010511

Document Sample
010511 Powered By Docstoc
					                         Ministry of Health price list for ambulatory and hospitalization services
                                                    Onset date: 01/05/11
                                                          Sorted by service code




Service
 code                                      Service name                                      Price A     Price B     Price C
 01996
          Day care management of epidural/subarachnoid continuous drug administration           430.00      421.00      430.00
 01999
          General anesthesia for ambulatory treatment, under anesthesiologist supervision     1,104.00    1,080.00    1,104.00
 10060    Incision and drainage of abscess/cyst                                                 352.00      344.00      352.00
 11100    Biopsy, excluding breast                                                              169.00      165.00      169.00
 11750    Excision of ingrown nail                                                              270.00      264.00      270.00
 11770    Excision of cyst, eg, pilonidal                                                       537.00      525.00      537.00
 11975    Insertion, implantable contraceptive capsules (eg, Norplant), including the cost
                                                                                              1,614.00    1,579.00    1,614.00
          of contraceptive
 11976    Removal, implantable contraceptive capsules                                           150.00      147.00      150.00
 12001    Simple repair of superficial wounds                                                   127.00      124.00      127.00
 16030    Dressings and/or debridement, without anesthesia, large lesion                        326.00      319.00      326.00
 17000    Removal of skin lesions, any method                                                   169.00      165.00      169.00
 17311    Mohs micrographic technique                                                         7,675.00    7,510.00    7,675.00
 17999    Soft laser treatment, 1/2 level, per treatment                                        169.00      165.00      169.00
 19100    Biopsy of breast; needle core, not using imaging guidance                             169.00      165.00      169.00
 19101    Biopsy of breast; open, incisional                                                    403.00      394.00      403.00
 19102    Biopsy of breast, using imaging guidance, excluding CT/MRI                          1,926.00    1,885.00    1,926.00
 19499    Breast examination                                                                      0.00        0.00        0.00
 20205    Biopsy, muscle, including histological examinations                                   957.00      936.00      957.00
 20206    Biopsy, muscle, including all tests, stains, EM                                     2,689.00    2,631.00    2,689.00
 20220    Biopsy, bone, trocar/needle, superficial                                              218.00      213.00      218.00
 20520    Foreign body removal, muscle/tendon, local anaesthesia                                120.00      117.00      120.00
 20600    Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers,
                                                                                                218.00      213.00      218.00
          toes)
 20605
          Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg,
                                                                                                218.00      213.00      218.00
          temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
 20610    Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder,
                                                                                                218.00      213.00      218.00
          hip, knee joint, subacromial bursa)
 20902    Harvesting of cortical bone, cartilage                                              3,544.00    3,468.00    3,544.00
 21310    Closed treatment of nasal bone fracture                                               218.00      213.00      218.00
 28899    Intra compartment pressure                                                            493.00      482.00      493.00
 29035    Application, body cast, shoulder to hips                                              280.00      274.00      280.00
 29065    Application, cast; shoulder to hand (long arm)                                        169.00      165.00      169.00
 29075    Application, cast, elbow to finger (short arm)                                        120.00      117.00      120.00
 29085    Application, cast, hand and lower forearm (gauntlet)                                  120.00      117.00      120.00
 29345    Application, cast, long leg (thigh to toes)                                           169.00      165.00      169.00
 29405    Application, cast, short leg (below knee to toes)                                     120.00      117.00      120.00
 29700    Cast removal                                                                           99.00       97.00       99.00
 29720    Repair of spica, body cast or jacket                                                    0.00        0.00        0.00
 29999
          Arthroscopy, diagnostic and/or surgical procedures, without using implants          6,579.00    6,437.00    6,579.00
 30110    Excision, nasal polyp(s), simple                                                      218.00      213.00      218.00
 30200    Injection into turbinate(s)                                                           124.00      121.00      124.00
 30300    Foreign body removal, intranasal, superficial                                           0.00        0.00        0.00
 30801
          Cautery and/or ablation, mucosa of turbinates, unilateral/bilateral, any method       218.00      213.00      218.00
 31002    Sinuses lavage                                                                        124.00      121.00      124.00
 31575    Laryngoscopy, flexible fiberoptic, diagnostic                                          82.00       80.00       82.00
 31579    Laryngoscopy, fiberoptic, with stroboscopy                                            136.00      133.00      136.00
 31622    Bronchoscopy, diagnostic, with/without brushing/washing                             1,253.00    1,226.00    1,253.00
Service
 code                                      Service name                                     Price A     Price B     Price C
 31636    Bronchoscopy, rigid or flexible, with placement of bronchial stent(s)             11,333.00   11,089.00   11,333.00
 32000    Thoracentesis, puncture of pleural cavity for aspiration                             218.00      213.00      218.00
 36005    Injection of contrast material, including radiology/fluoroscopy                      461.00      451.00      461.00
 36468    Injections of sclerosing solutions, spider veins (telangiectasia)                     99.00       97.00       99.00
 36511    Therapeutic apheresis, for white blood cells                                       3,159.00    3,091.00    3,159.00
 36513    Therapeutic apheresis, for platelets                                               2,547.00    2,492.00    2,547.00
 36515    Therapeutic apheresis; with extracorporeal immunoadsorption and plasma
                                                                                             8,319.00    8,140.00    8,319.00
          reinfusion
 36522    Photopheresis, extracorporeal                                                      6,689.00    6,545.00    6,689.00
 36590    Removal of tunneled central venous access device, with subcutaneous port or
                                                                                               311.00      304.00      311.00
          pump, central or peripheral insertion
 36600    Arterial blood sampling and diagnosis                                                169.00      165.00      169.00
 38220    Bone marrow aspiration and smear                                                     351.00      343.00      351.00
 38221    Bone marrow biopsy and smear                                                         351.00      343.00      351.00
 38505    Biopsy or excision of lymph node(s); by needle, superficial                          169.00      165.00      169.00
 40808    Biopsy, vestibule of mouth                                                           155.00      152.00      155.00
 40840    Vestibuloplasty, anterior                                                            712.00      697.00      712.00
 41010    Incision of lingual frenum (frenotomy)                                               521.00      510.00      521.00
 42699    Salivary glands endoscopy                                                          6,772.00    6,626.00    6,772.00
 42700    Incision and drainage of peritonsillar abscess                                       218.00      213.00      218.00
 42809    Foreign body removal, pharynx, superficial                                             0.00        0.00        0.00
 43200    Esophagoscopy, diagnostic                                                            254.00      249.00      254.00
 43204    Esophagoscopy, with injection sclerosis of esophageal varices                      3,129.00    3,062.00    3,129.00
 43219    Esophageal dilation and insertion of stent                                        15,155.00   14,829.00   15,155.00
 43235    UGI endoscopy, with/without sampling                                               1,054.00    1,031.00    1,054.00
 43240    Endoscopic drainage of pseudocyst of pancreas, using EUS guidance                  8,648.00    8,462.00    8,648.00
 43259
          Upper gastrointestinal endoscopy; with endoscopic ultrasound examination           1,271.00    1,244.00    1,271.00
 43260    ERCP (Endoscopic retrograde cholangiopancreatography), diagnostic                  3,395.00    3,322.00    3,395.00
 43264    ERCP (Endoscopic retrograde cholangiopancreatography), therapeutic                 5,767.00    5,643.00    5,767.00
 43450    Esophageal dilation, without using imaging guidance                                  254.00      249.00      254.00
 43750    PEG (Percutaneous Endoscopic Gastrostomy)                                          2,075.00    2,030.00    2,075.00
 43760    Replacement of PEG (Percutaneous Endoscopic Gastrostomy)                           1,142.00    1,117.00    1,142.00
 44360    Small intestinal endoscopy, enteroscopy, diagnostic, with/without collection of
                                                                                             2,355.00    2,304.00    2,355.00
          specimen(s)
 45300    Proctosigmoidoscopy, diagnostic                                                      187.00      183.00      187.00
 45331    Sigmoidoscopy, flexible, with/without biopsy                                         607.00      594.00      607.00
 45378    Colonoscopy, flexible; diagnostic, with/without collection of specimen(s),
                                                                                               948.00      928.00      948.00
          population at risk
 45383    Colonoscopy, with excision of lesion                                               1,945.00    1,903.00    1,945.00
 45387    Colonoscopy, with dilation and stent placement                                    15,155.00   14,829.00   15,155.00
 45905    Dilation of anal sphincter                                                           288.00      282.00      288.00
 46080
          Sphincterotomy, anal, division of sphincter under general/regional anesthesia      1,831.00    1,792.00    1,831.00
 46500    Injection of sclerosing solution, hemorrhoids                                         99.00       97.00       99.00
 46600    Anoscopy, diagnostic                                                                  77.00       75.00       77.00
 47999    Extracorporeal shockwave lithotripsy, biliary ducts; simple                        5,597.00    5,477.00    5,597.00
 49321    Laparoscopy, surgical, with biopsy (single or multiple)                            5,142.00    5,031.00    5,142.00
 50040    Nephrostomy, nephrotomy with drainage                                              2,421.00    2,369.00    2,421.00
 50398    Repositioning/change of nephrostomy or pyelostomy tube                             1,445.00    1,414.00    1,445.00
 50590    Extracorporeal shockwave lithotripsy, kidney; simple                               5,806.00    5,681.00    5,806.00
 51045    Insertion of urethral or ureteral stent                                            2,421.00    2,369.00    2,421.00
 51700    Bladder irrigation, simple, lavage and/or instillation                               120.00      117.00      120.00
 51703    Insertion of urethral catheter                                                       124.00      121.00      124.00
 51720    Bladder instillation of anticarcinogenic agent                                       310.00      303.00      310.00
 51726    Cystometrogram                                                                       461.00      451.00      461.00
 51736    Simple uroflowmetry (UFR)                                                            218.00      213.00      218.00
 51741    Complex uroflowmetry                                                               1,513.00    1,480.00    1,513.00
 51772    Urethral pressure profile studies (UPP) (urethral closure pressure profile)          461.00      451.00      461.00
Service
 code                                      Service name                                       Price A     Price B     Price C
 51784    EMG of anal/urethral sphincter, any technique                                          461.00      451.00      461.00
 52000    Cystourethroscopy                                                                      451.00      441.00      451.00
 52204    Cystourethroscopy, with biopsy/other surgical procedure                              1,173.00    1,148.00    1,173.00
 53000    Urethrotomy or urethrostomy                                                            451.00      441.00      451.00
 53850    Destruction of prostate tissue by thermotherapy                                      4,094.00    4,006.00    4,094.00
 54235    Injection of corpora cavernosa                                                          83.00       81.00       83.00
 54250    Nocturnal penile tumescence and/or rigidity test                                       595.00      582.00      595.00
 55000    Puncture aspiration of hydrocele, with/without injection of medication                 254.00      249.00      254.00
 55700    Biopsy, prostate; needle or punch, single or multiple, any approach                  1,619.00    1,584.00    1,619.00
 55870    Electroejaculation                                                                   5,678.00    5,556.00    5,678.00
 57452    Colposcopy, vaginoscopy                                                                117.00      114.00      117.00
 57510    Cautery of cervix, any method                                                          120.00      117.00      120.00
 58120    Dilation and curettage, diagnostic and/or therapeutic, excluding induced
                                                                                               2,413.00    2,361.00    2,413.00
          abortion
 58300    Insertion of intrauterine device (IUD)                                                 254.00      249.00      254.00
 58301    Removal of intrauterine device (IUD)                                                   120.00      117.00      120.00
 58321    Artificial insemination, intra-cervical                                                120.00      117.00      120.00
 58322    Artificial insemination, intra-uterine                                                 164.00      160.00      164.00
 58323    Sperm washing for artificial insemination                                              494.00      483.00      494.00
 58345    Fallopian tube dilation, catheterization, diagnostic/therapeutic                     3,575.00    3,498.00    3,575.00
 58555    Hysteroscopy                                                                           451.00      441.00      451.00
 58558    Hysteroscopy, surgica, with biopsy/other surgical procedure                            824.00      806.00      824.00
 58563    Uterine thermal therapy                                                              5,281.00    5,167.00    5,281.00
 58974    Cryopreserved embryos transfer, intrauterine                                         3,608.00    3,530.00    3,608.00
 59000    Amniocentesis                                                                          223.00      218.00      223.00
 59012    Cordocentesis (intrauterine), any method                                             2,538.00    2,483.00    2,538.00
 59015    Chorionic villus sampling, any method                                                1,009.00      987.00    1,009.00
 59020    Fetal contraction stress test                                                          649.00      635.00      649.00
 59025    Fetal NST (non stress test)                                                            305.00      298.00      305.00
 59866    Multifetal pregnancy reduction(s) (MPR), including US guidance                       2,413.00    2,361.00    2,413.00
 59871    Removal of cerclage suture                                                             169.00      165.00      169.00
 62270    Spinal puncture, lumbar, diagnostic                                                    614.00      601.00      614.00
 62272    Spinal puncture, therapeutic                                                           614.00      601.00      614.00
 62310    Injection, epidural/subarachnoid; cervical/thoracic                                    430.00      421.00      430.00
 62311    Injection, epidural/subarachnoid; lumbar/sacral (caudal)                               430.00      421.00      430.00
 62360    Spinal intrathecal pump for pain relief                                             62,032.00   60,697.00   62,032.00
 64400    Injection, anesthetic agent (eg, Lignocaine)                                           212.00      207.00      212.00
 64470    Paravertebral injection                                                                124.00      121.00      124.00
 64550    Application of surface (transcutaneous) neurostimulator                                218.00      213.00      218.00
 64612    Botolinum Toxin, 10 units Botox administration                                         233.00      228.00      233.00
 65205    Foreign body removal, external eye, superficial                                          0.00        0.00        0.00
 66984    Extracapsular cataract removal with insertion of intraocular lens prosthesis, any
                                                                                               4,833.00    4,729.00    4,833.00
          methods, lens included
 66999    Intracorneal rings for keratoconus treatment, Intacs                                 6,329.00    6,193.00    6,329.00
 67210    Retinal photocoagulation, PDT, without material                                      1,637.00    1,602.00    1,637.00
 67912    Implantation of upper eyelid gold weight                                             4,182.00    4,092.00    4,182.00
 68810    Probing of nasolacrimal duct, with/without irrigation                                1,148.00    1,123.00    1,148.00
 68811    Probing of nasolacrimal duct, with/without irrigation; requiring general
                                                                                               3,096.00    3,029.00    3,096.00
          anesthesia
 69000    Puncture/drainage external ear abscess/hematoma                                        218.00      213.00      218.00
 69200    Foreign body removal, ear, superficial                                                   0.00        0.00        0.00
 69210    Removal impacted cerumen                                                               124.00      121.00      124.00
 69420    Myringotomy including puncture/aspiration                                              218.00      213.00      218.00
 69436
          Tympanostomy (requiring insertion of ventilating tube), general anesthesia           1,321.00    1,293.00    1,321.00
 70030    Eye radiology, foreign body detection                                                  266.00      260.00      266.00
 70100    Mandible radiology, up to two views                                                    221.00      216.00      221.00
 70120    Mastoids radiology, up to two views                                                    120.00      117.00      120.00
 70170    Dacryocystography, radiological supervision and interpretation                         164.00      160.00      164.00
Service
 code                                     Service name                         Price A     Price B     Price C
 70200    Orbits radiology, up to two views                                       158.00      155.00      158.00
 70210    Paranasal sinuses radiology, up to two views                            156.00      153.00      156.00
 70240    Sella turcica radiology                                                 218.00      213.00      218.00
 70250    Skull radiology, up to two views                                        109.00      107.00      109.00
 70332    TMJ arthrography, including injection and interpretation                280.00      274.00      280.00
 70336    TMJ (temporomandibular joint(s)) MRI                                  1,975.00    1,932.00    1,975.00
 70360    Neck, soft tissue radiology, trachea                                    352.00      344.00      352.00
 70390    Salivary glands radiology, sialography                                  330.00      323.00      330.00
 70540    Orbit, face and neck, without contrast material                       1,975.00    1,932.00    1,975.00
 70551    Brain/brain stem MRI, without contrast material                       1,975.00    1,932.00    1,975.00
 71020    Chest radiology, up to two views                                        100.00       98.00      100.00
 71023    Chest radiology, up to two views, with fluoroscopy                      310.00      303.00      310.00
 71100    Ribs radiology, up to two views                                         152.00      149.00      152.00
 71120    Sternum radiology, up to two views                                      164.00      160.00      164.00
 71550    Thorax MRI, without contrast material                                 1,896.00    1,855.00    1,896.00
 72010    Spine radiology, entire, up to two views                                158.00      155.00      158.00
 72040    Cervical spine radiology, up to two views                               109.00      107.00      109.00
 72070    Thoracic spine radiology, up to two views                               109.00      107.00      109.00
 72080    Thoracolumbar spine radiology, up to two views                          109.00      107.00      109.00
 72100    Lumbosacral spine radiology, up to two views                            109.00      107.00      109.00
 72141    Cervical spine, MRI, per patient                                      1,975.00    1,932.00    1,975.00
 72146    Thoracic spine, MRI, per patient                                      1,975.00    1,932.00    1,975.00
 72148    Lumbar spine, MRI, per patient                                        1,975.00    1,932.00    1,975.00
 72170    Pelvis radiology, up to two views                                       123.00      120.00      123.00
 72200    SIJ radiology, up to two views                                          164.00      160.00      164.00
 72270    Myelography                                                           1,255.00    1,228.00    1,255.00
 73000    Clavicle radiology                                                      129.00      126.00      129.00
 73010    Scapula radiology                                                       129.00      126.00      129.00
 73030    Shoulder radiology, complete, one side, up to two views                 120.00      117.00      120.00
 73040    Shoulder arthrography, including injection and interpretation           280.00      274.00      280.00
 73060    Humerus radiology, up to two views                                      109.00      107.00      109.00
 73070    Elbow radiology, up to two views                                        109.00      107.00      109.00
 73085    Elbow arthrography, including injection and interpretation              280.00      274.00      280.00
 73090    Forearm radiology, up to two views                                      109.00      107.00      109.00
 73092    Upper extremity radiology, infant, up to two views                      109.00      107.00      109.00
 73100    Wrist radiology, up to two views                                        109.00      107.00      109.00
 73115    Wrist, arthrography, including injection and interpretation             280.00      274.00      280.00
 73120    Hand radiology, up to two views                                         109.00      107.00      109.00
 73140    Finger(s) radiology, up to two views                                    109.00      107.00      109.00
 73221    Upper extremity joints MRI, without contrast material, per patient    1,896.00    1,855.00    1,896.00
 73500    Hip radiology, unilateral, one view                                     109.00      107.00      109.00
 73520    Hip radiology, bilateral, including pelvis                              109.00      107.00      109.00
 73525    Hip arthrography, including injection and interpretation                280.00      274.00      280.00
 73542    SIJ arthrography, including injection and interpretation                280.00      274.00      280.00
 73550    Femur radiology, up to two views                                        109.00      107.00      109.00
 73560    Knee radiology, up to two views, per side                               109.00      107.00      109.00
 73562    Knee radiology, third or more additional views                          120.00      117.00      120.00
 73580    Knee arthrography, including injection and interpretation               280.00      274.00      280.00
 73590    Tibia and fibula radiology, up to two views                             109.00      107.00      109.00
 73592    Lower extremity radiology, infant, up to two views                      109.00      107.00      109.00
 73610    Ankle radiology, complete, one side                                     109.00      107.00      109.00
 73615    Ankle arthrography, including injection and interpretation              280.00      274.00      280.00
 73620    Foot radiology, up to two views                                         109.00      107.00      109.00
 73721    Hip joint, MRI; without contrast material, per patient                1,896.00    1,855.00    1,896.00
 74000    Abdomen radiology, without contrast material                            156.00      153.00      156.00
 74181    Abdomen, MRI, per patient                                             1,975.00    1,932.00    1,975.00
 74220    Esophagus radiology                                                     387.00      379.00      387.00
 74230    Swallowing function, with cineradiography/videoradiography              618.00      605.00      618.00
 74241    UGI fluoroscopy and/or radiology, with/without delayed films            649.00      635.00      649.00
Service
 code                                      Service name                                   Price A     Price B     Price C
 74245    UGI fluoroscopy, including serial films                                            803.00      786.00      803.00
 74249    Abdomen radiology, small intestine follow-through                                  387.00      379.00      387.00
 74270    Barium enema                                                                       461.00      451.00      461.00
 74280    Air barium enema, with/without glucagon                                            741.00      725.00      741.00
 74290    Cholecystography, oral contrast                                                    385.00      377.00      385.00
 74360    Esophageal dilation, using imaging guidance                                      5,159.00    5,048.00    5,159.00
 74400    IVP, with or without tomography                                                    571.00      559.00      571.00
 74420    Urography, retrograde                                                              469.00      459.00      469.00
 74450
          Urethrocystography, retrograde, radiological supervision and interpretation        364.00      356.00      364.00
 74455    Urethrocystography, radiological supervision and interpretation                    455.00      445.00      455.00
 74740    Hysterosalpingography, radiology                                                   473.00      463.00      473.00
 75552    MRI cardiac morphology, per patient                                              5,223.00    5,111.00    5,223.00
 75554    Cardiac FMRI; with/without morphology, complete study, per patient               5,223.00    5,111.00    5,223.00
 75803    Lymphangiography, extremities                                                    1,825.00    1,786.00    1,825.00
 75822    Phlebography, venography, including injection and imaging                          614.00      601.00      614.00
 76000    Fluoroscopy                                                                         99.00       97.00       99.00
 76120    Cineradiography/videoradiography, video capsule                                  4,640.00    4,540.00    4,640.00
 76140    Interpretation/consultation on imaging made elsewhere                              120.00      117.00      120.00
 76390    MRS,Magnetic resonance spectroscopy, per patient                                 5,223.00    5,111.00    5,223.00
 76512    Ophthalmic US (ultrasound)                                                         152.00      149.00      152.00
 76514    Ophthalmic US, corneal pachymetry, determination of corneal thickness, per
                                                                                              85.00       83.00       85.00
          patient
 76536    Head and neck soft tissues US, with image documentation                            306.00      299.00      306.00
 76604    Chest US, including mediastinum, with image documentation                          525.00      514.00      525.00
 76645    Breasts and chest wall US, with image documentation                                213.00      208.00      213.00
 76700    Abdomen US, with image documentation                                               306.00      299.00      306.00
 76805    Fetal anatomic US, with image documentation                                        786.00      769.00      786.00
 76813    Fetal nuchal translucency US, per one fetus, with image documentation              322.00      315.00      322.00
 76814    Fetal nuchal translucency US, per each additional fetus, with image
                                                                                             213.00      208.00      213.00
          documentation
 76815    Obstetric US, with image documentation                                             430.00      421.00      430.00
 76825    Echocardiography, fetal, with image documentation                                  899.00      880.00      899.00
 76827    Doppler echocardiography, fetal                                                  1,113.00    1,089.00    1,113.00
 76830    TVUS (Transvaginal Ultrasound)                                                     250.00      245.00      250.00
 76831    Uterus and fallopian tube sonography, with contrast material                       874.00      855.00      874.00
 76857    Gynecological US, follicles                                                        160.00      157.00      160.00
 76870    Scrotum US, with image documentation                                               525.00      514.00      525.00
 76872    TRUS (transrectal ultrasound), with image documentation                            762.00      746.00      762.00
 76942    Biopsy/surgical procedure, US guidance                                           2,420.00    2,368.00    2,420.00
 77002    Biopsy/surgical procedure, using fluoroscopic guidance                           2,420.00    2,368.00    2,420.00
 77012    Biopsy/surgical procedure, using CT guidance                                     4,385.00    4,291.00    4,385.00
 77021    Biopsy/surgical procedure, using MRI guidance                                    6,579.00    6,437.00    6,579.00
 77031    Stereotactic localization guidance for breast biopsy/needle placement,
                                                                                           4,383.00    4,289.00    4,383.00
          including biopsy, using imaging guidance (eg, mammography)
 77032
          Mammographic guidance for needle placement, breast (eg, for wire localization
                                                                                             665.00      651.00      665.00
