|
Established Patient Office Visit (level 2)
|
$284.00 |
$284.00 |
$284.00 |
$138.60
|
|
Established Patient Office Visit (level 3)
|
$351.99 |
$351.99 |
$351.99 |
$186.60
|
|
Established Patient Office Visit (level 4)
|
$490.31 |
$490.31 |
$490.31 |
$231.00
|
|
Established Patient Office Visit (level 5)
|
$638.52 |
$638.52 |
$638.52 |
$283.28
|
|
Estrogens total-sendout
|
$21.95 |
$21.95 |
$21.95 |
$89.25
|
|
Etanercept injection
|
$558.54 |
$558.54 |
$558.54 |
$1,561.32
|
|
Ethanolamine oleate 100 mg
|
$3,048.34 |
$3,048.34 |
$3,048.34 |
$933.59
|
|
Ethylene glycol -sendout
|
$15.18 |
$15.18 |
$15.18 |
$78.00
|
|
Etoposide 50 mg cap
|
$1,077.21 |
$1,077.21 |
$1,077.21 |
$203.41
|
|
Euglobulin lysis
|
$56.70 |
$56.70 |
$56.70 |
$37.70
|
|
Evaluation heart device
|
$25,748.10 |
$25,748.10 |
$25,748.10 |
$2,523.52
|
|
Evaluation psychiatric diagnostic
|
$1,077.26 |
$1,077.26 |
$1,077.26 |
$324.00
|
|
Evoked oa emissions ltd
|
$293.11 |
$293.11 |
$293.11 |
$240.07
|
|
Evoked potentials upper limbs
|
$2,559.00 |
$2,559.00 |
$2,559.00 |
$908.54
|
|
External chromosome analysis 20-25 cells
|
$136.48 |
$136.48 |
$136.48 |
$389.35
|
|
F-18 fdg pet diag
|
$4,288.47 |
$4,288.47 |
$4,288.47 |
$609.85
|
|
Facial bones <3
|
$2,479.90 |
$2,479.90 |
$2,479.90 |
$241.75
|
|
Factor ix non-recombinant
|
$117.22 |
$117.22 |
$117.22 |
$1.41
|
|
Factor viii recombinant nos
|
$16.28 |
$16.28 |
$16.28 |
$4.80
|
|
Famotidine in ns IV syringe 0.4 mg/ml (neo/ped) - cnr
|
$28.88 |
$28.88 |
$28.88 |
$22.20
|
|
Fecal microbiota, live-jslm 150 ml rectal suspension enema
|
$783.23 |
$783.23 |
$783.23 |
$63.30
|
|
Feno poc
|
$473.15 |
$473.15 |
$473.15 |
$86.00
|
|
Ferritin
|
$415.15 |
$415.15 |
$415.15 |
$103.95
|
|
Fetal biophys profile w/nst 76818
|
$7,431.38 |
$7,431.38 |
$7,431.38 |
$541.74
|
|
Fetal chrom aneuploidy gsa panel
|
$795.00 |
$795.00 |
$795.00 |
$1,222.00
|
|
Fetal fibronectin
|
$1,963.09 |
$1,963.09 |
$1,963.09 |
$343.88
|
|
Fetal hemoglobin (kleihauer betke)
|
$60.50 |
$60.50 |
$60.50 |
$85.00
|
|
Fetal hemoglobin rosette
|
$1,230.54 |
$1,230.54 |
$1,230.54 |
$76.70
|
|
Fibrin degradation d dimer quantitative
|
$1,225.47 |
$1,225.47 |
$1,225.47 |
$111.68
|
|
Fibrin degrade semiquant
|
$1,019.17 |
$1,019.17 |
$1,019.17 |
$90.35
|
|
Fibrinolysins/coagulopathy screen interpretation/report
|
$85.14 |
$85.14 |
$85.14 |
$66.00
|
|
Fibrinolytic antiplasmin
|
$40.73 |
$40.73 |
$40.73 |
$58.25
|
|
Filtered speech hearing test
|
$72.19 |
$72.19 |
$72.19 |
$56.80
|
|
Flecainide (tambocor)-sendout
|
$12.22 |
$12.22 |
$12.22 |
$66.43
|
|
