.95 159.56 $ 136.87 229.38 $ 192.68 $ 172.29 $ 163.62 $ 163.62 $ 71.11 $ 71.11 $ 53.41 $ 206.44 $ 155.06 $ 183.50 204.84 $ 175.70 246.41 $ 206.99 $ 185.08 $ 175.77 $ 175.77 $ 76.39 $ 76.39 $ 57.38 $ 221.77 $ 166.57 $ 197.13 220.05 $ 188.75 191.88 $ 161.18 $ 144.12 $ 136.87 $ 136.87 $ 59.48 $ 59.48 $ 44.68 $ 172.69 $ 129.71 $ 153.50 171.35 $ 146.98 145.94 $ 122.59 $ 109.61 $ 104.10 $ 104.10 $ 45.24 $ 45.24 $ 33.98 $ 131.34 $ 98.65 $ 116.75 130.32 $ 111.79 lower extremity, with or wit 73725 $ 5,022.24 $ 4,218.69 $ 3,772.21 $ 3,582.37 $ 3,582.37 $ 1,556.90 $ 1,556.90 $ 1,169.38 $ 4,520.02 $ 3,394.99 $ 4,017.80 4,484.86 $ 3,847.04 132.63 $ 118.59 $ 112.62 $ 112.62 $ 48.95 $ 48.95 $ 36.76 $ 142.10 $ 106.73 $ 126.31 141.00 $ 120.95 468.05 $ 393.16 $ 351.55 $ 333.86 $ 333.86 $ 145.10 $ 145.10 $ 108.98 $ 421.25 $ 316.40 $ 374.44 417.97 $ 358.53 + w/o Contrast 74178 $ 3,012.75 $ 2,530.71 $ 2,262.87 $ 2,148.99 $ 2,148.99 $ 933.95 $ 933.95 $ 701.49 $ 2,711.47 $ 2,036.59 $ 2,410.20 2,690.38 $ 2,307.76 4,344.23 $ 3,649.15 $ 3,262.95 $ 3,098.74 $ 3,098.74 $ 1,346.71 $ 1,346.71 $ 1,011.51 $ 3,909.81 $ 2,936.66 $ 3,475.38 3,879.40 $ 3,327.68 450.67 $ 402.97 $ 382.69 $ 382.69 $ 166.32 $ 166.32 $ 124.92 $ 482.86 $ 362.67 $ 429.21 479.10 $ 410.97 593.48 $ 498.52 $ 445.76 $ 423.33 $ 423.33 $ 183.98 $ 183.98 $ 138.19 $ 534.13 $ 401.19 $ 474.78 529.98 $ 454.60 715.51 $ 601.03 $ 537.42 $ 510.37 $ 510.37 $ 221.81 $ 221.81 $ 166.60 $ 643.96 $ 483.68 $ 572.41 638.95 $ 548.08 487.23 $ 409.27 $ 365.96 $ 347.54 $ 347.54 $ 151.04 $ 151.04 $ 113.45 $ 438.50 $ 329.36 $ 389.78 435.09 $ 373.21 1,053.53 $ 884.96 $ 791.30 $ 751.48 $ 751.48 $ 326.59 $ 326.59 $ 245.30 $ 948.17 $ 712.17 $ 842.82 940.80 $ 807.00

(3)

Page 3

Cigna -

Sagamore

Aetna

Humana

Shoppable Service

Ancillary Services

Code

Charge

150 US Liver (Hepatic) 76705 $ 541.64 $ 454.98 $ 406.83 $ 386.35 $ 386.35 $ 167.91 $ 167.91 $ 126.12 $ 487.48 $ 366.15 $ 433.32 483.69 $ 414.90 151 US AAA Screening 76706 $ 582.89 $ 489.63 $ 437.81 $ 415.78 $ 415.78 $ 180.70 $ 180.70 $ 135.72 $ 524.60 $ 394.03 $ 466.31 520.52 $ 446.50 152 US OB Less Than 14 Weeks 1st Gest 76801 $ 601.89 $ 505.59 $ 452.08 $ 429.33 $ 429.33 $ 186.59 $ 186.59 $ 140.15 $ 541.70 $ 406.87 $ 481.51 537.49 $ 461.05 153 US Pregnancy Limited 76815 $ 338.22 $ 284.10 $ 254.03 $ 241.25 $ 241.25 $ 104.85 $ 104.85 $ 78.75 $ 304.39 $ 228.63 $ 270.57 302.03 $ 259.07 154 US Testicular 76870 $ 521.59 $ 438.14 $ 391.77 $ 372.05 $ 372.05 $ 161.69 $ 161.69 $ 121.45 $ 469.43 $ 352.59 $ 417.27 465.78 $ 399.54 155 US Guided Amniocentesis 76946 $ 902.80 $ 758.35 $ 678.09 $ 643.97 $ 643.97 $ 279.87 $ 279.87 $ 210.21 $ 812.52 $ 610.29 $ 722.24 806.20 $ 691.55 156 MRI Breast w/o Contrast Right 77046 $ 1,852.45 $ 1,556.06 $ 1,391.38 $ 1,321.36 $ 1,321.36 $ 574.26 $ 574.26 $ 431.33 $ 1,667.21 $ 1,252.24 $ 1,481.96 1,654.24 $ 1,418.98 157 MRI Breast w/ + w/o Contrast Bilateral 77049 $ 3,699.59 $ 3,107.65 $ 2,778.76 $ 2,638.92 $ 2,638.92 $ 1,146.87 $ 1,146.87 $ 861.42 $ 3,329.63 $ 2,500.89 $ 2,959.67 3,303.73 $ 2,833.89 158 BD Bone Density DEXA Axial Skeleton 77080 $ 598.99 $ 503.16 $ 449.90 $ 427.26 $ 427.26 $ 185.69 $ 185.69 $ 139.47 $ 539.09 $ 404.91 $ 479.20 534.90 $ 458.83 159 PET w/ CT Scan Skull Base to Midthigh 78815 $ 8,899.07 $ 7,475.22 $ 6,684.09 $ 6,347.71 $ 6,347.71 $ 2,758.71 $ 2,758.71 $ 2,072.07 $ 8,009.17 $ 6,015.68 $ 7,119.26 7,946.87 $ 6,816.69 160 PET w/ CT Scan Whole Body 78816 $ 8,899.07 $ 7,475.22 $ 6,684.09 $ 6,347.71 $ 6,347.71 $ 2,758.71 $ 2,758.71 $ 2,072.07 $ 8,009.17 $ 6,015.68 $ 7,119.26 7,946.87 $ 6,816.69

