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Shoppable Service Primary Service and Ancillary Services Revenue Code CPT/HCPCS Code Cash Price Service Location Site Type Aetna Commercial Arcadian Medicare Advantage BCBS Commercial HMO Blue BCBS Commercial PPO BCBS Commercial Blue Premier BCBS Commercial Traditional Cigna Commercial Connected Senior Care Medicare Advantage Elder Health TX Medicare Advantage Fair Price Commercial Healthcare Highways Commercial Humana Commercial HMO Humana Commercial PPO Humana Military Occunet UT Athletes Oscar Exchange Prime Health Commercial Prime Health Workers Compensation Prime Health Medicare Advantage Sendero Exchange Sendero CHAP Seton CHIP & STAR Seton Commercial Superior Exchange Superior Medicare Advantage & Dual United Healthcare Commercial Wellmed Medicare Advantage De-identified Minimum Negotiated Charge De-identified Maximum Negotiated Charge
Removal of Breast Growth Primary Procedure 360 19120 4284.48 Northwest Hills Surgical Hospital OP 2069.00 510.00 1776.83 1991.03 1776.83 1974.26 1273.00 2856.32 507.08 4284.48 1500.00 2324.00 8796.00 892.80 3427.58 1301.00 4532.50 3527.56 2856.32 4998.56 2799.19 408.42 4548.76 3093.15 2856.32 1919.00 2856.32 408.42 8796.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 199.15 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 199.15 199.15
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1029.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1029.00 1029.00
Endoscopic Removal of Single Knee Cartilage Primary Procedure 360 29881 3871.38 Northwest Hills Surgical Hospital OP 2549.00 630.00 1940.10 2179.99 1940.10 2155.67 4725.00 2580.92 1400.00 3871.38 4500.00 2869.00 10862.00 1203.42 3097.10 1606.00 5292.00 3187.44 2580.92 4516.61 2529.30 503.08 4077.22 2772.51 2580.92 2277.00 2580.92 503.08 10862.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 433.48 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 433.48 433.48
Supply / Implants 278 C1713 Included in Primary Procedure Northwest Hills Surgical Hospital OP 1892.00 Included in Primary Procedure 1754.40 1754.40 1754.40 1754.40 1806.00 Included in Primary Procedure 3612.00 1806.00 1548.00 2580.00 2580.00 Included in Primary Procedure 1754.40 Included in Primary Procedure 3612.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1720.00 1548.00 3612.00
OR Services 360 29876 Included in Primary Procedure Northwest Hills Surgical Hospital OP 1274.50 Included in Primary Procedure 970.05 1089.99 970.05 1077.84 2362.50 Included in Primary Procedure 700.00 Included in Primary Procedure 2250.00 1434.50 5431.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 5848.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 4077.22 2772.51 Included in Primary Procedure 1138.50 Included in Primary Procedure 700.00 5848.50
OR Services 360 29879 Included in Primary Procedure Northwest Hills Surgical Hospital OP 517.25 Included in Primary Procedure 485.03 545.00 485.03 538.92 1181.25 Included in Primary Procedure 700.00 Included in Primary Procedure 2250.00 581.00 2199.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 5439.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 4077.22 2772.51 Included in Primary Procedure 569.25 Included in Primary Procedure 485.03 5439.00
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 445.20 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 445.20 445.20
Endoscopic diagnostic examination of esophagus, stomach, and/or upper small bowel Primary Procedure 360 43235 1111.47 Northwest Hills Surgical Hospital OP 1296.00 333.00 603.42 678.28 603.42 670.47 950.00 740.98 331.10 1111.47 1100.00 1517.00 5741.00 357.12 889.18 854.00 1501.50 915.11 740.98 1296.72 726.16 265.97 1166.24 793.04 740.98 1200.00 740.98 265.97 5741.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 75.78 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 75.78 75.78
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 210.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 210.00 210.00
Endoscopic biopsy of the esophagus, stomach, and/or upper small bowel Primary Procedure 360 43239 1111.47 Northwest Hills Surgical Hospital OP 1695.00 446.00 603.42 678.28 603.42 670.47 1125.00 740.98 443.45 1111.47 1100.00 2032.00 7693.00 491.04 889.18 1139.00 1589.00 915.11 740.98 1296.72 726.16 356.12 1166.24 793.04 740.98 1200.00 740.98 356.12 7693.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 78.58 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 78.58 78.58
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 315.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 315.00 315.00
Endoscopic diagnostic examination of large bowel Primary Procedure 750 45378 1080.30 Northwest Hills Surgical Hospital OP Included in Primary Procedure 446.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 720.20 Included in Primary Procedure 1080.30 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 491.04 864.24 1139.00 1666.00 889.45 720.20 1260.35 705.80 356.12 1143.26 Included in Primary Procedure 720.20 Included in Primary Procedure Included in Primary Procedure 356.12 1666.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 99.05 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 99.05 99.05
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 210.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 210.00 210.00
Endoscopic biopsy of Large Bowel Primary Procedure 360 45380 1420.20 Northwest Hills Surgical Hospital OP 1695.00 446.00 663.16 685.01 663.16 736.84 1125.00 946.80 443.45 1420.20 1100.00 2032.00 7693.00 541.26 1136.16 1139.00 1753.50 1169.30 946.80 1656.90 927.86 356.12 1493.75 1015.75 946.80 1200.00 946.80 356.12 7693.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 99.05 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 99.05 99.05
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 420.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 420.00 420.00
Endoscopic removal of polyps or growths of large bowel Primary Procedure 750 45385 1420.20 Northwest Hills Surgical Hospital OP Included in Primary Procedure 446.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 946.80 Included in Primary Procedure 1420.20 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 541.26 1136.16 1139.00 1879.50 1169.30 946.80 1656.90 927.86 356.12 1493.75 Included in Primary Procedure 946.80 Included in Primary Procedure Included in Primary Procedure 356.12 1879.50
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 135.45 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 135.45 135.45
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 315.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 315.00 315.00
Removal of cataract with insertion of lens Primary Procedure 360 66984 2859.38 Northwest Hills Surgical Hospital OP 3889.00 973.00 794.70 794.29 794.70 883.01 2975.00 1906.25 968.29 2859.38 750.00 4488.00 16995.00 1203.42 2287.50 2532.00 4245.50 2354.22 1906.25 3335.94 1868.13 844.15 2995.05 2036.63 1906.25 959.50 1906.25 750.00 16995.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 496.13 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 496.13 496.13
Sterile Supply 272 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 735.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 735.00 735.00
Supply / Implants 278 V2632 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure 107.10 107.10 107.10 107.10 Included in Primary Procedure Included in Primary Procedure 220.50 110.25 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 107.10 Included in Primary Procedure 220.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 105.00 105.00 220.50
OR Services 360 67036 Included in Primary Procedure Northwest Hills Surgical Hospital OP 1274.50 Included in Primary Procedure 2754.30 1588.59 2754.30 3060.33 780.00 Included in Primary Procedure 313.20 Included in Primary Procedure 2000.00 1434.50 5431.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 7287.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 5643.54 3837.61 Included in Primary Procedure 2738.00 Included in Primary Procedure 313.20 7287.00
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 445.20 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 445.20 445.20
Shaving of shoulder bone using an endoscope Primary Procedure 360 29826 Included in Primary Procedure Northwest Hills Surgical Hospital OP 517.25 Included in Primary Procedure 0.00 0.00 0.00 0.00 4725.00 Included in Primary Procedure 1400.00 Included in Primary Procedure 4500.00 1162.00 4398.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 7444.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 0.00 0.00 Included in Primary Procedure 79.50 Included in Primary Procedure 0.00 7444.50
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1092.88 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1092.88 1092.88
Supply/ Implants 278 C1713 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure 331.84 331.84 331.84 331.84 Included in Primary Procedure Included in Primary Procedure 683.20 341.60 292.80 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 331.84 Included in Primary Procedure 683.20 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 325.33 292.80 683.20
OR Services 360 23430 Included in Primary Procedure Northwest Hills Surgical Hospital OP 1274.50 Included in Primary Procedure 3403.48 4522.03 3403.48 3781.64 390.00 Included in Primary Procedure 313.20 Included in Primary Procedure 1000.00 2869.00 10862.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 8438.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 9024.72 6136.81 Included in Primary Procedure 4450.00 Included in Primary Procedure 313.20 10862.00
OR Services 360 29822 3871.38 Northwest Hills Surgical Hospital OP 3667.00 510.00 970.05 1089.99 970.05 1077.84 2362.50 2580.92 700.00 3871.38 2250.00 581.00 2199.00 674.25 3097.10 1301.00 6195.00 3187.44 2580.92 4516.61 2529.30 408.42 4077.22 2772.51 2580.92 1485.00 2580.92 408.42 6195.00
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 2017.40 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 2017.40 2017.40
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance Primary Procedure 360 64483 1148.43 Northwest Hills Surgical Hospital OP 1296.00 333.00 602.92 532.50 602.92 669.91 950.00 765.62 331.10 1148.43 750.00 1517.00 5741.00 357.12 918.74 854.00 3724.00 945.54 765.62 1339.84 750.31 265.97 1184.76 805.64 765.62 788.00 765.62 265.97 5741.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 113.05 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 113.05 113.05
DX X-ray 320 77003 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 311.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 311.50 311.50
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital OP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital OP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 315.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 315.00 315.00
Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC). MS-DRG 470 17587.71 Northwest Hills Surgical Hospital IP 17734.00 11725.14 14596.69 9281.28 12794.63 16218.54 17000.00 Not Applicable Not Applicable 17587.71 16268.00 8517.00 0.00 Not Applicable 11725.14 15293.88 0.00 16740.90 11725.14 20519.00 11725.14 8234.21 18049.05 11941.06 11725.14 15373.99 11725.14 0.00 20519.00
Room and Board 110 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 6300.00 Not Applicable Included in Primary Procedure Included in Primary Procedure 5880.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 5880.00 6300.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1139.81 Not Applicable Included in Primary Procedure Included in Primary Procedure 1063.83 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1063.83 1139.81
Medical/surgical Supplies 270 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 731.03 Not Applicable Included in Primary Procedure Included in Primary Procedure 682.29 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 682.29 731.03
Supply/ Implants 278 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure 9356.26 9356.26 9356.26 9356.26 9631.44 Not Applicable Not Applicable 9631.44 8255.52 13759.20 20638.80 Not Applicable 9356.26 Included in Primary Procedure 19262.88 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 8255.52 20638.80
Laboratory 300 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 80.43 Not Applicable Included in Primary Procedure Included in Primary Procedure 75.07 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 75.07 80.43
Laboratory / Chemistry 301 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 24.56 Not Applicable Included in Primary Procedure Included in Primary Procedure 22.93 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 22.93 24.56
DX X-ray 320 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 108.75 Not Applicable Included in Primary Procedure Included in Primary Procedure 101.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 101.50 108.75
OR Services 360 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 29180.63 Not Applicable Included in Primary Procedure Included in Primary Procedure 27235.25 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 27235.25 29180.63
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital IP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Ultrasound 402 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 613.11 Not Applicable Included in Primary Procedure Included in Primary Procedure 572.24 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 572.24 613.11
