| Code | Description | Default | Price |
| 10021 | FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE | $1,048.93 | $1,048.93 |
| 10060 | INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE | $1,475.67 | $1,475.67 |
| 10061 | INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE | $1,990.64 | $1,990.64 |
| 10080 | INCISION & DRAINAGE PILONIDAL CYST SIMPLE | $2,639.79 | $2,639.79 |
| 10081 | INCISION & DRAINAGE PILONIDAL CYST COMPLICATED | $3,316.63 | $3,316.63 |
| 10120 | INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE | $1,749.35 | $1,749.35 |
| 10160 | PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST | $2,563.46 | $2,563.46 |
| 11011 | DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC | $4,353.53 | $4,353.53 |
| 11040 | DEBRIDEMENT SKIN PARTIAL THICKNESS | $278.78 | $278.78 |
| 11042 | DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< | $1,615.20 | $1,615.20 |
| 11200 | REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 | $797.71 | $797.71 |
| 11400 | EXC B9 LESION MRGN XCP SK TG T/A/L 0.5 CM/< | $760.18 | $760.18 |
| 11404 | EXC B9 LESION MRGN XCP SK TG T/A/L 3.1-4.0 CM | $7,446.19 | $7,446.19 |
| 11719 | TRIMMING NONDYSTROPHIC NAILS ANY NUMBER | $291.20 | $291.20 |
| 11730 | AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 | $1,240.47 | $1,240.47 |
| 11740 | EVACUATION SUBUNGUAL HEMATOMA | $737.84 | $737.84 |
| 11750 | EXCISION NAIL MATRIX PERMANENT REMOVAL | $2,004.06 | $2,004.06 |
| 11760 | REPAIR NAIL BED | $2,857.14 | $2,857.14 |
| 11765 | WEDGE EXCISION SKIN NAIL FOLD | $1,513.89 | $1,513.89 |
| 11771 | EXCISION PILONIDAL CYST/SINUS EXTENSIVE | $10,393.31 | $10,393.31 |
| 12001 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less | $1,023.18 | $1,023.18 |
| 12002 | SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM | $1,078.86 | $1,078.86 |
| 12004 | SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM | $1,155.39 | $1,155.39 |
| 12005 | SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM | $1,663.95 | $1,663.95 |
| 12011 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less | $1,240.94 | $1,240.94 |
| 12013 | SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM | $1,238.63 | $1,238.63 |
| 12014 | SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM | $1,339.79 | $1,339.79 |
| 12015 | SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM | $1,514.68 | $1,514.68 |
| 12020 | TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE | $2,419.82 | $2,419.82 |
| 12031 | REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< | $2,444.10 | $2,444.10 |
| 12032 | REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM | $2,408.22 | $2,408.22 |
| 12034 | REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM | $2,877.78 | $2,877.78 |
| 12041 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< | $2,410.34 | $2,410.34 |
| 12042 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM | $3,141.10 | $3,141.10 |
| 12044 | REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM | $3,724.28 | $3,724.28 |
| 12051 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< | $2,643.80 | $2,643.80 |
| 12052 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM | $2,431.61 | $2,431.61 |
| 12053 | REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM | $3,071.28 | $3,071.28 |
| 13101 | REPAIR COMPLEX TRUNK 2.6-7.5 CM | $3,927.74 | $3,927.74 |
| 13120 | REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM | $3,098.72 | $3,098.72 |
| 13121 | REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM | $4,108.34 | $4,108.34 |
| 13122 | REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/< | $1,104.98 | $1,104.98 |
| 13131 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM | $3,297.60 | $3,297.60 |
| 13132 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM | $4,398.80 | $4,398.80 |
| 13133 | REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/< | $1,203.55 | $1,203.55 |
| 13151 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM | $4,080.92 | $4,080.92 |
| 13152 | REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM | $3,783.59 | $3,783.59 |
| 13153 | REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/< | $1,476.63 | $1,476.63 |
| 15839 | EXCISION EXCESSIVE SKIN & SUBQ TISSUE OTHER AREA | #DIV/0! | #DIV/0! |
| 16000 | INITIAL TX 1ST DEGREE BURN LOCAL TX | $1,164.77 | $1,164.77 |
| 16020 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL | $1,220.52 | $1,220.52 |
| 16025 | DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM | $1,425.04 | $1,425.04 |
| 17250 | CHEMICAL CAUTERIZATION GRANULATION TISSUE | $729.85 | $729.85 |
| 17999 | UNLISTED PX SKIN MUC MEMBRANE & SUBQ TISSUE | $929.09 | $929.09 |
| 20520 | REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE | $5,533.02 | $5,533.02 |
| 20552 | INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES | $896.88 | $896.88 |
| 20600 | ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US | $1,132.34 | $1,132.34 |
| 20605 | ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US | $1,485.24 | $1,485.24 |
| 20610 | ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US | $1,339.50 | $1,339.50 |
| 20612 | ASPIRATION&/INJECTION GANGLION CYST ANY LOCATJ | $532.80 | $532.80 |
| 21310 | CLOSED TREATMENT NASAL FRACTURE W/O MANIPULATION | $1,469.06 | $1,469.06 |
| 21315 | CLOSED TX NASAL FRACTURE W/O STABILIZATION | $4,067.07 | $4,067.07 |
| 21501 | I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX | $13,210.12 | $13,210.12 |
| 21800 | CLOSED TX RIB FRACTURE UNCOMPLICATED EACH | $576.58 | $576.58 |
| 23500 | CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION | $1,982.60 | $1,982.60 |
| 23650 | CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES | $2,262.77 | $2,262.77 |
| 23655 | CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES | $3,225.77 | $3,225.77 |
| 23931 | INCISION&DRAINAGE UPPER ARM/ELBOW BURSA | $7,746.02 | $7,746.02 |
| 24500 | CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION | $3,166.34 | $3,166.34 |
| 24530 | CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/WO MANJ | $2,938.70 | $2,938.70 |
| 24535 | CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ | $5,499.10 | $5,499.10 |
| 24600 | TREATMENT CLOSED ELBOW DISLOCATION W/O ANES | $2,879.54 | $2,879.54 |
| 24640 | CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ | $1,352.30 | $1,352.30 |
| 24650 | CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION | $2,234.00 | $2,234.00 |
| 24655 | CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION | $3,940.20 | $3,940.20 |
| 24670 | CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ | $2,940.35 | $2,940.35 |
| 25505 | CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION | $7,285.31 | $7,285.31 |
| 25520 | CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT | $3,054.33 | $3,054.33 |
| 25565 | CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ | $5,060.62 | $5,060.62 |
| 25600 | CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ | $2,638.88 | $2,638.88 |
| 25605 | CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF | $4,309.34 | $4,309.34 |
| 25622 | CLOSED TX CARPAL SCAPHOID FRACTURE W/O MANJ | $2,753.24 | $2,753.24 |
| 25635 | CLTX CARPAL BONE FX W/MANJ EACH BONE | $7,611.92 | $7,611.92 |
| 25675 | CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ | $2,963.16 | $2,963.16 |
| 26010 | DRAINAGE FINGER ABSCESS SIMPLE | $1,911.36 | $1,911.36 |
| 26160 | EXC LESION TDN SHTH/JT CAPSL HAND/FNGR | $5,188.78 | $5,188.78 |
| 26600 | CLTX METACARPAL FX W/O MANIPULATION EACH BONE | $2,429.42 | $2,429.42 |
| 26605 | CLTX METACARPAL FX W/MANIPULATION EACH BONE | $2,313.96 | $2,313.96 |
| 26607 | CLTX METACARPAL FX W/MANJ W/XTRNL FIXJ EA BONE | $8,575.09 | $8,575.09 |
| 26705 | CLTX METACARPOPHALANGEAL DISLC W/MANJ W/ANES | $6,140.78 | $6,140.78 |
| 26720 | CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MANJ EA | $1,854.68 | $1,854.68 |
| 26725 | CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA | $2,692.52 | $2,692.52 |
| 26750 | CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA | $1,870.75 | $1,870.75 |
| 26755 | CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA | $2,841.95 | $2,841.95 |
| 26770 | CLTX IPHAL JT DISLC W/MANJ W/O ANES | $2,336.72 | $2,336.72 |
| 27096 | INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA | #DIV/0! | #DIV/0! |
| 27301 | I&D DEEP ABSC BURSA/HEMATOMA THIGH/KNEE REGION | $6,024.06 | $6,024.06 |
| 27372 | REMOVAL FOREIGN BODY DEEP THIGH/KNEE | $13,815.46 | $13,815.46 |
| 27520 | CLOSED TX PATELLAR FRACTURE W/O MANIPULATION | $2,598.74 | $2,598.74 |
| 27550 | CLOSED TX KNEE DISLOCATION W/O ANESTHESIA | $2,832.62 | $2,832.62 |
| 27560 | CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA | $3,331.61 | $3,331.61 |