-$

Oncology

$

-161 Bone Marrow BX & Aspiration Tech 38222 $ 4,094.32 $ 3,439.23 $ 3,075.24 $ 2,920.48 $ 2,920.48 $ 1,269.24 $ 1,269.24 $ 953.33 $ 3,684.89 $ 2,767.72 $ 3,275.45 3,656.23 $ 3,136.25 162 CHEMO IV INFUSION 1 HOUR 96413 $ 856.93 $ 719.82 $ 643.64 $ 611.25 $ 611.25 $ 265.65 $ 265.65 $ 199.53 $ 771.24 $ 579.28 $ 685.54 765.24 $ 656.41 163 CHEM0 IV INFUSION ADDL HR 96415 $ 856.93 $ 719.82 $ 643.64 $ 611.25 $ 611.25 $ 265.65 $ 265.65 $ 199.53 $ 771.24 $ 579.28 $ 685.54 765.24 $ 656.41 164 CHEMO PROLONG INFUSE W/PUMP 96416 $ 609.78 $ 512.21 $ 458.00 $ 434.95 $ 434.95 $ 189.03 $ 189.03 $ 141.98 $ 548.80 $ 412.20 $ 487.82 544.53 $ 467.09 165 CHEMO IV INF SUBS DRUG 1 HOUR 96417 $ 856.93 $ 719.82 $ 643.64 $ 611.25 $ 611.25 $ 265.65 $ 265.65 $ 199.53 $ 771.24 $ 579.28 $ 685.54 765.24 $ 656.41 166 Neulasta 6 mg/0.6 mL syringe 636 $ 31,378.21 $ 26,357.70 $ 23,568.17 $ 22,382.08 $ 22,382.08 $ 9,727.25 $ 9,727.25 $ 7,306.13 $ 28,240.39 $ 21,211.36 $ 25,102.57 28,020.74 $ 24,035.71 167 Prolia 60 mg/1 mL syringe 636 $ 6,186.41 $ 5,196.59 $ 4,646.61 $ 4,412.77 $ 4,412.77 $ 1,917.79 $ 1,917.79 $ 1,440.45 $ 5,567.77 $ 4,181.95 $ 4,949.13 5,524.47 $ 4,738.79 168 Keytruda 100 mg/4 mL SDVia 636 $ 24,484.11 $ 20,566.65 $ 18,390.01 $ 17,464.51 $ 17,464.51 $ 7,590.07 $ 7,590.07 $ 5,700.90 $ 22,035.70 $ 16,551.01 $ 19,587.29 21,864.31 $ 18,754.83