          or for injection), each lesion, radiological supervision and interpretation
 77054    Mammary ductogram/galactogram, including interpretation                            862.00      843.00      862.00
 77056    Mammography; bilateral                                                             215.00      210.00      215.00
 77059    MRI, breast, without and/or with contrast material(s); bilateral                 1,975.00    1,932.00    1,975.00
 77073    Bone length studies (orthoroentgenogram, scanogram)                                308.00      301.00      308.00
 77080    DXA, bone density study                                                            192.00      188.00      192.00
 77261    Therapeutic radiology treatment planning, radiotherapy                             501.00      490.00      501.00
 77280    Radiotherapy simulation                                                          1,995.00    1,952.00    1,995.00
 77295    Radiology simulation-aided field setting, three-dimensional                      2,496.00    2,442.00    2,496.00
 77401    Radiation treatment delivery, per field                                            438.00      384.00      394.00
 78000    Thyroid uptake, single determination                                               250.00      245.00      250.00
 78001    Thyroid uptake, multiple determinations                                            427.00      418.00      427.00
Service
 code                                     Service name                                       Price A     Price B     Price C
 78007    Thyroid imaging, with uptake, multiple determinations                                 856.00      838.00      856.00
 78010    Thyroid imaging                                                                       557.00      545.00      557.00
 78018    Thyroid imaging; I-131, whole body                                                  2,582.00    2,526.00    2,582.00
 78070    Parathyroid imaging                                                                 1,287.00    1,259.00    1,287.00
 78075    Adrenal imaging, medulla; I-123 MIBG                                                8,341.00    8,161.00    8,341.00
 78104    Bone marrow imaging, whole body                                                     2,409.00    2,357.00    2,409.00
 78122    Whole blood volume determination, radiopharmaceutical technique                     1,597.00    1,563.00    1,597.00
 78130    Red cell survival study                                                             2,727.00    2,668.00    2,727.00
 78191    Platelet survival study                                                               866.00      847.00      866.00
 78195    Lymphatics and lymph nodes imaging                                                  2,384.00    2,333.00    2,384.00
 78205    Liver and spleen imaging, SPECT                                                       752.00      736.00      752.00
 78215    Liver and spleen imaging, static                                                      665.00      651.00      665.00
 78216    Liver and spleen imaging, dynamic and static                                          707.00      692.00      707.00
 78223    Hepatobiliary imaging, with/without pharmacologic intervention, with/without
                                                                                              1,963.00    1,921.00    1,963.00
          quantitative measurement of gallbladder function
 78231    Salivary gland imaging, with serial images                                            819.00      801.00      819.00
 78258    Esophageal motility, dynamic                                                          847.00      829.00      847.00
 78262    Gastroesophageal reflux study                                                         640.00      626.00      640.00
 78264    Gastric emptying study                                                              2,541.00    2,486.00    2,541.00
 78270    Vitamin B-12 absorption, without intrinsic factor                                     611.00      598.00      611.00
 78271    Vitamin B-12 absorption, with intrinsic factor                                        838.00      820.00      838.00
 78278    Acute GI bleeding imaging, dynamic and static                                       2,477.00    2,424.00    2,477.00
 78290    Intestine imaging (eg, Meckel's, ectopic gastric mucosa)                            1,227.00    1,201.00    1,227.00
 78291    Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt)                 1,734.00    1,697.00    1,734.00
 78300    Bone and/or joint imaging, limited area                                             1,034.00    1,012.00    1,034.00
 78306    Bone and/or joint imaging, whole body                                                 647.00      633.00      647.00
 78315    Bone and/or joint imaging, three phase                                              2,086.00    2,041.00    2,086.00
 78320    Bone and/or joint imaging, SPECT                                                      730.00      714.00      730.00
 78399    Bone and/or joint imaging, whole body, 24 hours later                                 297.00      291.00      297.00
 78428    Cardiac shunt detection, dynamic                                                      682.00      667.00      682.00
 78445    Vascular flow imaging, perfusion                                                      890.00      871.00      890.00
 78458    Venous thrombosis imaging, bilateral                                                1,174.00    1,149.00    1,174.00
 78461    Myocardial perfusion imaging, at rest and/or stress, planar                         2,855.00    2,794.00    2,855.00
 78465    Myocardial perfusion imaging, rest and/or stress, SPECT                             3,236.00    1,505.00    1,542.00
 78466    Myocardial imaging, infarct, planar                                                 2,125.00    2,079.00    2,125.00
 78468    Myocardial imaging, infarct, planar first pass, EF                                  2,520.00    2,466.00    2,520.00
 78469    Myocardial imaging, infarct, SPECT                                                  2,924.00    2,861.00    2,924.00
 78472    Cardiac BP imaging, gated planar, rest/stress, EF                                   1,340.00    1,311.00    1,340.00
 78473    Cardiac BP imaging, gated, rest and stress, EF                                      3,172.00    3,104.00    3,172.00
 78478    Myocardial perfusion imaging, with wall motion                                      3,956.00    3,871.00    3,956.00
 78480    Myocardial perfusion study with EF                                                  4,136.00    4,047.00    4,136.00
 78481    Cardiac BP imaging, gated planar, rest/stress, first pass, EF                       1,320.00    1,292.00    1,320.00
 78499    Cardiac BP (pool imaging)imaging, static                                              642.00      628.00      642.00
 78580    Pulmonary imaging, perfusion                                                          764.00      748.00      764.00
 78585    Pulmonary imaging, ventilation and perfusion, Xenon                                 1,225.00    1,199.00    1,225.00
 78587    Pulmonary imaging, ventilation, aerosol                                             1,472.00    1,440.00    1,472.00
 78594    Pulmonary imaging, ventilation, xenon                                               1,533.00    1,500.00    1,533.00
 78596
          Pulmonary imaging, ventilation and perfusion, quantitative differential function    2,260.00    2,211.00    2,260.00
 78605    Brain imaging, static                                                               1,065.00    1,042.00    1,065.00
 78606    Brain imaging, dynamic and static                                                   1,434.00    1,403.00    1,434.00
 78607    Brain imaging, SPECT                                                                2,742.00    2,683.00    2,742.00
 78610    Brain imaging, dynamic                                                                990.00      969.00      990.00
 78630    CSF (Cerebrospinal fluid) imaging, cisternography                                   4,115.00    4,026.00    4,115.00
 78645    CSF flow imaging, shunt evaluation                                                    845.00      827.00      845.00
 78650    CSF leakage detection and localization                                              2,442.00    2,389.00    2,442.00
 78660    Radiopharmaceutical dacryocystography                                               1,028.00    1,006.00    1,028.00
 78699    Brain tumor imaging, SPECT                                                          2,474.00    2,421.00    2,474.00
 78700    Kidney imaging, static                                                              1,264.00    1,237.00    1,264.00
Service
 code                                      Service name                                      Price A     Price B     Price C
 78701    Kidney imaging, dynamic, GFR                                                        1,434.00    1,403.00    1,434.00
 78707    Kidney imaging, dynamic, without pharmacological intervention                         975.00      954.00      975.00
 78708    Kidney imaging, dynamic, with pharmacological intervention                          1,162.00    1,137.00    1,162.00
 78710    Kidney imaging, SPECT                                                               1,250.00    1,223.00    1,250.00
 78740    Ureteral reflux imaging (cystogram)                                                 1,093.00    1,069.00    1,093.00
 78761    Testicular imaging, dynamic and static                                                635.00      621.00      635.00
 78802    Tumor imaging, planar                                                               3,876.00    3,793.00    3,876.00
 78803    Tumor imaging, SPECT                                                                3,378.00    3,305.00    3,378.00
 78805    Inflammatory process imaging, limited area                                          3,787.00    3,705.00    3,787.00
 78806    Inflammatory process imaging, whole body                                            3,018.00    2,953.00    3,018.00
 78807    Inflammatory process imaging, SPECT                                                 3,378.00    3,305.00    3,378.00
 78813    PET-FDG imaging                                                                     3,859.00    3,776.00    3,859.00
 78999    Tumor imaging, monoclonal antibodies, SPECT                                         7,142.00    6,988.00    7,142.00
 79101    Radiopharmaceutical therapy, polycythemia vera                                      1,804.00    1,765.00    1,804.00
 79403    Radiopharmaceutical therapy, intravenous administration, Zevalin, 90Y-
                                                                                              1,533.00    1,500.00    1,533.00
          Ibritumomab tiuxetan
 79440    Radiopharmaceutical therapy, by intra-articular administration                      4,951.00    4,844.00    4,951.00
 80053    Chemistry panel                                                                        53.00       52.00       53.00
 80061    Lipids panel - blood: Cholesterol, TG, HDL, LDL                                        42.00       41.00       42.00
 80076    Hepatic function panel                                                                 57.00       56.00       57.00
 80100    Drug, qualitative - urine                                                             115.00      113.00      115.00
 80101    Drug, qualitative                                                                     169.00      165.00      169.00
 80162    Digoxin                                                                                82.00       80.00       82.00
 80178    Lithium                                                                               124.00      121.00      124.00
 80195    Sirolimus                                                                             278.00      272.00      278.00
 80299    Drug, quantitative                                                                    169.00      165.00      169.00
 80400    ACTH stimulation, including blood hormones levels                                     431.00      422.00      431.00
 80420    Dexamethasone suppression test, 48 hour, include: free cortisol, urine cortisol,
                                                                                                128.00      125.00      128.00
          volume measurement
 81000    Urinalysis, with microscopy                                                            37.00       36.00       37.00
 81002    Urinalysis stick, manual - urine, panel billing code                                   16.00       16.00       16.00
 82010    Acetone, quantitative                                                                  77.00       75.00       77.00
 82013    Acetylcholinesterase - amniotic fluid                                                 473.00      463.00      473.00
 82017    Acylcarnitine, quantitative - blood/urine                                             572.00      560.00      572.00
 82030    Cyclic AMP - blood and urine                                                          678.00      663.00      678.00
 82040    Albumin - serum                                                                        14.00       14.00       14.00
 82042    Albumin, quantitative - urine/other source, excluding serum                            14.00       14.00       14.00
 82043    Microalbumin - urine / 24 hours                                                        82.00       80.00       82.00
 82085    Aldolase                                                                              169.00      165.00      169.00
 82088    Aldosterone                                                                           221.00      216.00      221.00
 82103    Alpha 1 antitrypsin, total                                                            254.00      249.00      254.00
 82105    Alpha-fetoprotein - serum                                                              31.00       30.00       31.00
 82128    Amino acids, qualitative                                                              105.00      103.00      105.00
 82131    Amino acids, quantitative                                                             303.00      296.00      303.00
 82135    Aminolevulinic acid (ALA), quantitative - urine                                       291.00      285.00      291.00
 82140    Ammonia                                                                               166.00      162.00      166.00
 82150    Amylase                                                                                30.00       29.00       30.00
 82154    Androstenedione/androstenediol glucoronide                                            181.00      177.00      181.00
 82160    Androsterone                                                                          364.00      356.00      364.00
 82172    Apolipoprotein B1/A1                                                                  124.00      121.00      124.00
 82180    Vitamin C, ascorbic acid - blood                                                      120.00      117.00      120.00
 82205    Barbiturates, qualitative - urine                                                     169.00      165.00      169.00
 82232    Beta 2 microglobulin                                                                  253.00      248.00      253.00
 82239    Bile acids degradation test                                                           256.00      250.00      256.00
 82247    Bilirubin, total                                                                       14.00       14.00       14.00
 82248    Bilirubin, direct                                                                      14.00       14.00       14.00
 82261    Biotinidase                                                                           240.00      235.00      240.00
 82270    Occult blood - feces                                                                   77.00       75.00       77.00
 82306    Calcifediol (25-OH Vitamin D-3)                                                       106.00      104.00      106.00
Service
 code                                       Service name                    Price A     Price B     Price C
 82307    Calciferol (Vitamin D)                                               106.00      104.00      106.00
 82308    Calcitonin                                                           221.00      216.00      221.00
 82310    Calcium, total, excluding urine                                       14.00       14.00       14.00
 82340    Calcium - urine                                                       29.00       28.00       29.00
 82360    Calculus, quantitative and qualitative analysis                      898.00      879.00      898.00
 82374    Carbon dioxide (bicarbonate)                                          99.00       97.00       99.00
 82378    CEA (Carcinoembryonic Ag), including dilution                         31.00       30.00       31.00
 82380    Carotene                                                             120.00      117.00      120.00
 82382    Catecholamines, total                                                525.00      514.00      525.00
 82390    Ceruloplasmin                                                        169.00      165.00      169.00
 82435    Chloride - blood                                                      29.00       28.00       29.00
 82436    Chloride - urine                                                      29.00       28.00       29.00
 82438    Chloride - other source, excluding blood/urine                        29.00       28.00       29.00
 82465    Cholesterol, total - blood                                            14.00       14.00       14.00
 82480    Cholinesterase - serum                                                77.00       75.00       77.00
 82486    Chromatography, qualitative                                          124.00      121.00      124.00
 82492    Chromatography, quantitative, any method                             124.00      121.00      124.00
 82525    Copper                                                                66.00       65.00       66.00
 82533    Cortisol, total                                                       37.00       36.00       37.00
 82540    Creatine                                                              77.00       75.00       77.00
 82550    CK (Creatine Kinase, CPK), total                                      14.00       14.00       14.00
 82552    CK (Creatine Kinase, CPK) isoenzymes                                 242.00      237.00      242.00
 82565    Creatinine - blood                                                    17.00       17.00       17.00
 82570    Creatinine - other fluids, excluding blood                            37.00       36.00       37.00
 82575    Creatinine clearance test                                             52.00       51.00       52.00
 82585    Cryofibrinogen                                                       247.00      242.00      247.00
 82595    Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit)        124.00      121.00      124.00
 82607    Vitamin B-12, cyanocobalamin                                         136.00      133.00      136.00
 82608    Vitamin B-12, cyanocobalamin, binding capacity                        49.00       48.00       49.00
 82626    Dehydroepiandrosterone (DHEA)                                         57.00       56.00       57.00
 82627    Dehydroepiandrosterone-sulfate (DHEA-S)                               57.00       56.00       57.00
 82652    Vitamin D (Calciferol) 1,25-Dihydroxy                                431.00      422.00      431.00
 82657    Enzyme activity in blood cells, cultured cells, or tissue, each      169.00      165.00      169.00
 82670    Estradiol                                                             57.00       56.00       57.00
 82672    Estrogens, total, all derivatives                                    364.00      356.00      364.00
 82677    Estriol                                                              254.00      249.00      254.00
 82679    Estrone                                                              247.00      242.00      247.00
 82705    Fat, qualitative - feces                                             120.00      117.00      120.00
 82710    Fat, quantitative - feces                                            385.00      377.00      385.00
 82726    Very long chain fatty acids                                          820.00      802.00      820.00
 82728    Ferritin                                                              28.00       27.00       28.00
 82731    Fetal fibronectin                                                    400.00      391.00      400.00
 82746    Folic acid - serum                                                   123.00      120.00      123.00
 82757    Fructose - seminal fluid                                             254.00      249.00      254.00
 82759    Galactokinase                                                        719.00      704.00      719.00
 82760    Galactose                                                            247.00      242.00      247.00
 82775    Galactose 1 phosphate uridyl transferase, quantitative               385.00      377.00      385.00
 82787    Gammaglobulin, immunoglobulin subclasses                             608.00      595.00      608.00
 82800    Gases, pH only - blood                                               124.00      121.00      124.00
 82803    Gases - blood                                                        155.00      152.00      155.00
 82941    Gastrin                                                              221.00      216.00      221.00
 82945    Glucose - other fluids, excluding blood                               77.00       75.00       77.00
 82947    Glucose, quantitative - blood                                         14.00       14.00       14.00
 82951    Glucose tolerance test (GTT)                                         169.00      165.00      169.00
 82955    Glucose-6-phosphate dehydrogenase (G6PD), quantitative               364.00      356.00      364.00
 82960    Glucose-6-phosphate dehydrogenase (G6PD), screen                     247.00      242.00      247.00
 82977    Gamma glutamyltransferase (GGT)                                       28.00       27.00       28.00
 82985    Fructosamine/glycated protein                                        364.00      356.00      364.00
 83001    Gonadotropin, FSH (Follicle stimulating hormone)                      28.00       27.00       28.00
Service
 code                                     Service name                                  Price A     Price B     Price C
 83002    Gonadotropin, LH (Luteinizing hormone)                                            55.00       54.00       55.00
 83003    GH (Growth hormone), somatotropin                                                 57.00       56.00       57.00
 83010    Haptoglobin, quantitative                                                        280.00      274.00      280.00
 83013    Rapid urease test, helicobacter pylori - exhaled air                              42.00       41.00       42.00
 83015    Heavy metal (arsenic, barium, beryllium, bismuth, antimony, mercury,
                                                                                           169.00      165.00      169.00
          thallium), screen
 83020    Hemoglobin, electrophoresis                                                      102.00      100.00      102.00
 83036    Hemoglobin; glycosylated (A1C)                                                    38.00       37.00       38.00
 83045    Hemoglobin, methemoglobin, qualitative                                           364.00      356.00      364.00
 83069    Hemoglobin - urine                                                               212.00      207.00      212.00
 83070    Hemosiderin, qualitative - urine                                                 218.00      213.00      218.00
 83071    Hemosiderin, quantitative - urine                                                218.00      213.00      218.00
 83090    Homocysteine                                                                     228.00      223.00      228.00
 83491    Hydroxycorticosteroids, 17- (17-OHCS)                                            279.00      273.00      279.00
 83497    Hydroxyindolacetic acid, 5-(HIAA)                                                132.00      129.00      132.00
 83525    Insulin, total                                                                    57.00       56.00       57.00
 83540    Iron                                                                              37.00       36.00       37.00
 83550    Iron binding capacity                                                            169.00      165.00      169.00
 83586    Ketosteroids , total                                                             247.00      242.00      247.00
 83593    Ketosteroids, 17- (17-KS), fractionation                                       1,372.00    1,342.00    1,372.00
 83605    Lactate (lactic acid)                                                             89.00       87.00       89.00
 83615    Lactate dehydrogenase (LD), (LDH)                                                 14.00       14.00       14.00
 83625    Lactate dehydrogenase (LD), (LDH), isoenzymes, total                             364.00      356.00      364.00
 83655    Lead                                                                              82.00       80.00       82.00
 83661    Fetal lung maturity assessment, Lecithin/Sphingomyelin ratio                     461.00      451.00      461.00
 83690    Lipase                                                                            30.00       29.00       30.00
 83700    Lipoprotein, electrophoresis - blood                                              24.00       23.00       24.00
 83718    Lipoprotein, HDL cholesterol                                                      29.00       28.00       29.00
 83719    Lipoprotein, VLDL cholesterol                                                     29.00       28.00       29.00
 83735    Magnesium                                                                         14.00       14.00       14.00
 83825    Mercury, quantitative                                                            169.00      165.00      169.00
 83866    Mucopolysaccharides, screen - urine, per patient                                 265.00      259.00      265.00
 83872    Mucin/other material - synovial fluid, including biochemistry, cytology and
                                                                                           266.00      260.00      266.00
          culture
 83874    Myoglobin                                                                        229.00      224.00      229.00
 83896    Molecular diagnosis of hematologic malignancies                                1,167.00    1,142.00    1,167.00
 83898    RT-PCR, molecular diagnostics                                                  2,837.00    2,776.00    2,837.00
 83918    Organic acids, quantitative - urine                                              536.00      524.00      536.00
 83930    Osmolality - blood                                                                77.00       75.00       77.00
 83935    Osmolality - urine                                                                77.00       75.00       77.00
 83945    Oxalate, qualitative/quantitative - urine                                        306.00      299.00      306.00
 83970    Parathormone (parathyroid hormone)                                               208.00      204.00      208.00
 84060    Acid phosphatase, total                                                           77.00       75.00       77.00
 84061    Acid phosphatase stain                                                           169.00      165.00      169.00
 84066    Acid phosphatase, prostatic                                                      120.00      117.00      120.00
 84075    Alkaline phosphatase                                                              14.00       14.00       14.00
 84080    Alkaline phosphatase isoenzymes                                                  364.00      356.00      364.00
 84100    Phosphorus - blood                                                                14.00       14.00       14.00
 84105    Phosphorus - urine                                                                14.00       14.00       14.00
 84110    Porphobilinogen, quantitative, collection - urine                                214.00      209.00      214.00
 84119    Porphobilinogen, quantitative - urine                                            120.00      117.00      120.00
 84127    Porphyrins, qualitative - feces                                                  191.00      187.00      191.00
 84132    Potassium - blood                                                                 14.00       14.00       14.00
 84135    Pregnanediol                                                                     247.00      242.00      247.00
 84138    Pregnanetriol                                                                    364.00      356.00      364.00
 84144    Progesterone                                                                      57.00       56.00       57.00
 84146    Prolactin                                                                         86.00       84.00       86.00
 84153    PSA (Prostate specific Ag), total                                                 37.00       36.00       37.00
 84154    PSA (Prostate specific Ag), free                                                  77.00       75.00       77.00
Service
 code                                      Service name                          Price A     Price B     Price C
 84155    Protein, total - serum                                                     14.00       14.00       14.00
 84156    Protein, total - urine                                                     14.00       14.00       14.00
 84165    Protein electrophoretic                                                    82.00       80.00       82.00
 84207    Vitamin B-6 (pyridoxal phosphate)                                         259.00      253.00      259.00
 84210    Phenylpyruvic acid - urine                                                 37.00       36.00       37.00
 84233    Receptor assay, estrogene                                                 569.00      557.00      569.00
 84244    Renin                                                                     221.00      216.00      221.00
 84260    Serotonin                                                                 132.00      129.00      132.00
 84295    Sodium - blood                                                             14.00       14.00       14.00
 84375    Sugars chromatography                                                     124.00      121.00      124.00
 84376    Sugars (mono-, di-, and oligosaccharides), qualitative - body fluids      265.00      259.00      265.00
 84402    Testosterone, free                                                        120.00      117.00      120.00
 84403    Testosterone, total                                                        57.00       56.00       57.00
 84432    Thyroglobulin                                                             314.00      307.00      314.00
 84436    Thyroxine, total                                                           33.00       32.00       33.00
 84443    Thyroid stimulating hormone (TSH)                                          33.00       32.00       33.00
 84446    Tocopherol alpha (Vitamin E)                                              169.00      165.00      169.00
 84450    AST (GOT) Aspartate aminotransferase                                       28.00       27.00       28.00
 84460    ALT (GPT) Alanine amino transferase                                        28.00       27.00       28.00
 84466    Transferrin                                                               108.00      106.00      108.00
 84478    Triglycerides                                                              14.00       14.00       14.00
 84479    Thyroid hormone (T3/T4) uptake or binding ratio (THBR)                     67.00       66.00       67.00
 84480    Triiodothyronine T3, total (TT-3)                                          67.00       66.00       67.00
 84484    Troponin, quantitative                                                    140.00      137.00      140.00
 84490    Chymotrypsin, quantitative - feces                                        212.00      207.00      212.00
 84520    Urea, quantitative - blood                                                 14.00       14.00       14.00
 84540    Urea, quantitative - urine/other fluids, excluding blood                   37.00       36.00       37.00
 84550    Uric acid - blood                                                          14.00       14.00       14.00
 84560    Uric acid - body fluids, excluding blood                                   37.00       36.00       37.00
