Attachment9PriceMatrix13Feb18.xlsx
XLSX spreadsheet 145 KB Posted
- Attached to
- MEPCOM Referral Services Federal contract opportunity
- Solicitation number
- W81K04-18-R-0006
- Issued by
- Department of the Army Medical Command
About this file
Attachment 9-Medical Referral Price Matrix
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| W81K0418R00060003-15_Mar_18.pdf | ||
| W81K0418R00060003_Atch1Question_and_Answer-14_Mar_18.pdf | ||
| Attachment_12-Consults_Order_History-8_Mar_18.pdf | ||
| Attachment_11_Processing_Times-8_Mar_18.xlsx | XLSX spreadsheet | |
| W81K0418R00020002_Atch1Question_and_Answer-8_Mar_18.pdf | ||
| W81K0418R00020002-Amendment-8_Mar_18.pdf | ||
| W81K04-18-R-0006_0001.pdf | ||
| Exhibit_E_Standard_Form_513.pdf | ||
| Attachment10SubcontractingPlanChecklist.doc | DOC document | |
| Exhibit_D_DD_Form_1966.pdf | ||
| Exhibit_A_MEPS_LocationsMAP.pptx | PPTX presentation | |
| Attachment5PerformanceAssessmentInformation.xlsx | XLSX spreadsheet | |
| Exhibit_H_Flowchart.pdf | ||
| Exhibit_F_FY18OperatingSchedule.pdf | ||
| W81K0418R0006-21_Feb_18.pdf |
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Text version
Instructions
INSTRUCTIONS FOR COMPLETING PRICE MATRIX SPREADSHEET
1. Ancillary Offerors shall propose a "Price Per Service" for all Ancillary Services listed in each tab of this spreadsheet for all ordering periods. Once the offeror inputs their price for each Ancillary Service, the spreadsheet will automatically sum the total based on the "Price Per Service" multiplied by "Estimated Quantity".
2. Laboratory Offerors shall propose a "Price Per Service" rate for all Laboratory Services listed in each tab of this spreadsheet for all ordering periods. Once the offeror inputs their price for each Laboratory Service, the spreadsheet will automatically sum the total based on the "Price Per Service" multiplied by "Estimated Quantity".
3. Medical Consultations Offerors shall propose a "Price Per Consultation" rate for all Medical Consultations listed in each tab of this spreadsheet for all ordering periods. Once the offeror inputs their price for each Medical Consultation, the spreadsheet will automatically sum the total based on the "Price Per Service" multiplied by "Estimated Quantity".
4. Dental Consultations Offerors shall propose a "Price Per Consultation" rate for all Dental Consultations listed in each tab of this spreadsheet for all ordering periods. Once the offeror inputs their price for each Dental Consultation, the spreadsheet will automatically sum the total based on the "Price Per Service" multiplied by "Estimated Quantity".
5. No Show/Cancellation Fee Offerors shall propose a Price per No Show or Cancelled Appointment. Once the offeror inputs their price for each No Show or Cancelled appointment for all ordering periods, the spreadsheet will automatically sum the total based on the "Price Per Service" multiplied by "Estimated Quantity".
6. Contractor Manpower Report There is a requirement for a Contractor Manpower Report. This report is due at the end of each period of performance. Although it is listed on spreadsheet, the offeror shall not include a price. In CLIN 0006 it will be listed as a Not Separately Priced.
| 7. Summary Tab |
| The Summary Tab is comprised of the totals from each type of service/consultation in each "Ordering Period" tab. As such, when the offeror inputs its prices into the required cell for each service/consultation in each "Ordering Period" tab the total for that ordering period will populate in the "Summary" tab to calculate the "Total for All Ordering Periods". |
| 8. Document Protection. |
Certain columns in this spreadsheet are password protected to maintain the values and embedded formulas. Offerors shall return this document intact. Do not attempt to unlock cells or change values or formulas in this document.
1st Ordering Period
| ANCILLARY SERVICES | CPT | QTY | PRICE PER SERVICE | TOTAL PRICE | |
| 10022 - Fine needle aspiration; with imaging guidance | 10022 | 10 | $0.00 | $0.00 | |
| 11100 - Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion | 11100 | 10 | $0.00 | $0.00 | |
| 11101 - Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure) | 11101 | 2 | $0.00 | $0.00 | |
| 31231 - Nasal Endoscopy, Diagnostic, Unilateral Or Bilateral (Separate Procedure) | 31231 | 10 | $0.00 | $0.00 | |
| 31505 - Laryngoscopy, Diagnostic | 31505 | 10 | $0.00 | $0.00 | |
| 31575 - Laryngoscopy, Flexible Fiberoptic; Diagnostic | 31575 | 1 | $0.00 | $0.00 | 1 |
| 36000 - Introduction of needle or intracatheter, vein | 36000 | 1 | $0.00 | $0.00 | |
| 36415 - Venipuncture Fee | 36415 | 100 | $0.00 | $0.00 | |
| 51741 - Complex Uroflowmetry (Eg, Calibrated Electronic Equipment) | 51741 | 1 | $0.00 | $0.00 | |
| 51798 - Measurement Of Post-Voiding Residual Urine And/Or Bladder Capacity By Ultrasound, Non-Imaging | 51798 | 1 | $0.00 | $0.00 | |
| 52000 - Cystourethroscopy (separate procedure) | 52000 | 1 | $0.00 | $0.00 | |
| 69200 - Removal Foreign Body From External Auditory Canal; Without General Anesthesia | 69200 | 10 | $0.00 | $0.00 | |
| 69210 - Wax Removal | 69210 | 1500 | $0.00 | $0.00 | |
| 70160 - Radiologic Examination, Nasal Bones, Complete, Minimum Of 3 Views | 70160 | 1 | $0.00 | $0.00 | |
| 70210 - Radiologic Examination, Sinuses, Paranasal, Less Than 3 Views | 70210 | 1 | $0.00 | $0.00 | |
| 70220 - Radiologic Examination, Sinuses, Paranasal, Complete, Minimum Of 3 Views | 70220 | 1 | $0.00 | $0.00 | |
| 70260 - Radiologic Examination, Skull; Complete, Minimum Of 4 Views | 70260 | 1 | $0.00 | $0.00 | |
| 70310 - Radiologic examination, teeth; partial exam, less than full mouth | 70310 | 60 | $0.00 | $0.00 | |
| 70370 – Throat & Fluoroscopy | 70370 | 1 | $0.00 | $0.00 | |
| 70371 – Speech Evaluation, Complex | 70371 | 1 | $0.00 | $0.00 | |
| 70450 - CT Scan, Head/Brain, W/O Contrast, Global | 70450 | 1 | $0.00 | $0.00 | |
| 70460 - CT Scan, Head/Brain, With Contrast, Global | 70460 | 1 | $0.00 | $0.00 | |
| 70480 - CT Scan, Renal W/O Contrast | 70480 | 1 | $0.00 | $0.00 | |
| 70481 - CT Scan, Renal With Contrast | 70481 | 1 | $0.00 | $0.00 | |
| 70482 - Ct Scan, Middle/Inner Ear, Global | 70482 | 1 | $0.00 | $0.00 | |
| 70486 - Computed Tomography, Maxillofacial Area; Without Contrast Material | 70486 | 1 | $0.00 | $0.00 | |
| 70551 - MRI Head, W/O Contrast, Global | 70551 | 1 | $0.00 | $0.00 | |
| 70552 - MRI Head, With Contrast, Global | 70552 | 1 | $0.00 | $0.00 | |
| 70553 - Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem); Without Contrast Material, Followed By Contrast Material(S) And Further Sequences | 70553 | 1 | $0.00 | $0.00 | |
| 71010 – Chest X-Ray | 71010 | 1 | $0.00 | $0.00 | |
| 71020 - Radiologic Examination, Chest, 2 Views, Frontal And Lateral; | 71020 | 130 | $0.00 | $0.00 | |
| 71022 - Radiologic Examination, Chest, 2 Views, Frontal And Lateral; With Oblique Projections | 71022 | 15 | $0.00 | $0.00 | |
| 71023 – Chest X-Ray And Fluoroscopy | 71023 | 1 | $0.00 | $0.00 | |
| 71100 – X-Ray Exam Of Ribs | 71100 | 1 | $0.00 | $0.00 | |
