Rates and Fees

Burn Unit

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
BURN UNIT	ROOM RATE/DAY (BURN)	–	–	2,500.00	2,500.00	2,500.00

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Cendu

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
CENDU	BRONCHOSCOPY	1,970.00	8,310.00	8,730.00	9,140.00	10,520.00
CENDU	CHOLEDOCHOSCOPY (DIAGNOSTIC)	1,400.00	3,500.00	3,950.00	4,380.00	4,590.00
CENDU	CHOLEDOCHOSCOPY (THERAPEUTIC)	1,970.00	6,440.00	7,080.00	7,410.00	7,730.00
CENDU	COLONOSCOPY (DIAGNOSTIC)	1,400.00	4,410.00	4,850.00	5,070.00	5,300.00
CENDU	COLONOSCOPY (THERAPEUTIC)	2,510.00	6,710.00	7,380.00	7,710.00	8,050.00
CENDU	ENDOSCOPIC RETROGADE CHOLANGIOPANCREATOGRAPHY	3,260.00	6,650.00	7,320.00	7,650.00	7,820.00
CENDU	ENDOSCOPIC ULTRASOUND (DIAGNOSTIC)	6,240.00	15,080.00	18,970.00	21,110.00	23,270.00
CENDU	ENDOSCOPIC ULTRASOUND (THERAPEUTIC)	8,460.00	15,080.00	18,970.00	21,110.00	23,270.00
CENDU	GASTROSCOPY (DIAGNOSTIC)	1,400.00	3,490.00	3,950.00	4,380.00	4,590.00
CENDU	GASTROSCOPY (THERAPEUTIC)	2,510.00	4,690.00	5,160.00	5,390.00	5,620.00
CENDU	POLYPECTOMY	770.00	0.00	3,025.00	3,375.00	3,490.00
CENDU	PROCTOSIGMOIDOSCOPY	250.00	0.00	780.00	875.00	875.00

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Cenicu

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
CENTRAL INTENSIVE CARE UNIT (CENICU)	ROOM RATE/DAY (CENICU)	–	2,500.00	2,500.00	2,500.00	2,500.00

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Dentistry

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
DENTISTRY	ALVEOLECTOMY	80	210	210	210	210
DENTISTRY	ALVEOLOPLASTY	80	210	210	210	210
DENTISTRY	APICOECTOMY	65	165	165	165	165
DENTISTRY	CURETTAGE	75	202	202	202	202
DENTISTRY	CYSTECTOMY	75	202	202	202	202
DENTISTRY	FRENECTOMY	75	202	202	202	202
DENTISTRY	GINGIVECTOMY	65	165	165	165	165
DENTISTRY	HARD TISSUE REMOVAL	75	202	202	202	202
DENTISTRY	IDW-MMF	95	247	247	247	247
DENTISTRY	INCISION & DRAINAGE	75	202	202	202	202
DENTISTRY	ODONTECTOMY	65	165	165	165	165
DENTISTRY	OPERCULECTOMY	60	142	142	142	142
DENTISTRY	ORO-ANTRAL MANAGEMENT	75	202	202	202	202
DENTISTRY	PERIO THERAPY (PREVENTIVE)	30	90	90	90	90
DENTISTRY	PERIO THERAPY (TREATMENT)	65	165	165	165	165
DENTISTRY	PULPECTOMY	35	97	97	97	97
DENTISTRY	SOFT TISSUE EXCISION	75	202	202	202	202
DENTISTRY	TMJ, TOMOGRAPH	470	730	770	820	860
DENTISTRY	TOOTH EXTRACTION	35	97	97	97	97
DENTISTRY	VESTIBULOPLASTY	75	202	202	202	202
DENTISTRY	X-RAY, CEPHALOMETRIC	570	670	710	750	790
DENTISTRY	X-RAY OCCLUSAL	335	550	550	550	550
DENTISTRY	X-RAY, PANORAMIC	500	750	790	840	880
DENTISTRY	X-RAY PERIAPICAL	160	265	265	265	265
DENTISTRY	CBCT	2,800	5,000	5,300	5,590	5,880

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Dietary

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
DIETARY	ADULT TUBE FEEDING – BOOST OPTIMUM	305.00	–	–	305	–
DIETARY	ADULT TUBE FEEDING – ENSURE	350.00	–	–	350	–
DIETARY	PEDIATRIC TUBE FEEDING – PEDIASURE	285.00	–	–	–	–
DIETARY	HOSPITAL DIETETICS PRACTICUM FOR 500 HOURS	2,240.00	–	–	2,240.00	–
DIETARY	SUPPORTAN PER 750 CALORIES	320.00	520	520	520	520
DIETARY	VITAL HP PER 1000 CALORIES	390.00	630	630	630	630
DIETARY	GLUCERNA SR PER 1000 CALORIES	410.00	410	410	410	410
DIETARY	HOSPITAL DIETETICS PRACTICUM FOR 600 HOURS	2,690.00	–	–	2,690.00	–
DIETARY	TUBE FEEDING FORMULA-JEVITY RTH, 500 KCAL/500ML BOTTLE	230.00	–	–	230	–
DIETARY	TUBE FEEDING FORMULA-OXEPA RTH, 750 KCAL/500ML BOTTLE	560.00	–	–	560	–
DIETARY	ADULT TUBE FEEDING/1,000 CAL, NUTREN DIABETES	635.00	635	635	635	635
DIETARY	ADULT TUBE FEEDING/1,000 CAL, PEPTAMEN	705.00	705	705	705	705
DIETARY	COMMERCIAL FORMULA/1,000 CAL, ISOCAL	360.00	360	360	360	360
DIETARY	COMMERCIAL FORMULA/1,000 CAL, NUTREN FIBER	480.00	480	480	480	480
DIETARY	DIET PRESCRIPTIONS FOR CARDIOVASCULAR DISORDERS	300.00	300	300	300	300
DIETARY	DIET PRESCRIPTIONS FOR DIABETICS	300.00	300	300	300	300
DIETARY	DIET PRESCRIPTIONS FOR FOLLOW-UP & REVIEW OF NUTRITIONAL CARE PLAN	150.00	150	150	150	150
DIETARY	DIET PRESCRIPTIONS-LOW CHOLESTEROL DIET	250.00	250	250	250	250
DIETARY	DIET PRESCRIPTIONS-LOW IODINE DIET	250.00	250	250	250	250
DIETARY	DIET PRESCRIPTIONS-LOW PURINE DIET	250.00	250	250	250	250
DIETARY	DIET PRESCRIPTIONS-RENAL DIET	300.00	300	300	300	300
DIETARY	DIET PRESCRIPTIONS-WEIGHT CONTROL/MANAGEMENT	300.00	300	300	300	300
DIETARY	HOSPITAL-PREPARED TUBE FEEDING/1,000 CAL, BANANA BASED	130.00	130	130	130	130
DIETARY	HOSPITAL-PREPARED TUBE FEEDING/1,000 CAL, PAPAYA BASED	130.00	130	130	130	130
DIETARY	HOSPITAL-PREPARED TUBE FEEDING/1,000 CAL, PLAIN	130.00	130	130	130	130
DIETARY	PEDIATRIC TUBE FEEDING/1,000 CAL, NUTREN JUNIOR	335.00	335	335	335	335
DIETARY	TUBE FEEDING FORMULA-BOOST FIBRE PER 1000 CALORIES	360.00	–	–	360	–
DIETARY	TUBE FEEDING FORMULA-NEPHRISOL-D PER 1000 CALORIES	680.00	–	–	680	–
DIETARY	TUBE FEEDING FORMULA-NEPHRISOL PER 1000 CALORIES	565.00	–	–	565	–

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DEM

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
DEM	BASIC EMERGENCY SERVICES	–	–	950.00	950.00	–
DEM	ER BED FEE	500	1,200.00	1,200.00	1,200.00	1,200.00
DEM	AMBULANCE CONDUCTION (CHARGE/KILOMETER IN EXCESS OF TWENTY (20) KILOMETERS)	130	150	150.00	150.00	150
DEM	AMBULANCE CONDUCTION	1,230.00	2,070.00	2,070.00	2,070.00	2,070.00

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CI

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
CI	AMBULATORY CHEMO THERAPY	500	800.00	800.00	800.00	800.00
CI	MAMMOGRAPHY	795	870.00	870.00	870.00	870.00
CI	ROOM RATE- BRACHYTHERAPY ROOM/DAY	–	2,500.00	2,500.00	2,500.00	2,500.00

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DIVISION OF NUCLEAR MEDICINE

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
DIVISION OF NUCLEAR MEDICINE	FBB PET + DIAGNOSTIC CT WITH CONTRAST	11,400.00	13,500.00	–	13,500.00	–
DIVISION OF NUCLEAR MEDICINE	FBB PET + DIAGNOSTIC CT WITHOUT CONTRAST	9,500.00	11,300.00	–	11,300.00	–
DIVISION OF NUCLEAR MEDICINE	FBB PET + NON-DIAGNOSTIC CT	8,900.00	10,600.00	–	10,600.00	–
DIVISION OF NUCLEAR MEDICINE	FDG PET + DIAGNOSTIC CT WITH CONTRAST	11,400.00	13,500.00	–	13,500.00	–
DIVISION OF NUCLEAR MEDICINE	FDG PET + DIAGNOSTIC CT WITHOUT CONTRAST	9,500.00	11,300.00	–	11,300.00	–
DIVISION OF NUCLEAR MEDICINE	FDG PET + NON-DIAGNOSTIC CT	8,900.00	10,600.00	–	10,600.00	–
DIVISION OF NUCLEAR MEDICINE	FPSMA PET + DIAGNOSTIC CT WITH CONTRAST	11,400.00	13,500.00	–	13,500.00	–
DIVISION OF NUCLEAR MEDICINE	FPSMA PET + DIAGNOSTIC CT WITHOUT CONTRAST	9,500.00	11,300.00	–	11,300.00	–
DIVISION OF NUCLEAR MEDICINE	FPSMA PET + NON-DIAGNOSTIC CT	8,900.00	10,600.00	–	10,600.00	–

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INTENSIVE MATERNAL CARE UNIT (IMU)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
INTENSIVE MATERNAL CARE UNIT (IMU)	ROOM RATE/DAY (IMU)	–	2,500.00	2,500.00	2,500.00	2,500.00

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FAMED

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
FAMED	FLU VACCINE	550.00	550.00	550.00	550.00	550.00
FAMED	HEPATITIS A & B COMBINATION	1,700.00	1,700.00	1,700.00	1,700.00	1,700.00
FAMED	HEPATITIS A VACCINE	1,800.00	1,800.00	1,800.00	1,800.00	1,800.00
FAMED	HEPATITIS B VACCINE	500.00	500.00	500.00	500.00	500.00
FAMED	MEDICAL CERTIFICATE	200.00	200.00	200.00	200.00	200.00
FAMED	MMR VACCINE	400.00	400.00	400.00	400.00	400.00
FAMED	PPD EXAM	175.00	175.00	175.00	175.00	175.00
FAMED	VARICELLA VACCINE	1,200.00	1,200.00	1,200.00	1,200.00	1,200.00

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ECG

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
ECG	24 HOURS MONITORING	2,460.00	2,565.00	2,695.00	2,820.00	2,950.00
ECG	48 HOURS MONITORING	3,320.00	3,465.00	3,635.00	3,810.00	3,980.00
ECG	72 HOURS MONITORING	4,180.00	4,360.00	4,580.00	4,795.00	5,015.00
ECG	24-HOUR HOLTER MONITORING STATION	–	–	1,782.00	1,913.00	2,000.00
ECG	LONG LEAD II/RHYTHM STRIP	40	80	80	80	80
ECG	12-LEAD ELECTROCARDIOGRAM- (ADDITIONAL FOR STAT/EMERGENCY)	70	80	80	90	135
ECG	12-LEAD ELECTROCARDIOGRAM-BEDSIDE	70	383	383	457	591
ECG	12-LEAD ELECTROCARDIOGRAM-STATION	70	317	317	378	496
ECG	24-HOUR HOLTER MONITORING (PGH & UPM EMPLOYEE CONFINED AT INFIRMARY WARD)	–	850	–	–	–
ECG	ADDITIONAL COPY OF TRAINING CERTIFICATE FOR THE EKG OBSERVERSHIP TRAINING PROGRAM/	100	100	100	100	100
ECG	24-HOUR HOLTER MONITORING	–	1,782.00	1,782.00	1,913.00	2,000.00

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EAR

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
EAR	AABR	2,800.00	3,290.00	3,290.00	3,290.00	3,290.00
EAR	ASSR	3,035.00	3,575.00	3,575.00	3,575.00	3,575.00
EAR	BRAINSTEM EVOKED RESPONSE AUDIOMETRY	1,885.00	1,830.00	1,925.00	2,015.00	2,110.00
EAR	CORTICAL AUDITORY EVOKED POTENTIAL (CAEP)	195.00	290.00	325.00	335.00	350.00
EAR	ELECTROCOCHLEAOGRAPHY	2,405.00	2,855.00	3,001.00	3,140.00	3,285.00
EAR	HEARING AND NOISE TEST (HINT)	255.00	225.00	240.00	245.00	260.00
EAR	OTOACOUSTIC EMMISSIONS (DPOAE OR TEOAE)	420.00	670.00	670.00	670.00	670.00
EAR	SPEECH AIDED	255.00	440.00	465.00	485.00	510.00
EAR	TINNITUS MATCHING	700.00	830.00	830.00	830.00	830.00
EAR	VESTIBULO EVOKED MYOGENIC POTENTIAL (VEMP)	1,185.00	2,040.00	2,140.00	2,245.00	2,345.00
EAR	VIDEO HEAD IMPULSE TEST (VHIT)	1,200.00	1,420.00	1,420.00	1,420.00	1,420.00
EAR	VIDEONYSTAFMOGRAPHY (VNG) COMPLETE	3,850.00	4,530.00	4,530.00	4,530.00	4,530.00
EAR	ACOUSTIC REFLEX	560.00	670.00	670.00	670.00	670.00
EAR	PLAY AUDIOMETRY	850.00	995.00	995.00	995.00	995.00
EAR	STAPEDIAL REFLEX	730.00	860.00	860.00	860.00	860.00
EAR	TYMPANOMETRY	560.00	670.00	670.00	670.00	670.00
EAR	DISTORTION PRODUCT OTOACOUSTIC EMMISSIONS (DPOAE)	370.00	390.00	450.00	450.00	520.00
EAR	PURETONE AUDIOMETRY SPEECH TEST	195.00	440.00	460.00	480.00	500.00
EAR	AIDED AUDIOMETRY	650.00	770.00	770.00	770.00	770.00
EAR	PTA/ST	650.00	765.00	765.00	765.00	765.00
EAR	PURETONE AUDIOMETRY WITH PATCH TESTING	650.00	765.00	765.00	765.00	765.00
EAR	CO2 LASER	1,250.00	5,000.00	5,000.00	5,000.00	5,000.00
EAR	KTP LASER	1,625.00	6,500.00	6,500.00	6,500.00	6,500.00

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DPPS (ROOM RATE)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Private	Suite/ Deluxe
DPPS (ROOM RATE)	BIG PRIVATE	–	–	2,750.00	–
DPPS (ROOM RATE)	WARD	–	–	715.00	–
DPPS (ROOM RATE)	SUPERIOR	–	–	3,300.00	–
DPPS (ROOM RATE)	STUDIO ROOM	–	–	1,650.00	–
DPPS (ROOM RATE)	SMALL PRIVATE	–	–	2,200.00	–
DPPS (ROOM RATE)	CUBICLE	–	–	1,100.00	–
DPPS (ROOM RATE)	EXECUTIVE ROOM	–	–	5,500.00	–
DPPS (ROOM RATE)	SEMI-PRIVATE II (1-2BEDS)	–	–	1,430.00	–
DPPS (ROOM RATE)	SEMI-PRIVATE I (1-3 BEDS)	–	–	1,000.00	–
DPPS (ROOM RATE)	PRESIDENTIAL SUITE	–	–	6,600.00	–

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LAB_IMMUNOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LAB_IMMUNOLOGY	ANTI-LIVER KIDNEY MICROSOMAL ANTIBODY	1,255.00	1,255.00	1,305.00	1,370.00	1,435.00
LAB_IMMUNOLOGY	ANTI-SMOOTH MUSCLE ANTIBODY	3,140.00	3,140.00	3,270.00	3,420.00	3,575.00
LAB_IMMUNOLOGY	CSF BACTIGEN	1,145.00	1,500.00	1,800.00	2,025.00	2,130.00
LAB_IMMUNOLOGY	CYCLOSPORIN	6,795.00	6,795.00	7,075.00	7,410.00	7,750.00
LAB_IMMUNOLOGY	HERPES 1 IGG	705.00	1,080.00	1,130.00	1,190.00	1,240.00
LAB_IMMUNOLOGY	HERPES 2 IGG	705.00	1,080.00	1,130.00	1,190.00	1,240.00
LAB_IMMUNOLOGY	HIV CONFIRMATORY TEST (RHIVDA)	110.00	140.00	150.00	155.00	160.00
LAB_IMMUNOLOGY	H-PYLORI IGG	1,045.00	1,045.00	1,095.00	1,150.00	1,150.00
LAB_IMMUNOLOGY	INTERLEUKIN – 6	2,180.00	2,970.00	3,370.00	3,560.00	3,960.00
LAB_IMMUNOLOGY	MUMPS IGG	1,115.00	1,735.00	1,820.00	1,905.00	1,995.00
LAB_IMMUNOLOGY	RUBEOLA IGG	1,285.00	2,475.00	2,600.00	2,720.00	2,845.00
LAB_IMMUNOLOGY	SERUM AFP QUALI	450.00	985.00	1,280.00	1,430.00	1,500.00
LAB_IMMUNOLOGY	SERUM AFP QUANTI	730.00	1,445.00	2,025.00	2,245.00	2,355.00
LAB_IMMUNOLOGY	SERUM ANTI-HAV IGM	350.00	670.00	965.00	1,070.00	1,125.00
LAB_IMMUNOLOGY	SERUM ANTI-HBC IGM	450.00	735.00	885.00	995.00	1,045.00
LAB_IMMUNOLOGY	SERUM ANTI-HBC TOTAL	340.00	695.00	830.00	945.00	990.00
LAB_IMMUNOLOGY	SERUM ANTI-HBE	310.00	645.00	965.00	1,035.00	1,085.00
LAB_IMMUNOLOGY	SERUM ANTI-HBS	320.00	545.00	570.00	600.00	630.00
LAB_IMMUNOLOGY	SERUM ANTI-HCV	620.00	1,105.00	1,160.00	1,215.00	1,275.00
LAB_IMMUNOLOGY	SERUM ASO	285.00	385.00	540.00	580.00	610.00
LAB_IMMUNOLOGY	SERUM CA125	790.00	1,270.00	1,400.00	1,570.00	1,650.00
LAB_IMMUNOLOGY	SERUM CA125 DILUTED	1,005.00	1,485.00	1,560.00	1,635.00	1,715.00
LAB_IMMUNOLOGY	SERUM CA 15-3	1,010.00	1,585.00	1,665.00	1,740.00	1,830.00
LAB_IMMUNOLOGY	SERUM CA 19-9	1,060.00	1,655.00	1,740.00	2,155.00	2,265.00
LAB_IMMUNOLOGY	SERUM CA19-9 DILUTED	1,270.00	1,865.00	1,960.00	2,330.00	2,445.00
LAB_IMMUNOLOGY	SERUM CEA	455.00	755.00	1,635.00	1,815.00	1,905.00
LAB_IMMUNOLOGY	SERUM CEA DILUTED	615.00	915.00	1,780.00	1,960.00	2,060.00
LAB_IMMUNOLOGY	SERUM CRP	235.00	395.00	495.00	535.00	560.00
LAB_IMMUNOLOGY	SERUM DENGUE IGG/IGM	1,225.00	1,355.00	1,420.00	1,555.00	1,635.00
LAB_IMMUNOLOGY	SERUM DENGUE NSI AG	1,135.00	1,535.00	1,610.00	1,785.00	1,875.00
LAB_IMMUNOLOGY	SERUM DHEA-S	625.00	980.00	1,030.00	1,075.00	1,130.00
LAB_IMMUNOLOGY	SERUM ESTRADIOL	395.00	605.00	635.00	725.00	760.00
LAB_IMMUNOLOGY	SERUM FREE T3	475.00	735.00	775.00	810.00	850.00
LAB_IMMUNOLOGY	SERUM FREE T4	365.00	570.00	600.00	660.00	690.00
LAB_IMMUNOLOGY	SERUM FSH	350.00	550.00	580.00	660.00	695.00
LAB_IMMUNOLOGY	SERUM HBEAG	335.00	640.00	1,010.00	1,195.00	1,255.00
LAB_IMMUNOLOGY	SERUM HBSAG	235.00	440.00	505.00	595.00	620.00
LAB_IMMUNOLOGY	SERUM HCG DILUTED	910.00	1,340.00	1,410.00	1,475.00	1,550.00
LAB_IMMUNOLOGY	SERUM HCG TOTAL UNDILUTED	540.00	605.00	665.00	725.00	760.00
LAB_IMMUNOLOGY	SERUM HE4	1,255.00	1,860.00	1,950.00	2,045.00	2,145.00
LAB_IMMUNOLOGY	SERUM HEPATITIS B PROFILE	1,940.00	2,895.00	3,430.00	3,900.00	4,095.00
LAB_IMMUNOLOGY	SERUM HEPATITIS PROFILE	3,110.00	4,650.00	5,480.00	6,280.00	6,590.00
LAB_IMMUNOLOGY	SERUM HIV COMBI AG/AB	330.00	595.00	885.00	940.00	985.00
LAB_IMMUNOLOGY	SERUM INSULIN	530.00	1,210.00	1,270.00	1,330.00	1,400.00
LAB_IMMUNOLOGY	SERUM LEPTOSPIRA IGG/IGM (RAPID)	500.00	640.00	670.00	735.00	770.00
LAB_IMMUNOLOGY	SERUM LH	525.00	705.00	740.00	810.00	850.00
LAB_IMMUNOLOGY	SERUM PROGESTERONE	495.00	875.00	920.00	965.00	1,010.00
LAB_IMMUNOLOGY	SERUM PROLACTIN	365.00	560.00	590.00	645.00	675.00
LAB_IMMUNOLOGY	SERUM RF	200.00	335.00	475.00	575.00	605.00
LAB_IMMUNOLOGY	SERUM RPR QUALI	140.00	210.00	420.00	455.00	480.00
LAB_IMMUNOLOGY	SERUM RPR QUANTI	270.00	270.00	405.00	425.00	445.00
LAB_IMMUNOLOGY	SERUM SALMONELLA IGG/IGM	1,485.00	1,705.00	1,790.00	1,910.00	2,005.00
LAB_IMMUNOLOGY	SERUM SHBG	640.00	1,260.00	1,325.00	1,450.00	1,520.00
LAB_IMMUNOLOGY	SERUM TESTOSTERONE	870.00	1,835.00	1,925.00	2,015.00	2,115.00
LAB_IMMUNOLOGY	SERUM TOTAL PSA	570.00	900.00	990.00	1,175.00	1,230.00
LAB_IMMUNOLOGY	SERUM TOTAL PSA DILUTED	755.00	1,110.00	1,165.00	1,220.00	1,285.00
LAB_IMMUNOLOGY	SERUM TSH	345.00	600.00	690.00	780.00	820.00
LAB_IMMUNOLOGY	SIROLIMUS	5,190.00	5,190.00	5,405.00	5,660.00	5,925.00
LAB_IMMUNOLOGY	TACROLIMUS	2,515.00	2,515.00	2,620.00	2,740.00	2,870.00
LAB_IMMUNOLOGY	TORCH PANEL	7,330.00	9,340.00	10,275.00	10,740.00	12,025.00
LAB_IMMUNOLOGY	TOXO IGG	880.00	1,025.00	1,150.00	1,275.00	1,335.00
LAB_IMMUNOLOGY	TOXO IGM	775.00	1,130.00	1,360.00	1,475.00	1,545.00
LAB_IMMUNOLOGY	ANTI-NMDA RECEPTOR	6,795.00	7,296.00	7,662.00	8,025.00	8,390.00
LAB_IMMUNOLOGY	SERUM ANTI-TREPONEMA PALLIDUM IGG-FTA-ABS	1,275.00	1,370.00	1,435.00	1,505.00	1,575.00
LAB_IMMUNOLOGY	TB QUANTIFERON	4,710.00	5,060.00	5,310.00	5,565.00	5,820.00
LAB_IMMUNOLOGY	ANTI-ACETYLCHOLINE RECEPTOR IGG	2,000.00	2,370.00	2,549.00	2,731.00	2,913.00
LAB_IMMUNOLOGY	ANTI-AQUAPORIN-4	3,350.00	3,960.00	4,266.00	4,570.00	4,875.00
LAB_IMMUNOLOGY	ANTI-BP180 IGG	1,160.00	1,370.00	1,480.00	1,585.00	1,691.00
LAB_IMMUNOLOGY	ANTI-BP230 IGG	1,160.00	1,370.00	1,480.00	1,585.00	1,691.00
LAB_IMMUNOLOGY	ANTI-DESMOGLEIN 1 IGG	1,160.00	1,370.00	1,480.00	1,585.00	1,691.00
LAB_IMMUNOLOGY	ANTI-DESMOGLEIN 3 IGG	1,160.00	1,370.00	1,480.00	1,585.00	1,691.00
LAB_IMMUNOLOGY	ANTI-MITOCHONDRIAL ANTIBODY	1,910.00	3,030.00	3,210.00	3,390.00	3,560.00
LAB_IMMUNOLOGY	TB QUANTIFERON (FOR OPERATIONAL RESEARCH ONLY)	1,565.00	0.00	0.00	1,565.00	0.00
LAB_IMMUNOLOGY	CSF, CALAS	810.00	1,735.00	1,820.00	1,910.00	2,005.00
LAB_IMMUNOLOGY	CMV IGM	1,190.00	1,190.00	1,285.00	1,475.00	1,545.00
LAB_IMMUNOLOGY	CMV IGG	775.00	1,045.00	1,100.00	1,150.00	1,200.00
LAB_IMMUNOLOGY	MMR	2,805.00	4,540.00	4,770.00	4,995.00	5,225.00
LAB_IMMUNOLOGY	RUBEOLA, IGG (CSF)	970.00	2,475.00	2,600.00	2,720.00	2,845.00
LAB_IMMUNOLOGY	RUBELLA IGG	545.00	1,080.00	1,130.00	1,190.00	1,240.00
LAB_IMMUNOLOGY	RUBELLA IGM	1,175.00	1,925.00	2,020.00	2,985.00	3,120.00
LAB_IMMUNOLOGY	SYPHILIS	390.00	444.00	675.00	740.00	740.00
LAB_IMMUNOLOGY	SERUM ANTI-HAV IGG	400.00	540.00	580.00	630.00	670.00
LAB_IMMUNOLOGY	SERUM METHOTREXATE	3,370.00	4,900.00	5,210.00	5,520.00	5,820.00
LAB_IMMUNOLOGY	SERUM PHENYTOIN	660.00	965.00	1,030.00	1,090.00	1,180.00
LAB_IMMUNOLOGY	VARICELLA IGG	820.00	1,515.00	1,590.00	1,670.00	1,745.00
LAB_IMMUNOLOGY	EBV IGG	2,010.00	2,385.00	2,505.00	2,620.00	2,740.00
LAB_IMMUNOLOGY	EBV IGM	2,010.00	2,280.00	2,395.00	2,510.00	2,620.00
LAB_IMMUNOLOGY	PROCALCITONIN	2,935.00	3,040.00	3,190.00	3,345.00	3,495.00
LAB_IMMUNOLOGY	ANTI-MULLERIAN HORMONE (AMH)	3,410.00	4,360.00	4,410.00	4,500.00	4,560.00

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LAB_HEMATOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LAB_HEMATOLOGY	CLOT RETRACTION TIME (CRT)	65.00	190	190.00	240.00	250.00
LAB_HEMATOLOGY	FIBRINOGEN	870.00	–	1,350.00	1,510.00	1,590.00
LAB_HEMATOLOGY	PLATELET AGGREGOMETRY	4,790.00	7,410.00	7,840.00	8,280.00	8,710.00
LAB_HEMATOLOGY	BLEEDING TIME (BT)	65.00	190	190.00	240.00	250.00
LAB_HEMATOLOGY	CLOTTING TIME (CT)	65.00	190	190.00	240.00	250.00
LAB_HEMATOLOGY	DIFFERENTIAL COUNT	110.00	210	210.00	310.00	325.00
LAB_HEMATOLOGY	FILARIAL SMEAR	80.00	240	240.00	280.00	300.00
LAB_HEMATOLOGY	HEMATOCRIT	110.00	210	210.00	310.00	325.00
LAB_HEMATOLOGY	HEMOGLOBIN	110.00	210	210.00	310.00	325.00
LAB_HEMATOLOGY	LE CELL PREPARATION	100.00	265	265.00	305.00	320.00
LAB_HEMATOLOGY	MALARIAL SMEAR	80.00	240	240.00	280.00	300.00
LAB_HEMATOLOGY	RBC/WBC MORPHOLOGY (PBS)	80.00	280	280.00	310.00	320.00
LAB_HEMATOLOGY	PLATELET COUNT	110.00	210	210.00	310.00	325.00
LAB_HEMATOLOGY	PROTHROMBIN TIME	180.00	240	240.00	285.00	300.00
LAB_HEMATOLOGY	RETICULOCYTE COUNT	90.00	250	250.00	310.00	330.00
LAB_HEMATOLOGY	WHITE BLOOD CELL COUNT	110.00	210	210.00	310.00	310.00
LAB_HEMATOLOGY	ACTIVATED PARTIAL THROMBOPLASTIN TEST (APTT)	175.00	510	510.00	565.00	595.00
LAB_HEMATOLOGY	CBC (HB, WBC, RBC & DIFF. CT)	180.00	300	300.00	400.00	430.00
LAB_HEMATOLOGY	ERYTHROCYTE SEDIMENTATION RATE (ESR)	100.00	230	230.00	240.00	250.00
LAB_HEMATOLOGY	D DIMER	3,360.00	3,680.00	3,680.00	3,855.00	4,060.00
LAB_HEMATOLOGY	FACTOR IX	930.00	1,345.00	1,345.00	1,390.00	1,465.00
LAB_HEMATOLOGY	FACTOR VIII	930.00	1,345.00	1,345.00	1,390.00	1,465.00
LAB_HEMATOLOGY	LUPUS CONFIRM	1,775.00	2,105.00	2,105.00	2,220.00	2,335.00
LAB_HEMATOLOGY	LUPUS SCREEN	1,440.00	2,585.00	2,585.00	2,705.00	2,850.00
LAB_HEMATOLOGY	PROTEIN C	2,400.00	3,275.00	3,275.00	3,430.00	3,560.00
LAB_HEMATOLOGY	PROTEIN S	4,315.00	6,390.00	6,390.00	6,740.00	7,095.00
LAB_HEMATOLOGY	SCT	820.00	1,270.00	1,350.00	1,420.00	1,500.00
LAB_HEMATOLOGY	CBC W/ VCS (VOLUME CONDUCTIVITY SCATTER)	200.00	–	0.00	0.00	0.00