 84585    Vanillylmandelic acid (VMA) - urine                                       169.00      165.00      169.00
 84588    Vasopressin (antidiuretic hormone, ADH)                                   431.00      422.00      431.00
 84590    Vitamin A                                                                 120.00      117.00      120.00
 84620    Xylose absorption test - blood/urine                                      124.00      121.00      124.00
 84681    C-peptide                                                                 120.00      117.00      120.00
 84702    hCG (Human chorionic gonadotropin), qualitative/quantitative               82.00       80.00       82.00
 85002    Bleeding time                                                              72.00       70.00       72.00
 85007    Manual differential                                                        35.00       34.00       35.00
 85009    Blood count, manual differential, buffy coat                              169.00      165.00      169.00
 85025    CBC (complete blood count) with differential                               24.00       23.00       24.00
 85032    Blood smear, manual test                                                   99.00       97.00       99.00
 85044    Reticulocytes manual count                                                 57.00       56.00       57.00
 85049    Platelet, thrombocyte                                                      63.00       62.00       63.00
 85170    Clot retraction                                                            99.00       97.00       99.00
 85210    Clotting, factor II, prothrombin                                          190.00      186.00      190.00
 85220    Clotting, factor V (AcG or proaccelerin)                                  247.00      242.00      247.00
 85230    Clotting, factor VII, proconvertin                                        190.00      186.00      190.00
 85244    Clotting, factor VIII related antigen                                     244.00      239.00      244.00
 85245    Clotting, factor VIII, ristocetin cofactor                                571.00      559.00      571.00
 85250    Clotting, factor IX                                                       276.00      270.00      276.00
 85260    Clotting, factor X (Stuart-Prower)                                        190.00      186.00      190.00
 85270    Clotting, factor XI (PTA)                                                 190.00      186.00      190.00
 85280    Clotting, factor XII (Hageman)                                            461.00      451.00      461.00
 85290    Clotting, factor XIII (fibrin stabilizing)                                247.00      242.00      247.00
 85301    Clotting anticoagulant, antithrombin III antigen                          272.00      266.00      272.00
 85302    Protein C, anticoagulant                                                  337.00      330.00      337.00
 85305    Protein S, anticoagulant                                                  280.00      274.00      280.00
 85362    Fibrinogen degradation (split) products (FDP) (FSP                        461.00      451.00      461.00
 85384    Fibrinogen activity                                                        82.00       80.00       82.00
 85390    Fibrinolysins or coagulopathy, screen                                     364.00      356.00      364.00
Service
 code                                    Service name                                   Price A     Price B     Price C
 85460    HbF (Hemoglobin fetal) stain                                                     169.00      165.00      169.00
 85475    Hemolysin, acid, Ham test                                                        218.00      213.00      218.00
 85540    LAP (Leukocyte Alkaline Phosphatase) with count                                  247.00      242.00      247.00
 85549    Muramidase                                                                       431.00      422.00      431.00
 85557    Osmotic fragility                                                                247.00      242.00      247.00
 85576    Platelet aggregation                                                             385.00      377.00      385.00
 85597    Platelet neutralization                                                          473.00      463.00      473.00
 85610    PT (Prothrombin time)                                                             34.00       33.00       34.00
 85635    Reptilase test                                                                   169.00      165.00      169.00
 85651    Sedimentation rate - blood                                                        16.00       16.00       16.00
 85670    TT (Thrombin time) - plasma                                                       77.00       75.00       77.00
 85730    PTT (Thromboplastin time) - plasma/blood                                          38.00       37.00       38.00
 85810    Viscosity - blood                                                                247.00      242.00      247.00
 86000    Agglutinins, febrile, per test                                                    99.00       97.00       99.00
 86021    Leucocyte, Ab                                                                    212.00      207.00      212.00
 86022    Platelet, Ab                                                                     436.00      427.00      436.00
 86038    ANA (Antinuclear antibodies)                                                     223.00      218.00      223.00
 86060    ASL0 (Antistreptolysin 0), titer                                                 124.00      121.00      124.00
 86140    C-reactive protein                                                                44.00       43.00       44.00
 86147    Cardiolipin, Ab                                                                   57.00       56.00       57.00
 86155    Chemotaxis assay                                                               1,165.00    1,140.00    1,165.00
 86156    Cold agglutinin, screen                                                           99.00       97.00       99.00
 86157    Cold agglutinin, quantitative                                                     99.00       97.00       99.00
 86162    Complement total hemolytic activity                                              670.00      656.00      670.00
 86171    Complement fixation                                                              152.00      149.00      152.00
 86225    DNA, native or double stranded, Ab                                               747.00      731.00      747.00
 86235    Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B,
                                                                                           101.00       99.00      101.00
          Sm, RNP, Sc170, J01), each antibody
 86255    Fluorescent noninfectious agent Ab, not otherwise specified                       86.00       84.00       86.00
 86300    CA 15.3 tumor antigen                                                             42.00       41.00       42.00
 86301    CA 19.9, tumor antigen                                                            87.00       85.00       87.00
 86304    CA 125 tumor antigen                                                              37.00       36.00       37.00
 86320    Immunoelectrophoresis - serum                                                    263.00      257.00      263.00
 86325    Immunoelectrophoresis - body fluids, excluding serum, eg, urine, CSF              77.00       75.00       77.00
 86336    Inhibin - serum                                                                  201.00      197.00      201.00
 86337    Insulin, Ab                                                                      240.00      235.00      240.00
 86341    Islet cell, Ab                                                                   101.00       99.00      101.00
 86344    Leukocyte phagocytosis                                                         1,976.00    1,933.00    1,976.00
 86353    Lymphocyte transformation                                                      1,421.00    1,390.00    1,421.00
 86359    T and B cell count                                                               559.00      547.00      559.00
 86360    T cells absolute CD4 and CD8 count, including ratio                            1,751.00    1,713.00    1,751.00
 86376    Microsomal antibodies, eg, thyroid or liver-kidney                               238.00      233.00      238.00
 86382    Virus neutralization test                                                        285.00      279.00      285.00
 86403    Agglutination, screen (latex, Rose Waller)                                       120.00      117.00      120.00
 86406    Agglutination, particle, titer, each Ab                                          254.00      249.00      254.00
 86431    Rheumatoid factor, qualitative/quantitative                                       99.00       97.00       99.00
 86580    Skin test; tuberculosis, intradermal                                              54.00       53.00       54.00
 86592    Syphilis test, VDRL, RPR, TPHA, FTA, ELISA                                        99.00       97.00       99.00
 86619    Borrelia (relapsing fever), Ab                                                   336.00      329.00      336.00
 86644    CMV (cytomegalovirus) Ab                                                         204.00      200.00      204.00
 86648    Diphtheria, Ab                                                                   169.00      165.00      169.00
 86677    Helicobacter pylori, Ab - B                                                       42.00       41.00       42.00
 86692    Hepatitis delta, Ab                                                               87.00       85.00       87.00
 86703    HIV screening, central blood bank                                                  0.00        0.00        0.00
 86704    Hepatitis B core antibody (HBcAb), IgG and IgM                                    52.00       51.00       52.00
 86705    Hepatitis B core Ab (HBcAb), IgM                                                  55.00       54.00       55.00
 86706    Hepatitis B surface Ab (HBsAb)                                                    28.00       27.00       28.00
 86707    Hepatitis Be Ab (HBeAb)                                                           71.00       69.00       71.00
 86708    Hepatitis A antibody (HAAb), total, IgG and IgM                                   74.00       72.00       74.00
Service
 code                                      Service name                                 Price A     Price B     Price C
 86709    Hepatitis A Ab (HAAb), IgM or IgG                                                 90.00       88.00       90.00
 86720    Leptospira, Ab                                                                   152.00      149.00      152.00
 86738    Mycoplasma, Ab                                                                   212.00      207.00      212.00
 86762    Rubella virus IgG and IgM                                                        102.00      100.00      102.00
 86778    Toxoplasma IgM                                                                    63.00       62.00       63.00
 86789    West Nile virus IgG and IgM                                                      329.00      322.00      329.00
 86790    Virus/bacteria Ab, not otherwise specified                                       169.00      165.00      169.00
 86800    Thyroglobulin, Ab                                                                254.00      249.00      254.00
 86803    Hepatitis C, Ab                                                                   31.00       30.00       31.00
 86805    Lymphocytotoxicity assay, visual crossmatch; with titration                      271.00      265.00      271.00
 86813    HLA typing, A, B, C                                                            1,386.00    1,356.00    1,386.00
 86817    HLA typing, DR/DQ                                                              1,794.00    1,755.00    1,794.00
 86821    HLA typing, MLC (mixed lymphocyte culture)                                     1,794.00    1,755.00    1,794.00
 86880    DAT (Direct Antiglobulin Test) / Coombs                                          124.00      121.00      124.00
 86900    Blood typing, including RH                                                        81.00       79.00       81.00
 86901    Rh test                                                                           99.00       97.00       99.00
 86903    Blood typing and Rh, Ab, screen                                                  352.00      344.00      352.00
 86904    Blood typing and Rh, Ab                                                          696.00      681.00      696.00
 86905    Blood typing; RBC antigens, other than ABO or Rh (D)                           1,059.00    1,036.00    1,059.00
 86940    Hemolysins and agglutinins, screen                                               364.00      356.00      364.00
 87001    Animal inoculation, eg, tuberculosis                                             364.00      356.00      364.00
 87040    Blood culture and susceptibility                                                  76.00       74.00       76.00
 87045    Feces culture                                                                     99.00       97.00       99.00
 87070    Culture, other source, excluding blood/urine/feces                                76.00       74.00       76.00
 87081    Urine culture, non quantitative                                                   99.00       97.00       99.00
 87086    Urine culture, quantitative                                                      202.00      198.00      202.00
 87088    Urine culture and susceptibility                                                 114.00      112.00      114.00
 87106    Fungi culture                                                                     99.00       97.00       99.00
 87109    Mycoplasma culture                                                               152.00      149.00      152.00
 87110    Chlamydia culture                                                                310.00      303.00      310.00
 87116    Mycobacteria culture and identification                                          330.00      323.00      330.00
 87118    Mycobacterial definitive identification, MTb                                     168.00      164.00      168.00
 87140    Fluorescence or darkfield microscopy                                              99.00       97.00       99.00
 87177    Ova and parasites, direct smear, identification - feces                           77.00       75.00       77.00
 87181    Susceptibility studies, antimicrobial agent, per agent                            99.00       97.00       99.00
 87190    Susceptibility studies, antimycobacterial agent, mycobacteria                    226.00      221.00      226.00
 87205    Smear interpretation, stain for bacteria, fungi, parasites or cell types          77.00       75.00       77.00
 87207    Smear, special stain for parasites                                                99.00       97.00       99.00
 87250    Virus isolation, including nucleic acid identification, polymerase chain
                                                                                           387.00      379.00      387.00
          reaction, PCR
 87252    Virus isolation, tissue culture                                                  124.00      121.00      124.00
 87253    Virus isolation and identification, tissue culture, any method                   614.00      601.00      614.00
 87278    Legionella Ag - urine                                                            150.00      147.00      150.00
 87299    Immunofluorescent study; not otherwise specified                                 212.00      207.00      212.00
 87340    Hepatitis B surface antigen (HBsAg), any method, including
                                                                                            86.00       84.00       86.00
          immunofluorescent study
 87350
          Hepatitis Be antigen (HBeAg), any method, including immunofluorescent study       71.00       69.00       71.00
 87449    Infectious agent antigen detection, not otherwise specified                      351.00      343.00      351.00
 87472    Bartonella henselae and Bartonella quintana, quantification                      268.00      262.00      268.00
 87517    Hepatitis B virus DNA/RNA quantification - blood                                 473.00      463.00      473.00
 87536    HIV-1 DNA/RNA quantification - blood                                           1,232.00    1,205.00    1,232.00
 87539    HIV-2 DNA/RNA quantification - blood                                           1,232.00    1,205.00    1,232.00
 87556    Mycobacteria tuberculosis, AMTD                                                  423.00      414.00      423.00
 87590    Gonorrhoeae smear                                                                  0.00        0.00        0.00
 87620    Papillomavirus (HPV) - tissue, including biopsy                                1,749.00    1,711.00    1,749.00
 87622    HPV (Human Papillomavirus) smear                                                 365.00      357.00      365.00
 88036    Necropsy (autopsy), limited, gross and/or microscopic; regional                  614.00      601.00      614.00
 88130    Sex chromatin identification, Barr bodies                                        124.00      121.00      124.00
Service
 code                                    Service name                                     Price A     Price B     Price C
 88141    Pap smear, cervical/vaginal, cytopathology, including sampling                     103.00      101.00      103.00
 88160    Cytopathology examination and interpretation                                       169.00      165.00      169.00
 88230    Karyotype, leukocyte culture                                                     1,062.00    1,039.00    1,062.00
 88233    Karyotype, tissue culture                                                        1,372.00    1,342.00    1,372.00
 88240    Cryopreservation of cells (eg, bone marrow), per year                            1,334.00    1,305.00    1,334.00
 88299    B &T cell receptor gene rearrangment analysis                                      991.00      970.00      991.00
 88305    Histologic examination, microscopy and interpretation                              169.00      165.00      169.00
 88313    Bone marrow sampling and iron stain                                                385.00      377.00      385.00
 88319    Histochemistry/cytochemistry stain for enzyme identification                       169.00      165.00      169.00
 88346    Immunofluorescent study, each antibody; direct method                              898.00      879.00      898.00
 88347    Immunofluorescent study, each antibody; indirect method                            898.00      879.00      898.00
 88348    EM (Electron microscopy), diagnostic                                             3,010.00    2,945.00    3,010.00
 89051    Cell count - body fluids, eg, CSF, joint fluid, excluding blood                    120.00      117.00      120.00
 89258    Cryopreserved embryos storage for 5 years                                          614.00      601.00      614.00
 89259    Cryopreservation, sperm, one year, up to 5 test tubes/straws                       677.00      662.00      677.00
 89280    Assisted oocyte fertilization, microtechnique                                    4,070.00    2,977.00    3,055.00
 89290    Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-
                                                                                           8,772.00    8,583.00    8,772.00
          implantation genetic diagnosis)
 89300    Semen analysis; presence and/or motility of sperm including Huhner test (post
                                                                                             232.00      227.00      232.00
          coital)
 89320    Semen analysis, complete (volume, count, motility, and differential)               141.00      138.00      141.00
 89325    Sperm Ab                                                                           226.00      221.00      226.00
 90371    HBIg (Hepatitis B immune globulin), IM                                           3,880.00    3,796.00    3,880.00
 90375    Rlg (Rabies immune globulin), IM and/or subcutaneous                             2,652.00    2,595.00    2,652.00
 90384    Rho(D) immune globulin (Rhlg), Anti-D                                              473.00      463.00      473.00
 90585    BCG (Bacillus Calmette-Guerin) vaccine for tuberculosis                              0.00        0.00        0.00
 90586    BCG vaccine for bladder, live, for intravesical use, per treatment, including
                                                                                             856.00      838.00      856.00
          material
 90749    Immune globulin (Ig), not otherwise specified                                       99.00       97.00       99.00
 90772    Subcutaneous/IM injection, therapeutic/prophylactic/diagnostic                      35.00       34.00       35.00
 90862    Pharmacological management/review, mental health                                   103.00      101.00      103.00
 90870    Electroconvulsive therapy                                                        1,055.00    1,032.00    1,055.00
 90880    Hypnotherapy                                                                       126.00      123.00      126.00
 90882    Psychosocial intervention - follow up                                              122.00      119.00      122.00
 90889    Psychiatric medical opinion                                                        578.00      566.00      578.00
 90901    Biofeedback training                                                               375.00      367.00      375.00
 90935    Hemodialysis procedure, per treatment                                            1,158.00    1,133.00    1,158.00
 90945    Dialysis procedure other than hemodialysis (eg, peritoneal dialysis)               523.00      512.00      523.00
 91010    Esophageal motility (manometric study)                                           1,038.00    1,016.00    1,038.00
 91034    Esophagus, acid reflux test, with intraluminal pH electrode for dection of
                                                                                           1,038.00    1,016.00    1,038.00
          gastroesophageal reflux; prolonged recording
 91065    Breath hydrogen test (eg, for detection of lactase deficiency)                     192.00      188.00      192.00
 91122    Anorectal manometry                                                              1,038.00    1,016.00    1,038.00
 92004    Ophthalmological examination, initial                                              461.00      451.00      461.00
 92065    Orthoptic evaluation and therapy                                                    99.00       97.00       99.00
 92081    Computerised visual field examination                                              155.00      152.00      155.00
 92083    Visual field examination (eg, Goldmann visual fields)                              124.00      121.00      124.00
 92230    Fluorescein angioscopy, unilateral                                                 654.00      640.00      654.00
 92235    Fluorescein angioscopy, bilateral                                                  902.00      883.00      902.00
 92240    ICGI eye imaging, with interpretation and report                                 1,655.00    1,619.00    1,655.00
 92250    Fundus photography, one eye                                                        197.00      193.00      197.00
 92270    Electro-oculography with interpretation and report                                 310.00      303.00      310.00
 92275    Electroretinography with interpretation                                            717.00      702.00      717.00
 92283    Color vision examination                                                           124.00      121.00      124.00
 92284    Dark adaptation examination with interpretation                                    364.00      356.00      364.00
 92285    External eye photography, with interpretation and report                           387.00      379.00      387.00
 92286    Anterior segment photography, one eye                                              310.00      303.00      310.00
 92287    Anterior segment photography, two eyes                                             464.00      454.00      464.00
 92310    Contact lens fitting, including adjustment                                          99.00       97.00       99.00
Service
 code                                     Service name                                      Price A     Price B     Price C
 92355    Fitting of telescopic lens system, age-related macular degeneration                  139.00      136.00      139.00
 92506    Evaluation of speech, language, voice                                                124.00      121.00      124.00
 92507    Speech therapy, individual                                                           121.00      118.00      121.00
 92508    Speech therapy, group, per hour                                                       99.00       97.00       99.00
 92512    Rhinomanometry                                                                       192.00      188.00      192.00
 92526    Feeding and swallowing therapy, per treatment                                        114.00      112.00      114.00
 92541    Spontaneous nystagmus test, ENG (electronystagmography)                              461.00      451.00      461.00
 92551    Hearing test, screening                                                               28.00       27.00       28.00
 92557    Hearing test, comprehensive                                                          169.00      165.00      169.00
 92567    Tympanometry (impedance testing)                                                      74.00       72.00       74.00
 92568    Acoustic reflex testing                                                              164.00      160.00      164.00
 92585    Brain auditory evoked potentials, adult                                              588.00      575.00      588.00
 92588    Brain evoked potentials, child                                                       800.00      783.00      800.00
 92590    Hearing aid fitting                                                                  223.00      218.00      223.00
 92593    Hearing aid check/counselling, binaural                                              169.00      165.00      169.00
 92601
          Diagnostic analysis and programing of cochlear implant, binaural, under age 7      1,561.00    1,527.00    1,561.00
 92602    Diagnostic analysis and subsequent programing of cochlear implant, monaural,
                                                                                               508.00      497.00      508.00
          under age 7
 92603
          Diagnostic analysis and programing of cochlear implant, binaural, age 7 or over    1,561.00    1,527.00    1,561.00
 92604    Diagnostic analysis and subsequent programing of cochlear implant, monaural,
                                                                                               508.00      497.00      508.00
          age 7 or over
 92620    Central auditory function test(s)                                                    331.00      324.00      331.00
 92633    Auditory rehabilitation following cochlear implant                                   120.00      117.00      120.00
 93000    ECG (Electrocardiogram), with interpretation and report                               34.00       33.00       34.00
 93012    CardioBeeper device loan                                                             176.00      172.00      176.00
 93015    Cardiovascular stress test                                                           263.00      257.00      263.00
 93224    ECG monitoring for 24 hours (Holter)                                                 467.00      457.00      467.00
 93307    TTE (transthoracic echocardiography)                                                 396.00      387.00      396.00
 93312    TEE (transesophageal echocardiography)                                             1,499.00    1,467.00    1,499.00
 93350    Effort or Dobutamine stress echocardiography (DSE)                                   935.00      915.00      935.00
 93720    Pulmonary function tests, infant, with interpretation                              2,876.00    2,814.00    2,876.00
 93784    Blood pressure monitoring, for 24 hours                                              414.00      405.00      414.00
 93797    Cardiac rehabilitation, per month                                                    772.00      755.00      772.00
 93880    Cervical arteries duplex, bilateral                                                  367.00      359.00      367.00
 93923    Extremities arteries duplex, stress and rest                                         345.00      338.00      345.00
 93925    Extremity arteries/bypass grafts duplex                                              367.00      359.00      367.00
 93965    Peripheral vessels flow study (eg, Doppler)                                          152.00      149.00      152.00
 93975    Abdomen, pelvis and retroperitoneal vessels duplex                                   345.00      338.00      345.00
 93980    Penile vessels duplex, per patient                                                   471.00      461.00      471.00
 94010    Spirometry, simple                                                                   107.00      105.00      107.00
 94060    Spirometry with bronchodilator                                                       129.00      126.00      129.00
 94070    Prolonged bronchi evaluation, methacholine or other chemical agent                   764.00      748.00      764.00
 94200    Maximal voluntary ventilation                                                         53.00       52.00       53.00
 94240    Functional residual volume, noble gas                                                549.00      537.00      549.00
 94250    Expired gas collection, quantitative                                                 275.00      269.00      275.00
 94360    Resistance to airflow, plethysmographic method                                       467.00      457.00      467.00
 94400    Breathing response to CO2 (CO2 response curve)                                       915.00      895.00      915.00
 94620    Pulmonary stress test, simple, including pre- and post-spirometry                    150.00      147.00      150.00
 94621    Pulmonary stress testing, complex                                                  1,158.00    1,133.00    1,158.00
 94640    Inhalation treatment                                                                  35.00       34.00       35.00
 94664    Demonstration of an aerosol/inhaler use                                               62.00       61.00       62.00
 94667    Physiotherapy, lung patient, per treatment                                           121.00      118.00      121.00
 94720    Carbon monoxide diffusing capacity                                                   275.00      269.00      275.00
 94760    Noninvasive ear or pulse oximetry for oxygen saturation                               77.00       75.00       77.00
 94762    Oxygen saturation, overnight oximetry                                                155.00      152.00      155.00
 94772    Pulmonary function tests, passive, child                                           2,870.00    2,808.00    2,870.00
 95004    Aeroallergens/food, up to 10 allergens, screen                                       120.00      117.00      120.00
Service
 code                                      Service name                                      Price A     Price B     Price C
 95012    Nitric oxide determination - exhaled air, per patient                                 288.00      282.00      288.00
 95028    Aeroallergens/food, 11 or over allergens, extended test                               280.00      274.00      280.00
 95044    Patch or application skin alergy test                                                 151.00      148.00      151.00
 95120    Allergen immunotherapy, normal allergen                                               168.00      164.00      168.00
 95130    Allergen immunotherapy, pure allergen                                                 340.00      333.00      340.00
 95199    Susceptibility studies, antimicrobial agent; lymphocyte and serum                     898.00      879.00      898.00
 95810    Polysomnography, including EEG                                                      1,013.00      991.00    1,013.00
 95812    EEG (Electroencephalogram)                                                            364.00      356.00      364.00
 95813    EEG (Electroencephalogram) extended monitoring                                        786.00      769.00      786.00