| 71101 – X-Ray Exam Of Ribs/Chest | 71101 | 1 | $0.00 | $0.00 | |
| 71110 - Radiologic Examination, Ribs, Bilateral; 3 Views | 72110 | 80 | $0.00 | $0.00 | |
| 71111 – X-Ray Exam Of Ribs | 71111 | 1 | $0.00 | $0.00 | |
| 71120 – X-Ray Exam Of Breastbone | 71120 | 1 | $0.00 | $0.00 | |
| 71130 – X-Ray Exam Of Breastbone | 71130 | 1 | $0.00 | $0.00 | |
| 71250 - CT Scan, Chest, W/O Contrast, Global | 71250 | 1 | $0.00 | $0.00 | |
| 71275 - Computed tomographic angiography, chest (noncoronary), with contrast material, including noncontrast images, if performed, and image postprocessing | 71275 | 1 | $0.00 | $0.00 | |
| 72020 - Radiologic Examination, Spine, Single View, Specify Level | 72020 | 150 | $0.00 | $0.00 | |
| 72040 – X-Ray Exam Of Neck Spine | 72040 | 50 | $0.00 | $0.00 | |
| 72050 - Radiologic examination, spine, cervical; 4 or 5 views | 72050 | 30 | $0.00 | $0.00 | |
| 72052 - Radiologic Examination, Spine, Cervical; 6 Or More Views | 72052 | 1 | $0.00 | $0.00 | |
| 72070 - Radiologic Examination, Spine; Thoracic, 2 Views | 72070 | 60 | $0.00 | $0.00 | |
| 72072 - Radiologic Examination, Spine; Thoracic, 3 Views | 72072 | 1 | $0.00 | $0.00 | |
| 72074 -Radiologic Examination, Spine; Thoracic, Minimum Of 4 Views | 72074 | 35 | $0.00 | $0.00 | |
| 72080 – X-Ray Exam Of Trunk Spine | 72080 | 100 | $0.00 | $0.00 | |
| 72081 - Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view | 72081 | 40 | $0.00 | $0.00 | |
| 72082 - Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views | 72082 | 250 | $0.00 | $0.00 | |
| 72100 – X-Ray Exam Of Lower Spine | 72100 | 100 | $0.00 | $0.00 | |
| 72114 - Radiologic Examination, Spine, Lumbosacral; Complete, Including Bending Views, Minimum Of 6 Views | 72114 | 50 | $0.00 | $0.00 | |
| 72120 - Radiologic Examination, Spine, Lumbosacral; Bending Views Only, 2 Or 3 Views | 72120 | 1 | $0.00 | $0.00 | |
| 72125 - CT Scan, LS Spine, W/O Contrast, Global | 72125 | 1 | $0.00 | $0.00 | |
| 72131 - Computed tomography, lumbar spine; without contrast material | 72131 | 1 | $0.00 | $0.00 | |
| 72141 - MRI C/Spine, W/O Contrast, Global | 72141 | 3 | $0.00 | $0.00 | |
| 72142 - MRI C/Spine, With Contrast, Global | 72142 | 3 | $0.00 | $0.00 | |
| 72146 - MRI Extremity, W/O Contrast, Global | 72146 | 3 | $0.00 | $0.00 | |
| 72147 - MRI Extremity, With Contrast, Global | 72147 | 3 | $0.00 | $0.00 | |
| 72148 - MRI T-Spine, W/O Contrast, Global | 72148 | 3 | $0.00 | $0.00 | |
| 72149 - MRI T-Spine, With, Contrast, Global | 72149 | 3 | $0.00 | $0.00 | |
| 72170 – X-Ray Exam Of Pelvis | 72170 | 50 | $0.00 | $0.00 | |
| 72190 – X-Ray Exam Of Pelvis | 72190 | 40 | $0.00 | $0.00 | |
| 72192 - CT Scan, Pelvis, W/O Contrast, Global | 72192 | 8 | $0.00 | $0.00 | |
| 72195 - MRI Pelvis, W/O Contrast, Global | 72195 | 3 | $0.00 | $0.00 | |
| 72200 – X-Ray Exam Sacroiliac Joints | 72200 | 15 | $0.00 | $0.00 | |
| 72202 - X-Ray Exam Sacroiliac Joints | 72202 | 15 | $0.00 | $0.00 | |
| 72220 – X-Ray Exam Of Tailbone | 72220 | 15 | $0.00 | $0.00 | |
| 72240 – Contract X-Ray Of Neck Spine | 72240 | 15 | $0.00 | $0.00 | |
| 72255 – Contrast X-Ray, Thorax Spine | 72255 | 15 | $0.00 | $0.00 | |
| 72265 – Contract X-Ray, Lower Spine | 72265 | 15 | $0.00 | $0.00 | |
| 72270 – Contrast X-Ray Of Spine | 72270 | 15 | $0.00 | $0.00 | |
| 72285 – X-Ray C/T Spine Disk | 72285 | 15 | $0.00 | $0.00 | |
| 72295 – X-Ray Of Lower Spine Disk | 72295 | 15 | $0.00 | $0.00 | |
| 73000 – X-Ray Exam Of Collar Bone | 73000 | 75 | $0.00 | $0.00 | |
| 73010 – X-Ray Exam Of Shoulder Blade | 73010 | 30 | $0.00 | $0.00 | |
| 73020 – X-Ray Exam Of Shoulder | 73020 | 30 | $0.00 | $0.00 | |
| 73030 – X-Ray Exam Of Shoulder | 73030 | 450 | $0.00 | $0.00 | |
| 73040 – X-Ray Exam Of Shoulder | 73040 | 55 | $0.00 | $0.00 | |
| 73050 - Radiologic Examination; Acromioclavicular Joints, Bilateral, With Or Without Weighted Distraction | 73050 | 1 | $0.00 | $0.00 | |
| 73060 – X-Ray Exam Of Humerus | 73060 | 55 | $0.00 | $0.00 | |
| 73070 – X-Ray Exam Of Elbow | 73070 | 90 | $0.00 | $0.00 | |
| 73080 – X-Ray Exam Of Elbow | 73080 | 100 | $0.00 | $0.00 | |
| 73085 – Contrast X-Ray Of Elbow | 73085 | 15 | $0.00 | $0.00 | |
| 73090 – X-Ray Exam Of Forearm | 73090 | 70 | $0.00 | $0.00 | |
| 73100 – X-Ray Of Wrist 2 Views | 73100 | 70 | $0.00 | $0.00 | |
| 73110 – X-Ray Exam Of Wrist | 73110 | 100 | $0.00 | $0.00 | |
| 73115 – Contrast X-Ray Of Wrist | 73115 | 15 | $0.00 | $0.00 | |
| 73120 – X-Ray Exam Of Hand | 73120 | 30 | $0.00 | $0.00 | |
| 73130 – X-Ray Exam Of Hand | 73130 | 55 | $0.00 | $0.00 | |
| 73140 – X-Ray Exam Of Finder (S) | 73140 | 55 | $0.00 | $0.00 | |
| 73221 - MRI Shoulder, W/O Contrast, Global | 73221 | 3 | $0.00 | $0.00 | |
| 73501 - Radiologic examination, hip, unilateral, with pelvis when performed; 1 view | 73501 | 95 | $0.00 | $0.00 | |
| 73502 - Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views | 73502 | 30 | $0.00 | $0.00 | |
| 73503 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views | 73503 | 1 | $0.00 | $0.00 | |
| 73521 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views | 73521 | 30 | $0.00 | $0.00 | |
| 73522 - Radiologic examination, hip, unilateral, with pelvis when performed; 3-4 views | 73522 | 30 | $0.00 | $0.00 | |
| 73522 - Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views | 73552 | 30 | $0.00 | $0.00 | |
| 73523 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 5 views | 73523 | 15 | $0.00 | $0.00 | |
| 73525 – Contrast X-Ray Of Hip | 73525 | 30 | $0.00 | $0.00 | |
| 73551 - Radiologic examination, femur; 1 view | 73551 | 65 | $0.00 | $0.00 | |
| 73560 – X-Ray Exam Of Knee, 1 Or 2 | 73560 | 300 | $0.00 | $0.00 | |
| 73562 – X-Ray Exam Of Knee, 3 | 73562 | 350 | $0.00 | $0.00 | |
| 73564 – X-Ray Exam, Knee 4 Or More | 73564 | 225 | $0.00 | $0.00 | |
| 73565 – X-Ray Exam Of Knees | 73565 | 65 | $0.00 | $0.00 | |
| 73580 – Contrast X-Ray Of Knee Joint | 73580 | 1 | $0.00 | $0.00 | |
| 73590 – X-Ray Exam Of Lower Leg | 73590 | 100 | $0.00 | $0.00 | |
| 73600 – X-Ray Exam Of Ankle | 73600 | 150 | $0.00 | $0.00 | |
| 73610 – X-Ray Exam Of Ankle | 73610 | 300 | $0.00 | $0.00 | |
| 73615 – Contrast X-Ray Of Ankle | 73615 | 1 | $0.00 | $0.00 | |
| 73620 – X-Ray Exam Of Foot | 73620 | 150 | $0.00 | $0.00 | |
| 73630 – X-Ray Foot 2 Views | 73630 | 350 | $0.00 | $0.00 | |
| 73650 – X-Ray Exam Of Heel | 73650 | 40 | $0.00 | $0.00 | |
| 73660 – X-Ray Exam Of Toe (S) | 73660 | 40 | $0.00 | $0.00 | |
| 73700 - CT Scan, Lower Extremity, W/O Contrast, Global | 73700 | 1 | $0.00 | $0.00 | |
| 73721 - MRI Lower Extremity Joint, W/O Contrast, Global | 73721 | 3 | $0.00 | $0.00 | |
| 73723- Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences | 73723 | 3 | $0.00 | $0.00 | |
| 74000 – X-Ray Exam Of Abdomen | 74000 | 50 | $0.00 | $0.00 | |
| 74010 – X-Ray Exam Of Abdomen | 74010 | 1 | $0.00 | $0.00 | |
| 74020 – X-Ray Exam Of Abdomen | 74020 | 1 | $0.00 | $0.00 | |
| 74022 – X-Ray Exam Series, Abdomen | 74022 | 1 | $0.00 | $0.00 | |