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LAB_CHEMISTRY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LAB_CHEMISTRY	BLOOD – ALCOHOL	215	345.00	360.00	380.00	400.00
LAB_CHEMISTRY	BLOOD – DTIBC	575	915.00	955.00	1,005.00	1,050.00
LAB_CHEMISTRY	BLOOD – FERRITIN	765	1,830.00	1,920.00	2,220.00	2,330.00
LAB_CHEMISTRY	BLOOD – HBA1C	450	755.00	800.00	915.00	1,005.00
LAB_CHEMISTRY	BLOOD – LIPID – DIRECT LDL	170	200.00	225.00	235.00	245.00
LAB_CHEMISTRY	BLOOD – LITHIUM	215	345.00	360.00	380.00	400.00
LAB_CHEMISTRY	BLOOD – LIVER FUNCTION TEST (LFT) – AST, ALT, ALP, LDH, TPAG, TBIL, DBIL,IBIL	685	1,560.00	2,995.00	3,070.00	3,225.00
LAB_CHEMISTRY	BLOOD – NEONATAL BILIRUBIN- TB/DB/IB (0-15 DAYS)	160	415.00	505.00	570.00	625.00
LAB_CHEMISTRY	BLOOD – PLASMA LACTATE	215	305.00	320.00	340.00	355.00
LAB_CHEMISTRY	BLOOD – PRE-ALBUMIN	480	815.00	855.00	895.00	895.00
LAB_CHEMISTRY	BLOOD – RAPID HEP-ANTI-HCV (QUALITATIVE)	260	570.00	600.00	625.00	640.00
LAB_CHEMISTRY	BLOOD – SALICYLATES	245	415.00	435.00	455.00	478.00
LAB_CHEMISTRY	BLOOD – SERUM IRON	240	425.00	445.00	470.00	490.00
LAB_CHEMISTRY	BLOOD – TROPONIN I (QUANTITATIVE)	890	1,475.00	1,650.00	1,725.00	1,810.00
LAB_CHEMISTRY	BLOOD – VALPROIC	730	1,220.00	1,280.00	1,340.00	1,400.00
LAB_CHEMISTRY	BLOOD – VANCOMYCIN	745	1,240.00	1,300.00	1,365.00	1,430.00
LAB_CHEMISTRY	COVID IGG ASSAY	750	1,090.00	1,150.00	1,210.00	1,280.00
LAB_CHEMISTRY	COVID TOTAL ANTIBODY ASSAY (IGG,IGM,IGA)	810	1,260.00	1,330.00	1,400.00	1,480.00
LAB_CHEMISTRY	CSF & OTHER BODY FLUIDS – CREATININE	50	105.00	215.00	230.00	250.00
LAB_CHEMISTRY	ELECTROPHORESIS – HEMOGLOBIN	1,960	2,125.00	2,235.00	2,340.00	2,385.00
LAB_CHEMISTRY	ELECTROPHORESIS – HEMOGLOBIN – PACKAGE	2,205	3,955.00	4,155.00	4,350.00	4,550.00
LAB_CHEMISTRY	ELECTROPHORESIS – SERUM PROTEIN	1,655	1,795.00	1,885.00	1,930.00	1,990.00
LAB_CHEMISTRY	ELECTROPHORESIS – URINE PROTEIN	4,615	6,495.00	6,820.00	7,145.00	7,145.00
LAB_CHEMISTRY	HSCRP	730	1,130.00	1,190.00	1,260.00	1,320.00
LAB_CHEMISTRY	NT PRO BNP	2,210	3,270.00	3,430.00	3,600.00	3,760.00
LAB_CHEMISTRY	URINE – ELECTROLYTES (NA, K, CL)	310	780.00	830.00	875.00	965.00
LAB_CHEMISTRY	URINE – MALB (MICROALBUMIN TEST)	525	845.00	890.00	930.00	970.00
LAB_CHEMISTRY	NEPHROCHECK	4,110	4,755.00	4,995.00	5,230.00	5,470.00
LAB_CHEMISTRY	BLOOD – ALBUMIN	75	155.00	260.00	285.00	310.00
LAB_CHEMISTRY	BLOOD – ALT (SGPT)	65	130.00	270.00	300.00	330.00
LAB_CHEMISTRY	BLOOD – AMYLASE	105	170.00	305.00	335.00	370.00
LAB_CHEMISTRY	BLOOD – AST (SGOT)	60	130.00	290.00	320.00	350.00
LAB_CHEMISTRY	BLOOD EXTRACTION FEE	0	0.00	110.00	114.00	120.00
LAB_CHEMISTRY	BLOOD – BUN	50	105.00	210.00	230.00	255.00
LAB_CHEMISTRY	BLOOD – CALCIUM (CA), SERUM	90	245.00	270.00	300.00	330.00
LAB_CHEMISTRY	BLOOD – CK-MB	280	525.00	825.00	910.00	1,000.00
LAB_CHEMISTRY	BLOOD – CK TOTAL	190	380.00	550.00	605.00	665.00
LAB_CHEMISTRY	BLOOD – CHLORIDE (CL)	85	150.00	270.00	300.00	330.00
LAB_CHEMISTRY	BLOOD – CREATININE	50	105.00	215.00	230.00	250.00
LAB_CHEMISTRY	BLOOD – GGT	150	530.00	625.00	690.00	755.00
LAB_CHEMISTRY	BLOOD – LIPID -HDL	135	210.00	450.00	495.00	545.00
LAB_CHEMISTRY	BLOOD – POTASSIUM (K)	75	150.00	280.00	310.00	340.00
LAB_CHEMISTRY	BLOOD – LIPASE	165	420.00	470.00	515.00	570.00
LAB_CHEMISTRY	BLOOD – SODIUM (NA)	75	150.00	275.00	305.00	335.00
LAB_CHEMISTRY	BLOOD – AMMONIA	165	1,105.00	1,225.00	1,355.00	1,490.00
LAB_CHEMISTRY	BLOOD – PLASMA K	75	150.00	285.00	315.00	345.00
LAB_CHEMISTRY	BLOOD – TPAG/GLOBULIN	170	440.00	730.00	815.00	855.00
LAB_CHEMISTRY	URINE – AMYLASE	135	265.00	345.00	380.00	420.00
LAB_CHEMISTRY	URINE – CALCIUM	85	245.00	295.00	325.00	360.00
LAB_CHEMISTRY	URINE – CHLORIDE (CL)	105	230.00	250.00	255.00	280.00
LAB_CHEMISTRY	URINE – CREATININE	90	180.00	240.00	290.00	305.00
LAB_CHEMISTRY	URINE – POTASSIUM (K)	105	275.00	290.00	320.00	350.00
LAB_CHEMISTRY	URINE – UREA NITROGEN	75	165.00	210.00	230.00	255.00
LAB_CHEMISTRY	URINE – SODIUM (NA)	105	275.00	290.00	320.00	350.00
LAB_CHEMISTRY	URINE – PHOSPHOROUS (PO4)	75	230.00	245.00	290.00	375.00
LAB_CHEMISTRY	URINE – SUGAR	105	185.00	195.00	205.00	225.00
LAB_CHEMISTRY	URINE – URIC ACID	60	200.00	210.00	245.00	265.00
LAB_CHEMISTRY	BLOOD – DRUG ASSAY -ACETAMINOPHEN	190	665.00	760.00	835.00	920.00
LAB_CHEMISTRY	BLOOD – ALKALINE PHOSPHATASE (ALP)	75	145.00	295.00	325.00	355.00
LAB_CHEMISTRY	BLOOD EXTRACTION FEE (IN EXCESS OF 1 TEST TUBE/TUBE	0	0.00	9.50	9.50	9.50
LAB_CHEMISTRY	BLOOD – LIPID-TOTAL CHOLESTEROL	50	105.00	240.00	265.00	290.00
LAB_CHEMISTRY	CSF & OTHER BODY FLUIDS – ALBUMIN	75	150.00	260.00	285.00	310.00
LAB_CHEMISTRY	CSF & OTHER BODY FLUIDS – CHOLESTEROL	90	195.00	230.00	250.00	275.00
LAB_CHEMISTRY	CSF & OTHER BODY FLUIDS – SUGAR	90	200.00	210.00	225.00	245.00
LAB_CHEMISTRY	CSF & OTHER BODY FLUIDS – TRIGLYCERIDES	180	255.00	345.00	400.00	440.00
LAB_CHEMISTRY	BLOOD – BILIRUBIN -DB (ADULT)	90	215.00	270.00	300.00	330.00
LAB_CHEMISTRY	BLOOD – ELECTROLYTES (NA, K, CL)	240	460.00	785.00	840.00	880.00
LAB_CHEMISTRY	BLOOD – RAPID HEP-HBSAG (QUALITATIVE)	165	265.00	270.00	295.00	325.00
LAB_CHEMISTRY	BLOOD – LACTIC DEHYDROGENASE (LDH)	105	195.00	295.00	325.00	355.00
LAB_CHEMISTRY	BLOOD – DRUG ASSAY -PHENOPBARBITAL	455	1,265.00	1,420.00	1,440.00	1,455.00
LAB_CHEMISTRY	BLOOD – SUGAR – FBS/ RBS, 2HRS. PPBS	60	105.00	215.00	235.00	260.00
LAB_CHEMISTRY	CSF & OTHER BODY FLUIDS – TOTAL PROTEIN/SUGAR (QUANTITATIVE)	210	420.00	475.00	490.00	540.00
LAB_CHEMISTRY	BLOOD – BILIRUBIN -TB (ADULT)	90	210.00	270.00	300.00	330.00
LAB_CHEMISTRY	BLOOD – BILIRUBIN -TB DB IB/IB (ADULT)	160	333.00	475.00	535.00	535.00
LAB_CHEMISTRY	BLOOD – IONIZED CALCIUM, PLASMA,	385	425.00	470.00	495.00	545.00
LAB_CHEMISTRY	IMMUNOTYPING	4,590	6,285.00	6,600.00	7,040.00	7,040.00
LAB_CHEMISTRY	BLOOD – LIPID -LIPID PROFILE (TRIGLYCERIDE, TOTAL CHOLESTEROL, HDL, LDL)	410	690.00	1,240.00	1,340.00	1,530.00
LAB_CHEMISTRY	BLOOD – LIPID -TRIGLYCERIDES,	120	170.00	420.00	460.00	505.00
LAB_CHEMISTRY	CSF & OTHER BODY FLUIDS – LDH,	150	280.00	295.00	325.00	355.00
LAB_CHEMISTRY	CSF & OTHER BODY FLUIDS – TOTAL PROTEIN,	150	220.00	270.00	300.00	330.00
LAB_CHEMISTRY	BLOOD – MAGNESIUM (MG),	200	335.00	420.00	460.00	510.00
LAB_CHEMISTRY	BLOOD – SUGAR -OGCT (50 GMS),	210	210.00	430.00	475.00	520.00
LAB_CHEMISTRY	BLOOD – SUGAR -OGTT (100 GMS),	260	425.00	820.00	900.00	990.00
LAB_CHEMISTRY	BLOOD – SUGAR -OGTT (75 GMS),	230	315.00	820.00	900.00	990.00
LAB_CHEMISTRY	BLOOD – PHOSPHOROUS (PO4),	80	150.00	260.00	285.00	315.00
LAB_CHEMISTRY	BLOOD – URIC ACID,	75	105.00	210.00	230.00	255.00
LAB_CHEMISTRY	URINE – MAGNESIUM (FOR 24 HRS URINE COLLECTION),	210	305.00	320.00	340.00	370.00
LAB_CHEMISTRY	URINE – TOTAL PROTEIN,	150	220.00	270.00	300.00	330.00
LAB_CHEMISTRY	BLOOD – TOTAL CARBON DIOXIDE (TCO2)	135	195.00	220.00	245.00	265.00
LAB_CHEMISTRY	BLOOD – TOTAL PROTEIN,	105	150.00	270.00	300.00	330.00

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LAB_BLOODBANK

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LAB_BLOODBANK	ALIQUOT LEUKOREDUCED PRBC	1,250.00	–	1,475.00	1,475.00	–
LAB_BLOODBANK	ANTIBODY IDENTIFICATION	–	–	140.00	140.00	–
LAB_BLOODBANK	ANTIBODY SCREENING FOR BLOOD UNITS	–	–	950.00	950.00	–
LAB_BLOODBANK	ANTIBODY SCREENING/INDIRECT COOMBS	415	–	710.00	710.00	–
LAB_BLOODBANK	BLOOD TYPING (ABO & RH)- AUTOMATED	615	–	660.00	660.00	660
LAB_BLOODBANK	CONVALESCENT PLASMA	17,800.00	–	20,585.00	20,585.00	–
LAB_BLOODBANK	LEUKOREDUCED PRBC	1,340.00	–	2,550.00	2,550.00	–
LAB_BLOODBANK	PLATELET CONCENTRATE (PC)	670	–	950.00	950.00	–
LAB_BLOODBANK	ROUTINE CROSSMATCHING – AUTOMATED	940	–	1,010.00	1,010.00	–
LAB_BLOODBANK	AUTOLOGOUS DONATION	150	670	670.00	670.00	–
LAB_BLOODBANK	ALIQUOT PRBC W/ DONOR	670	750	810.00	870.00	870
LAB_BLOODBANK	CRYOPRECIPITATE	305	950	950.00	950.00	870
LAB_BLOODBANK	DIFFICULT CROSSMATCHING	855	1,275.00	1,275.00	1,275.00	–
LAB_BLOODBANK	DIRECT COOMBS	90	305	305.00	305.00	–
LAB_BLOODBANK	FRESH FROZEN PLASMA (FFP)	305	950	950.00	950.00	–
LAB_BLOODBANK	LEUKOREDUCED PRBC W/DONOR	825	1,720.00	1,720.00	1,720.00	1,720.00
LAB_BLOODBANK	PLATELETPHERESIS	16,825.00	19,460.00	19,460.00	19,460.00	–
LAB_BLOODBANK	ROUTINE CROSSMATCHING – STAT	1,225.00	1,225.00	1,315.00	1,315.00	–
LAB_BLOODBANK	WHOLE BLOOD W/DONOR	525	1,720.00	1,720.00	1,720.00	1,720.00
LAB_BLOODBANK	BLOOD TYPING (ABO & RH)- STAT	800	790	790.00	790.00	790
LAB_BLOODBANK	PACKED RED BLOOD CELL (PRBC)	1,340.00	1,425.00	1,425.00	1,425.00	1,425.00
LAB_BLOODBANK	PACKED RED BLOOD CELL (PRBC) W/ DONOR	450	1,430.00	1,430.00	1,430.00	1,430.00
LAB_BLOODBANK	RESOLVING ABO TYPING DISCREPANCY	805	1,205.00	1,205.00	1,205.00	–
LAB_BLOODBANK	THERAPEUTIC PLASMA EXCHANGE/PLASMAPHERESIS	17,775.00	22,000.00	22,000.00	22,000.00	–
LAB_BLOODBANK	CYROSUPERNATE	305	950	950.00	950.00	–

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MEDICAL INTENSIVE CARE UNIT (MICU)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICAL INTENSIVE CARE UNIT (MICU)	ROOM RATE/DAY (MICU)	–	2,500.00	2,500.00	2,500.00	2,500.00

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LABORATORY INFORMATION

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LABORATORY INFORMATION	ANTIGEN TEST KIT FOR COVID-19 (INDIVIDUALLY PACKED)	281.75	–	–	–	–

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LABORATORIES-SURGICAL PATHOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LABORATORIES-SURGICAL PATHOLOGY	PHOTOMICROGRAPHY	120.00	120.00	120.00	120.00	120.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – ANTIHISTONE	1,510.00	2,340.00	2,480.00	2,620.00	2,750.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – ATRX	1,980.00	2,590.00	2,720.00	2,850.00	2,980.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – BER-EP4	1,920.00	2,120.00	2,225.00	2,330.00	2,440.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CD31	1,920.00	2,120.00	2,225.00	2,330.00	2,440.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CD7	1,920.00	2,120.00	2,225.00	2,330.00	2,440.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CMYC	2,010.00	3,290.00	3,455.00	3,619.00	3,785.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – DOG1	2,815.00	3,020.00	3,170.00	3,320.00	3,475.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – GLYPICAN 3	1,470.00	2,280.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – GRANZYME B	2,645.00	3,090.00	3,245.00	3,400.00	3,555.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – KAPPA LIGHT CHAIN	1,920.00	2,120.00	2,225.00	2,330.00	2,440.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – LAMBDA LIGHT CHAIN	1,920.00	2,120.00	2,225.00	2,330.00	2,440.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – MDM2	1,920.00	2,970.00	3,140.00	3,320.00	3,490.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – MYOGENIN	1,920.00	2,120.00	2,225.00	2,330.00	2,440.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – NAPSIN A	2,520.00	2,900.00	3,045.00	3,190.00	3,335.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – NKX3.1	1,470.00	2,280.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – SOX10	3,180.00	3,650.00	3,835.00	4,015.00	4,220.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – STAT 6	2,025.00	2,415.00	2,535.00	2,655.00	2,775.00
LABORATORIES-SURGICAL PATHOLOGY	A-1 ANTITRYPSIN	1,890.00	2,930.00	3,100.00	3,270.00	3,440.00
LABORATORIES-SURGICAL PATHOLOGY	ANDROGEN RECEPTOR	1,380.00	2,140.00	2,260.00	2,390.00	2,510.00
LABORATORIES-SURGICAL PATHOLOGY	ANTI-ADENOCORTICOTROPIN HORMONE (ACTH)	1,380.00	2,140.00	2,260.00	2,390.00	2,510.00
LABORATORIES-SURGICAL PATHOLOGY	ARGINASE 1	2,790.00	4,320.00	4,570.00	4,820.00	5,080.00
LABORATORIES-SURGICAL PATHOLOGY	BCL 10	2,510.00	3,890.00	4,120.00	4,340.00	4,570.00
LABORATORIES-SURGICAL PATHOLOGY	BCOR	2,570.00	3,970.00	4,200.00	4,440.00	4,670.00
LABORATORIES-SURGICAL PATHOLOGY	BIOSAFETY CABINET CLASS II	50.00	0.00	0.00	50.00	0.00
LABORATORIES-SURGICAL PATHOLOGY	CD123 IL-3RA	2,410.00	3,730.00	3,950.00	4,160.00	4,380.00
LABORATORIES-SURGICAL PATHOLOGY	CD23	1,550.00	2,400.00	2,540.00	2,690.00	2,830.00
LABORATORIES-SURGICAL PATHOLOGY	CD235A GLYCOPHORIN A	1,380.00	2,140.00	2,260.00	2,390.00	2,510.00
LABORATORIES-SURGICAL PATHOLOGY	HHV-8	1,470.00	0.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	IGD	1,550.00	2,400.00	2,540.00	2,690.00	2,830.00
LABORATORIES-SURGICAL PATHOLOGY	MUC 5AC	1,550.00	2,400.00	2,540.00	2,690.00	2,830.00
LABORATORIES-SURGICAL PATHOLOGY	MUC 6	2,300.00	3,560.00	3,770.00	3,980.00	4,190.00
LABORATORIES-SURGICAL PATHOLOGY	MUTS PROTEIN HOMOLOG 2	1,980.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	MUTS PROTEIN HOMOLOG 6	1,980.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	NKX 2.2	3,170.00	0.00	5,190.00	5,480.00	5,770.00
LABORATORIES-SURGICAL PATHOLOGY	OLIG-2	2,360.00	0.00	3,870.00	4,080.00	5,770.00
LABORATORIES-SURGICAL PATHOLOGY	PAN-TRK	3,720.00	5,750.00	6,090.00	6,430.00	6,770.00
LABORATORIES-SURGICAL PATHOLOGY	PHOX 2-B	3,700.00	0.00	6,050.00	6,390.00	6,730.00
LABORATORIES-SURGICAL PATHOLOGY	PREALBUMIN/TRANSTHYRETIN	2,290.00	3,550.00	3,760.00	3,960.00	4,170.00
LABORATORIES-SURGICAL PATHOLOGY	TIA-A	2,210.00	3,420.00	3,620.00	3,820.00	4,020.00
LABORATORIES-SURGICAL PATHOLOGY	UROPLAKIN III	2,420.00	3,750.00	3,970.00	4,190.00	4,410.00
LABORATORIES-SURGICAL PATHOLOGY	1P19Q FISH	14,910.00	19,450.00	20,425.00	21,395.00	22,370.00
LABORATORIES-SURGICAL PATHOLOGY	BRACHYURY	1,780.00	0.00	2,920.00	3,080.00	3,240.00
LABORATORIES-SURGICAL PATHOLOGY	CAM 5.2	2,570.00	3,295.00	3,390.00	3,425.00	3,555.00
LABORATORIES-SURGICAL PATHOLOGY	CHORIONIC GONADOTROPIN	1,550.00	2,400.00	2,540.00	2,690.00	2,830.00
LABORATORIES-SURGICAL PATHOLOGY	CK 18/8	2,755.00	2,905.00	2,915.00	2,920.00	2,925.00
LABORATORIES-SURGICAL PATHOLOGY	ERG	1,980.00	0.00	0.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ESTROGEN RECEPTOR	1,550.00	2,400.00	2,540.00	2,690.00	2,830.00
LABORATORIES-SURGICAL PATHOLOGY	EWSR FISH	8,380.00	0.00	0.00	9,620.00	10,060.00
LABORATORIES-SURGICAL PATHOLOGY	FOLLICLE STIMULATING HORMONE (FSH)	1,380.00	2,140.00	2,260.00	2,390.00	2,510.00
LABORATORIES-SURGICAL PATHOLOGY	GAB I/GRB 2- ASSOCIATED BINDING PROTEIN I	2,310.00	0.00	3,790.00	4,000.00	4,210.00
LABORATORIES-SURGICAL PATHOLOGY	GROWTH HORMONE	1,380.00	2,140.00	2,260.00	2,390.00	2,510.00
LABORATORIES-SURGICAL PATHOLOGY	HERCEPT	3,110.00	4,800.00	5,090.00	5,370.00	5,650.00
LABORATORIES-SURGICAL PATHOLOGY	IIMMUNISTAINS – CALDESMON	1,730.00	0.00	0.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – BETA CATENIN	1,980.00	2,250.00	2,360.00	2,475.00	2,585.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD2	1,980.00	2,250.00	2,360.00	2,475.00	2,585.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – MDM2	2,365.00	3,140.00	3,295.00	3,455.00	3,610.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – PMSI-2	1,980.00	1,980.00	2,250.00	2,475.00	2,585.00
LABORATORIES-SURGICAL PATHOLOGY	INHIBIN-A	1,980.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	LANGERIN	2,250.00	3,480.00	3,680.00	3,890.00	4,090.00
LABORATORIES-SURGICAL PATHOLOGY	LIQUID BASED CYTOLOGY FOR GYNECOLOGICAL SAMPLES	1,695.00	1,915.00	2,010.00	2,105.00	2,205.00
LABORATORIES-SURGICAL PATHOLOGY	LIQUID BASED CYTOLOGY FOR NON-GYNECOLOGICAL SAMPLES	2,305.00	2,605.00	2,735.00	2,865.00	2,995.00
LABORATORIES-SURGICAL PATHOLOGY	LIQUID BASED CYTOLOGY FOR NON-GYNECOLOGICAL SAMPLES WITH CELLBOOK	2,715.00	3,030.00	3,180.00	3,335.00	3,485.00
LABORATORIES-SURGICAL PATHOLOGY	LUTEINIZING HORMONE (LH)	1,380.00	2,140.00	2,260.00	2,390.00	2,510.00
LABORATORIES-SURGICAL PATHOLOGY	LYSOZYME	1,160.00	1,790.00	1,900.00	2,000.00	2,110.00
LABORATORIES-SURGICAL PATHOLOGY	MASPIN	2,420.00	3,750.00	3,970.00	4,190.00	4,410.00
LABORATORIES-SURGICAL PATHOLOGY	MDM2-FISH	8,380.00	8,745.00	9,185.00	9,620.00	10,060.00
LABORATORIES-SURGICAL PATHOLOGY	MUC 2	1,550.00	2,400.00	2,540.00	2,690.00	2,830.00
LABORATORIES-SURGICAL PATHOLOGY	MUC-4	2,395.00	2,500.00	2,625.00	2,750.00	2,875.00
LABORATORIES-SURGICAL PATHOLOGY	MUTS PROTEIN HOMOLOG 1	1,980.00	2,065.00	2,165.00	2,270.00	0.00
LABORATORIES-SURGICAL PATHOLOGY	PAP SMEAR, CONVENTIONAL	225.00	645.00	660.00	665.00	670.00
LABORATORIES-SURGICAL PATHOLOGY	PROGESTERONE RECEPTOR	1,550.00	2,400.00	2,540.00	2,690.00	2,830.00
LABORATORIES-SURGICAL PATHOLOGY	PSMA	1,980.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	SATB2	1,470.00	2,280.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – DIFF QUICK STAIN	1,025.00	1,070.00	1,125.00	1,175.00	1,230.00
LABORATORIES-SURGICAL PATHOLOGY	SS18	9,225.00	9,625.00	10,105.00	10,590.00	11,070.00
LABORATORIES-SURGICAL PATHOLOGY	TFT3	2,565.00	2,675.00	2,810.00	2,945.00	3,075.00
LABORATORIES-SURGICAL PATHOLOGY	TLE 1	2,710.00	2,830.00	2,970.00	3,110.00	3,250.00
LABORATORIES-SURGICAL PATHOLOGY	HPV DNA PCR TEST	2,840.00	4,380.00	0.00	4,380.00	0.00
LABORATORIES-SURGICAL PATHOLOGY	LBC-GYNE + HPV DNA PCR TEST (PACKAGE)	3,550.00	4,780.00	0.00	4,780.00	0.00
LABORATORIES-SURGICAL PATHOLOGY	TISSUE BIOPSY – EXTRA-LARGE	765.00	1,820.00	1,910.00	2,000.00	2,090.00
LABORATORIES-SURGICAL PATHOLOGY	CELL BLOCKS/CYTOLOGY (CB)	360.00	685.00	720.00	755.00	790.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – GIEMSA	365.00	420.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – RETICULIN	365.00	420.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – WRIGHTS	365.00	0.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	SLIDE REVIEW (SR)	245.00	290.00	300.00	315.00	330.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – ALK (CD46)	3,110.00	4,700.00	4,700.00	4,700.00	4,700.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD3	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 34	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 56	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD99	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD117	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CEA	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CK7	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CK 56	1,980.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CK20	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – DESMIN	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – EMA	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – GFAP	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – ER OR PR ONLY	1,980.00	2,405.00	2,525.00	2,645.00	2,765.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – ER & PR ASSAY	3,200.00	4,680.00	4,915.00	5,150.00	5,380.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – HMB 45	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – HEP PAR1	1,980.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – HER2NEU	995.00	1,560.00	1,560.00	1,560.00	1,560.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – IDH1	2,670.00	2,785.00	2,840.00	2,870.00	2,895.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – KI67	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – NSE	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – P53	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – P63	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – PLAP	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – SMA	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – S-100	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – TDT	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – TTF-1	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – VIMENTIN	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	TISSUE BIOPSY – SMALL (< 1 CM)	345.00	670.00	705.00	740.00	770.00
LABORATORIES-SURGICAL PATHOLOGY	TISSUE BIOPSY – MEDIUM (1 CM <= 2CM AGGREGATES)	410.00	740.00	755.00	810.00	850.00
LABORATORIES-SURGICAL PATHOLOGY	TISSUE BIOPSY – LARGE (>2 CM)	630.00	910.00	955.00	1,000.00	1,045.00
LABORATORIES-SURGICAL PATHOLOGY	ASPIRATES, SMEARS (MAXIMUM OF 4 SLIDES)	270.00	410.00	460.00	485.00	505.00
LABORATORIES-SURGICAL PATHOLOGY	TISSUE BIOPSY – FROZEN SECTION	590.00	1,030.00	1,080.00	1,130.00	1,180.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – PERIODIC ACID SCHIFF	365.00	420.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CK (CYTOKERATIN)	1,540.00	2,175.00	2,280.00	2,305.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – ER/PR WITH HER2NEU	4,360.00	6,240.00	6,550.00	6,865.00	7,175.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – SYNAPTHOPHYSIN	1,470.00	2,280.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	HER2 FISH	8,895.00	9,510.00	0.00	0.00	0.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD138	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 68	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CHROMOGRANIN	1,470.00	0.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CK19	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CK (CYTOKERATIN) 8 & 18	1,850.00	0.00	1,950.00	1,950.00	1,950.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CK HMW (34BE12)	1,980.00	0.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CYCLIN D1	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – E-CADHERIN	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – INI-1	2,645.00	0.00	2,900.00	2,875.00	2,905.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – MELANIN A	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – MUSCLE SPECIFIC ACTIN (MSA)	1,980.00	0.00	2,320.00	2,430.00	2,540.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – P40	1,470.00	2,280.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – P57	1,470.00	2,280.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – PAX5	2,070.00	2,780.00	2,920.00	3,060.00	3,195.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – CONGO RED	365.00	0.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – ELASTIC STAIN	365.00	0.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – FITE FERACO	365.00	0.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – MASSON TRICHROME	365.00	0.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	SPECIAL STAINS – PAPANICOLAOU STAIN	365.00	0.00	425.00	440.00	445.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – AFP	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – AMACR	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – BCL6	1,730.00	2,785.00	2,830.00	2,995.00	3,145.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CA19-9	1,460.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CALDESMON	1,160.00	1,800.00	1,900.00	2,010.00	2,110.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CD1A	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CD21	1,920.00	2,120.00	2,225.00	2,330.00	2,440.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CD4	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CD79A	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CD8	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – CDX2	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – GATA3	1,470.00	2,280.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – HBME1	1,370.00	2,250.00	2,250.00	2,360.00	2,475.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – MUMI	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – MYELOPEROXIDASE	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – MYOD1	1,385.00	2,130.00	2,235.00	2,340.00	2,445.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – NEUROFILAMENT	1,730.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – P16	2,670.00	3,900.00	3,900.00	3,900.00	3,900.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – PAX-8	2,460.00	2,770.00	2,910.00	3,045.00	3,185.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – PD-LHHC	4,025.00	5,700.00	5,985.00	6,270.00	6,555.00
LABORATORIES-SURGICAL PATHOLOGY	ANTIBODIES – SALL4	1,470.00	2,280.00	2,280.00	2,280.00	2,280.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – BCL2	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CALRETININ	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 10	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 15	1,540.00	2,240.00	2,285.00	2,305.00	2,370.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 20	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 30	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 45	1,540.00	2,065.00	2,165.00	2,270.00	2,375.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CD 5	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – CKLMW	2,520.00	2,690.00	2,825.00	2,960.00	3,095.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – HERCEP 2	3,275.00	4,045.00	4,245.00	4,450.00	4,650.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – MAMMAGLOBIN	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS -THYROGLOBULIN	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – TOXOPLASMA	2,250.00	2,845.00	2,985.00	3,130.00	3,270.00
LABORATORIES-SURGICAL PATHOLOGY	IMMUNOSTAINS – WT 1	1,980.00	2,295.00	2,410.00	2,525.00	2,640.00