 95822    EEG (Electroencephalogram), sleep                                                     595.00      582.00      595.00
 95830    EEG (Electroencephalogram), sphenoidal recording                                      649.00      635.00      649.00
 95857    Tensilon test for myasthenia gravis                                                   164.00      160.00      164.00
 95861    EMG (electromyography)                                                                218.00      213.00      218.00
 95872    EMG (Electromyography)                                                                629.00      615.00      629.00
 95900    NCT (Nerve conduction test)                                                           501.00      490.00      501.00
 95922    Testing of autonomic nervous system function; vasomotor adrenergic
          innervation (sympathetic adrenergic function), including beat-to-beat blood
                                                                                                437.00      428.00      437.00
          pressure and R-R interval changes during Valsalva maneuver and at least five
          minutes of passive tilt
 95923    Electrolyte concentration determination, sweat imprint                                124.00      121.00      124.00
 95930    VEP (visual evoked potential), adult                                                  588.00      575.00      588.00
 95950    EEG (electroencephalogram), 24 hours                                                1,769.00    1,731.00    1,769.00
 95990    Refilling and maintenance of implantable pump or reservoir for drug delivery,
                                                                                                802.00      785.00      802.00
          spinal (intrathecal, epidural) or brain (intraventricular)
 96001
          Computerized three dimensional motion and walking analysis, per patient             3,380.00    3,307.00    3,380.00
 96567
          Photodynamic therapy (PDT), dermal lesions, non-melanoma/solar keratosis              811.00      794.00      811.00
 96910    Phototherapy by UVB and tar/petrolatum                                                123.00      120.00      123.00
 96912    Photochemotherapy by PUVA, including psoralens                                        141.00      138.00      141.00
 97001    Physiotherapy, evaluation and treatment planning, adult                               191.00      187.00      191.00
 97003    Occupational therapy, evaluation and treatment planning, adult                        191.00      187.00      191.00
 97113    Aquatic physiotherapy/rehabilitation, individual, hydrotherapy                        186.00      182.00      186.00
 97140    Physiotherapy, individual                                                             121.00      118.00      121.00
 97150    Physiotherapy/rehabilitation, group, 4 or more individuals, including child, per
                                                                                                 35.00       34.00       35.00
          individual
 97530    Occupational therapy, individual                                                      121.00      118.00      121.00
 97750
          Physical performance test or measurement (eg, musculoskeletal, functional
                                                                                                559.00      547.00      559.00
          capacity), with written report, eg, evaluation of pressure on sole
 97802    Medical nutrition counselling and therapy                                             120.00      117.00      120.00
 97810    Acupuncture                                                                           169.00      165.00      169.00
 99001    Histopathology slides preparation for shipment                                        268.00      262.00      268.00
 99002    Histopathology slides preparation in Israel                                           385.00      377.00      385.00
 99075    Forensic medical opinion                                                            1,561.00    1,527.00    1,561.00
 99080    Medical opinion                                                                       571.00      559.00      571.00
 99183    Elective hyperbaric oxygen therapy, per treatment, up to 2 hours                      803.00      786.00      803.00
 99195    Phlebotomy                                                                            120.00      117.00      120.00
 99212    Follow up allergy testing after 95028                                                  99.00       97.00       99.00
 99214    Post hospitalization examination                                                        0.00        0.00        0.00
 99223    Pre-operation evaluation, serial tests                                                758.00      742.00      758.00
 99242    Physician examination, excluding tests with specific code                             218.00      117.00      119.00
 99283    ER visit, global payment                                                              710.00      695.00      710.00
 99315    Clinic nurse service, up to 30 minutes                                                 67.00       66.00       67.00
 99316
          Clinic nurse service, over 30 minutes (eg, guidance for patient with stoma)           145.00      142.00      145.00
 99362    Multidisciplinary team examination                                                    461.00      451.00      461.00
 99371
          Telephonic consultation for poisoning/medication information/teratology               183.00      179.00      183.00
Service
 code                                     Service name                                        Price A     Price B     Price C
99600 Home visit, care worker                                                                    159.00      156.00      159.00
C0443 Release of carpal tunnel, in surgical day care                                           1,737.00    1,700.00    1,737.00
C0449 Peripheral nerve decompression/lysis of adhesions, excluding endoneurolysis,
                                                                                               3,384.00    3,311.00    3,384.00
      in surgical day care
C0460 Peripheral nerve transposition, eg, ulnar nerve, in surgical day care                    3,384.00    3,311.00    3,384.00
C0476 Peripheral nerve repair, old traumatic injury, eg, ulnar nerve, in surgical day
                                                                                               3,384.00    3,311.00    3,384.00
      care
C0492 Implantation/replacement of sacral nerve stimulation electrode/lead, in surgical
                                                                                               3,384.00    3,311.00    3,384.00
      day care, excluding device cost
C0670 Excision of thyroglossal/branchial cleft cyst/sinus, in surgical day care                3,384.00    3,311.00    3,384.00
C0823 Excision of lesion(s) and/or tissue of eyelid, excluding chalazion, in surgical
                                                                                               3,384.00    3,311.00    3,384.00
      day care
C0849 Repair of eyelid position, excluding complex repair, in surgical day care                3,384.00    3,311.00    3,384.00
C0870 Reconstruction of eyelid, in surgical day care                                           3,384.00    3,311.00    3,384.00
C0889 Repair of eyelid position, complex, in surgical day care                                 3,384.00    3,311.00    3,384.00
C0920 Lacrimal system operation, excluding fistulization, in surgical day care                 3,384.00    3,311.00    3,384.00
C1000 Conjunctiva operation, excluding removal of superficial foreign body, in
                                                                                               3,384.00    3,311.00    3,384.00
      surgical day care
C1139 Excision of pterygium, without graft, in surgical day care                               3,384.00    3,311.00    3,384.00
C1511 Extraocular muscle(s) operation for strabismus repair, in surgical day care              3,384.00    3,311.00    3,384.00
C2169 Turbinectomy, in surgical day care                                                       3,384.00    3,311.00    3,384.00
C2189 Nose operation/rhinoplasty, in surgical day care                                         3,384.00    3,311.00    3,384.00
C2220 Intranasal antrotomy, excluding FESS, in surgical day care                               3,384.00    3,311.00    3,384.00
C2840 Excision of tonsil tag/lingual tonsil or adenoidectomy without tonsillectomy, in
                                                                                               3,384.00    3,311.00    3,384.00
      surgical day care
C3143 Laryngoscopy with biopsy, in surgical day care                                           3,384.00    3,311.00    3,384.00
C3321 Bronchoscopy through artificial stoma, in surgical day care                              3,384.00    3,311.00    3,384.00
C3324 Bronchoscopy with biopsy, in surgical day care                                           3,384.00    3,311.00    3,384.00
C4011 Biopsy of lymphatic structure, in surgical day care                                      3,384.00    3,311.00    3,384.00
C4021
      Excision of lymph node(s), excluding internal mammary, in surgical day care              3,384.00    3,311.00    3,384.00
C4911
          Anal fistulotomy/fistulectomy under general anesthesia, in surgical day care         3,384.00    3,311.00    3,384.00
C4943
          Destruction of hemorrhoids by cauterization/cryotherapy, in surgical day care        3,384.00    3,311.00    3,384.00
C5011 Biopsy of liver, needle; percutaneous, not using CT/MRI guidance, in surgical
                                                                                               3,384.00    3,311.00    3,384.00
      day care
C5349 Umbilical hernia repair, up to 5 years of age, in surgical day care                      3,384.00    3,311.00    3,384.00
C5810 Urethral meatotomy, in surgical day care                                                 3,384.00    3,311.00    3,384.00
C5860 Dilation of urethra, in surgical day care                                                3,384.00    3,311.00    3,384.00
C6120 Excision of lesion(s) and/or hydrocele and/or varicocele of tunica
                                                                                               3,384.00    3,311.00    3,384.00
      vaginalis/spermatic cord, in surgical day care
C6250 Orchiopexy, in surgical day care                                                         3,384.00    3,311.00    3,384.00
C6420 Excision/destruction of lesion(s) and/or tissue of penis under general
                                                                                               3,384.00    3,311.00    3,384.00
      anesthesia, in surgical day care
C6720 Biopsy/conization of cervix, excluding by cauterization/cryosurgery, in
                                                                                               3,384.00    3,311.00    3,384.00
      surgical day care
C6739 Excision of lesion(s) of cervix, including by cauterization/cryosurgery, in
                                                                                               3,384.00    3,311.00    3,384.00
      surgical day care
C6759 Cerclage/repair of uterine cervix, in surgical day care                                  3,384.00    3,311.00    3,384.00
C7011 Hymenotomy/hymenectomy, in surgical day care                                             3,384.00    3,311.00    3,384.00
C7024 Biopsy/excision/destruction of lesion(s) of vagina, in surgical day care                 3,384.00    3,311.00    3,384.00
C7129
      Bartholin's gland/cyst operation under general anesthesia, in surgical day care          3,384.00    3,311.00    3,384.00
C7744
          Biopsy of bone/arthrotomy of hand/foot and finger(s)/toe(s), in surgical day care    3,384.00    3,311.00    3,384.00
C7751
          Bunion, eg, hallux valgus / hammer toe/claw operation, in surgical day care          3,384.00    3,311.00    3,384.00
Service
 code                                      Service name                                 Price A     Price B     Price C
C7860 Removal of implanted device from bone, excluding face/hand/foot, in surgical
                                                                                         3,384.00    3,311.00    3,384.00
      day care
C8044 Capsulotomy of hand/foot and finger(s)/toe(s), in surgical day care                3,384.00    3,311.00    3,384.00
C8201 Tendon sheath incision, in surgical day care                                       3,384.00    3,311.00    3,384.00
C8313 Tenotomy, excluding of hand, in surgical day care                                  3,384.00    3,311.00    3,384.00
C8331 Excision of lesion(s) of tendon sheath, in surgical day care                       3,384.00    3,311.00    3,384.00
C8350 Excision of bursa, in surgical day care                                            3,384.00    3,311.00    3,384.00
C8611
      Biopsy of subcutaneous tissue under general anesthesia, in surgical day care       3,384.00    3,311.00    3,384.00
C8630 Excision/destruction of lesions of skin and subcutaneous tissue, 4 or more, in
                                                                                         3,384.00    3,311.00    3,384.00
      surgical day care
C8660 Free skin grafting, includes excision of skin for autogenous graft, in surgical
                                                                                         3,384.00    3,311.00    3,384.00
      day care
C8689
      Repair and reconstruction of skin and subcutaneous tissue, in surgical day care    3,384.00    3,311.00    3,384.00
C8694 Implantation/replacement of sacral nerve stimulation generator, in surgical day
                                                                                         3,384.00    3,311.00    3,384.00
      care, excluding device cost
C9802 Esophagoscopy for removal of foreign body, in surgical day care                    3,384.00    3,311.00    3,384.00
C999C Surgical hospital day care, excluding procedures with specific code                3,384.00    3,311.00    3,384.00
D0210 Intra oral radiograph - complete series                                              316.00      309.00      316.00
D0220 Intraoral periapical film                                                             35.00       34.00       35.00
D0230 Intraoral periapical, each additional film                                            35.00       34.00       35.00
D0240 Intraoral occlusal film                                                               77.00       75.00       77.00
D0330 Panoramic film                                                                       280.00      274.00      280.00
D1201 Application of fluoride, complete                                                     89.00       87.00       89.00
D1351 Sealant - per tooth                                                                  129.00      126.00      129.00
D1510 Space maintainer, fixed                                                              655.00      641.00      655.00
D2140 Restoration - one surface, local anesthesia                                          221.00      216.00      221.00
D2150 Restoration -2/more surfaces, any material                                           280.00      274.00      280.00
D2330 Resin-based composite restoration - one surface, anterior                            377.00      369.00      377.00
D2335 Resin-based composite restoration, anterior                                          465.00      455.00      465.00
D2390 Resin-based composite restoration - crown                                            407.00      398.00      407.00
D2752 Crown - porcelain fused to noble metal                                             2,386.00    2,335.00    2,386.00
D2980 Crown repair                                                                         218.00      213.00      218.00
D3220 Pulpotomy, primary/permanent tooth                                                   203.00      199.00      203.00
D3230
      Pulpal therapy, resorbable filling - primary tooth, excluding final restoration      407.00      398.00      407.00
D3310     Root canal therapy - anterior, excluding final restoration                       832.00      814.00      832.00
D3320     Root canal therapy - bicuspid, excluding final restoration                       832.00      814.00      832.00
D3330     Root canal therapy - molar, excluding final restoration                          832.00      814.00      832.00
D3351     Apexification                                                                    334.00      327.00      334.00
D3410
          Apicoectomy, anterior, including placement of retrograde filling material        834.00      816.00      834.00
D3421
          Apicoectomy - bicuspid, including placement of retrograde filling material     1,041.00    1,019.00    1,041.00
D3425     Apicoectomy - molar, including placement of retrograde filling material        1,769.00    1,731.00    1,769.00
D3450     Root amputation                                                                1,041.00    1,019.00    1,041.00
D3920     Hemisection                                                                      730.00      714.00      730.00
D4240     Gingival flap, with root planing, per quadrant                                   716.00      701.00      716.00
D4249     Clinical crown lengthening                                                       666.00      652.00      666.00
D4260     Osseous surgery, including flap entry and closure, per quadrant                  920.00      900.00      920.00
D4341     Periodontal scaling and root planing, per meeting, 30 minutes                    124.00      121.00      124.00
D5110     Complete acrylic denture - pair                                                6,981.00    6,831.00    6,981.00
D5213     Partial denture                                                                6,433.00    6,295.00    6,433.00
D5730     Reline denture (chairside)                                                       745.00      729.00      745.00
D5750     Reline denture - laboratory                                                    1,838.00    1,798.00    1,838.00
D5951     Feeding aid; feeding prosthesis                                                  576.00      564.00      576.00
D5952     Speech aid prosthesis, pediatric                                                 576.00      564.00      576.00
D7111     Extraction, coronal remnants - deciduous tooth                                   220.00      215.00      220.00
Service
 code                                     Service name                                    Price A     Price B     Price C
D7140 Extraction, erupted tooth or exposed root, single                                      220.00      215.00      220.00
D7141 Extraction, erupted tooth or exposed root, second in the same session                  164.00      160.00      164.00
D7142 Extraction, erupted tooth or exposed root, each additional tooth in the same
                                                                                             109.00      107.00      109.00
      session
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap
                                                                                             229.00      224.00      229.00
      and removal of bone and/or section of tooth
D7220 Removal of impacted tooth - soft tissue                                                521.00      510.00      521.00
D7230 Removal of impacted tooth - partially bony                                             730.00      714.00      730.00
D7240 Removal of impacted tooth - completely bony                                            730.00      714.00      730.00
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced
                                                                                             531.00      520.00      531.00
      tooth and/or alveolus
D7280 Exposure of impacted/unerupted tooth for orthodontic reasons, including
                                                                                             730.00      714.00      730.00
      orthodontic attachments
D7320 Alveoloplasty not in conjunction with extractions - per quadrant                       537.00      525.00      537.00
D7340 Vestibuloplasty - ridge extension (secondary epithelialization)                        712.00      697.00      712.00
D7450 Removal of odontogenic cyst                                                            537.00      525.00      537.00
D7960 Frenulectomy (frenectomy or frenotomy)                                                 521.00      510.00      521.00
D8080 Comprehensive orthodontic treatment of the adolescent dentition, for one year,
                                                                                           3,715.00    3,635.00    3,715.00
      up to 3 years
D8089 Follow up code of D8080, established adolescent patient for comprehensive
                                                                                               0.00        0.00        0.00
      orthodontic treatment
D8999 Orthodontic preparation for orthognatic face mask                                    1,401.00    1,371.00    1,401.00
D9110 Emergency treatment of dental pain                                                     155.00      152.00      155.00
D9220 Deep sedation/general anesthesia, for dental procedure - first hour                  1,104.00    1,080.00    1,104.00
D9221 Deep sedation/general anesthesia, for complex dental procedure - more than
                                                                                           1,250.00    1,223.00    1,250.00
      one hour
D9230 Analgesia, including nitrous, excluding dental treatment                               202.00      198.00      202.00
J0011 Methylglutaconic aciduria, molecular diagnostics, special case                         404.00      395.00      404.00
J0021 Adrenoleukodystrophy X-linked, molecular diagnostics, special case                     404.00      395.00      404.00
J0031 Canavan disease, molecular diagnostics, special case                                   404.00      395.00      404.00
J0041 Carnitine Palmitoyl Tranferase, molecular diagnostics, special case                    404.00      395.00      404.00
J0051 Cystinuria, molecular diagnostics, special case                                        404.00      395.00      404.00
J0061 Glycogen storage disease type 1, molecular diagnostics, special case                   404.00      395.00      404.00
J0071 Hyperglycinemia, nonketotic, molecular diagnostics, special case                       404.00      395.00      404.00
J0081 Hyperoxaluria, primary, type 1, molecular diagnostics, special case                    404.00      395.00      404.00
J0091 Isovalericacidemia, molecular diagnostics, special case                                404.00      395.00      404.00
J0101
      Lipoamide Dehydrogenase Deficiency, molecular diagnostics, special case                404.00      395.00      404.00
 J0111    Maple syrup urine disease, molecular diagnostics, special case                     404.00      395.00      404.00
 J0121
          Methylmalonicaciduria, mutase deficiency, molecular diagnostics, special case      404.00      395.00      404.00
 J0131    Molybdenum cofactor deficiency, molecular diagnostics, special case                404.00      395.00      404.00
 J0141    Peroxysomal disorders, molecular diagnostics, special case                         404.00      395.00      404.00
 J0151    Phenylketonuria, molecular diagnostics, special case                               404.00      395.00      404.00
 J0161
          Thiamine-responsive megaloblastic anemia, molecular diagnostics, special case      404.00      395.00      404.00
 J0171    Tyrosinemia, molecular diagnostics, special case                                   404.00      395.00      404.00
 J0181    Very Long-Chain Acyl-CoA Dehydrogenase, VLCAD deficiency, molecular
                                                                                             404.00      395.00      404.00
          diagnostics, special case
 J0191    Wilson disease, molecular diagnostics, special case                                404.00      395.00      404.00
 J0201    Xanthinuria, type I, molecular diagnostics, special case                           404.00      395.00      404.00
 J0211
          CTX (Cerebrotendinous xanthomatosis), molecular diagnostics, special case          404.00      395.00      404.00
 J0221    Hypercholesterolemia, familial, molecular diagnostics, special case                404.00      395.00      404.00
 J0232    Lysosomal acid phosphatase deficiency, biochemical diagnostics                   1,146.00    1,121.00    1,146.00
 J0241    Aspartylglucosaminuria, molecular diagnostics, special case                        404.00      395.00      404.00
 J0242    Aspartylglucosaminuria, biochemical diagnostics                                  1,146.00    1,121.00    1,146.00
 J0251    Ceroid lipofuscinosis, molecular diagnostics, special case                         404.00      395.00      404.00
 J0252    Ceroid lipofuscinosis, biochemical diagnostics                                   1,146.00    1,121.00    1,146.00
Service
 code                                     Service name                                  Price A     Price B     Price C
 J0262    Cholesteryl ester storage disease, biochemical diagnostics                     1,146.00    1,121.00    1,146.00
 J0272    Cystinosis, nephropathic, biochemical diagnostics                              1,146.00    1,121.00    1,146.00
 J0281    Fabry disease, molecular diagnostics, special case                               404.00      395.00      404.00
 J0282    Fabry disease, biochemical diagnostics                                         1,146.00    1,121.00    1,146.00
 J0292    Free sialic acid storage disease, biochemical diagnostics                      1,146.00    1,121.00    1,146.00
 J0302    Fucosidosis, biochemical diagnostics                                           1,146.00    1,121.00    1,146.00
 J0312    GM1 gangliosidosis, biochemical diagnostics                                    1,146.00    1,121.00    1,146.00
 J0322    Galactosialidosis, biochemical diagnostics                                     1,146.00    1,121.00    1,146.00
 J0331    Gaucher disease, molecular diagnostics, special case                             519.00      508.00      519.00
 J0332    Gaucher disease, biochemical diagnostics                                       1,146.00    1,121.00    1,146.00
 J0341
          Glycogen storage disease type 2, Pompe, molecular diagnostics, special case      404.00      395.00      404.00
 J0342    Glycogen storage disease type 2, Pompe, biochemical diagnostics                1,146.00    1,121.00    1,146.00
 J0351    Ichthyosis, X-linked, molecular diagnostics, special case                        404.00      395.00      404.00
 J0352    Ichthyosis, X-linked, biochemical diagnostics                                  1,146.00    1,121.00    1,146.00
 J0361    Krabbe disease, molecular diagnostics, special case                              404.00      395.00      404.00
 J0362    Krabbe disease, biochemical diagnostics                                        1,146.00    1,121.00    1,146.00
 J0372    Mannosidosis, alpha, biochemical diagnostics                                   1,146.00    1,121.00    1,146.00
 J0382    Mannosidosis, beta, biochemical diagnostics                                    1,146.00    1,121.00    1,146.00
 J0392    Maroteaux-Lamy syndrome, biochemical diagnostics                               1,146.00    1,121.00    1,146.00
 J0400
          Metachromatic leukodystrophy, pseudo deficiency, molecular diagnostics           519.00      508.00      519.00
 J0401    Metachromatic leukodystrophy, molecular diagnostics, special case                404.00      395.00      404.00
 J0402    Metachromatic leukodystrophy, biochemical diagnostics                          1,146.00    1,121.00    1,146.00
 J0412    Mucolipidosis II, biochemical diagnostics                                      2,604.00    2,548.00    2,604.00
 J0421    Mucolipidosis III, molecular diagnostics, special case                           404.00      395.00      404.00
 J0422    Mucolipidosis III, biochemical diagnostics                                     2,604.00    2,548.00    2,604.00
 J0431    Mucolipidosis IV, molecular diagnostics, special case                            404.00      395.00      404.00
 J0442    Mucopolysaccharidosis II, biochemical diagnostics                              1,146.00    1,121.00    1,146.00
 J0452    Mucopolysaccharidosis IV, biochemical diagnostics                              1,146.00    1,121.00    1,146.00
 J0462    Mucopolysaccharidosis I, biochemical diagnostics                               1,146.00    1,121.00    1,146.00
 J0472    Mucopolysaccharidosis VII, biochemical diagnostics                             1,146.00    1,121.00    1,146.00
 J0482    Multiple sulfatase deficiency, biochemical diagnostics                         2,604.00    2,548.00    2,604.00
 J0491    Niemann-Pick disease, molecular diagnostics, special case                        404.00      395.00      404.00
 J0492    Niemann-Pick disease, biochemical diagnostics                                  1,146.00    1,121.00    1,146.00
 J0501    Niemann-Pick disease, type C, molecular diagnostics, special case                404.00      395.00      404.00
 J0502    Niemann-Pick disease, type C, biochemical diagnostics                          3,894.00    3,810.00    3,894.00
 J0511    Pycnodysostosis, molecular diagnostics, special case                             404.00      395.00      404.00
 J0512    Pycnodysostosis, biochemical diagnostics                                       1,146.00    1,121.00    1,146.00
 J0522    Salla disease, biochemical diagnostics                                         1,146.00    1,121.00    1,146.00
 J0532    Sanfilippo syndrome, biochemical diagnostics                                   2,604.00    2,548.00    2,604.00
 J0542    Schindler disease, biochemical diagnostics                                     1,146.00    1,121.00    1,146.00
 J0552    Sialidosis, biochemical diagnostics                                            1,146.00    1,121.00    1,146.00
 J0561    Tay Sachs disease, molecular diagnostics, special case                           404.00      395.00      404.00
 J0562    Tay Sachs disease, biochemical diagnostics                                     1,146.00    1,121.00    1,146.00
 J0572    Wolman disease, biochemical diagnostics                                        1,146.00    1,121.00    1,146.00
 J0581    Mitochondrial disorder, molecular diagnostics, special case                      404.00      395.00      404.00
 J0582    Mitochondrial disorder, biochemical diagnostics
 J0591    Deafness, mitochondrial, molecular diagnostics, special case                     404.00      395.00      404.00
 J0600    Kearns Sayre Syndrome, KSS, molecular diagnostics                                950.00      930.00      950.00
 J0610    Leber Optic Atrophy, LHON, molecular diagnostics                                 519.00      508.00      519.00
 J0621    Leigh syndrome, molecular diagnostics, special case                              404.00      395.00      404.00
 J0622    Leigh syndrome, biochemical diagnostics
 J0631    Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke-like
                                                                                           519.00      508.00      519.00
          episodes, MELAS, molecular diagnostics, special case
 J0641    Myoclonic Epilepsy with Ragged Red Fibers, MERFF, molecular diagnostics,
                                                                                           950.00      930.00      950.00
          special case
 J0651    Mitochondrial depletion syndrome, molecular diagnostics, special case            404.00      395.00      404.00
 J0652    Mitochondrial depletion syndrome, biochemical diagnostics
Service
 code                                      Service name                                        Price A     Price B     Price C
 J0661    Alzheimer, early onset/familial, molecular diagnostics, special case                    404.00      395.00      404.00
 J0671    Ataxia Telangiectasia, molecular diagnostics, special case                              404.00      395.00      404.00
 J0673    Ataxia Telangiectasia, cytogenetic diagnostics                                        2,937.00    2,874.00    2,937.00
 J0681    Charcot-Marie-Tooth neuropathy, molecular diagnostics, special case                     823.00      805.00      823.00
 J0691    Creutzfeldt-Jakob disease, familial, molecular diagnostics, special case                404.00      395.00      404.00
 J0701    Duchenne, Becker muscular dystrophy, molecular diagnostics                            5,736.00    5,613.00    5,736.00
 J0710    Familial dysautonomia, molecular diagnostics                                            262.00      256.00      262.00
 J0720    Dystonia, torsion, molecular diagnostics                                                519.00      508.00      519.00