| 74150 - CT Scan, Abdomen, With & W/O Contrast, Global | 74150 | 1 | $0.00 | $0.00 | |
| 74160 - Computed tomography, abdomen; with contrast material(s) | 74160 | 1 | $0.00 | $0.00 | |
| 74176 - Computed tomography, abdomen and pelvis; without contrast material | 74176 | 1 | $0.00 | $0.00 | |
| 74178 - Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(S) And Further Sections In One Or Both Body Regions | 74178 | 1 | $0.00 | $0.00 | |
| 74190 – X-Ray Exam Or Peritoneum | 74190 | 1 | $0.00 | $0.00 | |
| 74210 – Contrast X-Ray Exam Of Throat | 74210 | 1 | $0.00 | $0.00 | |
| 74220 – Contrast X-Ray, Esophagus | 74220 | 1 | $0.00 | $0.00 | |
| 74240 – X-Ray Exam, Upper Gi Tract | 74240 | 1 | $0.00 | $0.00 | |
| 74241 – X-Ray Exam, Upper Gi Tract | 74241 | 1 | $0.00 | $0.00 | |
| 74245 – X-Ray Exam, Upper Gi Tract | 74245 | 1 | $0.00 | $0.00 | |
| 74246 – Contrast X-Ray Upper Gi Tract | 74246 | 1 | $0.00 | $0.00 | |
| 74247 – Contrast X-Ray Upper Gi Tract | 74247 | 1 | $0.00 | $0.00 | |
| 74249 – Contrast X-Ray Upper Gi Tract | 74249 | 1 | $0.00 | $0.00 | |
| 74250 – X-Ray Exam Of Small Bowel | 74250 | 1 | $0.00 | $0.00 | |
| 74251 – X-Ray Exam Of Small Bowel | 74251 | 1 | $0.00 | $0.00 | |
| 74260 – X-Ray Exam Of Small Bowel | 74260 | 1 | $0.00 | $0.00 | |
| 74270 – Contrast X-Ray Exam Of Colon | 74270 | 1 | $0.00 | $0.00 | |
| 74280 – Contrast X-Ray Exam Of Colon | 74280 | 1 | $0.00 | $0.00 | |
| 74283 – Contrast X-Ray Exam Of Colon | 74283 | 1 | $0.00 | $0.00 | |
| 74290– Contrast X-Ray, Gallbladder | 74290 | 1 | $0.00 | $0.00 | |
| 74300 – X-Ray Bile Ducts/Pancreas | 74300 | 1 | $0.00 | $0.00 | |
| 74328 – X-Ray Bile Duct Endoscopy | 74328 | 1 | $0.00 | $0.00 | |
| 74329 – X-Ray For Pancreas Endoscopy | 74329 | 1 | $0.00 | $0.00 | |
| 74330 – X-Ray Bile/Pancreas Endoscopy | 74330 | 1 | $0.00 | $0.00 | |
| 74340 – X-Ray Guide For GI Tube | 74340 | 1 | $0.00 | $0.00 | |
| 74355 – X-Ray Guide, Intestinal Tube | 74355 | 1 | $0.00 | $0.00 | |
| 74360 – X-Ray Guide, Gi Dilation | 74360 | 1 | $0.00 | $0.00 | |
| 74363 – X-Ray, Bile Duct Dilation | 74363 | 1 | $0.00 | $0.00 | |
| 74400 – Contrast X-Ray, Urinary Tract | 74400 | 1 | $0.00 | $0.00 | |
| 74410 - Contrast X-Ray, Urinary Tract | 74410 | 1 | $0.00 | $0.00 | |
| 74415 - Contrast X-Ray, Urinary Tract | 74415 | 1 | $0.00 | $0.00 | |
| 74420 - Contrast X-Ray, Urinary Tract | 74420 | 1 | $0.00 | $0.00 | |
| 74425 - Contrast X-Ray, Urinary Tract | 74425 | 1 | $0.00 | $0.00 | |
| 74430 – Contrast X-Ray, Bladder | 74430 | 1 | $0.00 | $0.00 | |
| 74440 – X-Ray, Male Genital Tract | 74440 | 1 | $0.00 | $0.00 | |
| 74445 – X-Ray Exam Of Penis | 74445 | 1 | $0.00 | $0.00 | |
| 74450 – X-Ray, Urethra/Bladder | 74450 | 1 | $0.00 | $0.00 | |
| 74455 – X-Ray, Urethra/Bladder | 74455 | 1 | $0.00 | $0.00 | |
| 74470 – X-Ray Exam Of Kidney Lesion | 74470 | 1 | $0.00 | $0.00 | |
| 74485 – X-Ray Guide, Gu Dilation | 74485 | 1 | $0.00 | $0.00 | |
| 74740 – X-Ray, Female Genital Tract | 74740 | 1 | $0.00 | $0.00 | |
| 74742 – X-Ray, Fallopian Tube | 74742 | 1 | $0.00 | $0.00 | |
| 76511 - Ophthalmic Ultrasound, Diagnostic; Quantitative A-Scan Only | 76511 | 1 | $0.00 | $0.00 | |
| 76514 - Ophthalmic Ultrasound, Diagnostic; Corneal Pachymetry, Unilateral Or Bilateral (Determination Of Corneal Thickness) | 76514 | 1 | $0.00 | $0.00 | |
| 76536 - Ultrasound, Head, Global | 76536 | 24 | $0.00 | $0.00 | |
| 76604 - Ultrasound, Chest, Global | 76604 | 1 | $0.00 | $0.00 | |
| 76641 - Ultrasound, breast, unilateral, real time with image documentation, including axilla whn performed; complete | 76641 | 40 | $0.00 | $0.00 | |
| 76700 - Ultrasound, Abdomen, Global | 76700 | 30 | $0.00 | $0.00 | |
| 76705 - Ultrasound, Abdominal, Real Time With Image Documentation; Limited (Eg, Single Organ, Quadrant, Follow-Up) | 76705 | 15 | $0.00 | $0.00 | |
| 76770 - Ultrasound, Kidney(Renal), Global | 76770 | 25 | $0.00 | $0.00 | |
| 76775 - Ultrasound, Retroperitoneal (Eg, Renal, Aorta, Nodes), Real Time With Image Documentation; Limited | 76775 | 15 | $0.00 | $0.00 | |
| 76800 - Ultrasound, Spinal Canal, Global | 76800 | 1 | $0.00 | $0.00 | |
| 76830 - Ultrasound, Ovaries, Global | 76830 | 1 | $0.00 | $0.00 | |
| 76856 - Ultrasound, Pelvic (Nonobstetric), Global | 76856 | 1 | $0.00 | $0.00 | |
| 76870 - Ultrasound, Scrotum, Global | 76870 | 250 | $0.00 | $0.00 | |
| 76872 - Ultrasound, tranrectal | 76872 | 1 | $0.00 | $0.00 | |
| 76881 - Ultrasound, Extremities, Global | 76881 | 1 | $0.00 | $0.00 | |
| 77051 - Mammogram, Digital, Bilateral, Global | 77051 | 1 | $0.00 | $0.00 | |
| 77052 - Computer-Aided Detection (Computer Algorithm Analysis Of Digital Image Data For Lesion Detection) With Further Review For Interpretation, With Or Without Digitization Of Film Radiographic Images; Screening Mammography (List Separately In Addition To Code For Primary Procedure) | 77052 | 1 | $0.00 | $0.00 | |
| 77056 - Mammogram, Conventional, Bilateral, (Global) | 77056 | 25 | $0.00 | $0.00 | |
| 77057 - Screening Mammography, Bilateral (2-View Film Study Of Each Breast) | 77057 | 1 | $0.00 | $0.00 | |
| 78708 - Kidney Imaging Morphology; With Vascular Flow And Function, Single Study, With Pharmacological Intervention (Eg, Angiotensin Converting Enzyme Inhibitor And/Or Diuretic) | 78708 | 1 | $0.00 | $0.00 | |
| 91065 - Hydrogen Breath Test | 91065 | 20 | $0.00 | $0.00 | |
| 92015 - Refraction Test | 92015 | 8000 | $0.00 | $0.00 | |
| 92025 - Corneal Topography Test | 92025 | 6750 | $0.00 | $0.00 | |
| 92060 - Sensorimotor Examination With Multiple Measurements Of Ocular Deviation (Eg, Restrictive Or Paretic Muscle With Diplopia) With Interpretation And Report (Separate Procedure) | 92060 | 10 | $0.00 | $0.00 | |
| 92081 - Visual Field Testing (Automated Perimeter) | 92081 | 50 | $0.00 | $0.00 | |
| 92082 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report; Intermediate Examination (Eg, At Least 2 Isopters On Goldmann Perimeter, Or Semiquantitative, Automated Suprathreshold Screening Program, Humphrey Suprathreshold Automatic Diagnostic Test, Octopus Program 33) | 92082 | 125 | $0.00 | $0.00 | |
| 92083 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report | 92083 | 460 | $0.00 | $0.00 | |
| 92100 - Contact Tonometry | 92100 | 50 | $0.00 | $0.00 | |
| 92132 - Scanning Computerized Ophthalmic Diagnostic Imaging, Anterior Segment, With Interpretation And Report, Unilateral Or Bilateral | 92132 | 25 | $0.00 | $0.00 | |
| 92133 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Optic Nerve | 92133 | 40 | $0.00 | $0.00 | |
| 92134 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Retina | 92134 | 30 | $0.00 | $0.00 | |
| 92225 - Ophthalmoscopy, Extended, With Retinal Drawing (Eg, For Retinal Detachment, Melanoma), With Interpretation And Report; Initial | 92225 | 550 | $0.00 | $0.00 | |
| 92235 - Fluorescein angiography (includes multiframe imaging) with interpretation and report | 92235 | 10 | $0.00 | $0.00 | |
| 92250 - Fundus Photography With Interpretation And Report | 92250 | 60 | $0.00 | $0.00 | |
| 92275 - Electroretinography With Interpretation And Report | 92275 | 1 | $0.00 | $0.00 | |