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LABORATORIES-DRUG TESTING UNIT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LABORATORIES-DRUG TESTING UNIT	CONFIRMATORY DRUG TESTING FEE (BENZODIAZEPINES)	1,500.00	–	–	1,500.00	–
LABORATORIES-DRUG TESTING UNIT	CONFIRMATORY DRUG TESTING FEE (COCAINE)	1,500.00	–	–	1,500.00	–
LABORATORIES-DRUG TESTING UNIT	CONFIRMATORY DRUG TESTING FEE (ECSTASY)	1,500.00	–	–	1,500.00	–
LABORATORIES-DRUG TESTING UNIT	CONFIRMATORY DRUG TESTING FEE (OPIATES/MORPHINE)	1,500.00	–	–	1,500.00	–
LABORATORIES-DRUG TESTING UNIT	DUAL PANEL (MET/THC)	250.00	250	–	250.00	–
LABORATORIES-DRUG TESTING UNIT	FIVE PANEL	660.00	1,020.00	–	1,020.00	–
LABORATORIES-DRUG TESTING UNIT	URINE ALCOHOL	300.00	–	–	460.00	–
LABORATORIES-DRUG TESTING UNIT	URINE BARBITURATES	480.00	–	–	740.00	–
LABORATORIES-DRUG TESTING UNIT	URINE BENZODIAZEPINE	480.00	–	–	740.00	–
LABORATORIES-DRUG TESTING UNIT	URINE COTININE	260.00	–	–	390.00	–

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LAB_MICROSCOPY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LAB_MICROSCOPY	CLOSTRIDIUM DIFFICILE ANTIGEN	1,325.00	1,495.00	1,570.00	1,645.00	1,720.00
LAB_MICROSCOPY	CSF – PH	95.00	120.00	130.00	190.00	200.00
LAB_MICROSCOPY	CSF – QUALITATIVE	140.00	225.00	405.00	600.00	630.00
LAB_MICROSCOPY	CSF – RBC COUNT	95.00	150.00	350.00	525.00	550.00
LAB_MICROSCOPY	CSF – SPECIFIC GRAVITY	95.00	120.00	130.00	190.00	200.00
LAB_MICROSCOPY	OTHER BODY FLUIDS- PH	95.00	120.00	130.00	190.00	200.00
LAB_MICROSCOPY	OTHER BODY FLUIDS- QUALITATIVE	140.00	225.00	405.00	600.00	630.00
LAB_MICROSCOPY	OTHER BODY FLUIDS- RBC MORPHOLOGY	60.00	145.00	150.00	170.00	180.00
LAB_MICROSCOPY	OTHER BODY FLUIDS- SPECIFIC GRAVITY	65.00	120.00	130.00	190.00	200.00
LAB_MICROSCOPY	SEMEN- SEMINALYSIS	510.00	785.00	835.00	880.00	925.00
LAB_MICROSCOPY	STOOL – CRYPTO/GIARDIA ANTIGEN	2,045.00	3,020.00	3,200.00	3,375.00	3,545.00
LAB_MICROSCOPY	STOOL – DIRECT FECAL SMEAR W/ FECAL CONCENTRATION TECHNIQUE	220.00	340.00	360.00	380.00	440.00
LAB_MICROSCOPY	STOOL – E-HISTOLYTICA ANTIGEN	2,125.00	3,145.00	3,330.00	3,515.00	3,690.00
LAB_MICROSCOPY	STOOL – FECAL IMMUNO-CHEMICAL TEST FOR OCCULT BLOOD (FIT)	215.00	320.00	340.00	360.00	370.00
LAB_MICROSCOPY	STOOL – OCCULT BLOOD (GUAIAC)	85.00	100.00	195.00	270.00	285.00
LAB_MICROSCOPY	STOOL – ROTAVIRUS ANTIGEN	930.00	1,375.00	1,455.00	1,535.00	1,610.00
LAB_MICROSCOPY	SYNOVIAL FLUID- TEST FOR CRYSTALS	160.00	240.00	250.00	265.00	275.00
LAB_MICROSCOPY	VAGINAL FLUID – FERNING TEST	70.00	100.00	150.00	200.00	210.00
LAB_MICROSCOPY	VAGINAL FLUID – VAGINAL WASHING ANALYSIS FOR SPERM CELLS	55.00	100.00	205.00	270.00	285.00
LAB_MICROSCOPY	STONE ANALYSIS	770.00	1,190.00	1,260.00	1,330.00	1,400.00
LAB_MICROSCOPY	URINE – PREGNANCY TEST	180.00	0.00	375.00	385.00	395.00
LAB_MICROSCOPY	URINE – ALBUMIN (QUALI)	65.00	95.00	150.00	195.00	205.00
LAB_MICROSCOPY	URINE – BILIRUBIN	65.00	110.00	170.00	195.00	205.00
LAB_MICROSCOPY	URINE – HEMOGLOBIN	65.00	110.00	170.00	195.00	205.00
LAB_MICROSCOPY	URINE – KETONE	65.00	110.00	170.00	195.00	205.00
LAB_MICROSCOPY	URINE – LEUKOCYTE	65.00	110.00	170.00	195.00	205.00
LAB_MICROSCOPY	URINE – MYOGLOBIN	95.00	170.00	180.00	200.00	220.00
LAB_MICROSCOPY	URINE – NITRITE	65.00	110.00	170.00	195.00	205.00
LAB_MICROSCOPY	URINE – PH	60.00	95.00	115.00	165.00	170.00
LAB_MICROSCOPY	URINE – SUGAR (QUALI)	65.00	95.00	115.00	165.00	175.00
LAB_MICROSCOPY	URINE – SPECIFIC GRAVITY	50.00	95.00	115.00	165.00	175.00
LAB_MICROSCOPY	URINE – UROBILINOGEN	65.00	110.00	170.00	195.00	205.00
LAB_MICROSCOPY	CSF & OTHER BODY FLUIDS – DIRECT WET MOUNT	50.00	0.00	150.00	205.00	205.00
LAB_MICROSCOPY	URINE – URINALYSIS (AUTOMATED)	240.00	260.00	275.00	290.00	300.00
LAB_MICROSCOPY	CSF- RBC MORPHOLOGY	60.00	145.00	150.00	170.00	180.00
LAB_MICROSCOPY	DIRECT FECAL SMEAR WITH FECAL CONCENTRATION TECHNIQUE	45.00	325.00	343.00	363.00	380.00
LAB_MICROSCOPY	DIRECT FECAL SMEAR WITH FECAL CONCENTRATION TECHNIQUE AND OCCULT BLOOD (GUAIAC M	290.00	420.00	535.00	620.00	640.00
LAB_MICROSCOPY	URINE- RBC MORPHOLOGY	40.00	140.00	155.00	230.00	240.00

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LAB_MICROBIOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
LAB_MICROBIOLOGY	BLOOD CS	825.00	1,800.00	2,430.00	2,550.00	2,680.00
LAB_MICROBIOLOGY	FUNGAL CS	795.00	1,570.00	1,760.00	1,810.00	1,900.00
LAB_MICROBIOLOGY	MAKI ENVIROMENTAL	420.00	440.00	460.00	490.00	505.00
LAB_MICROBIOLOGY	STOOL GS/CS	875.00	1,295.00	2,430.00	2,550.00	2,680.00
LAB_MICROBIOLOGY	PNEUMONIA PANEL	13,450.00	15,900.00	17,120.00	18,340.00	19,560.00
LAB_MICROBIOLOGY	RT-PCR FOR MDR-TB	5,420.00	5,820.00	6,110.00	6,405.00	6,695.00
LAB_MICROBIOLOGY	AFB STAIN (AURAMINE)	105.00	145.00	350.00	415.00	435.00
LAB_MICROBIOLOGY	AFB CS	2,040.00	2,475.00	2,630.00	2,785.00	2,845.00
LAB_MICROBIOLOGY	CSF GS/CS	665.00	1,295.00	2,430.00	2,550.00	2,680.00
LAB_MICROBIOLOGY	GRAM STAIN	105.00	145.00	150.00	160.00	165.00
LAB_MICROBIOLOGY	INDIA INK	105.00	115.00	130.00	135.00	140.00
LAB_MICROBIOLOGY	MRSA SCREENING	710.00	1,065.00	4,855.00	5,100.00	5,355.00
LAB_MICROBIOLOGY	TMG SMEAR	270.00	320.00	560.00	670.00	705.00
LAB_MICROBIOLOGY	URINE GS/CS	735.00	1,260.00	2,430.00	2,550.00	2,680.00
LAB_MICROBIOLOGY	KOH MOUNT	70.00	114.00	114.00	129.00	129.00
LAB_MICROBIOLOGY	EXUDATES GS/CS	1,090.00	1,295.00	2,430.00	2,550.00	2,680.00
LAB_MICROBIOLOGY	RESPIRATORY GS/CS	970.00	1,295.00	2,430.00	2,550.00	2,680.00
LAB_MICROBIOLOGY	ANAEROBIC CULTURE	765.00	890.00	940.00	990.00	1,025.00
LAB_MICROBIOLOGY	HMI (HUMAN MILK SPECIMEN)	230.00	0.00	430.00	430.00	430.00
LAB_MICROBIOLOGY	TPN SOLUTION	415.00	300.00	325.00	340.00	345.00
LAB_MICROBIOLOGY	AFB (MODIFIED)	105.00	150.00	350.00	415.00	435.00

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MEDICINE (CARDIAC CATHETERIZATION)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICINE (CARDIAC CATHETERIZATION)	HIGH FLOW O2 SYSTEM	1,910.00	–	2,030.00	2,030.00	2,030.00
MEDICINE (CARDIAC CATHETERIZATION)	CENTRAL LINE INSERTION/WC FILTER INSERTION	3,875.00	11,250.00	11,250.00	12,500.00	12,500.00
MEDICINE (CARDIAC CATHETERIZATION)	CORONARY ANGIOGRAM (CATH LAB)	4,815.00	20,185.00	20,185.00	22,425.00	–
MEDICINE (CARDIAC CATHETERIZATION)	DIGITAL SUBTRACIONAL ANGIOGRAM	4,540.00	15,000.00	15,000.00	16,675.00	16,675.00
MEDICINE (CARDIAC CATHETERIZATION)	FLUOROSCOPY	1,980.00	4,470.00	4,470.00	5,175.00	–
MEDICINE (CARDIAC CATHETERIZATION)	HEMODYNAMIC STUDIES	5,705.00	24,325.00	24,325.00	27,025.00	–
MEDICINE (CARDIAC CATHETERIZATION)	ITC HEMOCHRON 401 ACT MACHINE ANTI-COAGULATION MANAGEMENT UNIT	550.00	550	550.00	550.00	550
MEDICINE (CARDIAC CATHETERIZATION)	PERCUTANEOUS SET INCLUSIVE OF: (1) MOSQUITO FORCEP, CURVED; (1) BLADE HOLDER; (1) TRA	145.00	145	145.00	145.00	145
MEDICINE (CARDIAC CATHETERIZATION)	PERCUTANEOUS TRANSEPTAL MITRAL COMMISUROTOMY (EXCLUDES OTHER SPECIAL ITEMS)	7,975.00	28,465.00	28,465.00	31,625.00	31,625.00
MEDICINE (CARDIAC CATHETERIZATION)	PERCUTANEOUSTRANSLUMINAL CORONARY ANGIOPLASTY (EXCLUDES OTHER SPECIAL ITEMS)	5,225.00	28,465.00	28,465.00	31,625.00	31,625.00
MEDICINE (CARDIAC CATHETERIZATION)	PERMANENT PACEMAKER INSERTION	4,250.00	13,050.00	13,050.00	14,500.00	–
MEDICINE (CARDIAC CATHETERIZATION)	PPI SET	570.00	570	570.00	570.00	570
MEDICINE (CARDIAC CATHETERIZATION)	PTBD INSERTION	3,550.00	9,315.00	9,315.00	10,350.00	10,350.00
MEDICINE (CARDIAC CATHETERIZATION)	TEMPORARY PACEMAKER INSERTION	3,110.00	13,500.00	13,500.00	15,000.00	–
MEDICINE (CARDIAC CATHETERIZATION)	TEMPORARY PULSE GENERATOR	400.00	400	400.00	400.00	400
MEDICINE (CARDIAC CATHETERIZATION)	WATERS WHOLE BLOOD OXIMETER	600.00	600	600.00	600.00	600
MEDICINE (CARDIAC CATHETERIZATION)	DIGITAL SUBTRACTION ANGIOGRAPHY	4,540.00	15,000.00	15,000.00	16,675.00	–
MEDICINE (CARDIAC CATHETERIZATION)	IABP INSERTION	3,550.00	9,315.00	9,315.00	10,350.00	–
MEDICINE (CARDIAC CATHETERIZATION)	PERMANENT PACEMAKER INSERTION (W/ USE OF PPI SET)	0.00	–	13,620.00	15,070.00	–
MEDICINE (CARDIAC CATHETERIZATION)	PTCA	5,255.00	28,465.00	28,465.00	31,625.00	–
MEDICINE (CARDIAC CATHETERIZATION)	PTMC	7,975.00	28,465.00	28,465.00	31,625.00	–
MEDICINE (CARDIAC CATHETERIZATION)	SWAN GANZ INSERTION	3,875.00	11,250.00	11,250.00	12,500.00	–

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MEDICAL RESEARCH LABORATORY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICAL RESEARCH LABORATORY	DIF (DIRECT IMMUNOFLOURESCENCE)	2,605.00	2,000.00	2,985.00	3,130.00	3,270.00
MEDICAL RESEARCH LABORATORY	IFF (INDIRECT IMMUNOFLOURESCENCE)	1,000.00	2,000.00	2,000.00	2,000.00	2,000.00
MEDICAL RESEARCH LABORATORY	SILICA CLOTTING TIME (SCT)	890.00	1,350.00	1,350.00	1,420.00	1,500.00

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MEDICAL RECORDS DIVISION

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICAL RECORDS DIVISION	AFFIDAVIT TO USE SURNAME OF FATHER FOR BIRTH CERTIFICATE REGISTRATION	30	30	30	30	30
MEDICAL RECORDS DIVISION	PHOTOCOPY OF PHYSICAL RECORDS AND PRINTING OF ELECTRONIC HEALTH RECORDS / PAGE	2	2	2	2	2
MEDICAL RECORDS DIVISION	FEE FOR LOST CHART (PER CHART)	150	150	150	150	150
MEDICAL RECORDS DIVISION	PENALTY FOR FAILURE TO RETURN BORROWED CHART ON DUE DATE (PER WORKING DAY)	15	15	15	15	15
MEDICAL RECORDS DIVISION	REPLACEMENT OF BLUE CARD (LOST)	5	5	5	5	5
MEDICAL RECORDS DIVISION	ADMISSION FEE FOR NEW OPD PATIENTS (BLUE CARD)	7	7	7	7	7
MEDICAL RECORDS DIVISION	ISSUANCE OF CERTIFIED TRUE COPY OF A DOCUMENT (PER DOCUMENT)	30	30	30	30	30
MEDICAL RECORDS DIVISION	MEDICAL CERFICATES EXCLUDING FOR INSURANCE PURPOSES	30	–	30	30	30
MEDICAL RECORDS DIVISION	MEDICAL CERFICATES FOR INSURANCE PURPOSES	90	–	90	90	90
MEDICAL RECORDS DIVISION	MEDICO LEGAL CERTIFICATE	30	30	30	30	30
MEDICAL RECORDS DIVISION	PREPARATION OF BIRTH CERTICATE AND AFFIDAVIT FOR LATE REGISTRATION	50	50	50	50	50
MEDICAL RECORDS DIVISION	VERIFICATION OF BIRTH CERTIFICATES PREPARED AND TRANSMITTED TO LCR	30	30	30	30	30
MEDICAL RECORDS DIVISION	MEDICAL CERFICATES EXCLUDING FOR INSURANCE PURPOSES	30	30	30	30	30
MEDICAL RECORDS DIVISION	MEDICAL CERFICATES FOR INSURANCE PURPOSES	90	90	90	90	90

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MEDICINE (SECTION OF DERMATOLOGY)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 301-350 PULSES	5,580.00	–	–	7,000.00	–
MEDICINE (SECTION OF DERMATOLOGY)	68WHITENING BUTT (B) 576 CM2	4,980.00	6,790.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	68WHITENING ELBOWS (B) 128 CM2	2,135.00	2,910.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	68WHITENING FACE 512 CM2	2,980.00	4,065.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	68WHITENING GROIN (B) 192 CM2	3,065.00	4,180.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	68WHITENING KNEES (B) 128 CM2	2,135.00	2,910.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	68WHITENING UNDERARMS (B) 64 CM2 + 2 TEST SPOTS	2,355.00	3,210.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	CARBON PEELING 512 CM2	3,230.00	–	–	4,405.00	–
MEDICINE (SECTION OF DERMATOLOGY)	DERMAL PIGMENTED LESIONS (NEVUS OF OTA, ITO) 64 CM2	1,140.00	–	–	1,555.00	–
MEDICINE (SECTION OF DERMATOLOGY)	EPIDERMAL PIGMENTED LESIONS (SK, LENTIGO) 64 CM2	1,140.00	–	–	1,555.00	–
MEDICINE (SECTION OF DERMATOLOGY)	HAIR REDUCTION BIKINI 192 CM2	3,275.00	–	–	4,470.00	–
MEDICINE (SECTION OF DERMATOLOGY)	HAIR REDUCTION LEGS/ARMS 640 CM2	5,365.00	–	–	7,320.00	–
MEDICINE (SECTION OF DERMATOLOGY)	HAIR REDUCTION SKIN REJUVENATION 512 CM2	3,230.00	–	–	4,405.00	–
MEDICINE (SECTION OF DERMATOLOGY)	HAIR REDUCTION SKIN TIGHTENING 512 CM2	3,230.00	–	–	4,405.00	–
MEDICINE (SECTION OF DERMATOLOGY)	HAIR REDUCTION UNDERARMS 64 CM2 + 2 TEST SPOTS	2,505.00	–	–	3,415.00	–
MEDICINE (SECTION OF DERMATOLOGY)	HAIR REDUCTION UPPER LIP 64 CM2	1,140.00	–	–	1,555.00	–
MEDICINE (SECTION OF DERMATOLOGY)	HAIR REDUCTION UPPER LIP AND CHIN 2 TEST SPOTS	1,365.00	–	–	1,860.00	–
MEDICINE (SECTION OF DERMATOLOGY)	HALF A PALM SIZEN 64 CM2 585 NM LASER QUANTA SYSTEM	1,065.00	1,455.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	HALF FACE/PALM SIZE 128 CM2 585 NM LASER QUANTA SYSTEM	2,000.00	2,725.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	HEMANGIOMA/PORT WINE STAIN 64 CM2	1,140.00	–	–	1,555.00	–
MEDICINE (SECTION OF DERMATOLOGY)	INFLAMMATORY ACNE/ROSECEA 128 CM2	2,135.00	–	–	2,915.00	–
MEDICINE (SECTION OF DERMATOLOGY)	LASER TONING AND REJUVENATION 512 CM2	3,230.00	–	–	4,405.00	–
MEDICINE (SECTION OF DERMATOLOGY)	MELASMA, ROSACEA 128 CM2	2,000.00	2,725.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	MELASMA, ROSACEA 64 CM2	1,065.00	1,455.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	ONYCHOMYCOSIS TEST SPOT	680.00	–	–	930	–
MEDICINE (SECTION OF DERMATOLOGY)	PWS, HEMANGIOMA 128 CM2	2,000.00	2,725.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	PWS, HEMANGIOMA 64 CM2	1,065.00	1,455.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	SKIN REJUVENATION 512 CM2	2,980.00	4,065.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	SPIDER NEVI, LEG TELANGIECTASIAS 64 CM2	1,140.00	–	–	1,555.00	–
MEDICINE (SECTION OF DERMATOLOGY)	STRIAE, WRINKLES 128 CM2	2,000.00	2,725.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	STRIAE, WRINKLES 64 CM2	1,065.00	1,455.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	TATTOO REMOVAL 64 CM2	1,140.00	–	–	1,555.00	–
MEDICINE (SECTION OF DERMATOLOGY)	TATTOO REMOVAL BUTT (B) 640 CM2	5,365.00	–	–	7,315.00	–
MEDICINE (SECTION OF DERMATOLOGY)	TATTOO REMOVAL ELBOWS (B) 128 CM2	2,280.00	–	–	3,110.00	–
MEDICINE (SECTION OF DERMATOLOGY)	TATTOO REMOVAL GROIN (B) 192 CM2	3,275.00	–	–	4,470.00	–
MEDICINE (SECTION OF DERMATOLOGY)	TATTOO REMOVAL KNEES (B) 128 CM2	2,280.00	–	–	3,110.00	–
MEDICINE (SECTION OF DERMATOLOGY)	TATTOO REMOVAL UNDERARMS (B) 64 CM2 + 2 TEST SPOTS	2,505.00	–	–	3,415.00	–
MEDICINE (SECTION OF DERMATOLOGY)	TEST SPOTS 585 NM LASER QUANTA SYSTEM	645.00	880	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	VASCULAR LESION (SPIDER ANGIOMA VASCULARIZED SCARS) 128 CM2	2,000.00	2,725.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	VASCULAR LESION (SPIDER ANGIOMA VASCULARIZED SCARS) 64 CM2	1,065.00	1,455.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	WARTS, LENTIGO, SK 64 CM2	1,065.00	1,455.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	WHOLE FACE 512 CM2 585 NM LASER QUANTA SYSTEM	2,980.00	4,065.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	YAG LASER HALF A PALM SIZE 64 CM2	1,140.00	–	–	1,555.00	–
MEDICINE (SECTION OF DERMATOLOGY)	YAG LASER HALF FACE/PALM SIZE 128 CM2	2,135.00	–	–	2,915.00	–
MEDICINE (SECTION OF DERMATOLOGY)	YAG LASER TEST SPOTS	680.00	–	–	930	–
MEDICINE (SECTION OF DERMATOLOGY)	YAG LASER WHOLE FACE 512 CM2	3,230.00	–	–	4,405.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO ABNOM (HORI’S NEVUS) PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO ABNOM (HORI’S NEVUS) PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO ACNE PIH PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO ACNE PIH PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO AGE SPOTS PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO AGE SPOTS PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO CAFE-AU-LAIT PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO CAFE-AU-LAIT PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO FOR ACNE SCARS (ROLLING, BOX AND ICE-PICK TYPES) PER 100 CM2 (FRACTIONAL AND FULL	3,300.00	–	–	5,100.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO FOR ACNE SCARS (ROLLING, BOX AND ICE-PICK TYPES) PER 50 CM2 (FRACTIONAL AND FULL	1,650.00	–	–	2,550.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO FRECKLES PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO FRECKLES PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO FULL FACE WHITENING (OR AREA/SPOT WHITENING) PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO FULL FACE WHITENING (OR AREA/SPOT WHITENING) PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO MELASMA PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO MELASMA PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO NEVUS OF OTA/ITA PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO NEVUS OF OTA/ITA PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO PIH (HYPERPIGMENTATION) PER 100 CM2 (FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO PIH (HYPERPIGMENTATION) PER 50 CM2 (FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO SKIN REVITALIZATION -WHOLE FACE (FULL BEAM) 512 CM2	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO SKIN TIGHTENING PROCEDURE OF THE FACE-WHOLE FACE (FRACTIONAL AND FULL BEAM) 5	3,300.00	–	–	5,100.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO TATTOO REMOVAL PER 100 CM2 (FRACTIONAL AND FULL BEAM)	2,870.00	–	–	4,430.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PICO TATTOO REMOVAL PER 50 CM2 (FRACTIONAL AND FULL BEAM)	1,435.00	–	–	2,215.00	–
MEDICINE (SECTION OF DERMATOLOGY)	TEST SPOTS PER 1-2 CM2	60.00	–	–	90	–
MEDICINE (SECTION OF DERMATOLOGY)	VISIA HIGH RESOLUTION PHOTOGRAPHY (NO LASER PROCEDURE) FULL FACE	350.00	–	–	500	–
MEDICINE (SECTION OF DERMATOLOGY)	ZIMMER CRYO6	75.00	–	–	100	–
MEDICINE (SECTION OF DERMATOLOGY)	FOREIGN OBSERVERSHIP PROGRAM	12,647.70	–	–	12,647.70	–
MEDICINE (SECTION OF DERMATOLOGY)	FRACTIONAL CO2 LASER – HALF A PALM SIZE (64 CM2)	1,030.00	1,590.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	FRACTIONAL CO2 LASER – HALF FACE (128 CM2)	1,650.00	2,550.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	FRACTIONAL CO2 LASER -TEST SPOTS	610.00	940	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	FRACTIONAL CO2 LASER – WHOLE FACE (512 CM2)	2,350.00	4,160.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	LOCAL OBSERVERSHIP PROGRAM	5,480.00	–	–	5,480.00	–
MEDICINE (SECTION OF DERMATOLOGY)	MOHS MICROGRAPHIC SURGERY ADDITIONAL LABOR PER STAGE	950.00	950	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	MOHS MICROGRAPHIC SURGERY (TUMOR SIZE IS GREATER THAN 2.0CM)	7,670.00	11,860.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	MOHS MICROGRAPHIC SURGERY (TUMOR SIZE IS LESS THAN OR EQUAL TO 2.0CM)	4,470.00	6,900.00	–	–	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 101-150 PULSES	2,950.00	–	–	4,570.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 1-3 PULSES	1,100.00	–	–	2,000.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 151-200 PULSES	3,610.00	–	–	5,400.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 201-250 PULSES	3,970.00	–	–	6,000.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 251-300 PULSES	4,920.00	–	–	6,600.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 26-50 PULSES	1,810.00	–	–	2,790.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 351-400 PULSES	6,230.00	–	–	7,600.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 401-450 PULSES	6,890.00	–	–	8,000.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 451-500 PULSES	7,540.00	–	–	8,600.00	–
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 51-100 PULSES	2,300.00	–	–	3,550.00	–
MEDICINE (SECTION OF DERMATOLOGY)	PLATELET RICH PLASMA-HAIR LOSS (GENERIC SODIUM CITRATE)	2,000.00	3,350.00	3,350.00	3,350.00	3,350.00
MEDICINE (SECTION OF DERMATOLOGY)	PLATELET RICH PLASMA-HAIR LOSS (REGEN LAB)	6,500.00	10,150.00	10,150.00	10,150.00	10,150.00
MEDICINE (SECTION OF DERMATOLOGY)	PLATELET RICH PLASMA-SKIN REJUVENATION (GENERIC SODIUM CITRATE)	2,000.00	3,350.00	3,350.00	3,350.00	3,350.00
MEDICINE (SECTION OF DERMATOLOGY)	PLATELET RICH PLASMA-SKIN REJUVENATION (REGEN LAB)	6,500.00	10,150.00	10,150.00	10,150.00	10,150.00
MEDICINE (SECTION OF DERMATOLOGY)	PLATELET RICH PLASMA-WOUND CARE (GENERIC SODIUM CITRATE)	2,000.00	3,350.00	3,350.00	3,350.00	3,350.00
MEDICINE (SECTION OF DERMATOLOGY)	PLATELET RICH PLASMA-WOUND CARE (REGEN LAB)	6,500.00	10,150.00	10,150.00	10,150.00	10,150.00
MEDICINE (SECTION OF DERMATOLOGY)	VBEAM 4-25 PULSES	1,500.00	–	–	2,320.00	–
MEDICINE (SECTION OF DERMATOLOGY)	4-5 LESIONS/FOR EPIDERMAL NEVUS, MAXIMUM AREA 5 X 5 CM	800.00	1,100.00	1,100.00	1,100.00	1,100.00
MEDICINE (SECTION OF DERMATOLOGY)	ACNE SURGERY (FOR COMEDONES)	450.00	625	625	625	625
MEDICINE (SECTION OF DERMATOLOGY)	ED (ELECTRODESSICATION) BIG – 1-3 LESIONS/FOR EPIDERMAL NEVUS, MAXIMUM AREA OF 3 X 3	600.00	900	900	900	900
MEDICINE (SECTION OF DERMATOLOGY)	ED (ELECTRODESSICATION) SMALL – EXCLUDING EMLA	505.00	615	615	615	615
MEDICINE (SECTION OF DERMATOLOGY)	EXTRACTION- EXCLUDING EMLA 1-10 LESIONS	300.00	450	450	450	450
MEDICINE (SECTION OF DERMATOLOGY)	EXTRACTION- EXCLUDING EMLA 11-20 LESIONS	450.00	600	600	600	600
MEDICINE (SECTION OF DERMATOLOGY)	ILSI (INTRALESIONAL CORTICOSTEROID INJECTION) – EXCLUDING TRIAMCINOLENE ACETONIDE	335.00	410	410	410	410

