| EMERGENCY LEVEL I | $391.00 |
| EMERGENCY LEVEL II | $611.00 |
| EMERGENCY LEVEL III | $732.00 |
| EMERGENCY LEVEL IV | $1,096.00 |
| EMERGENCY LEVEL V | $1,509.00 |
| ER NEW/EST BRIEF | $398.00 |
| ER NEW/EST LIMITED | $605.00 |
| ER NEW/EST INTERMED | $673.00 |
| ER NEW/EST EXTENDED | $818.00 |
| LACERATION REPAIR/SIMP-UP TO 2.5 CM | $485.00 |
| LACERATION TRAY | $90.00 |
| ACCUCHECK | $11.00 |
| ACE 2 | $3.30 |
| ACE 3 | $3.30 |
| ACE 4 | $3.30 |
| Acetomenophen 500mg TABLET | $3.85 |
| ADM IMM/TOXOID SUB/IM | $148.00 |
| ADM/IV DRUG – IV PUSH | $148.00 |
| ADM/THER DRUG SUB/IM | $148.00 |
| ALBERTOL | $4.80 |
| Amoxicillian 250 mg Cap | $149.00 |
| Amoxicillian 250mg/5mL SUSP | $10.62 |
| ARM SLING UNIVERSAL | $47.70 |
| ASA 81 mg Chewable | $3.85 |
| CARDIAC MONITOR E/R | $544.00 |
| CATH IV 20GX1 | $16.11 |
| CATH IV 22GX1 | $16.11 |
| CRUTCHES REGULAR ADULT | $87.73 |
| DEXAMETHASONE (DECADRO | $15.85 |
| DRESSING TEGADERM 1624 | $3.30 |
| EMESIS BAG UM | $3.30 |
| EXTENSION SET | $14.49 |
| HYDROcodone / APAP 7.5 | $5.31 |
| HYDROcodone/APAP 5 mg | $3.85 |
| HYDROmorphone (DILAUDI | $11.00 |
| IBUPROFEN (CHILDRENS) | $5.85 |
| IPRATRO/ALBUTEROL(DUON | $13.24 |
| IV INFUSION THERAPY EACH | $85.00 |
| IV INFUSION THERAPY IN | $440.00 |
| IV PRIMARY SET | $25.92 |
| IV PUSH ADDITIONAL DOS | $85.00 |
| IV PUSH SEQUENT – EA. | $120.00 |
| KETOROLAC 30 MG / ML V | $36.00 |
| KETOROLAC 60 MG / 2 ML | $45.00 |
| KLING 2 | $3.30 |
| KLING 3 | $3.30 |
| LIDOCAINE (XYLOCAINE) | $20.52 |
| LIDOCAINE 5 ML 1% INJ | $24.41 |
| LORAZEPAM (ATIVAN) 2 M | $18.30 |
| MASK NEBULIZER ADULT | $10.40 |
| METHOCARBAMOL 500 MG T | $3.85 |
| methylPREDNISolone 125 | $38.50 |
| NALBUPHINE 10 MG AMP I | $23.65 |
| NEBUL TREATMENT EACH | $73.00 |
| NEBULIZER MTHPC W/TP | $8.78 |
| ONDANSETRON 2 MG / ML | $14.40 |
| ONDANSETRON ODT(ZOFRAN | $122.61 |
| OXYGEN ER | $39.00 |
| predniSONE 20 MG TAB | $1.70 |
| Promethazine 25 mg AMP | $11.00 |
| SENSOR O’2 PEDIATRIC | $93.33 |
| SODIUM CHL 10 ML SYR F | $3.30 |
| SOL NACL IRR 500ML , 6 | $30.00 |
| SOL NS-1000ml, 7983-09 | $60.00 |
| SPECIMEN CONT STERILE | $3.30 |
| SPECIMEN MIDSTRM KIT | $3.30 |
| SPONGES 4X4X10 STERILE | $3.30 |
| TET/DIP/TOX/ACEL/PERT | $228.10 |
| XEROFORM 1X8 | $3.63 |
| ACCUCHECK | $11.00 |
| ACETAMINOPHEN (TYLENOL | $3.85 |
| ACETAMINOPHEN(TYLENOL | $3.85 |
| ALBUTEROL (VENTOLIN)2. | $4.80 |
| AMLODIPINE (NORVASC) 5 | $3.85 |
| ASPIRIN 81 MG CHEWABLE | $3.85 |
| ASPIRIN 81 MG EC TAB | $3.85 |
| ATORVASTATIN (LIPITOR) | $3.00 |
| CARVEDILOL(COREG) 3.12 | $12.60 |
| CLOPIDOGREL(PLAVIX) 75 | $26.17 |