| 92283 - Color Vision Examination, Extended, Eg, Anomaloscope Or Equivalent | 92283 | 1 | $0.00 | $0.00 | |
| 92285 - External Ocular Photography With Interpretation And Report For Documentation Of Medical Progress (Eg, Close-Up Photography, Slit Lamp Photography, Goniophotography, Stereo-Photography) | 92285 | 30 | $0.00 | $0.00 | |
| 92285 - Stereoscopic | 92285 | 175 | $0.00 | $0.00 | |
| 92286 - Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell analysis | 92286 | 10 | $0.00 | $0.00 | |
| 92504 - Binocular Ear Test | 92504 | 20 | $0.00 | $0.00 | |
| 92504 - Binocular Microscopy (Separate Diagnostic Procedure) | 92504 | 15 | $0.00 | $0.00 | |
| 92550 - Tympanometry And Reflex Threshold Measurements | 92550 | 30 | $0.00 | $0.00 | |
| 92552 - Pure Tone Audiometry (Threshold); Air Only | 92552 | 30 | $0.00 | $0.00 | |
| 92553 - Audiogram W/Air & Bone Conduction | 92553 | 150 | $0.00 | $0.00 | |
| 92555 - Speech Audiometry Threshold; | 92555 | 10 | $0.00 | $0.00 | |
| 92556 - Speech Audiometry Threshold; With Speech Recognition | 92556 | 50 | $0.00 | $0.00 | |
| 92557 - Audiogram W/Speech Reception Threshold | 92557 | 120 | $0.00 | $0.00 | |
| 92567 - Tympanometry (Impedance Testing) | 92567 | 100 | $0.00 | $0.00 | |
| 92571 - Filtered Speech Test | 92571 | 30 | $0.00 | $0.00 | |
| 92577 - Stenger Test, Speech | 92577 | 1 | $0.00 | $0.00 | |
| 92587 - Distortion Product Evoked Otoacoustic Emissions; Limited Evaluation (To Confirm The Presence Or Absence Of Hearing Disorder, 3-6 Frequencies) Or Transient Evoked Otoacoustic Emissions, With Interpretation And Report | 92587 | 1 | $0.00 | $0.00 | |
| 93000 - Ecg – Complete, 12-Lead | 93000 | 900 | $0.00 | $0.00 | |
| 93005 - Electrocardiogram, Routine Ecg With At Least 12 Leads; Tracing Only, Without Interpretation And Report | 93005 | 25 | $0.00 | $0.00 | |
| 93010 - Electrocardiogram, Routine Ecg With At Least 12 Leads; Interpretation And Report Only | 93010 | 30 | $0.00 | $0.00 | |
| 93015 - Stress Test | 93015 | 250 | $0.00 | $0.00 | |
| 93016 - Cardiovascular Stress Test Using Maximal Or Submaximal Treadmill Or Bicycle Exercise, Continuous Electrocardiographic Monitoring, And/Or Pharmacological Stress; Supervision Only, Without Interpretation And Report | 93016 | 10 | $0.00 | $0.00 | |
| 93017 - Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report | 93017 | 10 | $0.00 | $0.00 | |
| 93018 - Cardiovascular Stress Test Using Maximal Or Submaximal Treadmill Or Bicycle Exercise, Continuous Electrocardiographic Monitoring, And/Or Pharmacological Stress; Interpretation And Report Only | 93018 | 35 | $0.00 | $0.00 | |
| 93224 - External Electrocardiographic Recording Up To 48 Hours By Continuous Rhythm Recording And Storage; Includes Recording, Scanning Analysis With Report, Review And Interpretation By A Physician Or Other Qualified Health Care Professional | 93224 | 30 | $0.00 | $0.00 | |
| 93306 - Echocardiogram (2D-M/Mode W/Color), Global | 93306 | 325 | $0.00 | $0.00 | |
| 93307 - EEG, Echocardiogram (2D-M/Mode Doppler W/O Color) | 93307 | 50 | $0.00 | $0.00 | |
| 93320 - Doppler Echocardiography, Pulsed Wave And/Or Continuous Wave With Spectral Display (List Separately In Addition To Codes For Echocardiographic Imaging); Complete | 93320 | 1 | $0.00 | $0.00 | |
| 93325 - Doppler Echocardiography Color Flow Velocity Mapping (List Separately In Addition To Codes For Echocardiography) | 93325 | 10 | $0.00 | $0.00 | |
| 93350 - Stress Echocardiogram | 93350 | 35 | $0.00 | $0.00 | |
| 93351 - Echocardiography, Transthoracic, Real-Time With Image Documentation (2d), | 93351 | 8 | $0.00 | $0.00 | |
| 93880 - Duplex scan of extracranial arteries; complete bilateral study | 93880 | 25 | $0.00 | $0.00 | |
| 93888 - Transcranial Doppler Study Of The Intracranial Arteries; Limited Study | 93880 | 10 | $0.00 | $0.00 | |
| 93965 - Doppler Vascular Study, Upper Or Lower Extremities Multiple | 93965 | 24 | $0.00 | $0.00 | |
| 93970 - Duplex Doppler Scan, Upper Or Lower Extremities | 93970 | 24 | $0.00 | $0.00 | |
| 93975 - Duplex Scan Of Arterial Inflow And Venous Outflow Of Abdominal, Pelvic, Scrotal Contents And/Or Retroperitoneal Organs; Complete Study | 93975 | 10 | $0.00 | $0.00 | |
| 93976 - Urology | 93976 | 35 | $0.00 | $0.00 | |
| 94010 - Pft – Pre/Post Bronchodilator, Global | 94010 | 175 | $0.00 | $0.00 | |
| 94060 - Bronchodilation Responsiveness, Spirometry As In 94010, Pre- And Post-Bronchodilator Administration | 94060 | 500 | $0.00 | $0.00 | |
| 94070 - Bronchospasm Provocation Evaluation, Multiple Spirometric Determinations As In 94010, With Administered Agents (Eg, Antigen[S], Cold Air, Methacholine) | 94070 | 70 | $0.00 | $0.00 | |
| 94620 - Pft – Pre/Post Exercise, Global | 94620 | 90 | $0.00 | $0.00 | |
| 94664 - Demonstration and/or evaluation of patient utilizatoin of an aerosol generator, nebulizer, metered dose inhaler or IPPB device | 94664 | 15 | $0.00 | $0.00 | |
| 94726: -Plethysmography For Determination Of Lung Volumes And, When Performed, Airway Resistance | 94726 | 40 | $0.00 | $0.00 | |
| 94727 - Gas Dilution Or Washout For Determination Of Lung Volumes And, When Performed, Distribution Of Ventilation And Closing Volumes | 94727 | 40 | $0.00 | $0.00 | |
| 94729 - Diffusing Capacity (Eg, Carbon Monoxide, Membrane) (List Separately In Addition To Code For Primary Procedure) | 94729 | 50 | $0.00 | $0.00 | |
| 95004 - Allergy Test | 95004 | 150 | $0.00 | $0.00 | |
| 95017 - Allergy Testing, Any Combination Of Percutaneous (Scratch, Puncture, Prick) And Intracutaneous (Intradermal), Sequential And Incremental, With Venoms, Immediate Type Reaction, Including Test Interpretation And Report, Specify Number Of Tests | 95017 | 40 | $0.00 | $0.00 | |
| 95018 - Allergy Testing, Any Combination Of Percutaneous (Scratch, Puncture, Prick) And Intracutaneous (Intradermal), Sequential And Incremental, With Drugs Or Biologicals, Immediate Type Reaction, Including Test Interpretation And Report, Specify Number Of Tests | 95018 | 40 | $0.00 | $0.00 | |
| 95024 - Intracutaneous (Intradermal) Tests With Allergenic Extracts, Immediate Type Reaction, Including Test Interpretation And Report, Specify Number Of Tests | 95024 | 35 | $0.00 | $0.00 | |
| 95044 - Patch Or Application Test(S) (Specify Number Of Tests) | 95044 | 20 | $0.00 | $0.00 | |
| 95070 - Pft – Methacholine Challenge, Global | 95070 | 150 | $0.00 | $0.00 | |
| 95076 - Ingestion Challenge Test (Sequential And Incremental Ingestion Of Test Items, Eg, Food, Drug Or Other Substance); Initial 120 Minutes Of Testing | 95076 | 35 | $0.00 | $0.00 | |
| 95134 - Venom Test Battery – All 5 Venom Tests | 95134 | 20 | $0.00 | $0.00 | |
| 95805 - Sleep Studies | 95805 | 3 | $0.00 | $0.00 | |
| 95812 - Eeg, Interpretation | 95812 | 20 | $0.00 | $0.00 | |
| 95816 - EEG, Resting, Complete | 95816 | 70 | $0.00 | $0.00 | |
| 95819 - Electroencephalogram (Eeg); Including Recording Awake And Asleep | 95819 | 30 | $0.00 | $0.00 | |
