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19120 Excision of breast lump thru incision OP Services Max Min Contract Pricing

Range ChargeCode Units CPTCode CPTCodeDescription NDC TotalCharge Cash Discount UHC BCBS 1st Choice

1_Low 4 1 PACK GENERAL CUSTOM 176.92

600 1 SUTURE DERMABOND 101.00

678 1 MANIFOLD DRIP REDUCTION 106.00

4020300 1 SURGERY 1ST 1/2 HR 2,474.00

4030001 1 RECOVERY 1ST 1/2 HOUR 628.00

4030002 1 RECOVERY ADDL 1/4 HR 193.00

4040034 1 MAC 1ST 1/2 HR 961.00

4160944 1 IBUPROFEN 800MG TAB 63739069110 4.00

4161506 1 J3010 FENTANYL 100MCG/2ML INJ 00641602725 7.55

4164459 1 J2250 MIDAZOLAM INJ 1mg (2mg/2ml) 00409230521 4.00

4165131 1 J0694 CEFOXITIN INJ 2GM DUPLEX 00264312511 112.80

4166415 1 LIDOCAINE INJ 1% MPF 5ML 00143959525 20.30

4167051 1 PROPOFOL INJ 10mg/ml (20ml vial) 63323026937 36.00

4167145 1 BUPIVACAINE 0.25% W/EPI 1:200K INJ 30ML 00409904217 16.30

4250040 5 00400 ANESTH SKIN EXT/PER/ATR 685.00

4259120 1 19120 REMOVAL OF BREAST LESION 1,867.00

1_Low Total 7,392.87 6,653.58 7,023.23 7,023.23 6,798.81

3_High 4 1 PACK GENERAL CUSTOM 176.92


4020300 1 19120 SURGERY 1ST 1/2 HR 2,575.00

4030001 1 RECOVERY 1ST 1/2 HOUR 654.00

4030002 3 RECOVERY ADDL 1/4 HR 603.00

4040034 1 MAC 1ST 1/2 HR 1,001.00


4167051 1 J2704 PROPOFOL INJ 10mg/ml (20ml vial) 63323026937 36.00

4250040 10 00400 ANESTH SKIN EXT/PER/ATR 1,400.00

4259120 1 19120 REMOVAL OF BREAST LESION 1,905.00

4020034 3 SURGERY ADD 1/4 HR 3,528.00

4040035 3 MAC ADD 1/4 HR 969.00

4070921 1 88307 PATH DX HIGH DIFFICULTY 447.00

4070923 1 88342 IMMUNOCHEMISTRY 188.00

4070924 2 88360 IMMUNOHISTOCHEMISTRY,QUAN 402.00

4070941 1 88341 IMMUNOCHEMISTRY 188.00

4166371 2 J0690 CEFAZOLIN DUPLEX 500mg (2gm) 00264310511 87.60

4166453 1 J2704 PROPOFOL INJ 10mg (500mg/50ml vial) 63323026950 93.75

4167166 1 BUPIVACAINE INJ 0.5% W/EPI 1:200K 50ML VIAL 00409904601 68.15

3_High Total 14,432.97 12,989.67 13,711.32 13,711.32 13,323.51

29826 Decompression of shoulder thru scope


1_Low 27 1 PACK EXTREMITY CUSTOM 190.80

666 1 PUMP PAIN BUSTER Q 239.00


56440 1 TUBING REDEUCE W/CONNECTOR PUMP 8FT 190.80

56441 1 TUBING REDEUCE W/CONNECTOR PATIENT 8FT 125.00

56446 1 BURR OVAL 12 FLUTE 5.5MM 190.80

56474 1 SHAVER EXCALIBUR 5.5MM 190.80

4020034 3 SURGERY ADD 1/4 HR 3,600.00

4020300 1 29822 SURGERY 1ST 1/2 HR 2,627.00

4030001 1 RECOVERY 1ST 1/2 HOUR 668.00

4030002 2 RECOVERY ADDL 1/4 HR 412.00

4040005 1 01630 GEN ANESTHESIA 1ST 1/2 HR 1,022.00

4040006 3 GEN ANESTHESIA ADD 1/4 HR 990.00

4040033 1 REGIONAL ANESTHESIA 252.00

4091630 74 01630 ANESTH SURGERY OF SHOULDER 2,860.10

4096441 1 64415 N BLOCK INJ BRACHIAL PLE 1,346.00

4160583 1 J2765 METOCLOPRAMIDE 10MG INJ 00409341418 6.65

4160900 1 VECURONIUM INJ 10MG VIAL 00703291401 37.80


4161870 1 J3490 SOD CHLORIDE 0.9% 10ML 00409488810 4.00

4163104 1 J1885 KETOROLAC 30MG/1ML INJ 63323016212 5.20


4164777 4 J2405 ONDANSETRON INJ 4MG/2ML VIAL (BU=4) 00641608001 16.00

4165014 1 CLINDAMYCIN 600MG/50ML INJ PREMIX 00781922191 74.20

4165798 4 J3490 BUPIVACAINE 0.5% MPF INJ 30ML 00409116202 43.40

4166415 2 J3490 LIDOCAINE INJ 1% MPF 5ML 00143959525 40.50

4166656 30 J0171 EPINEPHRINE 1MG/ML VIAL 42023015901 342.00

4166760 1 S0028 FAMOTIDINE INJ 20MG/2ML 63323073912 5.40


4167203 1 J3490 SUGAMMADEX INJ 200MG/2ML BRAND 00006542312 456.00

4167233 2 BUPIVACAINE 0.5% MPF INJ (SENSORCAINE MPF) 10ML 00409116218 54.70

4167281 1 DROPERIDOL 5MG/2ML INJ 00517970225 21.25

4509822 1 29822 SHOULDER ARTHROSCOPY/SURG 5,342.00


4096942P 1 76942 XRAY,ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION ...216.00

1_Low Total 28,292.60 25,463.34 26,877.97 26,877.97 25,826.69

3_High 27 1 PACK EXTREMITY CUSTOM 190.80



55439 1 CANNULA WITH OBTURATOR DISPOSABLE 8.5X72MM 144.00

Powell Valley Healthcare is happy to provide a complete listing of our Charge Description Report along with the 300 shoppable services as required by Section 2718 of the Public Health Service Act.

We understand health care can be complicated, therefore, we are here to assist with questions you may have regarding the costof a visit or a procedure. Each of our patients are unique and we will strive to answer questions specific to you. Please call our Patient Financial Services Department 307-754-4559.

To utilize the required Shoppable Services, please enter description in the search box. (Ctrl+F) to bring up a search box

This list includes the 300 required items and is not inclusive of all our procedures. Please see our complete ChargeDescription Report By Department for a listing of all of our charges.