 J0730    Facioscapulohumeral muscular dystrophy-1A, molecular diagnostics                        823.00      805.00      823.00
 J0740    Hereditary Nerve Pressure Palsy, HNPP, molecular diagnostics                            950.00      930.00      950.00
 J0750    Huntington disease, molecular diagnostics                                               950.00      930.00      950.00
 J0761    Inclusion body myopathy, autosomal recessive, molecular diagnostics, special
                                                                                                  404.00      395.00      404.00
          case
 J0771    Insensitivity to pain, congenital, with anhidrosis, molecular diagnostics, special
                                                                                                  404.00      395.00      404.00
          case
 J0781    Muscular dystrophy, limb-girdle, dysferlin deficiency, molecular diagnostics,
                                                                                                  404.00      395.00      404.00
          special case
 J0790    Myotonic dystrophy, molecular diagnostics                                               950.00      930.00      950.00
 J0801    Neurofibromatosis, type 1, molecular diagnostics, special case                          404.00      395.00      404.00
 J0810    Oculopharyngeal muscular dystrophy, molecular diagnostics                               950.00      930.00      950.00
 J0820    Spinal Muscular Atrophy, SMA, molecular diagnostics                                     950.00      930.00      950.00
 J0830    Spinocerebellar ataxia due to an expansion including Friedrich ataxia,
                                                                                                  950.00      930.00      950.00
          molecular diagnostics
 J0840    Adenomatous polyposis coli, molecular diagnostics                                     4,614.00    4,515.00    4,614.00
 J0841    Adenomatous polyposis coli, molecular diagnostics, special case                         404.00      395.00      404.00
 J0850    Multiple endocrine neoplasia 2A, molecular diagnostics                                1,038.00    1,016.00    1,038.00
 J0851    Multiple endocrine neoplasia 2A, molecular diagnostics, special case                    404.00      395.00      404.00
 J0860    Retinoblastoma, molecular diagnostics                                                 4,614.00    4,515.00    4,614.00
 J0861    Retinoblastoma, molecular diagnostics, special case                                     404.00      395.00      404.00
 J0870    Von Hippel-Lindau, molecular diagnostics                                                846.00      828.00      846.00
 J0871    Von Hippel-Lindau, molecular diagnostics, special case                                  404.00      395.00      404.00
 J0881    Adrenal hyperplasia, congenital, 11-beta-hydroxylase deficiency, molecular
                                                                                                  404.00      395.00      404.00
          diagnostics, special case
 J0891    Adrenal hyperplasia, congenital, 17-alpha-hydroxylase deficiency, molecular
                                                                                                  404.00      395.00      404.00
          diagnostics, special case
 J0901    Adrenal hyperplasia, congenital, 21-hydroxylase deficiency, molecular
                                                                                                  404.00      395.00      404.00
          diagnostics, special case
 J0911    Adrenal hypoplasia, congenital, molecular diagnostics, special case                     404.00      395.00      404.00
 J0921    Pendred syndrome, molecular diagnostics, special case                                   404.00      395.00      404.00
 J0931    Persistent hyperinsulinemic hypoglycemia of infancy, molecular diagnostics,
                                                                                                  404.00      395.00      404.00
          special case
 J0941
          Combined factor V and VII deficiency, molecular diagnostics, special case               404.00      395.00      404.00
 J0951    Factor V deficiency, molecular diagnostics, special case                                404.00      395.00      404.00
 J0961    Factor VII deficiency, molecular diagnostics, special case                              404.00      395.00      404.00
 J0971    Factor XI deficiency, molecular diagnostics, special case                               404.00      395.00      404.00
 J0981    Factor XIIIA deficiency, molecular diagnostics, special case                            404.00      395.00      404.00
 J0991    Fanconi anemia, molecular diagnostics, special case                                     404.00      395.00      404.00
 J0993    Fanconi anemia, cytogenetic diagnostics                                               2,937.00    2,874.00    2,937.00
 J1001    Hemoglobinopathies alpha, alpha thalassemias, molecular diagnostics, special
                                                                                                1,222.00    1,196.00    1,222.00
          case
 J1011
          Hemoglobinopathies beta, beta thalassemias, molecular diagnostics, special case       1,222.00    1,196.00    1,222.00
 J1021    Hemophilia A, factor VIII deficiency, molecular diagnostics, special case               404.00      395.00      404.00
 J1031    Hemophilia B, factor IX deficiency, molecular diagnostics, special case                 404.00      395.00      404.00
 J1040    Achondroplasia/thanatophoric dwarfism, molecular diagnostics                            404.00      395.00      404.00
 J1051    Achromatopsia, molecular diagnostics, special case                                      404.00      395.00      404.00
 J1061    Albinism, molecular diagnostics, special case                                           404.00      395.00      404.00
 J1070    Angelman syndrome/Prader Willi, molecular diagnostics                                   823.00      805.00      823.00
Service
 code                                     Service name                                    Price A     Price B     Price C
 J1081
          Autoimmune polyglandular disease, type I, molecular diagnostics, special case      404.00      395.00      404.00
 J1091    Bardet-Biedl syndrome, molecular diagnostics, special case                         404.00      395.00      404.00
 J1100    Beckwith-Wiedemann syndrome, molecular diagnostics                                 823.00      805.00      823.00
 J1111    Bloom syndrome, molecular diagnostics, special case                                262.00      256.00      262.00
 J1113    Bloom syndrome, cytogenetic diagnostics                                          2,937.00    2,874.00    2,937.00
 J1121    Cockayne syndrome, molecular diagnostics, special case                             404.00      395.00      404.00
 J1122    Cockayne syndrome, biochemical diagnostics                                       3,894.00    3,810.00    3,894.00
 J1131    Craniosynostosis, molecular diagnostics, special case                              404.00      395.00      404.00
 J1140    Cystic fibrosis, molecular diagnostics                                             519.00      508.00      519.00
 J1151    Deafness, congenital, molecular diagnostics, special case                          404.00      395.00      404.00
 J1161    Epidermolysis Bullosa, congenital, molecular diagnostics, special case             404.00      395.00      404.00
 J1171    Osteopetrosis, recessive, molecular diagnostics, special case                      404.00      395.00      404.00
 J1181    Polycystic kidneys, dominant, molecular diagnostics, special case                  404.00      395.00      404.00
 J1191    Polycystic kidneys, recessive, molecular diagnostics, special case                 404.00      395.00      404.00
 J1203    Roberts syndrome, cytogenetic diagnostics                                        2,937.00    2,874.00    2,937.00
 J1211    Tuberous sclerosis, molecular diagnostics, special case                            404.00      395.00      404.00
 J1222    Xeroderma pigmentosum, biochemical diagnostics                                   3,894.00    3,810.00    3,894.00
 J1233    DiGeorge/velocardiofacial syndrome, FISH, cytogenetic diagnostics                1,232.00    1,205.00    1,232.00
 J1243    Rubinstein-Taybi syndrome, FISH, cytogenetic diagnostics                         1,232.00    1,205.00    1,232.00
 J1253    Smith-Magenis syndrome, FISH, cytogenetic diagnostics                            1,232.00    1,205.00    1,232.00
 J1263    Williams syndrome, FISH, cytogenetic diagnostics                                 1,232.00    1,205.00    1,232.00
 J1271    FMF, molecular diagnostics, special case                                           519.00      508.00      519.00
 J1311
          BRCA1/BRCA2 founder mutation analysis, breast/ovarian cancer, per patient          486.00      476.00      486.00
 J3001    Familial known mutation, molecular diagnostics                                     404.00      395.00      404.00
 J9900    Fragile X, molecular diagnostics                                                   479.00      469.00      479.00
 J9903    Mental retardation, cytogenetic diagnostics                                        730.00      714.00      730.00
 J9913    Male infertility, cytogenetic diagnostics                                          730.00      714.00      730.00
 J9941    Y chromosome deletion, molecular diagnostics, special case                         788.00      771.00      788.00
 J9991    Monogenic disease in family, gene location known, molecular diagnostics,
                                                                                           2,942.00    2,879.00    2,942.00
          special case
L0005     Long cast, local anesthesia                                                        247.00      242.00      247.00
L0019     Elastic bandage, elstoplast                                                         11.00       11.00       11.00
L0020     Needle aspiration, US guidance, including cytology                                 454.00      444.00      454.00
L0021     Breast needle aspiration, US guidance, including cytology                          454.00      444.00      454.00
L0022     Thyroid needle aspiration, US guidance, including cytology, per patient          1,338.00    1,309.00    1,338.00
L0023     Bandage placement or replacement                                                    72.00       70.00       72.00
L0025     Stitches                                                                             0.00        0.00        0.00
L0026     Stitches removal                                                                    39.00       38.00       39.00
L0030     Parotid needle aspiration, US guidance, including cytology, per patient          1,218.00    1,192.00    1,218.00
L0042     Nephrostomy tube removal                                                           279.00      273.00      279.00
L0062     Vaginal smear, sampling, processing and interpretation                             169.00      165.00      169.00
L0080     Rehabilitation day care                                                            683.00      668.00      683.00
L0100     TMJ radiology, up to two views                                                     221.00      216.00      221.00
L0106     Radiology additional view, not elsewhere specified                                  54.00       53.00       54.00
L0107     Jaw radiology, third or more additional views                                       54.00       53.00       54.00
L0108     Mastoids radiology, third or more additional views                                  54.00       53.00       54.00
L0109     Nasal bones radiology, third or more additional views                               54.00       53.00       54.00
L0110     Paranasal sinuses radiology, third or more additional views                         54.00       53.00       54.00
L0111     Skull radiology, third or more additional views                                     54.00       53.00       54.00
L0112     Pelvis radiology, third or more additional views                                    54.00       53.00       54.00
L0113     Shoulder radiology, complete, one side, third or more additional views              54.00       53.00       54.00
L0114     Elbow radiology, third or more additional views                                     54.00       53.00       54.00
L0115     Wrist radiology, third or more additional views                                     54.00       53.00       54.00
L0116     Hand radiology, third or more additional views                                      54.00       53.00       54.00
L0117     Hip radiology, unilateral, second or more additional views                          54.00       53.00       54.00
L0118     Ankle radiology, third or more additional views                                     54.00       53.00       54.00
L0119     Abdomen radiology, second or more additional views                                  54.00       53.00       54.00
Service
 code                                    Service name                                      Price A      Price B      Price C
L0120     TMJ radiology, third or more additional views                                        54.00        53.00        54.00
L0121     Calcaneus radiology, third or more additional views                                  54.00        53.00        54.00
L0122     Toe(s) radiology, third or more additional views                                     54.00        53.00        54.00
L0123     Cervicothoracic spine radiology, Pawlow/Twining, up to two views                     54.00        53.00        54.00
L0124     Cervicothoracic spine radiology, Pawlow/Twining, third or more additional
                                                                                               54.00        53.00        54.00
          views
L0125     Pelvis radiology, outlet                                                              54.00        53.00       54.00
L0126     Pelvis radiology, inlet                                                               54.00        53.00       54.00
L0138     Spine radiology, two parts, up to three views                                        247.00       242.00      247.00
L0151     Arthrography, including injection and interpretation                                 280.00       274.00      280.00
L0160     Chest radiology, third or more additional views                                       99.00        97.00       99.00
L0167     Additional charge for device for insertion of left atrial appendage device        36,832.00    36,832.00   36,832.00
L0168
          Additional charge for device for implantation of diaphragmatic pacemaker         163,350.00   163,350.00 163,350.00
L0194     Large bandage, bandages & cotton                                                     218.00       213.00      218.00
L0209     Pregnancy termination approval committee                                             343.00       336.00      343.00
L0210     Nasal bones radiology, up to two views                                               156.00       153.00      156.00
L0248     Storage of corpse, 2 to 24 hours                                                     301.00       295.00      301.00
L0268     Spotting and copying patient records, first 10 pages                                  83.00        81.00       83.00
L0269     Copying patient records, each 2 additional pages                                       1.00         1.00        1.00
L0372     HBIg (Hepatitis B immune globulin), IV                                             5,582.00     5,462.00    5,582.00
L0396     Varicella Zoster passive immunization, under 12 years of age, eg, varitect         2,422.00     2,370.00    2,422.00
L0397     Varicella Zoster passive immunization, age 12 years or older, eg, varitect         8,491.00     8,308.00    8,491.00
L0409     Small splints, occupational therapy, including cost of material and number of
                                                                                              177.00       173.00       177.00
          sessions
L0410     Medium splints, static mouth splint, occupational therapy, including cost of
                                                                                              342.00       335.00       342.00
          material and number of sessions
L0411     Medium splints, occupational therapy, including cost of material and number of
                                                                                              342.00       335.00       342.00
          sessions
L0412     Complex medium splints, occupational therapy, including cost of material and
                                                                                              500.00       489.00       500.00
          number of sessions
L0413     Big splints, occupational therapy, including cost of material and number of
                                                                                              673.00       659.00       673.00
          sessions
L0415     JOBST suit measurement                                                              218.00       213.00       218.00
L0416     Complex medium splints, dynamic mouth splint, occupational therapy,
                                                                                              500.00       489.00       500.00
          including cost of material and number of sessions
L0438     TRH (Thyrotropin releasing hormone) stimulation panel                                614.00       601.00      614.00
L0444     MRI (Magnetic resonance imaging), excluding tests with specific code               2,009.00     1,966.00    2,009.00
L0446     MRI under general anesthesia, per test                                             7,127.00     6,974.00    7,127.00
L0486     Geriatric hospital day care                                                          528.00       517.00      528.00
L0487     Cognitive geriatric hospital day care                                                276.00       270.00      276.00
L0491     Cytotoxic capacity testing                                                           800.00       783.00      800.00
L0534     Orthoptic treatment, per treatment                                                    77.00        75.00       77.00
L0546     Auditory test for cochlear implant surgery candidate                                 602.00       589.00      602.00
L0554     FMRI (functional magnetic resonance imaging)                                       4,401.00     4,306.00    4,401.00
L0560     Internal hospital day care                                                         1,093.00     1,069.00    1,093.00
L0561     Rehabilitative hospital day care                                                   1,093.00     1,069.00    1,093.00
L0564     Histochemical staining including immunohistochemistry                              1,591.00     1,557.00    1,591.00
L0574     Breathing capability test                                                             77.00        75.00       77.00
L0591     Extracorporeal shockwave lithotripsy, kidney; complex                             18,230.00    17,838.00   18,230.00
L0621     Kit test                                                                             866.00       847.00      866.00
L0690     Hotel care, per day, including medical supervision                                   385.00       377.00      385.00
L0692     Home care, per day, including medical supervision                                    578.00       566.00      578.00
L0717     Harvesting of cornea                                                               5,483.00     5,365.00    5,483.00
L0749     MRI, additional payment for gadolinum contrast                                       220.00       215.00      220.00
L0784     IV (Intravenous) infusion of fluids                                                  218.00       213.00      218.00
L0785     IV (Intravenous) infusion of drugs                                                   218.00       213.00      218.00
L0787     Deflux injection, vesicoureteral reflux therapy, unilateral                        6,381.00     6,244.00    6,381.00
L0788     Deflux injection, vesicoureteral reflux therapy, bilateral                        11,274.00    11,031.00   11,274.00
Service
 code                                     Service name                                     Price A     Price B     Price C
L0790     Preparation of blood unit, price per preparation of one unit                        220.00      215.00      220.00
L0791     Blood unit, price per one unit                                                      256.00      250.00      256.00
L0799     IV (Intravenous) ileoprost                                                        1,029.00    1,007.00    1,029.00
L0800     Psychotherapy, individual, combined                                                 306.00      299.00      306.00
L0801     Psychiatric clinic evaluation                                                       147.00      144.00      147.00
L0802     Diagnostic interview/intake                                                         147.00      144.00      147.00
L0803     Home visit, member of psychiatric team                                              126.00      123.00      126.00
L0804     Home visit, psychiatric team                                                        345.00      338.00      345.00
L0805     Comprehensive cognitive testing, 3 visits                                         1,010.00      988.00    1,010.00
L0806     Multiprofessional evaluation for rehabilitation planning                          1,391.00    1,361.00    1,391.00
L0807     Psychological assessment for rehabilitation framework                               911.00      891.00      911.00
L0808     Psychodiagnostic assessment - full battery                                          911.00      891.00      911.00
L0809     Psychodiagnostic assessment - partial battery                                       467.00      457.00      467.00
L0820     Psychiatric hospital day care, adult, all hospitals                                 351.00      343.00      351.00
L0821     Psychiatric hospital day care, children and adolescents, all hospitals              375.00      367.00      375.00
L0822     Psychiatric community day care, adult                                               377.00      369.00      377.00
L0823     Psychiatric community day care, children and adolescents                            408.00      399.00      408.00
L0841     Psychotherapy/counseling, individual                                                221.00      216.00      221.00
L0843     Patient's treatment framework assessment                                            911.00      891.00      911.00
L0846     Family or conjoint therapy/counseling                                               370.00      362.00      370.00
L0849     Psychotherapy, group, per session                                                   103.00      101.00      103.00
L0885     Psychotherapy/counselling, group, institutions/families/schools                     467.00      457.00      467.00
L0886     Guidance for other agencies, individual, within service site                        258.00      252.00      258.00
L0887     Guidance for other agencies, goup, within service site                              174.00      170.00      174.00
L0888     Guidance for other agencies, outside service site                                   370.00      362.00      370.00
L0899     Psychosocial diagnosis and evaluation                                               156.00      153.00      156.00
L0911     Hearing test, complete, anamnesis, child                                            218.00      213.00      218.00
L0914     Biofeedback training, gastroenterology, single session                              301.00      295.00      301.00
L0915     Biofeedback training, gastroenterology, 6 sessions                                1,807.00    1,768.00    1,807.00
L0934     Circulating anticoagulants, eg, LAC                                                 310.00      303.00      310.00
L0959     Sexual counseling and therapy                                                       364.00      356.00      364.00
L0962     ER (Emergency room) medical examination                                             253.00      248.00      253.00
L0964     ER (Emergency room) fee                                                             170.00      166.00      170.00
L0969     Collar or sling, including materials                                                120.00      117.00      120.00
L1015     Enzymes activity with cells separation, six or more enzymes                       1,165.00    1,140.00    1,165.00
L1028     US (ultrasound), with image documentation                                           305.00      298.00      305.00
L1039     CT (Computed Tomography), excluding tests with specific code                        549.00      537.00      549.00
L1040     CTA / CTArthro / CT urography, per patient, excluding CTA chest, coronary
                                                                                              987.00      966.00      987.00
          arteries
L1077     Surgical obturator, assessment and preparation                                    9,837.00    9,625.00    9,837.00
L1079     Interim obturator                                                                 5,165.00    5,054.00    5,165.00
L1080     Definitive obturator                                                             14,142.00   13,838.00   14,142.00
L1133     Establishing paternity, per patient, including medical forensic opinion           1,594.00    1,560.00    1,594.00
L1139     Pilot medical examination                                                         1,308.00    1,280.00    1,308.00
L1275     CTA chest, coronary arteries                                                      2,433.00    2,381.00    2,433.00
L1611     Initial insertion/replacement of speech prosthesis post laryngectomy              2,495.00    2,441.00    2,495.00
L1720     Bladder instillation of Mitomycin, per treatment, including material                936.00      916.00      936.00
L1721     Bladder hyperthermia and Mitomycin instillation, per treatment                    3,953.00    3,868.00    3,953.00
L1922     CT under general anesthesia                                                       1,597.00    1,563.00    1,597.00
L1996     Chronic pain control, infiltration                                                  266.00      260.00      266.00
L1997     Chronic pain control, nerves block, using fluoroscopic guidance, with contrast
                                                                                            1,325.00    1,296.00    1,325.00
          material
L1998     Chronic pain control, nerves block, using fluoroscopic guidance, with
                                                                                            1,325.00    1,296.00    1,325.00
          neurolytic substance
L2001     Radiofrequency treatment for pain control, per treatment                          4,215.00    4,124.00    4,215.00
L2002     Intrathecal pump loading, Baclofen                                                3,055.00    2,989.00    3,055.00
L2003     Ozone treatment for skin ulcers, per day                                            210.00      205.00      210.00
L2004     Negative pressure treatment for skin ulcers, per session                            542.00      530.00      542.00
L2005     Maggot debridement therapy, per session                                             433.00      424.00      433.00
Service
 code                                       Service name                                     Price A     Price B     Price C
L2013     Acetylcholinesterase, Ab - serum                                                      345.00      338.00      345.00
L2136     OCT3 (Optical Coherence Tomography), per patient                                      308.00      301.00      308.00
L2196     Pelvis/genitalia MRI, excluding prostate                                            1,975.00    1,932.00    1,975.00
L2197     Prostate MRI                                                                        3,946.00    3,861.00    3,946.00
L2250     Fundus photography, two eyes                                                          305.00      298.00      305.00
L2340     Optometry by an optometrist, per patient                                              124.00      121.00      124.00
L2498     Corneal imaging                                                                       161.00      158.00      161.00
L2528     Nasal potential difference measurements for cystic fibrosis diagnonsis              1,359.00    1,330.00    1,359.00
L2529
          Rectal biopsy sampling and testing for Cystic Fibrosis diagnosis, per patient       1,359.00    1,330.00    1,359.00
L2585     Auditory screening test, OAE, infant                                                    0.00        0.00        0.00
L2586     Auditory screening test, AABR, infant                                                   0.00        0.00        0.00
L2588     OAE (Otoacoustic Emissions), diagnostic                                                76.00       74.00       76.00
L2589     Auditory screening test, AABR, subsequent test, baby                                  153.00      150.00      153.00
L2699     Extracorporeal shock wave lithotripsy, salivary glands                              4,451.00    4,355.00    4,451.00
L2731     Fibronectin                                                                           400.00      391.00      400.00
L2999
          Arthroscopy, complex and/or high skill surgical procedures, using implants         13,157.00   12,874.00   13,157.00
L3003     ECG monitoring, Flecainide infusion, IV                                               596.00      583.00      596.00
L3013     Rapid urease test, helicobacter pylori, child - exhaled air                            42.00       41.00       42.00
L3239
          Biopsy, additional payment to EUS, excluding EUS (Endoscopic ultrasound)            2,075.00    2,030.00    2,075.00
L3250     Endoscopic polyp marking, in addition to endoscopy, per patient                       739.00      723.00      739.00
L3255     Double balloon enteroscopy                                                          9,648.00    9,440.00    9,648.00
L3307     TTE (transthoracic echocardiography), child                                           396.00      387.00      396.00
L3560     Patella radiology, up to two views, per side                                          109.00      107.00      109.00
L3562     Patella radiology, third or more additional views                                     120.00      117.00      120.00
L3620     Toe(s) radiology, up to two views                                                     109.00      107.00      109.00
L3621     Calcaneus radiology, up to two views                                                  109.00      107.00      109.00
L3711     Apolipoprotein E, genotype                                                            376.00      368.00      376.00
L3727
          Implantation of loop recorder system, including retrieval of recorded and stored
                                                                                             10,912.00   10,677.00   10,912.00
          ECG data, physician review and interpretation of retrieved ECG data, per ILR
L3795     External Counter Pulsation Therapy (ECPT) / Enhanced External Counter
                                                                                                608.00      595.00      608.00
          Pulsation (EECP) therapy
L3799     Rehabilitation workshop, lung diseases patients, per session                           63.00       62.00       63.00
L3890     Apolipoprotein E4, genotype                                                           898.00      879.00      898.00
L3900
          Prenatal molecular diagnostics, age 35-37 years, including lab tests and US         2,280.00    2,231.00    2,280.00
L3902
          Prenatal molecular diagnostics, over 37 years of age, including lab tests and US    1,496.00    1,464.00    1,496.00
L4110     Porphobilinogen deaminase, quantitative - RBC                                         393.00      385.00      393.00
L4152     Hospital circumcision, excluding newborn                                            2,219.00    2,171.00    2,219.00
L4233     Her-2/neu, immunohistochemistry                                                       310.00      303.00      310.00
L4234     Her-2/neu, FISH method                                                              2,706.00    2,648.00    2,706.00
L4283     Enema                                                                                  22.00       22.00       22.00
L4298     Electrolytes, sodium and potassium                                                     21.00       21.00       21.00
L4450     Urethrocystography, retrograde, under sedation                                      1,023.00    1,001.00    1,023.00
L4581     Additional charge for device for implantation/replacement of sacral nerve