Radiation Therapy

169 3-D PLAN IFC 77295 $ 5,792.01 $ 4,865.29 $ 4,350.38 $ 4,131.44 $ 4,131.44 $ 1,795.52 $ 1,795.52 $ 1,348.62 $ 5,212.81 $ 3,915.34 $ 4,633.61 5,172.26 $ 4,436.68 170 BASIC DOSIMETRY CALC IFC 77300 $ 693.98 $ 582.94 $ 521.25 $ 495.01 $ 495.01 $ 215.13 $ 215.13 $ 161.59 $ 624.58 $ 469.12 $ 555.18 619.72 $ 531.59 171 INT MOD RADIOTHERAPY IMRT IFC 77301 $ 6,486.01 $ 5,448.25 $ 4,871.64 $ 4,626.47 $ 4,626.47 $ 2,010.66 $ 2,010.66 $ 1,510.21 $ 5,837.41 $ 4,384.48 $ 5,188.81 5,792.00 $ 4,968.28 172 RDT COMPLEX DEVICE IFC 77334 $ 1,165.18 $ 978.75 $ 875.16 $ 831.12 $ 831.12 $ 361.20 $ 361.20 $ 271.30 $ 1,048.66 $ 787.65 $ 932.14 1,040.50 $ 892.53 173 RDT COMPLEX IMRT IFC 77386 $ 2,201.26 $ 1,849.06 $ 1,653.36 $ 1,570.16 $ 1,570.16 $ 682.39 $ 682.39 $ 512.54 $ 1,981.13 $ 1,488.03 $ 1,761.00 1,965.72 $ 1,686.16 174 77412 RDT COMPLEX TREATMENT IFC 77412 $ 883.65 $ 742.27 $ 663.71 $ 630.31 $ 630.31 $ 273.93 $ 273.93 $ 205.75 $ 795.28 $ 597.34 $ 706.92 789.10 $ 676.88 175 77385 RDT SIMPLE IMRT IFC 77385 $ 2,201.26 $ 1,849.06 $ 1,653.36 $ 1,570.16 $ 1,570.16 $ 682.39 $ 682.39 $ 512.54 $ 1,981.13 $ 1,488.03 $ 1,761.00 1,965.72 $ 1,686.16

Nuclear Medicine

176 NM Myocardial Spect Multi Rest/Stress 78452 $ 4,677.80 $ 3,929.35 $ 3,513.49 $ 3,336.67 $ 3,336.67 $ 1,450.12 $ 1,450.12 $ 1,089.18 $ 4,210.02 $ 3,162.14 $ 3,742.24 4,177.27 $ 3,583.19 177 NM Bone Imaging Limited 78300 $ 988.18 $ 830.07 $ 742.22 $ 704.87 $ 704.87 $ 306.33 $ 306.33 $ 230.09 $ 889.36 $ 668.00 $ 790.54 882.44 $ 756.94 178 NM Bone Imaging Whole Body 78306 $ 1,280.02 $ 1,075.22 $ 961.42 $ 913.04 $ 913.04 $ 396.81 $ 396.81 $ 298.04 $ 1,152.02 $ 865.28 $ 1,024.01 1,143.06 $ 980.49 179 NM Bone Three Phase Study 78315 $ 1,280.02 $ 1,075.22 $ 961.42 $ 913.04 $ 913.04 $ 396.81 $ 396.81 $ 298.04 $ 1,152.02 $ 865.28 $ 1,024.01 1,143.06 $ 980.49 180 NM Myocardial Perf Spect 78451 $ 4,011.97 $ 3,370.06 $ 3,013.39 $ 2,861.74 $ 2,861.74 $ 1,243.71 $ 1,243.71 $ 934.15 $ 3,610.78 $ 2,712.05 $ 3,209.58 3,582.69 $ 3,073.17 181 NM Myocardial Perf Spect 78451 $ 4,011.97 $ 3,370.06 $ 3,013.39 $ 2,861.74 $ 2,861.74 $ 1,243.71 $ 1,243.71 $ 934.15 $ 3,610.78 $ 2,712.05 $ 3,209.58 3,582.69 $ 3,073.17 182 NM Myocardial Spect Multi Rest/Stress 78452 $ 4,680.63 $ 3,931.73 $ 3,515.62 $ 3,338.69 $ 3,338.69 $ 1,451.00 $ 1,451.00 $ 1,089.84 $ 4,212.57 $ 3,164.06 $ 3,744.50 4,179.80 $ 3,585.36 183 NM Pulmonary Perfusion Imaging 78580 $ 1,078.25 $ 905.73 $ 809.87 $ 769.12 $ 769.12 $ 334.26 $ 334.26 $ 251.06 $ 970.43 $ 728.89 $ 862.60 962.88 $ 825.94

Medicine & Surgery Services

184 Major joint replacement or reattachment of lower extremity

wihout major comorbid conditions or complications -470 $ - $ - $ - $ - $ - $ - 0.00 $ -Pro fee (including surgical assistant) 27447 $ 4,935.88 $ 4,146.14 $ 3,707.34 $ 3,520.77 $ 3,520.77 $ 1,530.12 $ 1,530.12 $ 1,149.28 $ 4,442.29 $ 3,336.61 $ 3,948.71 4,407.74 $ 3,780.89

Anesthesia $ 1,260.94 $ 1,059.19 $ 947.09 $ 899.43 $ 899.43 $ 390.89 $ 390.89 $ 293.60 $ 1,134.85 $ 852.38 $ 1,008.75 1,126.02 $ 965.88 Mes/Surg Room (semi-private) $1185.80/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day

Recovery Room (PACU) $17.39/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min

Supply/Implants Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Lab Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Rehab Services (PT/OT) Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Pathology Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Inhalation Services $362.54/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test Pulmonary Function $189.76/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test

Pharmacy Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Radiology Services Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Supplies Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