55441 1 LASSO SUTURE QUICKPASS 25* TIGHT CURVE LEFT 320.00

55442 1 LASSO SUTURE QUICKPASS 25* TIGHT CURVE RIGHT 320.00

55445 1 C1713 ANCHOR SUTURE PUSHLOCK BIOCOMPOSITE 3.5X19.5MM 1,200.00






56641 1 SHAVER OVAL 8 FLUTE 4.0MM 190.80

56896 1 SUTURE FIBERWIRE #2 38IN NO NEEDLE 1 BLUE/1 WHITE BLACK 147.20

58236 1 BIT DRILL CANNULATED 2.3X120MM 620.00

58237 3 KWIRE SMOOTH 1.2X150MM 498.00

58505 1 SCREW HEADED SHORT THREAD 3.5X40MM 1,050.00

61226 1 SCREW HEADED SHORT THREAD 3.5X46MM 1,050.00

4020034 10 SURGERY ADD 1/4 HR 12,000.00

4020300 1 29806 SURGERY 1ST 1/2 HR 2,627.00

4030001 1 RECOVERY 1ST 1/2 HOUR 668.00

4030002 7 RECOVERY ADDL 1/4 HR 1,442.00

4040005 1 GEN ANESTHESIA 1ST 1/2 HR 1,022.00

4040006 10 GEN ANESTHESIA ADD 1/4 HR 3,300.00


4140028 1 73060 RT HUMERUS 313.00

4160153 1 EPHEDRINE INJ 50MG/ML 17478051500 187.50





4161870 1 SOD CHLORIDE 0.9% 10ML 00409488810 4.00



4165572 1 J2370 PHENYLEPHRINE PR IN 0.9% NACL SYR 1000MCG/10ML 70092104646 27.60





4166457 1 GLYCOPYRROLATE INJ 0.4MG/2ML 00517460225 143.75

4166656 10 J0171 EPINEPHRINE 1MG/ML VIAL 42023015901 114.00

20 J0171 EPINEPHRINE 1MG/ML VIAL 42023015901 228.00

4166760 1 FAMOTIDINE INJ 20MG/2ML 63323073912 5.40


4167203 1 SUGAMMADEX INJ 200MG/2ML BRAND 00006542312 456.00

4167233 4 BUPIVACAINE 0.5% MPF INJ (SENSORCAINE MPF) 10ML 00409116218 136.17

4167281 1 DROPERIDOL 5MG/2ML INJ 00517970225 21.25

4251630 184 01630 ANESTH SURGERY OF SHOULD 2,574.16

4256441 1 64415 N BLOCK INJ BRACHIAL PLE 1,346.00

4502367 1 23670 OPEN TX SHOULDER DISLOC W/HUMERAL TUBEROSITY FX 5,038.80



4256942P 1 76942 XRAY,ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION ...216.00

3_High Total 55,843.63 50,259.27 53,051.45 53,051.45 51,161.68

29881 Removal of meniscus thru scope


1_Low 27 1 PACK EXTREMITY CUSTOM 190.80


50772 1 CUFF TOURNIQUET DUAL PORT SINGLE BLADDER 24IN 147.20




4020034 3 SURGERY ADD 1/4 HR 3,600.00

4020300 1 29881 SURGERY 1ST 1/2 HR 2,627.00

4030001 1 RECOVERY 1ST 1/2 HOUR 668.00

4030002 3 RECOVERY ADDL 1/4 HR 618.00


4040006 3 GEN ANESTHESIA ADD 1/4 HR 990.00

4090014 66 01400 ANESTH KNEE JOINT SURGER 1,287.00


4161567 1 J2270 MORPHINE INJ 10MG/ML 1ML 00641612725 6.05

4163509 1 SENSORCAINE/EPI 0.5% INJ 63323046357 79.25



4165425 10 J1100 DEXAMETHASONE PHOS INJ 1mg (10mg/1ml) 00641036725 50.00

4165498 2 HYDROCODONE/ACETAMINOPHEN 5/325MG TAB 00406012310 8.00




4509881 1 29881 KNEE ARTHROSCOPY/SURGERY 6,635.00

1_Low Total 19,012.75 17,111.48 18,062.11 18,062.11 17,444.20

3_High 27 1 PACK EXTREMITY CUSTOM 190.80


50086 1 PIN BEATH GUIDE 2.4X254MM 10IN 158.00

50745 2 SUTURE FIBERWIRE #2 38IN TAPER NEEDLE 12/BX 218.00

51890 1 CUFF TOURNIQUET DUAL PORT SINGLE BLADDER 34IN 133.00

55768 1 SET PUSHER KNOT SUTURE CUTTER SLOTTED CANNULA 285.00

55769 1 NEEDLE CURVED DELIVERY SYSTEM FAST FIX 360 932.00

56137 1 DRILL CANNULATED 4.5MM 263.00

56138 1 PIN BEATH GUIDE DRILL TIP W/EYELET 2.4X431MM 17IN 190.80





56671 1 ENDOBUTTON CL ULTRA FIXATION 20MM 1,027.00

59240 1 SUCTION FLOOR WATER BUG 10/CS 115.00

60825 1 C1713 SCREW INTERFERENCE FAST THREAD BIOCOMPOSITE 11X30MM 1,266.00

4020034 6 SURGERY ADD 1/4 HR 7,200.00

4020300 1 29888 SURGERY 1ST 1/2 HR 2,627.00

4030001 1 RECOVERY 1ST 1/2 HOUR 668.00

4030002 6 RECOVERY ADDL 1/4 HR 1,236.00



4090014 117 01400 ANESTH KNEE JOINT SURGER 1,716.39

4160193 2 J1170 HYDROMORPHONE 2MG/ML INJ 00641012125 17.30



4161567 1 J2270 MORPHINE INJ 10MG/ML 1ML 00641612725 6.05













3_High Total 50,793.89 45,714.50 48,254.20 48,254.20 46,349.86

43235 Upper GI exam thru scope


1_Low 4020020 1 43235 GASTROSCOPY 1,623.00

4040034 1 MAC 1ST 1/2 HR 1,022.00

4090740 11 00731 ANESTH UPPER GI VISUALIZ 1,144.00

4160573 1 J3490 LIDOCAINE TOPICAL SOLN 4% 50ML 00054350547 91.60



4533235 1 43235 UPPR GI ENDOSCOPY DIAGNO 1,256.00

1_Low Total 5,516.85 4,965.17 5,241.01 5,241.01 5,058.67

3_High 4020020 1 43235 GASTROSCOPY 1,623.00

4020039 1 45385 COLONSCOPY W/POLY&BIOPSY 2,598.00

4040034 1 00813 MAC 1ST 1/2 HR 1,022.00

4040035 1 MAC ADD 1/4 HR 330.00

4070011 1 85610 PROTHROMBIN TIME/INR 67.00

4070900 1 36415 DRAWING FEE 35.00

4090813 56 00813 ANESTHESIA FOR COMBINED UPPER AND LOWER GASTROINTESTINAL ENDOSCOPIC PROCEDURES, ENDOSCOPE ...1,715.84

4160573 1 LIDOCAINE TOPICAL SOLN 4% 50ML 00054350547 91.60





4535385 1 45385 LESION REMOVAL COLONOSCOPY 2,171.00

3_High Total 11,173.44 10,056.10 10,614.77 10,614.77 10,237.01

43239 Upper GI exam with biopsy via scope


1_Low 551 1 FORCEP THERMAL BIOPSY 147.20

3070500 1 G0500 Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care P... 81.00

4020042 1 43239 GASTROSCOPY W/BIOPSY 2,028.00

4070058 1 87077 CLO TEST 83.00




4533239 1 43239 UPPER GI ENDOSCOPY BIOPSY 1,288.00

1_Low Total 3,766.40 3,389.76 3,578.08 3,578.08 3,464.11

3_High 551 1 FORCEP THERMAL BIOPSY 147.20

4020020 1 43239 GASTROSCOPY 1,623.00

4020037 1 45380 COLONOSCOPY W/BIOPSY 2,471.00


4040034 1 00813 MAC 1ST 1/2 HR 1,022.00

4040035 2 MAC ADD 1/4 HR 660.00

4070058 1 87077 CLO TEST 83.00



4165524 1 ALBUTEROL HFA INH 8GM 00173068220 204.84


4166819 1 J3490 KETAMINE 50MG/ML INJ 1ML SYRINGE 70092112043 70.50

4253239 1 43239 UPPER GI ENDOSCOPY BIOPS 1,288.00

4255380 1 45380 COLONOSCOPY AND BIOPSY 1,989.00

3_High Total 13,185.90 11,867.31 12,526.61 12,526.61 12,117.38

45378 Colonoscopy


1_Low 3070500 1 G0500 Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care P... 81.00

3079153 1 99153 Moderate Sedation Services Provided By The Same Physician Or Other Qualified Health Care P... 28.00