Physical Therapy 420 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1192.50 Not Applicable Included in Primary Procedure Included in Primary Procedure 1113.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1113.00 1192.50
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 364.50 Not Applicable Included in Primary Procedure Included in Primary Procedure 340.20 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 340.20 364.50
Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC). MS-DRG 473 22523.04 Northwest Hills Surgical Hospital IP 19196.00 15015.36 13439.28 10323.41 11780.11 14932.53 16000.00 Not Applicable Not Applicable 22523.04 20833.00 8517.00 0.00 Not Applicable 15015.36 19585.53 0.00 22382.87 15015.36 26276.88 15015.36 8164.54 24131.90 15965.41 15015.36 20555.30 15015.36 0.00 26276.88
Room and Board 110 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 3150.00 Not Applicable Included in Primary Procedure Included in Primary Procedure 2940.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 2940.00 3150.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1293.75 Not Applicable Included in Primary Procedure Included in Primary Procedure 1207.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1207.50 1293.75
Supply/ Implants 278 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure 3457.80 3457.80 3457.80 3457.80 3559.50 Not Applicable Not Applicable 3559.50 3051.00 5085.00 7627.50 Not Applicable 3457.80 Included in Primary Procedure 7119.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 3051.00 7627.50
DX X-ray 320 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 333.75 Not Applicable Included in Primary Procedure Included in Primary Procedure 311.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 311.50 333.75
OR Services 360 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 43446.32 Not Applicable Included in Primary Procedure Included in Primary Procedure 40549.90 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 40549.90 43446.32
Anesthesia 370 May be separately billed Northwest Hills Surgical Hospital IP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1407.00 Not Applicable Included in Primary Procedure Included in Primary Procedure 1313.20 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1313.20 1407.00
Spinal fusion except cervical without major comorbid conditions or complications (MCC) MS-DRG 460 35534.36 Northwest Hills Surgical Hospital IP 33233.00 23689.57 24598.97 17912.41 21562.06 27332.19 29000.00 Not Applicable Not Applicable 35534.36 32868.00 8517.00 0.00 Not Applicable 23689.57 30899.88 0.00 34652.84 23689.57 41456.75 23689.57 12469.28 37360.65 24717.41 23689.57 31823.41 23689.57 0.00 41456.75
Room and Board 110 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 6300.00 Not Applicable Included in Primary Procedure Included in Primary Procedure 5880.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 5880.00 6300.00
Pharmacy 250 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 926.81 Not Applicable Included in Primary Procedure Included in Primary Procedure 865.03 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 865.03 926.81
Sterile Supply 272 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 2587.50 Not Applicable Included in Primary Procedure Included in Primary Procedure 2415.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 2415.00 2587.50
Supply/ Implants 278 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure 19967.71 19967.71 19967.71 19967.71 20554.99 Not Applicable Not Applicable 20554.99 17618.57 29364.28 44046.41 Not Applicable 19967.71 Included in Primary Procedure 41109.99 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 17618.57 44046.41
Laboratory 300 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 13.29 Not Applicable Included in Primary Procedure Included in Primary Procedure 12.40 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 12.40 13.29
DX X-ray 320 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 637.50 Not Applicable Included in Primary Procedure Included in Primary Procedure 595.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 595.00 637.50
OR Services 360 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 38638.55 Not Applicable Included in Primary Procedure Included in Primary Procedure 36062.65 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 36062.65 38638.55
Anesthesia (Medication Only) 370 May be separately billed Northwest Hills Surgical Hospital IP May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed May be separately billed
Physical Therapy 420 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 356.25 Not Applicable Included in Primary Procedure Included in Primary Procedure 332.50 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 332.50 356.25
Physical Therapy Evaluation 424 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 337.50 Not Applicable Included in Primary Procedure Included in Primary Procedure 315.00 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 315.00 337.50
Recovery Room 710 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1824.00 Not Applicable Included in Primary Procedure Included in Primary Procedure 1702.40 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1702.40 1824.00
Other DX Services 920 Included in Primary Procedure Northwest Hills Surgical Hospital IP Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Not Applicable Not Applicable Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1141.98 Not Applicable Included in Primary Procedure Included in Primary Procedure 1065.85 Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure Included in Primary Procedure 1065.85 1141.98
X-Ray, lower back, minimum four views 72110 158.51 Northwest Hills Surgical Hospital OP 77.72 104.65 81.80 100.69 81.80 90.89 228.67 105.67 104.65 158.51 51.00 59.94 115.60 104.65 126.80 Not Applicable 119.00 130.50 105.67 184.92 103.56 68.00 156.97 106.74 104.65 99.77 105.67 51.00 228.67
Basic metabolic panel 80048 12.69 Northwest Hills Surgical Hospital OP 0.00 8.46 10.39 11.52 10.39 11.54 18.70 8.46 8.46 12.69 9.90 15.51 22.44 8.46 8.46 Not Applicable 23.10 11.49 8.46 14.81 8.29 13.20 12.69 8.63 8.46 11.51 8.46 0.00 23.10
Blood test, comprehensive group of blood chemicals 80053 15.84 Northwest Hills Surgical Hospital OP 0.00 10.56 12.97 14.39 12.97 14.41 23.35 10.56 10.56 15.84 12.30 19.37 27.88 10.56 10.56 Not Applicable 28.70 14.35 10.56 18.48 10.35 16.40 15.84 10.77 10.56 14.37 10.56 0.00 28.70
Kidney function panel test 80069 13.02 Northwest Hills Surgical Hospital OP 0.00 8.68 10.67 11.83 10.67 11.85 19.21 8.68 8.68 13.02 10.20 15.92 23.12 8.68 8.68 Not Applicable 23.80 11.79 8.68 15.19 8.51 13.60 13.02 8.85 8.68 11.82 8.68 0.00 23.80
Liver function blood test panel 80076 12.26 Northwest Hills Surgical Hospital OP 0.00 8.17 10.03 11.13 10.03 11.14 18.05 8.17 8.17 12.26 9.60 14.98 21.76 8.17 8.17 Not Applicable 22.40 11.10 8.17 14.30 8.01 12.80 12.26 8.33 8.17 11.11 8.17 0.00 22.40
Blood test, thyroid stimulating hormone (TSH) 84443 25.20 Northwest Hills Surgical Hospital OP 0.00 16.80 20.64 22.89 20.64 22.93 37.16 16.80 16.80 25.20 19.50 30.81 44.20 16.80 16.80 Not Applicable 45.50 22.82 16.80 29.40 16.46 26.00 25.20 17.14 16.80 22.87 16.80 0.00 45.50
Complete blood cell count, with differential white blood cells, automated 85025 11.66 Northwest Hills Surgical Hospital OP 0.00 7.77 9.55 10.59 9.55 10.61 17.19 7.77 7.77 11.66 11.70 14.24 26.52 7.77 7.77 Not Applicable 27.30 10.56 7.77 13.60 7.61 15.60 11.66 7.93 7.77 10.58 7.77 0.00 27.30
Complete blood count, automated 85027 9.71 Northwest Hills Surgical Hospital OP 0.00 6.47 7.95 8.81 7.95 8.83 14.32 6.47 6.47 9.71 7.50 11.85 17.00 6.47 6.47 Not Applicable 17.50 8.79 6.47 11.32 6.34 10.00 9.71 6.60 6.47 8.81 6.47 0.00 17.50
Blood test, clotting time 85610 6.44 Northwest Hills Surgical Hospital OP 0.00 4.29 4.83 5.36 4.83 5.37 8.69 4.29 4.29 6.44 4.50 7.21 10.20 4.29 4.29 Not Applicable 10.50 5.83 4.29 7.51 4.20 6.00 6.44 4.38 4.29 5.35 4.29 0.00 10.50
Coagulation assessment blood test 85730 9.02 Northwest Hills Surgical Hospital OP 0.00 6.01 7.37 8.18 7.37 8.19 13.28 6.01 6.01 9.02 5.40 11.01 12.24 6.01 6.01 Not Applicable 12.60 8.16 6.01 10.52 5.89 7.20 9.02 6.13 6.01 8.17 6.01 0.00 13.28
Physical therapy, therapeutic exercise 97110 46.29 Northwest Hills Surgical Hospital OP 44.41 30.86 27.52 32.58 27.52 30.58 120.00 30.86 30.86 46.29 90.00 71.25 64.60 30.86 30.86 Not Applicable 66.50 41.92 30.86 54.01 30.24 38.00 46.29 31.48 30.86 108.00 30.86 27.52 120.00
Electrocardiogram, routine, with interpretation and report 93000 Please Contact for Details Northwest Hills Surgical Hospital OP 374.00 0.00 14.37 17.19 14.37 15.97 Not Applicable 0.00 0.00 0.00 114.60 286.50 259.76 0.00 0.00 Not Applicable 267.40 0.00 0.00 0.00 0.00 152.80 0.00 0.00 0.00 568.00 0.00 0.00 568.00
Repair Biceps Tendon 23430 8459.85 Northwest Hills Surgical Hospital OP 2549.00 630.00 3403.48 4522.03 3403.48 3781.64 1560.00 5639.90 626.40 8459.85 2000.00 2869.00 10862.00 806.31 6767.88 1606.00 8438.50 6965.28 5639.90 9869.83 5527.10 503.08 9024.72 6136.81 6016.48 4450.00 5639.90 503.08 10862.00
Shoulder Arthroscopy/Surgery 29822 3871.38 Northwest Hills Surgical Hospital OP 3667.00 510.00 1940.10 2179.99 1940.10 2155.67 4725.00 2580.92 1400.00 3871.38 4500.00 2324.00 8796.00 674.25 3097.10 1301.00 6195.00 3187.44 2580.92 4516.61 2529.30 408.42 4077.22 2772.51 2718.15 2970.00 2580.92 408.42 8796.00
Knee Arthroscopy/Surgery 29876 3871.38 Northwest Hills Surgical Hospital OP 2549.00 630.00 1940.10 2179.99 1940.10 2155.67 4725.00 2580.92 1400.00 3871.38 4500.00 2869.00 10862.00 1203.42 3097.10 1606.00 5848.50 3187.44 2580.92 4516.61 2529.30 503.08 4077.22 2772.51 2718.15 2277.00 2580.92 503.08 10862.00
Knee Arthroscopy/Surgery 29879 3871.38 Northwest Hills Surgical Hospital OP 2069.00 510.00 1940.10 2179.99 1940.10 2155.67 4725.00 2580.92 1400.00 3871.38 4500.00 2324.00 8796.00 1203.42 3097.10 1301.00 5439.00 3187.44 2580.92 4516.61 2529.30 408.42 4077.22 2772.51 2718.15 2277.00 2580.92 408.42 8796.00
Removal Of Inner Eye Fluid 67036 5400.00 Northwest Hills Surgical Hospital OP 2549.00 630.00 2754.30 1588.59 2754.30 3060.33 1560.00 3600.00 626.40 5400.00 2000.00 2869.00 10862.00 806.31 4320.00 1606.00 7287.00 4446.00 3600.00 6300.00 3528.00 503.08 5643.54 3837.61 3762.36 2738.00 3600.00 503.08 10862.00
Routine Venipuncture 36415 4.50 Northwest Hills Surgical Hospital OP 0.00 3.00 0.00 0.00 0.00 0.00 4.88 3.00 3.00 4.50 2.48 6.19 5.61 3.00 3.00 Not Applicable 5.78 4.08 3.00 5.25 2.94 3.30 4.50 3.06 3.00 3.00 3.00 0.00 6.19
Unlisted Eye Surgery Procedure 66999 2859.38 Northwest Hills Surgical Hospital OP 1296.00 1996.70 155.14 1588.59 155.14 172.38 Not Applicable 1906.25 1996.70 2859.38 1100.00 75.00 68.00 1203.42 2287.50 Not Applicable 70.00 2354.22 1906.25 3335.94 1868.13 40.00 2995.05 2036.63 1996.70 1200.00 1906.25 40.00 3335.94
Treatment Of Fibula Fracture 27780 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 156.82 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 163.10 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Insj Temp Ndwellg Bladder Catheter Simple 51702 154.20 Northwest Hills Surgical Hospital OP 1296.00 182.09 33.48 82.97 33.48 37.20 1825.00 102.80 151.74 154.20 2050.00 171.00 646.00 203.33 123.36 91.04 212.44 126.96 102.80 179.90 100.74 121.39 161.27 109.66 107.51 318.00 102.80 33.48 2050.00
Treat Big Toe Fracture 28490 304.97 Northwest Hills Surgical Hospital OP 1296.00 190.68 53.78 87.70 53.78 59.76 1825.00 203.31 158.90 304.97 2050.00 329.00 1254.00 212.93 243.97 95.34 222.46 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 53.78 2050.00
Simple Repair Of Superficial Wounds Of Scalp, Neck, Axillae, External Genitalia, Trunk And/Or Extremities (Including Hands And Feet); 2.5 Cm Or Less 12001 247.11 Northwest Hills Surgical Hospital OP 1296.00 225.23 36.55 107.23 36.55 40.61 1825.00 164.74 187.69 247.11 2050.00 215.00 812.00 251.50 197.69 112.61 262.77 203.45 164.74 288.30 161.45 150.15 258.64 175.88 172.43 318.00 164.74 36.55 2050.00
Repair Of Nail Bed - Minor Surgery - Nail Charges 11760 702.90 Northwest Hills Surgical Hospital OP 1296.00 225.23 179.13 390.09 179.13 199.03 1825.00 468.60 187.69 702.90 2050.00 393.00 1500.00 674.25 562.32 112.61 262.77 578.72 468.60 820.05 459.23 182.00 755.07 513.45 503.38 318.00 468.60 112.61 2050.00
Skin Sub Graft T/A/L Add-On 15272 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 126.75 316.88 287.30 0.00 0.00 Not Applicable 295.75 0.00 0.00 0.00 0.00 169.00 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet); 12.6 Cm To 20.0 Cm 12035 451.86 Northwest Hills Surgical Hospital OP 1695.00 446.00 368.47 205.25 368.47 409.41 1125.00 301.24 443.45 451.86 2050.00 417.00 1577.00 541.26 361.49 1139.00 309.90 372.03 301.24 527.17 295.22 356.12 498.19 338.77 332.12 318.00 301.24 205.25 2050.00
Incisional Biopsy Of Skin 11106 451.86 Northwest Hills Surgical Hospital OP 1296.00 503.38 100.86 101.98 100.86 112.07 950.00 301.24 503.38 451.86 134.98 337.44 305.95 541.26 361.49 Not Applicable 314.94 372.03 301.24 527.17 295.22 83.38 755.07 513.45 503.38 318.00 301.24 83.38 1296.00
Simple Repair Of Superficial Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 2.5 Cm Or Less 12011 247.11 Northwest Hills Surgical Hospital OP Not Applicable 298.46 41.63 107.23 41.63 46.26 1825.00 164.74 248.72 247.11 2050.00 215.00 812.00 333.28 197.69 149.23 348.20 203.45 164.74 288.30 161.45 198.97 258.64 175.88 172.43 318.00 164.74 41.63 2050.00
Punch Biopsy Skin Single Lesion 11104 247.11 Northwest Hills Surgical Hospital OP Not Applicable 332.12 81.77 82.67 81.77 90.85 1825.00 164.74 332.12 247.11 149.23 373.07 338.25 541.26 197.69 Not Applicable 348.20 203.45 164.74 288.30 161.45 67.59 498.19 338.77 332.12 318.00 164.74 67.59 1825.00
Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or Ext 12041 451.86 Northwest Hills Surgical Hospital OP 1296.00 315.95 98.96 59.96 98.96 109.95 1825.00 301.24 263.30 451.86 2050.00 393.00 1500.00 357.12 361.49 157.98 368.61 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 59.96 2050.00
Unlisted Procedure, Musculoskeletal System, General - Other Procedures - Orthopedic Charges 20999 304.97 Northwest Hills Surgical Hospital OP 1296.00 198.01 1475.16 1324.29 1475.16 1639.07 Not Applicable 203.31 198.01 304.97 180.05 450.14 408.12 541.26 243.97 Not Applicable 420.13 251.09 203.31 355.79 199.24 240.07 297.02 201.97 198.01 318.00 203.31 180.05 1639.07
Shoulder Surgery Procedure 23929 304.97 Northwest Hills Surgical Hospital OP 1296.00 360.11 97.35 156.82 97.35 108.17 Not Applicable 203.31 300.09 304.97 2050.00 2114.00 10862.00 541.26 243.97 180.05 420.13 251.09 203.31 355.79 199.24 240.07 297.02 201.97 198.01 318.00 203.31 97.35 10862.00
Closed Treatment Of Calcaneal Fracture; With Manipulation - Closed Treatement - Foot/Toes Charges 28405 304.97 Northwest Hills Surgical Hospital OP 1695.00 446.00 404.03 216.13 404.03 448.92 1125.00 203.31 443.45 304.97 2050.00 471.00 1786.00 541.26 243.97 1139.00 443.57 251.09 203.31 355.79 199.24 356.12 297.02 201.97 198.01 318.00 203.31 198.01 2050.00
Graft Repair Of Spine Defect 63710 Please Contact for Details Northwest Hills Surgical Hospital OP Not Applicable 0.00 967.82 1028.61 967.82 1075.35 Not Applicable 0.00 0.00 0.00 190.20 475.50 431.12 0.00 0.00 Not Applicable 443.80 0.00 0.00 0.00 0.00 253.60 0.00 0.00 0.00 1317.00 0.00 0.00 1317.00
Unlisted Procedure, Humerus Or Elbow - Other Procedures - Orthopedic Charges 24999 304.97 Northwest Hills Surgical Hospital OP 1296.00 198.01 97.35 156.82 97.35 108.17 Not Applicable 203.31 198.01 304.97 190.37 475.92 431.50 541.26 243.97 Not Applicable 444.19 251.09 203.31 355.79 199.24 253.82 297.02 201.97 198.01 318.00 203.31 97.35 1296.00
Closed Treatment Of Calcaneal Fracture; Without Manipulation - Closed Treatement - Foot/Toes Charges 28400 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 216.13 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 451.42 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet); 20.1 Cm To 30.0 Cm 12036 702.90 Northwest Hills Surgical Hospital OP 1695.00 446.00 368.47 390.09 368.47 409.41 1125.00 468.60 443.45 702.90 2050.00 417.00 1577.00 541.26 562.32 1139.00 476.47 578.72 468.60 820.05 459.23 356.12 755.07 513.45 503.38 318.00 468.60 318.00 2050.00
Chemodervate Facial/Trigem/Cerv Musc Migraine 64615 370.20 Northwest Hills Surgical Hospital OP 1296.00 250.81 38.91 54.09 38.91 43.23 1825.00 246.80 250.81 370.20 218.57 171.00 646.00 357.12 296.16 Not Applicable 509.99 304.80 246.80 431.90 241.86 33.11 376.22 255.83 250.81 318.00 246.80 33.11 1825.00
Debrid Extensive Eczemati 11001 377.50 Northwest Hills Surgical Hospital OP 1296.00 453.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 377.50 377.50 2050.00 171.00 646.00 505.85 0.00 226.50 528.50 0.00 0.00 0.00 0.00 302.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Destruct Premalg Lesion 17000 247.11 Northwest Hills Surgical Hospital OP 1296.00 453.00 33.25 107.23 33.25 36.94 1825.00 164.74 377.50 247.11 2050.00 171.00 646.00 505.85 197.69 226.50 528.50 203.45 164.74 288.30 161.45 302.00 258.64 175.88 172.43 318.00 164.74 33.25 2050.00
Injection Intraesional Up 11900 247.11 Northwest Hills Surgical Hospital OP 1296.00 453.00 22.40 107.23 22.40 24.89 1825.00 164.74 377.50 247.11 2050.00 171.00 646.00 505.85 197.69 226.50 528.50 203.45 164.74 288.30 161.45 302.00 258.64 175.88 172.43 318.00 164.74 22.40 2050.00
Destruct B9 Lesion 1-14 17110 247.11 Northwest Hills Surgical Hospital OP 1296.00 453.00 41.63 107.23 41.63 46.26 1825.00 164.74 377.50 247.11 2050.00 171.00 646.00 505.85 197.69 226.50 528.50 203.45 164.74 288.30 161.45 302.00 258.64 175.88 172.43 318.00 164.74 41.63 2050.00
Biopsy Skin Subcutaneous 11100 377.50 Northwest Hills Surgical Hospital OP Not Applicable 453.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 226.50 377.50 377.50 2050.00 171.00 646.00 505.85 Not Applicable 226.50 528.50 Not Applicable Not Applicable Not Applicable Not Applicable 302.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 171.00 2050.00
Destruction Of Skin Lesions 17264 451.86 Northwest Hills Surgical Hospital OP 1296.00 453.00 73.28 114.78 73.28 81.42 1825.00 301.24 377.50 451.86 2050.00 215.00 812.00 505.85 361.49 226.50 528.50 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 73.28 2050.00
Removal Skin Tags M 11200 247.11 Northwest Hills Surgical Hospital OP 1296.00 453.00 36.08 107.23 36.08 40.09 1825.00 164.74 377.50 247.11 2050.00 171.00 646.00 505.85 197.69 226.50 528.50 203.45 164.74 288.30 161.45 302.00 258.64 175.88 172.43 318.00 164.74 36.08 2050.00
Removal Of Fixation Device 20665 514.20 Northwest Hills Surgical Hospital OP 1296.00 453.00 88.43 82.97 88.43 98.25 1825.00 342.80 377.50 514.20 2050.00 171.00 646.00 505.85 411.36 226.50 528.50 423.36 342.80 599.90 335.94 265.97 389.25 264.69 259.50 318.00 342.80 82.97 2050.00
Incision And Drainage Of Abscess; Simple Or Single - Incision And Drainage Charges 10060 247.11 Northwest Hills Surgical Hospital OP 1296.00 453.00 45.28 59.96 45.28 50.31 1825.00 164.74 377.50 247.11 2050.00 215.00 812.00 674.25 197.69 226.50 528.50 203.45 164.74 288.30 161.45 52.87 258.64 175.88 172.43 318.00 164.74 45.28 2050.00
Closed Treatment Of Phalangeal Shaft Fracture, Proximal Or Middle Phalanx, Finger Or Thumb; Without Manipulation, Each 26720 304.97 Northwest Hills Surgical Hospital OP 1296.00 453.00 53.78 87.70 53.78 59.76 1825.00 203.31 377.50 304.97 2050.00 329.00 1254.00 541.26 243.97 226.50 528.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 53.78 2050.00
Closed Treatment Of Radial And Ulnar Shaft Fractures; Withou - Closed Treatment - Upper Extremity  Charges 25560 304.97 Northwest Hills Surgical Hospital OP 1296.00 453.00 53.78 87.70 53.78 59.76 1825.00 203.31 377.50 304.97 2050.00 329.00 1254.00 541.26 243.97 226.50 528.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 53.78 2050.00
Injection For Hip X-Ray 27095 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 226.50 566.25 513.40 0.00 0.00 Not Applicable 528.50 0.00 0.00 0.00 0.00 302.00 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Closed Treatment Of Fracture Great Toe, Phalanx Or Phalanges; With Manipulation 28495 304.97 Northwest Hills Surgical Hospital OP 1296.00 349.36 74.75 87.70 74.75 83.06 1825.00 203.31 291.14 304.97 2050.00 329.00 1254.00 390.12 243.97 174.68 528.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 74.75 2050.00
Control Nasal Hemorrhage, Anterior, Simple (Limited Cautery - Nasal Hemorrhage Charges 30901 154.20 Northwest Hills Surgical Hospital OP 1296.00 453.00 34.66 82.97 34.66 38.51 1825.00 102.80 377.50 154.20 2050.00 171.00 646.00 505.85 123.36 226.50 528.50 126.96 102.80 179.90 100.74 302.00 161.27 109.66 107.51 318.00 102.80 34.66 2050.00
Biopsy Of Uterus Lining 58100 234.84 Northwest Hills Surgical Hospital OP 1296.00 453.00 32.07 44.64 32.07 35.63 1825.00 156.56 377.50 234.84 2050.00 171.00 646.00 357.12 187.87 226.50 528.50 193.35 156.56 273.98 153.43 265.97 245.35 166.84 163.57 318.00 156.56 32.07 2050.00
N Block Inj Plantar Digit 64455 370.20 Northwest Hills Surgical Hospital OP 1296.00 465.00 12.74 17.92 12.74 14.15 Not Applicable 246.80 387.50 370.20 2050.00 171.00 646.00 357.12 296.16 232.50 542.50 304.80 246.80 431.90 241.86 265.97 376.22 255.83 250.81 Not Applicable 246.80 12.74 2050.00
Place Needle Wire Breast 19290 392.50 Northwest Hills Surgical Hospital OP Not Applicable 333.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 235.50 331.10 392.50 2050.00 2114.00 10862.00 525.95 Not Applicable 854.00 549.50 Not Applicable Not Applicable Not Applicable Not Applicable 314.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 235.50 10862.00
Wound Prep F/N/Hf/G 15004 702.90 Northwest Hills Surgical Hospital OP 1695.00 446.00 368.47 390.09 368.47 409.41 1125.00 468.60 396.55 702.90 2050.00 1473.00 5575.00 541.26 562.32 1139.00 555.17 578.72 468.60 820.05 459.23 356.12 755.07 513.45 503.38 318.00 468.60 318.00 5575.00
Repair, Complex, Forehead, Cheeks, Chin, Mouth, Neck, Axillae, Genitalia, Hands And/Or Feet; 1.1 Cm To 2.5 Cm 13131 451.86 Northwest Hills Surgical Hospital OP 1695.00 446.00 179.13 390.09 179.13 199.03 1125.00 301.24 443.45 451.86 2050.00 417.00 1577.00 541.26 361.49 1139.00 555.17 372.03 301.24 527.17 295.22 356.12 498.19 338.77 332.12 318.00 301.24 179.13 2050.00
Debridement, Muscle And/Or Fascia (Includes Epidermis, Dermi - Debridement  Charges 11043 702.90 Northwest Hills Surgical Hospital OP 1695.00 446.00 247.33 390.09 247.33 274.81 1125.00 468.60 443.45 702.90 2050.00 749.00 2836.00 541.26 562.32 1139.00 555.17 578.72 468.60 820.05 459.23 356.12 755.07 513.45 503.38 318.00 468.60 247.33 2836.00
Debridement, Subcutaneous Tissue (Includes Epidermis And Dermis, If Performed); First 20 Sq Cm Or Less 11042 451.86 Northwest Hills Surgical Hospital OP 1695.00 446.00 247.33 205.25 247.33 274.81 1125.00 301.24 443.45 451.86 2050.00 749.00 2836.00 204.60 361.49 1139.00 555.17 372.03 301.24 527.17 295.22 356.12 498.19 338.77 332.12 318.00 301.24 204.60 2836.00
Closed Treatment Of Distal Radial Fracture (Eg, Colles Or Smith Type) Or Epiphyseal Separation, Includes Closed Treatment Of Fracture Of Ulnar Styloid, When Performed; Without Manipulation 25600 304.97 Northwest Hills Surgical Hospital OP 1296.00 480.00 86.24 120.85 86.24 95.82 1825.00 203.31 400.00 304.97 2050.00 329.00 1254.00 541.26 243.97 240.00 560.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 86.24 2050.00
Repair, Intermediate, Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 2.6 Cm To 5.0 Cm 12052 451.86 Northwest Hills Surgical Hospital OP 1296.00 495.00 98.96 114.78 98.96 109.95 1825.00 301.24 412.50 451.86 2050.00 393.00 1500.00 541.26 361.49 247.50 577.50 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 98.96 2050.00
Chemodenerv 1 Extremity 1-4 64642 883.97 Northwest Hills Surgical Hospital OP 1296.00 609.42 46.93 65.49 46.93 52.14 1825.00 589.31 609.42 883.97 750.00 215.00 812.00 674.25 707.17 Not Applicable 577.60 727.80 589.31 1031.29 577.52 38.79 914.13 621.61 609.42 788.00 589.31 38.79 1825.00
Repair, Intermediate, Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 2.5 Cm Or Less 12051 451.86 Northwest Hills Surgical Hospital OP 1296.00 513.00 98.96 114.78 98.96 109.95 1825.00 301.24 427.50 451.86 2050.00 393.00 1500.00 357.12 361.49 256.50 598.50 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 98.96 2050.00
Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet); 2.6 Cm To 7.5 Cm 12032 451.86 Northwest Hills Surgical Hospital OP 1296.00 519.00 98.96 114.78 98.96 109.95 1825.00 301.24 432.50 451.86 2050.00 393.00 1500.00 357.12 361.49 259.50 605.50 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 98.96 2050.00
Debridement Including Removal Of Foreign Material At The Site Of An Open Fracture And/Or An Open Dislocation (Eg, Excisional Debridement); Skin, Subcutaneous Tissue, Muscle Fascia, Muscle, And Bone 11012 3279.45 Northwest Hills Surgical Hospital OP 1695.00 446.00 576.82 1286.99 576.82 640.91 1125.00 2186.30 443.45 3279.45 750.00 1146.00 4338.00 541.26 2623.56 1139.00 606.38 2700.08 2186.30 3826.03 2142.57 356.12 3414.02 2321.54 2276.02 788.00 2186.30 356.12 4338.00
Excision Of Nail And Nail Matrix, Partial Or Complete, For P - Minor Surgery - Nail Charges 11750 451.86 Northwest Hills Surgical Hospital OP 1296.00 519.75 84.65 111.10 84.65 94.06 950.00 301.24 433.13 451.86 2050.00 417.00 1577.00 892.80 361.49 259.88 606.38 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 84.65 2050.00
Excise Benign Lesion 11422 1941.17 Northwest Hills Surgical Hospital OP 1296.00 519.75 70.04 99.05 70.04 77.82 950.00 1294.11 433.13 1941.17 750.00 403.00 1526.00 674.25 1552.93 259.88 606.38 1598.23 1294.11 2264.69 1268.23 265.97 2026.80 1378.22 1351.20 788.00 1294.11 70.04 2264.69
Debridement, Bone (Includes Epidermis, Dermis, Subcutaneous - Debridement  Charges 11044 1941.17 Northwest Hills Surgical Hospital OP 1695.00 446.00 576.82 857.20 576.82 640.91 1125.00 1294.11 443.45 1941.17 750.00 1927.00 7294.00 541.26 1552.93 1139.00 606.38 1598.23 1294.11 2264.69 1268.23 356.12 2026.80 1378.22 1351.20 788.00 1294.11 356.12 7294.00
Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or External Genitalia; 2.6 Cm To 7.5 Cm 12042 451.86 Northwest Hills Surgical Hospital OP 1296.00 537.00 98.96 114.78 98.96 109.95 1825.00 301.24 447.50 451.86 2050.00 393.00 1500.00 491.04 361.49 268.50 626.50 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 98.96 2050.00
Bone Marrow Aspiration Bone Grfg 20939 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 274.50 686.25 622.20 0.00 0.00 Not Applicable 640.50 0.00 0.00 0.00 0.00 366.00 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet); 2.5 Cm Or Less 12031 451.86 Northwest Hills Surgical Hospital OP 1296.00 511.58 98.96 114.78 98.96 109.95 1825.00 301.24 426.32 451.86 2050.00 393.00 1500.00 357.12 361.49 255.79 644.00 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 98.96 2050.00
Repair Complex Trunk 13102 477.50 Northwest Hills Surgical Hospital OP 1296.00 333.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 477.50 477.50 2050.00 417.00 1577.00 357.12 0.00 854.00 668.50 0.00 0.00 0.00 0.00 382.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Destruction Of Skin Lesions 17263 247.11 Northwest Hills Surgical Hospital OP 1296.00 573.00 73.28 107.23 73.28 81.42 1825.00 164.74 477.50 247.11 2050.00 215.00 812.00 639.85 197.69 286.50 668.50 203.45 164.74 288.30 161.45 382.00 258.64 175.88 172.43 318.00 164.74 73.28 2050.00