                                                                                             13,000.00   13,000.00   13,000.00
          stimulation electrode/lead
L4583     Additional charge for device for implantation/replacement of sacral nerve
                                                                                             56,331.00   56,331.00   56,331.00
          stimulation generator
L4612     Botolinum Toxin, 30 units Dysport administration                                      233.00      228.00      233.00
L4705     hCG and PAPP-A, quantitative - serum                                                  161.00      158.00      161.00
L4793     Ambulatory evaluaiton of TB suspected patient                                       1,366.00    1,337.00    1,366.00
L4794     Basic evaluation of Mantoux positive patient                                          167.00      163.00      167.00
L4795     Treatment of active TB patient, first 5 months                                      6,535.00    6,394.00    6,535.00
L4796     Treatment of active TB patient, last month                                          8,520.00    8,337.00    8,520.00
L4797     Evaluation of close contact of Tb patient                                             542.00      530.00      542.00
Service
 code                                     Service name                                  Price A     Price B     Price C
L4798     Ambulatory treatment of close contact patient, prevention                        192.00      188.00      192.00
L4799
          Ambulatory pharmacological treatment of close contact patient, last month        254.00      249.00      254.00
L4990     Genotype characterization by caryotype analysis                                2,642.00    2,585.00    2,642.00
L4991     Malignancies genotype, FISH (Fluorescent in Situ Hybridization)                1,181.00    1,156.00    1,181.00
L4992     Malignancies genotype, DNA index                                                 881.00      862.00      881.00
L4999     Orotic acid - urine                                                               75.00       73.00       75.00
L5339     Laser, additional payment to endoscopy, excluding endoscopy                      942.00      922.00      942.00
L5378
          Colonoscopy, flexible; diagnostic, with/without collection of specimen(s)        948.00      928.00      948.00
L5400     Endoscopic Argon laser treatment                                                 326.00      319.00      326.00
L5441     Femur head from bone bank                                                      1,408.00    1,378.00    1,408.00
L5461     Kappa or Lambda light chain, Ig, free - blood                                    308.00      301.00      308.00
L5799     Angiography                                                                    2,813.00    2,752.00    2,813.00
L5810     Polysomnography, including EEG, child                                          1,013.00      991.00    1,013.00
L5858     Tensilon test for myasthenia gravis; with electromyographic recording            461.00      451.00      461.00
L5872     Single fiber electromyography, per patient                                       649.00      635.00      649.00
L5925     Sensory evoked potentials (SEP) study, per patient                               404.00      395.00      404.00
L5990
          Minor ambulatory surgery, including foreign body removal, local anesthesia       280.00      274.00      280.00
L6002     Cytokins                                                                         253.00      248.00      253.00
L6015     Gliadin, Ab                                                                      197.00      193.00      197.00
L6031     Intraocular injection of Bevacizumab (Avastin)                                   591.00      578.00      591.00
L6160     KRAS mutation, per patient                                                     1,392.00    1,362.00    1,392.00
L6171
          Additional charge for intraocular shunt, eg, Ex-PRESS, for trabeculectomy      3,748.00    3,748.00    3,748.00
L6312     CA 72.4 tumor antigen                                                            119.00      116.00      119.00
L6313     NSE (Neuron specific enolase), tumor antigen                                     119.00      116.00      119.00
L6316     Immunoassay for tumor antigen, quantitative; CA 21-1                             104.00      102.00      104.00
L6358     Lymphocyte CD antigen determination, over 6 CD                                 2,459.00    2,406.00    2,459.00
L6375     CT (Computed tomographic) virtual colonoscopy                                    993.00      972.00      993.00
L6414     Hickman placement, angiography guidance                                        2,731.00    2,672.00    2,731.00
L6415     Hickman placement under general anasthesia                                     4,093.00    4,005.00    4,093.00
L6416     Portacath placement, angiography guidance                                      3,959.00    3,874.00    3,959.00
L6417     Portacath placement under general anasthesia                                   5,449.00    5,332.00    5,449.00
L6418     Declotting by thrombolytic agent of Hickman/portacath catheter                   150.00      147.00      150.00
L6497     Copying video, echo, catheterization, CD                                          89.00       87.00       89.00
L6498     Administrative radiologic procedure                                               35.00       34.00       35.00
L6499     Administrative radiologic procedure                                               16.00       16.00       16.00
L6520     Low density lipoprotein (LDL) apheresis                                        8,772.00    8,583.00    8,772.00
L6550     Oncological treatment, adult, with chemotherapeutic/biological medications,
                                                                                         1,246.00    1,219.00    1,246.00
          per patient per day
L6551     Oncological treatment, child, with chemotherapeutic/biological medications,
                                                                                         1,619.00    1,584.00    1,619.00
          per patient per day
L6552     Oncological/hematological treatment, adult, without chemotherapeutic/
                                                                                           748.00      732.00      748.00
          biological medications, per patient per day
L6553     Oncological/hematological treatment, child, without chemotherapeutic/
                                                                                           972.00      951.00      972.00
          biological medications, per patient per day
L6611     Bartonella henselae (Cat scratch) IgG - blood                                    222.00      217.00      222.00
L6612     Bartonella henselae (Cat scratch) IgM - blood                                    222.00      217.00      222.00
L6689     HIV or HTLV resistance to medication                                           2,270.00    2,221.00    2,270.00
L6705     HBV, HCV and HIV-1 detection, NAT, at blood bank                                 119.00      116.00      119.00
L6707     Hepatitis E, Ab                                                                  221.00      216.00      221.00
L6762     Rubella virus IgG or IgM                                                         109.00      107.00      109.00
L6776     Toxoplasma, Sabin Feldman dye test                                               196.00      192.00      196.00
L6777     Toxoplasmosis confirmation test                                                  505.00      494.00      505.00
L6778     Toxoplasma avidity testing                                                       270.00      264.00      270.00
L6815     Ultrasound, pregnant uterus, without image documentation                         279.00      273.00      279.00
L6821     Ophthalmic YAG laser treatment, per patient                                      367.00      359.00      367.00
Service
 code                                       Service name                                     Price A     Price B     Price C
L6822     Ophthalmic Argon laser treatment, per patient                                         284.00      278.00      284.00
L6830     Creation of arteriovenous fistula for renal dialysis, native or using graft        11,515.00   11,267.00   11,515.00
L6831
          Therapeutic catheterization of AV shunt for renal dialysis, native/with graft      19,358.00   18,941.00   19,358.00
L6849     Interferon Ab                                                                         293.00      287.00      293.00
L6856     Pelvis US, nonobstetric, with image documentation, complete                           306.00      299.00      306.00
L6857     Hips US                                                                               306.00      299.00      306.00
L7001     Physiotherapy, evaluation and treatment planning, child                               340.00      333.00      340.00
L7002     Isokinetic assessment and treatment planning                                          226.00      221.00      226.00
L7003     Occupational therapy, evaluation and treatment planning, child                        340.00      333.00      340.00
L7004     Isokinetic physiotherapeutic treatment                                                189.00      185.00      189.00
L7118     NTM (Non Tuberculous Mycobacteria) identification                                     362.00      354.00      362.00
L7140     Physiotherapy/rehabilitation, group, up to 4 individuals, including child, per
                                                                                                 74.00       72.00       74.00
          individual
L7154     Toxoplasma, molecular diagnostics - body fluids                                       990.00      969.00      990.00
L7204     Spermatic veins embolization                                                        6,656.00    6,513.00    6,656.00
L7210     Photocoagulation, PDT, retina, including material                                   9,714.00    9,505.00    9,714.00
L7525     Replacement/repositioning of biliary drain, percutaneous                            2,476.00    2,423.00    2,476.00
L7619     Malignant hyperthermia diagnosis test (muscle biopsy)                               7,590.00    7,427.00    7,590.00
L7751     Brachytherapy, gynecological                                                        9,322.00    9,121.00    9,322.00
L7752     Brachytherapy, lung cancer                                                          5,815.00    5,690.00    5,815.00
L7753     Brachytherapy, prostate cancer treatment                                           37,281.00   36,478.00   37,281.00
L7771     Occupational therapy, group                                                            74.00       72.00       74.00
L8076     Adrenal imaging, cortex                                                             9,173.00    8,976.00    9,173.00
L8170     Semen production from testis, surgical                                              5,406.00    5,290.00    5,406.00
L8180     Chemotherapy resistance, Facs                                                         715.00      700.00      715.00
L8181     CD membrane antigen, up to 4 antigens                                               1,028.00    1,006.00    1,028.00
L8182
          Testes removal, for sperm isolation; cadaver, at the forensic medicine institute    1,036.00    1,014.00    1,036.00
L8183
          Pathological specimen, preparation of slides, at the forensic medicine institute       85.00       83.00       85.00
L8184     DNA analysis in liquid blood, soft tissue, semen, at the forensic institute         2,251.00    2,203.00    2,251.00
L8186     DNA analysis in dry blood, at the forensic institute                                2,373.00    2,322.00    2,373.00
L8188     DNA analysis in bone tissue, at the forensic institute                              8,276.00    8,098.00    8,276.00
L8190     Harvesting of cardiac valve (homograft bank)                                        1,418.00    1,387.00    1,418.00
L8213     Aminolevulinic acid dehydratase (ALA-D), quantitative - RBC                           590.00      577.00      590.00
L8242     Allogeneic donor lymphocyte infusions, DLI                                          3,157.00    3,089.00    3,157.00
L8244     Allogeneic lymphocyte proliferation                                                 4,750.00    4,648.00    4,750.00
L8245     Allogeneic lymphocyte activation                                                   30,052.00   29,405.00   30,052.00
L8250     Chromosome 1 and 19 analysis, per patient                                           1,684.00    1,648.00    1,684.00
L8252     FLT3 and NPM1 internal random duplications, PCR                                       696.00      681.00      696.00
L8268     Cholyl-14-C-Glycine breath test for bile salts deconjugation
L8269     C-13 urea test, helicobacter pylori - exhaled air                                     140.00      137.00      140.00
L8299     Spleen imaging, with heated RBC (red blood cells)                                     985.00      964.00      985.00
L8307     Examination of abortus for diagnosis of malformations                               5,228.00    5,115.00    5,228.00
L8379     EGFR (Epidermal Growth Factor Receptor) mutation, per patient                         936.00      916.00      936.00
L8410     Porphyrins, qualitative - plasma                                                      132.00      129.00      132.00
L8411     Porphyrins, chromatography - plasma                                                   501.00      490.00      501.00
L8412     Porphyrins, chromatography - urine                                                    463.00      453.00      463.00
L8413     Porphyrins, chromatography - feces                                                    531.00      520.00      531.00
L8414     Porphyrins, chromatography - RBC                                                      575.00      563.00      575.00
L8599     Pulmonary imaging, dynamic, mucociliary clearence                                   3,207.00    3,138.00    3,207.00
L8802     Somatostatin receptor scintegraphy                                                 17,744.00   17,362.00   17,744.00
L8970     First stage IVF, including hormonal tests                                           4,641.00    3,395.00    3,482.00
L8971     First stage IVF, excluding hormonal tests                                           3,619.00    2,648.00    2,714.00
L8972     Second stage IVF, excluding hospitalization days                                    5,596.00    4,093.00    4,196.00
L8975     Ovarian tissue cryopreservation                                                     4,610.00    4,511.00    4,610.00
L8976     Cryopreserved ovarian tissue storage for 5 years                                      614.00      601.00      614.00
L8977     Oocyte retrieval and cryopreservation, eg, vitrification                            5,596.00    4,093.00    4,196.00
Service
 code                                     Service name                                        Price A     Price B     Price C
L8978     Cryopreserved oocytes storage for 5 years                                              614.00      601.00      614.00
L8979
          Cryopreserved oocytes transfer, intrauterine, including thawing and fertilization    3,608.00    3,530.00    3,608.00
L9000     Radiopharmaceutical therapy, hyper-thyroidism                                        1,423.00    1,392.00    1,423.00
L9030     Radiopharmaceutical ablation of gland for thyroid carcinoma                          5,867.00    5,741.00    5,867.00
L9035     Radiopharmaceutical therapy for metastases of thyroid carcinoma                      9,312.00    9,112.00    9,312.00
L9079     Injection (eg, neurolytic substance)                                                    83.00       81.00       83.00
L9080     Medical opinion for appointment of legal guardian, including completion of
                                                                                                 572.00      560.00      572.00
          form and reports
L9183     Emergency hyperbaric oxygen therapy, excluding diving accidents                      9,833.00    9,621.00    9,833.00
L9184     Hyperbaric pretreatment assessment                                                   1,387.00    1,357.00    1,387.00
L9201     Physician consulation for a patient insured by another sick fund                       139.00      136.00      139.00
L9211     Fire arm license physician examination                                                 103.00      101.00      103.00
L9212     Driving license physician examination                                                  103.00      101.00      103.00
L9215     Fire arm license specialist examination                                                305.00      298.00      305.00
L9232     Routine examinations for candidates for renal transplantation                        4,409.00    4,314.00    4,409.00
L9241     Perenatal genetic consultation                                                         486.00      476.00      486.00
L9242     Examination by medical specialist for appointment of legal guardian, for
                                                                                                 218.00      213.00      218.00
          established patient
L9243     Genetic consultation                                                                   486.00      476.00      486.00
L9244     Physician examination, oncologist                                                      218.00      117.00      119.00
L9245     Physician examination, hematologist                                                    218.00      117.00      119.00
L9246     Physician examination, hemato-oncologist                                               218.00      117.00      119.00
L9247     Physician examination, internal physician                                              218.00      117.00      119.00
L9248     Physician examination, urologist                                                       218.00      117.00      119.00
L9249     Physician examination, orthopedic physician                                            218.00      117.00      119.00
L9250     Stammering treatment, individual/group, per course                                   7,627.00    7,463.00    7,627.00
L9251     Stammering treatment, individual/group, per patient/session                            146.00      143.00      146.00
L9252     Physician examination, alergologist                                                    218.00      117.00      119.00
L9253     Physician examination, endocrinologist                                                 218.00      117.00      119.00
L9254     Physician examination, otorhinolaryngologist                                           218.00      117.00      119.00
L9255     Physician examination, obstetrician/gynecologist                                       218.00      117.00      119.00
L9256     Physician examination, genetician                                                      218.00      117.00      119.00
L9257     Physician examination, gastroenterologist                                              218.00      117.00      119.00
L9258     Physician examination, pediatrician                                                    218.00      117.00      119.00
L9259     Cryopreservation, sperm, any additional year, up to 5 test tubes/straws                274.00      268.00      274.00
L9260     Physician examination, surgeon                                                         218.00      117.00      119.00
L9261     Physician examination, thoracic surgeon                                                218.00      117.00      119.00
L9262     Physician examination, vascular surgeon                                                218.00      117.00      119.00
L9263     Physician examination, hand surgeon                                                    218.00      117.00      119.00
L9264     Physician examination, maxillofacial surgeon                                           218.00      117.00      119.00
L9265     Physician examination, proctologist surgeon                                            218.00      117.00      119.00
L9266     Physician examination, breast surgeon                                                  218.00      117.00      119.00
L9267     Physician examination, plastic surgeon                                                 218.00      117.00      119.00
L9268     Physician examination, anesthesiologist                                                218.00      117.00      119.00
L9269     Physician examination, neurosurgeon                                                    218.00      117.00      119.00
L9270     Physician examination, neurologist                                                     218.00      117.00      119.00
L9271     Consultation with a specialist                                                         364.00      356.00      364.00
L9273     Physician examination, nephrologist                                                    218.00      117.00      119.00
L9274     Physician examination, dermatologist                                                   218.00      117.00      119.00
L9275     Physician examination, ophthalmologist                                                 218.00      117.00      119.00
L9276     Physician examination, cardiologist                                                    218.00      117.00      119.00
L9277     Physician examination, rheumatologist                                                  218.00      117.00      119.00
L9278     Physician examination, pulmonologist                                                   218.00      117.00      119.00
L9279     Physician examination, rehabilitation physician                                        218.00      117.00      119.00
L9281     Emergency physician consulation at sick fund clinic                                    229.00      224.00      229.00
L9301     Clinic nurse evaluation for a patient insured by another sick fund                      98.00       96.00       98.00
L9311     Home visit, nurse                                                                      124.00      121.00      124.00
L9321     Outpatient social treatment                                                            124.00      121.00      124.00
Service
 code                                      Service name                                        Price A      Price B      Price C
L9331     Rehabilitative day care center - long term                                               238.00       233.00      238.00
L9342     Prosthesis extension                                                                     221.00       216.00      221.00
L9343     Sheltered housing, per day                                                                30.00        29.00       30.00
L9345     Care hostel, per day                                                                     110.00       108.00      110.00
L9346     Care hostel, extended, per day                                                           136.00       133.00      136.00
L9347     Short term treatment center, per day                                                     103.00       101.00      103.00
L9348     Club activity, per month, 8 visits at least, child                                       296.00       290.00      296.00
L9349     Treatment boarding school services, per month                                          6,048.00     5,918.00    6,048.00
L9350     Club activity, per month, 8 visits at least                                              238.00       233.00      238.00
L9351     Occupational club activity, per day                                                       38.00        37.00       38.00
L9352     Sheltered factory, per day                                                                55.00        54.00       55.00
L9353     Occupational rehabilitation, extended, per day                                            67.00        66.00       67.00
L9354     Sheltered housing, extended, per day                                                      75.00        73.00       75.00
L9355     School, per month, child/adolescent                                                      932.00       912.00      932.00
L9359     Medical evaluation based on documents                                                    101.00        99.00      101.00
L9360     Risk assessment of sex offenders                                                       2,978.00     2,914.00    2,978.00
L9377     Physician services in parent home                                                        221.00       216.00      221.00
L9379     Physician services in hostel                                                             120.00       117.00      120.00
L9394     Physician services in boarding school                                                     74.00        72.00       74.00
L9413     Medical records printout                                                                  37.00        36.00       37.00
L9420     Calibration of instruments for measuring radiation                                       601.00       588.00      601.00
L9480     Results reporting, no charge                                                               0.00         0.00        0.00
L9490     Follow up service, free of charge                                                          0.00         0.00        0.00
L9499     Social worker services                                                                   132.00       129.00      132.00
L9500     Medical examination, first visit - child development                                     560.00       548.00      560.00
L9501     Medical examination, follow up - child development                                       334.00       327.00      334.00
L9502     Psychological cognitive testing - child development                                      691.00       676.00      691.00
L9503     Family workup and diagnosis - child development                                          334.00       327.00      334.00
L9504     Psychoneurology assessment - child development                                           945.00       925.00      945.00
L9505     Cognitive evaluation for rehabilitation - child development                              858.00       840.00      858.00
L9506     Learning disabilities evaluation - child development                                   1,165.00     1,140.00    1,165.00
L9507     Multidisciplinary team for rehabilitation - child development                          1,174.00     1,149.00    1,174.00
L9510     Speech therapy, evaluation and treatment planning - child development                    340.00       333.00      340.00
L9511     Aquatic physiotherapy/rehabilitation, group, up to 4 individuals, inculding
                                                                                                  131.00       128.00       131.00
          child, hydrotherapy
L9512     Speech therapy, individual - child development                                           173.00       169.00      173.00
L9513     Occupational therapy, individual - child development                                     173.00       169.00      173.00
L9514     Physiotherapy, individual - child development                                            191.00       187.00      191.00
L9516     Psycho/behavioral therapy - child development                                            212.00       207.00      212.00
L9517     Developmental examination - nurse - child development                                    151.00       148.00      151.00
L9518     Therapy/counseling, family/conjoint - child development                                  464.00       454.00      464.00
L9519     Biofeedback training - child development                                                 375.00       367.00      375.00
L9520     Evaluation of supportive communication - child development                             1,238.00     1,211.00    1,238.00
L9521     Staff meeting with parents - child development                                           417.00       408.00      417.00
L9523     Multiprofessional consulation for parents - child development                            129.00       126.00      129.00
L9525     Additional consulation - child development                                               161.00       158.00      161.00
L9528     Physiotherapy, group - child development                                                 136.00       133.00      136.00
L9529     Speech therapy, group - child development                                                136.00       133.00      136.00
L9530     Occupational therapy, group - child development                                          136.00       133.00      136.00
L9600     Home visit, health care professional - child development                                 244.00       239.00      244.00
L9617     Neuropsychological tests before epilepsy surgery                                       1,108.00     1,084.00    1,108.00
L9637     Plerixafor (Mozobil) injection, including medication, per patient per cycle (up to
                                                                                               106,290.00   104,002.00 106,290.00
          4 days)
L9855     Induced abortion, surgical, including curettage                                        2,413.00     2,361.00    2,413.00
L9856     Induced abortion, pharmaceutical                                                       1,738.00     1,701.00    1,738.00
L9857     Induced abortion, surgical, following pharmaceutical abortion                              0.00         0.00        0.00
L9899     Prenatal course                                                                          525.00       514.00      525.00
L9900     Provision of therapeutic radiopharmaceutical(s)                                          722.00       706.00      722.00
Service
 code                                      Service name                                        Price A      Price B      Price C
L9999
          Radiopharmaceutical therapy, pheochromocytoma/neuroblastoma; I-131-MIBG               23,954.00    23,438.00    23,954.00
G0018     Transjugular intrahepatic portosystemic stent/shunt, TIPS                             29,004.00    28,380.00    29,004.00
G0024     Obstetric and neonatal hospitalization                                                 2,588.00                 10,523.00
G0026     Preterm infant hospitalization                                                         2,588.00                159,056.00
G0028     Cryotherapy of prostatic cancer                                                       30,669.00    30,009.00    30,669.00
G0031     Insertion of stent to abdominal aortic aneurysm, stent graft                          98,683.00    96,559.00    98,683.00
G0032     Bone marrow transplantation, haploid, including stem cells separation                510,492.00   499,503.00   510,492.00
G0033     Isolated limb perfusion in patient with sarcoma                                       93,617.00    91,602.00    93,617.00
G0035     Interventional neuro-radiology for intracranial aneurysm by catheterization,
                                                                                                82,235.00    80,465.00    82,235.00
          including use of stent, eg, SILK
G0036     Insertion of intraocular lens, lens included                                           4,833.00     4,729.00     4,833.00
G0037     Tension free vaging tape for incontinence (TVT)                                        7,421.00     7,261.00     7,421.00
G0045     Mastectomy, bilateral                                                                 22,709.00    22,220.00    22,709.00
G0047     Breast reconstruction, bilateral                                                      24,927.00    24,390.00    24,927.00
G0048     Breast reconstruction following mastectomy, bilateral                                 43,641.00    42,702.00    43,641.00
G0049     Breast reconstruction following mastectomy, unilateral                                26,453.00    25,884.00    26,453.00
G0050     Breast reconstruction, unilateral, including nipple reconstruction                    21,929.00    21,457.00    21,929.00
G0051     Mastectomy, unilateral                                                                15,136.00    14,810.00    15,136.00
G0054     Lower extremities veins surgery, including varicose veins                             10,237.00    10,017.00    10,237.00
G0055     Blood vessels surgery, including nonautogenous graft                                  53,529.00    52,377.00    53,529.00
G0057     Lung transplantation                                                                 326,272.00   319,249.00   326,272.00
G0058     Heart-lung transplant                                                                456,785.00   446,952.00   456,785.00
G0059     Bone marrow transplantation; allogenic                                               302,935.00   296,414.00   302,935.00
G0060     Bone marrow transplantation; autologous                                              199,026.00   194,742.00   199,026.00