185 Uterine and adnexa procedures for non-malignancy without cormorbid conditions or complications -743

Pro fee 58150 $ 3,068.04 $ 2,577.16 $ 2,304.41 $ 2,188.44 $ 2,188.44 $ 951.09 $ 951.09 $ 714.37 $ 2,761.24 $ 2,073.97 $ 2,454.43 2,739.76 $ 2,350.12 Surgical Asst (if needed) 58150 $ 3,068.04 $ 2,577.16 $ 2,304.41 $ 2,188.44 $ 2,188.44 $ 951.09 $ 951.09 $ 714.37 $ 2,761.24 $ 2,073.97 $ 2,454.43 2,739.76 $ 2,350.12 Med/Surg Room (semi-private) $1185.80/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day

Recovery Room (PACU) $17.39/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min

Inhalation Services $362.54/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test $347.93/test Pulmonary Function $189.76/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test $182.11/test

Lab/Path Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Surgery Class A 1 minute $41.22/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min

Anesthesia Separate Cost #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

Recovery Room PACU $17.39/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min

186 Colonoscopy with Lesion Ablation or Removal by snare (OPC)

Pro fee 45385 $ 1,679.03 $ 1,410.38 $ 1,261.12 $ 1,197.65 $ 1,197.65 $ 520.50 $ 520.50 $ 390.95 $ 1,511.12 $ 1,135.00 $ 1,343.22 1,499.37 $ 1,286.13 Moderate Sedation 99152 $ 116.29 $ 97.68 $ 87.34 $ 82.95 $ 82.95 $ 36.05 $ 36.05 $ 27.08 $ 104.66 $ 78.61 $ 93.03 103.84 $ 89.07 OR Services/Facility Fee 45385 $ 3,040.14 $ 2,553.72 $ 2,283.45 $ 2,168.53 $ 2,168.53 $ 942.44 $ 942.44 $ 707.87 $ 2,736.13 $ 2,055.10 $ 2,432.11 2,714.84 $ 2,328.75 Pathology/Lab 88305 $ 322.63 $ 271.01 $ 242.33 $ 230.14 $ 230.14 $ 100.02 $ 100.02 $ 75.12 $ 290.37 $ 218.10 $ 258.11 288.11 $ 247.14 Non- Ster Supply $ 301.40 $ 253.17 $ 226.38 $ 214.99 $ 214.99 $ 93.43 $ 93.43 $ 70.18 $ 271.26 $ 203.74 $ 241.12 269.15 $ 230.87 Sterile Supply $ 485.50 $ 407.82 $ 364.66 $ 346.31 $ 346.31 $ 150.50 $ 150.50 $ 113.04 $ 436.95 $ 328.19 $ 388.40 433.55 $ 371.89

Drugs/Medications Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Recovery Room $4.19/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min

187 Removal of 1 or more breast growth, open procedure

Pro fee 19120 $ 1,316.92 $ 1,106.22 $ 989.14 $ 939.36 $ 939.36 $ 408.25 $ 408.25 $ 306.63 $ 1,185.23 $ 890.23 $ 1,053.54 1,176.01 $ 1,008.76

Lab/Chemistry 81025 $ 141.23 $ 118.63 $ 106.07 $ 100.74 $ 100.74 $ 43.78 $ 43.78 $ 32.88 $ 127.10 $ 95.47 $ 112.98 126.11 $ 108.18 Pathology/Lab 88307 $ 466.03 $ 391.47 $ 350.04 $ 332.42 $ 332.42 $ 144.47 $ 144.47 $ 108.51 $ 419.43 $ 315.03 $ 372.83 416.17 $ 356.98

Surgery Class B 1 min 19120 $32.43/min 31.12/min 31.12/min 31.12/min 31.12/min 31.12/min 31.12/min 31.12/min 31.12/min 31.12/min 31.12/min 31.12/min 31.12/min

Anesthesia $ 574.21 $ 482.33 $ 431.29 $ 409.58 $ 409.58 $ 178.00 $ 178.00 $ 133.70 $ 516.79 $ 388.16 $ 459.37 512.77 $ 439.84

SDS Recovery Room 1 min $4.19/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min

Recovery PACU per 1 min $17.39/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min

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Shoppable Service

Ancillary Services

Code

Charge

188 Removal of one knee cartlidge using an endoscope

Pro fee 29881 $ 1,735.05 $ 1,457.44 $ 1,303.20 $ 1,237.61 $ 1,237.61 $ 537.87 $ 537.87 $ 403.99 $ 1,561.55 $ 1,172.88 $ 1,388.04 1,549.40 $ 1,329.05 Surgery Class A 1 min 29881 $ 41.22 $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min

Lab/Chemistry 81025 $ 141.23 $ 118.63 $ 106.07 $ 100.74 $ 100.74 $ 43.78 $ 43.78 $ 32.88 $ 127.10 $ 95.47 $ 112.98 126.11 $ 108.18

Anesthesia $ 574.21 $ 482.33 $ 431.29 $ 409.58 $ 409.58 $ 178.00 $ 178.00 $ 133.70 $ 516.79 $ 388.16 $ 459.37 512.77 $ 439.84

SDS Recovery 1 min $4.19/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min