Flow cytometry marker each additional
|
$623.26 |
$623.26 |
$623.26 |
$103.00
|
|
Flow cytometry one marker technical component
|
$37.51 |
$37.51 |
$37.51 |
$298.04
|
|
Floxuridine injection
|
$2,057.23 |
$2,057.23 |
$2,057.23 |
$774.69
|
|
Fludarabine 50 mg intravenous solution
|
$2,570.19 |
$2,570.19 |
$2,570.19 |
$592.00
|
|
Fluoroguide for spine inject 77003-26
|
$839.05 |
$839.05 |
$839.05 |
$507.00
|
|
Fluoroguide needle placement
|
$3,696.09 |
$3,696.09 |
$3,696.09 |
$539.38
|
|
Fluoroscopy up to 1 hour
|
$558.45 |
$558.45 |
$558.45 |
$489.84
|
|
Fluorouracil 50 mg/ml intravenous solution (wrapper)
|
$48.14 |
$48.14 |
$48.14 |
$97.74
|
|
Follow-up angiography
|
$3,608.54 |
$3,608.54 |
$3,608.54 |
$1,875.00
|
|
Fomepizole 1 gram/ml intravenous solution
|
$5,337.21 |
$5,337.21 |
$5,337.21 |
$3,052.35
|
|
Forensic cytopathology
|
$4.23 |
$4.23 |
$4.23 |
$63.23
|
|
Fosaprepitant 150 mg intravenous powder for solution
|
$1,441.80 |
$1,441.80 |
$1,441.80 |
$470.29
|
|
Fosphenytoin 50 mg pe/ml injection (wrapper)
|
$1,160.27 |
$1,160.27 |
$1,160.27 |
$94.85
|
|
Fresh frozen plasma thawing ea un
|
$984.35 |
$984.35 |
$984.35 |
$131.25
|
|
Fructosamine glycated protein
|
$138.83 |
$138.83 |
$138.83 |
$64.20
|
|
Full mouth x-ray of teeth
|
$5,668.15 |
$5,668.15 |
$5,668.15 |
$267.78
|
|
Ga-67 gallium 0.1 mci
|
$2,501.99 |
$2,501.99 |
$2,501.99 |
$163.80
|
|
Gadopentetate dimeglumine 469.01 mg/ml (46.9 %) intravenous (wrapper)
|
$83.75 |
$83.75 |
$83.75 |
$144.98
|
|
Gamma glutamyltransferase
|
$327.70 |
$327.70 |
$327.70 |
$55.28
|
|
Ganciclovir in ns IV syringe 10 mg/ml (neo/ped) - cnr
|
$371.12 |
$371.12 |
$371.12 |
$221.64
|
|
Gastroesophageal reflux study
|
$5,318.52 |
$5,318.52 |
$5,318.52 |
$917.28
|
|
Gated heart multiple
|
$10,338.69 |
$10,338.69 |
$10,338.69 |
$1,368.90
|
|
Gemtuzumab ozogamicin 4.5 mg (1 mg/ml initial concentration) IV soln
|
$27,224.56 |
$27,224.56 |
$27,224.56 |
$21,306.71
|
|
General health panel
|
$1,419.23 |
$1,419.23 |
$1,419.23 |
$280.00
|
|
G-esoph reflx tst w/electrod
|
$3,184.18 |
$3,184.18 |
$3,184.18 |
$1,352.03
|
|
Ghs acetylcholinesterase, rbc
|
$9.50 |
$9.50 |
$9.50 |
$39.60
|
|
Ghs bleeding time (ivy)
|
$677.31 |
$677.31 |
$677.31 |
$55.90
|
|
Ghs community re-entry 15 minutes
|
$265.90 |
$265.90 |
$265.90 |
$87.60
|
|
Ghs flow volume loop
|
$822.94 |
$822.94 |
$822.94 |
$308.69
|
|
Ghs hcv amplificaiton
|
$54.57 |
$54.57 |
$54.57 |
$195.60
|
|
Ghs hepatitis c virus (hcv riba)
|
$75.00 |
$75.00 |
$75.00 |
$106.05
|
|
Ghs hgb stability-thal
|
$346.85 |
$346.85 |
$346.85 |
$85.28
|
|