Repair Complex Trunk 13101 702.90 Northwest Hills Surgical Hospital OP 2069.00 510.00 368.47 390.09 368.47 409.41 1273.00 468.60 507.08 702.90 2050.00 1473.00 5575.00 674.25 562.32 1301.00 668.50 578.72 468.60 820.05 459.23 408.42 755.07 513.45 503.38 318.00 468.60 318.00 5575.00
Nasal Endoscopy, Diagnostic, Unilateral Or Bilateral (Separa - Endoscopic Procedures Charges 31231 221.40 Northwest Hills Surgical Hospital OP 1695.00 573.00 74.78 71.91 74.78 83.09 1825.00 147.60 477.50 221.40 2050.00 215.00 812.00 892.80 177.12 286.50 668.50 182.29 147.60 258.30 144.65 265.97 236.81 161.03 157.87 318.00 147.60 71.91 2050.00
Injection Intraesional Mo 11901 247.11 Northwest Hills Surgical Hospital OP 1296.00 582.60 24.53 107.23 24.53 27.25 1825.00 164.74 485.50 247.11 2050.00 171.00 646.00 650.57 197.69 291.30 679.70 203.45 164.74 288.30 161.45 388.40 258.64 175.88 172.43 318.00 164.74 24.53 2050.00
Correction Hallux Bunion 28291 8459.85 Northwest Hills Surgical Hospital OP 2069.00 6016.48 4697.42 4749.62 4697.42 5219.36 Not Applicable 5639.90 6016.48 8459.85 2400.00 6097.00 23086.00 674.25 6767.88 Not Applicable 688.80 6965.28 5639.90 9869.83 5527.10 1036.82 9024.72 6136.81 6016.48 3290.00 5639.90 674.25 23086.00
Repair, Complex, Forehead, Cheeks, Chin, Mouth, Neck, Axillae, Genitalia, Hands And/Or Feet; Each Additional 5 Cm Or Less 13133 497.50 Northwest Hills Surgical Hospital OP 1296.00 333.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 417.00 1577.00 357.12 0.00 854.00 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Repair, Complex, Scalp, Arms, And/Or Legs; Each Additional 5 - Complex Wound Closures Charges 13122 497.50 Northwest Hills Surgical Hospital OP 1296.00 333.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 417.00 1577.00 357.12 0.00 854.00 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Dressings And/Or Debridement Of Partial-Thickness Burns Initial Or Subsequent; Small 16020 247.11 Northwest Hills Surgical Hospital OP 1296.00 597.00 35.14 107.23 35.14 39.04 950.00 164.74 497.50 247.11 2050.00 171.00 646.00 666.65 197.69 298.50 696.50 203.45 164.74 288.30 161.45 398.00 258.64 175.88 172.43 318.00 164.74 35.14 2050.00
Arthrocentesis, Aspiration And/Or Injection, Intermediate Joint Or Bursa; Without Ultrasound Guidance 20605 370.20 Northwest Hills Surgical Hospital OP 1296.00 597.00 15.33 21.83 15.33 17.03 950.00 246.80 497.50 370.20 2050.00 171.00 646.00 491.04 296.16 298.50 696.50 304.80 246.80 431.90 241.86 17.89 376.22 255.83 250.81 318.00 246.80 15.33 2050.00
15819 Plastic Surgery Neck 15819 2294.93 Northwest Hills Surgical Hospital OP 1695.00 597.00 1234.07 1284.20 1234.07 1371.19 950.00 1529.95 497.50 2294.93 1100.00 393.00 1500.00 666.65 1835.94 298.50 696.50 1889.49 1529.95 2677.41 1499.35 408.42 2470.99 1680.28 1647.33 1200.00 1529.95 298.50 2677.41
Arthrocentesis, Aspiration And/Or Injection, Major Joint Or - Arthocentesis/Aspiration/Injection-Joint Or Bursa 20610 370.20 Northwest Hills Surgical Hospital OP 1296.00 597.00 18.86 26.39 18.86 20.96 950.00 246.80 497.50 370.20 2050.00 171.00 646.00 491.04 296.16 298.50 696.50 304.80 246.80 431.90 241.86 21.63 376.22 255.83 250.81 318.00 246.80 18.86 2050.00
15157 Cult Epiderm Grft F/N/Hfg +% 15157 497.50 Northwest Hills Surgical Hospital OP 1296.00 333.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 1517.00 5741.00 357.12 0.00 854.00 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 5741.00
15152 Cult Skin Graft T/A/L +% 15152 497.50 Northwest Hills Surgical Hospital OP 1296.00 333.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 1517.00 5741.00 357.12 0.00 854.00 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 5741.00
Closed Treatment Of Scapular Fracture; Without Manipulation - Closed Treatment - Shoulder Charges 23570 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 97.35 156.82 97.35 108.17 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 97.35 2050.00
Closed Treatment Of Shoulder Dislocation, With Manipulation; Without Anesthesia 23650 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 156.82 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 204.60 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
21820 Treat Sternum Fracture 21820 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 97.35 156.82 97.35 108.17 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 97.35 2050.00
Closed Treatment Of Ulnar Fracture, Proximal End; Without Ma - Closed Treatment - Upper Extremity  Charges 24670 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 97.35 156.82 97.35 108.17 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 97.35 2050.00
Closed Treatment Of Clavicular Fracture; Without Manipulatio - Closed Treatment - Shoulder Charges 23500 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 97.35 156.82 97.35 108.17 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 97.35 2050.00
Closed Treatment Of Acromioclavicular Dislocation; Without M - Closed Treatment - Shoulder Charges 23540 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 156.82 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Closed Treatment Of Temporomandibular Dislocation; Initial O - Closed Treatment - Skull/Face Charges 21480 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 75.71 117.65 75.71 84.12 950.00 203.31 331.10 304.97 2050.00 688.00 2597.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 75.71 2597.00
Closed Treatment Of Supracondylar Or Transcondylar Humeral F 24530 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 216.13 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
21800 Treatment Of Rib Fracture 21800 497.50 Northwest Hills Surgical Hospital OP Not Applicable 333.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 298.50 331.10 497.50 2050.00 2114.00 10862.00 357.12 Not Applicable 854.00 696.50 Not Applicable Not Applicable Not Applicable Not Applicable 398.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 298.50 10862.00
Closed Treatment Of Humeral Condylar Fracture, Medial Or Lateral; Without Manipulation 24576 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 216.13 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation 24560 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 97.35 156.82 97.35 108.17 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 97.35 2050.00
Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each 26725 304.97 Northwest Hills Surgical Hospital OP 1695.00 597.00 86.24 120.85 86.24 95.82 1825.00 203.31 497.50 304.97 2050.00 329.00 1254.00 541.26 243.97 298.50 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 86.24 2050.00
Treat wrist dislocation 25660 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 216.13 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 696.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Fine Needle Aspiration W 10022 760.00 Northwest Hills Surgical Hospital OP Not Applicable 912.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 456.00 760.00 760.00 750.00 813.00 3093.00 1018.40 Not Applicable 456.00 1064.00 Not Applicable Not Applicable Not Applicable Not Applicable 608.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 456.00 3093.00
Acne surgery 10040 247.11 Northwest Hills Surgical Hospital OP Not Applicable 912.00 34.43 107.23 34.43 38.25 1825.00 164.74 760.00 247.11 2050.00 171.00 646.00 1018.40 197.69 456.00 1064.00 203.45 164.74 288.30 161.45 608.00 258.64 175.88 172.43 318.00 164.74 34.43 2050.00
Deb musc/fascia add-on 11046 650.00 Northwest Hills Surgical Hospital OP 1296.00 780.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 650.00 650.00 2050.00 471.00 1786.00 871.00 0.00 390.00 910.00 0.00 0.00 0.00 0.00 520.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Trim skin lesion 11055 247.11 Northwest Hills Surgical Hospital OP 1296.00 912.00 22.64 107.23 22.64 25.15 1825.00 164.74 760.00 247.11 2050.00 171.00 646.00 1018.40 197.69 456.00 1064.00 203.45 164.74 288.30 161.45 608.00 258.64 175.88 172.43 318.00 164.74 22.64 2050.00
Shave skin lesion >2.0 cm 11303 451.86 Northwest Hills Surgical Hospital OP Not Applicable 912.00 68.38 107.23 68.38 75.98 1825.00 301.24 760.00 451.86 2050.00 215.00 812.00 1018.40 361.49 456.00 1064.00 372.03 301.24 527.17 295.22 608.00 498.19 338.77 332.12 318.00 301.24 68.38 2050.00
Shave skin lesion 0.5 cm/< 11305 247.11 Northwest Hills Surgical Hospital OP Not Applicable 912.00 41.63 107.23 41.63 46.26 1825.00 164.74 760.00 247.11 2050.00 171.00 646.00 1018.40 197.69 456.00 1064.00 203.45 164.74 288.30 161.45 608.00 258.64 175.88 172.43 318.00 164.74 41.63 2050.00
Shave skin lesion >2.0 cm 11308 451.86 Northwest Hills Surgical Hospital OP Not Applicable 912.00 61.31 107.23 61.31 68.12 1825.00 301.24 760.00 451.86 2050.00 171.00 646.00 1018.40 361.49 456.00 1064.00 372.03 301.24 527.17 295.22 608.00 498.19 338.77 332.12 318.00 301.24 61.31 2050.00
Shave skin lesion 1.1-2.0 cm 11312 451.86 Northwest Hills Surgical Hospital OP Not Applicable 912.00 69.80 99.70 69.80 77.55 1825.00 301.24 760.00 451.86 2050.00 171.00 646.00 541.26 361.49 456.00 1064.00 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 69.80 2050.00
Shave skin lesion >2.0 cm 11313 451.86 Northwest Hills Surgical Hospital OP Not Applicable 912.00 73.28 108.83 73.28 81.42 1825.00 301.24 760.00 451.86 2050.00 171.00 646.00 1018.40 361.49 456.00 1064.00 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 73.28 2050.00
Exc tr-ext b9+marg 0.6-1 cm 11401 451.86 Northwest Hills Surgical Hospital OP 1296.00 870.00 62.96 89.27 62.96 69.96 950.00 301.24 725.00 451.86 2050.00 329.00 1254.00 491.04 361.49 435.00 1015.00 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 62.96 2050.00
Exc tr-ext mal+marg 1.1-2 cm 11602 451.86 Northwest Hills Surgical Hospital OP 1296.00 846.00 101.39 143.69 101.39 112.66 950.00 301.24 705.00 451.86 2050.00 579.00 2192.00 357.12 361.49 423.00 987.00 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 101.39 2192.00
Biopsy nail unit 11755 862.70 Northwest Hills Surgical Hospital OP 1296.00 753.00 55.18 77.54 55.18 61.31 950.00 575.13 627.50 862.70 750.00 306.00 1154.00 541.26 690.16 376.50 878.50 710.29 575.13 1006.48 563.63 265.97 895.95 609.25 597.30 788.00 575.13 55.18 1296.00
Correct skin color ea 20.0cm 11922 732.50 Northwest Hills Surgical Hospital OP 1296.00 879.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 732.50 732.50 2050.00 171.00 646.00 981.55 0.00 439.50 1025.50 0.00 0.00 0.00 0.00 586.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Remove contraceptive capsule 11976 862.70 Northwest Hills Surgical Hospital OP 1296.00 912.00 47.87 66.79 47.87 53.19 950.00 575.13 760.00 862.70 750.00 215.00 812.00 541.26 690.16 456.00 1064.00 710.29 575.13 1006.48 563.63 139.50 895.95 609.25 597.30 788.00 575.13 47.87 1296.00
Implant hormone pellet(s) 11980 514.20 Northwest Hills Surgical Hospital OP 1296.00 813.00 28.76 82.97 28.76 31.96 1825.00 342.80 677.50 514.20 2050.00 171.00 646.00 907.85 411.36 406.50 948.50 423.36 342.80 599.90 335.94 542.00 389.25 264.69 259.50 318.00 342.80 28.76 2050.00
Wnd prep f/n/hf/g addl cm 15005 627.50 Northwest Hills Surgical Hospital OP 1296.00 333.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 627.50 627.50 2050.00 1473.00 5575.00 357.12 0.00 854.00 878.50 0.00 0.00 0.00 0.00 356.12 0.00 0.00 0.00 318.00 Not Applicable 0.00 5575.00
Skin pinch graft 15050 702.90 Northwest Hills Surgical Hospital OP 1695.00 446.00 368.47 390.09 368.47 409.41 1125.00 468.60 443.45 702.90 2050.00 1473.00 5575.00 541.26 562.32 1139.00 871.50 578.72 468.60 820.05 459.23 356.12 755.07 513.45 503.38 318.00 468.60 318.00 5575.00
Epidrm autogrft t/a/l add-on 15111 627.50 Northwest Hills Surgical Hospital OP 1296.00 333.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 627.50 627.50 2050.00 1517.00 5741.00 357.12 0.00 854.00 878.50 0.00 0.00 0.00 0.00 502.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 5741.00
Cult skin grft t/arm/leg 15150 2294.93 Northwest Hills Surgical Hospital OP 1695.00 446.00 1234.07 1945.12 1234.07 1371.19 1125.00 1529.95 565.00 2294.93 1800.00 2032.00 7693.00 541.26 1835.94 1139.00 791.00 1889.49 1529.95 2677.41 1499.35 356.12 2470.99 1680.28 1647.33 1919.00 1529.95 356.12 7693.00
Cult skin graft f/n/hf/g 15155 4210.58 Northwest Hills Surgical Hospital OP 1695.00 446.00 2034.41 1284.20 2034.41 2260.46 1125.00 2807.05 565.00 4210.58 1800.00 2032.00 7693.00 541.26 3368.46 1139.00 791.00 3466.71 2807.05 4912.34 2750.91 356.12 5073.69 3450.11 3382.46 2277.00 2807.05 356.12 7693.00
Acell Graft T/Arm/Leg Add-On 15171 665.00 Northwest Hills Surgical Hospital OP 2549.00 798.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 2114.00 10862.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 10862.00
Acell Graft F/N/Hf/G Add-On 15176 665.00 Northwest Hills Surgical Hospital OP 2549.00 798.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 2114.00 10862.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 10862.00
Aply Acell Grft T/A/L Add-On 15331 502.50 Northwest Hills Surgical Hospital OP 2549.00 333.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 301.50 502.50 502.50 2050.00 2114.00 10862.00 357.12 Not Applicable 854.00 703.50 Not Applicable Not Applicable Not Applicable Not Applicable 402.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 301.50 10862.00
Apply Cult Skin Substitute 15340 692.50 Northwest Hills Surgical Hospital OP 2549.00 831.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 415.50 692.50 692.50 2050.00 2114.00 10862.00 927.95 Not Applicable 415.50 969.50 Not Applicable Not Applicable Not Applicable Not Applicable 554.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 415.50 10862.00
