6. The charge shown is only for patients without insurance.

Transcription

1 OTHER THERAPEUTIC PROCEDURES AND DIAGNOSTIC TESTING EMERGENCY ROOM, IV THERAPY, CARDIAC CATHETERIZATION, EKG, EEG, VACCINATION, ARTERIAL AND VASCULAR STUDIES For the Time Period : 10/01/16 and 09/30/2017 IF YOU ARE COVERED BY HEALTH INSURANCE, YOU ARE STRONGLY ENCOURAGED TO CONSULT WITH YOUR HEALTH INSURER TO DETERMINE ACCURATE INFORMATION ABOUT YOUR FINACIAL RESPONSIBILITY FOR A PARTICULAR HEALTH CARE SERVICE PROVIDED AT THIS HEALTHCARE FACILITY. IF YOU ARE NOT COVERED BY HEALTH INSURANCE YOU ARE STRONGLY ENCOURAGED TO CONTACT THE BUSINESS OFFICE AT (719) OR TOLL FREE AT TO DISCUSS PAYMENT OPTIONS PRIOR TO RECEIVING A HEALTH CARE SERVICE FROM THIS HEALTH CARE FACILITY SINCE POSTED HEALTHCARE SERVICES MAY NOT REFLECT THE ACTUAL AMOUNT OF YOUR FINANCIAL RESPONSIBILITY. Note: 1. The pricing on this page is for diagnostic and therapeutic procedures listed only. It is not combined pricing with other testing 2. Charging is based on the Length of Stay, amount of supplies used, therapies provided, testing given as well as other care provided 3. This pricing is based on an average charge and not intended to be the exact charge for any particular patient 4. The self pay charge shown is an estimate and that actual charges for the service depend on the patient's circumstances at the time the service is provided. 5. Any insurance discount is negotiated by the insurance carrier. Most insurance carriers should be able to tell their what financial responsibility they will have. 6. The charge shown is only for patients without insurance. CPT Plain Language Description Self Pay Price HEPATITIS B IMMUNE GLOBULIN INTRAMUSCULAR OR SUBCUTANEOUS $ 1, RABIES IMMUNE GLOBULIN INTRAMUSCULAR OR SUBCUTANEOUS $ 4, IMUNIZATION ADMINISTRATION - INITIAL $ IMMUNIZATION ADMINISTRATION EACH ADD'L VACCINE $ RABIES VACCINE INTRAMUSCULAR $ INFLUENZA VACCINE, PRESERVATIVE FREE.25 ML $ 9.50

2 90686 INFLUENZA VACCINE, PRESERVATIVE FREE.5 ML $ TETUNUS, DIPTHERIA TOXIODS VACCINE OLDER THAN 7 YRS - PRESERVATIVE FREE $ TETUNUS, DIPTHERIA TOXIODS VACCINE OLDER THAN 7 YRS $ PNEUMOCOCAL POLYSACCHARIDE VACCINE 23 VALENT ADULT OT $ IMMUNOSUPRESSED, GREATER THAN 2 YRS HEPATITIS B VACCINE ADULT DOSAGE - 3 TIMES INTRAMUSCULAR $ PSYCOTHERAPY W/PATIENT - 30 MINS $ FAMILY PSYCOTHERAPY W/PATIENT PRESENT - 50 MINS $ DIALYSISPROCEDURE OTHER THAN HEMODIALYSIS- ONE EVALUATION $ ESOPOGEAL MOTILITY STUDY $ 1, GASTROESOPHAGEAL, ESOPHAGAS REFLUS TEST $ 1, GASTROESOPHAGEAL, ESOPHAGAS REFLUS TEST W/PH ELECTRODE $ 1, GI TRACT CAPSULE ENDOSCOPY $ 1, GENERAL GASTROENTEROLOGIC PROCEDURE $ NASOPHARRYNGOSCOPY WITH ENDOSCPE $ CARDIOPULONARY RESUSITATION - CPR $ 1, CARDIOVERSION - USING ELECTRODES $ 2, INTRAVASCULAR ULTRASOUND - ENDOLUMINAL - INITIAL PROCEDURE $ INTRAVASCULAR ULTRASOUND - ADD'L VESSEL $ ELECTROCARDIOGRAM TRACING ONLY $ CARDIOVASCULAR STRESS TEST TRACING ONLY W/OUT INTERPRETAION OR REPORT $ RHYTHM ELECTROCADIOGRAM W/OUT INTERPRETATION OR REPORT $ ELECTROCARDIOGRAM UP TO 48 HRS RECORDING - CONNECTION AND $ DISCONNECTION ELECTROCARDIOGRAM 30 DAY REMOTE RECORDING - CONNECTION AND $ DISCONNECTION ELETROCARDIOGRAM - TRANSMISSION & ANALYSIS $ TRANSTHORACIC ECHOCARDIAGRAM - COMPLETE $ 1, ECHOCARDIOGRAPHY, TRANSTHORACIC - COMPLETE STUDY, WITH DOPPLAR $ ECHOCARDIOGRAPHY, TRANSTHORACIC - COMPLETE STUDY, NO DOPPLAR $ ECHOCARDIOGRAPHY, TRANSTHORACIC - FOLLOW UP OR LIMITED STUDY $ TRANSESOPHAGEAL ECHOCARDIAGRAPHY - TEE $ 1,345.06

