| Breast lesion removal (open) (19120) |
— |
$8,942.65 |
— |
| Shoulder arthroscopy with decompression (29826) |
— |
$13,312.70 |
— |
| Knee arthroscopy with meniscectomy (29881) |
— |
$8,942.65 |
— |
| Tonsillectomy and adenoidectomy (under age 12) (42820) |
— |
$8,942.65 |
— |
| Upper GI endoscopy (EGD), diagnostic (43235) |
— |
$2,373.10 |
— |
| Upper GI endoscopy (EGD) with biopsy (43239) |
— |
$2,373.10 |
— |
| Diagnostic colonoscopy (45378) |
— |
$2,373.10 |
— |
| Colonoscopy with biopsy (45380) |
— |
$2,373.10 |
— |
| Colonoscopy with lesion removal (45385) |
— |
$2,373.10 |
— |
| Colonoscopy with endoscopic ultrasound (45391) |
— |
$2,373.10 |
— |
| Laparoscopic gallbladder removal (47562) |
— |
$13,312.70 |
— |
| Inguinal hernia repair (age 5+) (49505) |
— |
$13,312.70 |
— |
Epidural injection, lumbar/sacral (with imaging) (62322)
range across 2 matching MRF lines |
— |
$1,274.60–$2,373.10 |
— |
Transforaminal epidural injection, lumbar/sacral (64483)
range across 13 matching MRF lines |
— |
$644.83–$8,682.20 |
— |
| CT head/brain without contrast (70450) |
— |
$1,671.60 |
— |
| MRI brain without contrast (70551) |
— |
$3,776.15 |
— |
| MRI brain with contrast (70552) |
— |
$4,331.80 |
— |
| MRI brain without and with contrast (70553) |
— |
$5,600.60 |
— |
| X-ray lower spine, 4+ views (72110) |
— |
$554.50 |
— |
| MRI lumbar spine without contrast (72148) |
— |
$4,007.70 |
— |
| CT pelvis with contrast (72193) |
— |
$2,163.55 |
— |
MRI lower-extremity joint without contrast (73721)
range across 5 matching MRF lines |
— |
$2,708.85–$5,086.60 |
— |
| CT abdomen and pelvis with contrast (74177) |
— |
$3,948.65 |
— |
| Ultrasound, abdomen complete (76700) |
— |
$762.85 |
— |
| Ultrasound, pregnant uterus (≥14 weeks) (76805) |
— |
$762.85 |
— |
Ultrasound, transvaginal (76830)
range across 6 matching MRF lines |
— |
$762.85–$1,525.70 |
— |
| Mammography, one breast (diagnostic) (77065) |
— |
$402.80 |
— |
| Mammography, both breasts (diagnostic) (77066) |
— |
$512.80 |
— |
| Mammography, screening (bilateral) (77067) |
— |
$412.25 |
— |
| Basic metabolic panel (80048) |
— |
$107.80 |
— |
| Comprehensive metabolic panel (80053) |
— |
$125.75 |
— |
| Obstetric panel (80055) |
— |
$358.85 |
— |
| Lipid panel (80061) |
— |
$143.70 |
— |
| Renal function panel (80069) |
— |
$134.70 |
— |
| Hepatic function panel (80076) |
— |
$112.25 |
— |
| Urinalysis, non-automated, with microscopy (81000) |
— |
$50.30 |
— |
| Urinalysis, non-automated, without microscopy (81002) |
— |
$39.35 |
— |
| PSA, total (84153) |
— |
$172.65 |
— |
| Thyroid stimulating hormone (TSH) (84443) |
— |
$143.85 |
— |
| CBC with automated differential (85025) |
— |
$90.60 |
— |
| CBC, automated (85027) |
— |
$85.75 |
— |
| Prothrombin time (PT) (85610) |
— |
$58.75 |
— |
| Partial thromboplastin time (PTT) (85730) |
— |
$83.20 |
— |
| Sleep study (attended polysomnography) (95810) |
— |
$5,464 |
— |
| Physical therapy, therapeutic exercise (per 15 min) (97110) |
— |
$99.95 |
— |