| 27750 | CLTX TIBIAL SHAFT FX W/O MANIPULATION | $2,174.64 | $2,174.64 |
| 27752 | CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ | $2,796.19 | $2,796.19 |
| 27760 | CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION | $2,576.38 | $2,576.38 |
| 27780 | CLTX PROX FIBULA/SHFT FX W/O MANJ | $2,711.80 | $2,711.80 |
| 27786 | CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ | $2,167.65 | $2,167.65 |
| 27810 | CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ | $4,767.28 | $4,767.28 |
| 27824 | CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MANJ | $2,807.28 | $2,807.28 |
| 27840 | CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA | $3,334.60 | $3,334.60 |
| 28190 | REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS | $2,045.12 | $2,045.12 |
| 28430 | CLOSED TX TALUS FRACTURE W/O MANIPULATION | $1,580.66 | $1,580.66 |
| 28470 | CLOSED TX METATARSAL FRACTURE W/O MANIPULATION | $1,702.66 | $1,702.66 |
| 28490 | CLTX FX GRT TOE PHLX/PHLG W/O MANJ | $1,178.58 | $1,178.58 |
| 28510 | CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ | $1,045.09 | $1,045.09 |
| 28515 | CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ | $1,654.72 | $1,654.72 |
| 28635 | CLTX METATARSOPHLNGL JT DISLC REQ ANES | $1,584.10 | $1,584.10 |
| 28660 | CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES | $1,142.24 | $1,142.24 |
| 29085 | APPLICATION CAST HAND & LOWER FOREARM GAUNTLET | $610.47 | $610.47 |
| 29105 | APPLICATION LONG ARM SPLINT SHOULDER HAND | $1,125.96 | $1,125.96 |
| 29125 | APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC | $569.08 | $569.08 |
| 29126 | APPLICATION SHORT ARM SPLINT DYNAMIC | $583.10 | $583.10 |
| 29130 | APPLICATION FINGER SPLINT STATIC | $455.21 | $455.21 |
| 29240 | STRAPPING SHOULDER | $577.15 | $577.15 |
| 29280 | STRAPPING HAND/FINGER | $390.98 | $390.98 |
| 29505 | APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES | $560.90 | $560.90 |
| 29515 | APPLICATION SHORT LEG SPLINT CALF FOOT | $539.06 | $539.06 |
| 29540 | STRAPPING ANKLE &/FOOT | $468.77 | $468.77 |
| 29550 | STRAPPING TOES | $330.77 | $330.77 |
| 29580 | STRAPPING UNNA BOOT | $301.19 | $301.19 |
| 29584 | APPL MLTLAYR COMPRES SYS UPARM LWARM HAND&FING | $714.70 | $714.70 |
| 29700 | REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST | $508.14 | $508.14 |
| 30000 | DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH | $2,128.24 | $2,128.24 |
| 30300 | REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE | $1,507.98 | $1,507.98 |
| 30901 | CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE | $1,322.40 | $1,322.40 |
| 30903 | CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX | $1,463.95 | $1,463.95 |
| 30905 | CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST | $2,492.92 | $2,492.92 |
| 31500 | INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE | $1,695.22 | $1,695.22 |
| 31502 | TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT | $1,014.12 | $1,014.12 |
| 31515 | LARYNGOSCOPY W/WO TRACHEOSCOPY ASPIRATION | $2,704.55 | $2,704.55 |
| 31525 | LARYNGOSCOPY W/WO TRACHEOSCOPY DX EXCEPT NEWBORN | $7,462.92 | $7,462.92 |
| 31530 | LARYNGOSCOPY W/FOREIGN BODY REMOVAL | $7,242.51 | $7,242.51 |
| 32421 | THORACENTESIS PUNCTURE PLEURAL CAVITY ASPIRATION | $1,821.60 | $1,821.60 |
| 32552 | RMVL NDWELLG TUNNELED PLEURAL CATHETER W/CUFF | #DIV/0! | #DIV/0! |
| 33415 | RESECTION/INCISION SUBVALVULAR TISSUE | $10,144.65 | $10,144.65 |
| 36000 | INTRODUCTION NEEDLE/INTRACATHETER VEIN | $313.73 | $313.73 |
| 36415 | COLLECTION VENOUS BLOOD VENIPUNCTURE | $112.16 | $112.16 |
| 36416 | COLLECTION CAPILLARY BLOOD SPECIMEN | $161.86 | $161.86 |
| 36558 | INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> | $15,347.26 | $15,347.26 |
| 36571 | INSJ PRPH CTR VAD W/SUBQ PORT AGE 5 YR/> | $17,554.47 | $17,554.47 |
| 36573 | (PICC), without subcutaneous port or pump, including all imaging guidance,age 5 years or older | $735.26 | $735.26 |
| 36591 | COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE | $611.65 | $611.65 |
| 38300 | DRG LYMPH NODE ABSC/LYMPHADENITIS SMPL | $7,901.23 | $7,901.23 |
| 41250 | RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG | $1,725.81 | $1,725.81 |
| 41251 | RPR LAC 2.5 CM/< PST ONE-THIRD TONGUE | $2,753.21 | $2,753.21 |
| 43752 | NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE | $1,957.09 | $1,957.09 |
| 43753 | GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE | $202.51 | $202.51 |
| 46040 | I&D ISCHIORECTAL&/PERIRECTAL ABSCESS SPX | $4,884.93 | $4,884.93 |
| 46050 | I&D PERIANAL ABSCESS SUPERFICIAL | $4,339.13 | $4,339.13 |
| 46083 | INCISION THROMBOSED HEMORRHOID EXTERNAL | $1,645.24 | $1,645.24 |
| 46270 | SURG TX ANAL FISTULA SUBQ | $4,606.92 | $4,606.92 |
| 46320 | EXC THROMBOSED HEMORRHOID XTRNL | $2,740.75 | $2,740.75 |
| 51700 | BLDR IRRIGATION SMPL LAVAGE &/INSTLJ | $1,432.31 | $1,432.31 |
| 51701 | INSJ NON-NDWELLG BLADDER CATHETER | $720.19 | $720.19 |
| 51702 | INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE | $814.14 | $814.14 |
| 54220 | IRRIGATION CORPORA CAVERNOSA PRIAPISM | $1,794.60 | $1,794.60 |
| 54450 | FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING | $1,381.26 | $1,381.26 |
| 56405 | I&D VULVA/PERINEAL ABSCESS | $1,733.84 | $1,733.84 |
| 56420 | I&D OF BARTHOLINS GLAND ABSCESS | $1,316.26 | $1,316.26 |
| 62270 | SPINAL PUNCTURE LUMBAR DIAGNOSTIC | $3,215.54 | $3,215.54 |
| 64400 | NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH | $1,580.64 | $1,580.64 |
| 64402 | INJECTION ANESTHETIC AGENT FACIAL NERVE | $1,304.43 | $1,304.43 |
| 64450 | INJECTION ANES OTHER PERIPHERAL NERVE/BRANCH | $2,869.71 | $2,869.71 |
| 64640 | DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE | $3,210.44 | $3,210.44 |
| 65210 | RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR | $1,833.80 | $1,833.80 |
| 65220 | RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP | $950.24 | $950.24 |
| 65222 | RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP | $1,001.22 | $1,001.22 |
| 65435 | RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION | $3,304.20 | $3,304.20 |
| 67700 | BLEPHAROTOMY DRAINAGE ABSCESS EYELID | $2,785.22 | $2,785.22 |
| 69000 | DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPLE | $3,574.13 | $3,574.13 |
| 69005 | DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA CMPLX | $1,909.36 | $1,909.36 |
| 69200 | RMVL FB XTRNL AUDITORY CANAL W/O ANES | $917.26 | $917.26 |
| 69205 | RMVL FB XTRNL AUDITORY CANAL ANES | $823.48 | $823.48 |
| 69209 | REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT | $431.36 | $431.36 |
| 69210 | REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT | $564.88 | $564.88 |
| 70030 | RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY | $548.15 | $548.15 |
| 70100 | RADIOLOGIC EXAMINATION MANDIPLE PRTL <4 VIEWS | $587.13 | $587.13 |
| 70110 | RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS | $926.62 | $926.62 |
| 70140 | RADEX FACIAL BONES < 3 VIEWS | $566.39 | $566.39 |
| 70150 | RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS | $916.81 | $916.81 |
| 70160 | RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS | $632.01 | $632.01 |
| 70220 | RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS | $749.47 | $749.47 |
| 70250 | RADIOLOGIC EXAMINATION SKULL 4/> VIEWS | $807.62 | $807.62 |
| 70328 | RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH UNILAT | $480.90 | $480.90 |
| 70350 | CEPHALOGRAM ORTHODONTIC | $419.80 | $419.80 |
| 70360 | RADIOLOGIC EXAMINATION NECK SOFT TISSUE | $772.52 | $772.52 |
| 70380 | RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS | $446.27 | $446.27 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST MATERIAL | $4,671.35 | $4,671.35 |
| 70460 | CT HEAD/BRAIN W/CONTRAST MATERIAL | $4,149.16 | $4,149.16 |
| 70470 | CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL | $5,146.12 | $5,146.12 |
| 70480 | CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL | $3,013.69 | $3,013.69 |
| 70481 | CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL | $4,382.53 | $4,382.53 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST MATERIAL | $3,801.44 | $3,801.44 |
| 70487 | CT MAXILLOFACIAL W/CONTRAST MATERIAL | $4,735.32 | $4,735.32 |
| 70488 | CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL | $4,419.16 | $4,419.16 |
| 70490 | CT SOFT TISSUE NECK W/O CONTRAST MATERIAL | $3,669.21 | $3,669.21 |
| 70491 | CT SOFT TISSUE NECK W/CONTRAST MATERIAL | $5,824.93 | $5,824.93 |
| 70492 | CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL | $4,397.30 | $4,397.30 |
| 70496 | CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST | $4,244.79 | $4,244.79 |