4020025 1 45378 COLONOSCOPY 2,471.00



4535378 1 45378 DIAGNOSTIC COLONOSCOPY 1,548.00

1_Low Total 4,205.60 3,785.04 3,995.32 3,995.32 3,864.77


4020025 1 45378 COLONOSCOPY 2,471.00


4040034 1 00813 MAC 1ST 1/2 HR 1,022.00

4040035 1 MAC ADD 1/4 HR 330.00





4255378 1 45378 DIAGNOSTIC COLONOSCOPY 1,548.00

3_High Total 10,544.34 9,489.91 10,017.12 10,017.12 9,678.25

45380 Colonscopy with biopsy




4040034 1 00811 MAC 1ST 1/2 HR 1,022.00

4090081 27 00811 ANESTH LOW INTESTINE SCO 1,143.99



1_Low Total 6,873.19 6,185.87 6,529.53 6,529.53 6,332.40


50489 1 CATH INJECTION BIPOLAR 25G 2.5X2000MM 147.20

50654 1 SYRINGE INDIA INK MARKER 151.00



4040034 1 MAC 1ST 1/2 HR 1,022.00

4040035 3 MAC ADD 1/4 HR 990.00








4255381 1 45381 COLONOSCOPY SUBMUCOUS IN 2,040.00

4255384 1 45384 LESION REMOVE COLONOSCOPY 2,018.00

3_High Total 16,399.06 14,759.15 15,579.11 15,579.11 14,979.59

45385 Colonoscopy with removal of polyp



4020039 1 45385 COLONSCOPY W/POLY&BIOPSY 2,598.00

4040034 1 00811 MAC 1ST 1/2 HR 1,022.00

4070170 1 83540 IRON SERUM 68.00

4070316 1 82728 FERRITIN SERUM 129.00

4070325 1 83550 IRON BINDING CAP 87.00

4070900 1 36415 DRAWING FEE 35.00

4090081 33 00811 ANESTH LOW INTESTINE SCO 1,001.22




1_Low Total 7,374.42 6,636.98 7,005.70 7,005.70 6,763.04


551 1 FORCEP THERMAL BIOPSY 147.20


4020034 6 SURGERY ADD 1/4 HR 7,200.00

4020300 1 49585 SURGERY 1ST 1/2 HR 2,627.00

4030001 1 RECOVERY 1ST 1/2 HOUR 668.00

4030002 2 RECOVERY ADDL 1/4 HR 412.00



4090832 60 00832 ANESTH REPAIR OF HERNIA 1,573.20







4166789 1 LIDOCAINE TOP SOLN 4% LTA PREATTACHED KIT 00409469801 32.45

4166819 1 J3490 KETAMINE 50MG/ML INJ 1ML SYRINGE 70092112043 70.50

4166838 1 FENTANYL CIT 250MCG/5ML INJ 00409909425 7.10



4167215 1 ROCURONIUM INJ 10ML VIAL 39822420005 45.00

4167330 1 SUCCINYLCHOLINE 140MG/7ML SYR INJ 70092133746 181.45

4535384 1 45384 LESION REMOVE COLONOSCOPY 2,018.00


4539585 1 49585 RPR UMBIL HERN REDUC > 5 3,046.00

3_High Total 24,464.95 22,018.46 23,241.70 23,241.70 22,488.16

47562 Removal of gall badder via scope



532 1 ENDOPOUCH 10MM 190.80


645 1 TROCAR ENDO 5MM BLADELESS 147.20

662 1 CLIP APPLIER 5MM 342.00

50202 1 TROCAR BLADELESS 12MM 176.92

50262 2 SLEEVE BLADELESS TROCAR 5MM 212.00

51864 1 SUCTION IRRIGATOR STRYKER 161.00

4020034 4 SURGERY ADD 1/4 HR 4,704.00

4020300 1 47562 SURGERY 1ST 1/2 HR 2,575.00

4030001 1 RECOVERY 1ST 1/2 HOUR 654.00

4030002 5 RECOVERY ADDL 1/4 HR 1,005.00






4161870 1 SOD CHLORIDE 0.9% 10ML 00409488810 4.00




4165015 1 CLINDAMYCIN 900MG/5ML PREMIX 00338955324 90.60





4250790 13 00790 ANESTH SURG UPPER ABDOME 1,820.00

4254756 1 47562 LAPAROSCOPIC CHOLECYSTECT 5,404.00

1_Low Total 20,934.49 18,841.04 19,887.77 19,887.77 19,252.36


532 1 ENDOPOUCH 10MM 190.80

534 1 TUBING INSUFFLATOR WARMING 160.00


645 1 TROCAR ENDO 5MM BLADELESS 113.11

662 1 CLIP APPLIER 5MM 359.00

50202 1 TROCAR BLADELESS 12MM 176.92

51864 1 SUCTION IRRIGATOR STRYKER 161.00

4020034 6 SURGERY ADD 1/4 HR 7,056.00

4020300 1 SURGERY 1ST 1/2 HR 2,575.00

4030001 1 47562 RECOVERY 1ST 1/2 HOUR 654.00

4030002 9 RECOVERY ADDL 1/4 HR 1,809.00



4160193 1 J1170 HYDROMORPHONE 2MG/ML INJ 00641012125 8.65






4166122 2 J0690 CEFAZOLIN INJ 500mg (1GM) 00143926225 13.20




4166819 1 KETAMINE 50MG/ML INJ 1ML SYRINGE 70092112043 70.50





4170051 1 SOD CHLORIDE 0.9% 50ML 00264180031 17.00

4250790 15 00790 ANESTH SURG UPPER ABDOME 2,100.00

4254756 1 47562 LAPAROSCOPIC CHOLECYSTECT 5,404.00

3_High Total 24,901.85 22,411.67 23,656.76 23,656.76 22,933.60

49505 Repair of groin hernia




50831 1 MESH PATCH SHEET KEYHOLE PRESHAPED 2.4X5.4IN 269.00

4020034 5 SURGERY ADD 1/4 HR 6,000.00

4020300 1 49505 SURGERY 1ST 1/2 HR 2,627.00

4030001 1 RECOVERY 1ST 1/2 HOUR 668.00

4030002 4 RECOVERY ADDL 1/4 HR 824.00














4534905 1 49505 PRP I/HERN INIT REDUC >5 2,879.00

1_Low Total 18,223.37 16,401.03 17,312.20 17,312.20 16,814.16



50260 1 MESH PATCH FLAT SHEET POLYPROPYLENE 3X6IN 200.00

4020020 1 43235 GASTROSCOPY 1,623.00

4020025 1 G0105 COLONOSCOPY 2,471.00

4020034 7 SURGERY ADD 1/4 HR 8,400.00

4020300 1 49505 SURGERY 1ST 1/2 HR 2,627.00

4030001 1 RECOVERY 1ST 1/2 HOUR 668.00

4030002 1 RECOVERY ADDL 1/4 HR 206.00
















4530105 1 G0105 COLORECTAL SCRN; HI RISK 1,465.00


4534905 1 49505 PRP I/HERN INIT REDUC >5 2,879.00

3_High Total 28,535.45 25,681.91 27,108.68 27,108.68 26,309.89

59400 Routine obstetric care for vaginal delivery, including pre-and post-delivery care Please see our OB Package for additional savings!