189 Diagnostic exam of esophagus, stomach and/or upper small bowel using an endocope

Pro fee 43235 $ 823.23 $ 691.51 $ 618.33 $ 587.21 $ 587.21 $ 255.20 $ 255.20 $ 191.68 $ 740.90 $ 556.49 $ 658.58 735.14 $ 630.59 Moderate Sedation 99152 $ 116.29 $ 97.68 $ 87.34 $ 82.95 $ 82.95 $ 36.05 $ 36.05 $ 27.08 $ 104.66 $ 78.61 $ 93.03 103.84 $ 89.07 OR Services 43235 $ 2,062.95 $ 1,732.88 $ 1,549.48 $ 1,471.50 $ 1,471.50 $ 639.51 $ 639.51 $ 480.34 $ 1,856.66 $ 1,394.53 $ 1,650.36 1,842.22 $ 1,580.22 Non-Sterile Supply $ 259.37 $ 217.87 $ 194.81 $ 185.01 $ 185.01 $ 80.40 $ 80.40 $ 60.39 $ 233.43 $ 175.33 $ 207.49 231.62 $ 198.68

Sterile Supply $ 350.61 $ 294.52 $ 263.35 $ 250.09 $ 250.09 $ 108.69 $ 108.69 $ 81.64

OPC Recovery 1 min $4.19/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min

190 Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope Pro fee 43239 $ 978.49 $ 821.93 $ 734.94 $ 697.96 $ 697.96 $ 303.33 $ 303.33 $ 227.83 $ 880.64 $ 661.45 $ 782.79 873.79 $ 749.52 Moderate Sedation 99152 $ 116.29 $ 97.68 $ 87.34 $ 82.95 $ 82.95 $ 36.05 $ 36.05 $ 27.08 $ 104.66 $ 78.61 $ 93.03 103.84 $ 89.07 Non-Sterile Supply $ 301.87 $ 253.57 $ 226.74 $ 215.33 $ 215.33 $ 93.58 $ 93.58 $ 70.29 $ 271.69 $ 204.06 $ 241.50 269.57 $ 231.24 Sterile Supply $ 350.61 $ 294.52 $ 263.35 $ 250.09 $ 250.09 $ 108.69 $ 108.69 $ 81.64 $ 315.55 $ 237.01 $ 280.49 313.10 $ 268.57 OR Services 43239 $ 2,497.26 $ 2,097.70 $ 1,875.69 $ 1,781.29 $ 1,781.29 $ 774.15 $ 774.15 $ 581.46 $ 2,247.53 $ 1,688.12 $ 1,997.81 2,230.05 $ 1,912.90

OPC Recovery Room 1 min $4.19/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min $4.02/min

Pathology/Lab Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

191 Diagnostic exam of large bowel

Pro fee 45378 $ 1,226.48 $ 1,030.24 $ 921.21 $ 874.85 $ 874.85 $ 380.21 $ 380.21 $ 380.21 $ 1,103.83 $ 1,103.83 $ 981.18 1,095.25 $ 939.48 Sterile Supply $ 342.54 $ 287.73 $ 257.28 $ 244.33 $ 244.33 $ 106.19 $ 106.19 $ 106.19 $ 308.28 $ 308.28 $ 274.03 305.89 $ 262.38 Non-Sterile Supply $ 259.37 $ 217.87 $ 194.81 $ 185.01 $ 185.01 $ 80.40 $ 80.40 $ 80.40 $ 233.43 $ 233.43 $ 207.49 231.62 $ 198.68 OR Services 45378 $ 2,605.83 $ 2,188.90 $ 1,957.24 $ 1,858.74 $ 1,858.74 $ 807.81 $ 807.81 $ 807.81 $ 2,345.25 $ 2,345.25 $ 2,084.67 2,327.01 $ 1,996.07

192 Biopsy of large bowel using an endoscope

Pro fee 45380 $ 1,349.28 $ 1,133.39 $ 1,013.44 $ 962.44 $ 962.44 $ 418.28 $ 418.28 $ 418.28 $ 1,214.35 $ 1,214.35 $ 1,079.42 1,204.91 $ 1,033.55 Moderate Sedation 99152 $ 116.29 $ 97.68 $ 87.34 $ 82.95 $ 82.95 $ 36.05 $ 36.05 $ 36.05 $ 104.66 $ 104.66 $ 93.03 103.84 $ 89.07 Non-sterile supply $ 259.37 $ 217.87 $ 194.81 $ 185.01 $ 185.01 $ 80.40 $ 80.40 $ 80.40 $ 233.43 $ 233.43 $ 207.49 231.62 $ 198.68 Sterile supply $ 451.85 $ 379.56 $ 339.39 $ 322.31 $ 322.31 $ 140.07 $ 140.07 $ 140.07 $ 406.67 $ 406.67 $ 361.48 403.50 $ 346.12

Pathology/Lab Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

OR Services 45380 $ 3,040.14 $ 2,553.72 $ 2,283.45 $ 2,168.53 $ 2,168.53 $ 942.44 $ 2,736.13 $ 2,736.13 $ 2,432.11 2,714.84 $ 2,328.75