| 70498 | CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST | $4,476.20 | $4,476.20 |
| 70544 | MRA HEAD W/O CONTRST MATERIAL | $4,093.40 | $4,093.40 |
| 70547 | MRA NECK W/O CONTRST MATERIAL | $3,934.92 | $3,934.92 |
| 70551 | MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL | $3,267.77 | $3,267.77 |
| 70553 | MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL | $4,518.63 | $4,518.63 |
| 71010 | RADIOLOGIC EXAMINATION CHEST SINGLE VIEW FRONTAL | $614.71 | $614.71 |
| 71020 | RADIOLOGIC EXAM CHEST 2 VIEWS FRONTAL&LATERAL | $813.48 | $813.48 |
| 71030 | RADEX CHEST COMPLETE MINIMUM 4 VIEWS | $794.38 | $794.38 |
| 71045 | Radiologic examination, chest; single view | $818.89 | $818.89 |
| 71046 | RADIOLOGIC EXAM CHEST 2 VIEWS FRONTAL&LATERAL | $1,019.77 | $1,019.77 |
| 71100 | RADEX RIBS UNILATERAL 2 VIEWS | $620.93 | $620.93 |
| 71101 | RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS | $1,114.08 | $1,114.08 |
| 71111 | RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS | $1,179.13 | $1,179.13 |
| 71120 | RADEX STERNUM MINIMUM 2 VIEWS | $546.85 | $546.85 |
| 71250 | CT THORAX W/O CONTRAST MATERIAL | $4,571.81 | $4,571.81 |
| 71260 | CT THORAX W/CONTRAST MATERIAL | $5,033.61 | $5,033.61 |
| 71270 | CT THORAX W/O & W/CONTRAST MATERIAL | $4,516.59 | $4,516.59 |
| 71275 | CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST | $4,920.97 | $4,920.97 |
| 71550 | MRI CHEST W/O CONTRAST MATERIAL | $3,429.71 | $3,429.71 |
| 72020 | RADEX SPINE 1 VIEW SPECIFY LEVEL | $552.54 | $552.54 |
| 72040 | RADEX SPINE CERVICAL 2 OR 3 VIEWS | $909.96 | $909.96 |
| 72050 | RADEX SPINE CERVICAL 4 OR 5 VIEWS | $1,015.81 | $1,015.81 |
| 72052 | RADEX SPINE CERVICAL 6 OR MORE VIEWS | $1,328.39 | $1,328.39 |
| 72069 | RADEX SPI THORACOLMBR STANDING SCOLIOSIS | $556.44 | $556.44 |
| 72070 | RADEX SPINE THORACIC 2 VIEWS | $1,032.81 | $1,032.81 |
| 72072 | RADEX SPINE THORACIC 3 VIEWS | $1,036.58 | $1,036.58 |
| 72074 | RADEX SPINE THORACIC MINIMUM 4 VIEWS | $966.95 | $966.95 |
| 72100 | RADEX SPINE LUMBOSACRAL 2/3 VIEWS | $1,188.17 | $1,188.17 |
| 72110 | RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS | $1,022.58 | $1,022.58 |
| 72114 | RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 | $1,099.74 | $1,099.74 |
| 72120 | RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS | $997.79 | $997.79 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST MATERIAL | $4,544.62 | $4,544.62 |
| 72126 | CT CERVICAL SPINE W/CONTRAST MATERIAL | $4,043.71 | $4,043.71 |
| 72127 | CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL | $4,101.01 | $4,101.01 |
| 72128 | CT THORACIC SPINE W/O CONTRAST MATERIAL | $4,362.18 | $4,362.18 |
| 72129 | CT THORACIC SPINE W/CONTRAST MATERIAL | $4,350.44 | $4,350.44 |
| 72130 | CT THORACIC SPINE W/O & W/CONTRAST MATERIAL | $5,035.91 | $5,035.91 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST MATERIAL | $4,855.36 | $4,855.36 |
| 72132 | CT LUMBAR SPINE W/CONTRAST MATERIAL | $5,178.59 | $5,178.59 |
| 72141 | MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL | $3,793.50 | $3,793.50 |
| 72146 | MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL | $3,485.24 | $3,485.24 |
| 72148 | MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL | $3,065.24 | $3,065.24 |
| 72156 | MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL | $4,524.08 | $4,524.08 |
| 72157 | MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL | $4,539.97 | $4,539.97 |
| 72158 | MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL | $4,547.78 | $4,547.78 |
| 72170 | RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS | $999.28 | $999.28 |
| 72190 | RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS | $956.11 | $956.11 |
| 72191 | CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST | $2,471.81 | $2,471.81 |
| 72192 | CT PELVIS W/O CONTRAST MATERIAL | $4,224.62 | $4,224.62 |
| 72193 | CT PELVIS W/CONTRAST MATERIAL | $4,131.51 | $4,131.51 |
| 72194 | CT PELVIS W/O & W/CONTRAST MATERIAL | $5,264.45 | $5,264.45 |
| 72195 | MRI PELVIS W/O CONTRAST MATERIAL | $3,173.67 | $3,173.67 |
| 72196 | MRI PELVIS W/CONTRAST MATERIAL | $4,769.41 | $4,769.41 |
| 72220 | RADEX SACRUM & COCCYX MINIMUM 2 VIEWS | $623.20 | $623.20 |
| 73000 | RADEX CLAVICLE COMPLETE | $636.47 | $636.47 |
| 73010 | RADEX SCAPULA COMPLETE | $837.01 | $837.01 |
| 73020 | RADEX SHOULDER 1 VIEW | $476.48 | $476.48 |
| 73030 | RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS | $881.43 | $881.43 |
| 73050 | RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ | $670.12 | $670.12 |
| 73060 | RADEX HUMERUS MINIMUM 2 VIEWS | $858.07 | $858.07 |
| 73070 | RADEX ELBOW 2 VIEWS | $608.29 | $608.29 |
| 73080 | RADEX ELBOW COMPLETE MINIMUM 3 VIEWS | $1,117.13 | $1,117.13 |
| 73090 | RADEX FOREARM 2 VIEWS | $958.60 | $958.60 |
| 73092 | RADEX UPPER EXTREMITY INFANT MINIMUM 2 VIEWS | $1,098.82 | $1,098.82 |
| 73100 | RADEX WRIST 2 VIEWS | $569.44 | $569.44 |
| 73110 | RADEX WRIST COMPLETE MINIMUM 3 VIEWS | $881.75 | $881.75 |
| 73120 | RADEX HAND 2 VIEWS | $837.48 | $837.48 |
| 73130 | RADEX HAND MINIMUM 3 VIEWS | $891.14 | $891.14 |
| 73140 | RADEX FINGR MINIMUM 2 VIEWS | $759.85 | $759.85 |
| 73200 | CT UPPER EXTREMITY W/O CONTRAST MATERIAL | $3,894.76 | $3,894.76 |
| 73201 | CT UPPER EXTREMITY W/CONTRAST MATERIAL | $3,485.23 | $3,485.23 |
| 73220 | MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS | $4,775.85 | $4,775.85 |
| 73221 | MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL | $2,982.41 | $2,982.41 |
| 73501 | RADEX HIP UNILATERAL WITH PELVIS 1 VIEW | $391.62 | $391.62 |
| 73502 | RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS | $740.98 | $740.98 |
| 73520 | RADEX HIPS BI 2 VIEWS ANTEROPOST PELVIS | $662.52 | $662.52 |
| 73521 | RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS | $728.26 | $728.26 |
| 73552 | RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS | $506.86 | $506.86 |
| 73560 | RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS | $505.13 | $505.13 |
| 73562 | RADIOLOGIC EXAMINATION KNEE 3 VIEWS | $677.00 | $677.00 |
| 73564 | RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS | $937.40 | $937.40 |
| 73565 | RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST | $327.42 | $327.42 |
| 73590 | RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS | $706.57 | $706.57 |
| 73592 | RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS | $495.09 | $495.09 |
| 73600 | RADIOLOGIC EXAMINATION ANKLE 2 VIEWS | $527.50 | $527.50 |
| 73610 | RADEX ANKLE COMPLETE MINIMUM 3 VIEWS | $755.86 | $755.86 |
| 73620 | RADIOLOGIC EXAMINATION FOOT 2 VIEWS | $563.97 | $563.97 |
| 73630 | RADEX FOOT COMPLETE MINIMUM 3 VIEWS | $788.50 | $788.50 |
| 73650 | RADEX CALCANEUS MINIMUM 2 VIEWS | $575.07 | $575.07 |
| 73660 | RADEX TOE MINIMUM 2 VIEWS | $713.88 | $713.88 |
| 73700 | CT LOWER EXTREMITY W/O CONTRAST MATERIAL | $2,540.84 | $2,540.84 |
| 73701 | CT LOWER EXTREMITY W/CONTRAST MATERIAL | $2,863.19 | $2,863.19 |
| 73702 | CT LOWER EXTREMITY W/O & W/CONTRAST MATRL | $3,209.53 | $3,209.53 |
| 73721 | MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL | $3,001.66 | $3,001.66 |
| 73722 | MRI ANY JT LOWER EXTREM W/CONTRAST MATERIAL | $4,911.61 | $4,911.61 |
| 73723 | MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL | $5,726.84 | $5,726.84 |
| 73725 | MRA LOWER EXTREMITY W/WO CONTRAST MATERIAL | $5,804.92 | $5,804.92 |
| 74000 | RADEX ABDOMEN 1 ANTEROPOSTERIOR VIEW | $556.20 | $556.20 |
| 74010 | RADEX ABD ANTEROPOST&ADDL OBLQ&CONE VIEWS | $690.00 | $690.00 |
| 74018 | Radiologic examination, abdomen; 1 view | $667.39 | $667.39 |
| 74019 | Radiologic examination, abdomen; 2 views | $933.64 | $933.64 |
| 74021 | Radiologic examination, abdomen; 3 or more views | $707.79 | $707.79 |
| 74022 | RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH | $1,123.35 | $1,123.35 |
| 74150 | CT ABDOMEN W/O CONTRAST MATERIAL | $2,766.05 | $2,766.05 |
| 74160 | CT ABDOMEN W/CONTRAST MATERIAL | $3,776.86 | $3,776.86 |
| 74170 | CT ABDOMEN W/O & W/CONTRAST MATERIAL | $3,510.54 | $3,510.54 |
| 74175 | CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST | $4,180.85 | $4,180.85 |
| 74176 | CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL | $4,666.16 | $4,666.16 |
| 74177 | CT ABDOMEN & PELVIS W/CONTRAST MATERIAL | $5,200.02 | $5,200.02 |
| 74178 | CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE | $4,945.75 | $4,945.75 |
| 74181 | MRI ABDOMEN W/O CONTRAST MATERIAL | $3,306.74 | $3,306.74 |
| 74183 | MRI ABDOMEN W/O & W/CONTRAST MATERIAL | $4,580.93 | $4,580.93 |
| 74241 | RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/KUB | $1,721.29 | $1,721.29 |
| 74247 | RADEX UPPER GI W/WO GLUCAGON/DELAY IMAGES W/KUB | $1,802.39 | $1,802.39 |