Apply Cult Skin Sub Add-On 15341 665.00 Northwest Hills Surgical Hospital OP 2549.00 798.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 2114.00 10862.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 10862.00
Apply Cult Derm Sub T/A/L 15360 665.00 Northwest Hills Surgical Hospital OP 2549.00 798.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 2114.00 10862.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 10862.00
Aply Cult Derm Sub T/A/L Add 15361 665.00 Northwest Hills Surgical Hospital OP 2549.00 798.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 2114.00 10862.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 10862.00
Apply Cult Derm Sub F/N/Hf/G 15365 665.00 Northwest Hills Surgical Hospital OP 2549.00 798.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 2114.00 10862.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 10862.00
Apply Cult Derm F/Hf/G Add 15366 665.00 Northwest Hills Surgical Hospital OP 2549.00 798.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 2114.00 10862.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 10862.00
Apply Skn Xenogrft T/A/L Add 15401 565.00 Northwest Hills Surgical Hospital OP 2549.00 446.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 339.00 443.45 565.00 2050.00 2114.00 10862.00 541.26 Not Applicable 1139.00 791.00 Not Applicable Not Applicable Not Applicable Not Applicable 452.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 339.00 10862.00
Apply Acellular Xenograft 15430 667.50 Northwest Hills Surgical Hospital OP 2549.00 446.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 400.50 667.50 667.50 2050.00 2114.00 10862.00 894.45 Not Applicable 1139.00 934.50 Not Applicable Not Applicable Not Applicable Not Applicable 534.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 400.50 10862.00
Chemical peel face dermal 15789 702.90 Northwest Hills Surgical Hospital OP Not Applicable 912.00 73.28 114.78 73.28 81.42 1825.00 468.60 760.00 702.90 2050.00 215.00 812.00 1018.40 562.32 456.00 1064.00 578.72 468.60 820.05 459.23 608.00 755.07 513.45 503.38 318.00 468.60 73.28 2050.00
Dress/debrid p-thick burn l 16030 451.86 Northwest Hills Surgical Hospital OP 1695.00 446.00 132.65 205.25 132.65 147.39 1125.00 301.24 565.00 451.86 2050.00 451.00 1719.00 541.26 361.49 1139.00 791.00 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 132.65 2050.00
Incision of burn scab initi 16035 451.86 Northwest Hills Surgical Hospital OP 1695.00 780.00 132.65 390.09 132.65 147.39 Not Applicable 301.24 650.00 451.86 2050.00 488.00 1843.00 871.00 361.49 390.00 910.00 372.03 301.24 527.17 295.22 356.12 498.19 338.77 332.12 318.00 301.24 132.65 2050.00
Destruct premalg les 2-14 17003 760.00 Northwest Hills Surgical Hospital OP 1296.00 912.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 760.00 760.00 2050.00 171.00 646.00 1018.40 0.00 456.00 1064.00 0.00 0.00 0.00 0.00 608.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Destruction of skin lesions 17106 451.86 Northwest Hills Surgical Hospital OP 1296.00 729.00 124.04 179.20 124.04 137.82 950.00 301.24 607.50 451.86 2050.00 488.00 1843.00 541.26 361.49 364.50 850.50 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 124.04 2050.00
Destruction of skin lesions 17273 451.86 Northwest Hills Surgical Hospital OP 1296.00 798.00 79.94 113.71 79.94 88.82 1825.00 301.24 665.00 451.86 2050.00 451.00 1719.00 891.10 361.49 399.00 931.00 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 79.94 2050.00
Drainage of breast lesion 19000 862.70 Northwest Hills Surgical Hospital OP 1296.00 699.00 52.11 73.64 52.11 57.90 950.00 575.13 582.50 862.70 750.00 329.00 1254.00 541.26 690.16 349.50 815.50 710.29 575.13 1006.48 563.63 65.23 895.95 609.25 597.30 788.00 575.13 52.11 1296.00
Bx breast 1st lesion us imag 19083 1941.17 Northwest Hills Surgical Hospital OP 1695.00 1351.20 631.87 857.20 631.87 702.08 1273.00 1294.11 1351.20 1941.17 1100.00 1698.00 6431.00 541.26 1552.93 Not Applicable 965.09 1598.23 1294.11 2264.69 1268.23 265.97 2026.80 1378.22 1351.20 1200.00 1294.11 265.97 6431.00
Us bone stimulation 20979 32.52 Northwest Hills Surgical Hospital OP Not Applicable 912.00 18.86 27.76 18.86 20.96 1825.00 21.68 760.00 32.52 2050.00 171.00 646.00 1018.40 26.02 456.00 1064.00 26.77 21.68 37.94 21.25 608.00 35.54 24.17 23.69 318.00 21.68 18.86 2050.00
Neck/chest surgery procedure 21899 288.00 Northwest Hills Surgical Hospital OP Not Applicable 203.21 75.71 117.65 75.71 84.12 Not Applicable 192.00 203.21 288.00 345.93 864.83 784.11 541.26 230.40 Not Applicable 807.17 237.12 192.00 336.00 188.16 461.24 304.81 207.27 203.21 318.00 192.00 75.71 864.83
Closed tx vert fx w/o manj 22310 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 216.13 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 899.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Injection for hip x-ray 27093 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 301.37 753.41 683.09 0.00 0.00 Not Applicable 703.19 0.00 0.00 0.00 0.00 401.82 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Fixation of ankle joint 27860 3871.38 Northwest Hills Surgical Hospital OP 1296.00 333.00 1039.01 997.77 1039.01 1154.45 950.00 2580.92 331.10 3871.38 1100.00 1517.00 5741.00 357.12 3097.10 854.00 802.24 3187.44 2580.92 4516.61 2529.30 265.97 4077.22 2772.51 2718.15 1200.00 2580.92 265.97 5741.00
Drainage of nose lesion 30000 288.00 Northwest Hills Surgical Hospital OP 1296.00 798.00 41.82 65.79 41.82 46.47 1825.00 192.00 665.00 288.00 2050.00 451.00 1719.00 891.10 230.40 399.00 931.00 237.12 192.00 336.00 188.16 71.14 304.81 207.27 203.21 318.00 192.00 41.82 2050.00
Largsc w/ther injection 31573 2023.22 Northwest Hills Surgical Hospital OP 1695.00 1437.04 1142.33 1155.02 1142.33 1269.25 2575.00 1348.81 1437.04 2023.22 1100.00 3263.00 12368.00 1437.04 1618.57 Not Applicable 902.41 1665.78 1348.81 2360.42 1321.83 574.31 2155.56 1465.78 1437.04 1200.00 1348.81 574.31 12368.00
Diagnostic laryngoscopy 31575 221.40 Northwest Hills Surgical Hospital OP 1695.00 597.00 47.87 65.81 47.87 53.19 1825.00 147.60 497.50 221.40 2050.00 215.00 812.00 541.26 177.12 298.50 696.50 182.29 147.60 258.30 144.65 265.97 236.81 161.03 157.87 318.00 147.60 47.87 2050.00
Laryngoscopy telescopic 31579 534.42 Northwest Hills Surgical Hospital OP 1695.00 819.00 82.76 112.73 82.76 91.96 950.00 356.28 682.50 534.42 2050.00 488.00 1843.00 914.55 427.54 409.50 955.50 440.01 356.28 623.49 349.15 77.43 542.37 368.81 361.58 318.00 356.28 77.43 2050.00
Bronchial brush biopsy 31717 534.42 Northwest Hills Surgical Hospital OP 1296.00 333.00 332.61 341.37 332.61 369.57 950.00 356.28 331.10 534.42 2050.00 1076.00 4073.00 357.12 427.54 854.00 784.00 440.01 356.28 623.49 349.15 265.97 542.37 368.81 361.58 318.00 356.28 265.97 4073.00
Clearance of airways 31720 260.16 Northwest Hills Surgical Hospital OP 1296.00 333.00 70.37 136.01 70.37 78.19 950.00 173.44 331.10 260.16 2050.00 215.00 812.00 357.12 208.13 854.00 696.50 214.20 173.44 303.52 169.97 398.00 270.64 184.04 180.43 318.00 173.44 70.37 2050.00
Thoracentesis For Aspiration 32421 717.50 Northwest Hills Surgical Hospital OP 2549.00 861.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 430.50 717.50 717.50 2050.00 2114.00 10862.00 961.45 Not Applicable 430.50 1004.50 Not Applicable Not Applicable Not Applicable Not Applicable 574.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 430.50 10862.00
Lyse chest fibrin subq day 32562 891.69 Northwest Hills Surgical Hospital OP 1296.00 840.00 436.67 439.38 436.67 485.19 950.00 594.46 700.00 891.69 750.00 2114.00 10862.00 938.00 713.35 420.00 980.00 734.16 594.46 1040.31 582.57 560.00 780.21 530.54 520.14 788.00 594.46 420.00 10862.00
Pseudoaneurysm injection trt 36002 891.69 Northwest Hills Surgical Hospital OP 1296.00 897.00 171.76 379.29 171.76 190.84 950.00 594.46 747.50 891.69 750.00 417.00 1577.00 1001.65 713.35 448.50 1046.50 734.16 594.46 1040.31 582.57 265.97 780.21 530.54 520.14 788.00 594.46 171.76 1577.00
Vein access cutdown > 1 yr 36425 514.20 Northwest Hills Surgical Hospital OP 1296.00 798.00 10.99 82.97 10.99 12.21 1825.00 342.80 665.00 514.20 2050.00 171.00 646.00 891.10 411.36 399.00 931.00 423.36 342.80 599.90 335.94 532.00 389.25 264.69 259.50 318.00 342.80 10.99 2050.00
Inj w/fluor eval cv device 36598 259.85 Northwest Hills Surgical Hospital OP 1695.00 798.00 54.71 75.91 54.71 60.79 950.00 173.23 665.00 259.85 2050.00 417.00 1577.00 891.10 207.88 399.00 931.00 213.94 173.23 303.15 169.77 265.97 293.14 199.34 195.43 318.00 173.23 54.71 2050.00
Insert needle bone cavity 36680 514.20 Northwest Hills Surgical Hospital OP 1296.00 798.00 48.10 82.97 48.10 53.44 1825.00 342.80 665.00 514.20 2050.00 171.00 646.00 891.10 411.36 399.00 931.00 423.36 342.80 599.90 335.94 532.00 389.25 264.69 259.50 318.00 342.80 48.10 2050.00
Dx bone marrow aspirations 38220 1941.17 Northwest Hills Surgical Hospital OP 1296.00 798.00 78.53 112.73 78.53 87.25 950.00 1294.11 665.00 1941.17 750.00 488.00 1843.00 806.31 1552.93 399.00 931.00 1598.23 1294.11 2264.69 1268.23 265.97 2026.80 1378.22 1351.20 788.00 1294.11 78.53 2264.69
Dx bone marrow biopsies 38221 1941.17 Northwest Hills Surgical Hospital OP 1296.00 798.00 76.17 107.20 76.17 84.63 950.00 1294.11 665.00 1941.17 750.00 580.00 2200.00 806.31 1552.93 399.00 931.00 1598.23 1294.11 2264.69 1268.23 265.97 2026.80 1378.22 1351.20 788.00 1294.11 76.17 2264.69
Io map of sent lymph node 38900 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 390.00 975.00 884.00 0.00 0.00 Not Applicable 910.00 0.00 0.00 0.00 0.00 520.00 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Biopsy of mouth lesion 40808 624.69 Northwest Hills Surgical Hospital OP 1296.00 798.00 100.69 140.10 100.69 111.88 1825.00 416.46 665.00 624.69 2050.00 451.00 1719.00 674.25 499.75 399.00 931.00 514.33 416.46 728.81 408.13 112.68 651.63 443.11 434.42 318.00 416.46 100.69 2050.00
Drainage of mouth lesion 41005 288.00 Northwest Hills Surgical Hospital OP 1296.00 333.00 234.98 284.77 234.98 261.09 950.00 192.00 331.10 288.00 2050.00 688.00 2597.00 357.12 230.40 854.00 696.50 237.12 192.00 336.00 188.16 265.97 304.81 207.27 203.21 318.00 192.00 188.16 2597.00
Drainage of mouth lesion 41015 624.69 Northwest Hills Surgical Hospital OP 1296.00 333.00 234.98 284.77 234.98 261.09 950.00 416.46 331.10 624.69 2050.00 688.00 2597.00 357.12 499.75 854.00 696.50 514.33 416.46 728.81 408.13 265.97 651.63 443.11 434.42 318.00 416.46 234.98 2597.00
Repair tongue laceration 41251 288.00 Northwest Hills Surgical Hospital OP 1695.00 446.00 234.98 284.77 234.98 261.09 1125.00 192.00 443.45 288.00 2050.00 688.00 2597.00 541.26 230.40 1139.00 791.00 237.12 192.00 336.00 188.16 356.12 304.81 207.27 203.21 318.00 192.00 188.16 2597.00
Drainage of gum lesion 41800 154.20 Northwest Hills Surgical Hospital OP 1296.00 333.00 143.69 82.97 143.69 159.66 950.00 102.80 331.10 154.20 2050.00 403.00 1526.00 357.12 123.36 854.00 696.50 126.96 102.80 179.90 100.74 398.00 161.27 109.66 107.51 318.00 102.80 82.97 2050.00
Repair palate 42180 624.69 Northwest Hills Surgical Hospital OP 1296.00 333.00 234.98 284.77 234.98 261.09 950.00 416.46 331.10 624.69 2050.00 688.00 2597.00 357.12 499.75 854.00 696.50 514.33 416.46 728.81 408.13 265.97 651.63 443.11 434.42 318.00 416.46 234.98 2597.00
Preparation palate mold 42280 624.69 Northwest Hills Surgical Hospital OP 1296.00 798.00 69.80 97.42 69.80 77.55 1825.00 416.46 665.00 624.69 2050.00 329.00 1254.00 891.10 499.75 399.00 931.00 514.33 416.46 728.81 408.13 532.00 651.63 443.11 434.42 318.00 416.46 69.80 2050.00
Control nose/throat bleeding 42970 288.00 Northwest Hills Surgical Hospital OP 1296.00 798.00 41.82 65.79 41.82 46.47 1825.00 192.00 665.00 288.00 2050.00 171.00 646.00 541.26 230.40 399.00 931.00 237.12 192.00 336.00 188.16 71.14 304.81 207.27 203.21 318.00 192.00 41.82 2050.00
Dx gastr intub w/asp spec 43754 357.95 Northwest Hills Surgical Hospital OP 1296.00 780.00 88.43 200.52 88.43 98.25 950.00 238.63 650.00 357.95 2050.00 171.00 646.00 871.00 286.36 390.00 910.00 294.71 238.63 417.60 233.86 520.00 380.94 259.04 253.96 318.00 238.63 88.43 2050.00
Dx gastr intub w/asp specs 43755 195.66 Northwest Hills Surgical Hospital OP 1296.00 780.00 117.95 118.07 117.95 131.06 950.00 130.44 650.00 195.66 2050.00 171.00 646.00 871.00 156.53 390.00 910.00 161.09 130.44 228.27 127.83 520.00 201.02 136.70 134.02 318.00 130.44 117.95 2050.00
Dx duod intub w/asp spec 43756 1111.47 Northwest Hills Surgical Hospital OP 1296.00 780.00 141.00 91.63 141.00 156.67 950.00 740.98 650.00 1111.47 1100.00 171.00 646.00 871.00 889.18 390.00 910.00 915.11 740.98 1296.72 726.16 520.00 1166.24 793.04 777.49 1200.00 740.98 91.63 1296.72
Dx duod intub w/asp specs 43757 1111.47 Northwest Hills Surgical Hospital OP 1296.00 780.00 141.00 678.28 141.00 156.67 950.00 740.98 650.00 1111.47 1100.00 171.00 646.00 871.00 889.18 390.00 910.00 915.11 740.98 1296.72 726.16 265.97 1166.24 793.04 777.49 1200.00 740.98 141.00 1296.72
Reduction of rectal prolapse 45900 1080.30 Northwest Hills Surgical Hospital OP 1296.00 333.00 425.57 448.13 425.57 472.86 950.00 720.20 331.10 1080.30 750.00 1417.00 5380.00 357.12 864.24 854.00 980.00 889.45 720.20 1260.35 705.80 265.97 1143.26 777.42 762.17 788.00 720.20 265.97 5380.00
Destruction anal lesion(s) 46900 451.86 Northwest Hills Surgical Hospital OP 1296.00 798.00 109.18 114.78 109.18 121.31 950.00 301.24 665.00 451.86 2050.00 488.00 1843.00 541.26 361.49 399.00 931.00 372.03 301.24 527.17 295.22 117.53 498.19 338.77 332.12 318.00 301.24 109.18 2050.00