1_Low 1475 1 PACK OB DELIVERY IV CUSTOM 126.00

57009 1 LINER BIRTHING POOL MINI 147.20

4000005 1 SEMI PRIVATE OB 1,804.00

4000009 1 DELIVERY LEVEL 1 2,537.00

4000026 1 VAGINAL DELIVERY ROOM 531.00

4070002 3 85025 CBC AND DIFF 321.00

4070339 1 86900 ABO GROUP 75.00

4070340 1 86901 RH 74.00

4070411 1 86885 ANTIBODY SCREEN (CROSS M) 74.00

4070900 2 36415 DRAWING FEE 70.00

4160333 1 J2550 PROMETHAZINE 25MG/ML INJ( PHENERGAN) 00641095525 5.15

4160944 2 IBUPROFEN 800MG TAB 63739069110 8.00

3 IBUPROFEN 800MG TAB 63739069110 12.00

4161163 4 MISOPROSTOL 200MCG TAB 68084004101 38.40


4163447 1 90707 MEASLESMUMPSRUBELLA VIRUS VACCINE INJ 00006468100 140.00

4164509 2 DIPHENOXYLATE/ATROPINE 2.5 MG TAB 59762106101 8.00

4165326 1 J2590 OXYTOCIN 20UNITS/1000ML NS PREMIX BAG 70092106708 40.70

4166581 1 METHYLERGONOVINE 0.2MG/ML VIAL FOR INJ 00517074020 34.40

4170051 1 J3490 SOD CHLORIDE 0.9% 50ML 00264180031 18.00

4519400 1 59400 OBSTETRICAL CARE 5,063.00

PRE/POST OFFICE VISITS & (2) ULTRASOUNDS 2,794.00

1_Low Total 13,955.65 12,560.09 13,257.87 13,257.87 12,826.86

3_High 617 1 TRAY EPIDURAL MUTLI PORT CATHETER 123.00

4000005 3 SEMI PRIVATE OB 5,412.00

4000011 1 DELIVERY LEVEL 3 6,082.00

4000014 1 EPIDURAL ANALGESIA LABOR 504.00



4070002 4 85025 CBC AND DIFF 428.00

4070140 1 83615 LDH 62.00

4070149 3 84550 .URIC ACID SERUM 207.00

4070339 1 86900 ABO GROUP 75.00

4070340 1 86901 RH 74.00

4070347 1 86870 ANTIBODY ID ROUTINE 336.00


4070413 1 85461 FETAL SCREEN 94.00

4070451 3 80053 COMPREHENSIVE PANEL 531.00

4070900 4 36415 DRAWING FEE 140.00

4100013 1 90384 RHOGAM PRODUCT ONLY 239.00

4160944 1 IBUPROFEN 800MG TAB 63739069110 4.00

3 IBUPROFEN 800MG TAB 63739069110 12.00

4 IBUPROFEN 800MG TAB 63739069110 16.00

4161906 2 LEVOTHYROXINE 88MCG TAB 42292003820 8.00




4167274 1 FENTANYL 2MCG/ML ROPIVACAINE 0.1% PF 200ML EPIDURAL 70092120737 102.30

4170051 2 J3490 SOD CHLORIDE 0.9% 50ML 00264180031 36.00

4259400 1 59400 OBSTETRICAL CARE 5,063.00


3_High Total 23,323.40 20,991.06 22,157.23 22,157.23 21,538.87

59510 Routine obstetric care for cesarean delivery, including pre-and post-delivery care Please see our OB Package for additional savings!


1_Low 5 1 PACK CSECTION 226.00

389 1 TRAY SPINAL ANESTHESIA 105.00



3070013 1 SEMI PRIVATE 1,859.00

4000010 1 DELIVERY LEVEL 2 4,310.00

4020034 4 SURGERY ADD 1/4 HR 4,800.00

4020300 1 59510 SURGERY 1ST 1/2 HR 2,627.00

4040034 1 01961 MAC 1ST 1/2 HR 1,022.00

4040035 4 MAC ADD 1/4 HR 1,320.00

4070002 3 85025 CBC AND DIFF 321.00

4070339 1 86900 ABO GROUP 75.00

4070340 1 86901 RH 74.00


4070573 1 81001 UAROUTINEAUTO 104.00

4070900 2 36415 DRAWING FEE 70.00

4091961 85 01961 ANESTH CS DELIVERY 1,858.95

4160334 4 J2590 OXYTOCIN 10U/ML INJ 63323001201 35.80

4160536 1 J1200 DIPHENHYDRAMINE INJ 50MG/ML INJ 00641037625 16.50


4160907 1 J2300 NALBUPHINE 10MG/ML INJ 00409146349 19.70

4160944 1 IBUPROFEN 800MG TAB 63739069110 4.00



https://res.cloudinary.com/dpmykpsih/image/upload/powell-valley-site-298/media/d56295971f174a2cbd4164f87f43e81a/private-pay-or-commercial-insurance-delivery-packages.pdf




4166292 200 J0131 ACETAMINOPHEN INJ 10mg (1000mg vial) 43825010201 450.00


4166754 1 HYDROMORPHONE 1MG/ML PF INJ 00409255201 6.40

4166760 1 S0028 FAMOTIDINE INJ 20MG/2ML 63323073912 5.40

4170051 1 J3490 SOD CHLORIDE 0.9% 50ML 00264180031 18.00

4515591 1 59510 CESAREAN DELIVERY 5,964.00


1_Low Total 28,753.90 25,878.51 27,316.21 27,316.21 26,589.24

3_High 5 1 PACK CSECTION 194.00

88 1 BINDER ABD UNIVERSAL 28IN 50IN (LG) 17.25

389 1 TRAY SPINAL ANESTHESIA 104.00



4000005 2 SEMI PRIVATE OB 3,608.00

4000011 1 DELIVERY LEVEL 3 6,082.00

4020034 8 SURGERY ADD 1/4 HR 9,600.00

4020300 1 59510 SURGERY 1ST 1/2 HR 2,627.00


4040034 1 01961 MAC 1ST 1/2 HR 1,022.00

4040035 8 MAC ADD 1/4 HR 2,640.00

4070002 2 85025 CBC AND DIFF 214.00

4070339 1 86900 ABO GROUP 75.00

4070340 1 86901 RH 74.00


4070900 2 36415 DRAWING FEE 70.00

4091961 150 01961 ANESTH CS DELIVERY 2,431.50

4160334 2 J2590 OXYTOCIN 10U/ML INJ 63323001201 17.90

4160536 1 J1200 DIPHENHYDRAMINE INJ 50MG/ML INJ 00641037625 6.40


3 J2765 METOCLOPRAMIDE 10MG INJ 00409341418 19.95

4160992 4 LABETALOL 100MG TAB 00591060501 16.00

4163046 1 J1885 KETOROLAC 15MG INJ 00409379301 6.90

2 J1885 KETOROLAC 15MG INJ 00409379301 13.80

4 J1885 KETOROLAC 15MG INJ 00409379301 27.60

4163150 1 SCOPOLAMINE 1.5MG PATCH 10019055302 107.55

4164417 1 J2270 MORPHINE SULF 10MG/10ML P 00641601910 70.10




2 HYDROCODONE/ACETAMINOPHEN 5/325MG TAB 00406012310 8.00


4165678 2 VENLAFAXINE ER 75MG CAP 65862052830 46.70


4166292 200 J0131 ACETAMINOPHEN INJ 10mg (1000mg vial) 43825010201 450.00


4166540 1 TRANEXAMIC ACID INJ 1000MG/10ML 39822100107 124.20

4166760 1 J3490 FAMOTIDINE INJ 20MG/2ML 63323073912 5.40

4167230 2 BUPROPION 75MG TAB 00378043301 8.00

4515591 1 59510 CESAREAN DELIVERY 5,964.00

4518611 1 58611 LIGATE OVIDUCT(S) ADDON 1,299.60

4519514 1 59514 CESAREAN DELIVERY ONLY 771.80


3_High Total 41,512.05 37,360.85 39,436.45 39,436.45 38,454.32

59610 Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care Please see our OB Package for additional savings!


1_Low 1475 1 PACK OB DELIVERY IV CUSTOM 113.11

4000005 1 SEMI PRIVATE OB 1,804.00

4000009 1 DELIVERY LEVEL 1 2,537.00

4000023 1 59025 NON STRESS TEST 717.00


4070002 1 85025 CBC AND DIFF 107.00

4070339 1 86900 ABO GROUP 75.00

4070340 1 86901 RH 74.00


4070574 1 81003 UA CHEMAUTO 60.00

4070900 1 36415 DRAWING FEE 35.00


4519610 1 59610 VBAC DELIVERY 5,602.00


1_Low Total 14,544.86 13,090.37 13,817.62 13,817.62 10,704.74

3_High 617 1 TRAY EPIDURAL MUTLI PORT CATHETER 176.92

1475 1 PACK OB DELIVERY IV CUSTOM 134.00

57783 1 CATH INTRAUTERINE KOALAL 113.11

4000005 2 SEMI PRIVATE OB 3,536.00

4000010 1 DELIVERY LEVEL 2 4,144.00

4000014 1 EPIDURAL ANALGESIA LABOR 484.00

4000023 1 59025 NON STRESS TEST 689.00



4070002 3 85025 CBC AND DIFF 321.00

4070900 3 36415 DRAWING FEE 105.00

4160944 5 IBUPROFEN 800MG TAB 63739069110 20.00



4165618 1 J2795 ROPIVACAINE INJ 0.2% 1mg (200MG/100ML PREMIX) 63323028561 231.80

4251967 14 01967 ANESTH/ANALG VAG DELIVER 1,960.00

4259610 1 59610 VBAC DELIVERY 5,492.00


3_High Total 21,028.73 18,925.86 19,977.29 19,977.29 16,734.74


62322 Epidural injections


1_Low 716 1 TRAY EPIDURAL SINGLE SHOT 132.00


4020076 1 62321 MINOR OP PROC W/IV SED 1,967.00

4140262 10 Q9967 LOCM 200 INTRATHECAL 9.00



4166022 1 J1094 DEXAMETHASONE PHOS PF INJ 1mg (10mg VIAL) 70069002125 4.00

4166539 1 ROPIVACAINE 1mg Inj (2MG/ML 20ML SDV) 63323028523 15.00

4252322 1 62322 Injection(S), Of Diagnostic Or Therapeutic Substance(S) (Eg, Anesthetic, Antispasmodic, Op... 1,034.00