| 75635 | CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP | $5,726.99 | $5,726.99 |
| 76010 | RADEX FROM NOSE RECTUM FOREIGN BODY 1 VIEW CHLD | $417.66 | $417.66 |
| 76376 | 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION | $1,043.18 | $1,043.18 |
| 76380 | CT LIMITED/LOCALIZED FOLLOW UP STUDY | #DIV/0! | #DIV/0! |
| 76536 | US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM | $1,109.83 | $1,109.83 |
| 76641 | US BREAST UNI REAL TIME WITH IMAGE COMPLETE | $1,058.54 | $1,058.54 |
| 76645 | US BREAST R-T W/IMAGE DOCUMENTATION | $1,291.67 | $1,291.67 |
| 76700 | US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION | $1,207.09 | $1,207.09 |
| 76705 | US ABDOMINAL REAL TIME W/IMAGE LIMITED | $1,182.32 | $1,182.32 |
| 76770 | US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE | $1,342.69 | $1,342.69 |
| 76775 | US RETROPERITONEAL REAL TIME W/IMAGE LIMITED | $1,423.19 | $1,423.19 |
| 76800 | ULTRASOUND SPINAL CANAL & CONTENTS | $1,258.84 | $1,258.84 |
| 76801 | US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT | $1,324.15 | $1,324.15 |
| 76802 | US PREG UTERUS 14 WK TRANSABDL EACH GESTATION | $565.12 | $565.12 |
| 76805 | US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION | $1,211.99 | $1,211.99 |
| 76813 | US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION | $823.22 | $823.22 |
| 76815 | US PREGNANT UTERUS LIMITED 1/> FETUSES | $1,003.87 | $1,003.87 |
| 76817 | US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG | $1,303.64 | $1,303.64 |
| 76818 | FETAL BIOPHYSICAL PROFILE NON-STRESS TESTING | $1,085.77 | $1,085.77 |
| 76830 | US TRANSVAGINAL | $1,379.48 | $1,379.48 |
| 76856 | US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE | $1,714.94 | $1,714.94 |
| 76857 | US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U | $998.79 | $998.79 |
| 76870 | US SCROTUM & CONTENTS | $1,410.93 | $1,410.93 |
| 76880 | US EXTREMITY NON-VASC REAL-TIME IMG | $1,287.27 | $1,287.27 |
| 76882 | US EXTREMITY NON-VASC REAL-TIME IMG LMTD | $927.35 | $927.35 |
| 76942 | US GUIDANCE NEEDLE PLACEMENT IMG S&I | $358.70 | $358.70 |
| 77079 | CT BONE MINERAL DENSITY STUDY 1+ SITS APPND | $607.80 | $607.80 |
| 78075 | ADRENAL IMAGING CORTEX &/MEDULLA | $7,151.38 | $7,151.38 |
| 78223 | HIDA SCAN - HEPATBL DUX SYS IMG GLBLDR | $3,733.20 | $3,733.20 |
| 78306 | BONE &/JOINT IMAGING WHOLE BODY | $2,800.10 | $2,800.10 |
| 78315 | BONE &/JOINT IMAGING 3 PHASE STUDY | $2,932.10 | $2,932.10 |
| 78320 | BONE &/JOINT IMAGING TOMOGRAPHIC SPECT | $2,633.09 | $2,633.09 |
| 78472 | CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS | $2,903.38 | $2,903.38 |
| 80047 | BASIC METABOLIC PANEL CALCIUM IONIZED | $458.21 | $458.21 |
| 80048 | BASIC METABOLIC PANEL CALCIUM TOTAL | $337.63 | $337.63 |
| 80050 | GENERAL HEALTH PANEL | $532.57 | $532.57 |
| 80051 | ELECTROLYTE PANEL | $335.85 | $335.85 |
| 80053 | COMPREHENSIVE METABOLIC PANEL | $477.64 | $477.64 |
| 80061 | LIPID PANEL | $364.76 | $364.76 |
| 80074 | ACUTE HEPATITIS PANEL | $823.72 | $823.72 |
| 80076 | HEPATIC FUNCTION PANEL | $441.80 | $441.80 |
| 80100 | DRUG SCR QUAL MLT DRUG CLASSES CHROM EA PX | $568.81 | $568.81 |
| 80101 | UDS - URINE DRUG SCREEN QUAL 1 DRUG CLASS METH EA DRUG CLASS | $318.00 | $318.00 |
| 80164 | DRUG ASSAY VALPROIC DIPROPYLACETIC ACID TOTAL | $274.48 | $274.48 |
| 80178 | DRUG SCREEN QUANTITATIVE LITHIUM | $173.66 | $173.66 |
| 80185 | DRUG SCREEN QUANTITATIVE PHENYTOIN TOTAL | $187.15 | $187.15 |
| 80196 | SALICYLATE | $226.63 | $226.63 |
| 80197 | DRUG SCREEN QUANTITATIVE TACROLIMUS | $527.67 | $527.67 |
| 80202 | DRUG SCREEN QUANTITATIVE VANCOMYCIN | $366.57 | $366.57 |
| 80300 | Urine Drug Screening | $240.00 | $240.00 |
| 80305 | DRUG TEST PRSMV QUAL DIR OPTICAL OBS PER DAY | $339.35 | $339.35 |
| 80320 | ALCOHOLS | $315.02 | $315.02 |
| 80329 | DRUG SCREEN ANALGESICS NON-OPIOID 1 OR 2 | $325.81 | $325.81 |
| 81000 | URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY | $194.63 | $194.63 |
| 81001 | URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY | $153.63 | $153.63 |
| 81002 | URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP | $157.43 | $157.43 |
| 81003 | URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY | $163.66 | $163.66 |
| 81005 | URINALYSIS QUAL/SEMIQUANT EXCEPT IMMUNOASSAYS | $93.70 | $93.70 |
| 81015 | URINALYSIS MICROSCOPIC ONLY | $161.66 | $161.66 |
| 81020 | URINALYSIS 2/3 GLASS TEST | $105.30 | $105.30 |
| 81025 | URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS | $218.77 | $218.77 |
| 81250 | G6PC GENE ANALYSIS COMMON VARIANTS | #DIV/0! | #DIV/0! |
| 82003 | ACETAMINOPHEN | $400.70 | $400.70 |
| 82009 | KETONE BODIES SERUM QUALITATIVE | $106.39 | $106.39 |
| 82010 | KETONE BODIES SERUM QUANTITATIVE | $191.16 | $191.16 |
| 82055 | ALCOHOL ANY SPEC XCPT BRTH | $442.42 | $442.42 |
| 82075 | ASSAY OF ALCOHOL BREATH | $253.30 | $253.30 |
| 82105 | ALPHA-FETOPROTEIN SERUM | $218.83 | $218.83 |
| 82140 | ASSAY OF AMMONIA | $238.22 | $238.22 |
| 82150 | ASSAY OF AMYLASE | $319.91 | $319.91 |
| 82164 | ANGIOTENSIN I-CONVERTING ENZYME | $170.98 | $170.98 |
| 82248 | BILIRUBIN DIRECT | $158.37 | $158.37 |
| 82270 | BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER | $237.28 | $237.28 |
| 82272 | BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1-3 SPEC | $179.86 | $179.86 |
| 82274 | BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3 | $193.01 | $193.01 |
| 82310 | CALCIUM TOTAL | $144.90 | $144.90 |
| 82365 | CALCULUS INFRARED SPECTROSCOPY | $227.69 | $227.69 |
| 82376 | CARBOXYHEMOGLOBIN QUALITATIVE | $140.20 | $140.20 |
| 82465 | CHOLESTEROL SERUM/WHOLE BLOOD TOTAL | $184.32 | $184.32 |
| 82491 | CHROM QUAN COLUMN 1 ANAL NES | $187.40 | $187.40 |
| 82540 | ASSAY OF CREATINE | $130.09 | $130.09 |
| 82541 | COL-CHR/MS QUAL 1 STATIONARY&MOBILE PHASE | $240.32 | $240.32 |
| 82550 | CREATINE KINASE TOTAL | $312.90 | $312.90 |
| 82553 | CREATINE KINASE MB FRACTION ONLY | $346.93 | $346.93 |
| 82565 | CREATININE BLOOD | $198.64 | $198.64 |
| 82607 | CYANOCOBALAMIN VITAMIN B-12 | $232.33 | $232.33 |
| 82608 | CYANOCOBALAMIN VIT B-12 UNSAT BINDING CAPACITY | $321.52 | $321.52 |
| 82705 | FAT/LIPIDS FECES QUALITATIVE | $122.69 | $122.69 |
| 82747 | ASSAY OF FOLIC ACID RBC | $293.26 | $293.26 |
| 82784 | ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH | $175.74 | $175.74 |
| 82787 | GAMMAGLOBULIN IMMUNOGLOBULIN SUBCLASSES | $156.07 | $156.07 |
| 82800 | GASES BLOOD PH ONLY | $203.03 | $203.03 |
| 82803 | BLOOD GASES ANY COMBINATION PH PCO2 PO2 CO2 HCO3 | $507.58 | $507.58 |
| 82810 | GASES BLOOD O2 SATURATION ONLY DIRECT MEAS | $134.86 | $134.86 |
| 82945 | GLUCOSE BODY FLUID OTHER THAN BLOOD | $195.33 | $195.33 |
| 82947 | GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP | $162.70 | $162.70 |
| 82948 | GLUCOSE BLOOD REAGENT STRIP | $131.43 | $131.43 |
| 82962 | GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE | $124.68 | $124.68 |
| 82977 | ASSAY OF GLUTAMYLTRASE GAMMA | $149.49 | $149.49 |
| 83009 | HPYLORI BLOOD ANAL UREASE ACT NON-RADACT ISOTOPE | $793.56 | $793.56 |
| 83020 | HEMOGLOBIN FRACTJ/QUANTJ ELECTROPHORESIS | $282.82 | $282.82 |
| 83036 | HEMOGLOBIN GLYCOSYLATED A1C | $149.64 | $149.64 |
| 83516 | IMMUNOASSAY ANALYTE QUAL/SEMIQUAL MULTIPLE STEP | $235.30 | $235.30 |
| 83520 | IMMUNOASSAY ANALYTE QUANTITATIVE NOS | $258.44 | $258.44 |
| 83540 | ASSAY OF IRON | $222.51 | $222.51 |
| 83605 | ASSAY OF LACTATE | $206.41 | $206.41 |
| 83615 | LACTATE DEHYDROGENASE LDH | $123.36 | $123.36 |
| 83690 | ASSAY OF LIPASE | $211.15 | $211.15 |
| 83735 | ASSAY OF MAGNESIUM | $222.02 | $222.02 |
| 83874 | MYOGLOBIN | $265.58 | $265.58 |
| 83880 | BNP- NATRIURETIC PEPTIDE | $517.85 | $517.85 |
| 83970 | ASSAY OF PARATHORMONE | $532.74 | $532.74 |
| 84075 | ASSAY OF PHOSPHATASE ALKALINE | $107.75 | $107.75 |
| 84110 | ASSAY OF PORPHOBILINOGEN URINE QUANTITATIVE | $204.42 | $204.42 |
| 84144 | ASSAY OF PROGESTERONE | $295.57 | $295.57 |
| 84145 | PROCALCITONIN (PCT) | $352.90 | $352.90 |
| 84146 | ASSAY OF PROLACTIN | $228.43 | $228.43 |
| 84152 | ASSAY OF PROSTATE SPECIFIC ANTIGEN COMPLEXED | $197.02 | $197.02 |
| 84153 | ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL | $289.50 | $289.50 |
| 84155 | Protein, total, except by refractometry; serum, plasma or whole blood | $96.55 | $96.55 |
| 84157 | PROTEIN TOT XCPT REFRACTOMETRY OTH SRC | $110.41 | $110.41 |
| 84403 | ASSAY OF TESTOSTERONE TOTAL | $434.42 | $434.42 |
| 84436 | ASSAY OF THYROXINE TOTAL | $253.93 | $253.93 |
| 84439 | ASSAY OF FREE THYROXINE | $228.74 | $228.74 |
| 84443 | ASSAY OF THYROID STIMULATING HORMONE TSH | $366.08 | $366.08 |
| 84478 | ASSAY OF TRIGLYCERIDES | $177.42 | $177.42 |