193 Removal of polyps or growths of large bowel using an endoscope Pro fee 45385 $ 1,679.03 $ 1,410.38 $ 1,261.12 $ 1,197.65 $ 1,197.65 $ 520.50 $ 520.50 $ 520.50 $ 1,511.12 $ 1,511.12 $ 1,343.22 1,499.37 $ 1,286.13 Moderate Sedation 99152 $ 116.29 $ 97.68 $ 87.34 $ 82.95 $ 82.95 $ 36.05 $ 36.05 $ 36.05 $ 104.66 $ 104.66 $ 93.03 103.84 $ 89.07 Non-Sterile supply $ 4,644.45 $ 3,901.34 $ 3,488.45 $ 3,312.89 $ 3,312.89 $ 1,439.78 $ 1,439.78 $ 1,439.78 $ 4,180.01 $ 4,180.01 $ 3,715.56 4,147.50 $ 3,557.65 Sterile supply $ 485.50 $ 407.82 $ 364.66 $ 346.31 $ 346.31 $ 150.50 $ 150.50 $ 150.50 $ 436.95 $ 436.95 $ 388.40 433.55 $ 371.89 OR Services 45385 $ 3,040.14 $ 2,553.72 $ 2,283.45 $ 2,168.53 $ 2,168.53 $ 942.44 $ 2,736.13 $ 2,736.13 $ 2,432.11 2,714.84 $ 2,328.75

194 Laparoscopic cholecystectomy, surgical

Pro fee 47562 $ 1,745.26 $ 1,466.02 $ 1,310.86 $ 1,244.89 $ 1,244.89 $ 541.03 $ 541.03 $ 541.03 $ 1,570.73 $ 1,570.73 $ 1,396.21 1,558.51 $ 1,336.87

Lab Services Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Surgery Class A 1 min 47562 $41.22/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min

Anesthesia Billed Separately #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

Recovery PACU 1 min $17.39/min $16.69 min $16.69 min $16.69 min $16.69 min $16.69 min $16.69 min $16.69 min $16.69 min $16.69 min $16.69 min $16.69 min $16.69 min

195 Repair of groin hernia patient age 5 years or older

Pro fee 49505 $ 1,382.94 $ 1,161.67 $ 1,038.72 $ 986.45 $ 986.45 $ 428.71 $ 428.71 $ 428.71 $ 1,244.64 $ 1,244.64 $ 1,106.35 1,234.96 $ 1,059.33

Surgery Class A 1 min 49505 $41.22/min

SDS Recovery 1 min $4.19/min

Implants $ 706.30 $ 593.29 $ 530.50 $ 503.80 $ 503.80 $ 218.95 $ 218.95 $ 218.95 $ 635.67 $ 635.67 $ 565.04 630.73 $ 541.03

196 LAPAROSCOPY, SURGICAL, APPENDECTOMY ProFee Pro fee 44970 $ 1,596.51 $ 1,341.07 $ 1,199.14 $ 1,138.79 $ 1,138.79 $ 494.92 $ 494.92 $ 494.92 $ 1,436.86 $ 1,436.86 $ 1,277.21 1,425.68 $ 1,222.92 Initial hospital care 99219 $ 265.36 $ 222.90 $ 199.31 $ 189.28 $ 189.28 $ 82.26 $ 82.26 $ 82.26 $ 238.82 $ 238.82 $ 212.29 236.97 $ 203.27 ER Dept Visit 99285 $ 895.97 $ 752.62 $ 672.96 $ 639.10 $ 639.10 $ 277.75 $ 277.75 $ 277.75 $ 806.38 $ 806.38 $ 716.78 800.10 $ 686.31

IV Solutions Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

IV Therapy Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Pathology/Lab 88304 $ 291.41 $ 244.78 $ 218.88 $ 207.86 $ 207.86 $ 90.34 $ 90.34 $ 90.34 $ 262.27 $ 262.27 $ 233.13 260.23 $ 223.22 Surgery Class A 1 min 44970 $41.22/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min

Observation Room 197 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER;

REDUCIBLE ProFee Pro fee 49585 $ 826.05 $ 693.88 $ 620.45 $ 589.22 $ 589.22 $ 256.08 $ 256.08 $ 256.08 $ 743.44 $ 743.44 $ 660.84 737.66 $ 632.75

Supplies/Implants Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

lab Services Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Surgery Class A 1 min $41.22/min 39.56/min 39.56/min 39.56/min 39.56/min 39.56/min 39.56/min 39.56/min 39.56/min 39.56/min 39.56/min 39.56/min 39.56/min

Anesthesia Bill Separately #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

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Page 5

Cigna -

Sagamore

Aetna

Humana

Shoppable Service

Ancillary Services

Code

Charge

198 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX),

WITH OR WITHOUT REMOVAL Pro fee 58150 $ 3,068.04 $ 2,577.16 $ 2,304.41 $ 2,188.44 $ 2,188.44 $ 951.09 $ 951.09 $ 951.09 $ 2,761.24 $ 2,761.24 $ 2,454.43 2,739.76 $ 2,350.12 Semi-private room/day $1185.80/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day $1138.00/day

Supplies/Impants Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Surgery Class 1 A per min $41.22/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min $$39.56/min