1_Low Total 3,261.00 2,934.90 3,097.95 3,097.95 2,999.28

2_High 716 1 TRAY EPIDURAL SINGLE SHOT 132.00

4020076 1 62322 MINOR OP PROC W/IV SED 1,967.00




4161851 2 J1040 METHYLPREDNISOLONE ACETATE INJ 80MG/ML 00009347522 172.40


4165842 1 BUPIVACAINE 0.25% MPF INJ 30ML 00409115919 10.00

4250610 1 20610 INJ ASP. MAJOR JOINT/BURSA 278.00


4259832 1 77002 Read only Fluoroscopic Guidance For Needle Placement (Eg, Biopsy, Aspiration, Injection, Localizatio...117.00

2_High Total 4,293.40 3,864.06 4,078.73 4,078.73 3,958.33

62323 Epidural Injection using imaging guidance



4020306 1 62321 Pain OP Procedure Level 2 w/IV Sedation 2,969.00

4140262 10 Q9967 LOCM 200 INTRATHECAL 00407141491 90.00



4166314 1 J2400 CHLOROPROCAINE 2% MPF VIAL 20ML 63323047727 127.85

4167261 1 J3490 SODIUM BICARBONATE 4.2% INJ 5ML 00409555502 45.80


1_Low Total 4,651.55 4,186.40 4,418.97 4,418.97 4,287.75




4140262 10 Q9967 LOCM 200 INTRATHECAL 00407141491 90.00


4161851 1 J1040 METHYLPREDNISOLONE ACETATE INJ 80MG/ML 00009347522 110.05






3_High Total 4,931.00 4,437.90 4,684.45 4,684.45 4,547.64

64483 Injection of lumbar spine nerve root for pain





4070011 1 85610 PROTHROMBIN TIME/INR 67.00

4070900 1 36415 DRAWING FEE 35.00








4524483 1 64483 INJ FORAMEN EPIDURAL L/S 1,556.00

1_Low Total 5,183.95 4,665.56 4,924.75 4,924.75 4,774.39












4520257 1 64484 INJ FORAMEN EPIDURAL ADD 1,934.00

4524483 1 64483 INJ FORAMEN EPIDURAL L/S 3,112.00

3_High Total 8,629.95 7,766.96 8,198.45 8,198.45 7,874.47

93000 Electrocardiogram, routine, with interpretation and report


1_Low 4259214 1 99214 EST OFFICE LEVEL 4 239.00

42530000 1 93000 Electrocardiogram Complete 344.00

1_Low Total 583.00 524.70 553.85 553.85 530.82

2_High 4259204 1 99204 NEW OFFICE LEVEL 4 352.00

42530000 1 93000 Electrocardiogram Complete 344.00

2_High Total 696.00 626.40 661.20 661.20 633.71

97110 Physical therapy, therapeutic exercise

HospitalService ChargeCode Units CPTCode CPTCodeDescription NDC TotalCharge Cash Discount UHC BCBS 1st Choice

Occupational Therapy 4790523 1 97110 THERAPEUTIC EXER/ 15 MIN 104.00 93.60 98.80 98.80 96.72

Physical Therapy 4200045 1 97110 THERAPEUTIC EXER /15 MIN 102.00 91.80 96.90 96.90 94.86

PROCEDURES BY DEPARTMENT MAX MIN Contract Pricing

CPT Description Column1 Price Cash Discount UHC BCBS 1st Choice

MRI

70540 MRI Orbit Face or Neck W/O Contrast 2,400.00 2,160.00 2,280.00 2,280.00 2,232.00

70542 MRI Orbit Face or Neck with Contrast 3,500.00 3,150.00 3,325.00 3,325.00 3,255.00

70544 MRA Head W/O Contrast 2,400.00 2,160.00 2,280.00 2,280.00 2,232.00

70545 MRA Head with Contrast 3,400.00 3,060.00 3,230.00 3,230.00 3,162.00

70553 MRI HEAD/BRAIN W & WO Contrast 3,800.00 3,420.00 3,610.00 3,610.00 3,534.00

72141 MRI C-SPINE W/O 2,800.00 2,520.00 2,660.00 2,660.00 2,604.00

72142 MRI C-Spine with Contrast 3,500.00 3,150.00 3,325.00 3,325.00 3,255.00

72146 MRI Spinal Canal & Contents, Thorasic; W/O Contrast 2,800.00 2,520.00 2,660.00 2,660.00 2,604.00

72148 MRI L Spine W/O Contrast 2,800.00 2,520.00 2,660.00 2,660.00 2,604.00

72158 MRI L Spine W/WO Contrast 4,200.00 3,780.00 3,990.00 3,990.00 3,906.00

72195 MRI Pelvis W/O Contrast 2,100.00 1,890.00 1,995.00 1,995.00 1,953.00

72197 MRI Pelvis W/O and With Contrast 3,800.00 3,420.00 3,610.00 3,610.00 3,534.00

73218 MRI Upper Extremity Other than Joint (Hand, Forearm, Humerus) W/O Contrast 2,200.00 1,980.00 2,090.00 2,090.00 2,046.00

73221 MRI Upper Extremity, Any Joint W/O Contrast (Shoulder, Elbow) 2,200.00 1,980.00 2,090.00 2,090.00 2,046.00

73221 MRI Upper Extremity, Any Joint W/O Contrast (Wrist) 2,800.00 2,520.00 2,660.00 2,660.00 2,604.00

73222 MRI Upper Joint of Upper Extremity With Contrast (Wrist Elbow, Shoulder) 2,900.00 2,610.00 2,755.00 2,755.00 2,697.00