| 95886 - Needle Electromyography, Each Extremity, With Related Paraspinal Areas, When Performed | 95886 | 1 | $0.00 | $0.00 | |
| 95908 - Nerve Conduction Studies; 3-4 Studies | 95908 | 1 | $0.00 | $0.00 | |
| 95909 - Nerve Conduction Studies; 5-6 Studies | 95909 | 1 | $0.00 | $0.00 | |
| 96101 - Psychological Testing (Includes Psychodiagnostic Assessment Of Emotionality, Intellectual Abilities | 96101 | 300 | $0.00 | $0.00 | |
| 96374 - Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug | 96374 | 10 | $0.00 | $0.00 | |
| 97750 - Physical Performance Test Or Measurement (Eg, Musculoskeletal, Functional Capacity), With Written Report, Each 15 Minutes | 97750 | 20 | $0.00 | $0.00 | |
| J7674 - Methacholine Chloride Administered As Inhalation Solution Through A Nebulizer, Per 1 Mg | J7674 | 400 | $0.00 | $0.00 | |
| Q0091 - Screening Papanicolaou Smear; Obtaining, Preparing And Conveyance Of Cervical Or Vaginal Smear To Laboratory | Q0091 | 10 | $0.00 | $0.00 | |
| TOTAL PRICE FOR ANCILLARY SERVICES | 28462 | $0.00 |
| LABORATORY SERVICES | CPT | QTY | PRICE PER SERVICE | TOTAL PRICE |
| 80048 - Basic Metabolic Panel (Calicum, Total) | 80048 | 1100 | $0.00 | $0.00 |
| 80053 - Comprehensive Metabolic Panel This Panel Must Include The Following: Albumin (82040) Bilirubin, Total (82247) Calcium, Total (82310) Carbon Dioxide (Bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, Alkaline (84075) Potassium (84132) Protein, Total (84155) Sodium (84295) Transferase, Alanine Amino (Alt) (Sgpt) (84460) Transferase, Aspartate Amino (Ast) (Sgot) (84450) Urea Nitrogen (Bun) (84520) | 80053 | 10 | $0.00 | $0.00 |
| 80061 - Lipid, Pnl W/Rfl Dldl | 80061 | 700 | $0.00 | $0.00 |
| 80076 - Hepatic Func Pnl | 80076 | 150 | $0.00 | $0.00 |
| 81000 - Urinalysis, By Dip Stick Or Tablet Reagent For Bilirubin, | 81000 | 125 | $0.00 | $0.00 |
| 81001 - Urinalysis, By Dip Stick Or Tablet Reagent For Bilirubin, | 81001 | 400 | $0.00 | $0.00 |
| 81002 - Urinalysis, By Dip Stick Or Tablet Reagent For Bilirubin, Glucose, Hemoglobin, Ketones, Leukocytes, Nitrite, Ph, Protein, Specific Gravity, Urobilinogen, Any Number Of These Constituents; Non-Automated, Without Microscopy | 81002 | 50 | $0.00 | $0.00 |
| 81003 - Glucose, Urine, Qaulitative | 81003 | 200 | $0.00 | $0.00 |
| 81015 - Urinalysis; Microscopic Only | 81015 | 175 | $0.00 | $0.00 |
| 82105 – Alpha-Fetoprotein (Afp); Serum | 82105 | 75 | $0.00 | $0.00 |
| 82270 - Occult Blood Feces 3 | 82270 | 150 | $0.00 | $0.00 |
| 82465 - Cholesterol | 82465 | 2300 | $0.00 | $0.00 |
| 82530 – Cortisol; Free | 82530 | 50 | $0.00 | $0.00 |
| 82533 – Cortisol Total | 82533 | 50 | $0.00 | $0.00 |
| 82565 - Creatinine | 82565 | 175 | $0.00 | $0.00 |
| 82570 - Creatinine, Random Urine | 82570 | 400 | $0.00 | $0.00 |
| 82575 – Creatinine Clearance | 82575 | 170 | $0.00 | $0.00 |
| 82670 - Estradiol | 82670 | 5 | $0.00 | $0.00 |
| 82947 - Glucose | 82947 | 400 | $0.00 | $0.00 |
| 82951 - Glucose, Tolerance Test, 2 Specimen | 82951 | 300 | $0.00 | $0.00 |
| 82955 - Glucose-6-Phosphate Dehydrogenase (G-6-Pd), Blood | 82955 | 150 | $0.00 | $0.00 |
| 82977 - GTT, Each Additional Beyond 3 Specimens | 82977 | 375 | $0.00 | $0.00 |
| 82985 - A-1-1 Glycoprotein | 82985 | 100 | $0.00 | $0.00 |
| 83001 - Gonadotropin; follicle stimulating hormone (FSH) | 83001 | 0 | $0.00 | $0.00 |
| 83002 - Lh (Luteinizing Hormone) | 83002 | 80 | $0.00 | $0.00 |
| 83036 - Glycoslated (A1c) | 83036 | 100 | $0.00 | $0.00 |
| 83050 - Hemoglobin A1c | 83050 | 150 | $0.00 | $0.00 |
| 83690 - Lipase | 83690 | 150 | $0.00 | $0.00 |
| 83718 - Hdl Cholesterol | 83718 | 2300 | $0.00 | $0.00 |
| 83721 Cholesterol, Direct Ldl | 83721 | 2300 | $0.00 | $0.00 |
| 84146 - Prolactin | 84146 | 5 | $0.00 | $0.00 |
| 84156 - Protein, Total Random Urine | 84156 | 150 | $0.00 | $0.00 |
| 84403 - Testosterone, Total | 84403 | 80 | $0.00 | $0.00 |
| 84436 - Thyroxine, total | 84436 | 5 | $0.00 | $0.00 |
| 84439 - Thyroxine; fee | 84439 | 5 | $0.00 | $0.00 |
| 84443 - Thyroid stimulating hormone (TSH) | 84443 | 5 | $0.00 | $0.00 |
| 84450 - Aspartate Aminotransferase (Ast) | 84450 | 150 | $0.00 | $0.00 |
| 84460 - Alanine Aminotransferase (Alt) | 84460 | 150 | $0.00 | $0.00 |
| 84478 - Triglycerides, Serum | 84478 | 2300 | $0.00 | $0.00 |
| 84520 -Urea Nitrogen (Bun) | 84520 | 150 | $0.00 | $0.00 |
| 84702 - Hcg, Serum, Quant | 84702 | 80 | $0.00 | $0.00 |
| 85014 - Hematocrit | 85014 | 150 | $0.00 | $0.00 |
| 85018 - Hemoglobin | 85018 | 150 | $0.00 | $0.00 |
| 85025 - Cbc (Diff/Plt) | 85025 | 550 | $0.00 | $0.00 |
| 85027 - Blood count; complete (CBC), automated (HGB, HCT, RBC, WBC and platelet count) | 85027 | 5 | $0.00 | $0.00 |
| 85041- Blood Count; Red Blood Cell (Rbc), Automated | 85041 | 5 | $0.00 | $0.00 |
| 85049 - Platelet Count | 85049 | 150 | $0.00 | $0.00 |
| 85370 - Fibrin Degradation Products, D-Dimer; Quantitative | 85370 | 50 | $0.00 | $0.00 |
| 85610 - Prothrombin Time | 85610 | 75 | $0.00 | $0.00 |
| 85730 - Thromboplastin Time, Partial (Ptt); Plasma Or Whole Blood 100 | 85730 | 75 | $0.00 | $0.00 |
| 86003 - Allergen Specific Ige; Quantitative Or Semiquantitative, Each Allergen | 86003 | 10 | $0.00 | $0.00 |
| 86005 - Allergen specific IGE; qualitive, multiallergen screen (dipstick, paddle, or disk) | 86005 | 10 | $0.00 | $0.00 |
| 86480 - Quantifeon(R)Tb Gold | 86480 | 80 | $0.00 | $0.00 |
| 86617 - Lyme Disease, Igg/Igm Western | 86617 | 80 | $0.00 | $0.00 |
| 87086 - Culture, bacterial; quantitative colony count, uring | 87086 | 5 | $0.00 | $0.00 |
| 87220 - Tissue Examination By Koh Slide Of Samples From Skin, Hair, Or Nails For Fungi Or Ectoparasite Ova Or Mites (Eg, Scabies) | 87220 | 30 | $0.00 | $0.00 |
| 88104 - Cytopathology, Fluids, Washings Or Brushings, Except Cervical Or Vaginal; Smears With Interpretation | 88104 | 500 | $0.00 | $0.00 |
| 88142 - Cytopathology, Cervical Or Vaginal (Any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation; Manual Screening Under Physician Supervision | 88142 | 30 | $0.00 | $0.00 |
| 88154 - Cytopathology, Slides, Cervical Or Vaginal; With Manual Screening And Computer-Assisted Rescreening Using Cell Selection And Review Under Physician Supervision | 88154 | 5 | $0.00 | $0.00 |
| 88164 - Cytopathology, Slides, Cervical Or Vaginal (The Bethesda System); Manual Screening Under Physician Supervision | 88164 | 5 | $0.00 | $0.00 |
| 88305 - Level Iv - Surgical Pathology, Gross And Microscopic Examination Abortion | 88305 | 5 | $0.00 | $0.00 |
| TOTAL PRICE FOR LABORATORY SERVICES | 17740 | $0.00 |
| MEDICAL CONSULTATIONS | CPT | QTY | PRICE PER CONSULTATION | TOTAL PRICE |
| 99242 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: An Expanded Problem Focused History; An Expanded Problem Focused Examination; And Straightforward Medical Decision Making. Counseling And/Or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or Agencies Are Provided Consistent With The Nature Of The Problem(S) And The Patient's And/Or Family's Needs. Usually, The Presenting Problem(S) Are Of Low Severity. Typically, 30 Minutes Are Spent Face-To-Face With The Patient And/Or Family. | 99242 | 22000 | $0.00 | $0.00 |