3 93320 DOPPLAR ECHOCARDIOGRAPHY HEART $ DOPPLAR ECHOCARDIOGRAPHY COLOR FLOW MAPPING - ADD'L TO PRIMARY $ PROCEDURE ECHOCARDIOGRAPHY, TRANSTHORACIC 2D W/CONTIUOUS ELETROCARDIOGRAPIC $ MONITORING RIGHT HEART CATHETERIZATION $ 3, LEFT HEART CATHETERIZATION W/VENTRICULAROGRAPHY $ 5, COMBINED RIGHT & LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYPASS $ 10, GRAFT CATHETER PLACEMENT IN CORONARY ARTERY FOR CORONARY $ 4, CORONARY W/CATH PLACEMENT(S) IN BYPASS GRAFTS FOR BY PASS $ 6, GRAFT LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYBASS GRAFT $ 9, LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYBASS GRAFT $ 9, RIGHT/LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYPASS GRAFT $ 11, RIGHT/LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYPASS GRAFT $ 11, LEFT HEART CATHETERIZATION BY TRANSSEPITAL PUNCTURE $ 2, INJECTION OF SUPRAVALVULAR AORTOGRAPHY - ADD'L TO PRIMARY PROCEDURE $ INTRAVASCULAR DOPPAL VELOCITY &/OR PRESSURE DERIVED CORONARY FLOW $ EACH ADD'L VESSAL - ADD'L TO PRIMARY PROCEDURE $ PERCUTANIOUS TRANSCATHTER CLOUSER OF CONGENITAL DEFECT $ 9, BUNDLE OF HIS RECORDING $ 2, INTRA-ATRIAL RECORDING $ 1, RIGHT VENTRICULAR RECORDING $ 1, MAP TACHYCARDIA ADD-ON $ INTRA-ATRIAL PACING $ 1, INTRAVENTRICULAR PACING $ 1,904.56