73721 MRI Lower Extremity Other than Joint (Foot, Tib/Fib, Femur) 2,200.00 1,980.00 2,090.00 2,090.00 2,046.00

74181 MRI Abdomen W/O Contrast 2,800.00 2,520.00 2,660.00 2,660.00 2,604.00

74183 MRI Abdomen; W/O Contrast 3,500.00 3,150.00 3,325.00 3,325.00 3,255.00

77049 MRI Breast W/O and With Contrast 2,700.00 2,430.00 2,565.00 2,565.00 2,511.00

Radiology

70110 X-Ray Mandible Complete 4 or more views 384.00 345.60 364.80 364.80 357.12

70150 X-Ray Facial Bones Complete 3 or more views 398.00 358.20 378.10 378.10 370.14

70160 X-Ray Nasal Bones Complete 3 or more views 339.00 305.10 322.05 322.05 315.27

70220 X-Ray Sinuses Paranasal Complete 3 or more views 393.00 353.70 373.35 373.35 365.49

70330 X-Ray TMJ Bilateral (Temporomandibular Joint Open And Closed Mouth) 552.00 496.80 524.40 524.40 513.36

70360 X-Ray Head and Neck 232.00 208.80 220.40 220.40 215.76

71045 X-Ray Chest; Single View 226.00 203.40 214.70 214.70 210.18

71046 X-Ray Chest; 2 Views 287.00 258.30 272.65 272.65 266.91

71100 X-Ray Ribs Unilateral 2 View 352.00 316.80 334.40 334.40 327.36

71101 X-Ray Ribs Unilateral 3 View 398.00 358.20 378.10 378.10 370.14

71111 X-Ray Ribs Bilateral 4 Views 559.00 503.10 531.05 531.05 519.87

71120 X-Ray Sternum 327.00 294.30 310.65 310.65 304.11

72020 X-Ray Spine Single View 248.00 223.20 235.60 235.60 230.64

72020 X-Ray Spine Thoracic Level IV 248.00 223.20 235.60 235.60 230.64

72020 X-Ray Spine Lumbar Level IV 251.00 225.90 238.45 238.45 233.43

72040 X-Ray Spine Cervical 2 or 3 Views 459.00 413.10 436.05 436.05 426.87

72050 X-Ray Spine Cervical 4 or 5 views 473.00 425.70 449.35 449.35 439.89

72052 X-Ray Spine Cervical 6 or more Views 857.00 771.30 814.15 814.15 797.01

72070 X-Ray Spine Thoracic 2 Views 272.00 244.80 258.40 258.40 252.96



72100 X-Ray Spine Lumbar 2 or 3 views 358.00 322.20 340.10 340.10 332.94

72110 X-Ray L-Spine Comp 4 Views 495.00 445.50 470.25 470.25 460.35

72170 X-Ray Pelvis 1 or 2 views 284.00 255.60 269.80 269.80 264.12

72202 X-Ray Sacroiliac Joints 3 or more views 390.00 351.00 370.50 370.50 362.70

72220 X-Ray Sacrum and Coccyx 2 or more views 405.00 364.50 384.75 384.75 376.65

73000 X-Ray Clavicle Complete 268.00 241.20 254.60 254.60 249.24

73010 X-Ray Scapula Complete 316.00 284.40 300.20 300.20 293.88

73030 X-Ray Shoulder Complete 2 views 352.00 316.80 334.40 334.40 327.36

73040 X-Ray Shoulder Arthrography 600.00 540.00 570.00 570.00 558.00

73060 X-Ray Humerus 2 or more views 313.00 281.70 297.35 297.35 291.09

73070 X-Ray Elbow 2 views 293.00 263.70 278.35 278.35 272.49

73080 X-Ray Elbow 3 views 327.00 294.30 310.65 310.65 304.11

73090 X-Ray Forearm 2 views 284.00 255.60 269.80 269.80 264.12

73100 X-Ray Wrist 2 views 263.00 236.70 249.85 249.85 244.59

73110 X-Ray Wrist Complete; 3 views 387.00 348.30 367.65 367.65 359.91

73115 X-Ray Wrist Arthrography 544.00 489.60 516.80 516.80 505.92

73120 X-Ray Hand 2 views 301.00 270.90 285.95 285.95 279.93

73130 X-Ray Hand 3 views 374.00 336.60 355.30 355.30 347.82

73140 X-Ray Fingers 251.00 225.90 238.45 238.45 233.43

73502 X-Ray Hip Unilateral 2-3 views 342.00 307.80 324.90 324.90 318.06

73521 X-Ray Hips Bilateral with Pelvis 2 views 331.00 297.90 314.45 314.45 307.83

73552 X-Ray Femur 2 views 293.00 263.70 278.35 278.35 272.49

73560 X-Ray Knee 1 or 2 views 339.00 305.10 322.05 322.05 315.27

73562 X-Ray Knee 3 views 393.00 353.70 373.35 373.35 365.49

73564 X-Ray Knee 4 or more views 418.00 376.20 397.10 397.10 388.74

73590 X-Ray Lower Leg 2 views 306.00 275.40 290.70 290.70 284.58

73592 X-Ray Lower Extremity Infant 2 or more views 234.00 210.60 222.30 222.30 217.62

73600 X-Ray Ankle 1-2 views 284.00 255.60 269.80 269.80 264.12

73610 X-Ray Ankle 3 views 334.00 300.60 317.30 317.30 310.62

73620 X-Ray Foot 2 views 217.00 195.30 206.15 206.15 201.81

73630 X-Ray Foot 3 views 327.00 294.30 310.65 310.65 304.11

73650 X-Ray Heel 2 views or more 158.00 142.20 150.10 150.10 146.94

73660 X-Ray Toes 268.00 241.20 254.60 254.60 249.24

74018 X-Ray Abdomen Flat 1 view 337.00 303.30 320.15 320.15 313.41

74019 X-Ray Abdomen Flat 2 views 394.00 354.60 374.30 374.30 366.42

74220 X-Ray Esophagus 576.00 518.40 547.20 547.20 535.68

77065 Mammography 1 Breast 276.00 248.40 262.20 262.20 256.68

77066 Mammography 2 Breast 317.00 285.30 301.15 301.15 294.81

77067 Mammography Screening Bilateral 303.00 272.70 287.85 287.85 281.79

77080 X-Ray Absorptiometry (Dxa) Bone Density Study 1 Or More Sites 556.00 500.40 528.20 528.20 517.08

Ultra Sound

76536 US Soft Tissues of Head and Neck - Thyroid 642.00 577.80 609.90 609.90 597.06

76604 US Chest 1,061.00 954.90 1,007.95 1,007.95 986.73

76642 US Breast Unilateral - Specific Area 591.00 531.90 561.45 561.45 549.63

76700 US Abdomen 648.00 583.20 615.60 615.60 602.64

76770 US Renal Bilateral 741.00 666.90 703.95 703.95 689.13

76801 US OB 1st Trimester 372.00 334.80 353.40 353.40 345.96

76805 US OB after 1st Trimester 372.00 334.80 353.40 353.40 345.96

76816 US OB Followup 2nd Fetus 533.00 479.70 506.35 506.35 495.69

76830 US OB Transvaginal 581.00 522.90 551.95 551.95 540.33

76856 US Pelvic Non OB Complete 686.00 617.40 651.70 651.70 637.98

76870 US Testicular 461.00 414.90 437.95 437.95 428.73

76881 US Complete Joint, Non-Vascular 909.00 818.10 863.55 863.55 845.37

93306 US Cardiac Echo Complete 2,825.00 2,542.50 2,683.75 2,683.75 2,627.25

93307 US Heart Echo 2D M-Mode 1,870.00 1,683.00 1,776.50 1,776.50 1,739.10

93325 US Cardiac Echo Color Flow Velocity Mapping 1,140.00 1,026.00 1,083.00 1,083.00 1,060.20

93350 US Cardiac Strss Echo 2,155.00 1,939.50 2,047.25 2,047.25 2,004.15

93880 US Carotid Complete Bilateral Study 1,921.00 1,728.90 1,824.95 1,824.95 1,786.53

93970 US Bilateral Vein DVT 1,250.00 1,125.00 1,187.50 1,187.50 1,162.50

93971 US Unilateral Vein DVT 849.00 764.10 806.55 806.55 789.57

CT

70450 CT Head W/O Contrast 1,534.00 1,380.60 1,457.30 1,457.30 1,426.62

70470 CT Head With W/O contrast 2,158.00 1,942.20 2,050.10 2,050.10 2,006.94

70480 CT Orbit/Auditory Canal W/O Contrast 1,514.00 1,362.60 1,438.30 1,438.30 1,408.02

70486 CT Sinus/Facial W/O Contrast 1,435.00 1,291.50 1,363.25 1,363.25 1,334.55

70487 CT Sinus/Facial with Contrast 1,630.00 1,467.00 1,548.50 1,548.50 1,515.90

70490 CT Soft Tissue Neck W/O Contrast 1,665.00 1,498.50 1,581.75 1,581.75 1,548.45

70491 CT Soft Tissue Neck With Contrast 1,784.00 1,605.60 1,694.80 1,694.80 1,659.12

70498 CT Angiography Neck With Contrast 2,556.00 2,300.40 2,428.20 2,428.20 2,377.08

71250 CT Thorax W/O Contrast 1,717.00 1,545.30 1,631.15 1,631.15 1,596.81

71260 CT Thorax With Contrast 2,015.00 1,813.50 1,914.25 1,914.25 1,873.95

71270 CT Thorax With / W/O Contrast 2,350.00 2,115.00 2,232.50 2,232.50 2,185.50

71275 CT Angiography Chest (Noncoronary) With Contrast 2,891.00 2,601.90 2,746.45 2,746.45 2,688.63

72125 CT Cervical Spine W/O Contrast 1,776.00 1,598.40 1,687.20 1,687.20 1,651.68

72126 CT Cervical Spine with Contrast 2,093.00 1,883.70 1,988.35 1,988.35 1,946.49

72128 CT Thoracic Spine W/O Contrast 1,686.00 1,517.40 1,601.70 1,601.70 1,567.98

72129 CT Thoracic Spine with Contrast 1,976.00 1,778.40 1,877.20 1,877.20 1,837.68

72131 CT Lumbar Spine W/O Contrast 1,680.00 1,512.00 1,596.00 1,596.00 1,562.40

72132 CT Lumbar Spine with Contrast 2,280.00 2,052.00 2,166.00 2,166.00 2,120.40

72193 CT Pelvis with Contrast 1,698.00 1,528.20 1,613.10 1,613.10 1,579.14

73200 CT Upper Extremity W/O Contrast (Shoulder, Humerus, Elbow, Forearm, Wrist, Elbow) 1,336.00 1,202.40 1,269.20 1,269.20 1,242.48