| 99243 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: A Detailed History; A Detailed Examination; And Medical Decision Making Of Low Complexity. Counseling And/Or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or Agencies Are Provided Consistent With The Nature Of The Problem(S) And The Patient's And/Or Family's Needs. Usually, The Presenting Problem(S) Are Of Moderate Severity. Typically, 40 Minutes Are Spent Face-To-Face With The Patient And/Or Family. | 99243 | 1600 | $0.00 | $0.00 |
| 99244 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: A Comprehensive History; A Comprehensive Examination; And Medical Decision Making Of Moderate Complexity. Counseling And/Or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or Agencies Are Provided Consistent With The Nature Of The Problem(S) And The Patient's And/Or Family's Needs. Usually, The Presenting Problem(S) Are Of Moderate To High Severity. Typically, 60 Minutes Are Spent Face-To-Face With The Patient And/Or Family. | 99244 | 4500 | $0.00 | $0.00 |
| TOTAL PRICE FOR MEDICAL CONSULTATIONS | 28100 | $0.00 |
| DENTAL CONSULTATIONS | CPT | QTY | PRICE PER CONSULTATION | TOTAL PRICE |
| G0202 - Screening mammography, producing direct digital image, bilateral, all views | G0202 | 5 | $0.00 | $0.00 |
| G0204 - Diagnostic mammography, producing direct 2-D digital image, bilateral, all views | G0204 | 5 | $0.00 | $0.00 |
| D0150 – Comprehensive Oral Evaluation – New or Established Patient | D0150 | 20 | $0.00 | $0.00 |
| D0220 - Intraoral-periapical first film; | D0220 | 20 | $0.00 | $0.00 |
| D0230 - Intraoral-periapical each additional film. | D0230 | 20 | $0.00 | $0.00 |
| D0272 – Bitewings – Two Radiographic Images | D0272 | 20 | $0.00 | $0.00 |
| D0273 – Bitewings – Three Radiographic Images | D0273 | 20 | $0.00 | $0.00 |
| D0274 – Bitewings – Four Radiographic Images | D0274 | 30 | $0.00 | $0.00 |
| TOTAL PRICE FOR DENTAL CONSULTATIONS | 140 | $0.00 |
| NO SHOW/LATE CANCELLATION FEE | CPT | QTY | COST PER NO SHOW/CANCELLATION | TOTAL PRICE |
| Fee for No Show/Late Cancellation | 6000 | $0.00 | $0.00 |
| CONTRACTOR MANPOWER REPORTING | CPT | QTY | NOT SEPERATELY PRICED - NO FEE | TOTAL PRICE |
| Contractor Manpower Reporting (Not Seperately Priced - No Fee) | 1 | $0.00 | $0.00 |
TOTAL FOR 1ST ORDERING PERIOD $0.00
2nd Ordering Period
| ANCILLARY SERVICES | CPT | QTY | PRICE PER SERVICE | TOTAL PRICE | |
| 10022 - Fine needle aspiration; with imaging guidance | 10022 | 10 | $0.00 | $0.00 | |
| 11100 - Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion | 11100 | 10 | $0.00 | $0.00 | |
| 11101 - Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure) | 11101 | 2 | $0.00 | $0.00 | |
| 31231 - Nasal Endoscopy, Diagnostic, Unilateral Or Bilateral (Separate Procedure) | 31231 | 10 | $0.00 | $0.00 | |
| 31505 - Laryngoscopy, Diagnostic | 31505 | 10 | $0.00 | $0.00 | |
| 31575 - Laryngoscopy, Flexible Fiberoptic; Diagnostic | 31575 | 1 | $0.00 | $0.00 | 1 |
| 36000 - Introduction of needle or intracatheter, vein | 36000 | 1 | $0.00 | $0.00 | |
| 36415 - Venipuncture Fee | 36415 | 100 | $0.00 | $0.00 | |
| 51741 - Complex Uroflowmetry (Eg, Calibrated Electronic Equipment) | 51741 | 1 | $0.00 | $0.00 | |
| 51798 - Measurement Of Post-Voiding Residual Urine And/Or Bladder Capacity By Ultrasound, Non-Imaging | 51798 | 1 | $0.00 | $0.00 | |
| 52000 - Cystourethroscopy (separate procedure) | 52000 | 1 | $0.00 | $0.00 | |
| 69200 - Removal Foreign Body From External Auditory Canal; Without General Anesthesia | 69200 | 10 | $0.00 | $0.00 | |
| 69210 - Wax Removal | 69210 | 1500 | $0.00 | $0.00 | |
| 70160 - Radiologic Examination, Nasal Bones, Complete, Minimum Of 3 Views | 70160 | 1 | $0.00 | $0.00 | |
| 70210 - Radiologic Examination, Sinuses, Paranasal, Less Than 3 Views | 70210 | 1 | $0.00 | $0.00 | |
| 70220 - Radiologic Examination, Sinuses, Paranasal, Complete, Minimum Of 3 Views | 70220 | 1 | $0.00 | $0.00 | |
| 70260 - Radiologic Examination, Skull; Complete, Minimum Of 4 Views | 70260 | 1 | $0.00 | $0.00 | |
| 70310 - Radiologic examination, teeth; partial exam, less than full mouth | 70310 | 60 | $0.00 | $0.00 | |
| 70370 – Throat & Fluoroscopy | 70370 | 1 | $0.00 | $0.00 | |
| 70371 – Speech Evaluation, Complex | 70371 | 1 | $0.00 | $0.00 | |
| 70450 - CT Scan, Head/Brain, W/O Contrast, Global | 70450 | 1 | $0.00 | $0.00 | |
| 70460 - CT Scan, Head/Brain, With Contrast, Global | 70460 | 1 | $0.00 | $0.00 | |
| 70480 - CT Scan, Renal W/O Contrast | 70480 | 1 | $0.00 | $0.00 | |
| 70481 - CT Scan, Renal With Contrast | 70481 | 1 | $0.00 | $0.00 | |
| 70482 - Ct Scan, Middle/Inner Ear, Global | 70482 | 1 | $0.00 | $0.00 | |
| 70486 - Computed Tomography, Maxillofacial Area; Without Contrast Material | 70486 | 1 | $0.00 | $0.00 | |
| 70551 - MRI Head, W/O Contrast, Global | 70551 | 1 | $0.00 | $0.00 | |
| 70552 - MRI Head, With Contrast, Global | 70552 | 1 | $0.00 | $0.00 | |
| 70553 - Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem); Without Contrast Material, Followed By Contrast Material(S) And Further Sequences | 70553 | 1 | $0.00 | $0.00 | |
| 71010 – Chest X-Ray | 71010 | 1 | $0.00 | $0.00 | |
| 71020 - Radiologic Examination, Chest, 2 Views, Frontal And Lateral; | 71020 | 130 | $0.00 | $0.00 | |
| 71022 - Radiologic Examination, Chest, 2 Views, Frontal And Lateral; With Oblique Projections | 71022 | 15 | $0.00 | $0.00 | |
| 71023 – Chest X-Ray And Fluoroscopy | 71023 | 1 | $0.00 | $0.00 | |
| 71100 – X-Ray Exam Of Ribs | 71100 | 1 | $0.00 | $0.00 | |
| 71101 – X-Ray Exam Of Ribs/Chest | 71101 | 1 | $0.00 | $0.00 | |
| 71110 - Radiologic Examination, Ribs, Bilateral; 3 Views | 72110 | 80 | $0.00 | $0.00 | |
| 71111 – X-Ray Exam Of Ribs | 71111 | 1 | $0.00 | $0.00 | |
| 71120 – X-Ray Exam Of Breastbone | 71120 | 1 | $0.00 | $0.00 | |
| 71130 – X-Ray Exam Of Breastbone | 71130 | 1 | $0.00 | $0.00 | |
| 71250 - CT Scan, Chest, W/O Contrast, Global | 71250 | 1 | $0.00 | $0.00 | |
| 71275 - Computed tomographic angiography, chest (noncoronary), with contrast material, including noncontrast images, if performed, and image postprocessing | 71275 | 1 | $0.00 | $0.00 | |
| 72020 - Radiologic Examination, Spine, Single View, Specify Level | 72020 | 150 | $0.00 | $0.00 | |
| 72040 – X-Ray Exam Of Neck Spine | 72040 | 50 | $0.00 | $0.00 | |
| 72050 - Radiologic examination, spine, cervical; 4 or 5 views | 72050 | 30 | $0.00 | $0.00 | |
| 72052 - Radiologic Examination, Spine, Cervical; 6 Or More Views | 72052 | 1 | $0.00 | $0.00 | |
| 72070 - Radiologic Examination, Spine; Thoracic, 2 Views | 72070 | 60 | $0.00 | $0.00 | |
| 72072 - Radiologic Examination, Spine; Thoracic, 3 Views | 72072 | 1 | $0.00 | $0.00 | |
| 72074 -Radiologic Examination, Spine; Thoracic, Minimum Of 4 Views | 72074 | 35 | $0.00 | $0.00 | |
| 72080 – X-Ray Exam Of Trunk Spine | 72080 | 100 | $0.00 | $0.00 | |
| 72081 - Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view | 72081 | 40 | $0.00 | $0.00 | |