4 93613 INTRACARDIAC ELECTROPHYSIOLOGIC 3D MAPPING ADD'L TO PRIMARY PROCEDURE $ 3, COMPERHANSIVE ELECTROPHYSIOLOGIC EVALUATION W/INSERTION & REPOSITION $ 7, OF MULTIPLE ELECTRODES - PRIMARY PROCEDURE LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM - $ ADD'L TO PRIMARY PROCEDURE LEFT VENTRICULAR PACING ADD'L TO PRIMARY PROCEDURE $ PROGRAMED STIMULATION AND PACING AFTER IV DRUG INFUSION $ ELECTROPHYSIOLOGIC EVAL OF SINGLE DUAL CHAMBER TRANSVENOUS PAGING $ CARDIOVERTER -DEFIBRULATOR INTRACARDIAC CATHER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION $ 5, COMPERHANSIVE ELECTROPHYSIOLOGIC EVALUATION W/INSERTION & REPOSITION $ 9, OF MULTIPLE ELECTRODES INTRACARDIAC CATHETER ABLATION OF DISCRETE MECH OF ARRHYTHMIA - PRIMARY $ 9, ABLATION INTRACARDIAC CATHETER ABLATION OF DISCRETE MECH OF ARRHYTHMIA - ADDED $ 4, AFTER PRIMARY ABLATION COMPREHENSIVE ELETROPHYSIOLOGIC EVAL INCLUDING TRANSEPTAL $ 19, CATHETERIAZATION, INSERT & REPOSITION ELECTRODES ADD'L LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION $ 8, EVAL OF CARDIAC FUNCTION WITH TILT TABLE EVAL, CONINUOUS ECG MONITORING $ INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC.DIAGNOSTIC $ INTERVENTION DUPLEX SCAN OF ESCTRACRANIAL ARTERIES, COMPLETE - BILATERAL $ 1, NONINVASIVE PHYSIOLOGIC STUDIES, UPPER OR LOWER EXTREMITIES ARTERIES - 1 TO $ LEVELS NONINVASIVE PHYSIOLOGIC STUDIES, UPPER OR LOWER EXTREMITIES ARTERIES - $ BILATERAL 3 OR MORE LEVELS NONINVASIVE PHYSIOLOGIC STUDIES, LOWER EXTREMITIES ARTERIES BILATERAL $ DUPLEX SCAN OF LOWER EXTREMITY - BILATERAL OR COMPLETE STUDY $ DUPLEX SCAN OF LOWER EXTREMITY - UNILATERAL OR LIMITED STUDY $ DUPLEX SCAN OF EXTREMITY VEINS - COMPLETE BILATERAL STUDY $ 1,218.61

5 93975 DUPLEX SCAN OF ARTERIAL & VENOUS INFLOW AND OUTFLOW - COMPLETE STUDY $ DUPLEX SCAN OF ARTERIAL & VENOUS INFLOW AND OUTFLOW - LIMITED STUDY $ DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA COMPLETE STUDY $ DUPLEX SCAN OF HEMODIALYSIS ACCESS $ VENTILATOR MANAGEMENT - INITIATION - 1ST DAY $ 1, VENTILATOR MANAGEMENT - EACH ADD'L DAY $ 1, SPIROMETRY, INCLUDING GRAPHIC RECORD & MEASUREMENTS $ BRONCHODILATION RESPONSIVENESS EVALUATION - SPIROMETRY PRE & POST $ BRONCHODILATOR ADMIN BRONCHOSPASM PROVACATION EVALUATION, MULTI DETERMINATIONS $ PRESURIZED OR NONPRESSURIZED INHALATION TREATMENT $ CONTINUOUS INHALATION TREATMENT W/AEROSAL MEDICATION - 1ST HR $ CONTINUOUS INHALATION TREATMENT W/AEROSAL MEDICATION - EACH ADD'L HR $ CONTINUOUS POSATIVE AIRWAY PRESSURE (CPAP) $ CHEST WALL MANIPULATION - INITIAL $ CHEST WALL MANIPULATION - SUBSEQUENT $ MECHANICAL CHEST WALL OSCILLATION TO FACILITATE LUNG FUNCTION $ PLETHYSMOGRAPHY - PULMONARY FUNCTION TEST $ CARBON MONOXIDE DIFFUSING CAPACITY $ MEASURE BLOOD OXYGEN LEVEL CONTINUOUS OVERNIGHT MONITORING $ GENERAL PULMONARY SERVICE OR PROCEDURE $ CONTINUOUS GLUCOSE MONITORING $ MULTIPLE SLEEP LATENCY TEST - MAINTENANCE OF WAKEFULNESS $ 1, SLEEP STUDY UNATTENDED, SIMMULTANIOUS RECORDING OF HEART, RESP, O2, RESP $ AIR FLOW SLEEP STUDY ATTENDED $ POLYSOMNOGRAPHY, MORE THAN 6 YRS W/OUT CPAP MORE THAN 4 PARAMETERS $ 1, POLYSOMNOGRAPHY, MORE THAN 6 YRS W/CPAP MORE THAN 4 PARAMETERS $ 1, ELECTROENCEPHALOGRAM - MONITORED, MIN $ 1,102.38