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MEDICINE (SECTION OF CARDIOLOGY) CVS

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICINE (SECTION OF CARDIOLOGY) CVS	PRESSURES WITH PULSE VOLUME RECORDING (UPPER OR LOWER EXTREMITIES)	1,020.00	1,845.00	1,940.00	2,030.00	2,125.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	3D ONLY	3,110.00	–	3,135.00	3,285.00	3,435.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	AMBULATORY BLOOD PRESSURE MONITORING	1,000.00	–	2,230.00	2,340.00	2,445.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	ARTERIAL DUPLEX SCAN, LOWER EXTREMITIES	1,495.00	–	3,425.00	3,590.00	3,755.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	CAROTID DUPLEX SCAN (BILATERAL)	1,650.00	–	3,215.00	3,365.00	3,520.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	DUPLEX ULTRASOUND OF VASCULAR MASS (PSEUDO-ANEURYSM)	1,665.00	–	1,680.00	1,760.00	1,840.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	FOCUSED CARDIAC ULTRASOUND	935.00	–	940.00	985.00	1,030.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	POINT OF CARE VASCULAR ULTRASOUND	765.00	–	770.00	810.00	845
MEDICINE (SECTION OF CARDIOLOGY) CVS	TOE BRACHIAL INDEX (TBI)	355.00	–	460.00	480.00	505
MEDICINE (SECTION OF CARDIOLOGY) CVS	TRANSTHORACIC ECHO, BRIEF STUDY (FOLLOW-UP STUDY WITHIN 6 MONTHS)	1,510.00	–	2,845.00	2,980.00	–
MEDICINE (SECTION OF CARDIOLOGY) CVS	TRANSTHORACIC ECHOCARDIOGRAPHY, (FULL-BEDSIDE)- IN PATIENT ONLY	2,015.00	–	3,850.00	4,030.00	4,215.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	TRANSTHORACIC ECHOCARDIOGRAPHY (FULL STUDY)	1,680.00	–	3,150.00	3,300.00	3,450.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	VENOUS DUPLEX SCAN, LOWER EXTREMITIES	1,495.00	–	3,425.00	3,590.00	3,755.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	WRIST BRACHIAL INDEX (WBI)	350.00	–	460.00	480.00	505
MEDICINE (SECTION OF CARDIOLOGY) CVS	DOBUTAMINE STRESS ECHOCARDIO-GRAPHY (DSE)	2,940.00	6,995.00	7,345.00	7,695.00	8,045.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	TREADMILL EXERCISE TEST	1,400.00	–	1,685.00	1,765.00	1,845.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	TILT TABLE TEST	2,520.00	3,570.00	3,750.00	3,925.00	4,105.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	ARTERIAL DUPLEX SCAN, UPPER EXTREMITIES	1,495.00	3,265.00	3,425.00	3,590.00	3,755.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	ARTERIAL & VEIN MAPPING	2,840.00	4,510.00	4,735.00	4,960.00	5,185.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	AVF GRAFT SURVEILLANCE	2,080.00	3,775.00	3,965.00	4,150.00	4,340.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	DVT SCREENING	1,090.00	1,970.00	2,065.00	2,165.00	2,265.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	VENOUS DUPLEX SCAN, UPPER EXTREMITIES	1,495.00	3,265.00	3,425.00	3,590.00	3,755.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	ANKLE-BRACHIAL INDEX (ABI)	1,080.00	1,515.00	1,590.00	1,665.00	1,740.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	CONTRAST ECHOCARDIOGRAPHY	65.00	160	165.00	175.00	180
MEDICINE (SECTION OF CARDIOLOGY) CVS	INTRA-OPERATIVE TRANSESO-PHAGEAL ECHOCARDIO-GRAPHY (IOTEE)	5,040.00	11,995.00	12,595.00	13,195.00	13,795.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	TRANSESO-PHAGEAL ECHOCARDIO-GRAPHY (TEE)	3,360.00	7,995.00	8,395.00	8,795.00	9,195.00
MEDICINE (SECTION OF CARDIOLOGY) CVS	TREADMILL STRESS ECHOCARDIO-GRAPHY (TSE)	1,975.00	4,700.00	4,935.00	5,170.00	5,405.00

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MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	IMPORTED ALLERGEN – COCKROACH	–	–	–	3,380.00	–
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	IMPORTED ALLERGEN – HOUSEDUSTMITE	–	–	–	2,465.00	–
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	LOCAL ALLERGEN IN STERILE VIAL – FOOD/ML	–	–	–	480.00	–
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	LOCAL ALLERGEN IN STERILE VIAL – POLLEN/ML	–	–	–	530.00	–
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	LOCAL ALLERGEN – POLLEN/ML	310	–	–	350.00	–
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	LOCAL ALLERGEN – FOOD/ML	265	–	–	300.00	–
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	IMMUNOTHERAPY TO COACKROACH	280	390	390	390.00	390
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	IMMUNOTHERAPY TO HOUSEDUST MITE	280	390	390	390.00	390
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	IMMUNOTHERAPY TO POLLENS	90	190	190	190.00	190
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	INTRADERMAL TESTING TO INDOOR ALLERGEN	450	450	450	450.00	450
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	SKIN TESTING TO AEROALLERGENS	750	1,800.00	1,800.00	1,800.00	1,800.00
MEDICINE (SECTION OF ALLERGY & IMMUNOLOGY)	SKIN TESTING TO FOOD ALLERGENS	450	1,350.00	1,350.00	1,350.00	1,350.00

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MEDICINE (SECTION OF GASTROENTEROLOGY)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICINE (SECTION OF GASTROENTEROLOGY)	PROCEDURE- PROCTO / RI	250	690.00	780.00	875.00	875.00
MEDICINE (SECTION OF GASTROENTEROLOGY)	BIOPSY- LIVER BIOPSY, PERCUTANEOUS	95	295.00	333.00	370.00	370.00
MEDICINE (SECTION OF GASTROENTEROLOGY)	PROCEDURE- ARGON PLASMA LASER	2,465.00	4,555.00	4,810.00	5,060.00	5,060.00
MEDICINE (SECTION OF GASTROENTEROLOGY)	PROCEDURE- COLONOSCOPY (MEDICINE)	580	1,600.00	1,790.00	1,995.00	1,995.00
MEDICINE (SECTION OF GASTROENTEROLOGY)	PROCEDURE- COLONOSCOPY W/POLYPECTOMY	–	2,745.00	3,025.00	3,375.00	3,490.00
MEDICINE (SECTION OF GASTROENTEROLOGY)	PROCEDURE- ERCP (FLUORO NOT INCLUDED)	1,030.00	2,140.00	2,260.00	2,385.00	2,385.00
MEDICINE (SECTION OF GASTROENTEROLOGY)	PROCEDURE- GASTROSCOPY (MEDICINE)	580	1,570.00	1,780.00	1,970.00	1,970.00
MEDICINE (SECTION OF GASTROENTEROLOGY)	PROCEDURE- SCLEROTHERAPY AND GASTROSCOPY	–	2,830.00	3,205.00	3,550.00	3,695.00

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MRL-CLINICAL CHEMISTRY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MRL-CLINICAL CHEMISTRY	HBA1C	300.00	450.00	450.00	450.00	450.00
MRL-CLINICAL CHEMISTRY	SERUM IRON	280.00	450.00	450.00	450.00	450.00
MRL-CLINICAL CHEMISTRY	TIBC (TOTAL IRON BINDING CAPACITY)	450.00	750.00	750.00	750.00	750.00
MRL-CLINICAL CHEMISTRY	URINE METANEPHRINE	2,500.00	3,500.00	3,500.00	3,500.00	3,500.00
MRL-CLINICAL CHEMISTRY	URINE MICRAL TEST	100.00	200.00	200.00	200.00	200.00

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MOLECULAR PATHOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MOLECULAR PATHOLOGY	RT-PCR TEST FOR SARS-COV2	3,300.00	–	3,400.00	3,400.00	3,400.00
MOLECULAR PATHOLOGY	BD SARS COV-2/ FLU ASSAY USING BD MAX SYSTEM	3,500.00	–	–	–	–
MOLECULAR PATHOLOGY	BIOFIRE RESPIRATORY 2.1 PANEL	2,040.00	3,160.00	3,350.00	3,530.00	3,720.00
MOLECULAR PATHOLOGY	RT-PCR TEST FOR SARS-COV2 USING GENEXPERT SYSTEM	1,000.00	3,400.00	3,400.00	3,400.00	3,400.00
MOLECULAR PATHOLOGY	PACU KIT	–	–	–	200	–
MOLECULAR PATHOLOGY	FISH B-CELL LYMPHOMA PANEL	14,370.00	19,600.00	–	19,600.00	–
MOLECULAR PATHOLOGY	CEPHEID 4PLEX TEST	3,500.00	5,000.00	5,000.00	5,000.00	5,000.00

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MILK BANK & LACTATION UNIT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MILK BANK & LACTATION UNIT	LACTATION COUNSELING	–	490	–	550	580
MILK BANK & LACTATION UNIT	LACTATION MASSAGE	–	540	–	600	630

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MEDICINE (SECTION OF PULMONOLOGY)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICINE (SECTION OF PULMONOLOGY)	SPIROMETRY	670.00	1,160.00	1,310.00	1,310.00	1,310.00
MEDICINE (SECTION OF PULMONOLOGY)	6-MINUTE WALK TEST (MWT)	500.00	750	800.00	850.00	900.00
MEDICINE (SECTION OF PULMONOLOGY)	ABG	370.00	–	1,280.00	1,415.00	1,485.00
MEDICINE (SECTION OF PULMONOLOGY)	ULTRASOUND-GUIDED FNAB	600.00	1,190.00	1,190.00	1,340.00	1,490.00
MEDICINE (SECTION OF PULMONOLOGY)	ULTRASOUND-PLAIN CHEST	210.00	450	450.00	545.00	650.00
MEDICINE (SECTION OF PULMONOLOGY)	PROCEDURE- VIDEOBRONCHOSCOPY (PULMO)	400.00	1,905.00	1,905.00	2,145.00	2,380.00
MEDICINE (SECTION OF PULMONOLOGY)	ULTRASOUND-GUIDED THORACENTESIS (EXCLUDES PF AND THORACENTESIS NEEDS)	600.00	1,100.00	1,100.00	1,330.00	1,500.00
MEDICINE (SECTION OF PULMONOLOGY)	CARDIO-PULMONARY EXERCISE TESTING (CPET)	1,900.00	2,800.00	2,970.00	3,130.00	3,300.00
MEDICINE (SECTION OF PULMONOLOGY)	PULMONARY FUNCTION TEST WITH BODY BOX	4,210.00	5,290.00	5,290.00	5,600.00	5,910.00

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MEDICINE (SECTION OF NEPHROLOGY)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MEDICINE (SECTION OF NEPHROLOGY)	ULTRASOUND- CHEST	210.00	450	545.00	650.00	650.00
MEDICINE (SECTION OF NEPHROLOGY)	ULTRASOUND- GUIDED BIOPSY	210.00	450	545.00	650.00	650.00
MEDICINE (SECTION OF NEPHROLOGY)	ULTRASOUND- KUB	230.00	850	850.00	1,030.00	1,030.00
MEDICINE (SECTION OF NEPHROLOGY)	INITIAL DIALYSIS (COST OF DIALYZER NOT INCLUDED)	1,905.00	2,425.00	2,425.00	2,425.00	2,425.00
MEDICINE (SECTION OF NEPHROLOGY)	INITIAL DIALYSIS (COST OF DIALYZER NOT INCLUDED) PGH EMPLOYEE	1,800.00	–	2,220.00	2,220.00	2,220.00
MEDICINE (SECTION OF NEPHROLOGY)	SPECIAL DIALYZER – HIPS 15	1,700.00	1,700.00	1,700.00	1,700.00	1,700.00
MEDICINE (SECTION OF NEPHROLOGY)	SPECIAL DIALYZER – HIPS 18	2,000.00	2,000.00	2,000.00	2,000.00	2,000.00
MEDICINE (SECTION OF NEPHROLOGY)	SPECIAL DIALYZER – HIPS 20	2,300.00	2,300.00	2,300.00	2,300.00	2,300.00
MEDICINE (SECTION OF NEPHROLOGY)	STANDARD DIALYZER – LOPS 15	800.00	800	800.00	800.00	800.00
MEDICINE (SECTION OF NEPHROLOGY)	STANDARD DIALYZER – LOPS 18	850.00	850	850.00	850.00	850.00
MEDICINE (SECTION OF NEPHROLOGY)	STANDARD DIALYZER – LOPS 20	900.00	900	900.00	900.00	900.00
MEDICINE (SECTION OF NEPHROLOGY)	SUBSEQUENT DIALYSIS	1,905.00	2,425.00	2,425.00	2,425.00	2,425.00
MEDICINE (SECTION OF NEPHROLOGY)	SUBSEQUENT DIALYSIS PGH EMPLOYEE	1,800.00	–	2,220.00	2,220.00	2,220.00
MEDICINE (SECTION OF NEPHROLOGY)	ULTRASOUND- GUIDED KIDNEY BIOPSY	500.00	1,190.00	1,190.00	1,490.00	1,490.00
MEDICINE (SECTION OF NEPHROLOGY)	ULTRASOUND- GUIDED THORACENTESIS (NEPHRO)	600.00	1,100.00	1,330.00	1,500.00	1,500.00
MEDICINE (SECTION OF NEPHROLOGY)	INITIAL DIALYSIS (COST OF DIALYZER NOT INCLUDED) PGH EMPLOYEE	1,800.00	2,220.00	2,220.00	2,220.00	2,220.00
MEDICINE (SECTION OF NEPHROLOGY)	SUBSEQUENT DIALYSIS PGH EMPLOYEE	1,800.00	2,220.00	2,220.00	2,220.00	2,220.00

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MRL-MICROBIOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MRL-MICROBIOLOGY	DSSM	230	–	–	–	–
MRL-MICROBIOLOGY	TB SPECIES IDENTIFICATION	400	–	–	–	–
MRL-MICROBIOLOGY	XPERT MTB/RIF ASSAY	435	–	–	–	–
MRL-MICROBIOLOGY	AEROBIC CULTURE & SENSITIVITY- CSF	350	700	700	700	700
MRL-MICROBIOLOGY	AEROBIC CULTURE & SENSITIVITY- EXUDATES & OTHER BODY FLUIDS	350	700	700	700	700
MRL-MICROBIOLOGY	AEROBIC CULTURE & SENSITIVITY- RESPIRATORY	350	700	700	700	700
MRL-MICROBIOLOGY	AEROBIC CULTURE & SENSITIVITY- THROAT SWAB	300	500	500	500	500
MRL-MICROBIOLOGY	AEROBIC CULTURE & SENSITIVITY- TISSUE	350	700	700	700	700
MRL-MICROBIOLOGY	AEROBIC CULTURE & SENSITIVITY- URINE	300	600	600	600	600
MRL-MICROBIOLOGY	AFB SMEAR	120	150	150	150	150
MRL-MICROBIOLOGY	BACTIGEN	700	1,400.00	1,400.00	1,400.00	1,400.00
MRL-MICROBIOLOGY	CALAS	700	1,400.00	1,400.00	1,400.00	1,400.00
MRL-MICROBIOLOGY	CONVENTIONAL TB CULTURE	1,230	–	–	–	–
MRL-MICROBIOLOGY	FUNGAL CULTURE	350	700	700	700	700
MRL-MICROBIOLOGY	GIEMSA STAIN FOR TZANK	350	700	700	700	700
MRL-MICROBIOLOGY	GRAM STAIN MRL	120	150	150	150	150
MRL-MICROBIOLOGY	HSV 1 & 2 PCR	0	3,000.00	3,000.00	3,000.00	3,000.00
MRL-MICROBIOLOGY	INDIA INK (CSF)	100	150	150	150	150
MRL-MICROBIOLOGY	KOH MOUNT	105	145	150	160	170
MRL-MICROBIOLOGY	LEPTO MAT	245	520	555	585	615
MRL-MICROBIOLOGY	LEPTOSPIROSIS CULTURE	650	775	820	865	910
MRL-MICROBIOLOGY	MB BACT TB CULTURE	0	2,585.00	2,740.00	2,900.00	3,040.00
MRL-MICROBIOLOGY	MODIFIED KINYOUN	350	700	700	700	700
MRL-MICROBIOLOGY	ORTHOTOLUIDINE BLUE FOR PCP	350	700	700	700	700
MRL-MICROBIOLOGY	SLIDEX	700	1,400.00	1,400.00	1,400.00	1,400.00
MRL-MICROBIOLOGY	TB PCR	0	4,540.00	4,810.00	5,075.00	5,340.00
MRL-MICROBIOLOGY	TB PCR AND MB BACT TB CULTURE PACKAGE	0	6,270.00	6,645.00	7,020.00	7,375.00
MRL-MICROBIOLOGY	TB CULTURE	1,400	–	–	–	–

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MRL-IMMUNOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MRL-IMMUNOLOGY	ANA CTD ELIA (BATCH RUN)	1,200.00	1,550.00	1,600.00	1,650.00	1,750.00
MRL-IMMUNOLOGY	ANA CTD ELIA (BATCH RUN)-SEND OUT	–	1,750.00	1,750.00	1,750.00	1,750.00
MRL-IMMUNOLOGY	ANA CTD ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	ANA IF (BATCH RUN)	1,200.00	1,500.00	1,600.00	1,650.00	1,750.00
MRL-IMMUNOLOGY	ANA IF (BATCH RUN)-SEND OUT	–	1,750.00	1,750.00	1,750.00	1,750.00
MRL-IMMUNOLOGY	ANA IF (STAT RUN)	–	6,000.00	6,000.00	6,000.00	6,000.00
MRL-IMMUNOLOGY	ANTICARDIOLIPIN (ACA)IGG	1,600.00	2,200.00	2,475.00	2,750.00	3,300.00
MRL-IMMUNOLOGY	ANTICARDIOLIPIN (ACA)IGG-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	ANTICARDIOLIPIN (ACA)IGG (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	ANTICARDIOLIPIN (ACA)IGM	1,600.00	2,200.00	2,475.00	2,750.00	3,300.00
MRL-IMMUNOLOGY	ANTICARDIOLIPIN (ACA)IGM-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	ANTICARDIOLIPIN (ACA)IGM (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	ANTI-CCP ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	ANTI-CCP ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	ANTI-CCP ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	ANTI-JO1 ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	ANTI-JO1 ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	ANTI-JO1 ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	ANTI-RO/SSA ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	ANTI-RO/SSA ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	ANTI-RO/SSA ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	ANTI-SCL70 ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	ANTI-SCL70 ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	ANTI-SCL70 ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	ANTI-SM (ANTI-SMITH) ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	ANTI-SM (ANTI-SMITH) ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	ANTI-SM (ANTI-SMITH) ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	ANTI-U1RNP ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	ANTI-U1RNP ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	ANTI-U1RNP ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	APAS PANEL PACKAGE (ACA,APTT, DRVVT,SCT)	4,650.00	6,800.00	7,500.00	8,050.00	9,075.00
MRL-IMMUNOLOGY	APAS PANEL PACKAGE-SEND OUT	–	9,100.00	9,100.00	9,100.00	9,100.00
MRL-IMMUNOLOGY	APAS PANEL PACKAGE (STAT RUN)	–	17,500.00	17,500.00	17,500.00	17,500.00
MRL-IMMUNOLOGY	APTT (FULLY AUTOMATED)	400	720.00	800.00	800.00	850.00
MRL-IMMUNOLOGY	APTT (FULLY AUTOMATED)-SEND OUT	–	850.00	850.00	850.00	850.00
MRL-IMMUNOLOGY	APTT (FULLY AUTOMATED) (STAT RUN)	–	1,600.00	1,600.00	1,600.00	1,600.00
MRL-IMMUNOLOGY	BETA2 GLYCOPROTEIN IGG ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	BETA2 GLYCOPROTEIN IGG ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	BETA2 GLYCOPROTEIN IGG ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	BETA2 GLYCOPROTEIN IGM ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	BETA2 GLYCOPROTEIN IGM ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	BETA2 GLYCOPROTEIN IGM ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	C3	985	1,150.00	1,200.00	1,250.00	1,300.00
MRL-IMMUNOLOGY	C3-SEND OUT	–	1,500.00	1,500.00	1,500.00	1,500.00
MRL-IMMUNOLOGY	C3 (STAT RUN)	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	C-ANCA ELIA	3,000.00	3,150.00	3,200.00	3,250.00	3,300.00
MRL-IMMUNOLOGY	C-ANCA ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	C-ANCA ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	CD4	1,800.00	2,250.00	2,435.00	2,555.00	2,875.00
MRL-IMMUNOLOGY	CD4-SEND-OUT	–	2,875.00	2,875.00	2,875.00	2,875.00
MRL-IMMUNOLOGY	CD4 (STAT RUN)	–	6,000.00	6,000.00	6,000.00	6,000.00
MRL-IMMUNOLOGY	CENP (CENTROMERE) ELIA	–	3,000.00	3,000.00	3,000.00	3,000.00
MRL-IMMUNOLOGY	DRVVT/LAC	715	1,200.00	1,300.00	1,350.00	1,400.00
MRL-IMMUNOLOGY	DRVVT/LAC-SEND OUT	–	1,400.00	1,400.00	1,400.00	1,400.00
MRL-IMMUNOLOGY	DRVVT/LAC (STAT RUN)	–	3,000.00	3,000.00	3,000.00	3,000.00
MRL-IMMUNOLOGY	DSDNA ELIA	1,000.00	2,000.00	2,050.00	2,100.00	2,150.00
MRL-IMMUNOLOGY	DSDNA ELIA-SEND OUT	–	2,150.00	2,150.00	2,150.00	2,150.00
MRL-IMMUNOLOGY	DSDNA ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	L A T	4,000.00	4,000.00	4,000.00	4,000.00	4,000.00
MRL-IMMUNOLOGY	L A T-SEND OUT	–	4,000.00	4,000.00	4,000.00	4,000.00
MRL-IMMUNOLOGY	L A T (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	LUPUS PANEL ELIA	–	19,000.00	19,000.00	19,000.00	19,000.00
MRL-IMMUNOLOGY	LUPUS PANEL ELIA-SEND OUT	–	21,000.00	21,000.00	21,000.00	21,000.00
MRL-IMMUNOLOGY	LUPUS PANEL ELIA (STAT RUN)	–	30,000.00	30,000.00	30,000.00	30,000.00
MRL-IMMUNOLOGY	P-ANCA ELIA	3,000.00	3,150.00	3,150.00	3,150.00	3,150.00
MRL-IMMUNOLOGY	P-ANCA ELIA-SEND OUT	–	3,500.00	3,500.00	3,500.00	3,500.00
MRL-IMMUNOLOGY	P-ANCA ELIA (STAT RUN)	–	8,000.00	8,000.00	8,000.00	8,000.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGA	1,550.00	1,875.00	1,920.00	1,965.00	2,010.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGA-SEND OUT	–	2,200.00	2,200.00	2,200.00	2,200.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGA (STAT RUN)	–	5,000.00	5,000.00	5,000.00	5,000.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGG	1,550.00	1,875.00	1,920.00	1,965.00	2,010.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGG-SEND OUT	–	2,200.00	2,200.00	2,200.00	2,200.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGG (STAT RUN)	–	5,000.00	5,000.00	5,000.00	5,000.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGM	1,550.00	1,875.00	1,920.00	1,965.00	2,010.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGM-SEND OUT	–	2,200.00	2,200.00	2,200.00	2,200.00
MRL-IMMUNOLOGY	SERUM IMMUNOGLOBULINS IGM (STAT RUN)	–	5,000.00	5,000.00	5,000.00	5,000.00
MRL-IMMUNOLOGY	ANTI-LA/SSB ELIA	–	3,150.00	3,250.00	3,300.00	0.00

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MRL-HISTOPATHOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MRL-HISTOPATHOLOGY	HISTOPATHOLOGY	150	300	300	300	300
MRL-HISTOPATHOLOGY	SPECIAL STAINS ALCIAN BLUE STAIN	100	–	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS FITE FARACO	100	–	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS GIEMSA	100	–	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS PAS	100	–	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS PEARL STAIM	100	–	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS ALCIAN BLUE STAIN	100	200	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS FITE FARACO	100	200	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS GIEMSA	100	200	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS PAS	100	200	200	200	200
MRL-HISTOPATHOLOGY	SPECIAL STAINS PEARL STAIM	100	200	200	200	200

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MRL-HEMATOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MRL-HEMATOLOGY	ANTI-THROMBIN III	800.00	3,500.00	3,500.00	3,500.00	3,500.00
MRL-HEMATOLOGY	BONE MARROW ASPIRATE	300.00	–	–	–	–
MRL-HEMATOLOGY	CBC WITH PLATELET COUNT & RBC INDICES	240.00	340	340	340	340
MRL-HEMATOLOGY	D-DIMER / FDP	2,000.00	3,500.00	3,500.00	3,500.00	3,500.00
MRL-HEMATOLOGY	ESR	150.00	200	200	200	200
MRL-HEMATOLOGY	FACTOR IX	1,850.00	3,500.00	3,500.00	3,500.00	3,500.00
MRL-HEMATOLOGY	FACTOR VIII	1,800.00	3,500.00	3,500.00	3,500.00	3,500.00
MRL-HEMATOLOGY	FACTOR VIII INHIBITOR	9,000.00	17,500.00	17,500.00	17,500.00	17,500.00
MRL-HEMATOLOGY	FACTOR XI	2,000.00	3,500.00	3,500.00	3,500.00	3,500.00
MRL-HEMATOLOGY	FIBRINOGEN	690.00	1,350.00	1,350.00	1,510.00	1,590.00
MRL-HEMATOLOGY	HAM’S TEST	400.00	800	800	800	800
MRL-HEMATOLOGY	IRON STAIN	500.00	1,000.00	1,000.00	1,000.00	1,000.00
MRL-HEMATOLOGY	LAP (LEUKOCYTE ALKALINE PHOS.)	1,000.00	3,500.00	3,500.00	3,500.00	3,500.00
MRL-HEMATOLOGY	MPO (MYELOPEROXIDASE)	550.00	1,500.00	1,500.00	1,500.00	1,500.00
MRL-HEMATOLOGY	OFT (OSMOTIC FRAGILITY TEST)	500.00	1,000.00	1,000.00	1,000.00	1,000.00
MRL-HEMATOLOGY	PAS (PERIODIC ACID SCHIFF)	550.00	1,500.00	1,500.00	1,500.00	1,500.00
MRL-HEMATOLOGY	PBS (PERIPHERAL BLOOD SMEAR)	110.00	160	160	160	160
MRL-HEMATOLOGY	PROTEIN C	3,500.00	4,800.00	4,800.00	4,800.00	4,800.00
MRL-HEMATOLOGY	PROTEIN S	4,300.00	6,150.00	6,150.00	6,150.00	6,150.00
MRL-HEMATOLOGY	PT (PROTIME) HIGHLY SPECIFIC	380.00	550	550	550	550
MRL-HEMATOLOGY	PTT (PARTIAL THROMBOPLASTIN TIME)	400.00	720	800	800	800
MRL-HEMATOLOGY	PTT WITH MIXING	800.00	1,440.00	1,600.00	1,600.00	1,600.00
MRL-HEMATOLOGY	PTT W/ MIXING STUDIES, 1 HR, 2 HRS, 3 HRS	2,000.00	3,600.00	4,000.00	4,000.00	4,000.00
MRL-HEMATOLOGY	RETICULOCYTE COUNT	70.00	160	160	160	160
MRL-HEMATOLOGY	SERUM ELECTROPHORESIS	1,100.00	1,600.00	1,600.00	1,600.00	1,600.00
MRL-HEMATOLOGY	BONE MARROW ASPIRATE (BMA) MATERIALS	300.00	–	–	–	–

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MRL-CLINICAL MICROSCOPY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
MRL-CLINICAL MICROSCOPY	AUTOLOGOUS SERUM SKIN TEST	250	400	400	400	400
MRL-CLINICAL MICROSCOPY	CRYSTAL IDENTIFICATION (BODY FLUIDS)	300	450	450	450	450
MRL-CLINICAL MICROSCOPY	URINALYSIS	100	200	200	200	200
MRL-CLINICAL MICROSCOPY	URINALYSIS W/RBC MORPHOLOGY	200	400	400	400	400
MRL-CLINICAL MICROSCOPY	URINE WRIGHT STAIN	200	500	500	500	500

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NEUROLOGY (PEDIATRIC)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEUROLOGY (PEDIATRIC)	CRANIAL ULTRASOUND	265	660	850	850	850

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NEUROLOGY (NEUROMUSCULAR)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEUROLOGY (NEUROMUSCULAR)	MUSCLE BIOPSY	7,250.00	9,500.00	9,500.00	9,500.00	9,500.00
NEUROLOGY (NEUROMUSCULAR)	SURAL NERVE BIOPSY	3,750.00	8,250.00	8,250.00	8,250.00	8,250.00
NEUROLOGY (NEUROMUSCULAR)	SYMPHATHETIC SKIN RESPONSE (SSR)	1,800.00	2,230.00	2,230.00	2,230.00	2,230.00
NEUROLOGY (NEUROMUSCULAR)	TILT TABLE	1,975.00	3,750.00	3,750.00	3,750.00	3,750.00
NEUROLOGY (NEUROMUSCULAR)	TRANSCRANIAL DOPPLER (TCD)	1,125.00	3,000.00	3,000.00	3,000.00	3,000.00