| 84479 | THYROID HORM UPTK/THYROID HORMONE BINDING RATIO | $267.11 | $267.11 |
| 84481 | ASSAY OF TRIIODOTHYRONINE T3 FREE | $346.49 | $346.49 |
| 84484 | ASSAY OF TROPONIN QUANTITATIVE | $331.58 | $331.58 |
| 84512 | ASSAY OF TROPONIN QUALITATIVE | $257.11 | $257.11 |
| 84520 | ASSAY OF UREA NITROGEN QUANTITATIVE | $183.12 | $183.12 |
| 84550 | ASSAY OF BLOOD/URIC ACID | $192.17 | $192.17 |
| 84560 | ASSAY OF URIC ACID OTHER SOURCE | $223.03 | $223.03 |
| 84702 | GONADOTROPIN CHORIONIC QUANTITATIVE | $308.70 | $308.70 |
| 84703 | GONADOTROPIN CHORIONIC (HCG); QUALITATIVE | $266.35 | $266.35 |
| 84704 | GONADOTROPIN CHORIONIC (HCG) FREE BETA CHAIN | $211.87 | $211.87 |
| 85014 | BLOOD COUNT HEMATOCRIT | $150.45 | $150.45 |
| 85018 | BLOOD COUNT HEMOGLOBIN | $154.95 | $154.95 |
| 85025 | BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC | $237.87 | $237.87 |
| 85027 | BLOOD COUNT COMPLETE AUTOMATED | $207.74 | $207.74 |
| 85032 | BLOOD COUNT MANUAL CELL COUNT EACH | $194.48 | $194.48 |
| 85044 | BLOOD COUNT RETICULOCYTE AUTOMATED | $176.80 | $176.80 |
| 85060 | BLOOD SMEAR PERIPHERAL INTERP PHYS W/WRIT REPORT | $201.60 | $201.60 |
| 85347 | COAGULATION TIME ACTIVATED | $120.88 | $120.88 |
| 85378 | FIBRIN DGRADJ PRODUCTS D-DIMER QUAL/SEMIQUAN | $250.78 | $250.78 |
| 85379 | FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE | $381.95 | $381.95 |
| 85380 | FIBRIN DGRADJ PRODUCTS D-DIMER ULTRASENSITIVE | $472.94 | $472.94 |
| 85610 | PROTHROMBIN TIME | $254.57 | $254.57 |
| 85651 | SEDIMENTATION RATE RBC NON-AUTOMATED | $185.25 | $185.25 |
| 85652 | SEDIMENTATION RATE RBC AUTOMATED | $131.13 | $131.13 |
| 85730 | THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD | $213.11 | $213.11 |
| 86038 | ANTINUCLEAR ANTIBODIES ANA | $222.53 | $222.53 |
| 86039 | ANTINUCLEAR ANTIBODIES ANA TITER | $157.36 | $157.36 |
| 86140 | C-REACTIVE PROTEIN | $110.03 | $110.03 |
| 86255 | FLUORESCENT NONNFCT AGT ANTB SCREEN EA ANTIBODY | $96.00 | $96.00 |
| 86304 | IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125 | $298.13 | $298.13 |
| 86308 | HETEROPHILE ANTIBODIES SCREEN | $157.11 | $157.11 |
| 86328 | Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative; severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (Coronavirus disease [COVID-19]) | $414.82 | $414.82 |
| 86403 | PARTICLE AGGLUTINATION SCREEN EACH ANTIBODY | $234.76 | $234.76 |
| 86430 | RHEUMATOID FACTOR QUALITATIVE | $143.16 | $143.16 |
| 86431 | RHEUMATOID FACTOR QUANTITATIVE | $170.55 | $170.55 |
| 86480 | TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON | $440.92 | $440.92 |
| 86486 | SKIN TEST UNLISTED ANTIGEN EACH | $167.12 | $167.12 |
| 86580 | SKIN TEST TUBERCULOSIS INTRADERMAL | $168.23 | $168.23 |
| 86592 | SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL | $103.09 | $103.09 |
| 86611 | ANTIBODY BARTONELLA | $137.39 | $137.39 |
| 86617 | ANTIBODY BORRELIA BURGDORFERI CONFIRMATORY TST | $184.10 | $184.10 |
| 86631 | ANTIBODY CHLAMYDIA | $217.49 | $217.49 |
| 86645 | ANTIBODY CYTOMEGALOVIRUS CMV IGM | $169.27 | $169.27 |
| 86663 | ANTIBODY EPSTEIN-BARR EB VIRUS EARLY ANTIGEN EA | $391.21 | $391.21 |
| 86664 | ANTIBODY EPSTEIN-BARR EB VIRUS NUCLEAR AG EBNA | #DIV/0! | #DIV/0! |
| 86665 | ANTIBODY EPSTEIN-BARR EB VIRUS VIRAL CAPSID VCA | #DIV/0! | #DIV/0! |
| 86677 | ANTIBODY HELICOBACTER PYLORI | $201.66 | $201.66 |
| 86689 | ANTIBODY HTLV/HIV ANTIBODY CONFIRMATORY TEST | $362.55 | $362.55 |
| 86694 | ANTIBODY HERPES SMPLX NON-SPECIFIC TYPE TEST | $172.45 | $172.45 |
| 86695 | ANTIBODY HERPES SMPLX TYPE 1 | $211.14 | $211.14 |
| 86696 | ANTIBODY HERPES SMPLX TYPE 2 | $231.72 | $231.72 |
| 86701 | ANTIBODY HIV-1 | $218.50 | $218.50 |
| 86702 | ANTIBODY HIV-2 | $291.80 | $291.80 |
| 86703 | ANTIBODY HIV-1&HIV-2 SINGLE RESULT | $169.07 | $169.07 |
| 86704 | HEPATITIS B CORE ANTIBODY HBCAB TOTAL | $359.52 | $359.52 |
| 86706 | HEPATITIS B SURF ANTIBODY HBSAB | $357.70 | $357.70 |
| 86708 | HEPATITIS A ANTIBODY HAAB | $389.62 | $389.62 |
| 86710 | ANTIBODY INFLUENZA VIRUS | $260.18 | $260.18 |
| 86756 | ANTIBODY RESPIRATORY SYNCTIAL VIRUS | $254.31 | $254.31 |
| 86759 | ANTIBODY ROTAVIRUS | $341.94 | $341.94 |
| 86787 | ANTIBODY VARICELLA-ZOSTER | $244.32 | $244.32 |
| 86789 | ANTIBODY WEST NILE VIRUS | $206.68 | $206.68 |
| 86790 | ANTIBODY VIRUS NOT ELSEWHERE SPECIFIFED | $200.81 | $200.81 |
| 86803 | HEPATITIS C ANTIBODY | $218.87 | $218.87 |
| 86850 | ANTIBODY SCREEN RBC EACH SERUM TECHNIQUE | $310.38 | $310.38 |
| 86900 | BLOOD TYPING SEROLOGIC ABO | $460.54 | $460.54 |
| 86901 | BLOOD TYPING SEROLOGIC RH (D) | $243.01 | $243.01 |
| 86906 | BLOOD TYPING SEROLOGIC RH PHENOTYPING COMPLETE | $249.16 | $249.16 |
| 87040 | CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES | $436.88 | $436.88 |
| 87045 | CUL BACT STOOL AEROBIC ISOL SALMONELLA&SHIGELL | $320.21 | $320.21 |
| 87046 | CUL BACT STOOL AEROBIC ADDL PATHOGENS&ID EA | $218.16 | $218.16 |
| 87070 | CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL | $254.70 | $254.70 |
| 87075 | CULTURE BACTERIAL ANY SOURCE ANAEROBIC ISO&ID | $347.08 | $347.08 |
| 87076 | CUL BACT ANAEROBIC ADDL METHS DEFINITIVE EA ISOL | $170.03 | $170.03 |
| 87077 | CUL BACT AEROBIC ADDL METHS DEFINITIVE EA ISOL | $146.13 | $146.13 |
| 87081 | CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ | $285.94 | $285.94 |
| 87086 | CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE | $282.74 | $282.74 |
| 87088 | CULTURE BCT ISOL&PRSMPTV ID ISOLATE EA URINE | $136.71 | $136.71 |
| 87106 | CULTURE FUNGI DEFINITIVE ID EACH ORGANISM YEAST | $235.88 | $235.88 |
| 87110 | CULTURE CHLAMYDIA ANY SOURCE | $380.09 | $380.09 |
| 87140 | CULTURE TYPING IMMUNOFLUORESCENT EACH ANTISERUM | $175.72 | $175.72 |
| 87149 | CULTURE TYPING NUCLEIC ACID PROBE DIR EA ORGANSM | $320.52 | $320.52 |
| 87158 | CULTURE TYPING OTHER METHODS | $189.66 | $189.66 |
| 87177 | OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID | $175.09 | $175.09 |
| 87181 | SUSCEPTBILTY STDY ANTIMICRBIAL AGNT AGAR DILUTJ | $132.29 | $132.29 |
| 87186 | SUSCEPTIBLTY STDY ANTIMICRBIAL MICRO/AGAR DILUTJ | $145.32 | $145.32 |
| 87205 | SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL | $188.47 | $188.47 |
| 87207 | SMR PRIM SRC SPEC STAIN BODIES/PARASITS | $236.40 | $236.40 |
| 87209 | SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS | $257.05 | $257.05 |
| 87210 | SMR PRIM SRC WET MOUNT NFCT AGT | $142.83 | $142.83 |
| 87324 | IAAD IA CLOSTRIDIUM DIFFICILE TOXIN | $369.92 | $369.92 |
| 87332 | IAAD IA CYTOMEGALOVIRUS | $259.22 | $259.22 |
| 87338 | IAAD IA HPYLORI STOOL | $207.62 | $207.62 |
| 87339 | IAAD IA HPYLORI | $315.22 | $315.22 |
| 87389 | IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE | $270.65 | $270.65 |
| 87390 | IAAD IA HIV-1 | $225.12 | $225.12 |
| 87400 | IAAD IA INFLUENZA A/B EACH | $238.24 | $238.24 |
| 87425 | IAAD IA ROTAVIRUS | $254.41 | $254.41 |
| 87426 | severe acute respiratory syndromecoronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) | $450.82 | $450.82 |
| 87427 | IAAD IA SHIGA-LIKE TOXIN | $159.80 | $159.80 |
| 87430 | IAAD IA STREPTOCOCCUS GROUP A | $324.27 | $324.27 |
| 87449 | IAAD IA MULT STEP METHOD NOS EACH ORGANISM | $119.88 | $119.88 |
| 87481 | IADNA CANDIDA SPECIES AMPLIFIED PROBE TQ | $350.92 | $350.92 |
| 87486 | IADNA CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE TQ | $406.70 | $406.70 |
| 87491 | IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ | $388.15 | $388.15 |
| 87493 | INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE | $372.82 | $372.82 |
| 87505 | NFCT AGENT DNA/RNA GASTROINTESTINAL PATHOGEN | $379.20 | $379.20 |
| 87507 | IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 12-25 | $4,167.82 | $4,167.82 |
| 87512 | IADNA GARDNERELLA VAGINALIS QUANTIFICATION | $417.60 | $417.60 |
| 87528 | IADNA HERPES SIMPLX VIRUS DIRECT PROBE TQ | $360.94 | $360.94 |
| 87581 | IADNA MYCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ | $136.80 | $136.80 |
| 87591 | IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | $373.73 | $373.73 |
| 87633 | IADNA RESPIRATRY PROBE & REV TRNSCR 12-25 TARGET | $2,841.71 | $2,841.71 |
| 87635 | Infectious
agent detection by nucleic acid (DNA or RNA); severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]),
amplified probe technique. |
$554.36 | $554.36 |
| 87637 | Infectious agent detection by nucleic acid (DNA or RNA)severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [COVID-19), influenza virus types A and B, RSV | $3,500.00 | $3,500.00 |
| 87641 | IADNA S AUREUS METHICILLIN RESIST AMP PROBE TQ | #DIV/0! | #DIV/0! |
| 87661 | IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH | $406.51 | $406.51 |