| 72082 - Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views | 72082 | 250 | $0.00 | $0.00 | |
| 72100 – X-Ray Exam Of Lower Spine | 72100 | 100 | $0.00 | $0.00 | |
| 72114 - Radiologic Examination, Spine, Lumbosacral; Complete, Including Bending Views, Minimum Of 6 Views | 72114 | 50 | $0.00 | $0.00 | |
| 72120 - Radiologic Examination, Spine, Lumbosacral; Bending Views Only, 2 Or 3 Views | 72120 | 1 | $0.00 | $0.00 | |
| 72125 - CT Scan, LS Spine, W/O Contrast, Global | 72125 | 1 | $0.00 | $0.00 | |
| 72131 - Computed tomography, lumbar spine; without contrast material | 72131 | 1 | $0.00 | $0.00 | |
| 72141 - MRI C/Spine, W/O Contrast, Global | 72141 | 3 | $0.00 | $0.00 | |
| 72142 - MRI C/Spine, With Contrast, Global | 72142 | 3 | $0.00 | $0.00 | |
| 72146 - MRI Extremity, W/O Contrast, Global | 72146 | 3 | $0.00 | $0.00 | |
| 72147 - MRI Extremity, With Contrast, Global | 72147 | 3 | $0.00 | $0.00 | |
| 72148 - MRI T-Spine, W/O Contrast, Global | 72148 | 3 | $0.00 | $0.00 | |
| 72149 - MRI T-Spine, With, Contrast, Global | 72149 | 3 | $0.00 | $0.00 | |
| 72170 – X-Ray Exam Of Pelvis | 72170 | 50 | $0.00 | $0.00 | |
| 72190 – X-Ray Exam Of Pelvis | 72190 | 40 | $0.00 | $0.00 | |
| 72192 - CT Scan, Pelvis, W/O Contrast, Global | 72192 | 8 | $0.00 | $0.00 | |
| 72195 - MRI Pelvis, W/O Contrast, Global | 72195 | 3 | $0.00 | $0.00 | |
| 72200 – X-Ray Exam Sacroiliac Joints | 72200 | 15 | $0.00 | $0.00 | |
| 72202 - X-Ray Exam Sacroiliac Joints | 72202 | 15 | $0.00 | $0.00 | |
| 72220 – X-Ray Exam Of Tailbone | 72220 | 15 | $0.00 | $0.00 | |
| 72240 – Contract X-Ray Of Neck Spine | 72240 | 15 | $0.00 | $0.00 | |
| 72255 – Contrast X-Ray, Thorax Spine | 72255 | 15 | $0.00 | $0.00 | |
| 72265 – Contract X-Ray, Lower Spine | 72265 | 15 | $0.00 | $0.00 | |
| 72270 – Contrast X-Ray Of Spine | 72270 | 15 | $0.00 | $0.00 | |
| 72285 – X-Ray C/T Spine Disk | 72285 | 15 | $0.00 | $0.00 | |
| 72295 – X-Ray Of Lower Spine Disk | 72295 | 15 | $0.00 | $0.00 | |
| 73000 – X-Ray Exam Of Collar Bone | 73000 | 75 | $0.00 | $0.00 | |
| 73010 – X-Ray Exam Of Shoulder Blade | 73010 | 30 | $0.00 | $0.00 | |
| 73020 – X-Ray Exam Of Shoulder | 73020 | 30 | $0.00 | $0.00 | |
| 73030 – X-Ray Exam Of Shoulder | 73030 | 450 | $0.00 | $0.00 | |
| 73040 – X-Ray Exam Of Shoulder | 73040 | 55 | $0.00 | $0.00 | |
| 73050 - Radiologic Examination; Acromioclavicular Joints, Bilateral, With Or Without Weighted Distraction | 73050 | 1 | $0.00 | $0.00 | |
| 73060 – X-Ray Exam Of Humerus | 73060 | 55 | $0.00 | $0.00 | |
| 73070 – X-Ray Exam Of Elbow | 73070 | 90 | $0.00 | $0.00 | |
| 73080 – X-Ray Exam Of Elbow | 73080 | 100 | $0.00 | $0.00 | |
| 73085 – Contrast X-Ray Of Elbow | 73085 | 15 | $0.00 | $0.00 | |
| 73090 – X-Ray Exam Of Forearm | 73090 | 70 | $0.00 | $0.00 | |
| 73100 – X-Ray Of Wrist 2 Views | 73100 | 70 | $0.00 | $0.00 | |
| 73110 – X-Ray Exam Of Wrist | 73110 | 100 | $0.00 | $0.00 | |
| 73115 – Contrast X-Ray Of Wrist | 73115 | 15 | $0.00 | $0.00 | |
| 73120 – X-Ray Exam Of Hand | 73120 | 30 | $0.00 | $0.00 | |
| 73130 – X-Ray Exam Of Hand | 73130 | 55 | $0.00 | $0.00 | |
| 73140 – X-Ray Exam Of Finder (S) | 73140 | 55 | $0.00 | $0.00 | |
| 73221 - MRI Shoulder, W/O Contrast, Global | 73221 | 3 | $0.00 | $0.00 | |
| 73501 - Radiologic examination, hip, unilateral, with pelvis when performed; 1 view | 73501 | 95 | $0.00 | $0.00 | |
| 73502 - Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views | 73502 | 30 | $0.00 | $0.00 | |
| 73503 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views | 73503 | 1 | $0.00 | $0.00 | |
| 73521 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views | 73521 | 30 | $0.00 | $0.00 | |
| 73522 - Radiologic examination, hip, unilateral, with pelvis when performed; 3-4 views | 73522 | 30 | $0.00 | $0.00 | |
| 73522 - Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views | 73552 | 30 | $0.00 | $0.00 | |
| 73523 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 5 views | 73523 | 15 | $0.00 | $0.00 | |
| 73525 – Contrast X-Ray Of Hip | 73525 | 30 | $0.00 | $0.00 | |
| 73551 - Radiologic examination, femur; 1 view | 73551 | 65 | $0.00 | $0.00 | |
| 73560 – X-Ray Exam Of Knee, 1 Or 2 | 73560 | 300 | $0.00 | $0.00 | |
| 73562 – X-Ray Exam Of Knee, 3 | 73562 | 350 | $0.00 | $0.00 | |
| 73564 – X-Ray Exam, Knee 4 Or More | 73564 | 225 | $0.00 | $0.00 | |
| 73565 – X-Ray Exam Of Knees | 73565 | 65 | $0.00 | $0.00 | |
| 73580 – Contrast X-Ray Of Knee Joint | 73580 | 1 | $0.00 | $0.00 | |
| 73590 – X-Ray Exam Of Lower Leg | 73590 | 100 | $0.00 | $0.00 | |
| 73600 – X-Ray Exam Of Ankle | 73600 | 150 | $0.00 | $0.00 | |
| 73610 – X-Ray Exam Of Ankle | 73610 | 300 | $0.00 | $0.00 | |
| 73615 – Contrast X-Ray Of Ankle | 73615 | 1 | $0.00 | $0.00 | |
| 73620 – X-Ray Exam Of Foot | 73620 | 150 | $0.00 | $0.00 | |
| 73630 – X-Ray Foot 2 Views | 73630 | 350 | $0.00 | $0.00 | |
| 73650 – X-Ray Exam Of Heel | 73650 | 40 | $0.00 | $0.00 | |
| 73660 – X-Ray Exam Of Toe (S) | 73660 | 40 | $0.00 | $0.00 | |
| 73700 - CT Scan, Lower Extremity, W/O Contrast, Global | 73700 | 1 | $0.00 | $0.00 | |
| 73721 - MRI Lower Extremity Joint, W/O Contrast, Global | 73721 | 3 | $0.00 | $0.00 | |
| 73723- Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences | 73723 | 3 | $0.00 | $0.00 | |
| 74000 – X-Ray Exam Of Abdomen | 74000 | 50 | $0.00 | $0.00 | |
| 74010 – X-Ray Exam Of Abdomen | 74010 | 1 | $0.00 | $0.00 | |
| 74020 – X-Ray Exam Of Abdomen | 74020 | 1 | $0.00 | $0.00 | |
| 74022 – X-Ray Exam Series, Abdomen | 74022 | 1 | $0.00 | $0.00 | |
| 74150 - CT Scan, Abdomen, With & W/O Contrast, Global | 74150 | 1 | $0.00 | $0.00 | |
| 74160 - Computed tomography, abdomen; with contrast material(s) | 74160 | 1 | $0.00 | $0.00 | |
| 74176 - Computed tomography, abdomen and pelvis; without contrast material | 74176 | 1 | $0.00 | $0.00 | |
| 74178 - Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(S) And Further Sections In One Or Both Body Regions | 74178 | 1 | $0.00 | $0.00 | |
| 74190 – X-Ray Exam Or Peritoneum | 74190 | 1 | $0.00 | $0.00 | |
| 74210 – Contrast X-Ray Exam Of Throat | 74210 | 1 | $0.00 | $0.00 | |
| 74220 – Contrast X-Ray, Esophagus | 74220 | 1 | $0.00 | $0.00 | |
| 74240 – X-Ray Exam, Upper Gi Tract | 74240 | 1 | $0.00 | $0.00 | |
| 74241 – X-Ray Exam, Upper Gi Tract | 74241 | 1 | $0.00 | $0.00 | |
| 74245 – X-Ray Exam, Upper Gi Tract | 74245 | 1 | $0.00 | $0.00 | |
| 74246 – Contrast X-Ray Upper Gi Tract | 74246 | 1 | $0.00 | $0.00 | |
| 74247 – Contrast X-Ray Upper Gi Tract | 74247 | 1 | $0.00 | $0.00 | |
| 74249 – Contrast X-Ray Upper Gi Tract | 74249 | 1 | $0.00 | $0.00 | |
| 74250 – X-Ray Exam Of Small Bowel | 74250 | 1 | $0.00 | $0.00 | |
| 74251 – X-Ray Exam Of Small Bowel | 74251 | 1 | $0.00 | $0.00 | |
| 74260 – X-Ray Exam Of Small Bowel | 74260 | 1 | $0.00 | $0.00 | |
| 74270 – Contrast X-Ray Exam Of Colon | 74270 | 1 | $0.00 | $0.00 | |
| 74280 – Contrast X-Ray Exam Of Colon | 74280 | 1 | $0.00 | $0.00 | |
| 74283 – Contrast X-Ray Exam Of Colon | 74283 | 1 | $0.00 | $0.00 | |