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NEUROLOGY (EEG-NCV)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEUROLOGY (EEG-NCV)	BRAINSTEM AUDITORY EVOKED RESPONSE (BAER)	380.00	1,140.00	1,140.00	1,140.00	1,140.00
NEUROLOGY (EEG-NCV)	ELECTROMYOGRAPHY AND NERVE CONDUCTION STUDIES (EMG NCS)	760.00	1,800.00	1,800.00	1,800.00	1,800.00
NEUROLOGY (EEG-NCV)	ELECTROMYOGRAPHY NCV	450.00	–	1,300.00	1,300.00	1,300.00
NEUROLOGY (EEG-NCV)	ELECTROMYOGRAPHY RNS	450.00	–	1,300.00	1,300.00	1,300.00
NEUROLOGY (EEG-NCV)	VISUAL EVOKED RESPONSE (VER)	380.00	1,140.00	1,140.00	1,140.00	1,140.00
NEUROLOGY (EEG-NCV)	FACIAL NERVE CONDUCTION STUDIES WITH BLINK REFLEX	380.00	1,120.00	1,120.00	1,120.00	1,120.00
NEUROLOGY (EEG-NCV)	ELECTROENCEPHALOGRAPHY(EEG)	750.00	–	2,712.00	2,712.00	2,712.00
NEUROLOGY (EEG-NCV)	EMG-NCV W/ SSR	3,665.00	–	3,750.00	3,750.00	3,750.00
NEUROLOGY (EEG-NCV)	SINGLE FIBER ELECTROMYOGRAPHY (SF EMG)	760.00	1,800.00	1,800.00	1,800.00	1,800.00
NEUROLOGY (EEG-NCV)	SOMATOSENSORY EVOKED RESPONSE (SSEP)	380.00	1,140.00	1,140.00	1,140.00	1,140.00
NEUROLOGY (EEG-NCV)	SYMPHATHETIC SKIN RESPONSE (SSR)	1,800.00	–	2,230.00	2,230.00	2,230.00
NEUROLOGY (EEG-NCV)	TILT TABLE	1,975.00	–	3,750.00	3,750.00	3,750.00
NEUROLOGY (EEG-NCV)	ELECTROMYOGRAPHY EMG-NCV W/ SSR	880.00	2,240.00	2,240.00	2,240.00	2,240.00
NEUROLOGY (EEG-NCV)	NERVE CONDUCTION STUDIES (NCS)	380.00	1,120.00	1,120.00	1,120.00	1,120.00
NEUROLOGY (EEG-NCV)	REPETITIVE NERVE STIMULATION (RNS)	380.00	1,120.00	1,120.00	1,120.00	1,120.00

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NEUROLOGY (EEG)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEUROLOGY (EEG)	ROUTINE EEG	1,680.00	2,410.00	2,410.00	2,410.00	2,410.00
NEUROLOGY (EEG)	EEG MONITORING – 6-HOUR VIDEO EEG	6,880.00	7,500.00	7,500.00	7,500.00	7,500.00
NEUROLOGY (EEG)	PORTABLE EEG	1,690.00	3,220.00	3,220.00	3,220.00	3,220.00
NEUROLOGY (EEG)	EEG MONITORING 24-HOUR VIDEO EEG	12,150.00	15,000.00	15,000.00	15,000.00	15,000.00
NEUROLOGY (EEG)	EEG MONITORING 2-HOUR VIDEO EEG	2,680.00	4,000.00	4,000.00	4,000.00	4,000.00

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NEUROLOGY (CENTER FOR MEMORY AND COGNITION)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEUROLOGY (CENTER FOR MEMORY AND COGNITION)	DEMENTIA AND MEMORY SCREENING	480	500	650	800	800
NEUROLOGY (CENTER FOR MEMORY AND COGNITION)	MEMORY SCREENING	480	500	500	500	500

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NEONATAL INTENSIVE CARE UNIT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEONATAL INTENSIVE CARE UNIT	RADIANT WARMER-DR (PER HOUR)	60	70	70	70	70
NEONATAL INTENSIVE CARE UNIT	STERILIZED/PASTEURIZED BREAST MILK (PER 4OZ)	220	–	225	225	225
NEONATAL INTENSIVE CARE UNIT	COMPRESSED AIR/USE (NICU)	–	90	90	90	90
NEONATAL INTENSIVE CARE UNIT	PULSE OXIMETER (PER DAY)	160	180	180	180	180
NEONATAL INTENSIVE CARE UNIT	RADIANT WARMER-NICU (PER DAY)	1,440.00	1,680.00	1,680.00	1,680.00	1,680.00
NEONATAL INTENSIVE CARE UNIT	LACTATION COUNSELING ,	–	490	520	550	580
NEONATAL INTENSIVE CARE UNIT	LACTATION MASSAGE,	–	540	570	600	630
NEONATAL INTENSIVE CARE UNIT	STERILIZED/PASTEURIZED 8.0Z BREASTMILK	–	550	–	–	–

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DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEONATAL INTENSIVE CARE UNIT	RADIANT WARMER-DR (PER HOUR)	60	70	70	70	70
NEONATAL INTENSIVE CARE UNIT	STERILIZED/PASTEURIZED BREAST MILK (PER 4OZ)	220	–	225	225	225
NEONATAL INTENSIVE CARE UNIT	COMPRESSED AIR/USE (NICU)	–	90	90	90	90
NEONATAL INTENSIVE CARE UNIT	PULSE OXIMETER (PER DAY)	160	180	180	180	180
NEONATAL INTENSIVE CARE UNIT	RADIANT WARMER-NICU (PER DAY)	1,440.00	1,680.00	1,680.00	1,680.00	1,680.00
NEONATAL INTENSIVE CARE UNIT	LACTATION COUNSELING ,	–	490	520	550	580
NEONATAL INTENSIVE CARE UNIT	LACTATION MASSAGE,	–	540	570	600	630
NEONATAL INTENSIVE CARE UNIT	STERILIZED/PASTEURIZED 8.0Z BREASTMILK	–	550	–	–	–

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NEUROSCIENCES

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEUROSCIENCES	MAGNETIC RESONANCE GUIDED HIGH-INTENSITY FOCUSED ULTRASOUND (MRGFUS) TREATMENT	28,240.00	–	46,220.00	48,780.00	51,350.00
NEUROSCIENCES	COMBINED DIAGNOSTIC AND THERAPEUTIC STUDY,	12,870.00	19,200.00	–	–	–
NEUROSCIENCES	PORTABLE EEG,	1,690.00	3,220.00	–	–	–
NEUROSCIENCES	TITRATION POLYSOMNOGRAPHY,	9,340.00	13,900.00	–	–	–

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NEUROLOGY INTENSIVE CARE UNIT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEUROLOGY INTENSIVE CARE UNIT	ROOM RATE/DAY (NEURO ICU)	–	2,500.00	2,500.00	2,500.00	2,500.00
NEUROLOGY INTENSIVE CARE UNIT	DEPOSIT- ACUTE STROKE UNIT	–	–	25,000.00	25,000.00	25,000.00
NEUROLOGY INTENSIVE CARE UNIT	ROOM RATE/DAY- ACCUTE STROKE UNIT	–	–	2,500.00	2,500.00	2,500.00

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NEUROLOGY ACUTE STROKE UNIT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
NEUROLOGY ACUTE STROKE UNIT	DEPOSIT	–	25,000.00	25,000.00	25,000.00	25,000.00
NEUROLOGY ACUTE STROKE UNIT	ROOM RATE/DAY	–	2,500.00	2,500.00	2,500.00	2,500.00

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OB-GYN (PERINATOLOGY)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
OB-GYN (PERINATOLOGY)	3D/4D	–	2,200.00	2,200.00	2,400.00	2,400.00
OB-GYN (PERINATOLOGY)	3D/4D (SINGLETON)	600	–	–	–	–
OB-GYN (PERINATOLOGY)	3D/4D (TWINS/MULTIFETAL)	600	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY	–	700	700	750	750
OB-GYN (PERINATOLOGY)	BIOMETRY,BPP,DOPPLERS	–	1,200.00	1,200.00	1,200.00	1,200.00
OB-GYN (PERINATOLOGY)	BIOMETRY,BPP,DOPPLERS AND NST (TWINS/MULTIFETAL)	650	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY, BPP & NON-STRESS TEST (TWINS)	600	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY, BPP & NON-STRESS TEST WITH DOPPLERS STUDIES	600	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY, BPP & NST	500	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY (SINGLETON)	400	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY (TWINS/MULTIFETAL)	400	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY W/ DOPPLERS	–	1,000.00	1,000.00	1,200.00	1,200.00
OB-GYN (PERINATOLOGY)	BIOMETRY W/ DOPPLERS (SINGLETON)	600	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY W/ DOPPLERS (TWINS/MULTIFETAL)	650	–	–	–	–
OB-GYN (PERINATOLOGY)	BIOMETRY WITH BPP	–	800	800	900	900
OB-GYN (PERINATOLOGY)	BPP	–	500	700	750	750
OB-GYN (PERINATOLOGY)	BPP W/ DOPPLERS	–	1,000.00	1,000.00	1,200.00	1,200.00
OB-GYN (PERINATOLOGY)	BPP W/ DOPPLERS (SINGLETON)	600	–	–	–	–
OB-GYN (PERINATOLOGY)	BPP W/ DOPPLERS (TWINS/MULTIFETAL)	650	–	–	–	–
OB-GYN (PERINATOLOGY)	BPP WITH NST (SINGLETON)	500	–	–	–	–
OB-GYN (PERINATOLOGY)	BPP WITH NST (TWINS/MULTIFETAL)	600	–	–	–	–
OB-GYN (PERINATOLOGY)	CAS, BPP W/ DOPPLERS	–	1,500.00	1,500.00	1,500.00	1,500.00
OB-GYN (PERINATOLOGY)	CAS W/ DOPPLERS	–	1,500.00	1,500.00	1,500.00	1,500.00
OB-GYN (PERINATOLOGY)	CONGENITAL ANOMALY SCAN, CAS	–	1,000.00	1,000.00	1,200.00	1,200.00
OB-GYN (PERINATOLOGY)	CONGENITAL ANOMALY SCAN, (CAS) (SINGLETON)	600	–	–	–	–
OB-GYN (PERINATOLOGY)	CONGENITAL ANOMALY SCAN, (CAS) (TWINS/MULTIFETAL)	650	–	–	–	–
OB-GYN (PERINATOLOGY)	CONGENITAL ANOMALY SCAN FOR (CAS), BIOMETRY, BPP WITH OR WITHOUT DOPPLERS	600	–	–	–	–
OB-GYN (PERINATOLOGY)	CONGENITAL ANOMALY SCAN FOR (CAS), BIOMETRY, BPP WITH OR WITHOUT DOPPLERS (TWINS/	700	–	–	–	–
OB-GYN (PERINATOLOGY)	NON STRESS TEST (NST)	–	500	600	650	700
OB-GYN (PERINATOLOGY)	NON STRESS TEST (NST) (SINGLETON)	300	–	–	–	–
OB-GYN (PERINATOLOGY)	NON STRESS TEST (NST) (TWINS/MULTIFETAL)	400	–	–	–	–
OB-GYN (PERINATOLOGY)	TRANSVAGINAL ULTRASOUND	–	700	700	750	750
OB-GYN (PERINATOLOGY)	TRANSVAGINAL ULTRASOUND (SINGLETON)	400	–	–	–	–
OB-GYN (PERINATOLOGY)	TRANSVAGINAL ULTRASOUND (TWINS/MULTIFETAL)	400	–	–	–	–

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OB-GYN (ORTOLL)

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OB-GYN (OPD)

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OB-GYN

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NEUROSURGICAL ICU (NSSCU)

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ORL

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
ORL	COLD/HOT CALORICS	760	2,160.00	2,380.00	2,480.00	2,590.00
ORL	ELECTRONYSTAGMOGRAPHY	400	1,690.00	1,860.00	1,940.00	2,030.00
ORL	SISI/TDT	195	290.00	325.00	335.00	350.00
ORL	STAPEDIAL REFLEX DECAY	135	475.00	495.00	525.00	550.00
ORL	STROBOSCOPY/LARYNGOSCOPY	1,120.00	1,950.00	2,350.00	2,600.00	3,250.00
ORL	VIDEOSTROBOSCOPY	1,150.00	2,620.00	2,620.00	2,620.00	3,010.00
ORL	AIDED THRESHOLD TESTING AND/OR HEARING AID TRIAL	–	390.00	430.00	450.00	470.00
ORL	AUDITORY BRAINSTEM RESPONSE	380	1,220.00	1,340.00	1,400.00	1,460.00
ORL	HEARING INSTRUMENT ANALYSIS PER UNIT	–	215.00	240.00	250.00	260.00
ORL	SINUS ENDOSCOPY-MINOR OR (ORL)	280	430.00	460.00	480.00	510.00
ORL	ADD-ON CONDYLE PROSTHESIS (L/R)	174,000.00	0.00	0.00	174,000.00	0.00
ORL	ADHEAR	234,600.00	0.00	0.00	234,600.00	0.00
ORL	ARCHBAR WITH GAUGE 24 & 26 AND RUBBERBANDS	11,400.00	0.00	0.00	11,400.00	0.00
ORL	BONEBRIDGE	469,200.00	0.00	0.00	469,200.00	0.00
ORL	COCHLEAR BAHA 6 MAX (NON SURGICAL)	428,400.00	0.00	0.00	428,400.00	0.00
ORL	COCHLEAR BAHA 6 MAX (SURGICAL)	663,000.00	0.00	0.00	663,000.00	0.00
ORL	COCHLEAR NUCLEUS N7S SOUND PROCESSOR CP1002	1,009,800.00	0.00	0.00	1,009,800.00	0.00
ORL	DOUBLE T PLATE REGULAR	33,600.00	0.00	0.00	33,600.00	0.00
ORL	DOUBLE Y PLATE REGULAR	33,600.00	0.00	0.00	33,600.00	0.00
ORL	ERICH ARCHBAR	4,200.00	0.00	0.00	4,200.00	0.00
ORL	MICRO PLATES 16HOLES	25,830.00	0.00	0.00	0.00	0.00
ORL	PRE-FORMED ORBITAL FLOOR	72,000.00	0.00	0.00	72,000.00	0.00
ORL	PRE-FORMED ORBITAL PLATE	72,000.00	0.00	0.00	72,000.00	0.00
ORL	RONDO 3	1,071,000.00	0.00	0.00	1,071,000.00	0.00
ORL	SINUS ENDOSCOPY- OPD (ORL)	360	0.00	0.00	0.00	0.00
ORL	SONNET 1	897,600.00	0.00	0.00	897,600.00	0.00
ORL	SONNET 2	1,173,000.00	0.00	0.00	1,173,000.00	0.00
ORL	STAINLESS LIGATURE WIRE 0.5MM	1,800.00	0.00	0.00	1,800.00	0.00
ORL	SYNCHRONY – RONDO 3	1,428,000.00	0.00	0.00	1,428,000.00	0.00
ORL	SYNCHRONY – SONNET 2	1,428,000.00	0.00	0.00	1,428,000.00	0.00
ORL	Y PLATE REGULAR	33,600.00	0.00	0.00	33,600.00	0.00
ORL	4-HOLE PLATE STRAIGHT	32,400.00	0.00	0.00	32,400.00	0.00
ORL	SINUS ENDOSCOPY-MAJOR OR (WITH ENDOSCOPE VIDEO) (ORL)	1,840.00	2,850.00	3,020.00	3,190.00	3,350.00
ORL	SINUS ENDOSCOPY-MINOR OR/CLINIC/OPD	210	300.00	330.00	330.00	330.00

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OB-GYN(ULTRASOUND SECTION)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- BIOMETRY	300	–	700.00	750.00	750.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- BIOMETRY, BPP, DOPPLER	400	800	800.00	800.00	800.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- BIOMETRY W/ BIO-PHYSICAL PROFILE (BPP)	400	800	800.00	800.00	800.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- CONGENITAL ANOMALY SCAN (CAS)	–	1,000.00	1,000.00	1,200.00	1,200.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- CONGENITAL ANOMALY SCAN (CAS) W/ DOPPLER	300	800	800.00	800.00	800.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- GUIDED PROCEDURES – 4D ULTRASOUND (WITH CAS)	600	2,200.00	2,200.00	2,200.00	2,200.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- GUIDED PROCEDURES – 4 D ULTRASOUND (WITHOUT CAS)	600	1,600.00	1,600.00	1,600.00	1,600.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- GUIDED PROCEDURES – SONOHYSTEROGRAM	400	700	700.00	750.00	750.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- GUIDED PROCEDURES – ULTRASOUND-GUIDED ASPIRATION	400	1,000.00	1,000.00	1,000.00	1,000.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- GUIDED PROCEDURES – ULTRASOUND-GUIDED BIOPSY	400	–	700.00	750.00	750.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- TRANSVAGINAL	300	–	700.00	750.00	750.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- GUIDED IUD REMORAL	400	–	400.00	400.00	400.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- PARACENTHESIS	400	–	700.00	400.00	750.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- PELVIC	300	–	700.00	750.00	750.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- TRANSRECTAL	300	–	700.00	750.00	750.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- ON SITE/BEDSIDE	–	–	1,000.00	1,000.00	1,000.00
OB-GYN(ULTRASOUND SECTION)	ULTRASOUND- TRANSVAGINAL/TRANSRECTAL	300	500	500.00	500.00	500.00

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OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )	CHLAMYDIA ANTIGEN TEST	–	800.00	590.00	590.00	590.00
OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )	NTX (N-TELOPEPTIDE) ASSAY	–	3,500.00	1,980.00	1,980.00	1,980.00
OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )	PARVOVIRUS B19 IGG / IGM	–	2,400.00	1,800.00	1,800.00	1,800.00
OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )	HYBRID CAPTURE CHLAMYDIA TRACHOMATIS (CT) DNA TEST	–	800.00	590.00	590.00	590.00
OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )	HYBRID CAPTURE II NEISSERIA GONORRHOEAE (GC) DNA TEST	–	1,200.00	900.00	900.00	900.00
OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )	INSULIN-LIKE GROWTH FACTOR BINDING PROTEIN 1 (IGFBP-1)	–	1,300.00	980.00	980.00	980.00
OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )	VAGINITIS DNA TEST (CANDIDA, G. VAGINALIS [BACTERIAL VAGINOSIS] AND TRICHOMONAS)	–	880.00	590.00	590.00	590.00
OB-GYN(REPRODUCTIVE BIOLOGY LABORATORY )	HYBRID CAPTURE II HUMAN PAPILLOMAVIRUS (HPV) DNA TEST	–	2,500.00	2,000.00	2,000.00	2,000.00

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OB-GYN(EMERGENCY ROOM AND OBAS)

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OB-GYN (UROGYNECOLOGY)

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ORTHO (GAITLAB)

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ORTHO

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
ORTHO	AMNION DRESSING	2,320.00	–	–	4,010.00	4,220.00
ORTHO	BONE CHIP	750	–	–	1,300.00	1,360.00
ORTHO	CRANIAL FLAP ALLOGRAFT	1,500.00	–	–	2,600.00	2,730.00
ORTHO	EXTRACTS (PER ML)	4	–	–	7.00	7.00
ORTHO	FEMORAL HEAD ALLOGRAFT	3,720.00	–	–	6,430.00	6,760.00
ORTHO	ARTHROSCOPE – FIRST HOUR	–	–	2,500.00	2,500.00	2,500.00
ORTHO	MAXI DRIVE/USE	–	500	500	500.00	500.00
ORTHO	MINI DRIVER/USE	–	500	500	500.00	500.00
ORTHO	ARTHROSCOPE – ADDITIONAL PER HOUR IN EXCESS OF ONE (1) HOUR	–	1,000.00	1,000.00	1,000.00	1,000.00
ORTHO	CELL SAVER/USE (COST OF DISPOSABLE TUBES/USE)	–	7,000.00	7,000.00	7,000.00	7,000.00
ORTHO	SSEP (INTRATOP SPINAL CORD MONITORING)-ADDITIONAL PER HOUR IN EXCESS OF ONE (1) HOU	–	250	250	250.00	250.00
ORTHO	SSEP (INTRATOP SPINAL CORD MONITORING)-FIRST HOUR	–	750	750	750.00	750.00
ORTHO	ARTHROSCOPE	10,000.00	20,000.00	20,000.00	20,000.00	20,000.00

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ORMAT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
ORMAT	ELECTROCAUTERY MACHINE WITH ARGON PLASMA	9,820.00	–	–	–	–
ORMAT	NAVIGATION SYSTEM WITH OPTICAL TRACKING FOR CRANIAL, ENT AND SPINE TRAUMA APPLICAT	19,000.00	–	–	28,000.00	–
ORMAT	ENDOSCOPIC PROCEDURE	5,090.00	7,470.00	8,030.00	8,620.00	9,890.00
ORMAT	ULTRASONIC & ADV BIPOLAR W/ POSITIVE TEMP CO-EFFICIENT (GEN-11) FOR MIN INV SURGERY	1,240.00	1,920.00	2,030.00	2,150.00	2,260.00
ORMAT	AIDA DOCUMENTATION SYSTEM FOR MINIMALLY INVASIVE SURGERY AND SURGICAL PROCEDURE	1,070.00	1,650.00	1,750.00	1,850.00	1,940.00
ORMAT	AIDA DOCUMENTATION SYSTEM FOR MINIMALLY INVASIVE SURGERY AND SURGICAL PROCEDURE	360.00	550	580	620	650
ORMAT	MOBILE SLAVE MONITOR FOR MINIMALLY INVASIVE SURGERY AND SURGICAL PROCEDURES – FIRS	1,100.00	1,710.00	1,810.00	1,910.00	2,010.00
ORMAT	MOBILE SLAVE MONITOR FOR MINIMALLY INVASIVE SURGERY AND SURGICAL PROCEDURES – PER	370.00	570	600	640	670
ORMAT	ORL MIS TOWER AND SCOPES AND INSTRUMENTS – FIRST 3 HOURS	3,200.00	4,950.00	5,240.00	5,540.00	5,830.00
ORMAT	ORL MIS TOWER AND SCOPES AND INSTRUMENTS – PER HOUR IN EXCESS OF 3 HOURS	1,070.00	1,650.00	1,750.00	1,850.00	1,940.00
ORMAT	ULTRASONIC AND ADV. BIPOLAR WITH POSITIVE TEMP. CO-EFFICIENT (GEN-11) FOR MIN. INVASIV	3,730.00	5,760.00	6,100.00	6,440.00	6,780.00

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PEDIATRICS GENETICS

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PEDIATRICS NEUROLOGY

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PEDIATRICS HEMATOLOGY & ONCOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
PEDIATRICS HEMATOLOGY & ONCOLOGY	CBC WITH PLATELET	75.00	–	–	–	–
PEDIATRICS HEMATOLOGY & ONCOLOGY	PACKAGE 1- BMA WITHOUT SEDATION	1,000.00	–	–	–	–
PEDIATRICS HEMATOLOGY & ONCOLOGY	PACKAGE 2- BMA WITH SEDATION	1,000.00	–	–	–	–
PEDIATRICS HEMATOLOGY & ONCOLOGY	PACKAGE 3- IT/LUMBAR TAP W/O SEDATION	700.00	–	–	–	–
PEDIATRICS HEMATOLOGY & ONCOLOGY	PACKAGE 4- IT/LUMBAR TAP W/ SEDATION	700.00	–	–	–	–
PEDIATRICS HEMATOLOGY & ONCOLOGY	PACKAGE 5- BMA + IT W/O SEDATION	1,000.00	–	–	–	–
PEDIATRICS HEMATOLOGY & ONCOLOGY	PACKAGE 6- BMA + IT W/ SEDATION	1,000.00	–	–	–	–
PEDIATRICS HEMATOLOGY & ONCOLOGY	RETICULOCYTE COUNT	90.00	170	180	190	195

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PEDIATRICS

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
PEDIATRICS	PEDIA-AMBULATORY BLOOD PRESSURE	1,200.00	2,000.00	2,110.00	2,220.00	2,330.00
PEDIATRICS	PEDIA-AUTOMATED PERITONEAL DIALYSIS MACHINE (FOR INPATIENTS ONLY)	200.00	–	330	350	370
PEDIATRICS	PEDIA-BODY COMPOSITION MONITOR	300.00	460	490	510	540
PEDIATRICS	PEDIA-RENAL ULTRASOUND	1,000.00	1,700.00	1,800.00	1,900.00	2,000.00
PEDIATRICS	PEDIA-URINE ANALYZER	170.00	270	280	300	320
PEDIATRICS	PERITONITIS PREVENTION CARE / EXIT SITE CARE ADDITIONAL RATE PER HOUR BEYOND OFFICE H	350.00	350	350	350	350
PEDIATRICS	PERITONITIS PREVENTION CARE / EXIT SITE CARE ADDITIONAL RATE PER HOUR IN EXCESS OF 3 HO	330.00	510	540	570	600
PEDIATRICS	PERITONITIS PREVENTION CARE / EXIT SITE CARE (RETRAINING ONLY DURING OFFICE HOURS)	180.00	300	310	330	350
PEDIATRICS	PERITONITIS PREVENTION CARE / EXIT SITE CARE (RETRAINING WITH LECTURE-3 HOURS)	1,000.00	1,540.00	1,630.00	1,720.00	1,810.00
PEDIATRICS	PHOTOTHERAPY (PER DAY)	1,000.00	–	–	–	–
PEDIATRICS	SUCTION MACHINE- ADDITIONAL PER HOUR IN EXCESS OF THREE (3) HRS.	35.00	–	–	–	–
PEDIATRICS	SUCTION MACHINE- FIRST THREE (3) HOURS	115.00	–	–	–	–

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PEDIA (SECTION OF CARDIOLOGY)

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RADIO_UTZ

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RADIO_UTZ	LIVER [ULTRASOUND]	275	690	725	760	795
RADIO_UTZ	GALLBLADDER [ULTRASOUND]	315	625	655	685	720
RADIO_UTZ	PANCREAS [ULTRASOUND]	315	625	655	685	720
RADIO_UTZ	KIDNEYS [ULTRASOUND]	345	625	655	685	720
RADIO_UTZ	SPLEEN [ULTRASOUND]	315	625	655	685	720
RADIO_UTZ	URINARY BLADDER [ULTRASOUND]	275	625	655	685	720
RADIO_UTZ	ABDOMINAL AORTA [ULTRASOUND]	380	555	580	640	665
RADIO_UTZ	THYROID [ULTRASOUND]	275	690	725	760	795
RADIO_UTZ	PROSTATE [ULTRASOUND]	275	625	655	685	720
RADIO_UTZ	PELVIS [ULTRASOUND]	275	625	655	685	720
RADIO_UTZ	TESTES [ULTRASOUND]	275	625	655	685	720
RADIO_UTZ	CRANIAL [ULTRASOUND]	330	625	655	685	720
RADIO_UTZ	TWO (2) ORGANS [ULTRASOUND]	345	855	900	940	985
RADIO_UTZ	THREE (3) ORGANS [ULTRASOUND]	380	1,030	1,080	1,130	1,185
RADIO_UTZ	FOUR (4) ORGANS [ULTRASOUND]	410	1,195	1,255	1,315	1,375
RADIO_UTZ	FIVE (5) ORGANS [ULTRASOUND]	445	1,280	1,345	1,410	1,475
RADIO_UTZ	SIX (6) TO TEN (10) ORGANS [ULTRASOUND]	520	1,720	1,805	1,890	1,975
RADIO_UTZ	PROSTATE (TRANSRECTAL) [ULTRASOUND]	445	0	1,080	1,130	1,185
RADIO_UTZ	TRANSVAGINAL/ TRANSRECTAL	445	1,030	1,080	1,130	1,185
RADIO_UTZ	BIOPHYSICAL PROFILE [ULTRASOUND]	445	895	935	980	1,025
RADIO_UTZ	FETAL GENETIC STUDY [ULTRASOUND]	340	1,070	1,070	1,240	1,240
RADIO_UTZ	CAROTID ARTERY (UNILATERAL) [ULTRASOUND]	970	1,640	1,725	1,805	1,890
RADIO_UTZ	CAROTID ARTERY (BILATERAL) [ULTRASOUND]	1,550	2,630	2,760	2,895	3,025
RADIO_UTZ	SIMULATION [ULTRASOUND]	400	600	600	800	800
RADIO_UTZ	RISE WANGESTEIN	145	455	510	565	625
RADIO_UTZ	SCAPULA APL	165	375	395	470	510
RADIO_UTZ	SONOMAMMOGRAM	345	690	725	755	790
RADIO_UTZ	TRANSPHENOIDAL	435	1,190	1,335	1,485	1,635
RADIO_UTZ	FETAL & OBSTETRICAL INCL. BIOPHYSICAL PROFILE [ULTRASOUND]	470	970	1,015	1,065	1,115
RADIO_UTZ	UPPER/LOWER EXTREMITY ARTERY & VEIN (UNILATERAL) [ULTRASOUND]	970	1,875	1,970	2,065	2,160
RADIO_UTZ	UPPER/LOWER EXTREMITY ARTERY & VEIN (BILATERAL) [ULTRASOUND]	1,550	2,630	2,760	2,895	3,025
RADIO_UTZ	ULTRASOUND GUIDED BIOPSY (EXCL. MAT’LS) [ULTRASOUND]	745	1,290	1,350	1,415	1,480
RADIO_UTZ	VENOGRAM BIL. (CONVENTIONAL)	195	720	815	905	995
RADIO_UTZ	VENOGRAM UNI (CONVENTIONAL)	130	480	545	605	660
RADIO_UTZ	CHEST [ULTRASOUND]	185	0	0	0	0
RADIO_UTZ	PROSTATE (TRANSRECTAL))	300	865	865	1,050	1,050

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RADIO_OTHERS

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RADIO_OTHERS	PORTAL FILMS (4-FILMS)	225.00	380.00	405.00	455.00	455.00
RADIO_OTHERS	PORTAL FILMS (5-FILMS)	280.00	450.00	470.00	515.00	515.00
RADIO_OTHERS	ACCESSORY-TATTOO KIT	50.00	50.00	50.00	50.00	50.00
RADIO_OTHERS	ACCESSORY-THERMOPLASTIC MASK	2,200.00	3,500.00	3,500.00	3,500.00	3,500.00
RADIO_OTHERS	BLOCKS-LARGE TRAY	1,005.00	1,480.00	1,570.00	1,655.00	1,655.00
RADIO_OTHERS	BLOCKS-SMALL TRAY	910.00	1,345.00	1,425.00	1,505.00	1,505.00
RADIO_OTHERS	PORTAL FILMS (1-FILM)	110.00	200.00	220.00	245.00	245.00
RADIO_OTHERS	PORTAL FILMS (2-FILMS)	150.00	255.00	270.00	285.00	285.00
RADIO_OTHERS	PORTAL FILMS (3-FILMS)	190.00	315.00	330.00	350.00	350.00
RADIO_OTHERS	PORTAL FILMS (6-FILMS)	310.00	525.00	545.00	565.00	565.00
RADIO_OTHERS	ACCESSORY- ALPHA CRADLE (INCLUDES SOLUTION AND PLASTIC BAG)	300.00	500.00	500.00	500.00	500.00
RADIO_OTHERS	DOCUMENTATION FEE- CD/ROM/PC., PAPER PRINT	65.00	250.00	250.00	250.00	250.00
RADIO_OTHERS	DOCUMENTATION FEE- FILM/PC., DRYVIEW PRINT	150.00	250.00	250.00	250.00	250.00