| DIAPER, XL 59X66 | $3.30 |
| DIAPERS PULL UP X. LAR | $3.30 |
| DILTIAZEM CD (CARDIZEM | $8.98 |
| DOCUSATE(COLACE) 100 M | $3.85 |
| DONEPEZIL(ARICEPT) 5 M | $46.73 |
| FUROSEMIDE (LASIX) 20 | $3.85 |
| GABAPENTIN (NEURONTIN) | $9.96 |
| HEPARIN SODIUM 5,000 U | $14.80 |
| HYDRALAZINE (APRESOLIN | $3.85 |
| INSULIN LANTUS 100 U/M | $3.30 |
| INSULIN novoLOG ASPAR | $3.30 |
| IPRATRO/ALBUTEROL(DUON | $13.24 |
| IPRATROPIUM (ATROVENT) | $7.92 |
| ISOSORBIDE DINIT 5 MG | $5.91 |
| IV INFUSION THER EACH | $85.00 |
| LACTOBACILLUS GG(CULTU | $3.30 |
| LACTULOSE(CEPHULACE ) | $5.85 |
| LEVOFLOXACIN 250 MG TA | $90.71 |
| LEVOTHYROXINE 50 MCG T | $7.92 |
| LIPITOR | $3.00 |
| MED PASS 4 OZ ORIGINAL | $3.30 |
| METFORMIN 500 MG TAB | $3.85 |
| METHOCARBAMOL 500 MG T | $3.85 |
| METOPROLOL 25 MG TAB | $3.85 |
| METOPROLOL (TOPROL XL) | $8.58 |
| MULTIVITAMIN TABLET | $3.85 |
| NEBUL TREATMENT EACH | $73.00 |
| OMEPRAZOLE 20 MG CAP | $6.68 |
| OXYCODONE IR 5 MG TAB | $3.85 |
| OXYGEN PER 24HR | $513.00 |
| PANTOPRAZOLE SOD DR 40 | $2.06 |
| POTASSIUM CHLOR ER 20 | $5.58 |
| PRAVASTATIN 20 MG TABL | $19.60 |
| PREDNISONE 20 MG TAB | $1.70 |
| RANITIDINE 150 MG TAB | $3.85 |
| SODIUM CHL 10 ML SYR F | $3.30 |
| TAMSULOSIN(FLOMAX) 0.4 | $2.84 |
| TRAMADol (ULTRAM) 50 M | $3.85 |
| WARFARIN(COUMADIN) 2.5 | $3.85 |
| ARTERIAL BLOOD GAS | $273.00 |
| BIPAP SETUP | $410.00 |
| CARDIAC MONITOR E/R | $544.00 |
| CPAP SETUP | $385.00 |
| EKG | $341.00 |
| INCENTIVE SPIROMETER TRTMT | $101.00 |
| MDI TREATMENT EACH | $89.00 |
| NEB SUBSEQUENT EACH AD | $70.15 |
| NEB, MDI, IPPB EDUCATI | $99.00 |
| NEBULIZER TREATMENT EACH | $73.00 |
| OXYGEN PER 24HR | $513.00 |
| OXYGEN PRN (PER 24HR) | $408.00 |
| PULMONARY FUNCTION TEST | $447.00 |
| PULMONARY STRESS TEST | $132.00 |
| PULSE OXIMETER MULTIPL | $139.00 |
| PULSE OXIMETRY SINGLE | $519.00 |
| SIMPLE SPIROMETRY TEST | $132.00 |
| TELEMETRY DAILY | $380.50 |
| TELEMETRY SET UP | $184.45 |
| ADL Self Care 15 mins | $66.00 |
| Balance | $99.00 |
| Dressing Change | $55.00 |
| E Stim | $83.00 |
| Electrode | $30.00 |
| Gait Training | $121.00 |
| Hot-Cold Packs | $44.00 |
| Initial Evaluation | $186.00 |
| Manual Therapy/Back | $15.00 |
| Manual Therapy Tech | $89.00 |
| Neuromuscular Re-Ed | $99.00 |
| Orthotic/Prost Use per 15 mins | $140.00 |
| Re-Eval | $125.00 |
| TENS | $57.00 |
| Ther Act | $103.00 |
| Ther Ex | $76.00 |
| Traction | $48.00 |
| Ultrasound per 15 mins | $61.00 |
| Whirlpool | $105.00 |
| ADL Self-Care | $103.00 |
| Contrast Bath | $54.00 |
| Dressing Change | $44.00 |