G0061     Renal transplantation                                                                217,516.00   212,834.00   217,516.00
G0062     Heart transplantation                                                                326,272.00   319,249.00   326,272.00
G0063     Liver transplantation                                                                940,193.00   919,954.00   940,193.00
G0064     Corneal surgery, including cost of cornea                                             18,639.00    18,238.00    18,639.00
G0066     Inguinal/femoral hernia repair, hospital day care                                      3,307.00     3,236.00     3,307.00
G0067     Craniotomy                                                                            60,706.00    59,399.00    60,706.00
G0070     Open prostatectomy                                                                    17,202.00    16,832.00    17,202.00
G0072     Heart surgery, including bypass                                                       70,814.00    69,290.00    70,814.00
G0073     Diagnostic catheterization                                                            13,697.00    13,402.00    13,697.00
G0074     Therapeutic catheterization, excluding cardiac catheterization                        32,099.00    31,408.00    32,099.00
G0075     Hysterectomy                                                                          14,171.00    13,866.00    14,171.00
G0077     Transurethral prostatectomy                                                           10,630.00    10,401.00    10,630.00
G0078     Hospital circumcision, excluding newborn                                               2,219.00     2,171.00     2,219.00
G0083     Osteotomy of spine, including implants, diskectomy                                    26,414.00    25,845.00    26,414.00
G0084     Osteotomy of spine, including implants - other surgeries                              48,506.00    47,462.00    48,506.00
G0085
          Cardiac catheterization, therapeutic, including insertion of drug eluting stent(s)    38,495.00    37,666.00    38,495.00
G0089     Treatment of heavy burns                                                             184,946.00   180,965.00 184,946.00
G0090     Treatment of medium burns                                                            105,680.00   103,405.00 105,680.00
G0096     Laparoscopic gastric banding, excluding band cost                                     11,586.00    11,337.00 11,586.00
G0100     Additional charge for DRG in multiple trauma, admission from ER                       10,965.00    10,729.00 10,965.00
G0101     ORIF/CRIF of pelvis, closed/open fracture                                             57,212.00    55,980.00 57,212.00
G0102     Arthroplasty with prosthetic replacement/implant of radial head, excluding
                                                                                                33,445.00    32,725.00    33,445.00
          open fracture
G0103
          Arthroplasty with prosthetic replacement/implant of radial head, open fracture        55,015.00    53,831.00    55,015.00
G0104     ORIF of foot, closed fracture, excluding calcaneus                                    36,156.00    35,378.00    36,156.00
G0105     ORIF of foot, open fracture, excluding calcaneus                                      55,015.00    53,831.00    55,015.00
G0106     ORIF of calcaneus/operation on femur, excluding neck, closed fracture                 29,048.00    28,423.00    29,048.00
G0107     ORIF of calcaneus/operation on femur, excluding neck, open fracture                   45,496.00    44,517.00    45,496.00
G0108     Operation on clavicle/humerus/forearm, closed fracture, including closed
          dislocation of acromioclavicular joint, excluding distal humerus and shaft of         24,882.00    24,346.00    24,882.00
          radius/ulna, including bone graft
Service
 code                                   Service name                                  Price A     Price B     Price C
G0109 Operation on clavicle/humerus/forearm, open fracture, including open
      dislocation of acromioclavicular joint, excluding distal humerus and shaft of   37,051.00   36,253.00   37,051.00
      radius/ulna, including bone graft
G0110 ORIF/CRIF/EF of tibia and/or fibula, closed fracture                            33,548.00   32,826.00   33,548.00
G0111 ORIF/CRIF/EF of tibia and/or fibula, open fracture, including use of bone
                                                                                      57,752.00   56,509.00   57,752.00
      marrow aspiration concentrate
G0112 ORIF of patella/ankle / CRIF of calcaneus, closed fracture                      20,376.00   19,937.00   20,376.00
G0113 ORIF of patella/ankle / CRIF of calcaneus, open fracture                        33,763.00   33,036.00   33,763.00
G0114 CRIF of ankle/foot, closed fracture, excluding calcaneus                        11,433.00   11,187.00   11,433.00
G0115 CRIF of ankle/foot, open fracture, excluding calcaneus                          21,516.00   21,053.00   21,516.00
G0116 Exploration of tendon/nerve of upper limb, including ganglion
                                                                                       7,155.00    7,001.00    7,155.00
      decompression/lysis of adhesions
G0117 Suture of extensor tendons of hand                                              12,074.00   11,814.00   12,074.00
G0118
      Suture of tendons/nerves of upper limb, excluding extensor tendons of hand      20,670.00   20,225.00   20,670.00
G0120 ORIF/EF of phalange of hand, closed fracture, including bone graft              12,330.00   12,065.00   12,330.00
G0121 ORIF/EF of phalange of hand, open/complex fracture                              18,264.00   17,871.00   18,264.00
G0122 ORIF/EF of phalange of hand, with suture of tendons/nerves, closed/open
                                                                                      27,579.00   26,985.00   27,579.00
      fracture
G0123 ORIF/EF of phalanges of hand, closed fractures, including bone graft            17,935.00   17,549.00   17,935.00
G0124 ORIF/EF of phalanges of hand, open/complex fractures                            24,324.00   23,800.00   24,324.00
G0125 ORIF/EF of phalanges of hand, with suture of tendons/nerves, closed/open
                                                                                      33,639.00   32,915.00   33,639.00
      fractures
G0126 ORIF/EF of metacarpal, closed fracture, including bone graft                    13,581.00   13,289.00   13,581.00
G0127 ORIF/EF of metacarpal, open/complex fracture                                    19,617.00   19,195.00   19,617.00
G0128
      ORIF/EF of metacarpal, with suture of tendons/nerves, closed/open fracture      28,931.00   28,308.00   28,931.00
G0129 ORIF/EF of metacarpals, closed fractures, including bone graft                  21,117.00   20,662.00   21,117.00
G0130 ORIF/EF of metacarpals, open/complex fractures                                  27,763.00   27,165.00   27,763.00
G0131
      ORIF/EF of metacarpals, with suture of tendons/nerves, closed/open fractures    37,078.00   36,280.00   37,078.00
G0132 ORIF of carpal(s), closed fracture, including bone graft                        17,972.00   17,585.00   17,972.00
G0133 ORIF of carpal(s), open/complex fracture, including bone graft                  24,362.00   23,838.00   24,362.00
G0134 ORIF of carpal(s), with suture of tendons/nerves, closed/open fracture,
                                                                                      33,678.00   32,953.00   33,678.00
      including bone graft
G0135 CRIF of hand, with suture of tendons/nerves, closed/open fracture(s)            30,831.00   30,167.00   30,831.00
G0136 Open reduction of closed dislocation of wrist                                   21,117.00   20,662.00   21,117.00
G0137 Open reduction of open/complex dislocation of wrist                             27,763.00   27,165.00   27,763.00
G0138 Open reduction of dislocation of wrist, with suture of tendons/nerves           37,078.00   36,280.00   37,078.00
G0139 Reattachment of any part of upper extremity                                     63,061.00   61,704.00   63,061.00
G0140 Open/close reduction of fracture(s) of zygoma/maxilla/mandible, including
                                                                                      21,558.00   21,094.00   21,558.00
      internal fixation
G0141
      Open reduction of fractures of orbit/ Le Fort type 2 or 3 / TMJ fracture with
                                                                                      33,479.00   32,758.00   33,479.00
      dislocation, with insertion of synthetic implant/bone graft to facial bone
G0142 Open reduction of comminuted fractures of facial bones, with insertion of
                                                                                      95,485.00   93,430.00   95,485.00
      synthetic implant/bone graft
G0144 ORIF of distal humerus, closed fracture, including bone graft                   33,445.00   32,725.00   33,445.00
G0145 ORIF of distal humerus, open fracture                                           55,015.00   53,831.00   55,015.00
G0146 ORIF/EF of shaft of radius/ulna, closed fracture, including bone graft          18,847.00   18,441.00   18,847.00
G0147 ORIF/EF of shaft of radius/ulna, open fracture                                  33,763.00   33,036.00   33,763.00
G0148
      CRIF of distal humerus/forearm/hand, closed fracture, including bone graft      10,578.00   10,350.00   10,578.00
G0149 CRIF of distal humerus/forearm/hand, open fracture, including complex
                                                                                      21,516.00   21,053.00   21,516.00
      fracture(s) of hand
G0150 Removal of gastric band                                                         11,586.00   11,337.00   11,586.00
G0151 Sleeve gastrectomy                                                              40,017.00   39,156.00   40,017.00
G0152 Sleeve gastrectomy with removal of gastric band                                 41,062.00   40,178.00   41,062.00
G0153 Sleeve gastrectomy with repair of diaphragmatic hernia                          41,062.00   40,178.00   41,062.00
Service
 code                                      Service name                                     Price A      Price B      Price C
G0154     Sleeve gastrectomy with total cholecystectomy                                      42,336.00    41,425.00   42,336.00
G0155     Gastric bypass surgery with removal of gastric band                                50,418.00    49,333.00   50,418.00
G0156     Gastric bypass surgery with repair of diaphragmatic hernia                         50,418.00    49,333.00   50,418.00
G0157     Gastric bypass surgery with total cholecystectomy                                  51,607.00    50,496.00   51,607.00
G0158     Laparoscopic ovarian tissue retrieval                                               6,238.00     6,104.00    6,238.00
G0160     Implantation/replacement/removal of cochlear prosthetic device, excluding
                                                                                             13,999.00    13,698.00   13,999.00
          device cost
G0161     Repair of cystocele with graft/prosthesis                                          10,174.00     9,955.00   10,174.00
G0162     Repair of rectocele with graft/prosthesis                                          10,174.00     9,955.00   10,174.00
G0163     Repair of cystocele and rectocele with graft/prosthesis                            16,563.00    16,206.00   16,563.00
G0164     Repair of cystocele with graft/prosthesis and tension free vaging tape for
                                                                                             15,086.00    14,761.00   15,086.00
          incontinence
G0165     Repair of rectocele with graft/prosthesis and tension free vaging tape for
                                                                                             15,086.00    14,761.00   15,086.00
          incontinence
G0166     Repair of cystocele and rectocele with graft/prosthesis and tension free vaging
                                                                                             21,474.00    21,012.00   21,474.00
          tape for incontinence
G0167
          Percutaneous insertion of left atrial appendage device, excluding device cost      11,574.00    11,325.00   11,574.00
G0168 Implantation of diaphragmatic pacemaker, excluding device cost                         14,952.00    14,630.00   14,952.00
G0169 Intrathecal pump system for spasticity treatment (Baclofen) preimplantation
                                                                                             12,447.00    12,179.00   12,447.00
      assessment
G0175 Open cholecystectomy, partial/complete                                                 15,182.00    14,855.00 15,182.00
G0176 Laparoscopic cholecystectomy, partial/complete                                         15,182.00    14,855.00 15,182.00
G00A1 Transcatheter placement of an intravascular stent graft, thoracic aorta               158,904.00   155,483.00 158,904.00
G00A2 Hyperbaric chamber treatment of patients injured in diving accidents, up to 8
                                                                                             31,549.00    30,870.00   31,549.00
      hours
G00A3 Hyperbaric chamber treatment of patients injured in diving accidents, over 8
                                                                                             42,793.00    41,872.00   42,793.00
      hours, and/or using a mixture of gases eg, Heliox
G00A4 Spermatic veins embolization                                                            6,656.00     6,513.00    6,656.00
G00A5
      Chemotherapy administration, inpatients, in addition to inpatient day charge            2,633.00     2,576.00    2,633.00
G00A6 Open/closed reduction with internal fixation of fracture of neck of femur or
                                                                                             24,354.00    23,830.00   24,354.00
      internal fixation only of fracture of neck of femur
G00A8 Insertion of biventricular cardiac pacemaker                                           49,112.00    48,055.00   49,112.00
G00A9 Insertion of cardiac pacemaker/defibrillator, excluding machine cost
G00B1 Repair of cleft lip                                                                    17,453.00    17,077.00   17,453.00
G00B2 Correction of cleft palate (including Push-Back palatoplasty)                          17,453.00    17,077.00   17,453.00
G00B3 Revision of cleft palate repair, velopharyngoplasty                                    17,453.00    17,077.00   17,453.00
G00B4 Repair of cleft lip & limited rhinoplasty, for cleft palate                            17,453.00    17,077.00   17,453.00
G00B5 Closure of fistulae of mouth, for cleft palate                                         11,828.00    11,573.00   11,828.00
G00B6 Bone graft to facial bone, for cleft palate                                            20,730.00    20,284.00   20,730.00
G00B7
      Bone distraction osteogenesis jaw without internal device, for cleft palate            17,453.00    17,077.00   17,453.00
G00B8     Orthognatic surgery, for cleft palate                                              34,572.00    33,828.00   34,572.00
G00C1     Fallopian tube catheterization, diagnostic or therapeutic                           3,575.00     3,498.00    3,575.00
G00C2     Radiofrequency ablation of liver lesion(s) (tumor or metastases)                   13,339.00    13,052.00   13,339.00
G00C3     Esophageal dilation and insertion of stent                                         15,155.00    14,829.00   15,155.00
G00C4     Minimally invasive radioguided parathyroidectomy (MIRP)                             5,618.00     5,497.00    5,618.00
G00C5     Local excision of lesion or tissue of bone (i.e. osteoid osteoma), using CT
                                                                                              8,291.00     8,113.00    8,291.00
          guidance
G00C6     Intra-amniotic injection for late abortion                                          3,001.00     2,936.00    3,001.00
G00C7     Arthroplasty with prosthetic replacement or implant of total or partial wrist
                                                                                             11,166.00    10,926.00   11,166.00
          (distal radius, carpocarpal or carpometacarpal joints)
G00C8     Arthroplasty with prosthetic replacement or implant of foot or toe joint           19,353.00    18,936.00   19,353.00
G00D1     Implantation or replacement of artificial urinary sphincter                        43,858.00    42,914.00   43,858.00
G00D2     Insertion of skin tissue expander(s), excluding breast                             18,624.00    18,223.00   18,624.00
G00D3
          Closed (percutaneous) biopsy of brain, stereotactic method including burr holes    14,022.00    13,720.00   14,022.00
G00D4 Orthopedic oncologic surgery, excision of soft tissues                                 58,453.00    57,195.00   58,453.00
Service
 code                                       Service name                                    Price A      Price B      Price C
G00D5     Orthopedic oncologic surgery, revision of an artificial joint or implant          186,036.00   182,031.00 186,036.00
G00D6     Orthopedic oncologic surgery, complex amputation or disarticulation                67,297.00    65,848.00 67,297.00
G00D7     Orthopedic oncologic surgery, destructive and reconstructive surgery              166,554.00   162,969.00 166,554.00
G00D8     Thoracic surgery                                                                   36,099.00    35,322.00 36,099.00
G00D9     Implantation or replacement of intracranial neurostimulator                       126,504.00   123,781.00 126,504.00
G00E1     Intra-arterial administration of chemotherapy or chemoembolization, under
                                                                                             11,502.00    11,254.00   11,502.00
          angiography
G00E2
          Arthroscopy, diagnostic and/or surgical procedures, without using implants          6,579.00     6,437.00    6,579.00
G00E3
          Arthroscopy, complex and/or high skill surgical procedures, using implants         13,157.00    12,874.00   13,157.00
G00E4 Arthroscopy, complex, unusual surgical procedures, including cartilage
                                                                                             26,315.00    25,749.00   26,315.00
      transplantation
G00E5
      Insertion (initial or replacement) of single or dual chamber cardiac pacemaker         24,704.00    24,172.00   24,704.00
G00E6 Radical trachelectomy and lymphadenectomy                                              15,335.00    15,005.00   15,335.00
G00E7 Brachytherapy for ocular tumors                                                        27,412.00    26,822.00   27,412.00
G00E8
      Implantation of vagus (vagal) nerve stimulator (VNS) ("pacemaker") for epilepsy       134,525.00   131,629.00 134,525.00
G00E9     Video and radio-telemetered electroencephalographic monitoring                     42,290.00    41,380.00   42,290.00
G00F1     Creation of arteriovenous fistula for renal dialysis, native or using graft        11,515.00    11,267.00   11,515.00
G00F2     Laparoscopic gastric bypass                                                        49,374.00    48,311.00   49,374.00
G00F3     Thoracic sympathectomy                                                              8,175.00     7,999.00    8,175.00
G00F4     Thyroidectomy, complete/partial                                                    14,803.00    14,484.00   14,803.00
G00F5     Gastrectomy, total/partial                                                         50,412.00    49,327.00   50,412.00
G00F6     Laparoscopic appendectomy                                                          16,132.00    15,785.00   16,132.00
G00F7     Whipple operation (radical pancreatic duodenectomy or radical subtotal
                                                                                             87,718.00    85,830.00   87,718.00
          pancreatectomy)
G00F8     Vertebroplasty                                                                      8,773.00     8,584.00    8,773.00
G00F9     Wada test                                                                           9,578.00     9,372.00    9,578.00
G00G1     Catheterization, insertion of umbrella like device for repair of cardial septal
                                                                                             70,814.00    69,290.00   70,814.00
          defects or patent ductus arteriosus (PDA)
G00G2     Kyphoplasty                                                                        41,588.00    40,693.00   41,588.00
G00G3     Mastectomy, partial (eg, lumpectomy), excludes biopsy of breast                     7,675.00     7,510.00    7,675.00
G00G4     Brachytherapy, prostate cancer treatment                                           37,281.00    36,478.00   37,281.00
G00G5
          Therapeutic catheterization of AV shunt for renal dialysis, native/with graft      19,358.00    18,941.00   19,358.00
G00G6     Extracorporeal shockwave lithotripsy, salivary stones                               4,451.00     4,355.00    4,451.00
G00G7     Deflux injection, vesicoureteral reflux therapy, unilateral                         6,381.00     6,244.00    6,381.00
G00G8     Deflux injection, vesicoureteral reflux therapy, bilateral                         11,274.00    11,031.00   11,274.00
G00G9     Extracorporeal shockwave lithotripsy, kidney; simple                                5,806.00     5,681.00    5,806.00
G00H2     Inpatient, per day, up to 3 days in acute care hospital, excluding departments
                                                                                              2,588.00     2,463.00    2,517.00
          with specific code
G00H4     Inpatient, per day, for fourth day or longer in acute care hospital, excluding
                                                                                              2,252.00     2,143.00    2,190.00
          departments with specific code
G00H5     Inpatient, per day, Dermatology and Venereology Department in acute care
                                                                                              2,252.00     2,143.00    2,190.00
          hospital
G00H6     Inpatient, per day, Ophthalmology and Pediatric Ophthalmology Departments
                                                                                              2,252.00     2,143.00    2,190.00
          in acute care hospital
G00H7     Inpatient, per day, Rehabilitation Department in acute care hospital                2,252.00     2,143.00    2,190.00
G00J3
          Inpatient day, tariff D: Department of Internal Medicine in general hospital        1,745.00     1,660.00    1,697.00
G00J4
          Inpatient day, tariff D: Department of Internal Medicine in general hospital        1,090.00     1,037.00    1,060.00
G00J5
          Inpatient day, tariff D: Department of Internal Medicine in general hospital         658.00       626.00       640.00
G00J7
          Inpatient day, tariff D: Department of Internal Medicine in general hospital         241.00       229.00       234.00
Service
 code                                     Service name                                       Price A      Price B      Price C
G00J8
          Inpatient day, tariff D: Department of Internal Medicine in general hospital          385.00       366.00       374.00
G00M1 Inpatient day, Department of Internal Medicine in acute care hospital                    1,833.00     1,744.00    1,782.00
G00M2 Inpatient day, Rheumatology Department in acute care hospital                            1,833.00     1,744.00    1,782.00
G00M3 Inpatient day, Department of Pulmonary Medicine in acute care hospital                   1,833.00     1,744.00    1,782.00
G00M4
      Inpatient day, Department of Geriatric Internal Medicine in acute care hospital          1,833.00     1,744.00    1,782.00
G00M5 Inpatient day, Gastroenterology Department in acute care hospital                        1,833.00     1,744.00    1,782.00
G00M6 Inpatient day, Observation Department in acute care hospital                             1,833.00     1,744.00    1,782.00
G00N1 Inpatient day, General Intensive Care Department in acute care hospital                  2,252.00     2,143.00    2,190.00
G00N3
      Inpatient day, Respiratory Intensive Care Department in acute care hospital              2,252.00     2,143.00    2,190.00
G00N5 Inpatient day, Pediatric Intensive Care Department in acute care hospital                2,252.00     2,143.00    2,190.00
G00N7
      Inpatient day, Neurosurgical Intensive Care Department in acute care hospital            2,252.00     2,143.00    2,190.00
G00N9 Additional inpatient day charge, up to 4, in Intensive Care Departments:
                                                                                               4,506.00     4,288.00    4,382.00
      General, Respirtory, Pediatric and Neurosurgical
G00P1 Inpatient day, Acute geriatric Department in acute care hospital                         1,364.00     1,298.00    1,327.00
G00P2 Inpatient day, Geriatric Rehabilitation Department in acute care hospital                1,364.00     1,298.00    1,327.00
G00P3
      Inpatient day, Department of high Dependency Nursing in acute care hospital              1,364.00     1,298.00    1,327.00
G00Q1 Acute inpatient day, psychiatric departments, all hospitals                               936.00       891.00       911.00
G00Q2 Long term inpatient day, psychiatric departments, all hospitals                           720.00       685.00       700.00
G00Q3
      Inpatient day, children and adolescents, psychiatric departments, all hospitals          1,124.00     1,070.00    1,094.00
G00Q7     Artificial liver therapy, eg, MARS, additional inpatient day charge                 23,167.00    22,668.00 23,167.00
G00Q8     Chronic artificial ventilation care, per day, all hospitals                          1,454.00     1,384.00   1,414.00
G00R1     Extracorporeal shockwave lithotripsy, kidney; complex                               18,230.00    17,838.00 18,230.00
G00R2     Closed percutaneous biopsy using CT guidance                                         4,385.00     4,291.00   4,385.00
G00R3     Closed percutaneous biopsy using MRI guidance                                        6,579.00     6,437.00   6,579.00
G00R4     Continuous intra-arterial administration of chemotherapeutic substance              17,529.00    17,152.00 17,529.00
G00R5     Vertebral excision and fusion                                                      166,554.00   162,969.00 166,554.00
G00R6     Vertebral refusion                                                                 186,036.00   182,031.00 186,036.00
G00R7     Secondary insertion of intraocular lens prosthesis                                   3,077.00     3,011.00   3,077.00
G00R8     Single suture loop pupilloplasty                                                     4,920.00     4,814.00   4,920.00
G00R9     Removal of vitreous                                                                 13,329.00    13,042.00 13,329.00
G00S1     Bronchoscopy, rigid or flexible, with placement of bronchial stent(s) (including
                                                                                              11,333.00    11,089.00   11,333.00
          tracheal/bronchial dilation as required)
G00S2     Partial/primary hip/shoulder replacement                                            38,377.00    37,551.00 38,377.00
G00S3     Total joint replacement and/or revision                                             42,298.00    41,387.00 42,298.00
G00S4     Radical neck lymph nodes dissection, unilateral/bilateral                           24,264.00    23,742.00 24,264.00
G00S5     Lobectomy of liver                                                                  71,836.00    70,290.00 71,836.00
G00S6     Partial hepatectomy                                                                 40,209.00    39,343.00 40,209.00
G00S7     Maxillectomy, total/partial, for insertion of surgical obturator                    34,554.00    33,810.00 34,554.00
G00S8     Stereotactic radiosurgery, brain                                                    43,046.00    42,119.00 43,046.00
G00S9     Implantation of heart assist system                                                495,125.00   484,467.00 495,125.00
G00T1     Bone Anchored Hearing Aid (BAHA), adult                                             44,567.00    43,608.00 44,567.00
G00T2     Bone Anchored Hearing Aid (BAHA), child                                             48,000.00    46,967.00 48,000.00
G00T3     Isolated limb perfusion in patient with melanoma                                    93,617.00    91,602.00 93,617.00
G00T4     Colonoscopy, with dilation and stent placement                                      15,155.00    14,829.00 15,155.00
G00T5     Removal of heart pacemaker lead(s) (electrodes) without replacement                 30,602.00    29,943.00 30,602.00
G00T6     Removal of heart pacemaker lead(s) (electrodes) with replacement of electrodes
                                                                                              42,956.00    42,031.00   42,956.00
          and pacemaker device
G00T7     Scoliosis/kyphosis repair operation                                                107,361.00   105,050.00 107,361.00
G00T8     Emergency coronary artery catheterization for removal of obstruction,
                                                                                              47,477.00    46,455.00   47,477.00
          including insertion of drug eluting stent(s)
G00T9     Radical hysterectomy, abdominal/vaginal                                             21,929.00    21,457.00   21,929.00
G00U1     Colorectal surgery                                                                  43,945.00    42,999.00   43,945.00
Service
 code                                     Service name                                     Price A      Price B      Price C
G00U2 Surgical fistulization of lacrimal tract to nasal cavity using balloon dilatation,
                                                                                             6,391.00     6,253.00    6,391.00
      including dacryocystorhinostomy
G00U3 Intravenous injection of tPA, acute cerebrovascular stroke within 3 hours of
                                                                                            38,377.00    37,551.00   38,377.00
      stroke symptoms
G00U4 Therapeutic catheterization, acute cerebrovascular stroke within 8 hours of
                                                                                            98,683.00    96,559.00   98,683.00
      stroke symptoms
G00U5 Functional endoscopic nasal/sinus surgery (FESS), simple                              13,157.00    12,874.00   13,157.00
G00U6 Functional endoscopic nasal/sinus surgery (FESS), complex                             31,570.00    30,890.00   31,570.00
G00U7 Tonsillectomy without/with adenoidectomy                                               3,617.00     3,539.00    3,617.00
G00U8
      Implantation of intrathecal pump system for spasticity treatment, Baclofen            72,740.00    71,174.00   72,740.00
G00U9 Enucleation of eyeball                                                                13,192.00    12,908.00 13,192.00
G00V1 Implantation of vertical expandable prosthetic titanium rib system                   148,592.00   145,393.00 148,592.00
G00V2 Lengthening and adjustment of vertical expandable prosthetic titanium rib
                                                                                            21,356.00    20,896.00   21,356.00
      system
G00V3
      Replacement of vertical expandable prosthetic titanium rib system implants            47,801.00    46,772.00   47,801.00
G00V4     Percutaneous pulmonary valve replacement                                          36,067.00    35,291.00   36,067.00
G00V5     Percutaneous aortic valve replacement                                             41,054.00    40,170.00   41,054.00
G00V6     Repair of inguinal/femoral hernia, unilateral, inpatient                           9,459.00     9,255.00    9,459.00
G00V7     Repair of inguinal/femoral hernia, bilateral, inpatient                           12,609.00    12,338.00   12,609.00
G00V8     Plastic surgery following significant weight loss                                 30,053.00    29,406.00   30,053.00
G00W1     Scleral buckling with implant                                                      9,428.00     9,225.00    9,428.00
G00W2     Trabeculectomy                                                                     4,563.00     4,465.00    4,563.00
G00W3     Intraocular valve implantation, eg, Ahmed, for glaucoma therapy                   12,484.00    12,215.00   12,484.00
G00W4     Repair of blepharoptosis, under 18 years                                           7,281.00     7,124.00    7,281.00
G00W5     Repair of blepharoptosis, 18 years and older                                       4,512.00     4,415.00    4,512.00
h price list for ambulatory and hospitalization services
          Onset date: 01/05/11
        Sorted by service code