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RADIO_MRI

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RADIO_MRI	ABDOMEN, LOWER – CONTRAST	9,300.00	14,380.00	15,230.00	16,070.00	16,920.00
RADIO_MRI	ABDOMEN, LOWER – PLAIN	4,480.00	6,920.00	7,330.00	7,740.00	8,150.00
RADIO_MRI	ADRENAL PROTOCOL – CONTRAST	9,300.00	14,380.00	15,230.00	16,070.00	16,920.00
RADIO_MRI	ANGIOGRAM, PHASE – CONTRAST	9,840.00	12,720.00	13,610.00	14,510.00	15,400.00
RADIO_MRI	ANGIOGRAM, PHASE – PLAIN	6,710.00	10,380.00	10,990.00	11,600.00	12,210.00
RADIO_MRI	ANGIOGRAM, TOF – PLAIN	6,710.00	10,380.00	10,990.00	11,600.00	12,210.00
RADIO_MRI	ANKLE, UNILATERAL – CONTRAST	8,750.00	11,120.00	11,780.00	12,430.00	13,090.00
RADIO_MRI	ANKLE, UNILATERAL – PLAIN	4,305.00	5,200.00	5,500.00	5,810.00	6,110.00
RADIO_MRI	ARM/FOREARM, UNILATERAL – CONTRAST	6,970.00	14,700.00	15,435.00	16,170.00	16,905.00
RADIO_MRI	ARM/FOREARM, UNILATERAL – PLAIN	6,675.00	6,920.00	7,330.00	7,740.00	8,150.00
RADIO_MRI	CERVIX PROTOCOL – CONTRAST	10,835.00	16,100.00	17,050.00	18,000.00	18,950.00
RADIO_MRI	CERVIX PROTOCOL – PLAIN	5,005.00	7,245.00	7,610.00	7,970.00	8,330.00
RADIO_MRI	CRANIAL – CONTRAST	8,750.00	10,210.00	10,810.00	11,410.00	12,010.00
RADIO_MRI	CRANIAL – PLAIN	4,305.00	5,200.00	5,500.00	5,810.00	6,110.00
RADIO_MRI	ELBOW, UNILATERAL – CONTRAST	8,750.00	10,150.00	10,750.00	11,340.00	11,940.00
RADIO_MRI	ELBOW, UNILATERAL – PLAIN	4,305.00	5,200.00	5,500.00	5,810.00	6,110.00
RADIO_MRI	FIA PROTOCOL – CONTRAST	10,835.00	16,100.00	17,050.00	18,000.00	18,950.00
RADIO_MRI	FIA PROTOCOL – PLAIN	6,410.00	7,245.00	7,610.00	7,970.00	8,330.00
RADIO_MRI	FOOT/HAND, UNILATERAL – CONTRAST	8,750.00	10,800.00	11,430.00	12,070.00	12,700.00
RADIO_MRI	FOOT/HAND, UNILATERAL – PLAIN	4,305.00	5,200.00	5,500.00	5,810.00	6,110.00
RADIO_MRI	HIP, UNILATERAL – CONTRAST	8,750.00	10,490.00	11,110.00	11,720.00	12,340.00
RADIO_MRI	HIP, UNILATERAL – PLAIN	4,480.00	6,920.00	7,330.00	7,740.00	8,150.00
RADIO_MRI	IAC PROTOCOL – CONTRAST	9,895.00	9,960.00	10,540.00	11,130.00	11,720.00
RADIO_MRI	IAC PROTOCOL – PLAIN	5,005.00	5,200.00	5,500.00	5,810.00	6,110.00
RADIO_MRI	IMAGE GUIDED SURGERY PROTOCOL (IGS) – CONTRAST	9,230.00	10,865.00	11,700.00	12,540.00	13,380.00
RADIO_MRI	IMAGE GUIDED SURGERY PROTOCOL (IGS) – PLAIN	4,305.00	5,700.00	6,030.00	6,370.00	6,700.00
RADIO_MRI	LEG, UNILATERAL – CONTRAST	10,385.00	12,250.00	12,865.00	13,475.00	14,090.00
RADIO_MRI	LEG, UNILATERAL – PLAIN	6,385.00	7,070.00	7,490.00	7,900.00	8,320.00
RADIO_MRI	MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) – CONTRAST	13,755.00	12,210.00	13,050.00	13,890.00	14,730.00
RADIO_MRI	MAGNETIC RESONANCE CHOLANGIOPANCREATO-GRAPHY (MRCP) – PLAIN	5,500.00	8,495.00	8,920.00	9,340.00	9,765.00
RADIO_MRI	NECK, UNILATERAL – CONTRAST	8,535.00	11,470.00	12,140.00	12,820.00	13,490.00
RADIO_MRI	NECK, UNILATERAL – PLAIN	5,005.00	6,460.00	6,785.00	7,105.00	7,430.00
RADIO_MRI	ORBITS – CONTRAST	10,880.00	11,470.00	12,140.00	12,820.00	13,490.00
RADIO_MRI	ORBITS – PLAIN	5,735.00	6,920.00	7,330.00	7,740.00	8,150.00
RADIO_MRI	PELVIC – CONTRAST	8,625.00	9,660.00	10,230.00	10,800.00	11,360.00
RADIO_MRI	PELVIC – PLAIN	4,325.00	5,200.00	5,500.00	5,810.00	6,110.00
RADIO_MRI	PNS – CONTRAST	10,880.00	11,825.00	12,415.00	13,005.00	13,600.00
RADIO_MRI	PNS – PLAIN	5,005.00	6,710.00	7,045.00	7,380.00	7,715.00
RADIO_MRI	PROSTATE PROTOCOL – CONTRAST	10,920.00	14,380.00	15,230.00	16,070.00	16,920.00
RADIO_MRI	PROSTATE PROTOCOL – PLAIN	5,005.00	7,220.00	7,585.00	7,945.00	8,305.00
RADIO_MRI	RECTAL PROTOCOL – CONTRAST	10,835.00	16,100.00	17,050.00	18,000.00	18,950.00
RADIO_MRI	RECTAL PROTOCOL – PLAIN	6,450.00	7,290.00	7,655.00	8,020.00	8,385.00
RADIO_MRI	SEIZURE PROTOCOL – CONTRAST	10,855.00	12,275.00	12,885.00	13,500.00	14,115.00
RADIO_MRI	SEIZURE PROTOCOL – PLAIN	5,005.00	7,245.00	7,610.00	7,970.00	8,330.00
RADIO_MRI	SELLA – CONTRAST	5,005.00	12,275.00	12,885.00	13,500.00	14,115.00
RADIO_MRI	SELLA – PLAIN	5,005.00	7,270.00	7,630.00	7,995.00	8,360.00
RADIO_MRI	SHOULDER, UNILATERAL – CONTRAST	8,750.00	9,890.00	10,385.00	10,880.00	11,375.00
RADIO_MRI	SHOULDER, UNILATERAL – PLAIN	4,305.00	5,200.00	5,500.00	5,810.00	6,110.00
RADIO_MRI	SPINE, ONE-SEGMENT – CONTRAST	8,775.00	10,750.00	11,285.00	11,825.00	12,360.00
RADIO_MRI	SPINE, ONE-SEGMENT – PLAIN	5,005.00	7,525.00	6,830.00	7,155.00	7,480.00
RADIO_MRI	SPINE, TWO-SEGMENT – CONTRAST	16,805.00	21,890.00	22,985.00	24,080.00	25,175.00
RADIO_MRI	SPINE, TWO-SEGMENT – PLAIN	10,000.00	14,505.00	15,230.00	15,960.00	16,680.00
RADIO_MRI	SPINE, WHOLE – CONTRAST	25,360.00	29,985.00	31,485.00	32,985.00	34,485.00
RADIO_MRI	SPINE, WHOLE – PLAIN	13,335.00	19,360.00	20,330.00	21,300.00	22,265.00
RADIO_MRI	STROKE PROTOCOL – CONTRAST	9,315.00	12,345.00	12,960.00	13,580.00	14,195.00
RADIO_MRI	STROKE PROTOCOL – PLAIN	6,155.00	7,316.00	7,680.00	8,045.00	8,415.00
RADIO_MRI	THIGH, UNILATERAL – CONTRAST	10,385.00	12,295.00	12,910.00	13,525.00	14,140.00
RADIO_MRI	THIGH, UNILATERAL – PLAIN	6,410.00	7,245.00	7,610.00	7,970.00	8,330.00
RADIO_MRI	VENOGRAM – CONTRAST	10,710.00	14,380.00	15,230.00	16,070.00	16,920.00
RADIO_MRI	VENOGRAM – PLAIN	6,390.00	7,220.00	7,585.00	7,945.00	8,305.00
RADIO_MRI	WRIST, UNILATERAL – CONTRAST	8,750.00	11,450.00	12,120.00	12,800.00	13,470.00
RADIO_MRI	WRIST, UNILATERAL – PLAIN	4,305.00	5,200.00	5,500.00	5,810.00	6,110.00
RADIO_MRI	AORTOGRAM W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	CARDIAC (PLAIN)	9,060.00	13,860.00	14,660.00	15,450.00	16,250.00
RADIO_MRI	CARDIAC W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	DIFFUSION TENSOR IMAGING (DTI) (PLAIN)	9,060.00	13,860.00	14,660.00	15,450.00	16,250.00
RADIO_MRI	DIFFUSION TENSOR IMAGING (DTI) W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	FETAL (PLAIN)	9,060.00	13,860.00	14,660.00	15,450.00	16,250.00
RADIO_MRI	FETAL W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	FUNCTIONAL MRI (PLAIN)	9,060.00	13,860.00	14,660.00	15,450.00	16,250.00
RADIO_MRI	FUNCTIONAL MRI W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	IMAGE-GUIDE BRACHYTHERAPY PROTOCOL (PLAIN)	9,060.00	13,860.00	14,660.00	15,450.00	16,250.00
RADIO_MRI	IMAGE-GUIDE BRACHYTHERAPY PROTOCOL W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	NECK MRI (PLAIN)	9,060.00	13,860.00	14,660.00	15,450.00	16,250.00
RADIO_MRI	NECK MRI W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	PERFUSION (PLAIN)	9,060.00	13,860.00	14,660.00	15,450.00	16,250.00
RADIO_MRI	PERFUSION W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	PLACENTA (PLAIN)	9,060.00	13,860.00	14,660.00	15,450.00	16,250.00
RADIO_MRI	PLACENTA W/ CONTRAST	13,320.00	18,110.00	18,910.00	19,710.00	20,510.00
RADIO_MRI	HEAD – CONTRAST STUDY	8,750.00	10,210.00	10,810.00	11,410.00	12,010.00
RADIO_MRI	HEAD – PLAIN STUDY	5,960.00	7,525.00	7,545.00	8,275.00	8,425.00
RADIO_MRI	MRA, HEAD – CONTRAST STUDY	8,435.00	10,125.00	10,630.00	11,140.00	11,645.00
RADIO_MRI	MRA, HEAD – PLAIN STUDY	6,430.00	7,600.00	7,980.00	8,500.00	8,740.00
RADIO_MRI	CERVICAL, THORACIC, LUMBAR – CONTRAST STUDY	5,960.00	8,270.00	8,685.00	9,095.00	9,260.00
RADIO_MRI	CERVICAL, THORACIC, LUMBAR – PLAIN STUDY	5,960.00	7,525.00	7,545.00	8,275.00	8,425.00
RADIO_MRI	HEAD, STROKE, IAC, SELLA – CONTRAST STUDY	6,260.00	9,015.00	9,465.00	9,915.00	10,005.00
RADIO_MRI	HEAD, STROKE, IAC, SELLA – PLAIN STUDY	6,260.00	8,270.00	8,290.00	9,100.00	9,260.00
RADIO_MRI	KNEE (UNILATERAL) – CONTRAST STUDY	9,985.00	9,910.00	10,730.00	10,730.00	10,730.00
RADIO_MRI	KNEE (UNILATERAL) – PLAIN STUDY	5,400.00	7,200.00	7,560.00	8,040.00	8,280.00
RADIO_MRI	SHOULDER, ELBOW, LEG, PELVIS – CONTRAST STUDY	5,960.00	8,270.00	8,685.00	9,095.00	9,260.00
RADIO_MRI	SHOULDER, ELBOW, LEG, PELVIS – PLAIN STUDY	5,960.00	7,525.00	7,900.00	8,275.00	8,425.00
RADIO_MRI	ABDOMEN, UPPER – CONTRAST	9,990.00	13,440.00	14,220.00	15,020.00	15,800.00
RADIO_MRI	ABDOMEN, UPPER – PLAIN	5,930.00	7,990.00	8,450.00	8,910.00	9,380.00
RADIO_MRI	ABDOMEN, WHOLE – CONTRAST	15,330.00	20,610.00	21,820.00	23,030.00	24,250.00
RADIO_MRI	ABDOMEN, WHOLE – PLAIN	8,890.00	11,970.00	12,660.00	13,360.00	14,060.00
RADIO_MRI	BREAST – CONTRAST	10,815.00	12,225.00	12,840.00	13,450.00	14,090.00
RADIO_MRI	BREAST – PLAIN	5,835.00	7,220.00	7,585.00	7,945.00	8,305.00
RADIO_MRI	CHEST (MEDIASTNUM) – CONTRAST	11,100.00	14,940.00	15,820.00	16,700.00	17,590.00
RADIO_MRI	CHEST (MEDIASTNUM) – PLAIN	5,990.00	8,060.00	8,520.00	9,000.00	9,480.00
RADIO_MRI	SPECTROSCOPY – CONTRAST	8,475.00	9,580.00	10,060.00	10,540.00	11,015.00
RADIO_MRI	SPECTROSCOPY – PLAIN	5,930.00	7,225.00	7,585.00	7,945.00	8,305.00

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RADIO_CT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RADIO_CT	CT SCAN-ANGIOGRAM, THORACIC AORTA	8,600.00	14,000.00	15,000.00	16,300.00	17,500.00
RADIO_CT	CT SCAN-HEPATIC ANGIOGRAM, PEDIATRICS	7,600.00	11,800.00	18,400.00	20,000.00	21,700.00
RADIO_CT	CT SCAN-THORACIC SPINE W/3D CONTRAST	4,600.00	8,500.00	9,400.00	10,300.00	11,200.00
RADIO_CT	BRAIN/HEAD/CRANIAL- PLAIN [CT SCAN]	1,500.00	3,100.00	3,720.00	3,875.00	4,185.00
RADIO_CT	UPPER ABDOMEN- PLAIN [CT SCAN]	2,580.00	4,200.00	4,700.00	5,100.00	5,500.00
RADIO_CT	LOWER ABDOMEN- PLAIN [CT SCAN]	2,200.00	4,200.00	4,700.00	5,100.00	5,500.00
RADIO_CT	WHOLE ABDOMEN- PLAIN [CT SCAN]	2,600.00	7,900.00	8,700.00	9,600.00	10,400.00
RADIO_CT	ADRENAL GLANDS- PLAIN [CT SCAN]	2,535.00	4,200.00	5,040.00	5,250.00	5,670.00
RADIO_CT	STONOGRAM- PLAIN [CT SCAN]	2,200.00	5,900.00	6,500.00	7,200.00	7,800.00
RADIO_CT	CERVICAL SPINE- PLAIN [CT SCAN]	2,200.00	4,100.00	4,715.00	5,125.00	5,535.00
RADIO_CT	THORACIC SPINE- PLAIN [CT SCAN]	3,300.00	4,500.00	4,900.00	5,400.00	5,900.00
RADIO_CT	LUMBAR SPINE- PLAIN [CT SCAN]	2,430.00	4,100.00	4,600.00	5,000.00	5,400.00
RADIO_CT	LUMBAR SPINE WITH 3D- PLAIN [CT SCAN]	3,015.00	5,700.00	6,300.00	6,900.00	7,500.00
RADIO_CT	EXTREMITY- PLAIN [CT SCAN]	2,300.00	4,400.00	4,900.00	5,300.00	5,800.00
RADIO_CT	EXTREMITY WITH 3D- PLAIN [CT SCAN]	2,640.00	6,400.00	7,000.00	7,700.00	8,400.00
RADIO_CT	ORBITS- PLAIN [CT SCAN]	1,360.00	4,400.00	4,900.00	5,300.00	5,800.00
RADIO_CT	PNS (SCREENING)- PLAIN [CT SCAN]	1,810.00	3,400.00	3,700.00	4,100.00	4,400.00
RADIO_CT	PNS (REGULAR)- PLAIN [CT SCAN]	2,500.00	4,400.00	4,900.00	5,300.00	5,800.00
RADIO_CT	NECK/NASOPHARYNX- PLAIN [CT SCAN]	2,500.00	4,400.00	4,900.00	5,400.00	5,800.00
RADIO_CT	TEMPORAL BONE- PLAIN [CT SCAN]	2,500.00	4,500.00	5,000.00	5,500.00	5,900.00
RADIO_CT	CHEST- PLAIN [CT SCAN]	2,000.00	4,200.00	4,830.00	5,040.00	5,670.00
RADIO_CT	EXTREMITY- CONTRAST-ENHANCED [CT SCAN]	5,980.00	6,965.00	7,315.00	7,800.00	8,500.00
RADIO_CT	ORBITS- CONTRAST-ENHANCED [CT SCAN]	5,490.00	6,275.00	6,600.00	7,200.00	7,900.00
RADIO_CT	CHEST- CONTRAST-ENHANCED [CT SCAN]	5,530.00	6,320.00	6,635.00	6,950.00	7,900.00
RADIO_CT	VIRTUAL COLONOSCOPY [SPECIAL EXAM]	4,600.00	8,500.00	9,300.00	10,200.00	11,100.00
RADIO_CT	CHEST/LUNGS HIGH RESOLUTION- PLAIN [CT SCAN]	1,490.00	3,400.00	3,700.00	4,100.00	4,400.00
RADIO_CT	CERVICAL SPINE WITH 3D- PLAIN [CT SCAN]	2,685.00	6,000.00	6,900.00	7,350.00	7,950.00
RADIO_CT	THORACIC SPINE WITH 3D- PLAIN [CT SCAN]	2,705.00	6,400.00	7,100.00	7,800.00	8,500.00
RADIO_CT	CRANIAL WITH FACIAL CUTS/3D- PLAIN [CT SCAN]	2,500.00	4,000.00	4,400.00	4,800.00	5,200.00
RADIO_CT	CHEST WITH HIGH RESOLUTION- PLAIN [CT SCAN]	2,620.00	5,500.00	6,325.00	6,600.00	7,200.00
RADIO_CT	BRAIN/HEAD/CRANIAL- CONTRAST-ENHANCED [CT SCAN]	4,915.00	5,585.00	5,865.00	6,145.00	6,420.00
RADIO_CT	UPPER ABDOMEN DOUBLE/TRIPLE- CONTRAST-ENHANCED [CT SCAN]	8,935.00	10,410.00	10,930.00	11,450.00	11,970.00
RADIO_CT	LOWER ABDOMEN- CONTRAST-ENHANCED [CT SCAN]	6,555.00	8,470.00	8,890.00	9,315.00	10,000.00
RADIO_CT	WHOLE ABDOMEN SINGLE PHASE- CONTRAST-ENHANCED [CT SCAN]	9,385.00	10,075.00	11,630.00	12,185.00	12,740.00
RADIO_CT	WHOLE ABDOMEN DOUBLE/TRIPLE- CONTRAST-ENHANCED [CT SCAN]	9,695.00	13,400.00	14,900.00	16,400.00	18,000.00
RADIO_CT	ADRENAL GLANDS- CONTRAST-ENHANCED [CT SCAN]	6,260.00	10,875.00	11,420.00	11,965.00	12,510.00
RADIO_CT	CT UROGRAM- CONTRAST-ENHANCED [CT SCAN]	8,640.00	10,970.00	12,070.00	12,620.00	13,600.00
RADIO_CT	CERVICAL SPINE- CONTRAST-ENHANCED [CT SCAN]	6,095.00	7,030.00	7,380.00	7,805.00	8,790.00
RADIO_CT	CERVICAL SPINE WITH 3D- CONTRAST-ENHANCED [CT SCAN]	6,170.00	8,500.00	9,775.00	10,625.00	11,475.00
RADIO_CT	THORACIC SPINE- CONTRAST-ENHANCED [CT SCAN]	6,150.00	7,030.00	7,380.00	8,085.00	8,500.00
RADIO_CT	CRANIAL WITH FACIAL CUTS/3D- CONTRAST-ENHANCED [CT SCAN]	5,565.00	5,400.00	5,900.00	6,500.00	7,000.00
RADIO_CT	LUMBAR SPINE- CONTRAST-ENHANCED [CT SCAN]	6,015.00	6,100.00	6,800.00	7,500.00	8,100.00
RADIO_CT	LUMBAR SPINE WITH 3D- CONTRAST-ENHANCED [CT SCAN]	6,715.00	7,900.00	8,800.00	9,600.00	10,400.00
RADIO_CT	EXTREMITY WITH 3D- CONTRAST-ENHANCED [CT SCAN]	6,115.00	8,300.00	9,200.00	10,100.00	11,000.00
RADIO_CT	PNS (REGULAR)- CONTRAST-ENHANCED [CT SCAN]	5,900.00	6,945.00	7,300.00	7,640.00	7,985.00
RADIO_CT	NECK/NASOPHARYNX- CONTRAST-ENHANCED [CT SCAN]	6,115.00	6,985.00	7,335.00	7,700.00	8,400.00
RADIO_CT	TEMPORAL BONE- CONTRAST-ENHANCED [CT SCAN]	6,075.00	6,945.00	7,290.00	7,640.00	7,985.00
RADIO_CT	CHEST WITH HIGH RESOLUTION- CONTRAST-ENHANCED [CT SCAN]	6,110.00	7,655.00	8,040.00	8,420.00	8,805.00
RADIO_CT	UPPER ABDOMEN SINGLE PHASE- CONTRAST-ENHANCED [CT SCAN]	6,110.00	8,505.00	8,930.00	9,355.00	9,780.00
RADIO_CT	ANGIOGRAM, PERIPHERAL [SPECIAL EXAM]	8,600.00	15,000.00	16,000.00	17,400.00	18,800.00
RADIO_CT	CORONARY ANGIOGRAM (RADIOLOGY) [SPECIAL EXAM]	8,600.00	14,000.00	15,300.00	16,600.00	17,800.00
RADIO_CT	HEPATIC ANGIOGRAM-ADULT [SPECIAL EXAM]	8,700.00	19,000.00	20,000.00	21,800.00	23,600.00
RADIO_CT	ANGIOGRAM, PULMONARY ARTERIES [SPECIAL EXAM]	8,600.00	15,000.00	16,200.00	17,600.00	19,000.00
RADIO_CT	ANGIOGRAM, ABDOMINAL AORTA [SPECIAL EXAM]	8,600.00	14,000.00	15,000.00	16,300.00	17,500.00
RADIO_CT	ANGIOGRAM, RENAL/ABDOMINAL [SPECIAL EXAM]	8,600.00	15,000.00	16,200.00	17,600.00	19,000.00
RADIO_CT	BIOPSY [SPECIAL EXAM]	3,300.00	4,400.00	4,600.00	4,800.00	5,000.00
RADIO_CT	BRAIN PERFUSION [SPECIAL EXAM]	7,600.00	12,000.00	13,300.00	14,300.00	15,400.00
RADIO_CT	ANGIOGRAM, CEREBRAL AND NECK [SPECIAL EXAM]	8,100.00	13,000.00	14,100.00	15,200.00	16,300.00
RADIO_CT	CALCIUM SCORING [SPECIAL EXAM]	3,000.00	8,300.00	9,100.00	9,800.00	10,600.00
RADIO_CT	PITUITARY FOSSA- CONTRAST-ENHANCED	5,395.00	5,800.00	6,300.00	6,800.00	7,300.00
RADIO_CT	CONED-BEAM COMPUTER TORNOGRAPHY (CBCT)	2,800.00	5,000.00	5,300.00	5,590.00	5,880.00

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PSYCHIATRY & BEHAVIORAL MEDICINE

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PSYCHIATRY

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PERITONEAL DIALYSIS

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RADIOLOGY – ONCOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RADIOLOGY – ONCOLOGY	SIMPLE IMRT-DAILY TREATMENT	5,200.00	6,000.00	6,000.00	6,000.00	6,000.00
RADIOLOGY – ONCOLOGY	SIMPLE IMRT-TREATMENT PLANNING	9,600.00	–	–	–	–
RADIOLOGY – ONCOLOGY	COMPLEX IMRT-DAILY TREATMENT	5,200.00	6,000.00	6,000.00	6,000.00	6,000.00
RADIOLOGY – ONCOLOGY	CT SIMULATION 2D	17,550.00	17,713.00	17,713.00	17,713.00	17,713.00
RADIOLOGY – ONCOLOGY	CT SIMULATION 3D	17,550.00	17,713.00	17,713.00	17,713.00	17,713.00
RADIOLOGY – ONCOLOGY	CT SIMULATION COMPLEX IMRT	17,550.00	17,713.00	17,713.00	17,713.00	17,713.00
RADIOLOGY – ONCOLOGY	CT SIMULATION SIMPLE IMRT	17,550.00	17,713.00	17,713.00	17,713.00	17,713.00
RADIOLOGY – ONCOLOGY	DAILY TREATMENT 2D	2,750.00	2,860.00	2,860.00	2,860.00	2,860.00
RADIOLOGY – ONCOLOGY	DAILY TREATMENT 3D	2,860.00	2,970.00	2,970.00	2,970.00	2,970.00
RADIOLOGY – ONCOLOGY	PLANNING 2D	12,000.00	12,480.00	12,480.00	12,480.00	12,480.00
RADIOLOGY – ONCOLOGY	PLANNING 3D	12,480.00	14,300.00	14,300.00	14,300.00	14,300.00
RADIOLOGY – ONCOLOGY	PLANNING COMPLEX IMRT	12,480.00	14,520.00	14,520.00	14,520.00	14,520.00
RADIOLOGY – ONCOLOGY	PLANNING SIMPLE IMRT	12,480.00	14,520.00	14,520.00	14,520.00	14,520.00
RADIOLOGY – ONCOLOGY	CT SIMULATION/TUMOR LOCALIZATION (COMPLEX PLAIN) PLUS	5,000.00	6,000.00	6,000.00	6,000.00	6,000.00
RADIOLOGY – ONCOLOGY	CONTRAST	3,500.00	4,200.00	4,200.00	4,200.00	4,200.00
RADIOLOGY – ONCOLOGY	CT SIMULATION/TUMOR LOCALIZATION (COMPLEX PLAIN)	5,000.00	6,000.00	6,000.00	6,000.00	6,000.00
RADIOLOGY – ONCOLOGY	CT SIMULATION/TUMOR LOCALIZATION (SIMPLE PLAIN)	2,500.00	3,000.00	3,000.00	3,000.00	3,000.00
RADIOLOGY – ONCOLOGY	DAILY TREATMENT 3D CONFORMAL	2,200.00	2,700.00	2,700.00	2,700.00	2,700.00
RADIOLOGY – ONCOLOGY	DAILY TREATMENT CONVENTIONAL	2,200.00	2,200.00	2,200.00	2,200.00	2,200.00
RADIOLOGY – ONCOLOGY	DAILY TREATMENT IMRT	5,000.00	6,000.00	6,000.00	6,000.00	6,000.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES ABDOMEN, HIP AND PELVIS BOARD WITH REINFORCED THE	5,000.00	7,000.00	7,000.00	7,000.00	7,000.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES – A&B SOLUTION	300.00	500	500	500	500
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES BELLY BOARD (REUSABLE)	2,000.00	2,500.00	2,500.00	2,500.00	2,500.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES BREAST BOARD (REUSABLE)	2,000.00	2,500.00	2,500.00	2,500.00	2,500.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES CUSTOMIZED BLOCKS – ELECTRON BLOCKS	2,000.00	2,500.00	2,500.00	2,500.00	2,500.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES CUSTOMIZED BLOCKS – PHOTON BLOCKS	900.00	1,500.00	1,500.00	1,500.00	1,500.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES – HEAD MASK (SEMI REUSABLE) HEAD & NECK	2,200.00	3,500.00	3,500.00	3,500.00	3,500.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES – HEAD MASK (SEMI REUSABLE) HEAD, NECK & SHOULDER	4,000.00	5,000.00	5,000.00	5,000.00	5,000.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES VACLOC (REUSABLE) HALF BODY	3,000.00	4,000.00	4,000.00	4,000.00	4,000.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES VACLOC (REUSABLE) WHOLE BODY	5,000.00	6,000.00	6,000.00	6,000.00	6,000.00
RADIOLOGY – ONCOLOGY	IMMOBILIZATION AND ACCESSORIES WING BOARD (REUSABLE)	2,000.00	2,500.00	2,500.00	2,500.00	2,500.00
RADIOLOGY – ONCOLOGY	PLANNING TPS/TREATMENT DOSIMETRY 3D CONFORMAL	9,600.00	13,000.00	13,000.00	13,000.00	13,000.00
RADIOLOGY – ONCOLOGY	PLANNING TPS/TREATMENT DOSIMETRY CONVENTIONAL	9,600.00	9,600.00	9,600.00	9,600.00	9,600.00
RADIOLOGY – ONCOLOGY	PLANNING TPS/TREATMENT DOSIMETRY IMRT	15,000.00	25,000.00	25,000.00	25,000.00	25,000.00

