Sutter Health Plus Effective for Calendar Year 2015

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1 Sutter Health Plus Effective for Calendar Year 2015 CPTs CPT Descriptions 2015 Cost Under Deducible (Single Unit) Doctor's Office Visit for a New Patient (Also Urgent Care) Low Level Visit $ Low to Moderate Level Visit $ Moderate Level Visit $ Moderate to High Level Visit $ High Level Visit $ Doctor's Office Visit for an Established Patient (Also Urgent Care) Low Level Visit $ Low to Moderate Level Visit $ Moderate Level Visit $ Moderate to High Level Visit $ High Level Visit $ Specialist Consultation Low Level Specialist Consultation $ Low to Moderate Level Specialist Consultation $ Moderate Level Specialist Consultation $ Moderate to High Level Specialist Consultation $ High Level Specialist Consultation $ Eye Exams New Patient Intermediate Eye Exam $ New Patient Comprehensive Eye Exam $ Established Patient Intermediate Eye Exam $ Established Patient Comprehensive Eye Exam $ Eye Refraction for Vision Correction $52.00 Physical / Occupational Therapy Physical therapy evaluation $ Physical Therapy Re evaluation $ Occupational therapy evaluation $ Occupational Therapy Re evaluation $ Electric stimulation therapy, treatment only $ Physical Therapy Ultrasound, treatment only $ Physical therapy exercises, treatment only $ Physical therapy manual therapy $82.00 Allergy Injections Allergy shot single injection (does not include antigen serum) $26.00 Allergy shot two or more injections (does not include antigen serum) $30.00 CT Scans

2 70450 Head CT scan $ Sinus CT scan $ Chest CT scan $ Chest, including dye $ Pelvis CT Scan $ Pelvis CT Scan, including dye $ Abdomen CT Scan $ Abdomen CT Scan, including dye $ Abdomen CT Scan with and without dye $ Abdomen/Pelvis CT $ Abdomen/Pelvis CT with dye $ Abdomen/Pelvis CT with and without dye $1, MRIs Brain MRI without dye $1, Brain MRI with and without dye $1, Cervical Spine MRI without dye $1, Lumbar Spine MRI without dye $1, Pelvis MRI $1, Upper Extremity Joint MRI without dye $ Knee MRI without dye $ Breast MRI with and without dye $1, Pregnancy & Prenatal Tests Fetal non stress test $ Pregnancy ultrasound, first trimester $ Pregnancy ultrasound, after first trimester $ Obstetric ultrasound, Limited $ Obstetric ultrasound after first trimester $ Obstetric ultrasound, transvaginal $ Urine Pregnancy Test $10.00 Ultrasounds Breast ultrasound $ Abdominal ultrasound $ Abdominal ultrasound, limited $ Transvaginal ultrasound $ Pelvic ultrasound exam, complete $ X rays Chest x ray (one views) $ Chest x ray (two views) $ Bronchography $ Cervical Spine X ray, minimun 4 5 views $ Lumbar spine x ray (two or three views) $ Pelvis X ray, AP view only $ Shoulder x ray complete $ Elbow X ray, complete $ Wrist X ray, 2 views $ Wrist X ray, complete $ Hand X ray, complete $93.00