                                                           Price for
                                                            patient
                                                             from
                                                           abroad
                                                              632.00

                                                             1,620.00
                                                              516.00
                                                              248.00
                                                              396.00
                                                              788.00
                                                             2,369.00
                                                               221.00
                                                               186.00
                                                               479.00
                                                               248.00
                                                            11,265.00
                                                               248.00
                                                               248.00
                                                               591.00
                                                             2,828.00
                                                                 0.00
                                                             1,404.00
                                                             3,947.00
                                                               320.00
                                                               176.00
                                                              320.00


                                                              320.00


                                                              320.00
                                                             5,202.00
                                                               320.00
                                                               723.00
                                                               411.00
                                                               248.00
                                                               176.00
                                                               176.00
                                                               248.00
                                                               176.00
                                                               146.00
                                                                 0.00
                                                             9,656.00
                                                              320.00
                                                              182.00
                                                                0.00
                                                              320.00
                                                               182.00
                                                               120.00
                                                               200.00
                                                             1,839.00
Price for
 patient
  from
abroad
 16,634.00
    320.00
    677.00
    146.00
  4,637.00
  3,738.00
 12,210.00
  9,818.00
   456.00
    248.00
    515.00
    515.00
    248.00
    228.00
  1,046.00
    765.00
  9,939.00
    320.00
      0.00
    374.00
  4,593.00
 22,244.00
  1,547.00
 12,693.00
  1,866.00
  4,983.00
  8,465.00
    374.00
  3,045.00
  1,676.00
  3,456.00
   275.00
   891.00
  1,392.00
  2,855.00
 22,244.00
    423.00
  2,688.00
    146.00
    113.00
  8,216.00
  7,547.00
  3,554.00
  2,121.00
  8,522.00
  3,554.00
    176.00
    182.00
    455.00
    677.00
    320.00
  2,220.00
    677.00
Price for
 patient
  from
abroad
    677.00
    662.00
  1,722.00
    662.00
  6,009.00
    122.00
    873.00
    374.00
  2,376.00
  8,334.00
    171.00
    176.00
  3,542.00
    374.00
    176.00
    176.00
    240.00
    725.00
  5,247.00
    662.00
  1,209.00
  7,751.00
  5,295.00
    327.00
  3,725.00
  1,481.00
    953.00
    447.00
  3,542.00
    248.00
    902.00
    902.00
    632.00
    632.00
 91,046.00
    311.00
    182.00
    320.00
    342.00
      0.00
  7,094.00
  9,290.00
  2,403.00
  6,138.00
  1,685.00
  4,544.00
   320.00
     0.00
   182.00
   320.00
  1,940.00
   390.00
   324.00
   176.00
   240.00
Price for
 patient
  from
abroad
    233.00
    230.00
    320.00
    161.00
    411.00
  2,898.00
    516.00
    485.00
  2,898.00
  2,898.00
    147.00
    455.00
    224.00
    240.00
  2,783.00
    233.00
    161.00
    161.00
    161.00
    161.00
  2,898.00
  2,898.00
  2,898.00
    180.00
    240.00
  1,842.00
    189.00
    189.00
    176.00
    411.00
    161.00
    161.00
    411.00
    161.00
    161.00
    161.00
    411.00
    161.00
    161.00
  2,783.00
    161.00
    161.00
    411.00
    411.00
    161.00
    161.00
    176.00
    411.00
    161.00
    161.00
    161.00
    411.00
    161.00
  2,783.00
    230.00
  2,898.00
    569.00
    908.00
    953.00
Price for
 patient
  from
abroad
  1,179.00
    569.00
    677.00
  1,088.00
    566.00
  7,572.00
    839.00
    689.00
   534.00
    668.00
    695.00
  7,667.00
  7,667.00
  2,679.00
    902.00
    146.00
  6,810.00
    176.00
  7,667.00
    224.00
   125.00
    449.00
    771.00
    312.00
    449.00
  1,154.00
    473.00
   312.00
    632.00
  1,320.00
  1,634.00
    368.00
  1,283.00
    236.00
    771.00
  1,119.00
  3,552.00
  3,552.00
  6,437.00
  9,656.00
  6,434.00


   977.00

  1,265.00
    315.00
  2,898.00
    452.00
    282.00
    735.00
  2,928.00
  3,663.00
    643.00
    368.00
    627.00
Price for
 patient
  from
abroad
  1,257.00
    818.00
  3,789.00
  1,889.00
 12,242.00
  3,536.00
  2,345.00
  4,002.00
  1,271.00
  3,500.00
  1,104.00
    977.00
  1,038.00
  2,882.00
  1,202.00
  1,244.00
    939.00
  3,729.00
    897.00
  1,230.00
  3,636.00
  1,802.00
  2,546.00
  1,518.00
    950.00
  3,062.00
  1,071.00
    437.00
  1,001.00
  1,307.00
  1,724.00
  4,191.00
  4,750.00
  3,119.00
  3,699.00
  4,292.00
  1,967.00
  4,656.00
  5,807.00
  6,071.00
  1,938.00
    942.00
  1,122.00
  1,799.00
  2,160.00
  2,250.00
  3,317.00
  1,563.00
  2,105.00
  4,025.00
  1,454.00
  6,039.00
  1,241.00
  3,584.00
  1,509.00
  3,632.00
  1,856.00
Price for
 patient
  from
abroad
  2,105.00
  1,431.00
  1,706.00
  1,835.00
  1,604.00
    932.00
  5,690.00
  4,958.00
  5,558.00
  4,430.00
  4,958.00
  5,664.00
 10,482.00
  2,648.00
  2,250.00
  7,266.00
     78.00
     62.00
     84.00
    170.00
    248.00
    120.00
    182.00
    408.00
    248.00
    633.00
   188.00
    54.00
    24.00
   113.00
   695.00
   840.00
   995.00
    21.00
    21.00
   120.00
   248.00
   324.00
   374.00
    45.00
   155.00
   444.00
   428.00
   243.00
    44.00
   266.00
   534.00
   182.00
   176.00
   248.00
   372.00
   375.00
    21.00
    21.00
   353.00
   113.00
   156.00
Price for
 patient
  from
abroad
    156.00
    324.00
     21.00
     42.00
  1,319.00
    146.00
     45.00
    176.00
    771.00
    248.00
     42.00
     42.00
     42.00
     21.00
    113.00
    182.00
    182.00
     98.00
     54.00
    113.00
     21.00
    356.00
     26.00
     54.00
     77.00
    363.00
    182.00
    200.00
     72.00
     84.00
     84.00
    633.00
    248.00
     84.00
    534.00
    374.00
    363.00
    176.00
    566.00
  1,203.00
     41.00
    587.00
    180.00
    374.00
  1,056.00
    363.00
    566.00
    893.00
    182.00
    228.00
    324.00
    113.00
     21.00
    248.00
    534.00
    363.00
     41.00
    534.00
     41.00
Price for
 patient
  from
abroad
    81.00
    84.00
   411.00
    62.00
   248.00
    150.00
     56.00
    534.00
    311.00
    320.00
    320.00
    335.00
    410.00
    194.00
     84.00
     54.00
    248.00
    363.00
  2,013.00
    131.00
     21.00
    534.00
    120.00
    677.00
     44.00
     35.00
     42.00
     42.00
     21.00
    248.00
    389.00
   390.00
    336.00
  1,713.00
  4,164.00
    786.00
    113.00
    113.00
    449.00
    306.00
    113.00
    248.00
    176.00
     21.00
    534.00
     21.00
     21.00
    314.00
    176.00
    281.00
     21.00
    363.00
    534.00
     84.00
    126.00
     54.00
    113.00
Price for
 patient
  from
abroad
    21.00
    21.00
   120.00
   380.00
    54.00
   836.00
   324.00
   194.00
    21.00
   182.00
   389.00
   176.00
    84.00
   461.00
    48.00
    48.00
   248.00
    41.00
    41.00
   159.00
    21.00
    99.00
    99.00
   206.00
   311.00
    21.00
    54.00
    21.00
    54.00
   248.00
   633.00
   176.00
   182.00
   176.00
   120.00
   105.00
    51.00
   248.00
    35.00
   146.00
    84.00
    93.00
   146.00
   279.00
   363.00
   279.00
   359.00
   839.00
   405.00
   279.00
   279.00
   677.00
   363.00
   399.00
   495.00
   411.00
   677.00
   120.00
   534.00
Price for
 patient
  from
abroad
    248.00
    320.00
    363.00
    633.00
    363.00
    566.00
    695.00
     50.00
    248.00
     24.00
    113.00
     56.00
    363.00
    146.00
    311.00
    641.00
    327.00
    182.00
     65.00
     84.00
  1,710.00
    146.00
    146.00
    984.00
    224.00
  1,097.00
   149.00
    126.00
     62.00
    128.00
     54.00
    386.00
    113.00
    296.00
    353.00
    149.00
  2,900.00
  2,085.00
    821.00
  2,570.00
    350.00
    419.00
    176.00
    374.00
    146.00
     80.00
    146.00
    494.00
    300.00
    248.00
     62.00
    128.00
      0.00
     77.00
     81.00
     41.00
    104.00
    108.00
Price for
 patient
  from
abroad
    132.00
    224.00
    311.00
    150.00
     93.00
    483.00
    248.00
    374.00
     45.00
    398.00
  2,034.00
  2,633.00
  2,633.00
    182.00
    119.00
    146.00
    516.00
  1,022.00
  1,554.00
    534.00
    534.00
    111.00
    146.00
    111.00
    146.00
    297.00
    168.00
    146.00
    224.00
    455.00
    485.00
    246.00
    146.00
    113.00
    146.00
    332.00
    113.00
    146.00
   569.00
   182.00
   902.00
   221.00
   311.00
   126.00

   104.00
    515.00
    393.00
    695.00
  1,808.00
  1,808.00
    621.00
      0.00
  2,567.00
    536.00
    902.00
    182.00
Price for
 patient
  from
abroad
    152.00
    248.00
  1,559.00
  2,013.00
  1,958.00
  1,455.00
    248.00
    566.00
    248.00
  1,319.00
  1,319.00
  4,418.00
    176.00
    902.00
    993.00
  5,976.00
 12,875.00

   341.00
    207.00
    332.00
  5,694.00
  3,893.00
    695.00
      0.00
  1,257.00
    146.00
     51.00
    152.00
  1,548.00
    185.00
    179.00
    849.00
    551.00
  1,700.00
    768.00
  1,524.00
  1,524.00
    282.00
  1,524.00
    677.00
    146.00
    228.00
    182.00
    960.00
  1,325.00
  2,429.00
    290.00
    455.00
  1,053.00
    182.00
    534.00
    569.00
    455.00
    681.00
    146.00
Price for
 patient
  from
abroad
    204.00
    182.00
    177.00
    146.00
    282.00
    168.00
    677.00
     41.00
    248.00
    108.00
    240.00
    863.00
  1,175.00
    327.00
    248.00
  2,291.00

   746.00

  2,291.00

   746.00
    486.00
    176.00
     50.00
    258.00
    386.00
    686.00
    581.00
  2,201.00
  1,373.00
  4,221.00
    608.00
  1,133.00
    539.00
    507.00
    539.00
    224.00
    507.00
    692.00
    158.00
    189.00
  1,122.00
     78.00
    806.00
    404.00
    686.00
  1,343.00
    221.00
  1,700.00
     51.00
     92.00
    177.00
    404.00
    113.00
    228.00
  4,212.00
    176.00
Price for
 patient
  from
abroad
    423.00
    411.00
    222.00
    246.00
    500.00
  1,319.00
  1,487.00
    534.00
  1,154.00
    873.00
    953.00
    240.00
    320.00
    923.00
    735.00


   642.00


    182.00
    863.00
  2,597.00
  1,178.00

  4,961.00

  1,191.00
   180.00
   207.00
   281.00
   281.00
   273.00
   177.00
    51.00
   177.00

   821.00

    176.00
    248.00
    393.00
    566.00
  2,291.00
    839.00
  1,179.00
    176.00
    146.00
      0.00
  1,113.00
    321.00
  1,043.00
     99.00
   213.00
   677.00
   269.00
Price for
 patient
  from
abroad
    234.00
  2,550.00
  4,967.00
  4,967.00
  4,967.00

  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00

  4,967.00

  4,967.00

  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00

  4,967.00

  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00

  4,967.00

  4,967.00
Price for
 patient
  from
abroad
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00
  4,967.00

  4,967.00

  4,967.00

  4,967.00

  4,967.00
  4,967.00
  4,967.00
    464.00
     51.00
     51.00
    113.00
    411.00
    131.00
    189.00
    962.00
    324.00
    411.00
    554.00
    683.00
    597.00
  3,503.00
    320.00
    299.00
   597.00
  1,221.00
  1,221.00
  1,221.00
    491.00
  1,224.00

  1,529.00
  2,597.00
  1,529.00
  1,071.00
  1,052.00
    978.00
  1,350.00
    182.00
 10,247.00
  9,443.00
  1,094.00
  2,697.00
    846.00
    846.00
    323.00
Price for
 patient
  from
abroad
   323.00
   240.00
   161.00

   336.00
    765.00
  1,071.00
  1,071.00
   780.00

  1,071.00
    788.00
  1,046.00
    788.00
    765.00
  5,453.00

      0.00
  2,057.00
    228.00
  1,620.00
  1,835.00
   297.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
   593.00
    593.00
  1,682.00
    593.00
  1,682.00
    593.00
  1,682.00
Price for
 patient
  from
abroad
  1,682.00
  1,682.00
    593.00
  1,682.00
  1,682.00
  1,682.00
  1,682.00
  1,682.00
    762.00
  1,682.00
   593.00
  1,682.00
    593.00
  1,682.00
    593.00
  1,682.00
  1,682.00
  1,682.00
  1,682.00
   762.00
    593.00
  1,682.00
  3,822.00
    593.00
  3,822.00
    593.00
  1,682.00
  1,682.00
  1,682.00
  1,682.00
  3,822.00
    593.00
  1,682.00
    593.00
  5,715.00
    593.00
  1,682.00
  1,682.00
  3,822.00
  1,682.00
  1,682.00
    593.00
  1,682.00
  1,682.00
    593.00

    593.00
  1,395.00
    762.00
    593.00


   762.00

  1,395.00
   593.00
Price for
 patient
  from
abroad
    593.00
    593.00
  4,311.00
  1,208.00
    593.00
  8,420.00
    384.00
    762.00
  1,208.00
  1,395.00
  1,395.00
   593.00

   593.00

   593.00
  1,395.00
    593.00
  1,395.00
  1,395.00
  1,395.00
  6,773.00
    593.00
  1,524.00
    593.00
  6,773.00
    593.00
  1,242.00
    593.00
   593.00

   593.00

   593.00
   593.00
   593.00
   593.00

   593.00
    593.00
    593.00
    593.00
    593.00
    593.00
  4,311.00
  1,794.00

  1,794.00
    593.00
    593.00
    593.00
    593.00
    593.00
  1,208.00
Price for
 patient
  from
abroad
   593.00
    593.00
  1,208.00
    384.00
  4,311.00
    593.00
  5,715.00
    593.00
    762.00
    593.00
    593.00
    593.00
    593.00
    593.00
  4,311.00
    593.00
  5,715.00
  1,808.00
  1,808.00
  1,808.00
  1,808.00
    762.00
   714.00
    593.00
    704.00
  1,071.00
  1,071.00
  1,157.00
  4,319.00
    363.00
     17.00
    666.00
    666.00
  1,964.00
    105.00
      0.00
     57.00
  1,788.00
    410.00
    248.00
  1,002.00
    324.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
Price for
 patient
  from
abroad
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
     80.00
    363.00
    411.00
    146.00
 36,832.00
163,350.00
    320.00
    504.00
    230.00
    443.00
    122.00
      2.00
  8,193.00
  3,555.00
 12,462.00
   260.00

   503.00

   503.00

   734.00

   989.00
   320.00
   734.00
    902.00
  2,949.00
 10,461.00
    776.00
    405.00
  1,175.00
    113.00
    884.00
  6,459.00
  1,604.00
  1,604.00
  2,336.00
    113.00
 26,757.00
  1,271.00
    566.00
    849.00
  8,048.00
    323.00
    320.00
    320.00
  9,366.00
 16,547.00
Price for
 patient
  from
abroad
    323.00
    375.00
  1,511.00
    449.00
    216.00
    216.00
    185.00
    507.00
  1,482.00
  2,042.00
  1,337.00
  1,337.00
    686.00
    515.00
    551.00
    554.00
    599.00
    324.00
  1,337.00
    543.00
    152.00
    686.00
    378.00
    255.00
    543.00
    230.00
    320.00
    443.00
  2,652.00
    455.00
    534.00
    372.00
    249.00
    176.00
  1,710.00
    447.00
    806.00
  1,449.00
 14,438.00
  7,581.00
 20,757.00
  2,340.00
  1,920.00
  3,572.00
  3,662.00
  1,374.00
  5,802.00
  2,345.00
    390.00
  1,944.00

  1,944.00
  6,186.00
  4,484.00
    308.00
    795.00
    636.00
Price for
 patient
  from
abroad
    507.00
    452.00
  2,898.00
  5,792.00
    447.00
    182.00
    237.00
  1,995.00
  1,995.00
      0.00
      0.00
    111.00
    225.00
  6,533.00
    587.00
 19,311.00
   875.00
    62.00
  3,045.00
  1,085.00
 14,160.00
    581.00
    161.00
    176.00
    161.00
    161.00
    552.00

 16,016.00


   893.00
     93.00
  1,319.00
  3,347.00

  2,196.00
    578.00
  3,257.00
    455.00
  3,972.00
     33.00
     32.00
  1,502.00
 13,000.00

 56,331.00
    342.00
    237.00
  2,006.00
    245.00
  9,591.00
 12,506.00
    795.00
Price for
 patient
  from
abroad
   282.00
   374.00
  3,878.00
  1,734.00
  1,293.00
    110.00
  1,383.00
  1,392.00
    479.00
  2,067.00
    452.00
  4,128.00
  1,487.00
    677.00
    953.00
    593.00
   411.00
    372.00
    290.00
    867.00
  2,043.00
  3,748.00
    174.00
    174.00
    153.00
  3,609.00
  1,458.00
  4,008.00
  6,008.00
  5,811.00
  7,998.00
    221.00
    131.00
     51.00
     24.00
 12,875.00
  1,829.00

  2,376.00

  1,098.00

  1,427.00
    326.00
    326.00
  3,332.00
    174.00
    324.00
    161.00
    288.00
    741.00
    396.00
    410.00
    539.00
Price for
 patient
  from
abroad
    417.00
 16,901.00
 28,412.00
   431.00
   449.00
   449.00
   500.00
   332.00
   500.00
   278.00
   531.00
   108.00
  1,454.00
  9,770.00
 14,258.00
  3,635.00
 11,141.00
 13,682.00
  8,535.00
 54,717.00
    108.00
 13,464.00
  7,935.00
  1,050.00
  1,509.00
  1,521.00

   125.00
  3,305.00
  3,483.00
 12,147.00
  2,081.00
    866.00
  4,634.00
  6,972.00
 44,108.00
  2,472.00
  1,022.00

    206.00
  1,446.00
  7,673.00
  1,374.00
    194.00
    735.00
    680.00
    780.00
    845.00
  4,707.00
 26,043.00
  6,811.00
  5,311.00
  8,214.00
  6,767.00
    902.00
  8,214.00
Price for
 patient
  from
abroad
   902.00
  5,295.00
  2,088.00
  8,612.00
 13,668.00
    122.00
   840.00
 14,432.00
  2,036.00
    204.00
    152.00
    152.00
    447.00
  6,471.00
    714.00
   320.00
    714.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
 11,195.00
    215.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    402.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    534.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    321.00
    336.00
    144.00
    182.00
    182.00
Price for
 patient
  from
abroad
    350.00
    324.00
     44.00
    162.00
    200.00
    152.00
    435.00
  8,877.00
    350.00
     56.00
     81.00
     99.00
    110.00
  1,368.00
    149.00
  4,371.00
    324.00
    176.00
    108.00
     54.00
    882.00
      0.00
      0.00
    194.00
    822.00
    491.00
  1,014.00
    491.00
  1,388.00
  1,260.00
  1,710.00
  1,724.00
    500.00
   192.00
    254.00
    254.00
    281.00
    311.00
    222.00
    681.00
    551.00
  1,817.00
    612.00
    189.00
    237.00
    200.00
    200.00
    200.00
    359.00
  1,626.00
156,003.00
  3,542.00
  2,552.00
      0.00
    771.00
  1,059.00
Price for
 patient
  from
abroad
 35,157.00
 28,380.00
  4,926.00
  4,926.00
 30,009.00
 96,559.00
499,503.00
 91,602.00
 80,465.00
  7,094.00
  7,261.00
 22,220.00
 24,390.00
 42,702.00
 25,884.00
 21,457.00
 14,810.00
 10,017.00
 52,377.00
319,249.00
446,952.00
296,414.00
194,742.00
212,834.00
319,249.00
919,954.00
 18,238.00
  4,854.00
 59,399.00
 16,832.00
 69,290.00
 13,402.00
 31,408.00
 13,866.00
 10,401.00
  3,257.00
 25,845.00
 47,462.00
 37,666.00
180,965.00
103,405.00
 11,337.00
 10,729.00
 55,980.00
 32,725.00

 53,831.00
 35,378.00
 53,831.00
 28,423.00
 44,517.00

 24,346.00
Price for
 patient
  from
abroad

 36,253.00

 32,826.00
 56,509.00
 19,937.00
 33,036.00
 11,187.00
 21,053.00
  7,001.00
 11,814.00
 20,225.00
 12,065.00
 17,871.00
 26,985.00
 17,549.00
 23,800.00
 32,915.00
 13,289.00
 19,195.00
 28,308.00
 20,662.00
 27,165.00
 36,280.00
 17,585.00
 23,838.00
 32,953.00
 30,167.00
 20,662.00
 27,165.00
 36,280.00
 61,704.00
 21,094.00


 32,758.00


 93,430.00
 32,725.00
 53,831.00
 18,441.00
 33,036.00
 10,350.00

 21,053.00
 11,337.00
 39,156.00
 40,178.00
 40,178.00
Price for
 patient
  from
abroad
 41,425.00
 49,333.00
 49,333.00
 50,496.00
  6,104.00
 13,698.00
  9,955.00
  9,955.00
 16,206.00
 14,761.00

 14,761.00

 21,012.00

 11,325.00
 14,630.00
 12,179.00
 14,855.00
 14,855.00
155,483.00
 30,870.00

 41,872.00
  9,770.00
  3,864.00

 23,830.00
 48,055.00

 17,077.00
 17,077.00
 17,077.00
 17,077.00
 11,573.00
 20,284.00
 17,077.00
 33,828.00
  5,247.00
 13,052.00
 22,244.00
  5,497.00
  8,113.00
  2,936.00
 10,926.00
 18,936.00
 42,914.00
 18,223.00
 13,720.00
 57,195.00
Price for
 patient
  from
abroad
182,031.00
 65,848.00
162,969.00
 35,322.00
123,781.00
 11,254.00

  9,656.00

 19,311.00

 25,749.00

 24,172.00
 15,005.00
 26,822.00
131,629.00
 41,380.00
 16,901.00
 48,311.00
  7,999.00
 14,484.00
 49,327.00
 15,785.00
 85,830.00
  8,584.00
  9,372.00
 69,290.00
 40,693.00
  7,510.00
 54,717.00
 28,412.00
  6,533.00
  9,366.00
 16,547.00
  8,522.00
  4,926.00

  4,286.00

  4,286.00

  4,286.00
  4,286.00
  3,320.00

  2,074.00

  1,252.00

   458.00
Price for
 patient
  from
abroad
   732.00
  3,488.00
  3,488.00
  3,488.00
  3,488.00
  3,488.00
  3,488.00
  4,286.00
  4,286.00
  4,286.00
  4,286.00

  8,576.00
  2,596.00
  2,596.00
  2,596.00
  1,782.00
  1,370.00
  2,140.00
 34,002.00
  2,768.00
 26,757.00
  6,437.00
  9,656.00
 17,152.00
162,969.00
182,031.00
  3,011.00
  4,814.00
 13,042.00
 16,634.00
 37,551.00
 41,387.00
 23,742.00
 70,290.00
 39,343.00
 33,810.00
 42,119.00
484,467.00
 43,608.00
 46,967.00
 91,602.00
 22,244.00
 29,943.00
 42,031.00
105,050.00
 46,455.00
 21,457.00
 42,999.00
Price for
 patient
  from
abroad
  6,253.00

 37,551.00

 96,559.00
 12,874.00
 30,890.00
  3,539.00
 71,174.00
 12,908.00
145,393.00
 20,896.00

 46,772.00
 35,291.00
 40,170.00
  9,255.00
 12,338.00
 29,406.00
  9,225.00
  4,465.00
 12,215.00
  7,124.00
  4,415.00

				
DOCUMENT INFO