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RADIOLOGY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RADIOLOGY	DUCTOGRAM – WITH FILM	3,800.00	5,870.00	6,210.00	6,560.00	6,900.00
RADIOLOGY	DUCTOGRAM – WITHOUT FILM	3,130.00	4,840.00	5,120.00	5,410.00	5,690.00
RADIOLOGY	MAMMOGRAPHY (2 VIEWS) – WITH FILM	980.00	1,520.00	1,610.00	1,700.00	1,790.00
RADIOLOGY	MAMMOGRAPHY (2 VIEWS) – WITHOUT FILM	650.00	1,000.00	1,060.00	1,110.00	1,170.00
RADIOLOGY	MAMMOGRAPHY (4 VIEWS) – WITH FILM	1,520.00	2,350.00	2,490.00	2,630.00	2,760.00
RADIOLOGY	MAMMOGRAPHY (4 VIEWS) – WITHOUT FILM	850.00	1,320.00	1,390.00	1,470.00	1,550.00
RADIOLOGY	NEEDLE LOCALIZATION – WITH FILM	3,570.00	5,520.00	5,840.00	6,170.00	6,490.00
RADIOLOGY	NEEDLE LOCALIZATION – WITHOUT FILM	2,570.00	3,980.00	4,210.00	4,450.00	4,680.00
RADIOLOGY	INTRAOPERATIVE RADIATION THERAPY (IORT)	19,050.00	–	21,978.00	26,883.00	38,331.00
RADIOLOGY	COBALT THERAPY	360.00	500	600.00	670.00	670.00
RADIOLOGY	IGBT (ADDITIONAL FOR THE USE OF CT SCAN)	3,125.00	3,900.00	3,900.00	3,900.00	3,900.00
RADIOLOGY	HDR BRACHYTHERAPY (1ST SESSION)	18,875.00	19,630.00	19,630.00	19,630.00	19,630.00
RADIOLOGY	HDR BRACHYTHERAPY (SUCCEEDING SESSIONS)	17,000.00	17,680.00	17,680.00	17,680.00	17,680.00

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RADIO_XRAY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RADIO_XRAY	CERVICO-THORACIC (AP, LAT)	210.00	620	650.00	750.00	790.00
RADIO_XRAY	SCOLIOTIC SERIES (6 FILMS)	475.00	1,230.00	1,290.00	1,490.00	1,560.00
RADIO_XRAY	WATER-SOLUBLE ENEMA (PEDIA)	6,690.00	–	6,750.00	7,075.00	7,395.00
RADIO_XRAY	ANKLE (APL) BIL.	270.00	440	460.00	525.00	555.00
RADIO_XRAY	ANKLE (APL) UNI.	165.00	375	395.00	470.00	490.00
RADIO_XRAY	BABYGRAM	215.00	430	450.00	535.00	590.00
RADIO_XRAY	BONE AGING- ADULT	165.00	560	590.00	695.00	730.00
RADIO_XRAY	CERVICAL VERTEBRAE (AP, LAT)	210.00	420	440.00	525.00	555.00
RADIO_XRAY	CHEST BUCKY	165.00	375	395.00	490.00	515.00
RADIO_XRAY	CHEST (PA)	165.00	315	330.00	425.00	445.00
RADIO_XRAY	CHEST (PA AND LAT)	210.00	465	485.00	515.00	540.00
RADIO_XRAY	CLAVICLE AP (BIL)	230.00	470	490.00	585.00	640.00
RADIO_XRAY	CLAVICLE AP (UNI)	165.00	350	365.00	430.00	495.00
RADIO_XRAY	CYSTOGRAPHY	2,730.00	2,625.00	2,850.00	3,045.00	3,365.00
RADIO_XRAY	ELBOW (APL)	165.00	275	290.00	355.00	370.00
RADIO_XRAY	ELBOW BIL.	560.00	470	490.00	610.00	645.00
RADIO_XRAY	ENTIRE SPINES (AP, LAT)	485.00	895	935.00	1,120.00	1,180.00
RADIO_XRAY	ENTIRE SPINES (APL-OBLIQUES)	1,195.00	1,205.00	1,265.00	1,460.00	620.00
RADIO_XRAY	ESOPHAGRAM/ BARIUM SWALLOW	1,385.00	1,795.00	1,885.00	1,975.00	2,065.00
RADIO_XRAY	FEMUR (APL)	185.00	565	575.00	595.00	620.00
RADIO_XRAY	FEMUR BIL.	580.00	840	885.00	885.00	925.00
RADIO_XRAY	FISTULOGRAM	570.00	–	1,055.00	1,095.00	1,205.00
RADIO_XRAY	FOOT (APL) BIL.	230.00	440	460.00	525.00	555.00
RADIO_XRAY	FOOT (APL) UNI.	165.00	375	395.00	470.00	490.00
RADIO_XRAY	FOREARM (APL)	180.00	360	380.00	440.00	460.00
RADIO_XRAY	FOREARM BIL.	560.00	470	490.00	610.00	645.00
RADIO_XRAY	FOREIGN BODY NECK	210.00	355	375.00	525.00	555.00
RADIO_XRAY	HUMERUS (APL)	180.00	410	435.00	440.00	460.00
RADIO_XRAY	HUMERUS BIL.	560.00	470	490.00	610.00	645.00
RADIO_XRAY	HYPOTONIC DUODENOGRAPHY	600.00	1,685.00	1,685.00	1,685.00	2,040.00
RADIO_XRAY	KNEES (APL) BIL.	230.00	480	505.00	580.00	610.00
RADIO_XRAY	KNEES (APL) UNI.	165.00	360	380.00	440.00	460.00
RADIO_XRAY	KUB	195.00	405	425.00	480.00	505.00
RADIO_XRAY	LEG (APL)	185.00	360	380.00	440.00	460.00
RADIO_XRAY	LEG BIL.	605.00	520	545.00	685.00	720.00
RADIO_XRAY	MANDIBLE (AP & OBLIQUES)	240.00	425	445.00	595.00	625.00
RADIO_XRAY	NASAL BONE (WATER’S AND LAT)	210.00	405	425.00	495.00	520.00
RADIO_XRAY	PELVIMETRY	300.00	860	905.00	1,165.00	1,225.00
RADIO_XRAY	PELVIS, HIP, HIP JOINT(APL)	180.00	540	545.00	595.00	625.00
RADIO_XRAY	PLAIN ABDOMEN (AP)	195.00	405	425.00	480.00	505.00
RADIO_XRAY	PNS (PA, WATERS, LAT VIEWS)	260.00	470	490.00	440.00	705.00
RADIO_XRAY	PNS (WATER’S VIEW ONLY)	155.00	325	345.00	440.00	460.00
RADIO_XRAY	REGTROGRADE PYELOGRAPHY	3,935.00	3,890.00	4,085.00	4,280.00	4,475.00
RADIO_XRAY	SACRO-ILIAC JOINTS	315.00	420	440.00	525.00	555.00
RADIO_XRAY	SHOULDER (APL) BIL.	285.00	480	505.00	580.00	610.00
RADIO_XRAY	SHOULDER (APL) UNI	185.00	495	520.00	470.00	490.00
RADIO_XRAY	SHUNT SERIES/ SHUNTOGRAM	425.00	895	940.00	875.00	965.00
RADIO_XRAY	SIALOGRAM	3,345.00	3,365.00	3,530.00	3,700.00	3,865.00
RADIO_XRAY	SINUGRAM	570.00	–	1,055.00	1,095.00	1,205.00
RADIO_XRAY	SKULL (AP OR PA AND LAT)	215.00	610	625.00	675.00	705.00
RADIO_XRAY	SOFT TISSUE NECK	210.00	355	375.00	525.00	555.00
RADIO_XRAY	THORACO-LUMBAR (AP, LAT)	305.00	660	695.00	650.00	685.00
RADIO_XRAY	VOIDING CYSTOURETHROGRAM	3,890.00	4,445.00	4,670.00	4,890.00	5,110.00
RADIO_XRAY	WRIST, HAND (APL)	165.00	345	365.00	355.00	370.00
RADIO_XRAY	WRIST, HAND BIL.	375.00	470	490.00	610.00	645.00
RADIO_XRAY	ZYGOMA BONE (BILATERAL)	240.00	580	610.00	700.00	735.00
RADIO_XRAY	ADDITIONAL CHEST (OBLIQUE, LORDOTIC)	135.00	305	310.00	335.00	355.00
RADIO_XRAY	BARIUM ENEMA (SINGLE CONTRAST)	975.00	–	2,005.00	2,250.00	2,100.00
RADIO_XRAY	CERVICAL VERTEBRAE (APL, OBLIQUE)	290.00	660	675.00	710.00	745.00
RADIO_XRAY	CERVICO-THORACIC (APL, OBLIQUES)	330.00	830	870.00	1,005.00	1,060.00
RADIO_XRAY	COLONOGRAM (ANTE OR RETROGRADE)	660.00	–	1,165.00	1,500.00	1,450.00
RADIO_XRAY	DACROCYSTOGRAPHY (DYE EXCLUDED)	285.00	720	720.00	875.00	875.00
RADIO_XRAY	FLOUROSCOPY MACHINE PER HOUR	685.00	715	740.00	785.00	820.00
RADIO_XRAY	HYSTERO-SALPINGOGRAPHY/ TUBE VAGINOGRAM	2,785.00	2,835.00	3,210.00	3,225.00	3,295.00
RADIO_XRAY	LUMBO-SACRAL VERTEBRAE (AP, LAT)	255.00	480	505.00	580.00	610.00
RADIO_XRAY	LUMBO-SACRAL VERTEBRAE (APL, OBLIQUES)	410.00	555	585.00	670.00	705.00
RADIO_XRAY	MASTOID(TOWNES, CALDWELLS, SCHULLERS)	290.00	485	510.00	680.00	715.00
RADIO_XRAY	ONE-SHOT OR ORAL CHOLANGIOGRAM/GALL BALDDER SERIES OR ORAL CHOLE	520.00	680	680.00	680.00	935.00
RADIO_XRAY	OPERATIVE CHOLANGIOGRAM & UROLOGRAM	1,430.00	2,135.00	2,140.00	2,345.00	2,455.00
RADIO_XRAY	PELVIS, HIP, HIP JOINT (AP, LAT, OR OBLIQUE)	270.00	470	470.00	540.00	565.00
RADIO_XRAY	PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE (PTBD)	1,340.00	1,910.00	1,940.00	2,105.00	2,200.00
RADIO_XRAY	PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM (PTC)	895.00	1,415.00	1,485.00	1,560.00	1,630.00
RADIO_XRAY	PLAIN ABDOMEN (FLAT & UPRIGHT)	195.00	575	605.00	570.00	560.00
RADIO_XRAY	SACRUM-COCCYX (AP, LATERAL)	215.00	420	440.00	580.00	610.00
RADIO_XRAY	SACRUM-COCCYX (APL, OBLIQUES)	345.00	625	655.00	610.00	640.00
RADIO_XRAY	SELLA TURCICA (TOWNES AND LAT)	210.00	405	425.00	495.00	520.00
RADIO_XRAY	SHOULDER (INT. EXT. NEUTRAL) UNI.	320.00	480	505.00	580.00	610.00
RADIO_XRAY	SIALGORAPHY (DYE EXCLUDED)	425.00	880	910.00	970.00	1,020.00
RADIO_XRAY	SKELETAL SURVEY ADULT & CHILDREN	910.00	1,925.00	2,020.00	2,330.00	2,445.00
RADIO_XRAY	THORACIC VERTEBRAE (AP, LAT)	305.00	500	525.00	610.00	640.00
RADIO_XRAY	THORACIC VERTEBRAE (APL, OBLIQUES)	430.00	840	885.00	925.00	970.00
RADIO_XRAY	THORACO-LUMBAR (APL, OBLIQUE)	430.00	1,010.00	1,060.00	1,115.00	1,170.00
RADIO_XRAY	TMJ (CLOSED, OPEN MOUTH VIEWS)	260.00	590	620.00	650.00	680.00
RADIO_XRAY	T-TUBE CHOLANGIOGRAM / RETROGRADE CHOLANGIOGRAM	2,530.00	2,430.00	2,550.00	3,180.00	3,295.00
RADIO_XRAY	UGIS W/SMALL INTESTINE SERIES OR SIS ONLY/LOOPOGRAM	1,040.00	–	2,105.00	3,200.00	3,400.00
RADIO_XRAY	UPPER GASTROINTESTINAL SERIES	1,340.00	2,630.00	2,760.00	2,895.00	3,025.00
RADIO_XRAY	DUCTOGRAM	3,400.00	3,270.00	3,430.00	3,515.00	3,595.00
RADIO_XRAY	VOLDING CYTOURETHROGRAM	2,610.00	–	3,680.00	3,700.00	3,780.00
RADIO_XRAY	WATER-SOLUBLE ENEMA (ADULT)	12,210.00	10,170.00	10,680.00	11,190.00	11,695.00
RADIO_XRAY	X-RAY, CEPHALOMETRIC	500.00	750	790.00	840.00	880.00
RADIO_XRAY	X-RAY, PANORAMIC	570.00	670	710.00	750.00	790.00
RADIO_XRAY	BARIUM ENEMA	3,245.00	3,120.00	3,315.00	3,670.00	3,770.00
RADIO_XRAY	CARDIAC SERIES ADULT	405.00	960	960.00	1,165.00	1,165.00
RADIO_XRAY	CARDIAC SERIES INFANT	280.00	960	960.00	1,165.00	1,165.00
RADIO_XRAY	COLONOGRAM (ANTE OR RETROGRADE, USING BARIUM SULFATE)	1,925.00	1,850.00	1,940.00	2,250.00	2,590.00
RADIO_XRAY	COLONOGRAM (ANTE OR RETROGRADE, USING WATER SOLUBLE CONTRAST)	5,635.00	5,330.00	5,595.00	5,905.00	6,180.00
RADIO_XRAY	FISTULOGRAM/ SINUGRAM	2,740.00	2,635.00	2,765.00	2,900.00	3,030.00
RADIO_XRAY	KUB – IVP	2,420.00	–	0.00	0.00	0.00
RADIO_XRAY	ONE – SHOT INTRAVENOUS PYELOGRAM (IVP)	520.00	680	680.00	680.00	935.00
RADIO_XRAY	ORBIT AND OPTIC FORAMEN	240.00	470	490.00	680.00	715.00
RADIO_XRAY	SINUGRAM (SAME AS FISTOLUGRAM)	3,620.00	3,620.00	3,805.00	3,985.00	4,165.00
RADIO_XRAY	T – TUBE CHOLANGIOGRAM/RETROGRADE CHOLANGIOGRAM	2,235.00	2,665.00	2,950.00	3,495.00	3,605.00
RADIO_XRAY	UGIS USING BARIUM SULFATE	2,190.00	3,525.00	3,705.00	3,880.00	4,055.00
RADIO_XRAY	UGIS USING WATER-SOLUBLE CONTRAST	5,830.00	6,020.00	6,325.00	7,105.00	7,255.00
RADIO_XRAY	UGIS W/SMALL INTESTINE SERIES OR SIS USING BARIUM SULFATE	2,400.00	3,570.00	3,750.00	4,080.00	4,335.00
RADIO_XRAY	UGIS W/SMALL INTESTINE SERIES OR SIS USING WATER-SOLUBLE CONTRAST (ADULT)	5,910.00	6,430.00	6,750.00	7,735.00	7,990.00
RADIO_XRAY	UGIS W/SMALL INTESTINE SERIES OR SIS USING WATER-SOLUBLE CONTRAST (PEDIA)	3,190.00	3,065.00	3,215.00	3,370.00	3,525.00

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REHAB. MED-OTHERS

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
REHAB. MED-OTHERS	EMG	630.00	–	1,500.00	1,500.00	1,500.00
REHAB. MED-OTHERS	MSK-UTZ	850.00	–	1,380.00	1,460.00	1,540.00
REHAB. MED-OTHERS	UTILITIES/HOUR	32.90	32.9	32.90	32.90	32.90
REHAB. MED-OTHERS	ADAPTED SEAT (PERMAHARD FOAM)	550.00	2,500.00	2,500.00	2,500.00	2,500.00
REHAB. MED-OTHERS	ADAPTIVE DEVICES – ADAPTED SEAT (PERMAHARD FOAM)	590.00	2,630.00	2,750.00	2,880.00	3,000.00
REHAB. MED-OTHERS	ADAPTIVE DEVICES – BOBATH SLING/HEMI SLING	860.00	950	990.00	1,040.00	1,080.00
REHAB. MED-OTHERS	ADAPTIVE DEVICES – DYNAMIC ADA	430.00	530	550.00	580.00	600.00
REHAB. MED-OTHERS	ADAPTIVE DEVICES – UNIVERSAL CUFF	160.00	210	220.00	230.00	240.00
REHAB. MED-OTHERS	ADAPTIVE DEVICES – UNIVERSAL CUFF (AMPUTEE)	300.00	400	420.00	440.00	440.00
REHAB. MED-OTHERS	BOBATH SLING/HEMI SLING	800.00	900	900.00	900.00	900.00
REHAB. MED-OTHERS	DYNAMIC ADA	400.00	500	500.00	500.00	500.00
REHAB. MED-OTHERS	EMG-NCV,	630.00	1,500.00	0.00	0.00	0.00
REHAB. MED-OTHERS	TRANSCRANIAL MAGNETIC STIMULATION (10 SESSIONS)	17,425.00	25,755.00	0.00	0.00	0.00
REHAB. MED-OTHERS	TRANSCRANIAL MAGNETIC STIMULATION (15 SESSIONS)	26,138.00	38,632.00	0.00	0.00	0.00
REHAB. MED-OTHERS	TRANSCRANIAL MAGNETIC STIMULATION (5 SESSIONS )	8,710.00	12,878.00	0.00	0.00	0.00
REHAB. MED-OTHERS	TRANSCRANIAL MAGNETIC STIMULATION (PER SESSION)	2,050.00	3,030.00	0.00	0.00	0.00
REHAB. MED-OTHERS	UNIVERSAL CUFF	150.00	200	200.00	200.00	200.00
REHAB. MED-OTHERS	UNIVERSAL CUFF (AMPUTEE)	280.00	380	380.00	380.00	380.00

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REHAB. MED-EQUIPMENT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
REHAB. MED-EQUIPMENT	USE OF HOCOMA LOKOMAT MACHINE	2,700.00	–	–	4,000.00	–
REHAB. MED-EQUIPMENT	BALANCE TRAINER	425	630	630	665.00	705
REHAB. MED-EQUIPMENT	COLD AIR AND THERAPY SYSTEM	375	550	550	585.00	615
REHAB. MED-EQUIPMENT	CONTINOUS PASSIVE MOTION MACHINE	340	500	500	530.00	560
REHAB. MED-EQUIPMENT	DEFIBRILLATOR/DAY	115	400	400	400.00	400
REHAB. MED-EQUIPMENT	SHOCKWAVE THERAPY	370	550	550	585.00	615
REHAB. MED-EQUIPMENT	SHOCKWAVE THERAPY AND COLD AIR AND THERAPY SYSTEM	–	500	570	640.00	710
REHAB. MED-EQUIPMENT	TREADMILL MACHINE	390	580	580	610.00	645

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REHAB. MED- SERVICES

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
REHAB. MED- SERVICES	ADVANCED PHYSICAL THERAPY CLINICAL OBSERVERSHIP PROGRAM (APTOP) / MONTH	5,000.00	5,000.00	5,000.00	5,000.00	5,000.00
REHAB. MED- SERVICES	PSYCHOLOGICAL EVALUATION PER TEST	200	650	715	780	810
REHAB. MED- SERVICES	PSYCHOLOGICAL TESTING (BATTERY OF TEST)	650	5,200.00	–	–	–
REHAB. MED- SERVICES	PSYCHOTHERAPY (COUNSELING OR BEHAVIOR THERAPY)	200	1,300.00	550	600	600
REHAB. MED- SERVICES	ADVANCED PHYSICAL THERAPY HANDS-ON TRAINING PROGRAM (APTHTP) / WEEK	2,000.00	2,000.00	2,000.00	2,000.00	2,000.00
REHAB. MED- SERVICES	OCCUPATIONAL THERAPY CLINICAL TRAINING PROGRAM (OCTP)	4,500.00	–	–	4,500.00	–
REHAB. MED- SERVICES	SPEECH AND LANGUAGE THERAPY (BASE RATE)	–	500	–	600	625
REHAB. MED- SERVICES	SPEECH AND LANGUAGE THERAPY (FORMAL TEST)	–	500	–	600	625
REHAB. MED- SERVICES	BALANCE TRAINER AND TREADMILL MACHINE	–	500	570	640	710
REHAB. MED- SERVICES	EVALUATION: BASE RATE	–	500	550	600	625
REHAB. MED- SERVICES	EVALUATION : FORMAL TEST (PER TEST)	–	500	550	600	625
REHAB. MED- SERVICES	OCCUPATIONAL THERAPY	200	650	715	780	810
REHAB. MED- SERVICES	PHYSICAL THERAPY SERVICES	240	795	870	980	1,090.00
REHAB. MED- SERVICES	PSYCHOLOGICAL/BEHAVIORAL THERAPY,	150	500	550	600	625
REHAB. MED- SERVICES	PSYCHOLOGICAL EVALUATION	–	1,000.00	1,140.00	1,290.00	1,430.00
REHAB. MED- SERVICES	PSYCHOLOGICAL TESTING	–	3,000.00	3,430.00	3,860.00	4,290.00
REHAB. MED- SERVICES	SHOCKWAVE THERAPY AND COLD AIR THERAPY SYSTEM,	–	500	570	640	710
REHAB. MED- SERVICES	SPEECH AND LANGUAGE THERAPY,	200	650	715	780	810

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RADIOLOGY-INTERVENTIONAL

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RADIOLOGY-INTERVENTIONAL	BRONCHOGRAM [INTERVENTIONAL]	365.00	1,670.00	1,670.00	2,085.00	2,085.00
RADIOLOGY-INTERVENTIONAL	MYELOGRAM [INTERVENTIONAL]	435.00	1,685.00	1,685.00	2,040.00	2,040.00
RADIOLOGY-INTERVENTIONAL	VENTRICULOGRAPHY [INTERVENTIONAL]	510.00	1,685.00	1,685.00	2,040.00	2,040.00
RADIOLOGY-INTERVENTIONAL	AORTOGRAM [INTERVENTIONAL]	3,000.00	4,770.00	4,770.00	5,960.00	5,960.00
RADIOLOGY-INTERVENTIONAL	ARTHROGRAPHY [INTERVENTIONAL]	615.00	2,145.00	2,145.00	2,680.00	2,680.00
RADIOLOGY-INTERVENTIONAL	CEREBRAL ANGIOGRAM – ONE (1) VESSEL [INTERVENTIONAL]	3,070.00	4,770.00	4,770.00	5,960.00	5,960.00
RADIOLOGY-INTERVENTIONAL	CEREBRAL ANGIOGRAM – THREE (3) VESSELS [INTERVENTIONAL]	4,370.00	8,940.00	8,940.00	11,175.00	11,175.00
RADIOLOGY-INTERVENTIONAL	CEREBRAL ANGIOGRAM – TWO (2) VESSELS [INTERVENTIONAL]	3,900.00	5,960.00	5,960.00	7,450.00	7,450.00
RADIOLOGY-INTERVENTIONAL	ENDOSCOPIC RETROGRADE CHOLANGIOGRAM (ERCP) [INTERVENTIONAL]	750.00	1,820.00	1,820.00	2,280.00	2,280.00
RADIOLOGY-INTERVENTIONAL	PERIPHERAL ARTENOGRAM [INTERVENTIONAL]	3,225.00	3,575.00	3,575.00	4,470.00	4,470.00
RADIOLOGY-INTERVENTIONAL	RENAL ARTENOGRAM & SUPERSELECTIVE ARTENOGRAM [INTERVENTIONAL]	3,225.00	3,575.00	3,575.00	4,470.00	4,470.00

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TCVS – OR (PROCEDURES)

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
TCVS – OR (PROCEDURES)	AV FISTULA SURVEILANCE	375	–	460	490	490
TCVS – OR (PROCEDURES)	DIAGNOSTIC ULTRASOUND BILATERAL	230	–	280	300	300
TCVS – OR (PROCEDURES)	DIAGNOSTIC ULTRASOUND TO RULE OUT DVT	560	–	680	730	730
TCVS – OR (PROCEDURES)	DIAGNOSTIC ULTRASOUND UNILATERAL	195	–	235	255	255
TCVS – OR (PROCEDURES)	THERAPEUTIC ULTRASOUND (T/PCI/PCI)	560	–	680	730	730
TCVS – OR (PROCEDURES)	ULTRASOUND FOR ASSESMENT OF PSEUDOANEURYSM	375	–	460	490	490
TCVS – OR (PROCEDURES)	ULTRASOUND GUIDED BIOPSY (M/PP)	560	–	680	730	730
TCVS – OR (PROCEDURES)	ULTRASOUND-GUIDED CANNULATION OF THE GREATER SAPHENOUS VEIN FOR ENDOVENOUS LA	560	–	680	730	730
TCVS – OR (PROCEDURES)	ULTRASOUND-GUIDED HD CATHETER PLACEMENT (IJ/F/S)	195	–	235	255	255
TCVS – OR (PROCEDURES)	ULTRASOUND-GUIDED PLACEMENT OF ARTERIAL/VENOUS CATHETER BOTH UPPER OR LOWER EX	195	–	235	255	255
TCVS – OR (PROCEDURES)	ULTRASOUND-GUIDED PLACEMENT OF CENTRAL VENOUS CATHETER	195	–	235	255	255
TCVS – OR (PROCEDURES)	ULTRASOUND-GUIDED PLACEMENT OF PICC LINE	375	–	460	490	490
TCVS – OR (PROCEDURES)	VALLEYLAB LIGASURE	4,000	–	6,000	6,000	6,000
TCVS – OR (PROCEDURES)	(VATS) TOWER – DIAGNOSTIC	2,220	–	2,700	2,895	2,895
TCVS – OR (PROCEDURES)	VEIN MAPPING (TCVS)	195	–	235	255	255
TCVS – OR (PROCEDURES)	VEIN MAPPING WITH DOPPLER ULTRASOUND OF ARTERIES	375	–	460	490	490

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SURGICAL INTENSIVE CARE UNIT

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SURGERY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
SURGERY	ULTRASOUND-GUIDED VACUUM-ASSISTED BREAST BIOPSY	20,850.00	–	–	23,410.00	–
SURGERY	CRANIOTONE (STRYKER)	2,400.00	3,710.00	3,930.00	4,140.00	4,360.00
SURGERY	NEUROENDOSCOPE (STORZ)	1,170.00	1,800.00	1,910.00	2,010.00	2,120.00
SURGERY	OPERATING MICROSCOPE (LEICA F50)	5,870.00	9,070.00	9,610.00	10,140.00	10,680.00
SURGERY	3D FULL HIGH DEFINITION LAPAROSCOPY TOWERS	4,530.00	7,000.00	7,410.00	7,825.00	8,240.00
SURGERY	ADULT (RIGID) CYSTOSCOPE	1,290.00	2,000.00	2,120.00	2,240.00	2,350.00
SURGERY	AV FISTULA SURVEILLANCE	375.00	425	460	490.00	490
SURGERY	BREAST – CORE NEEDLE BIOPSY	2,050.00	3,000.00	3,180.00	3,360.00	3,530.00
SURGERY	BREAST – ULTRASOUND GUIDED CORE NEEDLE BIOPSY	2,140.00	3,300.00	3,500.00	3,690.00	3,880.00
SURGERY	CHOLEDOSCHOSCOPY	420.00	1,575.00	1,780.00	1,975.00	2,070.00
SURGERY	CHOLEDOSCHOSCOPY WITH LITHOTRIPSY	600.00	1,950.00	2,315.00	2,400.00	2,550.00
SURGERY	COLONOSCOPY	420.00	1,600.00	1,790.00	1,995.00	1,995.00
SURGERY	COLONOSCOPY WITH POLYPECTOMY	760.00	2,745.00	3,025.00	3,375.00	3,490.00
SURGERY	COMBINED PNEUMATIC AND ULTRASONIC (FOR PCNL)	4,530.00	7,000.00	7,410.00	7,830.00	8,240.00
SURGERY	DIAGNOSTIC ULTRASOUND TO RULE OUT DVT	560.00	635	680	730.00	730
SURGERY	ENDOANAL ULTRASOUND (EAUS)	1,620.00	2,500.00	2,650.00	2,800.00	2,940.00
SURGERY	ENDORECTAL ULTRASOUND (ERUS)	1,620.00	2,500.00	2,650.00	2,800.00	2,940.00
SURGERY	ENDOSCOPIC ULTRSOUND (EUS)	2,330.00	6,800.00	8,540.00	9,510.00	10,490.00
SURGERY	FLEXIBLE CYSTONEPHROSCOPE	12,290.00	19,000.00	20,120.00	21,240.00	22,350.00
SURGERY	FLEXIBLE CYSTOSCOPE	1,290.00	2,000.00	2,120.00	2,240.00	2,350.00
SURGERY	FLEXIBLE SIGMOIDOSCOPY	200.00	690	805	920.00	1,150.00
SURGERY	FORCETRIAD	4,530.00	7,000.00	7,410.00	7,825.00	8,240.00
SURGERY	HARMONIC SCALPEL	3,780.00	5,850.00	6,190.00	6,540.00	6,880.00
SURGERY	KARL STORZ HD VIDEO TOWER FOR CYSTOSCOPY/PCNL	650.00	1,000.00	1,060.00	1,120.00	1,180.00
SURGERY	LASER LITHOTRIPTER	3,240.00	5,000.00	5,300.00	5,590.00	5,880.00
SURGERY	LITHOLAPAXY (STONE CRUSHER)	1,290.00	2,000.00	2,120.00	2,240.00	2,350.00
SURGERY	PEDIATRIC CYSTOSCOPE	1,290.00	2,000.00	2,120.00	2,240.00	2,350.00
SURGERY	PNEUMATIC LITHOTRIPTER	2,850.00	4,400.00	4,660.00	4,920.00	5,180.00
SURGERY	RESECTOSCOPE (FOR TURP/TURBT)	1,290.00	2,000.00	2,115.00	2,240.00	2,350.00
SURGERY	TELEPAK: FLEXIBLE SIGMOIDOSCOPY	450.00	690	730	770.00	810
SURGERY	THERAPEUTIC ULTRASOUND (THORACENTESIS/PIGTAIL CATHETER INSERTION/PLEURAL CATHETER	560.00	635	680	730.00	730
SURGERY	THUNDERBEAT	4,530.00	7,000.00	7,410.00	7,825.00	8,240.00
SURGERY	THYROID – FINE NEEDLE ASPIRATION BIOPSY	240.00	375	400	420.00	440
SURGERY	THYROID – FLEXIBLE NASOPHARYGOSCOPY	200.00	805	935	1,035.00	2,070.00
SURGERY	THYROID – ULTRASOUND GUIDED FINE NEEDLE BIOPSY	410.00	635	670	710.00	750
SURGERY	THYROID – ULTRASOUND GUIDED FNAB AND LIVER BIOPSY	350.00	1,265.00	1,265.00	1,530.00	1,530.00
SURGERY	TRANSANAL ENDOSCOPIC MICROSURGERY (TEM)	2,590.00	4,000.00	4,240.00	4,470.00	4,700.00
SURGERY	ULTRASOUND FOR ASSESSMENT OF PSEUDOANEURYSM	375.00	425	460	490.00	490
SURGERY	ULTRASOUND GUIDED BIOPSY (MEDIASTURAL/PLEURAL PARENCHYMA)	560.00	635	680	730.00	730
SURGERY	ULTRASOUND GUIDED CANNULATION OF THE GREAT SAPHENOUS VEIN FOR ENDOVENOUS LASER	560.00	635	680	730.00	730
SURGERY	ULTRASOUND GUIDED HD CATHETER PLACEMENT (IJ/FEMORAL/SUBCLAVIAN)	195.00	220	235	255.00	255
SURGERY	ULTRASOUND GUIDED PLACEMENT OF ARTERIAL/VENOUS CATHETER BOTH UPPER OR LOWER EX	195.00	220	235	255.00	255
SURGERY	ULTRASOUND GUIDED PLACEMENT OF CENTRAL VENOUS CATHETER	195.00	220	235	255.00	255
SURGERY	ULTRASOUND GUIDED PLACEMENT OF PICC LINE	375.00	425	460	490.00	490
SURGERY	ULTRASOUND MACHINE	780.00	1,200.00	1,270.00	1,340.00	1,410.00
SURGERY	URETEROSCOPE	1,940.00	3,000.00	3,175.00	3,350.00	3,530.00
SURGERY	URODYNAMICS MACHINE (PRESSURE – FLOW/FULL STUDY)	2,910.00	4,500.00	4,765.00	5,030.00	5,300.00
SURGERY	URODYNAMICS MACHINE (UROFLOWMETRY WITH PVR)	3,060.00	4,730.00	5,010.00	5,290.00	5,570.00
SURGERY	UTZ CHEST – DIAGNOSTIC ULTRASOUND BILATERAL	230.00	260	280	300.00	300
SURGERY	UTZ CHEST- DIAGNOSTIC ULTRASOUND BILATERAL	230.00	260	280	300.00	300
SURGERY	UTZ CHEST – DIAGNOSTIC ULTRASOUND UNILATERAL	195.00	220	235	255.00	255
SURGERY	UTZ CHEST- DIAGNOSTIC ULTRASOUND UNILATERAL	195.00	220	235	255.00	255
SURGERY	VIDEO ASSISTED THORACIC SURGERY (VATS) TOWER – DIAGNOSTIC	2,220.00	2,510.00	2,700.00	2,895.00	2,895.00
SURGERY	VIDEO ASSISTED THORACIC SURGERY (VATS) TOWER-DIAGNOSTIC	2,220.00	2,510.00	2,700.00	2,895.00	2,895.00
SURGERY	VIDEO ASSISTED THORACIC SURGERY (VATS) TOWER – THERAPEUTIC	4,435.00	5,015.00	5,400.00	5,790.00	5,790.00
SURGERY	VIDEO ASSISTED THORACIC SURGERY (VATS) TOWER-THERAPEUTIC	4,435.00	5,015.00	5,400.00	5,790.00	5,790.00
SURGERY	VIEN MAPPING	195.00	220	235	255.00	255
SURGERY	VIEN MAPPING WITH DOPPLER ULTRASPUND OF ARTERIES	375.00	425	460	490.00	490