| 87798 | IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM | $199.38 | $199.38 |
| 87804 | IAADIADOO INFLUENZA | $197.87 | $197.87 |
| 87807 | IAADIADOO RESPIRATORY SYNCTIAL VIRUS | $172.32 | $172.32 |
| 87850 | IAADIADOO NEISSERIA GONORRHOEAE | $227.98 | $227.98 |
| 87880 | IAADIADOO STREPTOCOCCUS GROUP A | $202.35 | $202.35 |
| 89051 | CELL COUNT MISC BODY FLUIDS W/DIFFERENTIAL COUNT | $87.63 | $87.63 |
| 89055 | LEUKOCYTE ASSMT FECAL QUAL/SEMIQUANTITATIVE | $104.83 | $104.83 |
| 89060 | CRYSTAL ID LIGHT MICROSCOPY ALYS TISS/ANY FLUID | $139.74 | $139.74 |
| 89220 | SPUTUM OBTAINING SPEC AEROSOL INDUCED TX SPX | $151.26 | $151.26 |
| 90470 | H1N1 IMMUNIZATION ADMINISTRATION (INTRAMUSCULAR, INTRANASAL)... | $95.04 | $95.04 |
| 90471 | IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE | $375.36 | $375.36 |
| 90472 | IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE | $75.14 | $75.14 |
| 90658 | IIV3 VACCINE SPLIT VIRUS 0.5 ML DOSAGE IM USE | $168.29 | $168.29 |
| 90660 | LAIV3 VACCINE LIVE FOR INTRANASAL USE | $115.96 | $115.96 |
| 90662 | IIV VACCINE PRESERV FREE INCREASED AG COUNT IM | $234.04 | $234.04 |
| 90665 | LYME DISEASE VACCINE ADULT IM | $190.08 | $190.08 |
| 90675 | RABIES VACCINE INTRAMUSCULAR | $1,995.53 | $1,995.53 |
| 90703 | TETANUS TOXOID ADSORBED INTRAMUSCULAR | $225.32 | $225.32 |
| 90707 | MEASLES MUMPS RUBELLA VIRUS VACCINE LIVE SUBQ | $328.19 | $328.19 |
| 90714 | TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE | $248.37 | $248.37 |
| 90715 | Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use | $357.06 | $357.06 |
| 90716 | VAR VACCINE LIVE FOR SUBCUTANEOUS USE | $120.12 | $120.12 |
| 90718 | TD - TETANUS & DIPHTHERIA TOXOIDS ADSORBED 7 YR + IM | $225.32 | $225.32 |
| 90746 | HEPB VACCINE ADULT 3 DOSE SCHEDULE FOR IM USE | $300.27 | $300.27 |
| 90997 | HEMOPERFUSION | $769.83 | $769.83 |
| 92950 | CARDIOPULMONARY RESUSCITATION | $2,428.05 | $2,428.05 |
| 92960 | CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL | $3,291.32 | $3,291.32 |
| 93000 | ECG ROUTINE ECG W/LEAST 12 LDS W/I&R | $358.46 | $358.46 |
| 93005 | ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R | $245.41 | $245.41 |
| 93010 | ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY | $146.64 | $146.64 |
| 93040 | RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT | $137.16 | $137.16 |
| 93041 | RHYTHM ECG 1-3 LEADS TRACING ONLY W/O I&R | $457.06 | $457.06 |
| 93042 | RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON | $151.03 | $151.03 |
| 93224 | XTRNL ECG & 48 HR RECORD SCAN STOR W/R&I | $485.96 | $485.96 |
| 93303 | COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY | $3,104.12 | $3,104.12 |
| 93306 | ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D | $3,489.50 | $3,489.50 |
| 93307 | ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP | $2,750.42 | $2,750.42 |
| 93308 | ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD | $1,864.44 | $1,864.44 |
| 93312 | ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R | $3,136.70 | $3,136.70 |
| 93313 | ECHO R-T 2D W/PROBE PLACEMENT ONLY | $3,787.04 | $3,787.04 |
| 93320 | DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY | $629.07 | $629.07 |
| 93351 | ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG | $3,105.29 | $3,105.29 |
| 93875 | N-INVAS PHYSIOLOGIC STD XTRC ART COMPL BI STD | $1,250.04 | $1,250.04 |
| 93880 | DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY | $1,685.56 | $1,685.56 |
| 93882 | DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY | $1,319.57 | $1,319.57 |
| 93922 | NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL | $917.01 | $917.01 |
| 93926 | DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY | $1,273.01 | $1,273.01 |
| 93931 | DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY | $893.60 | $893.60 |
| 93965 | N-INVAS PHYSIOLOGIC STD XTR VEINS COMPL BI STD | $2,165.02 | $2,165.02 |
| 93970 | DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY | $2,425.66 | $2,425.66 |
| 93971 | DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY | $1,191.60 | $1,191.60 |
| 93975 | DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM | $2,832.06 | $2,832.06 |
| 94150 | VITAL CAPACITY TOTAL SEPARATE PROCEDURE | $467.21 | $467.21 |
| 94621 | PULMONARY STRESS TESTING COMPLEX | $1,767.71 | $1,767.71 |
| 94640 | PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT | $983.38 | $983.38 |
| 94760 | NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER | $348.59 | $348.59 |
| 94761 | NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER | $382.83 | $382.83 |
| 96360 | IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR | $1,363.22 | $1,363.22 |
| 96361 | IV INFUSION HYDRATION EACH ADDITIONAL HOUR | $627.99 | $627.99 |
| 96365 | IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR | $1,149.84 | $1,149.84 |
| 96366 | IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR | $438.01 | $438.01 |
| 96367 | IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR | $527.64 | $527.64 |
| 96368 | IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS | $422.01 | $422.01 |
| 96372 | THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM | $481.89 | $481.89 |
| 96373 | THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL | $717.98 | $717.98 |
| 96374 | THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG | $1,002.29 | $1,002.29 |
| 96375 | THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG | $489.41 | $489.41 |
| 96376 | THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC | $697.06 | $697.06 |
| 97597 | DEBRIDEMENT OPEN WOUND First 20 sq cm or less | $1,344.09 | $1,344.09 |
| 97598 | DEBRIDEMENT OPEN WOUND EACH ADDITIONAL 20 SQ CM | $511.60 | $511.60 |
| 99000 | HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB | $59.59 | $59.59 |
| 99001 | HANDLG&/OR CONVEY OF SPEC FOR TR FROM PT TO LAB | $81.79 | $81.79 |
| 99053 | SERVICES PROVIDED BTW 10 PM&8 AM AT 24-HR FACI | $344.44 | $344.44 |
| 99070 | SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP | $88.43 | $88.43 |
| 99143 | M-SEDATJ BY SM PHYS PERFRMG SVC < 5 YR | $971.16 | $971.16 |
| 99144 | ANESTHESIA - M-SEDAJ BY SM PHYS PERFRMG SVC 5+ YR | $724.22 | $724.22 |
| 99145 | M-SEDAJ BY SM PHYS PERFRMG SVC EA 15 MIN | $374.52 | $374.52 |
| 99148 | M-SEDATION BY PHYS OTH/THN HC PROF PERFRMG < 5 | $199.58 | $199.58 |
| 99149 | M-SEDATION BY PHYS OTH/THN HC PROF PERFRMG 5+ | $803.27 | $803.27 |
| 99151 | MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS | $530.40 | $530.40 |
| 99152 | MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS | $405.54 | $405.54 |
| 99153 | MOD SED SAME PHYS/QHP EACH ADDL 15 MINS | $149.91 | $149.91 |
| 99173 | SCREENING TEST VISUAL ACUITY QUANTITATIVE BILAT | $389.85 | $389.85 |
| 99217 | OBSERVATION CARE DISCHARGE MANAGEMENT | $1,034.79 | $1,034.79 |
| 99218 | INITIAL OBSERVATION CARE/DAY 30 MINUTES | $922.75 | $922.75 |
| 99219 | INITIAL OBSERVATION CARE/DAY 50 MINUTES | $1,393.19 | $1,393.19 |
| 99220 | INITIAL OBSERVATION CARE/DAY 70 MINUTES | $1,987.66 | $1,987.66 |
| 99226 | SBSQ OBSERVATION CARE/DAY 35 MINUTES | $381.60 | $381.60 |
| 99234 | OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES | $1,410.98 | $1,410.98 |
| 99235 | OBSERVATION/INPATIENT HOSPITAL CARE 50 MINUTES | $2,090.04 | $2,090.04 |
| 99236 | OBSERVATION/INPATIENT HOSPITAL CARE 55 MINUTES | $2,455.29 | $2,455.29 |
| 99281 | EMERGENCY DEPARTMENT VISIT LEVEL 1 | $626.00 | $626.00 |
| 99282 | EMERGENCY DEPARTMENT VISIT LEVEL 2 | $1,009.29 | $1,009.29 |
| 99283 | EMERGENCY DEPARTMENT VISIT LEVEL 3 | $2,073.90 | $2,073.90 |
| 99284 | EMERGENCY DEPARTMENT VISIT LEVEL 4 | $3,051.40 | $3,051.40 |
| 99285 | EMERGENCY DEPARTMENT VISIT LEVEL 5 | $4,116.02 | $4,116.02 |
| 99291 | CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN | $6,020.24 | $6,020.24 |
| 99292 | CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN | $1,395.81 | $1,395.81 |
| 99406 | TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES | $235.62 | $235.62 |
| 99407 | TOBACCO USE CESSATION INTENSIVE >10 MINUTES | $224.59 | $224.59 |
| A0394 | ALS IV DRUG THERAPY SUPPLIES | $28.42 | $28.42 |
| A0396 | ALS ESOPHAGEAL INTUB SUPPLS | $67.23 | $67.23 |
| A0716 | NEBULIZER DOME & MOUTHPIECE | $57.49 | $57.49 |
| A4206 | 1 CC STERILE SYRINGE&NEEDLE | $30.00 | $30.00 |
| A4207 | 2 CC STERILE SYRINGE&NEEDLE | $26.02 | $26.02 |
| A4208 | 3 CC STERILE SYRINGE&NEEDLE | $76.61 | $76.61 |
| A4209 | 5+ CC STERILE SYRINGE&NEEDLE | $80.21 | $80.21 |
| A4213 | 20+ CC SYRINGE ONLY | $37.87 | $37.87 |
| A4215 | STERILE NEEDLE | $51.69 | $51.69 |
| A4216 | Sterile water, saline and/or dextrose, diluent/flush, 10 ml | $52.67 | $52.67 |
| A4217 | STERILE WATER/SALINE, 500 ML | $70.28 | $70.28 |
