1. 74160 70450
CT, Abdomen, w/contrast CT, Head or Brain, w/o contrast
Stanford University Hospital 3671.00 2541.00
San Francisco General Hospital 2072.00 1429.00
Kaiser Hospital, Hayward 5693.00 3619.00
Washington Hospital, Fremont 2722.39 1881.42
Children's Hospital Oakland 2788.00 2768.00
Chinese Hospital 1477.00 1118.00
Alameda County Medical Center 2103.00 1382.00
Good Samaritan Hospital, San Jose 5434.00 4403.00
UCSF Medical Center 6360.00 2120.00

2. 72193 77057
CT, Pelvis, w/contrast Mammography, Screening, Bilateral
3671.00 NR
2072.00 NR
6051.00 215.00
NR 138.81
2896.00 NR
1477.00 116.00
1906.00 167.00
4658.00 446.00
6443.00 398.00

3. 70553 76700
MRI, Head or Brain, w/o contrast, followed by contrast Ultrasound, Abdomen, complete
NR 1329.00
7159.00 570.00
5259.00 1516.00
NR 890.88
5523.00 1296.00
NR 537.00
4349.00 730.00
6719.00 1513.00
7129.00 1252.00

4. 76805 72110
Ultrasound, OB, 14+ weeks, transabdominal X-Ray, Lower Back, four views
NR NR
946.00 301.00
765.00 1494.00
NR 573.11
NR 698.00
537.00 440.00
513.00 529.00
1428.00 1208.00
969.00 448.00

5. 71020
X-Ray, Chest, two views
488.00
181.00
992.00
398.66
543.00
255.00
325.00
642.00
932.00

6. 99282
ER Visit, Level 2 (low to moderate severity)
Stanford University Hospital 543.00
San Francisco General Hospital 711.00
Kaiser Hospital, Hayward 175.00
Washington Hospital, Fremont 459.15
Children's Hospital Oakland 498.00
Chinese Hospital 149.00
Alameda County Medical Center 235.00
Good Samaritan Hospital, San Jose 795.00
UCSF Medical Center 532.00

7. 99283 99284
ER Visit, Level 3 (moderate severity) ER Visit, Level 4 (high severity)
1563.00 5482.00
1521.00 2505.00
425.00 825.00
985.12 1263.88
1173.00 11943.00
494.00 990.00
300.00 416.00
1136.00 2213.00
952.00 1623.00

8. 99213
Outpatient Visit, established patient, 15 minutes
402.00
NR
170.00
NR
NR
NR
137.00
363.00
90.00

9. 80048 82805
Basic Metabolic Panel Blood Gas Analysis, incl O2 sat
Stanford University Hospital 300.00 NR
San Francisco General Hospital 141.00 NR
Kaiser Hospital, Hayward NR NR
Washington Hospital, Fremont 171.36 485.47
Children's Hospital Oakland 368.00 340.00
Chinese Hospital 54.00 NR
Alameda County Medical Center 104.00 NR
Good Samaritan Hospital, San Jose 546.00 NR
UCSF Medical Center NR NR

10. 85027 85025 80053
CBC, automated CBC w/diff WBC, automated Comprehensive Metabolic Panel
129.00 164.00 NR
66.00 76.00 147.00
855.00 NR NR
109.86 147.91 180.44
110.00 308.00 573.00
87.00 NR 155.00
32.00 47.00 178.00
221.00 301.00 802.00
1119.00 1423.00 NR

11. 82550 80061 85730 85610
Creatine Kinase (CK), (CPK), Total Lipid Panel Partial Thromboplastin Time Prothrombin Time
NR NR NR 110.00
77.00 182.00 58.00 48.00
NR 778.00 NR NR
106.16 225.07 170.43 102.12
201.00 220.00 180.00 165.00
102.00 98.00 106.00 74.00
NR 75.00 48.00 32.00
257.00 351.00 266.00 231.00
1332.00 223.00 1488.00 1218.00

12. 84443 84484 81002 or 81003
Thyroid Stimulating Hormone Troponin, Quantitative Urinalysis, w/o microscopy
NR NR NR
190.00 133.00 NR
903.00 NR NR
189.76 116.83 118.94
180.00 95.00 43.00
139.00 80.00 45.00
98.00 62.00 16.00
475.00 526.00 223.00
1213.00 1396.00 NR

13. 81000 or 81001
Urinalysis, w/microscopy
175.00
NR
NR
122.19
45.00
74.00
31.00
268.00
NR

14. 93510
Cardiac Catheterization, Left Heart, percutaneous
Stanford University Hospital NR
San Francisco General Hospital NR
Kaiser Hospital, Hayward NR
Washington Hospital, Fremont NR
Children's Hospital Oakland NR
Chinese Hospital NR
Alameda County Medical Center NR
Good Samaritan Hospital, San Jose 13895
UCSF Medical Center 36390