| 74290– Contrast X-Ray, Gallbladder | 74290 | 1 | $0.00 | $0.00 | |
| 74300 – X-Ray Bile Ducts/Pancreas | 74300 | 1 | $0.00 | $0.00 | |
| 74328 – X-Ray Bile Duct Endoscopy | 74328 | 1 | $0.00 | $0.00 | |
| 74329 – X-Ray For Pancreas Endoscopy | 74329 | 1 | $0.00 | $0.00 | |
| 74330 – X-Ray Bile/Pancreas Endoscopy | 74330 | 1 | $0.00 | $0.00 | |
| 74340 – X-Ray Guide For GI Tube | 74340 | 1 | $0.00 | $0.00 | |
| 74355 – X-Ray Guide, Intestinal Tube | 74355 | 1 | $0.00 | $0.00 | |
| 74360 – X-Ray Guide, Gi Dilation | 74360 | 1 | $0.00 | $0.00 | |
| 74363 – X-Ray, Bile Duct Dilation | 74363 | 1 | $0.00 | $0.00 | |
| 74400 – Contrast X-Ray, Urinary Tract | 74400 | 1 | $0.00 | $0.00 | |
| 74410 - Contrast X-Ray, Urinary Tract | 74410 | 1 | $0.00 | $0.00 | |
| 74415 - Contrast X-Ray, Urinary Tract | 74415 | 1 | $0.00 | $0.00 | |
| 74420 - Contrast X-Ray, Urinary Tract | 74420 | 1 | $0.00 | $0.00 | |
| 74425 - Contrast X-Ray, Urinary Tract | 74425 | 1 | $0.00 | $0.00 | |
| 74430 – Contrast X-Ray, Bladder | 74430 | 1 | $0.00 | $0.00 | |
| 74440 – X-Ray, Male Genital Tract | 74440 | 1 | $0.00 | $0.00 | |
| 74445 – X-Ray Exam Of Penis | 74445 | 1 | $0.00 | $0.00 | |
| 74450 – X-Ray, Urethra/Bladder | 74450 | 1 | $0.00 | $0.00 | |
| 74455 – X-Ray, Urethra/Bladder | 74455 | 1 | $0.00 | $0.00 | |
| 74470 – X-Ray Exam Of Kidney Lesion | 74470 | 1 | $0.00 | $0.00 | |
| 74485 – X-Ray Guide, Gu Dilation | 74485 | 1 | $0.00 | $0.00 | |
| 74740 – X-Ray, Female Genital Tract | 74740 | 1 | $0.00 | $0.00 | |
| 74742 – X-Ray, Fallopian Tube | 74742 | 1 | $0.00 | $0.00 | |
| 76511 - Ophthalmic Ultrasound, Diagnostic; Quantitative A-Scan Only | 76511 | 1 | $0.00 | $0.00 | |
| 76514 - Ophthalmic Ultrasound, Diagnostic; Corneal Pachymetry, Unilateral Or Bilateral (Determination Of Corneal Thickness) | 76514 | 1 | $0.00 | $0.00 | |
| 76536 - Ultrasound, Head, Global | 76536 | 24 | $0.00 | $0.00 | |
| 76604 - Ultrasound, Chest, Global | 76604 | 1 | $0.00 | $0.00 | |
| 76641 - Ultrasound, breast, unilateral, real time with image documentation, including axilla whn performed; complete | 76641 | 40 | $0.00 | $0.00 | |
| 76700 - Ultrasound, Abdomen, Global | 76700 | 30 | $0.00 | $0.00 | |
| 76705 - Ultrasound, Abdominal, Real Time With Image Documentation; Limited (Eg, Single Organ, Quadrant, Follow-Up) | 76705 | 15 | $0.00 | $0.00 | |
| 76770 - Ultrasound, Kidney(Renal), Global | 76770 | 25 | $0.00 | $0.00 | |
| 76775 - Ultrasound, Retroperitoneal (Eg, Renal, Aorta, Nodes), Real Time With Image Documentation; Limited | 76775 | 15 | $0.00 | $0.00 | |
| 76800 - Ultrasound, Spinal Canal, Global | 76800 | 1 | $0.00 | $0.00 | |
| 76830 - Ultrasound, Ovaries, Global | 76830 | 1 | $0.00 | $0.00 | |
| 76856 - Ultrasound, Pelvic (Nonobstetric), Global | 76856 | 1 | $0.00 | $0.00 | |
| 76870 - Ultrasound, Scrotum, Global | 76870 | 250 | $0.00 | $0.00 | |
| 76872 - Ultrasound, tranrectal | 76872 | 1 | $0.00 | $0.00 | |
| 76881 - Ultrasound, Extremities, Global | 76881 | 1 | $0.00 | $0.00 | |
| 77051 - Mammogram, Digital, Bilateral, Global | 77051 | 1 | $0.00 | $0.00 | |
| 77052 - Computer-Aided Detection (Computer Algorithm Analysis Of Digital Image Data For Lesion Detection) With Further Review For Interpretation, With Or Without Digitization Of Film Radiographic Images; Screening Mammography (List Separately In Addition To Code For Primary Procedure) | 77052 | 1 | $0.00 | $0.00 | |
| 77056 - Mammogram, Conventional, Bilateral, (Global) | 77056 | 25 | $0.00 | $0.00 | |
| 77057 - Screening Mammography, Bilateral (2-View Film Study Of Each Breast) | 77057 | 1 | $0.00 | $0.00 | |
| 78708 - Kidney Imaging Morphology; With Vascular Flow And Function, Single Study, With Pharmacological Intervention (Eg, Angiotensin Converting Enzyme Inhibitor And/Or Diuretic) | 78708 | 1 | $0.00 | $0.00 | |
| 91065 - Hydrogen Breath Test | 91065 | 20 | $0.00 | $0.00 | |
| 92015 - Refraction Test | 92015 | 8000 | $0.00 | $0.00 | |
| 92025 - Corneal Topography Test | 92025 | 6750 | $0.00 | $0.00 | |
| 92060 - Sensorimotor Examination With Multiple Measurements Of Ocular Deviation (Eg, Restrictive Or Paretic Muscle With Diplopia) With Interpretation And Report (Separate Procedure) | 92060 | 10 | $0.00 | $0.00 | |
| 92081 - Visual Field Testing (Automated Perimeter) | 92081 | 50 | $0.00 | $0.00 | |
| 92082 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report; Intermediate Examination (Eg, At Least 2 Isopters On Goldmann Perimeter, Or Semiquantitative, Automated Suprathreshold Screening Program, Humphrey Suprathreshold Automatic Diagnostic Test, Octopus Program 33) | 92082 | 125 | $0.00 | $0.00 | |
| 92083 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report | 92083 | 460 | $0.00 | $0.00 | |
| 92100 - Contact Tonometry | 92100 | 50 | $0.00 | $0.00 | |
| 92132 - Scanning Computerized Ophthalmic Diagnostic Imaging, Anterior Segment, With Interpretation And Report, Unilateral Or Bilateral | 92132 | 25 | $0.00 | $0.00 | |
| 92133 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Optic Nerve | 92133 | 40 | $0.00 | $0.00 | |
| 92134 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Retina | 92134 | 30 | $0.00 | $0.00 | |
| 92225 - Ophthalmoscopy, Extended, With Retinal Drawing (Eg, For Retinal Detachment, Melanoma), With Interpretation And Report; Initial | 92225 | 550 | $0.00 | $0.00 | |
| 92235 - Fluorescein angiography (includes multiframe imaging) with interpretation and report | 92235 | 10 | $0.00 | $0.00 | |
| 92250 - Fundus Photography With Interpretation And Report | 92250 | 60 | $0.00 | $0.00 | |
| 92275 - Electroretinography With Interpretation And Report | 92275 | 1 | $0.00 | $0.00 | |
| 92283 - Color Vision Examination, Extended, Eg, Anomaloscope Or Equivalent | 92283 | 1 | $0.00 | $0.00 | |
| 92285 - External Ocular Photography With Interpretation And Report For Documentation Of Medical Progress (Eg, Close-Up Photography, Slit Lamp Photography, Goniophotography, Stereo-Photography) | 92285 | 30 | $0.00 | $0.00 | |
| 92285 - Stereoscopic | 92285 | 175 | $0.00 | $0.00 | |
| 92286 - Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell analysis | 92286 | 10 | $0.00 | $0.00 | |
| 92504 - Binocular Ear Test | 92504 | 20 | $0.00 | $0.00 | |
| 92504 - Binocular Microscopy (Separate Diagnostic Procedure) | 92504 | 15 | $0.00 | $0.00 | |
| 92550 - Tympanometry And Reflex Threshold Measurements | 92550 | 30 | $0.00 | $0.00 | |
| 92552 - Pure Tone Audiometry (Threshold); Air Only | 92552 | 30 | $0.00 | $0.00 | |
| 92553 - Audiogram W/Air & Bone Conduction | 92553 | 150 | $0.00 | $0.00 | |
| 92555 - Speech Audiometry Threshold; | 92555 | 10 | $0.00 | $0.00 | |
| 92556 - Speech Audiometry Threshold; With Speech Recognition | 92556 | 50 | $0.00 | $0.00 | |
| 92557 - Audiogram W/Speech Reception Threshold | 92557 | 120 | $0.00 | $0.00 | |
| 92567 - Tympanometry (Impedance Testing) | 92567 | 100 | $0.00 | $0.00 | |
| 92571 - Filtered Speech Test | 92571 | 30 | $0.00 | $0.00 | |
| 92577 - Stenger Test, Speech | 92577 | 1 | $0.00 | $0.00 |
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