3 73140 Finger X ray $ Hip X ray $ Hip X ray, complete $ Femur X ray, 2 views $ Knee X ray one or two views $ Knee X ray 3 views $ Knee X ray, complete, 4+ views $ Knee X ray, bilateral $ Ankle X ray (3+ views) $ Foot X ray (complete) $ Toe X ray, minimum 2 views $ Abdomen $ Bone density scan (dexa scan) $ Other Radiology/Diagnostic Imaging G0202 Digital Mammogram, screening $ G0204 Digital Mammogram, bilateral $ G0206 Digital Mammogram, unilateral $ Radiologic Stress Test $1, Tone Screening Test $ Auditory Threshhold Evaluation $ Tympanometry $ Electrocardiogram (ECG) $ Cardiac Stress Test, complete $ Stress Test w/doppler, complete $ Echocardiogram, doppler $ Doppler Color Flow, add on $ Stress Test w/ Echocardiogram, real time image $ Duplex Scan of Extracranial Arteries $ Spirometry $ Lab Testing Basic Metabolic Panel $ Comprehensive Metabolic Panel $ Lipid Panel $ Renal Function Panel $ Acute Hepatitis Panel $ Hepatic Function Panel $ Urinalysis Manual with Micro Exam $ Urinalysis Automated with Micro Exam $ Urinalysis, Dipstick Only $ Urine Test, microanalysis only $ Alpha Fetoprotein Serum $ Amylase Test, serum $ Bilirubin Test, total $ Assay of Calcium $ Carcinoembryonic Antigen $ Total Cholesterol Test $ Cortisol, total $67.00

4 82550 Creatine Kinase $ Creatinine $ Vitamin B 12 $ Dehydrepiandrosterone Sulfate $ Assay of Ferritin $ Blood Folic Acid Serum $ Gammaglobulin IgE $ Glucose $ Blood Sugar Test, monitoring $ Gamma Glutamyltransferase $ Hemoglobin A1c $ Insulin, total $ Assay of Iron $ Lactate Dehydrogenase $ Lipase $ Low density Lipoprotein Cholesterol $ Assay of Magnesium $ Parathyroid Hormone, intact $ Alkaline Phosphatase, serum $ Assay of Phosphorus $ Potassium Test $ Prolactin $ Prostate Specific Antigen (PSA) $ Total Protein, urine $ Protein Electrophoresis, serum $ Sodium, serum $ Assay of Testosterone, total $ Assay of Thyroxine, total $ Thyroxine $ Thyroid Stimulating Hormone $ Transferase Aspartate Amino (AST) $ Transferase Alanine Amino (ALT) $ Triglycerides $ Assay Triidothyronine, total $ Triidothyronine, free $ Assay of Urea Nitrogen $ Uric Acid $ Chorionic Gonadotropin (hcg) Quantitative $ Hemoglobin $ Complete Blood Count $ Prothrombin Time $ Sedimentation Rate $ Allergen specific IgE Antibody Test $ Antinuclear Antibodies, direct $ C Reactive Protein $ High Sensitivity C Reactive Protein $ Thyroid Peroxidase Antibody $60.00

5 86431 Reheumatoid Arthritis Factor $ Blood Serology (RPR), Qualitative $ Herpes Simplex Type 1 Antibody $ Herpes Simplex Type 2 Antibody $ HIV 1/HIV 2 Single Assay $ Hepatitis B Surface Antibody $ Varicella Zoster Antibody $ Thyroglobulin Antibody $ Hepatitis C Antibody $ ABO Blood Typing $ RH (D) Blood Typing $ Hepatitis B Surface Antigen $ Chlamydia Amplified Probe $ Hepatitis C RNA by PCR Quant $ Gonorrhea Amplified Probe $ Papilloma Virus Amplified Probe (HPV) $ Influenza Rapid $ Strep Group A Rapid $ Pap Smear $84.00 Office Procedures Incision and Drainage $ Skin Biopsy 1 lesion $ Skin Lesion Destruction 1 lesion $ Injection, tendon $ Injection/Aspiration, small joint/bursa $ Injection/Aspiration, intermediate joint/bursa $ Arthrocentesis $ Apply Short Arm Cast $ Control Nosebleed, simple $ Impacted Cerumen Removal $ Bronchodilation $ Inhalation Treatment $54.00 Estimated cost above represents the fee for a single unit of service provided by a Sutter Medical Foundation / SMG, Sutter Gould / GMG, or Sutter Pacific Medical Foundation / SMGR physician. Similar services provided at a hospital or by a physician from a different medical group or IPA will vary. The amount you are charged for a service will vary depending on your plan coverage and if you have reached your deductible or out of pocket maximum.