Cryosurgery anal lesion(s) 46916 247.11 Northwest Hills Surgical Hospital OP 1695.00 798.00 73.28 114.78 73.28 81.42 1825.00 164.74 665.00 247.11 2050.00 215.00 812.00 891.10 197.69 399.00 931.00 203.45 164.74 288.30 161.45 61.51 258.64 175.88 172.43 318.00 164.74 61.51 2050.00
Drain bladder by needle 51100 332.21 Northwest Hills Surgical Hospital OP 1296.00 804.00 20.28 28.35 20.28 22.53 1825.00 221.47 670.00 332.21 750.00 171.00 646.00 897.80 265.76 402.00 938.00 273.52 221.47 387.57 217.04 265.97 383.38 260.70 255.58 788.00 221.47 20.28 1825.00
Cystometrogram w/vp&up 51729 787.07 Northwest Hills Surgical Hospital OP 1296.00 711.00 138.42 194.18 138.42 153.80 1825.00 524.71 592.50 787.07 750.00 488.00 1843.00 357.12 629.65 355.50 829.50 648.02 524.71 918.24 514.22 160.20 827.96 563.01 551.97 788.00 524.71 138.42 1843.00
Anal/urinary muscle study 51785 332.21 Northwest Hills Surgical Hospital OP 1296.00 333.00 189.99 188.02 189.99 211.10 950.00 221.47 331.10 332.21 2050.00 306.00 1154.00 357.12 265.76 854.00 696.50 273.52 221.47 387.57 217.04 265.97 383.38 260.70 255.58 318.00 221.47 188.02 2050.00
Dilate urethra stricture 53601 154.20 Northwest Hills Surgical Hospital OP 1296.00 798.00 28.30 82.97 28.30 31.44 950.00 102.80 665.00 154.20 2050.00 171.00 646.00 891.10 123.36 399.00 931.00 126.96 102.80 179.90 100.74 265.97 161.27 109.66 107.51 318.00 102.80 28.30 2050.00
Dilation of urethra 53660 195.66 Northwest Hills Surgical Hospital OP 1296.00 798.00 28.06 39.42 28.06 31.18 1825.00 130.44 665.00 195.66 2050.00 171.00 646.00 891.10 156.53 399.00 931.00 161.09 130.44 228.27 127.83 265.97 201.02 136.70 134.02 318.00 130.44 28.06 2050.00
Treatment of penis lesion 54220 332.21 Northwest Hills Surgical Hospital OP 1296.00 333.00 189.99 188.02 189.99 211.10 950.00 221.47 331.10 332.21 2050.00 598.00 2267.00 357.12 265.76 854.00 696.50 273.52 221.47 387.57 217.04 265.97 383.38 260.70 255.58 318.00 221.47 188.02 2267.00
Penis study 54240 195.66 Northwest Hills Surgical Hospital OP 1296.00 798.00 22.64 31.60 22.64 25.15 1825.00 130.44 665.00 195.66 2050.00 171.00 646.00 891.10 156.53 399.00 931.00 161.09 130.44 228.27 127.83 532.00 380.94 259.04 253.96 318.00 130.44 22.64 2050.00
Penis study 54250 332.21 Northwest Hills Surgical Hospital OP 1296.00 840.00 6.84 9.45 6.84 7.60 1825.00 221.47 700.00 332.21 2050.00 171.00 646.00 938.00 265.76 420.00 980.00 273.52 221.47 387.57 217.04 560.00 383.38 260.70 255.58 318.00 221.47 6.84 2050.00
Drainage of gland abscess 56420 234.84 Northwest Hills Surgical Hospital OP 1296.00 690.00 42.44 59.30 42.44 47.16 950.00 156.56 575.00 234.84 2050.00 215.00 812.00 770.50 187.87 345.00 805.00 193.35 156.56 273.98 153.43 265.97 245.35 166.84 163.57 318.00 156.56 42.44 2050.00
Biopsy of vulva/perineum 56605 902.93 Northwest Hills Surgical Hospital OP 1296.00 909.00 25.70 35.52 25.70 28.56 950.00 601.95 757.50 902.93 2050.00 171.00 646.00 1015.05 722.34 454.50 1060.50 743.41 601.95 1053.41 589.91 265.97 912.43 620.45 608.29 788.00 601.95 25.70 2050.00
Biopsy of vulva/perineum 56606 497.50 Northwest Hills Surgical Hospital OP 1296.00 597.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 171.00 646.00 666.65 0.00 298.50 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Exam of vulva w/scope 56820 234.84 Northwest Hills Surgical Hospital OP 1296.00 798.00 34.19 47.25 34.19 37.99 1825.00 156.56 665.00 234.84 2050.00 215.00 812.00 357.12 187.87 399.00 931.00 193.35 156.56 273.98 153.43 265.97 245.35 166.84 163.57 318.00 156.56 34.19 2050.00
Exam/biopsy of vulva w/scope 56821 382.86 Northwest Hills Surgical Hospital OP 1296.00 828.00 43.39 60.28 43.39 48.21 950.00 255.24 690.00 382.86 2050.00 215.00 812.00 924.60 306.29 414.00 966.00 315.22 255.24 446.67 250.14 265.97 405.47 275.72 270.32 318.00 255.24 43.39 2050.00
Ins vag brachytx device 57156 382.86 Northwest Hills Surgical Hospital OP 1695.00 780.00 170.49 228.32 170.49 189.43 950.00 255.24 650.00 382.86 2050.00 634.00 2399.00 871.00 306.29 390.00 910.00 315.22 255.24 446.67 250.14 110.76 405.47 275.72 270.32 318.00 255.24 110.76 2399.00
Exam of vagina w/scope 57420 382.86 Northwest Hills Surgical Hospital OP 1296.00 807.00 35.14 48.55 35.14 39.04 950.00 255.24 672.50 382.86 2050.00 215.00 812.00 901.15 306.29 403.50 941.50 315.22 255.24 446.67 250.14 265.97 405.47 275.72 270.32 318.00 255.24 35.14 2050.00
Exam of cervix w/scope 57452 234.84 Northwest Hills Surgical Hospital OP 1695.00 597.00 32.78 45.29 32.78 36.42 950.00 156.56 497.50 234.84 2050.00 171.00 646.00 357.12 187.87 298.50 696.50 193.35 156.56 273.98 153.43 265.97 245.35 166.84 163.57 318.00 156.56 32.78 2050.00
Bx/curett of cervix w/scope 57454 382.86 Northwest Hills Surgical Hospital OP 1695.00 666.00 40.56 56.04 40.56 45.07 950.00 255.24 555.00 382.86 2050.00 215.00 812.00 743.70 306.29 333.00 777.00 315.22 255.24 446.67 250.14 265.97 405.47 275.72 270.32 318.00 255.24 40.56 2050.00
Biopsy of cervix w/scope 57455 382.86 Northwest Hills Surgical Hospital OP 1296.00 816.00 42.21 58.98 42.21 46.90 950.00 255.24 680.00 382.86 2050.00 215.00 812.00 911.20 306.29 408.00 952.00 315.22 255.24 446.67 250.14 265.97 405.47 275.72 270.32 318.00 255.24 42.21 2050.00
Endocerv curettage w/scope 57456 382.86 Northwest Hills Surgical Hospital OP 1296.00 798.00 40.80 56.37 40.80 45.33 950.00 255.24 665.00 382.86 2050.00 215.00 812.00 891.10 306.29 399.00 931.00 315.22 255.24 446.67 250.14 265.97 405.47 275.72 270.32 318.00 255.24 40.80 2050.00
Cryocautery of cervix 57511 382.86 Northwest Hills Surgical Hospital OP 1296.00 798.00 44.80 62.55 44.80 49.78 950.00 255.24 665.00 382.86 2050.00 215.00 812.00 891.10 306.29 399.00 931.00 315.22 255.24 446.67 250.14 265.97 405.47 275.72 270.32 318.00 255.24 44.80 2050.00
Insert intrauterine device 58300 497.50 Northwest Hills Surgical Hospital OP 1296.00 597.00 44.96 50.18 44.96 49.95 1825.00 0.00 497.50 497.50 2050.00 2114.00 10862.00 674.25 0.00 298.50 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 10862.00
Remove intrauterine device 58301 382.86 Northwest Hills Surgical Hospital OP 1296.00 597.00 29.71 41.05 29.71 33.01 950.00 255.24 497.50 382.86 2050.00 171.00 646.00 674.25 306.29 298.50 696.50 315.22 255.24 446.67 250.14 33.91 405.47 275.72 270.32 318.00 255.24 29.71 2050.00
Transfer of embryo 58974 902.93 Northwest Hills Surgical Hospital OP 1296.00 333.00 332.24 228.32 332.24 369.16 950.00 601.95 331.10 902.93 2050.00 1122.00 4241.00 710.20 722.34 854.00 742.00 743.41 601.95 1053.41 589.91 424.00 912.43 620.45 608.29 788.00 601.95 228.32 4241.00
Transfer of embryo 58976 382.86 Northwest Hills Surgical Hospital OP 1296.00 333.00 170.49 228.32 170.49 189.43 950.00 255.24 331.10 382.86 2050.00 1122.00 4241.00 666.65 306.29 854.00 696.50 315.22 255.24 446.67 250.14 398.00 405.47 275.72 270.32 318.00 255.24 170.49 4241.00
Amniocentesis diagnostic 59000 902.93 Northwest Hills Surgical Hospital OP 1296.00 798.00 45.98 64.18 45.98 51.09 Not Applicable 601.95 665.00 902.93 750.00 329.00 1254.00 891.10 722.34 399.00 931.00 743.41 601.95 1053.41 589.91 52.60 912.43 620.45 608.29 788.00 601.95 45.98 1296.00
Transabdom amnioinfus w/us 59070 382.86 Northwest Hills Surgical Hospital OP 1296.00 798.00 332.24 228.32 332.24 369.16 950.00 255.24 665.00 382.86 2050.00 488.00 1843.00 891.10 306.29 399.00 931.00 315.22 255.24 446.67 250.14 532.00 405.47 275.72 270.32 318.00 255.24 228.32 2050.00
Umbilical cord occlud w/us 59072 382.86 Northwest Hills Surgical Hospital OP 1296.00 798.00 170.49 228.32 170.49 189.43 950.00 255.24 665.00 382.86 2050.00 488.00 1843.00 891.10 306.29 399.00 931.00 315.22 255.24 446.67 250.14 532.00 405.47 275.72 270.32 318.00 255.24 170.49 2050.00
Fetal fluid drainage w/us 59074 382.86 Northwest Hills Surgical Hospital OP 1296.00 798.00 170.49 228.32 170.49 189.43 950.00 255.24 665.00 382.86 2050.00 634.00 2399.00 891.10 306.29 399.00 931.00 315.22 255.24 446.67 250.14 110.76 405.47 275.72 270.32 318.00 255.24 110.76 2399.00
Fetal shunt placement w/us 59076 382.86 Northwest Hills Surgical Hospital OP 1296.00 798.00 170.49 228.32 170.49 189.43 950.00 255.24 665.00 382.86 2050.00 488.00 1843.00 891.10 306.29 399.00 931.00 315.22 255.24 446.67 250.14 532.00 405.47 275.72 270.32 318.00 255.24 170.49 2050.00
Biopsy of thyroid 60100 862.70 Northwest Hills Surgical Hospital OP 1296.00 825.00 35.37 49.19 35.37 39.30 950.00 575.13 687.50 862.70 750.00 215.00 812.00 541.26 690.16 412.50 962.50 710.29 575.13 1006.48 563.63 40.32 895.95 609.25 597.30 788.00 575.13 35.37 1296.00
Aspir/inj thyroid cyst 60300 862.70 Northwest Hills Surgical Hospital OP 1296.00 750.00 53.06 74.61 53.06 58.95 1825.00 575.13 625.00 862.70 750.00 215.00 812.00 837.50 690.16 375.00 875.00 710.29 575.13 1006.48 563.63 265.97 895.95 609.25 597.30 788.00 575.13 53.06 1825.00
Dx lmbr spi pnxr 62270 883.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 318.59 532.50 318.59 353.99 950.00 589.31 331.10 883.97 750.00 634.00 2399.00 204.60 707.17 854.00 896.00 727.80 589.31 1031.29 577.52 265.97 914.13 621.61 609.42 788.00 589.31 204.60 2399.00
Ther spi pnxr drg csf 62272 883.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 318.59 532.50 318.59 353.99 950.00 589.31 331.10 883.97 750.00 634.00 2399.00 357.12 707.17 854.00 959.00 727.80 589.31 1031.29 577.52 265.97 914.13 621.61 609.42 788.00 589.31 265.97 2399.00
Njx px discography lumbar 62290 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 399.00 997.50 904.40 0.00 0.00 Not Applicable 931.00 0.00 0.00 0.00 0.00 532.00 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Njx px discography crv/thrc 62291 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 399.00 997.50 904.40 0.00 0.00 Not Applicable 931.00 0.00 0.00 0.00 0.00 532.00 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Analyze spine infus pump 62367 383.13 Northwest Hills Surgical Hospital OP 1695.00 678.00 22.32 26.14 22.32 24.80 1125.00 255.42 565.00 383.13 2050.00 171.00 646.00 757.10 306.50 339.00 791.00 315.44 255.42 446.99 250.31 452.00 392.50 266.90 261.66 318.00 255.42 22.32 2050.00
Analyze sp inf pump w/reprog 62368 383.13 Northwest Hills Surgical Hospital OP 1695.00 678.00 30.28 36.52 30.28 33.64 1125.00 255.42 565.00 383.13 2050.00 171.00 646.00 757.10 306.50 339.00 791.00 315.44 255.42 446.99 250.31 452.00 392.50 266.90 261.66 318.00 255.42 30.28 2050.00
Njx aa&/strd trigeminal nrv 64400 370.20 Northwest Hills Surgical Hospital OP 1296.00 597.00 52.82 75.27 52.82 58.69 Not Applicable 246.80 497.50 370.20 2050.00 215.00 812.00 357.12 296.16 298.50 696.50 304.80 246.80 431.90 241.86 61.15 376.22 255.83 250.81 Not Applicable 246.80 52.82 2050.00
N Block Inj Facial 64402 665.00 Northwest Hills Surgical Hospital OP 1296.00 798.00 Not Applicable 82.97 Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 215.00 812.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 82.97 2050.00
Njx aa&/strd gr ocpl nrv 64405 370.20 Northwest Hills Surgical Hospital OP 1296.00 903.00 40.80 57.35 40.80 45.33 950.00 246.80 752.50 370.20 2050.00 215.00 812.00 491.04 296.16 451.50 1053.50 304.80 246.80 431.90 241.86 46.19 376.22 255.83 250.81 318.00 246.80 40.80 2050.00
N Block Inj Phrenic 64410 735.00 Northwest Hills Surgical Hospital OP 1296.00 333.00 Not Applicable 532.50 Not Applicable Not Applicable Not Applicable 441.00 331.10 735.00 750.00 1517.00 5741.00 984.90 Not Applicable 854.00 1029.00 Not Applicable Not Applicable Not Applicable Not Applicable 588.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 331.10 5741.00
Njx aa&/strd axillary nrv 64417 1148.43 Northwest Hills Surgical Hospital OP 1296.00 333.00 318.59 532.50 318.59 353.99 Not Applicable 765.62 331.10 1148.43 750.00 634.00 2399.00 357.12 918.74 854.00 696.50 945.54 765.62 1339.84 750.31 265.97 1184.76 805.64 789.84 Not Applicable 765.62 265.97 2399.00
Njx aa&/strd sprscap nrv 64418 883.97 Northwest Hills Surgical Hospital OP 1296.00 855.00 61.31 88.30 61.31 68.12 Not Applicable 589.31 712.50 883.97 750.00 329.00 1254.00 491.04 707.17 427.50 997.50 727.80 589.31 1031.29 577.52 71.02 914.13 621.61 609.42 Not Applicable 589.31 61.31 1296.00
Njx aa&/strd ntrcost nrv 1 64420 883.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 318.59 532.50 318.59 353.99 Not Applicable 589.31 331.10 883.97 750.00 634.00 2399.00 357.12 707.17 854.00 1008.00 727.80 589.31 1031.29 577.52 265.97 914.13 621.61 609.42 Not Applicable 589.31 265.97 2399.00
Njx aa&/strd ii ih nerves 64425 883.97 Northwest Hills Surgical Hospital OP 1296.00 831.00 43.62 61.25 43.62 48.47 Not Applicable 589.31 692.50 883.97 750.00 215.00 812.00 674.25 707.17 415.50 969.50 727.80 589.31 1031.29 577.52 48.60 914.13 621.61 609.42 Not Applicable 589.31 43.62 1296.00
Njx aa&/strd paracrv nrv 64435 883.97 Northwest Hills Surgical Hospital OP 1296.00 597.00 51.17 73.64 51.17 56.86 Not Applicable 589.31 497.50 883.97 750.00 329.00 1254.00 674.25 707.17 298.50 696.50 727.80 589.31 1031.29 577.52 59.28 914.13 621.61 609.42 Not Applicable 589.31 51.17 1296.00
Njx aa&/strd other pn/branch 64450 883.97 Northwest Hills Surgical Hospital OP 1296.00 741.00 34.19 47.57 34.19 37.99 950.00 589.31 617.50 883.97 750.00 215.00 812.00 892.80 707.17 370.50 864.50 727.80 589.31 1031.29 577.52 38.72 914.13 621.61 609.42 788.00 589.31 34.19 1296.00