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SOJR

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
SOJR	SELECTIVE LASER TRABECULOSCOPY (SLT)- BOTH EYES (WITHOUT PHILHEALTH)	5,000.00	5,600.00	5,600.00	5,600.00	5,600.00
SOJR	SELECTIVE LASER TRABECULOSCOPY (SLT)- BOTH EYES (WITH PHILHEALTH)	12,120.00	12,120.00	12,120.00	12,120.00	12,120.00
SOJR	SELECTIVE LASER TRABECULOSCOPY (SLT)- ONE EYE (WITHOUT PHILHEALTH)	2,500.00	2,800.00	2,800.00	2,800.00	2,800.00
SOJR	SELECTIVE LASER TRABECULOSCOPY (SLT)- ONE EYE (WITH PHILHEALTH)	12,120.00	12,120.00	12,120.00	12,120.00	–
SOJR	OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY (OCT-A)	1,910.00	2,960.00	3,130.00	3,310.00	3,480.00
SOJR	PHACOEMULSIFICATION (ANTERIOR SEGMENT) MACHINE USE OERTLI OS4	2,140.00	3,300.00	3,490.00	3,690.00	3,880.00
SOJR	PHACOEMULSIFICATION (POSTERIOR SEGMENT) MACHINE USE OERTLI OS4	2,580.00	3,980.00	4,210.00	4,450.00	4,680.00
SOJR	COMBINED FA+ICG	3,090.00	–	4,155.00	4,155.00	–
SOJR	FLUORECEIN ANGIOGRAPHY (FA)	2,100.00	–	3,040.00	3,040.00	–
SOJR	ICARE TONOMETER – ONE EYE	95.00	–	105.00	105.00	–
SOJR	ICARE TONOMETER – TWO EYE	115.00	–	125.00	125.00	–
SOJR	INDOCYANINE GREEN (ICG) ANGIOGRAPHY (EXCLUDING DYE)	990.00	–	1,115.00	1,115.00	–
SOJR	ULTRASOUND- BIOMICROSCOPY – ONE (1) EYE (CLEAR SCAN PROBE SET-UP INCLUDING PROBE)	3,280.00	–	3,705.00	3,705.00	–
SOJR	ULTRASOUND- BIOMICROSCOPY – ONE (1) EYE (WATER BATH TECHNIQUE)	1,500.00	–	2,125.00	2,125.00	–
SOJR	ULTRASOUND- BIOMICROSCOPY – TWO (2) EYES (CLEAR SCAN PROBE SET-UP INCLUDING PROBE)	3,565.00	–	4,030.00	4,030.00	–
SOJR	ULTRASOUND- BIOMICROSCOPY – TWO (2) EYES (WATER BATH TECHNIQUE)	2,800.00	–	3,570.00	3,570.00	–
SOJR	WIDE ANGLE PHOTO	700.00	–	1,100.00	1,100.00	–
SOJR	BIG PRIVATE SOJR	0.00	–	0.00	2,750.00	–
SOJR	532 NM LASER – BOTH EYE	2,300.00	3,650.00	3,650.00	3,650.00	3,650.00
SOJR	532 NM LASER – ONE EYE	1,180.00	1,915.00	1,915.00	1,915.00	1,915.00
SOJR	ARGON LASER- BOTH EYES	1,800.00	3,100.00	3,100.00	3,100.00	3,100.00
SOJR	ARGON LASER- ONE EYE	980.00	1,570.00	1,570.00	1,570.00	1,570.00
SOJR	BIOMETRY- BOTH EYES	500.00	610	610.00	610.00	610
SOJR	BIOMETRY- ONE EYE	200.00	245	245.00	245.00	245
SOJR	CORNEAL TOPOGRAPHY- BOTH EYES	560.00	680	680.00	680.00	680
SOJR	CORNEAL TOPOGRAPHY- ONE EYE	280.00	340	340.00	340.00	340
SOJR	DIODE LASER – BOTH EYES	2,000.00	2,870.00	2,870.00	2,870.00	2,870.00
SOJR	DIODE LASER – ONE EYE	980.00	1,480.00	1,480.00	1,480.00	1,480.00
SOJR	ELECTROOCULOGRAM (EOG)	400.00	900	900.00	900.00	900
SOJR	ELECTRORETIGRAPHY (ERG)	400.00	900	900.00	900.00	900
SOJR	FLUORESCEIN ANGIOGRAPHY- BOTH EYES	2,000.00	2,260.00	2,260.00	2,260.00	2,260.00
SOJR	FUNDUS / DISC PHOTO- BOTH EYES	500.00	785	785.00	785.00	785
SOJR	FUNDUS / DISC PHOTO- ONE EYE	275.00	435	435.00	435.00	435
SOJR	OCULAR COHERENCE TOMOGRAPHY (OCT)- BOTH EYES	2,335.00	2,990.00	2,990.00	2,990.00	2,990.00
SOJR	OCULAR COHERENCE TOMOGRAPHY (OCT)-ONE EYE	1,195.00	1,785.00	1,785.00	1,785.00	1,785.00
SOJR	OCULAR ULTRASOUND- BOTH EYES	1,100.00	2,085.00	2,085.00	2,085.00	2,085.00
SOJR	OCULAR ULTRASOUND- ONE EYE	800.00	1,610.00	1,610.00	1,610.00	1,610.00
SOJR	OPTICAL COHERENCE- BOTH EYES	1,085.00	1,600.00	1,600.00	1,600.00	1,600.00
SOJR	PACHYMETRY- BOTH EYES	315.00	470	470.00	470.00	470
SOJR	PACHYMETRY- ONE EYE	160.00	235	235.00	235.00	235
SOJR	PERIMETRY/AUTOMATED VISUAL FIELD- BOTH EYES	1,000.00	1,565.00	1,565.00	1,565.00	1,565.00
SOJR	SPECULAR MICROSCOPY- BOTH EYES	800.00	1,200.00	1,200.00	1,200.00	1,200.00
SOJR	SPECULAR MICROSCOPY- ONE EYE	400.00	600	600.00	600.00	600
SOJR	TONOPEN- BOTH EYES	150.00	200	200.00	200.00	200
SOJR	TONOPEN- ONE EYE	75.00	100	100.00	100.00	100
SOJR	ULTRASOUND- BIOMICROSCOPY- BOTH EYES	2,100.00	3,305.00	3,305.00	3,305.00	3,305.00
SOJR	ULTRASOUND- BIOMICROSCOPY- ONE EYE	1,060.00	1,795.00	1,795.00	1,795.00	1,795.00
SOJR	VISUAL EVOKED RESPONSE (VER)	400.00	900	900.00	900.00	900
SOJR	VITRECTOMY BOTH EYES	2,475.00	3,655.00	3,655.00	3,655.00	3,655.00
SOJR	YAG LASER BOTH EYES	2,300.00	3,435.00	3,435.00	3,435.00	3,435.00
SOJR	YAG LASER ONE EYE	1,180.00	1,740.00	1,740.00	1,740.00	1,740.00
SOJR	MAJOR BASIC OR FEE – ADDITIONAL PER HOUR IN EXCESS OF 1-1/2 HOURS	0.00	750	750.00	750.00	750
SOJR	MAJOR BASIC OR FEE- FIRST 1-1/2 HOURS	0.00	3,010.00	3,010.00	3,010.00	3,010.00
SOJR	MINOR BASIC OR FEE (30 MINS.)	1,500.00	2,100.00	2,100.00	2,100.00	2,100.00

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SLEEP LABORATORY

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RIL-OTHERS

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RIL-IODINE 131 THERAPY

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RIL-IODINE 131 THERAPY	10.0-12.9 MCI	3,900.00	4,200.00	4,200.00	4,200.00	4,200.00
RIL-IODINE 131 THERAPY	101.0-150.0 MCI	14,500.00	15,500.00	15,500.00	15,500.00	15,500.00
RIL-IODINE 131 THERAPY	1.0-3.9 MCI	2,400.00	2,500.00	2,500.00	2,500.00	2,500.00
RIL-IODINE 131 THERAPY	13.0-14.9 MCI	4,900.00	5,400.00	5,400.00	5,400.00	5,400.00
RIL-IODINE 131 THERAPY	15.0-20.0 MCI	5,000.00	5,600.00	5,600.00	5,600.00	5,600.00
RIL-IODINE 131 THERAPY	151.0-200.0 MCI	19,700.00	21,000.00	21,000.00	21,000.00	21,000.00
RIL-IODINE 131 THERAPY	21.0-25.0 MCI	5,600.00	6,000.00	6,000.00	6,000.00	6,000.00
RIL-IODINE 131 THERAPY	26.0-30.0 MCI	6,900.00	7,200.00	7,200.00	7,200.00	7,200.00
RIL-IODINE 131 THERAPY	31.0-50.0 MCI	9,200.00	9,700.00	9,700.00	9,700.00	9,700.00
RIL-IODINE 131 THERAPY	4.0-5.9 MCI	2,900.00	2,950.00	2,950.00	2,950.00	2,950.00
RIL-IODINE 131 THERAPY	51.0-80.0 MCI	9,800.00	10,000.00	10,000.00	10,000.00	10,000.00
RIL-IODINE 131 THERAPY	6.0-9.9 MCI	3,025.00	3,100.00	3,100.00	3,100.00	3,100.00
RIL-IODINE 131 THERAPY	81.0-100.0 MCI	11,500.00	12,000.00	12,000.00	12,000.00	12,000.00

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RIL-IMAGING

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RIL-IMAGING	BONE DENSITOMETRY-ROUTINE	2,235.00	2,545.00	2,675.00	2,800.00	2,930.00
RIL-IMAGING	BONE DENSITOMETRY-WHOLE BODY	2,915.00	3,180.00	3,340.00	3,500.00	3,655.00
RIL-IMAGING	DTPA/GFR/RENAL SCAN/CAPTOPRIL	4,970.00	5,230.00	5,995.00	6,160.00	6,460.00
RIL-IMAGING	DTPA/GFR/RENAL SCAN WITH LASIX	6,640.00	6,925.00	7,265.00	7,605.00	7,945.00
RIL-IMAGING	GI BLEED	9,280.00	10,945.00	12,010.00	13,760.00	14,430.00
RIL-IMAGING	I-131 MIBG WBS	39,825.00	41,555.00	45,020.00	47,320.00	47,785.00
RIL-IMAGING	I-131 WBS	8,750.00	9,545.00	10,020.00	10,500.00	10,975.00
RIL-IMAGING	LYMPHOSCINTIGRAPHY	18,345.00	20,760.00	21,805.00	22,915.00	23,240.00
RIL-IMAGING	MYOCARDIAL PERFUSION IMAGING SESTAMIBI STRESS & DIPYRIDAMOLE	10,510.00	14,960.00	16,400.00	18,800.00	19,720.00
RIL-IMAGING	MYOCARDIAL PERFUSION THALLIUM 201 STRESS & DIPYRIDAMOLE	13,765.00	17,660.00	19,420.00	22,320.00	23,435.00
RIL-IMAGING	PARATHYROID- MIBI	9,705.00	11,035.00	11,570.00	12,620.00	13,230.00
RIL-IMAGING	PARATHYROID-THALLIUM 201	9,055.00	11,380.00	12,380.00	13,050.00	13,085.00
RIL-IMAGING	RIA- 17-OHP	620.00	1,320.00	1,385.00	1,450.00	1,520.00
RIL-IMAGING	RIA- ACTH	1,795.00	4,500.00	4,725.00	4,950.00	5,175.00
RIL-IMAGING	RIA- ALDOSTERONE	1,130.00	3,150.00	3,310.00	3,465.00	3,620.00
RIL-IMAGING	RIA- ALDOSTERONE RENIN	2,590.00	5,000.00	5,250.00	5,500.00	5,750.00
RIL-IMAGING	RIA- ANTI-THYRO	975.00	1,165.00	1,225.00	1,280.00	1,340.00
RIL-IMAGING	RIA- ANTI-TPO	975.00	1,165.00	1,225.00	1,280.00	1,340.00
RIL-IMAGING	RIA- CORTISOL	500.00	635.00	665.00	695.00	730.00
RIL-IMAGING	RIA- DHEA SO4	920.00	1,135.00	1,190.00	1,250.00	1,305.00
RIL-IMAGING	RIA- ESTRADIOL	635.00	1,100.00	1,155.00	1,210.00	1,265.00
RIL-IMAGING	RIA- FERRITINE	785.00	1,100.00	1,155.00	1,210.00	1,265.00
RIL-IMAGING	RIA- FSH	570.00	760.00	800.00	835.00	875.00
RIL-IMAGING	RIA- FT3	475.00	780.00	820.00	860.00	895.00
RIL-IMAGING	RIA- FT3 TSH	735.00	1,185.00	1,245.00	1,305.00	1,365.00
RIL-IMAGING	RIA- FT4	475.00	780.00	820.00	860.00	895.00
RIL-IMAGING	RIA- FT4 FT3	760.00	1,205.00	1,315.00	1,375.00	1,440.00
RIL-IMAGING	RIA- FT4 FT3 TSH	1,115.00	1,805.00	1,895.00	1,985.00	2,075.00
RIL-IMAGING	RIA- FT4 TSH	735.00	1,185.00	1,245.00	1,305.00	1,365.00
RIL-IMAGING	RIA- HCG DILUTED	695.00	1,050.00	1,105.00	1,155.00	1,210.00
RIL-IMAGING	RIA- HCG UNDILUTED	530.00	1,020.00	1,070.00	1,120.00	1,175.00
RIL-IMAGING	RIA- INSULIN	710.00	1,100.00	1,155.00	1,210.00	1,265.00
RIL-IMAGING	RIA-INSULIN-LIKE GROWTH FACTOR-1 (IGF-1)	1,005.00	3,320.00	3,485.00	3,735.00	4,150.00
RIL-IMAGING	RIA- LH	600.00	725.00	760.00	800.00	835.00
RIL-IMAGING	RIA- PROLACTIN	500.00	710.00	745.00	780.00	815.00
RIL-IMAGING	RIA- PTH	1,955.00	4,500.00	4,725.00	4,950.00	5,175.00
RIL-IMAGING	RIA- RENIN	1,460.00	3,500.00	3,675.00	3,850.00	4,025.00
RIL-IMAGING	RIA- TESTOSTERONE	575.00	810.00	850.00	890.00	930.00
RIL-IMAGING	RIA- TG ATG	1,560.00	1,870.00	1,965.00	2,060.00	2,150.00
RIL-IMAGING	RIA- THYROGLOBULIN	975.00	1,175.00	1,235.00	1,290.00	1,350.00
RIL-IMAGING	RIA- TSH	445.00	700.00	735.00	770.00	805.00
RIL-IMAGING	RIA- TSH TG ATG	1,915.00	2,430.00	2.56	2,675.00	2,795.00
RIL-IMAGING	SENTINEL NODE MAPPING-FILTERED SULFUR COLLOID	19,340.00	20,485.00	21,530.00	22,640.00	22,850.00
RIL-IMAGING	SENTINEL NODE MAPPING-UNFILTERED SULFUR COLLOID	17,875.00	20,410.00	20,895.00	21,845.00	22,775.00
RIL-IMAGING	SESTAMIBI WBS	7,780.00	11,280.00	11,970.00	13,940.00	14,620.00
RIL-IMAGING	THALLIUM WBS	5,805.00	7,100.00	7,455.00	7,810.00	8,165.00
RIL-IMAGING	THREE PHASE BONE SCAN	6,510.00	7,440.00	7,810.00	8,185.00	8,555.00
RIL-IMAGING	MAG-3 RENAL SCAN	8,720.00	8,980.00	9,745.00	9,910.00	10,210.00
RIL-IMAGING	MAG-3 RENAL SCAN W/ LASIX	10,390.00	10,675.00	11,015.00	11,355.00	2,060.00
RIL-IMAGING	THALLIUM-201 WBS	6,035.00	7,330.00	7,685.00	8,040.00	8,395.00
RIL-IMAGING	BONE SCAN	6,510.00	7,440.00	7,810.00	8,185.00	8,555.00
RIL-IMAGING	BRAIN IMAGING	4,820.00	7,265.00	7,995.00	7,990.00	8,355.00
RIL-IMAGING	DMSA RENAL SCAN	4,960.00	5,655.00	5,930.00	6,210.00	6,485.00
RIL-IMAGING	GE REFLUX	14,280.00	15,150.00	15,670.00	16,205.00	16,780.00
RIL-IMAGING	HEPATO-BILIARY	11,510.00	12,115.00	12,585.00	13,050.00	13,515.00
RIL-IMAGING	INFARCT AVID IMAGING	4,150.00	4,330.00	4,540.00	4,750.00	4,953.00
RIL-IMAGING	LIVER/SPLEEN IMAGING	12,820.00	13,570.00	14,345.00	14,825.00	14,910.00
RIL-IMAGING	LUNG PERFUSION	5,770.00	6,925.00	7,520.00	8,505.00	8,880.00
RIL-IMAGING	LUNG VENTILATION	4,915.00	9,180.00	10,085.00	11,580.00	12,155.00
RIL-IMAGING	MECKEL’S DIVERTICULUM	3,330.00	4,520.00	4,960.00	5,680.00	5,950.00
RIL-IMAGING	TESTICULAR IMAGING	4,820.00	5,690.00	5,960.00	6,340.00	6,520.00
RIL-IMAGING	THYROID SCAN	1,710.00	1,790.00	1,920.00	2,050.00	2,140.00
RIL-IMAGING	VENOGRAPHY	5,640.00	6,835.00	7,420.00	8,555.00	8,755.00
RIL-IMAGING	WBS POST TX	3,655.00	4,390.00	4,610.00	4,830.00	5,050.00
RIL-IMAGING	CARDIAC AMYLOIDOSIS	8,070.00	9,520.00	10,440.00	11,965.00	12,550.00
RIL-IMAGING	SECTIONAL SPECT CT PER BED	1,200.00	1,500.00	1,550.00	1,600.00	1,700.00

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RIL – LABORATORIES

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RENAL / DIALYSIS UNIT

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RENAL / DIALYSIS UNIT	BLOODLINE	200.00	–	200.00	200.00	200.00
RENAL / DIALYSIS UNIT	HDF ONLINE TUBING	300.00	–	300.00	300.00	300.00
RENAL / DIALYSIS UNIT	HI-FLUX (NEW DIALYZER B-BRAUN)	2,800.00	–	2,800.00	2,800.00	2,800.00
RENAL / DIALYSIS UNIT	HI-FLUX (NEW DIALYZER PGH)	1,105.00	–	1,625.00	1,625.00	1,625.00
RENAL / DIALYSIS UNIT	HI-FLUX (RE-USE DIALYZER B-BRAUN)	1,450.00	–	1,450.00	1,450.00	1,450.00
RENAL / DIALYSIS UNIT	HI-FLUX (RE-USE DIALYZER PGH)	455.00	–	975.00	975.00	975.00
RENAL / DIALYSIS UNIT	HIPS 18	2,000.00	–	2,000.00	2,000.00	2,000.00
RENAL / DIALYSIS UNIT	HIPS 20	2,300.00	–	2,300.00	2,300.00	2,300.00
RENAL / DIALYSIS UNIT	LOPS 15	800.00	–	800.00	800.00	800.00
RENAL / DIALYSIS UNIT	LOPS 18	850.00	–	850.00	850.00	850.00
RENAL / DIALYSIS UNIT	LOPS 20	900.00	–	900.00	900.00	900.00
RENAL / DIALYSIS UNIT	LOPS LOT 12	750.00	–	750.00	750.00	750.00
RENAL / DIALYSIS UNIT	LOW FLUX (NEW DIALYZER B-BRAUN)	2,500.00	–	2,500.00	2,500.00	2,500.00
RENAL / DIALYSIS UNIT	LOW FLUX (NEW DIALYZER PGH)	255.00	–	775.00	775.00	775.00
RENAL / DIALYSIS UNIT	LOW FLUX (RE-USE DIALYZER B-BRAUN)	1,395.00	–	1,395.00	1,395.00	1,395.00
RENAL / DIALYSIS UNIT	LOW FLUX (RE-USE DIALYZER PGH)	510.00	–	1,030.00	1,030.00	1,030.00
RENAL / DIALYSIS UNIT	XEVONTA H123	2,200.00	–	2,200.00	2,200.00	2,200.00

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DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
OB-GYN (ORTOLL)	COMPLETION CURETTAGE	11,000.00	–	–	–	–
OB-GYN (ORTOLL)	INSERTION OF SUB-DERMAL CONTRACEPTIVE IMPLANT	3,000.00	–	–	–	–
OB-GYN (ORTOLL)	IUD INSERTION	2,000.00	–	–	–	–
OB-GYN (ORTOLL)	OB NORMAL DELIVERY (LOW RISK, NORMAL DELIVERIES)	5,000.00	–	–	–	–
OB-GYN (ORTOLL)	TUBAL LIGATION	4,000.00	–	–	–	–

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
OB-GYN (OPD)	CERVICAL POLYPECTOMY	5,680.00	–	–	–	–
OB-GYN (OPD)	CERVICAL PUNCH BIOPSY	5,680.00	–	–	–	–
OB-GYN (OPD)	ENDOMETRIAL BIOPSY	11,000.00	–	–	–	–

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
OB-GYN	COLPOSCOPY	200	600.00	600.00	600.00	600.00
OB-GYN	CRYOTHERAPY	300	1,000.00	1,000.00	1,000.00	1,000.00
OB-GYN	PAPS SMEAR	150	375.00	450.00	485.00	485.00

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
OB-GYN(EMERGENCY ROOM AND OBAS)	CONSULTATION FEE	–	500	500	500	500
OB-GYN(EMERGENCY ROOM AND OBAS)	OBAS PAY EXAMINATION KIT (STERILE GLOVES, LUBRICANT, BLUE SHEET, COTTON BALLS & STERI	150	–	150	150	150
OB-GYN(EMERGENCY ROOM AND OBAS)	OBAS PAY EXAMINATION KIT (STERILE GLOVES, LUBRICANT, BLUE SHEET, COTTON BALLS & STERI	150	150	150	150	150

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
OB-GYN (UROGYNECOLOGY)	CMG + URETHRAL PRESSURE PROFILOMETRY (UPP)	4,330.00	6,420.00	6,770.00	7,120.00	7,470.00
OB-GYN (UROGYNECOLOGY)	URODYNAMICS (CMG)	3,830.00	5,920.00	6,270.00	6,620.00	6,970.00
OB-GYN (UROGYNECOLOGY)	URODYNAMICS (CMG) +EMG	4,280.00	7,220.00	7,570.00	7,920.00	8,270.00
OB-GYN (UROGYNECOLOGY)	UROFLOWMETRY + CMG	4,330.00	6,420.00	6,770.00	7,120.00	7,470.00
OB-GYN (UROGYNECOLOGY)	UROFLOWMETRY +CMG + EMG	4,400.00	7,720.00	8,070.00	8,420.00	8,770.00
OB-GYN (UROGYNECOLOGY)	DIAGNOSTIC CYSTOURETHROSCOPY	5,030.00	7,770.00	8,220.00	8,680.00	9,140.00

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
ORTHO (GAITLAB)	ADMINISTRATIVE OVERHEAD (GAIT LAB)	618.00	1,075.50	1,075.50	1,075.50	1,075.50
ORTHO (GAITLAB)	GAITING LABORATORY PROCEDURES	1,442.00	2,509.50	2,509.50	2,509.50	2,509.50

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
PEDIATRICS GENETICS	CHROMOSOMAL ANALYSIS EXPEDITED STUDIES	3,000.00	3,000.00	3,000.00	3,000.00	3,000.00
PEDIATRICS GENETICS	CHROMOSOMAL ANALYSIS ROUTINE STUDIES	1,000.00	2,500.00	2,500.00	2,500.00	2,500.00

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
PEDIATRICS NEUROLOGY	EEG	750	2,012.00	2,012.00	2,012.00	2,012.00
PEDIATRICS NEUROLOGY	ULTRASOUND- CRANIAL (PEDIA)	220	525.00	525.00	635.00	635.00
PEDIATRICS NEUROLOGY	ULTRASOUND- CRANIAL (FIRST STUDY)	220	525.00	525.00	635.00	635.00
PEDIATRICS NEUROLOGY	ULTRASOUND- CRANIAL (FOLLOW-UP STUDY)	220	525.00	525.00	635.00	635.00

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
PEDIA (SECTION OF CARDIOLOGY)	PEDIATRICS-FETAL ECHOCARDIOGRAPHY	750	2,140.00	–	2,260.00	–
PEDIA (SECTION OF CARDIOLOGY)	PEDIATRICS-TRANSESOPHAGEAL ECHOCARDIOGRAPHY	–	–	–	3,390.00	–
PEDIA (SECTION OF CARDIOLOGY)	PEDIATRICS-TRANSESOPHAGEAL ECHOCARDIOGRAPHY AND FETAL ECHOCARDIOGRAPHY	–	–	–	3,390.00	–
PEDIA (SECTION OF CARDIOLOGY)	PEDIATRICS-TRANSTHORACIC ECHOCARDIOGRAPHY	750	1,800.00	–	1,910.00	–

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
SLEEP LABORATORY	DIAGNOSTIC POLYSOMNOGRAPHY + SEIZURE MONTAGE	11,925.00	13,630.00	14,315.00	14,995.00	15,675.00
SLEEP LABORATORY	MAINTENANCE OF WAKEFULNESS TEST (MWT)	8,515.00	8,885.00	9,330.00	9,775.00	10,220.00
SLEEP LABORATORY	COMBINED DIAGNOSTIC AND THERAPEUTIC POLYSOMNOGRAPHY (SPLIT NIGHT)	12,870.00	21,895.00	22,990.00	24,085.00	25,180.00
SLEEP LABORATORY	TITRATION/THERAPEUTIC POLYSOMNOGRAPHY	9,340.00	13,900.00	14,595.00	15,290.00	15,985.00
SLEEP LABORATORY	DIAGNOSTIC POLYSOMNOGRAPHY	8,760.00	13,090.00	13,745.00	14,400.00	15,055.00
SLEEP LABORATORY	MULTIPLE SLEEP LATENCY TEST (MSLT)	4,605.00	6,380.00	6,470.00	6,510.00	6,555.00

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RIL-OTHERS	C-PEPTIDE	760	2,480.00	2,605.00	2,790.00	3,100.00
RIL-OTHERS	HUMAN GROWTH HORMONE	795	1,515.00	1,590.00	1,705.00	1,895.00

DEPARTMENT-SECTION	PRODUCT/SERVICE DESCRIPTION	SERVICE RATES	Outpatient-Pay	Ward/Semi- Private	Private	Suite/ Deluxe
RIL – LABORATORIES	ANTI-R-TSH (TRAB)	1,680.00	2,980.00	3,150.00	3,320.00	3,510.00
RIL – LABORATORIES	VITAMIN D	1,060.00	1,890.00	1,990.00	2,100.00	2,210.00
RIL – LABORATORIES	EXTRACTION FEE FOR PAY PATIENTS	–	100.00	100.00	110.00	120.00