15. 93307 93005
Echocardiography, complete Electrocardiogram, routine, tracing only, w/o interpretation & report
2196.00 NR
330.00 NR
6531.00 NR
NR NR
1263.00 298.00
NR 153.00
848.00 197.00
2454.00 525.00
2431.00 NR

16. 94640 97001
Inhalation Treatment, pressurized or nonpressurize Physical Therapy, Evaluation
263.00 487.00
NR 317.00
NR NR
NR NR
253.00 420.00
17.00 NR
75.00 260.00
252.00 179.00
627.00 1306.00

17. 97116 97110
Physical Therapy, Gait Training Physical Therapy, Therapeutic Exercise
165.00 188.00
210.00 210.00
NR NR
NR 333.06
138.00 153.00
NR NR
68.00 68.00
492.00 135.00
3046.00 2256.00

18. 29881
Arthroscopy, Knee, w/meniscectomy (medial or lateral)
Stanford University Hospital NR
San Francisco General Hospital NR
Kaiser Hospital, Hayward 14061
Washington Hospital, Fremont NR
Children's Hospital Oakland NR
Chinese Hospital NR
Alameda County Medical Center 10644
Good Samaritan Hospital, San Jose 23130
UCSF Medical Center NR

19. 29826 64721
Arthroscopy, Shoulder, w/partial acromioplasty Carpal Tunnel Surgery
NR NR
NR NR
21217 NR
NR NR
NR NR
NR NR
11233 5620
29346 15901
NR NR

20. 66984 45378
Cataract Removal w/ Insertion of Intraocular Lens, 1 Stage Colonoscopy, Diagnostic
18852.00 5543.00
NR NR
NR 5973.00
NR NR
NR NR
NR 3150.00
8440.00 2501.00
20243.00 6448.00
NR NR

21. 45380 45385
Colonoscopy, w/biopsy Colonoscopy, w/lesion removal, by snare technique
8251.00 NR
NR NR
7566.00 7745.00
NR NR
NR NR
3150.00 3150.00
3101.00 2890.00
10000.00 8411.00
NR NR

22. 66821 43239
Discission, secondary membranous cataract, laser surgery Endoscopy, Upper GI, w/biopsy
NR 8253.00
NR NR
NR 8079.00
NR NR
NR NR
NR 2883.00
NR 2484.00
3121.00 13314.00
NR NR

23. 43235 19120 49505
Endoscopy, Upper GI, Diagnostic Excision, Breast Lesion Hernia Repair, Inguinal, 5 years & older
6831.00 NR NR
NR NR NR
6789.00 9262.00 NR
NR NR NR
NR NR NR
2883.00 NR NR
2045.00 8028.00 10112.00
8640.00 15116.00 19446.00
NR NR NR

24. 62311
Injection, Diagnostic or Therapeutic substance, epidural, sacral
NR
NR
NR
NR
NR
NR
6304.00
13396.00
6373.00

25. 64483 47562
Injection, Anesthetic or Steroid, transforaminal epidural Laparoscopic Cholecystectomy
6447.00 NR
NR NR
NR NR
NR NR
NR NR
NR NR
NR 19015.00
13745.00 33575.00
2879.00 NR

26. 69436
Tympanostomy (insert ventilating tube, general anesthesia)
NR
NR
NR
NR
NR
NR
NR
13684.00
NR

27. 42820
Tonsillectomy w/ Adenoidectomy, <12 years old
NR
NR
NR
NR
NR
NR
NR
18234.00
NR

28. 19125
Excision, Breast Lesion
Stanford University Hospital NR
San Francisco General Hospital NR
Kaiser Hospital, Hayward NR
Washington Hospital, Fremont NR
Children's Hospital Oakland NR
Chinese Hospital NR
Alameda County Medical Center 11914.00
UCSF Medical Center NR

29. 66982
Cataract Removal w/insertion of Intraocular Lens, 1 Stage Complex
NR
NR
NR
NR
NR
NR
6523.00
NR

30. 21462
Open Treatment Mandibular Fracture w/Interdental Fixation
NR
NR
NR
NR
NR
NR
20569.00
NR

31. 20680 50590 27792
Removal of Implant Deep, Wire or Pin Lithotripsy Open Treatment Ankle Fracture
NR NR NR
NR NR NR
NR NR NR
NR NR NR
NR NR NR
NR NR NR
8456.00 9746.00 12757.00
NR NR NR

32. 36565 27650
Insertion of Central Venous Access Device Primary Repaie Ruptured Achilles Tendon
NR NR
NR NR
NR NR
NR NR
NR NR
NR NR
10033.00 10143.00
NR NR

33. 64721 93000
Neuroplasty Median Nerve Carpal Tunnel Electrocardiogram, routine, w/interpretation & report
NR NR
NR NR
NR NR
NR NR
NR NR
NR NR
5608.00 NR
NR 5758