| Heat/Cold Packs | $33.00 |
| Initial Evaluation | $253.00 |
| Iontophoresis | $192.00 |
| Manual Therapy Tech | $89.00 |
| Neuromuscular Re-ed | $198.00 |
| Orthotic/Prosthetic Use (Initial) | $113.00 |
| Orthotic/Prosthetic Use (Established) | $140.00 |
| Re-eval | $99.00 |
| Ther Act | $103.00 |
| Ther Ex | $288.00 |
| Ultrasound | $50.00 |
| C-Splint/Hand-Based | $210.00 |
| IP Gutter Splint | $85.00 |
| Thumb Spica Splint | $285.00 |
| WHFO Wrist Support Splint | $420.00 |
| Evaluate Swallowing per hour | $286.00 |
| Cognitive Skills Dev each 15 mins | $110.00 |
| Eval/Re-eval per hour | $173.00 |
| Treatment per hour | $237.00 |
| Swallowing/Feed Treatment per hour | $256.00 |
| AC Joints | $304.00 |
| Abd 1 view | $326.00 |
| Abd 2 view | $244.00 |
| Abd Series | $506.00 |
| Ankle | $309.00 |
| C Spine | $347.00 |
| C Spine Complete | $386.00 |
| Chest 2v | $311.00 |
| Chest 1v | $266.00 |
| Clavicle | $365.00 |
| Elbow | $271.00 |
| Facial Bones | $365.00 |
| Femur | $365.00 |
| Fingers | $264.00 |
| Foot | $304.00 |
| Forearm | $347.00 |
| Hand | $304.00 |
| Hip | $413.00 |
| Humerus | $334.00 |
| Knee | $413.00 |
| L Spine | $405.00 |
| Mandible | $405.00 |
| Mastoids | $448.00 |
| Neck Soft Tissue | $235.00 |
| Orbit | $341.00 |
| Pelvis | $295.00 |
| Ribs Bilat | $537.00 |
| Ribs Unilat | $365.00 |
| Sacrum & Coccyx | $386.00 |
| SI Joints | $326.00 |
| Scapula | $304.00 |
| Shoulder | $339.00 |
| Sinuses | $457.00 |
| Skull | $365.00 |
| Scoliosis Series | $271.00 |
| Sternum | $285.00 |
| TMJ | $330.00 |
| T Spine | $426.00 |
| Tib Fib | $365.00 |
| Toe | $264.00 |
| Wrist | $347.00 |
| Abdomen | $847.00 |
| Aorta | $810.00 |
| Arterial Extremity | $880.00 |
| Arterial Extremity- Bilat | $1,075.00 |
| Breast | $494.00 |
| Carotid | $833.00 |
| Echo | $1,212.00 |
| Pelvic | $659.00 |
| Renal | $254.00 |
| Thyroid | $601.00 |
| Venous Bilat | $1,205.00 |
| Venous Unilat | $800.00 |
| Transvaginal | $659.00 |
| Establish Patient Preventative Visit <1 yr of age | $167.00 |
| Establish Patient Preventative Visit 1 – 4 yrs of age | $182.00 |
| Establish Patient Preventative Visit 5 – 11 yrs of age | $182.00 |
| Establish Patient Preventative Visit 12 -17 yrs of age | $196.00 |
| Establish Patient Preventative Visit 18 – 39 yrs of age | $196.00 |
| Establish Patient Preventative Visit 40 – 64 yrs of age | $196.00 |
| Establish Patient Preventative Visit >65 yrs of age | $196.00 |
| Establish Patient Visit Brief | $42.00 |
| Establish Patient Visit Minimal | $70.00 |
| Establish Patient Visit Moderate | $98.00 |