Anesthesia General Setup Bill Separately #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

Add't Anesthesia Bill Separately Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Cardio/Pulmonary Services Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Recovery Room PACU per 1 min $17.39/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min 199 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;

ProFee Pro fee 58260 $ 2,832.00 $ 2,378.88 $ 2,127.11 $ 2,020.06 $ 2,020.06 $ 877.92 $ 877.92 $ 877.92 $ 2,548.80 $ 2,548.80 $ 2,265.60 2,528.97 $ 2,169.31

Laboratory Services Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Surgery Class 1 A per min $41.22/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min Anesthesia General Set Up $ 574.21 $ 482.33 $ 431.29 $ 409.58 $ 409.58 $ 178.00 $ 178.00 $ 178.00 $ 516.79 $ 516.79 $ 459.37 512.77 $ 439.84

Cardiopulmonary Services Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Observation Med/Surg per day $ 617.71 $ 518.88 $ 463.96 $ 440.61 $ 440.61 $ 191.49 $ 191.49 $ 191.49 $ 555.94 $ 555.94 $ 494.17 551.62 $ 473.17 200 HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF

ENDOMETRIUM AND/OR POLYP Pro fee 58558 $ 1,416.02 $ 1,189.45 $ 1,063.57 $ 1,010.05 $ 1,010.05 $ 438.97 $ 438.97 $ 438.97 $ 1,274.42 $ 1,274.42 $ 1,132.81 1,264.50 $ 1,084.67

Laboratory Services Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Surgery Class B 1 min $32.43/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min

Anesthesia Setup $ 574.21 $ 482.33 $ 409.58 $ 178.00 $ 178.00 $ 178.00 $ 516.79 $ 516.79 $ 459.37 512.77 $ 439.84

201 Biopsy of prostate gland

Pro fee 55700 $ 926.27 $ 778.06 $ 695.72 $ 660.71 $ 660.71 $ 287.14 $ 287.14 $ 287.14 $ 833.64 $ 833.64 $ 741.01 827.15 $ 709.52

Surgery Class B 1 min $32.43/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min $31.12/min

US Biopsy Prostate $ 538.04 $ 451.95 $ 404.12 $ 383.78 $ 383.78 $ 166.79 $ 166.79 $ 166.79 $ 484.24 $ 484.24 $ 430.43 480.47 $ 412.14 Anesthesia $ 574.21 $ 482.33 $ 431.29 $ 409.58 $ 409.58 $ 178.00 $ 178.00 $ 178.00 $ 516.79 $ 516.79 $ 459.37 512.77 $ 439.84 SDS Recovery 1 min $ 4.36 $ 3.67 $ 3.28 $ 3.11 $ 3.11 $ 1.35 $ 1.35 $ 1.35 $ 3.93 $ 3.93 $ 3.49 3.90 $ 3.34 Pathology 88305 $ 3,226.35 $ 2,710.13 $ 2,423.31 $ 2,301.35 $ 2,301.35 $ 1,000.17 $ 1,000.17 $ 1,000.17 $ 2,903.71 $ 2,903.71 $ 2,581.08 2,881.13 $ 2,471.38

-$ $

-202 VASECTOMY Pro Fee 55250 $ 1,586.07 $ 1,332.30 $ 1,191.30 $ 1,131.35 $ 1,131.35 $ 491.68 $ 491.68 $ 491.68 $ 1,427.47 $ 1,427.47 $ 1,268.86 1,416.36 $ 1,214.93 Level 3 Visit Est Patient G0463 $ 198.15 $ 166.45 $ 148.83 $ 141.34 $ 141.34 $ 61.43 $ 61.43 $ 61.43 $ 178.34 $ 178.34 $ 158.52 176.95 $ 151.78 Drug Injection, subcutaneous or intramuscular 96372 $ 65.49 $ 55.01 $ 49.19 $ 46.72 $ 46.72 $ 20.30 $ 20.30 $ 20.30 $ 58.94 $ 58.94 $ 52.39 58.49 $ 50.17

-$ $ -203 Routine obstetric care for vaginal delivery, including pre-and

post- delivery care Fee Self Pay Fee #VALUE! #VALUE!

Pro fee 59400 $ 2,832.00 $ 2,378.88 $ 2,127.11 $ 2,020.06 $ 2,020.06 $ 877.92 $ 877.92 $ 877.92 $ 2,548.80 $ 2,548.80 $ 2,265.60 2,528.97 $ 2,169.31 Semi Private Room per day $ 1,125.94 $ 945.79 $ 845.69 $ 803.13 $ 803.13 $ 349.04 $ 349.04 $ 349.04 $ 1,013.34 $ 1,013.34 $ 900.75 1,005.46 $ 862.47 Lab/Chemistry $ 244.49 $ 205.37 $ 183.64 $ 174.40 $ 174.40 $ 75.79 $ 75.79 $ 75.79 $ 220.04 $ 220.04 $ 195.59 218.33 $ 187.28 Lab/Immunology $ 407.44 $ 342.25 $ 306.03 $ 290.63 $ 290.63 $ 126.31 $ 126.31 $ 126.31 $ 366.70 $ 366.70 $ 325.96 363.85 $ 312.10