Inj paravert f jnt c/t 2 lev 64491 497.50 Northwest Hills Surgical Hospital OP 1296.00 597.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 451.00 1719.00 357.12 0.00 298.50 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Inj paravert f jnt c/t 3 lev 64492 497.50 Northwest Hills Surgical Hospital OP 1296.00 597.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 451.00 1719.00 357.12 0.00 298.50 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Inj paravert f jnt l/s 2 lev 64494 497.50 Northwest Hills Surgical Hospital OP 1296.00 597.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 451.00 1719.00 357.12 0.00 298.50 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Inj paravert f jnt l/s 3 lev 64495 497.50 Northwest Hills Surgical Hospital OP 1296.00 597.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 497.50 497.50 2050.00 451.00 1719.00 357.12 0.00 298.50 696.50 0.00 0.00 0.00 0.00 398.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
N block spenopalatine gangl 64505 370.20 Northwest Hills Surgical Hospital OP 1296.00 732.00 34.90 48.22 34.90 38.78 950.00 246.80 610.00 370.20 2050.00 171.00 646.00 817.40 296.16 366.00 854.00 304.80 246.80 431.90 241.86 39.53 376.22 255.83 250.81 318.00 246.80 34.90 2050.00
N Block Carotid Sinus S/P 64508 497.50 Northwest Hills Surgical Hospital OP Not Applicable 597.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 298.50 497.50 497.50 2050.00 2114.00 10862.00 666.65 Not Applicable 298.50 696.50 Not Applicable Not Applicable Not Applicable Not Applicable 398.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 298.50 10862.00
Neuroeltrd stim post tibial 64566 370.20 Northwest Hills Surgical Hospital OP 1296.00 780.00 64.14 95.47 64.14 71.27 950.00 246.80 650.00 370.20 2050.00 451.00 1719.00 871.00 296.16 390.00 910.00 304.80 246.80 431.90 241.86 520.00 376.22 255.83 250.81 318.00 246.80 64.14 2050.00
Destroy nerve face muscle 64612 370.20 Northwest Hills Surgical Hospital OP 1296.00 798.00 48.34 66.79 48.34 53.71 950.00 246.80 665.00 370.20 2050.00 329.00 1254.00 891.10 296.16 399.00 931.00 304.80 246.80 431.90 241.86 265.97 376.22 255.83 250.81 318.00 246.80 48.34 2050.00
Destroy Nerve Neck Muscle 64613 665.00 Northwest Hills Surgical Hospital OP Not Applicable 798.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 665.00 665.00 2050.00 2114.00 10862.00 891.10 Not Applicable 399.00 931.00 Not Applicable Not Applicable Not Applicable Not Applicable 532.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 399.00 10862.00
Destr Paravertebral N Add-On 64623 735.00 Northwest Hills Surgical Hospital OP 2549.00 333.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 441.00 331.10 735.00 2050.00 2114.00 10862.00 984.90 Not Applicable 854.00 1029.00 Not Applicable Not Applicable Not Applicable Not Applicable 588.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 331.10 10862.00
Destr Paravertebral N Add-On 64627 625.00 Northwest Hills Surgical Hospital OP 2549.00 333.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 375.00 331.10 625.00 2050.00 2114.00 10862.00 837.50 Not Applicable 854.00 875.00 Not Applicable Not Applicable Not Applicable Not Applicable 500.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 331.10 10862.00
Destroy c/th facet jnt addl 64634 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 375.00 937.50 850.00 0.00 0.00 Not Applicable 875.00 0.00 0.00 0.00 0.00 500.00 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Remove skin nerve lesion 64788 2431.56 Northwest Hills Surgical Hospital OP 2069.00 510.00 1245.50 1267.23 1245.50 1383.89 1273.00 1621.04 507.08 2431.56 1500.00 2324.00 8796.00 674.25 1945.25 1301.00 1030.30 2001.98 1621.04 2836.82 1588.62 408.42 2527.22 1718.51 1684.81 1919.00 1621.04 408.42 8796.00
Ophthalmic endoscope add-on 66990 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 356.70 891.75 808.52 0.00 0.00 Not Applicable 832.30 0.00 0.00 0.00 0.00 475.60 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Injection eye drug 67028 437.85 Northwest Hills Surgical Hospital OP 1296.00 798.00 31.60 43.66 31.60 35.11 950.00 291.90 665.00 437.85 2050.00 403.00 1526.00 891.10 350.28 399.00 931.00 360.50 291.90 510.83 286.06 265.97 447.64 304.39 298.43 318.00 291.90 31.60 2050.00
Treatment of retina 67141 382.53 Northwest Hills Surgical Hospital OP 1695.00 446.00 386.63 237.54 386.63 429.59 1125.00 255.02 443.45 382.53 2050.00 1099.00 4167.00 541.26 306.02 1139.00 948.50 314.95 255.02 446.29 249.92 356.12 376.38 255.94 250.92 318.00 255.02 237.54 4167.00
Ocular photodynamic ther 67221 716.91 Northwest Hills Surgical Hospital OP 1296.00 798.00 103.99 144.34 103.99 115.54 950.00 477.94 665.00 716.91 750.00 600.00 2274.00 891.10 573.53 399.00 931.00 590.26 477.94 836.40 468.38 408.42 725.82 493.55 483.88 788.00 477.94 103.99 2274.00
Eye photodynamic ther add-on 67225 665.00 Northwest Hills Surgical Hospital OP 1296.00 798.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 665.00 665.00 2050.00 171.00 646.00 891.10 0.00 399.00 931.00 0.00 0.00 0.00 0.00 532.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Tr retinal les preterm inf 67229 716.91 Northwest Hills Surgical Hospital OP 1695.00 825.00 212.91 224.10 212.91 236.57 1825.00 477.94 687.50 716.91 750.00 952.00 3610.00 921.25 573.53 412.50 962.50 590.26 477.94 836.40 468.38 265.97 725.82 493.55 483.88 788.00 477.94 212.91 3610.00
Destroy nerve of eye muscle 67345 382.53 Northwest Hills Surgical Hospital OP 1296.00 798.00 81.59 113.06 81.59 90.65 950.00 255.02 665.00 382.53 2050.00 403.00 1526.00 541.26 306.02 399.00 931.00 314.95 255.02 446.29 249.92 92.65 376.38 255.94 250.92 318.00 255.02 81.59 2050.00
Inject/treat eye socket 67515 382.53 Northwest Hills Surgical Hospital OP 1296.00 759.00 29.48 40.73 29.48 32.75 950.00 255.02 632.50 382.53 2050.00 171.00 646.00 541.26 306.02 379.50 885.50 314.95 255.02 446.29 249.92 33.38 376.38 255.94 250.92 318.00 255.02 29.48 2050.00
Drainage of eyelid abscess 67700 382.53 Northwest Hills Surgical Hospital OP 1296.00 798.00 126.96 132.83 126.96 141.07 950.00 255.02 665.00 382.53 2050.00 488.00 1843.00 541.26 306.02 399.00 931.00 314.95 255.02 446.29 249.92 107.85 376.38 255.94 250.92 318.00 255.02 107.85 2050.00
Remove eyelid lesion 67800 382.53 Northwest Hills Surgical Hospital OP 1296.00 852.00 48.82 67.77 48.82 54.24 950.00 255.02 710.00 382.53 2050.00 215.00 812.00 541.26 306.02 426.00 994.00 314.95 255.02 446.29 249.92 265.97 376.38 255.94 250.92 318.00 255.02 48.82 2050.00
Biopsy eyelid & lid margin 67810 382.53 Northwest Hills Surgical Hospital OP 1296.00 828.00 81.12 115.34 81.12 90.13 950.00 255.02 690.00 382.53 2050.00 488.00 1843.00 541.26 306.02 414.00 966.00 314.95 255.02 446.29 249.92 265.97 376.38 255.94 250.92 318.00 255.02 81.12 2050.00
Close tear duct opening 68760 382.53 Northwest Hills Surgical Hospital OP 1296.00 723.00 88.43 123.16 88.43 98.25 1825.00 255.02 602.50 382.53 2050.00 403.00 1526.00 541.26 306.02 361.50 843.50 314.95 255.02 446.29 249.92 356.12 376.38 255.94 250.92 318.00 255.02 88.43 2050.00
Close tear duct opening 68761 382.53 Northwest Hills Surgical Hospital OP 1296.00 798.00 62.49 86.67 62.49 69.43 1825.00 255.02 665.00 382.53 2050.00 329.00 1254.00 541.26 306.02 399.00 931.00 314.95 255.02 446.29 249.92 265.97 376.38 255.94 250.92 318.00 255.02 62.49 2050.00
Probe nasolacrimal duct 68810 382.53 Northwest Hills Surgical Hospital OP 1296.00 333.00 229.82 237.54 229.82 255.36 950.00 255.02 331.10 382.53 2050.00 600.00 2274.00 357.12 306.02 854.00 980.00 314.95 255.02 446.29 249.92 265.97 376.38 255.94 250.92 318.00 255.02 229.82 2274.00
Explore/irrigate tear ducts 68840 382.53 Northwest Hills Surgical Hospital OP 1296.00 798.00 52.35 72.65 52.35 58.17 1825.00 255.02 665.00 382.53 2050.00 215.00 812.00 541.26 306.02 399.00 931.00 314.95 255.02 446.29 249.92 265.97 376.38 255.94 250.92 318.00 255.02 52.35 2050.00
Drain external ear lesion 69000 862.70 Northwest Hills Surgical Hospital OP 1296.00 852.00 79.38 116.16 79.38 88.20 1825.00 575.13 710.00 862.70 750.00 215.00 812.00 541.26 690.16 426.00 994.00 710.29 575.13 1006.48 563.63 96.92 895.95 609.25 597.30 788.00 575.13 79.38 1825.00
Remove impacted ear wax uni 69210 77.79 Northwest Hills Surgical Hospital OP 1296.00 798.00 16.97 50.91 16.97 18.86 1825.00 51.86 665.00 77.79 2050.00 171.00 646.00 891.10 62.23 399.00 931.00 64.05 51.86 90.76 50.82 532.00 80.18 54.52 53.45 318.00 51.86 16.97 2050.00
Incision of eardrum 69420 288.00 Northwest Hills Surgical Hospital OP 2069.00 834.00 92.91 127.72 92.91 103.23 950.00 192.00 695.00 288.00 2050.00 451.00 1719.00 541.26 230.40 417.00 973.00 237.12 192.00 336.00 188.16 265.97 304.81 207.27 203.21 318.00 192.00 92.91 2069.00
Application of finger splint; dynamic - Cast/Splint Application-Upper Body/Ext 29131 77.79 Northwest Hills Surgical Hospital OP Not Applicable 603.90 19.58 50.91 19.58 21.75 1825.00 51.86 503.25 77.79 2050.00 171.00 646.00 674.36 62.23 301.95 704.55 64.05 51.86 90.76 50.82 402.60 80.18 54.52 53.45 318.00 51.86 19.58 2050.00
Arterial puncture, withdrawal of blood for diagnosis - Diagnostic Procedures Charges 36600 154.20 Northwest Hills Surgical Hospital OP Not Applicable 798.00 88.43 82.97 88.43 98.25 1825.00 102.80 665.00 154.20 2050.00 2114.00 10862.00 891.10 123.36 399.00 931.00 126.96 102.80 179.90 100.74 532.00 161.27 109.66 107.51 318.00 102.80 82.97 10862.00
Change of gastrostomy tube, percutaneous, without imaging or - GI Tube Placement/Change Charges 43760 497.50 Northwest Hills Surgical Hospital OP Not Applicable 333.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 298.50 331.10 497.50 2050.00 660.00 2500.00 666.65 Not Applicable 854.00 696.50 Not Applicable Not Applicable Not Applicable Not Applicable 398.00 Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable 298.50 2500.00
Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each 26740 304.97 Northwest Hills Surgical Hospital OP 1296.00 840.00 86.24 120.85 86.24 95.82 1825.00 203.31 700.00 304.97 2050.00 329.00 1254.00 938.00 243.97 420.00 980.00 251.09 203.31 355.79 199.24 80.27 297.02 201.97 198.01 318.00 203.31 80.27 2050.00
Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone 25630 304.97 Northwest Hills Surgical Hospital OP 1296.00 798.00 86.24 87.70 86.24 95.82 1825.00 203.31 665.00 304.97 2050.00 329.00 1254.00 541.26 243.97 399.00 931.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 86.24 2050.00
Closed treatment of carpometacarpal fracture dislocation, th - Closed Treatment - Hand/Fingers Charges 26645 1916.84 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 997.77 156.11 173.46 950.00 1277.89 331.10 1916.84 2050.00 471.00 1786.00 357.12 1533.47 854.00 899.50 1578.19 1277.89 2236.31 1252.33 265.97 2005.69 1363.87 1337.13 318.00 1277.89 156.11 2236.31
Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each 28515 304.97 Northwest Hills Surgical Hospital OP 1296.00 798.00 66.97 94.49 66.97 74.41 1825.00 203.31 665.00 304.97 2050.00 329.00 1254.00 541.26 243.97 399.00 931.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 66.97 2050.00
Closed treatment of greater humeral tuberosity fracture; wit - Closed Treatment - Shoulder Charges 23620 304.97 Northwest Hills Surgical Hospital OP 1296.00 798.00 53.78 120.85 53.78 59.76 950.00 203.31 665.00 304.97 2050.00 329.00 1254.00 891.10 243.97 399.00 931.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 53.78 2050.00
Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation 24565 1916.84 Northwest Hills Surgical Hospital OP 1695.00 446.00 156.11 997.77 156.11 173.46 1125.00 1277.89 443.45 1916.84 2050.00 471.00 1786.00 541.26 1533.47 1139.00 892.50 1578.19 1277.89 2236.31 1252.33 356.12 2005.69 1363.87 1337.13 318.00 1277.89 156.11 2236.31
Closed treatment of humeral shaft fracture; without manipula - Closed Treatment - Upper Extremity  Charges 24500 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 216.13 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 745.50 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Closed treatment of metacarpal fracture, single; with manipu - Closed Treatment - Hand/Fingers Charges 26605 304.97 Northwest Hills Surgical Hospital OP 1695.00 446.00 156.11 216.13 156.11 173.46 1125.00 203.31 443.45 304.97 2050.00 471.00 1786.00 541.26 243.97 1139.00 791.00 251.09 203.31 355.79 199.24 356.12 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Closed treatment of nasal bone fracture without manipulation - Closed Treatment - Skull/Face Charges 21310 304.97 Northwest Hills Surgical Hospital OP 1695.00 446.00 75.71 117.65 75.71 84.12 1125.00 203.31 443.45 304.97 2050.00 688.00 2597.00 541.26 243.97 1139.00 791.00 251.09 203.31 355.79 199.24 356.12 297.02 201.97 198.01 318.00 203.31 75.71 2597.00
Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation 23600 304.97 Northwest Hills Surgical Hospital OP 1296.00 798.00 86.24 87.70 86.24 95.82 950.00 203.31 665.00 304.97 2050.00 329.00 1254.00 891.10 243.97 399.00 931.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 86.24 2050.00
Closed treatment of radial head or neck fracture; without ma - Closed Treatment - Upper Extremity  Charges 24650 304.97 Northwest Hills Surgical Hospital OP 1296.00 798.00 86.24 87.70 86.24 95.82 1825.00 203.31 665.00 304.97 2050.00 329.00 1254.00 891.10 243.97 399.00 931.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 86.24 2050.00
Closed treatment of radial shaft fracture; without manipulat - Closed Treatment - Upper Extremity  Charges 25500 304.97 Northwest Hills Surgical Hospital OP 1296.00 798.00 53.78 87.70 53.78 59.76 1825.00 203.31 665.00 304.97 2050.00 329.00 1254.00 891.10 243.97 399.00 931.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 53.78 2050.00
Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation 25680 304.97 Northwest Hills Surgical Hospital OP 1695.00 446.00 97.35 216.13 97.35 108.17 1125.00 203.31 443.45 304.97 2050.00 471.00 1786.00 541.26 243.97 1139.00 791.00 251.09 203.31 355.79 199.24 356.12 297.02 201.97 198.01 318.00 203.31 97.35 2050.00