| A4218 | Sterile saline or water, metered dose dispenser, 10 ml | $55.99 | $55.99 |
| A4222 | INFUSION SUPPLIES WITH PUMP | $235.62 | $235.62 |
| A4244 | ALCOHOL OR PEROXIDE PER PINT | $85.42 | $85.42 |
| A4245 | ALCOHOL WIPES PER BOX | $56.28 | $56.28 |
| A4246 | BETADINE/PHISOHEX SOLUTION | $85.82 | $85.82 |
| A4247 | BETADINE/IODINE SWABS/WIPES | $81.60 | $81.60 |
| A4248 | CHLORHEXIDINE ANTISEPT | $194.41 | $194.41 |
| A4252 | BLOOD KETONE TEST OR STRIP | $10.89 | $10.89 |
| A4310 | INSERT TRAY W/O BAG/CATH | $102.43 | $102.43 |
| A4311 | CATHETER W/O BAG 2-WAY LATEX | $97.74 | $97.74 |
| A4314 | CATH W/DRAINAGE 2-WAY LATEX | $70.43 | $70.43 |
| A4315 | CATH W/DRAINAGE 2-WAY SILCNE | $213.60 | $213.60 |
| A4320 | IRRIGATION TRAY | $93.91 | $93.91 |
| A4322 | IRRIGATION SYRINGE | $26.97 | $26.97 |
| A4327 | FEM URINARY COLLECT DEV CUP | $77.18 | $77.18 |
| A4332 | LUBE STERILE PACKET | $15.22 | $15.22 |
| A4335 | INCONTINENCE SUPPLY | $6.32 | $6.32 |
| A4344 | CATH INDW FOLEY 2 WAY SILICN | $42.72 | $42.72 |
| A4351 | STRAIGHT TIP URINE CATHETER | $36.64 | $36.64 |
| A4352 | COUDE TIP URINARY CATHETER | $32.83 | $32.83 |
| A4353 | INTERMITTENT URINARY CATH | $43.02 | $43.02 |
| A4354 | CATH INSERTION TRAY W/BAG | $130.09 | $130.09 |
| A4355 | BLADDER IRRIGATION TUBING | #DIV/0! | #DIV/0! |
| A4358 | URINARY LEG OR ABDOMEN BAG | $29.81 | $29.81 |
| A4364 | ADHESIVE, LIQUID OR EQUAL | $113.05 | $113.05 |
| A4450 | NON-WATERPROOF TAPE | $48.29 | $48.29 |
| A4452 | WATERPROOF TAPE | $57.00 | $57.00 |
| A4470 | GRAVLEE JET WASHER | $300.00 | $300.00 |
| A4550 | SURGICAL TRAYS | $484.91 | $484.91 |
| A4554 | DISPOSABLE UNDERPADS | $40.53 | $40.53 |
| A4556 | ELECTRODES, PAIR | $148.20 | $148.20 |
| A4565 | SLINGS | $198.94 | $198.94 |
| A4566 | SHOULD SLING/VEST/ABRESTRAIN | $220.20 | $220.20 |
| A4570 | SPLINT | $169.57 | $169.57 |
| A4590 | SPECIAL CASTING MATERIAL | $170.34 | $170.34 |
| A4606 | OXYGEN PROBE USED W OXIMETER | $129.60 | $129.60 |
| A4614 | HAND-HELD PEFR METER | $76.69 | $76.69 |
| A4615 | CANNULA NASAL | $66.81 | $66.81 |
| A4616 | TUBING (OXYGEN) PER FOOT | $14.08 | $14.08 |
| A4620 | VARIABLE CONCENTRATION MASK | $165.00 | $165.00 |
| A4649 | SURGICAL SUPPLIES | $79.20 | $79.20 |
| A4657 | SYRINGE W/WO NEEDLE | $51.60 | $51.60 |
| A4660 | SPHYG/BP APP W CUFF AND STET | $64.31 | $64.31 |
| A4670 | AUTOMATIC BP MONITOR, DIAL | $105.06 | $105.06 |
| A4673 | EXT LINE W EASY LOCK CONNECT | $22.05 | $22.05 |
| A4770 | BLOOD COLLECTION TUBE/VACUUM | $72.00 | $72.00 |
| A4927 | NON-STERILE GLOVES | $7.59 | $7.59 |
| A4930 | STERILE, GLOVES PER PAIR | $58.62 | $58.62 |
| A5120 | SKIN BARRIER, WIPE OR SWAB | $9.96 | $9.96 |
| A5200 | PERCUTANEOUS CATHETER ANCHOR | $160.00 | $160.00 |
| A6021 | COLLAGEN DRESSING <=16 SQ IN | $32.62 | $32.62 |
| A6203 | COMPOSITE DRSG <= 16 SQ IN | $33.49 | $33.49 |
| A6204 | COMPOSITE DRSG >16<=48 SQ IN | $55.20 | $55.20 |
| A6205 | COMPOSITE DRSG > 48 SQ IN | $34.20 | $34.20 |
| A6211 | FOAM DRG > 48 SQ IN W/O BRDR | $60.36 | $60.36 |
| A6213 | FOAM DRG >16<=48 SQ IN W/BDR | $30.37 | $30.37 |
| A6216 | NON-STERILE GAUZE<=16 SQ IN | $54.85 | $54.85 |
| A6217 | NON-STERILE GAUZE>16<=48 SQ | $66.54 | $66.54 |
| A6218 | NON-STERILE GAUZE > 48 SQ IN | $26.48 | $26.48 |
| A6219 | Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing | $86.00 | $86.00 |
| A6220 | GAUZE >16 <=48 SQ IN W/BORDR | $34.29 | $34.29 |
| A6222 | GAUZE <=16 IN NO W/SAL W/O B | $18.54 | $18.54 |
| A6224 | GAUZE > 48 IN NO W/SAL W/O B | $34.50 | $34.50 |
| A6231 | HYDROGEL DSG<=16 SQ IN | $97.02 | $97.02 |
| A6250 | SKIN SEAL PROTECT MOISTURIZR | $86.98 | $86.98 |
| A6257 | TRANSPARENT FILM <= 16 SQ IN | $19.90 | $19.90 |
| A6260 | WOUND CLEANSER ANY TYPE/SIZE | $125.86 | $125.86 |
| A6266 | IMPREG GAUZE NO H20/SAL/YARD | $76.44 | $76.44 |
| A6402 | Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing | $61.41 | $61.41 |
| A6407 | PACKING STRIPS, NON-IMPREG | $86.00 | $86.00 |
| A6410 | STERILE EYE PAD | $51.56 | $51.56 |
| A6412 | OCCLUSIVE EYE PATCH | $88.88 | $88.88 |
| A6413 | ADHESIVE BANDAGE, FIRST-AID | $61.47 | $61.47 |
| A6446 | KERLIX CONFORM BAND S W>=3 <5/YD | $50.10 | $50.10 |
| A6448 | LT COMPRES BAND <3/YD | $51.40 | $51.40 |
| A6449 | Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard | $54.12 | $54.12 |
| A6450 | LT COMPRES BAND >=5/YD | $54.09 | $54.09 |
| A6453 | SELF-ADHER BAND W <3/YD | $75.20 | $75.20 |
| A6454 | SELF-ADHER BAND W>=3 <5/YD | $64.67 | $64.67 |
| A6457 | TUBULAR DRESSING | $84.64 | $84.64 |
| A7002 | TUBING USED W SUCTION PUMP | $148.61 | $148.61 |
| A7003 | NEBULIZER ADMINISTRATION SET | $124.13 | $124.13 |
| A7011 | NONDISPOS CORRUGATED TUBING | $20.38 | $20.38 |
| A7015 | AEROSOL MASK USED W NEBULIZE | $114.17 | $114.17 |
| A7016 | NEBULIZER DOME & MOUTHPIECE | $94.28 | $94.28 |
| A7017 | NEBULIZER NOT USED W OXYGEN | $84.88 | $84.88 |
| A7520 | TRACH/LARYN TUBE NON-CUFFED | $65.69 | $65.69 |
| A9150 | MISC/EXPER NON-PRESCRIPT DRU | $28.75 | $28.75 |
| A9273 | HOT/COLD H2OBOT/CAP/COL/WRAP | $70.39 | $70.39 |
| A9579 | GAD-BASE MR CONTRAST NOS,1ML | $24.83 | $24.83 |
| C1751 | CATH, INF, PER/CENT/MIDLINE | $123.60 | $123.60 |
| C9285 | PATCH, LIDOCAINE/TETRACAINE | $98.86 | $98.86 |
| E0114 | CRUTCH UNDERARM PAIR NO WOOD | $212.42 | $212.42 |
| E0116 | CRUTCH UNDERARM EACH NO WOOD | $105.96 | $105.96 |
| E0144 | ENCLOSED WALKER W REAR SEAT | $1,240.31 | $1,240.31 |
| E0220 | HOT WATER BOTTLE | $50.00 | $50.00 |
| E0230 | ICE CAP OR COLLAR | $25.17 | $25.17 |
| E0275 | BED PAN STANDARD | $20.45 | $20.45 |
| E0325 | URINAL MALE JUG-TYPE | $18.98 | $18.98 |
| E0352 | DISPOSABLE PACK W/BOWEL SYST | $319.82 | $319.82 |
| E0445 | OXIMETER NON-INVASIVE | $814.80 | $814.80 |
| E0570 | NEBULIZER WITH COMPRESSION | $673.20 | $673.20 |
| E0580 | NEBULIZER FOR USE W/ REGULAT | $411.20 | $411.20 |
| G0168 | WOUND CLOSURE BY ADHESIVE | $276.46 | $276.46 |
| G0378 | HOSPITAL OBSERVATION PER HR | $1,554.68 | $1,554.68 |
| G0404 | EKG TRACING FOR INITIAL PREV | $73.31 | $73.31 |
| G0477 | DRUG TEST PRESUMP OPTICAL | #DIV/0! | #DIV/0! |
| G0478 | DRUG TEST PRESUMP OPT INST | #DIV/0! | #DIV/0! |
| G8895 | Oral aspirin or other antithrombotic therapy prescribed | $21.78 | $21.78 |
| J0153 | ADENOSINE INJ 1MG | $3.73 | $3.73 |
| J0171 | ADRENALIN EPINEPHRINE INJECT | $5.04 | $5.04 |
| J0282 | AMIODARONE HCL | $1.38 | $1.38 |
| J0295 | AMPICILLIN SODIUM PER 1.5 GM | $21.49 | $21.49 |
| J0330 | SUCCINYCHOLINE CHLORIDE INJ | $0.90 | $0.90 |
| J0360 | HYDRALAZINE HCL INJECTION, up to 20 mg | $22.60 | $22.60 |
| J0456 | Injection, azithromycin, 500 mg | $18.68 | $18.68 |
| J0500 | DICYCLOMINE INJECTION | $272.57 | $272.57 |
| J0558 | PENG BENZATHINE/PROCAINE INJ | $64.85 | $64.85 |
| J0561 | PENICILLIN G BENZATHINE INJ | $82.97 | $82.97 |
| J0570 | BUPRENORPHINE IMPLANT 74.2MG | $7,398.81 | $7,398.81 |
| J0595 | BUTORPHANOL TARTRATE 1 MG | $15.19 | $15.19 |
| J0641 | LEVOLEUCOVORIN INJECTION | $0.69 | $0.69 |
| J0690 | CEFAZOLIN SODIUM INJECTION | $4.90 | $4.90 |
| J0696 | CEFTRIAXONE SODIUM INJECTION | $3.20 | $3.20 |
| J0698 | CEFOTAXIME SODIUM INJECTION | $13.99 | $13.99 |
| J0735 | CLONIDINE HYDROCHLORIDE | $78.20 | $78.20 |
| J0744 | CIPROFLOXACIN IV | $7.02 | $7.02 |
| J0780 | PROCHLORPERAZINE INJECTION | $46.04 | $46.04 |
| J1020 | METHYLPREDNISOLONE 20 MG INJ | $20.63 | $20.63 |
| J1030 | METHYLPREDNISOLONE 40 MG INJ | $36.28 | $36.28 |
| J1040 | METHYLPREDNISOLONE 80 MG INJ | $69.78 | $69.78 |
| J1050 | MEDROXYPROGESTERONE ACETATE | $3.35 | $3.35 |
| J1094 | INJ DEXAMETHASONE ACETATE | $1.38 | $1.38 |
| J1100 | DEXAMETHASONE SODIUM PHOS | $0.81 | $0.81 |
| J1110 | INJ DIHYDROERGOTAMINE MESYLT | $383.57 | $383.57 |
| J1160 | DIGOXIN INJECTION | $28.41 | $28.41 |
| J1165 | PHENYTOIN SODIUM INJECTION | $5.00 | $5.00 |
| J1170 | HYDROMORPHONE INJECTION | $19.58 | $19.58 |
| J1200 | DIPHENHYDRAMINE HCL INJECTIO | $5.02 | $5.02 |
| J1240 | DIMENHYDRINATE INJECTION | $39.14 | $39.14 |
| J1335 | ERTAPENEM INJECTION | $230.70 | $230.70 |
| J1580 | GARAMYCIN GENTAMICIN INJ | $12.27 | $12.27 |
| J1610 | GLUCAGON HYDROCHLORIDE/1 MG | $1,199.30 | $1,199.30 |
| J1630 | HALOPERIDOL INJECTION | $4.96 | $4.96 |
| J1631 | HALOPERIDOL DECANOATE INJ | $92.72 | $92.72 |
| J1642 | INJ HEPARIN SODIUM PER 10 U | $0.10 | $0.10 |
| J1644 | INJ HEPARIN SODIUM PER 1000U | $1.49 | $1.49 |
| J1650 | INJ ENOXAPARIN SODIUM, 10MG | $4.28 | $4.28 |
| J1670 | TETANUS IMMUNE GLOBULIN INJ | $3,208.38 | $3,208.38 |
| J1720 | HYDROCORTISONE SODIUM SUCC I | $77.38 | $77.38 |
| J1790 | DROPERIDOL INJECTION | $12.84 | $12.84 |
| J1815 | INSULIN INJECTION | $5.33 | $5.33 |
| J1885 | KETOROLAC TROMETHAMINE INJ | $3.32 | $3.32 |
| J1940 | FUROSEMIDE INJECTION | $3.75 | $3.75 |
