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