6 95813 ELECTROENCEPHALOGRAM - MONITORED OVER 1 HR $ 1, ELECTROENCEPHALOGRAM - AWAKE AND DROWSY $ 1, ELECTROENCEPHALOGRAM - AWAKE AND ASLEEP $ 1, NEEDLE ELECTROMYOGRAPHY, HAND $ NEEDLE ELECTROMYOGRAPHY, ONE LIMB $ NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, LIMITED, RELATED PARASPINAL $ AREAS NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, COMPLETE 5 OR MORE MUSCLES $ NERVE CONDUCTION STUDIES 1-2 STUDIES $ NERVE CONDUCTION STUDIES 3-4 STUDIES $ VISUAL EVOKED POTENTIAL TEST $ VIDEO RECORDED EEG MONITORING RECORDING AND INTERP - 24 HRS $ 2, COMPUTERIZED EEG MONITORING RECORDING AND INTERP - 24 HRS $ 2, CANALITH REPOSITIONING PROCEDURE $ IV INFUSION FOR HYDRATION- 30 MIN TO 1 HOUR $ IV INFUSION FOR HYDRATION- ADD'L 1 HOUR $ THERAPUETIC, DIAGNOSTIC IV INFUSION - 1 HOUR - INTIAL $ THERAPUETIC, DIAGNOSTIC IV INFUSION - ADD'L 1 HOUR $ THERAPUETIC, DIAGNOSTIC IV INFUSION CONNCURRENT TO OTHER INFUSION -ADD'L $ SEQUENCE THERAPUETIC, DIAGNOSTIC IV INFUSION CONNCURRENT TO OTHER INFUSION $ THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION - INITIAL - DRUG NOT $ INCLUDED IV PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG - DRUG NOT INCLUDED $ THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION - ADD'L ADMINISTRATION $ DRUG NOT INCLUDED - NEW DRUG THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION - ADD'L ADMINISTRATION $ DRUG NOT INCLUDED CHEMOTHERAPY IV INFUSION - UP TO 1 HOUR $ CHEMOTHERAPY IV INFUSION ADD'L TIME- UP TO 1 HOUR $ CHEMOTHERAPY IV INFUSION DIFFERENT SUBSTANCE ADD'L TIME UP TO 1 HOUR $ 74.48

7 96523 IRRIGATION OF IMPLANTABLE VENOUS ACCESS DEVICE FOR DRUG DELIVERY $ WOUND DEBRIDEMENT 1ST 20 CM OR LESS - INITIAL $ WOUND DEBRIDEMENT 1ST 20 CM OR LESS - EACH ADD'L 20 CM $ NEGATIVE PRESSURE WOUND THERAPY - LESS THAN 50 CM $ NEGATIVE PRESSURE WOUND THERAPY - MORE THAN 50 CM $ MEDICAL NUTRITION THERAPY - INITIAL $ MEDICAL NUTRITION THERAPY - REASSESSMENT $ OSTOPATHIC MANIPULATION 1 TO 2 REGIONS $ MODERATE SEDATION PERFORMED BY THE SAME MD INITIAL 15 MINUTES LESS THAN $ YEARS OLD MODERATE SEDATION PERFORMED BY THE SAME MD INITIAL 15 MINUTES OVER 4 $ YEARS OLD MODERATE SEDATION PERFORMED BY THE SAME MD INITIAL 15 MINUTES LESS THAN $ YEARS OLD MODERATE SEDATION PERFORMED BY THE SAME MD INITIAL 15 MINUTES OVER 4 $ YEARS OLD MODERATE SEDATION PERFORMED BY THE SAME MD EACH ADD'L 15 MINUTES $ THERAPEUTIC PHLEBOTOMY (BLOOD DRAW) $ EMERGENCY DEPT VISIT - LEVEL 1 $ EMERGENCY DEPT VISIT - LEVEL 2 $ EMERGENCY DEPT VISIT - LEVEL 3 $ EMERGENCY DEPT VISIT - LEVEL 4 $ EMERGENCY DEPT VISIT - LEVEL 5 $ 1, TRUAMA CARE - 1ST HOUR $ 4, TRUAMA CARE - EACH 30 MINUTES AFTER 1 HOUR $