Lab/Hematology Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Laboratory Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

OB Labor and Delivery $ 3,481.61 $ 2,924.55 $ 2,615.04 $ 2,483.43 $ 2,483.43 $ 1,079.30 $ 1,079.30 $ 1,079.30 $ 3,133.45 $ 3,133.45 $ 2,785.29 3,109.08 $ 2,666.91

204 Routine obstetric care for cesarean delivery, including pre- and post- delivery care

Pro fee 59510 $ 3,303.98 $ 2,775.34 $ 2,481.62 $ 2,356.73 $ 2,356.73 $ 1,024.23 $ 1,024.23 $ 1,024.23 $ 2,973.58 $ 2,973.58 $ 2,643.18 2,950.45 $ 2,530.85 Semi Private Room per day $ 1,125.94 $ 945.79 $ 845.69 $ 803.13 $ 803.13 $ 349.04 $ 349.04 $ 349.04 $ 1,013.34 $ 1,013.34 $ 900.75 1,005.46 $ 862.47 Anesthesia $ 686.73 $ 576.86 $ 515.81 $ 489.85 $ 489.85 $ 212.89 $ 212.89 $ 212.89 $ 618.06 $ 618.06 $ 549.39 613.25 $ 526.04

Surgery Class A 1 min $41.22/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min $39.56/min

Implants $ 9.61 $ 8.07 $ 7.22 $ 6.85 $ 6.85 $ 2.98 $ 2.98 $ 2.98 $ 8.65 $ 8.65 $ 7.69 8.58 $ 7.36

OB Post Op recovery $ 1,050.67 $ 882.56 $ 789.16 $ 749.44 $ 749.44 $ 325.71 $ 945.60 $ 945.60 $ 840.54 938.25 $ 804.81

PACU min charge $17.39/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min $16.69/min

Laboratory services Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

205 FETAL NONSTRESS PRO FEE CHARGE 59025 $ 206.51 $ 173.47 $ 155.11 $ 147.31 $ 147.31 $ 64.02 $ 64.02 $ 64.02 $ 185.86 $ 185.86 $ 165.21 184.42 $ 158.19 206 LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY;

WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY

Pro Fee 59150 $ 1,946.99 $ 1,635.47 $ 1,462.39 $ 1,388.79 $ 1,388.79 $ 603.57 $ 603.57 $ 603.57 $ 1,752.29 $ 1,752.29 $ 1,557.59 1,738.66 $ 1,491.40

207 Thyroidectomy, total or complete Pro Fee 60240 $ 2,145.45 $ 1,802.18 $ 1,611.45 $ 1,530.35 $ 1,530.35 $ 665.09 $ 665.09 $ 665.09 $ 1,930.90 $ 1,930.90 $ 1,716.36 1,915.89 $ 1,643.41 208 Injection, nerve block, peripheral Procedure fee 64450 $ 236.10 $ 198.32 $ 177.33 $ 168.41 $ 168.41 $ 73.19 $ 73.19 $ 73.19 $ 212.49 $ 212.49 $ 188.88 210.84 $ 180.85 Office Visit 99202 $ 111.79 $ 93.90 $ 83.97 $ 79.74 $ 79.74 $ 34.65 $ 34.65 $ 34.65 $ 100.61 $ 100.61 $ 89.43 99.83 $ 85.63 209 Injections of anesthetic and/or steroid drug into lower or

sacral spine nerve root using imaging guidance

OPC Procedure Room 1 min 64483 $58.88/min $56.51/min $56.51/min $56.51/min $56.51/min $56.51/min $56.51/min $56.51/min $56.51/min $56.51/min $56.51/min $56.51/min $56.51/min

Xray Portable Service $ 128.16 $ 107.66 $ 96.26 $ 91.42 $ 91.42 $ 39.73 $ 39.73 $ 39.73 $ 115.35 $ 115.35 $ 102.53 114.45 $ 98.17 XR Fluoro Guidance Needle $ 1,341.19 $ 1,126.60 $ 1,007.37 $ 956.67 $ 956.67 $ 415.77 $ 415.77 $ 415.77 $ 1,207.07 $ 1,207.07 $ 1,072.95 1,197.68 $ 1,027.35 Sodium Chloride $ 17.33 $ 14.56 $ 13.02 $ 12.36 $ 12.36 $ 5.37 $ 5.37 $ 5.37 $ 15.60 $ 15.60 $ 13.86 15.47 $ 13.27 Drugs/Incident Rad $ 120.36 $ 101.10 $ 90.40 $ 85.85 $ 85.85 $ 37.31 $ 37.31 $ 37.31 $ 108.32 $ 108.32 $ 96.29 107.48 $ 92.19

Sterile/Non Sterile Supplis Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable Variable

Pharmacy $ 74.65 $ 62.70 $ 56.07 $ 53.25 $ 53.25 $ 23.14 $ 23.14 $ 23.14 $ 67.18 $ 67.18 $ 59.72 66.66 $ 57.18 MMH does not bill