Closed treatment of ulnar shaft fracture; without manipulati - Closed Treatment - Upper Extremity  Charges 25530 304.97 Northwest Hills Surgical Hospital OP 1296.00 798.00 53.78 87.70 53.78 59.76 1825.00 203.31 665.00 304.97 2050.00 329.00 1254.00 891.10 243.97 399.00 931.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 53.78 2050.00
Control nasal hemorrhage, anterior, complex (extensive caute - Other Minor Surgery - ENT Charges 30903 154.20 Northwest Hills Surgical Hospital OP 1296.00 333.00 75.71 117.65 75.71 84.12 950.00 102.80 331.10 154.20 2050.00 329.00 1254.00 357.12 123.36 854.00 696.50 126.96 102.80 179.90 100.74 265.97 161.27 109.66 107.51 318.00 102.80 75.71 2050.00
Control nasal hemorrhage, posterior, with posterior nasal pa - Nasal Hemorrhage Charges 30906 288.00 Northwest Hills Surgical Hospital OP 1296.00 333.00 75.71 117.65 75.71 84.12 950.00 192.00 331.10 288.00 2050.00 329.00 1254.00 357.12 230.40 854.00 696.50 237.12 192.00 336.00 188.16 265.97 304.81 207.27 203.21 318.00 192.00 75.71 2050.00
Control nasal hemorrhage, posterior, with posterior nasal pa - Other Minor Surgery - ENT Charges 30905 154.20 Northwest Hills Surgical Hospital OP 1296.00 333.00 75.71 117.65 75.71 84.12 950.00 102.80 331.10 154.20 2050.00 329.00 1254.00 357.12 123.36 854.00 696.50 126.96 102.80 179.90 100.74 265.97 161.27 109.66 107.51 318.00 102.80 75.71 2050.00
Debridement of nail(s) by any method(s); 1 to 5 - Debridement  Charges 11720 77.79 Northwest Hills Surgical Hospital OP 1296.00 912.00 13.20 82.97 13.20 14.67 1825.00 51.86 760.00 77.79 2050.00 171.00 646.00 1018.40 62.23 456.00 1064.00 64.05 51.86 90.76 50.82 608.00 80.18 54.52 53.45 318.00 51.86 13.20 2050.00
Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof 11045 650.00 Northwest Hills Surgical Hospital OP 1296.00 780.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 650.00 650.00 2050.00 471.00 1786.00 871.00 0.00 390.00 910.00 0.00 0.00 0.00 0.00 520.00 0.00 0.00 0.00 318.00 Not Applicable 0.00 2050.00
Declotting by thrombolytic agent of implanted vascular acces - Vascular Access  Charges 36593 437.85 Northwest Hills Surgical Hospital OP 1296.00 603.00 20.04 28.02 20.04 22.27 1825.00 291.90 502.50 437.85 2050.00 171.00 646.00 673.35 350.28 301.50 703.50 360.50 291.90 510.83 286.06 23.23 447.64 304.39 298.43 318.00 291.90 20.04 2050.00
Drainage of abscess of palate, uvula - Drainage of Abscess  Charges 42000 288.00 Northwest Hills Surgical Hospital OP 1695.00 446.00 234.98 284.77 234.98 261.09 1125.00 192.00 443.45 288.00 2050.00 688.00 2597.00 541.26 230.40 1139.00 791.00 237.12 192.00 336.00 188.16 356.12 304.81 207.27 203.21 318.00 192.00 188.16 2597.00
Drainage of finger abscess; complicated - Drainage of Abscess  Charges 26011 1941.17 Northwest Hills Surgical Hospital OP 1296.00 333.00 760.10 857.20 760.10 844.55 950.00 1294.11 331.10 1941.17 1100.00 1517.00 5741.00 357.12 1552.93 854.00 1030.84 1598.23 1294.11 2264.69 1268.23 265.97 2026.80 1378.22 1351.20 1200.00 1294.11 265.97 5741.00
Dressings and/or debridement of partial-thickness burns initial or subsequent; medium 16025 247.11 Northwest Hills Surgical Hospital OP 1695.00 446.00 132.65 205.25 132.65 147.39 1125.00 164.74 565.00 247.11 2050.00 306.00 1154.00 541.26 197.69 1139.00 791.00 203.45 164.74 288.30 161.45 61.51 258.64 175.88 172.43 318.00 164.74 61.51 2050.00
Gastric intubation and aspiration(s) therapeutic, necessitat - Other Minor Procedures - GI Charges 43753 357.95 Northwest Hills Surgical Hospital OP 1296.00 780.00 88.43 200.52 88.43 98.25 950.00 238.63 650.00 357.95 2050.00 171.00 646.00 871.00 286.36 390.00 910.00 294.71 238.63 417.60 233.86 520.00 380.94 259.04 253.96 318.00 238.63 88.43 2050.00
Incision and drainage of abscess; complicated or multiple - Incision and Drainage Charges 10061 451.86 Northwest Hills Surgical Hospital OP 1296.00 702.00 71.69 101.00 71.69 79.65 950.00 301.24 585.00 451.86 2050.00 215.00 812.00 541.26 361.49 351.00 819.00 372.03 301.24 527.17 295.22 265.97 498.19 338.77 332.12 318.00 301.24 71.69 2050.00
Incision and drainage of hematoma, seroma or fluid collectio - Incision and Drainage Charges 10140 1941.17 Northwest Hills Surgical Hospital OP 1296.00 883.58 66.02 92.86 66.02 73.36 1825.00 1294.11 736.32 1941.17 1100.00 329.00 1254.00 806.31 1552.93 441.79 1030.84 1598.23 1294.11 2264.69 1268.23 265.97 2026.80 1378.22 1351.20 1200.00 1294.11 66.02 2264.69
Incision and drainage of pilonidal cyst; simple - Incision and Drainage Charges 10080 862.70 Northwest Hills Surgical Hospital OP 1296.00 717.00 79.38 116.16 79.38 88.20 1825.00 575.13 597.50 862.70 750.00 215.00 812.00 541.26 690.16 358.50 836.50 710.29 575.13 1006.48 563.63 98.26 895.95 609.25 597.30 788.00 575.13 79.38 1825.00
Initial treatment, first degree burn, when no more than loca - Burns Charges 16000 247.11 Northwest Hills Surgical Hospital OP Not Applicable 912.00 22.40 107.23 22.40 24.89 1825.00 164.74 760.00 247.11 2050.00 171.00 646.00 1018.40 197.69 456.00 1064.00 203.45 164.74 288.30 161.45 608.00 258.64 175.88 172.43 318.00 164.74 22.40 2050.00
Inject for sacroiliac joint G0259 Please Contact for Details Northwest Hills Surgical Hospital OP 1296.00 0.00 0.00 0.00 0.00 0.00 Not Applicable 0.00 0.00 0.00 399.00 997.50 904.40 0.00 0.00 Not Applicable 931.00 0.00 0.00 0.00 0.00 532.00 0.00 0.00 0.00 318.00 0.00 0.00 1296.00
Naso- or oro-gastric tube placement, requiring physician's s - GI Tube Placement/Change Charges 43752 514.20 Northwest Hills Surgical Hospital OP 1695.00 798.00 136.11 174.69 136.11 151.23 1825.00 342.80 665.00 514.20 2050.00 215.00 812.00 891.10 411.36 399.00 931.00 423.36 342.80 599.90 335.94 105.89 389.25 264.69 259.50 318.00 342.80 105.89 2050.00
Removal of foreign body from pharynx - Foreign Body Removal  - Throat Charges 42809 514.20 Northwest Hills Surgical Hospital OP 1296.00 798.00 88.43 82.97 88.43 98.25 950.00 342.80 665.00 514.20 2050.00 171.00 646.00 891.10 411.36 399.00 931.00 423.36 342.80 599.90 335.94 532.00 389.25 264.69 259.50 318.00 342.80 82.97 2050.00
Repair of laceration 2.5 cm or less; floor of mouth and/or a - Laceration Repair - Mouth/Lip Charges 41250 154.20 Northwest Hills Surgical Hospital OP 1695.00 446.00 75.71 82.97 75.71 84.12 1125.00 102.80 443.45 154.20 2050.00 688.00 2597.00 541.26 123.36 1139.00 791.00 126.96 102.80 179.90 100.74 452.00 389.25 264.69 259.50 318.00 102.80 75.71 2597.00
Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm 12034 451.86 Northwest Hills Surgical Hospital OP 1695.00 446.00 179.13 205.25 179.13 199.03 1125.00 301.24 443.45 451.86 2050.00 417.00 1577.00 541.26 361.49 1139.00 822.50 372.03 301.24 527.17 295.22 356.12 498.19 338.77 332.12 318.00 301.24 179.13 2050.00
Treatment of closed elbow dislocation; without anesthesia - Closed Treatment - Upper Extremity  Charges 24600 304.97 Northwest Hills Surgical Hospital OP 1296.00 333.00 156.11 156.82 156.11 173.46 950.00 203.31 331.10 304.97 2050.00 471.00 1786.00 357.12 243.97 854.00 700.00 251.09 203.31 355.79 199.24 265.97 297.02 201.97 198.01 318.00 203.31 156.11 2050.00
Endoscopic Removal of Gallbladder 47562 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Injection of substance into spinal canal of lower back or sacrum using imaging guidance 62323 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Biopsy of prostate gland 55700 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC) 743 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Removal of tonsils and adenoid glands patient younger than age 12 42820 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Patient office consultation, typically 40 min 99243 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Patient office consultation, typically 60 min 99244 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Initial new patient preventive medicine evaluation (18-39 years) 99385 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Initial new patient preventive medicine evaluation (40-64 years) 99386 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
CT scan, head or brain, without contrast 70450 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
MRI scan of brain before and after contrast 70553 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
MRI scan of lower spinal canal 72148 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
CT scan, pelvis, with contrast 72193 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
MRI scan of leg joint 73721 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
CT scan of abdomen and pelvis with contrast 74177 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Ultrasound of abdomen 76700 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus 76805 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Ultrasound pelvis through vagina 76830 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Mammography of one breast 77065 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Mammography of both breasts 77066 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Mammography, screening, bilateral 77067 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Blood test, lipids (cholesterol and triglycerides) 80061 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Manual urinalysis test with examination using microscope 81001 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Automated urinalysis test 81003 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
PSA (prostate specific antigen) 84154 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Insertion of catheter into left heart for diagnosis 93452 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Sleep Study 95810 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
New patient office or other outpatient visit, typically 30 min 99203 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
New patient office of other outpatient visit, typically 45 min 99204 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
New patient office of other outpatient visit, typically 60 min 99205 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities 216 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care 59610 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Obstetric blood test panel 80055 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Psychotherapy, 30 min 90832 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Psychotherapy, 45 min 90834 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Psychotherapy, 60 min 90837 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Family psychotherapy, not including patient, 50 min 90846 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Family psychotherapy, including patient, 50 min 90847 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Group psychotherapy 90853 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Repair of groin hernia patient age 5 years or older 49505 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Surgical removal of prostate and surrounding lymph nodes using an endoscope 55866 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Removal of recurring cataract in lens capsule using laser 66821 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Ultrasound examination of lower large bowel using an endoscope 45391 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Routine obstetric care for vaginal delivery, including pre-and post- delivery care 59400 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Routine obstetric care for cesarean delivery, including pre-and post-delivery care 59510 Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided Service Not Provided
Notes and Disclaimers

The following pricing is subject to change at any time. Pricing listed may not reflect the total amount due on a claim, nor does it reflect your financial responsibility as a patient. Pricing and services below reflect a typical encounter; however, your physician may render a different variation of services to provide you the best level of care. The amount you pay may be less than what is reflected here.

The inclusion of pricing below does not indicate that a service is covered under your benefit plan. Likewise, the exclusion of a service below or pricing at $0 does not indicate that a service is not covered by your health plan, not offered by our facility, nor that the service may come at no cost to you.

"Included in primary procedure" indicates that, typically, the specified service is not separately priced; rather, it is considered packaged with the primary procedure. However, any variation in services provided – including whether individual services below are provided along with other services, rather than independently – can cause variation in pricing, due to payor policies.

Texas Medicaid utilizes a unique payment methodology for inpatient services that does not align with the coding reflected here; however, a median pricing estimate is shown in the grid. Your plan's rate may be more or less, depending upon the care you receive.

Workers' Compensation rates reflected below are based on claims filed in Texas. Rates may vary depending on the state in which the injury claim is filed.

Reimbursement by health plans can vary based on many factors including but not limited to benefit structures, diagnosis and case by case circumstances. Patients should always consult with their health plans and physician(s) to validate treatment and cost planning decisions.

Physician and other professional charges are not reflected here, as our facility does not negotiate such fees. These services may be separately billable by the physician/professional provider.

Please contact Richard Peters, Chief Operating Officer (512-346-1994, richard.peters@scasurgery.com) with any questions or for patient price estimates.

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