| Establish Patient Visit Complex | $142.00 |
| New Patient Preventative Visit <1 yr of age | $175.00 |
| New Patient Preventative Visit 1 – 4 yrs of age | $188.00 |
| New Patient Preventative Visit 5 -11 yrs of age | $188.00 |
| New Patient Preventative Visit 12 – 17 yrs of age | $196.00 |
| New Patient Preventative Visit 18 – 39 yrs of age | $202.00 |
| New Patient Preventative Visit 40 – 64 yrs of age | $209.00 |
| New Patient Preventative Visit >65 yrs of age | $196.00 |
| New Patient Visit Minimal Visit | $133.00 |
| New Patient Visit Moderate Visit | $196.00 |
| Pap Smear | $70.00 |
| Rapid Strep Test | $20.00 |
| Urine Dipstick Test | $11.00 |
| Accucheck | $12.00 |
| Pregnancy Test | $11.00 |
| Immunization – DTAP | $188.00 |
| Immunization – Hep A Peds | $253.00 |
| Immunization – Hep B up to age 11 | $194.00 |
| Immunization – HIB | $198.00 |
| Immunization – HPV | $760.00 |
| Immunization – Influenza | $98.00 |
| Immunization – Influenza 6 -35 months | $86.00 |
| Immunization – IPV (Polio) | $198.00 |
| Immunization – Kentrix (DTAP/Polio) | $308.00 |
| Immunization – MMR | $303.00 |
| Immunization – PCV 0-5 | $29.00 |
| Immunization – Pentacel (DTAP, Polio, HIB) | $473.00 |
| Immunization – Rotovirus | $506.00 |
| Immunization – TDAP | $293.00 |
| Immunization – VZV (Varicella) | $84.00 |
| Injection fee for Immunizations | $105.00 |
| Injection fee for therapeutics | $66.00 |
| Injection – B12 | $18.00 |
| Injection – Decadron | $22.88 |
| Injection – Depo Provera | $362.52 |
| Injection – Phenergan | $15.00 |
| Injection – Rocephin | $112.00 |
| Injection – Solumedrol | $28.00 |
| Injection – Toradol | $65.00 |
| Psychotherapy Services | $196.00 |
| LABORATORY: IN-HOUSE TESTING | INPATIENT CHARGE | OUTPATIENT CHARGE |
| CBC W/ auto DIFF | $209.30 | $67.00 |
| CBC /Hemogram | $120.00 | $51.00 |
| Manual Diff | $91.00 | $28.00 |
| Basic Metabolic Panel | $366.00 | $74.00 |
| Comprehensive Metabolic Panel | $435.00 | $105.00 |
| Urine dipstick only | $72.00 | $25.00 |
| Urine microscopic, complete | $114.00 | $42.00 |
| Troponin I | $165.00 | $165.00 |
| CKMB | $125.00 | $125.00 |
| Myoglobin | $195.00 | $195.00 |
| Lipase | $197.00 | $64.00 |
| HCG urine qual | $91.00 | $11.00 |
| Amylase | $178.00 | $46.00 |
| Magnesium | $167.00 | $33.00 |
| Creatine Kinase | $161.00 | $36.00 |
| PTINR | $125.00 | $44.00 |
| urine drug screens | $136.00 | $83.00 |
| BNP | $318.00 | $202.00 |
| APTT | $142.00 | $58.00 |
| Influenza A/B | $277.00 | $54.00 |
| Strep A test | $119.00 | $46.00 |
| Lipid Panel | $182.00 | $83.00 |
| Phosphorus | $106.00 | $28.00 |