| J1953 | LEVETIRACETAM INJECTION | $0.59 | $0.59 |
| J1956 | LEVOFLOXACIN INJECTION, 250 MG | $2.57 | $2.57 |
| J1980 | HYOSCYAMINE SULFATE INJ | $189.57 | $189.57 |
| J2001 | LIDOCAINE INJECTION | $0.19 | $0.19 |
| J2060 | LORAZEPAM INJECTION | $4.47 | $4.47 |
| J2150 | MANNITOL INJECTION | $12.66 | $12.66 |
| J2175 | MEPERIDINE HYDROCHL /100 MG | $30.02 | $30.02 |
| J2185 | MEROPENEM | $4.84 | $4.84 |
| J2250 | INJ MIDAZOLAM HYDROCHLORIDE | $0.65 | $0.65 |
| J2260 | INJ MILRINONE LACTATE / 5 MG | $9.95 | $9.95 |
| J2270 | MORPHINE SULFATE INJECTION | $22.39 | $22.39 |
| J2300 | INJ NALBUPHINE HYDROCHLORIDE | $15.59 | $15.59 |
| J2310 | INJ NALOXONE HYDROCHLORIDE | $74.17 | $74.17 |
| J2360 | ORPHENADRINE INJECTION | $46.25 | $46.25 |
| J2370 | PHENYLEPHRINE HCL INJECTION | $20.04 | $20.04 |
| J2405 | ONDANSETRON HCL INJECTION | $0.52 | $0.52 |
| J2543 | Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) | $10.95 | $10.95 |
| J2550 | PROMETHAZINE HCL INJECTION | $11.83 | $11.83 |
| J2650 | PREDNISOLONE ACETATE INJ | $3.12 | $3.12 |
| J2690 | PROCAINAMIDE HCL INJECTION | $583.89 | $583.89 |
| J2704 | INJ, PROPOFOL, 10 MG | $0.64 | $0.64 |
| J2730 | PRALIDOXIME CHLORIDE INJ | $551.40 | $551.40 |
| J2765 | METOCLOPRAMIDE HCL INJECTION | $7.45 | $7.45 |
| J2780 | RANITIDINE HYDROCHLORIDE INJ | $23.01 | $23.01 |
| J2790 | RHO D IMMUNE GLOBULIN INJ | $465.37 | $465.37 |
| J2800 | METHOCARBAMOL INJECTION | $43.36 | $43.36 |
| J2920 | METHYLPREDNISOLONE INJECTION | $26.87 | $26.87 |
| J2930 | METHYLPREDNISOLONE INJECTION | $38.35 | $38.35 |
| J2950 | PROMAZINE HCL INJECTION | $124.90 | $124.90 |
| J3010 | FENTANYL CITRATE INJECITON | $4.75 | $4.75 |
| J3030 | SUMATRIPTAN SUCCINATE / 6 MG | $311.34 | $311.34 |
| J3260 | TOBRAMYCIN SULFATE INJECTION | $23.84 | $23.84 |
| J3301 | TRIAMCINOLONE ACET INJ NOS | $9.02 | $9.02 |
| J3360 | DIAZEPAM INJECTION | $56.42 | $56.42 |
| J3370 | VANCOMYCIN HCL INJECTION | $17.80 | $17.80 |
| J3410 | HYDROXYZINE HCL INJECTION | $38.00 | $38.00 |
| J3411 | THIAMINE HCL 100 MG | $18.22 | $18.22 |
| J3420 | VITAMIN B12 INJECTION | $13.56 | $13.56 |
| J3475 | INJ MAGNESIUM SULFATE | $3.31 | $3.31 |
| J3480 | INJ POTASSIUM CHLORIDE | $0.75 | $0.75 |
| J3490 | DRUGS UNCLASSIFIED INJECTION | $1,050.00 | $1,050.00 |
| J7030 | NORMAL SALINE SOLUTION INFUS | $15.54 | $15.54 |
| J7040 | NORMAL SALINE SOLUTION INFUS | $7.77 | $7.77 |
| J7042 | 5% DEXTROSE/NORMAL SALINE | $6.11 | $6.11 |
| J7050 | Infusion, normal saline solution, 250 cc | $3.88 | $3.88 |
| J7060 | 5% DEXTROSE/WATER | $11.42 | $11.42 |
| J7070 | D5W INFUSION | $22.63 | $22.63 |
| J7120 | RINGERS LACTATE INFUSION | $14.48 | $14.48 |
| J7121 | 5% DEXTROSE IN LAC RINGERS | $72.00 | $72.00 |
| J7510 | PREDNISOLONE ORAL PER 5 MG | $0.59 | $0.59 |
| J7605 | ARFORMOTEROL NON-COMP UNIT | $64.38 | $64.38 |
| J7607 | LEVALBUTEROL COMP CON | $49.87 | $49.87 |
| J7610 | ALBUTEROL COMP CON | $46.54 | $46.54 |
| J7611 | ALBUTEROL NON-COMP CON | $1.58 | $1.58 |
| J7613 | ALBUTEROL NON-COMP UNIT | $0.25 | $0.25 |
| J7614 | LEVALBUTEROL NON-COMP UNIT | $0.34 | $0.34 |
| J7615 | LEVALBUTEROL COMP UNIT | $36.04 | $36.04 |
| J7620 | ALBUTEROL IPRATROP NON-COMP | $0.78 | $0.78 |
| J7626 | BUDESONIDE NON-COMP UNIT | $10.45 | $10.45 |
| J7637 | DEXAMETHASONE COMP CON | $51.86 | $51.86 |
| J7643 | GLYCOPYRROLATE COMP UNIT | $95.06 | $95.06 |
| J7644 | IPRATROPIUM BROMIDE NON-COMP | $1.25 | $1.25 |
| J7699 | INHALATION SOLUTION FOR DME | $31.34 | $31.34 |
| J8498 | ANTIEMETIC RECTAL/SUPP NOS | $49.56 | $49.56 |
| J8499 | ORAL PRESCRIP DRUG NON CHEMO | $81.19 | $81.19 |
| J8540 | ORAL DEXAMETHASONE | $0.44 | $0.44 |
| L0120 | CERV FLEX N/ADJ FOAM PRE OTS | $510.67 | $510.67 |
| L0150 | CERV SEMI-RIG ADJ MOLDED CHN | $486.80 | $486.80 |
| L0172 | CERV COL SR FOAM 2PC PRE OTS | $77.30 | $77.30 |
| L0450 | TLSO FLEX TRUNK/THOR PRE OTS | #DIV/0! | #DIV/0! |
| L1820 | KO ELAS W/ CONDYLE PADS & JO | $124.32 | $124.32 |
| L1830 | KO IMMOB CANVAS LONG PRE OTS | $105.32 | $105.32 |
| L1844 | KO W/ADJ JT ROT CNTRL MOLDED | #DIV/0! | #DIV/0! |
| L1900 | AFO SPRNG WIR DRSFLX CALF BD | $497.51 | $497.51 |
| L1906 | AFO MULTILIG ANK SUP PRE OTS | $216.38 | $216.38 |
| L3215 | ORTHOPEDIC FTWEAR LADIES OXF | $339.28 | $339.28 |
| L3219 | ORTHOPEDIC MENS SHOES OXFORD | $104.54 | $104.54 |
| L3260 | AMBULATORY SURGICAL BOOT EAC | $128.11 | $128.11 |
| L3540 | ORTHO SHOE ADD FULL SOLE | $315.81 | $315.81 |
| L3650 | SO 8 ABD RESTRAINT PRE OTS | $284.34 | $284.34 |
| L3660 | SO 8 AB RSTR CAN/WEB PRE OTS | $409.57 | $409.57 |
| L3670 | SO ACRO/CLAV CAN WEB PRE OTS | $683.54 | $683.54 |
| L3671 | SO CAP DESIGN W/O JNTS CF | $403.20 | $403.20 |
| L3806 | Wrist hand finger orthosis, includes one or more nontorsion joint(s), straps, custom fabricated, includes fitting and adjustment | $903.17 | $903.17 |
| L3807 | WHFO W/O JOINTS PRE CST | $855.96 | $855.96 |
| L3809 | WHFO W/O JOINTS PRE OTS | $322.61 | $322.61 |
| L3908 | Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf | $116.11 | $116.11 |
| L3919 | HO W/O JOINTS CF | $1,458.60 | $1,458.60 |
| L3933 | FO W/O JOINTS CF | $48.00 | $48.00 |
| L3999 | UPPER LIMB ORTHOSIS NOS | $217.20 | $217.20 |
| L4350 | ANKLE CONTROL ORTHO PRE OTS | $554.44 | $554.44 |
| L4360 | PNEUMAT WALKING BOOT PRE CST | $532.80 | $532.80 |
| L4361 | PNEUMA/VAC WALK BOOT PRE OTS | $368.90 | $368.90 |
| L4370 | PNEUM FULL LEG SPLNT PRE OTS | #DIV/0! | #DIV/0! |
| L4386 | NON-PNEUM WALK BOOT PRE CST | $579.20 | $579.20 |
| L4396 | STATIC OR DYNAMI AFO PRE CST | $138.00 | $138.00 |
| L4631 | AFO, WALK BOOT TYPE, CUS FAB | $90.00 | $90.00 |
| P7001 | CULTURE BACTERIAL URINE | $122.80 | $122.80 |
| P9612 | CATHETERIZE FOR URINE SPEC | $182.20 | $182.20 |
| Q0111 | WET MOUNTS/ W PREPARATIONS | $65.21 | $65.21 |
| Q0114 | FERN TEST | $58.44 | $58.44 |
| Q0144 | AZITHROMYCIN DIHYDRATE, ORAL | $217.26 | $217.26 |
| Q0162 | ONDANSETRON ORAL | $0.16 | $0.16 |
| Q0163 | DIPHENHYDRAMINE HCL 50MG | $1.68 | $1.68 |
| Q0177 | HYDROXYZINE PAMOATE 25MG | $0.24 | $0.24 |
| Q2038 | FLUZONE VACC, 3 YRS & >, IM | $96.60 | $96.60 |
| Q4006 | CAST SUP LONG ARM ADULT FBRG | $177.57 | $177.57 |
| Q4008 | CAST SUP LONG ARM PED FBRGLS | $97.65 | $97.65 |
| Q4010 | CAST SUP SHT ARM ADULT FBRGL | $172.20 | $172.20 |
| Q4018 | CAST SUP LNG ARM SPLINT FBRG | $1,080.81 | $1,080.81 |
| Q4020 | CAST SUP LNG ARM SPLNT PED F | $576.36 | $576.36 |
| Q4022 | CAST SUP SHT ARM SPLINT FBRG | $810.07 | $810.07 |
| Q4024 | CAST SUP SHT ARM SPLNT PED F | $646.42 | $646.42 |
| Q4025 | CAST SUP HIP SPICA PLASTER | $120.00 | $120.00 |
| Q4037 | CAST SUP SHRT LEG PLASTER | $246.79 | $246.79 |
| Q4038 | CAST SUP SHRT LEG FIBERGLASS | $141.00 | $141.00 |
| Q4042 | CAST SUP LNG LEG SPLNT FBRGL | $509.10 | $509.10 |
| Q4046 | CAST SUP SHT LEG SPLNT FBRGL | $330.67 | $330.67 |
| Q4048 | CAST SUP SHT LEG SPLNT PED F | $63.26 | $63.26 |
| Q4049 | FINGER SPLINT, STATIC | $271.58 | $271.58 |
| Q4051 | Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and other supplies | $181.33 | $181.33 |
| Q9954 | ORAL MR CONTRAST, 100 ML | $475.45 | $475.45 |
| Q9963 | HOCM 350-399MG/ML IODINE,1ML | $36.98 | $36.98 |
| Q9965 | LOCM 100-199MG/ML IODINE,1ML | $35.16 | $35.16 |
| Q9966 | LOCM 200-299MG/ML IODINE,1ML | $38.80 | $38.80 |
| Q9967 | LOCM 300-399MG/ML IODINE,1ML | $7.69 | $7.69 |
| S0012 | BUTORPHANOL TARTRATE, NASAL | $79.27 | $79.27 |
| S0020 | INJECTION, BUPIVICAINE HYDRO | $85.29 | $85.29 |
| S0028 | INJECTION, FAMOTIDINE, 20 MG | $88.85 | $88.85 |
| S0030 | INJECTION, METRONIDAZOLE | $163.15 | $163.15 |
| S0039 | INJECTION, SULFAMETHOXAZOLE | $41.40 | $41.40 |
| S0074 | INJECTION, CEFOTETAN DISODIU | $115.67 | $115.67 |
| S0077 | INJECTION, CLINDAMYCIN PHOSP | $44.16 | $44.16 |
| S0092 | HYDROMORPHONE 250 MG | $85.00 | $85.00 |
| S0119 | ONDANSETRON 4 MG | $90.53 | $90.53 |
| S0164 | INJECTION PANTROPRAZOLE | $190.28 | $190.28 |
| S0183 | PROCHLORPERAZINE 5 MG | $27.77 | $27.77 |
| S0630 | REMOVAL OF SUTURES | $116.32 | $116.32 |
| S1015 | IV TUBING EXTENSION SET | $129.78 | $129.78 |
| S5000 | PRESCRIPTION DRUG, GENERIC | $13.34 | $13.34 |
| S5001 | PRESCRIPTION DRUG,BRAND NAME | $20.00 | $20.00 |
| S5010 | 5% DEXTROSE AND 0.45% SALINE | $173.98 | $173.98 |
| S5550 | INSULIN RAPID 5 U | $48.08 | $48.08 |
| S8037 | MRCP - Magnetic resonance cholangiopancreatography | $1,476.00 | $1,476.00 |
| S8100 | SPACER WITHOUT MASK | $83.60 | $83.60 |
| S8101 | SPACER WITH MASK | $105.96 | $105.96 |
| S8120 | O2 CONTENTS GAS CUBIC FT | $17.37 | $17.37 |
| S8450 | SPLINT DIGIT | $143.95 | $143.95 |
| S8451 | SPLINT WRIST OR ANKLE | $176.11 | $176.11 |
| V2797 | VIS ITEM/SVC IN OTHER CODE | $40.07 | $40.07 |
| V2799 | MISC VISION ITEM OR SERVICE | $162.00 | $162.00 |