Ghs histoplasma antigen
|
$75.00 |
$75.00 |
$75.00 |
$144.50
|
|
Ghs HIV antibody
|
$493.15 |
$493.15 |
$493.15 |
$94.25
|
|
Ghs leukocyte alkaline phos (mayo)
|
$10.00 |
$10.00 |
$10.00 |
$59.40
|
|
Ghs mbp
|
$14.00 |
$14.00 |
$14.00 |
$77.35
|
|
Ghs moderate sedation, > 5 yr, 30 min, other
|
$1,098.08 |
$1,098.08 |
$1,098.08 |
$229.60
|
|
Ghs moderate sedation ea addtl 15 min, other
|
$1,098.08 |
$1,098.08 |
$1,098.08 |
$140.00
|
|
Ghs musc test done w/n test comp
|
$263.79 |
$263.79 |
$263.79 |
$349.80
|
|
Ghs myocardial strain img spckl track
|
$2,156.22 |
$2,156.22 |
$2,156.22 |
$501.79
|
|
Ghs o2 saturation
|
$220.76 |
$220.76 |
$220.76 |
$72.45
|
|
Ghs ppd (tb intradermal)
|
$20.00 |
$20.00 |
$20.00 |
$43.45
|
|
Ghs prostatic acid phosphatase (mayo)
|
$7.00 |
$7.00 |
$7.00 |
$39.90
|
|
Ghs protoporphyrins fract
|
$6.82 |
$6.82 |
$6.82 |
$64.35
|
|
Ghs quinidine
|
$11.57 |
$11.57 |
$11.57 |
$68.40
|
|
Ghs rsv eia (respir synctial vrs)
|
$592.90 |
$592.90 |
$592.90 |
$101.15
|
|
Ghs sedimentation rate
|
$987.79 |
$987.79 |
$987.79 |
$45.50
|
|
Ghs sensitivity (per antimicro)
|
$506.81 |
$506.81 |
$506.81 |
$59.90
|
|
Ghs sleep study unattended
|
$2,133.59 |
$2,133.59 |
$2,133.59 |
$503.38
|
|
Ghs somatosensory testing lower extremit
|
$2,559.00 |
$2,559.00 |
$2,559.00 |
$947.48
|
|
Ghs somatosensory testing upper & lower limbs
|
$4,014.88 |
$4,014.88 |
$4,014.88 |
$1,357.40
|
|
Ghs st - eval for alt comm
|
$72.19 |
$72.19 |
$72.19 |
$99.75
|
|
Ghs urine, hydroxproline total
|
$40.19 |
$40.19 |
$40.19 |
$61.60
|
|
Ghs urine, porphyrins quant
|
$5.18 |
$5.18 |
$5.18 |
$72.60
|
|
Giardia lamblia antibody
|
$43.00 |
$43.00 |
$43.00 |
$81.60
|
|
Gi inhouse confirmation
|
$985.18 |
$985.18 |
$985.18 |
$83.85
|
|
Gi tract capsule endoscopy (pillcam) 91110
|
$9,696.31 |
$9,696.31 |
$9,696.31 |
$2,418.92
|
|
Glucagon 1 mg solution for injection
|
$903.36 |
$903.36 |
$903.36 |
$592.05
|
|
Glucose blood quantitative
|
$150.78 |
$150.78 |
$150.78 |
$44.76
|
|
Glucose body fluid
|
$150.78 |
$150.78 |
$150.78 |
$50.70
|
|
Glucose tolerance test (gtt) >3 specimens each additional
|
$293.06 |
$293.06 |
$293.06 |
$33.57
|
|
Graft apligraf 3in 44sqcm-q4101-cost per sq cm
|
$5,982.20 |
$5,982.20 |
$5,982.20 |
$63.51
|
|
Graft jckt xpress 2ml flowable scaffold-q4113-cost per sq cm
|
$5,667.55 |
$5,667.55 |
$5,667.55 |
$2,274.83
|
|
Granisetron 1 mg tab
|
$775.95 |
$775.95 |
$775.95 |
$10.04
|
|
Granisetron hcl injection
|
$466.21 |
$466.21 |
$466.21 |
$40.33
|
|
Gu dilat ureter/urethra s&i
|
$487.06 |
$487.06 |
$487.06 |
$1,712.25
|