73201 CT Upper Extremity with Contrast (Shoulder, Humerus, Elbow, Forearm, Wrist, Elbow) 1,505.00 1,354.50 1,429.75 1,429.75 1,399.65

73700 CT Lower Extremity W/O Contrast (Hip, Femur, Knee, Tib/Fib, Ankle, Foot) 1,282.00 1,153.80 1,217.90 1,217.90 1,192.26

73701 CT Lower Extremity with Contrast (Hip, Femur, Knee, Tib/Fib, Ankle, Foot) 1,501.00 1,350.90 1,425.95 1,425.95 1,395.93

74177 CT Abd/Pelvis With Contrast 3,091.00 2,781.90 2,936.45 2,936.45 2,874.63

Lab

80048 Basic Metabolic Panel 118.00 106.20 112.10 112.10 109.74

80053 Comprehensive Metabolic Panel This Panel Must Include The Following: Albumin (82040) Bilir... 177.00 159.30 168.15 168.15 164.61

80055 Obstetric Blood Test Panel 266.00 239.40 252.70 252.70 247.38

80061 Blood test, lipids (cholesterol and triglycerides) 250.00 225.00 237.50 237.50 232.50

80069 Renel Function Panel 87.00 78.30 82.65 82.65 80.91

80076 Hepatic Function Panel 128.00 115.20 121.60 121.60 119.04

81001 UA Routine Auto 104.00 93.60 98.80 98.80 96.72

81002 UA Dip 26.00 23.40 24.70 24.70 24.18

81003 UA ChemAuto 60.00 54.00 57.00 57.00 55.80

82565 Creatinine; Blood 55.00 49.50 52.25 52.25 51.15

83036 Hemoglobin; Glycosylated (A1C) 97.00 87.30 92.15 92.15 90.21

83615 LDH 62.00 55.80 58.90 58.90 57.66

83690 Lipase 71.00 63.90 67.45 67.45 66.03

83721 Ldl Cholesterol 47.00 42.30 44.65 44.65 43.71

83735 Magnesium 68.00 61.20 64.60 64.60 63.24

83880 BNP 178.00 160.20 169.10 169.10 165.54

84153 PSA 181.00 162.90 171.95 171.95 168.33

84154 PSA Free 181.00 162.90 171.95 171.95 168.33

84439 Free T4 90.00 81.00 85.50 85.50 83.70

84443 TSH 123.00 110.70 116.85 116.85 114.39

84478 Triglycerides 60.00 54.00 57.00 57.00 55.80

84481 T-3 Free 168.00 151.20 159.60 159.60 156.24

84484 Troponin Quantitative 172.00 154.80 163.40 163.40 159.96

85014 Blood Count; Hematocrit (Hct) 51.00 45.90 48.45 48.45 47.43

85025 CBC and DIFF 107.00 96.30 101.65 101.65 99.51

85027 Hemogram 67.00 60.30 63.65 63.65 62.31

85610 Prothrombin Time/INR 67.00 60.30 63.65 63.65 62.31

85730 APTT 102.00 91.80 96.90 96.90 94.86

86140 C-Reactive Protein (Crp) 83.00 74.70 78.85 78.85 77.19

86308 Mono (Heterophile Antibodies; Screening) 55.00 49.50 52.25 52.25 51.15

86803 Hepatitis C Antibody; 142.00 127.80 134.90 134.90 132.06

86900 Blood Typing Serologic; Abo 75.00 67.50 71.25 71.25 69.75

86901 Blood Typing Serologic; Rh (D) 74.00 66.60 70.30 70.30 68.82

87040 Culture Bacterial; Blood Aerobic With Isolation And Presumptive Identification 156.00 140.40 148.20 148.20 145.08

87086 Culture Bacterial; Quantitative Colony Count Urine 80.00 72.00 76.00 76.00 74.40

87186 Antibiotic Sens 121.00 108.90 114.95 114.95 112.53

87205 Gram Stain 44.00 39.60 41.80 41.80 40.92

87389 HIV 135.00 121.50 128.25 128.25 125.55

87400 Influenz A&B Antigen 183.00 164.70 173.85 173.85 170.19

87491 Chylmd Trach Dna Amp Probe 182.00 163.80 172.90 172.90 169.26

87591 N.Gonorrhoeae Dna Amp Prob 133.00 119.70 126.35 126.35 123.69

36415 Drawing Fee 35.00 31.50 33.25 33.25 32.55

Emergency Department

99281 ER - LEVEL I 286.00 257.40 271.70 271.70 265.98

99282 ER - LEVEL II 431.00 387.90 409.45 409.45 400.83

99283 ER - LEVEL III 718.00 646.20 682.10 682.10 667.74

99284 ER - LEVEL IV 1,162.00 1,045.80 1,103.90 1,103.90 1,080.66

99285 ER - LEVEL V 1,621.00 1,458.90 1,539.95 1,539.95 1,507.53

99291 ER - Critical Care 1st Hour 2,015.00 1,813.50 1,914.25 1,914.25 1,873.95

99292 ER Critical Care Additional 1/2 Hour 980.00 882.00 931.00 931.00 911.40

ER Physician

99281 ER Visit - Physician Level I 159.00 143.10 151.05 151.05 143.10

99282 ER Visit - Physician Level II 235.00 211.50 223.25 223.25 211.50

99283 ER Visit - Physician Level III 359.00 323.10 341.05 341.05 323.10

99284 ER Visit - Physician Level IV 538.00 484.20 511.10 511.10 484.20

99285 ER Visit - Physician Level V 793.00 713.70 753.35 753.35 713.70

99291 ER Visit - Physician - Critical Care 1st Hour 899.00 809.10 854.05 854.05 809.10

99292 ER Visit - Physician - Critical Care Additional 1/2 Hour 452.00 406.80 429.40 429.40 406.80

OB/Gyn Clinic

99202 OB/Gyn Clinic New Patient Office Level 2 - MD 190.00 171.00 180.50 180.50 173.00

99202 OB/Gyn Clinic New Patient Office Level 2 - NP 166.00 149.40 157.70 157.70 151.14






99211 OB/Gyn Clinic Established Patient Office Level 1 - MD 82.00 73.80 77.90 77.90 74.66

99211 OB/Gyn Clinic Established Patient Office Level 1 - NP 72.00 64.80 68.40 68.40 65.56





99213 OB/Gyn Clinic Telehealth Visit - Level 3 142.00 127.80 134.90 134.90 129.29



99215 OB/Gyn Clinic Established Patient Office Visit Level 5 - MD 350.00 315.00 332.50 332.50 318.68

99215 OB/Gyn Clinic Established Patient Office Visit Level 5 - NP 304.00 273.60 288.80 288.80 276.79

99243 OB/Gyn Consultation - Level 3 343.00 308.70 325.85 325.85 312.30

99384 OB/Gyn Clinic Well Child Check, New Patient, 12-17 Yrs 245.00 220.50 232.75 232.75 223.07

99385 OB/Gyn Clinic Well Person Exam, New Patient, 18-39 Yrs 330.00 297.00 313.50 313.50 300.47

99385 OB/Gyn Clinic Well Person Exam, New Patient, 18-39 Yrs 354.00 318.60 336.30 336.30 322.32

99386 OB/Gyn Clinic Eval & Management Adult 40-64Yrs 361.00 324.90 342.95 342.95 328.69

99386 OB/Gyn Clinic Eval & Management Adult 40-64Yrs 387.00 348.30 367.65 367.65 352.36

99394 OB/Gyn Clinic Well Child Check Established Patient, 12-17 Yrs 202.00 181.80 191.90 191.90 183.92

99395 OB/Gyn Clinic Periodic Preventive Med 18-39 Years 274.00 246.60 260.30 260.30 249.48

99395 OB/Gyn Clinic Periodic Preventive Med 18-39 Years 294.00 264.60 279.30 279.30 267.69

99396 OB/Gyn Clinic Prev Visit Established Patient Age 40-64 298.00 268.20 283.10 283.10 271.33

99396 OB/Gyn Clinic Prev Visit Established Patient Age 40-64 322.00 289.80 305.90 305.90 293.18

99397 OB/Gyn Clinic Wellness Exam, 65 Years And Over 341.00 306.90 323.95 323.95 310.48

Ortho Clinic

99202 Ortho Clinic New Patient Office Level 2 - Pa-C 166.00 149.40 157.70 157.70 151.14

99202 Ortho Clinic New Patient Office Level 2 - MD 190.00 171.00 180.50 180.50 173.00





99211 Ortho Clinic Established Patient Office Level 1 - Pa-C 72.00 64.80 68.40 68.40 65.56

99211 Ortho Clinic Established Patient Office Level 1 - MD 82.00 73.80 77.90 77.90 74.66







72040 Ortho Clinic X-Ray Spine Cervical; 2 Or 3 Views 459.00 413.10 436.05 436.05 417.92

72050 Ortho Clinic X-Ray Cervical Spine 4 Or 5 Views 568.00 511.20 539.60 539.60 517.16

72100 Ortho Clinic X-Ray Spine Lumbar 2 Or 3 Views 426.00 383.40 404.70 404.70 387.87

72170 Ortho Clinic X-Ray Pelvis 1 Or 2 Views 362.00 325.80 343.90 343.90 329.60

73000 Ortho Clinic X-Ray Clavical Complete 328.00 295.20 311.60 311.60 298.64

73030 Ortho Clinic X-Ray Shoulder Complete 2 Views 425.00 382.50 403.75 403.75 386.96

73060 Ortho Clinic X-Ray Humerus 2 Views 378.00 340.20 359.10 359.10 344.17

73080 Ortho Clinic X-Ray Elbow 3 Views 390.00 351.00 370.50 370.50 355.10

73090 Ortho Clinic X-Ray Forearm 2 Views 341.00 306.90 323.95 323.95 310.48

73100 Ortho Clinic X-Ray Wrist 2 Views 318.00 286.20 302.10 302.10 289.54

73110 Ortho Clinic X-Ray Wrist 3 View Minimum 453.00 407.70 430.35 430.35 412.46

73130 Ortho Clinic Xray, Hand 3 Views 438.00 394.20 416.10 416.10 398.80

73140 Ortho Clinic Xray Fingers 2 Views 297.00 267.30 282.15 282.15 270.42

73501 Ortho Clinic X-Ray Hip Unilateral 324.00 291.60 307.80 307.80 295.00

73502 Ortho Clinic Xray Hip 2 Views 416.00 374.40 395.20 395.20 378.77

73521 Ortho Clinic Xray, Bilateral Hips 421.00 378.90 399.95 399.95 383.32

73551 Ortho Clinic X-Ray Femur; 1 View 136.00 122.40 129.20 129.20 123.83

73552 Ortho Clinic X-Ray Femur Minimum 2 Views 353.00 317.70 335.35 335.35 321.41

73560 Ortho Clinic X-Ray Knee Ap/Lat 395.00 355.50 375.25 375.25 359.65

73562 Ortho Clinic Xray Knee 3 View Ap/Lat 452.00 406.80 429.40 429.40 411.55

73564 Ortho Clinic Xray Knee 4 Views 492.00 442.80 467.40 467.40 447.97

73590 Ortho Clinic X-Ray Lower Leg 367.00 330.30 348.65 348.65 334.15

73610 Ortho Clinic Xray, Ankle 3 View Ap Lat 396.00 356.40 376.20 376.20 360.56

73630 Ortho Clinic Xray Foot 3 Views 388.00 349.20 368.60 368.60 353.27

73660 Ortho Clinic X-Ray Toes 2 Vies 317.00 285.30 301.15 301.15 288.63

Family Practice

99201 Family Practice New Patient Office Level 1 133.00 119.70 126.35 126.35 121.10





99211 Family Practice Established Patient Office Level 1 72.00 64.80 68.40 68.40 65.56


99212 Family Practice Telehealth Visit - Level 2 101.00 90.90 95.95 95.95 91.96





99215 Family Practice Established Patient Office Visit Level 5 304.00 273.60 288.80 288.80 276.79

99381 Family Practice New Patient Patient Preventive Med - Infant 199.00 179.10 189.05 189.05 181.19

99382 Family Practice New Patient Patient Preventive Med - Age 1-4 215.00 193.50 204.25 204.25 195.76

99383 Family Practice New Patient Patient Preventive Med - Age 5-11 229.00 206.10 217.55 217.55 208.50

99384 Family Practice Well Child Check, New Patient, 12-17 Yrs 245.00 220.50 232.75 232.75 223.07

99385 Family Practice Well Person Exam, New Patient, 18-39 Yrs 330.00 297.00 313.50 313.50 300.47

99386 Family Practice Eval & Management Adult 40-64Yrs 361.00 324.90 342.95 342.95 328.69

99391 Family Practice Prev Visit Established Patient Infant 165.00 148.50 156.75 156.75 150.23

99392 Family Practice Prev Visit Established Patient Age 1-4 175.00 157.50 166.25 166.25 159.34


99394 Family Practice Well Child Check Established Patient, 12-17 Yrs 202.00 181.80 191.90 191.90 183.92

99395 Family Practice Periodic Preventive Med 18-39 Years 274.00 246.60 260.30 260.30 249.48

99395 Family Practice Periodic Preventive Med 18-39 Years 294.00 264.60 279.30 279.30 267.69



99397 Family Practice Wellness Exam, 65 Years And Over 341.00 306.90 323.95 323.95 310.48

G0402 Family Practice Welcome to Medicare Initial Preventitive Exam 214.00 192.60 203.30 203.30 194.85

Psychotherapy

90832 Psychotherapy, 30 Minutes 186.00 167.40 176.70 176.70 169.35



90839 Psychotherapy, TeleHealth Crisis, First Hour 390.00 351.00 370.50 370.50 355.10

Room Charges

N/A ICU 6,083.00 5,474.70 5,778.85 5,778.85 5,538.57

N/A Semi Private 1,859.00 1,673.10 1,766.05 1,766.05 1,692.62

N/A Semi Private Pediatrics 1,923.00 1,730.70 1,826.85 1,826.85 1,750.89

N/A Semi Private Telemetry 2,678.00 2,410.20 2,544.10 2,544.10 2,438.32

N/A Swing Bed 933.00 839.70 886.35 886.35 849.50

N/A Newborn Care 1,499.00 1,349.10 1,424.05 1,424.05 1,364.84

N/A Semi Private OB 1,804.00 1,623.60 1,713.80 1,713.80 1,642.54

The following CMS Required Shoppable Services are not in our Active Procedure List at this time:

CPT Code CPT Description Price

216 N/A

460 N/A

470 N/A

473 N/A

743 N/A

42820 N/A

45391 N/A

55700 N/A

55866 N/A

66821 N/A

66984 N/A

90846 N/A

90847 N/A

90853 N/A

93452 N/A

95810 N/A

99244 N/A

Family psychotherapy, including patient, 50 min

Group psychotherapy

Insertion of catheter into left heart for diagnosis

Sleep study

Patient office consultation, typically 60 min

Family psychotherapy, not including patient, 50 min

Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with

major complications or comorbidities

Spinal fusion except cervical without major comorbid conditions or complications (MCC)

Major joint replacement or reattachment of lower extremity without major comorbid

conditions or complications (MCC).

Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or

complications (MCC).

Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or

major comorbid conditions or complications (MCC)

Removal of tonsils and adenoid glands patient younger than age 12

Ultrasound examination of lower large bowel using an endoscope

Biopsy of prostate gland

Surgical removal of prostate and surrounding lymph nodes using an endoscope

Removal of recurring cataract in lens capsule using laser

Removal of cataract with insertion of lens

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